art-mitova-170-176

PEDODONTICS
STUDYING DENTINE CARIES IN THE FIRST PERMANENT MOLARS IN CHILDREN
Original Articles
Nadezhda Georgieva Mitova1a , Nikolay Ishkitiev2b*

1
Department of Pediatric Dentistry, Faculty of Dental Medicine, Medical University of Sofia, Sofia, Bulgaria
2
Department of Medical Chemistry and Biochemistry, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria

DMD, PhD, Assistant Professor
a

DMD, PhD, Chief Assistant Professor
b

ABSTRACT DOI: https://doi.org/10.25241/stomaeduj.2019.6(3).art.2
OPEN ACCESS This is an Open Access
Introduction: Caries in permanent teeth most often start from the occlusal article under the CC BY-NC 4.0 license.

surfaces of the first molars, soon after eruption at the age of six. At that point the Peer-Reviewed Article
occlusal surfaces are at risk due to the presence of many retentive areas.
Citation: Mitova NG, Ishkitiev N. Studying dentine
Aim – To study the spread and characteristics of cavitated dentine caries in the first caries in the first permanent molars in children.
Stoma Edu J. 2019;6(3):170-176.
permanent molars after eruption.
Methodology: 351 children, distributed into two groups were subjected to the Received: August 06, 2019
Revised: August 22, 2019
study: the first group - 6 to 9-year olds, and the second group - 10 to 12-year Accepted: August 27, 2019
Published: August 29, 2019
olds. The registration of the oral status was carried out with an epidemiological
card for oral health assessment - brief bio, dental status and description of the *Corresponding author:
Chief Assistant Professor Nikolay Ishkitiev, DMD,
cavitated carious lesions in the dentine. The clinical description of the D3 carious PhD, Address: Zdrave 2 str., room 343, 1431 Sofia,
Bulgaria, Tel. / Fax: +359 885 108620,
lesions present was determined according to the localization of the carious lesions e-mail: ishkitiev@gmail.com.
(occlusal, approximal, cervical), the color and the consistency of the carious
Copyright: © 2019 the Editorial Council for the
dentine, via the Bjørndal et al scale. Stomatology Edu Journal.
Results: The results of this study show that children aged 6 to 12 have on average
three to four carious teeth. Dentine carious lesions D3 with occlusal localization
in the first permanent molars are plausibly more numerous than the carious
lesions with approximal and cervical localization. In the first permanent molars,
the dentine carious lesions with occlusal localization are characterized by darker
colors of carious dentine and a relatively hard consistency.
Conclusions: In the first permanent molars the more slowly progressing carious
lesions are predominant.
Keywords: Caries; Dental decay; Dentine; Occlusal surfaces; Permanent first molar.

1. Introduction of affected permanent teeth reaching six. Every
Caries formation is a dynamic process of imbalances fourth 18-year-old already has one extracted tooth.
in the oral environment that lead to the development Only 30% of the six-year-olds in the country are
of carious lesions, on predisposed surfaces in the caries free, and with the 12-year-olds the percentage
primary and permanent teeth in children [1]. The drops further down to 22% [6,7].
progression of the carious lesion may be influenced in Caries in permanent teeth most often start from the
its early stages of development by modeling the oral occlusal surfaces of the first permanent molars, soon
environment and remineralization [2-4]. Despite the after their eruption at the age of six. At that point
indisputable successes and the increased scientific the occlusal surfaces are at risk due to the presence
interest with respect to improving children’s dental of many retentive areas. The mineralization of the
health, the problem of reducing the frequency and enamel at that place is not complete. Difficulty in
severity of caries remains relevant [5-7]. On a world early diagnosing of the initial carious lesions present
scale, 60-90% of school-age children suffer from on the occlusal surfaces of the permanent first molars
caries (WHO, 2012). The disease also leads to serious and the lack of regular prophylactic examination
economic consequences for society as a whole [8]. leads to the quick development of cavitated dentine
According to the data from the last epidemiological lesions during the first years after eruption. This
study conducted in Bulgaria in 2011, approximately requires their early inclusion in the restoration cycle,
71% of the six-year-old children in the country have and not infrequently leads to their early loss.
caries, with the most frequently affected temporary Raising awareness for the spread and characteristics
teeth numbering three or four. In the 12-year-olds of dental caries in the permanent first molars,
group, 79% of them had caries of the permanent conducting effective prophylactics or timely
teeth, with an average of three permanent teeth microinvasive treatment of already developed
being affected, and in the 18 year-olds group the lesions could lead to a significant decrease of
same held true for 92% of the teeth, with the number occlusal caries in children with a mixed dentition.

170 Stoma Edu J. 2019;6(3): 170-176. http://www.stomaeduj.com
STUDYING DENTINE CARIES IN THE FIRST
PERMANENT MOLARS IN CHILDREN

Original Articles
Table 1. Visual-tactile criteria. (Bjørndal et al.)

Visual criteria – dentine color Tactile criteria (with probe) - dentine consistency

black Code 1 (very soft) – the probe penetrates and peels parts of it
away easily;
dark brown Code 2 (soft dentine) – probe can easily penetrate and exit the
dentine;
light brown Code 3 (moderately hard) – light resistance during probing;
yellow Code 4 (hard dentine) – the probe moves over the dentine with
light resistance leaving a white trail;
light yellow Code 5 (hard non-carious) – soft squeaking and resistance
during probing.

Number of dentine carios lesion
20
R e s tore d; 41.98%
15

C a rious ; 58.02%
10

0
6 years 7 years 8 years 9 years 10 years 11 years 12 years
Age
Figure 1. Ratio between carious and restored permanent first molars.
Figure 2. Spread of D3 lesions in first permanent molars.
t=5,00 р<0,05

Aim – To study the spread and characteristics of – enamel carious lesion visible after drying. Further
cavitated dentine caries in the permanent first noted were D2, D3a, D3b and D4 carious lesions.
molars, immediately after eruption. The DMFT index was used, and while registering it,
Tasks for the purposes of this study, DMF(T+t) was also
1. To study the general cariousness and the relative registered, due to the fact that part of the children
portion of occlusal caries in the permanent first were with a mixed dentition [9]. The fissure sealants
molars in children aged 6 – 12. were included in the number of restorations.
2. To provide a clinical description of the registered The clinical description of the D3 carious lesions
cavitated dentine carious lesions in the permanent present was determined according to the location
first molars of the children tested. of the carious lesions (occlusal, approximal, cervical),
the color and consistency of the carious dentine, via
2. Materials and Methods the Bjorndal et al scale [10].
351 children, distributed into two groups were the The statistical processing of the data was carried out
subject of the study, as follows: group one - 6 to with the statistical program SPSS (version 19, SPSS
9-year-olds; group two - 10 to 12-year-olds . We had Inc. USA). A 95% interval of plausibility (p<0.05) was
received an ethical approval from KENIMUS – Etical chosen as a level of significance at which the null
commission of the Medical University of Sofia – hypothesis is rejected.
24/07.12.2018.
Registration of the oral status of the children was 3. Results
carried out with an epidemiological card for oral 3.1. Cariousness of the children tested:
health assessment, which includes a brief biography, - General cariousness
dental status and description of the cavitated The results obtained in determining the cariousness
carious lesions in the dentine present – D3 according – DMF(T+t) of the children tested, are presented in
to the locally adopted Peneva et al. classification [9]. the following table.
All surfaces of a tooth were cleaned of debris and The results show that the general cariousness
plaque, the teeth were dried using an air syringe and (DMF(T+t) in all children is between three and four
visually examined without magnification. If there carious teeth. A plausible decrease in cariousness
were suspicious areas, then an explorer – a blunt is observed in temporary teeth, due to their
probe (periodontal probe) was used to check for the replacement, while an increase in cariousness is
surface texture and to remove plaque from fissures observed in permanent teeth with age (p<0.05).
using a dredging motion. - Relative portion of carious and restored permanent
The carious status of the children was diagnosed and first molars
registered in teeth with a D1b diagnostic threshold The following diagram presents the results, obtained

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Original Articles Table 2. Cariousness of the children tested – DMF(T+t) as grouped by ages.

DMFT DMFt DMF(T+t)

Children gr. N Mean ± SD Mean ± SD Mean ± SD Ind t-test
children (teeth) (teeth) (teeth)
1st gr.– 6 to 9 201 0.60 ± 0.87 3.60 ± 2.24 4.20 ± 2.31 ТT,t=-17.05 (Р=0.00)
ТT,T+t=-22.78 (Р=0.00)
Тt,T+t=-9.87 (Р=0.00)
2nd gr. -10 to 12 150 2.42 ± 1.76 0.99 ± 1.30 3.42 ± 1.74 ТT,t= 6.80 (Р=0.00)
ТT,T+t=-9.20 (Р=0.00)
Тt,T+t=-10.87 (Р=0.00)
Ind T-test Т=-12.73 Р=0.00 Т= 12.7 Р=0.00 Т=-1.61 Р=0.11

Table 3. Distribution of the carious lesions in the permanent first molars.

Diag. T-hold D1b D2 D3 D4 total

Children group n % ± Sp n % ± Sp n % ± Sp n % ± Sp n %
1st gr–6 to 9 12 12.90±3.48 27 29.04±4.71 54 58.06±5.12 0 93 100
2 gr–10 to 12
nd
73 40.11±3.63 76 41.76±3.66 28 15.38±2.67 5 4.12±1.34 182 100
total 85 103 82 5 275 100
T test T = 5.41 T = 2.14 T = 7.39

in determining the relative portion of carious and 3.2. Clinical description of the registetred dentine
restored permanent first molars of the children carious lesions (D3) in the permanent first molars of the
tested. The data in the diagram show that the carious children tested.
permanent first molars are plausibly predominant - Localization of the carious lesions
over the restored ones in both age groups (p<0.05). The data are presented in the table 4.
The data gathered in determining the severity of Between the ages of 6 and12, the D3 carious lesions
the registered carious lesions in the first molars with occlusal localization in the first molars are
are presented in the table 3. The data presented in 72% and are significantly more than those with
the table show that in the permanent first molars approximal (14.6%) and cervical (13.4%) localization
in the first age group, D1b take up only 12.9%, D2 in both age groups (p<0.05). As the children grow
carious lesions are 29%, and over a half (58%) of the in age, the caries with occlusal, approximal and
registered carious lesions are irreversible – D3 in the cervical localization remain within close parameters
period immediately after eruption of the examined (p>0.05). The anatomical peculiarities of the perma-
teeth (p<0.05). In the second age group the portion nent first molars are a primary risk factor for the onset
of reversible carious lesions plausibly increases, of an occlusal caries, immediately after eruption.
while the irreversible ones plausibly decrease, which They have a highly characteristic occlusal surface
is probably due to the restoration of the cavitated (narrow and deep fissures), thin to non-existent
lesions (p<0.05). The higher relative portion of enamel at the bottom of the fissures, significantly
irreversible carious lesions in the children of the lower mineralization, insufficient self-cleaning of
first age group (6-9 years) could be explained by the these surfaces, absence of established oral hygiene
specificities of the carious pathology of the fissures habits and lack of motivation for early control. Early
of these teeth in cases where adequate preliminary diagnostics in such cases is more difficult which
prophylactics are lacking. The data gathered in this leads to the development of cavitated dentine
study regarding the spread of cavitated dentine carious lesions in the molars [6,9].
carious lesions (D3) in first molars according to the - Color and consistency of the carious lesions
age of the children are presented in the following The color of the carious dentine of the D3 lesions in
diagram. The graph shows that the peak of registered the permanent first molars is predominantly black,
D3 carious lesions in the sixth teeth of the children followed by dark brown carious dentine, while the
tested can be observed as early as after the first or lowest is the number of registered D3 carious lesions
second year of their eruption. A quick progression which are light brown in color (p<0.05).
of the occlusal caries is present in the seven to eight The predominant darker colors in the carious
year period and development of D3 carious lesions. dentine may be due to delayed pigments and this is
Past eight years of age a significant decrease in the an indicator for a slower developing carious process,
cases of D3 lesions is observed, probably due to an which is conducive to microinvasive treatment. The
increase in the number of restored teeth. aim is to further slowdown or arrest the development

172 Stoma Edu J. 2019;6(3): 170-176. http://www.stomaeduj.com
STUDYING DENTINE CARIES IN THE FIRST
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Original Articles
Table 4. Distribution of D3 lesions in permanent first molars according to localization.

total occlusal approximal cervical

Children group n n % ± sp n % ± sp n % ± sp
1 gr – 6 to 9
st
54 40 74.1 ± 5.96 8 14.8 ± 4.83 6 11.1 ± 4.28 T1,2=6.08
T1,3=6.66
T2,3=0.56
2nd gr – 10 to 12 28 19 67.9 ± 8.83 4 14.3 ± 6.61 5 17.8 ± 7.24 T1,2=3.50
T1,3=3.19
T2,3=0.34
total 82 59 72.0 ± 4.96 12 14.6 ± 3.90 11 13.4 ± 3.76 T1,2=6.08
T1,3=6.66
T2,3=0.56
t2,3= 0.58 t2,3= 0.06 t2,3= 0.80

12.00%
brow n; 8.54%
12.00%
da rk brow n; 20.73%

bla c k ; 70.73%
76.00%

C ode 1 (v e ry s oft) C ode 2 (s oft dentine )
Figure 3. Color of the carious dentine in the first molars with D3 C ode 3 (m ode ra te ly ha rd)
carious lesions. Pearson Chi Square = 12,468 Sig = 0,000
Figure 4. Consistency of the dentine in the D3 carious lesions of the
first molars. Pearson Chi Square = 14,732 Sig = 0,000

of the dentine caries and provide conditions for index. The data are supported by high statistical
activating the natural defence mechanisms of the plausibility (p<0.01). Higher values of the DMFT+t
pulp-dentine complex. index are observed in the children with darker and
The diagram shows that in over 3/4 of the cases the relatively hard carious dentine in the cavitated
consistency of the carious dentine of the registered dentine lesions. In the first permanent molars of the
D3 carious lesions is that of a moderately hard children covered in this study, the cases of relatively
dentine (76%), while the remaining 1/4 of cases are hard, dry carious dentine with dark coloration are
distributed equally between soft (12%) and very soft predominant.
dentine (12%) (p<0.05).
The data show that the consistency of the carious 4. Discussion
dentine of the D3 carious lesions in permanent teeth The results of this study show that children between
is predominantly code 3 – moderately hard (p<0.05). aged 6 to 12 have on average three to four carious
Soft and very soft consistency (code 2 and code 1) of teeth. The general cariousness (DMFT+t) is higher
the carious dentine is found in a smaller percentage between the ages of 6-9 (4.20), while in older
of the cases of the registered D3 carious lesions. If children it decreases slightly (3.42). The results of
we adopt the notion that the consistency of the this study show that the ratio between carious and
carious dentine depends on the speed of the carious restored teeth of the children studied changes in
process and is indicative of this, we could reach the the separate age groups, with the cases of carious
conclusion that in the D3 carious lesions of the first teeth (D) decreasing at the expense of increasing the
permanent molars, registered in this study, the caries relative proportion of restored teeth (F) as the age of
with a slower development speed are predominant, the children increases.
which confirms the conclusion reached regarding The data gathered in this study match that of the
the color of the dentine. last national epidemiological study of the spread
- The study of the interdependency of the research of dental caries in children in 2011, which showed
parameters – color, consistency DMFT+t – is that in six-year-old children between three to four
presented via the Pearson correlation index at a carious teeth can be found, and three carious teeth in
plausibility level of p<0.05 and p<0.01. The data in 12-year-olds. The epidemiological study conducted
the table show that the color of the carious dentine in the Ruse region in 2010 shows that six-year-old
correlates with the consistency and the DMFT+t children have an average of six carious teeth [6,7].

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Original Articles Table 5. Correlation between color, consistency and DMFT in the children studied.

Pearson Correlation index
indicators color const. DMFT+t
color -0.767 **
-0.682**
consistency -0.767** 0.673**
DMFT+t -0.682** 0.673**

A2008 study by M. Peneva shows that DMFT is 4.3, The rapid development of occlusal caries in the
which includes only dentine carious lesions. If we dentine of newly erupted permanent molars has
add enamel caries, which are reversible, the data will steered numerous researchers in the direction of
show an average of seven carious teeth [11]. applying treatment methodologies that provide
The first permanent molars erupt in early childhood an optimally non-invasive excavation, leading to
and carry a maximal occlusal load as the main a minimal loss of hard dental structures. Careful
chewing teeth. They are among the most affected excavation would allow for the preservation of
form of dentine caries due to their morphological and dentine, which is partially demineralized, but with
functional characteristics, which is the motivation preserved regeneration capabilities, which are highly
behind this study of the spread and characteristics expressed in the permanent teeth of children [23,24].
of the dentine caries in this tooth group. This study has concluded that in the first molars, the
The higher relative portion of irreversible carious dentine carious lesions with occlusal localization are
lesions, established in this study, of first permanent characterized by darker colors of carious dentine
molars in the children of the first age group (6-9 and a relatively hard consistency. The results of this
year old) could be explained by the specificities of study confirm the idea that darker color and harder
the carious pathology of the fissures of these teeth dentine consistency are probable indicators of a
in cases where adequate preliminary prophylactics more slowly developing carious lesion, while lighter
are lacking. The stages conducive for non-operative color and softer consistency – of a faster developing
treatment in these instances pass quickly and can carious lesion [25].
easily be missed, which leads to the development of In our study we found that the newly erupted
dentine caries in the permanent teeth immediately permanent first molar evince high prevalence of
after their eruption, with a high risk of affecting cavitated carios lesion, which means that there is a
the highly exposed pulp. As to avoiding potential significant risk of affecting the highly exposed pulp.
complications in the treatment of such carious The features of the carious process in these teeth
lesions, the efforts of a number of authors are makes them especially appropriate for applying the
dedicated toward the development and application minimal invasive methods of treatment. The analysis
of methodologies for minimally invasive operative of the results shows that in the first permanent molars
treatment of dentine lesions, with the aim of the more slowly progressing carious lesions are
optimally preserving the structures of the recently predominant. This circumstance has been the basis
erupted permanent children’s teeth [12-15]. for trying to develop methodologies for a minimally-
Similar to our study some authors have reported invasive treatment of these carious lesions, with
high scores of cavitated dentine carious lesions in data being found in scientific literature in recent
children in Canada (between 38% to 44.1%) and years about a number of authors working in this
Thailand - in 3-year-olds [16,17]. direction [26-28]. The aim is to develop alternative
The levels of cavitated dentine carious lesions methods and methodologies for a treatment which
increase with age and they remain problematic in will lead to an additional slowdown and/or arrest
adults [18]. The cohort study reported that over a of the carious process in the dentine and provide
period of 38 years, an annual increase in number of conditions for the activation of the natural defense
tooth surfaces affected by cavitated dentine carious mechanisms of the pulp-dentine complex [29,30].
lesions [19]. The results of this study show that D3 The prevalence of occlusal dentinal caries lesion
carious lesions with occlusal localization in the first in the newly erupted permanent molars and their
permanent molars are plausibly more numerous early inclusion in the cycle of "caries-restoration-
than the carious lesions with approximal and cervical replacement of restoration" draws our attention
localization in both age groups. According to a to the need of an application of new therapeutic
study, the occlusal surfaces are only 6% of all dental methods of minimally-invasive treatment. The aim
surfaces, while occlusal caries account for 60% of all is to ensure the preservation of integrity of the pulp
caries. It is considered that this is due primarily to and apply the biological approach.
the plaque retentive anatomy of these surfaces [20].
According to studies, most frequent are occlusal 5. Conclusions
caries in molars, followed by approximal caries 1. Dentine carious lesions D3 with occlusal
in molars, while least carious are the approximal localization in the permanent first molars are
surfaces of the front teeth [21,22]. plausibly more numerous than the carious lesions

174 Stoma Edu J. 2019;6(3): 170-176. http://www.stomaeduj.com
STUDYING DENTINE CARIES IN THE FIRST
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with approximal and cervical localization; of the data. NI: contributed to the analysis,

Original Articles
2. In the permanent first molars, the dentine carious interpretation of the data and critically revised the
lesions with occlusal localization are characterized manuscript. Both authors agree to be accountable
by darker colors of carious dentine and a relatively for the content of the work.
hard consistency;
3. The more slowly progressing carious lesions are Acknowledgments
predominant in the permanent first molars. None.

Author Contributions
NM: contributed to formulating the concept,
protocol, data gathering, analysis and interpretation

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Nadezhda Georgieva MITOVA
Original Articles DMD, PhD, Assistant Professor
Department of Pediatric Dentistry
Faculty of Dental Medicine
Medical University of Sofia
Sofia, Bulgaria

CV
Nadezhda Georgieva Mitova graduated from the Medical School in 2006 and Dental Medicine in 2011. Since 2012 she has
been Assistant Professor in the Department of Pediatric Dentistry, Faculty of Dental Medicine, Medical University of Sofia, Sofia,
Bulgaria. She has specialized in Pedodontics. Her scientific interests are focused on dental caries and profilactics of oral diseases.

Questions
1. What is the most common location of caries in the permanent first molars?
qa. Approximal;
qb. Cervical;
qc. Occlusal;
qd. Other.

2. Which of the following most fully and accurately describes the causes of occlusal caries
in the first permanent molars?
qa. Deep and retentive fissures; unsatisfactory oral hygiene habits;
qb. A thin and slightly mineralized layer of enamel; unsatisfactory oral hygiene habits; difficult diagnosis;
qc. Deep and retentive fissures; a thin and slightly mineralized layer of enamel; unsatisfactory oral hygiene
habits; availability of timely and adequate prevention;
qd. Deep and retentive fissures; a thin and slightly mineralized layer of enamel; difficult diagnosis;
unsatisfactory oral hygiene habits; lack of timely and adequate prevention.

3. What is the characteristic of carious dentine in the occlusal caries of the permanent
first molars?
qa. Dark and relatively hard dentine;
qb. Dark and soft dentine;
qc. Light and soft carious dentine;
qd. Light and relatively hard dentine.

4. Which type of lesions prevails according to the speed and nature of the carious process
in the occlusal caries of the permanent first molars?
qa. Rapidly progressing carious lesions;
qb. Slowly progressing carious lesions;
qc. Both;
qd. Neither.

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176 Stoma Edu J. 2019;6(3): 170-176. http://www.stomaeduj.com