Download pulpotomy to stainless steel crown ratio

PULPOTOMY TO STAINLESS STEEL CROWN RATIO IN CHILDREN WITH
EARLY CHILDHOOD CARIES: A CROSS SECTIONAL ANALYSIS
A Thesis
Presented in Partial Fulfillment of the Requirements for
The Degree Master of Science in the
Graduate School of The Ohio State University
By
Sophie(Yoon-Mi) Matracia, D.M.D.
*****
The Ohio State University
2009
Master’s Examination Committee:
Dr. Sarat Thikkurissy, Advisor
Dr. Paul Casamassimo
Dr. Dennis McTigue
Dr. Mark Siegal
Approved by
_______________
Advisor
Graduate Program in Dentistry
1
Copyright by
Sophie (Yoon-Mi) Matracia
2009
2
ABSTRACT
Objective: The purpose of this study was to evaluate factors affecting
pulpotomies in primary teeth and determine a pulpotomy: stainless steel crown
(SSC) ratio.
Methods: This retrospective chart review was performed by five calibrated
reviewers using a standardized radiographic index. Pulpotomy: SSC ratios were
assessed by age, pain scale, ASA status, radiographic score, and operator
preference.
Results: A total of 1,365 SSC’s from 521 patients were reviewed. Most
radiographic caries were confined to dentin (70%). Increase in radiographic score
(p<.0001) and pain scale (p=.0001) had strong associations with pulpotomy
treatment. The overall ratio of pulpotomy: SSC was 1:2.8.The most common ASA
II diagnosis from this study was Asthma (32%) followed by ASD and ADHD
(19.5%).
Conclusion: There was a significant association between the pain scale and the
radiographic score and pulpotomies being performed. The overall ratio of
pulpotomy to crown was 35.7%, which falls within national benchmark
ii
ACKNOWLEDGMENTS
I would like to thank my advisor, Dr. Thikkurissy, for intellectual and moral
support on my thesis. Without his encouragement, enthusiasm, and patience,
this thesis would not been completed. Dr. Thikkurissy is surely one of the most
wonderful pediatric dentists and brilliant teachers in the profession.
I thank Debbie Weatherby, a dental assistant and my research assistant, for
being such a wonderful helper in this project.
Last, but not least, I wish to thank my husband, Jeff, for standing by my side
during this exciting journey in our lives, and for his patience with my research and
writing. Without his love and sacrifice, I would have not have made it thus far in
my studies.
iii
VITA
May 10, 1973
Born in Kim-Po City, South Korea
2003
B.S. Biochemistry
University of California Los Angeles
2007
D.M.D.
University of Pennsylvania
School of Dental Medicine
2007-present
Pediatric Dental Resident
The Ohio State University and
Nationwide Children’s Hospital
FIELDS OF STUDY
Major Field: Dentistry
iv
TABLE OF CONTENTS
Page
Abstract ------------------------------------------------------------------------------------------ ii
Acknowledgments --------------------------------------------------------------------------- iii
Vita ------------------------------------------------------------------------------------------------ iv
List of Tables ------------------------------------------------------------------------------------vi
List of Figures -----------------------------------------------------------------------------------vii
Sections:
Introduction --------------------------------------------------------------------------------- 1
Methods ------------------------------------------------------------------------------------- 8
Results --------------------------------------------------------------------------------------10
Discussion --------------------------------------------------------------------------------- 16
Conclusion --------------------------------------------------------------------------------- 23
Appendix --------------------------------------------------------------------------------------- 24
List of References ---------------------------------------------------------------------------- 26
v
LIST OF TABLES
Table 1. Regression Analysis of Predictor for Treatment ---------------------------11
Table 2. SSC:Pulpotomy ratios based on radiographic score --------------------- 15
Table 3. SSC:Pulpotomy ratios based on ASA Status ------------------------------ 15
vi
LIST OF FIGURES
Figure 1. Radiographic Score vs. SSC’s and Pulpotomies --------------------- 12
Figure 2. Treatment Performed vs. Age Cohort ----------------------------------- 13
Figure 3. Pulpotomy: SSC Ratio by Age Cohort ---------------------------------- 14
vii
INTRODUCTION
Early Childhood Caries (ECC) is one of the most serious public health
issues facing children today. This chronic infectious disease is found in nearly
30% of all US population 1, with a higher prevalence in families with lower
socioeconomic status 2, 3. Children who experience ECC as infants/toddlers are
more likely to have subsequent caries in their primary and permanent dentition 4.
Caries in the primary molars is the most reliable predictor of caries in permanent
teeth 5. Untreated ECC not only affects the dentition, but also influences the
general health of the young children 4. Children affected by ECC demonstrate:
insufficient physical development, frequent hospitalization, increased emergency
room visits, loss of school days and diminished oral health-related quality of life
when compared to healthy children 6. In addressing the direct morbidity of ECC,
the American Academy of Pediatric Dentistry(AAPD), recommends immediate
interventions including; home care, alternative restoration treatment (ART)
techniques, appropriate use of topical fluoride, and judicious use of full coverage
(e.g. stainless steel crown restorations) of carious teeth 1. Deep interproximal
caries in primary molars is an indication for vital pulp therapy, followed by the
placement of stainless steel crowns to preserve arch perimeter, and maintain
arch health.
1
The pulpotomy is the most widely used vital pulp treatment of primary
molars and involves the “amputation of the coronal portion of the dental pulp
affected by deep caries” 7. Treatment of the affected coronal pulp and treatment
of the remaining vital radicular pulp with a medicament, allows for the
preservation of the vitality and function of the primary teeth 7. A pulpotomy is
typically indicated on a deep tooth with a deep carious lesion, where complete
removal of caries may cause pulp exposure. The contraindications for the
pulpotomy procedure include: swelling on mucosa, pathologic mobility,
resorption, interadicular or periapical radiolucency, pulp calcification, or history of
spontaneous pain 8. After the pulpotomy the tooth may become brittle and prone
to cracks or fracture 9. Therefore, placing a full coverage restoration, such as a
stainless steel crown (SCC), is strongly recommended following a pulpotomy in
order to prevent the fracture, provide strength to the devitalized teeth, and reduce
microorganism invasion.
The overall failure rate for SSCs (8%) is significantly lower than the failure
rates of amalgam (21%) and composite (30%) 10. The common reason for SSC
failure is due to the loss of a crown, which may need to be re-cemented.
Amalgam and composite restoration often fail because of recurrent caries and
fracture 11. Additional advantages of using SSC include: less reported technique
sensitivity during dental restoration and better long-term cost effectiveness
compared to other dental materials. Considering the risk involved with general
anesthesia, its associated cost, the high post-operative recurrent caries rate, and
2
the documented longevity of restorative materials, it is strongly recommended to
use SSC in children who undergo general anesthesia for dental rehabilitation 11.
Assessing pulpotomy to crown ratio is important in understanding how
certain dental interventions are deployed in children with high caries risk. This
numeric value represents how many teeth being pulpotomized per teeth with
SSCs. The average mean of pulpotomy to crown ratio in most dental practices
has been shown to be about 37% 12. Although this may not represent the
absolute ratio of pulpotomy to crown in pediatric dental practices it has been
utilized by insurance companies as a marker of potential ‘over-treatment’ by
dental providers.
AAPD guidelines state that a tooth requiring a pulpotomy should be vital.
Often, obtaining a precise pulpal diagnosis in children is a significant challenge
for the dentist, primarily due to issues of cooperation and behavior
management 13. Children have been shown to be poor historians when reporting
the severity of the pain 14 and this may be an obstacle for receiving an accurate
pulp diagnosis. Any test that may induce unpleasant stimuli, such as an EPT or
thermal test is subject to behavior problems, and may lead to an inaccurate pulp
diagnosis. Children are not good at describing subjective symptoms of pain, and
if the dentist asks the child a leading question, false positive and false negative
results may occur 15. Children tend to adapt their behavior in order to avoid
painful stimuli 16 and this includes inaccurate response to a pulp test.
Most of the diagnostic tests used in conventional endodontic therapy
have questionable diagnostic value in evaluating primary teeth 17. Electric pulp
3
tests and thermal test are not normally conducted on primary teeth because the
child’s response is not reliable 17. Thermal test and EPT are difficult to administer
to children, and often times generate inconclusive results. In order for both
methods to be effective, the pulp must contain a sufficient number of mature A
delta neurons (which conveys sharp pain), and both primary and immature
permanent teeth are not yet fully innervated with the mature neurons 16.
Response to a pulp vitality test can also vary depending on the stage of root
development and resorption of primary teeth 18.
To this date, there is no totally reliable method to determine the
histopathologic status of the primary pulp with 100% certainty. Therefore, a
treating dentist needs to collect comprehensive information based on
medical/dental history, history of pain, radiographic findings, clinical examination,
and pulp tests to deliver successful pulp therapy 13. Many variables may
influence the decision making process of treating primary teeth that require pulp
therapy. Those variables include: the presence and characteristics of pain,
radiographic findings (such as proximity of caries to the pulp and
presence/absence of pathologic radiolucency), operator preference, operator
experience, age of the patient, and the location (outpatient/ inpatient) where the
dental care is delivered.
The presence and nature of pain is an important factor to consider before
finalizing a treatment for the symptomatic tooth. Most often an endodontic
treatment is performed on carious painful vital molars, and teeth without
symptoms may be infrequently treated 19. It is recommended that the history of
4
pain be assessed by a dentist before initiating pulp therapy, and symptoms
compatible with reversible pulpitis treated with vital pulpotomy 20. Reversible
pulpitis is a provoked pain by thermal, chemical and mechanical irritants, and
once the causative irritants are removed, the pain theoretically ceases 17. This
usually indicates minor inflammatory changes of pulp 17 and should be
distinguished from irreversible pulpitis.
Spontaneous or irreversible pulpitis is a constant or throbbing pain
without stimulation, and it may last a long time even after the causative irritants
are removed 17. A positive history of spontaneous irreversible pain is classically
associated with extensive degenerative changes extending into the root canal,
and is usually treated with a pulpectomy or extraction 7, 21. Treating some primary
molars that have irreversible pulpitis with a vital pulpotomy may result in a lower
success rate of pulp therapy 20.
Radiographs are a useful tool for diagnosing caries, and this diagnostic
method helps a dentist decide which teeth with deep caries need a pulpotomy.
Schroder’s study in 1977 shows that there is 80% correlation between the clinicoradiographic evaluation of a symptomatic primary tooth and histopathologic
findings in the pulp 22. It is reported that if more than 4 mm of the marginal ridge
of a primary molar is destroyed by caries, there is a high likelihood of pulpal
involvement 23. Radiographic signs of internal or external root resorption,
widened PDL, or pathologic radiolucency in the periapical or furcation areas are
signs of advanced pulpal pathosis, and, in the absence of other extenuating
circumstances, the recommended treatment is typically extraction 17.
5
Treatment decisions may also vary with operator preference and
experience. There has been no clear agreement among pediatric dentists
regarding the optimal treatment recommendation for deep proximal caries of
primary molars 24. In the United Kingdom (UK), the national clinical guideline in
pediatric dentistry recommends a pulpotomy when more than two-thirds of the
marginal ridge of primary molars is compromised with caries 25. Fuks et al
strongly recommend an Indirect Pulp Capping (IPC) as the most appropriate
treatment for symptom-free primary teeth with deep proximal caries 26. Coll et al
suggest not performing the pulpotomy procedure when the pulp is already
exposed from caries, due to the chance of radicular pulp being already infected,
and a low likelihood of being totally vital of the teeth 27. Depending on the
dentist’s educational background and work experience, the recommended
restorative procedure for deep proximal caries in primary molars can be
different 28, 29.
The treatment plan recommended by a dentist is often influenced by the
practitioner’s experience in dental materials and techniques 30. There is a lack of
evidence to support the most appropriate technique for pulpotomies in primary
teeth 26, and often times, a dentist chooses techniques and materials based on
their educational background and individual preference. Various pulpotomy
techniques and pulp dressing materials have been proposed to maintain the
vitality of radicular pulp 26. Formocresol is still the most widely used pulp therapy
medicament, but there is a new trend away from using formocresol in pulpotomy
due to the concern of systemic absorption of formaldehyde 31. Instead, ferric
6
sulfate has been favored as an alternative intrapulpal medicament due to its high
success rate and negative carcinogenic potential 32. Clinical and radiographic
success rates for ferric sulfate pulpotomy is compatible or slightly higher than
formocresol, but the differences were not statistically significant 33, 34.
The age of the patient can also influence on the decision making of
primary teeth pulpotomies. The earlier the child is affected by the cariogenic
bacteria, the greater risk of caries that exists in the child 35. In such a high-risk
population, more aggressive treatment, such as pulpotomies followed by
stainless steel crowns, may be recommended in order to arrest deep proximal
caries. Depending on the settings where the dental care is delivered, either at a
clinic or under general anesthesia, the treatment decision on pulpotomies may
vary 11. Due to cooperation issues and the extent of dental diseases, often times
children are placed under general anesthesia (GA) to receive comprehensive
dental care. This is a costly procedure and there is a risk involved in putting the
child to sleep 11. Considering the cost, the health risk, and the low level of
compliance with a follow-up, an aggressive approach to dental rehabilitation
under general anesthesia should be considered 1.
The purpose of this study is
i). to examine predictors for vital pulp therapy in primary teeth
ii). to determine pulpotomy to Stainless Steel Crown ratio in a pediatric
population with Early Childhood Caries (ECC), treated in a large, urban hospitalbased dental clinic.
7
MATERIALS AND METHODS
This retrospective quality assurance included retrospective chart review of
patients treated at Nationwide Children’s Hospital Dental Clinic Columbus, Ohio,
over a 6 month period. The data were collected from 521 patients who received
either stainless steel crowns or pulp treatment with stainless steel crowns on at
least one primary molar or canine. Children were categorized by age into one of
three subgroups: 0-36 months old, 37-72 months old, and older than 72 months.
The data collected also included; patient’s medical history, medications, the
FACES pain scale score (from 0 to 10), and location of treatment whether the
patient was treated in the outpatient dental clinic or under general anesthesia in
the Dental Surgery Center. History of over-the-counter pain medication usage
and the names of medication was also obtained from the chart review. A
standardized radiographic template and scoring system were established, and
calibration of all examiners was conducted. The scoring scale was an ordinal 0-4
based on the following; 0=Clinical decalcification (white spot), no radiographic
caries noted, 1=Radiographic caries confined to enamel, 2=Radiographic caries
confined to outer ½ dentin, 3=Radiographic caries extends to inner ½ dentin,
4=Radiographic caries contacting pulp chamber.
8
The total numbers of teeth treated at the time of each visit and tooth type
were also evaluated. Five calibrated examiners evaluated the radiographic
findings on the treated primary teeth, and the extent of caries was determined
according to the radiographic scoring. The type of treatment, whether stainless
steel crowns only or pulpotomies plus stainless steel crowns, and any records of
repeated visit for the same teeth, were also assessed. All pulpotomies were
performed using ferric sulfate as an intrapulpal medicament. Following removal
of the coronal pulp tissue IRM was placed in the pulp chamber. Stainless steel
crowns (3M) were used to restore the pulpotomized teeth, and all SSC were
cemented with Ketac cement, a glass-ionomer luting cement. Exclusion criteria
included any primary teeth with a history of swelling, resorption, pathologic
mobility, and periapical or furcal radiolucency. Collected data were entered into a
data base (Microsoft excel) from a data collection sheet (this will need to be
attached in Appendices). Data analysis of categorical variables was done using
Fishers exact est, and ordinal variables using two-tailed t-test. Finally multivariate
linear regression was used to detect significant association. Statistical
significance was established at p ≤ .05.
9
RESULTS
Demographic Information
Data from a total of 521 patient charts were collected between July 2008
and December 2008, representing 1,365 stainless steel crowns placed over the
period of six months. The majority of the children treated, 66.3% (901) were
classified as healthy according to the American Society of Anesthesiologists, with
the remaining 33.7% (458) ASA Class II. One thousand and eleven crowns
(76.5%) were placed by one of six pediatric dentistry faculties while the child was
under general anesthesia. The remaining 23.5% (350) were placed by pediatric
dental residents with faculty supervision. Of all the crowns placed, 44.7% (610)
were on maxillary teeth and 55.3% (755) on mandibular primary teeth.
Multivariate linear regression was performed and the associations are
presented in Table 1. Significant demographic associations as to whether a tooth
received a pulpotomy existed with parental report on the FACES pain scale
(p<.0001). Children reporting a higher pain level were more like to have a
pulpotomy performed. Additionally if a child’s medical status was ASA II, there
appeared to be a mildly significant association with pulpotomy therapy (p=.05).
10
Predictor Variable
p-value
Age
0.133
FACES pain scale score
.0001*
ASA Status
.05*
Maxillary or Mandibular
0.28
Radiographic Score
<.0001*
Operator
0.143
Location of treatment
0.312
Repeat visit
0.09
Use of Over the Counter Meds
0.235
Table 1. Regression Analysis of Predictors for Treatment
R2
0.02
0.05
0.006
0.007
0.03
0.578
0.578
0.007
0.002
Age of the patient.
Out of 521 patients, 9.9% (135) of the children were ages 0-36 months, 54.7%
(747) were 37-72 months, and 32.4% (442) were older than 72 months. The
mean age of the children from this study was 5.1 years (SD=1.9). Referring
Figure 1, the highest percentage of SSC and pulpotomies were performed with
children 36-72 months, and this comprised 60.8% (775) of the total treatment for
all ages. Only 9.7% (123) of all the teeth treated in this dental clinic or surgery
center were performed on children from 0-36 months. Children older than 72
months had 29.6% (377) of the total teeth treated with either SSC or
pulpotomies. There was no significant association between the age of the patient
and the overall number of teeth being treated (p=.133).
11
Treatment Performed Versus Age Cohort
775
800
700
600
500
377
Total Number 400
(N)
300
300
200
115
123
46
100
0
0‐36
36‐72
Age Cohort (in months)
>72
total SSC
Pulpotomy
Figure 1 . Overall numbers of teeth treated as a function of different age groups
The pulpotomy to SSC ratio based on various age groups is represented
in Figure 2. The highest ratio of pulpotomy to SSC (3.28) was observed in the
oldest age cohort (>72 months), followed by ages 0-36 months (2.67), and finally
36-72 months (2.58). The difference in the ratios between those 0-36 months and
36-72 months was insignificant.
12
Pulpotomy:SSC Ratio by Age Cohort
3.28
3.50
2.67
2.58
3.00
2.50
Pulpotomy:SSC Ratio
2.00
1.50
1.00
0.50
0.00
0‐36
36‐72
>72
Age Cohort
Figure 2. The ratio of pulpotomy to SSC based on different age groups.
Radiographic Score
Radiographs were present for 98.3%(1,343) of all stainless steel crowns
placed. A weighted kappa of 0.86 was obtained for the examiners indicating a
good level of inter-rater reliability. Less than 1% (12) of the teeth were
radiographically scored as a “1”, meaning no radiographic decay noted by the
examiners, and clinical decalcification noted in the chart progress notes /
treatment plan. A total of 51 teeth (3.8%) were scored as having radiographic
caries confined to enamel. Radiographic caries into dentin was noted in 942
teeth (70.2%), and this was further subdivided into caries in the outer ½ of dentin
(233/17.4%) and inner ½ of dentin (709/52.8%). Finally, 337 of the teeth (25.1%)
13
had caries which radiographically contacted the pulp chamber. There was a
strong association between an increase in radiographic score and a pulpotomy
being performed (p<.0001). A graphic representation of the relationship between
radiographic score and treatment performed is presented in Figure 3.
Radiographic Score Versus SSC's and Pulpotomies
SSC
Pulp
512
500
Number Of Teeth
400
300
264
225
197
200
100
73
48
0
0
9
3
11
1
1
2
Radiographic Score
3
4
Figure 3. Overall numbers of teeth with stainless steel crowns and pulpotomies
based on radiographic score
Ratios of Stainless Steel Crowns to Pulpotomies
When all 1,343 teeth are considered, the overall stainless steel crown to
pulpotomy ratio (SSC:P) was 1:2.8. The remaining SSC: P ratios are presented
in Table 2. Using regression analysis to determine the association between
14
treatment and radiographic score, we found teeth with higher radiographic scores
more likely to result in pulpotomy therapy (p<.0001).
radiographic score
SSC
Pulp
Number of SSC per pulpotomy
0
12
1
12
1
51
3
17
2
234
9
26
3
709
197
3.5
4
337
264
1.2
TOTAL
1343
474
2.8
Table 2. Stainless Steel Crown: Pulpotomy ratios based on radiographic score
When patient health status was considered, there was a marginally
significant association between medical status and whether the tooth received
pulp therapy (p=.05). Within the ASA II group the most common diagnosis was
Asthma
(32.0%)
followed
by
behavior
disorders
(Autism
Spectrum
Disorder=10.2%, ADD/ADHD=9.3%). The breakdown of pulp therapy and ratios
based on ASA status is presented in Table 3.
ASA Status
SSC
Pulpotomy
Ratio
I
899
335
2.6
II
458
142
3.2
Table 3. Stainless Steel Crown:Pulpotomy ratios based on ASA Status
15
DISCUSSION
The results from our study revealed that radiographic finding was a
significant diagnostic predictor for primary pulp treatment (p<.001) in our
population. Expectedly, as the caries involvement became more extensive, the
radiographic score increased. Diagnostic radiographs can provide information
regarding caries depth, pulpal involvement, restoration depth, periapical
pathology, root resorption or inflammatory changes, such as external
resorption8.Interpretation of pre-operative radiographs helps dentists diagnose
pulpal conditions more accurately, and therefore, whenever possible, it is
strongly recommended to order radiographs before any treatment.
Based on current literature, the reported sensitivity and specificity using
conventional radiographs to detect proximal caries are 0.48-0.80 and 0.84-1,
respectively 36, 37, 38. When the occlusal surfaces are analyzed with conventional
radiographs, the range of sensitivity and specificity are 0.50-1 and 0.48 to
1 39, 40, 41. Occlusal caries are more difficult to detect with intraoral radiographs
only, so a visual examination needs to be added in order to obtain an accurate
caries diagnosis. Our findings are consistent with AAPD recommendations with
respect to treatment planning pulpally involved primary teeth 42. After reviewing
individual medical/dental history and clinical findings, radiographs were ordered.
16
In our study radiographs were available for 98.3% of all stainless steel crowns
placed (1,342).
The FACES pain scale score was a strong predictor of pulpal treatment in
primary teeth (p=.0001). A significant association was observed between the pain
scores reported by parents and whether a tooth received a pulpotomy. A patient
with an increased pain score was more likely to receive a pulpotomy. This
corresponds to existing literature which reports that carious painful permanent
molars often receive more endodontic treatment than asymptomatic teeth 19.
Deep caries may induce reversible and or irreversible inflammatory changes in
the pulp with or without pain 43. The pain associated with reversible pulpitis can
be treated successfully either with the vital pulpotomy or Indirect Pulp Capping
(IPC) 43. There is some potential variance in the reliability of the FACES scores.
The pain score can be influenced by the child behavior such that parents of a
screaming/kicking kid may report the higher pain score than the true value. The
FACES scores may produce a questionable response from children with
cognitive impairment 44.
The operator type did not seem to affect the decision-making process of a
pulpotomy. (p=.143). The type of dental practitioners and their experience in
particular restorative materials or technique can cause inconsistencies in the
preferred treatment. A potential weakness of our study is that resident
preferences are largely based on attitudes and experiences of attendings.
Residents accounted for 23.5% of all crowns placed.
17
Pediatric dentists may have more experience with a risk-assessment tool
such as the caries risk. General dentists tend to recommend more amalgam
restoration in proximal restoration in primary teeth while many pediatric dentists
recommend a higher percentage of Stainless Steel Crowns (SSC) 30. Since
most general dentists have very little experience with SSC they tend to restore
proximal lesions more with amalgam, while pediatric dentists most often use
SSC for the same lesions 30. Historically, the decision-making process has been
also influenced by the gender of the practitioners and the characteristics of their
practice. Female dentists recommend more pulp treatment in deep carious
molars than males, and the dentist who treat an average of 6-16 children per
week in their practices more likely to recommend restoration with pulp therapy
than those who were not currently involved in treating children 24. Since all the
operators who performed the pulp therapy in this study were pediatric dentists
or dental residents, and most of them were trained with the similar
curricular/clinical guideline as mentioned before, it may be difficult to detect
operator preferences in this study.
Based on multivariate regression findings the age of the patient was not a
reliable indicator for pulp therapy in primary teeth (p=.133). However, the data
from this study indicated that the majority of primary teeth were treated in
children 36 to 72 months (3 to 6 years). Over a thousand crowns were placed
with this age group. This indicated that more than 62% of the children under 6
years old, who presented to either the out patient dental clinic or a Dental
Surgery Center, were treated with SSC, or SSC plus pulpotomy. This finding
18
corresponds with the current state of literature regarding the treatment of young
primary molars. Seale (2002) strongly recommends restoring multisurface
caries in primary molars with SSC when the patient is younger than 6 years of
age, or when the restoration lifespan is required to be longer than 2 years 11. It
is the chronological age of the patient, as well as size of the carious lesion, that
should be considered when determining restoration options for primary teeth 11.
There is a high degree of consensus that the longevity of SSC is superior to
amalgam restoration (the average life expectancy of Class II amalgam is about
2 years), so the best treatment option for primary molars, especially first primary
molars, in young children, would be placing a SSC 45, 46.
The pulpotomy to crown ratio is a clinical indicator that may show how
certain dental procedures are deployed in high risk populations 12. This numeric
value shows the ratio between the total number of teeth treated with pulpotomy
and the total number of teeth treated only with SSC. A higher ratio indicates that
more teeth are being treated with pulpotomies. In unstable socioeconomic
populations where caries prevalence is high and timely recall visits are low,
dentists may treat deep carious primary teeth with more aggressive and
definitive pulp therapy. This may result in an increase in the ratio of pulpotomy
to crowns. The opposite may be true that dentists practicing in stable
socioeconomic populations may perform less pulpotomies because the caries
rate is much lower in these patient pools. This may be reflected as a low
pulpotomy to crown ratio.
19
There is some debate as to the utility of this figure, in so far as there is a
scant literature on this topic. Data from university-based dental clinics or
hospital-based clinics in urban settings have reported the percentages of
pulpotomies somewhere between 30 to 46% 12. The average mean from these
clinics is 37% 12. The methodology used to obtain these values is unclear, and
often based on year-end production figures. Although this may not represent the
absolute figure of what a pulpotomy to crown ratio should be, it may still imply
the practice habits of specific dental providers. Based on their specialty training
and treatment philosophy, some pediatric dentists may treat interproximal caries
with more pulp therapy than others, and so far there has been no consensus
regarding when to perform pulpotomies. However, there is the possibility of
insurance companies reimbursement agencies attempting to use these figures
to imply ‘over-treatment’ or ‘under-treatment’ by certain dental providers. This
may create a dispute between the treating dentists and insurance companies,
and careful assessment and interpretation of the value of the ratio is critical.
From this study, pain assessment and radiographic involvement greatly
influenced a dentist decision-making process on pulpotomy of primary teeth.
More pulpotomies were performed when there was a high pain score and
radiographic decay. These two factors positively impacted the pulpotomy to
crown ratio. According to our study, the overall ratio of pulpotomy to crown was
35.7% at Nationwide Children’s Hospital, and this falls within reported normal
benchmarks of pulpotomy to crown ratio performed in urban pediatric
populations.
20
There are several clinical implications of this study. The treatment
indications for pulpotomy and indirect pulp capping (IPC), an alternative vital
pulp treatment, are identical according to AAPD guideline 7. IPC are placed in
deep carious teeth either with no or reversible pulpitis. During IPC procedure a
dentist removes the carious dentin incompletely to avoid a pulp exposure, and
treats the decay process with a biocompatible material 7. The advantages of
IPC are; avoiding the use of formocresol, known as a carcinogenic and
mutagenic agent; eliminating internal resorption caused by ferric sulfate, and
minimizing discomfort during the procedure 14,43.The success rate of IPC is
higher (93%) than in formocresol pulpotomy (74%) 43. During a 2007 American
Academy of Pediatric Dentistry (AAPD)-American Association of Endodontists
(AAE) joint symposium on pulp therapy 47% of pediatric dentists and 58% of
endodontists agreed that IPC is the “best treatment of choice for a reversibly
inflamed primary molar with a large carious lesion encroaching on the pulp” 47.
There were several limitations/weaknesses in this study. This was a
retrospective chart review from dental treatment performed over a period of six
months. Retrospective studies tend to examine the variables ‘in a vacuum’ and
ignores specific clinical presentations. The study design relied on information
purely from patient charts, and so detailed follow up was not possible. The
operative treatment was performed by a number of dentists including pediatric
dental faculty members and pediatric dental residents at Nationwide Children’s
Hospital Columbus. Each dentist uses slightly different techniques in performing
the same dental procedure, and this small difference may impact the treatment
21
outcome. Five examiners reviewed the treatment notes/charts. Although all
examiners were calibrated in a standardized way and had a good inter-rater
reliability, there were still some possibilities of examiner variance.
It should be noted that the range of the correlation coefficient (R²) values
associated with the regression analysis was .002-.578. This demonstrates that
even while the overall statistic was significant, the amount of variance of the
outcome variable explained by the predictor variable(s) was small. No other
studies examining the pulpotomy:SSC ratio have been conducted on this
magnitude, and it is entirely possible that this study was inadequately powered,
but the inadequacy was masked through a sizeable sample size.
If this study was repeated limiting the number of operators to reduce
potential bias would be recommended. Furthermore, collapsing the radiographic
categories 2 +3, which were most often the cause of question, could simplify
rating scale. This would potentially reduce rater-variance although doing this
would reduce the sensitivity of results. The inter-rater Kappa was 0.84 which
demonstrated good agreement.
Our results were intuitively what would be expected, namely practitioner
based decisions for vital pulp therapy of radiographic and a pain assessment.
The overall ratio we obtained 1:2.8 (35.7%) fell well within normal benchmarks.
22
CONCLUSIONS
There was significant association between the pain scale (p=.0001) and
the radiographic score (p<.0001) and pulpotomies being performed. The
operator type (p=.143) and the location of the treatment (p=.312) had no
significant association with treatment performed. The overall ratio of
pulpotomy to crown was 35.7% at Nationwide Children’s Hospital, and this
falls within reported normal benchmarks.
23
APENDIX
Ratio of Stainless Steel Crowns: Pulp Therapy
24
CQA Review-Ratio of stainless Steel Crowns: Pulp Therapy
Subject
MR #
DOB
_______________________
_______________________
_______________________
Age Group (Circle Appropriate Group)
0-36 months old
37-72 months old
Exclusion Criteria
*No history of swelling
*No history of resorption
*No pathologic mobility
>72 months old
Pain Scale
Medical Hx
Findings ________________________________
NSF
Medications _____________________________________________________
Operator (Circle Appropriate Group)
Group 1
Group 2
Amini
Griffen
daFonseca
McTigue
Kumar
Thikkurissy
Group 3
Residents
Setting (Circle Appropriate Location)
Clinic
operating Room/DSC
Teeth Treated _____________ Teeth Treated _____________
**If multiple teeth are treated using 2nd primary molars as standard **
**If primary 2nd molars and permanent first molars – use both ******
Tooth
Radiographic Score (0-4)
Treatment
Repeat Visit?
Radiographic Scoring
0= Clinical decalcification (white spot), no radiographic caries noted
1= Radiographic caries confined to enamel
2= Radiographic caries confined to outer ½ dentin
3= Radiographic caries extends to inner ½ dentin
4= Radiographic caries contacting pulp chamber
Any record of over-the-counter pain medication usage?
Yes
No
If yes, what medication?
________________________________________________________________
25
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