Radiographic assessment of the alveolar bone in children and adolescents.

The purpose of this study was to determine the prevalence of abnormal alveolar bone in children and adolescents. Radiographs of 1026 patients were classified as showing negative, questionable, or positive evidence of abnormal alveolar bone resorption, based on criteria that included the distance between the cementoenamel junction to the alveolar bone and the integrity of the alveolar crest. Approximately 9% of this population showed evidence of abnormal bone resorption related to periodontitis, proximal decay, stainless steel crowns, and pulp pathosis. The highest prevalence for children aged 4-11 years was 17.9% at age 7, whereas for adolescents aged 15-17 it was almost 7%. The most affected sites were found between the molars in the primary dentition and mesial to the first molar in the permanent dentition. The maxillary bone was more affected than the mandibular with the exception of sites where the alveolar defect was adjacent to proximal decay in the primary molars. These findings indicate that bite-wing radiographs should be examined for the early diagnosis of periodontal disease in children and adolescents. Periodontal disease in children often has been described as being limited to gingivitis (Magnusson et alo 1981; Walker and Mackenzie 1982). However, evidence of more advanced forms of periodontal disease in the primary dentition has been presented in clinical and radiographic studies (Jamison 1963; Ngan et al. 1985; Mandell et al. 1987; Sweeney et al. 1987). In addition, apical migration of the junctional epithelium of primary human teeth has been shown in stained extracted teeth (Keszthelyi and Szabo 1987) and histologic studies (Soskolne and Bimstein 1977; Bimstein et al. 1985). Furthermore, periodontal bone loss has been detected in radiographic studies of the permanent dentition of adolescents (Hull et al. 1975; Jorkjend and Birkeland 1976; Blankenstein et al. 1978; Davies et al. 1978; Latchan et al. 1983; Gjermo et al. 1984). The purposes of the present study were: to determine the prevalence and possible etiologic factors of abnormal bone resorption of the alveolar crest in the predominantly Hispanic population seen in a pediatric dentistry clinic in San Antonio, Texas; and to present simple objective criteria for the evaluation of abnormal bone resorption of the alveolar crest. Materials and Methods One thousand two hundred and sixty-one records constituting the emergency and recall records of the Mirasol Dental Clinic at San Antonio, which is operated by the Department of Pediatric Dentistry, University of Texas in San Antonio and the City of San Antonio, were reviewed. From these records, posterior radiographs in which proximal areas were considered "acceptable for examination" were selected based on the following criteria: (1) minimal evidence of distortion; (2) minimal overlapping between tooth surfaces; (3) a clear image the alveolar bone crest and the cementoenamel junction (CEJ). In the case that more than one set of radiographs were present in the same record, the most recent radiographs were chosen for examination. The projected images of the radiographs (9.6x), were examined on the screen of an ADA Products Inc. viewer (Milwaukee, WI), and the patients were rated as having negative (Group 1), questionable (Group 2) or definitive (Group 3) evidence of abnormal alveolar bone resorption based on the following criteria: Group 1 -The distance between the alveolar crest to the CEJ was judged to be normal (< 2 mm) and without evidence of loss of cortical and inter-radicular bone (Fig 1, next page). Group 2 -The distance between the alveolar crest to the CEJ was judged to be slightly increased (between and 3 mm), but without evidence of loss of cortical and inter-radicular bone (Fig 1). Group 3-The distance between the CEJ to the alveolar bone crest was judged to be increased (> 3 mm), and Pediatric Dentistry: September, 1988 Volume 10, Number 3 199 FIG 1. Bite-wing radiograph showing normal alveolar bone in the mandible, questionable (Q), and abnormal (A) alveolar bone resorption at the maxilla. Note the extensive proximal decay (D) adjacent to the abnormal alveolar bone resorption, and the normal increased distance from the CEJ to the alveolar bone at the distal area of the mandibular first primary molar. clear evidence of loss of cortical and inter-radicular bone was seen (Figs 1-3). In no case was the normal sloping of the alveolar bone associated with erupting permanent teeth, especially the first permanent molars, considered to be abnormal (Fig 3). Following interexaminer calibration, which was obtained by examining and discussing the findings by the three examiners from 40 records selected at random, all the radiographs were rated by at least two examiners (EB and JD or EB and ES). In cases of disagreement the examiners discussed the reasons for the differing diagnoses and a mutually agreed diagnosis was recorded. After all the radiographs were rated, those of group 3 were subjected to a second examination by the three authors simultaneously and only those patients and areas in which unanimous agreement of bone loss was obtained remained recorded in group 3. To evaluate the reliability of the examination, 5 cases from group 1 and 10 cases from group 2 were mixed among the group 3 cases during the second examination; 2 of the examiners were unaware of their inclusion and none of the 3 were able to identify them by any other means than radiographic examination. The age in years to the nearest birthday, sex, ethnic origin (Hispanic or non-Hispanic surname), and number of quadrants measured were recorded for every child. For patients in group 3, the tooth type, area affected, and the possible parameters related to the abnormal bone resorption such as extensive proximal decay suggesting food impaction, pulpal pathosis, and the presence of a stainless steel crown (SSC) were recorded. Fig 2. Bite-wing radiograph showing abnormal alveolar bone resorption from the mesial area of the maxillary canine to the distal area of the maxillary second primary molar. Note the normal increased distance from the CEJ to the alveolar bone, at the distal area of the mandibular first primary molar. Fig 3. Bite-wing radiograph showing lack of cortical bone and abnormal alveolar bone resorption adjacent to the SSC on the second maxillary primary molar. Note the normal slope of the alveolar bone related to the eruption of the mandibular first permanent molar (arrow).