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Provided by Elsevier - Publisher Connector The Saudi Journal for Dental Research (2016) 7, 29–33

King Saud University The Saudi Journal for Dental Research

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ORIGINAL ARTICLE Prevalence of developmental dental anomalies among adult population of Jazan, Saudi Arabia

Nandimandalam Venkata Vani *, Sanaa Mahmoud Saleh, Faisal Mohamed Tubaigy, Idris A.M.

Department of Oral Pathology, Faculty of , Jazan University, Jazan, Saudi Arabia

Received 23 January 2015; revised 24 February 2015; accepted 16 March 2015 Available online 21 March 2015

KEYWORDS Abstract Objective: This study was intended to determine the prevalence of developmental dental Developmental dental anomalies (DDA) among adults attending the outpatient dental clinics of college of dentistry, Jazan anomalies; University, Kingdom of Saudi Arabia. The data obtained are expected to increase the understand- rotation; ing of their etiology and also aid for better management and prevention. Jazan Materials and methods: The materials were retrieved from the files of patients reporting to the den- tal clinics of college of dentistry, Jazan University over a period of four months from December 2013 to March 2014. Panoramic radiographs of 1000 patients (500 males and 500 females) with an age range of 18–40 years were examined for anomalies in teeth number, shape, size and position. Descriptive statistics was performed using SPSS 20 and the value of significance obtained using Chi square and Fisher exact test. The level of significance was set at 95% confidence level. Results: The prevalence of DDA was 37.8% and distributed equally in both the sexes. The most common anomaly was rotation (20.2%) followed by ectopic eruption (7.6%). (0.9%), supernumerary roots (0.7%), (0.6%) and transposition (0.3%) were less com- mon. The prevalence of rotation is statistically significant (p < 0.05). Discussion and conclusion: A significant number of patients had DDA. The prevalence of rotation was high and associated with other common dental diseases. Comparison of our data with other studies showed variation in their prevalence suggesting the influence of genetic and environmental factors. The high prevalence of DDA suggests the need for proper diagnosis, intervention and

* Corresponding author. Tel.: +966 531409744. E-mail addresses: [email protected] (N.V. Vani), sanaasaleh54 @gmail.com (S.M. Saleh), [email protected] (F.M. Tubaigy), [email protected] (Idris A.M.). Peer review under responsibility of King Saud University.

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http://dx.doi.org/10.1016/j.sjdr.2015.03.003 2352-0035 ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 30 N.V. Vani et al.

treatment. Further research into etiological factors for dental anomaly presentation in adults in Saudi Arabia could create awareness and guide preventive strategies to assist in minimizing the associated dental problems. ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction All subjects were in the permanent dentition stage and had panoramic radiographs taken by the same technician using the Developmental dental anomalies (DDA) are considered as an same x-ray device and the same standardized method. The important category of morphological and structural dental radiographs were taken using Orthophos XG Sirona machine variations. Their etiology is complex resulting from the influ- and images were processed with Sidexis Next generation soft- ence of genetic, epigenetic and environmental factors.1 ware. The panoramic images were examined in a standardized Although genetic defects have been considered to be the most manner under good lighting conditions, standardized screen influential factor, etiological events in the prenatal and postna- brightness and resolution. All the radiographs were examined tal development period can further contribute to such anoma- by an experienced clinician to eliminate inter examiner differ- lies.1 Anomalies of tooth size (microdontia and macrodontia); ences. Repeatability was tested on 20 randomly selected radio- shape (, , , gem- graphs examined at least 2 weeks after the initial examination. ination, fusion, root dilacerations, and concres- The selected radiographs were reviewed for the following cence); number (, and oligodontia); DDA: hypodontia, hyperdontia, ectopic eruption, rotation, structure (, dentinogenesis imperfecta microdontia, macrodontia, transposition, gemination, fusion, and ) occur due to disturbances in the embry- dilacerations, taurodontism, dens evaginatus, dens invagina- ological development of teeth during the morphodifferentia- tus, talon cusp, , supernumerary roots and any tion or histodifferentiation stages of development.2 Positional other unusual dental conditions Descriptive statistics was per- anomalies such as rotation, ectopic eruption occur due to dis- formed for analyzing the data and group comparison was done turbances in the eruption pattern.2 The knowledge of their with Pearson chi square test and Fisher’s exact test. The level prevalence and the degree of expression can provide valuable of significance was set at 95% confidence interval. information for phylogenic and genetic studies and also help in the understanding of differences among population and 3. Results between various population groups.3 Many epidemiological studies on DDA have been conducted in different parts of Among the 1000 radiographs examined, a total of 378 (37.8%) the world showing geographic and ethnic variation in their had DDA which includes 192 (38.4%) males and 186 (37.2%) prevalence.4–10 Nevertheless, only a few studies have been con- females (Table 1). Around 287 (28.7%) had at least one anom- ducted in Saudi Arabia with differences in the prevalence of aly, 79 (7.9%) cases with two anomalies and only 12 (1.2%) these anomalies due to variable sampling and diagnostic cri- exhibited more than two anomalies (Table 1). Both males teria.11–15 The present study is intended to determine the and females were equally affected. Of these 378 anomalies, prevalence of DDA among the adult population of Jazan, 290 (76.7%) occurred in the age group 18–30 years compared Kingdom of Saudi Arabia. The data obtained are expected to 88 (23.3%) cases in 31–40 years range (Table 1). The most to increase the understanding of their etiology which can fur- common anomaly was rotation 202 (20.2%) followed by ecto- ther facilitate their diagnosis and effective management. pic eruption 76 (7.6%) and 72 (7.2%). (Table 2). Rotation was the most prevalent anomaly and statistically 2. Materials and methods significant. Moreover, it was predominant in 114 (22.8%) males compared to 88 (17.6%) females. Maxillary first premo- This retrospective cross sectional study was based on the eval- lars (7.9%) were most often rotated followed by mandibular uation of DDA on panoramic radiographs of 1000 outpatients canine (6.0%). Ectopic eruption of teeth was common in max- attending the dental clinics of college of dentistry, Jazan illary canine (2.2%) followed by mandibular first University over a period of four months from December (2.0%). An interesting finding noted during the evaluation of 2013 to March 2014. Digital computed panoramic radiographs radiographs was that many cases of rotation were associated of 500 males and 500 females of Saudi origin with an age range with ectopic eruption of adjacent teeth. In hypodontia, maxil- of 18–40 years were considered for the study. Patients of this lary lateral incisor (1.7%) was the most frequently missing age group were selected to avoid misinterpretation caused by tooth followed by mandibular (1.3%) and maxillary delayed eruption or uneruption of permanent teeth in young premolars (1.0%). Among the 10 cases of hyperdontia, 5 patients and also the regressive alterations or other dental dis- (0.5%) were supernumerary premolars, 3 (0.3%) supernumer- eases in older individuals. The exclusion criteria include ary lower incisors and 2 (0.2%) mesiodens. patients with syndromes that could cause DDA such as Taurodontism was present mostly in mandibular molars 28 Down’s syndrome, cleidocranial dysostosis, cleft lip and (2.8%) with only 1 (0.2%) case involving the maxillary molars. palate. Third molars were also excluded as they commonly Mandibular first premolar (2.4%) was commonly affected by exhibit variation in their morphology and position. In order dilaceration. Talon’s cusp was observed mostly in maxillary to reduce radiographic misinterpretation, blurred image teeth incisors. Maxillary premolars (0.6%) had more supernumerary were also excluded. roots followed by mandibular premolars (0.4%). A total of 9 Prevalence of developmental dental anomalies among adult population of Jazan 31

Table 1 Distribution of developmental dental anomalies by age and sex. Description Males n (%) Females n (%) Age (18–30 years) Age (31–40 years) Total n (%) n = 500 n = 500 n = 500 n = 500 n = 1000 No dental anomaly 308 (61.6) 314 (62.8) 210 412 622 (62.2) One dental anomaly 142(28.4) 145 (29.0) 216 71 287 (28.7) Two dental anomalies 42 (8.4) 37 (7.4) 68 11 79 (7.9) PTwo dental anomalies 8 (1.6) 4 (0.8) 6 6 12 (1.2) Total subjects with dental anomalies 192(38.4) 186(37.2) 290 88 378 (37.8)

13,15 Table 2 Prevalence of developmental dental anomalies in the dentition. There is no statistically significant difference study group. between both the sexes in congruence with other stud- ies.6,8,11,12,15 The female predominance in some studies is Dental anomalies Males n Females n Total n P probably due to high frequency of their visit to the dentist, (%) (%) (%) value as they are more conscious about esthetics and general oral n = 500 n = 500 n = 1000 health care.9,14 Rotation 114 (22.8) 88 (17.6) 202 0.049* * Rotation was the most frequent dental anomaly in the pre- (20.2) sent study. The exclusion of this entity in most studies, is Ectopic eruption 46 (9.2) 30 (6.0) 76 (7.6) 0.073 mainly because of the argument that rotation is not Transposition 2 (0.4) 1 (0.2) 3 (0.3) 1.000 7–15 Hypodontia 22 (4.4) 30 (6.0) 52 (5.2) 0.319 developmental. But literature cites that the etiology of rota- Hyperdontia 6 (1.2) 4 (0.8) 10 (1.0) 0.753 tion is multifactorial and based on pre-eruptive and posterup- 16 Taurodontism 13 (2.6) 16 (3.2) 29 (2.9) 0.707 tive disturbances. Several factors like trauma, ectopic Talons cusp 8 (1.6) 7 (1.4) 15 (1.5) 1.000 eruption, extraction, hypodontia, periodontitis of adjacent Dilaceration 28 (5.6) 44 (8.8) 72 (7.2) 0.066 teeth can lead to further change in the angulation of teeth Supernumerary 5 (1.0) 2 (0.4) 7 (0.7) 0.451 posteruptively. Likewise, rotation was associated with other roots dental problems in this study supporting their multifactorial Microdontia 5 (1.0) 4 (0.8) 9 (0.9) 1.000 etiology. Only a single study has included this entity reporting Macrodontia 3 (0.6) 3 (0.6) 6 (0.6) 1.000 only half of the prevalence rate noted in this study.6 Maxillary * Statistically significant (p 6 0.05). first premolars were commonly rotated with most of the cases showing ectopic eruption of adjacent maxillary canines. Few cases have been observed in patients with impacted canine which could be a likely cause for this anomaly. Furthermore, (0.9%) patients were seen with peg shaped lateral incisors, the the prevalence of dental caries in children is substantially high only tooth affected by microdontia predominantly unilateral. in this region17 with many cases of extracted deciduous molars Transposition was present only in 3 (0.3%) patients where which could further lead to rotation of succedaneous teeth. there was a change in the position of maxillary lateral incisor, Rotated teeth are predisposed to alveolar bone loss when com- canine and first premolar. Comparison of our data with similar pared to normally positioned teeth.18 Since rotation is high in type of studies conducted in different populations is shown in this population, the dentist should be aware of their possible Table 3. sequelae and therefore advocate appropriate therapeutic measures. 4. Discussion The prevalence of ectopic eruption was rather high com- pared to other studies on Saudi population.11,12 Gupta et al.6 The present study is the first large scale study of this type to be showed almost equal prevalence on Indian population whereas conducted in Jazan region. A similar but small scale study was the rate reported by Thongudomporn et al.7 on Australian conducted almost two decades back involving selected DDA population is quite high. An interesting finding is that the on children.13 Several studies have been conducted in other prevalence of retained deciduous teeth in this study population regions of Saudi Arabia with variable sampling and conflicting was higher, contributing for the increased occurrence of ecto- results.11–15 But these studies have analyzed selected dental pic eruption. Maxillary canine was the most common ectopi- anomalies and have not reported their overall prevalence. cally erupted tooth supporting the findings of previous The prevalence of DDA was close to that observed by studies.6–8,12 Gupta et al on an Indian population6 and Uslu et al. on Root dilaceration was present in 7.2% of cases which Turkish population.8 Few studies have shown a higher preva- was significantly greater than those observed in other lence, probably due to inclusion of third molars; a tooth that is studies.7–9,11,14 Possibility of misdiagnosis of dilaceration is known to exhibit anatomic variation.7,9 On the other hand, greater with panoramic radiographs as it is difficult to identify some studies were conducted on orthodontic patients who the root angulation in labial and lingual directions. The preva- might have a greater tendency to show dental anoma- lence of hypodontia was significantly lower compared to other lies.7,8,10,12 Many studies have focussed on outpatient dental studies,8,10 due to exclusion of third molars. Maxillary lateral patients, similar to this study.6,9,11,13–15 The present study incisor was the most common missing tooth, similar to the ascertains the prevalence rate in adults unlike other studies findings of Ghaznawi et al.14 The cause for hypodontia is which have been conducted in children with mixed mostly genetic but some environmental factors like trauma 32 N.V. Vani et al.

Table 3 Comparison of prevalence of developmental dental anomalies in various populations Studies Gupta Uslu Thongudomporn Nemati Kositbowornchai10 Ghaznawi Present study et al.6 et al.8 et al.7 et al.9 et al.14 2014 Sample size 1123 900 111 1224 570 1010 1000 Population Indian Turkish Australian Iranian Thai Saudi Arabian Saudi Arabian %%% % % % % Rotation 10.25 – – – – – 20.2 Ectopic eruption 7.93 0.6 14.4 – – – 7.6 Transposition – – – 0.1 1.6 0.2 0.3 Hypodontia 4.19 21.6 8.1 – 26.1 9.41 5.2 Hyperdontia 2.4 0.3 1.8 1.1 2.7 1.19 1.0 Taurodontism 2.49 1.0 9.9 0.5 – 8.61 2.9 Talons cusp 0.97 – – – – – 1.5 Dilaceration – 3.2 1.8 5.1 – 1.19 7.2 Supernumerary – – – – 2.2 – 0.7 roots Microdontia 2.58 0.7 9.9 3.8 13.7 5.35 0.9 Macrodontia – – – – 1.4 0.5 0.6 Total 34.28 40.3 74.7 47.5 – 26.45 37.8

in the tooth bearing areas like fractures, surgical procedures 5. Conclusion and extraction of primary teeth can also contribute to this 19 condition. Few cases of hypodontia were observed in families A significant number of Saudi subjects had dental anomaly. supporting their genetic etiology. The prevalence of rotation is strikingly high and associated The prevalence of supernumerary teeth was similar to other 11,12,14 15 with other dental problems. Both males and females were studies in Saudi Arabia except the one by Osuji et al. equally affected. Comparison of our data with similar studies who has reported a higher rate due to the inclusion of decidu- in Saudi or other populations showed variations and higher ous dentition. Although the prevalence of taurodontism was 7 prevalence. This may be due to genetic and environmental lower than that observed by Thongudomporn et al. and influence on tooth development. The high prevalence of Ghaznawi et al.,14 it was comparatively higher than most 8,9,11 DDA highlights the need for raising awareness about their studies. High prevalence of vitamin D deficiency in this diagnosis, intervention and treatment as they may complicate population can account for this rather increase in taurodon- 20 treatment of other dental diseases. Within its limitations, our tism. Talon’s cusp accounted for 1.5% with almost equal study presents the prevalence and distribution of DDA and unilateral and bilateral occurrence. But the incidence of talon’s 15 also proposes the possible contributing factors that could be cusp reported by Osuji et al. was markedly high, probably related to these anomalies. Further research into etiological due to the inclusion of deciduous dentition along with perma- factors for dental anomaly presentation in adults in Saudi nent dentition. Transposition was observed in 3 cases (0.3%) Arabia could create awareness and guide preventive strategies involving maxillary lateral incisor, canine and first premolar to assist in minimizing the associated dental problems. similar to the findings of Ghaznawi et al.14 This can be attrib- 21 uted mostly to genetic factors. Conflict of interest Supernumerary root was noted in only 7 patients (0.7%). Many studies have not included this entity except for 10 None. Kositbowornchai et al. with a slightly higher prevalence of 2.2%. Their determination, however is difficult in panoramic Acknowledgements radiographs as it represents a two dimensional image with more chances of misdiagnosis due to overlapping of normal The authors would like to express their gratitude to Dr. anatomic roots. The incidence of microdontia (0.9%) was Mohammed Badr Hassanin, Clinical Director of Dental comparatively lower in this study unlike other studies due to clinics; Miss. Helen Pio and Mrs. Erna Calip Purificacion, exclusion of third molars.10,14 Similar to other studies, the Radiology technicians; Ebtisam Hussain Moafa, Rana Jaber prevalence of macrodontia was also lower.10,14 Structural Nahari, Ebtihag Hassan Adawi, undergraduate dental stu- anomalies were not considered in this study, as it would be dif- dents, Faculty of Dentistry, Jazan University for their support ficult to detect them in radiographs thereby warranting clinical and co-operation. examination along with radiographic evaluation. Several investigators have shown significant differences in References the prevalence of DDA in different populations.4–10 Furthermore, variation was also observed among the studies 11–15 1. Kotsomitis N, Dunne MP, Freer TJ. A genetic aetiology for some done on Saudi Arabian population. A plausible explana- common dental anomalies: a pilot twin study. Aust Orthod J tion for these observations may be due to differences in study 1996;14(3):172–8. design, diagnostic criteria, sampling techniques; racial differ- 2. Neville DW, Damm DD, Allen CM, Bouquot JE. Abnormalities ences; influence of environmental factors and the effect of of teethOral and Maxillofacial Pathology. 2nd ed. Philadelphia, nutritional status on tooth development. PA: Elsevier; 2005. p. 49–89. Prevalence of developmental dental anomalies among adult population of Jazan 33

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