Second opinions are common in health care, whether a doctor is sorting out a difficult case or a patient is not sure what to do next.
In the context of our magazine, the first opinion will always belong to the reader. This feature will allow fellow dental professionals
to share their opinions on various topics, providing you with a "second opinion." Perhaps some of these observations will change
your mind, while others will solidify your position. In the end, our goal is to create discussion and debate to enrich our profession.
- Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine
The stainless-steel crown is an important restorative
tool in caring for the oral health of children. Although our
focus in providing the best oral health care for children is
clearly on prevention, unfortunately there are many children
who do not seek or obtain oral health preventive care
at an early enough age to prevent what can be devastating
disease at an early stage of their lives. All who care for children's
oral health see many cases of early childhood caries
present at the first visit to a dentist. Children as young as
18 months present to pediatric dental centers all over the
country each day with severe early childhood caries in need
of treatment to avert progression of significant infection.
Further, some children initially present with disease only
after the infection has spread beyond the teeth causing
facial swelling and a potentially life-threatening condition.
These children often need to be hospitalized, placed on
intravenous antibiotics and must have an incision and
drainage performed, along with extraction of the offending
tooth, to avoid a dangerous situation.
Of course I support medicinal therapeutic methods
(these are rapidly evolving but not all fully tested) of halting
disease progression and treating the infection. Though,
most commonly, presentation is at too late of a stage and
the literature supports restorative treatment to eliminate the
decayed tooth structure and to preserve the health of the
teeth in these very young children.
Most children with early childhood caries do initially
present (although late after the initiation of caries disease)
early enough to manage their disease progression via
restorative techniques. Given the pre-cooperative state of
these very young children and the lack of cognitive skills to
cooperate for a restorative procedure, we must be carefully
astute in planning the right care for the child, providing the
best care which will be definitive and avert progression of
disease. We want any restorative treatment performed on a
child to last the life of the primary tooth, to sustain the
health of the tooth in the mouth and to provide the appropriate
maintenance of space to allow the natural transition
into the permanent dentition several years later.
Based upon the anatomy of primary molars, with the
convergence of the buccal and lingual surfaces toward the
occlusal surface (from the proximal perspective), and therefore
having a small occlusal table, it becomes challenging to
place on intra-coronal restoration when the decay has
spread even a small amount beyond ideal size in the proximal
aspect of the tooth. Therefore, restorations placed with
amalgam, composite or glass ionomer must be of ideal size,
or perhaps slightly larger, to be retained properly and last
the life of the tooth. The scientific literature has shown the
strong support for the placement of stainless-steel crowns in
the event that restorative materials would extend beyond
the ideal size, not allowing retention of the restoration, to
avoid leakage after the placement of the restoration and
subsequent infection. A stainless-steel crown is easy to place
once trained to do so, fits well in a primary molar and provides
halting progression of caries to allow the tooth to be
retained in the mouth until natural exfoliation, and in a
healthy state.
Unfortunately, we often see placement of large intracoronal
restorations in primary molars, which should
have had stainless-steel crowns. Large intra-coronal
restorations can break, causing leakage and subsequent
infection. If not placed properly, there is immediate leakage
and subsequent infection, which can be very dangerous
for the child's overall health. Stainless-steel crowns
require proper local anesthesia, rubber dam isolation
and adequate tooth preparation followed by adequate
fitting of the crown, which comes in six stock sizes. After
fitting, the crown snaps over the buccal bulge of the molar
and is retained mechanically along with the adhesive glass ionomer cement. Glass ionomer cement creates a seal
between the tooth to which it is bonded chemically, and to
the stainless-steel crown to which it is bonded mechanically.
This tight seal, along with a well-fitting adapted stainless-
steel crown, will allow the natural contours, occlusion
and fit to restore the tooth adequately and retain its presence
in the mouth in a healthy state. We often see very large
restorations that break down quickly, causing subsequent
infection and requiring extraction of teeth or subsequent
restoration, subjecting the child to further treatments that
would not have been necessary had a stainless-steel crown
been placed in the first instance. Therefore it is clear that
there is an underutilization of stainless-steel crowns.
We often see in the press where a child has gone to a
provider who was inadequately trained to care for children
and certainly for their restorative treatment. There must be
proper training for the provider in terms of managing the
behavior of the child, in the proper venue, in order to provide
the best quality care, and to allay anxiety that might
otherwise ensue. Often, treatment of a very young child
needs to be performed under sedation – or more likely general
anesthesia – in order to provide the best conditions of
safety, quality of care and attenuation of anxiety, and to
allow the proper treatment to be performed in one appointment.
After completion of restorative care, focus on preventive
care can be presented to the caregivers and child to
avoid further decay and affected caries.
When we see in the press that a child came out of a
dental office with "eight stainless-steel crowns," the perception
is often that the crowns were unnecessarily placed.
This is an unfortunate perception in situations where the
crowns were necessary, which is often the case in severe
early childhood caries. This must be differentiated from
situations where stainless-steel crowns are placed when there is no decay. To be clear, a stainless-steel crown is not
a preventive employment. It is a restorative material (after
having removed the decayed substance from the tooth) to
allow the tooth to be retained in the mouth until its natural
exfoliation. If a stainless-steel crown is placed on the
tooth because it is suspected the tooth will become
decayed, when it is not (yet) decayed, this is indeed inappropriate.
This must be distinguished from the clear need
for stainless-steel crowns on many primary molars with
early childhood caries.
Given the inappropriate use of large intra-coronal
restorations in primary molars by practitioners who have
not had the adequate training to more appropriately place
stainless-steel crowns, it is clear there is a need to provide
additional training for the general practitioner who intends
to see children so he or she can be properly treated with the
restorations that will last the life of the tooth, and where the
tooth will be retained in a healthy state until its natural
exfoliation. If it is not within the skillset of the general dentist,
as with any other specialty-focused procedures in dentistry,
the child should be referred to a pediatric dentist who
has both the training and the access to provide care for children
in appropriate venues.
I want to be clear that there is more of an underutilization
of stainless-steel crowns (regarding preferred use
over the large intra-coronal restorations which very often
break down quickly) as opposed to an overuse of stainlesssteel
crowns.
Regardless, there is a need for additional training to
make sure the care given to children is definitive, provides
reduction of anxiety, makes the child and family focused on
preventive care and allows for removal of infection and
retention of restorations until the natural exfoliation of the
teeth in a healthy state.
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