Evidence
Alert

Primary prevention and shared decision-making are the key to managing decay in baby teeth

Sealing in decay, improving tooth hygiene and using conventional fillings all work to prevent future dental pain and infection for children with decay in baby teeth. The approaches are equally acceptable to children and parents.

Researchers tested three methods of managing decay in the primary molars of children aged three to seven:

  • best practice prevention (advice on cutting down on sugar, twice-daily tooth brushing with fluoride, application of fluoride varnish)
  • best practice prevention plus conventional local anaesthetic, and drilling out of decay and filling
  • best practice prevention plus sealing in of decay with caps or fillings

They found little difference in the chances of having an episode of pain or infection during 2.8 years of follow-up.

 

Why was this study needed?

Dental decay is the most common disease affecting children and can cause pain and time away from school. In 2013 to 2014, 62,747 children were admitted to hospital in England, Scotland and Wales with dental decay. However, it is unclear how decay of primary (baby) teeth is best treated.

Until 10 years ago, the standard treatment was to drill out all decayed tooth tissue and fill the hole. However, this does not seem to reduce future episodes of decay. Less invasive ‘biological’ treatment (sealing in decay) and preventive treatment have become more popular. Evidence based on young children in primary care was lacking, however.

This study aimed to compare the clinical and cost-effectiveness of the three management strategies for children at high risk of dental decay, treated in primary care, and to find out which strategy was more acceptable to children and parents.

 

What did this study do?

Researchers recruited 1,144 children aged three to seven years at high risk for dental decay, via 72 dental practices for the FiCTION randomised controlled trial. Dentists were trained in the three management strategies. Children were randomly assigned to one of the three strategies if they had one or more holes in their primary molar teeth.

To determine the clinical effectiveness of each strategy, children were followed up for subsequent episodes of dental pain or infection. Researchers also interviewed parents or caregivers about the children’s quality of life, and about their anxiety about dental treatment. Parents were asked about the acceptability of their experience of the chosen management.

The researchers calculated the cost-effectiveness of the three strategies, based on different levels of acceptability of cost.

 

What did it find?

  • There was no evidence of a difference in clinical effectiveness between the three management strategies in these children at high risk of dental decay.
  • An average 43% of children treated by any management strategy had at least one episode of pain or infection over an average follow-up period of 33.8 months: 36% had pain and 25% had an infection.
  • Those treated by sealing in decay had slightly different rates of pain or infection (40%) compared with conventional filling (42%) and prevention only (45%). The differences in outcome were not statistically significant meaning they could have arisen by chance.
  • In terms of cost-effectiveness, on average, best practice prevention alone was the least costly approach to manage holes in baby teeth. But it was also least effective for reducing episodes of dental pain and/or infection and resulted in the most referrals for tooth removal in hospital.
  • There was also no difference between the treatment groups for oral health-related quality of life or dental anxiety, and qualitative interviews suggested that each management option was acceptable to parents and children.
  • The interviews suggested that trust in the dental professional was important, with parents trusting dentists to decide on the best treatment for the child.
  • The researchers noted that only 48% of the children treated had an X-ray at any point during treatment.

 

What does current guidance say on this issue?

Guidance from the Scottish Dental Clinical Effectiveness Programme states: “For a child with a carious [decayed] lesion in a primary tooth, choose the least invasive feasible caries management strategy, taking into account: the time [the tooth is likely to fall out naturally], the site and extent of the lesion, the risk of pain or infection, the absence or presence of infection, preservation of tooth structure, the number of teeth affected, avoidance of treatment-induced anxiety.”

The UK guideline on the management of decay in paediatric dentistry dates back to 2001. It states that dental care for children should include “comprehensive prevention” and that “restorations or extractions” will usually be necessary to treat children with dental decay.

 

What are the implications?

The results emphasise the importance of early prevention for young children to avoid dental decay altogether, rather than trying to manage multiple decayed baby teeth.

Given that there was no evidence of a difference in clinical effectiveness, dentists may wish to discuss treatment options with parents and children. Children or their parents may have a preference because of the invasive nature of conventional fillings. Since dental treatment for children is free in the UK, society (and the NHS) need to decide what they are willing to pay to avoid pain and infection in primary teeth.

The findings could help inform future guidance on the management of decay in primary teeth.

 

Citation and Funding

Maguire A, Clarkson JE, Douglas GVA et al. Best-practice prevention alone or with conventional or biological caries management for 3- to 7-year-olds: the FiCTION three-arm RCT. Health Technol Assess. 2020;24(1).

The project was funded by the NIHR Health Technology Assessment Programme (project number 07/44/03).

 

Bibliography

Fayle SA, Welbury RR, Roberts JF on behalf of the British Society of Paediatric Dentistry (BSPD). British Society of Paediatric Dentistry: a policy document on management of caries in the primary dentition. Int J Paediatr Dent. 2001;11:153–7.

Scottish Dental Clinical Effectiveness Programme. Prevention and management of dental caries in children: dental clinical guidance (2nd edition). Dundee: Scottish Dental Clinical Effectiveness Programme; 2018.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Commentaries

Expert commentary

This fascinating study gives us an insight into the relative benefits of three different approaches for dental caries management provided by primary care dental professionals.

The conclusion, that there is no difference between the different approaches, should be interpreted with some caution. Evidence-based treatments such as pre-formed metal crowns, use of dental injections or X-rays were not often carried out. Therefore the results are unlikely to apply to dental services where these treatments are routinely used.

This study highlights that there are barriers to providing evidence-based dental care in the primary care dental sector.

Professor Paul Ashley, Paediatric Dentistry, UCL Eastman Dental Institute, London

The commentator declares no conflicting interests

Expert commentary

A debate on whether or not to fill cavities in decayed primary teeth raged throughout the dental profession in the 1990s and early 2000s, an argument which led to the funding of this study and perhaps naively in some quarters, the hope that a definitive answer to the controversy would result.

What this logistically complex trial has shown is that, at least where episodes of dental pain are concerned, there is no significant difference between the approaches adopted: conventional fillings and prevention, a biological approach sealing in caries and prevention, or prevention alone.

While there are minor differences in preference and cost, what can be concluded is that preventing cavities forming in the first place is likely the best option of all.

Professor Ivor G Chestnutt, Professor and Honorary Consultant in Dental Public Health, Cardiff University School of Dentistry

The commentator declares no conflicting interests