Sir, the articles and correspondence regarding restorative care for the primary dentition are disappointing. The guidelines of the British Society of Paediatric Dentists (BSPD) were not followed, resulting in 48% of British pre-school children suffering pain with the non-intervention approach. Your readers may be interested in a view from overseas.

The reason why the restored primary teeth were painful is explained by Drs Tickle, Milson and Blinkhorn's comment that all of these pre-school children had interproximal decay1. Once interproximal decay is clinically observable, there is a strong likelihood of advanced decay with breakdown of the marginal ridge and pulpal involvement2.

Restoration of such lesions with conventional Class II restorations are likely to fail due to the lack of proximal support3. As recommended both in texts3 and by the BSPD, only minimal interproximal lesions should be restored with conventional Class II preparations. Larger lesions should be restored with stainless steel crowns especially in the younger child where this restoration needs to last a longer time, which it does3,4,5. It is therefore no surprise to me that such restorations failed, resulting in pain. Simply put, when the wrong restorative choice is made, one can expect failure.

The authors state that they do not have the evidence to show that stainless steel crowns are more effective in reducing the risk of pain and minimising the possibility of developing anxiety1. This is true.

However, I would suggest this implied criticism of stainless steel crowns is wordsmithing at best. After all, if the stainless steel crown is placed once, and it lasts a lifetime of the tooth which the majority do4,5 how much future anxiety does the patient suffer when they are not subjected to having failed restorations redone or the tooth extracted?

This careful attention to the restoration brings the child's overall interest to the fore, by saving the child unnecessary retreatment. Two criteria of successful restorations are absence of pain and longevity of the restoration. The work being done falls short of the mark on both counts. In North America, such a high failure rate would result in medico legal and/or licensing problems. It is interesting that there appears to be no action in Britain regarding this, especially given the apparent waste of Government funding.

Based upon these results, one can only hope that parents of pre-school children who are subject to a non-intervention approach will be informed that nearly half of them will suffer pain. British children deserve better and should be treated according to the guidelines of the BSPD, consistent with proven techniques.4,5

The authors of the paper respond: Dr Kennedy's letter opens with the claim that because the BSPD guidelines were not followed, 48% of the children involved in the study experienced at least one episode of pain. Unfortunately, the study data does not support this position.

In defence of the stainless steel crown as the treatment of choice for primary molars with large two surface lesions, Dr Kennedy quotes a number of scientific papers. None of the studies he relies upon report on randomised controlled trials undertaken in NHS primary dental care. Thus it is not possible to conclude that, in the hands of NHS dentists, the stainless steel crown is better than any other material for the treatment of two surface caries in primary molars. We do know that stainless steel crowns are not a popular method of restoration with GDPs in England and Wales. Figures from the Dental Practice Board 6 show that in 2003 only 2,793 preformed crowns were fitted in NHS practice, a reduction of 35% over the previous two years. At the same time, the number of intracoronal restorations provided has remained reasonably constant. Dr Kennedy's assumption that the wrong restorative choice inevitably leads to failure may, in principle, be sound. Since the authors of the study are not clear what constitutes the optimal restorative option for primary teeth with large two surface lesions, they are unable to comment further on this point.

The authors feel that successful restorative care is that which addresses the needs of children first and the tooth second. In the UK, NHS GDPs are responsible for the care of over 90% of those children who visit a dentist. The UK public have faith in the service that is offered to children and the GDPs earn the confidence of the public by delivering what they feel is a high quality service. There is no robust evidence to suggest that the stainless steel crown is a better treatment option than other restorative approaches and therefore to suggest that money spent on alternative restorations is a 'waste of government funding' is clearly untenable.