Caries Experience and Gingivitis Levels of Permanent First Molars in Relation to Timing of Emergence Roos Leroy1, Luc C. Martens2, Jacques Vanobbergen3, Kris Bogaerts4, Dominique Declerck5 1 Ph.D., D.D.S. School of Dentistry, Oral Pathology and Maxillofacial Surgery, Catholic University Leuven, Leuven, Belgium. 2 Ph.D., D.D.S. Professor and Chair of Department, Paediatric Dentistry and Special Care, PaeCaMedresearch, Gent University, Gent, Belgium. 3 Ph.D., D.D.S. Professor Community Dentistry and Oral Public Health, Gent University, Gent, Belgium. 4 Ph.D. I-Biostat, Catholic University Leuven, Leuven and University Hasselt, Hasselt, Belgium. 5 Ph.D., D.D.S. Professor, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery, Catholic University Leuven, Leuven, Belgium. Abstract Aims: The present study examined the prevalence of dental caries in and gingivitis around permanent first molars (PFM) in relation to their timing of emergence. Methods: In a group of 1609 “early emergers” (all PFM present at baseline) and a group of 336 “late emergers” (no PFM present at baseline), caries experience, the presence of plaque, and gingival health were evaluated annually during five follow-up examinations. Results: Even though all children were born in the same year, mean DMFS scores for PFM remained higher in the early emergers throughout the study; mean buccal plaque and gingivitis scores were comparable in both subgroups. Early emergers had a significantly increased risk of caries experience in the occlusal surface of the PFM for two to four years. No consistent association was observed between timing of emergence and gingivitis levels. Conclusions: It is recommended that dental age as well as chronological age should be taken into account when caries prevalence data in young children are compared. Key Words: Tooth Emergence, Dental Caries, Gingivitis, Permanent First Molars
Introduction
authors ascribed this finding to the fact that the teeth of the Inuit emerge in the oral cavity earlier: emergence at younger age results in a longer exposure time at the moment of assessment and consequent higher caries experience scores [6]. Other researchers observed no evidence for a possible impact of early or late emergence on caries development at a young age [7,8]. Several epidemiological studies indicated that the prevalence and severity of gingivitis in children increased with age, beginning in the deciduous dentition and reaching a peak at puberty [9]. Research on the impact of tooth emergence on gingivitis levels is scarce. Hugoson et al. (1981) [9] observed a higher prevalence of gingivitis in regions with erupting teeth.
Several studies have indicated that the majority of caries experience in the permanent dentition of children is attributed to the permanent first molars, more specifically the occlusal surfaces [1,2]. Structural irregularities hamper efficient plaque removal in these sites, promote microbial colonisation, and interfere with salivary protection. Clinical experience and scientific research show a high incidence of caries lesions in permanent first molars during and shortly after the eruption process [3]. Earlier studies suggested that caries susceptibility of erupting teeth is related to pre- and post-eruptive maturation of enamel [4]. Carvalho et al. (1989) [5] pointed out that permanent first molars are more likely to develop dental caries during the eruption process, due to favourable conditions for plaque accumulation. Reports on the oral health of a Canadian Inuit community revealed a higher susceptibility for caries development in these children compared to age-matched southern Canadian children. The
Aims The present study examined the occurrence of dental caries in and the presence of gingivitis around permanent first molars in relation to their timing of emergence.
Corresponding author: Roos Leroy, Catholic University Leuven, School of Dentistry, Oral Pathology and Maxillofacial Surgery, Kapucijnenvoer 7 blok a bus 7001, B-3000 Leuven, Belgium; e-mail:
[email protected] 33
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Methods
plaque on the occlusal surfaces of first permanent molars was assessed using a simplified version of the index described by Carvalho et al. (1989) [5]: Code 0: No visible plaque (Carvalho et al., 1989: Code 0). Code 1: Detectable plaque restricted to fossae and grooves (Carvalho et al., 1989: Codes 1 and 2). Code 2: Surface partially or totally covered with heavy plaque accumulation (Carvalho et al., 1989: Code 3). The Sulcus Bleeding Index (SBI) described by Mühlemann and Son (1971) [13] was used to assess the level of gingivitis. As oral hygiene and gingival health were scored at maxillary right permanent first molars (tooth 16) and mandibular left permanent first molars (tooth 36), this manuscript focuses on the results obtained for these two teeth. Data on oral hygiene habits and dietary habits were obtained in every survey year through structured questionnaires, completed by the parents. For the present analyses only data obtained at baseline were used. A more elaborate description of the study sample and the applied methodology of the project has been published elsewhere [14]. Clinical and questionnaire data were entered directly in a database using the Dental Survey Plus® Programme, version 4.50 b (Providence Software, Cary, NC, U.S.A.) and converted into SAS® files for statistical analyses. The Fédération Dentaire Internationale (FDI) nomenclature was used to designate the teeth. Baseline characteristics (Table 1) of the two subgroups were evaluated using chi-square tests (categorical variables) and t-tests (continuous variables). Although the distribution of the responses was skewed, parametric t-tests were performed because the sample sizes were large (central limit theorem); results were verified with non-parametric Wilcoxon tests. For a more convenient presentation of results, it was opted to present the results of the parametric tests (i.e. means, SEM and 95% confidence intervals). Analysis of characteristics at follow-up was performed separately for boys and girls, to avoid confounding by gender. Because baseline mean age, mean dmfs score and reported brushing frequency differed significantly between the two subgroups, a possible confounding effect was tested. Only brushing frequency turned out to have a significant effect on some of the dependent variables. For consistency reasons, all statistical analyses were corrected for brushing frequency.
Data were obtained in the Signal-Tandmobiel® project, a prospective (1996-2001) oral health screening project in Flanders, Belgium. In this project, 2315 boys and 2153 girls were randomly selected through cluster (i.e. school) sampling, stratified by province and educational system. They represented 7% of Flemish children born in 1989; at the first examination the mean age of the children was 7.1 years (SD=0.4). Ethical approval was obtained at the Medical Ethics Committee from the Catholic University Leuven, Belgium. For this study, analyses were based on data obtained in two extreme subgroups. One subgroup consisted of 336 children (=113 girls and 223 boys; i.e. 7.5% of the original sample) who had no permanent first molars present at the baseline examination; they will be referred to as “late emergers”. A second subgroup consisted of 1609 children (=872 girls and 737 boys; i.e. 36% of the original sample) who had all four permanent first molars present at the first examination, representing the subgroup “early emergers”. A tooth was recorded as emerged when at least one cusp was visible. Each survey year, the children were examined by a trained dentist-examiner in a mobile dental clinic on school premises. The birth date of the child, obtained through school records, and the examination date were recorded. Teeth were examined using a World Health Organization/ Community Periodontal Index of Treatment Needs (WHO/CPITN) type E probe. Caries was recorded at the level of cavitation and scored according to the guidelines published by the British Association for the Study of Community Dentistry (BASCD) [10]. The examination methods and examiners were calibrated on a yearly basis. The obtained level of agreement for scoring caries between the 16 examiners and the benchmark examiner was good to excellent (ranged between 0.72-0.91) [11]. Because the examinations were not carried out in connection with routine check-ups or dental treatment appointments, no radiographs were available. The restorative index was defined as the ratio of the number of filled teeth (f) to the number of decayed (d) and filled teeth (f/d+f). Plaque accumulation and gingival health status were assessed on the buccal surfaces of Ramfjord teeth—16(55), 21(61), 24(64), 36(75), 41(81), 44(84); if present, permanent teeth were preferred. The presence of plaque on the buccal surfaces of reference teeth was scored using the Index of Silness and Löe (1964) [12]. The presence of 34
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Table 1. Sample Characteristics at Baseline Examination Variables Demographic characteristics Gender Number of girls (%) Number of boys (%) Mean age (95% CI) Dental variables Mean number of primary teeth present (95% CI) Mean number of permanent teeth present (95% CI) Caries experience Mean dmfs (95% CI) Mean restorative index-deciduous teeth (95% CI) Dietary habits Mean number of between-meals snacks (95% CI) % children taking sweets to school daily % children taking biscuits to school daily Oral hygiene habits Mean age at start brushing in yrs (95% CI) Frequency of brushing (%) less than daily daily more than once a day % children never receiving help with brushing
Late emergers
Early emergers
P-value
113 (34) 223 (66) 6.76 (6.72-6.79)
872 (54) 737 (46) 7.18 (7.16-7.20)
18.7 (18.5-18.9) 1.0 (0.9-1.1)
13.8 (13.7-13.9) 9.2 (9.1-9.3)
