Carious primary teeth: their fate in your hands

Key Points

• There have been concerns expressed about the decline in restorative care of primary teeth.

• This study describes the care and resultant outcomes of the carious primary teeth of children who were regular patients of 50 GDPs in the North West of England.

• Although extractions were common GDPs restored over 80 % of carious deciduous molars.

• The bulk of carious teeth exfoliated naturally irrespective of whether they were restored or not.

• The design of this study was limited but the results raise many important questions which require further investigation.

Abstract

Objective

To describe the care and resultant outcomes of the carious primary teeth of children who regularly attend the General Dental Service.

Subjects and Materials

A retrospective study of the case notes of 677 children who received their dental care from 50 general dental practitioners (GDPs). Each dentist had a minimum of ten and a maximum of 20 patients for whom care had been provided from or before the age of five to the age of 14. All children included in the study had a history of approximal caries. The outcomes of interest were: extraction due to pain or sepsis, or exfoliation whether or not a tooth had given rise to the prescription of a course of antibiotics. Teeth that did not have a history of extraction were assumed to have exfoliated naturally. Logistic regression models, taking into account the clustering of the teeth within patients were fitted to compare the outcomes for restored and unrestored teeth according to size of lesion (one or two surfaces), age caries was first recorded and tooth type.

Results

A total of 4,056 teeth had been either recorded as carious or had received an intervention of some kind. Some 44.1% (N=1789) of these teeth were extracted, however only 475 (11.7%) were extracted due to pain or sepsis. Of the teeth with a documented history of caries or restoration and for which an outcome was recorded (N= 3145), most first (81.1%) and second (84.3%) carious primary molars were filled during their lifetime, but only 40.5% of primary carious anterior teeth were filled. The majority of carious primary teeth exfoliated naturally. There was no difference in the proportions of teeth extracted due to pain or sepsis whether a carious tooth was restored or left unrestored, either by cavity type or by tooth type, after controlling for age when caries was first recorded. There was also no difference in the number of filled or unfilled carious teeth that caused a course of antibiotics to be prescribed.

Conclusions

Treatment by extraction was common, but GDPs restored the majority of carious primary molar teeth of their regularly attending child patients. The bulk of carious teeth exfoliated naturally irrespective of whether they were filled or not. The reasons for these findings require further investigation.

Main

The fate of the carious primary teeth of children who regularly attend the General Dental Service M Tickle, K Milsom, D King, P Kearney-Mitchell, A Blinkhorn Br Dent J 2002; 192: 219–223

Comment

The main finding of the study was that, irrespective of the intervention, or lack of it, there was no difference in the outcome as measured by the proportion of teeth extracted due to pain or sepsis. It is worth noting that 23% of the first molars that had never been restored and nearly 20% of the ones that had been restored were extracted due to pain or sepsis. Similar figures are reported for two surface lesions, so that roughly one in five teeth included in the study needed extraction due to pain or infection.

These findings provoke arguments which the authors have not alluded to. In view of the high percentage of restored teeth with two surface lesions that were extracted, it would seem logical to argue that there might be fundamental flaws in the restorative technique being practiced. Early studies¹ showed that in over 50% of primary molars with the loss of the marginal ridge, pulp inflammation was irreversible. Research has corroborated this, with most teeth manifesting inflammation involving the pulp horn adjacent to the proximal carious lesion, even when caries had involved less than half the marginal ridge.² This suggests that by the time most proximal caries is manifest clinically the pulp inflammation is quite advanced and large restorations in primary molars carried out without due consideration to the state of the pulp are doomed to failure.

Therefore, a logical conclusion of this study would be that the outcome of the restorations, as currently practiced by GDPs in primary molars is poor and teeth thus restored suffer the same fate as unrestored teeth. Certainly if they had compared the fate of unrestored teeth with those restored with due consideration to the principles discussed above and using techniques such as pulpotomies and stainless steel crowns, their results would may have been different. Indeed, excellent outcome for primary teeth, free from pain or sepsis, has been reported when primary teeth were restored using such techniques.^3,4 Untreated caries in the primary dentition can cause abscesses, pain and suffering in children, with severe caries affecting the quality of life of preschool children^5,6 which can be improved by eliminating dental disease.⁵

In view of all my comments I sincerely hope that general practitioners study this article, and continue to develop a philosophy of high quality restorative care for children, based on sound scientific principles.