8/28/2018 Development and evaluation of new clinical methods of age estimation in children based on the eruption status of primary

primary teeth :<b>…

Journal of Indian Society of Pedodontics and Preventive

Dentistry
Official journal of the Indian Society of Pedodontics and Preventive
Dentistry

Year : 2018 | Volume : 36 | Issue : 2 | Page : 185--190

Development and evaluation of new clinical methods of age estimation in children

based on the eruption status of primary teeth
Neil De Souza1, R Manju2, Amitha M Hegde2,
1 Department of Pedodontics and Preventive Dentistry, Government Dental College and Hospital, Bambolim, Goa, India
2 Department of Pedodontics and Preventive Dentistry, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore,
Karnataka, India

Correspondence Address:
Neil De Souza
Department of Pedodontics and Preventive Dentistry, Government Dental College and Hospital, Bambolim - 403 202, Goa
India

Abstract
Background: Age estimation methods in the permanent dentition are numerous in number and well established and
evaluated. However, there exists a dearth of methods available for the estimation of age based on the eruption status of
primary teeth, despite various studies displaying greater accuracy using such methods. Aim: The purpose of this study
was to develop the methods of age estimation based on the eruption status of primary teeth and based on previous
methods developed for permanent teeth and to assess the accuracy of the methods in a clinical situation. Materials and
Methods: A total of 50 children were randomly selected between the age group of 6 and 38 months for the assessment
of primary tooth emergence in the oral cavity. New methods of age estimation (triangles and regression equations) were
developed for used in the Indian population. Results: Data were analyzed using receiver operating characteristics curve
and intraclass correlation coefficient. Our results conducted in a validation sample of 30 children suggested high levels
of accuracy using the new methods, with greater accuracy displayed using the regressive equation (0.928) as compared
to the new triangle of age estimation (0.897). Conclusion: Such methods of age estimation will be of unparalleled
importance in rural setups, which cannot afford the luxury of panoramic radiography.

How to cite this article:

De Souza N, Manju R, Hegde AM. Development and evaluation of new clinical methods of age estimation in children based on
the eruption status of primary teeth.J Indian Soc Pedod Prev Dent 2018;36:185-190

How to cite this URL:

De Souza N, Manju R, Hegde AM. Development and evaluation of new clinical methods of age estimation in children based on
the eruption status of primary teeth. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2018 Aug 28 ];36:185-190
Available from: http://www.jisppd.com/text.asp?2018/36/2/185/235677

Full Text

Introduction

Forensic odontology has grown exponentially in stature worldwide in the last couple of decades. India, however, fails to
keep up with this global growth of the newest branch of dentistry, which is forensic odontology. Age estimation in the
living and the deceased is an important tool in the arsenal of forensic odontology, mainly used in medicolegal matters.[1]
Teeth are known to aid in personal identical and age estimation as they are highly durable and resist putrefaction, fire,
and chemicals.

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8/28/2018 Development and evaluation of new clinical methods of age estimation in children based on the eruption status of primary teeth :<b>…
In India however, a significant proportion of people still lack knowledge or records of their date of birth, which is required
by law enforcing agencies in matters such as criminal responsibilities, identification, judicial punishment, consent, rape,
criminal abortion, employment, attainment of majority, kidnapping, and prostitution.[2]

The times of eruption of primary and permanent teeth are fairly constant, and assessment of age of an individual by the
examination of teeth is one of the accepted methods of age determination. Eruption of teeth is one of the changes easily
observed among the various dynamic changes that occur from the formation of teeth to the final shedding of teeth.[3]
Teeth are known to aid in personal identification and age estimation as they are highly durable and resist putrefaction,
fire, and chemicals.

There is a dearth of methods based on the eruption of teeth, which can be evaluated in a clinical setup. Kusri's triangle
is an established method of clinical age estimation based on the eruption sequence of teeth. This method has been
used over a considerable period by forensic medicine experts for dental age estimation [Figure 1].[4],[5],[6] However,
this method is limited in its use, as it evaluates the presence of permanent teeth in the oral cavity and hence can be
used only in children above the age of 6 years.{Figure 1}

Various authors have established that age estimation based on primary tooth eruption is far more accurate than those
based on permanent teeth eruption.[7],[8],[9],[10] Hence, the present study was undertaken to develop and to evaluate
the new methods of age estimation based on the eruption status of primary teeth, to be used in the Indian population.

Materials and Methods

Aim of the study

The present study conducted was a prospective study done to develop and evaluate the accuracy of new methods of
age estimation based on the eruption status of primary teeth, to be used in the Indian population.

Sample selection

To reduce the patient selection bias, 50 children reporting to the Department of Pediatrics, were randomly selected to
comprise the preliminary sample group.

Inclusion criteria

Children between the age group of 6 and 38 months showing the presence of at least one erupted primary tooth in the
oral cavity were included in the study.

Exclusion criteria

Edentulous children and children suffering from any underlying systemic disease or debilitating condition were excluded
from the study.

Dental examination of the individual was conducted using a dental mouth mirror and dental probe under all the aseptic
precautionary measures. The dental examination data of the individuals were then recorded in a detailed pro forma.
Eruption of the tooth was considered to have happened if at least some part of it had pierced the gingiva (gingival
eruption/emergence). Informed consent was taken from the parents/guardians of the children before conducting the
examination.

Statistical analysis

Data collected was tabulated and subjected to statistical analysis using the receiver operating characteristics (ROC)
curve to estimate the sensitivity and specificity of Kusri's triangle in estimating the age of an individual.

Furthermore, a forward stepwise regression analysis of the data available was done to obtain the variables to be used in
the regressive model for age estimation based on the eruption of primary teeth. Descriptive statistics of the available
data were performed to derive a new statistical model for the estimation of age by primary teeth.

Results

Studies have demonstrated that the eruption status of primary teeth provides a more accurate estimate of age in
comparison to that of permanent teeth.[7],[8],[9],[10] Hence, we decided to develop a new triangle as well as a
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8/28/2018 Development and evaluation of new clinical methods of age estimation in children based on the eruption status of primary teeth :<b>…
regression equation for estimation of age based on the emergence of primary teeth.

Formulation of triangle based on primary tooth emergence

Data collected was subjected to analysis using a ROC curve to obtain the sensitivity and specificity values for each
variable to be used in the formulation of the modified triangle. Data were collected and analyzed for a mixed population
and separately in males and females, respectively. The results suggest excellent accuracy using the above-given
variables (area under curve >0.90). Furthermore, the values suggest high sensitivity and specificity using all the
variables [Table 1].{Table 1}

The results also suggest the high accuracy of the variables for both males and females as displayed by the high area
under curve values (>0.90). The high values of sensitivity and specificity for all the variables (excluding specificity values
for the upper central incisor [UCI] and lower lateral incisor in females) suggest good accuracy [Table 2] and [Table 3].
{Table 2}{Table 3}

Hence, using the above-obtained data, three new triangles were developed to be used in a random population as well
as for use in a male and female population separately [Figure 2], [Figure 3], [Figure 4].{Figure 2}{Figure 3}{Figure 4}

Calculation of new regression equation for age estimation based on eruption status of primary teeth

As there is a definite dearth of clinical methods available for the estimation of age based on the eruption status of
primary teeth, we decided to develop a new regression equation based on the eruption status of primary teeth.

Data collected was analyzed and subjected to multiple stepwise regression analysis to derive the variables to be used
for the calculation of a new Indian specific formula. The multiple stepwise regression analysis was performed to
determine which variables would display high levels of significance in estimating age in the Indian population [Table 4].
{Table 4}

Hence using the derived variables, a new regression formula was derived for accurate estimation of age based on the
eruption status of primary teeth.

AGE = 8.224 + 3.067 (LC) + 3.808 (U2M) + 2.742 (UCI) + 1.627 (U1M) + 2.308 (L2M)

Comparative evaluation of the accuracy of the new methods of age estimation

The accuracy of the new triangle method of age estimation was compared to the new regression equation in a validation
sample of 30 children. Inclusion criteria were similar to the pilot sample that included children in the age group of 6–38
months with at least one erupted primary tooth. Data were analyzed using the intraclass correlation coefficient method
and the accuracy of both methods was comparatively evaluated. [Table 5] depicts the criteria used to determine the
standard levels of accuracy to be used.{Table 5}

The results obtained depicted in [Table 6] suggest the greater accuracy of the regression formula as compared to the
new triangle in estimating the age of an individual based on the eruption status of primary teeth. The results suggest
“almost perfect” agreement with the actual age using both new triangle and new regression formula for age estimation
using primary teeth.{Table 6}

Discussion

In humans, age determination is done for various reasons. Age determination of cadavers is carried out for reasons
such as criminal cases and very mutilated victims of mass disasters such as fires, crashes, accidents, homicides,
feticides, and infanticides. In living persons, the age estimation is done to assess whether the child has attained the age
of criminal responsibility in cases such as rape, kidnapping, employment, marriage, premature births, adoption, illegal
immigration, pediatric endocrinopathy, and orthodontic malocclusion; and when the birth certificate is not available, and
records are suspect.[11],[12],[13],[14] In dental perspective, the importance of age determination pertains to many fields
including treatment planning in orthodontics and pediatric dentistry.

Many studies have concluded that tooth formation is a more reliable indicator of dental maturity than gingival emergence
or eruption, as it represents only one stage in the continuous process of dental eruption.[15],[16] Camps have described
that after birth and during a child is developing, it is possible to arrive at a close estimation of age by the presence of the
deciduous dentition at its stages of eruption and also the mixed dentition period and its stages of eruption of the
permanent teeth and loss of deciduous teeth. He also pointed that state of eruption only gives an indication of age since
eruption dates are subject to wide variations.[17] Biggerstaff found that forensic dentist can estimate the age of a person
by noting developing dentition. According to him, systemic observations can provide accurate age estimation depending

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on the criteria used.[18] Furthermore, the socioeconomic status of the child could also play a role. Studies show that
underprivileged children show comparative retarded eruption relative to their ethnic counterparts from higher
socioeconomic status. Eruption of the deciduous teeth in moderate-to-severe malnourished children showed 5%–29%
increase in times of emergence.[19]

However, in a developing country like India, there is a large percentage of the population that does not have access to
modern amenities such as digital radiography and a method devoid of the use of radiographic techniques, especially in
young children would be of great benefit to dentists, in a rural setup. While there are numerous methods based on the
eruption status of permanent teeth, Demirjians method being the most popular, there is an absolute dearth of methods
available based on primary teeth. Various studies have suggested that the clinical emergence of the primary teeth in the
oral cavity displays greater accuracy in estimating the age of an individual as compared to the emergence of the
permanent teeth.[20],[21],[22],[23]

The results we obtained suggested greater accuracy using the regressive equation (0.928) as compared to the new
triangle of age estimation (0.897). Both methods displayed excellent results with “almost perfect” correlation between
actual and estimated age [Table 6].

Choosing the right method of age estimation for an individual can be an arduous task. With the wide array of clinical,
radiographic, and skeletal methods is available, the onus is on the dentist to utilize the necessary literature, and arrive at
an informed decision on which method to choose. There is a severe lack of clinical methods of age estimation which can
be used in the absence of radiographs. These methods will be of significant relevance in a rural setup, where the facility
of panoramic radiography is unavailable.

Summary and Conclusion

Dental system in an integral part of the human body, its growth and development can be studied in parallel with other
physiological maturity indicators such as bone age, menarche, and height. Several authors have shown that dental
parameters are more suitable for age estimation in children because the variability is lower since calcification rate of
teeth is more controlled by environmental factors. The rate of formation of permanent teeth is not affected by the
premature loss of the primary teeth.

Forensic identification by its nature is a multidisciplinary team effect relying on positive identification methodologies as
well as presumption or exclusionary methodologies. Typically, this effort involves the cooperation and coordination of
low enforcement officers forensic pathologist, forensic odontologists, forensic anthropologists, serologists, criminalist,
and other specialists as deemed necessary. The most common roll of the forensic dentist is the identification of
deceased individuals.

Many studies have concluded that tooth formation is a more reliable indicator of dental maturity than gingival emergence
or eruption. Tooth eruption is mostly influenced by environmental factors such as available space in the dental arch,
extraction of primary tooth, teeth tipping, or impaction of teeth. Until quite recently, clinical eruption has been the only
criterion used for dental maturity or dental age. Tooth development shows less variability than other developmental
features and also low variability in relation to chronological age.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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