Managing Carious Primary Teeth

7/28/2019 Managing Carious Primary Teeth

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Are current methods of managingcarious primary teeth effective?

Dafydd EvansDundee Dental Hospital & School

4th

October 2002


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Primary teeth; some relevant facts

there are 20 of them

the last one may not be shed until 11-12 yrs

and the factor at the root of the problem

small teeth, big pulps


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Dental decay is common

BASCD 1999/2000 survey 5 year old

> 3.02.51-3.0

2.01-2.5

1.51-2.0

1.01-1.5

< 1.0

dmft


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Yes, it is skewed, with 25% of childrenhaving 75% of the decay, but still.

55% of Scottish 5 years old have decaySHDEP 1998

16% of Scottish 5 year olds have had at leastone extraction SHDEP 1998

42% of Scottish 8 year olds have had at leastone extraction

Childrens Dental Health in the United Kingdom, 1993


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Management options for carious primaryteeth

leave unless/until problems

prevention alone, and leave etc

prevention plus interventive treatment ofsome sort

So whats the evidence supporting any of

the above?


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Chocolate; its time to look at the healthbenefits

Evans D, Cadbury J & Rowntree MJournal of Wishful Thinking2001; 184;48-52

ConclusionThere is a positive association between

consumption of chocolate and life span


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British Society for Childrens Dentistry

there is the possibility of bias andconfounding factors in the study samples,and the results, although interesting,should be interpreted with caution

Atheroma Review

this is a dreadful piece of work


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Study data

Annual chocolate

consumption per capita

Lifespan

Sample A 13 kg 75-80 yrs

Sample B 2.5 kg 65-70 yrs

Sample C 0.16 kg 60-65 yrs

Significance p


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Evidence for the effectiveness ofdental treatment

The 5-year results of a clinical trial comparing aglass polyalkenoate (ionomer) cement restorationwith an amalgam restoration. Welbury R R, WallsA W G, Murray J J, Mccabe J F. Br Dent J

1991; 170: 177-181 The use of a reinforced glass-ionomer cermetfor the restoration of primary molars: a clinicaltrial. Kilpatrick N M, Murray J J, Mccabe J F.Br Dent J1995;179:175-179

The fate and survival of amalgams and PMCsfitted in specialist practice.Roberts & SherrifBr Dent J1990 169:237-244


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Dental treatment can be effective,but is it effective in primary care?


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Care index

1983: 15%

1993: 8%

1989: 18%

1999: 9%


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Scottish DPB Annual Report 1998/1999

155,474 extractions (under 18)

219,891 fillings

513 PMCs fitted 2,045 vital pulpotomies

5,303 non-vital pulpotomies

11,714 Gas (under 18)

2,118 sedations (under 18)


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Dental treatment can be effective,but is it effective in primary care?

The fate of the carious primary teeth ofchildren who regularly attend thegeneral dental services

Tickle M, Milsom K, King D, Kearney-Mitchell P &Blinkhorn A Br Dent J2002 192:219-223


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The fate of the carious primary teeth ofchildren Tickle et al Br Dent J2002 192:219-223

Three hypotheses offered as an explanation of thefindings:

There really is no advantage in restoring primaryteeth

The quality of treatment provided by the GDPs is nobetter than leaving the teeth unrestored

GDPs are actively deciding which teeth to restore andwhich they can leave unrestored to reach the same

result, which is exfoliation

The authors favour the latter (BDJ 192; 671)


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The fate of the carious primary teeth ofchildren who regularly attend the general dentalservices Tickle et al Br Dent J2002 192:219-223

Retrospective case study of 677 children, with 13,540teeth, under the care of 50 GDPs

1,789 teeth extracted, but only 475 due to pain/ sepsis

>80% of carious primary molars filledConclusions

no difference in the proportions of teeth extracted due topain or sepsis whether a carious tooth was restored or left

unrestored

The bulk of carious teeth exfoliated naturally irrespectiveof whether they were filled or not


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The fate of 1,587 unrestored carious deciduous teeth;a retrospective general dental practice based studyfrom northern England Levine R, Pitts N & NugentZ. Br Dent J2002 193:99-103

Retrospective case study of 1,587 unrestored cariousdeciduous teeth in 481 children, in 2 GDP practices

82% of untreated carious teeth exfoliated withoutcausing pain (if the 178 teeth extracted

prophylactically not included with the 190 extractedbecause of pain)

Conclusions

The carious teeth most likely to cause symptoms were

carious molars with pulpal involvement in 3 year olds

The majority of unrestored carious deciduous teethremain symptomless until shed.


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The majority may well exfoliate naturally,but.

16% of Scottish 5 year olds have had at leastone extraction SHDEP 1998

42% of Scottish 8 year olds have had at least

one extractionChildrens Dental Health in the United Kingdom, 1993

50% of children remember having toothacheThe prevalence of pain and impact of pain in 8 year olds in Harrow,

England. Shepherd M, Nadonovsky P & Sheiham A B Dent J1999;187:38-41


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If too many teeth are being extracted,and fillings work, wheres the complexity?

In some parts of the UK, the care index for 5year olds can rise to 37%

In Quebec, dmft 1.77, CI 65%

In Grampian, dmft 1.89, CI 15%


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If too many teeth are being extracted,and fillings work, wheres the complexity?

Daniella

5 years old

Referred for GA extractions


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Daniellas treatment

Prevention

Non-vital pulpotomy 65, and vital pulpotomies64 and 84

PMCs 64, 65, 84 & 85

Filling 55


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And the complexity?

Granny

GDP

Fees Radiographs, fear of failure, pressureof work,etc. etc.


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Alternative restorative techniques

Caries removal Laser ART Carisolv Air abrasion

Arresting caries Silver fluoride/ stannous fluoride Duraphat Saucerisation/ discing/ fenestration Chewing gum Copper phosphate cement

Sealing in caries GIC/ composite/ fissure sealant Hall Technique


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Copper phosphate cement


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Copper Phosphate Cementfailure rate at 6 months

%

failure

rate

Cl. I Cl. II

73.188.9

Foley et al. HealthBulletin 2000


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BCC

Chemfil%

weightloss

0

5

10

15

20

1000 200 300 400dys

Foley et al. Eur J Prosthodont Rest Dent 2002

Copper Phosphate Cement

Solubility


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Copper phosphate cement

Conclusion

It is significantly more bactericidal than other

restorative materials Solubility precludes its use, even as a lining

material


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The Hall technique

The Hall technique: a pilot trial of a novel useof preformed metal crowns for managingcarious primary teeth. Evans, D.J.P., Southwick,

C.A.P., Foley, J.I., Innes, N.P., Pavitt, S.H. , andHall, N. Tuith 2000

www.dundee.ac.uk/tuith


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Two Year Audit, Hall Technique,111 crowns fitted

Preformed crowns No. %

Still present or naturally exfoliated 91 82

Fell off; tooth filled conventionally 3 3Extracted 16 14

Crown removed as child unable to 1 1

tolerate it

Total 111 100%

N Hall


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Pilot Trial: Crowns Fitted

Dentists Recruited Fitted

GDP 1 10 10

GDP 2 10 10

GDP 3 4 3

GDP 4 0 0

Hosp 1 10 10

Hosp 2 10 10

Hosp 3 4 2

Hosp 4 1 0

49 45


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Time %

< 10 min 68%

< 10 min 89%< 15 min 96%

Time Taken to Fit Crown


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Amount Bite Propped Open

mm 0 1-2 2-3 3-4 5-6

% 11% 73% 2% 11% 2%


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Dentist Assessment of DiscomfortExperienced by Children

No apparent Very mild, Mild, not Moderate, Significant

Discomfort almost trivial significant but child and

coped unacceptable

61% 24% 15% 0% 0%


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Hall technique

analysis of Dr Halls practice records showedthat 978 crowns had been fitted since since1988

for all tooth types there was over 76%probability of the crown surviving for 1000days

and over 60% probability for 2000 days

highest failure rate was with Ds


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Hall technique

Conclusion

promising, not recommended for use untilstudy results are known (around December2003)

Possible ways forward


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Possible ways forward

Better funding

More training

Alternative techniques

More research into impact of restoring/ nonrestoring carious primary teeth

Patient and parent education

Reappraise role of CDS

Therapistsand finally


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best of all would be to stop trying to mopup the floor and start turning off thetap!

Caries prevention 0-5 yrs

Documents

Managing Carious Primary Teeth