Periodontal health at first permanent molars adjacent to primary molar stainless steel crowns Guelmann M, Matsson L and Bimstein E: Periodontal health at first permanent molars adjacent lo primary molar stainless steel crowns. J Ctin Periodontol 1988: 15: 531-533. Abstract. The present investigation was designed to study the effect of stainless steel crowns (SSC), placed on second primary molars, on the periodontal tissues of neighbouring first pennanent molars. 36 children (9-12 years old) with an SSC on a second primary molar on one side of the mouth only, were selected for the study. A clinical and radiographic examination was performed at the mesial surface of the first permanent molar, adjacent to the SSC, and at the corresponding area on the contraiateral side of the mouth. The ciinicai examination included gingival and plaque index scores and probing depth measurements. In the radiographic examination, the marginal bone level was assessed. No statistically significant differences in plaque index scores, gingival index scores and probing pocket depth were noted between the mesial surface of first permanent molars and the contraiateral control area. Nor were any significant differences in bone level seen. The present findings suggest that the presence of a well-adapted SSC on a second permanent molar does not affect the periodontal health of the neighbouring first permanent molar.
The Stainless steel crown (SSC). manufactured as a metal shell with the preformed anatomy of the occiusal surface, is mostly used for the semi-permanent restoration of badly decayed primary teeth. Its retention is based on margins that extend beyond the prepared portion of the tooth, adapted to the individual tooth by being trimmed, contoured and crimped (Mink & Bennet 1968, USDOHEW 1977), The adaptation of the SSC is limited and its possible deleterious effect on the surrounding gingival tissues of the tooth has been the subject of several studies (Webber 1974, Myers 1975. Sarafanov 1979, Ashraphi et a l 1981. Machen et al, 1981), Most of these investigations detected an increase in gingival irritation associated with SSC (Meyrs 1975, Sarafanov 1979, Ashraphi et al. 1981. Machen et al. 1981). This finding, and the fact that the mesial surface of the first permanent molars has been identified as a "risk area" for the early development of periodontal disease (Hugoson et al. 1981, Gjermo et al. 1984). led
to the hypothesis that an SSC placed ona second primary molar may have a deleterious effect on the mesial periodontal tissues of the first pennanent molar. The purpose of the present study was therefore to describe the effect of a second primary molar SSC on the periodontal tissues of the mesial surface of the first permanent molars.
Material and Methods The dental records of 280 children, aged 9-12 years, from a mixed socio-economic suburb of .Jerusalem, who received dental treatment at the Haddassah Health Community Center, were reviewed for cases in which an SSC had been applied to a second primary molar on one side of the mouth only. 40 cases were found that fulfilled these criteria. Of these, 36 (15 boys and 21 girls), in which the SSC and its contraiateral control tooth were still present in the mouth, were examined. Each child
Marcio Guelmann', Lars Matston' and Enrique Bimstein' 'Department ot Pediatric Dentistry, Haddassati Faculty of Dental Medicine, Hebrew University In Jerusalem, Israel, and 'Department ol Pedodontics, University of Umea, Sweden
UBRARY
Key words: periodontal disease steel crowns; pedodontics. Accepted for publication 28 November 1987
contrib uted with one SSC and one control tooth. The length of time that the SSC had been in the mouth was recorded. The age of the patients selected was chosen to represent the end stage of the functional period of the primary molars, A clinica] and radiographic examination was performed of the area at the mesial surface of the first permanent molar adjacent to the primary molar with an SSC and at the corresponding area on the contraiateral side of the mouth. All examinations were performed by one of the authors (MG). In each child, two bite-wing radiographs (Kodak Ultra Speed D) were taken using an X-ray unit equipped with a long cone (Philips Oralix CHF). The central ray was directed at the mesial surface of the first permanent molars. The radiographs were also used for diagnosis of caries disease and appointments for treatment were given to children who required treatment. The clinical examination included: (i) gingival index and plaque index scores
532
Guetmann et al. probing pocket depth and the bone level.
Table I, Distribution of examined areas in plaque index classes P.I. score
1
0
2-3 (%)
n
(%)
Adjacent to cro\vn mesiobuecal mesiolingual
12 10
33.3 27.8
14 13
38.9 36.1
10 13
27.8 36.1
Control mesiobuccal mesiolingual
12 11
33.3 30.6
17 II
47.2 30.6
7 14
19.4 38.9
(%1
~
Mesiobuccal: y^ = 0.82, N.S.: mesiiolingual: : z " - 0 . 2 5 . N.S.
(Loe 1967) mesiobuccaly and mesiolingualiy at the first permanent molar: (ii) subgingival depth of the SSC, measured at the deepest point on the distal surface of the primary molar; (iii) probing depth mesiohuccaUy and mesiolingualJy at the first permanent molar. All measurements were performed using a 1 mm graded periodontal probe (Hu-Friedy, GF-W, USA). In the radiographic examination, the marginal bone level (the distance from the cemento-enamel junction (CEJ) of the first permanent molar to the interdental alveolar crest (AC)) was measured with calipers on the image of the bite-wing radiographs projected onto a screen of a slide viewer (Singer Clearinate Caramate U SP. Rochester, N,Y.. enlargement X 7,2), The radiographs were selected in accordance with the following criteria; (i) minimal evidence of distortion; (ii) minimal overlapping between the proximal surfaces of the teeth; (iii) clear image of the cemento-enameJ junction. After selection, 27 pairs of radiographs from 16 girls and 11 boys remained for measurements. Statistical comparisons of plaque index and gingiva! index scores between the 2 groups were performed using the /'-test. For the comparisons of probing depth and bone level, the Student (-test for paired observations was applied, A correlation analysis between the time the SSC had been in the mouth, and the pocket depth and the radiographicaily assessed bone icvcK was performed. Differences at the 5% level of probability were considered statistically significant. Results
The SSC werejudged to be well-adapted at the distal surface of the tooth. In 32 of the 36 cases, the distal subgingival depth of the SSC was 2 mm or less. In the remaining cases, however, the subgingival depth was 3 mm. Comparison of the distribution of
plaque index scores and gingival index scores, between the first permanent molars adjacent to an SSC and their controls did not show any statistically significant differences (Tables 1. 2). Nor were any differences in probing pocket depth seen between the 2 groups (Table 3), The radiographic analysis revealed a mean bone level of 0,9 mm at the first permanent molars adjacent to an SSC compared with 0,7 mm at the controls. The differences was not statistically significant, information about the length of time the SSC had been in the mouth was available for 27 crowns. The mean time was 24.6 months (range 8-36), In 20 of these cases, acceptable radiographs for bone-ievei measurements were avail able. No significant correlation was found between the length of time the SSC had been in the mouth, and the Tcihle 2, Distribution of e
Discussion It has been stated that pre-formed SSC can be used successfully to restore primary molar teeth without adversely affecting the health of the gingivae or the status of the patient's oral hygiene (Webber 1974), However, other studies indicate that clinical evidence of gingivitis may be associated with the presence of an SSC, especially when defects such as poor crown crimp, contour or position, and/or cement remaining in the gingival sulcus are observed (Myers 1975. Sarafanov 1979, Ashraphi et al. ]98I, MachenetaJ. 1981). The possible relationship of gingiva! disease around primary molar SSC lo the gingival health of their permanent successor was studied by Fuks et al. (1983), who found no difference between the permanent successors of crowned primary molars and their homologues or the rest of the mouth. Even when gingivitis was present around the crowned primary tooth, it was resolved upon exfoliation of the primary tooth and subsequent eruption of the permanent tooth. An additional relationship, between the presence of an SSC on a primary molar and the periodontal health of the permanent den-
; in gingival index classes
G.I. score
1
0
2
n
(%)
Âť
(Vo)
r,
(%)
Adjacent to crown mesiobuccal mesiolingual
16 15
44.4 41.7
16 15
44.4 41.7
4 6
11.1 16.7
Control mesiobuccal mesiolingual
23 18
63.9 50.0
6 15
16.7 41.7
7 3
19.4 8.3
Mesiobuccal: /==2,01, N,S.: mesiolingual: /- = 0,22. N,S,: index score 1 and 2 treated as one cell, lahle 3, Probing pocket depth and marginal bone level; means (-v) and standard deviations (S,D.); /-test for paired observations applied Probing pocket level mesiobuccal adjacent to SSC control mesioiingual adjacent to SSC control Marginal bone level adjaeent to SSC control
tl
i-
S.D.
1
P
36 36
3.0 3.1
0.6 0.5
1.41
N.S.
36 36
3.1 3.2
0.6 0.5
0.77
N.S.
27 27
0.9 0.7
0.5 0.5
Feriodontal health related to preformed crowus tition, is the possible deleterious effect of a second primary molar SSC on the gingiva! health of the first permanent molars, induced either by the manipu]ation during placement of Ehe crown or by a possible increase in retention of dental piaque in the area. The mesial surface of first permanent molars has been identified as a risk area for the development of periodontal disease (Hugoson et al. 1981, Gjermo et al. 1984). The present findings of a lack of significant differences in the clinical and radiographic parameters between the side of the mouth with an SSC and the contro] side suggest that for the age group examined, the presence of an SSC on a second primary mo]ar does not significantly affect the adjacent periodonta] tissues of the first permanent mo]ar. However, in most cases examined in the present study, a weU-adapted SSC was found, and keeping in mind that previous studies have demonstrated an association between gingiva! disease and poorly adapted SSC, the present findings do not overrule the possibility of periodontal damage on the mesial surface of first permanent molars caused by poorly adapted SSC on second primary molars. Based on the present results and the findings of Fuks et al. (1983), it can be concluded that, provided the crown is we]]-adapted to the primary mo!ar, a stainless steel crown does not seem to have a detrimental effect upon the permanent dentition.
Zusammenfassung Die paradontale Gesundheit von ersten hleihenden Molaren, direkt neben. mit Stahlkronen versorglen Mihhmolaren Die vorliegende Untersuchung wurde konzi piert, um den Effekt von mil Stahlkronen versorgten Milchmolaren aufdie parodontalen Gewebe benachbarter, erster bleibender Molaren zu studieren. 36 Kinder (9-12 Jahri; alt) mit einer SSC (stainless steel crown) auf einem zweiten Milchmolaren in nur eincr Mundseite, wurden fur diese Studie ausgewahlt. An der mesialen OberHache des ersten bleibenden Molaren, direkt neben der SSC und an der entsprechenden Stelle der kontralatcralen Seite. wurdc cine klinische und rontgenographische Untersuchung vorgenommen. Die klinische Untersuchung beinhaltete Gingiva]- und P]aqueindex-Scores (Beurtei-
lungscinheiten) sowie Messungen der Sondierungsticfen. Bei der rontgenographischen Untersuchung wurde das marginale Knochennjveau bcstimmt. An den mesialen Oberriachen der ersten bleibenden Molaren und der kontraiateralen Region wurden keine statistisch signifikanten Unterschiede zwischen den Plaqueindex- und Gingival index-Scores beobachtet. Das gleiche gjU fiir die sondierten Taschentiefen. Auch zwischen den Knochenniveaus der gieichen Regionen wurden keinerlei abgesicherte Unterschiede gesehen. Die vorliegenden Resmtate besa^n, dass eine zweckentsprechend adaptierte SSC atif einem zweiten Milchmolaren, die parodontale Gesundheit des benayhbarten ersten bleiben Molaren nicht beeiiifiusst.
Resume Etai parodontal des premieres molaires permanentes adjacentes a des inoUiires de iait recouvertes de couronnes en acier inoxydahle
533
La presente etude a eu pour but d'evaluer l'effet de couronnes en acier inoxydable ( C A I ) placees sur des secondes molaires temporaires sur les tissus parodontaux des premieres molaires definitives adjacentes. Trenle six enfants ages de 9 a 12 ans avec une CAI sur une seconde molaire temporaire d'un cole de la bouche tiniquement ont ete selectionnes pour cette etude. Un examen clinique et radiographique a ele effectue en mesial de la premiere molaire definitive adjacente ainsi qu'au niveau contraiateral servant de controle, L'exameii clinique comprenaif k s indices de plaque et gingival ainsi que la profondeur des poches. L'examen radiographique a servi a controler le nJveau osseux. Aucune difference stalistique n'a ele trouvee entre ces donnees. Les resultats suggerent que le placement d'une CAI bien adaptee sur une seconde molaire temporaire n'affecte pas la same parodontale de la molaire defmitive adjacente.
References Ashraphi. M. H,, Durr. D. P. & Duncan, W, K, (!98I) Interrelationship between stainless steel crown, plaque Accumulation, and gingival health. American Academy of Pedodoniics - Annual Meeting Reports. Research Abstract R-26, Fuks. A, B.. Zadok, S. & Chosack, A, (1983) Gingival health of premolar successors to crowned primary molars. Pediatric Dentistry 5, 51-52. Gjermo, P.. Bellini, T . Santos, V: P., M'artiins, /. G, d Berracyo/t, /. R. (1984) Prevalence of bone loss in a group of Brazilian teenagers assessed on bite-wing radiographs. Journal of Clinical Periodontologv U . 104-113. Hugoson, A,, Koch, C}, & Rylander, H, (1981) Prevalence and distribution of gingivitisperiodontitis in children and adolescents. Scandinavian Dental Journal 5. 91-103. Loe. H, (1967) The gingival index, the piaque index and the retention index system. Journal of Feriodontology 38, 610-616. Machen, E., Rapp, R., Baumhammers, A, & Zullo, T, (1981) The effecl of stainless steel crowns on gingival tissue. American Academy of Pedodontics - Annual Meeting Reports. Research Abstract H-27. Mink, J, R. & Bennet, I. C, (1968) The stainless steel crown. Journal of Dentistry for Children 35, 188-196, Myers, D, R, (1975) A tlinical study of the response of the gingival tissue surrounding stainless sleel crowns. Journal of Dentistry for Children 42, 33-36, US Department of Health. Education and Welfare (USDOHEW). (1977) Project Tupp: Stainless steel crown, preparation and restoration (Quercus Corporanon). Sarafanov. S. R. (1979) Coronas de acero cromo para molares primarios (evaiuadon de dos tipos). Association Liental Mexicana 36, 134-147, Stoner, J. E, (1972) An investigation into the accuracy of measurements made on radiographs of ihe alveolar crests of dried mandibles. Journal of Periodontology 43, 699-702, Webber, D, L. (1974) Gingival health following placement of stainless steel crowns. Journal of Dentistry for Children 41, I86-IB9. Address: Lars Matsson Department of Pedodontics University of Umed S-9Q}H7Vmea Sweden