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Original Article

Gingival, oral hygiene and periodontal status of the teeth

restored with stainless steel crown: A prospective study
Shashikala Prabhu, SH Krishnamoorthy1, Savitha Sathyaprasad1, H Sharath Chandra2, Divyia J3,
Aiswarya Mohan4
Paedodontist and Preventive Dentist, Manipal, 1Department of Paedodontics and Preventive Dentistry, KVG Dental College, Sullia,
2
Department of Paedodontics and Preventive Dentistry, SJM Dental College, Chitradurga, Karnataka, 3 Paedodontist and Preventive
Dentist, Pettah, Trivendrum, Kerala, India, 4Dentist, Kings Dental Centre, Qatar

ABSTRACT Address for correspondence:

Aim: To compare the gingival health and
periodontal status in primary molars restored with
stainless steel crowns with unrestored contralateral
teeth. Materials and Methods: A split mouth design
study was conducted on 60 children aged 5- 10
years who required stainless steel crown restoration
on deciduous molars. The molar teeth restored
with stainless steel crown were selected for study
and healthy unrestored contralateral teeth were
selected as controls. Bitewing radiograph of study
and control tooth was taken at initial, three months
and at six months. The gingival status, oral hygiene
status was evaluated at three months and six month
intervals using gingival index and oral hygiene index
respectively. Result: On evaluating the oral hygiene
status at three months study group showed the mean
value of 0.7±0.700 whereas in control group it was
1±0.368. At six months it was 1.183±0.390 in study
group and 1.5±0.504 in control group. Chi square
test shows that the crown marginal adaptation
produced statistically significant difference at six
months. Crown marginal extension did not produce
any difference on gingival index and oral hygiene
index. Conclusion: When compared to control
teeth, the teeth restored with stainless steel crown
showed lesser plaque and debris accumulation at
three months and six months. Radiographic bone
level the control teeth showed higher level of bone
resorption compared to the teeth restored with
stainless steel crown.
KEYWORDS: Oral hygiene, radiographic bone level,
stainless steel crown
Dr. Shashikala Prabhu,
4-610, Alevoor Road, Manchikere, Manipal,
Karnataka - 576107, India.
E‑mail: shashikalaprabhu88@gmail.com
Access this article online
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DOI:
10.4103/JISPPD.JISPPD_227_17
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arch length, and cosmetic function. Pediatric dentistry
can play a vital role in the dental development
of the young patient by providing natural space
maintainers for the permanent teeth and by instilling
positive attitude toward oral health in the child. As
the treatment of primary and young permanent teeth
with advanced carious lesion has been a constant and
difficult problem for the dentist, the stainless steel
crown  (SSC) has become an important factor in the
restoration of the extensively carious lesion.[1]
SSCs provide durable and reliable full coverage
restorations and are retained for the lifetime of a
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License, which allows others to remix, tweak, and build upon the work
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Introduction How to cite this article: Prabhu S, Krishnamoorthy SH,

Dental caries is the most prevalent disease, especially
in children. The importance of primary teeth should be
considered in helping speech, mastication, maintaining
Sathyaprasad S, Chandra HS, Divyia J, Mohan A. Gingival, oral
hygiene and periodontal status of the teeth restored with stainless
steel crown: A prospective study. J Indian Soc Pedod Prev Dent
2018;36:273-8.

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Prabhu, et al.: Evaluation of gingival health after stainless steel crown placement
primary tooth.[2] The SSC has been shown to be the
restoration of choice, or the “gold standard,” because
it protects the tooth from fracture, minimizes the
possibility for leakage, and ensures a biological seal.[3]
Traditional SSCs have many advantages over other
crown types and dental restorative materials.[4] First,
their lifespan is the same as that of an intact primary
tooth. Second, they provide protection to the residual
tooth structure that may have been weakened after
excessive caries removal. Third, the technique
sensitivity or the risk of making errors during
their application is low. Fourth, their long‑term
cost‑effectiveness is good. Fifth, they have a low
failure rate.[5]
Aim
This study aims to compare the gingival health and
periodontal status in primary molars restored with
SSCs with unrestored contralateral teeth.
Objectives
To assess the gingival and periodontal status of the
teeth restored with SSC, to evaluate oral hygiene
status of children with SSC, to evaluate radiographic
changes in teeth restored with SSC, and to compare
with contralateral control teeth.
Methodology
A split‑mouth, parallel design, randomized controlled
study was conducted on 60 children age group of
5–10 years visiting K.V.G Dental College and Hospital,
Sullia, Dakshina Kannada, for treatment of molars
indicated for restoration with SSC. Contralateral tooth
of the same patient which not restored with SSC was
taken as control. Consent for the participants willing to
participate in the study was obtained.
Tooth preparation done and selected SSC was cemented
on it after proper reduction, crimping and polishing.
Radiograph of the tooth restored with SSC and
contralateral tooth was taken on the day of cementation of
the crown. The gingival index (GI) was measured for the
study tooth and control tooth. Oral Hygiene Index (OHI)
and radiographic bone health for the study tooth and
control tooth was measured. The bitewing radiographs
were placed on the X‑ray viewer and the height of
interdental bone was measured from the crest of the
interdental bone to the cementoenamel junction  (CEJ).
Height of the interdental bone was measured for the
study tooth and control tooth. Parameters affecting GI
and interproximal bone level were measured.
Scoring criteria for OHI:
• 0 – No debris
• 1  –  Soft‑tissue debris covering  <1/3rd  of tooth
surface
• 2 – Soft‑tissue debris covering >1/3rd but <2/3rd of
tooth surface
274 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 3 | July-September 2018
• 3 – Soft‑tissue debris covering >2/3rd of tooth surface.
Scoring criteria for GI:
• 0 – Normal gingiva
• 2 – Presence of mild inflammation
• 3 – Moderate inflammation
• 4 – Severe inflammation.
Radiographic evaluation was done using bitewing
radiograph. A standard angulation of X‑ray cone was
applied. The radiographs were selected on the basis of
minimal evidence of distortion, minimal overlapping
between the adjacent proximal surfaces, a clear image
of the CEJ, and the alveolar bone crest (ABC) between
the primary molars.
The radiographic criteria viewed were interproximal
bone level 2  mm or less from the crest of the
interdental bone and CEJ was considered normal
or nonresorbed. If the distance was  >2  mm, it was
considered as resorbed. If the crown margins were too
short or extended below the CEJ, it was considered as
inadequate crown.
Results
This study included 60 children aged 5–10  years of
with the mean age of 6.7 years. The mean OHIs score of
SCC group at 3 months was found to be 0.700 ± 0.462
and in control group, it was found to be 1 ± 0.368 and
there was a statistically significant difference between
group at 5% significance level  (P  <  0.001). The mean
OHIs score of SCC group at 6 months was found to be
1.183 ± 0.390 and in control group, it was found to be
1.500  ±  0.504 and there was a statistically significant
difference between groups at 5% significance
level  (P  <  0.001). The mean GI score of SCC group
at 6  months was found to be 1.216  ±  0.415 and in
control group, it was found to be 1 and there was a
statistically significant difference between groups at
5% significance level  (P  <  0.001). The mean RBH at
3 months in SCC group was found to be 1.841 ± 0.251
and in control group, it was found to be 1.866 ± 0.222,
and  there was no statistically significant difference
between group at 5% significance level (P = 0.566). The
mean RBH at 6 months in SCC group was 1.975 ± 0.282
and in control group, it was 2.333 ± 0.438 and there was
a statistically significant difference between group at
5% significance level (P < 0.001) [Table 1 and Graph 1].
Discussion
This study showed the time‑dependent comparison of
primary molar teeth restored with SSC with the intact
primary molars of the contralateral side at 3 months
and 6 months of intervals. The oral hygiene, gingival
status, and radiographic bone health of the study group
and the control group were assessed at 3 months and
6 months of duration.
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Prabhu, et al.: Evaluation of gingival health after stainless steel crown placement

Table 1: Paired sample statistics for the oral hygiene, margins in the gingival sulcus and to reproduce the
gingival index and radiographic bone health morphology of tooth.
Paired Samples Statistics
Gingivitis is the predominant form of periodontal
Mean Std. deviation t P
disease in children and adolescents, and it consists of a
Pair 1
nonspecific inflammation of the marginal gingiva. It has
SCCOHIS3 0.700 0.462 ‑6.600 <0.001
been reported that gingivitis often occurs around primary
SCCOHIS6 1.183 0.390
teeth restored with steel crowns due to diverse factors,
Pair 2
mainly to improper techniques during all the therapeutic
SCCGI3 1.000 0.000 ‑4.040 <0.001 process.[7] Waerhaug, however, reported that plaque can
SCCGI6 1.216 0.415 accumulate around crowns with well‑adapted margins.
Pair 3 He also proposed that the gingivitis around teeth that
SCCRBH3 1.841 0.251 ‑3.013 0.004 were restored with an SSC is dependent on the presence
SCCRBH6 1.975 0.282 of bacterial plaque and not dependent on mechanical
Pair 4 irritation due to the crown’s presence.[8]
CONOHIS3 1.000 0.368 ‑6.203 <0.001
CONOHIS6 1.500 0.504 In our study, the oral hygiene status of the study
Pair 5 group  (SSC) at 3 months was good with the mean
CONGI3 1.0000 0.000 NA NA of 0.7  ±  0.462 compared to the control healthy,
CONGI6 1.0000 0.000 uncrowned teeth which showed the mean value of
Pair 6 1 ± 0.368. At 6 months, the oral hygiene status of the
CONRBH3 1.8667 0.222 ‑6.747 <0.001 SSC and control teeth increased. Despite the increase
CONRBH6 2.3333 0.438 in the Simplified OHI‑S score, the mean score of SSC
teeth was less, that is, 1.183 ± 0.390 compare to healthy
control teeth 1.500 ± 0.504. This showed that the plaque
Table 2: Correlation of radiographic bone health and debris accumulation on the teeth restored with
for study and control teeth SSC was comparatively lesser than that on the control
Variable Group Mean SD t P teeth. This is in agreement with the study conducted
RBH SCC Baseline 1.800 0.061 ‑0.961 0.340 by Beldüz Kara and Yilmaz who found that plaque
3 months 1.841 0.063 did not accumulate for the first 9 months around the
RBH SCC Baseline 1.800 0.061 ‑3.960 <0.001 teeth that were restored with an SSC because of the
6 months 1.975 0.079 smooth surfaces of the SSC. The smooth surface of an
RBH CON Baseline 1.841 0.055 ‑0.503 0.616 SSC is a frequently cited reason for decreased plaque
3 months 1.866 0.222 adherence to surfaces that are adjacent to SSC.
RBH CON Baseline 1.841 0.055 ‑7.750 <0.001
6 months 2.333 0.438 Gingivitis is a relatively mild gum disease, which
without appropriate treatment can lead to periodontitis,
a more severe gum disease. Both affect many peoples,
Table 3: Gingival score distribution among various including children, which is when these diseases are
crown margins at 3 months usually manifested. In young individuals, gingival
Chi Square test and periodontal diseases tend to be less dramatic than
Marg adaptation* gi3 gi3 month P in adults.[8] Checchio et al. concluded that individuals
months 1.00 with poor oral hygiene showed pronounced tissue
Marg adaptation
degeneration despite the quality of the SSC and that
Open margin
improperly contoured restorations predispose the
Count 17 NA
gingiva to more severe inflammation.[9]
% 28.3%
Sealed
In our study, GI of SSC at 3 months showed a mean
value of 1 and control teeth also had the mean value
Count 43
of 1. This indicates that the gingival status of teeth
% 71.7%
around SSC was similar to the healthy control teeth
at the interval of 3 months. At 6‑month period, the
Studies found that good‑to‑moderate fitting crowns gingiva around SSC showed a mean of 1.216  ±  0.415
with well‑contoured crown margins facilitate good whereas the contralateral teeth showed the mean value
oral hygiene, healthy gingiva, and minimal plaque of 1 indicating that the gingival status of molar teeth
accumulation.[6] Plaque starts to accumulate when the restored with SSC deteriorates over time compared to
margins of an SSC begin to degenerate. The fit into control teeth in the children with good oral hygiene.
the residual undercuts help in the retention of the This result is in agreement with a study conducted
cemented crown (Savides et al., 1979). The purpose of by Webber who noticed clinically there was a slight
crown trimming and contouring is to leave the crown gingival change in patients 8–12 years old which may

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Prabhu, et al.: Evaluation of gingival health after stainless steel crown placement

Table 4: Gingival score distribution among various

crown margin adaptations at 6 months
Chi Square test
Marg adaptation* gi3 gi 6 month P
months 1.00 2.00
Marg adaptation
Open margin
Count 10 7 0.026
% 16.7% 11.7%
Sealed
Count 37 6
% 61.7% 10.0% Graph 1: Oral hygiene index, gingival index, and radiographic bone
health of study and control teeth

Table 5: Distribution of gingival index score on

radiographic crown extensions
Radiographic evaluation * gi3 gi3 Total
1.00
Radiographic evaluation
Adequate
Count 52 NA
% of Total 86.7%
Inadequate
Count 8
% of Total 13.3%

Graph 2: Distribution of oral hygiene score among various crown

Table 6: Gingival index score among different margins
radiographic extension of crown
Chi Square test
Radiographic evaluation gi6 Total
*gi6 1.00 2.00
Radiographic evaluation
Adequate
Count 40 12 0.475
% of Total 66.7% 20.0%
Inadequate
Count 7 1
% of Total 11.7% 1.7%

be due to a physiological process during the period

of mixed dentition. He stated that the length of time
using the crown did not seem to have any noticeable
effect on the gingival tissues.[2] Beldüz Kara and Yilmaz
found that the GI scores increased progressively with
time, it was never >1.
In our study, the radiographic examination of the
alveolar bone adjacent to the teeth restored with SSC had
a mean score of 1.841 ± 0.251 and mean value of control
teeth was 1.866 ± 0.222 at 3 months. This showed more
bone resorption in control teeth compared to the study
teeth. At 6‑month evaluation, the study teeth had mean
value of 1.975 ± 0.282 and in control teeth 2.333 ± 0.438
[Table 2]. This indicates that interdental bone around
control teeth underwent more resorption compared
to the study teeth. When the bitewing radiographs of
different intervals were compared, the alveolar bone
Graph 3: Distribution of oral hygiene score among various
radiographic crown extensions
had resorption at 3  months and at 6  months in the
control teeth. Moreover, in teeth restored with SSC, the
alveolar bone underwent resorption at 3 and 6 months
compared to the initial bitewing radiograph. On
comparing the values of the study teeth to control teeth,
there was more bone resorption in control teeth than
in study teeth. This is in agreement with the gingival
status of the two groups. This is in accordance with
the result found by  Koth et al. that the gingival margin
placement of a crown has only limited effect on the
indices of the periodontal health of patients with good
oral hygiene.[10] Palomo and Peden noted that crowns
with subgingival extensions produced more gingival
inflammation than those placed supragingivally.

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Prabhu, et al.: Evaluation of gingival health after stainless steel crown placement
Myers also reported a clinically significant association
between crown defects and gingivitis.[9]
In our study, 71.7% of the crowns had sealed margins
and 28.3% crowns had open margins. There was no
significant effect of level of crown margins on the
gingiva at 3 months [Table 3]. There was significant
difference at 6 months where the crowns with sealed
and open margins showed the signs of gingivitis
around them [Table 4 and Graph 2]. There was no
difference in the OHI at 3 months between two types
of margins. At 6 months, the OHI of both the types of
crown margins increased. This is in agreement with the
study conducted by Beldüz Kara and Yilmaz in which
the GI score increased as the increase in duration.
Wiland and Marcum found that the improper marginal
length and contouring of the crowns caused gingival
inflammation, and on the other hand, Richter and
Ueno found that margins of the crowns had no effect
on the gingival tissues.[6]
Crown marginal extensions were evaluated clinically
in our study, 30% crowns extended till gingiva and
70% extended below the gingival margin. Both the
types had the gingival score 1 at 3 and 6 months. On
evaluating the oral hygiene at 3 months, both the
crown had the score 0 and 1. At 6  months, 3 crowns
with margins at gingiva and 6 crowns with the margins
below gingiva had the score 2. This indicates that the
oral hygiene of the teeth restored with SSC deteriorates
with the time.
On evaluation of crown margins for the extension
radiographically, 86.7% crowns were extended
adequately whereas 13.35% crowns were extended
inadequately. On evaluating the GI at 3 months, both
the crown extensions had the score 1. On 6  month
evaluation, the score was 2 for 20% of adequately
extended crowns and 1.7% of inadequate crowns
[Table 5]. The OHI had the similar score for both the
crown extension types. At 6‑month evaluation, 16.7%
crowns with adequate extensions had the score 2 and
1.7% [Table 6 and Graph 3] of the crowns had the score
2 indicating plaque and debris accumulation on some
teeth restored with SSC. In another study, Sharaf and
Farsi reported that interproximal bone resorption
after placement of an SSC on primary molars was not
adversely affected by an extension or adaptation of
the crown’s margin, a tight proximal contact between
molars, the level of oral hygiene, or the duration of
crown’s presence. Discrepancies of the subgingival
margins of the SSC, however, have been implicated
by some investigators as one of the causes of gingival
inflammation after restoring a primary tooth with
an SSC. They also showed that crown extension and
adaptation or even maintaining intact contact between
teeth had no effect on interproximal bone level which
again agrees with published work that did not confirm
a direct correlation between SSCs and interproximal
bone resorption.[5]
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 3 | July-September 2018
The skill of the clinician in placing the SSC influences
in minimizing the defects in SSC. The SSC is a
valuable and indispensable part of the pedodontist’s
armamentarium. Properly utilized and handled SSCs
will more adequately measure up to the requirements
of dental excellence during modern research and
advances in dental materials and manufacturing
techniques.
Conclusion
Within the limitation of this study following
conclusions can be drawn:
1. When compared to control teeth, the teeth restored
with SSC showed lesser plaque and debris
accumulation at 3 months and 6 months
2. At 3  months, the gingival status around the
teeth restored with SSC and control teeth was
similar whereas the values around SSC increased
marginally at 6 months
3. Radiographic bone level of the control teeth
showed higher level of bone resorption compared
to the teeth restored with SSC
4. There was statistically significant difference in
the oral hygiene, gingival status, and periodontal
health around study and control teeth.
It showed that gingival and interproximal bone health
does not get altered by the presence of SSC. The
marginal extension and adaptation of the crown did
not affect the supporting structures of primary molar
teeth. There was less plaque accumulation on teeth
restored with SSC than remaining teeth which are not
restored with SSC. Hence, further studies are required
to investigate the effect of SSC on the oral health status
of children with long‑term follow‑up.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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