International Journal of Paediatric Dentistry - manuscript proof

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1 - manuscript proof Clinical Evaluation and Parental Satisfaction with Pediatric Zirconia Anterior Crowns Journal: Manuscript ID: IJPD-0--0 Manuscript Type: Original Article Keywords: Restorative dentistry/dental materials, Prevention, Behaviour

2 Page of - manuscript proof Clinical Evaluation and Parental Satisfaction with Pediatric Zirconia Anterior Crowns Early childhood caries has been called the silent epidemic by the surgeon general and is the most common disease of childhood surpassing asthma and hay fever. (US Dept of Health) National data suggest that caries has decreased in the American population in most age groups; however, the most recent data indicate that caries rose significantly in our - year old children, as nearly 0% of preschoolers have caries. The primary dentition is important in eating food, allowing good nutrition, and development of speech. Children who have premature tooth loss due to caries may damage their selfesteem and may have failure to thrive. The main predictor of caries in the permanent dentition is caries in the primary dentition. Early dental visits allow the practitioner to educate the parent in oral care and diet, and this anticipatory guidance is paramount for prevention of disease. However, when early visits are bypassed or ineffective in preventing disease then removal of the infective process and restoration of the primary dentition is necessary. Stainless steel crowns are the most widely used full coverage restorative material in the primary dentition. A survey of pediatric dentists reported that % of parents are concerned with the esthetics of even a posterior restoration. The poor esthetics of the stainless steel crown is becoming more problematic for the practitioner regarding its acceptance from parents as a suitable esthetic restoration for their children. Fishman et al. found that tooth colored composite resin material was the most preferred restoration and silver colored amalgam the least by children. The authors also found that ethnicity plays a factor in the acceptance of various materials as African American children were significantly more likely to find silver restorations acceptable. Resin strip crowns, preveneered stainless steel crowns, and open-faced crowns with a window have historically been offered as a substitute alternative for the classic anterior stainless steel crown. Each of these materials has had their own share of disadvantages and none are as good as the original tooth structure. Zirconia has been used for over a decade successfully in adult dentistry., Short term, in vivo studies suggest zirconia to be an acceptable restorative material., The application of this material has been adapted in pediatric dentistry to provide a more durable and esthetic alternative. EZPEDO was the first pediatric zirconia crown commercially available in the U.S. and came to market in 00. Use of all ceramic restorations is increasing as multiple other brands (NuSmile, Kinder Krowns, and Cheng Crowns) have since created pediatric zirconia products, and this trend is expected to continue. 0 Advantages to the zirconia

3 - manuscript proof Page of crown are the promise of excellent esthetics along with full coverage of the treated tooth. The potential disadvantages of the zirconia restoration are the inability to crimp the crown for mechanical retention such that retention relies solely on the cement bond, the inability to trim the crown or change its color, and the limited ability alter its shape. Due to the recent introduction of the material for pediatric use, studies evaluating the clinical success of zirconia anterior crowns are limited. At the time of this writing, no previous studies have been published (a PubMed search returned zero results) that have evaluated the clinical success of zirconia anterior crowns and/or the parental satisfaction associated with this restoration. The purpose of this retrospective study is to describe the clinical performance and parental satisfaction of zirconia anterior crowns manufactured by EZPEDO. Material and Methods The University human subject institutional board approved (-000-XP) this retrospective cross sectional study. Consent was obtained from each participant s parent or guardian, and verbal assent was obtained from the dependent. Fifty-three children ages to years who had been treated at the pediatric dental clinic from 00-0 were identified from electronic patient care records by the investigators for possible inclusion in the study. All crowns were placed by either a first or second year pediatric dental resident under the supervision of an attending faculty member. All crowns were placed in ideal conditions while the children were under general anesthesia or sedation. Subjects had or more EZPEDO crowns (EZPEDO, Loomis, CA, USA) placed on maxillary primary incisors at least months prior to evaluation and cemented with glass ionomer cement (Ketac, M ESPE, St. Paul, MN). Excluded were children with special needs and those households in which English was not the primary language. Only full zirconia anterior crowns purchased commercially and manufactured by EZPEDO were evaluated. During the study period parents/guardians of children with EZPEDO crowns were contacted by phone and approached by study personnel at their scheduled routine care appointment with the pediatric clinic to invite them to participate in the study and to complete a survey. One examiner (XX) completed all clinical evaluations and administered the survey. This examiner was calibrated in the first three examination sessions with one faculty member (YY) during the clinical evaluation of the crowns for consistency of chairside clinical assessment. For all three sessions, the examiner and faculty were in 00% agreement.

4 Page of - manuscript proof Data collected on the child included age, sex, overjet, overbite, and gingival score as described in previous studies. - Each crown was assessed as to teeth treated, date cemented, present or exfoliated status, crown retention, color match, crown contour, opposing tooth damage, marginal integrity, and recurrent caries. Marginal integrity was determined through visible inspection and tactile examination with an explorer. Each of these criteria was assessed and recorded according to the scales illustrated in Table. Each child s parent/guardian was asked to participate in a survey evaluating their satisfaction with the crowns and their perception of their child s quality of oral health prior to and after treatment. The survey captured sociodemographic information such as ethinicity/race, education level, and type of dental insurance. Criteria collected in the survey included: color, shape, and size. Each of these criteria were scored using the following scale from similar studies: = very dissatisfied; = dissatisfied; = neutral satisfied; = satisfied; = very satisfied., Durability was assessed by asking if the crowns had ever debonded and how long ago if they had. Quality of life questions regarding the child s oral health were asked to determine the parental perception of the impact of the restorations. Responses were recorded on a Likert scale of to with being not at all and being very much. Parents/ guardians were asked to rate their overall experience with the crowns on a scale, similar to other studies, - of to 0 with being very dissatisfied and 0 being very satisfied with the crowns. Parents were also asked if they would recommend (not recommend, recommend, or highly recommend) these crowns to another parent whose child needed anterior crowns. Finally, parents had the opportunity to give additional comments on their experience with the crowns. Results: Fifty-three patients received EZPEDO crowns from Eighteen children ( female and males) were available and willing to participate. A total of crowns were identified in the children.,eight of the teeth were lost to exfoliation, crowns de-bonded, and were extracted due to pathology. Of the teeth extracted, had received pulpal therapy. Forty-four crowns were available for evaluation. The average crown age at time of examination was 0. months (range - months). Seventeen mothers and father were surveyed. Fifty-six percent reported to be Black, African American, % Hispanic, and % White/Caucasian.

5 - manuscript proof Page of The children receiving the anterior crown treatment were generally from lower socioeconomic status. Eighty-nine percent were on public or government insurance while the remaining % had private insurance. Sixty-seven percent of parents were high school graduates or less, and % reported some college or an associates degree. The majority of parents were satisfied with the color, size, and shape of the crowns (Table ). All parents replied that they would recommend these crowns, and of the parents surveyed (%) reported that they would highly recommend these crowns to another parent whose child was in need of anterior restorations. Clinical outcomes were acceptable to excellent (Table ). Color shade mismatch was observed the most and the majority of gingival scores were acceptable considering the high caries risk population. The majority of crowns had closed margins and were retained. No wear was observed in any of the teeth opposing the crowns. Quality of Life responses from the parents perspective are recorded in Table. Parents expressed a clear opinion that the crown improved the appearance and oral health of their child as these items received the highest average scores. The lowest average score was in response to the child avoiding smiling before the crowns were placed. In this population, parents did not report smile avoidance prior to dental treatment. Eightythree percent of parents reported that the crowns had never fallen off and % reported that the crowns had fallen off at least once. Eleven parents (%) reported no problems at all. Parents were asked to choose from a prepared list of possible difficulties their child might have experienced after the crowns were placed. Multiple responses were allowed. Of the parents (%) who reported problems, reported bleeding, reported hot/cold sensitivity, and reported that food got stuck between the crowns. Discussion Parents are demanding more esthetic restorations. This is the first known study reporting the clinical longevity, parental satisfaction, and quality of life impact of zirconia anterior crowns. Prior to the introduction of zirconia restorations, the esthetic options for the pediatric dentist were strip crowns, pre-veneered resin stainless steel crowns, or stainless steel crowns which the dentist open-faced and placed a resin window.

6 Page of - manuscript proof Strip crowns have been shown to have a high parental acceptance but are highly technique sensitive and require adequate hemostasis and curing of the composite. Zirconia is less technique sensitive and can tolerate slightly less ideal isolation. Preveenered stainless steel crowns have also had high parental satisfaction but a major complaint is the esthetic facing debonding or fracturing., Zirconia crowns are unable to be crimped and require a passive fit with the retention dependent upon the strength of the luting agent. The results of this study indicate that good retention can be maintained with the passive fit. The cement used in this study is a glass ionomer cement as recommended by the manufacturer. Bioactive cements that may bond to both the zirconia and the tooth are available, and future studies may determine that these cements could further increase bond strength. None of the zirconia crowns in this study were chipped or had parital loss of material. Home care and oral hygiene practices would have affected the gingival index results; however, plaque scores were not recorded. This could have been valuable information to determine if the crown itself caused gingival inflammation or if poor oral hygiene was the culprit. Given that the majority of crowns had closed margins (%) and no inflammation (%), poor oral hygiene most likely played a significant role in the inflammation recorded. Another clinical concern was opposing tooth wear since permanent zirconia crowns have been shown to cause wear to the opposing tooth. In this study no wear was noted in the primary dentition. The primary investigator (XX) found a high color match (%) and natural, cosmetic shape (%) with the majority of crowns. These clinical findings correlated well with parent satisfaction as parents liked the color, size, and shape of the crowns as all variables received an average score of. or higher. Parents did identify some problems, but their overall satisfaction was excellent, and they reported that they would still recommend the crowns even after encountering these difficulties. Limitations of this study were the small sample size. Of the patients identified only were available and willing to participate. During phone contact it was found that many families had moved, had invalid phone numbers or lost phone service and were unable to be contacted. A more varied population regarding ethnicity and socioeconomic status would also be ideal. However, this population was a good representation of a high caries-risk group. Finding acceptable to excellent clinical results in this population could mean that an even higher success rate could be seen in lower risk populations given caries risk affects the longevity and success of restorations. Other limitations to

7 - manuscript proof Page of the study were the reliance on the parent to be a good historian and that multiple operators performed the treatment. Future research could further examine the improvement in quality of life regarding the child s diet. The authors were unable to determine if patients refused to eat certain foods due to confounders of multiple restorations, taste changes, and the young age of the patients. As discussed earlier, oral hygiene practices and plaque scores could be recorded to determine the true effects of the crowns on the gingival health. Several other brands of zirconia crowns have come to market and could be evaluated as each may perform differently, and finally, zirconia crowns may perform better in a lower caries risk population. Conclusions Based on the study s results, the following conclusions can be made: The majority of crowns were retained. The crowns did not cause significant gingival inflammation. The majority of crowns displayed an acceptable color match and contour. No opposing tooth wear was noted. Parental satisfaction with the treatment of anterior primary dentition caries with zirconia crowns is high. Zirconia crowns are an acceptable restorative option in primary anterior dentition. References:. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, - and -00. Vital Health Stat 00():-.. American Academy of Pediatric Dentistry Council on Clinical Affairs, Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment Options. Pediatr Dent 0-0;: -.. Seale NS. The use of stainless steel crowns. Pediatr Dent 00;():-.

8 Page of - manuscript proof Zimmerman JA, Feigal RJ, Till MJ, Hodges JS. Parental attitudes on restorative materials as factors influencing current use in pediatric dentistry. Pediatr Dent 00;():-0.. Fishman R, Guelmann M, Bimstein E. Children's selection of posterior restorative materials. J Clin Pediatr Dent 00;():-.. Zarone F, Russo S, Sorrentino R. From porcelain-fused-to-metal to zirconia: clinical and experimental considerations. Dent Mater 0;():-.. Conrad HJ, Seong WJ, Pesun IJ. Current ceramic materials and systems with clinical recommendations: a systematic review. J Prosthet Dent 00;():-.. Al-Amleh B, Lyons K, Swain M. Clinical trials in zirconia: a systematic review. J Oral Rehabil 00;():-.. Townsend JA, Knoell P, Yu Q, et al. In vitro fracture resistance of three commercially available zirconia crowns for primary molars. Pediatr Dent 0;():-. 0. Donovan TE. Factors essential for successful all-ceramic restorations. J Am Dent Assoc 00; Suppl:s-s.. Champagne C, Waggoner W, Ditmyer M, Casamassimo PS. Parental satisfaction with preveneered stainless steel crowns for primary anterior teeth. Pediatric Dentistry 00;():-.. Loe H, Silness J. Periodontal Disease in Pregnancy. I. Prevalence and Severity. Acta Odontol Scand ;:-.. Roberts C, Lee JY, Wright JT. Clinical evaluation of and parental satisfaction with resinfaced stainless steel crowns. Pediatr Dent 00;():-.. Shah PV, Lee JY, Wright JT. Clinical success and parental satisfaction with anterior preveneered primary stainless steel crowns. Pediatr Dent 00;():-.. Kupietzky A, Waggoner WF. Parental satisfaction with bonded resin composite strip crowns for primary incisors. Pediatr Dent 00;():-.. Gosnell ES, Thikkurissy S. Management of dental caries and esthetic issues in the pediatric patient. J Calif Dent Assoc 0;():-.. Stober T, Bermejo JL, Rammelsberg P, Schmitter M. Enamel wear caused by monolithic zirconia crowns after months of clinical use. J Oral Rehabil 0;():-.. Balevi B. Caries risk and number of restored surfaces have impact on the survival of posterior composite restorations. Evid Based Dent 0;():-.

9 - manuscript proof Page of Table. Clinical EvaluationCriteria Criteria Treated tooth exfoliated 0 Crown retention 0 Customized modified gingival index Score yes no Crown intact Crown chipped, small but noticeable areas of loss of material Large loss of material Complete loss of crown 0 Color match 0 Crown contour 0 Opposing tooth 0 Marginal integrity 0 Recurrent Caries 0 no inflammation mild inflammation moderate inflammation marked inflammation No noticeable difference from adjacent teeth Slight shade mismatch Obvious shade mismatch Crown appears very cosmetic and natural looking Crown appears acceptable, the size/shape is a little off Crown not esthetic, detracts from appearance of the mouth no wear wear closed margin open Margin yes no

10 Page of - manuscript proof Table. Parental Ratings of Satisfaction Characteristic Ratings n (%) Mean Score Scale* (Not at all) (Very Much) Size 0 0 () () 0(). Shape 0 0 () () (). Color 0 0 () () ().

11 - manuscript proof Page 0 of Table. Clinical Outcomes Crown Retention Intact () Chipped/partially broken 0(0) Large loss of material 0(0) Complete loss of crown () Gingival Index No inflammation () Mild inflammation () Moderate inflammation () Marked inflammation 0(0) Color Match No difference () Slight mismatch () Obvious mismatch () Crown Contour Crown is cosmetic, natural looking () Size/Shape is acceptable, not ideal () Crown not esthetic 0(0) Opposing Tooth Wear No wear (00) Wear 0(0) Marginal Integrity Closed margin () Open margin () Recurrent Caries Yes O No (00)

12 Page of - manuscript proof Table. Quality of Life Characteristic Ratings n (%) Scale* Oral health of child improved after crowns Parents concern about appearance before the crowns Child avoided smiling before crowns Child Smiled after Crowns Crowns improved the appearance of the child s teeth (Not at all) (Very Much) Mean Score 0 () 0 () (). () 0 () () ().0 () 0 () () 0. (.) 0 () (.) (). 0 0 () () ().