The fate of the carious primary teeth of children who regularly attend the general dental service

Parental preferences for the procedural sedation of children in dentistry: a discrete choice experiment

Purpose

The aim of this study was to explore parental preferences for the procedural sedation of children in dentistry through a discrete choice experiment (DCE) to inform clinical decisions and oral health management.

Methods

Based on literature reviews, interviews with parents of pediatric dental patients, and expert consultation, six attributes, including fasting time, recovery time, sedative administration routes, adverse reactions, sedation depth and procedure cost, were incorporated into the DCE questionnaire. The DCE questionnaire collected data on parental preferences for pediatric dental sedation treatment from June to August 2022. A conditional logit model was used to analyze preference and willingness to pay (WTP) for each attribute and its level. Subgroup analyses assessing the impact of parents' dental anxiety on procedural sedation preferences were also conducted using conditional logit models.

Results

A total of 186 valid questionnaires were gathered. Parents' preferences for fewer adverse reactions, a milder sedation depth, lower out-of-pocket cost, shorter fasting and recovery times and administration by inhalation were significantly associated with their choice of sedation model. The conditional logit model showed that parents were most interested in treatments with no adverse reactions (0% vs. 15%) (Coef, 1.033; 95% CI, 0.833-1.233), followed by those providing minimal sedation (vs. deep sedation) (Coef, 0.609; 95% CI, 0.448-0.769). Moreover, the relative importance of adverse reactions and fasting time was higher among anxious than nonanxious parents. The study found a WTP threshold of ¥1,538 for reducing adverse reactions (15% to 0%). The WTP threshold for the best sedation procedure scenario (no fasting requirement, 10 min recovery time, administration by inhalation, 0% adverse reaction incidence and minimal sedation) was ¥3,830.

Conclusion

Reducing the adverse reactions and depth of sedation are predominant considerations for parents regarding procedural sedation in pediatric dentistry, followed by lower cost, shorter fasting and recovery times and inhalation sedation. Parents with dental anxiety had a stronger preference for options with a lower incidence of adverse reactions and shorter fasting time than parents without dental anxiety. This discovery is helpful for doctors and can promote collaborative decision-making among parents and doctors.

Are childhood oral health behaviours and experiences associated with dental anxiety in adolescence?

BACKGROUND

Dental anxiety is associated with untreated dental caries. Understanding which childhood behaviours or experiences have the strongest association with later dental anxiety may help focus preventive strategies, subsequently limiting the burden of dental caries and anxiety.

AIM

The aim of this study was to explore whether behaviours and experiences during childhood were associated with adolescent dental anxiety.

DESIGN

Data were obtained from the Avon Longitudinal Study of Parents and Children (ALSPAC). Multivariable logistic regression was used to explore associations between adolescent dental anxiety and childhood behaviours and experiences. 1791 participants answered questions about oral health behaviours and experiences at 8 years of age and dental anxiety questions aged 17 years.

RESULTS

Children with experience of invasive dental treatment were more likely to have dental anxiety at 17 years of age than those who had not experienced dental treatment (OR 1.63; 95% CI: 1.12, 2.37; p = .011). Irregular dental attenders in childhood had over three times the odds of dental anxiety by adolescence, compared with regular attenders (OR 3.67 95% CI: 1.52, 8.88; p = .004).

CONCLUSIONS

Adolescent dental anxiety is associated with invasive treatment and irregular dental attendance in childhood. A history of irregular attendance or invasive treatment may serve as a useful predictor when considering dental anxiety in young adult patients. Early preventive care supports good attendance and oral health. These actions may have secondary effects of reducing future dental anxiety.

Dental procedures in children with or without intellectual disability and autism spectrum disorder in a hospital setting

BACKGROUND

This population-based cohort study investigated dental procedures in the hospital setting in Western Australian children with or without intellectual disability (ID) and/or autism spectrum disorder (ASD) aged up to 18 years. Considering previously reported disparities in dental disease between Indigenous and non-Indigenous Australian children, this study also investigated the effect of Indigenous status on dental procedures.

METHODS

Data on Western Australian live births from 1983 to 2010 from the Midwives Notification System were linked to the Intellectual Disability Exploring Answers database and the Hospital Morbidity Data collection. Primary admissions for relevant dental diagnoses were identified, and treatment procedures for dental hospitalization were investigated. Descriptive statistics and Pearson's chi-squared test of independence were used for analysis.

RESULTS

Overall, 76 065 episodes of dental hospitalization were recorded. Amongst children with ID and/or ASD, Indigenous children experienced more extractions and fewer restorations (68.7% and 16.2%) compared to non-Indigenous children (51.5% and 25.9%). After 6 years, extraction occurred less often in children with ID and/or ASD than in those without, where most surgical dental extractions were in the age group of 13-18 years.

CONCLUSIONS

This study indicates a need for further improvements in access to dental services and the quality of care provided in hospitals for children with ID/ASD. There is also concern that more vulnerable Indigenous and all disadvantaged children are receiving an inadequate level of dental services resulting in more emergency dental hospitalization and invasive treatment.

Economic Evaluation of the Protecting Teeth @ 3 Randomized Controlled Trial

INTRODUCTION

An economic evaluation (EE) was conducted alongside a randomized controlled trial (the Protecting Teeth @ 3 Study [PT@3]), exploring the additional preventive value of fluoride varnish (FV) application at 6-monthly intervals in nursery schools compared to treatment as usual (TAU) in the same nurseries. TAU represented a multicomponent national child oral health improvement intervention, the Childsmile program, apart from nursery FV.

METHODS

The EE was a within-trial cost-utility analysis (CUA) comparing the FV and TAU groups. The CUA was conducted from a National Health Service perspective and followed relevant methods guidance. Within-trial costs included intervention costs and health care resource use costs. Health outcomes were expressed in quality-adjusted life years (QALYs) accrued over the 2-y follow-up period. The Child Health Utility 9 Dimensions questionnaire was used to obtain utility scores. National reference costs were used, a discount rate of 1.5% for public health interventions was adopted, multiple imputation methods for missing data were employed, sensitivity analyses were conducted, and incremental cost-utility ratios were calculated.

RESULTS

Data from 534 participants from the 2014-2015 PT@3 intake were used in the EE analyses, n = 265 (50%) in the FV arm and n = 269 (50%) in the TAU arm. Mean incremental cost per child in the FV arm was £68.37 (P = 0.382; 95% confidence interval [CI], -£18.04 to £143.82). Mean incremental QALY was -0.004 (P = 0.636; 95% CI, -0.016 to 0.007). The probability that the FV intervention was cost-effective at the UK £20,000 threshold was 11.3%.

CONCLUSION

The results indicate that applying FV in nurseries in addition to TAU (all other components of Childsmile, apart from nursery FV) would not be deemed cost-effective given current UK thresholds. In view of previously proven clinical effectiveness and economic worthiness of the universal nursery toothbrushing component of Childsmile, continuation of the additional, targeted nursery FV component in its pre-COVID-19 form should be reviewed given its low probability of cost-effectiveness.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by child oral health policy makers and dental public health professionals. They can form part of the evidence to inform the Scottish, UK, and international guidance on community-based child oral health promotion programs.

The in-practice prevention programme: an example of flexible commissioning from Yorkshire and the Humber

Introduction An In-Practice Prevention (IPP) programme was developed by the Local Dental Network in the North Yorkshire and the Humber area in England in response to an oral health needs assessment. The underpinning logic model drew on a flexible commissioning approach and aimed to incentivise dental teams with NHS contracts to promote the delivery of prevention. This used care pathways that involved the whole dental team and was cost-neutral.Aim The programme was evaluated using realist methodology to identify 'what works, in which circumstances, how and for who?'.Design Realist evaluations are explanatory in nature and attempt to understand the factors that appear to influence the success (or not) of an intervention, rather than demonstrating causality.Methods and results Following a review of the pertinent literature, semi-structured interviews and focus groups, five theory areas were considered to be critical to the delivery of IPP. In order of stated priority, these were: 1) clinical leadership; 2) 'skill mix'; 3) financial incentives; 4) institutional logic/practice culture; and 5) behaviour change.Conclusion The results appear to show that clinically-led programmes could offer value to dental commissioners within a flexible commissioning model, although this would need to be further tested using an experiment design.

Impact of non-restorative cavity control on proximal carious lesions of anterior primary teeth on the tooth survival and patient-centered outcomes (CEPECO 2): study protocol for a non-inferiority randomized clinical trial

Background

Studies have questioned the necessity of restoring cavitated carious lesion on primary teeth, once the control of biofilm is the most important factor to arrest these lesions. This randomized clinical trial aimed to compare the survival of teeth treated with a non-restorative cavity control (NRCC) compared to resin composite restorations (RCR) on proximal carious lesion in anterior primary teeth, as well as the impact of these treatments on patient-centered outcomes.

Methods

A randomized clinical trial with two parallels arms (1:1) will be conducted. Children between 3 and 6 years old will be selected from the Center of Clinic Research of Pediatric Dentistry of Ibirapuera University (UNIB), a dental trailer (FOUSP) located on Educational Complex Professor Carlos Osmarinho de Lima, the Pediatric Dentistry Clinic of Santa Cecília University and from the Pediatric Dentistry Clinic of University Center UNINOVAFAPI. One hundred and forty-eight teeth will be randomly distributed in two experimental groups: (1) Selective removal of carious tissue and RCR; or (2) NRCC through cavity enlargement using a metallic sandpaper. The primary outcome will be tooth survival after 6, 12, 18 and 24 months. The duration and the cost of dental treatments will be considered for the estimation of the cost-effectiveness of the evaluated treatments. The discomfort reported by the participants will be measured after each treatment using the FIS scale. The participants’ satisfaction and perception of the parents/legal guardians will be evaluated through questionnaires. For the primary outcome, Kaplan–Meier’s survival and Long-Rank test will be used for comparison between the two groups. All the variables will be modeled by Cox regression with shared fragility. Significance will be considered at 5%.

Discussion

The NRCC could be an option to manage carious lesions on proximal surfaces of primary teeth, and the approach could be well accepted by the children and parents/legal guardians.

Trial registration Clinicaltrials.gov registration: NCT03785730, Registered on December 18th 2018, first participant recruited 30/04/2019, https://clinicaltrials.gov/ct2/show/NCT03785730.

Ethics Reference No: 91569118.8.0000.5597.

Trial Sponsor: Universidade Ibirapuera.

The Trial was prospectively registered.

Prevalence of Early Childhood Caries in Southern Italy: An Epidemiological Study

The purpose of this study was to assess the prevalence of Early Childhood Caries (ECC) and oral habits among preschool children from a southern Italian cohort. The survey population consisted of 300 subjects randomly selected among children attending two kindergartens in Catania, Italy. The prevalence of ECC and oral habits were clinically evaluated. During the clinical evaluation, the oral hygiene of children was also assessed. Parents were also interviewed using a brief and simple online questionnaire aimed at investigating eating and oral hygiene habits. The selected sample age ranged between 3 and 5 years. The prevalence of ECC was 9.34%, and the most affected teeth were primary molars. Moreover, the prevalence of oral habits was 44.66%. Only two-thirds of the sample brush their teeth at least once per day. The prevalence of ECC among Sicilian children (9.33%) seems suitable with the rest of the country. The results of the present study evidenced that oral habits showed a high prevalence among preschool children. The level of oral hygiene among preschool children is still not sufficient.

Selection and validation of a classification system for a child-centred preference-based measure of oral health-related quality of life specific to dental caries

Background

Caries Impacts and Experiences Questionnaire for Children (CARIES-QC) is a child-centred caries-specific quality of life measure. This study aimed to select, and validate with children, a classification system for a paediatric condition-specific preference-based measure, based on CARIES-QC.

Methods

First, a provisional classification system for a preference-based measure based on CARIES-QC was identified using Rasch analysis, psychometric testing, involvement of children and parents, and the developer of CARIES-QC. Second, qualitative, semi-structured ‘think aloud’ validation interviews were undertaken with a purposive sample of children with dental caries. The interviewer aimed to identify whether items were considered important and easily understood, whether any were overlapping and if any excluded items should be reintroduced. Interview recordings were transcribed verbatim and thematic analysis conducted.

Results

Rasch analysis identified poor item spread for the items ‘cross’ and ‘school’. Items relating to eating were correlated and the better performing items were considered for selection. Children expressed some confusion regarding the items ‘school’ and ‘food stuck’. Parent representatives thought that impacts surrounding toothbrushing (‘brushing’) were encompassed by the item ‘hurt’. Five items were selected from CARIES-QC for inclusion in the provisional classification system; ‘hurt’, ‘annoy’, ‘carefully’, ‘kept awake’ and ‘cried’. Validation interviews were conducted with 20 children aged 5–16 years old. Participants thought the questionnaire was straightforward and covered a range of impacts. Children thought an item about certain foods being ‘hard to eat’ was more relevant than one about having to eat more carefully because of their teeth and so the ‘carefully’ item was replaced with ‘hard to eat’.

Conclusion

Following child-centred modification, the preliminary five-item classification system is considered valid and suitable for use in a valuation survey. The innovative child-centred methods used to both identify and validate the classification system can be applied in the development of other preference-based measures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-020-00268-9.

Economic evaluations in paediatric dentistry clinical trials

Economic evaluations play an important role in identifying the cost-effectiveness of alternative healthcare programmes, informing decisions surrounding funding and the allocation of resources. This paper outlines the basic principles of economic evaluation and how it can be conducted alongside a clinical trial. Furthermore, it considers the ways in which evidence from these studies can be used, and the challenges researchers are faced with when conducting economic evaluations in the field of children's oral health.

Children and parents' perspectives on the acceptability of three management strategies for dental caries in primary teeth within the 'Filling Children's Teeth: Indicated or Not' (FiCTION) randomised controlled trial - a qualitative study

Background

The Filling Children’s Teeth: Indicated Or Not? (FiCTION) randomised controlled trial (RCT) aimed to explore the clinical- and cost-effectiveness of managing dental caries in children’s primary teeth. The trial compared three management strategies: conventional caries management with best practice prevention (C + P), biological management with best practice prevention (B + P) and best practice prevention alone (PA)-based approaches. Recently, the concept of treatment acceptability has gained attention and attempts have been made to provide a conceptual definition, however this has mainly focused on adults. Recognising the importance of evaluating the acceptability of interventions in addition to their effectiveness, particularly for multi-component complex interventions, the trial design included a qualitative component. The aim of this component was to explore the acceptability of the three strategies from the perspectives of the child participants and their parents.

Methods

Qualitative exploration, based on the concept of acceptability. Participants were children already taking part in the FiCTION trial and their parents. Children were identified through purposive maximum variation sampling. The sample included children from the three management strategy arms who had been treated and followed up; median (IQR) follow-up was at 33.8 (23.8, 36.7) months. Semi-structured interviews with thirteen child-parent dyads. Interviews were transcribed verbatim and analysed using a framework approach.

Results

Data saturation was reached after thirteen interviews. Each child-parent dyad took part in one interview together. The participants were eight girls and five boys aged 5–11 years and their parents. The children’s distribution across the trial arms was: C + P n = 4; B + P n = 5; PA n = 4. Three key factors influenced the acceptability of caries management in primary teeth to children and parents: i) experiences of specific procedures within management strategies; ii) experiences of anticipatory dental anxiety and; iii) perceptions of effectiveness (particularly whether pain was reduced). These factors were underpinned by a fourth key factor: the notion of trust in the dental professionals – this was pervasive across all arms.

Conclusions

Overall children and parents found each of the three strategies for the management of dental caries in primary teeth acceptable, with trust in the dental professional playing an important role.

Dental professionals' experiences of managing children with carious lesions in their primary teeth - a qualitative study within the FiCTION randomised controlled trial

Background

The lack of evidence for the effective management of carious lesions in children’s primary teeth has caused uncertainty for the dental profession and patients. Possible approaches include conventional and biological management alongside best practice prevention, and best practice prevention alone. The FiCTION trial assessed the effectiveness of these options, and included a qualitative study exploring dental professionals’ (DPs) experiences of delivering the different treatment arms. This paper reports on how DPs managed children with carious lesions within FiCTION and how this related to their everyday experiences of doing dentistry.

Methods

Overall, 31 DPs from FiCTION-trained dental surgeries in four regions of the UK participated in semi-structured interviews about their experiences of the three treatment arms (conventional management of carious lesions and prevention (C + P), biological management of carious lesions and prevention (B + P) or prevention alone (PA)). A theoretical framework, drawing on social practice theory (SPT), was developed for analysis.

Results

Participants discussed perceived effectiveness of, and familiarity with, the three techniques. The C + P arm was familiar, but some participants questioned the effectiveness of conventional restorations. Attitudes towards the B + P arm varied in terms of familiarity, but once DPs were introduced to the techniques, this was seen as effective. While prevention was familiar, PA was described as ineffective. DPs manage children with carious lesions day-to-day, drawing on previous experience and knowledge of the child to provide what they view as the most appropriate treatment in the best interests of each child. Randomisation undermined these normal choices. Several DPs reported deviating from the trial arms in order to treat a patient in a particular way. Participants valued evidence-based dentistry, and expect to use the results of FiCTION to inform future practice. They anticipate continuing to use the full range of treatment options, and to personally select appropriate strategies for individual children.

Conclusions

RCTs take place in the context of day-to-day practices of doing dentistry. DPs employ experiential and interpersonal knowledge to act in the best interests of their patients. Randomisation within a clinical trial can present a source of tension for DPs, which has implications for assuring individual equipoise in future trials.

Hall Technique for Carious Primary Molars: A Review of the Literature

The high frequency of caries in primary teeth and its inadequate treatment are major public health problems during childhood. Nowadays, the Hall technique is one of the methods used for biological sealing in carious lesions in primary molars. Thus, the bacteria will be sealed from oral environment and the caries will be inactive. The objective of this article was to provide an updated search on the Hall technique description, indication, contraindication, advantages, concerns, success and failure, cost-effectiveness, acceptability, and preference in pediatric dentistry, and to compare the Hall technique with traditional crown preparation and conventional treatment options for carious primary molars. A discussion of the recently published articles on the Hall technique reveals that the Hall technique is considered a promising restorative option with high acceptability and longevity; with low failure rate for managing carious primary molars compared to conventional treatment modalities used in primary care settings. Furthermore, the survival rate of stainless steel crowns (SSCs) is considered high, whether provided using Hall technique or traditional preparation by a pediatric dentist. Thus, the Hall technique can be an effective addition to the clinician’s range of treatment options for carious primary molars. However, it should be chosen in restricted cases.

Best-practice prevention alone or with conventional or biological caries management for 3- to 7-year-olds: the FiCTION three-arm RCT

BACKGROUND

Historically, lack of evidence for effective management of decay in primary teeth has caused uncertainty, but there is emerging evidence to support alternative strategies to conventional fillings, which are minimally invasive and prevention orientated.

OBJECTIVES

The objectives were (1) to assess the clinical effectiveness and cost-effectiveness of three strategies for managing caries in primary teeth and (2) to assess quality of life, dental anxiety, the acceptability and experiences of children, parents and dental professionals, and caries development and/or progression.

DESIGN

This was a multicentre, three-arm parallel-group, participant-randomised controlled trial. Allocation concealment was achieved by use of a centralised web-based randomisation facility hosted by Newcastle Clinical Trials Unit.

SETTING

This trial was set in primary dental care in Scotland, England and Wales.

PARTICIPANTS

Participants were NHS patients aged 3-7 years who were at a high risk of tooth decay and had at least one primary molar tooth with decay into dentine, but no pain/sepsis.

INTERVENTIONS

Three interventions were employed: (1) conventional with best-practice prevention (local anaesthetic, carious tissue removal, filling placement), (2) biological with best-practice prevention (sealing-in decay, selective carious tissue removal and fissure sealants) and (3) best-practice prevention alone (dietary and toothbrushing advice, topical fluoride and fissure sealing of permanent teeth).

MAIN OUTCOME MEASURES

The clinical effectiveness outcomes were the proportion of children with at least one episode (incidence) and the number of episodes, for each child, of dental pain or dental sepsis or both over the follow-up period. The cost-effectiveness outcomes were the cost per incidence of, and cost per episode of, dental pain and/or dental sepsis avoided over the follow-up period.

RESULTS

A total of 72 dental practices were recruited and 1144 participants were randomised (conventional arm, n = 386; biological arm, n = 381; prevention alone arm, n = 377). Of these, 1058 were included in an intention-to-treat analysis (conventional arm, n = 352; biological arm, n = 352; prevention alone arm, n = 354). The median follow-up time was 33.8 months (interquartile range 23.8-36.7 months). The proportion of children with at least one episode of pain or sepsis or both was 42% (conventional arm), 40% (biological arm) and 45% (prevention alone arm). There was no evidence of a difference in incidence or episodes of pain/sepsis between arms. When comparing the biological arm with the conventional arm, the risk difference was -0.02 (97.5% confidence interval -0.10 to 0.06), which indicates, on average, a 2% reduced risk of dental pain and/or dental sepsis in the biological arm compared with the conventional arm. Comparing the prevention alone arm with the conventional arm, the risk difference was 0.04 (97.5% confidence interval -0.04 to 0.12), which indicates, on average, a 4% increased risk of dental pain and/or dental sepsis in the prevention alone arm compared with the conventional arm. Compared with the conventional arm, there was no evidence of a difference in episodes of pain/sepsis among children in the biological arm (incident rate ratio 0.95, 97.5% confidence interval 0.75 to 1.21, which indicates that there were slightly fewer episodes, on average, in the biological arm than the conventional arm) or in the prevention alone arm (incident rate ratio 1.18, 97.5% confidence interval 0.94 to 1.48, which indicates that there were slightly more episodes in the prevention alone arm than the conventional arm). Over the willingness-to-pay values considered, the probability of the biological treatment approach being considered cost-effective was approximately no higher than 60% to avoid an incidence of dental pain and/or dental sepsis and no higher than 70% to avoid an episode of pain/sepsis.

CONCLUSIONS

There was no evidence of an overall difference between the three treatment approaches for experience of, or number of episodes of, dental pain or dental sepsis or both over the follow-up period.

FUTURE WORK

Recommendations for future work include exploring barriers to the use of conventional techniques for carious lesion detection and diagnosis (e.g. radiographs) and developing and evaluating suitable techniques and strategies for use in young children in primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77044005.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 1. See the NIHR Journals Library website for further project information.

To Compare the Efficacy of Two Intravenous Combinations of Drugs Ketamine-Propofol vs Ketamine-Dexmedetomidine for Sedation in Children Undergoing Dental Treatment

Objective

To compare the efficacy of two intravenous combinations of drugs ketamine–propofol (KP) vs ketamine–dexmedetomidine (KD) for sedation in children undergoing dental treatment.

Study design

Thirty patients were selected, evaluated according to the predetermined criteria and divided in equal numbers of 15 amongst 2 groups KP and KD.

Materials and methods

Informed consent was taken, nil per oral (NPO) guidelines were followed and the study drug was administered. Dental procedure was performed. Heart rate (HR), blood pressure (BP) and oxygen saturation (SPO₂) were monitored continuously throughout the procedure. The modified Ramsay sedation (MRS) score was recorded along with Houpt sedation score. Recovery status was accessed by modified Aldrete's recovery scale.

Statistical analysis

Student t test was used for comparing HR, BP and SPO₂. Chi-square test was used to compare MRS, Houpt sedation score and modified Aldrete's recovery scale amongst the two groups KP and KD.

Results

The sedation achieved with both the groups was adequate. Both the drugs produce adequate hemodynamic stability.

Conclusion

Ketamine–dexmedetomidine has a better efficacy over the other group, ketamine–propofol.

How to cite this article

Joshi AB, Shankaranarayan UR, Hegde A, et al. To Compare the Efficacy of Two Intravenous Combinations of Drugs Ketamine–Propofol vs Ketamine–Dexmedetomidine for Sedation in Children Undergoing Dental Treatment. Int J Clin Pediatr Dent 2020;13(5):529–535.

Parental Knowledge and Acceptance of Different Treatment Options for Primary Teeth Provided by Dental Practitioners

Background: Parents have an influence on dental treatment options for young children regarding type of care provided. The aim of this study was to assess parents' knowledge and acceptance of different treatment options for primary teeth provided by dental practitioners for their children.

Materials and Methods: In this descriptive, cross-sectional study, caregiver/child dyads (n = 476) were recruited from patients at Pediatric Dental Clinics, Jordan University of Science and Technology. The data collection questionnaire to parents included: 1-demographic data 2-parental knowledge and practices regarding child's oral hygiene, caries and caries prevention 3-parental knowledge and acceptance of different treatment options for primary teeth including two given clinical scenarios (ICDAS-5 molar requiring intra-coronal restoration, ICDAS-6 molar requiring pulp therapy and stainless steel crown) with pictures before and after treatment. Afterwards, the child underwent a dental examination to record dmft/DMFT, gingival and plaque indices. Data was analyzed using SPSS, significance was set at P ≤ 0.05.

Results: Children's ages were 2–12 years (mean/SD 6.97 ± 2.5); with 255/53.6% males, 221/46.4% females. There were (166) children 2–5 years in primary dentition; (108/166) 65% had ECC, and (n = 62/166) 37.4% had S-ECC, and (310) 6–12 years in mixed dentition; (278/310) 89.7% had caries. Scaling and extraction were the highest known and accepted treatments for primary teeth by parents (35.5 and 30.1%, respectively), while nitrous oxide/oxygen sedation was the least (3.6%). Parental educational level was significant for composite restorations, fluoride gel application and pulp therapy (P = 0.03, 0.02, and 0.03, respectively) and age above 40 for amalgam restorations (P = 0.04). In both scenarios, most parents preferred to leave any care decision in hands of the dentists with no effect of educational level (P > 0.05). There were 81.5% parents who reported that their children's dental status was good, however, 78.4%/42.8% children had an average dmft/DMFT score 5.34/2.32 and mean PI/GI scores 0.88 ± 0.20/0.17 ± 0.23.

Conclusion: Parental knowledge and acceptance about dental treatment options for primary dentition was generally low. Parental education and age had an impact on parental knowledge and practices regarding child's oral hygiene, caries and caries prevention, and some treatment options. There was an overrated parental opinion of their child's teeth status despite the high dmft/DMFT and PI.

Child Caries Management: A Randomized Controlled Trial in Dental Practice

This multicenter 3-arm, parallel-group, patient-randomized controlled trial compared clinical effectiveness of 3 treatment strategies over 3 y for managing dental caries in primary teeth in UK primary dental care. Participants aged 3 to 7 y with at least 1 primary molar with dentinal carious lesion were randomized across 3 arms (1:1:1 via centrally administered system with variable-length random permuted blocks): C+P, conventional carious lesion management (complete carious tooth tissue removal and restoration placement) with prevention; B+P, biological management (sealing in carious tooth tissue restoratively) with prevention; and PA, prevention alone (diet, plaque removal, fluorides, and fissure sealants). Parents, children, and dentists were not blind to allocated arm. Co–primary outcomes were 1) the proportion of participants with at least 1 episode of dental pain and/or infection and 2) the number of episodes of dental pain and/or infection during follow-up (minimum, 23 mo). In sum, 1,144 participants were randomized (C+P, n = 386; B+P, n = 381; PA, n = 377) by 72 general dental practitioners, of whom 1,058 (C+P, n = 352; B+P, n = 352; PA, n = 354) attended at least 1 study visit and were included in the primary analysis. The median follow-up was 33.8 mo (interquartile range, 23.8 to 36.7). Proportions of participants with at least 1 episode of dental pain and/or infection were as follows: C+P, 42%; B+P, 40%; PA, 45%. There was no evidence of a difference in incidence of dental pain and/or infection when B+P (adjusted risk difference [97.5% CI]: −2% [−10% to 6%]) or PA (4% [−4% to 12%]) was compared with C+P. The mean (SD) number of episodes of dental pain and/or infection were as follows: C+P, 0.62 (0.95); B+P, 0.58 (0.87); and PA, 0.72 (0.98). Superiority could not be concluded for number of episodes between B+P (adjusted incident rate ratio (97.5% CI): 0.95 [0.75 to 1.21]) or PA (1.18 [0.94 to 1.48]) and C+P. In conclusion, there was no evidence of a difference among the 3 treatment approaches for incidence or number of episodes of dental pain and/or infection experienced by these participants with high caries risk and established disease (trial registration: ISRCTN77044005).

Success rates of preformed metal crowns placed with the modified and standard hall technique in a paediatric dentistry setting

BACKGROUND

The Hall Technique is a less invasive caries management technique for treating carious primary molars. It has become a routine treatment at specialists' practices.

AIM

To retrospectively evaluate the clinical success and survival rates of preformed metal crowns placed on primary molars using the Hall Technique in a Paediatric Dentistry Setting.

DESIGN

Patient records of children receiving Hall crowns (with or without proximal slicing) between 2011 and 2017 were reviewed. Teeth with no clinical or radiographic evidence of pulp involvement at baseline and at least six months' follow-up were included. Kaplan-Meier survival analyses and Mantel-Cox statistics were carried out.

RESULTS

In total, 181 Hall crowns performed in 2- to 10-year-olds with a mean follow-up period of 22 months were included for analysis. Mean d₃ mft/D₃ MFT was 6.55 ± 3.48/0.18 ± 0.66. The majority of crowns were successful (92.3%; n = 167), four presented at least one minor failure (2.2%; reversible pulpitis, crown lost, or secondary caries) and ten were major failures (5.5%; irreversible pulpitis or abscess). When comparing crowns performed with no tooth preparation to crowns performed with proximal slicing, no differences were observed (P = 0.70, CI = 0.68-0.83).

CONCLUSION

The survival rate and clinical efficacy of Hall crowns were high in a secondary care-based setting. The HT is an effective and less invasive management option for asymptomatic carious primary molars.

Management of carious primary molars within the community dental setting in Wales: a retrospective observational study

Background Tertiary prevention is still an integral part of a child's healthcare. In community dental service (CDS), we aim to try to restore carious primary teeth in young children as a means of caries control.Aim To assess the survival rates of individual carious primary molars within CDS, based on the type of dental interventions.Design Retrospective observational study.Methods Fifty patients' notes were reviewed, and patients were selected using a defined protocol. The Kaplan-Meier method was used to estimate the survival curves.Results Out of 251 teeth, the estimated survival rates of teeth restored with stainless steel crowns (SSC) was the highest at 46.7 months, GIC-restored teeth at 45.8 months and unrestored teeth at 18.2 months. There was no correlation seen between the survival rates and the number of further interventions required. The difference between the survival rates of teeth restored with GIC, SSC and unrestored was statistically significant (p <0.05). There was minimal use of SSCs within this sample.Conclusion Our present findings indicate that restored teeth have higher survival rates than unrestored teeth. However, it must be emphasised that restorative treatment may not always be feasible and other factors should be considered in the treatment planning.

Selective carious tissue removal using subjective criteria or polymer bur: study protocol for a randomised controlled trial (SelecCT)

INTRODUCTION

Selective (incomplete/partial) carious tissue removal is suitable for treating deep carious lesions in teeth with vital, asymptomatic pulps. In the periphery of a cavity, removal to hard dentin is performed, while in pulpo-proximal areas, leathery or soft dentin is left to avoid pulp exposure. As the decision of what contains 'soft' or 'leathery' dentin is subjective, using self-limiting burs which help to standardise the hardness of the remaining dentin, has been suggested to increase the reliability of carious tissue removal. The trial compares subjectively measured selective carious tissue removal in deep lesions in primary teeth with objectively measured selective removal with a self-limiting bur (Polybur, Komet).

METHODS AND ANALYSIS

A community-based single-blind clustered randomised controlled superiority trial nested into a larger evaluation is performed. Recruitment for this trial has been concluded. We have recruited 115 children aged 6-8 years with ≥1 vital primary molar with a deep dentin lesion. The unit of randomisation was the child, with all eligible molars per child treated identically. Treatment was performed in a mobile dental unit. Subjective and objective carious tissue removal was performed at random. Teeth were restored using glass ionomer cement (Equia Forte, GC). Our primary outcome will be the time until complications occur, evaluated via multilevel survival analysis. Secondary outcomes will be the time until extraction is needed, subjective satisfaction of the child with the treatment (measured using a Likert scale) and cost-effectiveness. Re-examination will be performed after 12, 24 and 36 months (the final examination is expected in 2020).

ETHICS AND DISSEMINATION

This trial has been approved by the Ethics Committee of the Health Sciences of the University of Brasília (CAAE 51310415.0.0000.0030). Trial results will be published in peer-reviewed journals and presented on conferences.

TRIAL REGISTRATION NUMBER

NCT02754466.

Use of stainless steel crowns to restore primary molars in Germany: Questionnaire-based cross-sectional analysis

BACKGROUND

Stainless steel crowns (SSCs) have shown substantial clinical success and are the restoration of choice to treat multisurface carious primary molars.

AIM

To evaluate the use of and views on SSCs for treating primary molars in Germany.

METHODS

This is a questionnaire-based cross-sectional study, which assessed the views of dentists and dental schools on the use of SSCs (conventional and the Hall Technique [HT]) in Germany. Dentists were randomly selected (n = 267) and contacted by telephone, and a self-administered questionnaire was sent to all German dental schools (n = 27).

RESULTS

A total of 104 (39%) dentists agreed to participate. The majority of respondents (66%) do not use SSCs, being the main drawbacks: technique complexity (29%) and aesthetic concerns (23%). The majority of respondents (77%) were not familiar with the HT. The response rate from the universities was 85%. In 96% of the dental schools, the value of using SSCs is taught; however, in 27%, no practical training is provided. In addition, the dental schools' questionnaire revealed that the HT was known (91%), but neither taught to nor used for most of the dental students (76%).

CONCLUSION

Independent of the technique used, SSCs are considerably underutilized in the dental practice in Germany, although SSCs are well accepted by the universities, however, predominantly using the conventional approach.

Cost-effectiveness of the Hall Technique in a Randomized Trial

Clinical and patient-reported outcomes were reported for carious primary molars treated with the Hall technique (HT) as compared with conventional carious tissue removal and restorations (i.e., conventional restoration [CR]) in a 5-y randomized controlled practice-based trial in Scotland. We interrogated this data set further to investigate the cost-effectiveness of HT versus CR. A total of 132 children who had 2 matched occlusal/occlusal-proximal carious lesions in primary molars ( n = 264 teeth) were randomly allocated to HT or CR, provided by 17 general dental practitioners. Molars were followed up for a mean 5 y. A societal perspective was taken for the economic analysis. Direct dental treatment costs were estimated from a Scottish NHS perspective (an NHS England perspective was taken for a sensitivity analysis). Initial, maintenance, and retreatment costs, including rerestorations, endodontic treatments, and extractions, were estimated with fee items. Indirect/opportunity costs were estimated with time and travel costs from a UK perspective. The primary outcome was tooth survival. Secondary outcomes included 1) not having pain or needing endodontic treatments/extractions and 2) not needing rerestorations. Cost-effectiveness and acceptability were estimated from bootstrapped samples. Significantly more molars in HT survived (99%, 95% CI: 98% to 100%) than in CR (92%; 87% to 97%). Also, the proportion of molars retained without pain or requiring endodontic treatment/extraction was significantly higher in HT than CR. In the base case analysis (NHS Scotland perspective), cumulative direct dental treatment costs (Great British pound [GBP]) of HT were 24 GBP (95% CI: 23 to 25); costs for CR were 29 (17 to 46). From an NHS England perspective, the cost advantage of HT (29 GBP; 95% CI: 25 to 34) over CR (107; 86 to 127) was more pronounced. Indirect/opportunity costs were significantly lower for HT (8 GBP; 95% CI: 7 to 9) than CR (19; 16 to 23). Total cumulative costs were significantly lower for HT (32 GBP; 95% CI: 31 to 34) than CR (49; 34 to 69). Based on a long-term practice-based trial, HT was more cost-effective than CR with HT retained for longer and experiencing less complications at lower costs.

A study on the survival of primary molars with intact and with defective restorations

BACKGROUND

Failed restorations in primary teeth are not always re-restored. Is re-restoration not required anymore?

OBJECTIVE

To compare survival rates of primary molars with intact and defective amalgam and ART restorations.

METHODS

A total of 649 restored primary molars, of which 162 were assessed with defective restorations for mechanical reasons, from a cluster-randomised controlled clinical trial, were followed up over a period of 3.5 years. Restored primary molars, extracted because of dental sepsis or toothache, were considered a failure. Primary molars with defective restorations were followed up from the time they were assessed defective. Data were analysed using PHREG model with frailty correction, Wald test, t-test, and jackknife procedure.

RESULTS

The survival rate of primary molars with intact restorations (96.3%) was statistically significantly higher than that of primary molars with defective restorations (75.9%) over a 3-year period (P < 0.0001). Neither the effect of treatment protocol (amalgam or ART) (P = 0.05) nor the type of surface (single or multiple) (P = 0.73) was observed with respect to the survival rate of restored primary molars.

CONCLUSIONS

Survival rates for primary molars with intact and defective amalgam and ART restorations were high. The 3-year survival rate of primary molars with intact restorations was significantly higher than that of primary molars with defective restorations.

Bispectoral index scores of pediatric patients under dental treatment and recovery conditions: Study of children assigned for general anesthesia under propofol and isofloran regimes

Background:

This study was planned to determine the relationship between bispectoral index (BIS) during dental treatment and recovery conditions in children undergoing two regimes of anesthesia of propofol and isoflurane.

Materials and Methods:

In this single-blind clinical trial study, 57 4-7-year-old healthy children who had been referred for dental treatment under general anesthesia between 60 and 90 min were selected by convenience sampling and assigned to two groups, after obtaining their parents’ written consent. The anesthesia was induced by inhalation. For the first group, the anesthesia was preserved by a mixture of oxygen (50%), nitrous oxide (50%), and isoflurane (1%). For the second group, the anesthesia was preserved by a mixture of oxygen (50%), nitrous oxide (50%), and propofol was administered intravenously at a dose of 100 Ng/kg/min. The patients’ vital signs, BIS, and agitation scores were recorded every 10 min. The data were analyzed by repeated measure ANOVA and t-tests at a significance level of α = 0.05 using SPSS version 20.

Results:

The results of independent t-test for anesthesia time showed no statistically significant difference between isoflurane and propofol (P = 0.87). Controlling age, the BIS difference between the two anesthetic agents was not significant (P > 0.05); however, it was negatively correlated with the duration of anesthesia and the discharge time (P = 0.001, r = -0.308) and (P < 0.001, r = -0.55).

Conclusion:

The same depth of anesthesia is produced by propofol and isoflurane, but lower recovery complications from anesthesia are observed with isoflurane.

An Overview of Preformed Metal Crowns. Part 2: The Hall Technique

Part 2 of this series of two articles addresses the Hall Technique for preformed metal crowns. It will discuss the need for an effective child and dentist friendly method to restore carious primary molars. The technique is described in detail and the evidence for its effectiveness and acceptance by children, parents, dentists and dental educators is presented. CPD/Clinical Relevance: Dentists and dental care professionals should be aware of the evidence to support the adoption of the Hall Technique.

Materials for Paediatric Dentistry. Part 1: Background to the Treatment of Carious Primary Teeth

Dental caries is a disease that affects many people, including children, and presents numerous challenges to healthcare providers. As clinicians it is important that we consider the advantages and disadvantages of treating carious primary teeth, and make an informed decision about when it is appropriate or not. This paper describes the background to the treatment of carious primary teeth, looking at the differences between primary and permanent teeth, and the relevance of this. It also suggests points to consider when looking at restoration survival studies, as the ability to appraise the literature critically is important for us all in this 'evidence-based' age. CPD/Clinical Relevance: Our early life experiences have the ability to shape our future attitudes and behaviour. Children with carious teeth require careful management so that pain and suffering is minimized, and positive attitudes towards dentistry are fostered.

INVESTIGATING THE MANAGEMENT OF CARIOUS PRIMARY TEETH IN GENERAL DENTAL PRACTICE: AN OVERVIEW OF THE DEVELOPMENT AND CONDUCT OF THE FICTION TRIAL

The management of carious primary teeth is a challenge for patients, parents and clinicians. Most evidence supporting different management strategies originates from a specialist setting and therefore its relevance to the primary care setting is questionable. The UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) has commissioned the FiCTION (Filling Children's Teeth: Indicated Or Not?) trial; a multi-centre primary dental care randomised controlled trial (RCT) to determine the most clinically and cost- effective approach to managing caries in the primary dentition in the UK. This large trial began in 2012, is due to be completed in late 2017 and involves 72 practices and 1,124 children initially aged three to seven years with dentine caries, following randomisation to one of three caries management strategies. Clinical, radiographic, quality of life, treatment acceptability and health economics data are collected during the three-year follow up period. This article provides an overview of the development and conduct of FiCTION and discusses some approaches adopted to manage challenges and achieve the patient recruitment target.

Non-surgical treatment of dentin caries in preschool children--systematic review

Background

Untreated dentin caries in primary teeth is commonly found in preschool children worldwide. Recently, the use of simple non-surgical approaches to manage the situation has been advocated.

The aim of the study was to systematically review and evaluate the literature on effectiveness of non-surgical methods in arresting or slowing down the progression of active dentin caries in primary teeth in preschool children.

Methods

A systematic search of the main electronic databases (Pubmed, Cochrane Collaboration, EMBASE) was conducted to identify peer reviewed papers published in English in the years 1947–2014. Keywords and MeSH terms used in the search were “dental caries”, “primary dentition” and various non-surgical treatments (fluoride, sealant, resin infiltration, xylitol, chlorhexidine, CPP-ACP, ozone, etc.). The inclusion criteria were clinical studies conducted in children under 6 years old, and reported findings on caries arrest or caries progression in primary teeth. Retrieved papers were read by two reviewers independently to assess suitability for inclusion, and the final decision was made by consensus. Quality of the included studies was assessed and data were extracted for analysis.

Results

The search identified 323 papers for screening. Among these, 290 papers did not satisfy the study inclusion criteria. Consequently, 33 full papers were retrieved and reviewed. Finally, 4 studies were included. Three studies reported that topical applications of silver diammine fluoride (SDF) solution could arrest dentin caries in preschool children. One study supported that having a daily toothbrushing exercise in kindergarten using toothpaste with 1000 ppm fluoride could stabilize the caries situation in young children.

Conclusions

There is limited evidence to support the effectiveness of SDF applications or daily toothbrushing with fluoride toothpaste in arresting or slowing down the progression of active dentin caries in primary teeth in preschool children. More well-designed randomized controlled trials are required to confirm these findings.

Clinical Consequences of Untreated Dental Caries Evaluated with the Pulpal Involvement-Roots-Sepsis Index in the Primary Dentition of School Children from the Raipur and Durg Districts, Chhattisgarh State, India

Objective: To evaluate the prevalence of the clinical consequences of untreated dental caries in primary dentition among 6- to 8-year-old children using the prs [pulpal involvement (p), roots (r) and sepsis (s)] index and record the distribution of prs among boys and girls. Subjects and Methods: The study included a sample of 371 children aged 6-8 years with at least one carious primary molar tooth, who had been randomly selected from schools in the districts of Raipur and Durg, Chhattisgarh State, India. We recorded the presence of decayed, extracted and filled (i.e. def) teeth. The prevalence of the consequences of untreated dental caries was evaluated using the prs index. The data were statistically analyzed to express the prevalence of prs among boys and girls and the distribution of individual prs codes in the sample population. Results: The prevalence of carious lesions was very high (87%) and teeth with clinical consequences of untreated dental caries were found in 49.3% of the children. The prs distribution in children who were 8 years old (40.9%) was higher than in the 6-year-old children (25.6%). In the group of 8-year-olds, the occurrence of prs was greater among the boys whereas in the 6- and 7-year-old group, it was greater among the girls. Conclusion: The prs index is a valuable tool for measuring the clinical consequences of untreated dental caries. It could be useful for epidemiological studies and provide relevant information regarding treatment needs. © 2014 S. Karger AG, Basel.

Caries management strategies for primary molars: 1-yr randomized control trial results

Minimal invasive approaches to managing caries, such as partial caries removal techniques, are showing increasing evidence of improved outcomes over the conventional complete caries removal. There is also increasing interest in techniques where no caries is removed. We present the 1-yr results of clinical efficacy for 3 caries management options for occlusoproximal cavitated lesions in primary molars: conventional restorations (CR; complete caries removal and compomer restoration), Hall technique (HT; no caries removal, sealing in with stainless steel crowns), and nonrestorative caries treatment (NRCT; no caries removal, opening up the cavity, teaching brushing and fluoride application). In sum, 169 children (3-8 yr old; mean, 5.56 ± 1.45 yr) were enrolled in this secondary care-based, 3-arm, parallel-group, randomized clinical trial. Treatments were carried out by specialist pediatric dentists or postgraduate trainees. One lesion per child received CR, HT, or NRCT. Outcome measures were clinical failure rates, grouped as minor failure (restoration loss/need for replacement, reversible pulpitis, caries progression, etc.) and major failure (irreversible pulpitis, abscess, etc.). There were 148 children (87.6%) with a minimum follow-up of 11 mo (mean, 12.23 ± 0.98 mo). Twenty teeth were recorded as having at least 1 minor failure: NRCT, n = 8 (5%); CR, n = 11 (7%); HT, n = 1 (1%) (p = .002, 95% CI = 0.001 to 0.003). Only the comparison between NRCT and CR showed no significant difference (p = .79, 95% CI = 0.78 to 0.80). Nine (6%) experienced at least 1 major failure: NRCT, n = 4 (2%); CR, n = 5 (3%); HT, n = 0 (0%) (p = .002, 95% CI = 0.001 to 0.003). Individual comparison of NRCT and CR showed no statistically significant difference in major failures (p = .75, 95% CI = 0.73 to 0.76). Success and failure rates were not significantly affected by pediatric dentists' level of experience (p = .13, 95% CI = 0.12 to 0.14). The HT was significantly more successful clinically than NRCT and CR after 1 yr, while pairwise analyses showed comparable results for treatment success between NRCT and CR (ClinicalTrials.gov NCT01797458).

Factors associated with no dental treatment in preschoolers with toothache: a cross-sectional study in outpatient public emergency services

Many parents rely on emergency services to deal with their children's dental problems, mostly pain and infection associated with dental caries. This cross-sectional study analyzed the factors associated with not doing an oral procedure in preschoolers with toothache attending public dental emergency services. Data were obtained from the clinical files of preschoolers treated at all nine dental emergency centers in Goiania, Brazil, in 2011. Data were children's age and sex, involved teeth, oral procedures, radiography request, medications prescribed and referrals. A total of 531 files of children under 6 years old with toothache out of 1,108 examined were selected. Children's mean age was 4.1 (SD 1.0) years (range 1-5 years) and 51.6% were girls. No oral procedures were performed in 49.2% of cases; in the other 50.8%, most of the oral procedures reported were endodontic intervention and temporary restorations. Primary molars were involved in 48.4% of cases. With the exception of "sex", the independent variables tested in the regression analysis significantly associated with non-performance of oral procedures: age (OR 0.7; 95% CI 0.5-0.8), radiography request (OR 3.8; 95% CI 1.7-8.2), medication prescribed (OR 7.5; 95% CI 4.9-11.5) and patient referred to another service (OR 5.7; 3.0-10.9). Many children with toothache received no oral procedure for pain relief.

The 3.5-year survival rates of primary molars treated according to three treatment protocols: a controlled clinical trial

OBJECTIVES

This study aimed to test the hypothesis that there is no difference in the survival rates of molars treated according to the conventional restorative treatment (CRT) using amalgam, atraumatic restorative treatment (ART) using high-viscosity glass ionomer, and ultraconservative treatment (UCT) protocol after 3.5 years.

MATERIALS AND METHODS

Cavitated primary molars were treated according to CRT, ART, and UCT (small cavities were restored with ART and medium/large cavities were daily cleaned with toothpaste/toothbrush under supervision). Molar extractions resulting from toothache, sepsis, or pulp exposure were failures. The Kaplan-Meier method was used to estimate the survival curves.

RESULTS

The numbers of treated teeth, among the 302 6-7-year-old children, were 341 (CRT), 244 (ART), and 281 (for UCT group: 109 small ART, 166 open cavities, and 6 combinations). Protocol groups were similar at baseline regarding gender and mean decayed missing filled tooth score, but not regarding age and type of surface. The numbers of molars extracted were 22 (CRT), 16 (ART), and 26 (UCT). Fistulae were most often recorded. After 3.5 years, the cumulative survival rate ± standard error for all molars treated was 90.9 ± 2.0 % with CRT, 90.4 ± 2.4 % with ART, and 89.0 [corrected] ± 1.9 % with UCT (p = 0.13). Only a type of surface effect was observed over the 3.5-year period: survival rates for molars were higher for single- than for multiple-surface cavities.

CONCLUSION

There was no difference in the cumulative survival rates of primary molars treated according to the CRT, ART, and UCT protocols over a 3.5-year period.

CLINICAL RELEVANCE

Keeping cavities in primary molars biofilm-free might be another treatment option alongside restoring such cavities through conventional and ART protocols.

Improving oral healthcare for children--a great opportunity

Changes in commissioning and contracting of NHS dental services will impact on oral healthcare delivery, providing new challenges and opportunities for children's oral healthcare. Now is the time to assess clinical networks and specialised services to understand how the oral healthcare needs of all children can be met appropriately and effectively so that when change comes it can be embraced for the better.

The FiCTION dental trial protocol - filling children's teeth: indicated or not?

BACKGROUND

There is a lack of evidence for effective management of dental caries (decay) in children's primary (baby) teeth and an apparent failure of conventional dental restorations (fillings) to prevent dental pain and infection for UK children in Primary Care. UK dental schools' teaching has been based on British Society of Paediatric Dentistry guidance which recommends that caries in primary teeth should be removed and a restoration placed. However, the evidence base for this is limited in volume and quality, and comes from studies conducted in either secondary care or specialist practices. Restorations provided in specialist environments can be effective but the generalisability of this evidence to Primary Care has been questioned. The FiCTION trial addresses the Health Technology Assessment (HTA) Programme’s commissioning brief and research question “What is the clinical and cost effectiveness of restoration caries in primary teeth, compared to no treatment?” It compares conventional restorations with an intermediate treatment strategy based on the biological (sealing-in) management of caries and with no restorations.

METHODS/DESIGN

This is a Primary Care-based multi-centre, three-arm, parallel group, patient-randomised controlled trial. Practitioners are recruiting 1461 children, (3-7 years) with at least one primary molar tooth where caries extends into dentine. Children are randomized and treated according to one of three treatment approaches; conventional caries management with best practice prevention, biological management of caries with best practice prevention or best practice prevention alone. Baseline measures and outcome data (at review/treatment during three year follow-up) are assessed through direct reporting, clinical examination including blinded radiograph assessment, and child/parent questionnaires. The primary outcome measure is the incidence of either pain or infection related to dental caries. Secondary outcomes are; incidence of caries in primary and permanent teeth, patient quality of life, cost-effectiveness, acceptability of treatment strategies to patients and parents and their experiences, and dentists’ preferences.

DISCUSSION

FiCTION will provide evidence for the most clinically-effective and cost-effective approach to managing caries in children's primary teeth in Primary Care. This will support general dental practitioners in treatment decision making for child patients to minimize pain and infection in primary teeth. The trial is currently recruiting patients.

TRIAL REGISTRATION

Protocol ID: NCTU: ISRCTN77044005.

Alternative treatment strategies for carious primary teeth: An overview of the evidence

BACKGROUND

Dental decay in children's primary teeth is a major health problem in the Great Britain with, in some areas, nearly 60% of five-year-olds having some experience of caries and 16% already having had at least one tooth extracted. Whilst currently accepted best practice for the management of carious primary teeth involves complete caries removal and placement of a plastic restoration, such conventional treatment is unpopular with general dental practitioners. Indeed, less than 15% of carious cavities in five-year-olds are currently restored and as such, there has been recent interest in alternative 'minimal intervention' treatment techniques for managing dental caries.

REVIEW

This review summarises the literature and also recent research efforts directed towards understanding the role of alternative treatment regimens including: (1) alternative techniques for cavity preparation and excavation and (2) the isolation of the carious process (in some cases, using cariostatic materials) from the oral environment or sealing in dental caries.

Rationale for restoration of carious primary teeth: a review

BACKGROUND

The literature regarding dental and systemic effects of Early Childhood Caries (ECC), consequences of leaving carious primary teeth untreated, benefits of appropriate treatment, and concerns regarding dental treatment of young children and the potential for dental anxiety, is reviewed. ECC has consequences, affecting both the child's dental health and his/her general health. This paper reviews the literature regarding ECC and its consequences (pain, sepsis, space loss, disruption to quality of life, failure to thrive, effects on intellectual development, greater risk of new carious lesions in both primary and permanent dentitions, higher incidence of hospitalisation and emergency visits, and increased treatment costs and time). The effects of treatment of ECC are also reviewed; and concerns regarding purported associations between treatment of ECC and dental anxiety are addressed.

SEARCH METHOD

A Pub Med search was conducted of peer reviewed papers published in the English language in the years 1986-2011, using the search terms: Early Childhood Caries (ECC), Nursing Caries (NC), Consequences and ECC/NC, Treatment and ECC/NC, Treatment outcomes and ECC/NC, Dental anxiety, Dental fears, Onset of dental anxiety/fear, Dental experiences and dental fear/anxiety. More than 300 articles were studied. Reference lists of the selected articles were also studied, and frequently quoted articles were thus also located. Articles with small sample size, poor or poorly described methodology, and unclear or unsupportable conclusions were rejected. A representative sample is presented in this paper, citing the articles with greater levels of evidence, with a description of study methods, where appropriate.

CONCLUSION

This review has demonstrated that ECC has implications for both the dental and general health of the affected child. Such problems are potentially serious, even life-threatening. Evidence has been provided of the beneficial effects on dental and general health of dental rehabilitation of children with caries. Causes of dental anxiety are multi-factorial, and treatment of ECC does not invariably contribute to dental anxiety, as long as the child's experience of dentistry is not traumatic. Children with the highest levels of dental disease are primarily from disadvantaged communities. Failure to adequately treat their dental disease may further disadvantage these children. Paediatric Dental Societies, renowned experts in Paediatric Dentistry, and the Medical Protection Society (Dental Protection, Professional Insurance) do not support a policy of leaving carious primary teeth untreated.

Pulpal involvement-roots-sepsis index: a new method for describing the clinical consequences of untreated dental caries

OBJECTIVES

To describe a modification of the index of clinical consequences of untreated dental caries [pulpal involvement, ulceration, fistula and abscess (PUFA/pufa) index] to pulpal involvement-roots-sepsis (PRS/prs) and to compare the two indices using the example of caries in primary molar teeth in children aged 6-8 years.

SUBJECTS AND METHODS

The study sample included 542 children aged 6-8 years, from five randomly selected schools in the Bialystok District, Poland. The occurrence of clinical consequences of untreated caries in deciduous molars using the pufa and prs indices was evaluated. Data were analysed to express the prevalence, the experience and the distribution of particular pufa and prs codes in the sample population. The differences in layout of the pufa and prs components were expressed.

RESULTS

The response rate was 77.6%. The prevalence of the clinical consequences of untreated caries was 40.77%, mean pufa and prs were the same (0.85 ± 1.33). According to the pufa index, the following mean values were obtained: p = 0.79, u = 0.01, f = 0.04 and a = 0.01. For the prs index, the mean values were as follows: p = 0.45, r = 0.35 and s = 0.05.

CONCLUSION

The proposed prs index was a useful epidemiological instrument for the evaluation of the clinical consequences of untreated caries in the surveyed population. The PRS instrument could be a good alternative to the PUFA index.