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Age Estimation through the Measurement of Tooth Pulp Cavity Height among Orthodontic Patients (Klang Valley):
A Preliminary Study
Anggaran Umur melalui Pengukuran Tinggi Kaviti Pulpa Gigi dalam kalangan Pesakit Ortodontik (Lembah Klang): Kajian Preliminari
IWANA IZAH ABDULLAH & RUS DINA RUS DIN
ABSTRACT
The accuracy of age estimation methods of human remains is important in forensic anthropology. Previous studies had shown that secondary dentin deposition may reduce the size of the tooth pulp cavity as age increasing. Thus, secondary dentin is suitable to be used as an indicator of individual age. The aim of this study is to observe the correlation between age of individuals and height ratios of pulp cavity. A total of 100 samples of first premolar tooth were collected from UKM Kuala Lumpur Dental Clinic. For analysis, the first premolars were divided into three groups: Mandibular, Maxillary and both. Pulp cavity and tooth height ratios (tooth/root, pulp/tooth and pulp/root) were measured based on Kvaal’s method by using Image J software. Pearson correlation were used to observe the relationship between age and pulp cavity height ratios; pulp/tooth, pulp/root and pulp/tooth. Results showed that relationship between age and the pulp cavity height ratios for first premolar tooth were not significant.
Keywords: Forensic anthropology, age estimation, tooth pulp cavity, Kvaal’s method
ABSTRAK
Ketepatan kaedah penganggaran umur bagi tinggalan rangka manusia adalah penting dalam antropologi forensik.
Kajian terdahulu menunjukkan pemendapan dentin sekunder boleh mengurangkan saiz kaviti pulpa gigi seiring dengan pertambahan umur. Oleh itu, dentin sekunder sesuai digunakan sebagai indikator umur individu.
Matlamat kajian ini adalah untuk melihat korelasi di antara umur individu dan nisbah ketinggian kaviti pulpa.
Sebanyak 100 sampel gigi pramolar pertama diperolehi dari klinik pergigian UKM Kuala Lumpur. Untuk analisis, gigi pramolar pertama dibahagikan kepada 3 kumpulan: Mandibel, Maksila dan kedua-duanya. Nisbah ketinggian kaviti pulpa dan gigi (gigi/akar, pulpa/gigi dan pulpa/akar) diukur berdasarkan kaedah Kvaal’s dengan menggunakan perisian Image J. Korelasi Pearson dilakukan untuk melihat hubungan di antara umur dan nisbah ketinggian kaviti pulpa; gigi/akar, pulpa/gigi and pulpa/akar. Keputusan menunjukkan hubungan di antara umur dan nisbah ketinggian kaviti pulpa bagi gigi pramolar pertama adalah tidak signifikan.
Kata kunci: Antropologi forensik, anggaran umur, kaviti pulpa gigi, kaedah Kvaal
INTRODUCTION
Age estimation is an important factor for biological identification in forensic anthropology, as well as forensic dentistry and archeology. Although age at death estimation of a skeletal is most important in identifying the unknown individuals or human remains, it is also one of the most difficult to achieve due to the existing of poor skeletal condition (Kanchan-Talreja et al. 2012). Moreover, the age prediction is not just limited to post-mortem reconstructive identification, but it has also been an expanding interest by the courts for proper estimation of age in living people, associated with
minors without legitimate identification document related to criminal cases such as human trafficking, sexual exploitation, forced labor, refugees; and immigrants (Franklin et al. 2015).
In Italy, development of illegal immigration resulted in an increase in the prison population of foreign juvenile delinquents with no valid documents from a total of 7000 in 1991 to over 13000 in 1997 (Ritz-Timme et al. 2000). Therefore, the age estimation may be necessary to be used in deceased and living individuals. Commonly, teeth and skeleton morphologies have been used in age estimation. However, dental mineralization is considered as the best and accurate indicator of chronological age in sub adults (Franklin et al.
2015). This is because teeth always in a good condition in varying situations and can be preserved longer due to high resistance towards physical and chemical agents and cannot easily decompose (Bhakhar et al. 2013).
Forensic Odontologist is specially trained dentists who use their expertise to help identify unknown remains, trace bite marks of an individual and also the conformation identity of known individual in dental profiling. Based on the history, Adolf Hitler and his wife committed suicide on 30 April 1945, at the end of World War ׀׀ (Sognnaes 1974). In order to hide the truth about their death from Russian troops, the bodies were cremated (Sognnaes 1974). However, upon the discovery of the bodies, Hitler’s personal dentist, Dr. Blaschke had formally identified that the remains were owned by the couple based on their dental record (Sognnaes 1974). In addition, according to the former disaster that happened in the 2004 tsunami in Phuket, 61% of the victims were identified using dental examinations, 19% using fingerprint records, 1.3% using DNA analysis, 0.3% using physical evidence and 18% of cases using more than one type of evidence (Rai & Anand 2007). Therefore, dental identification is considered as simple, cheap and more accurate for identification process.
There are many methods that had been published which used dental tissue or tooth morphology as an indicator of age estimation. Most of the methods are based on extraction and sectioning of the tooth, which destructive and non- ethical for living individuals and human remains (Panchbhai 2011). Radiographic method (x-ray) commonly used because it is non-invasive, non- destructive and less time consuming (Godge et al.
2014). Generally, it is easy and accurate to estimate the age of children by observing their tooth eruption (Saxena 2011). However, it is more challenging to estimate the chronological age of an adult because most of the dentition is completely developed (Panchbhai 2011). Fortunately, the presence of the aging process and regressive changes of tooth such as attrition, apposition secondary dentin, cementum formation and dentin transparency are helpful for age estimation of adults (Jeon et al. 2015; Priyadarshini et al. 2015)).
In 1925, Bodeckar stated that aging cause significant changes in tooth structure and pointed out the apposition of secondary dentin was a suitable indicator for age estimation (Torkian et al.
2015). This is because the growth of secondary dentin may reduce the size of the pulp, which related with increasing age of an individual (Chandramala et al. 2012; Jeon et al. 2015). In 1995, Kvaal et al. introduced a method regarding age estimation of adults based on the relationship between age and the pulp size using full mouth dental radiographs. This method is widely accepted and improved upon procedures has been proven
which is examining ten parts of the tooth for measurements; tooth/root length, pulp/root length, pulp/tooth length, pulp/root width at the three levels, mean value of all ratios, mean value of width ratios, mean value of the length and difference values of mean length and width value with six types of teeth. Kvaal et al. (1995) found that tooth pulp cavity has a significant negative correlation with age. Thus, for the preliminary research, this study will focus only the height ratios between the tooth and pulp; pulp/tooth, pulp/root and tooth/root and its relationship with age. Only one type of tooth which is first premolars of Malaysia population will be used. Furthermore, this study will analysed direct radiographs of extracting first premolar as compared to full mouth radiographs.
MATERIALS AND METHODS
SAMPLE
Samples in the form of 2 dimensional radiographs were obtained from the UKM Kuala Lumpur Dental Clinic, from patients who had their first premolars removed prior to orthodontic treatment.
Thus, the sampling method is a convenience sampling. Each patient has given informed consent for the purposes of this study. A total of 100 first premolars were received from both male and female subjects. There are four types of first premolars; 14, 24, 34, and 44 according to FDI World Dental Federation notation system. Fig. 1 shows the location of four first premolars based on FDI system. 14 and 24 are the first premolars located in maxillary arch and usually consists of two roots while 34 and 44 are the single root first premolars located in mandibular arch (Fig. 1). The exclusion factors in this study are patients with disease that could cause pulp calcification (i.e.
atherosclerosis or renal disease), patients who have undergone corticosteroid therapy, patients who had suffered vitamin-D resistant rickets or dentin genesis imperfect, first premolar teeth with attrition, caries, crowns and teeth which were impacted or had radio-opaque fillings.
MEASUREMENT OF TOOTH PULP CAVITY All tooth samples from radiographic images were measured by using Image J software. Each first premolars of the test population were marked vertically at three different heights as shown in Fig.
2. The maximum tooth height would be measured from the highest cusps of the tooth crown till apical root. The highest point of pulp till root apex is the point for maximum pulp height while maximum root height would be measured from the enamel- cementum junction (ECJ) to the root apex. The
height ratios between the tooth and pulp were calculated according to Kvaal et al. (1995) technique; pulp/tooth (P/T), pulp/root (P/R) and tooth/ root (T/R). The height ratio measurements of the same tooth were calculated in order to avoid measurement errors due to differences in
magnification of the image on the radiograph. The height ratios were measured three times by the same researcher at three different days and the average value were further analysed.
FIGURE 1 FDI two-digits tooth numbering system of first premolars: 14, 24, 34 and 44
Figure 2
FIGURE 2 Key reference for height ratio of pulp chamber
STATISTICAL ANALYSIS
Statistical analysis was performed by using IBM SPSS Version 23 software. The ICC test was used to determine whether the height ratios between the
tooth and pulp measurements; pulp/tooth (P/T), pulp/root (P/R) and tooth/root (T/R) technique used is consistent by the same observer. Then, the relationship between age and height ratios was done using Pearson’s correlation test. The correlation
Key reference:
a) Maximum tooth height b) Maximum pulp height c) Maximum root height Root apex
Highest cups
Highest point of pulp
Enamel-cementum junction (ECJ) Maxillary arch
Mandibular arch
analysis was carried out three times; for all the samples together (n=100), maxillary samples (n=58) and mandibular samples (n=42).
RESULTS AND DISCUSSION
A total of 100 first premolar samples were received with age range from 13 to 34 years old. In this study, the ICC test shows an excellent reliability of
measurement which is 0.888 values. The scale of data can be considered excellent reliable if the alpha value shows more than 0.7. Then, Pearson’s correlation test was conducted to investigate the relationship between age and tooth/root, pulp/tooth and pulp/root ratios (Table 1). As a result, there is no significant relationship between age and tooth height ratios; pulp/tooth, pulp/root and tooth/root based on maxillary and mandibular of first premolars (p>0.05).
TABLE 1 Correlation coefficients between age and tooth height ratios of first premolar, n = 100
Dental Arch Height ratios r value P value Pulp/tooth -0.162 >0.05 Maxillary and mandibular Pulp/root -0.111 >0.05 Tooth/root 0.029 >0.05 Pulp/tooth 0.019 >0.05 Maxillary Pulp/root 0.051 >0.05 Tooth/root 0.078 >0.05 Pulp/tooth -0.199 >0.05 Mandibular Pulp/root -0.215 >0.05 Tooth/root -0.110 >0.05 p<0.05 = significant value
These findings were supported by previous studies by Lamia et al. (2009) and Marroquin et al. (2017) which also show no significant difference between age and height ratios by using Iraqi and Western Australia population respectively. However, studies by Kvaal et al. (1995) had stated that there is a significant negative correlation between age and height ratios by using Norwegian population except tooth/root ratio which were not significant with age.
Even though all of the studies were applied the same method that had been proposed by Kvaal et al. (1995), different results were achieved. This could be due to a few factors such as the target population, type of tooth as sample and also type of radiograph used.
Different populations would have different socioeconomic status and personal habits. In the study conducted by Kvaal et al. (1995), Norwegian population was used and they would always take care of their teeth by visiting the dentist and have less of poor socioeconomic status compared to other populations. Besides that, personal habits can also affect tooth structure or morphology, for example biting the nails which can affect the actual size of the tooth and frequent smoking, which can cause discoloration of teeth and rapid accumulation of dental plaque (Vodanović, et al. 2012).
Prapanpoch et al. (1992) had stated that generally the physiologic secondary dentin had grown inwardly into the pulp chamber that lead
width ratios of the pulp measurement was better as age indicators than height ratios of pulp. This study also had been supported by Drusini et al. (2008), Kvaal et al. (1995) and Bosmans et al. (2005).
However, studies by Talabani et al. (2015) had stated that secondary dentin deposition is not homogeneously spread all over the pulp chamber.
For example, the secondary dentin deposition in molar teeth occurs on the floor and roof of the pulp chamber that reduced height ratios rather than width ratios (Badar et al. 2016). Paewinsky et al.
(2005) and Lamia et al. (2009) stated that maxillary lateral and central incisor respectively, have high correlation and suitable to be used to estimate age in adults. Thus, type of teeth used also can influence the result. In the current study, first premolars were used as samples while Kvaal used more than 1 type of tooth which are maxillary central incisor, lateral incisors and second premolars, and mandibular lateral incisors, canines and first premolar
This current study was innovative in the way that direct radiographs of extracting first premolars were used instead of orthopantomograms or periapical radiographs (full mouth) of a patient’s jaw. The images of each sample on a flat plane combined with the use of ratios in measurement helped reduce the possibility of distortion from angulation greatly. In future studies, even more accurate results of correlation and application of
regression formula may be obtained if the measurements were taken with scale and radiographs were assured to be of high quality to maximize the discerning power of the observer.
Furthermore, sample collections should include wider range of age group (below 50 years old) and total every age of the group should be in similar quantities.
CONCLUSION
Based on the results of this study, there is no significant relationship between age and tooth pulp cavity in terms of height ratios: tooth/root, pulp/tooth and pulp/root of the first premolar. Thus, it can be concluded that height ratios based on Kvaal method are less suitable to be applied in first premolars of Malaysia population for age estimation.
ACKNOWLEDGEMENT
The authors would like to thank the Forensic Science Program, Universiti Kebangsaan Malaysia for their cooperation in providing us the facilities, encouragement and support throughout the completion of this research. Thanks to UKM Kuala Lumpur Dental Clinic for supplying the samples for this research.
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Iwana Izah binti Abdullah Forensic Science Program Faculty of Health Sciences Universiti Kebangsaan Malaysia 43600 Bangi, Selangor
Malaysia Rus Dina Rus Din
Center for Diagnostic, Therapeutic and Investigative Studies Faculty of Health Sciences,
Universiti Kebangsaan Malaysia 50300 Jalan Raja Muda Abdul Aziz Wilayah Persekutuan Kuala Lumpur Malaysia
Corresponding Author: Rus Dina Rus Din E-mail: [email protected]
Tel: 03-89217204 Fax: -
Received: 31 August 2021 Revised: 5 October 2021
Accepted for publication: 14 October 2021
