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Çocuk Hastaların Genel Anestezi ve Sedasyon Altında Yapılan Dental Tedavilerinin Retrospektif Olarak Değerlendirilmesi

Year 2022, Volume: 2 Issue: 1, 11 - 19, 29.04.2022

Abstract

Amaç: Dental işlemler genellikle lokal anestezi altında yapılabilse de bilhassa uyum problemi olan küçük yaştaki
çocuklarda kapsamlı bir tedavi gereksinimi, mental veya fiziksel yetersizliğin görüldüğü özel bakım ihtiyacı olan
çocuklarda kooperasyon güçlüğü, aşırı kaygılı ve korkulu hastalarda tedaviler genel anestezi/sedasyon altında
yapılabilmektedir. Bu çalışmada Ankara Yıldırım Beyazıt Üniversitesi Diş Hekimliği Fakültesi Tepebaşı Ağız ve Diş
Sağlığı Eğitim ve Araştırma Hastanesi Çocuk Diş Hekimliği Anabilim Dalı'nda genel anestezi/sedasyon altında diş
tedavisi gören çocuk hastaların retrospektif değerlendirilmesi ve farklı eğitim düzeylerine sahip üç diş hekiminin
tedavi yönelimleri araştırılmıştır.
Yöntem: Ankara Yıldırım Beyazıt Üniversitesi Sosyal ve Beşeri Bilimler Etik Kurulu onayı alındıktan sonra AYBÜ
Diş Hekimliği Fakültesi Tepebaşı Ağız ve Diş Sağlığı Eğitim ve Araştırma Hastane’sinde 01.08.2017 ile 01.08.2018
tarihleri arasında genel anestezi/sedasyon altında dental tedavileri yapılan 300 vaka çalışmaya alınmıştır. Genel diş
hekimi (A), Çocuk Diş Hekimliği’nde uzman diş hekimi (B) ve Çocuk Diş Hekimliği Anabilim Dalı’nda görevli
Dr.Öğr. Üyesi (C) olmak üzere üç diş hekimi tarafından tedavileri gerçekleştirilen hastalar 3 yaş ve altı, 4-6 yaş arası
ve 7 yaş ve üzeri olmak üzere üç grupta incelenmiştir. Bu retrospektif çalışmada hastaların verileri ilgili hastanenin
elektronik veri tabanından ve epikriz formundan elde edilmiştir. Veriler hastanın yaşı, cinsiyeti, tıbbi durumu ve
yapılan diş tedavilerini içermektedir. Elde edilen veriler veriler SPSS 21 paket programı aracılığı ile analiz edilmiştir.
Sonuç: Hastaların %55’i erkek, %45’i kızdır ve yaş ortalamaları 4.99±1.53’tür. Tedavi edilen engelli birey oranı
%2.6’dır. En çok tercih edilen tedavi restoratif tedavi olmakla birlikte bunu sırasıyla diş çekimi, kanal tedavisi ve
amputasyon takip etmektedir. 7 yaş ve üzeri çocuk hastalarda daha çok çekim tedavisi tercih edilmiştir

References

  • 1. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012. NCHS data brief. 2015(191):1-8.
  • 2. Gökalp SG, Doğan BG, Tekçiçek MT, Berberoğlu A, Unlüer S. National survey of oral health status of children and adults in Turkey. Community dental health. 2010;27(1):12-7.
  • 3. Kagihara LE, Niederhauser VP, Stark M. Assessment, management, and prevention of early childhood caries. Journal of the American Academy of Nurse Practitioners. 2009;21(1):1-10.
  • 4. Thitasomakul S, Thearmontree A, Piwat S, Chankanka O, Pithpornchaiyakul W, Teanpaisan R, et al. A longitudinal study of early childhood caries in 9- to 18-month-old Thai infants. Community dentistry and oral epidemiology. 2006;34(6):429-36.
  • 5. Takaoka LA, Goulart AL, Kopelman BI, Weiler RM. Enamel defects in the complete primary dentition of children born at term and preterm. Pediatric dentistry. 2011;33(2):171-6.
  • 6. Policy on early childhood caries (ECC): unique challenges and treatment options. Pediatric dentistry. 2005;27(7):34-5.
  • 7. Ramos-Jorge J, Pordeus IA, Ramos-Jorge ML, Marques LS, Paiva SM. Impact of untreated dental caries on quality of life of preschool children: different stages and activity. Community dentistry and oral epidemiology. 2014;42(4):311-22.
  • 8. Krisdapong S, Somkotra T, Kueakulpipat W. Disparities in early childhood caries and its impact on oral health-related quality of life of preschool children. Asia-Pacific journal of public health. 2014;26(3):285-94.
  • 9. Baghdadi ZD. Effects of dental rehabilitation under general anesthesia on children's oral health-related quality of life using proxy short versions of OHRQoL instruments. TheScientificWorldJournal. 2014;2014:308439.
  • 10. Guideline for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatric dentistry. 2016;38(6):216-45.
  • 11. Coté CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. 2000;105(4 Pt 1):805-14.
  • 12. Atan S, Ashley P, Gilthorpe MS, Scheer B, Mason C, Roberts G. Morbidity following dental treatment of children under intubation general anaesthesia in a day-stay unit. International journal of paediatric dentistry. 2004;14(1):9-16.
  • 13. Chen YP, Hsieh CY, Hsu WT, Wu FY, Shih WY. A 10-year trend of dental treatments under general anesthesia of children in Taipei Veterans General Hospital. Journal of the Chinese Medical Association : JCMA. 2017;80(4):262-8.
  • 14. Cantekin K DS, Aydinbelge M, Canpolat D, Yildirim M, Avci S. . Analysis of comprehensive dental rehabilitation under general anesthesia at a dental hospital in Turkey. Pediatr Dent. 2014;2(2):49-55.
  • 15. Tsai CL, Tsai YL, Lin YT, Lin YT. A retrospective study of dental treatment under general anesthesia of children with or without a chronic illness and/or a disability. Chang Gung medical journal. 2006;29(4):412-8.
  • 16. O'Sullivan EA, Curzon ME. The efficacy of comprehensive dental care for children under general anesthesia. British dental journal. 1991;171(2):56-8.
  • 17. Vermeulen M, Vinckier F, Vandenbroucke J. Dental general anesthesia: clinical characteristics of 933 patients. ASDC journal of dentistry for children. 1991;58(1):27-30.
  • 18. Wong FS, Fearne JM, Brook AH. Planning future general anaesthetic services in paediatric dentistry on the basis of evidence: an analysis of children treated in the Day Stay Centre at the Royal Hospitals NHS Trust, London, between 1985-95. International dental journal. 1997;47(5):285-92.
  • 19. Lee PY, Chou MY, Chen YL, Chen LP, Wang CJ, Huang WH. Comprehensive dental treatment under general anesthesia in healthy and disabled children. Chang Gung medical journal. 2009;32(6):636-42.
  • 20. Alkilzy M, Qadri G, Horn J, Takriti M, Splieth C. Referral patterns and general anesthesia in a specialized paediatric dental service. International journal of paediatric dentistry. 2015;25(3):204-12.
  • 21. Campbell RL, Shetty NS, Shetty KS, Pope HL, Campbell JR. Pediatric Dental Surgery Under General Anesthesia: Uncooperative Children. Anesthesia progress. 2018;65(4):225-30.
  • 22. Ganzberg S. The FDA Warning on Anesthesia Drugs. Anesthesia progress. 2017;64(2):57-8.
  • 23. Baygin O, Tuzuner T, Kusgoz A, Yahyaoglu G, Yilmaz N, Aksoy S. Effects of medical and mental status on treatment modalities in patients treated under general anaesthesia at the KTU Faculty of Dentistry in Trabzon, Turkey: A comparative retrospective study. JPMA The Journal of the Pakistan Medical Association. 2017;67(2):305-7.
  • 24. Ciftci V, Yazicioglu İ. A Retrospective Comparison of Dental Treatment under General Anesthesia Provided for Uncooperative Healthy Patients and Patients with Special Health Care Needs. The Journal of clinical pediatric dentistry. 2020;44(3):196-201.
  • 25. Haubek D, Fuglsang M, Poulsen S, Rølling I. Dental treatment of children referred to general anaesthesia--association with country of origin and medical status. International journal of paediatric dentistry. 2006;16(4):239-46.
  • 26. Guney SE, Araz C, Tirali RE, Cehreli SB. Dental anxiety and oral health related quality of life in children following dental rehabilitation under general anesthesia or intravenous sedation: A prospective cross-sectional study. Nigerian journal of clinical practice. 2018;21(10):1304-10.
  • 27. Ngu KP. Prospective evaluation of dental day case general anaesthetic for children: University of Sydney; 2001.
  • 28. Jamjoom MM, al-Malik MI, Holt RD, el-Nassry A. Dental treatment under general anaesthesia at a hospital in Jeddah, Saudi Arabia. International journal of paediatric dentistry. 2001;11(2):110-6.
  • 29. Vinckier F, Gizani S, Declerck D. Comprehensive dental care for children with rampant caries under general anaesthesia. International journal of paediatric dentistry. 2001;11(1):25-32.
  • 30. Mallineni SK, Yiu CK. Dental treatment under general anesthesia for special-needs patients: analysis of the literature. Journal of investigative and clinical dentistry. 2016;7(4):325-31.
  • 31. Al-Ogayyel S, Al-Haj Ali S. Comparison of dental treatment performed under general anesthesia between healthy children and children with special health care needs in a hospital setting, Saudi Arabia. Journal of clinical and experimental dentistry. 2018;10(10):e963-e9.
  • 32. Kakaounaki E, Tahmassebi JF, Fayle SA. Repeat general anaesthesia, a 6-year follow up. International journal of paediatric dentistry. 2011;21(2):126- 31.
  • 33. Guidry J, Bagher S, Felemban O, Rich A, Loo C. Reasons of repeat dental treatment under general anaesthesia: A retrospective study. European journal of paediatric dentistry. 2017;18(4):313-8.
  • 34. Clinch L. A longitudinal study of the results of premature extraction of deciduous teeth between 3-4 and 13-14 years of age. 1959;9:109-28.
  • 35. Richardson ME. The relationship between the relative amount of space present in the deciduous dental arch and the rate and degree of space closure subsequent to the extraction of a deciduous molar. The Dental practitioner and dental record. 1965;16(3):111-8.
  • 36. Ramakrishnan M, Dhanalakshmi R, Subramanian EMG. Survival rate of different fixed posterior space maintainers used in Paediatric Dentistry - A systematic review. The Saudi dental journal. 2019;31(2):165-72.
  • 37. Rani T RE, Merum K, Srujana M, Raju S, Seth M. General dentists' knowledge, attitude, and practice guidelines toward pediatric dentistry. CHRISMED J Health Res. 2020;7(1):24.
  • 38. Ibricevic H, Al-Jame Q, Honkala S. Pediatric dental procedures under general anesthesia at the Amiri Hospital in Kuwait. The Journal of clinical pediatric dentistry. 2001;25(4):337-42.
  • 39. Davies C, Harrison M, Roberts G. UK national clinical guidelines in paediatric dentistry: guideline for the use of general anaesthesia (GA) in paediatric dentistry. R Coll Surg Engl. 2008.

Retrospective Evaluation of Dental Treatments Under General Anesthesia and Sedation in Pediatric Patients

Year 2022, Volume: 2 Issue: 1, 11 - 19, 29.04.2022

Abstract

Aim: Although dental procedures can usually be performed under local anesthesia, treatment can be performed under
general anesthesia / sedation, especially in young children with adaptation problems, requiring comprehensive
treatment, in children with mental/physical impairment in need of special care, cooperation difficulties, excessively
anxious and fearful patients. In this study, retrospective evaluation of pediatric patients who received dental treatment
under general anesthesia / sedation in Ankara Yıldırım Beyazıt University Faculty of Dentistry Tepebaşı Oral and
Dental Health Education and Research Hospital Department of Pediatric Dentistry and treatment approach of three
dentists with different education levels were investigated.
Method: After receiving the approval of Ankara Yıldırım Beyazıt University Social Sciences and Humanities Ethics
Committee, 300 cases who had dental treatments under general anesthesia/sedation between 01.08.2017 and
01.08.2018 at AYBÜ Faculty of Dentistry Tepebaşı Oral and Dental Health Training and Research Hospital were
included in the study. The patients who are treated by three different dentists, namely, a general dentist (A), a
specialist dentist in pediatric dentistry (B) and a lecturer (C) in the Department of Pediatric Dentistry are in three
groups: 3 years and under, 4-6 years and 7 years and older has been examined. In this retrospective study, the data of
the patients were obtained from the electronic database of the relevant hospital and the epicrisis form. The data
includes the patient's age, gender, medical condition and dental treatments performed. The data obtained were
analyzed through the SPSS 21 package program.
Result: 55% of the patients are male and 45% are female and their average age is 4.99±1.53. The rate of disabled
patients treated is 2.6%. The most preferred treatment is restorative treatment, followed by tooth extraction, root canal
treatment and amputation, respectively. Extraction treatment has been preferred mostly for children aged 7 years and
older.

References

  • 1. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012. NCHS data brief. 2015(191):1-8.
  • 2. Gökalp SG, Doğan BG, Tekçiçek MT, Berberoğlu A, Unlüer S. National survey of oral health status of children and adults in Turkey. Community dental health. 2010;27(1):12-7.
  • 3. Kagihara LE, Niederhauser VP, Stark M. Assessment, management, and prevention of early childhood caries. Journal of the American Academy of Nurse Practitioners. 2009;21(1):1-10.
  • 4. Thitasomakul S, Thearmontree A, Piwat S, Chankanka O, Pithpornchaiyakul W, Teanpaisan R, et al. A longitudinal study of early childhood caries in 9- to 18-month-old Thai infants. Community dentistry and oral epidemiology. 2006;34(6):429-36.
  • 5. Takaoka LA, Goulart AL, Kopelman BI, Weiler RM. Enamel defects in the complete primary dentition of children born at term and preterm. Pediatric dentistry. 2011;33(2):171-6.
  • 6. Policy on early childhood caries (ECC): unique challenges and treatment options. Pediatric dentistry. 2005;27(7):34-5.
  • 7. Ramos-Jorge J, Pordeus IA, Ramos-Jorge ML, Marques LS, Paiva SM. Impact of untreated dental caries on quality of life of preschool children: different stages and activity. Community dentistry and oral epidemiology. 2014;42(4):311-22.
  • 8. Krisdapong S, Somkotra T, Kueakulpipat W. Disparities in early childhood caries and its impact on oral health-related quality of life of preschool children. Asia-Pacific journal of public health. 2014;26(3):285-94.
  • 9. Baghdadi ZD. Effects of dental rehabilitation under general anesthesia on children's oral health-related quality of life using proxy short versions of OHRQoL instruments. TheScientificWorldJournal. 2014;2014:308439.
  • 10. Guideline for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatric dentistry. 2016;38(6):216-45.
  • 11. Coté CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. 2000;105(4 Pt 1):805-14.
  • 12. Atan S, Ashley P, Gilthorpe MS, Scheer B, Mason C, Roberts G. Morbidity following dental treatment of children under intubation general anaesthesia in a day-stay unit. International journal of paediatric dentistry. 2004;14(1):9-16.
  • 13. Chen YP, Hsieh CY, Hsu WT, Wu FY, Shih WY. A 10-year trend of dental treatments under general anesthesia of children in Taipei Veterans General Hospital. Journal of the Chinese Medical Association : JCMA. 2017;80(4):262-8.
  • 14. Cantekin K DS, Aydinbelge M, Canpolat D, Yildirim M, Avci S. . Analysis of comprehensive dental rehabilitation under general anesthesia at a dental hospital in Turkey. Pediatr Dent. 2014;2(2):49-55.
  • 15. Tsai CL, Tsai YL, Lin YT, Lin YT. A retrospective study of dental treatment under general anesthesia of children with or without a chronic illness and/or a disability. Chang Gung medical journal. 2006;29(4):412-8.
  • 16. O'Sullivan EA, Curzon ME. The efficacy of comprehensive dental care for children under general anesthesia. British dental journal. 1991;171(2):56-8.
  • 17. Vermeulen M, Vinckier F, Vandenbroucke J. Dental general anesthesia: clinical characteristics of 933 patients. ASDC journal of dentistry for children. 1991;58(1):27-30.
  • 18. Wong FS, Fearne JM, Brook AH. Planning future general anaesthetic services in paediatric dentistry on the basis of evidence: an analysis of children treated in the Day Stay Centre at the Royal Hospitals NHS Trust, London, between 1985-95. International dental journal. 1997;47(5):285-92.
  • 19. Lee PY, Chou MY, Chen YL, Chen LP, Wang CJ, Huang WH. Comprehensive dental treatment under general anesthesia in healthy and disabled children. Chang Gung medical journal. 2009;32(6):636-42.
  • 20. Alkilzy M, Qadri G, Horn J, Takriti M, Splieth C. Referral patterns and general anesthesia in a specialized paediatric dental service. International journal of paediatric dentistry. 2015;25(3):204-12.
  • 21. Campbell RL, Shetty NS, Shetty KS, Pope HL, Campbell JR. Pediatric Dental Surgery Under General Anesthesia: Uncooperative Children. Anesthesia progress. 2018;65(4):225-30.
  • 22. Ganzberg S. The FDA Warning on Anesthesia Drugs. Anesthesia progress. 2017;64(2):57-8.
  • 23. Baygin O, Tuzuner T, Kusgoz A, Yahyaoglu G, Yilmaz N, Aksoy S. Effects of medical and mental status on treatment modalities in patients treated under general anaesthesia at the KTU Faculty of Dentistry in Trabzon, Turkey: A comparative retrospective study. JPMA The Journal of the Pakistan Medical Association. 2017;67(2):305-7.
  • 24. Ciftci V, Yazicioglu İ. A Retrospective Comparison of Dental Treatment under General Anesthesia Provided for Uncooperative Healthy Patients and Patients with Special Health Care Needs. The Journal of clinical pediatric dentistry. 2020;44(3):196-201.
  • 25. Haubek D, Fuglsang M, Poulsen S, Rølling I. Dental treatment of children referred to general anaesthesia--association with country of origin and medical status. International journal of paediatric dentistry. 2006;16(4):239-46.
  • 26. Guney SE, Araz C, Tirali RE, Cehreli SB. Dental anxiety and oral health related quality of life in children following dental rehabilitation under general anesthesia or intravenous sedation: A prospective cross-sectional study. Nigerian journal of clinical practice. 2018;21(10):1304-10.
  • 27. Ngu KP. Prospective evaluation of dental day case general anaesthetic for children: University of Sydney; 2001.
  • 28. Jamjoom MM, al-Malik MI, Holt RD, el-Nassry A. Dental treatment under general anaesthesia at a hospital in Jeddah, Saudi Arabia. International journal of paediatric dentistry. 2001;11(2):110-6.
  • 29. Vinckier F, Gizani S, Declerck D. Comprehensive dental care for children with rampant caries under general anaesthesia. International journal of paediatric dentistry. 2001;11(1):25-32.
  • 30. Mallineni SK, Yiu CK. Dental treatment under general anesthesia for special-needs patients: analysis of the literature. Journal of investigative and clinical dentistry. 2016;7(4):325-31.
  • 31. Al-Ogayyel S, Al-Haj Ali S. Comparison of dental treatment performed under general anesthesia between healthy children and children with special health care needs in a hospital setting, Saudi Arabia. Journal of clinical and experimental dentistry. 2018;10(10):e963-e9.
  • 32. Kakaounaki E, Tahmassebi JF, Fayle SA. Repeat general anaesthesia, a 6-year follow up. International journal of paediatric dentistry. 2011;21(2):126- 31.
  • 33. Guidry J, Bagher S, Felemban O, Rich A, Loo C. Reasons of repeat dental treatment under general anaesthesia: A retrospective study. European journal of paediatric dentistry. 2017;18(4):313-8.
  • 34. Clinch L. A longitudinal study of the results of premature extraction of deciduous teeth between 3-4 and 13-14 years of age. 1959;9:109-28.
  • 35. Richardson ME. The relationship between the relative amount of space present in the deciduous dental arch and the rate and degree of space closure subsequent to the extraction of a deciduous molar. The Dental practitioner and dental record. 1965;16(3):111-8.
  • 36. Ramakrishnan M, Dhanalakshmi R, Subramanian EMG. Survival rate of different fixed posterior space maintainers used in Paediatric Dentistry - A systematic review. The Saudi dental journal. 2019;31(2):165-72.
  • 37. Rani T RE, Merum K, Srujana M, Raju S, Seth M. General dentists' knowledge, attitude, and practice guidelines toward pediatric dentistry. CHRISMED J Health Res. 2020;7(1):24.
  • 38. Ibricevic H, Al-Jame Q, Honkala S. Pediatric dental procedures under general anesthesia at the Amiri Hospital in Kuwait. The Journal of clinical pediatric dentistry. 2001;25(4):337-42.
  • 39. Davies C, Harrison M, Roberts G. UK national clinical guidelines in paediatric dentistry: guideline for the use of general anaesthesia (GA) in paediatric dentistry. R Coll Surg Engl. 2008.
There are 39 citations in total.

Details

Primary Language Turkish
Subjects Dentistry
Journal Section Research Articles
Authors

Muhammed Demir This is me

Fatih Tulumbacı This is me

Publication Date April 29, 2022
Published in Issue Year 2022 Volume: 2 Issue: 1

Cite

APA Demir, M., & Tulumbacı, F. (2022). Çocuk Hastaların Genel Anestezi ve Sedasyon Altında Yapılan Dental Tedavilerinin Retrospektif Olarak Değerlendirilmesi. HRU International Journal of Dentistry and Oral Research, 2(1), 11-19.
AMA Demir M, Tulumbacı F. Çocuk Hastaların Genel Anestezi ve Sedasyon Altında Yapılan Dental Tedavilerinin Retrospektif Olarak Değerlendirilmesi. HRU Int J Dent Oral Res. April 2022;2(1):11-19.
Chicago Demir, Muhammed, and Fatih Tulumbacı. “Çocuk Hastaların Genel Anestezi Ve Sedasyon Altında Yapılan Dental Tedavilerinin Retrospektif Olarak Değerlendirilmesi”. HRU International Journal of Dentistry and Oral Research 2, no. 1 (April 2022): 11-19.
EndNote Demir M, Tulumbacı F (April 1, 2022) Çocuk Hastaların Genel Anestezi ve Sedasyon Altında Yapılan Dental Tedavilerinin Retrospektif Olarak Değerlendirilmesi. HRU International Journal of Dentistry and Oral Research 2 1 11–19.
IEEE M. Demir and F. Tulumbacı, “Çocuk Hastaların Genel Anestezi ve Sedasyon Altında Yapılan Dental Tedavilerinin Retrospektif Olarak Değerlendirilmesi”, HRU Int J Dent Oral Res, vol. 2, no. 1, pp. 11–19, 2022.
ISNAD Demir, Muhammed - Tulumbacı, Fatih. “Çocuk Hastaların Genel Anestezi Ve Sedasyon Altında Yapılan Dental Tedavilerinin Retrospektif Olarak Değerlendirilmesi”. HRU International Journal of Dentistry and Oral Research 2/1 (April 2022), 11-19.
JAMA Demir M, Tulumbacı F. Çocuk Hastaların Genel Anestezi ve Sedasyon Altında Yapılan Dental Tedavilerinin Retrospektif Olarak Değerlendirilmesi. HRU Int J Dent Oral Res. 2022;2:11–19.
MLA Demir, Muhammed and Fatih Tulumbacı. “Çocuk Hastaların Genel Anestezi Ve Sedasyon Altında Yapılan Dental Tedavilerinin Retrospektif Olarak Değerlendirilmesi”. HRU International Journal of Dentistry and Oral Research, vol. 2, no. 1, 2022, pp. 11-19.
Vancouver Demir M, Tulumbacı F. Çocuk Hastaların Genel Anestezi ve Sedasyon Altında Yapılan Dental Tedavilerinin Retrospektif Olarak Değerlendirilmesi. HRU Int J Dent Oral Res. 2022;2(1):11-9.