Sir, a recent cohort study of caries incidence in 739 children in the journal highlighted the importance of prevention in primary teeth.1 The authors observe that caries diagnosis in this study did not include radiographic examination, so it is likely, therefore, that many of these apparently caries-free children had undiagnosed approximal lesions at presentation.2 For this reason we agree wholeheartedly with the conclusion that, whether caries is obvious or not, all children require preventive care, for which evidence-based guidelines are readily available.3,4

However, none of these guidelines recommend a prevention-only approach to caries management once cavitation has been diagnosed. Based on their own retrospective data, the same group have suggested that the sequelae of dental caries (pain, sepsis, extractions) cannot be controlled by restorative intervention either.5

The question of whether primary tooth restorations are effective or not in managing caries would seem more complex than either side in this increasingly polarised argument are prepared to admit. Two recent systematic reviews show that amalgam,6 compomers, or resin modified glass ionomers7 can be used with success in primary teeth. Further inspection of the individual studies reported in these reviews suggests that pain and infection are uncommon sequelae. For example, Qvist8 followed over 1,500 Class II restorations in 971 children for seven years. Treatment was undertaken by non-specialists in the Danish Public Dental Health Services, and only 7% of teeth subsequently presented with sepsis or were extracted. However, a recent UK randomised controlled trial investigated clinical outcomes of the Hall Technique with those of standard restorations provided by GDPs for carious primary molars.9 For the 129 children followed up for two years, only 2% (n = 3) of the Hall crown teeth had abscessed or become unrestorable, while for the teeth with standard restorations this was 15% (n = 19), a figure approaching that reported by the Manchester group for teeth left unrestored! How could the UK results be so different from those reported by Qvist? There are a number of possible reasons, but further examination of the data shows that the material of choice for the majority of GDPs when restoring Class IIs was unmodified glass ionomer cement, a material now regarded as unsatisfactory for this purpose.7 GDPs clearly want to provide the best possible care for their child patients, so what are the barriers to the use of techniques and materials (amalgam, compomers, composites or resin modified glass ionomers) of proven effectiveness in general practice? These obstacles, be they funding, education, access to specialist care or something else altogether, need to be further explored and then addressed.

Repeated demonstration that what is currently being provided is inadequate for children in the UK does not mean that the baby (reduction in pain and sepsis for UK children) should be thrown out with the bathwater (current restorative methods in the general practice environment). Perhaps the bathwater simply needs changing!