THE ODONTAL STATUS AND CARIOUS AFFECTION LEVEL OF THE FIRST PERMANENT MOLAR IN YEAR-OLD ADOLESCENTS A CLINICAL STUDY

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1 Oral Biology THE ODONTAL STATUS AND CARIOUS AFFECTION LEVEL OF THE FIRST PERMANENT MOLAR IN 6-20 YEAR-OLD ADOLESCENTS A CLINICAL STUDY Mariana Ilie¹, Galina Pancu², {.L\c\tu[u³. PhD Student, Dept of Odontology, Faculty of Med. Dent., Gr.T.Popa U.M.Ph Iasi 2. Assist Prof., PhD., Dept of Odontology, Faculty of Med. Dent., Gr.T.Popa U.M.Ph Iasi 3. Prof., PhD. Dept of Odontology, Faculty of Med. Dent., Gr.T.Popa U.M.Ph Iasi Corresponding auhor:ilie Mariana; caragiale.ilie@gmail.com Abstract Introduction. In adolescents and young people, the first permanent molar has the longest functioning period, comparatively with the other permanent teeth from the molar-premolar region, the actual epidemiological studies evidencing their highest vulnerability to fissural or proximal caries. In the absence of well-established strategies aimed at maintaining these molars on their arches, their precocious extraction is ussually performed, which induces severe occlusal-articulary disequilibria, alteration of the temporo-mandibulary articulation and favorization of various periodontal diseases. Materials and method. The objective of the present study was to evaluate the odontal status and the level of carious affection and, by the complications thus induced, of the extent of affection of the first permanent molar in young people with ages between 6-20, as based on the clinical diagnosis criteria of the dental caries, alongwith the evaluation of its activity according to Nyvad indices. Results. The obtained results show that application of such an evaluation method assures a more complete and correct analysis of the affection extent of the odontal status of the first permanent molar, alongwith tracing even the incipient lesions and consequently their non-invasive subsequent treatment. Conclusions. A precocious caries diagnosis and, implicitly, a correct evaluation of its activity, represent essential steps for a correct establishment of the main either invasive or non-invasive - treatment requirements, through remineralization, as part of the carious disease managment, which is perfectly valid for the first permanent molar, as well. Keywords: first permanent molar, evaluation, diagnosis, caries INTRODUCTION The extent of affection, through caries, of the first molars, occurring during the mixed dentition period has been demonstrated, in epidemiological studies, (, 2) in ratios exceeding 87% in patients with high cariogenous risk. The presence of either non-cavitary or cavitary caries at the level of the first permanent molars is indica- 40 volume 5 issue 2 April / June 20 tive of the carious activity of each subject in part. Despite the decline registered in countries in which efficient preventive and treatment measures are currently applied in the manifestation of the carious disease, it was observed that 90% of the existing caries are localized in ditches and fossae?,the most affected among the permanent teeth being the first molars (3, 4). That is why, the carious processes occurring at these molars are, in most clinical situations, acute, with a rapid evolution, causing, within quite short time intervals, destruction of the masticatory surfaces and of the contact points, thus favorizing severe local, local-regional or general complications (5-0). In the absence of precise strategies aimed at preserving the molars on the arches, precociuos extractions are performed and serious occlusoarticulary disequilibria () occur, affecting the temporo-mandibulary joint and favorizing manifestation of various periodontal diseases (2, 3). Most of the national epidemiological studies controlling theprevalence of caries include exclusively the carious lesions with visible cavitation (4). In 999, Nyvad B. et al. proposed new clinical criteria for caries diagnosis, including both cavitary and non-cavitary caries, on considering, too, the activity of the carious lesions. Not always the incipient caries of the enamel develop cavitation, as they may be subjected to a remineralization therapy (5) through which their evolution is stopped. The modern diagnosis of the carious disease, including the activity degree of the caries and the incipient evolution stages is very important, becoming essential in planning, monitoring and appreciating the effipp 40-48

2 THE ODONTAL STATUS AND CARIOUS AFFECTION LEVEL OF THE FIRST PERMANENT MOLAR IN 6-20 YEAR-OLD ADOLESCENTS - A CLINICAL STUDY ciency of the applied prophylactic and therapeutical measures (6,7). THE AIM OF THE STUDY The study evaluates the odontal status, the level of carious affection and its complications in the first permanent molar in young people, with ages between 6-20, who came to a medical dentistry surgery in Galaþi between , on the basis of clinical criteria for the diagnosis of the dental caries, for estimating the extent of its activity. MATERIALS AND METHOD The experimental group included 96 youths, boys and girls, with ages between 6-20, selected from the persons having come to the private medical surgery, st year students of the University of Galaþi, to whom a free-of-charge examination was offered. The criteria for their inclusion in the experimental group were the following: a large range of diagnosed odontal pathologies, among which affection, through caries, or even premature loss, following some post-carious complications of the first permanent molars; age between 6 and 20 ; informed consent was obtained from the patients. The exclusion criteria referred to non-cooperant patients, with ages under 6 and over 20. The investigations observed the legislation in force in Romania and the deontological norms, namely Law 46/January 2, 2003, establishing the rights of the patient, following his consent for scientific experiments. Also, the privacy of the personal records was granted. The purpose and stage of development of the study was explained, after which informed consent was signed by the patients. The experimental group (n = 96) included: 46 boys and 50 girls with ages between 6-20 ; 57 persons came from the urban area, and 39 from the rural one. Clinical examination was performed in the desntistry surgery, under optimum confort conditions, and adequate light, by means of the classical medical kit (probe, clip and mirror), special attention being paid to the morphology and to the affected dental structures. The evaluation included:. calculation of the bacterial plaque index, OHI-S, 2. settlement of the carious affection level and of its complications in the first permanent molar was evaluated by a clinical method of dental caries diagnosis, applied according to the Nyvad B indices. The activity of the carious lesions was evaluated on all surfaces (vestibular, oral, mezial, distal, occlusal) of the examined teeth, their translucence, colour and texture being assessed, as well as the integrity and structure of the investigated surfaces (intact surfaces, loss of integrity in the enamel defect, presence of a cavity in dentine) (Tab.). Diagnosis criteria according to Nyvad indices Evaluation of the oral hygiene status involved calculation of the index of bacterial plaque, OHI-S. RESULTS The obtained data, recorded in the observation sheet, were statistically processed and analyzed with the SPSS 7 and EXCEL 2007 programs. The results thus obtained were employed for the development and optimization of future investigations devoted to the prophylactic and therapeutical aspects of the pathology of the carious disease and of some premature losses of the first permanent molars.. Distribution of cases as a function of the medium from which they come evidences their predominance in the urban area (75%) (Fig. ). Fig.. Distribution of cases according to medium (rural, urban) International Journal of Medical Dentistry 4

3 Mariana Ilie, Galina Pancu, {.L\c\tu[u Table Code Category Interpretation of codes D0 Healthy tooth D Active non-cavitary caries (unaffected surface integrity) D2 Active caries with defect (loss of integrity) in the enamel. Active cavitary caries Translucence, color and surface texture within normal limits (some coloration of the ditches and of the non-carious fossae is accepted) Enamel surface with white-chalky aspect or shades of yellow, loss of translucence. Usually, the surface is covered by plaque. Clinically, no loss of hard dental tissues occurs On the smooth surfaces, the carious lesion is localized typically, along the gingival margin. At the level of ditches and fossae, no integrity modification of the zone is observed, the white chalky stain being localized along the fissural walls. Same criteria as for code. Localization of surface defect (microcavity) affects only the enamel. No signs of dentinary affection (enamel prisms destroyed or not supported by dentine) traceable on probe palpation. Carious cavity with affected enamel and dentine, obviously identified through inspection. During mild probe palpation, dentine exposure and the presence of dentine soaked at the bottom of the cavity and on its walls. Pulpar affection is possible. Colour modification of white-, brown- or black-spot type may occur on the surface. The enamel preserves its translucence, remaining tough and smooth during careful probe palpation. Clinically, no losses of substance may be observed. On the smooth surfaces, the carious lesion is typically localized, slightly above the gingival margin. At the level of ditches and fossae, the integrity of the zone is not affected, the white chlaky spot being localized along the fissural walls. Same criteria as for code 4, to which one should associate some loss of surface integrity (microcavity) localized strictly at enamel level. Carious cavity, visible altertaion of both enamel and dentine. Probe palpation reveals the presence of some hard tissues at the bottom and on the walls of the cavity, while translucence is not affected. No signs of pulpar affection. No signs of affection by carious processes. Same criteria as for code 0. D3 D4 Inactive caries (intact surface). D5 Inactive caries (defect at enamel level). Inactive cavitary caries D6 D7 D8 D9 D0 Obturation (healthy surface) Obturation + active caries Active carious process, either cavitary or non-cavitary. Obturation+inactive Inactive carious process, either cavitary or non-cavitary. caries Tooth extracted from cariogeneous reasons 2. Distribution of patients as a function of sex reveals a slight predominance in girls versus boys (Fig. 2). 3. Distribution of patients as a function of age (Fig. 3). Fig. 2. Distribution of cases as a function of sex 42 Fig. 3. Distribution of cases as a function of age volume 5 issue 2 April / June 20 pp 40-48

4 THE ODONTAL STATUS AND CARIOUS AFFECTION LEVEL OF THE FIRST PERMANENT MOLAR IN 6-20 YEAR-OLD ADOLESCENTS - A CLINICAL STUDY Codes distrubution on surfaces 3 teeth (565 surfaces) (29.427%) - received code D0 healthy surface 89 teeth ( 445 surfaces) (23.77%) - received code D 0 (post-caries extracted). 82 teeth (90 surfaces) (47.395%) - received codes from D to D9 active non-cavitary caries D- 06 surfaces (5.520%) active cavitary caries in the enamel D2-25 surfaces (6.50%) active cavitary caries in dentine D3-2 surfaces (0.989%) inactive non-cavitary caries D4-82 surfaces (4.270%) Inactive cavitary caries in the enamel D5-24 surfaces (.25%) inactive cavitary caries in dentine D6-8 surfaces (0.46%) obturation (healthy surface) D7-94 surfaces (4.895%) obturation (with an associated active caries) D8-82 surfaces (9.479%) obturation (with an associated active caries) D9-78 surfaces (4.062%). Table 2 Teeth Surface % of D D D-D D D D D D D D D D9 TOTAL= % D0- D0 Analysis of results according to the index of oral hygiene, OHI-S, gives an average value of 2.86±0.46, corresponding to an unsatisfactory oral hygiene. A total number of 96 patients was examined, respectively 384 teeth (first permanent molars), 920 surfaces (O occlusal side, M mezial side, D distal side, Or. oral side), to which codes varying from K0 to K0 had been assigned, the following observations being made (Table 2): Only 3 teeth (565 surfaces) (29.4%) received code D0 healthy surface. 89 teeth ( 445 surfaces) (23.%) received code D 0 (post-caries extracted). 82 teeth (90 surfaces) (47.4%) received codes from D tod9, being affected by (Fig. 4): International Journal of Medical Dentistry 43

5 Mariana Ilie, Galina Pancu, {.L\c\tu[u o active non-cavitary caries D,- 06 surfaces (5.5%) o active cavitary caries in the enamel D2, 25 surfaces (6.5%) o active cavitary caries in dentine D3, 2 surfaces (0.9%) o inactive non-cavitary caries D4, 82 surfaces (4.27%) o inactive cavitary in the enamel D5, 24 surfaces (.25%) o inactive cavitary in dentine D6 8 surfaces (0.4%) or by its consequences (restorations with or without the presence of some active or inactive associated caries): o obturation (healthy surface) D7, 94 surfaces (4.89%) o obturation (with an active caries associated) D8, 82 surfaces (9.47%) o obturation (with an inactive caries associated) D9 78 surfaces (4.06%). Fig. 4. Percent distribution of codes on the 920 surfaces if considering localization, there prevailed the extractions (D0) at inferior molars (teeth 3.6, 4.6) (2.4%), comparatively with the superior ones (.6, 2.6) (0.93%). The most affected by caries, too, (D-D6) were the inferior molars (teeth 3.6, 4.6) (4.96%), comparatively with the superior ones (.6, 2.6) (4.27%). Deep caries with pulpar affection D3 (.6, 2.6) comparatively with the inferior teeth (3.6, 2.6) (Tab. 3, Fig. 5.); Table 3 /6 2/6 3/6 4/6 D Fig. 5. Distribution of code D3 versus localization: upper teeth.6, 2.6.or lower teeth 3.6, 4.6. Comparatively, the ratio of active cavitary caries is of 6.92% for the upper molars, versus 4.06% in the case of lower molars. D7 obturations at the upper teeth (.6, 2.6) comparatively with the lower teeth (3.6, 2.6) (Tab. 4., Fig. 6.) Table 4 /6 2/6 3/6 4/6 D Fig. 6. Distribution of code D7 versus localization: upper teeth.6, 2.6 or lower teeth 3.6, 4.6. A comparison among the incipient noncavitary enamel caries D and the cavitary ones in enamel and dentine D2, D3 leads to the following observations (Tab. 5): 44 volume 5 issue 2 April / June 20 pp 40-48

6 THE ODONTAL STATUS AND CARIOUS AFFECTION LEVEL OF THE FIRST PERMANENT MOLAR IN 6-20 YEAR-OLD ADOLESCENTS - A CLINICAL STUDY Table 5. Extent of disease through D,D 2, D 3, D4, D5, D6 Extent of disease through D 4, D 5, D 6 (Tab. 7, Fig. 8): Table 7. Extent of affection through D 4, D 5, D 6 /6 2/6 3/6 4/6 D 30(.56%) 76(3.96%) D2 54(2.8%) 7(3.7%) inactive noncavitary caries D4-82 surfaces (4.270%) D3 33(6.92) 78(4.06) inactive cavitary caries in the enamel D5 24 surfaces (.25%) D4 47 (2.44) 35 (.82) D5 6 (0.3) 8 (0.94) D6 4 (0.208) 4 (0.208) D of.56% on the upper molars and of 3.96%, respectively, on the lower ones. The ratio is maintained for D2, as well, 2.8% for the upper molars and 3.7%, respectively, for the lower ones. As to D3, a ratio of 6.92 is found for the upper molars, and of 4.06%, respectively, for the inferior ones. On the whole, the following distribution was obtained as to: The extent of disease through D,D 2, D 3 (Tab. 6, Fig. 7): Table 6. Extent of disease through D,D 2, D 3. active non-cavitary caries D 06 surfaces (5.520%) active cavitary caries in the enamel D2 25 surfaces (6.50%) active cavitary caries in dentine D3 2 surfaces (0.989%) inactive cavitary caries in dentine D6 8 surfaces (0.46%) Fig.8. Percent distribution of the codes of lesions D4D6 As to the distribution of the D3 lesions situated on the O (occlusal) sides, comparatively with sides M, D (mezial, distal) and D7 situated on the O (occlusal) sides, comparatively with sides M, D (mezial, distal), the following distribution was obtained (Tab. 8., Fig. 9, 0): Table 8. Distribution of lesions D D3 O D3 M D3 D D7 O D7 M D7 D 3 Fig. 7. Percent distribution of the codes of lesions D, D 2, D 3. International Journal of Medical Dentistry 45

7 Mariana Ilie, Galina Pancu, {.L\c\tu[u Fig. 9. Percent distribution of the codes of the cavitary caries D3 versus localization on the quadrants, upper.6, 2.6 and lower molars 3.6, 4.6 (occlusal, mezial, distal sides) Fig.0. Percent distribution of the codes of the cavitary caries D7 versus localization on the quadrants, upper.6, 2.6 and lower molars 3.6, 4.6 (occlusal,mezial,distal sides). DISCUSSION Some recent studies established a series of criteria (8) for assessing the extent of activity of the carious lesions, on the basis of their aspect (if the surface is smooth, glossy, tough the lesion is inactive/its evolution is stopped); if the surface is chalky and/or rugous, the lesion is active. Such criteria were adopted for reflecting theclinical observation, the fact that the noncavitary carious lesions ado not always develop into a cavity but, in most cases, their evolution is stopped or they get remineralized, as shown by longitudinal studies (9). An early diagnosis of caries and, implicitly, assessment of its activity, are essential for a correct selection of the treatment, (20) either invasive or non-invasive, through remineralization, for the managment of the carious disease (2, 22.), which are characteristics wholly valid for the first permanent molar, as well. Application of the method of lesion evaluation according to the Nyvad indices permitted a more complete and correct analysis of the extent of odontal disease of the first permanent molar, tracing even the incipient lesions, which could be subsequently treated in a non-invasive manner. Consequently: As to the affection level D0 (teeth with healthy surfaces), it registered a higher value in women, comparatively with men; For all levels of caries affection, from D to D3, the number of cavitary lesions in the enamel and dentine was higher in women than in men; The present study discusses the diseases caused by premature loss (extraction) of the first permanent molars (code D0) in 23.% of cases, more involved being the lower molars, comparatively with the upper ones. The number of complicated caries is two times higher in the lower molars, comparatively with the upper ones; The active caries cover 2.9% of the surfaces, while the inactive ones - only 5.93%; The obturations associated with the healthy surfaces represent 4.89%, the obturations with active associated caries % and the obturations with inactive associated caries %. As to localization, the extractions (D0) of the inferior molars (teeth 3.6, 4.6) (2.4%) were more numerous than those of the superior teeth (.6, 2.6) (0.93%). Also, most affected by caries (D-D6) were the inferior molars (teeth 3.6, 4.6) (4.96%), comparatively with the superior ones (.6, 2.6) (4.27%). Deep caries with pulpar involvement D3 (.6, 2.6), comparatively with the inferior teeth (3.6, 2.6); The authors of a study, performed in 2009 on a group of children from Cluj-Napoca, with ages between 9 and 2, evaluated the odontal 46 volume 5 issue 2 April / June 20 pp 40-48

8 THE ODONTAL STATUS AND CARIOUS AFFECTION LEVEL OF THE FIRST PERMANENT MOLAR IN 6-20 YEAR-OLD ADOLESCENTS - A CLINICAL STUDY status of the 6 year-old molar and the frequency of the dento-maxillary anomalies in the second phase of mixed dentition, on using index COE (9). In this way, the following results were obtained for the first permanent molar: at 9 (C=43%, O= 6%, A=0%), and at 2 (C=24.3%, O=46.3%, A=5.8%). The present study shows an even higher affection level in 6-8 year-old children, the more so that, according to Nyvad, it also permits evaluation of some incipient carious lesions (D, D 4) and of caries adjacent to restorations (D8, D9) which cannot be included in the evaluation with indices COE. Such elements may be subsequently employed in a more correct, more complete and less invasive therapeutical plan, which will assure a longer life of the molar on the arch. A similar study, performed in Belorussia according to the Nyvad criteria, showed that, in the 7-0 year group of age, when evaluation was made with code D, the carious disease was of 92% while, if analysis was performed with code D3, the extent of disease was much lower - of 49% (23). Application of the new evaluation criteria for carious affection permits its diagnosis as early as its incipient forms, as based on the real situation, thus permitting some prophylactic-therapeutical measures that consider the extent of activity of the carious process, as well. CONCLUSIONS The extent of carious disease and its complications in the first permanent molar is quite significant in the 6-20 group of age. The period as such is an especially critical and difficult one, covering the end of puberty (4-6 ) and the beginning of adolescence (6-20), characterized by a series of both physical (hormonal) and, mainly, psycho-social modifications, by the formation and development of characters, depending on a multitude of factors, all contributing to the formation of the young one s personality. All these changes also influence the parameters characterizing the health condition of the first permanent molar which, at this age, is the oldest tooth, being present on the arch from the age of 6, so that it is the most exposed one to all cariogeneous factors that may be involved in such a process. Considering the importance of the first permanent molar in the development of dentition, special stress should be laid on preventive education, so that the patients should come to the dentist s even prior to the installation of a caries, in a moment in which adequate prevention measures may be taken, together with the application of some modern methods and means for lesion diagnosis in its incipient stages, thus stopping the cavitary process, without any invasive and expensive treatments. References. LEROY R., CECERE S. LESAFFRE E., DECLERCK D. - Caries experience in primary molars and its impact on the variability in permanent tooth emergence sequences. J Dent Nov; 37 (ll): Epub 2009 Jul 7; 2. RIPA, L.W.; LESKE, G.S.; and VARMA, A.O. (988): Longitudinal Study of the Caries Susceptibility of Occlusal and Proximal Surfaces of First Permanent Molars, J Public HIth Dent 48: KONDEVA V., KUKLEVA M. PETROVA S, STOIKOVA M. - Occlusal caries of permanent molars of children - role of occlusal morphology. Stomatologiia (Mosk). 2008;87(6):56-62; 4. KONDEVA V.K., KUKLEVA M.T., PETROVA SG. MILEVA SP. - Dynamics of occlusal caries in permanent molars and premolars in children aged 7 to 4. Folia Med (Plovdiv) Jul-Sep; 50 (3): CHENG RB, TAO W, ZHANG Y, CHENG M, LI Y. - Analysis of the first permanent molar caries epidemiological investigation in area of northeast China. Hua Xi Kou Qiang Yi Xue Za Zhi Feb; 26 (l):73-6; 6. EKSTRAND KR., RICKETTS DN., KIDD EA., QVIST V., SCHOU S. - Detection, diagnosing, monitoring and logical treatment of occlusal caries in relation to lesion activity and severity: an in vivo examination with histological validation. Caries Res. 998; 32 (4):247-54; 7. PARNER E.T., HEIDMANN J.M., VAETH M., POULSEN S. - Surface-speciflc caries incidence in permanent molars in Danish children. Eur J Oral Sci Dec; 5 (6):49-6; 8. POPESCU S. M., RÃESCU M., DESPA G. - Susceptibilitatea la carie a molarului prim permanent la copiii între 6-6 ani studiu clinic. Revista International Journal of Medical Dentistry 47

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