Rationale for restoration of carious primary teeth:

A review.
D. Finucane
Dept. of Public and Child Dental Health, Dublin Dental University Hospital, and Private practice limited to Paediatric Dentistry,
Hermitage Medical Clinic, Lucan, Dublin, Ireland.

Introduction
Key words: Primary teeth, children, dental caries, restoration Early childhood caries (ECC) is the presence of one or more
Postal address: Dr D. Finucane. Dept. of Public and Child Dental Health,
cavitated or non-cavitated carious lesions before a childs
Dublin Dental School and Hospital, Lincoln Place, Dublin 2, Ireland 2.
sixth birthday. Severe early childhood caries (S-ECC) is
E-mail: david.finucane@dental.tcd.ie
smooth surface caries in a child less than three years old
[Ismail and Sohn, 1999] (Figures 1 and 2a-c). Recent reports
from several European countries, including Ireland, cast
Abstract doubt on the effectiveness of treatment of carious primary
BACKGROUND: The literature regarding dental and teeth, with the apparent rationale that they are shed before
systemic effects of Early Childhood Caries (ECC), con- causing symptoms in the majority of cases though when
sequences of leaving carious primary teeth untreated, such reports are scrutinised and what constitutes the major-
benefits of appropriate treatment, and concerns regarding ity is often dubious [Curzon, 2010].
dental treatment of young children and the potential for
dental anxiety, is reviewed. ECC has consequences, affect- Critical examination of the retrospective, Community-based
ing both the childs dental health and his/her general health. and Practice-based studies, which form much of the basis
This paper reviews the literature regarding ECC and its con- for the philosophy of non-restoration, or selective restoration
sequences (pain, sepsis, space loss, disruption to quality of asymptomatic carious primary teeth, reveals deficiencies
of life, failure to thrive, effects on intellectual development, [Tickle et al., 2002; Levine et al., 2002]: Data were collected
greater risk of new carious lesions in both primary and per-
solely from dental records, and so are only as reliable as the
manent dentitions, higher incidence of hospitalisation and
information entered on the patients records,
emergency visits, and increased treatment costs and time).
The effects of treatment of ECC are also reviewed; and n No patients were examined or interviewed,
concerns regarding purported associations between treat- n Radiographic examination was rarely performed,
ment of ECC and dental anxiety are addressed. SEARCH
METHOD: A Pub Med search was conducted of peer n There is no standardisation of restoration techniques
reviewed papers published in the English language in the practiced, nor of materials used,
years 1986-2011, using the search terms: Early Childhood n Thereis no comment on restorative techniques practiced,
Caries (ECC), Nursing Caries (NC), Consequences and nor on the quality of restorations placed,
ECC/NC, Treatment and ECC/NC, Treatment outcomes
and ECC/NC, Dental anxiety, Dental fears, Onset of dental n The experience of operators is not addressed.
anxiety/fear, Dental experiences and dental fear/anxiety. The quality of restorative work carried out on primary teeth
More than 300 articles were studied. Reference lists of the
has a bearing on its success or failure. Effective, evidence-
selected articles were also studied, and frequently quoted
articles were thus also located. Articles with small sample based restorative interventions for primary teeth exist;
size, poor or poorly described methodology, and unclear however inappropriate or poorly performed restorations,
or unsupportable conclusions were rejected. A representa- where the status of the pulp is not given due considera-
tive sample is presented in this paper, citing the articles tion, are likely to fail [Duggal, 2002; Evans, 2002; Fayle and
with greater levels of evidence, with a description of study Tahmassebi, 2002; Roberts and Attari, 2004]. The outcome
methods, where appropriate. CONCLUSION: This review measure of many studies, which cast doubt on the effec-
has demonstrated that ECC has implications for both the tiveness of treatment of ECC, is pain. However, as carious
dental and general health of the affected child. Such prob-
primary teeth can cause serious problems, sometimes with
lems are potentially serious, even life-threatening. Evidence
has been provided of the beneficial effects on dental and little or no pain, other outcome measures should also be
general health of dental rehabilitation of children with caries. considered [Low et al., 1999; Levine et al., 2002. The results
Causes of dental anxiety are multifactorial, and treatment of such retrospective studies [Tickle et al., 2002; Levine et
of ECC does not invariably contribute to dental anxiety, as al., 2002] contrast with those of most clinical trials and pro-
long as the childs experience of dentistry is not traumatic. spective studies of primary molar restorations [Stephenson
Children with the highest levels of dental disease are primar- et al., 2010].
ily from disadvantaged communities. Failure to adequately
treat their dental disease may further disadvantage these Objectives This paper reviews the evidence regarding
children. Paediatric Dental Societies, renowned experts in consequences of early childhood caries, treatment of
Paediatric Dentistry, and the Medical Protection Society carious primary teeth, and outcomes of treatment. Those
(Dental Protection, Professional Insurance) do not support who advocate a policy of non-intervention, in cases of ECC,
a policy of leaving carious primary teeth untreated.
often express concerns that treatment of young children
might result in dental anxiety. This topic is also reviewed.

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 D. Finucane

Figure 1. Definition of Early Childhood Caries [Ismail and Sohn, 1999] Table 1. Possible effects of Early Childhood Caries
as reported in the dental literature.
Early Childhood Caries (ECC):
n dmfs* 1 in any 10 tooth in a child 71 months old Possible Effects References
Severe Early Childhood Caries (S-ECC): of ECC
n Any sign of smooth surface caries in a child < 3 y.o. Pain Levine, et al. Br Dent J 2002
n dmfs 1 (smooth surface cavity) in 10 maxillary anterior teeth Shepherd, et al. Br Dent J 2002
at age 3-5 yrs Milsom, et al. Br Dent J 2002
n dmfs 4 (age 3 yrs) Slade Community Dent Health 2001
n dmfs 5 (age 4 yrs)
Sepsis Pine, et al. Br Dent J 2006
n dmfs 6 (age 5 yrs)
Unkel, et al. Pediatr Dent 1997
*d = non-cavitated or cavitated lesion, m = missing due to caries Lin Clin Pediatr 2009
Davies, et al. Clinical Intensive Care 2002
Figure 2. Intra-oral photographs of (Severe) Early Childhood Caries
showing: A. caries affecting maxillary primary incisors, B. caries Space loss Northway. J Am Dent Assoc 2000
affecting both maxillary primary incisors and molars, C. primary Laing, et al. Int J Paediatr Dent 2009
molars only ( photographs 2b and 2c courtesy of Dr E. Kratunova) Lin and Chang. J Clin Pediatr Dent 1998
Rao and Sarkar. J Indian Soc Pedod Prev
Dent 1999
A Padma Kumari, et al. J Indian Soc Pedod
Prev Dent 2006
Lin, et al. J Am Dent Assoc 2007
Disruption to Low, et al. Pediatr Dent 1999
quality of life Acs, et al. Pediatr Dent 2001
Cunnion, et al. J Dent Child 2010
Filstrup, et al. Pediatr Dent 2003
Sheiham. Br Dent J 2006
Casamassimo, et al. J Am Dent Assoc
2009
Disruption of growth Elice and Fields. Pediatr Dent 1990
and development Acs, et al. Pediatr Dent 1992
(failure to thrive)
Ayhan, et al. J Clin Pediatr Dent 1996
B Clarke, et al. Pediatr Dent 2006
Possible disruption Blumenshine, et al. J Publ Health Dent
of intellectual 2008
development Jackson, et al. Am J Public Health. 2011
Higher incidence Fleming, et al. Int J Paediatr Dent 1991
of hospitalisation Wilson, et al. Clin Pediatr 1997
and emergency visits
Sheller, et al. Pediatr Dent 1997
Oliva, et al. Pediatr Emerg Care 2008
Increased treatment Thikkurissy, et al. Am J Emerg Med 2010
costs and treatment
time
Greater risk of new Johnsen, et al. Pediatr Dent 1986
carious lesions in Grindefjord, et al. Caries Res 1995
C both primary and
OSullivan and Tinanoff. J Public Health
permanent dentitions
Dent 1996
Al-Shalan, et al. Pediatr Dent 1997
Skeie, et al. Int J Paed Dent 2006
Mejare, et al. Caries Res 2001

282 European Archives of Paediatric Dentistry 13 (Issue 6). 2012

 Restoration of Primary Teeth

Table 2. Benefits accruing from treatment of Early Childhood Caries unable to sleep, 27% had stopped playing, and 11% had
not been able to attend school. In a retrospective study of
Benefit References
dental records of 677 children aged 5-15 years with approxi-
Carious teeth are restored Stephenson, et al.
to function Caries Res 2010
mal primary molar caries, Milsom, et al. [2002] stated: the
majority of carious primary teeth exfoliate without causing
Pain and discomfort is Low, et al. Pediatr Dent 1999
resolved, or prevented pain. However, almost half the children whose records were
Acs, et al. Pediatr Dent 2001
analysed (48%) had experienced pain, with more than 1 in
Risk of sepsis is reduced Pine, et al. Br Dent J 2006 4 experiencing pain on 3 or more occasions, and 43% hav-
Space loss is lessened Laing, et al. Int J Paediatr Dent ing had extractions due to pain and sepsis. Those authors
or avoided 2009
acknowledged that: For those children who have decay in
The childs Oral Health-Related Low, et al. Pediatr Dent 1999 their primary molars, dental pain is a common finding.
Quality of Life improves Acs, et al. Pediatr Dent 2001
Cunnion, et al. J Dent Child Levine, et al. [2002] published a more refined retrospective
2010 study, of 481 case notes of patients with carious primary
Beneficial effects on the childs Acs, et al. Pediatr Dent 1992 teeth. In their study, in which standardised chart recording,
growth and development
and data extraction methods were used, the same opera-
The childs educational Blumenshine, et al. tor had treated all patients. Data were separated into caries
experience may be enhanced J Publ Health Dent 2008
affecting single surface, multiple surfaces, and pulp involve-
Jackson, et al. Am J Public
Health. 2011 ment. Their study revealed that:

n 18% of unrestored carious primary teeth had caused pain,

Figure. 3. Morbidity and mortality pyramid for Early Childhood n Painwas significantly more likely the earlier caries
Caries [Adapted from: Casamassimo, et al., 2009].
presented,
n Carious molars were the teeth most likely to cause pain,
n Teeth
with multiple carious surfaces or pulp exposure were
more likely to cause pain.

The authors cautioned that, while the outcome criteria of their

study focussed on pain, carious primary teeth could cause
painless dento-alveolar infection with potential for serious den-
tal and systemic consequences. They stressed that they were
not advocating a policy of not restoring carious primary teeth.

Slade [2001] found, in a critical analysis of epidemiological

studies of dental pain among children and adolescents and
that the prevalence of toothache correlated with caries experi-
ence. Correlations were stronger among lower socio-economic
groups, consistent with a 5 6% increase in probability of
toothache for each additional carious primary tooth.

Sepsis (Figure 4): A study by Pine, et al. [2006] in which

almost 7,000 Scottish children (mean age 5.3 yrs) with ECC
were examined, revealed:
Consequences of Early Childhood Caries The Surgeon
n Almost 5% of children had dental sepsis,
General of the USA has stated: you cannot be healthy
without good oral health [Satcher, 2000]. Early childhood n Those with sepsis had much higher caries experience
caries (ECC) has consequences, not only for the teeth of the (mean dmft 6.30) than those without sepsis (mean dmft
affected child, but also for the childs general health (Table 1, 2.36),
Figure 2). There are therefore consequences for both mor- n The greatest predictor of dental sepsis was untreated
bidity and mortality (Figure 3). decay, Failure to treat carious primary teeth markedly
Literature Review Pain: Shepherd, et al. [2002] interviewed increased the risk of sepsis. Those authors concluded that
589 eight-year-old children, and found that almost 50% had the findings from their study would not support a policy
suffered dental pain. The pain was of such severity that 73% of non-intervention for deciduous caries if oral sepsis is to
of those affected had been unable to eat, 31% had been be minimised.

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 D. Finucane

Figure 4. Examples of facial cellulitis, consequent to odontogenic A retrospective study, by Unkel, et al. [1997] of medical
infection. These children were seriously ill, and required records of child patients with facial cellulitis revealed:
hospitalisation. A. Cellulitis affecting right side upper face. There
is a risk of infection of the orbit, and spread to cavernous sinous; n 47% of facial cellulitis was of odontogenic origin,
B. Significant submandibular cellulitis which if untreated, this may
n Cellulitis
was more common in the upper facial region
progress to Ludwigs angina. C. Drainage of submandibular cellulitis,
under general anaesthesia (same patient as Figure 4B). (Figures 4B (65% of cases),
and 4C reproduced from Handbook of Pediatric Dentistry (2nd ed.), p.
n Odontogenic cellulitis was more common in the mixed
142. Sydney, Mosby 2003. Cameron AC, Widmer RP, eds. The author
gratefully acknowledges the permission of Profs. R. Widmer and A, dentition period (mean age 8.8 years),
Cameron, and Mosby Elsevier Ltd. to reproduce these images).
n Posterior
teeth were responsible for the highest number
(64.3%) of odontigenic cellulitis cases.
A
Dental sepsis can progress to cellulitis, and then to Ludwigs
angina, a rapidly progressing cellulitis of the floor of mouth
that compromises the airway; 1 in 3 cases of Ludwigs angina
occur in children and adolescents. The condition is potentially
fatal, with a mortality rate of 8-10 %, the risk being greater in
those with medical co-morbidity. Management requires spe-
cialist care, including IV antibiotics, securing of the airway,
and drainage. General Anaesthetic and Intensive Care facili-
ties are usually required [Davies et al., 2002; Lin et al., 2009].
A recent editorial in the Journal Pediatric Dentistry reports the
deaths of two American children as a result of complications
related to odontogenic infections [Adair, 2007].

Space loss. Premature loss of primary molars may contrib-

B ute to problems such as deviation of the mid-line, crowding,
dental impaction, ectopic eruption, and crossbite formation.

Longitudinal studies, with subjects who have had unilateral

premature loss of teeth, using the unaffected side as a con-
trol, [Lin and Chang, 1998; Rao and Sarkar, 1999; Padma
Kumari and Retnakumari, 2006; Lin et al., 2007; Northway,
2000; Laing et al., 2009] have revealed that:

n Following
early loss of a primary molar, adjacent molars
migrate mesially, while canines drift distally,
n Theextent to which migration of adjacent teeth occurs
depends on the timing of the tooth loss, the severity of
crowding, and the type of tooth that is prematurely lost,
n The reduction in arch length is more severe in the maxilla,
n Distal
movement of primary canines is greater in the
C mandible,
n Less
space is lost following early extraction of primary first
molars, compared to primary second molars,
n Eruptionof permanent maxillary canines can be impaired
following premature loss of primary first molars,
n Premature loss of a second primary molar, prior to eruption
of the first permanent molar, results in significant mesial
movement of the first permanent molar.
There are, to date, no prospective randomised controlled stud-
ies of the consequences of premature loss of primary teeth.

284 European Archives of Paediatric Dentistry 13 (Issue 6). 2012

 Restoration of Primary Teeth

Space maintainers may help to prevent change in arch length, there was a hierarchy of benefits, with the greatest improve-
following early loss of primary molars, however evidence ment noted in pain experience, followed by improved abilities
supporting their use is limited [Laing et al., 2009]. The United to eat and sleep. It was noteworthy that the children more
Kingdom (UK) National Clinical Guidelines in Paediatric Den- likely to have reported improvements in eating, sleeping, and
tistry recommended space maintenance under the following overall health, following treatment of ECC, were those who
circumstances [Rock, 2002]: were medically/developmentally-compromised.
n Followingloss of a primary second molar, in all but spaced A recent prospective multi-site study revealed that parents
arches, and, who had significantly poorer oral health reported children with
n Following loss of a primary first molar, where crowding is ECC and a worse perceived impact on physical functioning
greater than half a unit (3.5mm) per quadrant. and pain than caries-free children [Cunnion et al., 2010]. Post-
The disadvantages of space maintainers are that they are dental treatment, the children with ECC were rated by their
plaque retentive, they may impinge upon soft tissues, interfere parents as having significant improvements in oral health, and
with eruption of adjacent teeth, fracture, become dislodged, in physical, mental, and social functioning, compared with
or be lost. They require regular review by a dental practitioner. baseline. The authors concluded that childrens oral health
It is preferable, therefore, to retain primary molars, where pos- has significant impact on their well being, as assessed by their
sible, until their natural exfoliation [Laing et al., 2009]. parents. The positive effects of a dental intervention for the
children with ECC were significant at the 6- and 12-month
Disruption to Quality of Life (QOL) and effects of treatment follow-ups, and enhanced QOL in multiple domains. The
of ECC. Low, et al. [1999] carried out a questionnaire-based authors developed a new assessment instrument of QOL for
survey to investigate the impact of severe caries on QOL in this study, in which a large number of parents (n=501) reported
otherwise healthy young children (mean age 44 months). on their children.
Parents/guardians of children with severe ECC completed
questionnaires pre-treatment under general anaesthesia, In a longitudinal intervention study Filstrup, et al. [2003] inves-
and 4-8 weeks post-treatment. Pre-treatment, 48% of the tigated the effects of ECC on childrens oral health-related
children had complained of pain, 43% had problems eating QOL before and 4 weeks after its treatment, as assessed by
certain foods with 61% having reduced intake of food, 35% the children themselves, and by their parents/guardians. The
had experienced sleep disturbance, and 5% had reported study group comprised 69 otherwise healthy children with
problems of negative behaviour. Dental treatment had a sta- ECC (mean age 50.4 months), treated by full-mouth dental
tistically significant effect (p <0.001) on this cohort of patients, rehabilitation under GA (1 visit), or under local analgesia (LA)
in alleviating the complaint of pain, reversing certain eating with or without oral sedation (multiple visits). The control
problems, and improving sleep habits, while the effect on group was 43 healthy, age-matched children without caries.
behaviour was not statistically significant. Although all chil- The study revealed that:
dren in the sample were affected by S-ECC and required at
n Some children as young as 36 months are able to answer
least 1 pulpotomy or extraction, only 48% complained of pain.
questions about their own oral health and oral health-related
The authors pointed out the difficulty in measuring a young
childs degree of pain or discomfort, due to the childs level of QOL and, with increasing age, are able to do so reliably and
cognitive and language development. They noted that pain, validly,
caused by caries, could manifest in various ways: the child n Childrensself-reported oral health-related QOL is signifi-
may eat less, experience sleep disturbance, and/or exhibit cantly correlated with their oral health,
negative behaviour. They advised that, as some children do n Children with ECC had significantly worse oral health-
not complain verbally, it is equally important to assess pain related QOL than caries-free children, but this significantly
by indirect methods, such as through habits or behaviour. The improved post-treatment, Parents/Guardians evaluations
study demonstrated that ECC does affect the quality of life in of their childs oral health-related QOL are significantly
children, and that, though the children may not complain of related to their childs oral health.
pain, they manifest its effects by disrupted eating and sleep
Summarising the relationship of ECC and QOL:
habits.
n ECC negatively affects a childs QOL,
Acs, et al. [2001], who evaluated parents perceptions of out-
n Childrenwith ECC do not always complain of pain, but can
comes following their childrens complete dental rehabilitation
manifest disruption to QOL in other ways, such as eating,
under general anaesthesia (GA), reported similar improvement
sleeping, and behaviour problems,
in QOL. The children in their study were aged 3 to 5 years,
and were categorised upon presence of significant medical n Both parents/guardians and affected children are able to
or developmentally compromising conditions. Their data validly report on oral health-related QOL.
revealed that parents perceived improved QOL in their chil- n Treatment of ECC improves the childs QOL, Weight or
dren following comprehensive dental rehabilitation, and that height below the 3rd percentile for age,

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 D. Finucane

Disruption of Growth and Development (Failure to thrive) and Surveillance System of 2000. The data revealed that the
effects of treatment of ECC. Failure to thrive (FTT) is defined sample of children with S-ECC did not have a typical weight
by Elice and Fields, [1990] as: distribution. The percentage of study subjects in groups At
n Weight or height below the 3rd percentile for age risk for overweight and Overweight was lower than the
n Failure to maintain a previously established growth pat- reference sample, though the difference was not significant.
tern, and/or, However, 32% of those with S-ECC had unhealthy weights
n Growth failure of unknown origin. (being below the 5th or greater than the 85th percentile), of
which a significant number (11%) were underweight. The
Over the past two decades, several studies have revealed data also revealed that the AGS BMI percentile was not cor-
an association between ECC and failure to thrive. Acs, et
related with dmft, or the number of pulp-involved teeth, even
al. [1992] reviewed records of 115 children, aged 2-4 years,
after adjusting for confounding factors, though underweight
with otherwise non-contributory medical history, treated
children had the highest mean number of pulp involved teeth
for nursing caries using GA or sedation. They found that
(4.5) this was not statistically significant.
children with nursing caries weighed significantly less than
controls (approximately 1kg less), and were significantly A more refined study, by Clarke, et al. [2006] investigated the
more likely to weigh < 80% of their ideal weight. Affected nutritional status of 56 children (mean age 3.8 years), with
children, in the bottom 10th percentile for weight, were sig- S-ECC, attending hospital for complete oral rehabilitation
nificantly older than those children at or above their ideal under GA. Anthropometric measurements (height, weight,
weight, indicating that progression of nursing caries may
mid-arm muscle circumference indicative of protein stores,
adversely affect growth. Similar results were obtained in a
triceps skin fold a measure of fat storage), and blood
study by Ayhan, et al. [1996] in which young children (n=126)
samples (assessed for serum albumin, haemoglobin, mean
with rampant or nursing caries were found to be signifi-
corpuscular volume, and serum ferritin) were analysed. The
cantly lighter and shorter than controls without caries. The
mean weight of children with caries was between the 25th data revealed that ECC was a risk marker for under-nutrition
and 50th percentiles, whereas that of children without caries and iron deficiency. All nutrition tests detected malnourish-
was in the 50th 75th percentile. ment, with more cases of nutritional deficiency detected by
blood tests than by anthropometric measurements. 80%
The beneficial effect of dental rehabilitation on the weight
of children in the sample were found to have low iron lev-
and growth velocity of children with ECC was demonstrated
els. Anthropometric measurements revealed a significant
in a later study by Acs, et al. [1999]. Prior to dental rehabilita-
proportion of S-ECC children exhibited malnutrition, being
tion (under GA) children with ECC (aged 2.4 4.8 years at
baseline) weighed significantly less than the control group below the 90th percentile for Ideal Body Weight (17% of
(caries-free children), and were represented by significantly sample), and showing evidence of low fat stores (23%).
lower percentile weight categories. The authors advised that Despite the evidence of malnutrition from blood tests and
Delay in intervention (dental treatment) appears to have a anthropometry, tests of body mass index (BMI), using the 5th
tangible and adverse impact upon growth. percentile on childhood charts as a measure for malnutrition,
were insensitive and missed many cases.
Post-operatively, the children were reviewed for periods
between 10-28 months. Following dental rehabilitation, chil- The findings of Clarke, et al. [2006] that S-ECC is associated
dren with ECC had significantly increased growth velocities with anaemia are significant, as chronic iron deficiency in
until, after a time, there was no difference in age-adjusted infancy is associated with impaired brain development and
weights between the ECC and control groups, a phenomenon function, and can result in poor school performance. Cogni-
known as catch-up growth [Prader et al., 1963; Mosier, 1990]. tive scores and behaviour do not improve, even after iron
Using solely body weight as a measure of failure to thrive supplementation, if chronic iron deficiency occurs during
can lead to conflicting results, however, because some of the infancy [Lozoff et al., 1991;Lozoff et al., 2000; Pollitt, 2000;
food choices and eating behaviours that can put an individ- Saloojee and Pettifor, 2001].
ual at risk of caries are also risk factors for unhealthy weight.
Several papers have reported that chronic inflammation (e.g.
Sheller, et al. [2009] illustrated this in a retrospective, cross-
pulpitis, abscess) affects growth via metabolic pathways.
sectional case study of 293 otherwise healthy children (aged
2-6 yrs) who received treatment under GA for S-ECC [Sheller Cytokines (e.g. Il-1) can induce inhibition of erythropoiesis,
et al., 2009]. Age and gender-specific body mass index (AGS which leads to anaemia of chronic disease [Mears and
BMI) and dental status (dmft and number of pulp-involved Krantz, 1992; Mears, 2003; Sheiham, 2006]. Pain due to ECC
teeth, determined from operative reports and radiographs) may also contribute to failure to thrive due to reduced intake
were recorded for each subject. The comparison group (con- of food, and disturbed sleep, which affects glucosteroid pro-
trol) was a reference sample from the US Pediatric Nutrition duction and growth [Sheiham, 2006].

286 European Archives of Paediatric Dentistry 13 (Issue 6). 2012

 Restoration of Primary Teeth

Disruption of intellectual development. Blumenshine, et al. caries with provoked pain (12%), and cellulitis (9%). Only 9%
[2008] carried out a study in which randomly selected par- of those with caries presented without symptoms. Maxillary
ents of 2,871 schoolchildren were interviewed by telephone first primary molars were implicated in the development of
regarding their childs school performance, and oral health cellulitis in 40% of cases, while maxillary second primary
status. The relationship of oral health status and school molars were implicated in 17% of cellulitis cases.
performance was examined, while accounting for control
Of the 247 emergency hospital visits for non-traumatic
variables (sex, ethnicity, parental education, school type
dental complaints, over a 1-year period, Oliva et al. [2008]
[public/private], diagnosis of mental health disorder, diag-
found that 59% were by children younger than 5 years, 53%
nosis of behavioural health conditions, and diagnosis of
presented in pain, and 8% had severe infections, requiring
learning disability).
hospitalisation for intravenous antibiotics. Pain due to ECC
Parents were 2.3 times more likely to report poor school can lead to medical problems due to inappropriate use of
performance when a child had poor oral health in addition over-the-counter medications, which may ultimately result in
to poor general health. Children with either poor oral health the need for emergency hospital admission. Paracetamol is
or poor general health were 1.4 times more likely to have a frequently used for management of ECC-related pain in chil-
report of poor school performance. The study fell short of dren. Hepatotoxicity, due to excessive administration of the
implicating oral health as a stand-alone factor in poor school drug by parents, for management of their childs odontogenic
performance. pain, is a growing concern in paediatric emergency medical
care [Casamassimo et al., 2009; Squires et al., 2006].
A recently published follow-up study found that children
with poorer oral health status were more likely to experience Treatment time and financial costs. In terms of cost to a
dental pain, miss school, and perform poorly in school. The community, care of ECC consumes a significant amount of
authors stated that their findings suggest that improving chil- health-care budgets, due to the extent of the problem and
drens oral health status may be a vehicle to enhancing their the frequent need for use of emergency and general anaes-
educational experience [Jackson et al., 2011]. thetic facilities [Casamassimo et al., 2009]. A recent paper,
by Davis et al. [2010] investigated the costs involved in
Hospitalisation and Emergency visits. Emergencies related to
patients receiving emergency out-patient (ER) hospital treat-
dental caries in children constitute an important public health
ment (not including extractions or restorations) for dental
problem, with dental pain a common reason for attendance
problems, in Minneapolis-St. Paul, (USA). They found that
at hospital Accident and Emergency departments [Rowley
over a 1-year period there were over 10,000 visits to Hospital
et al., 2006; Casamassimo et al., 2009]. Previously, a retro-
Emergency Rooms (ER) for dental-related problems, 2% by
spective study by Fleming, et al. [1991] at the Royal Belfast
children aged less than 5 years, at an average cost of $459
Hospital for Sick Children, revealed that 4% of after-hours
per patient. Nearly 25% of the visits were second, or more,
emergency attendances were for dental problems. The ages
visits to the same ER for care of a dental problem, indicating
of the children attending with dental emergencies ranged
that while ER physicians treated acute pain and infection, the
from 1 month to 12 years 10 months, with 51% of attend-
underlying dental problem was often not resolved. Gift, et al.
ances by children aged 5 years or younger. Of the 407 dental
[1992] estimated 164 million hours of lost work time, and 51
emergencies (62% male), the most common complaint (49%)
million hours of lost school time as a result of dental prob-
was of toothache, with or without abscess. Of the 21% who
lems in the USA in 1989. A recent retrospective study also
presented with a dento-alveolar abscess, the majority were
from the USA, of medical records of children admitted for
related to the primary first molar.
treatment of odontogenic cellulitis, revealed that the mean
Wilson et al. [1997] found that of 1,459 children treated in length of stay in hospital was 2.08 days, while the mean cost
a Childrens Hospital for dental emergencies over a 1-year of hospitalisation was $4,166 [Thikkurissy et al., 2010].
period, 65% presented as a non-traumatic emergency. The
Greater risk of new carious lesions in both primary and
patients (52% male) had a mean age of 6.9 years. Dental car-
permanent dentitions. Many studies have demonstrated
ies was the aetiological factor prompting 73% of visits, with
an association between caries in pre-school children, and
33% of patients presenting with a dental abscess.
further caries development (incipient lesions becoming cavi-
In a review of emergency dental records over a 3- year period, tated, and/or development of new carious lesions) [Johnsen
Sheller, et al. [1997] found that 38% of attendances at the et al., 1986; Grindefjord et al., 1995; OSullivan and Tinanoff,
Childrens Hospital Seattle were for caries-related emergen- 1996; Al-Shalan et al., 1997]. In a longitudinal study, (n = 692
cies. The mean age of the children presenting in that study children, aged 2.5 years at baseline), Grindefjord et al. [1995]
with caries-related emergency was 6.4 years, and for 27% demonstrated that 92% of children diagnosed with caries
of the children, the emergency visit was their first contact at baseline, developed new carious lesions over a 1-year
with a dentist. The most frequent diagnoses were: abscess period. Of the children who were caries-free at baseline, 29%
with sinus tract (44%), caries with spontaneous pain (23%), developed caries during the study period. The difference

European Archives of Paediatric Dentistry 287

 D. Finucane

was significant (p<0.001). The majority of new lesions were They also observed that the greater the period of exposure
located on the occlusal surfaces of second primary molars. of the first permanent molars sound mesial surface to the
64% of the lesions, diagnosed at baseline as initial caries, carious lesion of the second primary molar, the greater is the
progressed to manifest lesions during the study period. The risk of developing caries on the sound surface. The risk of
children with caries at baseline developed significantly more developing mesial surface caries in first permanent molars
proximal lesions in molars than those who were caries free at was found to be different among the paired surfaces studied,
baseline. 56% of the children in this study were of immigrant indicating different cariogenic conditions at each proximal
background. The study indicated that children manifesting surface. The authors concluded that caries developing on
caries early in life exhibit high caries progression, as well as the mesial surface of mandibular first permanent molars
high risk for development of further new lesions. is primarily due to distal caries in second primary molars,
whereas in the maxillary teeth, other factors together with
It is well established that past dental caries experience in a
distal caries in the second primary molars, should be con-
child is the strongest single predictor of future caries [Grind-
sidered. They found that, if the distal surfaces of the second
efjord et al., 1996; Hausen, 1997; Skeie et al., 2006; Vadiakis,
primary molars are sound, the risk of developing mesial sur-
2008]. However, a recent prospective study by Fontana, et al.
face caries in first permanent molars is low.
[2011], in which 329 pre-school children (26 6 months old
at baseline) were examined, and subsequently re-examined Benefits accruing from treatment of ECC (Table 2). A recent
1 year later, revealed the risk factors for caries progression cohort study of data from more than 5,000 carious molars of
toward cavitation to be: 2,654 British children, aged 4-5 yrs at baseline, augmented
n family caries experience, with Dental Practice Board treatment data, assessed the
effect of restorative treatment on the likelihood of carious
n transmission-related behaviours,
teeth subsequently progressing to exfoliation or extraction
n dietary factors, health beliefs, and lower income. [Stephensen et al., 2010]. The study revealed that, beyond
Addition of clinical variables (baseline caries experience, 4 years of age, filling carious primary teeth substantially
dental plaque, gingivitis, mutans streptococci counts, pro- improves the likelihood of a successful outcome, (subse-
portion of mutans streptococci/total streptococci) did not quent natural exfoliation, without the need for extraction). It
improve the predictive power in this cohort of very young was found that more than 80% of all carious teeth that were
children. filled subsequently exfoliated naturally. The time of occur-
rence of caries was found to affect survival experience, with
In a prospective, longitudinal study of 186 children, examined
higher survival rates of those teeth in which caries occurred
at ages 5 and 10 years, Skeie, et al. [2006] found significant
later in life. When primary molars were filled, it was observed
correlations between the caries experience in the primary
that later occurrence of fillings was also associated with
and permanent dentitions, and between the primary second
higher survival rates. Studies demonstrating the beneficial
molars at baseline and the permanent teeth at 10 years old.
effects of treatment of ECC on the childs Quality of Life, and
The authors suggested that a clinically useful predictor at
Growth and Development, have been discussed previously
5 years of age for being at high caries risk at age 10 years-
[Low et al., 1999; Acs et al., 1999; Acs et al., 2001; Filstrup et
old, was primary second molars with more than two surfaces
al., 2003; Cunnion et al., 2010].
exhibiting caries.
Is treatment of ECC associated with dental anxiety? The
A retrospective study assessing annual bitewing radiographs
prevalence of dental fear in children has been reported as 5
of children (n=374), was conducted by Mejare et al. [2001] to
- 20% (mean 11%) [Klingberg and Broburg, 2007; Themessi-
investigate the influence of the caries status of the second
Huber et al., 2010]. Newton [2003] described a simple model
primary molars distal surface on the caries rate of the mesial
to explain the development of dental anxiety as:
surface of the proximal first permanent molar, from 6-12
n Directconditioning is a process whereby the experience
years of age. The study revealed that the caries rate for the
first permanent molar depended on the status of the distal of traumatic events or treatments is associated with
surface of the proximal second primary molar. The caries rate development of fear - the child learns to associate pain
for the mesial surface of the first permanent molar increased and distress with the dental setting. However, if the child
15 times if the distal surface of the proximal second primary has positive dental experiences, he/she will learn to have
molar had enamel/enamel-dentine caries, compared to a a positive attitude towards dental treatment.
sound distal surface of the second primary molar. n Latent inhibition is a process whereby, if positive dental
experiences are followed by a traumatic event, prior learn-
In a 4-year prospective study, (assessing annual bitewing
ing inhibits the childs development of dental fear.
radiographs of 196 children, aged 6-8 years at baseline),
Vanderas, et al. [2004] found that the presence of distal car- Dental anxiety disorders are, however, of multifactorial and
ies in second primary molars increased the risk of developing complex origin [Raadal et al., 2002]. Many people with no
mesial surface caries in the proximal first permanent molars. dental fear have had negative dental experiences, while

288 European Archives of Paediatric Dentistry 13 (Issue 6). 2012

 Restoration of Primary Teeth

some with considerable dental fear fail to recall any trau- In a cross-sectional questionnaire-based study of 5 year-old
matic incidents. A study by Davey [1989] revealed that children in which parents reported regarding their own, and
subjects who reported never having had anxieties about their childs anxiety, 10.8% judged their child to be dentally
dental treatment were less likely to have had a painful dental anxious [Milsom et al., 2003]. The childrens dental anxiety
treatment than those who did report an anxiety. Those who was associated with symptomatic, irregular attendance pat-
did report a painful dental experience, but did not acquire tern, a history of dental extraction, and having a dentally
anxiety, reported a history of dental treatment favourable to anxious parent. Dentally anxious children had significantly
the operation of latent inhibition. Under some conditions, in higher caries experience than those who were judged not to
which latent inhibition should have precluded the acquisition be anxious (dmft 2.58 v dmft 1.12). A history of restoration of
of a dental fear, anxiety appeared to be acquired because teeth was not found to be a significant predictor of anxiety
a very painful experience had attenuated the latent inhibi- in this cohort of children. The cause and effect dynamics of
tion process. Davey concluded that, those subjects, whose these relationships were not determined. The authors noted
dental anxiety did not remit, reported significantly more that children who are sporadic attenders often present in
painful and traumatic dental experiences than those whose pain, when extraction may be the only possible treatment
anxiety did remit. option. Such a pattern of attendance and treatment may
perpetuate dental anxiety.
A questionnaire-based survey by Armfield [2010], of more
than 1,000 adults chosen at random, revealed that nega- Locker, et al. [1996] carried out a questionnaire-based cross-
tive dental experiences were significantly associated with sectional study in which more than 3,000 randomly selected
dental fear. However, cognitive perceptions of uncontrol- adults participated. Data were obtained regarding negative
lability, unpredictability, danger, and disgust were superior dental experiences, and their relationship to dental anxiety.
predictors of dental fear, compared with negative dental Three quarters of those surveyed reported direct negative
experiences. This, according to the author, supports the experiences, of which 71% were painful, 23% frightening,
Cognitive Vulnerability Model Armfield [2006], which pro- and 9% embarrassing. Only 37% of the negative experiences
poses that a persons perception of a stimulus or situation occurred during childhood, with 23% occurring during ado-
is the important factor in determining anxiety or fear, rather lescence, and 40% in adulthood. The relationship between
than any particular experiences that he/she may have had. negative experiences and dental anxiety was found to be
strong. Those who experienced all 3 negative experiences
A longitudinal study by Raadal, et al. [2002] investigated
(pain, fright, embarrassment) were at 22.4 times greater risk
the relationship between caries prevalence at 5 years old,
of dental anxiety than those with no negative experience.
and dental anxiety at 10 years of age. Dental anxiety was
The data suggested that, while painful experiences were
measured at age 10 years by means of a psychometric
predictive of dental anxiety, other types of experience, alone
questionnaire, which parents completed by interviewing their
or in combination with pain, showed a stronger relationship.
children. At 5 years of age, the majority (68%) of children
The nature of the unpleasant experiences was found to be
who subsequently exhibited high dental anxiety at 10 had
more important than the age at which they occurred, in pre-
mean dmfs of 10.7, while those with low anxiety had sig-
dicting dental anxiety. The authors advised that the study
nificantly lower dmfs, (mean 4.7). Those authors concluded
results should be interpreted with caution as, though they
that children with many carious lesions at 5 years of age are
were consistent with a causal role, there could be no cer-
at high risk of being dentally anxious at 10. They proposed
tainty that the reported negative events preceded the onset
that the most likely reason is classical conditioning (including
of anxiety. They advised that the causal direction might be
procedural pain and other negative experiences during den-
opposite; that is, anxious subjects might be more likely to
tal treatment, as the unconditioned stimuli), but they offered
characterise previous dental experiences as negative, even if
no proof of this. The authors stated that the children sur-
they did not play an aetiological role in their anxiety.
veyed had received treatment of their carious teeth between
ages 5 and 10, and thus concluded that, the study supports A later study by Locker, et al. [1999] aimed to identify the
the assumption that treatment of caries in early childhood age of onset of dental anxiety, and to identify differences
represents a risk for acquisition of dental anxiety. Robust by age of onset with respect to aetiological factors, such as
proof to support their conclusion, however, was not demon- negative dental experiences, family history of dental anxi-
strated. They cautioned that high caries levels at age 5 years ety, and general psychological states. In this second study
do not necessarily lead to dental anxiety, as nearly 75% of 1,420 subjects responded to mailed questionnaires, which
5-year-olds with dmfs of 6 or greater did not report high den- revealed that 16.4% were dentally anxious. Half of the study
tal anxiety at 10 years of age, so demonstrating that dental population reported onset of dental anxiety in childhood,
anxiety is of multifactorial origin. They also advised that, as one-fifth in adolescence, and almost one-third in adulthood.
anxiety at 5 years of age was not measured, the findings at Logistic regression analysis indicated that negative dental
10 years of age are not a follow-up of dental anxiety during experiences were predictive of dental fear regardless of
this period. age of onset, while a family history of dental anxiety was

European Archives of Paediatric Dentistry 289

 D. Finucane

predictive of childhood onset only. Subjects whose onset the early introduction of children to dental healthcare and
of dental anxiety was in adolescence were characterised by prevention, in an attempt to prevent caries [EAPD, 2008;
trait anxiety, while those with onset in adulthood were char- AAPD, 2008; ECOH, 2008]. In addition to likely benefits in
acterised by multiple severe fears and symptoms indicative reducing onset of anxiety, early intervention to prevent and
of psychiatric problems. The authors concluded that sub- treat ECC has been modelled as both cost-effective and
jects with onset of dental anxiety in childhood were more cost saving [Ramos-Gomez and Shepard, 1999; Zavras et
likely to fall into the exogenous aetiological category, while al., 2000; Casamassimo et al., 2009].
those with adult-onset anxiety were more likely to fall into the
In summary, although it is often stated that treatment of ECC
endogenous category.
may contribute to dental anxiety, this is not invariably true.
According to Milgrom and Weinstein [1993] the conse- Traumatic early dental experiences seem more likely than
quences of traumatic dental experiences are dependent non-traumatic ones to result in anxiety, however the causes
on the context in which they occur. This means that pain of dental anxiety are multifactorial.
inflicted by a dentist is likely to have less psychological
impact if the dentist is perceived as caring, rather than one Conclusions
who is cold and controlling. This highlights the importance
This review has demonstrated that early childhood caries
of good, appropriate communication and behaviour man-
has implications for both the dental and general health of
agement techniques, which enhance the childs trust and
the affected child. Such problems are potentially serious,
feelings of control.
even life-threatening. Evidence has been provided of the
A recent study in which 1,303 children aged 5-12 years were beneficial effects on dental and general health of dental
examined and interviewed in school, revealed that those rehabilitation of children with caries. Causes of dental anxi-
who had previous restorative dental care were significantly ety are multifactorial, and treatment of early childhood caries
less anxious than those who had no previous dental care does not invariably contribute to dental anxiety, as long as
[Nicolas et al., 2010]. This indicates that early dental inter- the childs experience of dentistry is not traumatic. Children
vention, if properly managed and not stressful, can have a with the highest levels of dental disease are primarily from
positive impact on dental fear. It is not the purpose of this disadvantaged communities. Failure to adequately treat
paper to describe behaviour management techniques for their dental disease may further disadvantage these children
dental care of children. The reader is referred to relevant [Acs et al., 1992; Ayhan et al., 1996; Locker 2007; Clarke
articles and texts [Wright et al., 1987; Fayle and Tahmassebi et al., 2006; Casamassimo et al., 2009]. Paediatric Dental
2003; Welbury et al., 2005; Cameron and Widmer, 2008]. Societies, renowned experts in Paediatric Dentistry, and the
In a recent meta analysis of the relationship between paren- Medical Protection Society (Dental Protection, UK) do not
tal and child dental fear, the majority of the 43 international support a policy of leaving carious primary teeth untreated
experimental studies included confirmed a link between [Fayle et al., 2001; AAPD, 2009; Curzon, 2010; Kandiah et
parental and child dental fear, which was most evident in al., 2010; Dental Protection Ltd, 2010].
children aged 8 years or younger. The studies varied widely,
Finally, a quote from Professor Aubrey Sheiham [2006] is
however, in terms of research design, methods, age of chil-
particularly pertinent: Treating caries in pre-school children
dren, and reported link between parental and child dental
would increase growth rates and the quality of life of mil-
fear [Themessl-Huber at al., 2010]. Although a small number
lions of children. Prevention of caries would be preferable
of studies have established associations between negative
to treatment, but the high level of untreated caries world-
dental experiences and dental fear [Davey, 1989; Locker et
wide suggests that current preventive approaches are not
al., 1996; Locker et al., 1999; Milsom et al., 2003], these,
working.
according to Armfield, [2010] are the exception rather than
the rule. This does not, of course, negate the possible influ-
Acknowledgement
ence of aversive experiences in the aetiology of dental fear.
This article is reproduced with full permission of the editor of the Journal of
If difficult procedures are more likely to lead to dental anxi- the Irish Dental Association from the original review article published in 2012
ety, then dental intervention and where necessary treatment, by Finucane D. Rationale for restoration of carious primary teeth: A review. J
Ir Dent Assoc 2012; 58:31-42.
should ideally occur as early as possible before problems
escalate. Early intervention would result in easier, less trau- References
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