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P A E D I A T R I C PDAE E

ND
T II SATTRRY I C

D E N T I S T R Y

Case Study of an Anxious Child with


Extensive Caries Treated in General
Dental Practice: Financial Viability
under the Terms of the UK National
Health Service
ANDREW SHELLEY AND IAIN MACKIE
Abstract: This case study describes the management of Callum, an anxious 7-yearold boy with extensive caries. Callums 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

Andrew Shelley, BDS, MFGDP (UK), DPDS,


MGDS, General Dental Practitioner, Denton,
Manchester, and Iain Mackie, BDS, FDS, PhD,
MSc, DDPH, Senior Lecturer and Honorary
Consultant in Paediatric Dentistry, Unit of
Paediatric Dentistry, University Dental Hospital of
Manchester.

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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 Features
Callum 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

Management
Management 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
Dental Update October 2001

PA E D I AT R I C

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 Callums
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.

Figure 1. A preliminary chat was held with the


patient, talking about cartoons, to put him at his
ease.

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

c
Figure 2. Immediate emergency treatment
for the pain (mirror views). (a) Following
removal of glass ionomer from /D. (b)
Removal of all the caries. (c) Creosote sealed
in tooth using zinc oxide eugenol dressing.

D E N T I S T RY

Figure 3. Left (a) and right (b) bitewing


radiographs, supplemented with a periapical
view of the upper left quadrant (c).

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.
Callums carer confirmed that he was
taking the fluoride tablets as instructed,
but the diet sheets were not returned.
Time taken 30 minutes.
Visit 4: Endodontic Dressing /E
A loose glass ionomer dressing was in
place on /E, and there was a buccal

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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.
Time taken 15 minutes.

Visit 10: Fitting of Stainless Steel Crown /E,


Preventive Resin Restoration /6
Local anaesthesia was administered by
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.
Time taken 45 minutes.

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

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.
Callums carer was again reminded
about the diet sheet, which had still not
been returned.
Time taken 30 minutes.
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.
Time taken 45 minutes.
Visit 6: Amalgam Restoration D/
A disto-occlusal amalgam restoration
was placed at D/ under buccal
infiltration local anaesthesia.
Time taken 30 minutes.
Visit 7: Fitting of Stainless Steel Crowns
ED/
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
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formocresol paste.1 The teeth were


prepared for stainless steel crowns,3,4
which were fitted using conventional
glass ionomer cement (Figure 4).
Time taken 45 minutes.

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.
Callums initial course of treatment
was now complete (Figure 5).
Time taken 45 minutes.
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.

Visit 8: Fitting of Stainless Steel Crown /D


Local anaesthesia was administered by
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.
Time taken 30 minutes.
Visit 9: Reissue of Diet Sheet, Follow-up
Radiograph
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 Callums mother finally

Follow-up
At 6 month recall, bitewing radiography
and clinical examination revealed new
carious cavities mesially in E/ and
distally in /D. Amalgam restorations

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

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D E N T I S T RY

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.

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.

Financial Viability

DISCUSSION

The 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 Callums
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

It 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 Kravitzs
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

Fee ()

Two amalgam fillings /E, D/

11.70

Four stainless steel crowns ED/D, /E

61.80

Four endodontic treatments


ED/D, /E

47.00

Two preventive resin restorations


6/6

16.60

Six months capitation payments


for a 7-year-old patient

14.04

Total

151.14

Table 1. Remuneration from NHS for Callums


treatment (April 1999 figures).

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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.

CONCLUSION
Curzon 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 Pollards concerns are
justified.
Dental Update October 2001

PA E D I AT R I C

3.

R EFERENCES
1.

2.

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: Dental
Practice Board, 1997; pp814.
Blinkhorn AS. Introduction to the dental surgery.
In: Welbury RR, ed. Paediatric Dentistry. Oxford:
Oxford University Press, 1997; pp.2836.

ABSTRACT
BAD NEWS FOR MOTHERS!
Sealants and Xylitol Chewing Gum are
Equal in Caries Prevention. P. Alanen,
M.-L. Holsti and K. Pienihkkinen. Acta
Odontologica Scandinavica 2000; 58:
279284.
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

Dental Update October 2001

4.
5.

Papathanisou AG, Curzon ME, Fairpo CG. The


influence of restorative material on the survival
rate of restorations in primary molars. Paed Dent
1994; 16: 282288.
Kilpatrick NM. Durability of restorations in
primary molars. J Dent 1993; 21: 6773.
Walls AWG, Murray JJ, McCabe JF. The
management of occlusal caries in permanent
molars. A clinical trial comparing a minimal
composite restoration with an occlusal amalgam

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

6.

7.
8.
9.

D E N T I S T RY

restoration. Br Dent J 1998; 164: 288292.


Crawford PJM. Sealant restorations (preventive
resin restorations). An addition to the NHS
armamentarium. Br Dent J 1988; 165: 250253.
Bearne A, Kravitz AK. The 1999 BDA Heathrow
Timings Inquiry. Br Dent J 2000; 188: 189194.
Department of Health. Statement of Dental
Remuneration. Amendment no. 83, 1 April 1999.
Curzon ME, Pollard MA. Do we still care about
childrens teeth? Br Dent J 1997; 182: 242244.

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

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