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PaediatricDentistry Enhanced CPD DO C & DO A

René JM Gruythuysen

Non-Restorative Cavity Treatment:


Should This be the Treatment of
Choice? Reflections of a Teacher in
Paediatric Dentistry
Abstract: Non-Restorative Cavity Treatment (NRCT) is not favoured by many paediatric dentists. However, perhaps it should be the
treatment of choice rather than confronting child and parents with a restorative, symptomatic, often less child-friendly approach. Does the
child have a right to a viable biological treatment option, because solving a biological problem, basically caused by neglect, with technical
solutions is ethically not defensible in all cases? Restorations simply mask the caries activity. What matters is the oral health and the well-
being of the child. How can this best be served?
CPD/Clinical Relevance: This paper might serve as a discussion document for a group of oral health providers deciding practice policy
with regard to the management of caries in primary teeth.
Dent Update 2019; 46: 220–228

Questioning the restorative lesions cleansable. This was first advocated to plaque control. However, deciduous teeth
approach for use in young children by GV Black in are exfoliated and perhaps non-operative
Some definitions and their 1908.2 His non-restorative approach was treatments (plaque control, fluoride, diet) are all
corresponding acronyms start this section: based on his belief in plaque control to that are required to take cavitated teeth pain-
Non-Restorative Cavity Treatment (NRCT) manage caries and his insistence that the free to exfoliation’.3
is a non-restorative method of controlling most important thing in treating children The present paper stresses the
dentine lesions. It sits alongside Non- was not to frighten them. In addition, in 1908 role of the parent/carer and the oral health
Operative Caries Treatment Programme the filling materials available were amalgam team to NRCT, a technique which makes it
(NOCTP), a method of controlling enamel and gold inlays, neither really suitable for use possible for the carer to manage caries by
lesions. Taken together, this non-restorative in primary teeth. The method is still relevant plaque control rather than relying on fillings.
management of enamel and dentine lesions today because it is a biological, child-friendly The paper will start by describing the clinical
is called Non-Restorative Cavity Control approach to reduce, and preferably stop, the aspects of NRCT, then the significance of
(NRCC).1 caries activity. supporting the carer will be addressed. It is
NRCT manages cavitated caries Some years ago Edwina Kidd this person who controls caries and effective
lesions without placing fillings by making the questioned the traditional restorative communication between the oral health
approach to treating decayed deciduous team and the carer is essential to the success
teeth: ‘Whether deciduous teeth should be of the technique. Subsequently, the attitude
restored has caused controversy for at least of both the oral health team and the carer to
150 years and the argument rages on. Dental the technique will be considered. Do either
René JM Gruythuysen, PhD, Retired caries is a controllable process. The role of consider that they can be in control of the
Dentist, Post-academic Teacher Paediatric operative dentistry and restorations, as far oral health promoting outcome? At the end
Dentistry, Tandzorg.nl, Rotterdam, The as caries control is concerned, is to make of the paper the results of clinical trials will
Netherlands. Email: r.gruyt@planet.nl cavitated, uncleansable lesions accessible be discussed.
220 DentalUpdate March 2019
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a monitor the carer’s brushing and review


the caries activity of the lesion. The lesion
should be seen to arrest over weeks and
months (see: Monitoring caries activity). The
monitoring system is basically the same as
advocated by the performers of the non-
operative caries treatment programme
(NOCTP) for caries lesions in the enamel.5
It is important to prevent pain
and inflammation and adopt another
(restorative) approach when continuing
NRCT has not become in the interest of the
child.

The use of silver diamine


fluoride
Silver diamine fluoride (SDF) is
a safe, effective treatment for dental caries
across the age spectrum. SDF is indicated for
the following patients:
 Those with extreme caries risk;
 Those who cannot tolerate conventional
care;
 Patients who must be stabilized so that
they can be restored over time;
 Patients who are medically compromised
Figure 1. (a) Slice technique: try to keep the or too frail to be treated conventionally; and
b
contact in the cervical part and slice distal  Those in populations with little access to
surfaces rather flatter than mesial surfaces to care.6
facilitate plaque removal. Arrest progression A systematic review showed
of the cavitated lesion by prolonged, vigorous that SDF reduces the growth of cariogenic
brushing perpendicular to the dental arch. bacteria. It inhibits demineralization
Courtesy of BSL, Springer Media, Houten, the and promotes the remineralization of
Netherlands. (b) Bad, symptomatic approach on demineralized enamel and dentine.
the right side (lingual abscess), after referring,
Moreover, it hampers degradation
followed by well-performed aetiological
of the dentine collagen.7 In another
approach at the left side, combined with SDF
application. Courtesy of Thierry Boulanger.
systematic review it was concluded that,
at concentrations of 30% and 38%, SDF
shows potential as an alternative treatment
for caries arrest in the primary dentition
removal using a slicing technique for and permanent first molars.8 However, SDF
Non-restorative cavity treatment should never be applied as an alternative to
approximal lesions. A contact should be
NRCT is indicated in young kept in the cervical part of the tooth. Distal meticulous brushing plaque control (Figure
children with active, cavitated, caries lesions surfaces should be sliced rather flatter than 2a). It may assist lesion arrest, giving more
in the primary dentition and/or with dental mesial surfaces to facilitate the plaque time for the carer to perfect plaque control in
anxiety. The emphasis of NRCT is to treat removal (Figure 1a); cases of increased risks for pain/inflammation
the causes of caries over time, decreasing 3. Carious dentine may be treated with anti- (Figure 2b).
discomfort for children and promoting oral cariogenic agents (eg fluoride varnish, silver
health. Restoration of teeth is of secondary diamine fluoride) and/or a protective layer Communication
importance. NRCT requires some specific applied (eg glass ionomer cement) Good communication is central to
measures to manage cavitated caries lesions:4 (Figure 1b); the technique. A proven tool is Motivational
1. Gain the informed consent of the carer. 4. Communicate with carers on their role in Interviewing which can be the starting point
This role is critical to the technique and plaque control. This will certainly include for the communication about the carers’
acceptance of this responsibility is essential twice daily brushing of the sliced area with wishes.9 What do they want, or not want,
to promote the oral health of the child; fluoride-containing toothpaste; for their child? For many, this is not a new
2. Make cavities accessible for plaque 5. Fix a suitable recall appointment to technique but it takes a lot of practice to
March 2019 DentalUpdate 221
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a a caries activity of these specific lesions. This


is precisely what NRCT does. It is a biological
solution to a biological problem. The
difficulty comes when the carer considers a
technical solution, such as a filling, has solved
the biological problem.
However, monitoring caries
lesions requires experience. There is not a
clear demarcation in an individual lesion
between activity and inactivity. This is a
continuous scale and the clinician is deciding
b b
where on the scale this lesion is. For instance,
dark dentine lesions are not always inactive
and light dentine lesions are not always
active (Figures 3a and b). Lesion texture is
very useful. Determining the activity of a
dentine lesion can be aided by probing with
a blunt or a periodontal probe gently pressed
onto the dentine (Figure 4). Photography
aids monitoring, although it will not record
Figure 2. (a) The prescription ‘preformed crowns’ texture, but it is useful for showing the
on the right side by a postdoc in paediatric changes in plaque accumulation and lesion
dentistry was turned into NRCT, showing colour. Comparing two sets of photographs
stabilized caries lesions on the right side without will show the effect of the care.
application of SDF after more than 2 years.
Courtesy of BSL, Springer Media, Houten, the
Netherlands. (b) Young child with hypersensitive
Criticisms of NRCT
carious teeth successfully treated by application Figure 3. (a) Light-coloured stabilized caries Non-restorative cavity treatment
of SDF, and parental help with cleaning, diet. lesion with a hard texture after loss of a glass focuses on educating the carer in oral
Restorative treatment under general anaesthesia ionomer restoration. (b) Arrested lesion turned health care. The carer is put in charge of
could be avoided. Courtesy of Thierry Boulanger into a soft, caries active lesion after poor oral caries control. Despite this being essential,
and Ameera Paurobally. health care. Note visible plaque. Courtesy of BSL,
there is unease among some oral health
Springer Media, Houten, the Netherlands.
providers. Here are some specific criticisms
(among other things from a Dutch textbook
of Paediatric Dentistry in 2013),11 together
become familiar with this approach or another with suggestions that these worries may be
‘change model’.10 It may determine the level of unfounded: The criticisms are in italics.
oral care that parents or carers will provide and 1. Following slicing, space may be lost by
guide the recall interval that they are prepared mesial drift. Many years ago it was shown that
to accept. providing the slicing is done correctly, this is
Although called an ’interview’, not a problem.12
90% of the time is spent listening to the client. 2. Following slicing, there is likely to be food
It is not instruction, which is a one-sided impaction. Proper opening or slicing of the
communication. The professional should ask lesion can eliminate or minimize this (Figures
questions to gain insight to the motivation Figure 4. A blunt probe. Courtesy of BSL, 5a and b).
of the carer, rather than give unsolicited Springer Media, Houten, the Netherlands.
3. There may be lesion sensitivity after slicing.
advice. Clinicians should be prepared to
This can be managed by application of
be disappointed by relapse but hide their
fluoride varnish or silver diamine fluoride.
disappointment! See if what is not happening simplest way to determine caries risk. A child 4. Once a tooth is sliced, restoration is often
can be turned to advantage. Clinical pictures with lots of caries experience, where the no longer possible and extraction is the only
to show progress, or lack of it, can be very caries activity is now at a standstill, needs remaining alternative. In practice this concern
useful here. Show, in neutral words, how these rather less attention than a child who shows is usually unfounded. The technique opens
pictures can be interpreted and let carers draw little caries experience, but where the caries up the undisturbed area for the biofilm
their own conclusions about the caries activity.
activity has increased recently. In addition, it and with carer cleaning, the caries process
is important to know where in the dentition will slow down or arrest. If the oral health
Monitoring caries activity active caries lesions are located. Preventive provider now wants to place a traditional
Monitoring caries activity is the actions should be focused on arresting the restoration because of increased risk of
222 DentalUpdate March 2019
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a a

b Figure 7. Perfect restoration could not prevent


the development of a new caries lesion after 2
years. Courtesy of BSL, Springer Media, Houten,
the Netherlands.

result of ignorance, inability to deal with an


unco-operative child or parental neglect. Of
course, not following the advice of general
health care providers to visit an oral health
provider includes neglect of oral care too.
Figure 5. (a) Sliced surfaces too vertical, Poor oral health care in a child may be a sign
b
promoting food impaction. Courtesy of BSL, of more symptoms regarding child neglect.15
Springer Media, Houten, the Netherlands. (b) Based on a child neglect
Correct slice angle keeping cervical contact. systematic review it was concluded that:
Courtesy of Thierry Boulanger. ‘While it is indisputable that members of the
dental team are well positioned to observe
the signs of general and/or dental neglect,
pain/inflammation, an adhesive restoration lack of clinical confidence in identifying and
usually solves the problem (Figures 6a−c). referring neglect prevails…….Given the
Sometimes capping the cusps is needed for known consequences of dental neglect, it is
additional retention and a Hall crown would to be hoped that dental practitioners will be
c more pro-active in working with their local
be useful here when there is still enough
space. safeguarding team to ensure the safe and
5. A restoration is preferable because it appropriate care of these children.’14 Please
facilitates plaque removal. This frequently consider this conclusion in the light of the
stated assumption must be questioned whole child rather than a purely teeth-
(Figure 7). If the distal surface of the second centred approach. General health providers,
primary molar is carious, the mesial surface including GPs, paediatricians and public
of the first permanent molar is 15 times more health nurses, can all provide alerts regarding
likely to become carious, whether or not a neglect of oral care. They can investigate
restoration is placed.13 Indeed, it could be whether the oral problems indicate wider
argued that the non-restorative approach problems of neglect in the child.15 It is
is preferable because it allows access to recommended that general and oral health
the mesial surface of the permanent tooth Figure 6. (a) NRCT failed due to incorrect slicing, providers work together and make use of
for cleaning, fluoride application and inadequate carer guidance and lack of self-care. their respective expertise.
monitoring. In an open conversation with the mother in
the absence of the child, the mother drew the
conclusion that oral care in the family had to get
A contentious suggestion
Neglect of oral care more priority. (b) Correction of the slicing did ‘Restorative treatment of caries
Neglect of a child’s oral health not lead to the desired result. It was decided to lesions in a child with neglected teeth masks the
can lead to pain, poor growth and impaired place restorations. (c) Bitewing radiograph almost lack of oral health care’
quality of life. In populations where there 3 years after restoration. Primary teeth about to This sentence may be a surprise
is a high prevalence of dental caries, be shed. Meanwhile, the oral care in this family and even considered insulting by some
with three children had significantly improved. paediatric dentists! However, consider that
the determination of which children are
Courtesy of BSL, Springer Media, Houten, the
experiencing oral neglect is challenging.14 a restoration is a technical solution to a
Netherlands.
Inadequate oral care in children may be the biological problem and could mislead the
224 DentalUpdate March 2019
PaediatricDentistry

Figure 8. How to manage neglect of oral care?

parents with regard to the current state of can have an impact on our viewpoint and the with respect to the oral behaviour of their
the oral health. That’s why, despite preventive way we interact with our environment. People patients. Other oral health providers blame
instructions, fillings will often fail due to new who base their success on their own work outside forces, such as bad co-operation of
caries (Figure 7). Non-restorative treatment and believe that they control their life have patients and public services, for the poor
methods, on the other hand, focus solely on an internal locus of control. In contrast, people oral health behaviour of their patients. They
stopping caries activity by plaque removal. who attribute their success or failure to outside have an external locus of control. Their
These methods are all about guidance of oral influences have an external locus of control. attitude is: whatever they do is doomed to
health care and transferring responsibility to There is currently interest in the failure because of forces beyond their control
where it has to be, with the carer (Figure 8). locus of control in patients.17 Regarding caries (Figure 9). Could the unfounded criticisms
This means motivating parents to re-brush prevention and the management of pre- of NRCT be a sign of an external locus of
their child’s teeth every day. Failure is very cavitated caries lesions, it is stated that: ‘Non- control?
obvious to the carer on recall because the invasive therapies can also be effective to arrest Non-restorative cavity treatment
sliced tooth shows an active caries lesion. cavitated lesions but the success depends greatly may stand or fall with the locus of control of
on behavioural changes of patients to brush the oral health provider (Figure 9). Could it
Locus of control the lesions’.18 Patients’ locus of control may be be that oral health providers with an external
This section contains a suggestion relevant to whether they make the necessary locus of control focus on the weaknesses
for consideration. The suggestion is unproven behavioural changes. Do they believe that of non-restorative cavity treatment (see
and contentious!: they are in control and that their actions will criticisms above) in order to avoid its
Is an oral health provider’s attitude make a difference? However, should the locus application? Those with an internal locus
to NRCT dependent on his/her locus of control? of control of the oral health provider also be of control may see the same criticisms as
Locus of control is the framework considered? Might this also be relevant to the challenges to encourage improving the
of Rotter’s social-learning theory of outcome and to whether the NRCT approach is method. Hansen was the first researcher to
personality.16 It is the extent to which people chosen at all? And if ‘yes’, to what extent? show that self-reflection was relevant to at
believe that they can influence the events in Some oral health providers think least 33% of the failures in a 9−44 months
their lives. Is our locus of control internal or that they can improve the oral health of their prospective clinical evaluation of NRCT.19
external? Our perception of where control lies patients. They have an internal locus of control Unfortunately, there are no data of the locus
March 2019 DentalUpdate 225
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and CR showed no statistically significant


difference in major failures. The authors
concluded that the study’s preliminary results
(1 year) were at risk of bias but, after the
experiment, 89% of the oral health providers
continued to prefer a restorative covering.27
a Perhaps the locus of control
of these oral health providers remained
external and presumably these preferences
will have influenced the results. Since no
grinding/slicing protocol was published, the
reader has no way of knowing whether the
slicing was carried out correctly.
Figure 9. Is this rule ‘locus of control oral health provider’ in the case of diagnosed caries activity/dental The 2.5 year results of this study
fear justified? (Sketch based on: Ned Tijdschr Tandheelkd 2018; 125: 38). showed, for cumulative survival rates: HT
= 92.5%, NRCT = 70.5% and CR = 67.2% (p
= 0.012).28 NRCT and CR outcomes were
comparable. HT performed better than NRCT
of control of the oral health provider. We only efficacy for the non-restorative approach to and CR for all outcomes. In the study, 69% of
know that restoration of cavities is rather dentine lesions, in the eyes of some paediatric children in the NRCT armed with treatment
more popular than promoting prevention by dentists NRCT is a controversial treatment failures failed to attend the 3-month recalls
the non-restorative approach in paediatric concept. In a short communication about the regularly. Still, the results were comparable
dentistry. Some want to move from the acceptability of NRCT, it was discussed whether with making fillings. So, one could discuss
traditional ‘drill and fill’ towards a more ‘child it is ethical to apply NRCT to children with possible improvement of the results by
friendly’ approach, highlighting sealants approximal cavities in the temporary teeth.23 introducing stricter protocols (including
and sealing in demineralized dentine.20 The author suggested that NRCT can be youth care – Figure 8) for recall and by using
Interestingly, these rather more symptomatic viewed as dental neglect because it prevents the option to slow down the caries activity
than biological concepts still involve the oral a restorative treatment that would predictably with SDF.
health professional providing a technical deliver freedom from pain and infection. The Moreover, single tooth studies
solution. When can we expect the huge step author forgets that NRCT is not designed only are not designed to test the aetiological
forward to a biological (= plaque removal) to treat the symptoms but, in the first place, approach because they do not take into
approach in paediatric dentistry? aims to improve the oral health of the child. account the oral health benefits for the child
Following the Hippocratic tradition of these treatments.
of doing no harm, NRCT seeks to avoid Many Cochrane reviews are
Clinical trials of non- restorative
unnecessary invasive treatments. If these are critical of the methodology of the studies
approaches
performed under general anaesthesia, they available. Randomized clinical trials, favoured
Mijan et al carried out a clinical pose risks in young children.24 John Frachella, by Cochrane reviews, are designed for
study in which, in an experimental group a paediatric dentist in the United States, claims testing a simple hypothesis. It is interesting
(UltraConservative Treatment), small that he has decreased treatment under general to speculate whether NRCT protocols can
cavities were restored with glass ionomer anaesthesia by 90% by applying SDF ever be properly evaluated in these research
cement using an atraumatic restorative (Figure 2b).25 Preventing pain and methods. This is partly because the NRCT
technique, while medium/large cavities inflammation and adequate monitoring, are concept involves both a technical element
were left unrestored but cleaned daily with essential parts of the NRCT treatment concept.4 (slicing), but the behavioural content is
toothpaste/toothbrush under supervision.21 A systematic review on the critical to success or failure. Can patients and
Conventional restorative protocols were effectiveness of preformed steel crowns (Hall oral health providers be matched in these
used in control groups. After three and a crowns) in the treatment of carious temporary behavioural elements to produce unbiased
half years the clinical results were similar molars with high caries active children includes experimental and control groups? In other
in experimental and control groups. a ‘single tooth’ randomized controlled trial on words, what is the risk of bias due to validity
Another part of this study showed that well NRCT, compomer restorations (CR) and Hall problems? This will be another contentious
performed, non-restorative treatment is crowns (HT).26 Twenty teeth were recorded as point!
associated with a preservation of the Quality having at least one minor failure: NRCT, n = 8 Nevertheless, it has been
of Life. In other words, all treatment protocols (5%); CR, n = 11 (7%); HT, n = 1 (1%). The Hall known for over 30 years that caries activity
were effective in reducing children’s crown performed best and the comparison in dentine lesions can be arrested.29 What
experience of pain, their sleeping problems between NRCT and CR showed no significant might be needed is further qualitative
and their irritability and/or frustration levels difference. Nine (6%) experienced at least one research with a series of well-documented
over the 1-year period.22 major failure: NRCT, n = 4 (2%); CR, n = 5 (3%); case reports (successful and failed cases) so
Despite the clinical evidence of HT, n = 0 (0%). Individual comparison of NRCT that the results of NRCT in practice for the
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be ultimately more beneficial, and therefore pp235−257.


cheaper, because oral health has been 3. Kidd E. Should deciduous teeth be restored?
promoted through behavioural change and Reflections of a cariologist. Dent Update 2012;
fewer lesions subsequently develop. There 39: 159−166.
is already some indication that behavioural 4. Gruythuysen RJ. Non-restorative cavity
change can decrease caries activity and treatment. Managing rather than masking
decrease costs. When non-operative caries caries activity (Dutch). Ned Tijdschr
treatment and prevention were compared Tandheelkd 2010; 117: 173−180.
with traditional treatment, the non-operative 5. Ekstrand KR, Christiansen ME. Outcomes of a
programme was preferred after 3 years.31 non-operative caries treatment programme
NRCC has been advocated, for children and adolescents. Caries Res 2005;
particularly in primary dentitions, for families 39: 455−467.
able to accept responsibility for the disease 6. Horst JA, Ellenikiotis H, Milgrom PL. UCSF
and commit to remedial action, including protocol for caries arrest using silver diamine
diet modification and regular, frequent fluoride: rationale, indications and consent.
toothbrushing with a fluoride toothpaste.32 J Calif Dent Assoc 2016; 44: 16−28.
However, the approach seems particularly 7. Gao SS, Zhang S, Mei ML, Lo EC, Chu CH.
suitable for families where co-operation is Caries remineralisation and arresting effect
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this one stresses behaviour change as treatment − a systematic review. BMC Oral
the basis for successful treatment. Dutch Health 2016; 16: 12.
Figure 10. Superficial caries lesion mesially on
guidelines, based on five years of experience, 8. Contreras V, Toro MJ, Elías-Boneta AR,
the left first permanent upper molar could be
stabilized by NRCT done to the primary molar. suggest that NRCT is explicitly indicated in Encarnación-Burgos A. Effectiveness of silver
Courtesy of BSL, Springer Media, Houten, the young children with active caries lesions diamine fluoride in caries prevention and
Netherlands. and children with dental anxiety where arrest: a systematic literature review. Gen
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This applies to caries lesions in the enamel 9. Kay EJ, Vascott D, Hocking A, Nield H.
(NOCTP) or in the dentine (NRCT). The Motivational interviewing in general dental
individual child and oral health provider can be aim is to promote the self-care of caries- practice: a review of the evidence. Br Dent J
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process. After more than ten years of Dutch 10. Keat RM, Fricain JC, Catros S et al. The
Final observations experience there is no reason to change dentist’s role in smoking cessation
this guideline. That’s why, in the eyes of the management − a literature review and
A recent cost-effectiveness
author, non-restorative caries control should recommendations: Part 2. Dent Update 2018;
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trial compared the relative costs and clinical
before shedding primary teeth. 11. Stel G, Veerkamp JSJ, Amerongen WE van,
outcomes of three different approaches, Hall
Martens LC, Gemert-Schriks MCM van.
crowns (HT), non-restorative cavity control
Acknowledgement Treatment of (deep) caries lesions in primary
(NRCC, without the promising use of SDF),
Sincere thanks to Edwina Kidd teeth. In: Kindertandheelkunde Part 2. Houten:
and conventional compomer restorations
who has reviewed and criticized this offering. Bohn Stafleu van Loghum, 2013: Chapter 32.
(CR).30 The treatments were applied to a 12. Ingers G, Cromvik U, Gleerup A, Rönnerman
single tooth in each child. Hall crowns were A. The effect on space conditions of unilateral
less costly than the other two interventions, Compliance with Ethical Standards
grinding of carious proximal surfaces of
surviving longer and requiring fewer Conflict of Interest: The author
primary molars − a longitudinal study.
interventions. Cost studies are needed. This declares no conflict of interest.
ASDC J Dent Child 1982; 49: 30−34.
cost analysis is quite restricted (single tooth) Informed Consent: Informed
13. Mejàre I, Stenlund H, Julihn A, Larsson I,
and the subject deserves further study in consent was obtained from all individual
Permert L. Influence of approximal caries in
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21. Mijan M, de Amorim RG, Leal SC et al. The 3.5- Evans DJ, Alkilzy M, Splieth CH. Acceptability inactivation of carious tissue: non-restorative
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according to three treatment protocols: a primary molars in a RCT. Int J Paediatr Dent 124−136.

We are a specialist company for the supply,


installation, repair and maintenance of Inhalation
Sedation and associated equipment.

Offering free and friendly advice to help you with all


aspects of use, including establishing a
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including scavenging of nitrous oxide and monitoring.

We have a comprehensive selection of R A


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Inhalation Sedation is a well tried and trusted, safe and


non-invasive technique, suitable for 90% of the average
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R A Medical Services Limited
Holmes House, Skipton Road, Keighley BD20 6SD
Tel: 01535 652 444
www.ramedical.com - info@ramedical.com

228 DentalUpdate March 2019

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