The prevalence of developmental defects of enamel, a prospective cohort study of adolescents in Western Sweden: a Barn I TAnadvarden (BITA, children in dental care) study

The prevalence of developmental defects of enamel, a prospective cohort study of adolescents in... Aim To describe the prevalence of different types of developmental defects of the enamel (DDE) in varying age-cohorts and habitations, and to analyse if early trauma to the primary teeth and early subsequent serious health problems were related to DDE in the permanent dentition. Dental fear and anxiety, and aesthetic problems as a consequence of DDE were also investigated. Methods DDE was registered over 5 years annually in three age cohorts (796 children). The DDE index (FDI Commision on Oral Health, Research and Epidemiology, Int Dent J 42:411–426, 1992) was used. Information on diseases in early child- hood, trauma to the primary teeth, and dental fear and anxiety were collected. Results The prevalence of DDE was 33.2% (boys 37.1%, girls 29.3%, p = 0.02). Demarcated opacities (DEO), solely, were the most frequent kind of defect, affecting 18%. Five percent (5%) had diffuse opacities (DIO) and 1% had hypoplasias, whereas 7% had teeth with both DEO and DIO. The most frequently affected teeth of DEO, as well as of DIO, were the first permanent molars and maxillary central incisors. Dental injuries to the primary anterior teeth raised the risk for DDE in the permanent teeth, but early serious health problems did not. Generalised DDE was common (8.4%). The paediatric dentists assessed the DDE in the maxillary anterior teeth as more serious than did the affected children and their parents. Conclusions Generalised DDE was more frequent than expected, as well as the occurrence of both DEO and DIO in the same individual. The first permanent molars and the upper central incisors were the most affected teeth. Keywords Developmental defects of the enamel · Epidemiology · Aesthetics Introduction DDE teeth can be problematic for the affected child, as well as the treating dentist, with considerable aesthetic Developmental defects of enamel (DDE) are common. As problems ensuing. The teeth also may break down and be high as 50% of a population, living in a low uo fl ride district, impaired by shooting pain and difficulties in anaesthetising. has been shown to have at least one tooth with mineralisa- Dental fear and anxiety, as well as dental behaviour prob- tion disturbances. The fluoride content of drinking water lems as a consequence of DDE, have been reported (Jälevik has a considerable effect on the DDE prevalence (Dummer and Klingberg 2002). et al. 1990). For the dental staff, sound knowledge, early recognition, and treatment planning of DDE are of the utmost importance for optimal care and the prevention of dental fear. Developmental defects in the enamel are defined as dis- turbances in hard tissue matrices and in their mineralisation, * B. Jälevik birgitta.jalevik@gu.se arising during odontogenesis (Commission on Oral Health, Research and Epidemiology, FDI 1992). The defects may be Department of Pediatric Dentistry, Institute of Odontology localised, affecting single or multiple teeth, or systematic, at the Sahlgrenska Academy, University of Gothenburg, affecting groups of teeth developing at the time of distur - Gothenburg, Sweden 2 bance (Commission on Oral Health, Research and Epide- Clinic of Pediatric Dentistry, Public Dental Service, VGR, miology, FDI 1992). Uddevalla, Sweden Vol.:(0123456789) 1 3 188 European Archives of Paediatric Dentistry (2018) 19:187–195 has historically been low (Small and Murray 1978). Moreo- Nomenclature ver, before the DDE indexes were published, there was great confusion concerning the description and nomenclature of Historically, a wide variety of terms and definitions have enamel defects, making earlier studies of enamel opacities been used to describe developmental defects of the enamel. hard to interpret. Some are simply descriptive terms while others are linked to Studies on full mouth examinations of the permanent the causative agent, e.g., fluoride. To remedy this confusion, dentition, using the mDDE-index, are infrequent. Clarkson an FDI working group was established in 1982 and the DDE and O’Mullane (1992) showed that 63% of 15-year-olds index was published. This original index was complicated in a low-fluoride district had at least one tooth with DDE to use in practice and a modified DDE index (mDDE) was and that demarcated opacities (DEO) were predominant. presented in 1992. In short, DDE is classified as demarcated Seow (2011) found that 58% of a study group, with per- opacities, diffuse opacities, and hypoplasia. manent teeth and a mean age 13.5 years, had at least one Hypoplasia is defined as a quantitative defect of enamel tooth affected by DDE, and that DEO and DIO were equally involving the surface, with reduced thickness of the enamel. represented in the permanent dentition. Robies et al. (2013) The defective enamel may occur as shallow or deep pits or examined children 3–12 years old; 52% of those with only rows of pits arranged horizontally, or as small or large, wide permanent teeth, had at least one tooth affected. DEO was or narrow grooves. the most frequent defect. A prior prevalence study from the Opacity is defined as a qualitative defect of enamel iden- region of the present survey found that 33% of 8-year-olds tified, i.e., as an enamel hypomineralisation; visually as had at least one tooth affected (Jälevik et al. 2001). an abnormality in the translucency of enamel. A white or In the past decades, a number of prevalence studies of discoloured area is characteristic, but the enamel surface MIH have been published from different parts of the world. is smooth and its thickness is normal. There are two kinds A wide variation in MIH prevalence has been reported (Jäle- of opacities; demarcated opacity with a distinct and clear vik 2010). In spite of the EAPD criteria from 2003, cross- boundary to the adjacent normal enamel and can be white, comparisons of the results from these various studies have cream, yellow or brown in colour; diffuse opacity has a lin- been difficult due to the use of different indices and criteria, ear, patchy or confluent distribution, but there is no clear examination variability, methods of recording, and varying boundary to the adjacent normal enamel. age groups (Jälevik 2010). The examination prerequisites were given: tooth sur- faces were inspected visually and defective areas tactilely Aetiology explored with a probe. Natural or artificial light was used during examination and defects less than 1 mm were not Defects can be genetic or environmental and often the cause recorded. The teeth were not dried, but large debris was remains unknown. Environmental (also called acquired) den- removed with the help of a cotton roll. The number of sub- tal defects can be divided into those caused by local factors jects with one or more teeth affected, the mean number of and those caused by systemic factors. A local factor can teeth per child affected by any defect, and the type of defect be suspected when a single tooth or group of neighbouring were the standard data to be reported (Commission on Oral teeth is affected. General symmetric defects, related to the Health, Research and Epidemiology, FDI 1992). timing of the insult and thus to the sequence of the develop- In the twenty-first century, studies of DDE have mainly ment of the teeth, are denominating chronological defects. focused on MIH. The mDDE index was considered to be too The aetiology of general defects, not related to any particu- time-consuming and not adequate for MIH studies, as post- lar time period during tooth formation (non-chronological eruptive breakdown (PEB) is a prominent feature in MIH defects), are either genetic or due to non-genetic, longstand- and the mDDE index may not clearly differentiate PEB from ing environmental influences, e.g., intoxications, malnutri- hypoplasia. In addition, the mDDE does not represent atypi- tion or other medical conditions (Espelid et al. 2017; Wong cal restorations and extractions owing to MIH. In the EAPD 2014). seminar in 2003, specific criteria for MIH in epidemiological Well-known enamel defects are amelogenesis imperfecta, studies were established (Weerheim et al. 2003). dental fluorosis, enamel defects in permanent teeth caused by trauma or infection to the preceding primary teeth, and Prevalence MIH. Amelogenesis imperfecta (AI) is a genetically determined The relationship between dental fluorosis and the content of developmental defect of the enamel, affecting all or the fluoride in drinking water is well-documented since a long majority of teeth in the dentitions. The enamel defects are in time ago (Dean 1934; Møller 1982). However, the interest general more pronounced in the permanent dentition, com- in studying the presence of opacities in low fluoride areas pared to the primary dentition (Crawford et al. 2007). The 1 3 European Archives of Paediatric Dentistry (2018) 19:187–195 189 reported prevalence of AI varies from 0.06/1000 in the USA, The possibility of revealing diagnoses with the help of to 0.25/1000 in Southern Sweden and 1.4/1000 in Northern mDDE-index. Sweden (Witkop and Sauk 1976; Sundell and Koch 1985; The connection with early childhood traumatic injuries Bäckman and Holm 1986). in the primary dentition and DDE. Dental fluorosis is a well-known, environmental develop- The connection with serious health problems in early mental defect of the enamel. The causal connection between childhood and DDE. fluorosis and percentage of fluoride in drinking water is Dental fear and anxiety in children/adolescents with well-documented. Diffuse opacities affecting homologous DDE. teeth are characteristics of fluorosis. The opacities vary from The aesthetic perception of DDE judged by children/ado- fine white transverse lines to extensive opaque areas. The lescents, their caretakers, and paediatric dentists. border to normal enamel is always diffuse. Post-eruptive staining and shallow pits are common in more serious cases (Möller 1982; Cutress and Suckling 1990; Fejerskov et al. Materials and methods 1996). Trauma to the primary incisors is the most well-docu- The BITA study (BITA = Barn I TAndvården, which means mented local causative factor for DDE affecting the per - children in dental care) is a 5-year longitudinal study in manent successor. It has been shown that about 10% of Sweden, between the years 2008 and 2012, concerning dif- enamel defects in permanent incisors have been caused by ferent aspects of children in the dental situation. Four age trauma to the preceding incisor. Trauma at a very early age cohorts with children 3, 7, 11 and 15 years at the study start, involves a greater risk of hyperplastic defects, compared to from five Public Dental Service clinics in the Region Västra later trauma that can cause opacities in the permanent suc- Götaland, were invited to participate, representing both rural cessor (Andreasen et al. 1971). An infected primary tooth and urban areas with different socio-economic status. The may also increase the risk of DDE in the permanent succes- majority of the patients had municipal drinking water with sor (Turner’s teeth) (Turner 1912). a low level of fluoride (< 0.10 mg/ml). In the more rural Molar incisor mineralisation (MIH) is an acquired, sys- areas, some had drinking water from a well, but there was no temic enamel defect in the permanent first molars (PFM) accessible information on the fluoride status of any private (Weerheim et al. 2001) and is frequent in many populations drinking water supplies. (Jälevik 2010). Approximately every fifth child in Sweden Developmental defects of the enamel in all erupted per- has been shown to have MIH, often in combination with manent teeth were registered yearly for 5 years, discerning post-eruptive enamel disintegration. One, two, three or all between demarcated opacities, diffuse opacities, and hypo- PFM could be affected to some extent. One or more of the plasias, according to the mDDE-index (FDI 1992). Moreo- incisors are often affected at the same time. (Jälevik et al. ver, post-eruptive breakdown of the enamel in affected 2001). The causation of MIH is still not confirmed. teeth was recorded. The youngest cohort was excluded from the DDE part of the BITA study as the children were Aesthetic perception of DDE 7 years old by the study end and consequently, only had a few permanent teeth to examine. Few studies have considered aesthetic problems owing to After instruction and training, the ordinary dental staff DDE, with the appearance of fluorosis mostly discussed. carried out the examinations. A test protocol, composed of Chankanka et  al. (2010) showed that mild fluorosis was 24 digital photos of teeth with DDE, completed; 85% of the not associated with negative effects on Oral Health Related affected surfaces were correctly assessed. The study cohorts Quality of Life (OHRQoL), but severe fluorosis was con - were 11, 15 and 19 years old at study end. sistently reported to have negative effects on OHRQoL. In Data from the clinical examination concerning type and another study (McGrady et al. 2012), demarcated opacities distribution of DDE were analysed. Annual background in the incisor were judged to be more troublesome than mild data on traumatic injuries of the primary teeth 0–6 years of fluorosis. Sujak et al. (2004) investigated the affect of all age, severe illness during the first 4 years of life, and den - types of DDE. They suggested that very few subjects were tal fear and anxiety, were collected from the BITA study. concerned about the appearance of their teeth, or were not The CFSS-DS scale measured dental fear and anxiety. aware of their teeth being different. At the study end, information on fluoride in drinking The aim of the present study was to investigate: water and known family enamel defects were collected from those with registered DDE, in a questionnaire. The The prevalence of developmental defects (DDE) in the children/adolescents, as well as the caretakers, were also enamel of permanent teeth in varying age cohorts and asked for aesthetic and treatment problems caused by their habitations. enamel developmental disturbances. 1 3 190 European Archives of Paediatric Dentistry (2018) 19:187–195 Information on treatment measurements of the perma- Results nent first molars was collected from the record of all sub- jects with registered defects. At the BITA-study start, 964 children were eligible; 168 Ninety-six randomly selected children/adolescents, with left the study before the study end and 796 children (83%) observed DDE, were clinically examined by two paediatric remained. The reasons for dropping out were mainly moving dentists (BJ and AM) in order to verify the registrations. to another location, parents’ lack of time, unwillingness to Intraoral photos were taken. The aesthetic appearance on fill in questionnaires and non-appearance. the photos of the front teeth (canines and incisors) was The subsequent questionnaires were completed by 201 assessed by the paediatric dentists. That assessment was of 264 (76%) participants having developmental defects of compared to reported aesthetic problems for the patients the enamel (DDE). and their caretakers. Prevalence of DDE Analysis The distribution of gender was even in the study popula- Data were entered into a spreadsheet (Microsoft Excel, tion. Developmental defects (DDE) were registered in 264 Microsoft Corp, WA, USA) and then analysed using (33.2%) children. More boys than girls had DDE (Table 1). SPSS Version 22, (SPSS Inc, Chicago IL, USA). Descrip- DDE was more prevalent in the 15-year-olds (Cohort 3), tive statistics were used to assess the participants data. compared to the other age cohorts (p = 0.05) (Table 2). The Responses to questionnaires were analysed through the prevalence in the participating five clinics varied from 25.6 use of descriptive statistics, and comparisons between dif- to 45.2% (p = 0.02). The most rural clinic had the highest ferent dental groups were made with the Chi square test prevalence (Fig. 1). and odds ratio. Concerning CFSS-DS, the T-test was used. Results at an alpha level less than 0.05 were considered Type of DDE statistically significant. Half of those with DDE had solely demarcated opacities (DEO). However, fully one-quarter had teeth with DEO, as Ethical considerations well as one or more teeth with diffuse opacities (DIO) and/ or hypoplasias (Hypo). The most frequent “mixed DDE” BITA‑study was DEO + DIO, affecting more than one-fifth of those with DDE (Table 3). Application for an ethical review (Dnr: 286-07) was sub- Post-eruptive breakdown (PEB) of the enamel was reg- mitted in June 2007. The Regional Ethical Review Board istered in 19.3% of the subjects with DDE. PEB was more of the University of Gothenburg, Sweden, found the pro- common in subjects with one or more teeth with demarcated ject was not subject to the Swedish Act on Ethical Review. opacities (21.4%), compared to those with diffuse opacities The Board provided feedback on the information to the and/or hypoplasias (11.1%). patients, which was taken into account during further planning of the study. The caretakers and their children Distribution within the dentition received a letter with information regarding the project before entering the BITA-study. Respondents were asked The most frequently affected teeth were the upper first to participate in the study when they attended a routine molars and central incisors (16–17% of the total sample). dental appointment. In connection to the first clinical examination, the caretakers signed an informed consent to participate in the research project. Table 1 The distribution of developmental defects of the enamel (DDE) by gender DDE Total Questionnaire No Yes The study was approved by the Regional Ethical Review N (%) N (%) Board of the University of Gothenburg, Sweden, Dnr: 806- Girls 283 (70.8) 117 (29.3) 400 13 (2014-02-25). Children/adolescents and their caretak- Boys 249 (62.9) 147 (37.1) 396 ers were given written information regarding the study and Total 532 (66.8) 264 (33.2) 796 asked to give their consent to participate. The boys were significantly more affected than the girls, p = 0.02 1 3 European Archives of Paediatric Dentistry (2018) 19:187–195 191 Table 2 The distribution of Age DDE MIH General. DDE Total, N developmental defects of the enamel (DDE) among the age No, N (%) Yes, N (%) No, N (%) Yes, N (%) No, N (%) Yes, N (%) cohorts Cohort  11 185 (70.3%) 78 (29.7%) 218 (82.9%) 45 (17.1%) 262 (99.6%) 1 (0.4%) 263  15 163 (61.0%) 104 (39.0%) 237(88.8%) 30 (11.2%) 235 (88.0%) 32 (12.0%) 267  19 184 (69.2%) 82 (30.8%) 244 (91.7%) 22 (8.3%) 232 (87.2%) 34 (12.8%) 266 Total 532 (66.8%) 264 (33.2%) 699 (87.8%) 97 (12.2%) 729 (91.6%) 67 (8.4%) 796 p = 0.05 p = 0.01 p < 0.001 The table also shows the distribution of MIH and generalised DDE judged from the clinical registration and information in the dental records Fig. 1 The distribution of devel- 70% opmental defects of the enamel (DDE) among participating 60% clinics and the age cohorts 50% 40% 11yrs 15yrs 30% 19 yrs All age cohorts 20% 10% 0% Clinic 1, Clinic 2, Clinic 3, Clinic 4, Clinic 5, All clinics, N=84 N=104 N=290 N=154 N=164 N=796 Table 3 The distribution of the different types of developmental Chronological DDE, affecting FPM and incisors, was the defects of the enamel (DDE) among the affected dentitions most frequent defect, followed by generalised, non-chrono- logical and local defects (Table 4). DDE type N % affected (264) % total sample (796) Generalised DDE and MIH DEO 144 54.5 18.1 Generalised DDE was seen in 8.4% of the total sample, when DIO 42 15.9 5.3 denominating non-chronological defects ae ff cting more than Hypo 11 4.2 1.4 four teeth as generalised. The mean number of affected teeth DEO + DIO 54 20.5 6.8 in this group was 15.2 (SD 7.0). Almost 25% of those with DEO + Hypo 7 2.7 0.9 generalised DDE had both DEO and DIO. The remainder DIO + Hypo 1 0.4 0.1 had either solely DIO or DEO, to a similar extent. Only one DEO + DIO + Hypo 5 1.9 0.6 patient with generalised DDE had merely hypoplasia. The DEO demarcated opacities, DIO diffuse opacities, Hypo hypoplasias occurrence of generalised DDE in the different cohorts, as well as in the different clinics, was statistically significant. They were the most affected teeth with both DEO and DIO. When taking the clinical registrations and information The mandibular canines were the least affected teeth. Hypo- from dental records into account, 12.2% of the total sample plasia was an uncommon defect (Fig. 2). was judged to have MIH. There was no significant difference among the participating clinics, but the youngest cohort had a higher prevalence (17.1%) of MIH (Tables 2, 3). 1 3 192 European Archives of Paediatric Dentistry (2018) 19:187–195 Fig. 2 The frequency of demar- cated opacities (DEO), diffuse opacities (DIO) and hypoplasias (Hypo) by tooth type Table 4 The distribution of local, chronological and non-chronolog- (incisors and canines) (Table 4). In eight cases, a single pre- ical defects molar was the only affected tooth. N (% total) Affected teeth N (% total) Aetiological factors Local 52 (6.5%) Anterior teeth 42 (5.2%) Other teeth 10 (1.3%) Traumatic injuries to the primary front teeth before 4 years Chronological 119 (15%) FPM and incisors 104 (13%) of age raised the risk for DDE to the permanent successors (FP&I) (OR 2.3, CI 1.6–3.4). Injuries to 4–6-year-olds had no sig- Other chronological 15 (2%) nificant influence (OR 1.4, CI 0.8–2.3) (Table  5). Non-chronological 93 (12%) Generalised 67 (8%) One-third of the DDE group (34%) used drinking water FPM&I plus 1–2 other 18 (2%) from a well. Four of them reported raised fluoride content teeth in the water. The prevalence of diffuse opacities was slightly < 4 teeth 8 (1%) higher (p = 0.212) in this group, compare to those in the DDE-group with municipal water. Table 5 The relation between traumatic injuries of the primary fron- Reported health problems in early childhood did not raise tal teeth, before and after 3 year of age, and developmental defects of the prevalence of DDE. the enamel (DDE) in the permanent frontal teeth Twelve percent reported possible heredity. Trauma No trauma Total Dental fear and anxiety 0–3 years  DDE front teeth 52 121 173 The presence of DDE did not lead to dental fear and anxiety.  No DDE front 100 523 623 The DDE group scored 19.7 and the non-DDE group scored teeth 20.0 in the CFSS-DS instrument (p = 0.54).  Total 152 644 796 OR 2.3, CI 1.6–3.4 4–6 years Aesthetic considerations  Front teeth DDE 23 150 173  No front teeth 62 561 561 DDE Approximately 40% of the caretakers and children/adoles- cents had observed the DDE, with about half of them regard-  Total 85 711 796 OR 1.4, CI 0.8–2.3 ing the defects as an aesthetic problem. Those with anterior DDE were more concerned. The children/adolescents with frontal DDE were more troubled than their caretakers, with Local defects girls and their caretakers more concerned than boys and their caretakers. The paediatric dentists were more concerned The majority of the local defects were in the front teeth 1 3 European Archives of Paediatric Dentistry (2018) 19:187–195 193 50% One-third (33.2%) of the examined population had DDE NS 45% of any type, with demarcated opacities (DEO) as the most 40% NS p=0.01 35% frequent defect. Compared to other studies using the mDDE- 30% p=0.02 index (Clarkson and O’Mullane 1992; Seow 2011; Robies 25% NS et al. 2013), the DDE prevalence was lower in the present 20% Girl NS 15% study. The absence of malnutrition and well-functioning Boy 10% healthcare during early childhood, may have contributed to 5% a lower DDE prevalence. 0% 36%40% 13%18% 17%24% In the total sample, DDE was commoner in the 15-year- CaretakerPaentCaretaker Paent CaretakerPaent old cohort, possibly because not all permanent teeth had Observed DDEAesthecal problemsAnterior DDE/Aesthecal problems erupted in the younger cohort and some DDE in the older cohort had faded, e.g., in mild fluorosis, just a very superfi- Fig. 3 The observation of developmental defects of the enamel cial layer of the enamel is affected and might easily be worn (DDE) by the patients and the caretakers in relation to the gender of away (Wong et al. 2016). the patient In accordance with other studies, DEO was the dominat- ing type of defect (Clarkson and O’Mullane 1992; Robies 35% et al. 2013). However, this study also showed that DEO in combination with other defects, mostly diffuse opacities 30% (DIO), was common, e.g., in a number of cases with verified 25% MIH, DIO in the second permanent molars and/or premo- 20% lars was registered. A possible explanation could be that the 15% patients were affected by MIH as well as by mild fluorosis. 10% Another suggestion is that there could also be an individual susceptibility to enamel developmental defects. The mixture 5% of different types of DDE makes establishing the cause and 0% diagnosis problematic. CaretakersPaents Densts Only 4% of the study group had any teeth with hypo- Aesthec problems plasia comparable with the findings from Ireland (Clarkson p=0.000 and O’Mullane 1992), while the corresponding figure in Australia was 17% (Seow 2011). A suspicion is that enamel Fig. 4 The caretakers, the patients’ and the dentists’ judgments of disintegration may have been registered as hypoplasias. In aesthetic problems in cases with frontal developmental defects of the enamel (DDE) addition, all DDE was formerly denominated hypoplasias, and that term may have a tendency to survive. In accordance with other studies (Seow 2011; Robies with the aesthetic problems than the patients and their care- et al. 2013), the first permanent molars (FPM) and the max- takers (Figs. 3, 4). illary central incisors (PCIm) were the most affected teeth. The present study showed that DEO and DIO are the most prevalent type of defects in these teeth. Discussion MIH is the main reason for the elevated occurrence of DDE in PFM and PCI, but these teeth also seem to be the The frequency of developmental defects of the enamel target teeth for other types of enamel disturbances. However, (DDE) was comparable with an earlier cohort study in the the raised prevalence of DIO in FPM is hard to explain. present region. The mixture of different types of DDE within Possibly, the ameloblasts in teeth, mineralised at a very an individual was frequent, making diagnoses based on the early age, are more susceptible to any disturbances. The clinical appearance of DDE hazardous and doubtful. There estimated MIH prevalence was in concordance with other is also a risk of over-diagnosing MIH, as the first permanent studies (Jälevik 2010). The prevalence in the youngest age molars and upper incisors were the most frequently affected group was higher (17.1%). A comparable prevalence of teeth of demarcated, as well as diffuse opacities, especially 18.4% in 8-year-olds was shown in a prior MIH prevalence before it is possible to inspect premolars and second per- study in this region (Jälevik et al. 2001). In preventing mis- manent molars. Furthermore, the paediatric dentists were diagnosis as a result of disintegration, caries, or restorations, more concerned about the appearance of frontal DDE than the 8-year-olds have been considered to be the best age for the patients and their caretakers. the recognition of MIH (Weerheim et al. 2003). However, 1 3 194 European Archives of Paediatric Dentistry (2018) 19:187–195 there may be a risk of over-diagnosing when the defects Conclusions in FPM are mild, and when the second molars, premolars, and canines cannot be judged, because they are not erupted. The prevalence of any type of DDE was 33.2%, somewhat When searching for the aetiology of MIH, a correct diag- lower than other comparable studies. The 15-year age nosis is of utmost importance. The frequent occurrence of cohort and the most rural clinic had a significantly higher DIO in FPM could also lead to an over-diagnosis of MIH, prevalence. especially when only target teeth are examined. The mixture of different types of developmental defects in DDE in the permanent incisors can be caused by trau- enamel (DDE), within one individual, was frequent, making matic injuries to the primary incisors. In accordance with diagnoses based on the clinical appearance of DDE hazard- other research (Andreassen et al. 1971), the present study ous and doubtful. showed a significant risk for DDE in the permanent suc - There was a significant risk for DDE in the permanent cessor in cases of trauma in early childhood. Notably, the successor in cases of trauma before 4 years of age. risk for DDE diminished considerably in cases of injuries Reported health problems in early childhood did not raise to 4 to 6-year-olds. the prevalence of DDE. Few children (1%) had an affected, solitary premolar The presence of DDE did not lead to a raised level of that might have been caused by an infected primary molar. dental fear and anxiety. Almost one in ten had generalised, non-chronological The paediatric dentists were more concerned about the defects, which were either genetic or due to non-genetic, appearance of anterior DDE than the patients and their long-standing environmental influences (Espelid et  al. caretakers. 2017). The prevalence of amelogenesis imperfecta (AI) was 1/4000 in this region in 1985 (Sundell et al. 1985). Compliance with ethical standards It is not likely that the prevalence of AI has dramati- Conflict of interest Author B. Jälevik declares that she has no conflicts cally increased. Long-standing environmental influences of interest. Author A. Szigyarto-Matei declares that she has no con- remains to be suspected. Mild fluorosis, caused by the flicts of interest. Author A. Robertson declares that she has no conflicts ingestion of toothpaste or other fluoride supplements is of interest. plausible (Seow 2011), as there was no significant relation Ethical approval All procedures performed in studies involving human between drinking water from a well and generalised non- participants were in accordance with the ethical standards of the insti- chronological defects. However, this does not explain the tutional research committee and with the 1964 Helsinki declaration and frequent, generalised, non-chronological defects, solely its later amendments, or comparable ethical standards. with DEO. Informed consent Informed consent was obtained from all individual The CFSS-DS instrument results, scoring dental fear and participants (and their caretakers) included in the study. anxiety, was very low in the present study-group, indicat- ing good dental healthcare from an early age. In contrast Open Access This article is distributed under the terms of the Crea- to a previous study in this geographic region (Jälevik and tive Commons Attribution 4.0 International License (http://creat iveco Klingberg 2002), not even those with DDE showed raised mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- CFSS-DS scores. These improvements may depend on bet- tion, and reproduction in any medium, provided you give appropriate ter knowledge of caring for children with DDE, but also the credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. fact that the former study was dealing only with severe MIH. Frontal DDE led to aesthetic problems in every forth case. Thus, the majority did not worry about the deviant appear- ance of their front teeth. As expected, girls were significantly References more troubled than boys. These findings are in accordance Andreasen JO, Sundström B, Ravn JJ. The effect of traumatic injuries with Sujak et al. (2004). Notably, the dentists were signifi- to primary teeth and their permanent successors I. A clinical and cantly more concerned than the patients. Consequently, the histologic study of 117 injured permanent teeth. Scand J Dent dentists must be careful not to transmit their opinion con- Res. 1971;79:219–83. cerning appearance to the patients. Bäckman B, Holm AK. Amelogenesis imperfecta: prevalence and incidence in a nothern Swedish county. Community Dent Oral Epidemiol. 1986;14:43–7. Chankanka O, Levy SM, Warren JJ, Chalmers JM. A literature review of aesthetic perceptions of dental fluorosis and relationships with psychosocial aspects/oral health-related quality of life. Commu- nity Dent Oral Epidemiol. 2010;38:97–109. 1 3 European Archives of Paediatric Dentistry (2018) 19:187–195 195 Clarkson JJ, O’Mullane DM. Prevalence of enamel defects/fluorosis in other dental conditions in areas with and without water fluorida- fluoridated and non-fluoridated areas in Ireland. Community Dent tion. BMC Oral Health. 2012;10:4. Oral Epidemiol. 1992;20:196–9. Møller IJ. Fluorides and dental fluorosis. Int Dent J. 1982;32:135–47. Crawford PJ, Aldred M, Bloch-Zupan A. Amelogenesis Imperfecta. Robies MJ, Ruiz M, Bravo-Perez M, González E, Peñalver MA. Preva- Orphanet J Rare Dis. 2007;2:17. lence of enamel defects in primary and permanent teeth in a group Cutress TW, Suckling GW. Differential diagnosis of dental fluorosis. J of schoolchildren from Granada (Spain). Med Oral Patol Oral Cir Dent Res. 1990;69:714–20. Bucal. 2013;18:e187–93. Dean HT. Classification of mottled enamel diagnosis. J Am Dent Seow WK. Comparison of enamel defects in the primary and perma- Assoc. 1934;142–6. nent dentitions of children from a low-fluoride district in Aus- Dummer PMH, Kingdon A, Kingdon R. Prevalence and distribution by tralia. Paediatr Dent. 2011;33: 207–12. tooth type and surface of developmental defects of dental enamel Small BW, Murray JJ. Enamel opacities: prevalence, classifications and in a group of 15- to 16-year-old children in South Wales. Com- aetiological considerations. J Dent. 1978;6:33–42. munity Dent Health. 1990;7:369–77. Sujak SL, Abdul Kadir R, Dom TN. Esthetic perception and psycho- Espelid I, Haubek D, Jälevik B. Developmental defects of the dental social impact of developmental enamel defects among Malaysian hard tissues and their treatment. In: Koch G, Poulsen S, Espelid adolescents. J Oral Sci. 2004;46:221–6. I, Haubek D, editors. Paediatric dentistry—a clinical approach. Sundell S, Koch G. Heriditary amelogenesis imperfecta. Epidemiology Oxford: Wiley; 2017, pp. 261–90. and clinical classification in a Swedish child population. Swed FDI Commision on Oral Health, Research and Epidemiology. A review Dent J. 1985;9:157–69. of the developmental defects of enamel index (DDE Index) Int Turner JO. Two cases of hypoplasia of enamel. Br J Dent Sci. Dent J. 1992;42:411–26. 1912;55:227–8. Fejerskov O, Richards A, DenBesten P. The effect of fluoride on tooth Weerheijm KL, Jälevik B, Alaluusua S. Molar-incisor hypomineralisa- mineralization. In: Fejerskov O, Ekstrand J, Burt BA, editors. Flu- tion. Caries Res. 2001;35:390–1. oride in dentistry. Copenhagen: Munksgaard; 1996. pp. 112–52. Weerheijm KL, Duggal M, Mejare I et al. Judgement criteria for molar Jälevik B. Prevalence and diagnosis of molar-incisor-hypominer- incisor hypomineralisation (MIH) in epidemiologic studies: a alisation (MIH): a systematic review. Eur Arch Paediatr Dent. summary of the European meeting on MIH held in Athens, 2003. 2010;11:59–64. Eur J Paed Dent. 2003;4:110–3. Jälevik B, Klingberg G. Dental treatment, dental fear and behaviour Witkop CJ Jr, Sauk JJ Jr. Heritable defects of enamel. In: Stewart RE, management problems in children with severe enamel hypomin- Prescott GH, editors. Oral facial genetics. Saint Louis: CV Mosby; eralization of their permanent first molars. Int J Paediatr Dent. 1976. pp. 151–226. 2002;12:24–32. Wong HM. Aetiological factors for developmental defects of enamel. Jälevik B, Klingberg G, Barregård L, Norén JG. The prevalence of Austin J Anat. 2014;1:1003. demarcated opacities in permanent first molars in a group of Wong HM, Wen YF, King NM, Patrick C, McGrath J. Longitudinal Swedish children. Acta Odontol Scand. 2001;59:255–60. changes in developmental defects of enamel. Community Dent McGrady MG, Ellwood RP, Goodwin M, Boothman N, Pretty IA. Ado- Oral Epidemiol. 2016;44:255–62. lescents’ perceptions of the aesthetic impact of dental fluorosis vs. 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Archives of Paediatric Dentistry Springer Journals

The prevalence of developmental defects of enamel, a prospective cohort study of adolescents in Western Sweden: a Barn I TAnadvarden (BITA, children in dental care) study

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Dentistry; Dentistry
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Abstract

Aim To describe the prevalence of different types of developmental defects of the enamel (DDE) in varying age-cohorts and habitations, and to analyse if early trauma to the primary teeth and early subsequent serious health problems were related to DDE in the permanent dentition. Dental fear and anxiety, and aesthetic problems as a consequence of DDE were also investigated. Methods DDE was registered over 5 years annually in three age cohorts (796 children). The DDE index (FDI Commision on Oral Health, Research and Epidemiology, Int Dent J 42:411–426, 1992) was used. Information on diseases in early child- hood, trauma to the primary teeth, and dental fear and anxiety were collected. Results The prevalence of DDE was 33.2% (boys 37.1%, girls 29.3%, p = 0.02). Demarcated opacities (DEO), solely, were the most frequent kind of defect, affecting 18%. Five percent (5%) had diffuse opacities (DIO) and 1% had hypoplasias, whereas 7% had teeth with both DEO and DIO. The most frequently affected teeth of DEO, as well as of DIO, were the first permanent molars and maxillary central incisors. Dental injuries to the primary anterior teeth raised the risk for DDE in the permanent teeth, but early serious health problems did not. Generalised DDE was common (8.4%). The paediatric dentists assessed the DDE in the maxillary anterior teeth as more serious than did the affected children and their parents. Conclusions Generalised DDE was more frequent than expected, as well as the occurrence of both DEO and DIO in the same individual. The first permanent molars and the upper central incisors were the most affected teeth. Keywords Developmental defects of the enamel · Epidemiology · Aesthetics Introduction DDE teeth can be problematic for the affected child, as well as the treating dentist, with considerable aesthetic Developmental defects of enamel (DDE) are common. As problems ensuing. The teeth also may break down and be high as 50% of a population, living in a low uo fl ride district, impaired by shooting pain and difficulties in anaesthetising. has been shown to have at least one tooth with mineralisa- Dental fear and anxiety, as well as dental behaviour prob- tion disturbances. The fluoride content of drinking water lems as a consequence of DDE, have been reported (Jälevik has a considerable effect on the DDE prevalence (Dummer and Klingberg 2002). et al. 1990). For the dental staff, sound knowledge, early recognition, and treatment planning of DDE are of the utmost importance for optimal care and the prevention of dental fear. Developmental defects in the enamel are defined as dis- turbances in hard tissue matrices and in their mineralisation, * B. Jälevik birgitta.jalevik@gu.se arising during odontogenesis (Commission on Oral Health, Research and Epidemiology, FDI 1992). The defects may be Department of Pediatric Dentistry, Institute of Odontology localised, affecting single or multiple teeth, or systematic, at the Sahlgrenska Academy, University of Gothenburg, affecting groups of teeth developing at the time of distur - Gothenburg, Sweden 2 bance (Commission on Oral Health, Research and Epide- Clinic of Pediatric Dentistry, Public Dental Service, VGR, miology, FDI 1992). Uddevalla, Sweden Vol.:(0123456789) 1 3 188 European Archives of Paediatric Dentistry (2018) 19:187–195 has historically been low (Small and Murray 1978). Moreo- Nomenclature ver, before the DDE indexes were published, there was great confusion concerning the description and nomenclature of Historically, a wide variety of terms and definitions have enamel defects, making earlier studies of enamel opacities been used to describe developmental defects of the enamel. hard to interpret. Some are simply descriptive terms while others are linked to Studies on full mouth examinations of the permanent the causative agent, e.g., fluoride. To remedy this confusion, dentition, using the mDDE-index, are infrequent. Clarkson an FDI working group was established in 1982 and the DDE and O’Mullane (1992) showed that 63% of 15-year-olds index was published. This original index was complicated in a low-fluoride district had at least one tooth with DDE to use in practice and a modified DDE index (mDDE) was and that demarcated opacities (DEO) were predominant. presented in 1992. In short, DDE is classified as demarcated Seow (2011) found that 58% of a study group, with per- opacities, diffuse opacities, and hypoplasia. manent teeth and a mean age 13.5 years, had at least one Hypoplasia is defined as a quantitative defect of enamel tooth affected by DDE, and that DEO and DIO were equally involving the surface, with reduced thickness of the enamel. represented in the permanent dentition. Robies et al. (2013) The defective enamel may occur as shallow or deep pits or examined children 3–12 years old; 52% of those with only rows of pits arranged horizontally, or as small or large, wide permanent teeth, had at least one tooth affected. DEO was or narrow grooves. the most frequent defect. A prior prevalence study from the Opacity is defined as a qualitative defect of enamel iden- region of the present survey found that 33% of 8-year-olds tified, i.e., as an enamel hypomineralisation; visually as had at least one tooth affected (Jälevik et al. 2001). an abnormality in the translucency of enamel. A white or In the past decades, a number of prevalence studies of discoloured area is characteristic, but the enamel surface MIH have been published from different parts of the world. is smooth and its thickness is normal. There are two kinds A wide variation in MIH prevalence has been reported (Jäle- of opacities; demarcated opacity with a distinct and clear vik 2010). In spite of the EAPD criteria from 2003, cross- boundary to the adjacent normal enamel and can be white, comparisons of the results from these various studies have cream, yellow or brown in colour; diffuse opacity has a lin- been difficult due to the use of different indices and criteria, ear, patchy or confluent distribution, but there is no clear examination variability, methods of recording, and varying boundary to the adjacent normal enamel. age groups (Jälevik 2010). The examination prerequisites were given: tooth sur- faces were inspected visually and defective areas tactilely Aetiology explored with a probe. Natural or artificial light was used during examination and defects less than 1 mm were not Defects can be genetic or environmental and often the cause recorded. The teeth were not dried, but large debris was remains unknown. Environmental (also called acquired) den- removed with the help of a cotton roll. The number of sub- tal defects can be divided into those caused by local factors jects with one or more teeth affected, the mean number of and those caused by systemic factors. A local factor can teeth per child affected by any defect, and the type of defect be suspected when a single tooth or group of neighbouring were the standard data to be reported (Commission on Oral teeth is affected. General symmetric defects, related to the Health, Research and Epidemiology, FDI 1992). timing of the insult and thus to the sequence of the develop- In the twenty-first century, studies of DDE have mainly ment of the teeth, are denominating chronological defects. focused on MIH. The mDDE index was considered to be too The aetiology of general defects, not related to any particu- time-consuming and not adequate for MIH studies, as post- lar time period during tooth formation (non-chronological eruptive breakdown (PEB) is a prominent feature in MIH defects), are either genetic or due to non-genetic, longstand- and the mDDE index may not clearly differentiate PEB from ing environmental influences, e.g., intoxications, malnutri- hypoplasia. In addition, the mDDE does not represent atypi- tion or other medical conditions (Espelid et al. 2017; Wong cal restorations and extractions owing to MIH. In the EAPD 2014). seminar in 2003, specific criteria for MIH in epidemiological Well-known enamel defects are amelogenesis imperfecta, studies were established (Weerheim et al. 2003). dental fluorosis, enamel defects in permanent teeth caused by trauma or infection to the preceding primary teeth, and Prevalence MIH. Amelogenesis imperfecta (AI) is a genetically determined The relationship between dental fluorosis and the content of developmental defect of the enamel, affecting all or the fluoride in drinking water is well-documented since a long majority of teeth in the dentitions. The enamel defects are in time ago (Dean 1934; Møller 1982). However, the interest general more pronounced in the permanent dentition, com- in studying the presence of opacities in low fluoride areas pared to the primary dentition (Crawford et al. 2007). The 1 3 European Archives of Paediatric Dentistry (2018) 19:187–195 189 reported prevalence of AI varies from 0.06/1000 in the USA, The possibility of revealing diagnoses with the help of to 0.25/1000 in Southern Sweden and 1.4/1000 in Northern mDDE-index. Sweden (Witkop and Sauk 1976; Sundell and Koch 1985; The connection with early childhood traumatic injuries Bäckman and Holm 1986). in the primary dentition and DDE. Dental fluorosis is a well-known, environmental develop- The connection with serious health problems in early mental defect of the enamel. The causal connection between childhood and DDE. fluorosis and percentage of fluoride in drinking water is Dental fear and anxiety in children/adolescents with well-documented. Diffuse opacities affecting homologous DDE. teeth are characteristics of fluorosis. The opacities vary from The aesthetic perception of DDE judged by children/ado- fine white transverse lines to extensive opaque areas. The lescents, their caretakers, and paediatric dentists. border to normal enamel is always diffuse. Post-eruptive staining and shallow pits are common in more serious cases (Möller 1982; Cutress and Suckling 1990; Fejerskov et al. Materials and methods 1996). Trauma to the primary incisors is the most well-docu- The BITA study (BITA = Barn I TAndvården, which means mented local causative factor for DDE affecting the per - children in dental care) is a 5-year longitudinal study in manent successor. It has been shown that about 10% of Sweden, between the years 2008 and 2012, concerning dif- enamel defects in permanent incisors have been caused by ferent aspects of children in the dental situation. Four age trauma to the preceding incisor. Trauma at a very early age cohorts with children 3, 7, 11 and 15 years at the study start, involves a greater risk of hyperplastic defects, compared to from five Public Dental Service clinics in the Region Västra later trauma that can cause opacities in the permanent suc- Götaland, were invited to participate, representing both rural cessor (Andreasen et al. 1971). An infected primary tooth and urban areas with different socio-economic status. The may also increase the risk of DDE in the permanent succes- majority of the patients had municipal drinking water with sor (Turner’s teeth) (Turner 1912). a low level of fluoride (< 0.10 mg/ml). In the more rural Molar incisor mineralisation (MIH) is an acquired, sys- areas, some had drinking water from a well, but there was no temic enamel defect in the permanent first molars (PFM) accessible information on the fluoride status of any private (Weerheim et al. 2001) and is frequent in many populations drinking water supplies. (Jälevik 2010). Approximately every fifth child in Sweden Developmental defects of the enamel in all erupted per- has been shown to have MIH, often in combination with manent teeth were registered yearly for 5 years, discerning post-eruptive enamel disintegration. One, two, three or all between demarcated opacities, diffuse opacities, and hypo- PFM could be affected to some extent. One or more of the plasias, according to the mDDE-index (FDI 1992). Moreo- incisors are often affected at the same time. (Jälevik et al. ver, post-eruptive breakdown of the enamel in affected 2001). The causation of MIH is still not confirmed. teeth was recorded. The youngest cohort was excluded from the DDE part of the BITA study as the children were Aesthetic perception of DDE 7 years old by the study end and consequently, only had a few permanent teeth to examine. Few studies have considered aesthetic problems owing to After instruction and training, the ordinary dental staff DDE, with the appearance of fluorosis mostly discussed. carried out the examinations. A test protocol, composed of Chankanka et  al. (2010) showed that mild fluorosis was 24 digital photos of teeth with DDE, completed; 85% of the not associated with negative effects on Oral Health Related affected surfaces were correctly assessed. The study cohorts Quality of Life (OHRQoL), but severe fluorosis was con - were 11, 15 and 19 years old at study end. sistently reported to have negative effects on OHRQoL. In Data from the clinical examination concerning type and another study (McGrady et al. 2012), demarcated opacities distribution of DDE were analysed. Annual background in the incisor were judged to be more troublesome than mild data on traumatic injuries of the primary teeth 0–6 years of fluorosis. Sujak et al. (2004) investigated the affect of all age, severe illness during the first 4 years of life, and den - types of DDE. They suggested that very few subjects were tal fear and anxiety, were collected from the BITA study. concerned about the appearance of their teeth, or were not The CFSS-DS scale measured dental fear and anxiety. aware of their teeth being different. At the study end, information on fluoride in drinking The aim of the present study was to investigate: water and known family enamel defects were collected from those with registered DDE, in a questionnaire. The The prevalence of developmental defects (DDE) in the children/adolescents, as well as the caretakers, were also enamel of permanent teeth in varying age cohorts and asked for aesthetic and treatment problems caused by their habitations. enamel developmental disturbances. 1 3 190 European Archives of Paediatric Dentistry (2018) 19:187–195 Information on treatment measurements of the perma- Results nent first molars was collected from the record of all sub- jects with registered defects. At the BITA-study start, 964 children were eligible; 168 Ninety-six randomly selected children/adolescents, with left the study before the study end and 796 children (83%) observed DDE, were clinically examined by two paediatric remained. The reasons for dropping out were mainly moving dentists (BJ and AM) in order to verify the registrations. to another location, parents’ lack of time, unwillingness to Intraoral photos were taken. The aesthetic appearance on fill in questionnaires and non-appearance. the photos of the front teeth (canines and incisors) was The subsequent questionnaires were completed by 201 assessed by the paediatric dentists. That assessment was of 264 (76%) participants having developmental defects of compared to reported aesthetic problems for the patients the enamel (DDE). and their caretakers. Prevalence of DDE Analysis The distribution of gender was even in the study popula- Data were entered into a spreadsheet (Microsoft Excel, tion. Developmental defects (DDE) were registered in 264 Microsoft Corp, WA, USA) and then analysed using (33.2%) children. More boys than girls had DDE (Table 1). SPSS Version 22, (SPSS Inc, Chicago IL, USA). Descrip- DDE was more prevalent in the 15-year-olds (Cohort 3), tive statistics were used to assess the participants data. compared to the other age cohorts (p = 0.05) (Table 2). The Responses to questionnaires were analysed through the prevalence in the participating five clinics varied from 25.6 use of descriptive statistics, and comparisons between dif- to 45.2% (p = 0.02). The most rural clinic had the highest ferent dental groups were made with the Chi square test prevalence (Fig. 1). and odds ratio. Concerning CFSS-DS, the T-test was used. Results at an alpha level less than 0.05 were considered Type of DDE statistically significant. Half of those with DDE had solely demarcated opacities (DEO). However, fully one-quarter had teeth with DEO, as Ethical considerations well as one or more teeth with diffuse opacities (DIO) and/ or hypoplasias (Hypo). The most frequent “mixed DDE” BITA‑study was DEO + DIO, affecting more than one-fifth of those with DDE (Table 3). Application for an ethical review (Dnr: 286-07) was sub- Post-eruptive breakdown (PEB) of the enamel was reg- mitted in June 2007. The Regional Ethical Review Board istered in 19.3% of the subjects with DDE. PEB was more of the University of Gothenburg, Sweden, found the pro- common in subjects with one or more teeth with demarcated ject was not subject to the Swedish Act on Ethical Review. opacities (21.4%), compared to those with diffuse opacities The Board provided feedback on the information to the and/or hypoplasias (11.1%). patients, which was taken into account during further planning of the study. The caretakers and their children Distribution within the dentition received a letter with information regarding the project before entering the BITA-study. Respondents were asked The most frequently affected teeth were the upper first to participate in the study when they attended a routine molars and central incisors (16–17% of the total sample). dental appointment. In connection to the first clinical examination, the caretakers signed an informed consent to participate in the research project. Table 1 The distribution of developmental defects of the enamel (DDE) by gender DDE Total Questionnaire No Yes The study was approved by the Regional Ethical Review N (%) N (%) Board of the University of Gothenburg, Sweden, Dnr: 806- Girls 283 (70.8) 117 (29.3) 400 13 (2014-02-25). Children/adolescents and their caretak- Boys 249 (62.9) 147 (37.1) 396 ers were given written information regarding the study and Total 532 (66.8) 264 (33.2) 796 asked to give their consent to participate. The boys were significantly more affected than the girls, p = 0.02 1 3 European Archives of Paediatric Dentistry (2018) 19:187–195 191 Table 2 The distribution of Age DDE MIH General. DDE Total, N developmental defects of the enamel (DDE) among the age No, N (%) Yes, N (%) No, N (%) Yes, N (%) No, N (%) Yes, N (%) cohorts Cohort  11 185 (70.3%) 78 (29.7%) 218 (82.9%) 45 (17.1%) 262 (99.6%) 1 (0.4%) 263  15 163 (61.0%) 104 (39.0%) 237(88.8%) 30 (11.2%) 235 (88.0%) 32 (12.0%) 267  19 184 (69.2%) 82 (30.8%) 244 (91.7%) 22 (8.3%) 232 (87.2%) 34 (12.8%) 266 Total 532 (66.8%) 264 (33.2%) 699 (87.8%) 97 (12.2%) 729 (91.6%) 67 (8.4%) 796 p = 0.05 p = 0.01 p < 0.001 The table also shows the distribution of MIH and generalised DDE judged from the clinical registration and information in the dental records Fig. 1 The distribution of devel- 70% opmental defects of the enamel (DDE) among participating 60% clinics and the age cohorts 50% 40% 11yrs 15yrs 30% 19 yrs All age cohorts 20% 10% 0% Clinic 1, Clinic 2, Clinic 3, Clinic 4, Clinic 5, All clinics, N=84 N=104 N=290 N=154 N=164 N=796 Table 3 The distribution of the different types of developmental Chronological DDE, affecting FPM and incisors, was the defects of the enamel (DDE) among the affected dentitions most frequent defect, followed by generalised, non-chrono- logical and local defects (Table 4). DDE type N % affected (264) % total sample (796) Generalised DDE and MIH DEO 144 54.5 18.1 Generalised DDE was seen in 8.4% of the total sample, when DIO 42 15.9 5.3 denominating non-chronological defects ae ff cting more than Hypo 11 4.2 1.4 four teeth as generalised. The mean number of affected teeth DEO + DIO 54 20.5 6.8 in this group was 15.2 (SD 7.0). Almost 25% of those with DEO + Hypo 7 2.7 0.9 generalised DDE had both DEO and DIO. The remainder DIO + Hypo 1 0.4 0.1 had either solely DIO or DEO, to a similar extent. Only one DEO + DIO + Hypo 5 1.9 0.6 patient with generalised DDE had merely hypoplasia. The DEO demarcated opacities, DIO diffuse opacities, Hypo hypoplasias occurrence of generalised DDE in the different cohorts, as well as in the different clinics, was statistically significant. They were the most affected teeth with both DEO and DIO. When taking the clinical registrations and information The mandibular canines were the least affected teeth. Hypo- from dental records into account, 12.2% of the total sample plasia was an uncommon defect (Fig. 2). was judged to have MIH. There was no significant difference among the participating clinics, but the youngest cohort had a higher prevalence (17.1%) of MIH (Tables 2, 3). 1 3 192 European Archives of Paediatric Dentistry (2018) 19:187–195 Fig. 2 The frequency of demar- cated opacities (DEO), diffuse opacities (DIO) and hypoplasias (Hypo) by tooth type Table 4 The distribution of local, chronological and non-chronolog- (incisors and canines) (Table 4). In eight cases, a single pre- ical defects molar was the only affected tooth. N (% total) Affected teeth N (% total) Aetiological factors Local 52 (6.5%) Anterior teeth 42 (5.2%) Other teeth 10 (1.3%) Traumatic injuries to the primary front teeth before 4 years Chronological 119 (15%) FPM and incisors 104 (13%) of age raised the risk for DDE to the permanent successors (FP&I) (OR 2.3, CI 1.6–3.4). Injuries to 4–6-year-olds had no sig- Other chronological 15 (2%) nificant influence (OR 1.4, CI 0.8–2.3) (Table  5). Non-chronological 93 (12%) Generalised 67 (8%) One-third of the DDE group (34%) used drinking water FPM&I plus 1–2 other 18 (2%) from a well. Four of them reported raised fluoride content teeth in the water. The prevalence of diffuse opacities was slightly < 4 teeth 8 (1%) higher (p = 0.212) in this group, compare to those in the DDE-group with municipal water. Table 5 The relation between traumatic injuries of the primary fron- Reported health problems in early childhood did not raise tal teeth, before and after 3 year of age, and developmental defects of the prevalence of DDE. the enamel (DDE) in the permanent frontal teeth Twelve percent reported possible heredity. Trauma No trauma Total Dental fear and anxiety 0–3 years  DDE front teeth 52 121 173 The presence of DDE did not lead to dental fear and anxiety.  No DDE front 100 523 623 The DDE group scored 19.7 and the non-DDE group scored teeth 20.0 in the CFSS-DS instrument (p = 0.54).  Total 152 644 796 OR 2.3, CI 1.6–3.4 4–6 years Aesthetic considerations  Front teeth DDE 23 150 173  No front teeth 62 561 561 DDE Approximately 40% of the caretakers and children/adoles- cents had observed the DDE, with about half of them regard-  Total 85 711 796 OR 1.4, CI 0.8–2.3 ing the defects as an aesthetic problem. Those with anterior DDE were more concerned. The children/adolescents with frontal DDE were more troubled than their caretakers, with Local defects girls and their caretakers more concerned than boys and their caretakers. The paediatric dentists were more concerned The majority of the local defects were in the front teeth 1 3 European Archives of Paediatric Dentistry (2018) 19:187–195 193 50% One-third (33.2%) of the examined population had DDE NS 45% of any type, with demarcated opacities (DEO) as the most 40% NS p=0.01 35% frequent defect. Compared to other studies using the mDDE- 30% p=0.02 index (Clarkson and O’Mullane 1992; Seow 2011; Robies 25% NS et al. 2013), the DDE prevalence was lower in the present 20% Girl NS 15% study. The absence of malnutrition and well-functioning Boy 10% healthcare during early childhood, may have contributed to 5% a lower DDE prevalence. 0% 36%40% 13%18% 17%24% In the total sample, DDE was commoner in the 15-year- CaretakerPaentCaretaker Paent CaretakerPaent old cohort, possibly because not all permanent teeth had Observed DDEAesthecal problemsAnterior DDE/Aesthecal problems erupted in the younger cohort and some DDE in the older cohort had faded, e.g., in mild fluorosis, just a very superfi- Fig. 3 The observation of developmental defects of the enamel cial layer of the enamel is affected and might easily be worn (DDE) by the patients and the caretakers in relation to the gender of away (Wong et al. 2016). the patient In accordance with other studies, DEO was the dominat- ing type of defect (Clarkson and O’Mullane 1992; Robies 35% et al. 2013). However, this study also showed that DEO in combination with other defects, mostly diffuse opacities 30% (DIO), was common, e.g., in a number of cases with verified 25% MIH, DIO in the second permanent molars and/or premo- 20% lars was registered. A possible explanation could be that the 15% patients were affected by MIH as well as by mild fluorosis. 10% Another suggestion is that there could also be an individual susceptibility to enamel developmental defects. The mixture 5% of different types of DDE makes establishing the cause and 0% diagnosis problematic. CaretakersPaents Densts Only 4% of the study group had any teeth with hypo- Aesthec problems plasia comparable with the findings from Ireland (Clarkson p=0.000 and O’Mullane 1992), while the corresponding figure in Australia was 17% (Seow 2011). A suspicion is that enamel Fig. 4 The caretakers, the patients’ and the dentists’ judgments of disintegration may have been registered as hypoplasias. In aesthetic problems in cases with frontal developmental defects of the enamel (DDE) addition, all DDE was formerly denominated hypoplasias, and that term may have a tendency to survive. In accordance with other studies (Seow 2011; Robies with the aesthetic problems than the patients and their care- et al. 2013), the first permanent molars (FPM) and the max- takers (Figs. 3, 4). illary central incisors (PCIm) were the most affected teeth. The present study showed that DEO and DIO are the most prevalent type of defects in these teeth. Discussion MIH is the main reason for the elevated occurrence of DDE in PFM and PCI, but these teeth also seem to be the The frequency of developmental defects of the enamel target teeth for other types of enamel disturbances. However, (DDE) was comparable with an earlier cohort study in the the raised prevalence of DIO in FPM is hard to explain. present region. The mixture of different types of DDE within Possibly, the ameloblasts in teeth, mineralised at a very an individual was frequent, making diagnoses based on the early age, are more susceptible to any disturbances. The clinical appearance of DDE hazardous and doubtful. There estimated MIH prevalence was in concordance with other is also a risk of over-diagnosing MIH, as the first permanent studies (Jälevik 2010). The prevalence in the youngest age molars and upper incisors were the most frequently affected group was higher (17.1%). A comparable prevalence of teeth of demarcated, as well as diffuse opacities, especially 18.4% in 8-year-olds was shown in a prior MIH prevalence before it is possible to inspect premolars and second per- study in this region (Jälevik et al. 2001). In preventing mis- manent molars. Furthermore, the paediatric dentists were diagnosis as a result of disintegration, caries, or restorations, more concerned about the appearance of frontal DDE than the 8-year-olds have been considered to be the best age for the patients and their caretakers. the recognition of MIH (Weerheim et al. 2003). However, 1 3 194 European Archives of Paediatric Dentistry (2018) 19:187–195 there may be a risk of over-diagnosing when the defects Conclusions in FPM are mild, and when the second molars, premolars, and canines cannot be judged, because they are not erupted. The prevalence of any type of DDE was 33.2%, somewhat When searching for the aetiology of MIH, a correct diag- lower than other comparable studies. The 15-year age nosis is of utmost importance. The frequent occurrence of cohort and the most rural clinic had a significantly higher DIO in FPM could also lead to an over-diagnosis of MIH, prevalence. especially when only target teeth are examined. The mixture of different types of developmental defects in DDE in the permanent incisors can be caused by trau- enamel (DDE), within one individual, was frequent, making matic injuries to the primary incisors. In accordance with diagnoses based on the clinical appearance of DDE hazard- other research (Andreassen et al. 1971), the present study ous and doubtful. showed a significant risk for DDE in the permanent suc - There was a significant risk for DDE in the permanent cessor in cases of trauma in early childhood. Notably, the successor in cases of trauma before 4 years of age. risk for DDE diminished considerably in cases of injuries Reported health problems in early childhood did not raise to 4 to 6-year-olds. the prevalence of DDE. Few children (1%) had an affected, solitary premolar The presence of DDE did not lead to a raised level of that might have been caused by an infected primary molar. dental fear and anxiety. Almost one in ten had generalised, non-chronological The paediatric dentists were more concerned about the defects, which were either genetic or due to non-genetic, appearance of anterior DDE than the patients and their long-standing environmental influences (Espelid et  al. caretakers. 2017). The prevalence of amelogenesis imperfecta (AI) was 1/4000 in this region in 1985 (Sundell et al. 1985). Compliance with ethical standards It is not likely that the prevalence of AI has dramati- Conflict of interest Author B. Jälevik declares that she has no conflicts cally increased. Long-standing environmental influences of interest. Author A. Szigyarto-Matei declares that she has no con- remains to be suspected. Mild fluorosis, caused by the flicts of interest. Author A. Robertson declares that she has no conflicts ingestion of toothpaste or other fluoride supplements is of interest. plausible (Seow 2011), as there was no significant relation Ethical approval All procedures performed in studies involving human between drinking water from a well and generalised non- participants were in accordance with the ethical standards of the insti- chronological defects. However, this does not explain the tutional research committee and with the 1964 Helsinki declaration and frequent, generalised, non-chronological defects, solely its later amendments, or comparable ethical standards. with DEO. Informed consent Informed consent was obtained from all individual The CFSS-DS instrument results, scoring dental fear and participants (and their caretakers) included in the study. anxiety, was very low in the present study-group, indicat- ing good dental healthcare from an early age. In contrast Open Access This article is distributed under the terms of the Crea- to a previous study in this geographic region (Jälevik and tive Commons Attribution 4.0 International License (http://creat iveco Klingberg 2002), not even those with DDE showed raised mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- CFSS-DS scores. These improvements may depend on bet- tion, and reproduction in any medium, provided you give appropriate ter knowledge of caring for children with DDE, but also the credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. fact that the former study was dealing only with severe MIH. Frontal DDE led to aesthetic problems in every forth case. Thus, the majority did not worry about the deviant appear- ance of their front teeth. As expected, girls were significantly References more troubled than boys. These findings are in accordance Andreasen JO, Sundström B, Ravn JJ. The effect of traumatic injuries with Sujak et al. (2004). Notably, the dentists were signifi- to primary teeth and their permanent successors I. A clinical and cantly more concerned than the patients. Consequently, the histologic study of 117 injured permanent teeth. Scand J Dent dentists must be careful not to transmit their opinion con- Res. 1971;79:219–83. cerning appearance to the patients. Bäckman B, Holm AK. Amelogenesis imperfecta: prevalence and incidence in a nothern Swedish county. Community Dent Oral Epidemiol. 1986;14:43–7. Chankanka O, Levy SM, Warren JJ, Chalmers JM. A literature review of aesthetic perceptions of dental fluorosis and relationships with psychosocial aspects/oral health-related quality of life. Commu- nity Dent Oral Epidemiol. 2010;38:97–109. 1 3 European Archives of Paediatric Dentistry (2018) 19:187–195 195 Clarkson JJ, O’Mullane DM. Prevalence of enamel defects/fluorosis in other dental conditions in areas with and without water fluorida- fluoridated and non-fluoridated areas in Ireland. Community Dent tion. BMC Oral Health. 2012;10:4. Oral Epidemiol. 1992;20:196–9. Møller IJ. Fluorides and dental fluorosis. Int Dent J. 1982;32:135–47. Crawford PJ, Aldred M, Bloch-Zupan A. Amelogenesis Imperfecta. Robies MJ, Ruiz M, Bravo-Perez M, González E, Peñalver MA. Preva- Orphanet J Rare Dis. 2007;2:17. lence of enamel defects in primary and permanent teeth in a group Cutress TW, Suckling GW. Differential diagnosis of dental fluorosis. J of schoolchildren from Granada (Spain). Med Oral Patol Oral Cir Dent Res. 1990;69:714–20. Bucal. 2013;18:e187–93. Dean HT. Classification of mottled enamel diagnosis. J Am Dent Seow WK. Comparison of enamel defects in the primary and perma- Assoc. 1934;142–6. nent dentitions of children from a low-fluoride district in Aus- Dummer PMH, Kingdon A, Kingdon R. Prevalence and distribution by tralia. Paediatr Dent. 2011;33: 207–12. tooth type and surface of developmental defects of dental enamel Small BW, Murray JJ. Enamel opacities: prevalence, classifications and in a group of 15- to 16-year-old children in South Wales. Com- aetiological considerations. J Dent. 1978;6:33–42. munity Dent Health. 1990;7:369–77. Sujak SL, Abdul Kadir R, Dom TN. Esthetic perception and psycho- Espelid I, Haubek D, Jälevik B. Developmental defects of the dental social impact of developmental enamel defects among Malaysian hard tissues and their treatment. In: Koch G, Poulsen S, Espelid adolescents. J Oral Sci. 2004;46:221–6. I, Haubek D, editors. Paediatric dentistry—a clinical approach. Sundell S, Koch G. Heriditary amelogenesis imperfecta. Epidemiology Oxford: Wiley; 2017, pp. 261–90. and clinical classification in a Swedish child population. Swed FDI Commision on Oral Health, Research and Epidemiology. A review Dent J. 1985;9:157–69. of the developmental defects of enamel index (DDE Index) Int Turner JO. Two cases of hypoplasia of enamel. Br J Dent Sci. Dent J. 1992;42:411–26. 1912;55:227–8. Fejerskov O, Richards A, DenBesten P. The effect of fluoride on tooth Weerheijm KL, Jälevik B, Alaluusua S. Molar-incisor hypomineralisa- mineralization. In: Fejerskov O, Ekstrand J, Burt BA, editors. Flu- tion. Caries Res. 2001;35:390–1. oride in dentistry. Copenhagen: Munksgaard; 1996. pp. 112–52. Weerheijm KL, Duggal M, Mejare I et al. Judgement criteria for molar Jälevik B. Prevalence and diagnosis of molar-incisor-hypominer- incisor hypomineralisation (MIH) in epidemiologic studies: a alisation (MIH): a systematic review. Eur Arch Paediatr Dent. summary of the European meeting on MIH held in Athens, 2003. 2010;11:59–64. Eur J Paed Dent. 2003;4:110–3. Jälevik B, Klingberg G. Dental treatment, dental fear and behaviour Witkop CJ Jr, Sauk JJ Jr. Heritable defects of enamel. In: Stewart RE, management problems in children with severe enamel hypomin- Prescott GH, editors. Oral facial genetics. Saint Louis: CV Mosby; eralization of their permanent first molars. Int J Paediatr Dent. 1976. pp. 151–226. 2002;12:24–32. Wong HM. Aetiological factors for developmental defects of enamel. Jälevik B, Klingberg G, Barregård L, Norén JG. The prevalence of Austin J Anat. 2014;1:1003. demarcated opacities in permanent first molars in a group of Wong HM, Wen YF, King NM, Patrick C, McGrath J. Longitudinal Swedish children. Acta Odontol Scand. 2001;59:255–60. changes in developmental defects of enamel. Community Dent McGrady MG, Ellwood RP, Goodwin M, Boothman N, Pretty IA. Ado- Oral Epidemiol. 2016;44:255–62. lescents’ perceptions of the aesthetic impact of dental fluorosis vs. 1 3

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European Archives of Paediatric DentistrySpringer Journals

Published: May 14, 2018

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