*Dorota Olczak-Kowalczyk1, Anna Turska-Szybka1, Dariusz Gozdowski2, Urszula Kaczmarek3
Developmental defects of enamel in the population of Polish adolescents aged 18 years old: the prevalence and selected socio-demographic factors. A cross-sectional study**
Defekty rozwojowe szkliwa u młodzieży w wieku 18 lat w Polsce: rozpowszechnienie i wybrane czynniki socjodemograficzne. Badania przekrojowe**
1Paediatric Dentistry Division, Medical University of Warsaw
Head of Division: Professor Dorota Olczak-Kowalczyk, MD, PhD
2Department of Experimental Design and Bioinformatics, Warsaw University of Life Sciences
Head of Department: Professor Krzysztof Pawłowski, DSc (Eng)
3Department and Division of Conservative and Pediatric Dentistry, Wrocław Medical University
Head of Department and Division: Professor Urszula Kaczmarek, MD, PhD
Streszczenie
Wstęp. Brak aktualnych badań epidemiologicznych utrudnia ocenę skali problemu zdrowotnego, jakim są defekty rozwojowe szkliwa u młodzieży w Polsce.
Cel pracy. Ocena występowania defektów rozwojowych szkliwa w uzębieniu stałym u osób w wieku 18 lat w Polsce z uwzględnieniem wpływu wybranych czynników socjodemograficznych.
Materiał i metody. Do badań przekrojowych w 2017 roku kwalifikowano osoby w wieku 18 lat uczęszczające do szkół w 16 województwach Polski, wyłonionych losowaniem wielowarstwowym. Czynniki socjodemograficzne (płeć, miejsce zamieszkania, poziom wykształcenia rodziców, status ekonomiczny) oceniano badaniem ankietowym. Stan uzębienia z zastosowaniem DDE Index w modyfikacji Clarksona i wskaźnika Deana oceniali lekarze dentyści po szkoleniu i kalibracji. Przed rozpoczęciem badań uzyskano zgodę Komisji Bioetycznej Warszawskiego Uniwersytetu Medycznego (KB/134/2017 z dnia 6.06.2017 r.).
Wyniki. Zbadano 1611 osób (52,6% dziewcząt, 50,5% mieszkańców wsi). Defekty rozwojowe szkliwa zębów obserwowano u 16,3%, najczęściej o charakterze zmętnień ograniczonych (10,4%). U 2,7% osób kwalifikowano je jako fluorozę, najczęściej wątpliwą. Defekty częściej dotyczyły przyśrodkowych zębów siecznych i pierwszych zębów przedtrzonowych szczęki niż pozostałych zębów. U 2,5% badanych były to wady pojedynczych zębów, u 0,6% obejmowały całe uzębienie. Defekty nieklasyfikowane jako fluoroza występowały częściej u osób płci męskiej. Istniały istotne statystycznie różnice w częstości występowania defektów między województwami. Najczęściej obserwowano je w województwach położonych w południowej części kraju. Nie miały natomiast wpływu inne czynniki socjodemograficzne.
Wnioski. Przewaga występowania zmętnień ograniczonych wskazuje na duże znaczenie czynników miejscowych w etiologii defektów rozwojowych szkliwa zębów stałych w Polsce. Rzadko spotykaną wadą jest fluoroza zębów. Brak znaczenia czynników socjoekonomicznym i zróżnicowanie występowania DDE w różnych regionach Polski wskazują na potrzebę badań identyfikujących czynniki ryzyka związane z położeniem geograficznym.
Summary
Introduction. There has been a lack of current epidemiological data regarding the prevalence of developmental defects of enamel in Polish adolescents.
Aim. To evaluate the prevalence of developmental defect of enamel in the permanent dentition in the population of adolescents aged 18 years old, including the impact of selected sociodemographic factors.
Material and methods. A cross-sectional study conducted in 2017 covered adolescents aged 18 years old attending schools in 16 Polish voivodeships, selected by stratified sampling. Sociodemographic factors such as sex, place of residence, parents’ education level and subjective economic status were collected with a survey. The condition of enamel was assessed with the use of DDE Index modified by Clarkson and Dean’s Indicator by dentists specially trained and calibrated for this study. Prior to its initiation, the study was approved by the Bioethics Committee of the Medical University in Warsaw (Ref. No.: KB/134/217 of 6.06.217).
Results. A total of 1611 adolescents were examined (with 52.6% female and 50.5% were residents of rural areas). Developmental defects of enamel were identified in 16.3% of the participants of the study, most frequently in the form of demarcated opacities (10.4%). In 2.7%, they were classified as fluorosis, most frequently questionable. Maxillary central incisors and first premolars were most frequently affected. In 2.5% of the examined adolescents, the defects involved single teeth, whereas in 0.6% the defects were generalised. Defects not classified as fluorosis were more commonly identified in males. There were statistically significant differences in the prevalence between voivodeships, with defects most commonly observed in participants from southern voivodeships. No other sociodemographic factors, however, were identified as significant.
Conclusions. The highest prevalence of demarcated opacities suggests the significance of local factors in the aetiology of developmental enamel defects of permanent dentition in Poland. Fluorosis is a rarely encountered entity. The lack of the significance of sociodemographic factors and the regional differences in the prevalence of developmental defects of enamel suggest the need for further research, aimed at identifying geographical risk factors.
Introduction
Developmental defects of tooth enamel (DDE) are an important health problem, detrimental to a person’s quality of life. They may affect the appearance, increase teeth sensitivity, predispose for the development of caries, abrasion and erosion (1-3). In a study performed among adolescents aged 16 years old, 18.8% of the participants avoided showing their teeth when smiling due to DDE, 8.7% avoided social contacts and 5.7% had experienced mocking by peers (4).
DDE may be either quantitative, involving a decreased enamel thickness or local lack of enamel (hypoplasia), or qualitative, presenting as opacities or discoloration of enamel (1, 2). Depending on the putative factor at work during amelogenesis and the time frame of exposure, DDE may be generalised, or affect groups of teeth or single teeth. The defects found in single permanent teeth are caused by an injury or infection, e.g. of the primary predecessor (5, 6). In the case of defects involving a group of teeth or all teeth, various genetic and environmental factors may play a role (7-21), such as environmental pollution and a low socioeconomic status (13-21).
In 1990, a country-wide study evaluated the prevalence of DDE in Poland, confirming the role of the fluoride level in the drinking water and systemic factors for DDE aetiology (12, 22). The study covered adolescents living in areas supplied with naturally fluoridated drinking water and those with artificially fluoridated water. Since 1996, drinking water in Poland has not been artificially fluoridated any more. Hence the need for the update of the epidemiological data.
Aim
This study has been aimed at evaluating the prevalence of DDE in permanent dentition in the population of Polish adolescents aged 18 years old, including the impact of selected sociodemographic factors.
Material and method
The survey and the clinical examination covered adolescents 18 years old who were students of vocational and higher secondary schools country-wide. The participants provided their written consent for the participation in the study. The schools were selected by stratified sampling. In each of the voivodeships, poviats, communities (all Polish administrative units, województwa, powiaty and gminy, respectively) and then schools were randomly selected.
The study complied with WHO criteria (23) and was performed by 22 dental examiners (dentists) who were specially trained and calibrated. Inter-rater reliability between the reference examiner and other examiners ranged from 0.802 to 1.00 Cohen’s kappa coefficient, whereas intra-rater reliability was 0.998.
The survey was conducted with the use of a questionnaire including questions about sex, place of residence (urban/rural, which voivodeship), parents’ education level, family economic status in the participant’s opinion.
In the clinical examination, performed in artificial light with the WHO 621 probe, the teeth were evaluated for the presence and type of developmental enamel defects and their distribution. The defects were classified based on their macroscopic appearance according to DDE Index modified by Clarkson as diffuse or demarcated opacities, enamel hypoplasia, discolouration and “other” (a combination of more than one type of defects) (24). The following types of hypoplasia were accounted for: pits, grooves and enamel missing on dental surface or the incisal edge. Following WHO recommendations, Dean’s index was used to evaluate dental fluorosis (25).
Prior to its initiation, the study was approved by the Bioethics Committee of the Medical University in Warsaw (Ref. No.: KB/134/217 of 6.06.217).
The obtained results were statistically analysed. Means between two groups (urban vs rural area or male vs female) were compared with Student’s t-test, whereas percent values were compared with the chi-square test. The statistical significance level was set at p ≤ 0.05. The statistical analyses were performed with Statistica 12.0 software.
Results
A total of 1611 adolescents aged 18 years old were examined. The studied group comprised 847 females (52.6%) and 764 males (47.4%), and 797 (49.5%) residents of urban areas and 814 (50.5%) residents of rural areas. In different voivodeships, the number of participants ranged from 99 in Łódzkie Voivodeship to 110 in Małopolskie Voivodeship (mean 100.68 ± 2.52). The participants most frequently stated their family’s economic status as “average” (55.5%), followed by “above average” (23.7%), and least frequently as “below average” (2.9%). 17.9% did not provide their subjective economic status at all. The group’s composition according to parents’ level of education have been shown in figure 1.
Fig. 1. The level of education of the parents of the examined adolescents aged 18 years old
DDE were found in 16.3% of the examined adolescents, including 2.7% defects classified as fluorosis. The prevalence of DDE and the mean number of the affected teeth have been shown in table 1. The most common type of DDE were demarcated opacities (168/10.4%), followed by diffuse opacities (65/4.0%), hypoplasia (25/1.6%), discolouration (2/0.1%) and a combination of different defects (10/0.6%). Out of 26 noted cases of hypoplasia, dental surface hypoplasia (14/53.8%) and pits (9/34.6%) were the most commonly encountered, whereas grooves (2/7.7%) and missing enamel on the incisal edges (1/3.9%) were less frequent.
Tab. 1. The prevalence of DDE in the population of adolescents aged 18 years old according to the place of residence (urban vs. rural) and sex
| | DDE overall | DDE not classified as fluorosis | Fluorosis |
| Number of affected adolescents % | Mean number of teeth ± SD | Number of affected adolescents | Mean number of affected teeth ± SD | Number of affected adolescents | Mean number of affected teeth ± SD |
| Urban areas | 143/17.9% | 1.32 ± 5.02 | 119/14.9% | 0.91 ± 3.34 | 24/3.0% | 0.41 ± 2.76 |
| Rural areas | 120/14.7% | 1.09 ± 4.73 | 101/12.4% | 0.79 ± 3.34 | 19/2.3% | 0.30 ± 2.29 |
| p | 0.082 | 0.338 | 0.140 | 0.472 | 0.399 | 0.371 |
| Females | 130/15.3% | 1.11 ± 4.82 | 102/12.0% | 0.69 ± 2.88 | 28/3.3% | 0.42 ± 2.70 |
| Males | 133/17.4% | 1.31 ± 4.95 | 118/15.4% | 1.03 ± 3.78 | 15/2.0% | 0.28 ± 2.33 |
| p | 0.264 | 0.410 | 0.047* | 0.041* | 0.095 | 0.271 |
| Total | 263/16.3% | 1.21 ± 4.88 | 220/13.7% | 0.85 ± 3.34 | 43/2.7% | 0.35 ± 2.53 |
*statistical significance
Demarcated opacities were found in 1.8% of all examined teeth, diffuse opacities in 1.2% and hypoplasia – in 0.1%. The defects most commonly involved the enamel of maxillary central incisors and first premolars (fig. 2). Diffuse opacities were more evenly distributed than demarcated opacities and hypoplasia.
Fig. 2. The distribution of DDE according to given teeth in the entire examined population of adolescents aged 18 years old
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