ORIGINAL ARTICLE

Year : 2017 | Volume : 35 | Issue : 1 | Page : 56-62

Prevalence of dental anomalies in deciduous dentition and its

association with succedaneous dentition: A cross-sectional study of
4180 South Indian children
G Shilpa, Niraj Gokhale, Sreekanth Kumar Mallineni, Sivakumar Nuvvula
Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra
Pradesh, India

Date of Web Publication 31-Jan-2017

Correspondence Address:
G Shilpa
Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra
Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0970-4388.199228

Abstract

Objective: The objective of this study was to estimate the prevalence of dental anomalies in
primary dentition of Indian population. Materials and Methods: This cross-sectional study was
conducted on 4180 children in the age of 2–6 years. Anomalies were classified based on
Kreiborg criteria. The term “double tooth” was used to avoid misinterpretation between
gemination. and fusion. Patients having radiographs were also examined for associated dental
anomalies in permanent dentition. The occurrence and gender prevalence were evaluated using
descriptive statistics. Results: About 95. (2.27%) children exhibited at least one dental
anomaly. Thirty.seven children showed 51 missing teeth. (0.88%), mostly in lower right incisors
with a statistically significant difference between arches. (P = 0.0056) Nine children. (0.21%)
had supernumerary teeth commonly in the right maxilla. Two cases of oligodontia. (0.04%) and
talon cusps. (0.04%) and one case of triple tooth. (0.02%) were observed. Forty children.
(0.95%) had 43 double teeth mostly in the right mandible with a statistically significant difference
between the arches. (P = 0.0105). No significant difference was observed based on gender and
arch, but they were statistically significant between the right and left sides. (P = 0.018). Among
the children with radiographs available, 45% showed anomalies in the succedaneous
dentition. Conclusions: The prevalence rates of children with double tooth, hypodontia, and
hyperdontia in our study are 0.95%, 0.88%, and 0.21%, respectively. The overall prevalence
rate of anomalies among boys was higher than girls.
Keywords: Dental anomalies, double tooth, hypodontia, supernumerary teeth

How to cite this article:

Shilpa G, Gokhale N, Mallineni SK, Nuvvula S. Prevalence of dental anomalies in deciduous dentition
and its association with succedaneous dentition: A cross-sectional study of 4180 South Indian children. J
Indian Soc Pedod Prev Dent 2017;35:56-62

How to cite this URL:

Shilpa G, Gokhale N, Mallineni SK, Nuvvula S. Prevalence of dental anomalies in deciduous dentition
and its association with succedaneous dentition: A cross-sectional study of 4180 South Indian children. J
Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2019 Jan 4];35:56-62. Available
from: http://www.jisppd.com/text.asp?2017/35/1/56/199228

Introduction

Dental anomalies in children can lead to an increased risk of dental problems from esthetic to
orthodontic problems. Estimation of prevalence based on children attending as dental
outpatients would be a misjudgment in developing countries. Therefore, it is not surprising to
find no published data on the prevalence of dental anomalies in South Indian children. The
reported prevalence of overall dental anomalies in primary dentition in various studies ranges
from 0.4% to 8.1%.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] The prevalence studies are useful to understand the
magnitude of problems and in the formulation of oral health care programs. They would also
lead to increased awareness among the dental faculty, which would help in early diagnosis and
comprehensive management of these children. There have been only a few reported studies on
the prevalence of dental anomalies in primary dentition.

In developing countries like India with a grouping of social, cultural, and religions, a vast
economic gap exists between the poor and malnourished and affluent children. They would also
help in the comparison of rates between races, countries, etc., which would help in predicting
the possible etiological factors. These studies would also help geneticists and anthropologists in
their comparison studies. Nonetheless, the purpose of the present study was to estimate the
prevalence of dental anomalies in South Indian children.

Materials And Methods

This cross-sectional study was conducted in children in the age group of 2–6 years attending
various nurseries and primary schools (run by government and private organizations) in the
rural and urban sectors of South India. The Institutional Research and Ethical Committee
approved the proposal of this study. Among 170 primary schools in the rural and urban sectors,
64 schools were included in the present study. Children were examined during the school hours
after taking permission from school authorities. Clinical examination was performed to record
dental anomalies. All the children were examined using a mouth mirror and a probe. Children
with systemic anomalies were excluded from the study. The parents of children with dental
anomalies were informed, and with their consent, further evaluation was done at the department
of pedodontics and preventive dentistry using radiographs. Parents were counseled regarding
the anomaly and the need for regular follow-up. The nomenclature proposed by Kreiborg criteria
for dental anomalies was used in our study with the following modifications. [12]
 1. The following definitions from Kreiborg criteria were followed:

a. Supernumerary: Presence of an extra tooth

b. Hypodontia: Absence of one or more teeth
c. Microdontia: A single tooth smaller than normal.

2. We have used the term “double tooth” as suggested by Carvalho et al.[10] and “triple
tooth” as used by Knapp and McMahon [13] to describe anomalies with abnormally large
teeth irrespective of the presence or absence of normal complement. These
terminologies have been chosen for the following reasons:

a. To avoid the difficulty and lack of accuracy that exists in differentiating between
fusion and gemination based on clinical features alone [4],[5]
b. Various definitions for gemination in literature [8],[11]
c. Possibility of geminated tooth with hypodontia, supernumerary tooth (ST) fused
to a normal, and other differentials, as suggested by Knezevic et al.[14]
d. Similar treatment modalities for geminated/fused teeth.

The double teeth were further classified into the following types based on crown and
root morphology as used by Aguilo et al. This classification was chosen as it has a
clinical relevance in management.[15]

o Type I: Bifid crown-single root

o Type II: Large crown-large root
o Type III: Two fused crowns-double conical roots
o Type IV: Two fused crowns-two fused roots.

3. Oligodontia: Absence of more than six teeth.[16]

Clinical and radiological findings were correlated. The correlation between primary and
permanent dentition was also documented. Supernumerary teeth were classified based on
location, shape, and orientation. The classification of supernumerary teeth into mesiodens,
paramolar, and distomolar, which is widely used in permanent dentition, cannot be strictly
followed in primary dentition because of the terminology used. We have used the number of
children with anomalies in the numerator for the calculation of prevalence rates in our study.
Statistical analysis was done to find the significance of differences between genders' side and
location using Chi-square tests and tests of proportion (Z-test).

Results

A total of 4180 children (boys: 2473 and girls: 1707) were involved in the present study. Age of
the children ranged from 3½ to 6 years. At least one dental anomaly was present in 95 (2.27%)
patients. A total of 143 anomalies (missing tooth: 82, double tooth: 48, supernumerary: 10, talon
cusp: 2, and triple teeth: 1) were found in 95 children. The overall prevalence rate of anomalies
among boys was 2.5% (n = 62) and girls was 1.9% (n = 33). [Table 1] shows the demographic
variables and distribution of cases according to gender, site, and side. Distribution of anomalies
by number of children and type of anomalies is shown in [Figure 1].

Table 1: Demographic variables and statistical significances for

overall anomalies

Click here to view

Figure 1: Distribution of anomalies by type of anomalies (n = 143)

Click here to view

Forty children presented with 43 double teeth with a prevalence rate of 0.95% (40/4180; boys:
25 and girls: 15). The most common location was the right mandible. There was statistically
significant difference between mandibular and maxillary arches (28 vs. 15) (Z = 2.58 at 95%
confidence interval [CI], P = 0.0105). There was no significant difference between the right and
left sides (26 vs. 17) (Z = 1.72, P = 0.085). There were three cases with bilateral symmetrical
double tooth. In 15 cases, the radiological images could not be obtained because of reasons
such as parents giving no consent and transfer of some students. On radiological evaluation of
25 cases, there were 12 children with missing teeth (common site - right mandibular) and 1 child
with ST in succedaneous dentition. The details of cases with double teeth are summarized
in [Table 2]. Two cases presented with talons cusp with a prevalence rate of 0.04% (male: 1,
female: 1), and in both the cases, the anomaly was seen on the left side in the maxillary arch.
Thirty-seven children presented 51 missing teeth with a prevalence rate (hypodontia by number
of children) of 0.88% (37/4180). The prevalence among boys (1.02%) is double that of girls
(0.5%) that is not statistically significant (P = 0.08). Out of the 37 children, 10 (27%) showed
more than one tooth missing; with 8 of them showing two missing teeth (7 with bilateral and 1
with unilateral missing teeth) and each of the other 2 children showing four missing teeth (1 had
all the four anterior missing teeth in mandibular arch and 1 showed bilateral missing teeth in
maxillary arch and two teeth missing on the same side in mandibular arch). Apart from these,
there were two cases of oligodontia (with 14 missing teeth in each case). There was no
significant difference between the right and left sides (25 vs. 26) (Z = 0). The missing teeth were
twice more common in mandibular arch when compared to maxillary arch (33 vs. 18), the
difference being statistically different (Z = 2.77 at 95% CI, P = 0.0056). The most common
missing tooth was the right mandibular lateral incisor followed by the left mandibular lateral
incisor (31%). There were six children with available radiographs, among which two had missing
teeth in the succedaneous dentition also. The details are summarized in [Table 3].

Table 2: Distribution of double teeth by gender, region, location, and

type (43 in 40 children)

Click here to view

Table 3: Distribution of hypodontia by gender, region, location, and

type (51 missing teeth in 37 children

Click here to view

The overall prevalence rate of ST was 0.21% (9/4180) (male: 6, female: 3), with the most
common site being the right maxilla. All the nine patients showed ST in the maxillary arch with
eight of them on the right maxilla. Seven of the cases were supplemental type and two were
conical ST. Eight children showed normal orientation and one child showed transverse
orientation. Out of these nine cases, two patients showed supernumerary and one patient
showed missing teeth in the succedaneous dentition.

This study showed 12 cases of bilateral anomalies (0.28%), with 3 children presenting bilateral
double teeth and 9 with bilateral missing teeth. Four children (0.09%) presented with more than
one type of anomaly (three with double tooth and missing tooth and one with double tooth and
ST). One case showed diagonal presence of (maxillary and mandibular) double teeth, one case
(case 3) showed solitary median maxillary central incisor syndrome, and two cases showed
missing teeth in the succedaneous dentition.

Radiological images were available for 44 cases (25 cases of double teeth, 9 cases of ST, 6
cases of hypodontia, and 4 cases of multiple anomalies) of our study. Out of these, 20 (45%)
cases consisting of 13 with double tooth, 3 with ST, 2 with hypodontia, and 2 with multiple
anomalies showed anomalies in the succedaneous dentition also. Seventeen cases showed
hypodontia (85%) and three cases (two with supernumerary teeth and one with double tooth)
had ST.

Discussion

Dental anomalies and “Evolution”

Dental anomalies have been reported since ancient times. There are reports of dental
anomalies in several anthropological studies. A supernumerary lateral incisor has been reported
from a 1.7 million year old hominid fossil of Australopithecus robustus found in a cave of South
Africa.[17] Missing lateral incisors have been reported from Iron age Southeast
Asians.[18] Bennazi et al. have recently reported a case of triple teeth in a five-year- old child
discovered in a late medieval cemetery in Italy.[19] Dental anomalies have been of major concern
in various species including domestic animals such as horses and dogs. Presence of anomalies
will affect the chewing and thereby nutrition of these animals. The Merck veterinary
manual [20] clearly mentions about anodontia and supernumerary teeth in dogs (canines) and
horses (incisors and molars). Well aligned dentition plays a predominant role in the smile, which
is the unique feature of human beings standing at the top of evolution. Human beings with a
'dentition” that has contributed to their success in evolution are susceptible to various kinds of
dental anomalies due to developmental, genetic, environmental and other factors.

Embryology of Dental Anomalies

Malformation of teeth can be classified according to the size, shape, number, and structure.
During the early bell stage (14th week), the dental lamina starts breaking down and
degenerates. The enamel organ looses connection with the oral epithelium. According to the
dental lamina hyperactivity theory, a supplemental form of supernumerary tooth (ST) will
develop from the lingual extension of an accessory tooth bud whereas a rudimentary form
would develop from the proliferation of the epithelial remnants of the dental
lamina.[21] Gemination develops due to partial cleavage or complete division of tooth germ.
Fusion occurs due to the union of two adjacent tooth germs. Hypodontia develops due to arrest
of tooth development in the bud stage.

There were a lot of debits of fusion and gemination; consequently, various studies have started
using the term “double tooth” to indicate both fusion and gemination. Over the last one decade,
the terminology of “double tooth” is widely in usage to avoid the confusion of gemination versus
Fusion, especially gemination and ST fused to a normal tooth. Therefore, we have used the
term double tooth (irrespective of the number of teeth) to define various anomalies such as
fusion, gemination, gemination with hypodontia, and supernumerary fused to a normal tooth,
which are very difficult to distinguish clinically. The cause of double tooth (DT) may be
inheritance and local factors such as crowding or trauma. DT is more common in primary
dentition when compared to permanent dentition. Our study reports a prevalence of 0.95%.
There is a significant variation in the prevalence rates of various geographical regions. The
studies reported by Yonezu et al. from Japan and King from Hong Kong have reported a
prevalence of 4.1% each, which are the highest rates reported till date.[9],[21] In most of the
studies, there has been no gender difference though we found a greater prevalence in boys. In
our study, most of the DT were in the mandibular arch. Kramer et al. reported a significant
difference of mandibular double teeth over maxillary double teeth.[11] Aguilo et al. and Järvinen
reported no significant difference between the arches.[15],[22] Studies in primary dentition show no
significant difference between the right and left sides though we found a predominance of DT on
the right side. In our study, we found three children with more than one DT. Aguilo et al. in their
retrospective study on 6000 children found more than one DT in three children (one contiguous
and two bilateral).[15]

The prevalence of ST in primary dentition is lower when compared to permanent dentition.

According to Brabant, hyperdontia in the primary dentition has been in existence since the end
of the Neolithic period.[23] Various etiological factors for ST have been proposed: Atavism,
dichotomy of tooth germ, hyperactive dental lamina, which is the most favored
theory,[24],[25] genetic (autosomal recessive with incomplete penetrance or autosomal dominant
variety), and multifactorial. Rajab et al. reported that only 2 out of 152 cases with ST were in the
age group of 5–6 years (mean age - 10.1 ± 1.9 years).[24] De Oliveira Gomes et al. reported that
22 out of 305 patients with ST were in 3–6 years age group (mean age of 9.3 years).[26] In a
study reported from Hong Kong with 208 children with ST and a mean age of 7.3 ± 2.7 years, 42
children were with primary dentition.[27] Salem has studied 2393 children in the age group of 4–
12 years and reported a prevalence rate of 0.5%.[28] Kramer et al. have reported a prevalence
rate of 0.3% in their study on 1260 children in the age group of 2–5 years.[11] King et al. in their
study on 936 children aged 5 years reported a prevalence of 2.8%. [21] Osuji et al. reported that in
1878 children, there is no mention of the mean age group, but the prevalence of ST in primary
dentition was 0.58% (11/1878).[29] Whittington reported a prevalence of 0.17% in a survey on
1680 5-year-old children.[8] The reported prevalence of ST in primary dentition in literature
ranges from 0.2% (in Caucasians) to 2.8%.[21] The prevalence rate of 0.23% in our study is
comparable to the prevalence rate in most of the studies. Male predominance in our study (3:2)
is similar to other studies. Bolk et al. classified ST into mesiodens, paramolars, and distomolar,
strictly cannot be applied in primary dentition.[30] It is difficult to compare ST by location in
various studies in primary dentition because of absence of a uniform classification that could
apply only to primary dentition. In our study, the ST were predominantly located in the right
maxillary arch associated with central and lateral incisors. There were no cases of ST in the
mandibular arch in our study. Kramer et al. have reported ST in mandibular arch in only one
case in their series.[11] Supernumerary teeth can also be classified based on the morphology
(conical, tuberculate, supplemental, and odontoma) and orientation (normal, inverted,
transverse, and ectopic position). Multiple supernumerary teeth are rare (prevalence <1%) and
are usually associated with syndromes such as cleft lip and palate, Gardner's syndrome, and
cleido-cranial dysplasia.[24],[31]Cases of bilateral supernumerary teeth have also been
reported.[26],[31] There are no cases of multiple or bilateral supernumerary teeth in our study.
Recently, Mallineni and Nuvvula have proposed a detailed classification for supernumerary
teeth, based on location, position, morphology, and orientation.[32] Supernumerary teeth in
primary dentition are often overlooked because of normal shape, eruption, and alignment due to
the available spacing. Supernumerary teeth in primary dentition usually lead to crowding. In our
study, we found that in one case, ST was responsible for a crossbite of the adjacent lateral
incisor.

Hypodontia

Polygenic inheritance and environmental factors (invasive and noninvasive factors) have been
implicated in hypodontia.[33] Prevalence rate of hypodontia in primary dentition ranges from 0.4%
to 4.6%.[21] Clayton and Yonezu have reported high prevalence rates of 4.6% and 2.4%,
respectively.[2],[9] Hypodontia could be nonsyndromic or syndromic when it is associated with
several syndromes such as ectodermal dysplasia, Reiter's syndrome, Schwartz–Jampel
syndrome, and holoprosencephaly.[34] Recent studies have shown an increase in the prevalence
of hypodontia in the 20th century.[35] This wide range of difference could be due to the various
age groups included in these studies and geographical location (literature shows a high
prevalence of hypodontia in Japan when compared to other countries). The prevalence of
hypodontia in our study is 0.88%. Most of the studies on primary dentition show no statistically
significant gender difference for missing teeth. Nonetheless, the prevalence rate is higher
among girls when compared to boys in all these studies. In contrast, the prevalence among
boys in our study is high. The most common missing tooth in our study is lower right lateral
incisor. In most of the studies, missing teeth are more common in the maxillary arch. In our
study, we found a predominance of missing teeth in the mandibular arch. Kramer et al.[11] also
have found a similar predominance in mandibular arch (9 out of 14 teeth in their series).
Daugaard-Jensen et al.[36] in their study have analyzed the children (1.2–9 years) by the number
of missing teeth and found 87 out of 193 (45%) with more than one tooth missing.{45} In our
study, we found that 27% of the children with hypodontia had more than one tooth missing.
There are no studies on hypodontia with a clear analysis of bilateral missing teeth. Kramer et al.
have reported that two out of eight children in their series had bilateral missing
teeth.[11]Symmetrical occurrence has been reported to be higher in boys when compared to girls.
In our study, the prevalence of bilateral missing teeth was equal between boys and girls. We
had a very rare case with a finding of missing bilateral central mandibular incisors. Children with
simultaneous occurrence of more than one anomaly have been analyzed in our study, and we
found a prevalence of 0.09% (4/4180). Four of them had a double tooth associated with either a
hypodontia or ST.

Talon Cusps

Talon cusp refers to a rare developmental dental anomaly characterized by a cusp-like structure
projecting from the cingulum area or cement–enamel junction.[37],[38] This condition can occur in
the maxillary and mandibular arches of the primary and permanent dentitions.[39] In the present
study only talon cusps with a prevalence rate of 0.04% (male: 1, female: 1) observed and in
both the cases the anomaly was seen on the left side in the maxillary arch. The exact etiology of
talon cusp has not been stated clearly in the literature.[37],[38],[39]

Various studies have shown that in children with primary dentition anomalies, about 60% of
them had anomalies of succedaneous teeth.[40] In cases of hypodontia, almost 100% of them
had corresponding missing succedaneous teeth. This finding supports the ectodermal mucosal
defect as an etiological factor for missing teeth.[8]

In case of double teeth, about 53%–60% of the cases are reported to have anomalies in the
succedaneous dentition.[41],[42] As observed in our study, the most common anomaly in
succedaneous dentition in the presence of double tooth in primary dentition is hypodontia
followed by hyperdontia. Children with supernumerary teeth demonstrated anomalies in
succedaneous dentition in 50%–85% of the cases.[43],[44] In our study, 45% of the cases (in those
with available radiographs) with primary dentition anomalies had anomalies in succedaneous
dentition also. Knowledge on the prevalence of dental anomalies in primary dentition of Indian
subcontinent has not been clearly documented. It gives knowledge on different anomalies of
primary dentition and their influence on their successors so that anticipatory guidance can be
done.

Conclusions

The overall prevalence rate of primary dentition anomalies in our study is 2.27%, which is
comparable with most of the reported prevalence rates. This is the first prevalence study based
on 4180 children from India. Double tooth has been the most common anomaly in our study.
Classification of double tooth into four types helps in planning appropriate treatment. High
prevalence of missing teeth in boys and in mandibular arch in our study is in contrast to other
studies. We have reported the prevalence rates for triple teeth, oligodontia, and bilateral and
multiple anomalies in our study, which would help in comparative studies. Analysis of the
succedaneous dental anomalies in children with primary dental anomalies would help in
comparative and etiological studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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Figures

[Figure 1]

Tables

[Table 1], [Table 2], [Table 3]