Journal of the Royal Society of Medicine Supplement No. 7 Volume 78 1985 3 The management of dental caries in children J J Murray MDS FDSRCS Professor and Head of Department of Child Dental Health, Dental School, Framlington Place, University of Newcastle upon Tyne, NE2 4BW Introduction The dental scene changes, possibly more quickly than we realize. In this symposium we have been asked to define the problem areas in the diagnosis and treatment of dental caries, explore how the dental profession should adapt to change, and suggest how changes may be brought about. I would like to put forward four main points for consideration: (1) there has been a marked reduction in dental caries in children; (2) this reduction calls for a change in our clinical approach to managing the disease; (3) general, as well as clinical, attitudes need to change if prevention is to be truly successful; (4) the future dental needs of patients are often largely determined by the time they have reached 12-14 years of age. Reduction in dental caries A number of reports from 'westernized' countries have indicated a decreasing prevalence of dental caries during the last 10-15 years. The first conference on the subject, 'Evidence for declining caries prevalence' took place in Boston in June 1982 when information from ten countries - including the UK, Eire, Scandinavia, the Netherlands, New Zealand and the USA - was presented. All countries represented at the conference reported decreasing caries prevalence although the levels of the decrease varied (Glass 1982). In Britain, over the last 5 years or so, there have been many localized surveys pointing to a fall in caries in children. Perhaps the most conclusive evidence was provided by the initial report of the National Children's Dental Health Survey 1983 (OPCS Monitor 1983) which showed a reduction in caries of approximately 30'7 in decayed, missing and filled teeth (DMFT) values for children in England and Wales, compared with the previous survey 10 years earlier (Todd 1975) (Figure 1). Very detailed information on the changes over a 15-year period in dental caries in children from two schools in Somerset, including the effect of treatment on the DMF index, was reported by Anderson (1981). Dental caries prevalence had fallen by 3507o, the mouths were cleaner and there was less gingivitis and extrinsic stain. In both schools the amount of untreated decay had fallen dramatically and the need for extracting first permanent molars had been reduced almost to zero, but the number of fillings had increased slightly in one school and virtually doubled in the other school (Figure 2). In the first school, dental treatment was provided by the same practitioners as 15 years earlier, but there had been a marked change in the provision of general dental services in the catchment area of the second school, with the opening of new multipractitioner surgeries. Anderson (1981) pointed out that if carious lesions have been prevented, the dental profession must not spoil the situation by continuing to fill occlusal surface in teeth which may not become carious. He suggested that dentists' attitudes should change and that the maximum 'If in doubt, fill' should be changed to 'If in doubt, wait', especially for occlusal fissures of the permanent dentition of younger children. This question of a change in attitude lies at the heart of the clinician's dilemma concerning the diagnosis of caries, which was considered in detail in the Federation Dentaire Internationale (FDI) Technical Report of 1974 and was raised earlier by Jackson (1966). Jackson pointed out that when one investigator examined the same group of children twice, allowing one week between examinations, in only 6207o of cases was there agreement 89_ 3 2 9 ~~~~~~~~~~~~~1973 7 u-6 _ 05 24 wje 1983 5 T 7 8 9 10 11 12 13 14 15 Age in years Figure 1. Mean DMFT values in children age 5 to 15 years in England and Wales, 1973 to 1983 as found from National surveys for children's Dental Health
4 Journal of the Royal Society of Medicine Supplement No. 7 Volume 78 1985 4' 3 IF7OVOD...t.. F... SOUND *F;; 2 I 0 S.C SCHOO H SCHOOL S Figure 2. The average number of decayed, filled and sound first permanent molars of 12-year-old children from the two schools, examined in 1963 and 1978 (Anderson 1981).wn Figure 3. Results of intra-examiner reproducibility of caries diagnosis (Jackson 1966) concerning the diagnosis of caries (Figure 3). This variation in intra-examiner diagnosis has been confirmed by many workers and inter-examiner variability is even greater (Shaw & Murray 1975), a point confirmed recently by Horowitz (1983). Unless the inevitable variation in the diagnosis of the very earliest possible carious lesion is appreciated by all clinicians, the impact of the fall in caries may well be blunted by an increase in the number of 'preventive' (or unnecessary) restorations which will inflate the F (filled) component of the DMF index. In no way do I wish to denigrate the tremendous impact restorative dentistry has had in maintaining the dentition. The management of dental caries in children has changed dramatically for the better in this country. Up to the 1950s extraction of carious teeth was the principal method of treatment, but in the 1950s and 60s a welcome shift towards the restoration of such teeth occurred. However, if we wish to see the trend move onwards to real prevention, then changes in our approach to the management of dental caries will be required. Changes in our clinical approach There are at least three areas where a change in our clinical attitude towards the diagnosis and treatment of dental caries in children should be considered: (1) the place of fissure sealants as a primary preventive measure; (2) the management of radiolucent areas in approximal surfaces on bitewing radiographs; (3) the combination of composite restorations with fissure sealants for the treatment of small carious lesions in recently erupted permanent molars. One aspect of the problem is that at the moment over half the general dental practitioner's income is obtained from restorative dentistry. Income can be generated by filling teeth but not by preventive items such as fissure sealing and topical fluoride therapy, as far as general dental practitioners in the National Health Service (NHS) are concerned (Figure 4). Fissure sealants Gordon (1983) has recently reviewed the history of fissure sealants, summarized the res-ults of over 60 clinical trials and considered the cost effectiveness of fissure sealants. He concluded that if fissure sealants are used on first permanent molars, shortly after they erupt, the procedure soon becomes 'cost effective' even when allowing for the fact that in a proportion of cases the resin will have to be reapplied. In one study (Rantala 1979) fissure sealants
Fl LL FEE FROM DEB Journal of the Royal Society of Medicine Supplement No. 7 Volume 78 1985 5 OCCLUSAL SURFACES DMF INCREASED SEAL NO FEE NO INCREASE IN DMF Figure 4. Effect of restoration and fissure sealant on the occlusal surfaces of teeth were applied to first permanent molars as part of an overall programme for caries prevention. After about 2 years, sealing all the first molars had become cheaper simply in terms of money than filling those teeth that would have become carious. There were, of course, the additional benefits arising from the use of a procedure that was much more acceptable to the children involved. One of the recommendations of the Dental Strategy Review Group (DSRG 1981) was that fissure sealants should be allowed, as an item of service on the fee scale within the general dental practitioner service, for recently erupted permanent molar teeth. For my part I strongly supported this recommendation as I believed it would allow general dental practitioners to use their clinical judgment and apply fissure sealants in specific cases, so encouraging the trend onwards from restoration into primary prevention. The response from the British Dental Association to this proposal was rather cautious. They expressed their concern about the long-term value of fissure sealants. I agree that any item of service should be subjected to rigorous scrutiny, but fissure sealants have now been proved successful in a large number of clinical trials and there is certainly more data on retention rates of fissure sealants, over 5 or 7 years, than the durability of amalgam restorations placed in permanent molars of children. The only published study (Hunter 1982) of occlusal amalgam restorations placed in one dental practice in Scotland, showed that the median survival time of such restorations in children aged 8 years and under was 3 years, and only 32% survived for 5 years. A somewhat larger study carried out in the Department of Child Dental Health at Newcastle found that the median survival time of occlusal amalgam restorations placed in first permanent molars of 6-year-old children was 2 years 2 months, but this increased with age so that for 12-year-olds the median survival time had increased to 8 years 11 months (Walls et al. 1985). It is against this type of data that fissure sealants should be judged. Even if they only delay the onset of caries in some cases, this will increase the chance of a more durable restoration being placed in an older child. The second point made by the BDA was that to introduce preventive treatment items into the general dental service (GDS) would mean that such items would no longer be provided privately to patients who were otherwise being treated under the National Health Service (Editorial British Dental Journal 1984). This seems to be more contentious, because provided the fees for preventive items are set correctly, then the general dental practitioner should be able to earn a proportion of his target income from prevention rather than restoration. The fact that the BDA said there was a need to adjust NHS income targets so that dentists' earnings did not suffer overall does suggest that dental practitioners are sufficiently confident of the clinical usefulness of fissure sealants in the prevention of occlusal caries that they are prepared to charge privately for this service. Topical fluorides My concern about prevention also extends to approximal surfaces. Recently, I examined a teenager and took some bitewing radiographs (Figure 5) which were reported independently by the Department of Radiology in the Dental Hospital. They recorded caries on no fewer than five approximal sites and two occlusal surfaces. Now of course I can see the radiolucencies on the mesial surfaces of the first permanent molars. (One really has to have X-ray eyes to record a cavity on th'e distal of the upper left second premolar.) But in my view it would be totally unnecessary to provide four mesioocclusal (MO) amalgam restorations involving the removal of a considerable amount of sound tissue, for this young patient. Instead, oral hygiene, stressing the need to brush twice daily with a fluoride toothpaste, interdental flossing and the use of a fluoride mouth rinse, were prescribed. One most important finding from the toothpaste trial by Berman & Slack (1973) was that, of the approximal lesions noted on bitewings at baseline, 500(7o did not progress over a 3-year period. The clinical work for their study was completed in the 1960s when there was a much higher prevalence of approximal caries. I suspect that the progression of approximal lesions is slower today and justifies a 'preventive' approach. Topical fluorides do have a most important part to play in those patients with incipient approximal lesions in newly erupted teeth, in halting the spread of decalcified areas, and in many cases can prevent the need for two-surface restorations. Preventive resin restorations Let us move the argument one step further to an occlusal surface where indisputably the probe sticks and a very small cavity is diagnosed. According to Black's dictat (which still remains the basis for
6 Journal of the Royal Society of Medicine Supplement No. 7 Volume 78 1985 Figure 5. Bitewing radiograph on a 13-year-old girl where caries had been recorded radiographically remuneration on the GDS scale of fees) we should adopt the policy of 'extension for prevention'. I am all in favour of prevention, but not at the expense of removing a vast amount of sound tissue. Why not remove the caries, protect the exposed dentine with a calcium hydroxide preparation and use the acid etch technique to fill the small cavity with a filled composite resin and then fissure seal the rest of the occlusal surface (Figure 6)? In this way caries is removed, the principles of extension for prevention are adhered to, and sound tissue remains in place. Simonsen (1980) has adopted this policy with considerable success, reporting adequate retention in 970%o of cases involving first permanent molars, over a 3-year period. Would this be allowed on the scale of fees? Figure 6. Occlusal view of a lower arch of a patient showing composite restoration placed into defect of the lower left first permanent molar, with fissure sealant applied to the rest of the occlusal surface. Compare this with the occlusal amalgam restoration in the lower right permanent molar Dental attitudes, patient attitudes, remuneration and manpower From the previous section it is apparent that the trend towards prevention depends not only on the dentist's attitude, which is extremely important, but also on other more general factors which can be summarized under the headings Patient attitudes, Remuneration and Manpower. If the dentist is totally in favour of prevention, he needs an encouraging response from the patient (and in children's dentistry the patient's parents as well) to put prevention into practice. In the public mind, dentistry is associated, perhaps dominated, by the thought of 'drill and fill'. It will take time for the public to' become accustomed to the idea that dental caries is a truly preventable disease. Hand in hand with public attitudes are the attitudes of such bodies as Government, the Dental Rates Study Group and negotiating bodies like the BDA. It must be obvious that a dentist cannot practise prevention for nothing. If remuneration gets out of step with professional and public aspirations, then conflict or frustration will occur. One of the most telling comments in the conclusion of the first children's dental health survey was, 'Many of the policies which have attempted to tackle the problem of scarce resources have advocated limiting restorative dentistry to those who demonstrate favourable dental attitudes and behaviour. Any assessment of priorities on this basis accentuates the marked division in dental attitudes, thus perpetuating the limited expectations that some sections of the community have of dental health' (Todd 1975). Time moves on, and 10 years later, with falling caries rates, the resources required for restorative dentistry are not so scarce as they were, but if that statement were true 10
Journal of the Royal Society of Medicine Supplement No. 7 Volume 78 1985 7 years ago in a country which has two primary dental services, free at the point of need, providing restorative dentistry for children, is it not also true today in a more preventive era when only the community dental service can use preventive items at their clinical discretion, for their child patients? Yet the general dental service treats about 750o of the children in the country. General dental practitioners have to charge privately for preventive items and inevitably parents from the higher income bracket are more prepared to provide this care for their children. It would be a tragedy for the NHS at a time when dental manpower is now more plentiful than ever, and in certain parts of the country is probably getting into balance with the needs of the population, if we failed to add impetus to the fight to eliminate dental caries from all children in the country, not only those whose parents have the ability to pay for prevention. Dental care for children and its effects on dental needs of adults This symposium focuses on the diagnosis and treatment of dental caries, yet dental care for children encompasses so much more than the management of dental caries. The prevention of dental caries, by a combination of public health and individual preventive measures, gives us the opportunity to ensure that the whole dental environment for children is improved so that their future dental needs are reduced and simplified. It may be a gross simplification and generalization to say that by the age of 12-14 years the future dental needs of a patient are largely determined, but let me explain what I mean by the following examples from patients seen in my own department. The first, a 13-year-old boy, had his first permanent molars extracted some years ago (Figures 7, 8, 9). He was referred for orthodontic Figure 7. Anterior view of a 13-year-old boy showing upper canines crowding out of the arch Figure 8. Occlusal view of previous patient showing lack of space in upper canine. First permanent molars had been extracted and second permanent molars had moved forward closing the space Figure 9. View of the lower arch of this patient showing the poor alignment of second molar teeth treatment of misplaced maxillary canines. Our failure to manage the space created by extraction of first molars means that complex orthodontic treatment will be necessary and more teeth may have to be extracted in the upper arch in order to provide him with a reasonable occlusion. The next patient has fared so much better (Figures 10, 11). She has very good oral hygiene, well aligned incisor and canine teeth and an excellent upper arch. All second permanent molars have been fissure sealed, three first permanent molars have been restored, but for some reason the lower left first permanent molar was extracted shortly after eruption. The resulting occlusion in that quadrant is poor, the contact points non-existent and I suspect that she will have to concentrate more effort in that quadrant to ensure that periodontal disease is kept to a minimum in later life. The next patient (Figures 12, 13, 14) also has a beautiful smile and good oral hygiene. Her upper arch shows true prevention, with all four permanent molars fissure sealed. The lower arch has been
8 Journal of the Royal Society of Medicine Supplement No. 7 Volume 78 1985 Figure 10. Occlusal view of 14-year-old girl, showing small amalgam restorations and fissure sealant Figure 13. Occlusal view of upper arch of patient in Figure 12 showing fissure sealant in place Figure 11. Occlusal view of lower arch showing fissure sealants on the lower second permanent molars, occlusal amalgam restorations in lower right first permanent molar, but poor occlusion on left side Figure 12. This shows a 17-year-old patient Figure 14. Occlusal view of lower arch of patient showing occlusal and buccal amalgams preserved by amalgam restorations in the occlusal and buccal surfaces. Which arch will require further dental attention in future years? How often will those amalgams be replaced and extended in the next 50 years? Why were we able to prevent caries in the upper arch but only 'manage' caries in the lower arch? The bitewings (Figure 15) certainly suggest that some of the occlusal amalgams are minimal and might have been obviated by a more preventive approach. This preventive philosophy can be illustrated by the next case. If one sees a small brown line or the earliest signs of decalcification in first permanent molars in a 7-year-old child, it is very easy to feel that caries will inevitably occur in all first permanent molars, and that the patient is caries susceptible. However, if by fissure sealing and oral hygiene instruction. those same surfaces can be kept free from amalgams, the same child when 13 years of age, with all pre-molar and second molar teeth in occlusion, is labelled caries immune (Figures 16, 17). The bitewings show a caries-free dentition (Figure 18) and with reasonable oral hygiene it can be predicted that this patient will keep his teeth for
Journal of the Royal Society of Medicine Supplement No. 7 Volume 78 1985 9 Figure 15. Bitewing radiograph of 17-year-old patient (see Figures 12-14) Figure 16. Occlusal view of upper arch of a 13-year-old Figure 17. Occlusal view of lower arch, showing staining patient, showing staining in fissures of first permanent in the fissures of first permanent molars molar I Figure 18. Bitewing radiograph of patient (see Figures 16 and 17) life with the minimum of restorative treatment children in this country. Fifty percent of 5-yearbeing required. olds in England are caries-free and the mean DMF of 12-year-olds is 2.9 (OPCS 1983). This means that Conclusion we have already reached the two dental goals The dental profession has the responsibility of concerning children's dental health, set by the FDI, appreciating, and to a certain extent anticipating, to be achieved by the year 2000. The challenge is the changes occurring in the dental health of not to be downhearted about the 'dilemma' of
10 Journal of the Royal Society of Medicine Supplement No. 7 Volume 78 1985 caries, but be uplifted at the prospect of having within our grasp the possibility that this generation of children will have the lowest rate of tooth decay for over 100 years. Is this not a prize worth changing for? Of course we will still require our technical skills to restore some decayed and missing teeth. We will have to become adept at handling new dental materials that have evolved over the last 15 years, and we will undoubtedly see further improvements in the future. We will have the time to treat fractured and traumatized teeth, particularly anterior teeth and so improve aesthetics. We will be able to devote more time to the correction of deformity - either genetic or traumatic - but we should not have to work in a sea of unnecessary decay. Above all, we will be able to spend our time educating our patients to maintain their periodontal tissues, so that they can keep their teeth for life. Then, rather than having to react to the decayed and painful tooth, which in a child may require a general anaesthetic and an extraction, more and more we will be in an educational role, promoting the concept of prevention and preservation. I believe this will lead to a more rewarding and satisfying profession for our present dental students and will allow us to serve the whole community in a better way. References Anderson R J (1981) British Dental Journal 150, 218-221 Berman D S & Slack G L (1973) British Dental Journal 123, 51-57 DSRG (1981) Towards Better Dental health. The report of the Dental Strategy Report Group of the DHSS. HMSO, London Federation Dentaire International (1974) Principle requirements for controlled clinical trials of caries preventive agents and procedures. Technical Report No. 1. Ed. H S Horowitz, L J Baume, 0 Backer-Dirks, G N Davies & G L Slack Glass R L (1982) Journal of Dental Research 61, 1304-1383 Gordon P H (1983) In: The Prevention of Dental Disease. Ed. J J Murray. Oxford University Press, Oxford; pp 175-191 Editorial (1984) British Dental Journal 156, 195 Horowitz H S (1983) Community Dentistry and Oral Epidemiology 11, 384-385 Hunter B (1982) Journal of Dental Research 61, 537 (Abst. 18) Jackson D (1966) In: Advances in Fluorine Research and Dental Caries Prevention. Ed. P M C James, K G Konig & H R Held. Pergamon Press, Oxford; Vol. 4 pp 23-32 OPCS Monitor (1983) Children's Dental Health 1983. Office of Population Censuses and Surveys. Ref. SS83/2 Rantala E V (1979) Community Dentistry and Oral Epidemiology 7, 213-217 Shaw L and Murray J J (1975) International Dental Journal 25, 280-288 Simonsen R J (1980) Journal of the American Dental Association 100, 535-539 Todd J E (1975) Children's Dental Health in England and Wales 1973. HMSO, London Walls A W G, Wallwork A W, Holland I S and Murray J J (1985) British Dental Journal 158, 133-136