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DENTAL SCIENCE - ORIGINAL ARTICLE
Year : 2014  |  Volume : 6  |  Issue : 5  |  Page : 90-96  

Comparative evaluation of dental age, bone age, and chronological age in the human immunodeficiency virus positive children


1 Department of Pedodontics and Preventive Dentistry, Navodaya Dental College and Hospital, Raichur, Karnataka, India
2 Department of Ophthalmology, Raichur Institute of Medical Sciences, Raichur, Karnataka, India

Date of Submission30-Mar-2014
Date of Decision30-Mar-2014
Date of Acceptance09-Apr-2014
Date of Web Publication25-Jul-2014

Correspondence Address:
Dr. Vinod Kumar
Department of Pedodontics and Preventive Dentistry, Navodaya Dental College and Hospital, Raichur, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7406.137395

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   Abstract 

Background and Objective: The knowledge of bone age and dental age is of great importance for pediatrician and pediatric dentist. It is essential for pediatric dentist to formulate treatment plan and it is a source of complementary information for pediatrician. There are few studies in literature, which showed the relationship between dental age, bone age and chronological age in HIV-positive children. Therefore, objective of this study was to determine and compare dental age, bone age and chronological age in HIV-positive children. Materials and Methods: A total of 60 HIV-positive children between the age group of 18-14 years were selected. Chronological age was determined by recording date of birth. Dental age assessment was performed using orthopantamogram following the method described by Demirjian. Bone age estimation was carried out using hand-wrist radiograph following Bjork, Grave, and Brown's method. Results: Chronological age was advanced compared with dental age and bone age in both sexes. The correlation between chronological age, dental age and bone age were all positive in both sexes. Interpretation and Conclusion: The data supports the concept that dental age and bone age delay is a significant feature in HIV-positive children. It is important to consider dental age and bone age as variables for diagnosing growth retardation in HIV-positive children. To support our findings, further a well-designed, controlled as well as longitudinal study with a larger sample size is required.

Keywords: Bone age, Demirjian′s method, dental age


How to cite this article:
Kumar V, Patil K, Munoli KB. Comparative evaluation of dental age, bone age, and chronological age in the human immunodeficiency virus positive children. J Pharm Bioall Sci 2014;6, Suppl S1:90-6

How to cite this URL:
Kumar V, Patil K, Munoli KB. Comparative evaluation of dental age, bone age, and chronological age in the human immunodeficiency virus positive children. J Pharm Bioall Sci [serial online] 2014 [cited 2019 Nov 14];6, Suppl S1:90-6. Available from: http://www.jpbsonline.org/text.asp?2014/6/5/90/137395

Growth is an essential feature of life of a child that distinguishes him or her from an adult. The process of growth starts from the time of conception and continues until the child grows into a fully mature adult. Growth denotes a net increase in the size or mass of tissues, whereas development specifies maturation of functions. [1]

Hereditary, functional, environmental, nutritional, sexual, metabolic, social, emotional, cultural factors affect growth, and development greatly. [2]

Bone age is an indicator of physiological development and is distinct from the chronological age. [1]

The appearance and union of the different skeletal centers of ossification follows a fairly definite pattern and time schedule from birth to maturity. A roentgenographic study of these skeletal maturational processes provides a valuable criterion of the child's level of osseous maturation. The skeletal maturity of the individual is known as bone age. [2]

The development and eruption of the teeth are part of the child's total development. Estimation of dental age is based upon the rate of development and calcification of tooth buds and their progressive sequence of eruption in the oral cavity. The tooth calcification provides a valuable indicator of dental age and serves as an index of the maturation of the child. Dental calcification, which is a continuous development process, should be considered a better measure of physiological maturity than dental emergence. Several methods have been developed in order to assess the dental age according to the degree of calcification observed on permanent teeth. One such widely used method is that given by Demirjian, Goldstein and Tanner based on a large number of Canadian children. [3]

The early prevention and interception of dento-facial deformities is dependent upon an accurate interpretation of the inherent facio-skeletal pattern and the overall growth and development. [2]

HIV-positive children who are vertically infected present considerable weight loss and delayed development. [4],[5],[6],[7],[8]

They may also present the following changes: delayed dental eruption, fewer permanent teeth, prolonged retention of primary teeth [9] and a slightly larger number of dental anomalies. [10] The establishment of antiretroviral protocols has reduced the occurrence of oral changes. [11],[12]

However, some authors have reported delayed development even with the use of antiretroviral drugs. [13] To widen the scope of thinking about the impingement of growth and development on dental and bone maturation and perhaps to improve one's clinical judgment, a comprehensive study of the dental and bone development in HIV-positive children is very useful.

Bone age and dental age is useful to the dental practitioner in planning treatment. It's useful for the pediatrician and endocrinologist as a source of complimentary information. [14]

The relationship between dental, skeletal, and chronological age will be estimated in order to correlate the three ages for diagnostic purpose. The differences between dental, skeletal and chronological age is of great interest in indicating an advancement or delay compared with standard growth. [3]

There are few studies, which showed the bone and dental maturity in HIV-positive children. Accordingly, the aim of this study was to determine and compare dental age, bone age, and chronological age in HIV-positive children.


   Materials and Methods Top


A total of 60 HIV-positive children, aged between 8 and 14 years participated in this study. Among the children, 32 were males and 28 females who had been vertically infected and were under outpatient treatment at the Pediatric Hospital. All HIV-positive children were under antiretroviral therapy.

The study was approved by the Research Ethics Committees of the Hospital. The nature of study was explained and informed consent was taken from the parent of the patient.

Armamentarium included:

  1. Orthopantomograms (OPG)
  2. Hand-wrist radiographs
  3. X-ray viewer.


The chronological age was determined from the actual date of birth either stated by parents or guardians or as per school records.

An OPG and hand-wrist radiograph was taken for each of the child to determine dental age. Interpretation of the radiographs was carried out with the help of an X-ray viewer.

Dental age estimation

Determination of dental age was based upon the rate of development and calcification of tooth buds. Dental age estimation was done using Demirjian's method considering seven permanent left mandibular teeth from central incisor (CI) to II molar (If any tooth was congenitally missing, contra lateral tooth was considered).

Demirjian et al., [15],[16] divided tooth development into eight developmental stages from A to H [Figure 1]. Each tooth was assigned a score based on its developmental stage [Table 1] and [Table 2]. The sum of seven individual scores gives maturity score, which is converted into dental age using conversion chart [Table 1] and [Table 2].
Figure 2: Orthopantamogram

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Table 1: Self-weighted scores of dental stages of 7 teeth (mandibular left side) in boys


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Table 2: Self-weighted scores of dental stages of 7 teeth (mandibular left side) in girls


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Method of dental age estimation

Orthopantomograms's [Figure 2] were analyzed for the developmental stages of all the seven left permanent mandibular teeth as per Demirjian's method [Figure 1]. The developmental stage of each tooth was assessed and then each tooth was given a score according to its stage of development using the score table [Table 1] and [Table 2]. Adding seven individual scores from permanent CI to 2 nd permanent molar gives a maturity score, maturity score will be converted into dental age using conversion chart [Table 3] and [Table 4].
Table 3: Conversion of maturity score to dental age: For boys


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Table 4: Conversion of maturity score to dental age: For girls


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Figure 3: Hand-wrist radiograph

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Demirjians tooth mineralization stages [Figure 1] are as follows:

  • Stage A: Beginning mineralization of separate cusps
  • Stage B: Fusion of cusps
  • Stage C: Beginning of dentinal deposits is seen
  • Stage D: Crown formation completed down to the cemento-enamel junction
  • Stage E: The root length is less than the crown height
  • Stage F: The root length is equal to or greater than crown height
  • Stage G: The walls of the root canal are parallel and its apical end is still partially open
  • Stage H: The apical foramen is completed.


Bone age assessment

The bone age was assessed by means of hand-wrist radiograph using Bjork, Grave and Brown's method. [17] They have divided the maturation process of hand-wrist bones into nine developmental stages. Each of these stages represents a level of skeletal maturity. Appropriate age for each of the stage was given by Schopf in 1978.

Method of bone age assessment

Hand-wrist radiographs [Figure 3] were viewed on the X-ray viewer and its developmental stage was assessed in accordance with Bjork, Grave, and Brown's method.{Figure 3}

The appropriate age given for that developmental stage was recorded and the obtained age was known as bone age.

The obtained data were subjected to the statistical analysis.


   Results Top


This study comprised a total of 60 HIV-positive children, 32 males and 28 females in the age group of 8-14 years.

Dental age estimation was done using Demirjian's method and Bone age assessment was done using Bjork, Grave and Brown's method.

The chronological age, bone age and dental age were compared using the unpaired Students t-test and Pearson's correlation coefficient.

Following are the results obtained in both sexes:

In females

By comparing chronological age, dental age and bone age, the following was observed.

  • The mean difference between chronological age and dental age was 2.1 years, that is, dental age was reduced compared with chronological age by 2.1 years [Table 5] and [Table 6]
  • The mean difference between chronological age and bone age was 1.04 years, that is, bone age was retarded compare to chronological age by 1.04 years [Table 5] and [Table 6]
  • The mean difference between dental age and bone age was -1.06 years, that is, dental age was reduced compared with bone age by 1.06 years [Table 5] and [Table 6].
Table 5: Mean chronological age, dental age and bone age of females and males


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{Table 5}
Table 6: Comparison of chronological age, dental age and bone age in females


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By obtaining correlation between chronological age, dental age, and bone age the following was observed.

  • The chronological and dental age showed significant correlation (r = 0.62) [Table 7]
  • The chronological and bone age showed significant correlation (r = 0.75) [Table 7]
  • The dental age and bone age showed significant positive correlation (r = 0.57) [Table 7].
Table 7: Correlation between chronological age, dental age and bone age in females


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In males

By comparing the values of the chronological, dental age, and bone age, the following was observed.

  • The mean difference between chronological age and dental age was 2.32 years, that is, dental age was reduced compared to chronological age by 2.32 years [Table 5] and [Table 8]
  • The mean difference between chronological age and bone age was 1.11 years, that is, chronological age was advanced compared to bone age by 1.11 years [Table 5] and [Table 8]
  • The mean difference between dental age and bone age was -1.21 years, that is, bone age was advanced compared to dental age by 1.21 years [Table 5] and [Table 8].
Table 8: Comparison of chronological, dental age and bone age in males


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By obtaining correlation between chronological age, dental age and bone age the following was observed.

  • The chronological and dental age was found to be positively correlated and statistically significant (r = 0.72) [Table 9]
  • The chronological and bone age was found to be positively correlated and statistically significant (r = 0.54) [Table 9]
  • The dental age and bone age was found to be positively correlated and statistically significant (r = 0.59) [Table 9].
Table 9: Correlation between chronological age, dental age and bone age in males


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   Discussion Top


Before 1983, it was believed that acquired immunodeficiency syndrome was restricted to a specific group of people. In that year, however, the first cases were reported of the syndrome affecting children. The first reports of HIV infection in children date back to 1983, when Oleske et al. [18] have reported the different characteristics observed in children when compared with adults, including the transmission pattern. HIV infection may cause deficient bone maturation [6],[13] and delayed dental development. [9],[10]

  • In this study, in HIV-positive children of both sexes' skeletal and dental ages was delayed when compared with their chronological ages. Our results are in agreement with previous studies, in 1999, HIV-positive males presented significantly younger skeletal and dental ages than those of the control group. These results are consistent with the findings of Fine et al[11]
  • In our study, according to the Demirjians method, the HIV-positive male and female group presented a deficiency in dental development.
  • In the current study, dental age estimation was done using Demirjian's method.


Hägg and Matsson [19] compared the reliability of three different methods for the assessment of dental maturity and concluded that the method described by Demirjian and Goldstein affords a high degree of reliability and precision.

Nanda and Chawla, [20] Hegde and Sood [21] studied the applicability of Demirjian's method on Indian population. Their studies revealed the accuracy of Demirjian's method when applied to Indian population.

Vallejo-Bolaños et al.[22] using Demirjian's method also observed significant differences between chronological and dental ages in isolated growth hormone deficient children.

Fine et al.[11] showed that HIV-positive children present prolonged retention of primary teeth and delayed tooth eruption when compared with noninfected children. These findings, similar to the results of our study, may indicate impairment to normal development.

Ramos-Gomez et al.[9] reported a smaller number of erupted teeth in HIV-positive children. Laskaris [12] suggested that antiretroviral drugs may have caused a decrease in the number of oral alterations. This could explain why some HIV-positive children presented dental development similar to that of noninfected children.

The radiological study of hand-wrist is the single most useful method of studying bone age as stated by Greulich and Pyle. [23] In the present study, bone age estimation was done using Bjork Grave and Brown method. [17],[24]

Iguma: [24] Conducted a study to evaluate whether Martins and Sakima and Grave and Brown methods are useful for the bone age estimation using hand-wrist radiograph. They found that two methods appeared to be highly and significantly correlated regarding bone age estimation using hand-wrist radiograph.

In this study, using Bjork Grave and Brown method for bone age estimation we found bone maturation reduced compare to chronological age. Our findings are in agreement with Moye et al.[7] and Abuzaitoun and Hanson. [25]

Moye et al.[7] and Abuzaitoun and Hanson [25] reported that an immature immune system such as that of children may cause deficient organic growth and development, especially in HIV-positive children. This explains why, in our study, HIV-positive children presented younger bone ages when compared with their chronological ages.

Our results are also corroborated by Oliveira, [8] who observed the influence of the HIV virus on skeletal development in female children.

In our study, dental age and bone age delayed compared with chronologic age in both males and females.

The results of our study are in agreement with those of Vallejo-Bolaños et al., [22] Takano et al., [26] Keller et al. [27] and Sarnat et al. [28] They also discovered a delay in dental age and bone age.

Sarnat et al. [28] conducted a study on 19 patients with growth hormone deficiency and 13 patients with Laron type dwarfism discovered a delay in dental age of 1.8 and 1.7 years respectively for these two disorders.

There is also a marked delay in dental age and bone age compared to chronological age between two sexes. These finding are in agreement with that of Vallejo-Bolaños et al. [22]

In our findings, the co-relationships between dental age, bone age and chronological age were positive in both males and females.

We found similar results in other studies such as Vallejo-Bolaños et al., [22] Green, [2] Hegde and Sood, [21] Prabhakar et al., [3] who also discovered positive correlations between dental age, bone age, and chronological age.

Many authors have found the correlation ship between various maturity indicators of growth, and they are in agreement that there exists a positive correlation ship between various maturity indicators of growth.


   Conclusion Top


We conclude that HIV-positive children of both sexes present delayed bone and dental maturation despite the administration of antiretroviral drugs.

Bone age and dental age can be used as variables in diagnosing growth retardation in HIV-positive children.

Determination of bone age and dental age as opposed to chronological age is important to know the overall maturation of various tissue systems and it's useful in dentistry to formulate treatment plan and its additional source of information in the field of Orthopedics, Forensics, Hematology, Pediatrics and Anthropology.

 
   References Top

1.Ghai OP, Gupta P, Paul VK. GHAI Essential Pediatrics. 6 th ed. New Delhi: CBS Publisher; 2004.  Back to cited text no. 1
    
2.Green LJ. The Interrelationships among height, weight and chronological, dental and skeletal ages. Angle Orthod 1961;31:189-93.  Back to cited text no. 2
    
3.Prabhakar AR, Panda AK, Raju OS. Applicability of Demirjian's method of age assessment in children of Davangere. J Indian Soc Pedod Prev Dent 2002;20:54-62.  Back to cited text no. 3
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4.Arpadi SM. Growth failure in children with HIV infection. J Acquir Immune Defic Syndr 2000;25 Suppl 1:S37-42.  Back to cited text no. 4
    
5.Weight, height and human immunodeficiency virus infection in young children of infected mothers. The European Collaborative Study. Pediatr Infect Dis J 1995;14:685-90.  Back to cited text no. 5
    
6.Kaufman FR, Gomperts ED. Growth failure in boys with hemophilia and HIV infection. Am J Pediatr Hematol Oncol 1989;11:292-4.  Back to cited text no. 6
    
7.Moye J Jr, Rich KC, Kalish LA, Sheon AR, Diaz C, Cooper ER, et al. Natural history of somatic growth in infants born to women infected by human immunodeficiency virus. Women and Infants Transmission Study Group. J Pediatr 1996;128:58-69.  Back to cited text no. 7
    
8.Holderbaum RM, Veeck EB, Oliveira HW, Lucia Da silva C, Fernandes A. Comparison among dental, skeletal and chronological development in Hiv - Positive children:a radiographic study.Braz Oral Res 2005;19(3):209-215.  Back to cited text no. 8
    
9.Ramos-Gomez FJ, Petru A, Hilton JF, Canchola AJ, Wara D, Greenspan JS. Oral manifestations and dental status in paediatric HIV infection. Int J Paediatr Dent 2000;10:3-11.  Back to cited text no. 9
    
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13.Saavedra JM, Henderson RA, Perman JA, Hutton N, Livingston RA, Yolken RH. Longitudinal assessment of growth in children born to mothers with human immunodeficiency virus infection. Arch Pediatr Adolesc Med 1995;149:497-502.  Back to cited text no. 13
    
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18.Oleske J, Minnefor A, Cooper R Jr, Thomas K, dela Cruz A, Ahdieh H, et al. Immune deficiency syndrome in children. JAMA 1983;249:2345-9.  Back to cited text no. 18
    
19.Hägg U, Matsson L. Dental maturity as an indicator of chronological age: The accuracy and precision of three methods. Eur J Orthod 1985;7:25-34.  Back to cited text no. 19
    
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21.Hegde RJ, Sood PB. Dental maturity as an indicator of chronological age: Radiographic evaluation of dental age in 6 to 13 years children of Belgaum using Demirjian methods. J Indian Soc Pedod Prev Dent 2002;20:132-8.  Back to cited text no. 21
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22.Vallejo-Bolaños E, España-López AJ, Muñoz-Hoyos A, Fernandez-Garcia JM. The relationship between bone age, chronological age and dental age in children with isolated growth hormone deficiency. Int J Paediatr Dent 1999;9:201-6.  Back to cited text no. 22
    
23.Greulich WW, Pyle SL. Radiographic Atlas of Skeletal Development of Hand and Wrist. 2 nd ed. Stanford, CA: Stanford University Press; 1959.  Back to cited text no. 23
    
24.Iguma KE, Tavano O, Carvalho IM. Comparative analysis of pubertal growth spurt predictors: Martins and Sakima method and Grave and Brown method. J Appl Oral Sci 2005;13:58-61.  Back to cited text no. 24
    
25.Abuzaitoun OR, Hanson IC. Organ-specific manifestations of HIV disease in children. Pediatr Clin North Am 2000;47:109-25.  Back to cited text no. 25
    
26.Takano K, Ogiuchi H, Hizuka N, Sangu Y, Shizume K. Oro-maxillofacial development in patients with GH deficiency and in normal short children. Endocrinol Jpn 1986;33:655-64.  Back to cited text no. 26
    
27.Keller EE, Sather AH, Hayles AB. Dental and skeletal development in various endocrine and metabolic diseases. J Am Dent Assoc 1970;81:415-9.  Back to cited text no. 27
    
28.Sarnat H, Kaplan I, Pertzelan A, Laron Z. Comparison of dental findings in patients with isolated growth hormone deficiency treated with human growth hormone (hGH) and in untreated patients with Laron-type dwarfism. Oral Surg Oral Med Oral Pathol 1988;66:581-6.  Back to cited text no. 28
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]


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