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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 5  |  Page : 557-562

Clinical and morphological evaluation of permanent first molars in Turkey


1 Dokuz Eylul University, School of Dentistry Department of Pedodontics Inciralti, Inciralti, Turkey
2 Faculty of Medicine, Children's Dental Clinic, Dokuz Eylul University, Inciralti, Turkey
3 Mouth and Dental Health, Vocational Health High School, Dokuz Eylul University, Inciralti, Turkey
4 Private Practice, Izmir, Turkey

Date of Submission26-Aug-2021
Date of Acceptance28-Feb-2022
Date of Web Publication19-May-2022

Correspondence Address:
Dr. G Kilinc
Dokuz Eylul University, School of Dentistry Department of Pedodontics Inciralti, Izmir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1771_21

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   Abstract 


Aim: The aim of this study was to investigate the pit and fissure morphology of the permanent first molars (PFMs) in the dentition of 7- to 12-year-old patients in Turkish children. Patients and Methods: The study was conducted on 706 patients who attended the Dokuz Eylul University Child Clinic. Examinations of the patients were carried out with dental unit light, mouth mirror, and probe by two dentists. Age, gender, plaque scores, pit and fissure morphology, caries, restorations, and missing teeth were recorded. Results: Of the 706 patients included in this study, 441 (62.5%) of them have affected PFMs. Intermediate type fissure morphology (57.5%) was seen as the most common type. A positive correlation was observed between the age and the caries experience (p = 0.000). Patients with deep pits and fissure morphology have more caries affected teeth than patients with shallow pit and fissure morphology, and the difference was statistically significant (p = 0.000). Patients with deep pits and fissure morphology have significantly more plaque accumulation on PFMs compared to the patients with shallow and intermediate fissure morphology (p = 0.000). Conclusions: Despite the limitations of the study, we can conclude that the patients with deep pit-fissure morphology are more susceptible to caries development and plaque accumulation than the patients with shallow and intermediate type pit and fissure morphology.

Keywords: Morphology, pit and fissure, permanent first molars


How to cite this article:
Kilinc G, Cetin M, E Ertunç F U, Atesci A A. Clinical and morphological evaluation of permanent first molars in Turkey. Niger J Clin Pract 2022;25:557-62

How to cite this URL:
Kilinc G, Cetin M, E Ertunç F U, Atesci A A. Clinical and morphological evaluation of permanent first molars in Turkey. Niger J Clin Pract [serial online] 2022 [cited 2022 Jul 7];25:557-62. Available from: https://www.njcponline.com/text.asp?2022/25/5/557/345571




   Introduction Top


Dental caries is a multifactorial and infectious disease that could lead to several problems such as pain, inflammation, and tooth loss. World Health Organization (WHO) reported that children with active caries are still highly prevalent around the globe.[1] Progression of dental caries includes interactions between microbial byproducts and oral fluids, resulting in changes in the composition of dental hard tissues.[2] Plenty of risk factors were associated with dental caries in children, and dental plaque is considered one of the major factors among them. Although dental caries cannot progress without a bacterial plaque, it is not sufficient for caries progression in enamel and dentin.[3]

Previous studies investigating the role of biological factors affecting the progression of occlusal caries in young permanent teeth showed that the most influential factors were plaque accumulation and the stage of tooth eruption.[2] Permanent molars may have more risk for dental caries progression due to their complex anatomical shape which is considered as an ideal area for retention of microorganisms and food remnants.[4] In young patients, occlusal and approximal surfaces of the tooth had similar caries risk; however, occlusal surfaces were reported to be attacked more severely when consideration was given to the degree of severity of the caries lesions.[5],[6]

A literature review suggests that different type of occlusal morphology, such as fissure depth plays an important role in caries progression.[7],[8] Occlusal surfaces of permanent first molars (PFMs) have been considered as susceptible to dental caries because of their incomplete post-eruptive maturation, incomplete coalescence of the fissures and therefore permitting retention of the biofilm and harboring bacteria.[9],[10],[11] These retentive areas in the oral cavity are protected from tooth brushing, mechanical oral function of the tongue, lips and cheeks and permits dental plaque to be cariogenic.[12] In addition, it was reported that groove-like interlobal grooves were more prone to caries than fissure-like interlobal grooves.[13] These studies show that the macromorphology of the occlusal surface of PFMs might be a risk factor in dental caries progression.

The aim of this study was to report on caries experience in the dentition of 7- to 12-year-old patients and its interactions with plaque accumulation and macromorphology of the occlusal surface of PFMs in Turkish children.


   Material and Methods Top


This cross-sectional study was conducted on 7-12 aged patients who attended the Dokuz Eylul University Hospital Child Clinic between 01.01.2019 and 30.09.2019. Seven-year-old patients with partially erupted PFMs, patients with congenital or systemic disease, molar incisor hypomineralization (MIH) and permanent first molar (PFM) hypoplasia were excluded from the study. All procedures were approved by the University Ethics Committee on Human Research (2019/29-28), and written informed consents of the patients and the caregivers were received.

Clinical examination

Examinations of the patients were carried out with dental unit light, mouth mirror and probe by two experienced dentists. The calibration exercise was performed with randomly selected 20 patients who had not participated in the study. Intra-examiner reliability was tested by Kappa statistics. The Kappa coefficient was 0.83, and the examiners were considered suitable for the study. Patients' information such as age, gender, plaque scores, fissure morphology, caries, restorations and missing teeth were recorded by another dentist. No radiographs were taken for this study.

The pit and fissure morphology of the PFMs were assessed according to the classification described by Symons et al.[7] plaque accumulation on the PFMs teeth was assessed according to the criteria described by Carvalho et al.[14],[15] Caries in the PFMs were assessed according to Atraumatic Restorative Treatment (ART) classification described by the previous study[16][Table 1].
Table 1: Pit and fissure morphology index,[7] The Visible Occlusal Plaque Index (VOPI),[15] and Atraumatic Restorative Treatment (ART) caries index[16] were used in the present study

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Limitations of the study

The selected age interval (7-12 years old) and patients (who only attended Dokuz Eylul University) have been seen as the most important limitations for this study since they are not able to represent the whole population.

Statistical analysis

The collected data were calculated with Statistical Package for Social Science for Windows 20.0 software (SPSS Inc., Chicago, IL, USA). Chi-squared and Fisher's Exact test were used to examine the differences in proportions between groups. Statistical significance was described as p < 0.05. For all analyses, a significance level of 5% was considered to estimate the prevalence ratios (PR) and 95% confidence intervals (95% CL)


   Results Top


The age of the participants varied from 7 to 12 years, and the mean age was 9.54 ± 1.74. The study population included 706 patients, and there were more females 381 (54.0%) than males 325 (46.0%) in this study. Of the 706 patients included in this study, 441 (62.5%) of them have affected PFMs. From the total of 2824 PFMs, 1006 (35.6%) of them have caries, restorations, or missing teeth. There was no significant relationship between gender and caries experience (p < 0.641). However, a positive correlation was observed between the age and the caries experience (p = 0.000). From the pit and fissure morphology point, intermediate type fissure morphology (57.5%) was seen as the most common type, while the number of shallow (20.8%) and deep fissure morphology (21.7%) was similar [Table 2].
Table 2: Frequency distribution of PFMs according to the demographics, DMF status, and pit and fissure morphology

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All of the PFMs with caries were assessed according to the atraumatic restorative treatment (ART) criteria, and the left maxillary PFMs were seen as the least affected (24.5%) while right mandibular PFMs (47.0%) was seen as the most affected [Table 3]. The relationship between caries and pit and fissure morphology in PFMs is shown in [Table 4]. Patients with deep pits and fissure morphology have more caries affected teeth than patients with shallow pit and fissure morphology, and the difference was statistically significant (p < 0.05). Similarly, the relationship between pits and fissure morphology and Visible Occlusal Plaque Index (VOPI) scores showed that the children with deep pits and fissure morphology have more plaque accumulation on PFMs compared to the patients with shallow and intermediate fissure morphology and the differences were statistically significant (p < 0.05) [Table 5].
Table 3: Frequency distribution of PFMs according to the location in the dental arch and associations with ART caries index

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Table 4: Frequency distribution of PFMs according to caries status and associations with pit and fissure morphology

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Table 5: Frequency distribution of PFMs according to the occlusal plaque accumulation and associations with pit and fissure morphology

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   Discussion Top


The management of occlusal caries on PFMs has been a major challenge for the practitioners due to the early onset of caries taking place in a very short time period after their eruption.[17] In the present study, 62.5% of the patients have at least one or more affected PFMs, and fissure depth was associated with caries incidence as patients with deep pit, and fissure morphology had significantly more caries affected PFMs compared to patients with shallow and intermediate type pit and fissure morphology. Moreover, it has been shown that PFMs with deep pit and fissure morphology are more significantly susceptible to plaque accumulation compared to the shallow and intermediate type pit and fissure morphology.

In young patients, occlusal surfaces of the PFMs are one of the most susceptible areas to have caries experience, which is followed by second molars.[18],[19] It is well known that plaque accumulation on occlusal surfaces is the most important factor in the dental caries progression. In addition, pit and fissure macromorphology plays a key role in the caries process because of harboring bacteria and biofilm and its long eruption time with reduced mechanical oral functions such as tongue, lips, and cheeks.[20] These retentive areas allow more biofilm accumulation and maturation, which leads to development of more cariogenic biofilms that cause changes in the local conditions, such as a decrease in pH.[21] In this present study, the prevalence of intermediate type (57.5%) pit and fissure morphology was found to be the most common, which was followed by deep (21.7%) and shallow types (20.8%). The previous epidemiological study carried out by Wang et al.[6],[11] in 1043, 7- to 8-year-old, patients showed similar results, which were 58.1% for intermediate, 26.5% for deep, and 15.4% for shallow fissures. Our results showed that PFMs with deep pit and fissure morphology were found to be more affected by dental caries compared to the PFMs with shallow and intermediate type pit and fissure morphology. These findings are in accordance with the previous studies of Sanchez-Perez et al.[10] and Wang et al.[11]

Dental plaque is considered as one of the most important etiological factors in caries progression.[3],[22] The anatomical sites of the groove-fossa system of PFMs, especially with inaccessible deep fissure and pit morphology are protected from tooth brushing and mechanical oral function and therefore allows plaque accumulation which leads to caries on occlusal surfaces.[12],[13],[23] In the present study, to determine the level of plaque accumulation, VOPI were used as it is reported to be one of the most influential indexes for determining sound, active, or inactive occlusal lesions.[15],[24] The results of the present study showed that patients with deep pit and fissure morphology have significantly more plaque accumulation compared to the patients with shallow and intermediate pit and fissure morphology. Similar findings were reported in previous studies.[2],[10]

In the present study, mandibular PFMs showed a higher caries prevalence than maxillary PFMs, where nearly half of the mandibular molars were affected from caries while only a quarter of the maxillary molars was affected. These findings were in accordance with the previous studies.[10],[25] This may be attributed to several factors such as the earlier eruption of mandibular molars, their more complex pit and fissure morphology and different saliva effects.[26] In addition, our findings showed no statistically significant difference between right and left PFMs in terms of caries prevalence. However, caries prevalence of right PFMs was slightly higher than the left PFMs, which was in accordance with a previous study.[27] Hand selection/preference during tooth brushing may affect the brushing ability of both sides of the dental arch. A right-handed patient may brush the left maxillary teeth more effectively than other parts of the dental arch.[26]

Results of the present study revealed that the caries prevalence increased with aging from 7 to 12, which was found similar in the previous epidemiological studies.[28] This positive correlation between caries prevalence and age may be associated with the physical and psychological changes during adolescence as children face drastic changes such as dietary and oral hygiene habits.

In dental literature, caries prevalence for gender is a controversial topic. Several studies reported that females have higher caries prevalence[29] compared to males, while others studies showed the contrary.[30] In contrast, the present study showed no statistically significant difference between males and females, which was in accordance with the previous studies.[26] These differences may be attributed to the fact that gender-based diet plays an important role in gender-related caries prevalence.[30] Moreover, selected age intervals in previous studies may be another contributing factor in these varying results considering the significant difference between caries prevalence and gender at early ages may be diminished by aging.


   Conclusions Top


Despite the limitations of this study, our results showed that fissure depth and occlusal morphology play an important role in caries progression, and the application of pit and fissure sealants may be a good option for patients with deep fissures, which has shown to be a high-risk factor for caries development. Moreover, preventive public health programs and pediatric dentists should focus on evaluating the pit and fissure morphology to identify the patients with high caries risk.

Author contribution

GK conceived the ideas. GK, AAA, MÇ, and ÜEE led the writing. GK, MÇ, and ÜEE collected and analysed the data. GK and MÇ completed the examinations of the children.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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