25th IAPD Biennial Congress Glasgow Preformed Metal Crowns for treating primary molars in a General Practice setting – 24 months G.D Taylor, K Perry & R.R Welbury Greig D Taylor 25th IAPD Biennial Congress Glasgow Saturday 4th July 2015

Introduction Historically... …conventional glass ionomer was used to treat carious primary molars in my VT practice However, after this service evaluation… …non infected carious primary molars are now treated with Hall Preformed Metal Crowns (PMCs) Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Background BSPD “National Clinical Guidelines in Paediatric Dentistry: stainless steel preformed crowns for primary molars” highlights: “…preformed metal crowns outperform direct plastic restorations when restoring multi-surface carious primary molars1” A recent 5 year randomised control study showed statistically significant beneficial results for pulpal health and longevity when a PMC is cemented over an unprepared carious tooth without LA (Hall crown) in comparison to placement of conventional direct restorations2 Our body’s guideline suggets that SSC outperform direct plastic restorations when restoring multi-surface caries. This was used as the standard to which I compared my results to. Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Aims To assess the effect on primary caries and the patient experience, when introducing Hall PMCs as an option of treating carious primary molars in a general dental practice setting Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Design All Hall PMCs were placed by a single operator, without the use of local anaesthesia, in accordance with SDCEP guidelines3 over a 6 month period A data collection tool measured clinical and radiographic outcomes at baseline and 6 monthly intervals for a period of 24 months Consent was obtained from the child’s parent for involvement in this project Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Design Figure 1 – Baseline Data Collection pre-operative assessment of the patient, both clinically and radiographically (if applicable); assessment of whether the patient would accept conventional treatment under local anaesthetic; if any procedure was required to help the placement of a stainless steel crown; how safely the stainless steel crown was placed; if there was any occlusal discrepancy after placement; a subjective assessment of how the patient coped. Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Design Figure 2 – Six Monthly data collection Self reported history from patient; Clinical evaluation of tooth (if still in place; any evidence of infection, pain, mobiltiy, damage to ssc, replaced) Radiographic evaluation Overall success – clinician, parent and patient. Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Results N = 34 Hall PMCs placed Total = 17 patients (9 males : 8 females) Mean: 8.1years Carried out in Maryhill, Glasgow; Scottish Index of Multiple Deprivation (1 most deprived) Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Results Pre-Treatment Assessment Percentage Patients who would not tolerate LA or high speed drill 44.1% No reported symptoms or clinical signs of Reversible/Irreversible pulpitis 100% Evidence of Marginal breakdown (Range: 2mm-5mm) 35% Number of bitewings taken pre-operatively 79% Extent of caries “less than halfway” into dentine on pre-operative bitewing 56% Cases where combination of safety modalities used during placement (child sat upright; gauze to protect throat; PMC secured by tape) 4 patients were not able to tolerate the digital sensor Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Results Placement of Preformed Metal Crown 91% of patients (17 patients) showed none or very mild signs of discomfort during placement of SSC. No patient showed signs of signifcant and unacceptable signs of discomfort. Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Results 6 Month Assessment 97% of Hall PMCs were in situ 10 patients reported mild difficulty in eating immediately post placement One case of secondary caries detected One Hall PMC had to be re-cemented after 6 weeks One Crown was extracted due to severe dental trauma Only 30 stainless steel crowns could be assessed as issues with digital sensor tolerance was noted in a few cases. A few cases should early/moderate signs of physiological root resorption but minimal clinical mobility; One case showed signs of secondary caries around the margin…this was removed and replaced. Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Results 12 Month Assessment 71% Hall PMCs were in situ 26% Hall PMCs exfoliated naturally 1 patient reported mild difficulty eating One further case of secondary caries noted One case was repaired due to wear Normal physiological resorption was observed radiographically Only 30 stainless steel crowns could be assessed as issues with digital sensor tolerance was noted in a few cases. A few cases should early/moderate signs of physiological root resorption but minimal clinical mobility; One case showed signs of secondary caries around the margin…this was removed and replaced. Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Results 18 Month Assessment 56% of Hall PMCs were in situ 38% Hall PMCs had exfoliated naturally. 1 patient reported mild difficulty eating One crown was extracted due to an irreversible pulpitis One case of secondary caries Remaining Hall PMCs radiographed showed signs of normal physiological resorption Only 30 stainless steel crowns could be assessed as issues with digital sensor tolerance was noted in a few cases. A few cases should early/moderate signs of physiological root resorption but minimal clinical mobility; One case showed signs of secondary caries around the margin…this was removed and replaced. Greig D Taylor IAPD Biennial Congress Glasgow 2015

Results 24 Month Assessment 41% of Hall PMCs placed were in situ 53% had exfoliated naturally 3 patients reported mild difficulty eating No clinical signs of infection/mobility was noted in any of the remaining teeth A varied level of normal physiological resorption was observed Only 30 stainless steel crowns could be assessed as issues with digital sensor tolerance was noted in a few cases. A few cases should early/moderate signs of physiological root resorption but minimal clinical mobility; One case showed signs of secondary caries around the margin…this was removed and replaced. Greig D Taylor IAPD Biennial Congress Glasgow 2015

Overall Success of Hall PMCs Results Overall Success of Hall PMCs 6 months 12 months 18 months 24 months Operator 94% 97% 100% Parent Patient I was not happy with the secondary caries, however this was not replaced as the tooth showed signs that it would exfoliate in the near future. All the patients and parents were happy with the SSC and felt they were successful. Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Discussion Recognised minor failures: failure of cementation1,2,6 occlusal wear1,2,6 recurrent caries1,2,6 All of which were managed without sacrificing the tooth 2 Major failures were unavoidable Greig D Taylor IAPD Biennial Congress Glasgow 2015

Discussion Patients and parents reported the treatment to be a success both initially and at subsequent visits The majority of patients accepted the placement of a Hall PMCs with minimal or no discomfort with Bell et al5 showing similar results Discomfort was anecdotally noted: Initially to the “tightness around the gingivae” Laterally to the exfoliation process Greig D Taylor IAPD Biennial Congress Glasgow 2015

Implementation of Findings I disseminated the initial results at a monthly practice meeting Further results where shared at regular intervals I then ran a 30 minute presentation/demonstration session for all the staff within the practice and subsequently changed the practice protocol Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

Conclusion Hall PMCs are: An effective and successful way to treat carious primary molars in general dental practice Facilitate the transition of the child to the permanent dentition with minimal pain and sepsis Greig.D.Taylor IAPD Biennial Congress Glasgow 2015

References SA Kindelan, P Day, R Nichol, N Willmott, SA Fayle, Stainless Steel preformed crowns for primary molars. Int J Paed Dent 2008; 18 (suppl. 1): 20-28 Innes NPT, Evans DJP, Stirrups DR. (2011) Sealing caries in primary Molars: Randomised Control Trial, 5 year Results. J Dent Res 90:1405-1410 Scottish Dental Clinical Effectiveness Programme. Guidelines: Prevention and Management of Dental Caries in Children. SDCEP, April 2010 Inness NPT, Ricketts D, Evans DJP. Preformed metal crowns for decayed primary molar teeth. Cochrane Database of Systematic Reviews 2007 SJ Bell, AG Morgan, Z Marshman, HD Rodd. Child and parental acceptance of preformed metal crowns. European Archives of Paediatric Dentistry. 11(Issue 5) 2010 NPT Innes, DR Stirrups, DJP Evans, N Hall, M Leggate. A novel technique using preformed metal crowns for managing carious primary molars in general practice – A retrospective analysis. British Dental Journal. 2006; 200: 451-454   Greig.D.Taylor IAPD Biennial Congress Glasgow 2015