Dental anomalies in panoramic radiographs of pediatric patients

Abstract

A panoramic radiograph is more likely utilized in children with high caries risk and mixed dentition, and it can be complemented by other X-rays (such as periapical and/or bitewings). This study analyzed 1359 panoramic radiographs taken over 33 years at the Pedodontics Clinic of the State University of Rio de Janeiro in order to determine the prevalence of dental anomalies in mixed dentition children. The population evaluated had 670 (49.3%) boys and 689 (50.7%) girls, ranging in age from 5-12 years, with a median age of 8 years. The total prevalence of anomalies detected was 11.72%; anodontia and supernumerary teeth were the most reported (4.63% and 3.31%, respectively). Statistical differences noted were in the presence of supernumary teeth in males (4.9%, P <.001) and the presence of anodontia in females (6.1%, P = .009). Based on these findings, a panoramic radiograph can help to analyze transitional dentition, as well as complement the clinical examination at the first dental visit of a pediatric patient with a high risk for caries.

Full text

Dental anomalies in panoramic radiographs
of pediatric patients
Mirian de Waele Souchois de Marsillac, MS, PhD n Marcia Rejane Thomas Andrade, MS, PhD n Raquel de Oliveira Fonseca
Sonia Lucia Macedo Marcal, MS n Vera Lucia Campos Santos, MS
A panoramic radiograph is more likely utilized in children with high
caries risk and mixed dentition, and it can be complemented by other
X-rays (such as periapical and/or bitewings). This study analyzed 1359
panoramic radiographs taken over 33 years at the Pedodontics Clinic
of the State University of Rio de Janeiro in order to determine the
prevalence of dental anomalies in mixed dentition children. The popula-
tion evaluated had 670 (49.3%) boys and 689 (50.7%) girls, ranging in
age from 5-12 years, with a median age of 8 years. The total prevalence
of anomalies detected was 11.72%; anodontia and supernumerary
teeth were the most reported (4.63% and 3.31%, respectively).
Statistical differences noted were in the presence of supernumary
teeth in males (4.9%,
P
< .001) and the presence of anodontia in
females (6.1%,
P
= .009). Based on these findings, a panoramic radio-
graph can help to analyze transitional dentition, as well as complement
the clinical examination at the first dental visit of a pediatric patient
with a high risk for caries.
Received: June 25, 2012
Revised: January 21, 2013
Accepted: May 7, 2013
Key words: diagnosis, dental radiography, tooth
abnormalities, pediatric dentistry
Developmental anomalies of denti-
tion are defined as deviations from
normality due to congenital or
hereditary malformations, occurring either
as a unique entity or as a manifestation of a
systemic disturbance.1,2 The anomalies can
be classified as alterations of teeth in terms
of number—agenesis, germination, fusion,
and/or supernumeraries; form or shape—
microdontia, dens-in-dens, supernumerary
root, ghost tooth, taurodontism, odonto-
mas, coronary and/or root dilacerarions;
eruption—infraocclusion, impactation
transposition, ectopia, transmigration,
delayed and/or premature eruption; or
pathological process— periapical lesion,
dental calcification, pathological resorp-
tion, and/or cysts.2
Marques et al verified a prevalence of
42% of dental anomalies using panoramic
radiographs.3 Radiographic exams are
important for a complete and accurate
treatment plan, because countless dental
anomalies are asymptomatic.4 A clinical
examination combined with intraoral
radiographs can detect intraosseous anom-
alies, alterations of dental development,
and possible cases of ectopic eruption.
Besides being utilized to gather data in
a dental clinic, panoramic radiographs
are also very useful in forensic odontol-
ogy, anthropology, and research.5 This
type of exam offers an extensive area to
visualize the anatomical structures as the
complete dental alveolar area of the maxilla,
mandible, temporomandibullar joint, para-
nasal sinuses, and other facial bones in just
1 film.2,6-10 A panoramic radiograph cannot
replace an intraoral periapical X-ray of the
area, but it can provide additional informa-
tion to establish a diagnosis.7 Panoramic
radiographs can also be utilized in patients
with very limited mouth apertures.9
Jerman et al demonstrated that radio-
graphic examination using 1 panoramic
film and 2 bitewing X-rays reduced the
radiation exposure of a child by 82%
compared to a complete periapical exami-
nation.11 Taking a panoramic radiograph
is a quick, easy to use technique that is
well accepted by children. A comparative
table presented by the American Dental
Association (ADA) showed that a pan-
oramic radiograph has an estimated expo-
sure of 0.020-0.100 μSv (millisievert) while
a full-mouth series (approximately 19 films)
has a 0.150 μSv estimated exposure.12
The American Academy of Pediatric
Dentistry (AAPD) developed protocols
with the purpose of maximizing the value
of a dental radiographic examination
while minimizing the patient’s exposure
to ionizing radiation.13 According to those
protocols, there are 2 accepted dental exam-
inations for children with mixed dentition:
a panoramic radiograph plus bitewing films
complemented by individualized periapi-
cals, or a complete intraoral examination
plus bitewing radiographs. The main
disadvantages of a panoramic radiograph
are lack of detail, poor definition of certain
structures, and small distortions.7,9,10,14
Procedures such as interproximal cavi-
ties, alveolar bone crest anomalies, pulpal
pathologies, and/or root canal filling levels
require excellent radiographic detail with
less distortion. In these cases, bitewing
and periapical films are recommended to
complement the panoramic radiograph.8,13
The purpose of this study was to evaluate
the prevalence of dental anomalies through
panoramic radiographs of 1359 patients
treated at the Pediatric Clinic of the State
University of Rio de Janeiro (FO/UERJ)
during a period of 33 years.
Methods
This retrospective study received a favor-
able approval from the Ethic Committee
Research of the Pedro Ernesto Hospital
under the number 973-CEP/HUPE (Rio
de Janeiro, Brazil) in accordance with
the Helsinki Declaration. Panoramic
radiographs (n = 1379) from the archives
of the FO/UERJ were analyzed. The
radiographic images were from patients
of both genders treated from May 1973
to August 2008, with an age range of
5 to 12 years. Legal guardians signed a
detailed informed consent form to allow
the children to participate in this study.
Every 5-year-old participant had already
presented transitional dentition charac-
teristics. All children attending the FO/
UERJ lived in low income housing, had
Digital Radiology
www.agd.org General Dentistry November/December 2013 e29

families with limited means of support,
and presented with multiple cavities
and extensive tooth decay. In Brazil,
caries is still a major health problem
due to deprived circumstances. For this
reason, based on the AAPD guideline,
children with severe and extensive dental
caries had a panoramic film and 2
bitewing radiographs taken at their first
dental visit.13
All radiographs were examined and
interpreted by 2 skilled researchers in an
appropriate lighting environment with a
negatoscope (NGP 91, Odonto Larcon), a
black card mask, and a magnifying glass
lens (6X, Waltex-Lumagny). In case of a
disagreement, the issue was resolved by
consensus. The radiographs were always
analyzed during the morning period
and the limit of examinations was ≤15
films each session.
Seven radiographs were excluded from
this study due to poor quality. Panoramic
radiographs from 13 children diagnosed
with syndromes were not analyzed. A
radiographic interpretation of third molars
was not evaluated due to the patients’ ages.
The information obtained from these
radiographs was stored in Microsoft
Access 2000 (Microsoft). The statistical
package SPSS for Windows 8.0 (SPSS,
Inc.) evaluated the prevalence and the
relationship between the variables (chi-
square statistics test). The results were
considered significant when P < .05.
Results
The age and gender distribution for the
patients participating in this study is
detailed in Table 1. The anomalies detected
in the 1359 panoramic radiographs is
detailed in Table 2. Figures 1-6 illustrate the
most prevalent anomalies found. A review
of the incidence of supernumerary teeth
by gender (Table 3) showed that the male
gender was more affected (4.9%). A review
of the incidence of anodontia by gender
(Table 4) showed that the female gender
Digital Radiology Dental anomalies in panoramic radiographs of pediatric patients
e30 November/December 2013 General Dentistry www.agd.org
Table 1. Age distribution of the pediatric patients whose
radiographs were analyzed.
Gender
Age (years)
Total5678910 11 12
Male 87 78 132 126 12 3 68 35 21 670
Female 82 89 138 151 122 61 28 18 689
Total 169 167 270 277 245 12 9 63 39 1359
Mean age: 8 years (SD ± 1.7).
Table 2. Prevalence of anomalies in the 1359 panoramic
radiographs analyzed.
Anomaly Prevalence n(%)
Most affected
tooth or region
Anodontia 63 (4.63)* 20, 10, 7, 29
Supernumerary tooth 45 (3.31)* Mesiodens
Supernumerary root 12 ( 0.88) 16d, 29
Microdontia 10 ( 0.73 ) 10
Root dilaceration 10 ( 0.73 ) 9, 8
Odontoma 6 (0.44)
Anterior region of
the maxilla
Coronary dilaceration 4 (0.29) 8, 9
Gemination permanent teeth 3 (0.22) 8, 9
Taurodontism 2 ( 0.14 ) 3, 14
Gemination primary teeth 2 ( 0.14 ) 2d, 18d
Fusion primary teeth 1 (0.07) 19d
Fusion permanent teeth 1 (0.07) 8
Dens in dente 1 (0.07) 7
Total 16 0 (11.7 2 )
*Most prevalent anomalies
Table 3. Presence of supernumerary teeth related to gender.
Gender Absent Present Total
Male 63 7 ( 95.1 %) 33* (4.9%) 670 (100%)
Female 677 (98.3%) 12 (1.7%) 689 (100 %)
Total 1314 (96.7%) 45 ( 3.31%) 1359 (100 %)
*
P
= 0.0 01.
Table 4. Presence of anodontia related to gender.
Gender Absent Present Total
Male 649 (96.9%) 21 (3 .1%) 670 (100%)
Female 647 (93.9 %) 42* ( 6.1% ) 689 (100 %)
Total 1296 (95.4%) 63 (4.63%) 1359 (100 %)
*
P
= 0.009.

was more affected (6.1%). Both findings
demonstrated statistically significant differ-
ences of P < .001 and P = .009, respectively.
Discussion
The use of a panoramic film is more likely
to be indicated than a complete series of
intraoral periapical films because of its
many advantages, such as the exam of
both arches in 1 take, ease of technique,
reduction of time and work, standardiza-
tion, and low radiation dosage.6 -8,10
The prevalence of dental anomalies
detected in this retrospective study was
11.72%. This is compatible with the results
of Asaumi et al, who found a 12.8% inci-
dence of dental anomalies after analyzing
1092 panoramic films.15 Other studies
reported a higher prevalence of dental
anomalies with the panoramic technique.3,16
Marques et al verified a prevalence of 42%
of shape, number, and position anomalies
in 238 panoramic radiographs of children
(6 to 12 years).3 The frequency of dental
anomalies observed by Thongudomporn
& Freer was 30.6% in pediatric panoramic
radiographs (10.2 to 16.4 years).16
Marques et al verified from 238 pan-
oramic radiographs of Brazilian children
that anodontia was present in 9.6%, and
supernumerary teeth were present in 4.2%
of the patients.3 He did not emphasize the
statistical difference between genders (male,
10.5%; female, 9.0%).3 Locht also verified
a higher percentage of anodontia (7.7%)
than supernumerary teeth (1.7%).17 The
www.agd.org General Dentistry November/December 2013 e31
Fig. 3. Supernumerary root in teeth No. 14d and 16d. Fig. 4. Microdontia of teeth No. 24 and 25.
Fig. 5. Root dilaceration of tooth No. 8. Fig. 6. Compound odontoma in the region of teeth No. 7d and 8d.
Fig. 1. Anodontia of teeth No. 7, 10, and 25. Fig. 2. Two supernumerary teeth in the premaxilla and 2 others on both sides of
the premolar area in the mandible.

author did not distinguish the anomalies
by gender.17 However, Thongudomporn
& Freer observed the most frequent dental
anomalies were dens in dente in upper
incisors (26.1%) and anodontia (6.3%; the
incidence in females was 8.1%).16 In their
study of dental anomalies in 936 children
(5 years old) from south China (Hong
Kong), King et al found microdontia
(6.3%), anodontia (4.1%), gemination
and fusion (4.1%), supernumerary teeth
(2.8%), and macrodontia (1.1%).18
In the present study, permanent maxil-
lary right central and lateral incisors
and permanent mandibulary left second
premolars and right second premolars
were the most affected by anodontia.
Marques et al found that the permanent
mandibular y left second premolars and
right second premolars presented a higher
prevalence of anodontia (n = 12; 20%)
for both genders in Brazilian children.3
Calvano Kuchler et al evaluated 975
panoramic films from Brazilian children
searching for an association between
tooth agenesis and taurodontism, but
they did not find any.19 Of the 4.6% of
patients presenting anodontia, 2.6% were
female, 1.9% were male.19 The permanent
mandibular y left second premolars and
mandibulary right second premolars
(34.6%) were the most affected, followed
by the permanent maxillary right and
left second premolars (23%), permanent
maxillary right and left lateral incisors
(17.9%), permanent mandibulary right
and left lateral incisors (12.8%), and
permanent mandibulary right and left
central incisors (5.2%).19 Silva Meza
observed an anodontia frequency of 2.7%
when the third molars were not included
and 27% when they were included.20 The
female gender (35.7%) was more affected
by anodontia than the male (35.7% vs
27.6%), and the teeth most affected were
permanent maxillary right and left lateral
incisors (5.5%), followed by permanent
mandibulary left and right second pre-
molars (3.5%), and permanent mandibu-
lary right and left central incisors (2.7%).
According to Fujita et al, anodontia
frequency of lateral incisors was higher
in Japanese children (7.3%) when com-
pared to other ethnic groups, and more
frequent in girls than in boys.21 Lower
lateral incisors were missing in 4.8% of
the cases and upper lateral incisors were
missing in 2.7%. Asaumi et al observed
3.5% of anodontia in Japanese children.15
The teeth most affected were the perma-
nent maxillary and mandibulary right
and left central and lateral incisors, the
permanent maxillary and mandibulary
right and left canines, and the permanent
maxillary and mandibulary right and
left first and second premolars. Rolling
& Poulsen showed that the frequency
of anodontia in the permanent teeth of
Danish students was similar between the
years 1974 to 1979 (7.7%) and 1992 to
20 0 2 (7.1%).22 These findings were also
similar to other population studies of
children. The female gender was more
affected by anodontia than the male
gender, indicating a specific pattern for
female gender.22 Thus, the prevalence of
anomalies found in this study corrobo-
rates the results found in the literature,
where a higher frequency of anodontia
was found in females in premolars and
permanent lateral incisors.
Of the 45 cases (3.3%) of supernu-
merary teeth observed in this study, 22
(48.8%) were mesiodens. Other studies
of children and adolescents in Japan and
Brazil found similar results.3,15 However,
Thongudomporn & Freer and Costa
Pinho & Figueiredo Pollmann found a
small rate of supernumerary occurrence
in their studies, with rates of 1.8% and
0.76%, respectively.16, 23
Many population studies analyzing
panoramic radiographs of children and
adolescents have been performed in
Brazil, Japan, the Netherlands, Australia,
Hong Kong, Mexico, and Portugual.3 ,15 -2 3
Based on the findings of the present
study, a panoramic radiograph along with
the patient’s anamnesis is highly recom-
mended as part of the pediatric patient’s
first dental examination, especially for
children and adolescents of mixed denti-
tion considered to be at high risk for
caries. Complementary periapical radio-
graphs should be made only after con-
firming that a combination of bitewing
and panoramic radiographs do not offer
adequate information for a diagnosis.10,14
A panoramic radiograph of a patient with
mixed dentition provides information on
the dental development in the maxilla
and mandible with the added benefit of
reducing the ionizing radiation exposure
for that patient.2,8 ,9,11,24 A number of
anomalies that occur in mixed dentition,
such as anodontia and supernumerary
teeth, can also affect the permanent
dentition.25-28 Although the percentage
of dental anomalies found on panoramic
radiographs of Brazilian children (5 to
12 years) was not as high as observed by
other authors, a panoramic radiograph,
along with 2 posterior bitewings, is a
good way to complement a first time
clinical dental examination of children
with mixed dentition at high risk of caries
with no previous dental X-rays.3, 16 It is
important to obtain an early diagnosis of
any dental anomalies in order to establish
a better offer of treatment to the patient.
Conclusion
The authors of this study found that super-
numerary teeth (predominantly in males)
and anodontia (predominantly in females)
are the most prevalent dental anomalies in
children with mixed dentition who are at a
high risk for caries. Panoramic radiographs,
along with specific intraoral radiographs,
can serve as tools to establish a treatment
plan for these patients.
Author information
Dr. Souchois is an adjunct professor,
Department of Community and
Preventive Dentistry, State University
of Rio de Janeiro, Brazil, where Marcal
and Santos are associate professors. Dr.
Andrade is a professor, Pedodontics, Veiga
de Almeida Dental School, Rio de Janeiro,
Brazil. Fonseca is a pedodontic specialist in
private practice, Rio de Janeiro, Brazil.
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