European Archives of Paediatric Dentistry

3 downloads 0 Views 2MB Size Report
of the Irish Dental Association, Professor Leo Stassen. European ...... Jakobs W, Ladwig B, Cichon P, Ortel P, Kirch W. Serum levels of articaine 2% and 4% in ...
ISSN: 1818-6300

Official Journal of the European Academy of Paediatric Dentistry

Volume 13 (Issue 6) December 2012

European Archives of Paediatric Dentistry

ISSN 1818-6300

European Archives of Paediatric Dentistry Official Journal of the European Academy of Paediatric Dentistry

European Archives of Paediatric Dentistry

EDITOR IN CHIEF Jack Toumba (England) Paediatric Dentistry, Leeds Dental Institute, Leeds, UK LS2 9LU +44 (0)113 343 3141 [email protected] Editor Emeritus Martin Curzon (England) [email protected] scientific advisORS Goran Koch (Sweden) [email protected] Luc Martens (Belgium) [email protected] Marie-Cecile Maniere (France) maniere.marie-cecile@ chru-strasbourg.fr Assistant Editors Karin Weerheijm (Netherlands) (Special Issues) [email protected] John Roberts (England) (Copy Editor) [email protected] Nicky Kilpatrick (England) [email protected] Nick Lygidakis (Greece) [email protected] EDITOR EAPD WEB PAGE Elias Berdouses (Greece) [email protected] Published by: European Academy of Paediatric Dentistry Journal Office address: Dept. Paediatric Dentistry, Leeds Dental Institute, Clarendon Way, Leeds, England LS1 9JT Designed by: www.roomfordesign.co.uk Produced by: Print and Copy Bureau, University of Leeds Individual Annual Subscription:............... €175 Institutional Annual Subscription:............ €350 Individual Single Issue:.............................. €60 Institutional Single Issue:........................... €90

EAPD Board President: Monty Duggal (UK) [email protected] Past President: Norbert Kraemer (Germany) [email protected] President-Elect: Paddy Fleming (Ireland) [email protected] Secretary: Elias Berdouses (Greece) [email protected] Treasurer: Teresa Leisebach (Switzerland) [email protected] EDITORIAL BOARD AND COUNCILLORS Belgium: Jeroen Vandenbulcke (2012) [email protected] Croatia: Domagoj Glavina (2012) [email protected] Cyprus: Maria Spyridonos (2008) [email protected] Czech Republic: Romana Ivančaková (2012) [email protected]

Norway: Anne Skaare (2012) [email protected] Poland: Katarzyna Emerich (2008) [email protected] Portugal: Luis Pedro Ferreira [email protected] Russia: Larisa-Petrovna Kiselnikova (2010) [email protected] Slovenia: Rok Kosem (2008) [email protected] Serbia: Vesna Zivojinovic (2008) [email protected] Spain: Miguel Hernandez (2012) [email protected] Sweden: Chister Ullbro (2010) [email protected] Switzerland: Richard Steffen (2008) [email protected] Turkey: Figen Seymen (2012) [email protected] UK: Thayalan Kandiah (2012) [email protected]

Denmark: Dorte Haubek (2010) [email protected]

Observing Councillors Austria: Verena Buerkle (2006) [email protected]

Finland: Vuokko Anttonen (2012) [email protected]

Israel: Karin Ziskind (2002) [email protected]

France: Corinne Tardieu (2012) [email protected]

Romania: Rodica Luca (2008) [email protected]

Germany: Jan Kuhnisch (2010) [email protected] Greece: Katerina Kavvadia (2008) [email protected] Ireland: Michael Brosnan (2012) [email protected] Italy: Alessandra Majorana (2012) [email protected] Netherlands: Peter Lansen (2012) [email protected]

For subscriptions contact the Editor on [email protected]

European Archives of Paediatric Dentistry

277

European Archives of Paediatric Dentistry

Contents Guest Editorial: Quality care for children under threat

279

Review Articles D. Finucane

Rationale for restoration of carious primary teeth: A review.

281

R. Leith, K. Lynch, A.C. O’Connell

Articaine use in children: A review.

293

S.M. Cudney, A.R. Vieira

Molecular factors resulting in tooth agenesis and contemporary approaches for regeneration: A review.

297

I. Thorild, B. Lindau, S Twetman

Long-term effect of maternal xylitol exposure on their children’s caries prevalence

305

G. Ekbäck, S. Ordell, L. Unell

Can caries in the primary dentition be used to predict caries in the permanent dentition? An analysis of longitudinal individual data from 3-19 years of age in Sweden

308

M.O. Folayan, O.O. Sofola, A.B. Oginni

Caries incidence in a cohort of primary school students in Lagos State, Nigeria followed up over a 3 years period

312

Short Communication J.I. Foley

Dental students consistency in applying the ICDAS system within paediatric dentistry

319

Case Report Barry S, Allotey J, Brundler A.M, Duggal M.S

Case Report: Cystic Hygroma

278

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

323

European Archives of Paediatric Dentistry

Guest Editorial: Quality care for children under threat Over the past 50 years great advances have been made within Paediatric Dentistry for the dental care of children in many countries both in Europe and worldwide. As a result we can be justly proud that today most children, probably at least 80%, experience little or no dental caries and reach adulthood with acceptable primary and permanent dentitions. Thanks to discoveries and advances in preventive paediatric dental care, severe caries is confined to less than a fifth of children in most populations. We have evidence of which groups of children are more likely to be caries-prone and who are mainly located in disadvantaged groups. Those in dental societies/academies concernd with children’s oral health continue to work hard to develop strategies to bring quality care to this last 20%. We are not complacent about this and continue to strive, as clinicians, teachers and researchers to find ways of reducing the prevalence of dental diseases and improving oral health in children.

Thunderclouds are now unfortunately imminent, challenging the current systems of dental care for children and threatening to undermine the advances that have occurred in providing quality paediatric dental care with well researched outcomes. The suggested delivery of care, by our adversaries, appears to be at the level that was being provided in the UK and elsewhere in Europe before World War II. This statement is not made lightly because several reports in recent years have recommended changes to the way paediatric dental care is delivered, valued and paid for. These reports have completely ignored the considereable body of research showing the improved oral health-related quality-of-life outcomes that care achieves in the primary dentition. These challenges have come from within the dental profession and from government funding and private insurance agencies. The dentists who make these challenges appear to rely on misguided arguments that children do not suffer pain from teeth, that restorations in primary teeth do not survive, chronic infection is not a problem, quality of life is not affected by oral sepsis or that dental care for all children results in significant

anxiety. For the funding agencies, these opinions are seductive as it encourages moves to reduce the costs of dental care in these financially hard times. These adverse statments are appearing in many countries. Recently articles and statements have appeared in Ireland, The Netherlands and United Kingdom, amongst others within Europe, and worldwide colleagues report similar events in North America, New Zealand and Australia. The details of these claims that paediatric dental care is excessive fall into two groups. Quality preventive and restorative oral health care is not necessary. In this approach dentists, some in private practice and/or some in dental public health state that attempting to restore children’s teeth is unnecessary for several reasons. A prominent claim is the hoary old one - ‘…primary teeth fall out anyway and therefore restoration is a waste of time’. The proponents of this view are largely dentists who have chosen not to develop skills to manage and treat children often because they do not like treating children or never treat children anyway. Those in family practice may want to keep the adults but do not have the patience or skills to care for the children but realise that having the children in their practices keeps the parents and other family members. Thus they take an avoidance strategy and salve their consciences with their non-treatment argument. Related to this claim is ‘attempting restorations in children is very distressing, making them both upset and dentally phobic’. This statement only tells us those who make this argument are both unaware of the research and are unwilling to develop there own skills, particularly with behaviour management, to actually work with children to let them develop the acceptence to be able to have dentitsry for the rest of their lives. They are also often unwilling to refer children to paediatric dentists who have excellent skills to provide care when children have difficiulties coping. Recently some of the proponents of this approach to dental care of children have advocated ‘self-cleansing’. This means taking

European Archives of Paediatric Dentistry

279

European Archives of Paediatric Dentistry a dental bur and slicing away the tooth structure of primary molars mesially and distally, so allowing saliva to access the carious surfaces and improve the chances of remineralising early lesions. What would our orthodontic colleagues think of the recommendation of the wholesale removal of the leeway space that nature has provided for the permanent dentition by allowing subsequent mesial drift? It is a totally obsolete idea. Restoration of primary teeth is costly and not cost-effective. Those promoting this view come from different backgrounds including those who are providing some clinical care for children and those who are in management positions. Their motivation tends to be related to their budgets and financial constraints. These people know the cost of everything and the value of nothing, but appear to disregard the oral health related outcomes. They ignore or undervalue that the maintenance of a primary dentition in good function maintains the space for the eruption of the permanent teeth and decreases some of the risk of caries in the permanent dentition. By advocating this ‘supervised neglect’ they are sending a very clear message to people and particularly families that high quality dental care is unimportant and that oral health has no relevance to general health. It is difficault to understand how anyone in the dental profession could be trying to isolate oral health from the promotion of general health in this way, particularly for children. In many European countries the dental care of children is provided by the state at government, national or local, cost. There is always the conflict that such agencies want care but at minimal cost. Those involved with managing this funding are required to ‘spend’ it wisely. But they appear in some instances to be failing in their responsibility to apply the finance related to the most appropriate outcomes when the very research that suports the care is either ignored, or dismissed. But short term savings in children inevitably will mean long term higher costs to deal with the ravages of dental disease in adults. Other proponents of doing as little as possible for the lowest expense are located within funding agencies who always want lower costs. This ignores the longer-term increased costs of low quality care. It behoves these

280

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

agencies to be supporting good quality research to investigate outcomes of care to support their funding models. It is totally negligent, especially when public money is being applied, to refuse funding because the evidence is not present. Where is their evidence that their funding is appropriate? Speaking out. As paediatric dentists who care passionately about children’s oral health we must all be vigilant and speak out loudly and continuously to challenge these retrograde moves. As noted at the beginning of this editorial paediatric dental specialists have worked with determination in research, teaching and practice over many decades to provide excellent quality care for children. We must ensure that there is no going back and that we are not overwhelmed by those in our dental profession who diminish our specialty. It is curious that these challenges to care are not occurring for other patient groups and that they are being made against children who have no voice of their own. Children deserve nothing less than we act as their advocates in this. Within this issue of the EAPD are included a number of papers concerned with clinical care that will add to our ability to provide quality care. In addition, and uniquely, we publish, with permission, a paper from the Irish Dental Journal by David Finucane entitled ‘Rationale for the restoration of carious primary teeth: A review’. This paper is a most comprehensive discussion of the subject and substantially referenced. This is most pertinent to the developments outlined here and the Editors felt that it should be more widely publicised. Hence our inclusion of a copy of this paper herein. It answers many of the criticisms of our quality approach noted above and should be kept as a valuable resource statement of why quality really does matter. Martin Curzon Acknowledgements The review paper by Dr David Finucane is reproduced herein by kind permission of the Editor of the Journal of the Irish Dental Association, Professor Leo Stassen.

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. Key words: Primary teeth, children, dental caries, restoration Postal address: Dr D. Finucane. Dept. of Public and Child Dental Health, Dublin Dental School and Hospital, Lincoln Place, Dublin 2, Ireland 2. E-mail: [email protected]

Abstract BACKGROUND: The literature regarding dental and systemic effects of Early Childhood Caries (ECC), consequences of leaving carious primary teeth untreated, benefits of appropriate treatment, and concerns regarding dental treatment of young children and the potential for dental anxiety, is reviewed. ECC has consequences, affecting both the child’s dental health and his/her general health. This paper reviews the literature regarding ECC and its consequences (pain, sepsis, space loss, disruption to quality of life, failure to thrive, effects on intellectual development, greater risk of new carious lesions in both primary and permanent dentitions, higher incidence of hospitalisation and emergency visits, and increased treatment costs and time). The effects of treatment of ECC are also reviewed; and concerns regarding purported associations between treatment of ECC and dental anxiety are addressed. SEARCH METHOD: A Pub Med search was conducted of peer reviewed papers published in the English language in the years 1986-2011, using the search terms: Early Childhood Caries (ECC), Nursing Caries (NC), Consequences and ECC/NC, Treatment and ECC/NC, Treatment outcomes and ECC/NC, Dental anxiety, Dental fears, Onset of dental anxiety/fear, Dental experiences and dental fear/anxiety. More than 300 articles were studied. Reference lists of the selected articles were also studied, and frequently quoted articles were thus also located. Articles with small sample size, poor or poorly described methodology, and unclear or unsupportable conclusions were rejected. A representative sample is presented in this paper, citing the articles with greater levels of evidence, with a description of study methods, where appropriate. CONCLUSION: This review has demonstrated that ECC has implications for both the dental and general health of the affected child. Such problems are potentially serious, even life-threatening. Evidence has been provided of the beneficial effects on dental and general health of dental rehabilitation of children with caries. Causes of dental anxiety are multifactorial, and treatment of ECC does not invariably contribute to dental anxiety, as long as the child’s experience of dentistry is not traumatic. Children with the highest levels of dental disease are primarily from disadvantaged communities. Failure to adequately treat their dental disease may further disadvantage these children. Paediatric Dental Societies, renowned experts in Paediatric Dentistry, and the Medical Protection Society (Dental Protection, Professional Insurance) do not support a policy of leaving carious primary teeth untreated.

Introduction Early childhood caries (ECC) is the presence of one or more cavitated or non-cavitated carious lesions before a child’s sixth birthday. Severe early childhood caries (S-ECC) is 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 doubt on the effectiveness of treatment of carious primary teeth, with the apparent rationale that they are shed before causing symptoms “in the majority of cases” though when such reports are scrutinised and what constitutes the “majority” is often dubious [Curzon, 2010]. Critical examination of the retrospective, Community-based and Practice-based studies, which form much of the basis for the philosophy of non-restoration, or selective restoration of asymptomatic carious primary teeth, reveals deficiencies [Tickle et al., 2002; Levine et al., 2002]: Data were collected solely from dental records, and so are only as reliable as the information entered on the patients’ records, n No

patients were examined or interviewed,

n Radiographic

examination was rarely performed,

n There

is no standardisation of restoration techniques practiced, nor of materials used,

n There

is no comment on restorative techniques practiced, nor on the quality of restorations placed,

n The

experience of operators is not addressed.

The quality of restorative work carried out on primary teeth has a bearing on its success or failure. Effective, evidencebased restorative interventions for primary teeth exist; however inappropriate or poorly performed restorations, where the status of the pulp is not given due consideration, are likely to fail [Duggal, 2002; Evans, 2002; Fayle and Tahmassebi, 2002; Roberts and Attari, 2004]. The outcome measure of many studies, which cast doubt on the effectiveness of treatment of ECC, is pain. However, as carious primary teeth can cause serious problems, sometimes with little or no pain, other outcome measures should also be considered [Low et al., 1999; Levine et al., 2002. The results of such retrospective studies [Tickle et al., 2002; Levine et al., 2002] contrast with those of most clinical trials and prospective studies of primary molar restorations [Stephenson et al., 2010]. Objectives This paper reviews the evidence regarding consequences of early childhood caries, treatment of carious primary teeth, and outcomes of treatment. Those who advocate a policy of non-intervention, in cases of ECC, often express concerns that treatment of young children might result in dental anxiety. This topic is also reviewed.

European Archives of Paediatric Dentistry

281

D. Finucane Figure 1. Definition of Early Childhood Caries [Ismail and Sohn, 1999] Early Childhood Caries (ECC): n dmfs* ≥ 1 in any 10 tooth in a child ≤ 71 months old Severe Early Childhood Caries (S-ECC): sign of smooth surface caries in a child < 3 y.o. n dmfs ≥ 1 (smooth surface cavity) in 10 maxillary anterior teeth at age 3-5 yrs n dmfs ≥ 4 (age 3 yrs) n dmfs ≥ 5 (age 4 yrs) n dmfs ≥ 6 (age 5 yrs) n Any

Table 1. Possible effects of Early Childhood Caries as reported in the dental literature. Possible Effects of ECC

References

Pain

Levine, et al. Br Dent J 2002 Shepherd, et al. Br Dent J 2002 Milsom, et al. Br Dent J 2002 Slade Community Dent Health 2001

Sepsis

Pine, et al. Br Dent J 2006 Unkel, et al. Pediatr Dent 1997 Lin Clin Pediatr 2009 Davies, et al. Clinical Intensive Care 2002

Space loss

Northway. J Am Dent Assoc 2000 Laing, et al. Int J Paediatr Dent 2009 Lin and Chang. J Clin Pediatr Dent 1998 Rao and Sarkar. J Indian Soc Pedod Prev Dent 1999 Padma Kumari, et al. J Indian Soc Pedod Prev Dent 2006 Lin, et al. J Am Dent Assoc 2007

Disruption to quality of life

Low, et al. Pediatr Dent 1999 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 and development (failure to thrive)

Elice and Fields. Pediatr Dent 1990 Acs, et al. Pediatr Dent 1992 Ayhan, et al. J Clin Pediatr Dent 1996 Clarke, et al. Pediatr Dent 2006

Possible disruption of intellectual development

Blumenshine, et al. J Publ Health Dent 2008 Jackson, et al. Am J Public Health. 2011

Higher incidence of hospitalisation and emergency visits

Fleming, et al. Int J Paediatr Dent 1991 Wilson, et al. Clin Pediatr 1997 Sheller, et al. Pediatr Dent 1997 Oliva, et al. Pediatr Emerg Care 2008

Increased treatment costs and treatment time

Thikkurissy, et al. Am J Emerg Med 2010

Greater risk of new carious lesions in both primary and permanent dentitions

Johnsen, et al. Pediatr Dent 1986 Grindefjord, et al. Caries Res 1995 O’Sullivan and Tinanoff. J Public Health Dent 1996 Al-Shalan, et al. Pediatr Dent 1997 Skeie, et al. Int J Paed Dent 2006 Mejare, et al. Caries Res 2001

*d = non-cavitated or cavitated lesion, m = missing due to caries

Figure 2. Intra-oral photographs of (Severe) Early Childhood Caries showing: A. caries affecting maxillary primary incisors, B. caries affecting both maxillary primary incisors and molars, C. primary molars only ( photographs 2b and 2c courtesy of Dr E. Kratunova)

A

B

C

282

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

Restoration of Primary Teeth Table 2. Benefits accruing from treatment of Early Childhood Caries Benefit

References

Carious teeth are restored to function

Stephenson, et al. Caries Res 2010

Pain and discomfort is resolved, or prevented

Low, et al. Pediatr Dent 1999 Acs, et al. Pediatr Dent 2001

Risk of sepsis is reduced

Pine, et al. Br Dent J 2006

Space loss is lessened or avoided

Laing, et al. Int J Paediatr Dent 2009

The child’s Oral Health-Related Quality of Life improves

Low, et al. Pediatr Dent 1999 Acs, et al. Pediatr Dent 2001 Cunnion, et al. J Dent Child 2010

Beneficial effects on the child’s growth and development

Acs, et al. Pediatr Dent 1992

The child’s educational experience may be enhanced

Blumenshine, et al. J Publ Health Dent 2008 Jackson, et al. Am J Public Health. 2011

unable to sleep, 27% had stopped playing, and 11% had not been able to attend school. In a retrospective study of dental records of 677 children aged 5-15 years with approximal primary molar caries, Milsom, et al. [2002] stated: “the majority of carious primary teeth exfoliate without causing pain.” However, almost half the children whose records were analysed (48%) had experienced pain, with more than 1 in 4 experiencing pain on 3 or more occasions, and 43% having had extractions due to pain and sepsis. Those authors acknowledged that: “For those children who have decay in their primary molars, dental pain is a common finding.” Levine, et al. [2002] published a more refined retrospective study, of 481 case notes of patients with carious primary teeth. In their study, in which standardised chart recording, and data extraction methods were used, the same operator had treated all patients. Data were separated into caries affecting single surface, multiple surfaces, and pulp involvement. Their study revealed that: n 18%

Figure. 3. Morbidity and mortality pyramid for Early Childhood Caries [Adapted from: Casamassimo, et al., 2009].

of unrestored carious primary teeth had caused pain,

n Pain

was significantly more likely the earlier caries 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 dental 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 experience. Correlations were stronger among lower socio-economic groups, consistent with a 5 – 6% increase in probability of toothache for each additional carious primary tooth.

Consequences of Early Childhood Caries The Surgeon General of the USA has stated: “you cannot be healthy without good oral health” [Satcher, 2000]. Early childhood caries (ECC) has consequences, not only for the teeth of the affected child, but also for the child’s general health (Table 1, Figure 2). There are therefore consequences for both morbidity and mortality (Figure 3). Literature Review Pain: Shepherd, et al. [2002] interviewed 589 eight-year-old children, and found that almost 50% had suffered dental pain. The pain was of such severity that 73% of those affected had been unable to eat, 31% had been

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: n Almost

5% of children had dental sepsis,

n Those

with sepsis had much higher caries experience (mean dmft 6.30) than those without sepsis (mean dmft 2.36),

n The

greatest predictor of dental sepsis was untreated decay, Failure to treat carious primary teeth markedly increased the risk of sepsis. Those authors concluded that the findings from their study “would not support a policy of non-intervention for deciduous caries if oral sepsis is to be minimised.”

European Archives of Paediatric Dentistry

283

D. Finucane Figure 4. Examples of facial cellulitis, consequent to odontogenic infection. These children were seriously ill, and required hospitalisation. A. Cellulitis affecting right side upper face. There is a risk of infection of the orbit, and spread to cavernous sinous; B. Significant submandibular cellulitis which if untreated, this may progress to Ludwig’s angina. C. Drainage of submandibular cellulitis, under general anaesthesia (same patient as Figure 4B). (Figures 4B and 4C reproduced from Handbook of Pediatric Dentistry (2nd ed.), p. 142. Sydney, Mosby 2003. Cameron AC, Widmer RP, eds. The author gratefully acknowledges the permission of Profs. R. Widmer and A, Cameron, and Mosby Elsevier Ltd. to reproduce these images).

A

B

A retrospective study, by Unkel, et al. [1997] of medical records of child patients with facial cellulitis revealed: n 47%

of facial cellulitis was of odontogenic origin,

n Cellulitis

was more common in the upper facial region (65% of cases),

n Odontogenic

cellulitis was more common in the mixed dentition period (mean age 8.8 years),

n Posterior

teeth were responsible for the highest number (64.3%) of odontigenic cellulitis cases.

Dental sepsis can progress to cellulitis, and then to Ludwig’s angina, a rapidly progressing cellulitis of the floor of mouth that compromises the airway; 1 in 3 cases of Ludwig’s 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 specialist care, including IV antibiotics, securing of the airway, and drainage. General Anaesthetic and Intensive Care facilities 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 contribute 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 control, [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 The

extent 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

C

reduction in arch length is more severe in the maxilla,

n Distal

movement of primary canines is greater in the mandible,

n Less

space is lost following early extraction of primary first molars, compared to primary second molars,

n Eruption

of 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 studies 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, following early loss of primary molars, however evidence supporting their use is limited [Laing et al., 2009]. The United Kingdom (UK) National Clinical Guidelines in Paediatric Dentistry recommended space maintenance under the following circumstances [Rock, 2002]: n Following

loss of a primary second molar, in all but spaced arches, and,

n Following

loss of a primary first molar, where crowding is greater than half a unit (3.5mm) per quadrant.

The disadvantages of space maintainers are that they are plaque retentive, they may impinge upon soft tissues, interfere with eruption of adjacent teeth, fracture, become dislodged, or be lost. They require regular review by a dental practitioner. It is preferable, therefore, to retain primary molars, where possible, until their natural exfoliation [Laing et al., 2009]. Disruption to Quality of Life (QOL) and effects of treatment of ECC. Low, et al. [1999] carried out a questionnaire-based survey to investigate the impact of severe caries on QOL in otherwise healthy young children (mean age 44 months). Parents/guardians of children with severe ECC completed questionnaires pre-treatment under general anaesthesia, and 4-8 weeks post-treatment. Pre-treatment, 48% of the children had complained of pain, 43% had problems eating certain foods with 61% having reduced intake of food, 35% had experienced sleep disturbance, and 5% had reported problems of negative behaviour. Dental treatment had a statistically significant effect (p