Children oral health is an integral part in the systematic health of the children, ref as it can affect positively or negatively in their quality of life that includes physical and psychological impacts. Dental caries in children is one of the most common diseases in children worldwide affecting ( ) children ref. In the United Kingdom UK, % of children have dental caries ref. According to the British Society of Paediatric Dentistry BSPD, Severe dental caries in children possess a healthcare priority in the UK, in which it can have a great impact in the implications for policy makers, practice and dental education ref. This essay will thoroughly investigate wither children teeth are indicated for restoration or not. According to several factors, guidelines and research from the literature that will determine the indication and contraindication of dental restorations.
Historically, it was believed that dental caries is a progressive disease that destroy teeth and restorative or surgical interventions should be considered ref. Moreover, dental caries management was based on mechanical treatment of the destructed tooth structure and fill the remaining parts of tooth structures with different restorations according to the remaining tooth structure ref. While in the meantime, it is known that carious lesions may not progress, therefore, there are no need for restorations in some cases ref. Additionally, restorative treatment alone may not stop dental caries from further progression, as dental restorations have a limited lifespan ref. Evidence revealed that some carious lesions can be managed and controlled from progressing without complete excavation of caries. To illustrate this, removal of the infected dentine and preserve the affected dentine in order to maintain pulp vitality and arresting carious process. This technique found to be effective according to Neves et al 201.
Tickle et al. 2002 have found that more teeth were never restored either one or two surface lesions than restored teeth. For example, 18.6% of two surfaces lesions were restored. However, 21.6% of them were never restored. Similarly, 11.8% of one surface lesions were restored and 12.4% of one surface lesions were never restored.
The Children’s Dental Health Survey 2013 reported some statistical estimations on the oral health of children in the UK aged 5, 8, 12 and 15 year olds with higher rates eligibility for free school meal, and compared with children from lower socioeconomic status. 31% have experienced decays and untreated dental caries was 28%. The average dmft for children with decay was 3.0 and 49% was the percentage of caries into dentine. Additionally, the prevalence of dental caries was higher in lower socio economic groups. Thirty-one per cent of 5-year-old children had obvious dental caries and almost half (46%) of 8-year-old children as well. Decay into dentine was 28 % and 39% of 5-year-old and 8-year-old children respectively. 22% of 12 and 19% of 15 year olds reported experienced difficulty in eating in the past three months. Twenty-six per cent of the 15 year olds who were eligible for free school meals had severe or extensive tooth decay, compared to 12 per cent of 15 year olds who were not eligible for free school meals. However, these findings showed a reduction in terms of the extent and severity of dental caries presented in the permanent teeth of 12 and 15 year olds children when compared to the last survey in 2003.
As a general rule, in order to tackle such issue, risks and benefits in restorative therapy should be considered. The American Association of Paediatric Dentistry AAPD ref, summarised the main objectives of restorative care. They include repair or limit the defect caused by dental caries, restore aesthetic of teeth, re-establish adequate functional movement, preserve tooth structure as possible, providing ease in oral health maintenance and pulp vitality should be protected whenever possible. In contrast, there are risk of pulpal exposure during cavity preparation as the pulpal horns in the primary teeth are higher. A possible of errors in cavity preparations as it is common to fail to extend the outline of the cavity into susceptible pits and fissures, or the outline is too wide which could weaken the remaining tooth structure when receiving a dental restoration ref.
In the UK, many attempts have been done to investigate wither children teeth should be filled or not to establish an effective management of dental caries in primary teeth in children. Caries risk assessment, type of restorative materials, developmental stage of child, oral hygiene and parent child compliances are very important factors in the decision making for dental restorations ref.
The AAPD ref proposed guideline on caries risk assessment for children which facilitates decision making process in risk determination for every child individually. Generally, children consider to be at high risk for caries who have white spot lesions as these are precavitated lesions, and have more than one decayed/missing/filled surfaces or interproximal caries. Accumulation of plaque is additionally associated with caries development. Children aged 0-5 year olds of low socioeconomic conditions, whom their parents have active caries and consume more than 3 sugary snacks or beverages between meals or put on bed with bottle containing sugar are consider at high risk of developing caries. On the other hand, children who brush their teeth twice daily with fluoridated toothpaste, have regular dental care and receive topical fluoride and drink fluoridated water are consider at low risk. Those who are at moderate risk could be children who have plaque on their teeth and children with special needs or recent immigrants. These assessments are also corresponded to children of six years old and above. The AAPD 2018 recommendation in restorative dentistry concluded that dental caries management should include identifying caries progression as individual risk for every child and the decision when to restore should be achieved by clinical criteria of visual detection of cavitated enamel and radiographic examination. Regarding type of restorative materials, a Cochrane review and meta-analysis on the application of pits and fissure sealants should be on surfaces at high risk of caries development that already exhibit non cavitated incipient lesions to inhibit caries progression ref. For Class I and Class II cavities in permanent molars, there is a strong evidence from a systematic review with meta-analysis that composite resins showed successful results when properly isolated.
Recently, a group of researchers addressed a three randomised controlled trials over a period of follow up to three years in 3-7 years old children with carious lesions in primary teeth. The research question was “What is the clinical and cost effectiveness of filling caries in primary teeth, compared to no treatment?” It compared also the clinical cost-effectiveness of an intermediate treatment strategy based on the biological (sealing-in) management of caries with no treatment and with fillings. The first trial was conventional treatment with best practice prevention, the second trial was biological with best prevention and the third trial was best practice prevention alone. The primary outcome was to compare the pain incidence and number of toothache episodes, and dental sepsis experience in the three treatment strategies. The secondary outcomes were to compare the three treatment strategies in regards to, first: child quality of life and dental anxiety which reported by parents. Second: caries incidence in primary and permanent teeth throughout follow up period. Third: Cost effectiveness and finally the acceptability and associated experiences for parents and patients, and dentists’ preferences.
The first trial was approached by complete removal of caries by either using hand excavation or rotary instruments under local anaesthesia and placement of conventional restorations. The second trial based on the concept of changing the biofilm and environment in the oral cavity to cease carious process. This was achieved by covering the caries with metal crowns or application of adhesive materials on the caries without the need for local anaesthesia or rotary instruments.
The third trial was based on preventive methods that included dietary advice, tooth brushing with topical fluoride varnish application to all teeth and pits and fissure sealants for permanent teeth with respect to the current UK guidelines. Noting that no drilling and filling were used in this arm. In summary, there was no significant difference found in terms of the incidence of pain and or sepsis, quality of life, dental anxiety or incidence of permanent molars caries. In contrast, there was some evidence of a difference in the incidence of dental caries in primary teeth. Regarding cost effectiveness, on average, prevention arm was less costly but biological arm was more effective. Prevention would be recommended than biological if dentists focused on cost-saving, but with less effectiveness. In views of child participations and their parents, in the conventional arm, children reported dislike of extractions and use of local anaesthesia, and placement of Porcelain Metal Crowns PMCs. Children also reported that the conventional treatment found to be tolerated. In the biological arm, some parents had aesthetic concerns of PMCs but no concerns reported from the children. Most of parents and children expressed that the biological approach was acceptable and more suitable for children as it did not contain needle injections or drilling. Parents and children showed more satisfaction and being happy in the prevention alone arm as it did not involve any crowns, injections or drilling, and more importantly, carious teeth remained pain-free. Additional factors which were important to perceived in the preventional alone arm, regular attendance of children to decrease anxiety and continuity of dental care with the same dentist to gain trust of children and parents, flexibility of appointment times were beneficial for parents. From dental professionals’ perspectives, refusal of local anaesthesia was the reason for some arm deviations, biological arm was generally acceptable for parents, although PMC had aesthetic issues for some parents. Dental professionals in the prevention alone arm had some parents’ declination as they dislike the idea that their children were not receiving treatment. write more about guidelines in uk
This interventional study can provide a comprehensive view of the current situation regarding management of dental caries and decision making that will aid dental practitioners in their treatment to minimise infection and pain in primary teeth, and improve the outcomes of treatment by providing evidence from the most cost and clinical effective approaches.
In conclusion, this essay clearly mentioned several factors such as caries risk assessment, several dental materials, and patients’ compliances that can play a major role in the decision making of dental restorations. Supported by the most current randomized controlled trial interventional study that provided a clear idea of different aspects in considering restorations.
primary teeth with carious lesions which are near to exfoliate can be left untreated as there is no necessity to restore them, in order to minimise patient exposure to local anaesthesia or dental materials. Moreover, carious primary teeth with no signs and symptoms can be left untreated if the oral hygiene of the patients remained at optimal level and regular follow up obtained to insure no caries progression. When comparing the durability of restorations, Partial caries removal and restoring the teeth with cariostatic materials such as glass ionomer cements found to have greater durability and effectiveness than the conventional restorations over 24 months. This can be supported by a randomized controlled trial ref. In terms of cost saving and dental practitioners’ preferences, following a preventional approach in managing dental caries to minimise the financial burden of conventional restoration costs are found to be beneficial. In severe cases and high caries risk patients, dental restorations are indicated if pain is present and affecting the quality of life of children. There is lack of evidence in the role of policy makers in the indication or contraindication of dental restorations. Oral health promotion and dental education in a community level can be effective by advocating parents and/or caregivers about the importance of the oral health of their children, encourage them for routine dental check-up to detect early carious lesions and prevent them from progressing, application of topical fluoride varnish and dietary advice. These can reduce the indication of extensive restorations in low to moderate caries risk patients.