An evidence based approach to managing children with a carious primary dentition Nicola Innes Clinical Senior Lecturer in Paediatric Dentistry University of Dundee, Scotland Nyborg, Denmark, September 2014 What might be the barriers to providing high quality care using the surgical approach? Children find the surgical approach challenging Evidence that children don t like rotary instruments and injections comparing discomfort with bur and hand excavation (non-bur) bur-group 2x more pain than non-bur group behaviour and heart rate patients in non-bur group more relaxed (significant during deep preparation) comparing rotary instruments and hand excavation of caries hand excavationwithout LA gives the least discomfort the bur with LA the most discomfort during second treatment this effect is increased Rahimtoola S, et al., (2000) Pain related to different ways of minimal intervention in the treatment of small caries lesions. J Dent Child Mar-Apr;67(2):123-7, 83. Schriks MC, et al.,(2003) Atraumatic perspectives of ART: psychological and physiological aspects of treatment with and without rotary instruments. Community Dent OralEpidemiol ;31(1):15-20. van Bochove JA, Amerongen WE. (2006) The influence of restorative treatment approaches and the use of local analgesia on children's discomfort. EurArch PaediatrDent Mar;7(1):11-6. Administration of 190 local anaesthetic injections maxillary and mandibular; n=95 children; 5 12 yrs What might be the barriers to providing high quality care using the surgical approach? Children find the surgical approach challenging What we re doing in Dundee A Child Friendly approach Our study showed that the vast majority of children rated the injection experience as positive, although there were objective signs of pain like crying. This may be explained by the fact that in a good dentist-child rapport the child may want to satisfy the caregiver. Ram D et al. (2007) Reaction of children to dental injection with 27- or 30- gauge needles Int J Paed Dent 17(5); 383-387 And the approach can be difficult to deliver Motivational Interviewing and its use for teeth brushing instruction Can I borrow your car? Get them onside Gain empathy Develop your Develop discrepancy, arguments, counter any roll with resistance objections Your response to a defensive mother The mother s response is defensive: You see, Jack? This is what happens if you don t brush your teeth! I blame his Granny, always giving him sweets; it really annoys me What is the best way to respond to this?key MI concepts to look for Reflective listening? Affirmation or judgemental? Open or closed questions? Directive, or seeking permission/guiding? You feel frustrated that Jack s father gives him sweets? Can we talk about that? Reflective listening, Seeking permission Do you think that Jack is able to brush his own teeth, as he s only 5 years old? Closed question, and Judgemental Dr Dafydd Evans & Dr Nicola Innes University of Dundee When they relent, close with a thanks and claim your prize Elicit change talk, then act on it It must be so difficult; children can be tricky at this age, can t they? How do you feel about his teeth? Affirmation, open question I appreciate it must be difficult for you. Have you tried talking with his father about the sweets? Affirmation, but essentially a neutral response 1
Do you have to remove dental caries? When, why and how much? Why complete caries removal is not necessary What do we mean by caries? The overall clinical evidence for; 1 Complete caries removal and restore 2 Stepwise caries removal and restore 3 Partial caries removal and restore 4 No caries removal and fissure seal 5 No caries removal and restore 6 (Non-restorative caries treatment) Conclusions The goal we all share An adult with good oral health, which they have the knowledge, skills and attitude to maintain for themselves, having had only positive experiences of oral health care through childhood and adolescence Caries detectives - evidence what happens to teeth when all caries is not removed compared to those where all caries is removed? Comprehensive systematic review of ALL high quality evidence Cochrane review any language, any country, any publication 5 studies on primary teeth 4 studies on permanent teeth Also 2 other newer studies on primary teeth Cochrane review A systematic review American Dental Association recommendations Do you have to remove dental caries? When, why and how much? How NOT to do it 1 Complete caries removal and restore 2 Stepwise caries removal and restore 3 Partial caries removal and restore 4 No caries removal and fissure seal 5 No caries removal and restore 6 (Non-restorative caries treatment) 2
Further weakeni ng of tooth Reduces remaining dentine thickness risk of pulp exposure Operative intervention Restoration fails & is made larger Placement of restoration 10/10/2014 Complete caries removal? Restorative cycle is entered Need for local anaesthetic Reduces remaining dentine thickness Pulp exposure Fusayama showed decades ago that demineralised dentine has the ability to remineralise Remineralisation of demineralised dentine occurs through: odontoblast process, providing calcium & phosphate from vital pulp diffusion of ions (fluoride, calcium and phosphate) from materials placed on the floor of a restored cavity contact of saliva with the carious lesion, providing calcium and phosphate, notably in root dentine in conjunction with oral hygiene measures Fusayama T. A Simple Pain-Free Adhesive Restorative System by Minimal Reduction and Total Etching. Tokyo: Ishiyaku EuroAmerica Inc Tokyo; 1993. p. 1 21. Ngo HC, et al. Chemical exchange between glass-ionomer restorations and residual carious dentine in permanent molars: an in vivo study. J Dent 2006 34: 608 613. Peters MC, et al. In vivo dentin remineralization by calcium-phosphate cement. J Dent Res 2010 89: 286 291. 25 van Loveren C The role of diet in caries prevention. Int Dent J 2001 51: 399 406. Microbiology 10 teeth with caries duplicate standardized samples of infected dentine at baseline, before sealing and 5 months later - after the removal of the restorations Paddick et al (2005) Phenotypic and genotypic selection of microbiota surviving under dental restorations.. Appl Environ Microbiol 71(5):2467-72 initially soft and wet but on re-entry harder and dryer (no change in colour) acid etching significantly reduced the number of microorganisms recovered dentinal microbiota under the restorations were subject to significant environmental change reduction in the microbial load in the infected dentine microbial diversity 3
Cochrane Systematic Review Schwendicke F. J Dent 41 (2013) 5 569-80 Ricketts D.N.J. Lamont T, Innes N, Kidd E.A.M. Clarkson J. (2013). Operative caries management in adults and children. http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd003808.pub3/otherversions. 8 trials, 934 participants, 1372 teeth 3 comparisons: 1. stepwise caries removal vs complete caries removal (4 trials) 2. partial caries removal vs complete caries removal (3 trials) 3. no dentinal caries removal vscomplete caries removal (2 trials) *1 three-arm trial compared complete caries removal to both stepwise and partial caries removal **4 studies primary teeth, 3 permanent and 1 both Authors conclusions Stepwise and partial excavation reduced the incidence of pulp exposure in symptomless, vital, carious primary and permanent teeth. These techniques show clinical advantage over complete caries removal for managing dentinal caries. No difference in signs or symptoms of pulpal disease between stepwise excavation, and complete caries removal. Insufficient evidence to tell if there was a difference in signs and symptoms of pulp disease between partial caries removal and complete caries removal. Do you have to remove dental caries? When, why and how much? 1 Complete caries removal and restore 2 Stepwise caries removal and restore 3 Partial caries removal and restore 4 No caries removal and fissure seal 5 No caries removal and restore 6 (Non-restorative caries treatment) Stepwise vs complete caries removal? 2 studies in permanent teeth 2 studies in primary teeth Stepwise vs complete caries removal? 4 studies Pulp exposure (mean incidence) 15.4% in stepwise caries removal groups 34.7% in complete caries removal groups 56% less exposures in stepwise group* Magnusson, B.O. and Sundell S.O. J Int Assoc Dent Child, 1977. 8(2): p. 36-40. Orhan, A.I. et al. Pediatr Dent, 2010. 32(4): p. 347-55. Leksell E. et al. End & Dental Traumatology, 1996. 12(4):192-6. Bjorndal, L. et al. Eur J Oral Sciences, 2010. 118(3):p290-7. *RR 0.44; 95% CI 0.33 to 0.60, p<0.00001 4
Stepwise vs complete caries removal Stepwise vs complete caries removal? Pulp exposures with Stepwise caries removal Pulp exposures with Complete caries removal 4 studies Pulpal S&S at one year no difference Magnusson, B.O. and Sundell S.O. J Int Assoc Dent Child, 1977. 8(2): p. 36-40. Orhan, A.I. et al. Pediatr Dent, 2010. 32(4): p. 347-55. Leksell E. et al. End & Dental Traumatology, 1996. 12(4):192-6. Bjorndal, L. et al. Eur J Oral Sciences, 2010. 118(3):p290-7. Stepwise caries excavation 5
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Do you have to remove dental caries? When, why and how much? 1 Complete caries removal and restore 2 Stepwise caries removal and restore 3 Partial caries removal and restore 4 No caries removal and fissure seal 5 No caries removal and restore 6 (Non-restorative caries treatment) Partial caries removal vs Complete caries removal 4 studies 3 primary teeth 1 primary and permanent Partial vs complete caries removal Pulp exposure (mean incidence - 2 studies) 5% in the partial caries removal groups 21.9% in complete caries removal groups Partial vs complete caries removal Pulp exposures with Partial caries removal Pulp exposures with Complete caries removal Ribeiro, C.C., et al. Quintessence Int, 1999. 30(9): p. 591-9. Lula, E.C., et al. Caries Res, 2009. 43(5): p. 354-8. Orhan, A.I., F.T. Oz, and K. Orhan. Pediatr Dent, 2010. 32(4): p. 347-55. Phonghanyudh, A., et al., Comm Dent Health, 2012. 29(2): p. 173-8. 77% reduction in partial groups RR 0.23; 95% CI 0.08 to 0.69, p<0.009 Partial vs complete caries removal Partial caries removal; seal with a restoration Pulpal S&S no difference Restoration failure -?no difference but evidence not of good quality 7
Partial caries removal and restore Partial caries removal and restore Do you have to remove dental caries? When, why and how much? 1 Complete caries removal and restore 2 Stepwise caries removal and restore 3 Partial caries removal and restore 4 No caries removal and fissure seal 5 No caries removal and restore 6 (Non-restorative caries treatment) Fissure sealant vs Complete caries removal No caries removal, seal with a sealant No caries removal, seal with a sealant 1 study in primary teeth 2 years later Borges, B.C., et al. Int J Paediatr Dent, 2012. 22(1): p44-51. 8
fissure sealants don t fail we, or the parents/ carers fail Fissure seal vs complete caries removal Fissure seal vs complete caries removal Lesion progression - Fissure seal Lesion progression - Complete caries removal Lesion progression (radiographically) 11.5% in F/S 0% complete caries removal Sealant loss 11.5% partial loss in F/S 0% in complete caries removal Sealant loss - Fissure seal Lesion progression - Complete caries removal Do you have to remove dental caries? When, why and how much? 1 Complete caries removal and restore 2 Stepwise caries removal and restore 3 Partial caries removal and restore 4 No caries removal and fissure seal 5 No caries removal and restore 6 (Non-restorative caries treatment) 9
No caries removal and restore 2 studies 1 in primary teeth Hall Technique 1 in permanent teeth (children and adults) Amalgams and Sealed amalgams No dentinal caries removal vs complete Pulp exposures - None in either study Pulpal S&S Hall Technique No caries removal teeth better off Restoration in permanent teeth No failures in either group Restoration longevity Hall Technique No caries removal teeth better off Restoration in permanent teeth no difference Innes, N.P.T., D.J.P. Evans, and D.R. Stirrups, J Dent Res, 2011. 90(12): p. 1405-1410. Mertz-Fairhurst EJ et al. J American Dent Assoc. 1987; 115(5):689-94. 84 85 86 87 88 89 90 10
2 year follow up 11
Lois McLellan Non-restorative caries removal Non operative caries treatment Jason (age 5 years) Jason (age 5 years) Treatment plan Encouragement regarding attendance Intensive brushing support Duraphat varnish Diet advice Tooth Mousse Jason (5 months later) Jason (9 months later) Jason (one year later) Jason (11/2 years later) 12
Jason (2 years later) 2 years apart 2 1/2 years later 5 years later 113 114 Do you have to remove dental caries? When, why and how much? 1 Complete caries removal and restore 2 Partial caries removal and restore 3 Stepwise caries removal and restore 4 No caries removal and fissure seal 5 No caries removal and restore 6 (Non-restorative caries treatment) Conclusion 1. Stepwise and partial caries removal in symptomless, vital carious primary or permanent teeth significantly reduced the risk of pulp exposure Restoration failure and pulp S&S no worse Therefore, clinical advantageous How much to remove? Unknown but enough to get a seal and restore Conclusion 2. Stepwise or partial? Don t need to re-enter in primary teeth For permanent teeth, there is growing evidence to support partial over stepwise but this is less strong, so stepwise should be carried out 13
Conclusion 3. Fissure sealing over dentinal caries In symptomless, non/micro-cavitated primary teeth there was no increase in pulp S&S Still not a lot of evidence to be sure what results we can expect and not long-term evidence Restoration failure Possibility of material failing must be built into clinical decision Conclusion 4. No dentinal caries removal and restore Similar to partial caries removal Only 1 study in primary teeth Only 1 study in permanent teeth For permanent teeth not recommended as stronger evidence that other approaches can be successful For primary teeth the Hall Technique is recommended to seal caries in, in the right conditions. Overall Used to only have one word for caries there was only one thing we could do with it remove it Now, however Different options and need to learn when best to use each of them for our patients benefit Thank you! An adult with good oral health, which they have the knowledge, skills and attitude to maintain for themselves, having had only positive experiences of oral health care through childhood and adolescence 1. Magnusson (1977) 1. Consequently, judged by the clinical criteria used, [stepwise caries Stepwise vs Complete removal] with a calcium hydroxide inlay may obviate a considerable number of pulp treatments in primary molars. 2. Ribeiro (1999) 2. Application of an adhesive restorative system to irreversibly infected dentin Partial vs Complete did not affect the clinical performance of the restoration. 3. sealing-in caries by the Hall Technique statistically, and clinically, 3. Innes (2007 & 2011) significantly outperformed the GDPs standard restorations. These results Hall vs Complete strongly support the Hall Technique as a predictable restorative option, with low failure and, therefore, re-treatment, rates for managing carious primary molars in a Primary Care environment. 4. Lula (2009) Partial vs Complete 4. The results suggest that persistence of bacteria does not seem to be a reason for reopening of cavities in deciduous teeth after partial caries removal. 5. Orhan (2010) Partial vs Complete & 5. Indirect pulp therapy in both primary and young permanent teeth can be Stepwise vs Complete used successfully with a 1- or 2- visit approach. 6. Fissure sealing and tooth restoration were equally effective in the 6. Borges (2012) management of non-cavitated dentine occlusal caries in primary teeth. F/S vs Complete Invasive procedures can be replaced with the non-drilling approach with no adverse consequences for paediatric patients. 7. Phonghanyudh (2012) Partial vs Complete 7. The clinical and radiographic evaluations after 12 months indicated that partial soft caries removal at EDJ followed by GIC restoration was comparable to that of ART and conventional approaches. 8. Maltz (2013) 8. The retention of carious dentine does not interfere in pulp vitality. Data Partial vs Stepwise from theis 18-month study suggest that the procedure of reopening the cavity to remove the residual infected dentine is not necessary 14