Short communication: a pan-European comparison of the management of carious primary molar teeth by postgraduates in paediatric dentistry.
AIM: To assess the preferences amongst European postgraduates (PG)
in Paediatric Dentistry for the treatment of a child with differing
caries severity in a primary molar tooth. STUDY DESIGN: An on-line
structured questionnaire. METHODS: All European Paediatric Dentistry PGs
were contacted by e-mail and asked to participate in an on-line
questionnaire. The survey described four different case scenarios of a
5-year-old child, presenting with a mesio-occlusal cavity in tooth 85
with varying symptoms and signs. Treatment options were listed and
participants asked to select the single most preferred treatment for
each case. The same scenarios were presented for both non-anxious and
dentally-anxious patients. RESULTS: Responses were received from 32/56
(F: 27; M: 5) PGs. A range of treatment options were selected for
patients with no indication of pulpal involvement for non-anxious
patients whilst the Hall technique was selected by 16/32 students for a
dentally-anxious patient. For both a nonanxious and dentally-anxious
patient, the preferred option for a tooth which produced pulpal symptoms
was extraction selected by 16/32 students in both cases, although the
mode of extraction differed. CONCLUSION: There was no consistency of
response by PGs in Paediatric Dentistry within Europe. The Hall
technique appeared to be a favoured option by half of the students for
treatment of an asymptomatic carious primary molar tooth in a
dentally-anxious child patient. Dental extraction was an option for a
tooth demonstrating pulpal symptoms in both non-anxious and
Key words: Dental caries, postgraduate dental education
Dental caries (Care and treatment)
|Publication:||Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 European Academy of Paediatric Dentistry ISSN: 1818-6300|
|Issue:||Date: Feb, 2012 Source Volume: 13 Source Issue: 1|
|Topic:||Event Code: 200 Management dynamics|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Currently accepted best practice for the management of carious primary teeth involves complete caries removal and placement of either a plastic restoration or preformed metal crown (PMC) [Fayle et al., 2001; Innes et al., 2007a]. Within the dental profession in the United Kingdom there is on-going debate regarding the most effective way in which to treat dental caries [Milsom et al., 2003; Foley et al., 2004; Pine et al., 2006; Duggal, 2006; Tickle, 2006] and with this in mind, a number of novel techniques have been advocated for managing carious primary teeth [Ricketts et al., 2006; Foley, 2006; Innes et al., 2007b], particularly in the pre-cooperative child patient.
One previous study surveyed the approaches taken to treat a carious primary molar tooth by a random sample of non-specialist and Paediatric Dentists working within England using a postal questionnaire and found a wide variation between the two groups in relation to treating dental caries [Tickle et al., 2002]. A more recent on-line survey investigated the treatment preferences amongst UK postgraduates (PG) in Paediatric Dentistry for a symbolic child with a sample case history of differing caries severity in a primary molar tooth. There was no consistency of response by PGs in Paediatric Dentistry within the UK [Foley, 2010]. Based on this work, the aim of the current study was to assess the preferences amongst European postgraduates (PG) in Paediatric Dentistry for the treatment of a child with differing caries severity in a primary molar tooth.
Materials and methods
The Program Director for each of the seven EAPD-accredited postgraduate programmes in Paediatric Dentistry in Europe was contacted by e-mail in February 2011 to determine the e-mail distribution list for all current postgraduate students. The proposed on-line structured questionnaire investigating the opinions of PG in Paediatric Dentistry for the treatment of a child with differing severities of caries in a primary molar tooth was outlined. All students (n = 64) were contacted by e-mail during the first week of June 2011 inviting study participation and a web-link was provided. A second reminder e-mail was sent two weeks later to all potential participants encouraging non-responders to access and complete the survey which closed in July 2011.
Questionnaire. This was designed using www.kwiksurveys. com with the initial part of the questionnaire seeking personal details as follows:
* Gender and age range;
* Location of PG (Belgium, Greece, The Netherlands, Leeds, UK, London, UK, Sweden or Switzerland)
* Year of PG program;
* Full- or part-time PG program.
The second part of the survey described four different case scenarios of a five-year-old patient who was medically well and presented with a mesio-occlusal cavity in tooth 85 with varying symptoms and signs. The same scenarios were presented for both non-anxious (Case Scenarios 1-4) and dentally-anxious patients (Case Scenarios 5-8) (Table 1). No information was provided in relation to previous dental experience. Treatment options were listed and participants asked to select their single most preferred treatment option for each case (Table 2). To avoid ambiguity, the following definitions were listed within the questionnaire prior to case scenario presentation.
* Atraumatic Restorative Treatment (ART) involves the removal of soft, demineralised tooth tissue using predominately hand instruments followed by restoration of the tooth with a plastic restoration, not usually requiring the use of local analgesia (LA).
* Traditional Restorative Treatment involves the complete removal of soft, demineralised tooth tissue using predominately rotary instruments, followed by restoration of the tooth with either a plastic- or amalgam restoration, requiring use of LA.
* Conventional PMC involves the use of metal crowns cemented following LA, complete caries removal and tooth preparation and may be used for restoration of a non-pulpally involved tooth or following either pulpotomy or pulpectomy.
* The Hall Technique is a simplified method of managing carious primary molars using PMC cemented without LA, caries removal or tooth preparation.
Overall, 40 responses were received whilst eight e-mail addresses were returned as "non-deliverable". In total, 32 PGs fully completed the survey questionnaire (F: 27; M: 5) and of these, 11/32 were Year One, 15/22 were Year Two, 4/22 were Year Three and 2/22 were Year Four students. Their geographical location comprised the following: Belgium: 4; Greece: 3; Leeds: 11; London: 3; The Netherlands: 8; Sweden: 2; Switzerland: 1. In relation to age ranges, 16/32 were less than 29 years, 15/32 were aged between 30 and 39 years and 1 was greater than 60 years of age.
Regarding programmes, 25/32 and 7/32 were full-time and part-time respectively. A further eight PGs commenced the survey, although failed to complete all the case scenario responses and as such, the data for these students is not presented.
Analysis of Cases One and Five. In a child whose tooth 85 demonstrated loss of less than half the marginal ridge with neither clinical signs nor symptoms, a range of responses were noted for non-anxious patients with 6/32 favouring traditional restorative treatment, 8/32 choosing a vital pulpotomy technique (MTA or ferric sulphate) and 5/32 other forms of treatment. For a dentally-anxious patient, 6/32 postgraduates chose the Hall technique, 6/32 other forms of treatment, 5/32 traditional restorative treatment and 5/32 selected an indirect pulp cap and plastic restoration (Figures 1 and 2).
Analysis of Case Two and Six. In a scenario for tooth 85 resulting in loss of more than half the marginal ridge and with neither clinical symptoms nor signs, for a non-anxious patient, postgraduates selected vital pulpotomy (MTA or ferric sulphate), indirect pulp capping/conventional and plastic restoration, and other techniques in 12/32, 6/32 and 4/32 of cases respectively. For the same scenario for a dentallyanxious child, the Hall technique, indirect pulp capping and ferric sulphate pulpotomy were preferred by 10/32, 5/32 and 5/32 postgraduates respectively (Figures 1 and 2).
Analysis of Cases Three and Seven. In the treatment choices selected for a mesio-occlusal cavity tooth 85 resulting in loss of more than half the marginal ridge, although with no clinical symptoms but an associated sinus for a non-anxious child patient, pulpectomy (calcium hydroxide and zinc oxide) was selected by 8/32 respondents whilst extraction with LA by 4/32 and other treatments by 6/32 postgraduates. In comparison, choices selected for a dentally-anxious patient were extraction with sedation/LA and other treatments, both selected by 6/32 respondents (Figures 1 and 2).
Analysis of Cases Four and Eight. PG preferences for a patient with a mesio-occlusal cavity in tooth 85 resulting in loss of more than half the marginal ridge and with a history of pulpal pain and with signs of pulpal involvement with an associated sinus the preferred option was extraction. The preferred mode of extraction in the non-anxious child was LA which was selected in 8/32 of cases, followed by inhalation sedation/ LA chosen in a further 6/32 of cases. For a dentally-anxious patient, GA extraction and sedation/LA extraction were the preferred modes of treatment of 6/32 students in both cases. A further 6/32 postgraduates selected other forms of treatment (Figures 1 and 2).
This questionnaire study was designed to survey and assess the treatment options that postgraduates in paediatric dentistry within Europe might offer a young child presenting with differing severities of primary molar caries. All PGs in the discipline were contacted via e-mail to invite study participation to maximise replies and to minimise study costs. As the questionnaire was anonymous, all potential responders were also contacted by email two weeks later and the survey was closed eight weeks after the initial e-mail. Nearly two-thirds of potential respondents accessed the survey, although a small proportion of these did not fully complete the survey. Overall, a greater proportion of students within the initial year of their studies responded which perhaps reflects the number of students in the various years. The study author was not aware of the distribution of students within each year during the questionnaire survey. In addition, there were a greater number of responses from certain countries which was accounted for by certain institutions having a large volume of students compared to those within other countries. Nonetheless, the response was greater than previous e-mail and on-line questionnaire surveys [Creasy et al., 2009; Lee et al., 2009].
The study author acknowledges that the opinions of those who chose not to respond may have altered the study findings. In addition, the case scenarios presented were hypothetical and actual care provided could be influenced by other factors such as previous dental experience, parental attitude and availability of resources locally. Also, it should be noted that whilst this group of dentists in their every day clinical practice would undoubtedly plan for a patient according to relief of dental pain, a preventative regime and planned care, in this survey each PG was allowed to select only their single most favoured treatment option. The range of responses, however, given by PGs indicated that there is a potential for wide variation in treatment provision between individual clinicians. It would have been expected that whilst in a PG education programme that there would be more conformity of opinion.
The findings from the first two case scenarios would suggest that for a non-anxious patient, that traditional restorative treatment or a pulpal therapy with subsequent plastic restoration or conventional PMC would be provided. When the same scenarios were presented, however, for a child with anxiety in receipt of dental treatment, whilst traditional restorative treatment was selected, a greater proportion of postgraduates selected a Hall Technique PMC [Innes et al., 2007a] and particularly so when more than half the marginal ridge of the tooth had been lost. The same finding was noted in a previous survey of UK postgraduate students in Paediatric Dentistry [Foley, 2010].
The Hall technique is relatively new and was first described in the dental literature in 2006. It involves the placement of a pre-formed metal crown over a primary molar tooth which has demonstrated caries clinically into dentine, although from which no caries has been excavated. An initial retrospective analysis confirmed a similar success rate for the restoration when compared to other conventional restorative techniques [Innes et al., 2006]. A subsequent randomised controlled clinical trial conducted over two years demonstrated favourable outcomes for both restoration longevity and pulpal health. Also, the technique was preferred to conventional restorative techniques by the majority of child patients, their carers and the study dentists [Innes et al., 2007b]. In addition, a recent survey of dental practitioners in Scotland has confirmed that a significant proportion were providing Hall crowns for their patients and for those who were not currently doing so, nearly half of those expressed an interest in training in the technique [Dean et al., 2011].
It is interesting to note that survey respondents chose a Hall crown given the relatively minimal evidence-base currently available to support the use of the method.
Concerning the case scenarios where pulpal involvement of a carious primary molar tooth were described, whilst there were a range of preferred options selected, those favoured for a non-anxious patient were pulpectomy and extraction techniques. Within Paediatric Dentistry, pulpal therapy for the primary dentition continues to be an area of debate and research. Traditionally, it has been acknowledged that there are difficulties with the pulpectomy technique in the primary dentition given the radicular morphology, physiological root resorption and proximity of the permanent successor tooth [Rodd et al., 2006]. For a dentally-anxious patient, the preferred option appeared to be extraction. Where it was assumed that a patient was co-operative then the mode of treatment was LA with/without some form of sedation. For a dentally-anxious child patient, the mode of treatment for extraction was again either sedation or general anaesthetic. The European Academy of Paediatric Dentistry advocates the use of sedative techniques for the management of cooperative, although anxious child patients [Hallonsten et al., 2003]. Otherwise, within this group of scenarios, the use of formocresol for a pulpotomy procedure was chosen by a small minority of participants. This is perhaps surprising given the known genotoxic and carcinogenic nature of the material which has been shown to be therapeutically outdated within the past decade [IARC, 2004; Lewis, 2009].
In relation to all scenarios, where other options were chosen, ICON[R] was mentioned. This is an innovative technique which uses low viscosity resin which is applied to carious lesions which extend in to enamel or the outer third of dentine and subsequently light-cured. The procedure has been tested in vitro and in a small randomised clinical trial with the studies demonstrating favourable results in relation to enamel penetration, masking white spot lesions and for the cessation of caries progression [Paris et al., 2010; Rocha Gomes Torres et al., 2010; Meyer-Lueckel et al., 2011]. It is interesting to note, however, that the method was mentioned by a number of study respondents in relation to treatment of a primary tooth which demonstrated pulpal symptoms; to date, the use of a resin infiltrant has not been described in the literature for such scenarios.
This study has indicated that there may be wide variation amongst dentists across Europe training to be specialists in Paediatric Dentistry in relation to the management of carious primary molar teeth. It is acknowledged that the gold-standard treatment for such teeth involves complete caries removal and conventional restoration. It would be anticipated that amongst this group of dentists who will be both the future specialists in this discipline but also, the future educators to subsequent generations of dentists training to be Paediatric Dentists that they would strive to provide accepted best practice and as such, further work in the area of attitudes toward clinical approaches is indicated.
There was found to be wide variation in postgraduate responses to a variety of options to provide dental care for children. For those who were non-anxious, more conventional forms of dental treatment were chosen. The Hall technique appeared to be a favoured option by half of respondents for treatment of an asymptomatic carious primary molar tooth in a dentally-anxious child patient. Dental extraction was an option for a tooth demonstrating pulpal symptoms in both non-anxious and dentally-anxious patients.
Permission was sought from the EAPD-accredited Programme Directors to acquire the e-mail distribution list of all such dentists in the discipline.
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The University of Aberdeen Dental School and Hospital, Aberdeen, Scotland
Postal address: Dr J.I. Foley. Dept Paediatric Dentistry, University of Aberdeen Dental School and Hospital, Foresterhill, Aberdeen, AB25 2ZR
Table 1. Summary of the clinical case scenarios for assessment by postgraduate students. Scenario Description of Case Scenario One (NA) A 5-year-old female patient presents Five (DA) with a mesio-occlusal cavity in tooth 85 resulting in loss of less than half the marginal ridge. There are no symptoms of previous-or current dental pain. There are no other clinical signs. Two (NA) A 5-year-old female patient presents Six (DA) with a mesio-occlusal cavity in tooth 85 resulting in loss of more than half the marginal ridge. There are no symptoms of previous-or current dental pain and no other clinical signs. Three (NA) A 5-year-old female patient presents Seven (DA) with a mesio-occlusal cavity in tooth 85 resulting in loss of more than half the marginal ridge. There are no symptoms of previous- or current dental pain and there is an associated sinus. Four (NA) A 5-year-old female patient presents Eight (DA) with a mesio-occlusal cavity in tooth 85 resulting in loss of more than half the marginal ridge. There is a history of dental pain and there is an associated sinus and the tooth is tender to percussion. Key: NA: non-anxious; DA: dentally-anxious Table 2. Choice of Responses for the Case Scenarios. Choice of Responses * Home-based preventative regime * Fluoride application at recall appointments * Atraumatic restorative treatment technique * Traditional restorative treatment * Conventional PMC * Hall technique PMC * Direct pulp capping and restoration with either a plastic/ amalgam restoration * Direct pulp capping and restoration with a conventional PMC * Indirect pulp capping and restoration with either a plastic/ amalgam restoration * Indirect pulp capping and restoration with a conventional PMC * Vital pulpotomy/FS and restoration with either a plastic/ amalgam restoration * Vital pulpotomy/CaOH and restoration with either a plastic/ amalgam restoration * Vital pulpotomy/MTA and restoration with either a plastic/ amalgam restoration * Vital pulpotomy/FC and restoration with either a plastic/ amalgam restoration * Vital pulpotomy/FS and conventional PMC * Vital pulpotomy/CaOH and conventional PMC * Vital pulpotomy/MTA and conventional PMC * Vital pulpotomy/FC and conventional PMC * Pulpectomy/CaOH and restoration with either a plastic/ amalgam restoration * Pulpectomy/CaOH and conventional PMC * Pulpectomy/ZOE and restoration with either a plastic/ amalgam restoration * Pulpectomy/ZOE and conventional PMC * Extraction with LA * Extraction with inhalation sedation * Extraction with another form of sedation * Extraction with general anaesthetic * Prescribe antibiotics only * Prescribe analgesics only * Prescribe both antibiotics and analgesics * Other/Comment box Key: PMC: pre-formed metal crown; FS: ferric sulphate; CaOH: calcium hydroxide; MTA: mineral trioxide aggregate; FC: formcresol; ZOE: zinc oxide eugenol; LA: local analagesia. Table 3. Postgraduate Comments for all Case Scenarios for 'Other' Responses. Scenario Responses One (NA) ICON[R] sealant Five (DA) Habituation sessions until ICON[R] sealant Restoration with oral sedation Two (NA) ICON[R] sealant Six (DA) Habituation sessions until ICON[R] sealant Partial caries excavation with hand instruments and PMC Three (NA) ICON[R] sealant Pulpectomy with Vitapex[R] Seven (DA) Habituation sessions until ICON[R] sealant Dress with zinc oxide eugeonol [+ or -] Ledermix and keep under observation until co-operative for extraction with LA Four (NA) ICON[R] sealant Pulpectomy with Vitapex[R] (not CaOH) Eight (DA) Habituation sessions until ICON[R] sealant Dress with zinc oxide eugenol and ledermix; otherwise antibiotics and analgesics and organise for extraction with sedation or general anaesthetic Pulpectomy with Vitapex[R] and conventional PMC Key: NA: non-anxious; DA: dentally-anxious; CaOH: calcium hydroxide Figure 1. Postgraduate Responses for Case Scenarios One to Four. Scenario Scenario Scenario Scenario One Two Three Four Fluoride al Recall 3 2 2 2 ART 2 Traditional Restorative Treatment 6 3 Conventional PMC 3 3 2 Hall Technique PMC 2 Direct Pulp Cap and Plastic Restoration 2 Indirect Pulp Cap and Plastic Restoration 3 6 2 Indirect Pulp Cap and Conventional PMC 2 Vital Pulpolomy MTA and Plastic Restoration 2 3 Vital Pulpolomy Ferric Sulphate Pulpotomy and.. 4 6 Vital Pulpolomy MTA and Conventional PMC 2 3 2 Vital Pulpotomy Formocresol and Conventional PMC 2 Calcium Hydroxide Pulpectomy and Plastic Restoration 2 Calcium Hydroxide Pulpectomy and Conventional PMC 4 Zinc Oxide Pulpectomy and Conventional PMC 4 4 Extraction with LA 4 8 Extraction with Inhalation sedation and LA 2 5 Extraction with Other Sedation and LA 2 3 Extraction with General Anaesthetic Prescribe Antiotics Other 5 4 6 6 Note: Table made from bar graph. Figure 2. Postgraduate Responses for Case Scenarios Five to Eight. Scenario Scenario Scenario Scenario Five Six Seven Eight Fluoride al Recall 3 2 2 2 ART 3 2 4 Traditional Restorative Treatment 5 2 Conventional PMC 2 Hall Technique PMC 6 10 2 Direct Pulp Cap and Plastic Restoration Indirect Pulp Cap and Plastic Restoration 5 5 Indirect Pulp Cap and Conventional PMC Vital Pulpolomy MTA and Plastic Restoration Vital Pulpolomy Ferric Sulphate Pulpotomy and and Conventional PMC 4 5 4 Vital Pulpolomy MTA and Conventional PMC Vital Pulpotomy Formocresol and Conventional PMC Calcium Hydroxide Pulpectomy and Plastic Restoration Calcium Hydroxide Pulpectomy and Conventional PMC 2 2 Zinc Oxide Pulpectomy and Conventional PMC 2 2 Extraction with LA 2 Extraction with Inhalation sedation and LA 6 6 Extraction with Other Sedation and LA 4 Extraction with General Anaesthetic 6 Prescribe Antiotics 4 2 Other 6 4 6 6 Note: Table made from bar graph.
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