case study of an anxious child with extensive caries treated in general dental practice_financial...

4 1 8 Dental Update – October 2001

P A E D I A T R I C D E N T I S T R Y

Abstract: This case study describes the management of Callum, an anxious 7-year-

old boy with extensive caries. Callum’s dental care was carried out in a general dental

practice in the North of England under the terms of the National Health Service. A

preventive programme was carried out in conjunction with the restorative philosophy

according to guidelines published by the Dental Practice Board in 1997.

Dent Update 2001; 28: 418-423

Clinical Relevance: Restorative treatment of extensive caries in the primary

dentition may be possible by the use of a variety of treatment modalities but may not

always be viable within the NHS in the UK.


he document Setting Standards in

Dental Care for Children1 was

published in 1997 by the Dental

Practice Board and set out guidelines

for the care of children in general

dental practice in the UK. The

foreword to the document stated that

it was aimed at ‘practitioners who wish

to improve their everyday clinical care

of children’.

An anxious 7-year-old boy with

extensive caries attended a general

practice in the North of England

complaining of a painful tooth. A

course of dental care was planned and

carried out for the patient, according

to the principles and techniques set

out in this document. The treatment of

this boy is discussed in this article.

CASE STUDY

Key Clinical FeaturesCallum attended with the following key

features:

● pain /D;

● anxiety leading to inability to

accept dental treatment;

● extensive caries, involving six

primary molar teeth;

● suspicion of early caries in the

lower first permanent molar teeth;

● acute abscess /D, chronic abscess

/E.

Care Provided● Pain relief – endodontic treatment of

/D.

● Dietary advice.

● Advice on use of fluoride.

● Instruction in oral hygiene.

● Fissure sealing of 6/6.

● Preventive resin restorations 6/6.

● Amalgam restorations /E.

D/

● Endodontic treatment ED/D .

/E

● Pre-formed metal crowns ED/D .

/E

ManagementManagement progressed as follows.

Visit 1: Pain Relief, Endodontic Dressing /D

On the first visit there was a preliminary

chat with Callum on non-dental matters

followed by an explanation of the aim

of the visit.2

Discussion revealed that Callum was

interested in cartoons and had visited

Disneyland. The establishment of rapport

began by talking about cartoons and

making drawings (Figure 1). Callum

agreed to lie on the dental chair for an

examination. This revealed a buccal

swelling associated with /D and a loose

glass ionomer dressing.

Callum was shown rubber dam.

However, he was reluctant to try it

and it was decided that careful

handling and throat protection using

Case Study of an Anxious Child withExtensive Caries Treated in GeneralDental Practice: Financial Viability

under the Terms of the UK NationalHealth ServiceANDREW SHELLEY AND IAIN MACKIE

T

Andrew Shelley, BDS, MFGDP (UK), DPDS,MGDS, General Dental Practitioner, Denton,Manchester, and Iain Mackie, BDS, FDS, PhD,MSc, DDPH, Senior Lecturer and HonoraryConsultant in Paediatric Dentistry, Unit ofPaediatric Dentistry, University Dental Hospital ofManchester.


Dental Update – October 2001 4 1 9

a gauze square would be more

appropriate.

Using a tell/show/do approach the

glass ionomer was removed from the /D

to reveal a grossly carious tooth

(Figure 2a). The caries was removed

(Figure 2b) and a dressing of creosote

on a cotton wool pledget placed in the

pulp chamber.1 The cavity was sealed

with zinc oxide eugenol cement (Figure

2c).

Time taken – 30 minutes.

Visit 2: Full Examination, Fluoride Advice

At the start of the second visit there

was a brief chat with Callum about

cartoons (this became the custom

whenever he attended for treatment). It

was noted that the swelling buccal to

/D had resolved. A full history and

examination were carried out, including

bitewing radiographs (Figure 3).

Different treatment options were

discussed with Callum and his carer.

Everyone was keen to avoid extractions

so it was decided to adopt a preventive

restorative philosophy. However, this

would ultimately depend on Callum’s

ability to accept dental treatment,

including preventive resin restorations,

pulp treatments, amalgam restorations

and preformed crowns. Although

Callum had difficulty in sitting still on

the chair, he had been able to accept

emergency treatment for the acute

abscess on /D. It was therefore thought

that there was no need to resort to

general anaesthesia or sedation.

Management would need to proceed on

the basis of acclimatization, positive

reinforcement and establishment of

rapport.

A 3-day diet sheet was issued and 1

mg fluoride tablets prescribed. The

instructions for the tablets were to let

one tablet dissolve in the mouth on

return from school and at a similar time

at weekends. Toothbrushing with an

adult family toothpaste was

recommended in the morning and at

night. This meant that the teeth were

exposed to topical fluoride on three

occasions during the day.

Time taken – 30 minutes. Visit 3: Amalgam Restoration /E

Topical anaesthetic cream (5%

lignocaine) was applied for 1 minute on

a cotton wool roll and a 2% solution of

lignocaine hydrochloride with 1 in

80 000 adrenaline was administered by

buccal infiltration for /E using an

aspirating syringe. This combination

was used whenever local anaesthetic

was administered. A mesio-occlusal

amalgam restoration was placed in /E.

This restoration was chosen as an

introduction to active treatment with

local anaesthesia because of its relative

simplicity.

Callum’s carer confirmed that he was

taking the fluoride tablets as instructed,

but the diet sheets were not returned.


Visit 4: Endodontic Dressing /E

A loose glass ionomer dressing was in

place on /E, and there was a buccal

Figure 1. A preliminary chat was held with thepatient, talking about cartoons, to put him at hisease.

Figure 2. Immediate emergency treatmentfor the pain (mirror views). (a) Followingremoval of glass ionomer from /D. (b)Removal of all the caries. (c) Creosote sealedin tooth using zinc oxide eugenol dressing.

a b

c

Figure 3. Left (a) and right (b) bitewingradiographs, supplemented with a periapicalview of the upper left quadrant (c).

a

b

c



swelling associated with the tooth. The

glass ionomer was removed from the

cavity to reveal gross caries. The caries

was removed and a dressing of

creosote on a cotton wool pledget was

placed into the pulp chamber. The tooth

was sealed with zinc oxide eugenol

cement.1 Local anaesthesia was not

used for this procedure.

Callum’s carer was again reminded

about the diet sheet, which had still not

been returned.


Visit 5: Devitalization Pulpotomy ED/

Callum had coped well up to this point

and it was therefore decided to proceed

with restoration of the other carious

teeth. Local anaesthesia was

administered by buccal infiltration.

Devitalization pulpotomies were carried

out on the ED/ (Figure 4). The pulp

stumps were dressed with

paraformaldehyde-containing

dressings1 and the access cavities

sealed with zinc oxide eugenol cement.


Visit 6: Amalgam Restoration D/

A disto-occlusal amalgam restoration

was placed at D/ under buccal

infiltration local anaesthesia.


Visit 7: Fitting of Stainless Steel CrownsED/

Local anaesthesia was administered by

buccal infiltration and intrapapillary

infiltration. The dressings were

removed from the ED/ and the base of

the pulp chambers filled with a

formocresol paste.1 The teeth were

prepared for stainless steel crowns,3,4

which were fitted using conventional

glass ionomer cement (Figure 4).


Visit 8: Fitting of Stainless Steel Crown /D


buccal infiltration and intra-papillary

infiltration. The existing dressing in /D

was removed and the base of the pulp

chamber filled with a formocresol

paste.1 A stainless steel crown was

fitted using conventional glass ionomer

cement.


Visit 9: Reissue of Diet Sheet, Follow-upRadiograph

Callum and his mother were very late

for their appointment and the

objectives for the visit had to be

reviewed. The recently placed amalgam

restorations at /E and D/ were polished.

Despite reminders, the diet sheet

issued at the second visit had not been

returned, and Callum’s mother finally

admitted that it had been lost. A new

diet sheet was issued and the

importance of this exercise stressed. A

periapical radiograph was taken of the

upper left quadrant to investigate /6,

which was missed off the bitewing

radiographs.


Visit 10: Fitting of Stainless Steel Crown /E,Preventive Resin Restoration /6


inferior dental block to the lower left

quadrant. Endodontic treatment was

completed and a stainless steel crown

fitted on /E. A preventive resin

restoration5,6 was placed at /6. Callum

was instructed in toothbrushing.


Visit 11: Preventive Resin Restoration 6/,Fissure Sealing 6/6

The diet sheet was finally returned,

analysed and advice given. Operative

treatment was completed by placing a

preventive resin restoration5,6 in 6/ and

fissure sealing both upper permanent

molars.

Callum’s initial course of treatment

was now complete (Figure 5).


Callum underwent a total of 11 visits,

spread over 2 months. In addition to the

preventive advice, he was able to accept

all the necessary restorative treatment.

Follow-upAt 6 month recall, bitewing radiography

and clinical examination revealed new

carious cavities mesially in E/ and

distally in /D. Amalgam restorations

Figure 4. Restoration of the ED/ (mirror views). (a) Caries removal and exposure of the pulpstumps. (b) Preformed crowns cemented in place.

a b

Figure 5. Completion of the initial course of treatment (mirror views). (a) Upper arch. (b) Lower arch.

a b



were provided for these lesions. Advice

on diet and use of fluoride was

reinforced but once again there was

difficulty in obtaining a diet record for

Callum. The diet sheet was again

reported lost and had to be reissued.

Diet analysis and discussion revealed

that Callum and his parent had not acted

on previous advice.

At 12 month recall, recurrent caries

was noted in D/D. Stainless steel

crowns were fitted on these teeth.

Financial ViabilityThe financial viability of dental

treatment will depend on the

circumstances in an individual practice.

However, average figures for the UK

were published by Bearne and Kravitz

following the 1999 BDA timings

enquiry.7 These figures were intended

to draw conclusions about the average

earnings of a full-time dentist

committed to the NHS.

Bearne and Kravitz calculated the

average hourly rate generated from fees

to be £53, excluding laboratory bills.

The time spent on treating Callum was 6

hours 15 minutes. Thus a turnover of

£331.25 in gross fees would be

expected, according to average figures.

The fees generated for Callum’s

treatment on the April 1999 NHS

statement of dental remuneration8 are

given in Table 1. All other items such

as examination, radiographs and fissure

sealants would be covered by

capitation payments. It is considered

Treatment Fee (£)

Two amalgam fillings /E, D/ 11.70

Four stainless steel crowns ED/D, /E 61.80

Four endodontic treatmentsED/D, /E 47.00

Two preventive resin restorations6/6 16.60

Six months’ capitation paymentsfor a 7-year-old patient 14.04

Total 151.14

Table 1. Remuneration from NHS for Callum’streatment (April 1999 figures).

reasonable to include the capitation

payments for 6 months as part of the

calculation. The table indicates a

shortfall in this case of £180.11

compared to average figures.

Bearne and Kravitz calculate average

practice expenses to be £31 per hour,

excluding laboratory costs. The costs

of simply running a practice for 6 hours

and 15 minutes would therefore be

£193.75. Since the fees generated are

£151.14 the average cost to a

practitioner to provide this course of

treatment for Callum would be £42.61 –

plus, of course, loss of income.

These figures can be looked at in a

different way. If the gross hourly rate of

£53 was to be met, the course of

treatment for Callum would have to be

completed in 2 hours 51 minutes. There

were 11 visits in this course of

treatment. This would mean an average

of 15 minutes per visit, including

leading the patient to and from the

waiting area into the dental chair,

anxiety control, preventive advice,

treatment planning, record keeping and

infection control measures in addition

to the operative treatment.

DISCUSSIONIt could be argued that the philosophy

of capitation is that payments for those

children who need little care subsidize

those who need more. However, the

shortfall in this case is substantial and

in an area with high caries rates such as

the North of England a case such as

Callum is not unusual. Furthermore, the

capitation element of the remuneration

forms a very small proportion of the

total fee.

It might be suggested that the cost of

purchase of stainless steel crowns

(currently some £3.20 per crown)

should be regarded as the equivalent of

a laboratory bill. Bearne and Kravitz’s

hourly rate is of course an average

figure and thus some practitioners

might be able to complete this course

of treatment more cost effectively,

although others will not.

Callum was an anxious child and time

was needed at each visit to build

rapport and acclimatize him to dental

treatment. However, we feel that the

timings given are realistic for a great

many children treated in general dental

practice.

It could be argued that an alternative

approach would be to extract the carious

primary molars. It would certainly be

more cost effective for a general dental

practitioner to refer for extractions and

this may well have been a viable

alternative in the past. However, this

cannot be in the interests of a patient if

restoration is clearly possible. In the

first instance it is the responsibility of

the dentist to attempt treatment for a

child using good communication skills

and behavioural management

techniques. If these fail, inhalation

sedation may be a suitable alternative

before resorting to general anaesthesia.

The medicaments used in the

endodontic treatments in this case are

those given in the document Setting

Standards in Dental Care for

Children,1 the guidelines available at

the time of this course of dental care. It

is, however, recognized that concern

has been expressed over the use of

these medicaments and alternatives

have been proposed.

It is disappointing to report that,

despite repeated counselling and

advice on diet, fluoride use and oral

hygiene, further carious lesions were

present at the 6 month and 12 month

recall visits. This could have been

because Callum was usually

accompanied by his grandfather on his

dental visits, and perhaps the messages

were not being received at home.

CONCLUSIONCurzon and Pollard9 expressed concern

at the level of dental care for those

children with moderate to high caries,

stating that ‘The level of payment of

general dental practitioners is such that

they cannot afford to treat children’.

UK general dental practitioners must

make a profit or they will go out of

business and not be able to provide

general dental services for anyone.

This case study would suggest that

Curzon and Pollard’s concerns are

justified.


Dental Update – October 2001 4 2 3

REFERENCES

1. Crawford PJM, Davenport E, Page J, Williams S.Restorative dentistry for children. In: Ward P, ed.Setting Standards in Dental Care for Children,Dental Profile Special Edition. Eastbourne: DentalPractice Board, 1997; pp8–14.

2. Blinkhorn AS. Introduction to the dental surgery.In: Welbury RR, ed. Paediatric Dentistry. Oxford:Oxford University Press, 1997; pp.28–36.

3. Papathanisou AG, Curzon ME, Fairpo CG. Theinfluence of restorative material on the survivalrate of restorations in primary molars. Paed Dent1994; 16: 282–288.

4. Kilpatrick NM. Durability of restorations inprimary molars. J Dent 1993; 21: 67–73.

5. Walls AWG, Murray JJ, McCabe JF. Themanagement of occlusal caries in permanentmolars. A clinical trial comparing a minimalcomposite restoration with an occlusal amalgam

restoration. Br Dent J 1998; 164: 288–292.6. Crawford PJM. Sealant restorations (preventive

resin restorations). An addition to the NHSarmamentarium. Br Dent J 1988; 165: 250–253.

7. Bearne A, Kravitz AK. The 1999 BDA HeathrowTimings Inquiry. Br Dent J 2000; 188: 189–194.

8. Department of Health. Statement of DentalRemuneration. Amendment no. 83, 1 April 1999.

9. Curzon ME, Pollard MA. Do we still care aboutchildren’s teeth? Br Dent J 1997; 182: 242–244.

BAD NEWS FOR MOTHERS!

Sealants and Xylitol Chewing Gum are

Equal in Caries Prevention. P. Alanen,

M.-L. Holsti and K. Pienihäkkinen. Acta

Odontologica Scandinavica 2000; 58:

279–284.

Although both sealants and xylitol

chewing gum have been shown to be

effective in preventing decay, their

effect has never been compared in the

same study. These workers therefore

carried out a randomized study of the

caries experience of children, either by

following the application of fissure

sealants, or by observing those who

regularly chewed xylitol chewing gum

for two to three years.

No significant difference was found

between the two groups. However, the

authors observe that, for ethical

reasons, there was no negative control

to show that these effects were

absolute. Despite this, their results echo

those of many other workers who have

described the beneficial effects of both

treatment modalities.

In the light of the findings, it is

calculated that xylitol chewing gum

would actually prove cheaper than

fissure sealants, and may even be more

effective as fissure sealants may be lost,

requiring replacement.

Unfortunately the only aspect of

chewing gum not addressed by the

authors is that of the environment when

gum is carelessly disposed of! Sorry,

Mum!

Peter Carrotte

Glasgow Dental School

ABSTRACT

case study of an anxious child with extensive caries treated in general dental practice_financial...

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