Original Article Cementoenamel junction-alveolar bone crest distance in interproximal areas of intact primary molars in healthy 7-9 year old girls in Hamadan

Shariatmadar Ahmadi, R. * Torkzaban, P. ** Gholami, L. *** * Assistant Professor, Department of Periodontics, Faculty of Dentistry, Azad University of Medical Sciences. ** Assistant Professor, Department of Periodontics, Faculty of Dentistry, Hamadan University of Medical Sciences. *** Post-graduate student of Periodontics, Faculty of Dentistry, Hamadan University of Medical Sciences. ABSTRACT

Statement of the problem: Early detection of periodontal disease and distruction is important for prevention of further destruction of the tissues. We carried out this study to determine the normal cement enamel junction (CEJ) to alveolar bone crest (ABC) distance in the interproximal area of primary molars on bitewing (B. W) radiographs in healthy 7-9 year old girls living in Hamadan, Iran.

Materials and Methods: Four hundred healthy 7-9 year old junior school girls with no clinical evidence of dental caries, diastema and fillings in intermolar areas (D, E) were selected by cluster method and 800 bitewing radiographs were taken and examined. Results: From 3200 measurements, only 2582 sites were included in the study. The mean cementoenemal junction- alveolar bone crest distance of all primary teeth was 1.1 mm. 7.7% of the total examined surfaces showed distances of greater than 2mm indicating the prevalence of alveolar bone loss. The mean distances measured in the maxilla were greater than the which was statistically significant (P<0.05). Conclusion: This study provides useful base line data on alveolar bone height in assessment by radiographical examination. It is important to establish proper diagnostic measurements to identify patients at risk and further studies are recommended. Keywords: Periodontitis, Cementoenemal junction, Alveolar bone crest, Primary molars INTRODUCTION indicated that juvenile periodontitis in the Destruction of bone still remains as the permanent dentition of adolescents can (2-4) most important criterion for assessing the often rapidly destroy the periodontium. severity of periodontitis and identifying This indicates the importance of early individuals susceptible to periodontal tissue recognition and treatment of these patients breakdown. (1) Recent studies have to prevent the transition of the Early Onset Corresponding Author: P. Torkzaban Address: Periodontitis (EOP) is now considered as Member of Dental Research Center and Assisstant aggressive periodontitis, from the primary Professor, Dept. of Priodontology of Faculty of dentition to the permanent dentition. Dentistry of Hamadan University of Medical Children and adolescents susceptible to Sciences, Fahmideh Blv, Hamadan, Iran. Tel: +98 8118354018 Email:[email protected] periodontal disease should be identified as

DJH 2010; Vol.2, No.1 35 Torkzaban et al. Cementoenamel junction-alveolar bone… early as possible in order to prevent the backgrounds, sex, age, stage of dentition, advance of a possibly destructive disease. oral hygiene and values of the alveolar bone Several authors have introduced bitewing height in primary molars using direct radiographs as useful diagnostic methods of measurements in standardized bitewing (B. early detection of bone loss in the primary W) radiographs in healthy 7-9 year old girls and permanent dentitions. (5-7) Sometimes, it living in Iran, Hamadan, ( west of Iran). In can be difficult to diagnose alveolar bone addition, this study evaluated whether loss in the primary dentition due to alveolar bone height varied due to function increased distance between cementoenamel and dental arch position. junction (CEJ) and the level of alveolar MATERIALS & METHODS bone crest (ABC). However, in clinical In this study, 400 healthy 7-9 year old practice, general practitioners and junior school girls with no clinical evidence periodontists rely on both radiographic and of dental caries, diastema and fillings in the clinical measurements of bone loss as intermolar areas (D, E) were selected. Then, (5, 8) diagnostic tools. The radiographic signs bitewing radiographs were taken and as evidence of initial periodontal examined. The selected B.W. radiographs breakdown are 1- widening of the had the following criteria: minimal periodontal ligament space, 2- diffuseness evidence of distortion, minimal or absence of the crest cortical plate, 3- overlapping, and clear image of CEJ and thinning or absence of the trabeculae of the ABC in primary molars. Teeth restored crestal alveolar, and 4- quantitative changes with S.S.C (stainless steel ) but with in the distance from the cementoenamel visible CEJ were also included. Eight dental junction (CEJ) to the alveolar bone crest surfaces were studied for each one. The (9) (ABC). For diagnosis of alveolar bone radiographs were analyzed and the distance loss, the distance from CEJ to the ABC between the CEJ and the alveolar crest on (6, 10-13) should be greater than 2mm. the mesial of E and the distal of D were Periodontal diseases in children may measured using a digital caliper (Mituyoto, indicate the presence of predisposing with 0.01 mm accuracy) and a lens on a factors that can facilitate the establishment negatoscope. Measurements were only of disease in subsequent ages, which in preformed on fully erupted teeth which some cases are associated with systemic were in function. All measurements were (5, 14) diseases. Prevalence of periodontitis in done by one periodontist. The student’s children and adolescents ranges from 0% to ages were recorded. Data were analyzed by 51.5%. The wide range might be due to SPSS version 10. ANOVA test was used to differences in the patients regarding ethnic compare the variables.

36 DJH 2010; Vol.2, No.1 Torkzaban et al. Cementoenamel junction-alveolar bone…

RESULTS site or even more, which shows higher risk From 800 bitewing radiographs of 400 for early onset of periodontitis in them. girls, totally, 3200 surfaces were measured Based on the mean alveolar crest level of 8 but, only 2582 surfaces were included in examined sites in primary molars the this study. Table 1 shows the mean maximum prevalence of bone loss was distances and distribution of CEJ -ABC in found in URE (Upper right D) (18.4%). The interproximal areas of primary molars Minimum prevalence of bone loss was 1% according to age (Table 1). The mean CEJ- in LLD (left right D). (Table1) ABC distance for all primary teeth was 1.1 The mean distance of CEJ-ABC for the ± 0.5 mm. In 201 surfaces (7.7%) of the maxillary primary molars was greater than total examined surfaces the distances were that of the mandibular primary molars but greater than 2mm which indicates the the difference was statistically significant prevalence of alveolar bone loss. This value (P<0.0001) (Table2). The mean bone levels was 8.7% in 7-year- old girls , 6.4% in 8- in the right side of maxilla were more than year-girls and 8.3% in 9-year – old girls that in the left side (P<0.0001) (Table3). which showed no statistically significant There was no statistically significant differences. In 33% of girls, the CEJ -ABC difference in CEJ to alveolar crest distance distance was more than 2mm in at least one in different age groups. (P>0.05) (Table 4)

Table 4: The mean distance of CEJ- ABC and distribution in the interproximal surfaces of molars by age in girls.

Study Bone Level  2mm Bone Level >2mm No Bone Level *P.value groups (mean  SD)

percentage No. percentage No.

7years 91.2 1091 8.7 105 1196 1.09  0.573

8years 93.1 573 6.4 44 797 1.06±0.437

9years 92.6 537 8.3 52 589 1.15±0.49 P=0.542

Total 92.3 2381 7.7 201 2582 1.1±0.494

*ANOVA. One TEST

DJH 2010; Vol.2, No.1 37 Torkzaban et al. Cementoenamel junction-alveolar bone…

Table 2: The comparisons of mean bone level of the jaws.

Region of jaw No. Bone Level *P.value

(mean  SD)

Maxilla 173 1.18±0.616

Mandible 173 1.02±0.307 P=0.00

*Independent two samples t.test

Table 3: The comparison of mean bone level in maxillary and mandiblular quadrants.

Region of jaw Bone Level No. *P.value

(mean  SD)

Left Maxilla 1.06±0.759 272

Right Maxilla 1.38±0.644 272 0.000

Left mandible 0.293±0.98 250

Right mandible 0.03±0.472 250 0.132

*Independent two samples T.test

Table 1: Bone loss prevalence in different areas.

Mm2  Bone Level Mm2  Bone Level Region percentage Number percentage Number

(18.4) 61 (81.6) 271 URD

(15.9) 52 (84.1) 276 URE

(9.6) 31 (90.4) 293 ULE

(8.7) 28 (91.3) 294 ULD

(2.8) 9 (97.2) 315 URD

(2.7) 9 (97.3) 320 URE

(2.5) 8 (97.5) 318 LLE

(1) 3 (99) 294 LLD

(7.7) 201 (92.3) 2381 Total

38 DJH 2010; Vol.2, No.1 Torkzaban et al. Cementoenamel junction-alveolar bone…

DISCUSSION Bimstein et al.reported the prevalence of Previous studies have described that periodontitis in in 2.1-8.5% (17) juvenile periodontitis or early onset in New Zealand. In another study, periodontitis can be diagnosed in primary Sjodin et al. found a prevalence of 0.9- dentition when distances between CEJ- (12) 4.5%. In the present study, the mean ABC are more than 2 mm (according to B. ABC-CEJ distance for the maxillary (5-8) W. radiographs). Therefore, successful primary molars was more than that of treatment might be achieved before mandibular primary molars. This difference are getting involved. In all was statistically significant. In previous populations, practitioners should routinely studies, Needleman et al. Shapira measure the distance between ABC and et al. Dummer et al. and Bishop et al. have CEJ, using BW radiographs to detect early reported more bone loss in maxilla than signs of periodontal diseases and also to (15, 18-20) mandible. One possible explanation (5,6,8) recognize high-risk patients. In the is that plaque and calculus accumulation is present study, the mean CEJ -ABC distance more common in maxilla than mandible was 1.1 mm located in the range as found (due to location of parotid gland duct by Needleman et al. in the USA(0.58-1.39 orifice near the first upper ). Another mm), Sjodin & Matsson in Sweden (1mm ) possible reason could be that the cortical and Bimstein et al. in the USA.(0.97 bone in maxilla is thinner, less dense and (15-17) mm). In the current study, the more rigid than that in mandible; therefore, prevalence of bone loss in total examined the maxillary alveolar bone undergoes surfaces is 7.7%. Compared with previous resorption more readily than that of the studies this prevalence is located in the mandible. Contrarily, some studies showed (12, (21) range of Asian epidemiological reports. no significant difference in this issue. In 13) Some other studies have reported the this study, there was a significant difference prevalence of bone loss ranges from 0% to between right and left sides of the mandible (15) as all the distances of the right side were 51.5% . In this report, 33% of girls had greater than those of the left side. one or more sites with an ABC-CEJ McDonald suggested that the contralateral distance more than 2mm, which are side of a jaw (left side for the Right Handed suspected to have periodontal diseases person) is brushed more than the epilateral which is a little more than the amounts side and children spend more brushing time found in other similar studies .Mattson & (22) Sjodin reported a prevalence of marginal for the mandible than maxilla. But bone loss range of 0.2-4.5% in young Needleman and Bimstein et al. found no (10) significant differences between the school children in Sweden. In addition,

DJH 2010; Vol.2, No.1 39 Torkzaban et al. Cementoenamel junction-alveolar bone… corresponding teeth on the right and left groups of children. It is also possible that (15, 17) sides of the mouth. There was no within a short time interval (7-9 years) an significant association between age and increase in the CEJ-ABC distance can not marginal bone level in this study; however, be detected with the applied methods. It is gradual increase in CEJ-ABC distance worthy to note that our results are correct along with the increase of the age has been for normal CEJ-ABC distance in girls aged reported. Needleman et al. Bimstein & 7 - 9. However, this study does not evaluate Soskolon, Bimstein & Garcia-Godoy had the progression rate of periodontitis in (14, young individuals. But clinicians must be detected this relationship in their studies. 15, 23) aware that children may develop This finding may reflect the influence periodontal disease affecting the alveolar of eruption and exfoliation in the older age bone. CONCLUSION 2.Sjodin B, Crossner C.G, Unell, Ostland, P. A retrospective radiographic study of alveolar Accurate measurements presented in this bone loss in the primary dentition in-patients study may indicate the early stage of a with localized juvenile periodontitis. J Clin periodontal disease in primary dentition Periodontol 1989;16:124-127. and/or predisposing the development of 3.Cogen R.B, Tate A.L, and Wright JT. periodontal diseases in young girls. Destructive periodontal disease in healthy Therefore, patients at risk should be children. J Periodontol 1992; 63:761-5. identified and cured carefully. The most 4.Sjodin B, Mattsson L. Marginal bones loss in important step is to establish proper the primary dentition of patients with juvenile diagnostic measurements to prevent the periodontitis. J Clin Periodontol. 1993; 20: 321- chronicity and continuous progress of 36. 5.Lindeh, J. Karring, T. Lang, and N .P: Clinical periodontal disease. As there are few periodontology and Implant dentistry .4th Ed. epidemiological studies on periodontitis in Munksgaard; 2003. Chap: 1, 8, 9. the primary dentition and also because of 6.Carranza F .A, Newman M.G:Carranza’s the high prevalence of bone loss in Clinical Periodontology .9th Ed. Sounders Co; prepubertal years, further longitudinal 2002. Chap: 1,2,4,27,45. studies are suggested. 7.Bear P .N. The case for periodontal disease in REFERENCES the primary dentition. Journal of Pedodontics 1.Guimarães Mdo C, de Araújo VM, Avena 1984; 8: 206-210. MR, Duarte DR, Freitas FV. Prevalence of 8.Sweeny E.A, Alcoforado G.Ap, Nyman S & alveolar bone loss in healthy children treated at Slots J. Prevalence and microbiology of private pediatric dentistry clinics. J Appl Oral localized prepubertal periodontitis. Oral Sci. 2010; 18(3):285-90. microbiol and immunol 1987; 2: 65-70.

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