Effect of undernutrition on deciduous tooth emergence among Rajput children of Shimla District of Himachal Pradesh India.код для вставкиСкачать
AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 000:000–000 (2012) Effect of Undernutrition on Deciduous Tooth Emergence Among Rajput Children of Shimla District of Himachal Pradesh, India Rajan Gaur and Pawan Kumar Department of Anthropology, Panjab University, Chandigarh 160014, India KEY WORDS dental eruption; nutritional status; sequence; timing ABSTRACT This article examines the inﬂuence of nutritional status on the emergence of deciduous dentition in a cross-sectional sample of 510 rural Rajput children from the Jubbal and Kotkhai Tehsils, Shimla District, Himachal Pradesh, India. The nutritional status of each child was evaluated using Z-scores of height/supine length-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ). The effects of sex and side on deciduous dental emergence were not statistically signiﬁcant. Partial correlation indicates that the number of emerged teeth (T) was more strongly correlated with height than with other anthropo- metric variables. In most age groups, the stunted boys and girls (HAZ <22) had fewer emerged teeth than nonstunted age peers (HAZ >22). The mean T in underweight children was also less than that of the normal children, with a few exceptions. The stunted children have a signiﬁcantly greater likelihood of delayed emergence of deciduous dentition. Measures of linear growth status are more closely related to dental development than measures of growth in mass. The ﬁndings indicate that even moderate undernutrition can delay deciduous tooth emergence. Am J Phys Anthropol 000:000–000, 2012. V 2012 Wiley Periodicals, Inc. Tooth emergence is of interest to physical anthropologists, dental professionals, biologists, and forensic scientists. It provides a reliable indication of maturation and biological age (Zadzinska et al., 2000) and thus serves as a useful tool to determine age of children in populations without birth records (Folayan et al., 2007). Most of the authors deﬁne the time of clinical emergence as the instant at which any part of the crown emerges through the gingival surface, even though eruption continues as each tooth moves into occlusion (Hillson, 1998; Bastos et al., 2007b). Emergence is different from tooth calciﬁcation, which is the process whereby calcium salts are deposited in the dental enamel (Zwemer, 1993).While the former may be signiﬁcantly delayed by undernutrition, the latter is less affected by nutrition. It is now widely accepted that dental emergence is to a major extent under genetic control (Garn, 1977; Gaur and Singh, 1994; Hughes et al., 2007; Gaur et al., 2011). However, several environmental factors have been reported to inﬂuence tooth emergence. Studies show that underprivileged children have retarded eruption relative to their higher socioeconomic peers (Enwonwu, 1973; Saleemi et al., 1994). However, Folayan et al. (2007) did not ﬁnd any signiﬁcant impact of socioeconomic status on primary tooth emergence in Nigerians. Delayed emergence of deciduous teeth was reported by a few workers in low birth weight children (Viscardi et al., 1994; Lawoyin et al., 1996; Sajjadian et al., 2010). Emergence of deciduous dentition may also be retarded in stunted children as was demonstrated by Bastos et al. (2007b) in a sample of stunted Brazilian children. A couple of studies report that preterm children may have fewer teeth as compared with their full-term counterparts (Magnusson, 1982; Fadavi et al., 1992). A few studies, however, suggest that deciduous dentition develops independent of general body development (Voors, 1957; Shuper et al., 1986). Accelerated primary tooth emergence was reported among children born to mothers who smoked during pregnancy (Rantakallio and Makinen, 1984). Several studies report delayed emergence among children with poor nutritional status (Kitamura, 1942; Infante and Owen, 1973; Delgado et al., 1975; Ulizaszek, 1996; Kodali, 1998; Agarwal et al., 2003; Holman and Yamaguchi, 2005; Bastos et al., 2007b; Psoter et al., 2008). These studies suggest that apart from genetics, dental emergence may be inﬂuenced by some environmental factors also. Undernutrition in children is commonly assessed from derived indices of height/supine length and weight, namely weight-for-age (WAZ), height/supine length-forage (HAZ), and weight-for-height/supine length (WHZ), expressed as Z-scores. Low WAZ may reﬂect both past (chronic) and/or present (acute) undernutrition (Cogill, 2003) and is diagnostic of an ‘‘underweight child.’’ HAZ is an indicator of past or long-term (chronic) growth failure resulting in ‘‘stunting.’’ WHZ detects ‘‘wasting" that is a measure of current or acute very severe nutritional stress leading to weight falling signiﬁcantly below the expected weight for same height/supine length. The sequence and timing of emergence of deciduous dentition have been examined in many human populations (Liversidge, 2003). However, several issues related to deciduous tooth emergence, such as degree of population variability, the inﬂuence of growth, and effect of nutritional status have yet to be fully resolved. Several C 2012 V WILEY PERIODICALS, INC. C *Correspondence to: Prof. Rajan Gaur, H. No. 1452, Sector: 44-B, Chandigarh 160047, India. E-mail: email@example.com Received 3 January 2011; accepted 20 January 2012 DOI 10.1002/ajpa.22041 Published online in Wiley Online Library (wileyonlinelibrary.com). 2 R. GAUR AND P. KUMAR Fig. 1. Generalized location map of the area. TABLE 1. Distribution of sample children in various age groups according to sex Boys Girls 0.00–0.49 0.50–0.99 1.00–1.49 31 25 30 29 46 31 Age group (in years) 1.50–1.99 2.00–2.49 27 31 studies indicate that only severe undernutrition delays the emergence of deciduous dentition (Jelliffe and Jelliffe, 1973; Mukherjee, 1973; Billewicz and McGregor, 1975; el Lozy et al., 1975; Arvystas, 1976; Khan et al., 1981; Rao, 1985; Kodali et al., 1993; Saleemi et al., 1994; Kodali, 1998; Agarwal et al., 2003; Bastos et al., 2007a). These studies also suggest that moderate undernutrition did not have any substantial delaying effect on primary tooth emergence. However, a set of studies reports that even moderate undernutrition may result in delayed emergence of primary teeth (McLaren et al., 1964; Rao et al., 1973; Truswell and Hansen, 1973; Delgado et al., 1975; Hull, 1983; Shuper et al., 1985; Fadavi et al., 1992; Holman and Yamaguchi, 2005). A few workers found no effect of undernutrition on deciduous tooth emergence (Graham and Morales, 1963; Pindborg et al., 1967; Jelliffe and Jelliffe, 1968; McGregor et al., 1968; Trupkin, 1974). In contrast to these studies, Cifuentes and Alvarado (1973) reported early emergence in undernourished Guatemalan children. There are, thus, varied results with respect to the effect of undernutrition on deciduous tooth emergence and the issue remains unresolved. This article examines a sample of Rajput children from the state of Himachal Pradesh of India to assess American Journal of Physical Anthropology 33 34 2.50–2.99 3.00–3.49 3.50–3.99 Ages combined 31 32 33 33 34 30 265 245 the inﬂuence of undernutrition on the emergence of deciduous dentition. MATERIALS AND METHODS This investigation is based on a cross-sectional sample of 510 rural Rajput children (265 boys and 245 girls). The subjects included in the study were clinically healthy and ranged in age from birth to 48 months. The data were collected from the villages of Jubbal and Kotkhai Tehsils of the Shimla District of Himachal Pradesh (Fig. 1), through a house-to-house survey. The dates of birth of the subjects were taken either from the birth certiﬁcates or from the parents. The decimal age was calculated from the date of birth and date of examination (Tanner and Whitehouse, 1966). The children in this sample were grouped into eight age groups of 6 months each. The age-wise distribution of the sample children is given in Table 1. The study area and the people The Shimla District of Himachal Pradesh in North India lies between the longitudes 778 00 and 788 190 east 3 EFFECT OF UNDERNUTRITION ON DECIDUOUS TOOTH EMERGENCE TABLE 2. Median ages (MD) and interquartile ranges (IR) of emergence of deciduous dentition among Rajput children (years) Left Tooth Males i1 i2 c m1 m2 Females i1 i2 c m1 m2 Maxilla MD (IR) Right Mandible MD (IR) Maxilla MD (IR) Combined Mandible MD (IR) Maxilla MD (IR) Mandible MD (IR) 1.16 1.24 1.86 1.58 2.31 (0.28) (0.47) (0.81) (0.64) (1.39) 1.13 1.59 1.97 1.69 2.51 (0.39) (0.76) (1.01) (0.60) (1.18) 1.16 1.27 1.86 1.60 2.45 (0.28) (0.48) (0.81) (0.45) (1.22) 1.12 1.55 1.95 1.69 2.54 (0.43) (0.74) (0.95) (0.60) (1.07) 1.16 1.26 1.86 1.59 2.28 (0.28) (0.48) (0.81) (0.52) (0.90) 1.12 1.57 1.96 1.69 2.46 (0.42) (0.75)a (0.94) (0.60) (1.01) 1.17 1.25 1.88 1.64 2.37 (0.36) (0.50) (0.61) (0.49) (0.80) 0.93 1.47 2.04 1.64 2.34 (0.66) (0.56) (0.74) (0.72) (0.60) 1.17 1.27 1.88 1.62 2.34 (0.36) (0.43) (0.61) (0.43) (0.93) 1.00 1.47 1.97 1.71 2.24 (0.57) (0.56) (0.57) (0.79) (0.58) 1.17 1.25 1.88 1.63 2.35 (0.36) (0.41) (0.61) (0.44) (0.88) 0.96 1.47 2.00 1.68 2.34 (0.62)a (0.56) (0.71) (0.74) (0.59) Signiﬁcant interjaw difference (Bonferroni adjusted alpha level of P \ 0.01). Values in parentheses represent the interquartile ranges. a and latitudes 308 450 and 318 440 north. The area is mountainous with altitude ranging from 1200 to 2700 m above mean sea level. The staple food of the villagers of this area generally consists of wheat, rice, and maize. In addition, pulses like ‘‘Urd" (Black Lentil), ‘‘Lobia" (Blackeyed Bean), ‘‘Moong" (Green Lentil), and ‘‘Kulth" (Brown Lentil) are used almost daily. The people usually take three to four meals a day. They are very fond of rice, which is consumed at least once a day. The people also like meat and those who can afford consume it occasionally at dinner. A large majority (89%) of the children of this sample belong to the lower middle income families with a per capita income of \Rs. 800 per month. METHODS For this investigation, a cross-sectional study design was used. The subjects were examined only once for gingival emergence of deciduous dentition. The sequence and number of emerged deciduous teeth were recorded on a specially designed proforma. Each child was examined in daylight or, if necessary, with the help of a torch to record the number of emerged teeth (T). The appearance of any part of the cusp or crown through the gingiva was considered to be an emerged tooth (Demirjian, 1986; Holman and Jones, 1998, 2003; Suri et al., 2004; Bastos et al., 2007b; Folayan et al., 2007; Woodroffe et al., 2010). The teeth that had erupted but subsequently clinically extracted were also counted as emerged (only four such cases were recorded). In addition to dental emergence data, height/supine length and weight of each subject along with some general information reﬂecting the socioeconomic status were also recorded. The supine length, height, and weight of the children were measured using standard methods (Weiner and Lourie, 1981). Supine length was measured in children below the age of 18 months, height in children above this age. Median ages of emergence of permanent teeth were calculated employing the probit transformation (Mayhall et al., 1978). Height was measured with a Harpenden anthropometer with subject standing, with head in Frankfort plane, on a horizontal surface with heels together, stretching upward to the fullest extent, aided by gentle pressure on the mastoid processes by the measurer, with back as straight as possible. The horizontal arm of the anthropometer was brought down to touch the highest point on the subject’s head (vertex) in the mid sagittal plane. Supine length was measured with an infant measuring table, with infant lying supine. The infant’s head, in the vertical Frankfort plane, was brought to touch the ﬁxed headboard by one measurer, while the infant’s feet, with toes pointing directly upward, were held by the second measurer who also brought the moveable footboard to rest ﬁrmly against the infant’s heels. Weight was measured with a portable ﬁeld survey scale. The nutritional status of each subject was assessed with the help of height/supine length and weight, which are the two basic measurements for the assessment of nutritional status (WHO, 1986). As per the recommendations of World Health Organization (WHO, 1983), the following derived indices were calculated for each child to assess the nutritional status: WAZ, HAZ, and WHZ. The reference data of the World Health Organization (WHO, 2006) was used to assess the nutritional status. For each individual, the nutritional status was calculated as Z-scores or S.D. scores, following Waterlow et al. (1977). The cut-off point for undernourished children was taken as 22 SD scores below the reference median, as recommended by the WHO (1983). Stunting, underweight and wasting were deﬁned as Z-scores 22 SD or less of HAZ, WAZ and WHZ, respectively, of WHO (2006) reference standards. The usual cut-off points for moderate and severe undernutrition are: Z-scores of 22 S.D. and 23 S.D., respectively, below the reference median (WFP, 2005). The interjaw, bilateral, and gender differences, which were, largely, not signiﬁcant, were evaluated using Mann-Whitney test. The relationship between anthropometric parameters and T and its signiﬁcance was calculated using partial correlation. Where multiple ttests were involved, a Bonferroni adjusted alpha level was used to reduce the possibility of Type-I errors. RESULTS Table 2 shows the median age of emergence of deciduous teeth among the Rajput children according to sex, side, and jaw. The mandibular central incisors were the earliest set of teeth to emerge. The maxillary central incisors emerge next followed by the maxillary lateral incisors and mandibular lateral incisors. Next, emerge the maxillary and mandibular ﬁrst molars, canines, and last the second molars. The overall sequence of emergence of the full complement of deciduous teeth among Rajput children of this sample was i1, i1, i2, i2, m1, m1, American Journal of Physical Anthropology 4 R. GAUR AND P. KUMAR TABLE 3. Descriptive statistics (Mean 6 SD) of weight, height/supine length, and Z-scores of HAZ, WAZ, and WHZ of Rajput children according to age and sex Age (years) Males 0.00–0.49 0.50–0.99 1.00–1.49 1.50–1.99 2.00–2.49 2.50–2.99 3.00–3.49 3.50–3.99 Females 0.00–0.49 0.50–0.99 1.00–1.49 1.50–1.99 2.00–2.49 2.50–2.99 3.00–3.49 3.50–3.99 a Z-Scores Height/Supine Length (cm) Weight (kg) HAZ WAZ WHZ 61.1 67.3 75.6 80.2 85.1 88.3 93.2 96.8 6 6 6 6 6 6 6 6 5.37 2.89 4.67 3.70 3.76 3.90 4.07 4.23 5.46 7.59 9.47 10.76 11.47 12.30 13.56 13.78 6 6 6 6 6 6 6 6 1.26 1.41 1.35a 1.53 1.62 1.09 1.47 1.26 20.51 21.20 21.39 21.43 21.39 21.76 20.95 21.15 6 6 6 6 6 6 6 6 1.42 0.87 1.48 1.17 1.04 1.12 1.00 0.96 20.95 21.11 21.29 20.99 21.24 21.23 20.94 21.38 6 6 6 6 6 6 6 6 0.73 1.22 1.15 1.22 1.29 0.74 0.81 0.65 20.84 20.42 20.58 0.36 20.42 20.39 20.42 20.88 6 6 6 6 6 6 6 6 0.90 1.08 0.89 1.03 1.08 1.00 0.73 0.90 61.4 67.3 73.9 79.4 83.5 86.4 91.3 95.2 6 6 6 6 6 6 6 6 3.53 2.90 4.17 5.63 4.67 3.39 4.16 3.39 5.41 7.56 8.65 10.73 11.11 11.55 12.96 13.37 6 6 6 6 6 6 6 6 0.90 1.18 0.99 1.74 1.60 1.37 1.26 2.78 0.14 21.07 21.36 21.39 21.58 22.01 21.31 21.17 6 6 6 6 6 6 6 6 1.04 0.96 1.99 1.74 1.33 0.91 1.02 0.89 20.56 20.92 21.44 20.55 21.01 21.38 21.09 21.14 6 6 6 6 6 6 6 6 0.72 1.14 0.78 1.44 1.17 1.03 0.77 0.96 20.80 20.18 20.81 20.04 20.45 20.59 20.29 20.45 6 6 6 6 6 6 6 6 0.63 1.36 0.69 1.20 0.87 0.97 0.79 0.98 Signiﬁcant sex difference (Bonferroni adjusted alpha level of P \ 0.01). TABLE 4. Incidence (%) of undernourished children (<22 SD scores) based on the Z-scores of HAZ, WAZ, and WHZ Age (years) Males 0.00–0.49 0.50–0.99 1.00–1.49 1.50–1.99 2.00–2.49 2.50–2.49 3.00–3.49 3.50–3.99 Combined Females 0.00–0.49 0.50–0.99 1.00–1.49 1.50–1.99 2.00–2.49 2.50–2.49 3.00–3.49 3.50-3.99 Combined Stunting (\22 HAZ) Underweight (\22 WAZ) Wasting (\22 WHZ) 19.4 30.0 47.9 55.5 54.3 54.9 21.2 41.1 40.7 (6) (9) (22) (15) (18) (17) (7) (14) (108) 22.6 33.4 45.7 40.7 48.6 38.7 24.2 41.1 37.3 (7) (10) (21) (11) (16) (12) (8) (14) (96) 32.3 13.3 17.4 18.5 21.2 9.7 9.1 29.4 18.9 (10) (4) (8) (5) (7) (3) (3) (10) (50) 8.0 37.9 45.2 51.6 61.8 71.9 48.5 46.6 47.8 (2) (11) (14) (16) (21) (23) (16) (14) (117) 4.0 34.5 35.5 16.1 32.4 40.6 27.3 26.6 27.8 (1) (10) (11) (5) (11) (13) (9) (8) (68) 16.0 24.1 19.4 9.7 11.7 18.7 9.1 13.4 15.1 (4) (7) (6) (3) (4) (6) (3) (4) (37) Values in parentheses represent the number of individuals. c1, c1, m2, and m2 for males and i1, i1, i2, i2, m1, m1, c1, c1, m2, and m2, for females. The average length of time from the eruption of the ﬁrst tooth to the last tooth in mandible was 1.34 years in males and 1.38 years in females. In maxilla, it was 1.12 years in males and 1.18 years in females. On an average, deciduous dentition was almost complete by the age of 2.5 years. Table 3 shows the age and sex speciﬁc descriptive statistics of height/supine length, weight, and Z-scores of HAZ, WAZ, and WHZ. As expected, the mean height/ supine length and weight increase with increase in age in both boys and girls. The mean Z-scores of HAZ broadly increased up to the age of three in both sexes. The mean Z-scores of WAZ increased up to the age of 1.5 years in the boys as well as the girls; the trend was not clear thereafter. A clear trend could not be noticed for WHZ. A student’s t-test with Bonferroni adjusted alpha American Journal of Physical Anthropology level of 0.01 revealed that, on the average, the sex differences in mean height/supine length, weight, HAZ, WAZ, and WHZ were statistically not signiﬁcant. Table 4 depicts the rates (%) of undernutrition (\22 SD scores) based on Z-scores of HAZ, WAZ, and WHZ, according to age and sex, among the Rajput children of this sample. It can be seen in the table that 40.7% boys and 47.8% girls were stunted (\22 HAZ); of these 12.8% boys and 13.1% girls were severely undernourished (\23 HAZ). The incidence of underweight children (\22 WAZ) was 37.4 and 27.8% in boys and girls, respectively. The prevalence of wasting (\22 WHZ) was distinctly less (18.9% in boys and 15.1% in girls). It is also clear from the table that broadly, in both sexes, the percentage of stunted children was clearly higher than that of underweight children. The rate of wasting was the minimum. In this sample, a majority of the children were suffering from chronic or long-term rather than acute undernutrition. On the average, the rate of stunting increased up to 2.5 years. The percentage of underweight children broadly increased up to 1.5 years. The trend was not clear for wasting. An examination of Table 4 reveals that, up to 2 years, the rate of stunting was higher in boys; the girls overtook the boys thereafter. The percentage of underweight boys was higher up to 2.5 years. The pattern was not clear for rates of wasting. To evaluate the overall signiﬁcance of sex differences in rates of undernutrition a Chisquare (v2) test was used. The test resulted in v2 values of 38.97 for stunting, 142.99 for underweight, and 60.4 for wasting. The results of the test indicate that overall rate of stunting was signiﬁcantly (P \ 0.05) higher in the girls, while the rate of wasting and underweight individuals was signiﬁcantly (P \ 0.05) more in boys. Table 5 depicts the values of partial correlation between the T and height/supine length (Ht), weight (Wt), and Z-scores of HAZ, WAZ, and WHZ. The partial correlation for Ht/T was signiﬁcant (P \ 0.05) at 1–2 years for boys and 1–3 years in girls. The partial correlation for Wt/T was signiﬁcant (P \ 0.05) from 1 to 2 years in boys and from 1.5 to 2.5 years in case of girls. The Z-scores of HAZ showed signiﬁcant partial correlation (P \ 0.05) with T from 1 to 2 years in boys and from 5 EFFECT OF UNDERNUTRITION ON DECIDUOUS TOOTH EMERGENCE ber of emerged deciduous teeth was more strongly correlated with height/supine length than with weight. Table 6 displays the mean T among normal (>22 SD scores) and undernourished (\22 SD scores) children as speciﬁed by the Z-scores of HAZ, WAZ, and WHZ. Since multiple t-tests were employed, to reduce Type-I errors, a Bonferroni adjusted alpha level of 0.01 is used to evaluate the statistical signiﬁcance of t-tests. It is evident from the table that the stunted (\22 HAZ) boys and girls had less mean T as compared with their normal peers in most age groups. The differences were signiﬁcant (P \ 0.01) in 1.50–1.99 and 2.00–2.49 age groups in girls and 1.00–1.49, 1.50–1.99, 2.50–2.99, and 3.00–3.49 age groups in boys. The mean T in underweight children (\22 WAZ) was slightly less than that of their normal counterparts, with a few exceptions. However, the differences were not significant in both sexes. Children with low WHZ show a variable pattern. The low WHZ girls from 0.5 to 3 years showed a slightly less mean T than normal girls. However, low WHZ boys below the age of 1.5 years had slightly more mean T than even normal boys. These results are found in young age groups, and there is high variation. A closer examination of Table 6 reveals that in only one age group each in boys (2.00–2.49) and girls (1.00–1.49), the low WHZ or severely undernourished children showed signiﬁcant retardation in dental emergence. The mean T of the stunted (\–2 HAZ) and underweight (\–2 WAZ) boys was less than that of the girls in a majority of the age groups, which indicates that emergence delay was more among the undernourished boys than the girls. Interjaw differences were not clear in this respect. 1 to 3 years in girls. The partial correlation of Z-scores of WAZ was signiﬁcant from 1 to 2 years in boys and from 1 to 2.5 years in girls. The partial correlation of Z-scores of WHZ with the T was broadly not signiﬁcant in both sexes. Overall, the girls displayed a stronger correlation of the T with a majority of the parameters considered here. Table 5 further indicates that, overall, the partial correlation of the T was signiﬁcant at more age groups with height/supine length and Z-scores of HAZ than with weight and Z-scores of WAZ and WHZ. Thus, the numTABLE 5. Results of partial correlation (r) of number of emerged teeth (T) with Height/Supine length (Ht), Weight (Wt), and Z-scores of HAZ, WAZ, and WHZ of Rajput children Age (years) Males 0.00–0.49 0.50–0.99 1.00–1.49 1.50–1.99 2.00–2.49 2.50–2.99 3.00–3.49 3.50–3.99 Females 0.00–0.49 0.50–0.99 1.00–1.49 1.50–1.99 2.00–2.49 2.50–2.99 3.00–3.49 3.50–3.99 r (Ht/T) r (Wt/T) r (HAZ/T) r (WAZ/T) r (WHZ/T) 0.157 0.179 0.661a 0.702a 0.229 0.084 0.271 – 0.347 0.185 0.442a 0.635a 0.093 0.032 0.179 – 0.140 0.250 0.622a 0.679a 0.006 0.166 0.136 0.017 0.003 0.243 0.402a 0.636a 0.069 0.003 0.061 0.109 0.197 0.142 0.026 0.333 0.107 0.047 0.036 0.178 – 0.026 0.451a 0.644a 0.456a 0.559a – – – 0.071 0.225 0.454a 0.437a 0.256 – – – 0.038 0.496a 0.630a 0.456a 0.563a 0.150 – – 0.092 0.405a 0.448a 0.440a 0.240 0.070 – – 0.109 0.096 0.012 0.246 0.034 0.042 – DISCUSSION Signiﬁcant partial correlation (P \ 0.05). –: Correlation not computable because either no tooth had emerged in any individual of the age group or all individuals in the age group had a complete complement of 20 teeth. a Timing of tooth emergence is multifactorial (Alvarez and Navia, 1989). Several factors have been reported to inﬂuence the time and sequence of emergence of deciduous TABLE 6. Age and sex speciﬁc means 6 S.D. of T, according to nutritional status, as speciﬁed by Z-scores of HAZ, WAZ, and WHZ among Rajput children HAZ Age (years) Males 0.00–0.49 0.50–0.99 1.00–1.49 1.50–1.99 2.00–2.49 2.50–2.99 3.00–3.49 3.50–4.00 Females 0.00–0.49 0.50–0.99 1.00–1.49 1.50–1.99 2.00–2.49 2.50–2.99 3.00–3.49 3.50–4.00 22 S.D. scores or less (undernourished) WAZ [22 S.D. scores (normal) 22 S.D. scores or less (undernourished) WHZ [22 S.D. scores (normal) 22 S.D. scores or less (undernourished) [22 S.D. scores (normal) 0.00 1.00 5.90 10.70 16.33 17.92 18.50 20.00 6 6 6 6 6 6 6 6 0.00 2.13 1.96a 2.83a 1.80 1.62a 1.91a 0.00 0.19 0.77 9.41 15.12 16.46 19.37 19.81 19.83 6 6 6 6 6 6 6 6 0.87 1.90 4.98 4.01 2.66 1.38 0.58 0.76 0.00 0.86 7.53 12.37 15.88 18.80 19.00 19.60 6 6 6 6 6 6 6 6 0.00 2.27 3.90 4.86 3.05 1.78 1.73 0.89 0.25 0.83 8.82 15.63 16.88 19.53 19.73 19.97 6 6 6 6 6 6 6 6 1.00 1.87 5.07 3.25 2.23 1.21 0.83 0.18 0.26 2.00 11.00 11.00 13.75 20.00 19.00 19.75 6 6 6 6 6 6 6 6 1.03 3.46 8.18 7.07 3.30a 0.00 0.00 0.50 0.00 0.70 8.23 14.96 17.00 19.40 19.75 19.97 6 6 6 6 6 6 6 6 0.00 1.75 4.54 3.76 2.12 1.32 080 0.18 0.00 1.50 6.09 12.00 14.91 19.25 20.00 20.00 6 6 6 6 6 6 6 6 0.00 0.83 1.81 3.26a 3.12a 2.17 0.00 0.00 0.00 1.73 8.45 15.80 17.72 20.00 20.00 20.00 6 6 6 6 6 6 6 6 0.00 2.14 3.54 3.23 2.64 0.00 0.00 0.00 0.00 1.80 6.88 12.66 15.50 19.11 19.97 20.00 6 6 6 6 6 6 6 6 0.00 0.44 4.25 3.05 4.72 2.66 0.19 0.00 0.00 1.56 8.00 15.00 17.73 19.82 20.00 20.00 6 6 6 6 6 6 6 6 0.00 2.06 3.35 3.72 2.20 0.83 0.00 0.00 0.00 6 0.00 6 1.00 6 – 10.00 6 20.00 6 20.00 6 – 0.00 0.00 1.41a 0.00 1.67 8.14 14.77 17.42 19.59 19.97 20.00 6 6 6 6 6 6 6 6 0.00 1.96 3.22 3.68 2.81 1.64 0.18 0.00 0.00 19.58 0.00 a Signiﬁcant difference in the T between undernourished (22 S.D. or less) and normal children (Bonferroni adjusted alpha level of P \ 0.01). –: No undernourished individual in the age group. American Journal of Physical Anthropology 6 R. GAUR AND P. KUMAR teeth, which include weight, height, nutritional status, ethnicity, socioeconomic status, and disease (Al-Jasser and Bello, 2003; Gaur et al., 2011). Some studies have indicated marked sex differences in malnutrition in India, with a higher prevalence of undernutrition among girls (Sen and Sengupta, 1983; Tarozzi and Mahajan, 2007). Some reports linked this with gender inequalities in nutrient intake because of nutritional neglect of girls (Behrman, 1988; Borooah, 2004). This may not hold true for whole of India because of regional differences in nutritional status as has been reported by Tarozzi and Mahajan (2007) and Lancaster et al. (2006). The gender differences are reported to be more striking in northwest and east India where the presence of widespread son preference has been documented (Tarozzi and Mahajan, 2007). This sample did not show any nutritional neglect of girls. The rate of stunting, an indicator of long-term undernutrition, was higher in girls but the rates of underweight and wasting, indictors of acute and severe undernutrition, respectively, were higher in boys. Thus, the rates of undernutrition do not reﬂect any clear gender bias in this sample. The relationship between deciduous tooth emergence and height and weight has been the subject of several investigations. It has been reported that low-birth weight infants have delayed emergence (Fadavi et al., 1992; Harris and Barcott, 1993; Viscardi et al., 1994) and eruption is advanced in higher birth weight infants (Delgado et al., 1975; Khan et al., 1981; Sajjadian et al., 2010). Holman and Yamaguchi (2005) suggested that earlier emergence in higher birth weight children may be due to heavier infants being born at later gestational ages. There are, however, a few studies, which suggest that deciduous tooth emergence was an independent process and not related to height and weight (Falkner, 1957; Shuper et al., 1985, 1986; Haddad and Correa, 2005). In this study, a positive correlation was noticed between the number of emerged deciduous teeth and height/supine length and weight in some age categories. This is consistent with several other studies that report a positive correlation between height and weight and deciduous tooth emergence with taller and heavier children having a greater T at a given age (Billewicz, et al., 1973; Enwonwu, 1973; Infante and Owen, 1973; Jelliffe and Jelliffe, 1973; Rao, 1985, 1992). Infante and Owen (1973) suggested that since stature and weight are related to nutritional status, deciduous tooth emergence might be an indicator of nutritional status. Overall, the correlations in this sample were not signiﬁcant in the younger age groups and the oldest two age groups for a majority of the parameters considered here. It should be noted that the critical ages for assessing variation in emergence patterns are from 0.5 to 3.0 years. This is because, before 0.5 years, very few infants have any teeth, whereas after 3 years, almost all the children have a complete complement of 20 deciduous teeth. This probably accounts for poor correlation in the youngest and the older two age groups. The correlations were stronger with stature as compared to weight, which is consistent with the ﬁndings of Rao (1992) who reported that the correlation of height and T was more distinct. McGregor et al. (1968) and Infante and Owen (1973) also reported a strong positive association between stature and number of emerged deciduous teeth, with children having more deciduous teeth present for a given age being taller than those with fewer teeth. Spier (1918) noted that there was a American Journal of Physical Anthropology functional relationship between stature and physiological status as deﬁned by dentition. Garn et al. (1965) reported that taller children were slightly advanced in permanent tooth formation and movement. Sutow et al. (1954) and Lee et al. (1965) demonstrated a signiﬁcant positive association between permanent tooth emergence and skeletal maturation. Thus, a stronger correlation with stature could be because of the fact that development of dentition, a skeletal element, is more likely to be inﬂuenced by factors that affect skeletal growth. A better correlation with stature rather than weight may exist because there is a strong relationship between eruption and skeletal growth (Psoter et al., 2008). In view of a stronger correlation between tooth emergence and stature, Tanguay et al. (1986) suggest that clinical standards for emergence of deciduous teeth were more accurate and efﬁcient when scaled to height rather than chronological age. The results of this study suggest that deciduous dental emergence was more strongly correlated with linear growth (i.e., skeletal) as compared to growth in mass. Nutrition is an important environmental factor that inﬂuences deciduous tooth emergence. Yun (1957) concluded that deciduous tooth eruption may be greatly delayed by nutritional disturbance. Psoter et al. (2008) found that early childhood malnutrition not only delays emergence of deciduous teeth but could delay emergence of permanent dentition because of its delaying effect on the exfoliation of primary teeth. Previous studies have reported in the past that only severe undernutrition resulted in delayed emergence of deciduous dentition while moderate undernutrition had no signiﬁcant effect (Jelliffe and Jelliffe, 1973; Mukherjee, 1973; Billewicz and McGregor, 1975; el Lozy et al., 1975; Arvystas, 1976; Khan et al., 1981; Rao, 1985; Kodali et al., 1993; Saleemi et al., 1994; Kodali, 1998; Agarwal et al., 2003; Bastos et al., 2007a). Our ﬁndings are not consistent with these studies. In this case, even moderately undernourished (\22 Z-scores) Rajput children had, on the average, less T than their normal counterparts. Our ﬁndings are consistent with ﬁndings of several other studies, which also indicate that even moderate and less severe undernutrition could delay emergence of primary dentition (McLaren et al., 1964; Truswell and Hansen, 1973; Rao et al., 1973; Delgado et al., 1975; Hull, 1983; Shuper et al., 1985; Fadavi et al., 1992; Holman and Yamaguchi, 2005). In this sample, stunted children had signiﬁcantly less T as compared with their normal peers. In a sample of Brazilian children, Bastos et al. (2007b) had also reported fewer emerged deciduous teeth in stunted children as compared with their normal counterparts. Thus, it can be safely concluded that, in this sample, ‘‘chronic or long-term" undernutrition as indicated by low HAZ signiﬁcantly retards dental emergence. The impact of ‘‘acute/severe" undernutrition (low WHZ) on deciduous tooth emergence in this case was not clear. It emerges that the stunted children had a signiﬁcantly greater likelihood of having fewer emerged deciduous teeth at a given chronological age than their normal peers and that even moderate undernutrition may delay deciduous tooth emergence. These ﬁndings have implications for anthropologists, demographers, public health workers, and other researchers who use primary tooth emergence data for estimation of chronological age of infants and children from undernourished populations, particularly in rural EFFECT OF UNDERNUTRITION ON DECIDUOUS TOOTH EMERGENCE and tribal areas of the developing world, in which the tradition of maintaining birth records does not exist. The ﬁndings may also be relevant to dental clinicians as a delay in eruption can directly affect the accurate diagnosis, planning, and timing of treatment in orthodontic patients (Suri et al., 2004). Since these ﬁndings are based on a cross-sectional sample, these may require further conﬁrmation through additional longitudinal studies. CONCLUSIONS The results indicate a relationship between stature, weight, and the emergence of deciduous dentition. The number of emerged deciduous teeth is better correlated with stature than weight. 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