Supervised neglect--again!
Subject: Dentists (Practice)
Tooth diseases (Diagnosis)
Tooth diseases (Care and treatment)
Children (Diseases)
Children (Diagnosis)
Children (Care and treatment)
Author: Curzon, Martin
Pub Date: 04/01/2010
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: April, 2010 Source Volume: 11 Source Issue: 2
Topic: Event Code: 200 Management dynamics
Product: Product Code: 8021000 Dentists NAICS Code: 62121 Offices of Dentists
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 277106728
Full Text: Caring for the oral health of children is paramount for us as paediatric dentists. As such we are constantly concerned to make sure children are free of oral disease, and to provide best care with empathy and humanity. It is, therefore, terribly depressing to frequently hear of more publications or official directives saying that it is not necessary to restore primary teeth. Within the past few months such reports have appeared in publications from several European countries. There seems to be a resurgence of official opinion against the quality care of children and dumbing-down dentistry for children to low levels of care, perhaps because of the financial problems of our times.

The basis for these directives is that there is no evidence for routine restoration of primary teeth as that such decayed teeth are shed before causing any symptoms in 'the majority of cases'. Of course it is never spelt out what is meant by the majority of cases--is it 51%, 65% or 90%? This statistical approach belies the problem for the individual child. Each child should always be of prime concern, as an individual, not just a statistic, and all dentists should provide the highest possible care for each and every child. Not providing good quality care for children at risk leads to acute infections, often necessitating hospital admissions at much greater cost, as described by Tran et al. in this issue of the EAPD.

In 1997 I, together with the late Maxine Pollard, published an article 'Do we still care about kids? In which we pointed out that in no other branch of medicine was disease left untreated once diagnosed. This is still true and yet after another 12 years we have to address the issue yet again.

The main proponents of the 'let them fall out--or supervised neglect philosophy seems to be the statisticians who aid and abet the accountants in government offices and public health. Using crude statistics derived from epidemiological studies they indicate that many decayed primary teeth remain symptomless before exfoliation. When the supporting studies are examined critically they are always found to be deficient. In such studies there are always dmft/s data showing prevalence of dental caries and some indicator of whether there was ever an episode of toothache. However, when the recorded symptoms are looked at in detail it is only whether a child had an episode of pain. Many of these studies are based on data derived from the retrospective records of general dental practitioners, which may or not be reliable. If such studies are to be done properly then they must be prospective and the investigators would need to record: days of pain and discomfort, poor eating, measurements of any failure to thrive, sleepless nights, days off school, days off work for parents because of their child's dental problems, loss of earnings and costs of extractions. In addition there are never any assessments of early loss of primary teeth leading to permanent molar drifting making orthodontic treatment more complicated (and accruing later costs). None of these parameters are fully taken into account nor has there ever been a controlled prospective study comparing dental care provided by paediatric dental specialists care versus non-specialists.

It seems that the authors of these studies or reports, claiming that restorations are not necessary, almost seem to set out to prove their pre-determined hypothesis. Do they hate children? Are they afraid of children? Or do political masters dictate that they work entirely in terms of cutting dental costs? The old adage applies here, where administrators know the cost of everything but the value of nothing. The cost of properly caring for primary dentitions maybe high but the long-term value is great.

One claim often made is that restored primary teeth are just as likely to need extraction as unrestored teeth. But there is never any assessment or investigation of the quality of the restorations placed. The authors of these studies never seem to take account of those prospective studies, carefully carried out, indicating long-term success rates of about 90% for restoring primary teeth carefully and well done [Roberts et al., 2005]. If an assessment is adequately made as to how restorations have been placed, quality of cavity design and materials used, restorations that are not rushed and with well-chosen materials, then it would be found that such restorations are highly successful. These studies also show that when well done, restorations of primary teeth are one-off and do indeed last until exfoliation.

What is more, in placing quality restorations, dental caries is removed; we know that caries is an intra-oral infectious disease. Once all decay is properly eliminated from a child's mouth then the chance of recurrence is drastically reduced. This child focused approach leads to quality dental care for children preventing pain and disease [Schorer-Jensma and Veerkamp, 2010]

It may be indicative of the problem that the reference is always to 'deciduous fillings'. Deciduous derives from botany and refers to those trees whose leaves fall during the winter. This term of deciduous fillings must mean therefore fillings that fall out. Good dentists do not do such restorations but practice quality care for children and of course do not place restorations that fall out.

One other aspect of the claim that primary tooth restorations are not indicated, is that over-treatment of young children can lead to dental phobia in their future oral care. I have tried unsuccessfully to identify any such publications reporting well-conducted studies. Much evidence is anecdotal. Indeed there have been other papers recording that one particular aspect of dental treatment that does lead to phobia, and becomes etched into a child's memory, is extractions often under day-case general anaesthesia.

Good behaviour management, which may well be the key to this argument, leads to children who readily accept dental treatment leading to healthy mouths and a life-long appreciation of oral care. That should be the aim of all dentists, not only paediatric dental specialists. But it does require a philosophy of empathy and a consuming passion and willingness to provide quality care for all children.

Curzon MEJ, Pollard MA. Do we still care about kids? A personal opinion. Brit Dent J 1997;182: 242-244.

Roberts J F, Attari N, Sherriff M. The survival of resin modified glass ionomer and stainless steel crown restorations in primary molars, placed in a specialist paediatric dental practice. Br Dent J 2005; 198(7): 427-431.

Schorer-Jensma MA, Veerkamp JS. A comparison of paediatric dentists' and general dental practitioners' care patterns in paediatric dental care Eur Archs Paediatr Dent 2010; 11: 93-96

Tran C, Gussy M, Kilpatrick N. pathways to emerging dental care: An exploratory study. Eur Arch Paediatr Dent 2010; 11: 97-100
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