Article
This is the first time Dental Update has produced a special themed issue and I am really pleased that Trevor has chosen paediatric dentistry as the subject. I am also very pleased that so many of the papers come from the University of Sheffield. Caries remains a significant problem affecting the daily lives of thousands of British children. The most recent Child Dental Health survey reported 31% of 5-year-old and 46% of 8-year-old children having obvious dentinal decay experience.1 For the 5-year-olds, 4% had signs of abscesses and 5% of the teeth were clearly unrestorable. Of course it is often overlooked that this is a gross underestimation of the true prevalence of the disease that would be found following a clinical examination supported by radiographs. The families of a fifth of 5-year-olds and approximately one third of 8-, 12- and 15-year-old children reported recent negative impacts on family life of dental disease, for example time off work, lost sleep or feelings of guilt. The Care Index (proportion of decayed teeth restored) is only 13.7%. Those of you who read the Editorial in May are aware that the shocking end result of this is that 66,859 young people had to have a general anaesthetic for the management of dental disease in 2013–14.2
So we have a major problem but, as this issue demonstrates, there is a lot of opportunity to address and manage this. A study involving a sample of 2,650 children living in either the fluoridated Midlands of England or South Wales, where they do not have the benefit of fluoride, compared the effect of restorative treatment on the likelihood of carious primary teeth progressing to either exfoliation or extraction.3 The results showed that restored teeth had double the chance of surviving until exfoliation compared to unrestored carious teeth. This study clearly shows that the flawed studies from over a decade ago which have suggested that there is no benefit in restoring primary teeth are incorrect.4 Keeping the teeth is obviously beneficial in terms of dental health, quality of life, avoided pain and sepsis together with other morbidity and child anxiety, not to mention the reduced need for orthodontic treatment. It also has the benefit to the dentist of avoiding extractions, a procedure which even I, as a Consultant Paediatric Dentist, can find stressful. Some practitioners feel that there is something ‘second best’ about the Hall Technique and that it is only for use when other techniques are not possible. This is not the case; it is based on a strong theoretical model that the carious lesion will arrest when isolated from the biofilm on the surface. I would go so far as to say that the Hall Technique, given the available evidence, is now the gold standard for the management of two surface lesions in primary molar teeth.
I firmly believe that the Hall Technique for the placement of preformed metal crowns is a real game changer. Our experience in Sheffield is that we can treat more, and younger, children than with conventional care. It is the standard treatment we teach our undergraduates who, when they graduate, are extremely competent in the appropriate placement of stainless steel crowns. It is so sad that so many of our graduates go into training practices that do not even own a box of preformed metal crowns and are unwilling to purchase one when asked to do so. As the article in this issue states, they are well accepted by patients, parents and dental professionals alike, so this is an unacceptable situation. Like everything, they take a little bit of practice, but if you haven't used this technique I cannot recommend it strongly enough.
Excellent though the Hall Technique is, there are occasions when it is not the best choice or even, perhaps, an option. For that reason, conventional preformed metal crowns are also discussed. Many practitioners think that they are difficult to use; this is not the case – if you can cut a disto-occlusal restoration the preformed metal crown preparation is child's play.
Similarly, there are two articles updating us on the materials available for intra-coronal restorations; we have now such a range of materials that no situation should be beyond our ability to restore satisfactorily.
Although caries is the most common problem our patients present with, it is not the whole of paediatric dentistry. There are four articles looking at different aspects of dental anomalies and their management. For example, the article on the management of opacities updates us on a condition which I feel we are increasingly being asked to treat and, I am afraid to say, many patients are told that the only solution is veneers, which is so far from the truth. Staying on the subject of preparation and enamel removal, there is also a very interesting article on the ethics of interproximal reduction in orthodontics. As a cariologist, I must admit I think enamel is a very precious material.
I hope you enjoy reading this issue but, returning to the main thrust of this Editorial, I really hope it makes you reflect on your practice and, if you do not routinely restore carious primary teeth, that you start to do so and that you use the Hall Technique of preformed metal crowns to do so.