Zaid F.doc J Bagh College Dentistry Vol. 28(2), June 2016 The effect of nutritional Pedodontics, Orthodontics and Preventive Dentistry 152 The Effect of Nutritional Status on Mesiodistal and Bucco- Lingual (Palatal) Diameters of Primary Teeth among Five Years Old Kindergarten Children Zaid Saadi Hasan Ahmed, B.D.S., M.Sc., Ph.D. (1) Ban Sahib Diab, B.D.S., M.Sc., Ph.D. (2) ABSTRACT Background: Malnutrition in human life may adversely affect various aspects of growth at different stages of life. Teeth are particularly sensitive to malnutrition. Malnutrition may affect odontometric measurement involving tooth size dimensions. The aim of this study is to estimate the effect of nutrition on teeth size dimension measurements among children aged 5 years old. Materials and methods: This study was conducted among malnourished group in comparison to well-nourished group matching with age and gender. The present study included 158 children aged 5 years (78 malnourished and 80 well- nourished). The assessment of nutritional status was done by using three nutritional indicators, namely Height-for-age, Weight-for-age and Weight-for-height. Odontometric measurements including two different orientations. For both upper and lower study models, photographs were taken using special photographic apparatus for each child, and the data were then analyzed using special computer software. For primary dentitions, two linear measurements (mesiodistal and bucco/lingual or palatal) were utilized, representing tooth diameters for each tooth. Results: Among children aged 5 years, the findings revealed that all means of mesiodistal and bucco-lingual diameters values of maxillary and mandibular teeth were lower among malnourished than well-nourished groups with statistically significant, except for mesiodistal diameters of both canine and lateral incisor maxillary teeth, canine of mandibular teeth and for bucco-palatal diameters of central incisor of maxillary teeth, canine, lateral incisor and central incisor of mandibular teeth. Conclusions: Malnutrition effect on minimize the odontometric measurements (mesio-distal and bucco-lingual diameters) among children aged 5 years. Keyword: Mesiodistal diameter, bucco -lingual diameter, bucco -palatal diameter, primary teeth. (J Bagh Coll Dentistry 2016; 28(2):152-157). INTRODUCTION Nutrition is one of the essential needs of human beings and it provides human body with energy and essential nutrients necessary for adequate physical and social activities, and maintains or enhances its healthy state (1). Malnutrition can be defined as a “pathological state resulting from absolute or relative deficiency or excess of one or more of the essential nutrients" (2). Still malnutrition is one of the global highest priority health issues not only as its effects are so widespread and long lasting but also because it can be eradicated (3,4). The dental plaster models of a patient's dentition are necessary in dental measurement (5). Recently, dentistry looks to digital archive and tend to be paperless patient information systems. Especially when many methods have been used to determine and to analyze dental plaster casts (6). This is one of the reasons to use photograph technique to measure dimension of dental cast in this study. Protein Energy Malnutrition might responsible for the decrease in tooth diameters (7). (1) Lecturer. Department of Pedodontic and Preventive Dentistry College of Dentistry, University of Baghdad (2) Assist. Prof. Department of Pedodontic and Preventive Dentistry College of Dentistry, University of Baghdad This study represents the pioneering aspect. It's importance in terms of providing greater visibility to the harmful effects of malnutrition on oral pictures and change dental morphometric. MATERIALS AND METHODS The sample collection The sample of this study involved two age groups 5 years with different nutritional status. Age was recorded according to the last birthday (8). Out of 240 children who were initially examined, only 158 children (78 malnourished and 80 well-nourished) were candidates selected for the morphometric analysis in this study. The pupil should not suffer from any serious systemic disease or health problem as indicated by the schools’ records, all primary teeth were erupted with no permanent tooth, the children should be free from: congenital abnormalities, congenital missing teeth, supernumerary or abnormal shape tooth and clinical signs of attrition and enamel defect. Instruments and supplies Plane mouth dental mirror (No. 4), sickle shape explorer (No.00), bathroom scale for recording weight, The height of the individuals was measured by using the ordinary height measuring tape, electric vibrator (Quale Dental), J Bagh College Dentistry Vol. 28(2), June 2016 The effect of nutritional Pedodontics, Orthodontics and Preventive Dentistry 153 dental vernier (Dentaurum 0.05 mm (042-751) Germany, digital Camera (6 Mega pixels) Sony, photographic apparatus (Figure 1), software Auto Cad, 2006, product version Z.54.10. Fig. 1: Photographic Apparatus (13) Classification of nutritional status of children aged 5 years Three indicators of the subjects’ nutritional status were used to assess the nutritional status of each person in this study and they involve: Height for age (H.F.A), Weight for age (W.F.A) and Weight for height (W.F.H). Based on each nutritional status indicator, the cut off point used Z-Score below -2 SD and between median to +1 to classify malnutrition and well-nourished conditions respectively. And the person was classified as either malnourished or well- nourished depending on these three indicators. Each Z-score was considered in terms of standard deviation. The Z score = Individual value — median of reference population Standard deviation of the reference population Morphometric measurements ß Photographic technique and Cast orientation The three-dimension analysis of crown orientation was achieved by considering the three rotational axes of pitch, roll and yaw (9,10) . The three rotational axes introduced into the systematic description of dentofacial traits significantly improved the precision to descript tooth orientation which included crown angulation and inclination. The crown orientations represent the reference to classify each dental arch into three segments according the occlusal views (one anterior, right posterior and left posterior) to measure mesiodistal and bucco-lingual diameters of the tooth crown. Tooth diameters measurements permit by capturing with photographic technique depending on these three views for each arch. Before image acquisition, the cast should be oriented until incisal surfaces or occlusal surfaces of specific dental segment are orthogonal to the optical axis of the camera for each captures. This procedure was performed by putting the dental cast in surveyor base, and the cusp tips of specific segment teeth were reflected by the highest points. Cast orientation was done through the rotation through which the four sides of the tooth should be well defined. The next step of orientation would be restrained by balancing the movements in the three axes (x, y and z) (define above). The incisal or occlusal view of crowns for each segment was standardized by visually maximizing the visibility of the crown’s sides (buccal, lingual, mesial, and distal) in away that it could measure tooth bucco-lingual and mesio- distal diameters (note: it is necessary to use the same orientation system for each dental typology). For each arch, four image captures were taken to three different cast orientations involving: anterior incisal segment, right and left posterior occlusal segments and occlusal surfaces of whole arch. These three photograph capture views of cast were produced as: a) The posterior occlusal segment (right or/and left) views were standardized depending on overlap line A that represented the occlusal line of four posterior teeth and the index point* that should be located between first and second molar for primary dentition. b) The anterior incisal segment view was standardized according to overlap line B which represented the occlusal line of six anterior teeth and the index point * that should be located between right and left central J Bagh College Dentistry Vol. 28(2), June 2016 The effect of nutritional Pedodontics, Orthodontics and Preventive Dentistry 154 incisor for primary dentition (Line B is a line that present on translucent horizontal plate). A reference metric system: prepare a metric scale in position parallel to and at the same level of the incisal and /or occlusal surface of cast (for each capture). By means of this metric scale, the calibration of each image dimension could be prepared. It was used to give a real metric value of the cast measurement by obtaining hypothetical factory and multiplying it with an initial measurement value of the photograph cast. Final real (Actual) value = hypothetical factor X initial measurement value ß Taking dental cast captures After identifying landmark and orientation of each dental cast, the dental cast was placed on the portable part (5) of surveyor and oriented in an ideal way (Cusps heights were not used to orient the cast segment). Before taking a picture (in order to calibrate the image through suitable software), it is necessary to set a reference millimetric scale in correspondence to the occlusal surface of the tooth. ß Measurement of dental cast Measurements were made directly on upper and lower dental casts by photographic technique through photographic apparatus which provides a constant distance between digital camera and occlusal teeth surfaces through the plastic plate for standardization. Each set of dental casts were measured to the nearest 0.001 mm. Mesiodistal width is measured between two anatomical contact points (the greatest width from the anatomic mesial contact point to the distal one). Bucco-lingual measurement is the maximum diameter of the crown and perpendicular to the mesiodistal diameter (11,12) . All data analyses were performed using the SPSS statistical software programme (version 10 for Windows, SPSS). The confidence level was accepted at the level of 5%. *Index point is that point formed by crossing of two line (A,B), and it mark on the translucent horizontal plate to standardized the cast segment for capture, as it represent the point through which optical axis of camera pass. RESULTS For primary dentition, an initial analysis was made where tooth diameters (mesiodistal and/or bucco-lingual diameter) were calculated for right and left sides separately. Result found no significant difference between mean tooth diameter of right and left sides for all tooth categories (P>0.05). All subsequent statistical analysis were carried out on pooled data of right and left side measurements. Table (1) illustrates the measurement of mesiodistal diameters of maxillary teeth in malnourished group and well- nourished among children aged 5 years. Concerning the maxillary teeth, data reported that the mean values of second, first molars and central incisor diameters among malnourished group were highly significantly lower than well- nourished group (P< 0.01). Result observed that the mean values for both canine and lateral incisor diameters among malnourished group were lower than well-nourished, with no significant difference (P> 0.05). Table (2) illustrates the measurement of mesiodistal diameters of mandibular teeth in malnourished group and well-nourished of children aged 5 years. Concerning the mandibular teeth, result found that the mean values of second, first molars, lateral incisor and central incisor diameters among malnourished group were highly significantly lower than well-nourished group (P< 0.01). While the mean values for canine diameter among malnourished group were significantly lower than well-nourished, with significant difference (P< 0.05). Table (3) illustrates the measurement of bucco-palatal diameters of maxillary teeth in malnourished group and well-nourished among children aged 5 years. Concerning maxillary teeth, data showed that the mean values for maxillary second and first molars diameters among malnourished group were highly significantly lower than well-nourished group (P< 0.01). Result observed that the mean values of canine lateral and incisor diameters among malnourished group were significant lower than well-nourished (P< 0.05). Result reported that the mean values for central incisor diameter among malnourished group were lower than well-nourished, with no significant difference (P [>0.05). The measurement of bucco-lingual diameters of mandibular teeth in malnourished group and well-nourished among children aged 5 years are shown in Table (4). Concerning the mandibular teeth, data showed that the mean value for second and first molars diameters among malnourished group were highly significantly lower than well- nourished group (P< 0.01). Result observed that the mean values for canine, lateral incisor and central incisor diameters among malnourished group were lower than well-nourished, with no significant difference (P>0.05). J Bagh College Dentistry Vol. 28(2), June 2016 The effect of nutritional Pedodontics, Orthodontics and Preventive Dentistry 155 Table 1: Measurement of mesiodistal diameters (mm) of maxillary teeth in malnourished and well-nourished group among children aged 5 years by gender. Tooth Malnourished Well-nourished Statistical differences No. Mean ±SD No. Mean ±SD Z -value P-value Right maxillary second molar 78 8.347 0.539 80 8.623 0.53 -3.483** 0 Right maxillary first molar 78 6.704 0.289 80 6.959 0.274 -5.085** 0 Right maxillary canine 78 6.359 0.59 80 6.436 0.443 -0.756 0.449 Right maxillary lateral incisor 78 5 0.364 80 5.108 0.339 -1.852 0.064 Right maxillary central incisor 78 5.953 0.379 80 6.149 0.335 -3.099** 0.002 Left maxillary second molar 78 8.385 0.536 80 8.657 0.531 -3.429** 0.001 Left maxillary first molar 78 6.667 0.29 80 6.922 0.274 -5.172** 0 Left maxillary canine 78 6.324 0.59 80 6.401 0.443 -0.716 0.474 Left maxillary lateral incisor 78 5.036 0.367 80 5.145 0.342 -1.782 0.075 Left maxillary central incisor 78 5.918 0.378 80 6.113 0.336 -3.093** 0.002 Table 2: Measurement of mesiodistal diameters (mm) of mandibular teeth in malnourished and well-nourished group among children aged 5 years by gender. Tooth Malnourished Well-nourished Statistical differences No. Mean ±SD No. Mean ±SD Z -value P-value Right mandibular second molar 78 8.757 0.423 80 9.439 0.434 -7.908** 0 Right mandibular first molar 78 7.469 0.342 80 7.713 0.311 -4.511** 0 Right mandibular canine 78 5.616 0.373 80 5.74 0.34 -2.109* 0.035 Right mandibular lateral incisor 78 4.818 0.323 80 4.983 0.3 -3.653** 0 Right mandibular central incisor 78 4.296 0.284 80 4.445 0.316 -3.888** 0 Left mandibular second molar 78 8.792 0.426 80 9.474 0.435 -7.912** 0 Left mandibular first molar 78 7.433 0.339 80 7.678 0.31 -4.366** 0 Left mandibular canine 78 5.581 0.369 80 5.707 0.332 -2.221* 0.026 Left mandibular lateral incisor 78 4.854 0.323 80 5.019 0.301 -3.660** 0 Left mandibular central incisor 78 4.289 0.285 80 4.408 0.312 -3.123** 0.002 Table 3: Measurement of bucco-palatal diameters (mm) of maxillary teeth in malnourished and well-nourished group among children aged 5 years by gender Tooth Malnourished Well-nourished Statistical differences No. Mean ±SD No. Mean ±SD Z -value P-value Right maxillary second molar 78 9.752 0.482 80 10.011 0.48 -3.187** 0.001 Right maxillary first molar 78 8.348 0.394 80 8.993 0.483 -7.731** 0 Right maxillary canine 78 6.283 0.406 80 6.432 0.365 -2.315* 0.021 Right maxillary lateral incisor 78 5.25 0.388 80 5.403 0.364 -2.454* 0.014 Right maxillary central incisor 78 5.469 0.431 80 5.617 0.452 -1.911 0.056 Left maxillary second molar 78 9.788 0.482 80 10.046 0.485 -3.187** 0.001 Left maxillary first molar 78 8.314 0.396 80 8.958 0.477 -7.731** 0 Left maxillary canine 78 6.318 0.411 80 6.467 0.367 -2.335* 0.02 Left maxillary lateral incisor 78 5.217 0.39 80 5.37 0.367 -2.445* 0.014 Left maxillary central incisor 78 5.431 0.434 80 5.581 0.452 -1.901 0.057 DISCUSSION This study was conducted to assess the effects of malnutrition, on the oral health condition which include odontometric measurements and to compare these with the control group with similar characteristics to the study group except for the factor under investigation: therefore, the control group in the present study included well- nourished subjects who possess as much similarity as possible in terms of age, gender, social structure and geographic position. The 5 years index age was selected in the present study: this age is considered a critical human life stage which has recorded the past and present history of malnutrition and oral health conditions (14,15). Moreover, the study was conducted among children aged 5 years to represent the primary dentition stage, as teeth are considered to be full- size and within the appropriate normal time of complete eruption of all primary teeth (16-18). J Bagh College Dentistry Vol. 28(2), June 2016 The effect of nutritional Pedodontics, Orthodontics and Preventive Dentistry 156 Table 4: Measurement of bucco-lingual diameters (mm) of mandibular teeth in malnourished and well-nourished group among children aged 5 years by gender. Tooth Malnourished Well-nourished Statistical differences No. Mean ±SD No. Mean ±SD Z -value P-value Right mandibular second molar 78 9.036 0.427 80 9.439 0.436 -5.199** 0 Right mandibular first molar 78 7.313 0.755 80 7.86 0.675 -4.152** 0 Right mandibular canine 78 6.035 0.353 80 6.122 0.355 -1.442 0.149 Right mandibular lateral incisor 78 5.067 0.39 80 5.171 0.384 -1.647 0.1 Right mandibular central incisor 78 4.694 0.395 80 4.781 0.405 -1.4 0.162 Left mandibular second molar 78 9.073 0.431 80 9.477 0.437 -5.182** 0 Left mandibular first molar 78 7.278 0.757 80 7.822 0.676 -4.123** 0 Left mandibular canine 78 6.072 0.357 80 6.159 0.355 -1.478 0.139 Left mandibular lateral incisor 78 5.031 0.389 80 5.134 0.386 -1.619 0.105 Left mandibular central incisor 78 4.659 0.396 80 4.745 0.41 -1.191 0.234 In addition, the 5 age group can represent a proper time for prediction of arch dimension and they are also considered as a static stage. Moreover, the complete eruption of primary dentition was accomplished by the age of three. Protein energy malnutrition was assessed in the present study by using the anthropometric measurement (height, weight) through Z- score standard deviation value system which expresses the anthropometric value as a score below or above the reference mean: their major advantage for the population is based on that group of scores which can be subject to statistic. The present study used three indicators (height for age, weight for age and weight for height) to classify purely malnourished from well-nourished children aged 5 years. Furthermore, these measuring tools are simple and robust, and can be set up in any environment with non-invasive procedure (19). WHO (1995) recommended using a -2SD cut off point which represents purely statistical separation of malnourished from well-nourished; therefore, the present study used this particular cut off point for the three nutritional health indicator (height for age, height for weight and weight for age). Traditional casts were eliminated with the use of computer-aided diagnosis, particularly due to problems of storage in terms of space and cost, in addition to the risks of damage because of the brittle nature of dental cast. Therefore digital photography was used in this study. In the current study, it is obvious that the statistical analysis of tooth mean values of mesiodistal and bucco-lingual diameters in the upper and lower jaws revealed the absence of significant asymmetry between right and left sides for primary dentition. These findings indicated that the measurements for the right or left sides represent the mesio-distal and bucco-lingual tooth diameters for this particular sample. This finding agreed with the usual practice that teeth on one side of the jaw, or the average of the two could be used for analyzing the teeth diameters (20). This symmetrical may be attributed to the presence of similar genetic and environmental factors affecting the tooth size of teeth on the right and left sides. This particular finding is supported by other studies (19, 20). Similar finding was also reported in several Iraqi studies (16-18, 21-26). As for the mesio-distal and bucco-lingual diameters of the primary teeth among well- nourished, it is difficult to compare the data of present study with other studies. This may be due to differences in: the criteria of the sample selection and size; the methods used to determine tooth diameters; and the varying definitions of well-nourished group, as the previous studies might have included the different degrees of malnutrition. In general, there appears to be a clear relationship between a child's crown diameters and the mother's health during pregnancy, implying that their heritability included shared environmental as well as genetic factors. Some researchers reported that children submitted to a protein deficient diet during gestation and lactation might have their affect on dental development affected, whereas children with low birth weight condition have been observed to have small tooth size in deciduous dentition (27, 28). Reduction of tooth size is thought to result from a decrease in the volume of dentin rather than a reduction enamel thickness (29). Thus, it is conceivable that the influence of Protein Energy Malnutrition on tooth germs is different in the development period from that in a slightly later period. These explain the smaller mesiodistal and bucco-lingual diameters of deciduous teeth among malnourished as compared to well-nourished groups in the present study. 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