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CLINICAL DENTISTRY AND RESEARCH 2016; 40(3): 123-129 Original Research Article EVALUATION OF TREATMENT NEEDS OF PERMANENT FIRST MOLAR TEETH IN A GROUP OF SCHOOLCHILDREN ATTENDING TO UNIVERSITY DENTAL CLINICS IN ANKARA AND ISTANBUL Banu Öter, DDS, PhD Dr, Baskent University, İstanbul Research and Training Hospital, Istanbul, Turkey Resmiye Ebru Tirali DDS, PhD Associate Professor, Baskent University, Faculty of Dentistry, Department of Pedodontics, Ankara, Turkey Sevi Burçak Çehreli DDS, PhD Professor, Baskent University, Faculty of Dentistry, Department of Pedodontics, Ankara, Turkey ABSTRACT Background and Aim: The permanent first molar teeth (PFM) have a great importance because of playing a key role in occlusion. The aim of this study is to evaluate caries prevalance and treatment needs of first molar teeth in a group of schoolchildren attending to the university’s dental clinics in Ankara and Istanbul. Material and Methods: In this multi-centered retrospective study, records of 507 children aged between 6-12 (mean age 9.39±1.47) who attended to Başkent University Dental Faculty Department of Pedodontics (Ankara) and Başkent University Istanbul Hospital (Istanbul) were evaluated and dft, DMFT and treatment need index (TNI) were detected. One way ANOVA with Tukey’s multiple comparison tests, independent t tests and extension of Fisher’s exact test to r x c contingency table were performed. Results: Mean dft, DMFT scores were found 3.44±2.93, 1.35±1.72 in boys, and 3.24±2.94, 1.57±1.74 in girls respectively. Totally 2028 PFM teeth radiograph were examined, 20% needed fissure sealant, 21% needed one surface, 5% needed two surface restoration, 3% needed endodontic treatment, 0.2% extraction, 0.8% needed prosthetic treatment. When the study group was evaluated in three different age groups, DMF scores of first molars in 6-8 ages were found statistically lower than 9-10 and 11-12 age groups (p<0.001). Conclusion: According to the results obtained from schoolage children attending to the university dental clinics in two different cities, caries threatens first molar health severely. The treatment need increases with age, thus, as soon as molars erupt, preventive procedures are of great importance. Correspondence Banu Öter Clin Dent Res 2016: 40(3): 123-129 İstanbul Research and Training Hospital Baskent University, Istanbul, Turkey Mahir Iz St. 43 34662 Altunizade/Istanbul-Turkey Phone: +90 216 651 51 53 Fax: +90 651 38 82 Cellular phone: +90 532 681 96 17 E-mail: [email protected] Keywords: Children, Permanent First Molar, Treatment Needs Submitted for Publication: 03.15.2016 Accepted for Publication : 11.22.2016 123 CLINICAL DENTISTRY AND RESEARCH 2016; 40(3): 123-129 Orijinal Araştırma ANKARA VE İSTANBUL’DA ÜNİVERSİTE DİŞ KLİNİKLERİNE BAŞVURAN BİR GRUP OKUL ÇAĞI ÇOCUKLARINDA SÜREKLİ BİRİNCİ BÜYÜK AZI DİŞLERİNİN TEDAVİ GEREKSİNİMİNİN DEĞERLENDİRİLMESİ Banu Öter Dr., Başkent Üniversitesi, İstanbul Sağlık Uygulama ve Araştırma Merkezi Hastanesi, Ağız ve Diş Sağlığı Polikliniği İstanbul, Türkiye Resmiye Ebru Tirali Doç. Dr., Başkent Üniversitesi, Diş Hekimliği Fakültesi, Pedodonti Anabilim Dalı, Ankara, Türkiye. Sevi Burçak Çehreli Prof. Dr., Başkent Üniversitesi, Diş Hekimliği Fakültesi, Pedodonti Anabilim Dalı, Ankara, Türkiye. ÖZ Amaç: Birinci büyük azı dişleri okluzyonda kilit bir rol oynadığından büyük öneme sahiplerdir. Bu çalışmanın amacı, İstanbul ve Ankara illerinde üniversitenin diş kliniklerine başvuran bir grup okulçağı çocuklarında birinci büyük azı dişlerinin çürük prevalansını ve tedavi indekslerini değerlendirmektir. Gereç ve Yöntem: Bu çok merkezli retrospektif çalışmada, Başkent Üniversitesi Diş Hekimliği Fakültesi Pedodonti Anabilim Dalı’na (Ankara) ve Başkent Üniversitesi İstanbul Hastanesi’ne (İstanbul) başvuran ve yaşları 6-12 (ort 9.39±1.47) arasında değişen 507 çocuğun ilk muayene kayıtları incelenmiştir ve dft, DMFT ve tedavi gereksinimi indeksi (TGİ) belirlenmiştir. Tek yönlü varyans (ANOVA) analizi ve çoklu karşılaştırma için Tukey testi, bağımsız t testi ve rxc kontenjans tablolarına göre Fisher’s exact testleri yapılmıştır. Bulgular: Ortalama dft, DMFT değerleri erkeklerde sırasıyla 3.44±2.93, 1.35±1.72 ve kızlarda 3.24±2.94, 1.57±1.74 belirlendi. Toplam 2028 adet birinci büyük azı dişinin radyografları incelendi, bu dişlerin %20’sinde fissür örtücü gereksinimi, %21’inde bir yüzlü restorasyon, % 5’inde iki yüzlü restorasyon, %3’ünde endodontik tedavi, %0.2’sinde çekim ve %0.8’inde protetik tedavi gereksinimi bulunduğu kaydedildi. Üç farklı yaş grubu değerlendirildiğinde, 6-8 yaşları arasındaki çocuklarda DMF değerleri 9-10 ve 11-12 yaş gruplarına göre anlamlı derecede (p<0.001) düşük görüldü. Sorumlu Yazar Banu Öter Başkent Üniversitesi, İstanbul Sağlık Uygulama ve Araştırma Merkezi Hastanesi, Ağız ve Diş Sağlığı Polikliniği Mahir İz Cad. No:43 34662 Altunizade/İstanbul-Türkiye Telefon: +90 216 651 51 53 Fax: +90 651 38 82 Gsm: +90 532 681 96 17 E-mail: [email protected] 124 Sonuç: İki büyük ve farklı şehirde bulunan üniversite kliniklerine başvuran okulçağı çocuklarından elde edilen bilgilere göre, diş çürüklerinin birinci büyük azı dişlerinin sağlığını önemli derecede tehdit ettiği görülmüştür. Tedavi ihtiyacı yaşla birlikte artmaktadır, bu nedenden azı dişleri sürer sürmez koruyucu uygulamalar büyük önem taşımaktadır. Clin Dent Res 2016: 40(3): 123-129 Anahtar Kelimeler: Çocuklar, Birinci Büyük Azı Dişleri, Tedavi İhtiyacı Yayın Başvuru Tarihi : 15.03.2016 Yayına Kabul Tarihi : 22.11.2016 A multi-centered retrospective study INTRODUCTION Dental caries and periodontal diseases are important microbiologic diseases that threaten oral health in many countries, especially the developing ones. Since 1980s, a decline has been reported in the prevalence of dental caries by developed countries. 1,2 The situation was linked to a variety of factors such as (i) the increase in the use included in the study population. The PFM was considered as erupted once it is fully exposed to oral cavity or be suitable to examine with an explorer without displacing soft tissues. The records of children with systemic disease or the ones undergoing orthodontic treatment were excluded. Exclusion criteria and treatment needs of PFM in a group of schoolchildren Children with unerupted PFM and enamel hypoplasia and history of dental trauma were excluded from the study population. All intraoral examinations were performed by 3 pediatric dentists. All examiners were trained and calibrated in a postgraduate doctorate programme in pediatric dentistry in the diagnostic criteria guidelines based on those of the World Health Organisation and independently carried out the child’s oral examination for dental caries.9 The examinations were performed according to WHO criteria with a mouth mirror, an explorer and reflector light. In both departments, panoramic radigraphs were taken when needed during first appointment. Thus the researchers evaluated the orthopantomographs (OPGs) as well. In present study OPGs were used to aid clinical diagnosis of dental caries. According to the WHO guidelines on epidemiological studies the use of radiographs do not indicate diagnose dental caries 9 because of financial, ethical and practical reasons. However, all children attending in our university dental clinics should have radiographs taken routinely because health insurance system requests OPGs both prior to and following treatment of patients. attending to university dental clinics in Istanbul and Ankara, Ethics of toothpastes containing fluoride, (ii) decrease in sugar consumption (iii) the increase in socio-economic status, preventive dental services, and personal oral hygiene practices. 2,3 However, in developing countries which preventive dental practice is not yet widespread, dental health problems are still seriously effecting the population both socially and economically. 3.4.5 The permanent first molar teeth (PFM) are commonly the first permanent teeth to erupt in the posterior region and they play a key role in the developing occlusion. These teeth mostly emerge in the oral cavity at 5-7th years of life, which is the initiation of the transition stage for permanent dention and development of normal occlusion.3,6 PFMs are claimed to be the most susceptible tooth to carious attack due to several factors such as (i) deeper pit and fissures when compared with other posterior teeth (ii) lack of toothbrushing habits at the time they emerge (iii) patients’ lack of knowledge about these teeth are permanent teeth which do not have a predecessor .7,8 The aim of this study was to evaluate caries prevalence two biggest cities in Turkey. Although the data belongs to measures. This study was approved by Baskent University Institutional Review Board (Project No D-KA12/05). Informed consent forms were delivered as a routine procedure before dental examination or interventions in both clinics. Study population and methods Study design Study material The clinical data for present study were collected by following the general principles for Basic Oral Health surveys of the WHO.9 Traditional dft, DMFT (WHO) and treatment need index (TNI) were used. 10 Basic levels of treatment need were classified in seven groups in TNI index: (1) no treatment needed; (1) preventive treatment; fissure sealants; (3) initial conservative restorations; one surface restorations (4) moderate conservative restorations; two or more surface restorations (5) invasive treatment, including pulp therapy, (6) prosthetic restorations and (7) extractions. Children were divided into a small group among whole population, the findings will give light to construction and development of preventive This is a multi-centered retrospective study, which evaluated the records of a total of 507 children aged between 6-12 (med age 9.39±1.47) who attended to Baskent University Dental Faculty Department of Pedodontics (Ankara) and Baskent University İstanbul Hospital (İstanbul) between the years 2010-2012. Inclusion criteria Retrospective examination records of otherwise healthy children whose 4 permanent first molars had erupted were 125 CLINICAL DENTISTRY AND RESEARCH different groups according to sex (boys and girls) and age groups (6-8 and 9-10, 11-12 years). For each child, the overall caries experience and treatment needs of both primary and permanent teeth were calculated. Statistical analysis The data obtained was statistically analyzed by using statistical package of NCSS (Number Cruncher Statistical System) 2007 Statistical Software (Utah, USA). One way ANOVA with Tukey’s multiple comparison tests, independent t tests and extension of Fisher’s exact test to r x c contingency table tests were performed. The results were considered significant at p<0.05. Sample size was determined with power analysis prior to study. Accordingly,335 patients were needed for 1.9 incidence rate, 80 power and 0,05 significance rate. RESULTS A total of 507 children aged between 6-12 (med age 9.39±1.47) consisting of 267 boys (52.7%) and 240 girls (47.3%) were surveyed. All the children were in the mixed dentition. The mean dft, DMFT scores were found 3.44±2.93, 1.35±1.72 in boys, and 3.24±2.94, 1.57±1.74 in girls respectively. There was no significant difference between genders regarding dft and DMFT (p>0.05). The mean dft, DMFT scores according to age groups(6-8, 9-10, 11-12 ages) were shown in Table 1. The mean caries and fillings in primary teeth was found statistically lower (p=0.002) in 11-12 years old group compared with mean caries and fillings in 6-8 and 9-10 years old group. There was also significant difference in mean DMFT values (p=0.0001) between three age groups. In 6-8 years group mean DMFT values was significantly lower than 9-10 years and 11-12 year (Table 1). Table 2 shows the dental treatment needs of PFM on each quadrant (tooth number 16, 26, 36 and 46). Treatment need was seen in 47.9% and 48.3% of PFM 16 and 26 respectively. Although this ratio was lower in 36 and 46, almost half of the group needed (43.4% and 41.4%) at least one type of dental treatment. Totally 2028 PFM teeth were examined. On assessment of treatment need types nearly 20% of PFM needed fissure sealant. This is followed with one surface restoration which is the second highest treatment need (21%). The need for pulp therapy (3%), prosthetic (0.8%) and extraction (0.2%) treatment was minimal as compared with the need for fıssure sealant and other conservative restorations. Lower 126 PFM needed more two surface restorations, pulp therapy and prosthetic and extraction treatment as compared with upper PFM (Figure 1). There were significant differences in health, caries and clinic status of 16, 26, 36, 46 in different ages (p<0.001). From 139 upper right molar examined, 77.7% were sound and 21.60 % had caries, 0.70 % had filling. No missing tooth was present in 6-8 age. However healthy teeth were decreased to 63.60%, caries teeth were increased (22.70%), 12.90 % had filling and one tooth was extracted at 11-12 age. Overall, children at 11-12 years age showed a significantly higher percentage of filled and missing teeth in almost every PFM (p<0.001) (Table3). DISCUSSION In 1981 World Health Organisation (WHO) and the FDI World Dental Association (FDI) released the global targets to be achieved in terms of oral and dental health. Accordingly, by the year 2015 it targets DMFT was to be 1.5 for children under the age of 12.1,11 There is a limited number of studies on assessment of caries prevalence and treatment needs of permanent first molars in Turkey. Most of these were conducted in cities, in dental schools at universities, and covered a small group of children.4,5,12 According to the major pathfinder study on oral and dental health profile conducted in 2004, the DMFT at 12 years of age in Turkey was reported to be 1.9, that is close to WHO European Region’s target for the year 2000. Although there is an improvement compared to previous years, the goals of the 21st century are still far Figure1 Treatment need types and rates (percentage) of PFM 16, 26, 36, 46 A multi-centered retrospective study Table 1. Mean dmft, DMFT values in different age groups 6-8, 9-10, 11-12 ages 6-8 Year 9-10 Year 11-12 Year F p dft 3.65±3.02 3.6±2.95 2.55±2.68 6.50 0.002 DMFT 0.86±1.34 1.54±1.69 1.93±2 14.03 0.0001 Tukey Multiple Comparison Test dmft DMFT 6-8 Year / 9-10 Year 0.987 0.001 6-8 Year / 11-12 Year 0.006 0.0001 9-10 Year / 11-12 Year 0.003 0.087 t: t value obtained from t test p: the probability value dft: mean number of decayed (d), and filled (f) primary teeth DMFT: mean number of decayed (D), missing (M) and filled (F) permanent teeth Table 2. Dental treatment needs of each PFMs on each quadrant tooth number (13,26,36,46). Treatment need n % No need 264 52.1 Needed 243 47.9 No need 262 51.7 Needed 245 48.3 No need 287 56.6 Needed 220 43.4 No need 297 58.6 Needed 210 41.4 Tooth number 16 Tooth number 26 Tooth number 36 Tooth number 46 behind the group. 5 Kuvvetli SS et al.12 reported dmft score as 1.93 in a group of five year old Turkish children. Gökalp et al.5 surveyed the severity of dental caries and the periodontal status of 7,833 Turkish children aged 5.12-15 and reported mean dmft as 3.7, mean DMFT as 1.9 in 12-year-olds. The present study revealed similar results with previous studies about dental caries and in 12 years old children mean dmft was found 0.86 and mean DMFT was found 1.93. Most researchers showed that there was an increase in mean dmft and DMFT in PFM with age. 6.8.13 This information is important because knowledge about dental caries and treatment needs provides planning appropriate preventive and restorative oral health programmes in school children.13 In a study conducted in Spain, Alvarez-Arenal et al.13 aimed to observe caries prevalance, dmft and DMFT indices and treatment needs of schoolchildren, they showed a mean caries incidence as 2.7 dft and 0.25 DMFT in 6 years old, 2.38 dft and 1.50 DMFT in 9 years of age and 3.30 DMFT in 12 year olds. Dhar et al.8 divided their study population in two age groups 6-7 years and 8-10 years and showed that, dmft was significantly higher in 8-10 years and especially “decayed teeth” was the highest component of dmft. In this study, the children were also divided in three age groups 6-8, 9-10, 11-12 years. The importance of the 6-8 group is that, this period is thetime for emergence of PFM in oral cavity. After eruption, in 11-12 years PFMs are supposed to be more susceptible to develop dental caries. We have seen significant increase in caries, missing and fillings in both primary and permanent teeth in older ages. These findings were similar with previous studies conducted 127 CLINICAL DENTISTRY AND RESEARCH Table 3. The distribution of clinical status of 16,26,36,46 in different age groups 6-8, 9-10, 11-12 ages 6-8 Year 9-10 Year 11-12 Year healthy 108 77.70% 167 70.80% 84 63.60% caries 30 21.60% 65 27.50% 30 22.70% filling 1 0.70% 4 1.70% 17 12.90% χ²:30.17 missing 0 0.0% 0 0.00% 1 0.80% p<0.001 healthy 117 84.20% 166 70.30% 82 62.10% caries 21 15.10% 66 28.00% 32 24.20% filling 1 0.70% 4 1.70% 17 12.90% χ²:37.99 missing 0 0.00% 0 0.00% 1 0.80% p<0.001 healthy 108 77.70% 149 63.10% 70 53.00% caries 31 22.30% 82 34.70% 36 27.30% filling 0 0.00% 5 2.10% 24 18.20% χ²:56.82 missing 0 0.00% 0 0.00% 2 1.50% p<0.001 healthy 104 74.80% 142 60.20% 70 53.00% caries 34 24.50% 85 36.00% 40 30.30% filling 1 0.70% 9 3.80% 20 15.20% χ²:36.91 missing 0 0.00% 0 0.00% 2 1.50% p<0.001 Tooth 16 Tooth 26 Tooth 36 Tooth 46 in different age groups of children.6.8.13 In epidemiological studies, choosing an appropriate representation of a target population is a difficult problem for researchers.5 The relative homogenity of the study population (living in a developed city, being able to reach health providers easily) which the data was pooled in the present study is a drawback. From another point of view, it can be interpreted as the target population would have a greater treatment need for FPMs considering that the studied population herein represents relatively moderatehigh sociocultural level when compared to urban areas and towns. Another reason of highcaries risk might be attributed to our study group since they attend the dental clinic because of caries, trauma, orthodontic problems. Therefore they may have more problems with the dentition from the normal population. Estimating the caries risk and treatment need is important of individuals in increasing oral health.8,10 Mann J et al.10 suggested using the treatment needs index to traditional 128 DMFT index because it provides a more accurate description of caries severity and extent than does the traditional DMFT index, and can be used to estimate the time required to treat a community. In this study we used DMFT index for caries severity and treatment need index to estimate the treatment according to caries. The present data can be used to assess both the required time and money for treating FPMs in 6-12 years studied herein. To date, treatment need is studied in various populations and these researches concluded with different data. Thus, population based strategies are based on population based pathfinder studies.3,6,8,13,14 Devaki et al.3 evaluated permanent first molar caries status and treatment needs among school going children aged 6-14 years in Tenali, Guntur (India) district. They showed that the treatment needs out of 700 subjects were as follows: 57.35% had caries and 46.65% were caries free, 30.39% required treatment. In those, number of subjects requiring one surface restorations were 18.86%, number A multi-centered retrospective study of subjects requiring 2 or more surface restorations were 12.71%, number of subjects requiring pulp care were 2.86%, number of subjects requiring extraction were 3.43%, and number of subjects requiring crown/bridge were 1.57% .3 In Jain M et al’s14 study, among 127 institutionalized subjects aged 5-22 87.4% needed some sort of treatment and 12.6% did not. One surface filling was needed for 79.5% of 127 subjects, while 22% needed two surface fillings. At Alvarez-Arenal A et al’s study13, one and two surface fillings were required in all age groups; 58.39% of subjects one surface filling and 27.02% required two. Ebrahimi et al.6 showed that 95.3% of children needed some type of treatment. They found significant differences in needs for fissure sealant, fillings and orthodontic treatment between different age groups. 8-year-old children had the greatest need for fissure sealant, and 9-year-old children had the greatest need for fillings and orthodontic treatment. To our knowledge present study is the first study that evaluated treatment needs of each permanent first molars in schoolaged children attending the university’s dental clinic in Turkey. Treatment need was seen almost 50% of PFMsexamined on each dental quadrant. We found significant differences in health, caries and clinic status of 16, 26, 36, 46 in different age groups. From 139 upper right molar examined, 77.7% were sound and 21.60 % had caries, 0.70 % had filling in 6-8 years old. No missing tooth was present at this age. However healthy teeth were decreased 63.60% and teeth with caries were increased (22.70%), Among all PFMs, 12.90 % had filling and one tooth was extracted at 11-12 age. 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