THE ODONTAL STATUS AND CARIOUS AFFECTION LEVEL … ijmd nr 2-2011 final... · between 16-20 years,...

140 volume 15 • issue 2 April / June 2011 •

AbstractIntroduction. In adolescents and young people, the

first permanent molar has the longest functioning period,comparatively with the other permanent teeth from themolar-premolar region, the actual epidemiological stud-ies evidencing their highest vulnerability to fissural orproximal caries. In the absence of well-established strate-gies aimed at maintaining these molars on their arches,their precocious extraction is ussually performed, whichinduces severe occlusal-articulary disequilibria, alterationof the temporo-mandibulary articulation and favorizationof various periodontal diseases. Materials and method.The objective of the present study was to evaluate theodontal status and the level of carious affection and, bythe complications thus induced, of the extent of affectionof the first permanent molar in young people with agesbetween 16-20 years, as based on the clinical diagnosiscriteria of the dental caries, alongwith the evaluation ofits activity according to Nyvad indices. Results. The ob-tained results show that application of such an evalua-tion method assures a more complete and correct analy-sis of the affection extent of the odontal status of the firstpermanent molar, alongwith tracing even the incipientlesions and – consequently – their non-invasive subse-quent treatment. Conclusions. A precocious caries diag-nosis and, implicitly, a correct evaluation of its activity,represent essential steps for a correct establishment of themain – either invasive or non-invasive - treatment re-quirements, through remineralization, as part of the cari-ous disease managment, which is perfectly valid for thefirst permanent molar, as well.

Keywords: first permanent molar, evaluation, diagnosis,caries

INTRODUCTION

The extent of affection, through caries, of thefirst molars, occurring during the mixed denti-tion period has been demonstrated, in epidemio-logical studies, (1, 2) in ratios exceeding 87% inpatients with high cariogenous risk. The pres-ence of either non-cavitary or cavitary caries atthe level of the first permanent molars is indica-

THE ODONTAL STATUS AND CARIOUS AFFECTION LEVEL OF THEFIRST PERMANENT MOLAR IN 16-20 YEAR-OLD ADOLESCENTS –

A CLINICAL STUDY

Mariana Ilie¹, Galina Pancu², {.L\c\tu[u³

1. PhD Student, Dept of Odontology, Faculty of Med. Dent., ”Gr.T.Popa” U.M.Ph Iasi2. Assist Prof., PhD., Dept of Odontology, Faculty of Med. Dent., ”Gr.T.Popa” U.M.Ph Iasi3. Prof., PhD. Dept of Odontology, Faculty of Med. Dent., ”Gr.T.Popa” U.M.Ph IasiCorresponding auhor:Ilie Mariana; e-mail: [email protected]

tive of the carious activity of each subject in part.Despite the decline registered – in countries

in which efficient preventive and treatmentmeasures are currently applied – in the manifes-tation of the carious disease, it was observed that90% of the existing caries are localized in ditchesand fossae?,the most affected among the perma-nent teeth being the first molars (3, 4). That iswhy, the carious processes occurring at thesemolars are, in most clinical situations, acute,with a rapid evolution, causing, within quiteshort time intervals, destruction of the mastica-tory surfaces and of the contact points, thusfavorizing severe local, local-regional or generalcomplications (5-10) .

In the absence of precise strategies aimed atpreserving the molars on the arches, precociuosextractions are performed and serious occluso-articulary disequilibria (11) occur, affecting thetemporo-mandibulary joint and favorizingmanifestation of various periodontal diseases(12, 13). Most of the national epidemiologicalstudies controlling theprevalence of caries in-clude exclusively the carious lesions with visiblecavitation (14).

In 1999, Nyvad B. et al. proposed new clinicalcriteria for caries diagnosis, including both cavi-tary and non-cavitary caries, on considering, too,the activity of the carious lesions. Not alwaysthe incipient caries of the enamel develop cavi-tation, as they may be subjected to aremineralization therapy (15) through whichtheir evolution is stopped. The modern diagno-sis of the carious disease, including the activitydegree of the caries and the incipient evolutionstages is very important, becoming essential inplanning, monitoring and appreciating the effi-

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Oral Biology

International Journal of Medical Dentistry 141

ciency of the applied prophylactic and therapeu-tical measures (16,17).

THE AIM OF THE STUDY

The study evaluates the odontal status, thelevel of carious affection and its complicationsin the first permanent molar in young people,with ages between 16-20 years, who came to amedical dentistry surgery in Galaþi between2008-2010, on the basis of clinical criteria for thediagnosis of the dental caries, for estimating theextent of its activity.

MATERIALS AND METHOD

The experimental group included 96 youths,boys and girls, with ages between 16-20 years,selected from the persons having come to theprivate medical surgery, 1st year students of theUniversity of Galaþi, to whom a free-of-chargeexamination was offered.

The criteria for their inclusion in the experi-mental group were the following: a large rangeof diagnosed odontal pathologies, among whichaffection, through caries, or even premature loss,following some post-carious complications ofthe first permanent molars; age between 16 and20 years; informed consent was obtained fromthe patients.

The exclusion criteria referred to non-cooperantpatients, with ages under 16 and over 20 years.

The investigations observed the legislation inforce in Romania and the deontological norms,namely Law 46/January 21, 2003, establishingthe rights of the patient, following his consentfor scientific experiments. Also, the privacy ofthe personal records was granted. The purposeand stage of development of the study was ex-plained, after which informed consent wassigned by the patients. The experimental group(n = 96) included:

– 46 boys and 50 girls with ages between 16-20 years;

– 57 persons came from the urban area, and39 from the rural one.

Clinical examination was performed in thedesntistry surgery, under optimum confort con-

ditions, and adequate light, by means of the clas-sical medical kit (probe, clip and mirror), specialattention being paid to the morphology and tothe affected dental structures. The evaluationincluded:

1. calculation of the bacterial plaque index,OHI-S,

2. settlement of the carious affection leveland of its complications in the first per-manent molar was evaluated by a clinicalmethod of dental caries diagnosis, appliedaccording to the Nyvad B indices.

The activity of the carious lesions was evalu-ated on all surfaces (vestibular, oral, mezial,distal, occlusal) of the examined teeth, theirtranslucence, colour and texture being assessed,as well as the integrity and structure of the in-vestigated surfaces (intact surfaces, loss of integ-rity in the enamel defect, presence of a cavity indentine) (Tab.1).

Diagnosis criteria according to Nyvad indicesEvaluation of the oral hygiene status involved

calculation of the index of bacterial plaque,OHI-S .

RESULTS

The obtained data, recorded in the observa-tion sheet, were statistically processed andanalyzed with the SPSS 17 and EXCEL 2007 pro-grams. The results thus obtained were employedfor the development and optimization of futureinvestigations devoted to the prophylactic andtherapeutical aspects of the pathology of the cari-ous disease and of some premature losses of thefirst permanent molars.

1. Distribution of cases as a function of themedium from which they come evidences theirpredominance in the urban area (75%) (Fig. 1).

Fig. 1. Distribution of cases according to medium(rural, urban)

THE ODONTAL STATUS AND CARIOUS AFFECTION LEVEL OF THE FIRST PERMANENT MOLARIN 16-20 YEAR-OLD ADOLESCENTS - A CLINICAL STUDY


2. Distribution of patients as a function ofsex reveals a slight predominance in girls ver-sus boys (Fig. 2).

Fig. 2. Distribution of cases as a function of sex

3. Distribution of patients as a function ofage (Fig. 3).

years

years years years years

Fig. 3. Distribution of cases as a function of age

Code Category Interpretation of codes

D 0 Healthy tooth Translucence, color and surface texture within normal limits (some coloration of the ditches and of the non-carious fossae is accepted)

D 1 Active non-cavitary caries (unaffected surface integrity)

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.

D 2 Active caries with defect (loss of integrity) in the enamel.

Same criteria as for code 1. 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.

D 3 Active cavitary caries 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.

D 4 Inactive caries (intact surface).

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.

D 5 Inactive caries (defect at enamel level).

Same criteria as for code 4, to which one should associate some loss of surface integrity (microcavity) localized strictly at enamel level.

D 6 Inactive cavitary caries 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.

D 7 Obturation (healthy surface)

No signs of affection by carious processes. Same criteria as for code 0.

D 8 Obturation + active caries Active carious process, either cavitary or non-cavitary. D 9 Obturation+inactive

caries Inactive carious process, either cavitary or non-cavitary.

D10 Tooth extracted from cariogeneous reasons

Table 1

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Mariana Ilie, Galina Pancu, {.L\c\tu[u


Analysis of results according to the index oforal hygiene, OHI-S, gives an average value of2.86±0.46, corresponding to an unsatisfactoryoral hygiene.

A total number of 96 patients was examined,respectively 384 teeth (first permanent molars),1920 surfaces (O – occlusal side, M – mezial side,D – distal side, Or. – oral side), to which codesvarying from K0 to K10 had been assigned, the

following observations being made (Table 2):• Only 113 teeth (565 surfaces) (29.4%) – re-

ceived code D0 – healthy surface.• 89 teeth ( 445 surfaces) (23.1%) – received

code D 10 (post-caries extracted).• 182 teeth (910 surfaces) (47.4%) – received

codes from D1 toD9, being affected by(Fig. 4):

Codes distrubution on surfaces Teeth Surface % of 1920

113 teeth (565 surfaces) (29.427%) - received code D0 – healthy surface 113 565 29.427 D0

89 teeth ( 445 surfaces) (23.177%) - received code D 10 (post-caries

extracted). 89 445 23.177 D10

182 teeth (910 surfaces) (47.395%) - received codes from D1 to D9 182 910 47.395 D1-D9

active non-cavitary caries D1- 106 surfaces (5.520%) 106 5.520 D1

active cavitary caries in the enamel D2 - 125 surfaces (6.510%) 125 6.510 D2

active cavitary caries in dentine D3- 211 surfaces (10.989%) 211 10.989 D3

inactive non-cavitary caries D4- 82 surfaces (4.270%) 82 4.270 D4

Inactive cavitary caries in the enamel D5 - 24 surfaces (1.25%) 24 1.25 D5

inactive cavitary caries in dentine D6 - 8 surfaces (0.416%) 8 0.416 D6

obturation (healthy surface) D7- 94 surfaces (4.895%) 94 4.895 D7

obturation (with an associated active caries) D8- 182 surfaces (9.479%) 182 9.479 D8

obturation (with an associated active caries) D9 - 78 surfaces (4.062%). 78 4.062 D9

TOTAL= 384 1920 100% D0-D10

Table 2



o active non-cavitary caries D1,- 106 surfaces(5.5%)

o active cavitary caries in the enamel D2, –125 surfaces (6.5%)

o active cavitary caries in dentine D3, – 211surfaces (10.9%)

o inactive non-cavitary caries D4, – 82 sur-faces (4.27%)

o inactive cavitary in the enamel D5, – 24 sur-faces (1.25%)

o inactive cavitary in dentine D6 – 8 surfaces(0.41%) or by its consequences (restora-tions – with or without the presence ofsome active or inactive associated caries):

o obturation (healthy surface) D7, – 94 sur-faces (4.89%)

o obturation (with an active caries associ-ated) D8, – 182 surfaces (9.47%)

o obturation (with an inactive caries associ-ated) D9 – 78 surfaces (4.06%).

Fig. 4. Percent distribution of codes on the 1920 surfaces

• if considering localization, there prevailedthe extractions (D10) at inferior molars(teeth 3.6, 4.6) (12.14%), comparativelywith the superior ones (1.6, 2.6) (10.93%).

• The most affected by caries, too, (D1-D6)were the inferior molars (teeth 3.6, 4.6)(14.96%), comparatively with the superiorones (1.6, 2.6) (14.27%).

• Deep caries with pulpar affection D3 (1.6,2.6) comparatively with the inferior teeth(3.6, 2.6) (Tab. 3, Fig. 5.);

Table 3

1/6 2/6 3/6 4/6

D3 133 78

Fig. 5. Distribution of code D3 versus localization: upperteeth 1.6, 2.6.or lower teeth 3.6, 4.6.

Comparatively, the ratio of active cavitarycaries is of 6.92% for the upper molars, versus4.06% in the case of lower molars.

• D7 obturations at the upper teeth (1.6, 2.6)comparatively with the lower teeth (3.6,2.6) (Tab. 4., Fig. 6.)

Table 4

1/6 2/6 3/6 4/6

D7 47 47

Fig. 6. Distribution of code D7 versus localization: upperteeth 1.6, 2.6 or lower teeth 3.6, 4.6.

• A comparison among the incipient non-cavitary enamel caries D1 and the cavitaryones in enamel and dentine D2, D3 leadsto the following observations (Tab. 5):

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Table 5. Extent of disease through D 1,D 2, D 3, D4,D5, D6

1/6 2/6 3/6 4/6 D1 30(1.56%) 76(3.96%) D2 54(2.81%) 71(3.7%) D3 133(6.92) 78(4.06) D4 47 (2.44) 35 (1.82) D5 6 (0.31) 18 (0.94) D6 4 (0.208) 4 (0.208)

• D1 of 1.56% on the upper molars and of3.96%, respectively, on the lower ones.

• The ratio is maintained for D2, as well,2.81% for the upper molars and 3.7%, re-spectively, for the lower ones.

• As to D3, a ratio of 6.92 is found for theupper molars, and of 4.06%, respectively,for the inferior ones.

On the whole, the following distribution wasobtained as to:

• The extent of disease through D 1,D 2, D 3(Tab. 6, Fig. 7):

Table 6. Extent of disease through D 1,D 2, D 3.

active non-cavitary caries D1 – 106 surfaces (5.520%)

active cavitary caries in the enamel D2 – 125 surfaces (6.510%)

active cavitary caries in dentine D3 – 211 surfaces (10.989%)

Fig. 7. Percent distribution of the codes of lesionsD 1, D 2, D 3.

• 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

inactive noncavitary caries D4- 82 surfaces (4.270%)

inactive cavitary caries in the enamel D5 - 24 surfaces (1.25%)

inactive cavitary caries in dentine D6 – 8 surfaces (0.416%)

Fig.8. Percent distribution of the codes of lesions D4-D6

• As to the distribution of the D3 lesions situ-ated on the O (occlusal) sides, compara-tively with sides M, D (mezial, distal) andD7 situated on the O (occlusal) sides, com-paratively with sides M, D (mezial, distal),the following distribution was obtained(Tab. 8., Fig. 9, 10):

Table 8. Distribution of lesions D3

1.6 2.6 3.6 4.6 D3 O 39 10 10 10 D3 M 19 0 0 10 D3 D 38 0 2 20

D7 O 2 0 1 22 D7 M 1 18 4 2 D7 D 1 1 1 3



Fig. 9. Percent distribution of the codes of the cavitarycaries D3 versus localization on the quadrants,

upper 1.6, 2.6 and lower molars 3.6, 4.6(occlusal, mezial, distal sides)

Fig.10. Percent distribution of the codes of the cavitarycaries D7 versus localization on the quadrants,

upper 1.6, 2.6 and lower molars 3.6, 4.6(occlusal,mezial,distal sides).

DISCUSSION

Some recent studies established a series ofcriteria (18) for assessing the extent of activity ofthe carious lesions, on the basis of their aspect (ifthe surface is smooth, glossy, tough – the lesionis inactive/its evolution is stopped); if the sur-face is chalky and/or rugous, the lesion is active.Such criteria were adopted for reflectingtheclinical observation, the fact that the non-cavitary carious lesions ado not always developinto a cavity but, in most cases, their evolution isstopped or they get remineralized, as shown bylongitudinal studies (19).

An early diagnosis of caries and, implicitly,assessment of its activity, are essential for a cor-rect selection of the treatment, (20) either inva-

sive or non-invasive, through remineralization,for the managment of the carious disease (21,22.), which are characteristics wholly valid forthe first permanent molar, as well.

Application of the method of lesion evalua-tion according to the Nyvad indices permitted amore complete and correct analysis of the extentof odontal disease of the first permanent molar,tracing even the incipient lesions, which couldbe subsequently treated in a non-invasive man-ner. Consequently:

• As to the affection level D0 (teeth withhealthy surfaces), it registered a highervalue in women, comparatively with men;

• For all levels of caries affection, from D1 toD3, the number of cavitary lesions in theenamel and dentine was higher in womenthan in men;

• The present study discusses the diseasescaused by premature loss (extraction) ofthe first permanent molars (code D10) in23.1% of cases, more involved being thelower molars, comparatively with the up-per ones.

• The number of complicated caries is twotimes higher in the lower molars, compara-tively with the upper ones;

• The active caries cover 12.9% of the sur-faces, while the inactive ones - only 5.93%;

• The obturations associated with thehealthy surfaces represent 4.89%, theobturations with active associated caries -9.47% and the obturations with inactiveassociated caries - 4.06%.

• As to localization, the extractions (D10) ofthe inferior molars (teeth 3.6, 4.6) (12.14%)were more numerous than those of the su-perior teeth (1.6, 2.6) (10.93%).

• Also, most affected by caries (D1-D6) werethe inferior molars (teeth 3.6, 4.6) (14.96%),comparatively with the superior ones (1.6,2.6) (14.27%).

• Deep caries with pulpar involvement D3(1.6, 2.6), comparatively with the inferiorteeth (3.6, 2.6);

The authors of a study, performed in 2009 ona group of children from Cluj-Napoca, with agesbetween 9 and 12 years, evaluated the odontal

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status of the 6 year-old molar and the frequencyof the dento-maxillary anomalies in the secondphase of mixed dentition, on using index COE(9). In this way, the following results were ob-tained for the first permanent molar: at 9 years(C=43%, O= 16%, A=10%), and at 12 years(C=24.3%, O=46.3%, A=15.8%). The presentstudy shows an even higher affection level in 16-18 year-old children, the more so that, accordingto Nyvad, it also permits evaluation of some in-cipient carious lesions (D1, D 4) and of cariesadjacent to restorations (D8, D9) which cannotbe included in the evaluation with indices COE.Such elements may be subsequently employedin a more correct, more complete and less inva-sive therapeutical plan, which will assure alonger life of the molar on the arch.

A similar study, performed in Belorussia ac-cording to the Nyvad criteria, showed that, inthe 7-10 year group of age, when evaluation wasmade with code D1, the carious disease was of92% while, if analysis was performed with codeD3, the extent of disease was much lower - of49% (23).

Application of the new evaluation criteria forcarious affection permits its diagnosis as early asits incipient forms, as based on the real situation,thus permitting some prophylactic-therapeuticalmeasures that consider the extent of activity ofthe carious process, as well.

CONCLUSIONS

The extent of carious disease and its compli-cations in the first permanent molar is quite sig-nificant in the 16-20 years group of age. The pe-riod as such is an especially critical and difficultone, covering the end of puberty (14-16 years)and the beginning of adolescence (16-20), char-acterized by a series of both physical (hormonal)and, mainly, psycho-social modifications, by theformation and development of characters, de-pending on a multitude of factors, all contribut-ing to the formation of the young one’s person-ality.

All these changes also influence the param-eters characterizing the health condition of thefirst permanent molar which, at this age, is the

”oldest” tooth, being present on the arch fromthe age of 6, so that it is the most exposed one toall cariogeneous factors that may be involved insuch a process.

Considering the importance of the first per-manent molar in the development of dentition,special stress should be laid on preventive edu-cation, so that the patients should come to thedentist’s even prior to the installation of a caries,in a moment in which adequate preventionmeasures may be taken, together with the appli-cation of some modern methods and means forlesion diagnosis in its incipient stages, thus stop-ping the cavitary process, without any invasiveand expensive treatments.

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