Great new information on the management of child dental decay
You will have spotted that this post is not about orthodontics. I have decided to write about a groundbreaking trial that provides us with great information on the management of child dental decay. Everyone involved in dental care should read this. So please share this as much as you can.
This post is about a study that evaluated three methods of managing primary tooth caries.
Dental caries is the most common childhood disease. Surprisingly, there is a large amount of uncertainty about its management. This new trial investigated this common clinical dilemma. A UK based team did this trial. The Journal of Dental Research published the paper.
What did they ask?
They asked the following clinically relevant question;
“What is the best way of managing primary tooth caries”?
What did they do?
They did a 3 arm parallel-group RCT with a 1:1:1 allocation of patients. The main details are:
Participants:3-7-year-old children who were attending general dental practice with at least 1 primary tooth carious lesion extending into dentine.
Interventions: (i) Prevention alone (ii) conventional with best-practice prevention and (iii) Biological treatment with best-practice prevention.
Outcome: (i) The proportion of participants with at least one episode of dental pain and/or infection. (ii) The total number of episodes of dental pain and/or infection for each participant.
The trial was run in a sample of 72 UK general dental practices. 1,144 children were randomised to one of three interventions.
- PA (Best practice prevention alone)
Dietary investigation, analysis and relevant advice.
Tooth brushing with fluoridated toothpaste and mouth wash.
Topical fluoride application
Fissure sealants of secondary teeth.
- Conventional with best-practice prevention (C+P)
Local anaesthetic, complete removal of caries and restoration.
- Biological with best-practice prevention (B+P)
Sealing in carious tooth tissue with adhesive tooth tissue or a preformed metal crown with the Hall technique. LA was not routinely prescribed because this was not necessary.
They recorded the final outcomes after a median period of 34 months.
They did a relevant sample size calculation. Randomisation was done via a remote web-based system. Parents, participants and dental professionals were not blinded to the allocation. However, they analysed the data blind with the relevant modelling techniques.
What did they find?
Importantly, they analysed the data with an intention to treat analysis for 1058 participants.
At baseline, there were no differences between the groups.
They presented data on the co-primary outcomes of (i) proportion of dental pain and/or infection or (ii) number of episodes of dental pain/infection. I have put their data in this table.
|Prevention||Caries removal||Biological control|
|Proportion with dental pain (%)||45||42||40|
|Number of episodes of pain (n)||0.62||0.58||0.72|
They also measured cost-effectiveness, participants quality of life or any other outcomes.
Importantly, the authors pointed out that for all three interventions that they tested the incidence of complications was high. As a result, we should concentrate on the prevention of childhood dental decay.
Their overall conclusion was:
“There was no evidence of a difference in clinical effectiveness between the three interventions”.
What did I think?
I thought that this was a significant research project that answered a clinically relevant question about the treatment of child dental decay. The study was large and well carried out. It was difficult for me to find any significant deficiencies in their methodology. I am confident that the results will change clinical practice.
What does this mean clinically. If I were to treat a child with caries in their primary teeth, I certainly would avoid LA and mechanical caries removal, as this is very invasive for a young child. There may be some advantages in biological caries control, but these are not large. Maybe the best treatment is to provide prevention with no other intervention?
This paper provides excellent information that enables all dental carers to explain the risks and benefits of primary tooth caries treatment to our patients. I will be back to orthodontics next week.
Emeritus Professor of Orthodontics, University of Manchester, UK.