Journal of Babylon University/Pure and Applied Sciences/ No.(6)/ Vol.(21): 2013

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1 و% Journal of Babylon University/Pure and Applied Sciences/ No.(6)/ Vol.(21): 2013 Effect of Protein Energy Malnutrition Through Body Mass Index on Eruption Time Condition Among 6 and 9 Years Old In Primary School Children At Sammawa City Shayma Abdullah Hanoon Msc pediatric dentistry/college of medicine, Almuthanna University Abstract This study was conducted among urban primary school children d 6 and 9 years old in Sammawa city which lies 300 km south of Baghdad Purpose: to determine the eruption of primary and permanent teeth in relation to protein energy malnutrition. Materials and methods: The sample size composed of 400 children(200 for 6 years old and 200 for 9 years old) distributed in primary schools which were randomly selected from different areas in Sammawa city. The samples were examined physically by anthropometric measurements (weight and height) and orally for counting the number of erupted primary and permanent teeth. Results: The prevalence of malnutrition described by (height and weight) was found to be among 6 years old children 24%, 35% respectively, while among 9 years old was found to be 57%, 22% respectively, where as the mild malnutrition was the most prevalent grade. Mild malnutrition was found to be more prevalent in males than that among females. The results showed significant and high significant differences in the mean number of primary teeth between the well nourished and malnourished children with a higher number among malnourished children, while the apposite picture was found in permanent teeth. The prevalence of malnutrition was higher in 9 years old children than 6 years old children with mild malnutrition was the most prevalent grade of malnutrition and the mean number of primary teeth among malnourished children was found to be higher than among well nourished children for both groups, while the apposite picture was found regarding the permanent teeth. Recommendations: there is a need for continuous programmers for good diet and maintenance of good oral health conditions among primary school children to maintain a good oral health and to improve gingival condition of children especially malnourished group. الخلاصة أجریت هذه الد ارسة على طلاب المدارس الابتداي یة بعمر ٦ و ٩ سنوات في مدینة السماوة. العینة الكلیة تتا لف من ٤٠٠ طفل اختیروا عشواي یا من مدارس مختلفة في المدینة. الهدف: كان الهدف من الد ارسة تا ثیر الحالة الغذاي یة للا طفال على ظهور الا سنان اللبنیة والداي میة حسب العمر والجنس. المنهجیة: تم تقییم الحالة الغذاي یة بواسطة قیاس كتلة الجسم وقد سجلت نسبة انتشار سوء التغذیة بمؤش ارته(الطول حسب العمر والوزن حسب العمر)وقد كانت النتاي ج ٢٤% و ٣٥ % على التوالي للا طفال بعمر ٦ سنوات و ٥٧ ٢٢% على التوالي للا طفال بعمر ٩ سنوات حیث كانت الدرجة الخفیفة من سوء التغذیة أكثر انتشا ار بین الذكور منها من الا ناث. النتاي ج: أظهرت الد ارسة بصورة عامة أن هناك فرق معنوي اعتیادي وعالي في عدد الا سنان اللبنیة بین أطفال جیدي التغذیة والا طفال الذین یعانون من سوء التغذیة في الا ناث والذكور وفي العمرین حیث كان عدد الا سنان اللبنیة أعلى لدى الا طفال الذین لدیهم سوء تغذیة من أطفال جیدي التغذیة أما بالنسبة للا سنان الداي میة كانت الصورة مختلفة حیث أن عدد الا سنان الداي میة لدى أطفال جیدي التغذیة أعلى مما سجل للا طفال المصابین بسوء تغذیة وبفروق معنویة عالیة. التوصیات: یجب أن تتوافر ب ارمج مستمرة لطلبة المدارس الابتداي یة وخاصة للا طفال المصابین بسوء التغذیة حول كیفیة الحفاظ على بنیة سلیمة وتا ثیر التغذیة الجیدة على صحة الفم والا سنان. Introduction Growth is the increase in the mass of the body tissue as a child changes from an infant throughout childhood to adolescent during the most of the first two decades of life. Different body tissues in child grow at different rates or chronological s. These differences are magnified among children of the same gender, between the genders and among children of different racial backgrounds, so adequate nutrition and exercise are ٢١١٧

2 important for the fulfillment of growth and maturation (Khamarco et al., 2002). Therefore insufficient food for a significant period at any time during childhood may prevent an individual from reaching his full potential in height and weight (Hong et al,2009). Protein next to water is the most potential substances in the body, when there is any deficiency in protein in the food will lead to protein energy malnutrition and the main clinical symptoms are the failure of the body to grow in height and weight(latham, 1990) and this condition can be assessed by using anthropometric measurement(who, 1995). The developing human tooth, like other organ in the body, is unalterable to sever nutritional deprivation if the later occurs during the critical period of dental growth, if diet includes little or none of essential amino acids during the critical period of active growth, permanent dam can occurs (Winick and Nobel, 1965; Stayton et al, 2000). In the first half of previous century, a study found that 71% of the infant whose mothers had poor protein diet during pregnancy had retarded development of bone and teeth (Stuart, 1945), others improved that malnourishment was associated with greater delay in eruption, they suggested that acute malnutrition (low weight and height) had more pronounced effect on tooth exfoliation than chronic malnutrition (Jones et al., 2000). In experimental studies, an association of delayed eruption of teeth with malnutrition has been observed in rats fed protein(diorio et al,1973: Onis and Akre,2001), also delayed eruption of primary teeth due to protein energy malnutrition in humans was observed in many cross-sectional studies(rami Reddy et al,1986; Alvarez et al,1988). In Iraq, most of the maxillary primary teeth among normal children emerged earlier than mandibular teeth in both genders, also the number of primary teeth among well nourished children described by weight for nutritional status indicator was found to be higher than malnourished children(gatta,2005), others found that normal children reported to have higher number of erupted permanent teeth than malnourished children( Diab,2003; Droosh,2007), the objective of this study was to determine the relationship between malnourishment and the eruption time of primary and permanent teeth in children d 6 and 9 years old in Sammawa city comparing them with well nourished children. Materials And Methods The sample The study was conducted among urban primary school among children d 6 and 9 years old from to The sample size composed of 400 children includes 200 for 6 years old and 200 for 9 years old in Sammawa city in Iraq. The was calculated according to the last birthday and any child with systemic disease was excluded. Materials Plane dental mouth mirror no.4 and dental probe No.00 and tweezers and kidney dishes and cotton and gauze and disinfectants and portable lamp for artificial illumination and bathroom scale for weight records and height measuring board. Anthropometric measurement It represented by the measurements of height and weight. The measurement of weight was done by using bathroom scale for weight records nearest to 0.1 kg. The child was weighted with minimum clothes without touching anything with 500 gram was subtracted from the total weight to compensate for underneath clothes (Droosh, 2007). The scale ٢١١٨

3 Journal of Babylon University/Pure and Applied Sciences/ No.(6)/ Vol.(21): 2013 was checked against a known weight of 10 kg and adjusted before starting the measurements and after weighting every 20 children (Trowbridge,1988; Droosh, 2007). The measurements of height was done by using the ordinary measuring tape fixed at the wall and the child standing up after removing the shoes with feet parallel to each other and pointed forward and the back is straight in upright position. The knee was straight and the head was in position that Frankfort Plane (the line between the lower border of the orbit and the upper margin of the external auditory meatus) was horizontal. Malnutrition classification Each was considered in the terms of standard deviation (z-score) as a primary indicator of stunting, underweighting and wasting respectively. The Z score=individual value - median of reference population/standard deviation of reference population. Because of unavailability of Iraqi standard for comparism, the value of nutritional indicators was compared with the international reference values, for this purpose it was recommended to use the reference population that defined by US National Center for Health Statistics (NC). A recommended that endorsed by the WHO (1983) and urged that adequacy for these data for application for different ethnic background. The degree of malnutrition(mild, moderate, sever) represented in Z-score as:- Mild (Z=-1.0 SD to SD) Moderate (Z=-2.0 SD to SD) Sever (Z=-3.0 SD and below) (FAO/WHO,1992) Teeth eruption Examination was carried out while the child was seated in a straight chair with tall back on which the child head will be rested, portable lamp was used to provide constant source of light. A tooth was considered to be present in the mouth when any part of it was visible, retained deciduous teeth were recorded when both permanent and deciduous teeth were recorded when both permanent and deciduous teeth were present in the mouth, extracted teeth were recorded as erupted (WHO, 1997) Statistical analysis The data were processed and analyzed by using the statistics pack for social sciences (SPSS Inc, version it includes calculation of statistical parameter (mean and standard error of mean) and students t-test. Results The mean height of children d 6 years old was found to be cm while for children d 9 years old was cm (table1). Although the height of females was found to be higher than males but the differences were significant among children d 6 years, while the opposite picture was found in 9 years d children, where the height of males found to be higher than females with highly significant difference. The same table demonstrates the mean weight of children, for 6 years old children it was 20.41kg, while for children d 9 years old it was 30.05kg, for both s the weight of females was higher than males. ٢١١٩

4 Table (1) : Children height and weight by and gender Age Gender No. Height(cm) Weight(Kg) mean S.E. mean S.E. male female both male female both total male female both Height for z-score distribution is shown in table2. The well nourished children observed constitute 88% for 6 years d children and 71.5% for 9 years old children. Most of malnourished children d 6 years were of mild grade(8.5%) and only 3% were moderate malnourished, while sever malnourished were 0.5%, but among children d 9 years old mild malnutrition was found to be 27% where as moderate malnutrition were 1.5% and no case of sever malnutrition was reported.in 6 years d group, the prevalence of malnourishment were found to be higher among females than males, while the apposite picture take place in 9 years old group. Weight for z-score distribution is shown in table2 also, the percent of well nourished children d 6 years was found to be 82.5% and for 9 years was found to be 89%. Mild malnutrition was the most prevalent grade for both groups(11% for 6 years old and 9.5% for children d 9 years old), while moderate malnutrition was 5.5% for 6 years d group and 1% for 9 years d group, sever underweighting was 1% for 6 years old and 0.5% for 9 years old. The prevalence of underweighting was found to be higher in females than males in 6 years group and the apposite was found in 9 years d group. Table 3 demonstrates the mean number of erupted primary and permanent teeth by and gender. In 6 years old children males demonstrate a higher mean values than females in the mean number of erupted primary teeth, but these differences were not significant, while the apposite picture was found among 9 years old children where females have higher mean value than males but these differences were not significant. Concerning permanent teeth, females demonstrated a higher mean values of erupted permanent teeth than males in 6 years group but these difference was not significant(p>0.05), while the apposite thing was found for 9 years old children were males demonstrate a higher mean value than females but it was also not significant(p>0.05). ٢١٢٠

5 Journal of Babylon University/Pure and Applied Sciences/ No.(6)/ Vol.(21): 2013 Table (2):Distribution of children according to nutritional status indicators by and gender Indicator Age Gender Above -1 SD normal -1 to SD mild -2 to SD moderate -3 SD and below sever No. %within gender No %within gender No %within gender No. %within gender % within % within % within % within Height for 6 male 94 94% 47% 5 5% 2.5% % 0.5% female 82 82% 41% 12 12% 6% 6 6% both % 88% % 8.5% 6 3% 3% 1 0.5% 0.5% 9 male 51 51% 25.5% 49 49% 24.5% female 92 92% 46% 5 5% 2.5% 3 3% 1.5% both % 71.5% 54 27% 27% 3 1.5% 1.5% Weight for 6 male 86 86% 43% 9 9% 4.5% 5 5% 2.5% female 79 79% 39.5% 13 13% 6.5% 6 6% 3% 2 2% 1% 9 both % 82.5% 22 11% 11% % 5.5% 2 1% 1% male 88 88% 44% 11 11% 5.5% % 0.5% female 90 90% 45% 8 8% 4% 2 2% 1% both % 89% % 9.5% 2 1% 1% 1 0.5% 0.5% Table (3):Mean number of erupted primary and permanent teeth by and gender Age Gender No. Primary teeth Permanent teeth mean S.E. Mean S.E. 6 9 male female male female The mean number of erupted primary teeth according to nutritional status indicators by and gender is shown in table(4). The table shows that the mean number of primary teeth was higher among underweight children d6 and 9 years old than well ٢١٢١

6 nourished. Data analysis for the differences between malnourished and well nourished children in each gender were shown the same picture for children d 6 years old with highly significant difference for males(t=26.1, P<0.01) and females(t=42.96, P<0.05) while for children d 9 years old both underweight females and males had a highly significant higher number for primary teeth than well nourished. For data analysis for height for, the mean number of primary teeth was higher in wasted children than well nourished with highly significant for both s. Table (4): Mean number of erupted primary teeth according to nutritional status indicators by and gender indicator gender Well nourished Mal nourished t-test height weight No. mean SE No. mean SE d.f. t-vaue p- value male female S male S female male female male female *P 0.05 Significant **P 0.01 High significant The mean number of erupted permanent teeth among children according to nutritional status indicator by and gender is shown in table 5. Concerning height for, the mean numbers of erupted permanent teeth was significant and highly significant lower among malnourished children d 6 and 9 years old than well nourished children, concerning each gender in each, the difference was highly significant except among males d 9 years old whereby the difference was significant (P<0.05). the mean number of erupted permanent teeth according to the weight indicator was highly significant lower among underweight children than well nourished children described by the same indicator. ٢١٢٢

7 Journal of Babylon University/Pure and Applied Sciences/ No.(6)/ Vol.(21): 2013 Table(5):Mean number of erupted permanent teeth according to nutritional status indicators by and gender indicator gender Well nourished Mal nourished t-test No. mean SE No. mean SE d.f. t-vaue p- value height 6 male female male S female weight 6 male female male female *P 0.05 Significant **P 0.01 High significant Disscusion This study was designed to evaluate the nutritional status in relation to oral health among primary school children in Sammawa city. Two different s have been studied in the present study 6 and 9 years to see the effect of nutritional status on primary and permanent dentition and supporting structure among these two different s with mixed dentition. It was decided to conduct this study in urban areas only due to few number of schools in rural areas and too far and difficult to be reached. In the present study it was decided to use -1 SD as cut off point in order to include mild malnutrition which was reported by Alobaidi,1995; Diab,2003; and Droosh,2007 to have significant effect on dental health as well as many authors in different countries used -1 as a cut off point in order to separate well nourished population from malnourished one (Alvarez et al.,1988; Gatta,2005), also it was recommended to use -2 SD cut off point to estimate the prevalence of malnutrition in order to give help and support for the children with moderate and sever malnutrition(who,1981; WHO,1992). The Z-score standard deviation value system, which expresses the anthropometrical value as a number of standard deviation or Z-score below and above the reference mean, their major advant for population based uses is that a group of Z-score can be subjected to summary statistics (Yip and Sharp, 1993). Growth is taking place between 2-18 years old. The aver gain in weight in early school years, which represent relatively steady growth, is about kg/year and in height about 6 cm/year (Nelson, 1987; Attwood and Blikhorn, 2000). In the present study, result showed that in 6 years d children; females were showed growth retardation more than males. This could be explained partially by the fact that males still preferable person over females in eastern society, therefore family offered to males most of their advants. Also the calorie intake among girls was less than boys (Chen et al, 1989; Droosh,2007). ٢١٢٣

8 In 9 years d group, the apposite picture was seen, males were more malnourished than females. This finding supports the idea that boys are more active than girls and may be because of the work of the boys in order to earn income for their families (Dreze, 1991; Al-Shakh,2004). Concerning gender differences, males were found to be taller and heavier than females in all examples except children d 6 years, females being little higher and heavier than males. This is in line with the idea that the males were heavier and taller than females (Mohammed, 1996; Al-Azawi, 2000). The mean number of primary teeth was found to be lower among well nourished children compared to malnourished children described by nutritional status indicators(height and weight), this result is in accordance with the observation noted by a number clinicians and epidemiologists who found that the eruption of teeth is delayed among malnourished children and this lead to delayed exfoliation of primary dentition and delayed eruption of permanent teeth so increase in the number of primary teeth among malnourished children(gatta,2005). Eruption is a growth process and therefore have a relation with other process of the body especially height and weight (Menaker and Navia, 1973; Gatta, 2005). The process of exfoliation of primary teeth and eruption of permanent teeth are closely related physiologically. If primary teeth is not exfoliated at its time and remain in the mouth this will lead to increase in the number of primary teeth and decrease in the number of permanent teeth at certain (McDonald, 1997; Al-Jasser,2003) as seen in the present study that the mean number of erupted permanent teeth were lower among malnourished than well nourished children described by height and weight. Conclusion The prevalence of underweight and stunting children was 14.25% and 20.25% respectively. Mild malnutrition was the most prevalent grade. In 6 years d children, females shows growth retardation more than males. In 9 years old d group, the apposite picture was seen, males are more mal nourished than females. The mean number of primary teeth was found to be lower among well nourished children compared to malnourished children described by height and weight. The mean number of erupted permanent teeth were lower among malnourished than well nourished children described by height and weight. Recommendation In order to improve oral health conditions especially among malnourished children, educational programmers, good oral hygiene and proper diets must be performed. References Al-Azawi L.A. Oral health status and treatment among Iraqi five years old kindergarten children and fifteen years old student( A National survey)(2000). PhD thesis, University of Baghdad. Al-Jasser N.M.Bello L.L.(2003). Time of eruption of primary dentition in Saudi children. The journal of Contemporary Dental Practice.4,3 Al-obaidi W.(1995). Oral health status in relation to nutritional status among kindergarten children in Baghdad, Iraq. A master thesis, University of Baghdad. ٢١٢٤

9 Journal of Babylon University/Pure and Applied Sciences/ No.(6)/ Vol.(21): 2013 Al-Shakh N.J.(2004). Oral health status and treatment need among Institutionalized deaf children and adolescents in comparison to schools students in the middle region of Iraq. A master thesis, University of Baghdad. Alvarez J.O., Lewis C.A., Saman C.(1988). Chronic malnutrition, dental caries and tooth exfoliation in Peruvian children d3-9 years. Am.J.Clin.Nutr.,48: Attwood D., Blikhorn A.S. Mac Millan A.S.(2000). A three years follow up study of 12 and 15 years old of school children in Glasgow. Community Dental Health.7(2), Diab.B.S.(2003). Nutritional status in relation to oral health condition among6-10 years primary school children in middle region of Iraq. PhD thesis, University of Baghdad. Diorio L.P., Miller S.A., Navia J.M.(1973). The separate effect of protein and calorie malnutrition on the development and growth of rat bones and teeth. J. Nutr Droosh M.(2007). Protein energy malnutrition in relation to oral health condition among 6 and 9 years old primary school children in Sulaimania city in Iraq/ Master thesis, University of Baghdad. Gatta E.(2005). Primary teeth emergence and enamel anomalies in relation to nutritional status among 4-48 month old children in Baghdad city/iraq. A master thesis, University of Baghdad. Hong L., Levy S.M., Warren J.J., Broffitt(2009). Association between enamel hypoplasia and dental caries in primary second molars: a cohort study. Caries Res.43(5): Khamarco T.Y., Al-Naimi R.J., Makani L.A.(2002). Periodontal health and treatment needs of intermediate school children and its relation to educational level of parents. Al-Rafidain D.J.2, Latham M.C.(1990). Protein energy malnutrition.6 th ed. Washington D.C. International life science institute. Mc Donalds R.E.,Hennon D.K., Avery D.R.(1997). Dental caries in child and adolescent. In dentistry for child and adolescent.7 th ed;st, Louis; G.V. Mosby Co Menaker L. Navia J.M.(1973). Effect of under nutrition during parental period on caries development in the rat. In effect of differential tooth eruption and exposure to a cariogenic diet on subsequent dental caries incidence. J. Dent. Res.52(7):692. Mohammed M.M.(1996). Assessment of nutritional status of the mothers and primary school children in Al-Tammim governorate. PhD thesis, University of Baghdad. Nelson W.(1987). Assessment of growth and development.14 th ed.w.b. Sanders Company, Philadelphia, London, Toronto, Sydney: Onis M., Montero, Akre J Clugston G.(2001). The world wide magnitude of protein energy malnutrition: An overview from the WHO Global data base on child growth. WHO,Geneva. Rami Reddy V.,Vijayalakshmi P.B., Chandrasekhar R.B.(1986). Decideous teeth emergence and physics of Velema children of south eastrern andhra pradesh. Acta Odontol Pediatr.7:1-5. Stayton R.L., Warren J.J., Kanellis M.J., Levy S.M.(2000). Prevalence of enamel hypoplasia and isolated opacities in the primary dentition. Pediatric Dentistry.23: ٢١٢٥

10 Stuart T.(1945). Finding on examination of newborn infants during the neonatal period. Feds Proc.4: Trowbridge F.L.(1988). Evaluating nutritional status of infant and children in Paige D.M. eds, clinical nutrition. 2 nd edt. The c.v. mosby comp. St louis, Washington D.C. Toronto PD: Winick M. Nobel A.(1965). Quantitative changes in DNA, RNA and protein during parental and postnatal growth in the rat. Dev. Biol.12: World Health Organization(1981). Development of indicators for monitoring progress toward health for all by the year Health for all series. Pub. 4:4-10. World Health Organization(1987). Basic methods of the oral health survey. 3rd edt. WHO, Geneva. World Health Organization(1997).Oral Health Surveys. Basic Methods WHO; Geneva, Switzerland. Yip R. Sharp T(1993). Acute malnutrition and high childhood mortality related to diaarhea. J.Am.A.270: ٢١٢٦