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NIHR Signal Conventional fillings may not add much to standard prevention for decay in baby teeth

Published on 18 March 2020

doi: 10.3310/signal-000892

Sealing in decay, improving tooth hygiene and using conventional fillings all work to prevent future dental pain and infection for children with decay in baby teeth. The approaches are equally acceptable to children and parents.

Researchers tested three methods of managing decay in the primary molars of children aged three to seven:

  • best practice prevention (advice on cutting down on sugar, twice-daily tooth brushing with fluoride, application of fluoride varnish)
  • best practice prevention plus conventional local anaesthetic, and drilling out of decay and filling
  • best practice prevention plus sealing in of decay with caps or fillings

They found little difference in the chances of having an episode of pain or infection during 2.8 years of follow-up.

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Why was this study needed?

Dental decay is the most common disease affecting children and can cause pain and time away from school. In 2013 to 2014, 62,747 children were admitted to hospital in England, Scotland and Wales with dental decay. However, it is unclear how decay of primary (baby) teeth is best treated.

Until 10 years ago, the standard treatment was to drill out all decayed tooth tissue and fill the gap. However, this does not seem to reduce future episodes of decay. Less invasive ‘biological’ treatment (sealing in decay) and preventive treatment has become more popular. Evidence from young children in primary care was lacking, however.

This study aimed to compare the clinical and cost-effectiveness of the three management strategies and to find out which was more acceptable to children and parents.

What did this study do?

Researchers recruited 1,144 children aged three to seven years, via 72 dental practices for the FiCTION randomised controlled trial. Dentists were trained in the three management strategies. Children were randomly assigned to one of the three strategies if they had one or more holes in their primary molar teeth.

Children were followed up for subsequent episodes of pain or infection. Researchers also interviewed parents or caregivers about the children’s quality of life, and about their anxiety about dental treatment. Parents were asked about the acceptability of their experience of the chosen management.

The researchers calculated the cost-effectiveness of the three strategies, based on different levels of acceptability of cost.

What did it find?

  • An average 43% of children treated by any management strategy had at least one episode of pain or infection over a follow-up period of 33.8 months: 36% had pain and 25% had an infection.
  • Those treated by sealing in decay had slightly different rates of pain or infection (40%) compared with conventional filling (42%) and prevention only (45%). The differences in outcome were not statistically significant meaning they could have arisen by chance.
  • Prevention only was the cheapest option.
  • There was also no difference between the treatment groups for health-related quality of life or dental anxiety, and qualitative interviews suggested that each management option was generally acceptable.
  • The interviews suggested that trust in the dental professional was important, with parents trusting dentists to decide on the best treatment for the child.
  • The researchers noted that only 48% of the children treated had an X-ray at any point during treatment.

What does current guidance say on this issue?

Guidance from the Scottish Dental Clinical Effectiveness Programme states: “For a child with a carious [decayed] lesion in a primary tooth, choose the least invasive feasible caries management strategy, taking into account: the time [the tooth is likely to fall out naturally], the site and extent of the lesion, the risk of pain or infection, the absence or presence of infection, preservation of tooth structure, the number of teeth affected, avoidance of treatment-induced anxiety.”

The UK guideline on the management of decay in paediatric dentistry dates back to 2001. It states that dental care for children should include “comprehensive prevention” and that “restorations or extractions” will usually be necessary to treat children with dental decay.

What are the implications?

The results imply that interventions in addition to best-practice prevention of dental decay make little difference to the chances of children having pain or infection in the following two to three years.  Given no overall difference in outcomes, dentists may wish to discuss treatment options with parents and children. Based on the invasive nature of standard fillings or their relative costs children or their parents may have a preference.

The findings could help inform future guidance on the management of decay in primary teeth.

Citation and Funding

Maguire A, Clarkson JE, Douglas GVA et al. Best-practice prevention alone or with conventional or biological caries management for 3- to 7-year-olds: the FiCTION three-arm RCT. Health Technol Assess. 2020;24(1).

The project was funded by the NIHR Health Technology Assessment Programme (project number 07/44/03).

Bibliography

Fayle SA, Welbury RR, Roberts JF on behalf of the British Society of Paediatric Dentistry (BSPD). British Society of Paediatric Dentistry: a policy document on management of caries in the primary dentition. Int J Paediatr Dent. 2001;11:153–7.

Scottish Dental Clinical Effectiveness Programme. Prevention and management of dental caries in children: dental clinical guidance (2nd edition). Dundee: Scottish Dental Clinical Effectiveness Programme; 2018.

Why was this study needed?

Dental decay is the most common disease affecting children and can cause pain and time away from school. In 2013 to 2014, 62,747 children were admitted to hospital in England, Scotland and Wales with dental decay. However, it is unclear how decay of primary (baby) teeth is best treated.

Until 10 years ago, the standard treatment was to drill out all decayed tooth tissue and fill the gap. However, this does not seem to reduce future episodes of decay. Less invasive ‘biological’ treatment (sealing in decay) and preventive treatment has become more popular. Evidence from young children in primary care was lacking, however.

This study aimed to compare the clinical and cost-effectiveness of the three management strategies and to find out which was more acceptable to children and parents.

What did this study do?

Researchers recruited 1,144 children aged three to seven years, via 72 dental practices for the FiCTION randomised controlled trial. Dentists were trained in the three management strategies. Children were randomly assigned to one of the three strategies if they had one or more holes in their primary molar teeth.

Children were followed up for subsequent episodes of pain or infection. Researchers also interviewed parents or caregivers about the children’s quality of life, and about their anxiety about dental treatment. Parents were asked about the acceptability of their experience of the chosen management.

The researchers calculated the cost-effectiveness of the three strategies, based on different levels of acceptability of cost.

What did it find?

  • An average 43% of children treated by any management strategy had at least one episode of pain or infection over a follow-up period of 33.8 months: 36% had pain and 25% had an infection.
  • Those treated by sealing in decay had slightly different rates of pain or infection (40%) compared with conventional filling (42%) and prevention only (45%). The differences in outcome were not statistically significant meaning they could have arisen by chance.
  • Prevention only was the cheapest option.
  • There was also no difference between the treatment groups for health-related quality of life or dental anxiety, and qualitative interviews suggested that each management option was generally acceptable.
  • The interviews suggested that trust in the dental professional was important, with parents trusting dentists to decide on the best treatment for the child.
  • The researchers noted that only 48% of the children treated had an X-ray at any point during treatment.

What does current guidance say on this issue?

Guidance from the Scottish Dental Clinical Effectiveness Programme states: “For a child with a carious [decayed] lesion in a primary tooth, choose the least invasive feasible caries management strategy, taking into account: the time [the tooth is likely to fall out naturally], the site and extent of the lesion, the risk of pain or infection, the absence or presence of infection, preservation of tooth structure, the number of teeth affected, avoidance of treatment-induced anxiety.”

The UK guideline on the management of decay in paediatric dentistry dates back to 2001. It states that dental care for children should include “comprehensive prevention” and that “restorations or extractions” will usually be necessary to treat children with dental decay.

What are the implications?

The results imply that interventions in addition to best-practice prevention of dental decay make little difference to the chances of children having pain or infection in the following two to three years.  Given no overall difference in outcomes, dentists may wish to discuss treatment options with parents and children. Based on the invasive nature of standard fillings or their relative costs children or their parents may have a preference.

The findings could help inform future guidance on the management of decay in primary teeth.

Citation and Funding

Maguire A, Clarkson JE, Douglas GVA et al. Best-practice prevention alone or with conventional or biological caries management for 3- to 7-year-olds: the FiCTION three-arm RCT. Health Technol Assess. 2020;24(1).

The project was funded by the NIHR Health Technology Assessment Programme (project number 07/44/03).

Bibliography

Fayle SA, Welbury RR, Roberts JF on behalf of the British Society of Paediatric Dentistry (BSPD). British Society of Paediatric Dentistry: a policy document on management of caries in the primary dentition. Int J Paediatr Dent. 2001;11:153–7.

Scottish Dental Clinical Effectiveness Programme. Prevention and management of dental caries in children: dental clinical guidance (2nd edition). Dundee: Scottish Dental Clinical Effectiveness Programme; 2018.

Best-practice prevention alone or with conventional or biological caries management for 3- to 7-year-olds: the FiCTION three-arm RCT

Published on 13 January 2020

Maguire A, Clarkson J E, Douglas G V, Ryan V, Homer T, Marshman Z, McColl E, Wilson N, Vale L, Robertson M, Abouhajar A, Holmes R D, Freeman R, Chadwick B, Deery C, Wong F & Innes N P.

Health Technology Assessment Volume 24 Issue 1 , 2020

Background Historically, lack of evidence for effective management of decay in primary teeth has caused uncertainty, but there is emerging evidence to support alternative strategies to conventional fillings, which are minimally invasive and prevention orientated. Objectives The objectives were (1) to assess the clinical effectiveness and cost-effectiveness of three strategies for managing caries in primary teeth and (2) to assess quality of life, dental anxiety, the acceptability and experiences of children, parents and dental professionals, and caries development and/or progression. Design This was a multicentre, three-arm parallel-group, participant-randomised controlled trial. Allocation concealment was achieved by use of a centralised web-based randomisation facility hosted by Newcastle Clinical Trials Unit. Setting This trial was set in primary dental care in Scotland, England and Wales. Participants Participants were NHS patients aged 3–7 years who were at a high risk of tooth decay and had at least one primary molar tooth with decay into dentine, but no pain/sepsis. Interventions Three interventions were employed: (1) conventional with best-practice prevention (local anaesthetic, carious tissue removal, filling placement), (2) biological with best-practice prevention (sealing-in decay, selective carious tissue removal and fissure sealants) and (3) best-practice prevention alone (dietary and toothbrushing advice, topical fluoride and fissure sealing of permanent teeth). Main outcome measures The clinical effectiveness outcomes were the proportion of children with at least one episode (incidence) and the number of episodes, for each child, of dental pain or dental sepsis or both over the follow-up period. The cost-effectiveness outcomes were the cost per incidence of, and cost per episode of, dental pain and/or dental sepsis avoided over the follow-up period. Results A total of 72 dental practices were recruited and 1144 participants were randomised (conventional arm, n = 386; biological arm, n = 381; prevention alone arm, n = 377). Of these, 1058 were included in an intention-to-treat analysis (conventional arm, n = 352; biological arm, n = 352; prevention alone arm, n = 354). The median follow-up time was 33.8 months (interquartile range 23.8–36.7 months). The proportion of children with at least one episode of pain or sepsis or both was 42% (conventional arm), 40% (biological arm) and 45% (prevention alone arm). There was no evidence of a difference in incidence or episodes of pain/sepsis between arms. When comparing the biological arm with the conventional arm, the risk difference was –0.02 (97.5% confidence interval –0.10 to 0.06), which indicates, on average, a 2% reduced risk of dental pain and/or dental sepsis in the biological arm compared with the conventional arm. Comparing the prevention alone arm with the conventional arm, the risk difference was 0.04 (97.5% confidence interval –0.04 to 0.12), which indicates, on average, a 4% increased risk of dental pain and/or dental sepsis in the prevention alone arm compared with the conventional arm. Compared with the conventional arm, there was no evidence of a difference in episodes of pain/sepsis among children in the biological arm (incident rate ratio 0.95, 97.5% confidence interval 0.75 to 1.21, which indicates that there were slightly fewer episodes, on average, in the biological arm than the conventional arm) or in the prevention alone arm (incident rate ratio 1.18, 97.5% confidence interval 0.94 to 1.48, which indicates that there were slightly more episodes in the prevention alone arm than the conventional arm). Over the willingness-to-pay values considered, the probability of the biological treatment approach being considered cost-effective was approximately no higher than 60% to avoid an incidence of dental pain and/or dental sepsis and no higher than 70% to avoid an episode of pain/sepsis. Conclusions There was no evidence of an overall difference between the three treatment approaches for experience of, or number of episodes of, dental pain or dental sepsis or both over the follow-up period.

Expert commentary

This fascinating study gives us an insight into the relative benefits of three different approaches for dental caries management provided by primary care dental professionals.

The conclusion, that there is no difference between the different approaches, should be interpreted with some caution. Evidence-based treatments such as pre-formed metal crowns, use of dental injections or X-rays were not often carried out. Therefore the results are unlikely to apply to dental services where these treatments are routinely used.

This study highlights that there are barriers to providing evidence-based dental care in the primary care dental sector.

Professor Paul Ashley, Paediatric Dentistry, UCL Eastman Dental Institute, London

The commentator declares no conflicting interests

Expert commentary

A debate on whether or not to fill cavities in decayed primary teeth raged throughout the dental profession in the 1990s and early 2000s, an argument which led to the funding of this study and perhaps naively in some quarters, the hope that a definitive answer to the controversy would result.

What this logistically complex trial has shown is that, at least where episodes of dental pain are concerned, there is no significant difference between the approaches adopted: conventional fillings and prevention, a biological approach sealing in caries and prevention, or prevention alone.

While there are minor differences in preference and cost, what can be concluded is that preventing cavities forming in the first place is likely the best option of all.

Professor Ivor G Chestnutt, Professor and Honorary Consultant in Dental Public Health, Cardiff University School of Dentistry

The commentator declares no conflicting interests