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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