Treatment of Child Caries: Guidance Changes
- Details
- Published: Thursday, 27 March 2025 09:53
- Written by Peter Ingle
- Hits: 1656
The four nations of the UK may need four health ministers and four different systems of payment for NHS dental care, but they seem to manage with a single source for a good deal of clinical guidance.
The Scottish Dental Clinical Effectiveness Programme (SDCEP) has provided guidance on a range of topics including the Oral health management of patients prescribed bisphosphonates, which has become the UK ‘go-to’ document on this topic.
Amongst their other established publications is the Prevention and Management of Dental Caries in Children, first issued in 2010.This has now been updated and news of its arrival has been included in recent communications from the GDC and CGDent.
Much of the guidance remains unchanged from the previous edition but changes include a new section on silver diamine fluoride (SDF), a widening of the indications for vital pulp therapy in permanent teeth, and references to ‘values-based care/Realistic Dentistry’ and sustainability.
Realistic Medicine, of which Realistic Dentistry forms part, is the Scottish Government’s approach to delivering values-based health and care. It has six principles: Shared Decision Making, Personalised Approach to Care, Reduce Harm and Waste, Reduce Unwarranted Variation, Manage Risk Better, Become Improvers and Innovators.
SDCEP expect that adopting Realistic Medicine will align with environmental considerations and efforts to achieve more sustainable healthcare. Through the recommendations and advice the guidance follows current trends particularly within the present direction of NHS dentistry. Prevention is promoted with a view to reducing the provision of more complex care. Risk based individual care is also promoted with a view to increasing intervals between appointments for some patients. There is advice to avoid interventions not supported by evidence. These three approaches should also reduce environmental impact and carbon footprint.
The summary for managing caries in primary teeth is:
“For a child with a carious lesion in a primary tooth, choose the least invasive, feasible caries management strategy, taking into account: the time to exfoliation, 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. (Strong recommendation; low certainty evidence)”
“For a child in pain with pulpitis in a vital primary tooth with irreversible symptoms and no evidence of dental abscess, consider carrying out a pulpotomy to preserve the tooth and to avoid the need for an extraction. (Conditional recommendation; moderate certainty evidence)”
For a child with a carious lesion in a permanent tooth the guidance also advises similar considerations, with lifetime prognosis of the tooth, orthodontic considerations and occlusal development, added. (Strong recommendation; low certainty evidence) “For a child or young person in pain due to pulpitis in a vital permanent tooth with irreversible symptoms and no evidence of dental abscess, consider carrying out a pulpotomy to preserve the tooth and to avoid the need for an extraction. (Conditional recommendation; low certainty evidence)”
Application of SDF can be used as part of non-restorative cavity control. The silver is bactericidal and disrupts the cariogenic biofilm while fluoride promotes remineralisation of the tooth surface. There is very low to low certainty evidence of the effectiveness of SDF in arresting caries in primary teeth compared to no treatment. In addition it is uncertain whether SDF is more effective than comparative treatments, including fluoride varnish. The guidance does state that there is insufficient evidence to support the use of SDF for caries prevention.
SDF is still only licensed in the UK for the management of dentine hypersensitivity. Using SDF for the arrest of dental caries counts as “off-label” and requires explanation of what off-label use means to the patient and their parent/carer. Part of that conversation will need to include SDF permanently discolouring carious tooth tissue, and that it also may temporarily cause brown staining of the soft tissues.
The new guidance is accompanied by a Statement of intent which states that: “As guidance, the information presented here does not override the clinician’s right, and duty, to make decisions appropriate to each patient with the patient’s valid consent. It is advised that significant departures from this guidance, and the reasons for this, are fully documented in the patient’s clinical record.”
Despite the advice to avoid interventions not supported by evidence, the extracts quoted show that there are serious gaps in the amount of strong evidence to support much of this guidance. Nonetheless those dental professionals who do not follow its prescriptions may find that themselves having to justify their straying from the SDCEP line.
Prevention and Management of Dental Caries in Children 3rd Edition Guidance in Brief
You need to be logged in to leave comments.
Report
My comments