Fifty years of progress in paediatric dentistry

There have been many significant changes within the specialty of paediatric dentistry practice over the last half century, following the first issue of Dental Update. These advances are too numerous to discuss in just one article, so here we will present what we consider to be the key advancements within our field.

Prevention and management of caries

Prevention of caries

Not surprisingly, the management of caries, especially for younger children, has benefited from considerable advances in our understanding of the disease process and its impact over the past 50 years. Although fluoridated toothpaste was first marketed in the UK before the launch of Dental Update, its pivotal role in reducing caries prevalence in our population has been widely disseminated through the journal’s publications.^1,2

Another fluoride-containing product, fluoride varnish, has changed the face of dental practice-based prevention. Although first available in 1964, its use became much more widespread during the 1980s. This highly effective and simple intervention superseded other forms of topical fluoride, such as acidulated phosphate fluoride gel.³ The inclusion of fluoride varnishes in national guidance documents from the Scottish Clinical Effectiveness Programme and from Public Health England in the early 2000s, and monitoring of submitted claims data, are likely to have furthered its adoption.^4,56,7 Furthermore, its use in community-based prevention schemes, such as ‘Childsmile’ has seen significant caries reduction within some of the most deprived and hard-to-reach child populations.⁸ Another major contribution to caries prevention and management has been the modern resin-based fissure sealant, which was developed approximately 50 years ago.⁹ All these interventions are now mainstays of national guidance on the prevention of caries.⁶

Management of caries

If we reflect on how we restore caries in our young patients, there has been a paradigm shift from Black’s principles of radical caries removal and cavity preparation, to a biological, and far less destructive, approach. This has been facilitated by advances in dental materials, particularly those with adhesive properties. One of the first steps along this road was the development of the sealant restoration.¹⁰ Perversely, although less destructive as a technique, this may have led to over-treatment, with dentists cutting teeth to investigate sound surfaces for fear of missing caries. Fortunately, we have seen advances in the adoption of minimal intervention approaches, as our understanding of the carious process has evolved. Central to our modern practice is the knowledge that caries is driven by the biofilm on the tooth surface, together with greater understanding of the dentine–pulp complex’s capacity to repair. The routine surgical investigation of a suspected carious lesion can no longer be justified, rather a ‘sealing in’ (and monitoring) approach is advocated for non-cavitated lesions. For more advanced lesions, sealing is also used as part of the practice of stepwise caries removal.^11,12

Glass ionomer cements, which were invented in the early 1970s, have developed from a very difficult to manipulate material, with limited clinical use, to a material that can be used as a permanent restoration. The advent of resin-modified glass ionomer cements, alongside their fluoride-releasing properties, confer several advantages for use in children in the primary dentition.^13,14

The principle of sealing in caries has underpinned one of the most revolutionary changes in how we restore carious primary molars. Just over two decades ago, the non-invasive Hall technique was described for the placement of pre-formed metal crowns (Figure 1).¹⁵ This approach simply required the cementing of a pre-formed metal crown over a carious primary molar, without the need for local anaesthetic or caries removal.¹⁵ Initial scepticism was counteracted by reported success rates of over 90% at 5 years, significantly better than outcomes achieved for teeth treated with intra-coronal restorations. In terms of other major changes to our choice of restorative materials, 2018 saw the restriction of amalgam use in children under the age of 15 years (Figure 2).¹⁶ Although amalgam had served us well, because of its many disadvantages, its loss is to be welcomed.

However, despite significant advances in knowledge and techniques over the past five decades, we still find ourselves in a situation where dental disease and its consequences remain a significant problem, particularly for the most disadvantaged in our society.¹⁷ In 2013, nearly onethird (31%) of 5 year olds and nearly half (46%) of 8 year olds had obvious decay experience in their primary teeth. Overall, 58% of 12 year olds and 45% of 15 year olds reported that their daily life had been affected by problems with their teeth and mouth in the previous 3 months.¹⁸ The Care index, albeit a crude measure of operative care, remains very low at only 10.3% in 5 year olds and continues to raise concern about the lack of restorative intervention in some primary care settings.¹⁹

Clearly, we still have a long way to go before we have consigned dental caries in children to history. This can only be achieved by a collaborative focus on prevention aimed at reducing and eventually eliminating disparities in dental health.

Taking the ‘trauma’ out of traumatic dental injuries

Over the past 50 years, significant advances have been made in the understanding and treatment of different traumatic dental injuries (TDI). At the forefront of these developments has been Dr Jens Andreasen, who dedicated his career to furthering the field of dental traumatology.

International guidelines and research

There is a wide range of TDIs, involving both hard and soft tissues, and children may present with multiple different injury types following a severe impact. To help dental professionals in caring for this group, dental traumatology embraced good practice guidelines in the early 2000s, with the aim of identifying the best treatment options for different TDIs, taking the stage of dental development into account. Underpinning this guidance have been longitudinal cohort studies to quantify the outcomes from the treatment of different TDIs.^20,21 The improved understanding and quantification of prognosis for different injuries can be readily accessed using the bespoke tool available on the Dental Trauma website (https://dentaltraumaguide.org/free-version/?r=250&wcm_redirect_to=page&wcm_redirect_id=250). A key learning point from these TDI cohort studies is that, often, the injury itself determines the outcomes, and that treatment for these injuries can be both beneficial or detrimental. Research in this area continues with the development of core datasets for researchers and clinicians that aim to encourage consistent collection of information.²²

While dental professionals are well aware of the impact of TDI on children and their families, research has only recently started to collect and quantify the significant impacts that a TDI can have. The use of validated quality of life indices and qualitative research methods have begun to describe both short-and longer-term impacts. The importance of the ‘voice of the child’ and capturing impacts are a key priority for the future.²³

Advances in diagnosis

The development of cone beam computed tomography systems (CBCT) has greatly enhanced diagnosis of the extent and nature of TDIs, as well as the identification of trauma-related sequelae, such as root resorption. This imaging approach allows the 3D localization of pathology, the extent of pathological lesions and improves understanding of root canal morphologies. However, the benefits of CBCT, especially in children, have to be weighed against the increased radiation dose in comparison to conventional dental images.²⁴

Management and materials

With improved understanding of how injured tissues respond following TDI, as well as developments in dental material science, there have been some significant advances in how TDIs are treated. Flexible splinting materials have been developed, such as titanium trauma splints, that allow efficient and simple placement, while allowing patients to keep gingival tissues clean (Figure 3).²⁵ They also allow physiological tooth movement, which promotes improved healing compared with the use of earlier, more rigid materials.

The advent of bio-ceramic materials such as mineral trioxide aggregate (MTA) and Biodentine (Septodont, Saint-Maur-des-Fossés, France) have brought considerable benefits to the endodontic management of non-vital immature permanent incisors in our young patients. Traditionally, the aim of treatment was to try to achieve apical barrier formation (apexification) through the long-term use of non-setting calcium hydroxide, which generally had a poor long-term outcome. In contrast, MTA has been found to provide consistent, efficient and effective root treatment for immature non-vital and infected incisors (Figure 4). These teeth have a lower risk of crown/root fracture, and the child requires far fewer treatment visits when compared with calcium hydroxide apexification.²⁶ The application of tissue-engineering techniques to encourage continued root growth in immature non-vital and infected incisors is also an area of ongoing interest. However, evidence in the field is still inconsistent, potentially owing to the damage caused not only to the pulp, but also to the root surface complex.²⁶

Developments in treatment of developmental enamel defects

It is hard to imagine that 50 years ago our specialty had not heard the term ‘molar–incisor hypomineralization’ (MIH). This developmental enamel condition, affecting around 13% of children globally, has now become one of the most common reasons for children to be referred to specialist paediatric dentistry services.²⁷ The diagnostic criteria for MIH were first proposed in the early 2000s and describe hypomineralization of one or more first permanent molars, often in association with hypomineralization of some of the permanent incisors.²⁸ Affected teeth essentially have areas of poor enamel quality, which is discoloured, porous, soft, displays poor bonding properties, and is prone to caries and post-eruptive breakdown.²⁹ Teeth may have a variety of white, cream, yellow or brown opacities, which may be of considerable cosmetic concern to the child and their family. In addition, affected molars can be exquisitely sensitive to normally innocuous thermal and mechanical stimuli, restricting normal oral functions, such as eating and toothbrushing. Although a wealth of basic science and clinical research has been undertaken, the exact aetiology remains somewhat unclear, but is likely to involve both environmental and genetic factors.³⁰

Regrettably, in our current era of social media overload, children may now be exposed to more appearance-related bullying than they were in the past. Children with visible incisor opacities may experience a host of negative social and emotional impacts because of the way their teeth look, and frequently seek dental interventions. One of the challenges we then face is meeting children’s expectations of ‘removing’ incisor opacities, while still preserving tooth tissue. Since the 1980s, the use of micro-abrasion has been widely adopted as an effective and minimally invasive approach for reducing the visibility of brown incisor opacities.³¹ However, this approach is less effective for white/cream opacities. Therefore, a welcome, and relatively recent, addition to our armamentarium has been the use of resin infiltration; the most widely used system being Icon (DMG, Hamburg, Germany).

The theory being that the low viscosity resin infills the porous subsurface enamel, altering its refraction index to one that is closer to that of normal enamel, thus effectively ‘hiding’ the white colouration of the opacity. This technique has shown some promising, but not always predictable, results (Figure 5).³¹ However, even simple ‘cosmetic’ interventions can greatly improve how children feel about themselves.³²

If we look to the wider literature on developmental enamel defects, knowledge on the inherited condition, amelogenesis imperfecta (AI), has unquestionably seen the most significant advances. Since the identification, in 1991, of the first gene mutation to cause AI (located in AMELX), an astounding number of other novel gene mutations has also been implicated in nonsyndromic types of AI.³³ Of particular clinical relevance, is the finding that some patients with a mutation in the FAM20A gene not only have AI (a hypoplastic phenotype), but also have nephrocalcinosis, known as enamel–renal syndrome, which warrants an expedient urology referral.³⁴ The translation of this emerging genetic knowledge to everyday paediatric dentistry practice is, however, still in its infancy. Although there is now the opportunity to incorporate genetic testing for AI (using the ’21-gene AI panel test’) within our practice to aid more accurate classification and support patient understanding, there are some attitudinal, economic and competency barriers to overcome.³⁵

Greater insights into children’s dental fear and anxiety

As this article has highlighted, there have been significant achievements in the practice of paediatric dentistry during the past 50 years. However, something that has not changed, is that many children still experience fear and anxiety with dental visits. The evidence is that dental fear and anxiety (DFA) is common, with a prevalence of 25% of children globally.³⁶ Unfortunately, DFA still creates significant barriers for children to have appropriate dental care.^37,38,39 Consequently, children with DFA are not as likely to benefit from the advances in the prevention, diagnosis and treatment of dental caries now available.⁴⁰

During the past 50 years, DFA in children has been managed through the use of behaviour management strategies, such as ‘tell-show-do’, which is well accepted, but has little evidence to support its effectiveness, or children have been referred to specialist services for pharmacological interventions.^41,4243 However, there is evidence that if childhood DFA is not addressed, it can become a long-term condition, and persist into adult life.⁴⁴ Recently, researchers have recommended that dental professionals adopt a stepped treatment approach based on psychological techniques for children and adults who are concerned about dental care.^45,46 The overriding principle is that everyone can experience DFA, and that there are elements of the dental visit that can be changed to make dental care a more comfortable experience for all patients.^45,46Additionally, the development of a self-help cognitive behavioural therapy intervention (‘Your teeth, you are in control’) for children with DFA aged 9–16 years has shown promising results, and is currently being evaluated in a randomized controlled trial in primary dental care.⁴⁷ The use of virtual reality has also demonstrated potential for DFA.^48,49

Tooth erosion

Attention to tooth erosion as an issue within paediatric dentistry received greater scrutiny with its inclusion in the Child Dental Health Survey.⁵⁰ Tooth wear is seen across the ages of 5–15 years, and rates have been increasing, perhaps owing to the consumption of highly acidic beverages.⁵⁰ Research has suggested links between dietary practice, gastro-oesophageal reflux and socio-economic status.⁵⁰ Erosion in children, including in the primary dentition, can be recorded through the Basic Erosive Wear Examination index.⁵¹ Recommendations for the investigation, prevention and management of tooth erosion in children and young people is provided by the recently updated Faculty of Dental Surgery’s guidelines.⁵²

Safeguarding children

The dental team’s role in safeguarding children from maltreatment is an area of practice that has changed dramatically in the past two decades, evidenced by rising referrals from paediatric dentistry to children’s social care.⁵³

Children have a right to protection from all forms of abuse and neglect, and the dental team is obliged, under statutory and ethical guidance, to report any concerns to the authorities.^54,5556 However, diagnostic and organizational challenges, and lack of support, led to dental professionals’ reluctance to be involved in the past.⁵⁷

Physical, emotional and sexual abuse and neglect all present in child dental patients.^58,59 However, dental neglect is now recognized as by far the commonest reason for dental professionals to refer children and families to social services for assessment.^60,61,62 With one study estimating worldwide prevalence at 34% to 54%, dentistry has a key role in both its diagnosis and management.^63,64 Furthermore dental neglect is also a concern to both non-dental healthcare professionals and to parents.⁶⁵

Accepted good practice is that certain vulnerable groups benefit from designated dental care pathways and missed dental appointments must be viewed as the child ‘was not brought’, placing their needs centre stage.^66,67,68 Myriad other factors are now recognized as profoundly affecting children’s wellbeing, including domestic violence, parental substance abuse and mental illness, sexual exploitation and trafficking. Over the past two decades, the development of tools including the ‘Child Protection and the Dental Team’ document, and the ‘Was Not Brought’ pathway provide valuable guidance to support dental professionals when safeguarding vulnerable children.^69,70

Without doubt, in the past 50 years, paediatric dentistry has increased its contribution to safeguarding and promoting children’s overall wellbeing, well above and beyond oral health.

Collaborative working

Progress in all the areas described, has only been possible through effective interdisciplinary collaborations between dental health professionals and researchers from different specialties and environments. However, considering public health issues that pervade oral health, there is only so much that can be achieved if dentists only work with dentists. There is now real recognition that for us to see real progress in children’s oral health, we need to address the wider determinants of health and influence a broader audience including health visitors, paediatricians, school nurses, social workers and local authority partners. Nationally, there was a call to ‘put the mouth back in the body’ from the Chief Dental Officer and supported by the British Society of Paediatric Dentistry (BSPD) championing the fact that ‘Children’s oral health is everybody’s business’.^71,72 BSPD’s Dental Check by One and Mini Mouth Care Matters programmes began to ask non-dental healthcare professionals to ‘Lift the lip’ and engage in children’s oral health.^73,74 These ideas were not new, but they effectively embraced social media to inform, engage and influence. Crucial to the move to place-based commissioning, was the publication of the Commissioning Standard for Paediatric Dentistry in 2018, which led to the development of managed clinical networks for paediatric dentistry. Over the next 5 years, these networks of key stakeholders developed to provide clinical leadership across England (Figure 6) As integrated care systems assume their statutory responsibility in 2023, the managed clinical networks should play an increasingly vital role in advocating for children’s oral health, particularly with the publication of NHS England’s CORE20PLUS5 approach to reducing health inequalities in children and young people.^75,76

Dentists have long come together to support child oral health, the British Society of Paediatric Dentistry is an internationally recognized society and has been an advocate over the past six decades.⁷⁷ The group has achieved significant impact through working with government, bringing together those within the speciality and across disciplines, including medical specialities. This has highlighted child oral health nationally as an issue, along with supporting and developing solutions to improve child oral health. The Society has patient-focused resources to provide information directly to children and their carers, using many formats, including social media, popular children’s programmes and media personalities, to support good oral health through an engaging format for children and their parents.

Child-centred dentistry

The ultimate aim of paediatric dentistry is to provide all children with evidence-based and high-quality care while fostering a lifelong positive attitude to dentistry. Over the past 50 years there has been an increasing onus to adopt a child-centred approach not only within clinical care but also in health research.^78,79 It is therefore encouraging to see reports of more widespread engagement of children as active participants within dental research. Further progress is welcome and vital to ensure that the care we provide over the next 50 years is child-focused, to address their needs as new technologies and treatments develop and require evaluation.

Conclusion

This brief summary has aimed to show some of the areas of significant progress made within the specialty of paediatric dentistry since the first publication of Dental Update 50 years ago. Changes in attitudes, knowledge and practice have all led to measurable improvements in clinical- and patient-reported outcomes for children. However, there can be no room for complacency, so we continue to strive for further advances over the next half century.