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ORIGINALARTICLE
A Comparative Study on Emergence Pattern of Permanent
Teeth among four Communities of Nepal
P. Baral1
PhD
S. Bhattacharya2
PhD
S.S. Hiremath3
PhD
4
S.R. Niraula
PhD
5
PhD
D. Banstola
INTRODUCTION: Emergence of the tooth, in simpler term is (means) the appearance of tooth in oral cavity through the
gingiva. Emergence of permanent teeth has been studied among different population and among different ethnic groups.
Standards for tooth emergence should be derived from the population in which they are to be applied because factors related to
tooth emergence of both deciduous and permanent dentitions may vary among various races.
METHODOLOGY: The clinical dental examination of the children was carried out in Brahmin, Chhetri, Rai and Limbu
communities residing in Sunsari district of Eastern Nepal. A total of eight hundred fifty seven healthy children of pure races were
included in the study. Children were grouped age. Sex and community wise. The following age groups were considered: 3.55years 6.5-8years, 9.5-11years and 15-16years.
RESULTS: The study result shows that the permanent teeth emerge and mature earlier in Rai and Limbu compared to Brahmin
and Chhetri.
CONCLUSION: Our present study concludes that there is racial variation in emergence pattern of permanent teeth and there is
need to conduct study on children of each and every ethnic communities.
KEYWORDS: Emergence, permanent teeth, dentition, communities.
How To Cite: Baral, P. A Comparative Study on Emergence Pattern of Permanent Teeth among four Communities of Nepal. J
Pak Dent Assoc 2016; 25(1): 9-15.
Received: 1 December 2015, Accepted: 19 March 2016
northeastern Finland3, Jaswal in khasi children of India4,
Garcia-Godoy F et al. in southeastern Dominican school5,
Brown T in Australian children6, Koyoundijisky-kaye E et
al. in Israeli children7, Diamanti J et al. in Australian
children8, sharma K et al. in Gujjar children of india9,
Mayhall JT et al. in Canadian Eskimos10, Mugonzibwa EA et
al. in Tanzanian children11. Information on the permanent
teeth emergence used in clinical and academic situation in
Nepal is based on American and European standards.
Standards for tooth emergence should be derived from the
population in which they are to be applied because factors
related to tooth emergence of both deciduous and permanent
dentitions may vary among various races12. Therefore
adequate knowledge of the timing of emergence of
permanent teeth among Nepalese children is required for
diagnosis and treatment plan.
INTRODUCTION
E
mergence of the tooth, in simpler term is (means)
the appearance of tooth in oral cavity through the
gingiva. Emergence of permanent teeth has been
studied among different population and among different
ethnic groups like Muniz conducted study in Argentinean
children1, Eskeli et al. in Finish children2, pahkala et al. in
1 Associate Professor, Anatomy Department, B.P. Koirala Institute of
Health Sciences, Dharan, Nepal
2 Professor, Anatomy Department, B.P. Koirala Institute of Health
Sciences, Dharan, Nepal
3 Professor, Pedodontic Department, Noble Medical College,
Biratnagar, Nepal
4 Associate Professor of Bio-stastics, B.P. Koirala Institute of Health
Sciences, Dharan, Nepal
5 Associate Professor, Physiology Department, Institute of Medicine,
Kathmandu, Nepal
Corresponding author: “Dr. Prakash Baral”
< [email protected] >
JPDA Vol. 25 No. 01 Jan-Mar 2016
MATERIALS AND METHODS
The clinical dental examination of the children was
carried out in Brahmin, Chhetri, Rai and Limbu communities
residing in Sunsari district of Eastern Nepal from January
9
Baral P / Bhattacharya S / Hiremath SS /
Niraula SR / Banstola D
Table 1.
A Comparative Study on Emergence Pattern of Permanent Teeth
Distribution of subjects age, sex and community wise.
Age
(Years)
Rai
Limbu
Chhetri
Brahmin
Boys
Girls
Boys
Girls
Boys
Girls
Boys
Girls
3.5-5yrs
31
31
32
32
31
32
29
31
6.5-8yrs
24
23
21
30
29
29
26
22
9.5-11yrs
21
23
30
25
27
26
23
23
15-16yrs
30
25
27
27
25
25
23
24
Total
106
102
110
114
112
112
101
100
Table 2.
Comparison of frequency percentage of emergence of teeth between right and left sides of jaw in the entire study
population (n=857).
Maxilla Left Side
3
2
1
0
Maxilla Right Side
3
2
1
0
CI
63.0
4.3
31.0
1.7
CI
63.1
3.9
30.7
2.2
LI
60.4
3.5
33.9
2.2
LI
59.8
4.3
33.6
2.3
C
47.4
2.8
48.7
1.1
C
47.0
2.0
50.2
0.9
PM1
47.6
6.3
43.1
3.0
PM1
46.9
5.4
44.4
3.3
PM2
48.3
2.5
46.7
2.5
PM2
48.5
1.9
46.9
2.6
M1
69.0
1.8
27.0
2.2
M1
68.7
2.2
26.7
2.3
M2
45.9
2.3
49.8
2.1
M2
46.0
2.3
50.0
1.7
Mandible Left side
Mandible Right side
CI
64.9
4.2
29.4
1.6
CI
65.0
4.2
29.3
1.5
LI
62.5
4.9
31.7
0.9
LI
62.2
5.4
31.0
1.5
C
59.9
1.8
37.4
1.0
C
59.7
1.8
37.1
1.4
PM1
49.9
4.4
43.2
2.5
PM1
50.6
4.1
43.4
1.7
PM2
49.2
1.9
46.1
2.6
PM2
49.9
1.8
46.0
2.3
M1
69.3
1.7
27.4
1.5
M1
68.8
1.9
27.6
1.6
M2
46.6
2.6
49.1
1.7
M2
46.6
3.0
49.2
1.1
2012 to November 2012. A total of eight hundred fifty seven
healthy children of pure races were included in the study.
Children were grouped age. Sex and community wise. The
following age groups were considered: 3.5-5years 6.58years, 9.5-11years and 15-16years. Healthy children are
defined as those without any growth related disorders, any
genetic abnormalities having no prolonged disease like
diabetes mellitus, endocrine disorders, cardiac, renal and
intestinal disorders. Pure race means no intermingling i.e.
children whose parents and grandparents did not make
intercaste marriage. The data covered all urban and rural
children of high, medium and low economic status. Data was
collected from community including those attending dental
camps, school children in their schools and attendants of
patients coming to the pedodontic department of college of
dental surgery. Age of the patient was recorded by birth
certificates or looking at birth register in school. But incase
of children attending dental camps or clinics age of the child
was asked to his/her parent. Due informed consent was
obtained from guardians of subjects. All participants
understood and spoke nepali language and informed consent
was taken in nepali language. They were healthy and from
pure ethnic races of Brahmin, Chhetri, Rai and Limbu.
Ethical clearance was obtained from Institutional ethical
committee. In dental pedodontic OPD the subjects were
seated on dental chair and examination of oral cavity was
done under the dental chair right with the help of mouth
mirror. In case of dental camps and schools, subjects were
seated on wooden chair and examination was done under
torchlight and with the help of mouth mirror.
10
JPDA Vol. 25 No. 01 Jan-Mar 2016
Baral P / Bhattacharya S / Hiremath SS /
Niraula SR / Banstola D
A Comparative Study on Emergence Pattern of Permanent Teeth
Emergence of tooth can be defined as the appearance of
tooth in oral cavity through gingiva. The stages of
emergence of the permanent teeth were determined by
classifying the emergence of each tooth into following four
stages:-
were used to test the significance of the variables depending
upon the nature of data collected.
RESULTS
Eight hundred and fifty seven children were taken into
the study of the permanent teeth. 0.1% teeth were extracted
due to dental caries. Such children with history of teeth
extraction were also excluded.
0= tooth not visible in the oral cavity.
1= at least one cusp visible in oral cavity.
2= entire occlusal surface/mesio-distal width of the tooth
visible.
No statistically significant difference was detected in the
emergence pattern of the permanent teeth between the right
and left side as seen in Table 2, (Student paired ‘t’test was
applied to test the significane because there was comparison
of two means of right and left side with small standard
deviation) and therefore, the left side was selected arbitrarily
for the study analysis though study was carried out on both
sides hence emergence pattern of the teeth in the left side of
the maxilla and mandible are reported.
3= tooth in occlusion or at the occlusal level if
antagonistic tooth is not fully erupted.
Statistical Design and Analysis
This was a cross sectional study. Multistage random
sampling technique was adopted. It is multi stage because
research subjects are grouped into four communities like
Brahmin, Chhetri, Rai and Limbu. In each community they
are grouped into male and female. In each gender they are
grouped into four age groups like 3.5-5 years, 6.5-8 years,
9.5-11 years, 15-16 years. It is random sampling because
research subjects were selected randomly. The collected data
was entered in computer using Microsoft windows access
software. Analysis was done using SPSS (statistical package
for social sciences) version 10:00 software. Student “t” test
Table 3.
Emergence Stages
0= tooth not visible in the oral cavity
1= at least one cusp visible in oral cavity.
2= entire occlusal surface/mesio-distal width of the tooth
visible.
Distribution (in percentage) of subjects with at least one emerged permanent tooth according to emergence stages and age
group of 3.5-5years. (n=249).
Communities
Emergence
Stages
First
transitional
period
0
1
2
Rai
*83
8.5
Limbu
*84
Brahmin
Chhetri
Second
Transitional
period
3
0
1
2
3
5
3.5
100
0
0
0
9
5.5
1.5
100
0
0
0
*96
4
0
0
100
0
0
0
95
3
2
0
100
0
0
0
(*p<0.05).
Table 4.
Distribution (in percentage) of subjects with at least one emerged permanent tooth according to emergence stages and age
groups of 6.5-8years. (n=204).
Communities
Emergence
Stages
First transitional period
Second
transitional
period
0
1
2
3
0
1
2
3
Rai
0
0
0.5
99.5
*81
9
7
3
Limbu
0
0
3
97
*80
10
6
4
Brahmin
0
2
5
93
*92
6
2
0
Chhetri
0
1
3
96
87
7
4
2
(*p<0.05).
JPDA Vol. 25 No. 01 Jan-Mar 2016
11
Baral P / Bhattacharya S / Hiremath SS /
Niraula SR / Banstola D
Table 5.
A Comparative Study on Emergence Pattern of Permanent Teeth
Distribution (in percentages) of subjects with at least one emerged permanent tooth according to emergence stages and
age groups of 9.5-11years. (n=198).
Communities
Emergence
Stages
First
Transitional
Period
0
1
2
Rai
0
0
Limbu
0
Brahmin
Chhetri
Second
Transitional
Period
3
0
1
2
3
0
100
8
6
7
*79
0
0
100
4
7
11
*78
0
0
0
100
14
10
9
*67
0
0
0
100
14
11
7
68
(*p<0.05).
Table 6.
Distribution (in percentage) of subjects with at least one emerged permanent tooth according to emergence stages and age
groups of 15-16years. (n=206).
Communities
Emergence
Stages
First
Transitional
Period
0
1
2
Rai
0
0
Limbu
0
Brahmin
Chhetri
Second
Transitional
Period
3
0
1
2
3
0
100
0
0
0
100
0
0
100
0
0
0
100
0
0
0
100
0
0
0
100
0
0
0
100
0
0
0
100
3= tooth in occlusion or at the occlusal level if
antagonistic tooth is not fully erupted.
2= entire occlusal surface/mesio-distal width of the tooth
visible.
Teeth in the first transitional period: M1, CI, LI and in
the second transitional period:
3= tooth in occlusion or at the occlusal level if
antagonistic tooth is not fully erupted.
C, PM1, PM2, and M2.
Teeth in the first transitional period: M1, CI, LI and in
the second transition period:
Table 3 shows there is significant difference (p<0.05)
with score zero between Rai and Brahmin, Rai and Chhetri,
Limbu and Brahmin and Limbu and Chhetri but no
significant differences (p>0.05) between Rai and Limbu and
Brahmin and Chhetri. 83% of Rai and 84% Limbu and 96%
of Brahmin and 5% Chhetri having zero score in first
transitional period (Transitional period is the period between
the completion of eruption of primary dentition and the
emergence of the permanent teeth. In the first transitional
period there is emergence of first permanent molars(M1),
central and lateral incisors(CI & LI) and in the second
transition period there is emergence of Permanent
canines(C), first and second premolars(PM1 & PM2) and
second molars(M2)) at age of 3.5-3.5years age, suggest that
the permanent teeth emerge earlier in Rai and Limbu
compared to Brahmin and Chhetri. There is no significant
difference with score 1and 2
C, PM1, PM2, and M2.
Table 4 shows less percentage of Rai (81%) and Limbu
(80%) and greater percentage of Brahmin (92%) having zero
score suggest that the permanent teeth emerged earlier in
second transItional period at the age groups of 6.5-8 years in
Rai and Limbu compared to Brahmin. There is significant
difference (p<0.05) with score zero between Rai
andBrahmin, Limbu and Brahmin but no significant
difference between Chhetri and other communities as well as
Rai and Limbu. There is no significant difference with other
scores as well.
Emergence Stages
0= tooth not visible in the oral cavity
1= at least one cusp visible in oral caviy.
Emergence Stages
2= entire occlusal surface/mesio-distal width of the tooth
visible.
0= tooth not visible in the oral cavity
1= at least one cusp visible in oral caviy.
12
JPDA Vol. 25 No. 01 Jan-Mar 2016
Baral P / Bhattacharya S / Hiremath SS /
Niraula SR / Banstola D
Table 7.
A Comparative Study on Emergence Pattern of Permanent Teeth
Mean age of teeth for score 1 in the four communities.
Communities
Mean age of Teeth Emergence in Years
Maxillary Teeth
Mandibular Teeth
CI
LI
C
PM1
PM2
M1
M2
CI
LI
C
PM1
PM2
M1
M2
Brahmin
8.0
9.0
11.0
10.5
11.5
6.0
12.9
6.8
7.9
9.1
10.6
10.9
5.3
12.8
Chhetri
7.6
7.8
11.0
10.4
11.4
5.9
13.0
6.5
7.5
9.0
10.5
10.8
5.3
12.6
Rai
7.3
8.0
10.6
10.0
10.8
5.2
12.6
6.2
7.3
8.5
10.1
10.5
5.2
12.1
Limbu
7.4
8.0
10.8
10.5
10.7
5.1
12.5
6.3
7.1
8.2
10.2
10.3
5.1
12.0
CI= Central incisor, LI=lateral incisor, C= canine, PM1=first premolar, PM2= second premolar, M1=first molar, M2=second molar.
3= tooth in occlusion or at the occlusal level if
antagonistic tooth is not fully erupted.
different regions of world. It is important to have a standard
record of emergence of teeth pattern as it affects treatment
plan. Most studies on emergence of the permanent teeth have
shown that an emerged tooth was present when at least part
of the incisal edge or cusp of the permanent tooth was visible
in the oral cavity13,14,15,16 except Pahkala R et al.3 who also
considered the later emergence stages based on clinical
determination suitable for epidemiological studies.
Radiographic methodology to determine developmental
stages of the dentition may not be feasible in developing
countries and not be allowed in community based studies for
ethical reasons in either developing or developed
countries17,18,19.
Teeth in the first transitional period: M1, CI, LI and in
the second transition period:
C, PM1, PM2, and M2.
Table 5 shows there is significant difference (p<0.05)
with score 3 in between Rai and Brahmin, Rai and Chhetri as
well as Limbu and Brahmin. Greater percentage of Rai (79%)
and Limbu(78%) with score 3 compared to Brahmin(67%)
and Chhetri (68%)suggest that permanent teeth matures
earlier in Rai and Limbu as compared to that in Chhetri and
Brahmin. There is no significant difference with scores 0,1,2.
In our study it was not found significant difference
between right and left side in emergence of permanent teeth
(Table 2). It agrees to findings of Kochhar R et al.20,
Krumholt L etal21, Friedlaender JS et al.22, Billewicz WZ et
al.14, Pahkala R et al.3.
Emergence Stages
0= tooth not visible in the oral cavity
1= at least one cusp visible in oral caviy.
2= entire occlusal surface/mesio-distal width of the tooth
visible.
In the present study it was found that permanent teeth
emerged earlier in Rai and Limbu compare to Brahmin and
Chhetri in first transitional period (see Table 3) and in
second transitional period (Tables 4 and 5). In the present
study it was also found that mandibular teeth emerged earlier
than the maxillary counterpart in all community (Table 7).
This agrees to findings of Kochhar R et al.20.
3= tooth in occlusion or at the occlusal level if
antagonistic tooth is not fully erupted.
Teeth in the first transitional period: M1, CI, LI and in
the second transition period:
C, PM1, PM2, and M2.
Table 6 shows there is no significant difference among
the communites with any scores. It suggest that all
permanent teeth except third molar have got already emerged
into oral cavity by 15-16years in all communities.
Regarding the sequence of emergence of teeth, similar
sequencewas found in all four communities (Table 7). The
sequence for maxilla was first molar, central incisor, lateral
incisor, first premolar, second premolar, canine and second
molar and for mandible:- first molar, central incisor, lateral
incisor, canine, first premolar, second premolar and second
molar. This finding is in line with findings of Jaswal S4.
Table 7 shows the mean age of teeth for score 1 in
different four communities. The result shows the sequence of
emergence of teeth is similar in all four communities i.e. for
maxilla:- first molar, central incisor, lateral incisor, first
premolar, second premolar, canine and second molar and for
mandible:- first molar, central incisor, lateral incisor, canine,
first premolar, second premolar and second molar.
Mugonzibwa EA et al. studied on Tanzanian children
regarding emergence of permanent teeth and found that
permanent teeth in Tanzanian children clearly emerged
earlier than in Caucasions children11. Muniz B in Argentina
found no differences in mean times of emergence of
permanent teeth between the two ethnic groups (Caucasion
vs. Amerindian)1. Eskeli R et al. who conducted study in
Finnish children in Eastern and Western part of the country
found no regional variation in emergence of teeth2. Pahkala
R et al. observed that earlier eruption of the permanent teeth
DISCUSSION
Timing of emergence of teeth varies in different
population. Presently there is an increased tendency to study
and compare the emergence pattern and timing of teeth in
JPDA Vol. 25 No. 01 Jan-Mar 2016
13
Baral P / Bhattacharya S / Hiremath SS /
Niraula SR / Banstola D
A Comparative Study on Emergence Pattern of Permanent Teeth
in rural children in north eastern Finland than in other parts
of the country3. Jaswal S found that khasi children showed
early emergence of teeth whe compared to other population4.
Garcia-Goddy F et al. found advanced timing of permanent
tooth emergence in southeastern Dominican school children
population when compared with those of United States
whites and blacks, Danish, Canadian Eskimos, FrenchCanadians etc5. Brown T found that aboriginal Australian
children displayed earlier emergence of most teeth than that
other non-European populations. Genetic differences also
contribute to earlier emergence of teeth6. Koyoundijiskykaye E et al. found that some teeth like maxillary and
mandibular incisors and canines erupt somewhat later in
Israeli children compared to population of other parts of the
world. While comparing the emergence pattern and time
among males and females in the present study no significant
difference was observed7. However Diamanti J et al.
observed in Australian children that tooth emergence was
advanced in girls compared with boys averaging 4.5months
in maxilla and 3.5 months in mandible8. Sharma k et al. in
their cross sectional study in Gujjar children9, Muniz B in
Argentina1, Mayhall JT et al. in their study of Canadian
Eskimas10 and Koyoundijisky-Kaye E7 found that females
were markedly advanced in permanent tooth emergence time
over males. Kochhar R et al. observed that females tended to
erupt teeth before males with the exception of the 2nd molars
in both arches; however the only differences to reach
statistical significance related to upper and over canines and
upper lateral incisors20.
conduct study on children of each and every ethnic
communities.
AUTHORS CONTRIBUTION
Dr. P Baral have worked on the concept and the design of
the study.
Dr. S. Bhattacharya supervised the data collection, thesis
write up and reviewed the article.
Dr. SS Hiremath supervised the data collection, thesis write
up and reviewed the article.
Dr. SR Niraula supervised methods of the data collection
(sampling method), data entry and data analysis as well as
reviewed the article.
Dr. D Banstola edited and proof read the article.
DISCLOSURE
Declared none.
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Our present study concludes that there is racial variation
in emergence pattern of permanent teeth and there is need to
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