In line for the crown

Public health paediatric dentist, Prof Hanny Calache, director of Clinical Leadership Education and Research at Dental Health Services Victoria.
Public health paediatric dentist, Prof Hanny Calache, director of Clinical Leadership Education and Research at Dental Health Services Victoria.

A new technique championed by Professor Hanny Calache and Dental Health Services Victoria is tackling the problem of childhood decay. By Susanna Nelson

Rates of hospitalisation for childhood tooth decay in Australia are high, particularly in disadvantaged, indigenous and rural and remote communities—in fact, dental decay is one of the most common chronic diseases for children under the age of six. The condition causes concern and expense for patients and their carers and has a number of implications for development and health, including pain, abscesses and infection which in turn can cause reduced general health and poor sleep. In the longer term, it is thought that children can develop social and even academic problems from the stigma and discomfort of poor dental health.

Data from Dental Health Services Victoria (DHSV) revealed that, in 2009, 47 per cent of children aged under six attending public dental clinics had tooth decay. In the under-nine age group dental conditions are the second most common cause of hospital admissions after asthma. Yet the condition is, of course, highly preventable with the help of public health education about the formation of good early dental habits. It is also increasingly easy to treat—without the need for drastic and costly intervention.

A team in Victoria is investigating a method of treatment that will not only alleviate the distress of young children needing care for tooth decay in primary teeth, but relieve the strain of unnecessary admissions on the hospital system. Dental health ranks particularly highly in Ambulatory Care Sensitive Condition admissions data—that is, the markers of hospital admissions that could have been avoided through more effective primary care. Such unnecessary admissions are currently estimated to cost $9 million annually in Victoria alone.

Public health paediatric dentist, Prof Hanny Calache, director of Clinical Leadership Education and Research at Dental Health Services Victoria, is leading a study into the applicability of a drill- and needle-free dental technique that, in combination with good preventive health care, will substantially reduce the prevalence of the avoidable hospital admissions for childhood dental conditions and the unnecessary anxiety and discomfort tooth decay causes in young patients.

The Hall Technique is a method of treating early tooth decay in primary molars that involves no tooth cutting or preparation or local anaesthesia and is quick and inexpensive to perform. It was developed in Scotland, where there are high rates of untreated dental caries in primary teeth, and was subject to a five-year clinical trial in the UK. Results showed that the technique had similar outcomes to conventional treatments, where decay is removed under local anaesthetic, and that the method was well received by patients. Thus far, the technique has never been clinically trialled in Australia and has never been investigated in preschool-aged children.

Cassie with Dr John Brownbill, one of Plenty Valley Community Health Centre’s dentists.
Cassie with Dr John Brownbill, one of Plenty Valley Community Health Centre’s dentists.

The method is unique because decayed tooth tissue on the primary molar is not removed by the dentist, but sealed under a pre-formed stainless steel crown, which isolates the tooth from surrounding healthy teeth and prevents further decay by starving the dental decay-causing bacteria of the necessary oxygen and simple carbohydrates necessary for the bacterial proliferation that promotes the deterioration of the tooth.

“The crown is cemented in with glass ionomer cement for the life of the primary tooth,” says Prof Calache. “You ask the child to bite it into place to ensure that it fits properly. The procedure is the same as fitting a conventional crown. The difference is that you don’t remove the decay or any part of the tooth and there is therefore no need for local anaesthetic.”

In young children, the teeth are far enough apart that the crown can fit without any additional cutting of the tooth to make way for it, but where this isn’t the case, rubber orthodontic separators can be used prior to the procedure. The crown must fit the tooth well and must close over the tooth completely.

The technique can only be used where there is a definite band of dentine between the decay and the nerve. The tooth must not be in the advanced stages of decay. “It’s important to select cases for treatment appropriately, because the method will only be successful where the nerve is not affected,” says Prof Calache.

The technique promises to alleviate the suffering and anxiety many young children feel in the dentist’s chair, and in more serious cases, in hospital. “Children don’t want to sit for very long in the chair through drilling and removal of parts of the tooth, and very young children don’t like needles or the numb feeling and discomfort of a conventional treatment,” says Prof Calache. “It’s a very simple procedure—a lot quicker and more comfortable, with less anxiety for the patient.”

The method is also far less costly than hospital treatment under general anaesthetic, and easier to manage from the perspectives of both patient and practitioner. Evidence from overseas also indicates that having the child take an active and painless role in the procedure, while sitting in the dentist’s chair, may also have the positive psychological effect that is important to promoting good future self-esteem and prevention.

Mohamed is very happy with his stainless-steel crown.
Mohamed is very happy with his stainless-steel crown.

Prof Calache’s research seeks to dispel any concerns in the dental community about the method. The main issue that critics have with the technique is that the decay is not removed from the tooth before the crown is placed on it. This qualm is unwarranted, says Prof Calache: “There is a lot of literature in dentistry regarding techniques where we seal dental decay rather than remove it.”

“The second concern is that, if you don’t cut back the tooth before placing the crown on the tooth, you are opening up the bite by about two millimetres or so,” he says. “As far as this is concerned, all evidence demonstrates that within 30 days, this resolves itself and the bite returns to normal.

“The important thing is not to do, for example, 10 procedures at once,” continues Prof Calache. “This technique is not suited to general anaesthetic, where the aim is to do everything at once. The procedure should be conducted in the dental chair, and you’d do one on each side of the mouth at a time rather than have two crowns opposing each other, so that you don’t open the bite too much.”

Prof Calache hopes that, in the long term, guidelines, standards and training will be developed to encourage the positive reception and use of the technique among Australian dentists and that, in conjunction with good public preventive health education, this will coincide with a reduction in poor dental health outcomes for young children.

“This method generally hasn’t been used in Australia before, so this pilot study will allow us to test whether, in the Australian environment, this method would be accepted by the dentists and dental therapists who apply it, as well as children and their parents; and to present evidence on the longer-term outcomes for the teeth treated using this method.

“What we would like to do with a bigger study is to conduct it across the state and then look at making a comparison between a group receiving this study and a group receiving conventional treatment.”

Prof Calache is a strong public health advocate and is adamant that good community preventive health is part of the battle to reduce the rates of poor dental health in children. Fluoridated water has played a major part, though it too is only part of the solution, along with good dental hygiene and food choices.

“It’s a long way to saying this is the solution, but hopefully we will be able to provide the evidence for best practice for dentists to use the method with confidence as part of the solution.”

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