Innes N P, Clarkson J E, Douglas G V A et al. Child caries management: a randomised controlled trial in dental practice. J Dent Res 2019; DOI: 10.1177/0022034519888882.

Little difference between prevention, Hall technique and restoration.

In the research-naive environment of general dental practice trials are rare but important for their relevance to the realities of life in primary care. There is continuing uncertainty about the best way to treat dental caries in children. This study recruited 72 dental practices across England, Scotland and Wales and the researchers provided training in clinical procedures, research methods and data collection. Practitioners were requested to recruit into the study children aged between 3 to 7 years, who had at least one carious lesion into dentine. Over a 32-month period, 7,699 children were screened, of whom 1,144 (15%) had a carious lesion. Those with lesions were randomly assigned within each practice to one of three treatment protocols:

  1. 1.

    Best practice prevention alone (PA) - diet and toothbrushing advice, topical fluoride application and fissure sealants to permanent teeth

  2. .

    PA + removal of carious tissue under local anaesthetic and placement of a conventional restoration (C+P)

  3. .

    PA + sealing in the caries with an adhesive restoration or a preformed metal crown (B+P).

Over a median follow up period of 33 months, the incidence of dental pain or infection per child in each group was PA - 161 out of 354 (45%), C+P - 148/352 (42%) and B+P - 141/352 (40%). The authors conclude that there is no evidence of a difference between the three treatment approaches for the number of episodes of dental pain or infection experienced by this high-risk group.

The problems of carrying out research within primary care are highlighted, such as research fatigue due to the length of time taken for the study, requiring 'high levels of motivational input' to collect final data and verify questionable or missing data. The higher than anticipated incidence of dental pain observed in a developed country with 'comprehensive dental services' are of concern.

All three strategies were generally acceptable to all participants (practitioners, children and parents) with PA being the least costly, but least effective. The other strategies have greater cost implications and judgements are required to decide what value should be placed on the avoidance of dental pain. The importance of primary prevention to avoid dental caries all together, rather than managing multiple lesions, is highlighted.

The importance of trust in practitioners to make decisions in the best interest of the child is stressed but the paper ends by stating the practitioners 'willingness and abilities to deliver effective strategies and individual items of care' need to be considered in implementing policy change.