DOI: 10.1111/ipd.12074

Assessment of oral hygiene and periodontal health around posterior primary molars after their restoration with various crown types ¨ Z KARA1 & YUCEL YILMAZ2 NIHAL BELDU 1

Department of Paediatric Dentistry, Faculty of Dentistry, Ordu University, Ordu, and 2Department of Paediatric Dentistry, Faculty of Dentistry, Atatu¨rk University, Erzurum, Turkey

International Journal of Paediatric Dentistry 2014; 24: 303–313 Objective. To

compare the time-dependent changes in oral hygiene and periodontal health after restoring primary posterior molars with a traditional stainless steel crown (SSC) or an aesthetic crown using various measures of periodontal health and oral hygiene. Design. This investigation was a randomized, non-blinded prospective controlled clinical trial in which 264 crowns of different types were fitted onto the first and/or second primary molars of 76 children. The oral hygiene and the gingival health of the restored teeth and the antagonistic teeth were evaluated clinically and radiographically at

Introduction

The traditional stainless steel crown (SSC) has been proved to be a very successful and durable alternative to other restorative materials for restoring primary teeth with excessive substance loss1. Traditional SSCs have many advantages over other crown types and dental restorative materials2,3. First, their lifespan is the same as that of an intact primary tooth. Second, they provide protection to the residual tooth structure that may have been weakened after excessive caries removal. Third, the technique sensitivity or the risk of making errors during their application is low. Fourth, their long-term cost effectiveness is good. Fifth, they have a low failure rate. Nevertheless, tooth restoration with a traditional SSC often fails to meet the aesthetic demands of

Correspondence to: N. Beldu¨z Kara, Department of Pedodontics, Faculty of Dentistry, Ordu University, 52100 Gu¨zelyalı, Ordu, Turkey. E-mail: [email protected]

3- and 6-month intervals for 18 months after fitting the crowns. Results. The periodontal health of the control teeth was better than that of the remaining 215 restored teeth. The oral hygiene, as measured by the simplified oral hygiene index, and gingival health, as measured by the gingival index and the volume of gingival crevicular fluid, of the restored teeth, irrespective of crown type, progressively increased during the 18-month study period. Conclusions. Oral hygiene and gingival health around a restored primary tooth deteriorate with time. Our results suggest that SSC, an open-faced SSC, or a NuSmileâ pediatric crown should be the preferred crown type for restoring posterior primary teeth.

the patient and his/her parents because of its unsightly metallic appearance4,5. Numerous studies have informed on the gingival health of primary teeth that were restored with a traditional SSC. The results of some of these studies found that good- to moderate-fitting crowns with well-contoured crown margins facilitate good oral hygiene, healthy gingivae, and minimal plaque accumulation6–9. In another study, Sharaf and Farsi10 reported that interproximal bone resorption after placement of an SSC on primary molars was not adversely affected by (a) an extension or adaptation of the crown’s margin, (b) a tight proximal contact between molars, (c) the level of oral hygiene, or (d) the duration of crown’s presence. Discrepancies of the subgingival margins of the SSC, however, have been implicated by some investigators as one of the causes of gingival inflammation after restoring a primary tooth with an SSC6. An aesthetic crown is an SSC that is veneered with a tooth-colored resin composite or porcelain. As the veneer veils most of

© 2013 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

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aesthetic crown’s metal coping, such crowns allow the dentist to address the aesthetic demands of young patients and their parents, while effectively restoring the patient’s primary tooth or teeth11. There are only a few studies that have informed on gingival health, the clinical success, and the clinical performance of primary molar teeth restored with a pre-fabricated aesthetic crown11–13. Ram et al.11 reported on the long-term (4 years) clinical performance of aesthetic primary molar crowns and SSCs and found no difference for marginal extension, occlusion, crown adequacy, and periodontal health between SSCs and the aesthetic crowns. In their study on the clinical success of two commercially available aesthetic crowns, Leith and O’Connell13 found 83% of the restored posterior primary molars were free of gingival inflammation, 12 months after the restoration. These findings differ from those of Fuks et al.12 who reported on the short-term (6 months) clinical performance of aesthetic crowns and SSCs and found that the restoration of mandibular primary molars with aesthetic crowns resulted in poor gingival health. Furthermore, we are not aware of any published studies that have evaluated periodontal health of primary teeth that were restored with either an open-faced stainless steel crown (OSSC) or a veneered stainless steel crown (VSSC). Gingival crevicular fluid (GCF) is an inflammatory exudate that is continuously secreted by the sulcular epithelium in the gingival sulcus6. Therefore, changes in GCF volume could be used as an early indicator of a gingival reaction to the subgingival margins of a crown before tissue destruction occurs. Accordingly, its use as biomarker of oral hygiene and periodontal health would be a significant refinement over the existing methods of assessing periodontal health and oral hygiene, namely the simplified oral hygiene index (OHI-S), the plaque index (PI), the gingival index (GI), and measurement of the probing pocket depth (PPD) to assess the extent of periodontal destruction. It is against this background that we undertook a study whose aim was to compare the

time-dependent changes in oral hygiene and periodontal health of children after restoring their primary posterior molars with a traditional SSC or an aesthetic crown using the abovementioned measures of periodontal health and oral hygiene. Materials and methods

Study design and ethical approval The study was a randomized, non-blinded prospective controlled clinical trial. The children and their parents were informed about the purpose of the study, and an informed consent document prior to participation was also signed. The study was performed according to the principles of the Declaration of Helsinki and was approved by the Ethics Committee of Atatu¨rk University (No: 2006.4.1/15). Study subjects Seventy-six children (40 girls), who were aged between 5–8 years (6.6 (mean)  1.0 (standard deviation) and presented to the Department of Pedodontics, School of Dentistry, Atatu¨rk University for the restoration of at least two primary molars, participated in the study. For inclusion in the study, the teeth that required restoring had to have an antagonist tooth and met one of the following criteria: (a) extensive or chronic caries that did affect the pulp and whose scores were between 2 and 3 according to the radiographic criteria of Ekstrand et al.14 (b) localized hypoplastic defects, (c) a normal or non-resorbed interproximal bone level, namely the distance between the crest of interdental bone and cement–enamel junction was not greater than 2 mm on radiographic evaluation, or (d) a score of either Resi or Res1/4 for the extent of root resorption according to root resorption scale of Fanning15. Children with (a) a systemic disease, (b) an allergy to any drug, such as a local anesthetic agent, nickel, and/or a resin restorative material, (c) extremely poor oral hygiene, (d) periodontal disease, or (e) malocclusion were excluded from the study.

© 2013 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Periodontal health of primary crowns

Study crowns and restorative materials The traditional SSC that was used in this study was made by 3M ESPE, Seefeld, Germany. The aesthetic crowns that were used in the study were an OSSC (Fig. 1), a VSSC (Fig. 2), a NuSmileâ (NS) pediatric crown (Orthodontic Technologies Inc., Houston, TX, USA), and a Pedo PearlsTM (PP) crown (Cooley & Cooley Ltd, Houston, TX, USA). Two-hundred and sixty-four crowns were fitted onto the first and/or second primary molars of the 76 children. At least one molar was restored with a traditional SSC, and at least one molar was restored with an esthetic crown. The four aesthetic crowns were randomly assigned in a consecutive manner. An OSSC was assigned to be fitted to the first child who participated in the study. A VSSC was assigned to be fitted to the second child who participated in the study. An NS crown was assigned to be fitted to the third child who participated in the study, and a PP crown was assigned to be fitted to the fourth who participated in the study. This consecutive assignment of the aesthetic crowns was then repeated for all subsequent participating children. When all of the NS and PP crowns had been assigned, those children, who were

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scheduled to be fitted with one of these crown types, were fitted with either an OSSC or VSSC. An intact contralateral tooth served as the control in each child. The traditional SSCs, the OSSCs, and the VSSCs were fitted after traditional crown preparation of the tooth. The PP crowns were fitted according to the manufacturer’s instructions. For the NS crowns, which are thicker than the other crown types, the reduction in the occlusal surface was more extensive than that required for the fitting of a traditional SSC and the three other types aesthetic crowns. The traditional SSCs, the OSSCs, the VSSCs, and the PP crowns were contoured and trimmed before placement. Before cementing, each crown was adapted so that its fit between the gingival margins of the crown at the gingival bulge of the enamel was snug and intimate. The NS crowns were not contoured before placement. The lengths of the NS crowns, however, were altered if necessary by trimming the gingival margins with a polishing disk in a manner that is routinely done in pediatric dentistry. The lingual aspects of the NS crowns were only crimped slightly before placement, and excessive force was not used for their fitting.

(a)

(b)

(c)

(d) Figure 1. The fitting of an open-faced stainless steel crown (OSSC) (a) The clinical view of a left maxillary first primary molar (b) Radiographic image of picture ‘a’ (c) Preparation of the tooth (d) Radiographic evaluation of the adaptation (e) The clinical view of the fitted traditional stainless steel crown (SSC) (f) Opening the (g) vestibular face of the SSC (g) Acid etching with Vococid etching gel (Voco, Cuxhaven, Germany) (h) Bonding with Monobond-S (Ivoclar, Vivadent AG, FL-9494, Schaan, Liechtenstein) (i) Restoration with Tetric Flow (Ivoclar, Vivadent AG, FL-9494, Schaan, Liechtenstein).

(e)

(f)

(h)

(i)

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(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(k)

(l)

The fitted crowns were evaluated clinically and radiographically at 3- and 6- month intervals for eighteen months after crown placement. The fitted crowns were examined for their marginal adaptation and the presence of critical defects in their structure. The marginal adaptation of each crown was assessed along the buccal and lingual walls and was considered good when the margins were sealed or poor when the margins were open. Fitted crowns were excluded from the analysis when (a) the crown margins were found to be short, extended below the cement–enamel junction or had separated from tooth surface by more than 1 mm, or (b) any critical defects in the crown’s structure were detected. The restored teeth were assessed clinically for pain, swelling, cement washout, palpation sensitivity, and sensitivity to percussion. The restored teeth were assessed radiographically for radiolucency in the furcation and periapical areas, internal or

Figure 2. The fitting of a veneered stainless steel crown (VSSC) (a) The clinical view of a right mandibular first primary molar (b) Radiographic image of picture ‘a’ (c) Preparation of the tooth (d) Radiographic evaluation of the adaptation (e) Opening the grooves on the vestibular face of the traditional stainless steel crown (SSC) (f) Sandblasting (g) The clinical view of roughened SSC (h) Acid etching with Vococid etching gel (i) Bonding with Monobond-S (j) Application of Monopaque (k) Application of Tetric Flow (l) The clinical view of the VSSC.

external root resorption, widening of the periodontal space, interdental alveolar bone loss, and physiological root resorption. The interproximal bone level was considered normal and not resorbed when the distance between the crest of interdental bone and cement– enamel junction was less than 2 mm. Bone was considered resorbed when this distance was more than 2 mm16. Any restored tooth with one of these clinical or radiological features was excluded from the analysis. Clinical evaluation of periodontal health and oral hygiene The OHI-S was estimated by running the side of an explorer over the buccal surface of tooth numbers 55, 51, 65, 85, 71, and 75. The area was scored on a scale of 0 to 3, where 0 = no debris; 1 = soft debris that covered less than one-third of tooth surface; 2 = soft debris that covered between one-third and two-thirds of

© 2013 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Periodontal health of primary crowns

the tooth surface; 3 = soft debris that covered more than two-thirds of tooth surface. The PI, GI, and the PPD were measured by passing an explorer tip gently within the sulcus on the tooth’s mesial, distal, buccal, and lingual surface of each crowned and control tooth. The PI was scored on a scale of 0 to 3, where 0 = no plaque in the gingival area; 1 = a film of adherent plaque was present on the free gingival margin and the adjacent area of the tooth; 2 = moderate accumulation of soft deposits within the gingival pocket and on the gingival margin and/or adjacent tooth surface which could be seen by the naked eye; 3 = an abundance of soft matter within the gingival pocket and/or on the gingival margin and adjacent tooth surface. The GI was scored on a scale of 0 to 3, where 0 = normal gingivae; 1 = the presence of mild inflammation, a slight change in gingival color, negligible edema, and no bleeding on palpation; 2 = moderate inflammation, gingival redness, edema and glazing, and bleeding on probing; 3 = severe inflammation, marked gingival redness and edema, ulceration, and a tendency to spontaneous bleeding. The PPD was measured using a manual probe (Hu-Friedy Manufacturing Inc., Chicago, IL, USA). The Periotron 8000â gingival fluid meter (Oralflow Inc., Smithtown, NY, USA) was used to measure the GCF volume round each crowned and control tooth. For measurement of the GCF volume, each tooth was first isolated with cotton rolls and the gingival tissues were then air-dried to avoid contamination with saliva. A paper strip (Periopaper, ProFlow, Inc., Amityville, NY, USA) was then inserted into the gingival crevice until mild resistance was felt, and left in place for 30 s. The strip was discarded when it was visibly contaminated with blood. Statistical analysis of the data All clinical examinations and measurements were carried out by one of the authors (NK). The Kappa values for intra-examiner repeatability were determined for each study parameter which was first measured before the start of the investigation. All statistical

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analyses were carried out using a computerized statistical software program (SPSS 11.5 for Windows, (SPSS Inc., Chicago, IL, USA). A one-sample t-test was used to compare the periodontal health and oral hygiene outcomes of the crowned and control teeth. Pearson’s correlation analysis was used to determine the relationship between the periodontal health and the five different crowns that were used to restore the teeth. The Kruskal–Wallis test was used to compare the time-dependent changes in periodontal health after restoring the teeth with a traditional SSC or one of the four types of aesthetic crowns. A multiple significance test with the Bonferroni correction was used to compare the time-dependent changes in the PI, GI, PPD, and GCF measurements. Data are presented as the mean  standard deviation (SD), and the level of statistical significance was set at 5% for all analyses. Results

The Kappa values for the intra-examiner reproducibility for each examination, score, and measurement were greater than 0.90. The distribution of the SSCs and various types of aesthetic crowns with regard to age and sex of the child, and the tooth that was restored is presented in Table 1. Of the 264 restorations, 16 teeth that were restored with an SSC, 15 teeth that were restored with an OSSC, six teeth that were restored with a VSSC, eight teeth that were restored with a NS crown, and four teeth that were restored with a PP crown were excluded from the analysis. Table 2 summarizes the clinical and radiographic causes for their exclusion from the analysis. Table 3 summarizes the timedependent relationship between oral hygiene and periodontal health for all crown types that were used to restore the remaining 215 restorations. Oral hygiene, as measured by the OHI-S, was positively correlated with periodontal health, as measured by the PI and GI scores and the GCF volumes at the start of the study (baseline). This positive relationship was seen for the duration of the 18-month study, except at the 3-month, 6-month, and 9-month examinations. Moreover, the PI, GI

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Table 1. The distribution of the various crown types that were used to restore primary molars. Age

Sex

Tooth

SSC

OSSC

VSSC

NS

PP

Total

5

Female

IV V IV V

5 2 6 3 16 4 9 8 6 27 11 9 11 4 35 3 9 2 1 15 93

4 1 1 2 8 8 3 4 4 19 4 5 7 7 23 5 1 1 3 10 60

5 2 1 1 9 6 3 4 – 13 9 3 9 2 23 1 – 3 1 5 50

5 – 3 2 10 3 – 4 1 8 3 – 3 4 10 3 3 3 – 9 37

– – –

19 5 11 9 44 22 15 21 15 73 31 22 34 18 105 13 13 10 6 42 264

Male

6

Total Female Male

7

Total Female Male

8

Total Male Female Total

Total

IV V IV V IV V IV V IV V IV V

1 1 1 – 1 4 6 4 5 4 1 14 1 – 1 1 3 24

Table 2. The causes of exclusion of the crowns from the analysis. SSC Clinical Vestibule gingival abscess Fistula Sensitivity at palpation Sensitivity at percussion Cement wash-out Radiographic Radiolucency in the furcation/periapical areas Internal resorption External resorption Widened periodontal space Total number of crowns that were excluded from the analysis (%) Number of crowns that were lost to follow-up Total

OSSC

VSSC

NS

PP

8

2

3

1



2 4 4 –

2 2 2 3

– 1 1 1

1 2 2 2

– – – 3

15

4

3

7



– – 15

– – 4

– – 3

– – 7

– – –

4 (8.3)

8 (21.6)

3 (13)

15 (16.3)

7 (13.5)

1

8

2



1

16

15

6

8

4

SSC, stainless steel crown; OSSC, open-faced stainless steel crown; VSSC, veneered stainless steel crown; NS, NuSmile crown; PP, Pedo Pearls crown; IV, primary first molar; V, primary second molar.

SSC, stainless steel crown; OSSC, open-faced stainless steel crown; VSSC, veneered stainless steel crown; NS, NuSmile crown, PP, Pedo Pearls crown.

and GCF measurements were positively correlated with each other at each 3-monthly determination of these indices for the duration of the 18-month study. Over the 18-month study period, the PI and GI scores and the PPDs of the restored teeth and the control teeth increased (Table 4). Despite this time-dependent deterioration in periodontal health of the control and restored teeth, periodontal health of the control teeth was consistently better than that of the restored teeth: the values of these three measurements for the restored teeth were always higher than those for the control teeth. Although the mean GI scores of the restored teeth progressively increased with time, the GI scores were never greater than one. This finding indicates that the level of gingivitis in the study children was low for the entire duration of the 18-month study period. Table 5 summarizes the time-dependent changes in the PI scores of the restored teeth according to crown type. We found that the amount of clinically detectable plaque on the restored teeth was comparable to that on

the control teeth. The baseline and 3-month PI scores for those teeth that were restored with an OSSC or a VSSC were different to the equivalent scores for those teeth that were restored with an SSC, an NS crown, or a PP crown. Although the 3-month PI score of those teeth that were restored with an OSSC was lower than the baseline score, the PI scores of these restored teeth and those that were restored with a VSSC progressively increased with time. We found no statistical difference in the time-dependent changes in the PI scores of those teeth that were restored with an NS crown or a PP crown at each time point during the 18-month study period. Table 6 summarizes the time-dependent changes in the PPDs of the restored teeth according to crown type. The PPDs of the restored teeth progressively increased with time irrespective of crown type. Interestingly, the crown type seemed to influence these measurements: the 6-month and 9-month PPDs for those teeth that were restored with a PP crown were different to the equivalent measurements for those teeth that were restored with the other crown types.

© 2013 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Periodontal health of primary crowns Table 3. The time-dependent relationship between the oral hygiene and periodontal health for all crown types. Pearson’s correlation value Month

PI

Baseline

OHI-S PPD GI PI OHI-S PPD GI PI OHI-S PPD GI PI OHI-S PPD GI PI OHI-S PPD GI PI OHI-S PPD GI PI OHI-S PPD GI PI

3

6

9

12

15

18

GI

PPD

GCF

0.466** 0.109 0.466**

0.369** 0.077

0.108

0.113 0.111 0.499**

0.089 0.275**

0.117

0.111 0.213** 0.574**

0.103 0.329**

0.120

0.122 0.113 0.487**

0.103 0.472**

0.115

0.219** 0.234** 0.558**

0.179** 0.500**

0.127

0.202** 0.240** 0.611**

0.159* 0.449**

0.105

0.191** 0.267** 0.620**

0.145* 0.458**

0.108

0.340** 0.123 0.490** 0.358** 0.097 0.169* 0.749** 0.390** 0.101 0.188** 0.747** 0.497** 0.121 0.345** 0.670** 0.438** 0.156* 0.360** 0.734** 0.494** 0.151* 0.342** 0.781** 0.488** 0.150* 0.411** 0.760** 0.494**

*Correlation is significant at the P < 0.05 level. **Correlation is significant at the P < 0.01 level. OHI-S, simplified oral hygiene index; PI, plaque index; GI, gingival index; PPD, periodontal probing depth; GCF, gingival crevicular fluid volume.

Tables 7 and 8 summarize the timedependent changes in the GI scores and GCF volumes of the restored teeth according to crown type. The GI scores and the GCF

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volumes progressively increased after the placement of the crowns for the duration of the 18-month study period. Irrespective of crown type, no statistical differences were found in the GI scores and the GCF volumes of the restored teeth when the value of each study parameter was compared at each time point during the 18-month study period. Discussion

This study compared the time-dependent changes in oral hygiene and periodontal health after restoring primary posterior molars with a traditional SSC or an aesthetic crown using different measures of periodontal health and oral hygiene. When a crown is placed on a tooth in a healthy periodontal environment, the maintenance of good periodontal health depends on marginal integrity of the crown, the crown’s contour, the patient’s oral hygiene, and the patient’s intrinsic resistance to disease. The results of studies that have examined the relationship between full coverage restorations and the maintenance of a healthy periodontium and healthy gingivae are somewhat discouraging. Moreover, controversy exists on the occurrence of soft tissue reactions when an SSC is used to restore a primary tooth2. It has been suggested that the presence of a full veneer crown with subgingival margins on a permanent tooth encourages or promotes gingival inflammation17. Although their study did not include data on control teeth, Goto et al.18 reported that the degree of gingivitis was strongly associated with poor-fitting SSCs.

Table 4. The time-dependent changes in periodontal health of the teeth that were restored with a crown and the control teeth. Month

Crown PI

Baseline 3 6 9 12 15 18

0.60 0.59 0.58 0.60 0.65 0.71 0.76

      

0.40 0.40 0.41 0.42 0.40 0.43 0.42

Control PI 0.50 0.45 0.44 0.43 0.45 0.48 0.53

      

0.35 0.32 0.31 0.33 0.34 0.35 0.36

P

Crown GI

* * * * * * *

0.23 0.81 0.78 0.83 0.88 0.93 0.97

      

0.32 0.52 0.53 0.53 0.53 0.55 0.55

Control GI 0.25 0.36 0.37 0.36 0.39 0.42 0.48

      

0.29 0.30 0.32 0.33 0.32 0.36 0.36

*Significant at the P < 0.001 level. PI, plaque index; GI, gingival index; PPD, periodontal probing depth. Values are presented as mean score or depth (mm)  standard deviation. © 2013 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

P

Crown PPD

0.12 * * * * * *

1.10 1.24 1.33 1.40 1.44 1.50 1.58

      

0.26 0.34 0.37 0.77 0.42 0.44 0.48

Control PPD

P

      

* * * * * * *

1.03 1.07 1.08 1.13 1.18 1.25 1.30

0.23 0.23 0.24 0.28 0.29 0.32 0.35

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Table 5. Time-dependent changes in the plaque index scores of the restored teeth according to crown type. Month

SSC (n = 77)

OSSC (n = 45)

VSSC (n = 44)

NS (n = 29)

Baseline 3 6 9 12 15 18 F= P=

0.65  0.63  0.60  0.60  0.69  0.74  0.77  4.40

Assessment of oral hygiene and periodontal health around posterior primary molars after their restoration with various crown types.

To compare the time-dependent changes in oral hygiene and periodontal health after restoring primary posterior molars with a traditional stainless ste...
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