Signposting to excellence…Managing dental caries in children

Signposting to excellence… 

Managing dental caries in children 

  • Barbara Chadwick

The biggest change in the practice of dentistry since I graduated has I think been the acceptance of evidence-based as opposed to opinion-based practice. But how can a clinician in the 21st century determine what is best evidence? The Cochrane Systematic review has become the accepted gold standard for synthesising evidence and in some areas of oral health there is data to inform practice, for example there are 15 reviews on fluoride and one consequence of this is that the UK preventive national guidance documents on the use of fluorides in children broadly agree with each other.1, 2

But all too often there is insufficient data to answer a specific clinical question. For example, how should caries in primary teeth be managed? The differences between specialist recommendations and the realities of managing child patients with dental caries in primary dental care were debated in UK professional journals in the early 2000s. Specialists in paediatric dentistry cited broadly the same evidence to support their use of preformed metal crowns as the best restorative option3,4 as the authors who provoked the debate with the claim that restoring children’steeth was no better than providing no care at all since restored teeth were just as likely to cause pain and infection as those left untreated.5,6 They cannot both have been correct! It is worth noting that none of the evidence cited in these articles was of sufficient quality to be included in subsequent Cochrane reviews. Furthermore, as clinical trials are expensive and time consuming it was not until 2015 that a Cochrane review based on five trials concluded there was “moderate quality evidence that crowns are more effective than fillings for managing decay in primary molar teeth.7

The difficulty we face as clinicians is trying to determine what is the best option for the particular child we encounter on a given day? Often in the absence of definitive evidence. In the past practitioners developed approaches to care that they believed worked for them and frequently, as with the debate about managing children with caries, different practitioners come to completely different solutions for the same problem based on opinion. Guidelines assist clinicians by making recommendations, to optimise patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative options.8 I place a lot of preform crowns on carious primary molars, but I also manage caries in primary molars with fillings, extractions and on occasion with preventive treatment and advice alone; the skill is knowing how to match the child to the correct option, fortunately for me and the rest of the dental profession there is guidance to help.

In 2010 Scottish Dental Clinical Effectiveness Programme (SDCEP) published guidance (prevention and management of dental caries in children) to assist clinicians to make decisions on managing dental caries in children.9 The guidance is online, freely accessible, person-centred, evidence-based and written for dental teams. While some aspects of the guidance are clearly aligned to Scottish based preventive programmes it is applicable to primary care practitioners in the UK and beyond and it brings together best evidence for assessing, preventing and managing dental caries in children. It includes decision trees and clinical images of restorative techniques, so if you work with children and have not seen it then I would recommend that you download a copy. Then keep an eye out for the second edition as the guidance is currently being updated to incorporate new evidence. I promise you won’t regret it!

References

  • 1.Scottish Intercollegiate Guidelines Network (SIGN). Dental interventions to prevent caries in children. Edinburgh: SIGN; 2014. (SIGN publication no. 138)
  • 3.Fayle SA, Welbury RR, Roberts JF. British Society of Paediatric Dentistry: a policy document on management of caries in the primary dentition. Int J Paediatr Dent. 2001;11(2):153-7.
  • 4.Roberts JF, Attari N. Primary dentition 2. Brit Den J. 2004; 196(2):64-5.
  • 5.Tickle M, Milsom K, King D, Kearney-Mitchell P, Blinkhorn A. The fate of the carious primary teeth of children who regularly attend the general dental service. Brit Dent J. 2002;192(4):219–3.
  • 6.Milsom K M, Tickle M, King D. Does the dental profession know how to care for the primary dentition? Brit Dent J. 2003;195(6):301-303.
  • 7.Innes NPT, Ricketts D, Chong L, Keightley AJ, Lamont T, Santamaria R. Preformed crowns for decayed primary molar teeth. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD005512. DOI: 10.1002/14651858.CD005512.pub3
  • 8.Consensus report, Institute of Medicine. Clinical practice guidelines we can trust. March 23, 2011. http://www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx (Accessed on 3 January 2017).
  • About the author: Barbara is Professor of Paediatric Dentistry and Vice-Dean School of Dentistry, Cardiff University.

 

Correspondence: chadwickbl@cardiff.ac.uk

 




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