|Year : 2018 | Volume
| 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
|Date of Web Publication||2-Jul-2018|
Neil De Souza
Department of Pedodontics and Preventive Dentistry, Government Dental College and Hospital, Bambolim - 403 202, Goa
Source of Support: None, Conflict of Interest: None
| 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.
Keywords: Age estimation, clinical method, Kusri's triangle, primary teeth, regression equation, tooth eruption
|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;36:185-90
|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 2020 Jul 3];36:185-90. Available from: http://www.jisppd.com/text.asp?2018/36/2/185/235677
| 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. Teeth are known to aid in personal identical and age estimation as they are highly durable and resist putrefaction, fire, and chemicals.
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.
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. 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].,, 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.
Various authors have established that age estimation based on primary tooth eruption is far more accurate than those based on permanent teeth eruption.,,, 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.
To reduce the patient selection bias, 50 children reporting to the Department of Pediatrics, were randomly selected to comprise the preliminary sample group.
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.
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.
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.,,, Hence, we decided to develop a new triangle as well as a 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: Receiver operating characteristics curve analysis depicting sensitivity and specificity values for each variable to be used in the formulation of the modified triangle|
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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: Receiver operating characteristics curve analysis depicting sensitivity and specificity values for each variable to be used in the formulation of the modified triangle to be used in males|
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|Table 3: Receiver operating characteristics curve analysis depicting sensitivity and specificity values for each variable to be used in the formulation of the modified triangle to be used in females|
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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: Schematic representation of method of age estimation for use irrespective of sex (MASTER METHOD)|
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|Figure 3: Schematic representation of method of age estimation for use in males|
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|Figure 4: Schematic representation of method of age estimation for use in females|
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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: Significance values for variables to be used in formulation of an India specific regression equation|
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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: Values and their interpretation using the intraclass correlation (intraclass correlation coefficient) method|
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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: The correlation values obtained using the intraclass correlation method based on the eruption of deciduous teeth|
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| 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.,,, 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., 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. 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 on the criteria used. 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.
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.,,,
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]