status and survey ofpulp treatment by koreanpediatric dentists · 1 day ago · 할 수 있도록...

https://doi.org/10.5933/JKAPD.2020.47.3.277 JKoreanAcadPediatrDent47(3)2020ISSN(print)1226-8496ISSN(online)2288-3819

StatusandSurveyofPulpTreatmentbyKoreanPediatricDentists

Jee Soo Bae, Ik-Hwan Kim, Hyung-Jun Choi, Je Seon Song

DepartmentofPediatricDentistry,CollegeofDentistry,YonseiUniversity

Thepulptreatmentofprimaryandimmatureteethinthechildrenandadolescentsisaffectedbytheenvironmentof

thepatients,clinicalcareersanddentistsperformingthetechniques,aswellasclinicalmodalitiesandpulpaldiagnosis.

Thepurposeofthisstudywastoinvestigatethecurrentstatusofpulptreatmentperformedinrealclinicalpractice,as

wellasthereasonsbehindthechoiceoftreatmentmethods.

Thestudywasconductedonatotalof153membersoftheKoreanAcademyofPediatricDentistry,andstatisticaldata

fromtheHealthInsuranceReviewandAssessmentService(HIRA)from2010to2018wereanalyzedtogether.Boththe

surveyresultsandthestatisticsfromtheHIRAshowedthat1-visitpulpectomiesofprimaryteethweremostcommon,

andthefrequencyoftheuseoftheNi-Tifilewasincreasedinchildrenwithprimaryormixed-dentition.Inthetreatment

ofimmaturepermanentteeth,regenerativeendodontictreatmentbyindividualdentistswasfoundtobelessfrequent

thaninuniversityhospitals.

Key words : Pulpotomy, Pulpectomy, Endodontic treatment, Mineral trioxide aggregate

Abstract

277

Correspondingauthor:JeSeonSongDepartmentofPediatricDentistry,CollegeofDentistry,YonseiUniversity,50-1Yonsei-ro,Seodaemun-gu,Seoul,03722,RepublicofKoreaTel:+82-2-2228-3176/Fax:+82-2-365-7420/E-mail:[email protected],2019/RevisedFebruary12,2020/AcceptedFebruary10,2020

Ⅰ.서론

유치의결손은치열궁의공간감소를야기하기때문에유치를

보존하는것은소아치과영역에서가장중요한치료목표중하

나이다.이를위해우식에이환된유치를적극적으로치료해야

하는데,유치의경우영구치에비해법랑질및상아질두께가얇

고치수강의부피가크기때문에유구치우식제거시치수노출

이쉽게일어나게되어치수치료가빈번하게시행된다[1].

미성숙영구치의치료는외상받은치아,치외치의파절,molar-

incisalhypomineralization(MIH)환자의치아파절혹은심한우

식증이있을때시행하게된다.선행연구에따르면,학령기어

린이의25%가치아외상을경험하며[2],치외치의유병률추정

치는0.5-4.3%로다양하다[3-5].또한,MIH의유병률은국내연

구결과6.0-13.8%로보고되어[6-8]미성숙영구치의치수치료

를받게될가능성이있는환아가적지않음을알수있다.

이처럼유구치와미성숙영구치의치수치료는소아및청소년

영역에서빈번하게발생하는치료이며,치수치료방법을결정하

기위해정확한치수상태의진단및치료계획수립이필요하

다.그러나,어린이의경우증상에대한정확한표현을할수없

으며,임상검사에대한반응을신뢰할수없기때문에임상소

견에서치수의상태를확인하는데어려움이있다[1].

또한실제임상에서는환아의협조도및내원가능횟수,술식

소요시간,진정법사용유무등치수의상태이외에도치수치료

술식결정을위해고려해야할다양한요소들이존재한다.때문

에이론적인적응증과실제행해지는술식간의차이가발생하

게된다.그러나,우리나라임상의료현장에서소아및청소년환

J Korean Acad Pediatr Dent 47(3) 2020

278

자에게어떠한치수치료방법이사용되고있는지에대해조사한

연구결과는없었다.

따라서,이연구에서는소아치과학회원들을대상으로한설문

조사와건강보험심사평가원의공개된통계데이터를이용하여

현재국내에서이루어지고있는소아/청소년영역의치수치료현

황을조사하고자수행되었다.

Ⅱ.연구재료및방법

1.조사대상

설문조사대상은전국치과의사중유치및미성숙영구치의

치수치료에관심이많고,설문조사가용이한대한소아치과학회

전체회원으로하였다.이메일로설문조사URL을발송하여,그

중회신이있었던153명의설문지를조사대상으로하였다.

치수치료처방통계의경우건강보험심사평가원의보건의료

빅데이터개방시스템을통해공개된2010년부터2018년까지의

청구내역통계를바탕으로분석하였다.

2.조사방법

Google설문지프로그램을통해설문지를만들어2019년3

월메일로설문을보내었고한달동안응답한153명의자료를

다음과같은5가지항목으로정리하여분석하였다.모든설문의

항목은원하는선택지가없을경우주관식형태로답변을추가

할수있도록설계하였다(Fig.1).

1)치수치료를시행하는응답자에대한분석

-임상경력,진료대상,진료형태

2)유치의치수절단술

-시행여부,시행하지않는이유,사용재료,주로사용하는

mineraltrioxideaggregate(MTA)상품명

3)유치의치수절제술

-시행방법,1-visittechnique선호이유,사용재료,canal

enlargement방법,Ni-Tifile사용이유

4)미성숙영구치의생활치수치료

-선호하는술식,직접치수복조술에사용하는재료,치수절

단술에사용하는재료,치근단형성술에사용하는재료,주

로사용하는MTA상품명

5)미성숙영구치의치수재생치료

-시행여부,치수재생치료를하지않는이유,실활치수치료

시선호하는술식,irrigationmaterial,근관내첩약시사

용하는재료

3.통계분석

Ni-Tifile사용여부와치수절단술시행여부,Ni-Tifile사용여

부와선호하는치수절제술술식,응답자의근무지와치수재생치

료의시행여부의상관관계분석을위해Chi-squaretest를시행

하였다.각항목에해당하는자료의기술통계량은SPSS(version

25.0.0,SPSS,Chicago,IL,USA)를이용하여분석하였다.

Ⅲ.연구성적

1.설문대상자분석

1)진료기관형태

응답자153명은개인치과의원(개원의및페이닥터,전임의사)

102명(66.7%),대학병원(공직,수련의)44명(28.8%),군의관혹은

보건소/지소4명(2.6%),휴직3명(2.0%)으로대부분이개인치과

에근무하고있었다(Table1).

2)임상경력

임상경력이1-3년은20명(13.1%),4-6년26명(17.0%),7-9년

18명(10.8%),10-15년26명(17.0%),15-20년23명(15.0%),20년

이상40명(26.1%)이었다(Table2).

3)진료대상

소아/청소년및성인을모두진료하는경우가28명(18.3%),소

아/청소년만진료하는경우가125명(81.7%)으로대부분이소아/

청소년만진료하고있었다(Table3).

2.유치의치수절단술

1)유치치수절단술시행여부

유치의치수치료시,근관부치수염증이없는경우치수절단

술을시행한다고응답한사람은48명(31.4%),시행하지않는다

고응답한사람은105명(68.6%)로치수절단술을시행하지않

는경우가더많았으며,Ni-Ti file을사용하는경우치수절단

술을시행하는비율이통계적으로유의미하게낮았다(Table4,

p<0.001).


279

Fig. 1.Questionnaireaboutpulptreatmentinchildrenandadolescents.


280

Fig. 1.(Continued)Questionnaireaboutpulptreatmentinchildrenandadolescents.


281

2)유치치수절단술을시행하지않는이유

중복응답을통해유치치수절단술을시행하지않는다고응

답한105명의응답자중치수절단술을시행하지않는이유를조

사한결과,예후가불량한경우를많이경험했다는응답이73

회(69.5%),확실한감염조직제거를위해서라는응답이40회

(38.1%),지혈확인등술식과정의불편함이19회(18.1%),치수

절단술의저수가문제가9회(8.6%),예견할수없는치경부내흡

수가능성이1회(1.0%)순으로나타났다(Table5).

3)유치치수절단술에사용하는재료

유치치수절단술경험이있는111명의응답자를대상으로유

치치수절단술에주로사용하는재료에대해조사하였을때,

MTA가44명(39.6%), Formocresol (FC)이38명(34.2%), Ferric

sulfate24명(21.6%),수산화칼슘4명(3.6%),Theracal®(BiscoInc,

Schamburg,IL,USA)1명(0.9%)순으로나타났다(Table6).

4)유치치수절단술에MTA를사용하는경우주로사용하는

MTA의제품명

유치치수절단술에MTA를사용한경험이있는94명의응답

자를대상으로조사하였을때,유치치수절단술에주로사용하

는MTA로는RetroMTA® (BioMTA,Seoul,Korea)가39명(41.5%),

EndocemMTA® (Maruchi,Wonju,Korea)가26명(27.7%),Pro-

Table 1. Surveyrespondents’dutyplaces

Duty placeAnswer

n %

Local clinic 102 66.7

Universityhospital 44 28.7

Community Health Center 4 2.6

Leaveofabsence 3 2.0

Total 153 100.0

Table 2. Surveyrespondents’clinicalcareer

Career(years)Answer

n %

1-3 20 13.1

4-6 26 17.0

7-9 18 10.8

10 - 15 26 17.0

15 - 20 23 15.0

Longer than 20 40 26.1

Total 153 100.0

Table 3.Patientsvisitingsurveyrespondents’clinics

PatientAnswer

n %

Children and adolescents only 125 81.7

Children, adolescents and adults 28 18.3

Total 153 100.0

Table 4.Surveyrespondents’answersonwhetherornotpulpotomyisperformedwhenhemostasisofthepulpispossibleaccordingtousageofrotaryNi-Tifile

RotaryfileusageChoosePulpotomyWhenHemostasisisPossible

Totaln(%)

p -valueDon(%)

Don’tn(%)

User 26(23.0) 87(77.0) 113(100.0)

<0.001Non-user 22(55.0) 18(45.0) 40(100.0)

Total 48(31.4) 105(68.6) 153(100.0)

p -valuefromChi-squaredtest

Table 5. Reasonswhyasurveyrespondentdidnotchoosepulp-otomy(duplicateresponse)

Reason for Not Choosing Pulpotomy

Answer

n %

Poor prognosis 73 69.5

Removalofinfectivetissue 40 38.1

Inconvenientclinicalprocedure 19 18.1

Low charge 9 8.6

Cervicalinternalresorption 1 1.0

Total 105 100.0

Table 6. Preferred material for pulpotomy of primary teeth

Pulpotomy MaterialAnswer

n %

MTA 44 39.6

Formocresol 38 34.2

Ferric sulfate 24 21.6

Calcium hydroxide 4 3.6

Theracal® 1 0.9

Total 111 100.0


282

Root MTA® (DENTSPLYTulsaDental, Tulsa,OK,USA)17명

(18.1%), Biodentine® (Septodont, Saint-Maur-des-Fossés,

France)5명(5.3%),Theracal®1명(1.1%),BrightendoMTAseal-

er®(Dentium,Seoul,Korea)1명(1.1%)순으로나타났으며,MTA

제품명을모른다는응답도5명(5.3%)있었다(Table7).

3.유치의치수절제술

1)유치치수절제술에주로사용하는방법

유치치수절제술에주로사용하는방법을묻는질문에1-visit

technique을주로사용한다는응답이129명(84.3%), 2-visit

technique을주로사용한다는응답이24명(15.7%)로대부분이

1-visittechnique을선호하는것으로나타났으며,Ni-Tifile을사

용하는경우1-visittechnique을선호하는비율이통계적으로유

의미하게높았다(Table8,p=0.01).

2)1-visittechnique을선호하는이유

1-visittechnique을선호한다고응답한129명중중복응답을

통해1-visittechnique을선호하는이유를조사한결과‘적은내

원횟수등환자및보호자의편의를위해서’가113회(87.6%),‘행

동유도횟수감소등술자및보조인력의편의를위해서’가61회

(47.3%),‘임상경험상예후가좋아서’가27회(20.9%),‘의료수가

의차이때문에’가5회(3.9%)로나타났다(Table9).

3)유치치수절제술에주로사용하는충전재

유치치수절제술에주로사용하는충전재는Vitapex® (Neo-

dental,Tokyo, Japan)148명(96.7%),Metapex® (MetaBiomed

CompanyLtd.,Cheongju,Korea)3명(2.0%),Diapex® (Diadent,

Cheongju,Korea)2명(1.3%)순으로대부분이Vitapex®를사용

중인것으로나타났다(Table10).

4)유치치수절제술시사용하는canalenlargement방법

유치치수절제술에사용하는canalenlargement방법은hand

file과Ni-Tifile을동시에사용한다는응답이57명(37.3%),Ni-Ti

Table 7. Preferred MTA for pulpotomy of primary teeth

ProductAnswer

n %

RetroMTA® 39 41.5

EndocemMTA® 26 27.7

ProRoot MTA® 17 18.1

Biodentine® 5 5.3

Theracal® 1 1.1

Bright endo MTA sealer® 1 1.1

Do not know 5 5.3

Total 94 100.0

Table 8. PreferredpulpectomytechniqueaccordingtotheuseofrotaryNi-Tifile

Rotary File UsagePreferredTechnique

Totaln(%)

p -value1-visitn(%)

2-visitn(%)

User 103(91.2) 10(8.8) 113(100.0)

.001Non-user 26(65.0) 14(35.0) 40(100.0)

Total 129(84.3) 24(15.7) 153(100.0)


Table 9.Reasonswhyasurveyrespondentpreferred1-visitpulp-ectomy(duplicateresponse)

ReasonAnswer

n %

Fewervisits 113 87.6

Fewerbehavioralcontroltrials 61 47.3

Favorableoutcome 27 20.9

Amount 5 3.9

Total 129 100.0

Table 10. Preferredcanalfillingmaterial forpulpectomyofpri-mary teeth

Canal Filling MaterialAnswer

n %

Vitapex® 148 96.7

Metapex® 3 2.0

Diapex® 2 1.3

Total 153 100.0


283

file만사용한다는응답이56명(36.6%),handfile만사용한다는

응답이35명(22.9%),발수만시행한다는응답이4명(2.6%),low-

speedengine에K-file을연결하여사용한다는응답이1명(0.7%)

순으로나타났다(Table11).

5)유치치수절제술시Ni-Tifile을사용하는이유

유치치수절제술시Ni-Tifile을사용한다고응답한113명중

중복응답을통해Ni-Tifile의사용이유를조사한결과발수의

편의성이82회(72.6%),술식소요시간의감소가77회(68.1%),근

관형성의편의성이75회(66.4%)로가장많은응답횟수를보였

으며,이외추가적인수가의발생이22회(19.5%),‘Ni-Tifile을사

용한경우예후가좋았기때문에’라는응답이5회(4.4%)로나타

났다(Table12).

4.미성숙영구치의치수치료

1)미성숙영구치의생활치수치료시선호하는술식

중복응답을통해미성숙영구치의생활치수치료시선호하는

술식에대해조사한결과indirectpulpcapping80회(52.3%),di-

rectpulpcapping47회(30.7%),partialpulpotomy43회(28.1%),

cervicalpulpotomy23회(15.0%)순으로나타났고,별도의선호

하는술식없이증례에따라선택한다는응답이4회(2.6%)로나

타났다(Table13).

2)미성숙영구치의directpulpcapping시주로사용하는재료

중복응답을통해미성숙영구치의directpulpcapping시주

로사용하는재료에대해조사한결과MTA가117회(76.5%)로

가장많이나타났고,뒤이어수산화칼슘이28회(18.3%),Thera-

cal®등복합재료가25회(16.3%)순으로나타났다(Table14).

3)미성숙영구치의치수절단술에주로사용하는재료

중복응답을통해미성숙영구치의치수절단술에주로사용하

는재료에대해조사한결과MTA가118회(77.1%),수산화칼슘

이30회(19.6%),Formocresol이9회(5.9%),Ferricsulfate가3회

(2.0%),Tripleantibioticpaste가1회(0.7%)로대부분MTA를선

호하는것으로나타났다(Table15).

Table 11. Canal enlargement method in primary teeth

Canal Enlargement MethodAnswer

n %

HandfileandNi-Tifile 57 37.3

Ni-Tifileonly 56 36.6

Handfileonly 35 22.9

Extirpation only 4 2.6

K-filecombinedlow-speedengine 1 0.7

Total 153 100.0

Table 13.Preferredpulptreatmentforvitalpermanentteeth(du-plicateresponse)

Preferred TreatmentAnswer

n %

Indirect pulp capping 80 52.3

Direct pulp capping 47 30.7

Partial pulpotomy 43 28.1

Cervicalpulpotomy 23 15.0

Select according to pulp condition 4 2.6

Total 153 100.0

Table 12. ReasonswhyasurveyrespondentusesrotaryNi-Tifile(duplicateresponse)

ReasonAnswer

n %

Convenienceofextirpation 82 72.6

Shorter chair-time 77 68.1

Convenienceofcanalenlargement 75 66.4

Additional charge 22 19.5

Favorableoutcome 5 4.4

Total 113 100.0

Table 14. Preferred material for direct pulp capping of permanent teeth(duplicateresponse)

Pulp Capping Material Answer

n %

MTA 117 76.5


Theracal® 25 16.3

Total 153 100.0

Table 15. Preferred material for pulpotomy of permanent teeth (duplicateresponse)

Pulpotomy MaterialAnswer

n %

MTA 118 77.1


Formocresol 9 5.9

Ferric sulfate 3 2.0

Tripleantibioticpaste 1 0.7

Total 153 100.0


284

4)미성숙영구치의치근단형성술에주로사용하는재료의비율

미성숙영구치의치근단형성술에MTA와수산화칼슘의사용

비율을조사한결과MTA가50.5%,수산화칼슘이49.5%로두재

료를비슷한비율로사용하는것으로나타났다.

5)미성숙영구치의치근단형성술시MTA를사용하는경우주

로사용하는제품

미성숙영구치의치근단형성술에MTA를사용한경험이있

는130명의응답자를대상으로조사하였을때,미성숙영구치

의치근단형성술에주로사용하는MTA로는RetroMTA®가40

명(30.8%),ProRootMTA®가36명(27.7%),EndocemMTA®가17

명(13.1%),EndosealMTA®가15명(11.5%),OrthoMTA® (BioMTA,

Seoul,Korea)가12명(9.2%),Biodentine®이1명(0.8%),Bright

endo MTA sealer®가1명(0.8%)순으로나타났고,상품명을모른

다는응답이8명(6.2%)있었다(Table16).

5.미성숙영구치의치수재생치료

1)미성숙영구치의치수재생치료시행여부

미성숙영구치의치수재생치료시행여부를조사한결과,치수

재생치료를시행한다는응답이89명(58.2%),시행하지않는다는

응답이64명(41.8%)으로나타났다.이중,대학병원에근무하는

경우(공직혹은수련의)치수재생치료를시행하는비율이90.1%

로,개인의원혹은치과병원이나보건소에근무하는경우치수

재생치료를시행하는비율인45.0%보다통계적으로유의미하게

높았다(Table17,p<0.001).

2)미성숙영구치의실활치수치료시선호하는술식

미성숙영구치의실활치수치료시선호하는술식을1순위부

터3순위까지조사한결과,1순위로는치근단형성술(49.7%)-치

수재생치료(43.8%)-전통적인방법의근관치료(6.5%)순으로나타

났으며,2순위는치근단형성술(46.4%)-전통적인방법의근관치

료(39.9%)-치수재생치료(13.7%)순으로나타났고,3순위는전통

적인방법의근관치료(54.2%)-치수재생치료(39.9%)-치근단형성

술(5.9%)순으로나타났다(Fig.2).

Table 16. PreferredMTAforapexificationofpermanentteeth

Product Answer

n %

RetroMTA® 40 30.8

ProRoot MTA® 36 27.7

EndocemMTA® 17 13.1

EndosealMTA® 15 11.5

OrthoMTA® 12 9.2

Biodentine® 1 0.8

Bright endo MTA sealer® 1 0.8

Do not know 8 6.2

Total 130 100.0

Table 17. Surveyrespondents’answertowhetherornotregenerativeendodontictreatment isperformedwhenindicatedaccordingtoduty place

Duty PlaceTryRegenerativeEndodonticsWhenIndicated

Totaln(%)

p -valueDon(%)

Don’tn(%)

Universityhospital 40(91.9) 4(9.1) 44(100.0)

<0.001Local clinic 49(45.0) 60(55.0) 109(100.0)

Total 89(58.2) 64(41.8) 153(100.0)


Fig. 2.Preferencerankforthetreatmentofnon-vitalpre-maturepermanentteeth.*RCT=rootcanaltreatment


285

3)치수재생치료를시행하지않는이유

치수재생치료를시행하지않는다고응답한64명중중복응답

을통해치수재생치료를시행하지않는이유에대해조사한결

과,증례선택의어려움이35회(54.7%),불량한예후의가능성이

31회(48.4%),상급병원으로의뢰한다는답변이26회(40.6%),술

식의난이도가높기때문이라는답변이23회(35.9%),고난도술

식대비수가가낮기때문이라는응답이16회(25.0%)순으로나

타났으며,기타응답으로는치수재생치료의경험이없다는응답

이1회(1.6%),적절한수가항목이없다는응답이1회(1.6%)있

었다(Table18).

4)치수재생치료시사용하는irrigationmaterial

치수재생치료를시행한경험이있는111명의응답자중중

복응답을통해치수재생치료시사용하는irrigationmaterial에

대해조사한결과saline이89회(80.2%),NaOCl이86회(77.5%)

로두irrigant를가장많이사용하는것으로나타났으며,뒤이어

EDTA14회(12.6%),H2O2 12회(10.8%),Chlorhexidine11회(9.9%)

순으로나타났다.기타응답으로는tripleantibioticpaste가1회

(0.9%)있었다(Table19).

5)치수재생치료시내원사이근관내첩약에주로사용하는

약재

치수재생치료를시행한경험이있는111명의응답자중중복

응답을통해치수재생치료시내원사이근관내첩약에주로

사용하는약재를조사한결과수산화칼슘이37회(33.3%),triple

antibioticpaste32회(28.8%),doubleantibioticpaste가13회

(11.7%), tripleantibioticpaste중minocycline대체제를사용

한약제가8회(7.2%),MTA가1회(0.9%)순으로나타났으며,발수

및irrigation만하고별도의첩약을하지않는다는답변도29회

(26.1%)있었다(Table20).

6.소아및청소년영역에서의치수치료처방통계내역

2010년부터2018년처방통계를살펴보면,유치의1-visit

pulpectomy를시행받은환자의수와청구액은5세미만과5-9

세영역에서모두지속적으로증가하였다(Fig.3,4).

Ni-Tifile사용량의경우2014년부터의자료가공개되어있는

데,0-9세환자에서청구횟수가232,732회증가하여매우가

파른상승세를보였다(Fig.5).

Ⅳ.총괄및고찰

치아우식증은소아및청소년치과영역에서가장호발하는

구강내질환이다[9].특히,유치의경우영구치에비해법랑질과

상아질이얇으며치수강의부피가크기때문에우식을제거하

는과정에서치수노출이빈번하게일어난다[1].또한,유치의경

우동통조절과공간유지를위해치아를보존하기위해알맞은

Table 18.Reasonswhyasurveyrespondentdidnotchoosere-generativeendodontictreatment(duplicateresponse)

ReasonAnswer

n %

Difficultyofcaseselection 35 54.7

Poor prognosis 31 48.4

Refer to senior hospital 26 40.6

Difficultprocedure 23 35.9

Low charge 16 25.0

NeverdoneRET* 1 1.6

Nosuitablecategory 1 1.6

Total 64 100.0

*RET=Regenerativeendodontictreatment

Table 20.Preferred intracanalmedicamentforregenerativeend-odontictreatmentofpermanentteeth(duplicateresponse)

Intracanal MedicamentAnswer

n %



Doubleantibioticpaste 13 11.7

Tripleantibioticpaste(minocyclinesubstitute)

8 7.2

MTA 1 0.9

None 29 26.1

Total 111 100.0

Table 19.Preferredirrigationmaterialsforregenerativeendodon-tictreatmentofpermanentteeth(duplicateresponse)

Irrigation MaterialAnswer

n %

Saline 89 80.2

NaOCl 86 77.5

EDTA 14 12.6

H2O2 12 10.8

Chlorhexidine 11 9.9


Total 111 100.0


286

치수치료를시행하는것이매우중요하다.미성숙영구치의경우

외상혹은치외치의파절,MIH환자의치아우식증치료시주로

치료를진행하게되며,환아의연대연령이어릴때치료를진행

하게되므로가능한한소아및청소년의경우영구치의치수생

활력을유지하여영구치를장기간사용할수있도록하는것이

유리하다[10].때문에소아및청소년영역에서치수치료시치

수상태의진단및치료방법의결정은매우중요하며,특히소아

치과영역에서는환아의협조도,내원가능횟수,전신질환,탈락

시기등치수진단이외에도고려해야할요소가많아교과서와

가이드라인에서제시하고있는술식과실제임상에서행해지는

술식사이에는차이가있다.

이연구에서는실제로행해지는술식의현황에대해조사하기

위해설문조사와건강보험심사평가원의공개된통계데이터를

이용하여현재국내에서이루어지고있는소아/청소년영역의치

수치료현황에대해조사하였다.

이번연구결과유치의치수치료에서가장선호하는술식은

1-visitpulpectomy인것으로나타났다.과거에는hand file만

을이용하여치수절제술을시행하였으나,2000년Barr등[11]

에의해유치의치수치료에서Ni-Tifile의사용이처음으로소개

된후유치의치수절제술에서도Ni-Tifile이활발히사용되고있

Fig. 3.Prescriptionsstatisticfrom2010to2018inpatientsunder5yearsold.(A)Numberofpatientswhounderwent1-visitpulpectomies,pulpextirpations,pulpotomies,(B)Amountchargedfor1-visitpulpectomies,pulpextirpations,pulpotomies.

Fig. 4.Prescriptionsstatisticfrom2010to2018inpatientsbetween5and9yearsold.(A)Numberofpatientswhounder-went1-visitpulpectomies,pulpextirpations,pulpotomies, (B)Amountchargedfor1-visitpulpectomies,pulpextirpations,pulpotomies.


287

다.실제로,국내에서도소아및청소년영역에서Ni-Tifile의사

용이증가하고있다.2014년부터의치료재료청구내역을살펴

보면,0-9세환자에서Ni-Tifile의사용은2018년까지지속적으

로증가하였고,이는유치열기의환자에서도Ni-Tifile의사용이

늘어나고있다는것을의미한다(Fig.5).유치에서의근관치료는

소요시간이길고어려운술식이며,특히과정전체에서가장중

요한단계인근관형성단계가전체치료시간의결정에중요한

역할을한다[12].선행논문을살펴보면,유치의치수치료에Ni-

Tifile을사용하는경우handfile을사용하는경우보다유의미하

게치료소요시간이짧아지는것으로나타났다[13-18].이번설

문조사결과에서도치수치료시Ni-Tifile을사용하는주된이유

는발수,근관형성의편의성및chairtime의감소인것으로나

타났다.또한,Ni-Tifile을사용하는군과사용하지않는군을비

교하였을때,Ni-Tifile을사용한다는응답을한군이치수절제술

을선호하는비율과더불어,유치의치수절제술시행시1-visit

technique을선호하는비율이통계적으로유의미하게높았다

(Table8).1-visittechnique을선호하는이유로는환자의내원횟

수가적어져환자및진료인력의편의성이높아지기때문이라

는응답이가장많았다(Table9).때문에Ni-Tifile을사용함으로

써술식의소요시간이감소하여1-visittechnique을적용하기용

이해진현재의상황에서1-visittechnique을이용한치수치료의

예후가양호하다면1-visittechnique을시행하는것은자연스러

운현상이다.실제로1-visittechnique과2-visittechnique을사

용하여시행한유치치수절제술의예후를조사한연구결과,적

응증을잘선택한다면두술식간의성공률은통계적으로차이

가없었다[19,20].

술식소요시간을줄이는것뿐만아니라,Ni-Ti file의사용은

stainlesshand file을사용할때보다transportation, zipping,

ledging,perforation같은기구사용의오류를최소화한다[21,22].

그러나회전식Ni-Tifile은예기치못한근관내파절을야기하

는단점이있다[23].선행연구결과,Ni-Tifile의근관내파절빈

도가handfile에비해거의7배높다고보고되었다[24].또한,

Ni-Tifile사용의단점은유치의치근형태와밀접한관련이있

다.유치의상아질은영구치보다부드럽고밀도가낮으며뿌리

는더짧고얇으며만곡이심하다.유치의근관은리본형태를

형태를특징으로한다[25].회전식file의회전은근관의중심부

에서일어나기때문에,ismuth와fin에잠재적인감염조직을남

겨놓을수있다[25,26].또한,handfile에비해치근단에서의tac-

tilesensitivity가낮기때문에Ni-Tifile을유치에서사용하기전

술자의훈련이필수적이다[12].유치열에서의Ni-Tifile사용상의

한계와더불어Ni-Tifile의사용이늘어나고있는현상황을살

펴볼때,유치의해부학적특징에맞는회전식Ni-Tifilesystem

의개발및소아치과영역에서의Ni-Tifile사용에대한교육이

필요할것으로판단된다.

유치와영구치에서치수가기계적힘또는외상에의해노출

되었을때,치수절단술은근관부의치수생활력을유지하는보

존적치수치료방법으로서추천된다[27,28].과거FC,수산화칼

슘,MTA등이치수절단술재료로사용되어왔다[29].이전in-vivo

연구에따르면,MTA는조직재생을유도하는효과가있으며,생

활치수치료에성공적으로적용할수있음이입증되었다[30,31].

Fig. 5.Prescriptionsstatistic from2014to2018 inpatientsunder19yearsold. (A)Countscharged forNi-Ti filing, (B)AmountchargedforofNi-Tifiling.


288

Shirvani와Asgary에의해수행된systematic review에따르면,

MTA를치수절단술에사용했을때FC보다우수한결과를나타

낸다는강력한증거가입증되었다[32].Peng등이수행한meta-

analysis도MTA를치수절단술에이용하였을때FC보다더나

은예후가나타남을입증하였다[33].또한,FC의주요성분인포

름알데히드는치수절단술후에전신적으로분포되는것으로보

고되었으며[34],세포독성을나타내고,잠재적인발암물질으

로작용할수있으며,면역감작및돌연변이발생과같은유해

한부작용의가능성을배제할수없다[33].그러나조사결과응

답자중FC를사용한다는답변이유치치수절단술의경우38명

(34.2%),영구치치수절단술의경우9명(5.9%)으로,여전히적지

않은수의FC치수절단술이시행되고있음을알수있었다.MTA

의경우재료자체가고가이며,MTA의사용이급여항목으로고

시되어있지않아급여시술인치수절단술재료로선택하는것

에한계가있을수있다.그러나,MTA를이용한치수절단술의

높은성공률을고려해본다면,발치나재치료를최소화할수있

으므로MTA를사용하는것이비용대비효과가높은치료가될

수있을것이다.따라서유치및영구치의치수절단술에서MTA

의사용에급여적용이보건재정측면에서도유리할수있을것

으로보인다.

ProRoot MTA®는우수한생체친화성및밀폐능력을기반으

로치근단형성술,치수절단술,치수복조술및천공된치근의수

복,치근단수술등근관치료의여러영역에서활발히사용되

어왔으나[35],경화시간이길고,조작이어려우며,매치료시균

일하게혼합하는것이어렵다[36-38].이런특징또한MTA를소

아및청소년의치료에사용하기어렵게만든다.위와같은한계

를극복하기위해물성을개선한제품인RetroMTA®, Endocem-

MTA®가개발되었으며,ProRootMTA®와비교하였을때생활

치수치료의성공률에차이가없었다[39-41].그러나이제품들

모두적용직전mix해야하는불편함이있어pre-mixedtype의

MTA가개발되어각광받고있다.실제로,이번연구결과에서도

pre-mixedtype인EndosealMTA®나BrightendoMTAsealer®를

사용한다는응답이있었다.그러나두제품모두임상시험결과

가밝혀진바없어,앞으로pre-mixedtypeMTA의임상시험이시

행된다면,기존의MTA가가지는물성의한계를극복함으로써소

아및청소년의치수치료에광범위하게사용될수있을것이다.

이번연구결과에서특징적으로나타난것은,개인치과의원

혹은보건소등지에서근무하는응답자가대학병원에서근무하

는응답자에비해미성숙영구치의치수재생치료를시도하는비

율이낮았다는것이다(Table17).치수재생치료는미성숙치근의

경우치주조직으로의큰개통부가존재하기때문에,치수가부

분적으로괴사되고감염되었을때에도치근단병소가나타날수

있으며,치근단부위에는치수생활력이유지되는상태로유지

될수있다는관점에서치관부의감염된치수조직의제거와소

독을통해치근단복합체의세포생활력을유지한다면치근의성

장을도모할수있다는가설을바탕으로한술식으로,2001년

Iwaya등에의해처음소개되었다[36].치수재생치료는상아질

및치근구조뿐만아니라치수-상아질복합체의세포를포함하

여손상또는결손된구조의재생을유도하는술식으로,이상적

으로는치수-상아질복합체의정상적인생리기능을회복시킨

다[42].지난몇년동안이분야의발전은빠른속도로진행되었

다.

치수재생치료는치수-상아질복합체조직이재생된다면치근

발육이완전히이루어지지않은영구치에서가장이상적으로적

용할수있는술식이나,많은한계점과주의사항이존재한다.첫

번째고려사항은치수재생치료시혈병의유지문제이다.충분

한출혈량을얻기위해서는에피네프린이포함되지않은마취제

를사용해야하며,실제임상에서오랜시간이소요된다[43].또

한,혈병형성을위해예리한file로apicalpapilla의열상을유

도해야하나이과정에서Hetrwig상피수초(Hertwig’sepithelial

rootsheath,HERS)가손상된다면치근의비정상적인성장이나

타날수있으므로주의해야한다[44-46].두번째문제는치수재

생치료에사용되는약제에의한변색의위험성이존재한다는

것이다.치수재생치료시근관내소독을위해triple-antibiotic

paste (TAP)의사용을권장하고있으나[43],여기에포함된mi-

nocycline에의한치관부변색이여러문헌에서보고되었다[47-

49].또한,MTA에의해서도변색이나타날수있다.WhiteMTA

조차도cemento-enameljunction(CEJ)에위치되었을때심각한

변색을일으킨보고가있었다[50,51].

이처럼치수재생치료는상대적으로난이도가높은술식이며,

부작용을예방하기위해MTA나collagenmatrix같은고가의재

료를사용해야하나,그예후를예측하기어렵고적응증선택또

한어렵다.일부문헌은치수재생치료의경우생활력이완전히

소실되어있으며치수절단술,치근단형성술,근관충전이적합

하지않은경우에만조심스럽게적용할것을권유하고있다[52].

즉,고난도술식에비해책정된수가가낮다는단점이있다.이

번설문조사결과에서도치수재생치료를시도하지않는이유로

술식의난이도가높으며및증례선택의어려움,고난도술식대

비저수가의문제를꼽았으며,실제로청구가능한수가항목이

없다는문제도지적되었다(Table18).

치수재생치료는성공적으로수행된다면,치근의성장과더불

어치수생활력의유지가가능하다는점에서장기적으로보았을

때비용대비효과가높은치료가될수있으나,현실적으로앞

서기술한한계점때문에localclinic에서치수재생치료를시도


289

하는데제약이많다.이번설문에서도치수생활력이소실된미

성숙영구치의치료시가장선호하는치료는치수재생치료가아

닌치근단형성술로나타났으며,치수재생치료의선호도가가장

낮다는답변이38.8%에달해대부분의응답자가개인의원에근

무한다는점을미루어보아,개인의원에서치수재생치료의선호

도가낮음을확인할수있었다(Fig.2).

실제로이번설문조사에서도치수재생치료를위해환자를상

급병원으로의뢰한다는응답이40.6%로나타났고,대학병원근

무자에서치수재생치료의시도비율이통계적으로유의미하게

높았다(Table18).그러나상급병원으로의뢰되는과정에서치료

의지연이발생하며,치수조직의감염및괴사영역이확대되어

실제로환자가상급병원에내원하였을때에는치수재생치료의

적용이불가능한경우가발생한다.이를해소하기위해서는치

수재생치료시청구가능한적절한수가항목의신설과더불어,

치수재생치료에사용하는재료의급여고시와같은보건정책

의수립이필요할것으로보인다.

이연구는소아치과학회회원들을대상으로하였기때문에,

소아및청소년진료를하는전체치과의사를대표할수없다는

한계점이있다.향후연구대상을일반화하고연구기간을늘린

추가적인연구가필요할것으로생각된다.또한이연구에서는

처방내역을연령별로분석하여1-visitpulpectomy를제외하고

는실제술식이유치에시행되었는지의여부를알수없다는한

계점이있다.추후치식을포함한통계자료를분석한다면보다

더정확한현황파악이가능할것으로생각된다.

Ⅴ.결론

유치의치수치료에Ni-Ti file의사용이늘어나면서,1-visit

pulpectomy의빈도와선호도가증가하고있다.그러나유치에

서Ni-Tifile사용시filefracture,ismuth부위의조직잔존과같

은한계점이있으므로유치에적합한Ni-Tifilesystem개발및

교육이필요할것으로보인다.

유치및영구치의생활치수치료에MTA를사용한경우우수

한예후를나타내나,비급여재료라는점과조작이어렵고경화

시간이길다는한계가있어실제임상에서사용이어렵다.추후

MTA의급여고시와물성을개선한MTA의개발및임상시험이

필요하다.

미성숙영구치의치수재생치료는난이도가높으나청구가능

한적절한처방이존재하지않고난이도대비저수가로인해개

인의원에서실시하는데한계가있다.치수재생치료의활발한

시행을위해서는가이드라인제정및치수재생치료교육과더불

어적절한급여체계정립이필요할것이다.

Authors' Information

Jee Soo Bae https://orcid.org/0000-0002-9142-6036

Ik-Hwan Kim https://orcid.org/0000-0003-4444-532X

Hyung-Jun Choi https://orcid.org/0000-0002-3315-6912

Je Seon Song https://orcid.org/0000-0001-8620-5629

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JKoreanAcadPediatrDent47(3)2020

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국문초록

한국소아치과의사의치수치료술식에대한실태조사

배지수ㆍ김익환ㆍ최형준ㆍ송제선

연세대학교치과대학소아치과학교실

유치및미성숙영구치의치수치료는소아및청소년영역에서빈번하게행하지는치료이며,임상양상과치수진단뿐만아니라환

아및보호자,술자의환경에영향을받는다.이연구의목적은실제임상에서행해지는치수치료의현황에대한조사와더불어치료

방법을선택하게된배경에대해조사하는것이다.

이연구는소아치과학회회원을대상으로총153명의설문조사결과지를바탕으로시행되었으며,2010년부터2018년까지의건강

보험심사평가원의통계자료를함께분석하였다.설문조사결과와건강보험심사평가원의통계자료모두유치의1-visitpulpectomy가

가장활발하게시행되고있는술식으로나타났으며,유치열기또는혼합치열기어린이에서Ni-Tifile의사용빈도가증가하였다.미성

숙영구치의치료에서는개인치과의원에서치수재생치료의시행빈도가대학병원보다낮은것으로나타났다.

status and survey ofpulp treatment by koreanpediatric dentists · 1 day ago · 할 수 있도록...

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