Original Article

ENAMEL DEFECTS FREQUENCY IN DECIDUOUS TEETH 1Shehla Zahid,BDS, FCSP-ii Trainee 2Anser Maxood, BDS,MSc, FRACDS (Sydney) 3Saeeda Abdullah, BDS, MCPS, FCPS ABSTRACT Developmental defects of the enamel are the result of alterations during amelogenesis due to hereditary, systemic or environmental factors. The present study was done to determine the frequen- cy of developmental defects of enamel in primary teeth at Children Hospital PIMS, Islamabad from February 2011 to January 2012. The study was cross sectional and sample comprised of 300 children, which included 182 (60.7%) males and 118 (39.3%) females. The mean age of the studied population was 3.63±1.05 years. Enamel defects were present in 115 (38.3%) children. Out of 182 males 69 (37.9%) males and out of 118 females,46 (38.9%) females had enamel defect; thus frequency of enamel defect was not significantly different between the two genders (p=0.852). The mean age of the children with enamel defect was 3.74±1.00 and mean age of children without enamel defect was 3.55±1.06 years respectively. This difference was not statistically significant (p=0.124). Frequency of enamel defect was significantly higher among families with higher income categories (p=0.020).Out of 300 children, 185 (61.7%) had normal enamel, 5 (1%) had only demarcated opacity, 9 (3%) had only diffuse opaci- ty, 80 (26.7%) had only hypoplasia, 3 (1%) had demarcatead diffuse opacity, 3 (1%) had demarcated opacity with hypoplasia, 13 (4.3%) had diffuse opacity with hypoplasia and 2 (0.7%) had all three defects. Present study concluded that more than one third of the children had developmental defects of enamel in primary teeth and most frequent lesion was enamel hypoplasia. Key Words: Enamel defects; enamel hypoplasia; fluorosis; enamel hypomineralization.

INTRODUCTION diagnose enamel defects; such as whether enamel opacities were included in the diagnosis. Children from Developmental defects of enamel may be defined as developing countries are generally found to display a disturbances in hard tissue matrices and in their min- high incidence of enamel defects while a lower incidence eralization during odontogenesis. When this complex is found in children from developed countries.11 sequence of cytological and physico-chemical events is disrupted by genetic or environmental factors, the In the field of public health, developmental defects function of the ameloblast may be disrupted perma- in the enamel have taken on a high level of importance nently or temporarily.1,2 This results in the formation for being predictors of dental caries. Populations affect- of enamel exhibiting qualitative or quantitative defects ed by these changes require as a priority preventive that may range from a complete absence of enamel to intervention and early treatment. Dental enamel de- a normal thickness or no change in structure except fects are a frequent finding in primary . These for a slight abnormality in colour.3 The type of defect is defects are generally classified as enamel hypoplasia dependent on the stage of amelogenesis at the time of or enamel hypomineralization. Enamel hypoplasia is a the disturbance.4 More recently, as a result of the need quantitative defect, whereas enamel hypomineraliza- for uniform nomenclature, a working group of the Com- tion is a qualitative defect characterized by abnormal mission on Oral Health Research and Epidemiology of enamel translucency and is therefore also known as the "Federation Dentaire Internationale" has produced enamel opacity. In a study in which enamel defects an Epidemiological index of developmental defects of were classified and recorded according to the modified enamel (DDE Index).5,6 Studies conducted in different DDE index, its prevalence was 48.5% and boys were parts of the world revealed a prevalence of develop- more affected.12 The developmental defects of enamel mental defects of enamel varying from 0%-60%.7-10 The are changes in deciduous dentition that lead to aesthetic differences observed are dependent on the population problems, dental sensitivity and may be predictors of studied, the teeth examined and the criteria used to caries. In another cross-sectional study, prevalence of DDE was 24.4%. Diffuse opacities were the most com- 1 PIMS, Islamabad Email: [email protected] 2 mon defects (17.9%), followed by hypoplasia (11.1%) Professor Anser Maxood, BDS, MSc, FRACDS (Sydney) 13 HOD, Dental Department, PIMS and demarcated opacities (6.1%). 3 Assistant Professor,Dental Department,PIMS In the past levels of enamel hypoplasia were fre- Email: [email protected] quently used to study health. The study of Massoni Received for Publication: February 2, 2014 Accepted: February 16, 2014 revealed the proportion of individuals with enamel

Pakistan Oral & Dental Journal Vol 34, No. 1 (March 2014) 122 Development enamel defects hypoplasia in both genders and in young as well as Descriptive statistics like mean SD were calculated adults using the FDI developmental defects of enam- for quantitative variables like age. Frequencies and el (DDE) Index.14 Although males and females were percentages were calculated for qualitative variables equally affected but females had a higher prevalence like enamel defects and its types and gender. For cat- of enamel hypoplasia than males. Adults had a higher egorical comparisons chi square test was used and for prevalence of enamel hypoplasia than juveniles. These numerical comparisons independent samples t-test was differences were largely due to different patterns and used. A p value of <0.05 was considered statistically frequencies of enamel hypoplasia in deciduous teeth significant. compared to . In another study the prevalence of enamel defects was higher (49.6%) in male RESULTS (p<0.001). The most frequent type of defect was diffuse opacity (9.5%) and the most affected surface Out of 300 children 182 (60.7%) were males and 118 were the buccal surface (83.3%) and the gingival half were (39.3%) female (fig 1), mean age was 3.63±1.05 (6.7%).14 In another study 510 children were examined years. The median and mode ages were 4 and 5 years in nursery schools and the prevalence of DDE of any respectively. In high SE group of children enamel de- type was found to be 45.4%, with that of demarcated fects were also present in other family members. Study opacities being the highest, followed by hypoplasia. The found fathers of 3(1.0%) children, mothers of 15(5%) most frequently affected teeth were primary maxillary children and other siblings of 21(7%) children also had anterior teeth, while the least affected teeth were pri- enamel defects (Fig 2). Among the males, 69 out of 182 mary mandibular . The mean DMFT was 3.9. (37.9%) had enamel defect and among the females, 46 A positive association between DDE and caries was out of 118 (38.9%) had enamel defect; thus frequency of also observed in that study.15 enamel defect was not significantly different between the two genders; p=0.852 (Table 1). Enamel defects are serious challenges because of their unaesthetic appearance, dental sensitivity and The mean age of the children with enamel defect subsequent susceptibility to dental caries. Therefore was 3.74±1.00 years and the mean age of the children the aim of this study was to find out the frequency of without enamel defects was 3.55±1.06 years. This enamel defect in deciduous teeth. difference was not statistically significant( p=0.124) (Table 2). The findings of this study will provide a clear vision of the distribution of this oral condition and may well Twelve children (22%) out of 54 were from lower socio economic group, 26 (30%) out of 76 children were contribute to early detection and treatment planning. from middle socioeconomic group and 74 (39.6%) chil- METHODOLOGY dren out of 172 were from high socio-economic group, thus frequency of enamel defect was significantly higher A cross-sectional study was conducted at Dental among families with higher income categories (p=0.020) Department of Children Hospital, Pakistan Institute (Table 3). Table 5 shows the summary of enamel de- of Medical Sciences, Islamabad (PIMS), from 1st fects enamel hypoplasia was the most common enamel February 2011 to 31st January 2012. A total of 300 defect (26.7%) among all defects, diffuse opacity with children were included by using, purposive sampling hypoplasia was second most common defect, 13 (4.3%) (non-probability) technique. Co-operative patients while only 2 (0.7%) children showed all types of defects. between the age groups 2-5 years of both sexes were included. Whereas patients who were uncooperative, DISCUSSION having teeth extracted, suffering from any bone disease were excluded. Informed consent was taken from the Despite the fact that the DDE Index gives infor- parents of children. The patient’s history was taken mation on a wide range of defects, their location and from parents about any medical illnesses in childhood distribution and direct comparisons with other studies of the patient or the mother during pregnancy. The are still a little difficult. This is because the large amount socioeconomic status (SES) of the patient was divided of data generated has caused difficulties in presenting into 3 categories. Families with less then 6000 rupees data in a meaningful fashion for interpretation and per month were considered in low socioeconomic group, comparison of results. This is further hampered by the families with monthly income between 6000-10,000 method of assessment in the different studies, either rupees were in middle socioeconomic group and families photographic or clinical. Reports in the literature on with more than 10,000 rupees were considered high developmental defects of enamel from developed coun- socioeconomic group. tries show much higher values than those reported in developing countries in recent times.16,17 A review of the Clinical examination was carried out under the reports of recently published study has shown that the dental unit light with mirror and a round ended prevalence of enamel defects varies from 20- 77%.All probe. The teeth were cleaned with gauze and dried the reports give higher values for enamel defect when using triple syringe to see the presence of enamel de- compared with the present study. The result of the fects. Only buccal surfaces of the teeth were examined present study showed less prevalence of enamel defect and defects were recorded in history sheets. Data were when compared with these studies. Studies from South analysed by using software SPSS 12 version. Wales and on Chinese children showed the maxillary

Pakistan Oral & Dental Journal Vol 34, No. 1 (March 2014) 123 Development enamel defects

38.30% TABLE 4: SUMMARY OF TYPEs OF ENAMEL DEFECTS ACCORDING TO MODIFIED DDE INDEX

present Types of defects Code n=300 61.70% Absent Normal 0 185 (61.7%) Demarcated Opacity 1 5 (1.7%) Diffuse Opacity 2 9 (3%) Hypoplasia 3 80 (26.7%) Other Defects 4 None Fig 1: Percentage of enamel defects found Combinations code Demarcated Diffuse opacity 5 3 (1%) Demarcated opacity with 6 3(1%|) hypoplasia Diffuse opacity with 7 13(4.3%) hypoplasia All the three defects 8 2(0.7%)

7% and mandibular incisors were found to be the most frequently detected teeth with a prevalence of 18.7% 5% and 40.8% respectively.18,19 In the present study enamel defects were more abundant in maxillary primary inci- sors and mandibular primary canines while minimum 1% involvement was seen in maxillary primary second molars and mandibular primary lateral incisors. Father Mother Silblings In the present study only clinical examination for the diagnosis was used,while in other studies photographs Fig 2: Enamel defects in other family members for assessments were used and revealed more lesions. In the developed countries cosmetic considerations to TABLE 1: ENAMEL DEFECTs AND GENDER improve the appearance of teeth with enamel defects is of major public health concern. However, cosmetic Defect Male Female Total P value consideration in developing countries is still low so a lot Present 69 46 115 0.8522 of these unaesthetic lesions are left untreated. In present Absent 113 72 185 study there was no cosmetic complaint from patients or parents. Cutress et al established that 23(1%) of children Total 182 118 300 studied had poor appearance from a sample of 1758 as a result of defects other than fluoride. Observations TABLE 2: ENAMEL DEFECTs AND AGE from other studies have also given similar reports.20,21 The high figure reported in the present study implies Enamel N Mean age Std. Std. P that there is a need for improvement of the oral health defect of the Devi- Error Value awareness as also suggested by Hamadan.22 Parents patient ation Mean should be encouraged to bring their children early and Present 115 3.74 1.00 0.0933 0.124 regularly for treatment for maximum benefits especially on preventive oral health care. Absent 185 3.55 1.069 0.0786 In another study by Aminabadi et al the prevalence TABLE 3: ENAMEL DEFECTs AND MONTHLY and the position of enamel defects was studied in pri- INCOME mary teeth of 3-5 years old children. They found 55.37% of the children were affected by enamel defects, 23.96% Monthly In- Enamel Defect Absent P being categorized as hypocalcification and 22.31% as 23 come (RS) Present value hypoplasia. In the present study the frequency of enamel defects were more in maxillary incisors (central <6000 12 (22%) 42 0.020 incisors) in maxilla (p<0.05) whereas the mandibular 6000-10000 26 (30%) 47 canine were the most commonly effected in mandibular teeth (p<0.05). Enamel hypoplasia was >10000 74 (39.6%) 96 the most commonly found defect in children in present Total 115 185 study and similar results were found by Lunardelli.24

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Present study found deciduous maxillary incisors were 10 Salako NO, Adenubi JO. Chronological enamel hypoplasia. Trop the most commonly affected than other teeth which is Dent J. 1984; 29-37. similar to other studies in which the incisors were the 11 Clarkson JO, O’Mullane DA. Prevalence of enamel defects/ most affected teeth.25,26 In some other studies molars fluorosis in fluoridated and non-fluoridated areas in Ireland. were the most affected teeth.27,28 Community Dent Oral Epidemiol. 1992; 20: 196-99. 12 Enwonwu CO. Influence of socio-economic conditi ons on dental In a local study by Khan et al scoring for enamel development in Nigerian children. Arch Oral Biol. 1973; 18: defects was made from a sample of 1000 color pho- 95-107. 29 tographs. These photographs were of teeth 13 Osuji OO, Leake Jl, Chipman ML, Nikiforuk G, Locker D, of 10-year-old children living in an area with water Levine D. Risk factors for dental fluorosis in a fluoridated and fluoride levels below 0.45 parts per million. On mod- non-fluoridated community. J Dent Res 88; 67: 1488-92. ified Developmental Defects of Enamel (DDE) index, 14 Sawyer DR, Taiwo EO, Mosadomi A. Oral anomalies in Nigerian 652 (66.0%) children and 1086 (55.5%) teeth (upper Children. Community Dent Oral Epidemiol. 1984; 12: 269-73. central incisors) were scored as having enamel defects. 15 Adenubi J. Dental Health Status of 4/5 year old children in Diffuse defects were the most common in that study. Lagos private school. Nig Dent J 1980; 1: 28-39. The frequency was higher perhaps because different 16 Ellwood RP. A photographic study of developmental defects of method of examination was used. enamel in Brazilian School Children. University of Manchester, England. Msc. Thesis 1995. CONCLUSION 17 nunn JH, Ekanayake L, Rugg-Gunn AJ, Saparamandu KDG. Assessment of enamel opaciti es in children in and More than one third of the children had develop- England using a Photographic method. Community Dental mental defects of enamel in deciduous dentition and Health. 1993; 10: 175-88. most frequent lesion was enamel hypoplasia in present 18 Dummer PMH, Kingdon A, Kingdon R. Distribution of devel- study. opmental defects of by tooth type in 11-12 year old children in South Wales. Community Dent Oral Epidemiol. Recommendations 1986; 14: 341-44. Present study was based on clinical examination, 19 li Y, Navia JM, Blair JY. Prevalence and distribution of de- and only frequency of enamel defects was assessed. velopmental enamel defects in primary dentition of Chinese Further studies must be carried out to detect enamel children 3-5 years old. Community Dent Oral Epidemiol. 1995; defects with the help of other methods e.g. photographic 23: 72-9. or staining method. 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