Spine 5.

5 mm

ISSN: 0972-0707

Journal of
Conservative
Journal of Conservative Dentistry • Volume 24 • Issue 2 • March-April 2021 • Pages ***-***

Dentistry
Volume 24 Issue 2 March-April 2021

Official Publication of
Indian Association of
Conservative Dentistry and
Endodontics
Online full text at
www.jcd.org.in
Original Research

Comparing the pulp/tooth area ratio and dentin

thickness of mandibular first molars in different age
groups: A cone‑beam computed tomography study
Mathukan Chaleefong1, Sangsom Prapayasatok2, Sakarat Nalampang2, Phumisak Louwakul3
1
Master of Science Program in Geriatric Dentistry, Departments of 2Oral Biology and Oral Diagnostic Sciences,3Restorative Dentistry and
Periodontology, Faculty of Dentistry, Chiang Mai University,Chiang Mai, Thailand

Abstract
Context: Mandibular first molar frequently requires endodontic treatment. Understanding age‑related changes in pulp‑dentin
complex and root canal morphologies is essential for successful endodontic and restorative treatments.
Aim: This study aimed to compare pulp/tooth area ratio (PTAR) and dentin thickness (DT) in mandibular first molars in different
age groups through cone‑beam computed tomography (CBCT) imaging.
Subjects and Methods: One hundred CBCT images of mandibular first molar were divided into five groups; age 20–29, 30–39,
40–49, 50–59, and 60 years old and older. Axial images were used to determine PTAR at Level A (furcation), Level B (between
Levels A and C), and Level C (half distance between the furcation and apex of the root). The minimum DT of the distal wall
of mesiobuccal (MB) and mesiolingual (MLi) canal and mesial wall of distal canal at 2 and 3 mm under the furcation was
measured.
Statistical Analysis Used: Analysis of variance was used to determine differences among age groups.
Results: PTAR was determined to reduce as age increases, showing a significant difference among the age groups at Levels A,
B, and C of both roots (P < 0.05). The minimum DT was found to increase with age, demonstrating a significant difference
among the age groups of MB and MLi canal at 2 and 3 mm (P < 0.05). No statistically significant difference was observed in
the mesial DT of distal canal.
Conclusions: The reduction of PTAR and the increasing DT were confirmed with advanced age.
Keywords: Aging; cone‑beam computed tomography; molar; pulp/tooth area ratio; secondary dentin

INTRODUCTION advanced age, the risk of dental caries and periodontal

disease has been found to increase. Mandibular first
Mandibular first molar has an important role in chewing molar frequently requires endodontic treatment in order
and maintains the vertical dimension of the face. It is prone to retain its function and prevent tooth extraction. Thus,
to dental caries because of having deep pit and fissures, understanding age‑related changes in pulp‑dentin complex
in addition to poor oral hygiene during childhood.[1] With
and root canal morphologies is essential for successful
Address for correspondence: endodontic and restorative treatments.[2,3]
Dr. Phumisak Louwakul,
Department of Restorative Dentistry and Periodontology, Faculty Obliterated canal is clinically challenging in terms of locating
of Dentistry, Chiang Mai University, Suthep Road,
A. Muang, Chiang Mai 50200, Thailand. and negotiating the root canal.[4] The obliterated canal,
E‑mail: [email protected]
This is an open access journal, and articles are distributed under the terms
Date of submission : 24.01.2021 of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
Review completed : 19.02.2021 License, which allows others to remix, tweak, and build upon the work
Date of acceptance : 22.02.2021 non‑commercially, as long as appropriate credit is given and the new
Published : 09.10.2021 creations are licensed under the identical terms.
Access this article online For reprints contact: [email protected]
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Website:
How to cite this article: Chaleefong M, Prapayasatok S,
www.jcd.org.in
Nalampang S, Louwakul P. Comparing the pulp/tooth area ratio
and dentin thickness of mandibular first molars in different age
DOI: groups: A cone-beam computed tomography study. J Conserv
10.4103/jcd.jcd_47_21
Dent 2021;24:166-70.

166 © 2021 Journal of Conservative Dentistry | Published by Wolters Kluwer - Medknow

 Chaleefong, et al: Pulp/tooth area ratio and dentin thickness

which is often attributed to advanced age, is a degenerative Axial cone‑beam computed tomography
change of pulp‑dentin complex caused by secondary dentin image acquisition
deposition, which is formed throughout life after completed CS 3D imaging software (Version 3.7.1, Carestream Dental,
root formation.[3,5] The relationship between secondary Rochester, New York, USA) was used. The axial images were
dentin deposition and age was examined and used for age obtained at three levels of each root; Level A (furcation),
estimation using dental radiographs. Several researchers Level B (between Levels A and C), and Level C (half distance
have found that the pulp/tooth area ratio (PTAR) decreased between the furcation and apex of the root) to measure
with aging; however, the majority of the previous studies the PTAR and at 2 and 3 mm under furcation to measure
used single‑rooted teeth.[6‑8] DT. Then, the axial images were exported to ImageJ
software  (Version  1.50i, National Institutes of Health,
Strip perforation is another complication that can lead to Bethesda, Maryland, USA). The contrast and brightness of
the failure of endodontic treatment.[9] This is often caused the images were adjusted to achieve optimal visualization.
by overinstrumentation at the furcation area, known as a
danger zone.[10] In mandibular first molar, the distal wall Methods
of mesial root has limited dentin thickness  (DT), around Pulp and tooth area analysis
2–4 mm under the furcation.[11‑14] Data remain lacking in According to the axial images at Levels A, B, and C, twenty
terms of the correlation of DT and aging. points of tooth outline and ten points of pulp outline were
created[7] using polygon selection. The areas of pulp and
Cone‑beam computed tomography (CBCT), which has the tooth were measured thrice, and the mean values were
ability to create accurate three‑dimensional images, could recorded. The PTAR of each level was calculated for each
be a powerful tool in endodontic treatment. CBCT provides sample.
accurate information of internal root canal anatomy.[15]
Moreover, CBCT imaging can overcome problems related Dentin thickness analysis
to the superimposition of image from crowding of the According to the axial images at 2 and 3 mm under
teeth, providing axial images traditional radiographs furcation, the DT of distal wall of mesiobuccal  (MB) and
cannot.[8,16] Thus, this study aimed to compare PTAR and mesiolingual  (MLi) canals and mesial wall of distal canal
DT in mandibular first molars in different age groups using was measured by calculating the minimum distance from
CBCT imaging. the edge of the root canal to the external surface of its
root.[11] The values were measured thrice, and the mean
SUBJECTS AND METHODS values were recorded.

Subjects Before measurement, the calibration was performed

This study was approved by the Human Experimentation by an examiner and an experienced oral radiologist. To
Committee of the Faculty of Dentistry, Chiang Mai test the intraexaminer reproducibility, ten samples were
University, Thailand (Clearance#26/2019). One hundred re‑examined after an interval of 2 weeks using intra‑class
CBCT images were retrospectively collected from patients, correlation coefficient  (ICC). ICC for intraobserver
aged 20–85 years old (mean = 44.72 ± 15.692), which were agreement of PTAR was 0.816 and for DT was 0.909.
taken for the purpose of routine therapeutic and clinical
evaluation from 2012 to 2019. All images were obtained Statistical analysis
using DentiScan  (NSTDA, Bangkok, Thailand), which had Statistical Package for the Social Sciences, version 23 (IBM
good quality for diagnosis. The images were categorized Company, Chicago, IL, USA), was used for data analysis.
into five groups (n = 20); age 20–29, 30–39, 40–49, 50–59, One‑way analysis of variance was used to determine
and 60 years old and older. significant difference among age groups and least
significant difference test was performed to determine
The inclusion criteria were right/left fully erupted which pair was different. The significant level was set at
mandibular first molar with complete root formation. The P < 0.05.
outline of the roots and pulp must be clearly seen with no
radiopaque restorative or endodontic filling. Meanwhile, RESULTS
the exclusion criteria were as follows: those with large
dental caries or restorative filling, excessive tooth wear, Pulp/tooth area ratio
presence of periapical lesion or other odontogenic or The PTAR reduced as one’s age increased. The morphological
nonodontogenic pathology, presence of root canal filling changes of PTAR are shown in Figure 1. The means of PTAR
or post or crown restoration, and presence of two root of each group is shown in Table 1. Significant differences
canals of distal root. were found among age groups in each level (P < 0.05).

Journal of Conservative Dentistry | Volume 24 | Issue 2 | March-April 2021 167

Chaleefong, et al: Pulp/tooth area ratio and dentin thickness

Figure 1: Morphological changes of pulp/tooth area ratio  (Levels A, B, and C) in mesial  (left) and distal  (right) roots of
mandibular first molars

Table 1: Mean and standard deviation of the pulp/tooth area ratio by age groups
Level Age groups (years) P
20-29 30-39 40-49 50-59 60 and older
Mesial root
A 0.078±0.019X 0.085±0.034X 0.075±0.027X 0.054±0.021Y 0.052±0.021Y 0.000*
B 0.076±0.022X 0.077±0.027X 0.074±0.035X 0.048±0.024Y 0.052±0.025Y 0.001*
C 0.078±0.036X 0.067±0.029X, Z 0.073±0.042X, W 0.056±0.027Y, Z, W 0.048±0.035Y, Z 0.035*
Distal root
A 0.091±0.032X 0.091±0.030X 0.091±0.027X 0.067±0.021Y 0.061±0.030Y 0.001*
B 0.093±0.034X 0.096±0.037X 0.093±0.037X 0.062±0.029Y 0.056±0.024Y 0.000*
C 0.080±0.031X, Y 0.085±0.033X 0.092±0.038X 0.064±0.026Y 0.043±0.023Z 0.000*
*Significant difference at P<0.05. If all the letters are distinct, a significant difference between the corresponding tracks is shown using Fisher’s LSD. LSD: Least significant
difference

Dentine thickness between age groups. According to a study by Porto et al.,[19]

The DT has been found to increase with age. The morphological who examined CBCT images obtained from maxillary
changes of DT are shown in Figure 2. The average of DT of each central incisors, they reported that pulp/tooth volume
group is shown in Table 2. Significant differences were found varies among age groups. Kaya et al.[17] also reported the
in distal DT of MB and MLi canal at 2 and 3 mm (P < 0.05) difference of pulp width of the maxillary central incisor
among age groups. No statistical difference was found in between age groups.
mesial DT of distal canal among age groups.
At Levels A and B, a significant reduction of the PTAR was
DISCUSSION determined between 40 and 49 years old and 50–59 years
old in both roots. Kaya et al.[17] reported that the greatest
Understanding the internal anatomy of the teeth plays a decrease in the pulp width of the maxillary central incisor
significant role in the success of endodontic and restorative was determined in the age group of 45–54  years. In
treatments.[15] Increasing age has been observed to change premolars, the steepest reduction of pulp/tooth volume
of pulp‑dentin complex due to the physical deposition of
was in the age group of 20–50  years.[18] Therefore, this
secondary dentin, which results in the reduced size of pulp
reduction could be attributed to varying tooth types and
chamber and root canal diameter.[5,11,17]
genetic and other environmental factors that may affect
To explore the change of PTAR among different age groups, secondary dentin deposition.
we selected the coronal part of the root because the
deposition of secondary dentin in multirooted tooth begins At Level C, PTAR was observed to decline with increasing
at the floor of the pulp chamber following the coronal part age, which is deemed similar to other levels. However, its
and then the apical part of the root.[5] The change of pulp pattern of significant difference among age groups was
space at the coronal part is strongly correlated with age different from those at the Levels A and B. The possible
than at the apex of root.[18] reason could be the difficulty to clarify the boundary of the
root canal.[6] Lee et al.[8] also reported that PTAR at cervical
PTAR has been observed to be inversely correlated with age. area has shown strong correlation with age than other
The mean values of PTAR showed significant differences levels.

168 Journal of Conservative Dentistry | Volume 24 | Issue 2 | March-April 2021

 Chaleefong, et al: Pulp/tooth area ratio and dentin thickness

Figure 2: Morphological changes of dentin thickness at 2 mm (left) and 3 mm (right) below furcation of mandibular first molars

Table 2: Mean and standard deviation of distal dentin thickness in mesial root and mesial dentin thickness in distal root
by age groups
Canal Age groups (years) Total group Minimum Maximum P
20-29 30-39 40-49 50-59 60 and older
2 mm below furcation
MB 0.728±0.150X 0.698±0.152X 0.876±0.150Y 0.851±0.189Y 0.838±0.175Y 0.789 0.461 1.335 0.002*
MLi 0.741±0.138X 0.734±0.155X 0.876±0.128Y 0.869±0.193Y 0.883±0.153Y 0.821 0.480 1.300 0.001*
Distal 0.973±0.240 0.860±0.194 0.986±0.155 0.962±0.276 0.980±0.187 0.952 0.493 1.612 0.323
3 mm below furcation
MB 0.718±0.152X 0.700±0.187X 0.839±0.139Y 0.840±0.213Y 0.869±0.215Y 0.793 0.408 1.337 0.009*
MLi 0.714±0.173X 0.695±0.131X 0.791±0.146X, Y 0.787±0.186X, Y 0.840±0.203Y 0.765 0.467 1.304 0.049*
Distal 0.801±0.213 0.790±0.170 0.899±0.169 0.891±0.207 0.871±0.141 0.850 0.497 1.286 0.182
*Significant difference at P<0.05. If all the letters are distinct, a significant difference between the corresponding tracks is shown using Fisher’s LSD. LSD: Least significant
difference, MB: Mesiobuccal, MLi: Mesiolingual

These results suggested that locating and negotiating the At distal root, our study showed no significant difference in
calcified canals are practical challenges during endodontic the mesial DT of distal canal among age groups. We found
treatment in patients with advanced age. Thus, endodontic that 30–39  years old had the smallest DT. However, the
treatment in older patients is more likely to be complicated data in terms of DT and the correlation with aging of distal
than in younger patients. root remain to be limited.

Understanding DT, especially in the danger zone, plays an In this study, DT increased with age particularly between
important role in successful endodontic and restorative 30 and 39 years old and 40–49 years old. In accordance
treatments. The DT reduction during root canal and post with the study of Gani et al.,[20] who examined root canal
space preparation is a crucial point that can lead to strip morphology of mandibular first molars, they reported that
perforation.[10] As per our findings, the mean distal DT of the root canals in adults over 40 years were sharply defined
mesial root ranged from 0.765 to 0.821 mm, while the and narrow compared to others. Nitzan et al.[21] reported
mesial DT of distal root ranged from 0.850 to 0.952 mm. that secondary dentine has significantly increased after the
Previous studies have reported that the distal DT in mesial age of 39. Based on these findings, it can be indicated that
roots ranged from 0.789 to 1.27 mm,[12] whereas the mesial younger patients have larger canal and thinner root canal
DT of distal root was at 1.3 mm.[13] The mean values could wall compared to older patients.
vary for many reasons, for example, usage of different
measurement methods, range of the danger zone location, This study showed that distal DT of the mesial root was
races, and the age of patients. smaller in comparison with the mesial DT of the distal
root. It was affirmed that the mesial root is prone to strip
According to our study, the distal DT at two and three perforation and crack formation during root canal and
mm below the furcation of mesial roots was significantly post space preparations.[11‑14] The lowest recommended
different among age groups. These results were consistent residual DT of 1 mm is generally accepted to avoid the risk
with the study of Zhou et al.,[11] which examined the axial of jeopardizing root integrity.[22] However, the minimum
CBCT images obtained from a Chinese population. This DT after root canal instrumentation should be at least
study reported that distal DT of MB and MLi canal had 0.2–0.3 mm in order to withstand compaction force
significantly increased with age in every age groups. during root canal filling, which can lead to perforation or

Journal of Conservative Dentistry | Volume 24 | Issue 2 | March-April 2021 169

Chaleefong, et al: Pulp/tooth area ratio and dentin thickness

vertical root fracture.[23] Therefore, accurate preoperative 2. Agholor CN, Sede MA. Endodontic treatment: An analysis of demand by
adult patients in a tertiary hospital in southern Nigeria. Nig J Dent Res
radiographs should be taken into account to help 2018;3:72‑8.
evaluate root anatomy before any treatment. Dentists may 3. Johnstone  M, Parashos  P. Endodontics and the ageing patient. Aust
Dent J 2015;60 Suppl 1:20‑7.
consider using CBCT imaging as it reveals more accurate 4. Kiefner  P, Connert  T, ElAyouti  A, Weiger  R. Treatment of calcified root
three‑dimensional information compared to traditional canals in elderly people: A clinical study about the accessibility, the time
radiographs.[15] needed and the outcome with a three‑year follow‑up. Gerodontology
2017;34:164‑70.
5. Kumar GS. Orban’s Oral Histology and Embryology. 14th ed. New Delhi:
Based on the results of PTAR and DT, we have determined Elsevier; 2015.
6. Poommouang  A, Lamaroon  A, Prapayasatok  S, Prastiwattanaseree  S,
that a decrease in PTAR corresponds to the increase in the Nalampang  S. Age estimation using segmented pulp/tooth area ratio
DT with increasing age. It was confirmed that pulp‑dentin method in Thai population. J Dent Assoc Thai 2018;68:165‑72.
7. Cameriere R, Ferrante L, Cingolani M. Variations in pulp/tooth area ratio
complex changes over time due to the deposition of as an indicator of age: A preliminary study. J Forensic Sci 2004;49:317‑9.
secondary dentin, which contributes to the narrowing of 8. Lee SM, Oh S, Kin J, Kim YM, Choi YK, Kewak H, et al. Age estimation
root canal and increasing DT around root canal. However, using the maxillary canine pulp/tooth ratio in Korean adults: A  CBCT
buccolingual and horizontal section image analysis. J Forensic Radiol
the deposition of secondary dentin was not consistent. Imaging 2017;9:1‑5.
Besides aging process, the dentin deposition may be 9. Kim  S. Prevalence of referral reasons and clinical symptoms for
endodontic referrals. Restor Dent Endod 2014;39:210‑4.
influenced by several other factors such as tooth loss or 10. Abou‑Rass  M, Frank  AL, Glick  DH. The anticurvature filing method to
occlusal contact.[24] Further study may be needed to explore prepare the curved root canal. J Am Dent Assoc 1980;101:792‑4.
11. Zhou  G, Leng  D, Li  M, Zhou  Y, Zhang  C, Sun  C, et al. Root dentine
factors related to the deposition of secondary dentin in thickness of danger zone in mesial roots of mandibular first molars. BMC
advanced ages. Oral Health 2020;20:1‑6.
12. Sauáia TS, Gomes BP, Pinheiro ET, Zaia AA, Ferraz CC, Souza‑Filho FJ,
et al. Thickness of dentine in mesial roots of mandibular molars with
Although the sample size calculation was done and different lengths. Int Endod J 2010;43:555‑9.
achieved, limited sample sizes might be a limitation of this 13. Tabrizizadeh  M, Reuben  J, Khalesi  M, Mousavinasab  M, Ezabadi  MG.
Evaluation of radicular dentin thickness of danger zone in mandibular
study. Thus, it would be great to obtain more samples to first molars. J Dent (Tehran) 2010;7:196‑9.
determine the relationship between age and the changes 14. Leite Pinto  SS, Lins  RX, Videira Marceliano‑Alves  MF, Guimarães MD,
Da Fonseca BA, Radetic AE, et al. The internal anatomy of danger zone
of PTAR and DT. of mandibular molars: A cone‑beam computed tomography study.
J Conserv Dent 2018;21:481‑4.
15. Kashyap RR, Beedubail SP, Kini R, Rao PK. Assessment of the number
CONCLUSIONS of root canals in the maxillary and mandibular molars: A  radiographic
study using cone beam computed tomography. J Conserv Dent
The PTAR was found to reduce; meanwhile, the DT was 2017;20:288‑91.
16. Nemsi  H, Haj Salem  N, Bouanene  I, Ben Jomaa  S, Belhadj  M,
found to increase with age. Clinically, the calcified canals Mosrati MA, et al. Age assessment in canine and premolar by cervical
and thin furcation area have been identified to be practical axial sections of cone‑beam computed tomography. Leg Med  (Tokyo)
2017;28:31‑6.
challenges in endodontic and restorative treatments. Thus, 17. Kaya  S, Adiguzel  O, Yavuz  I, Tumen  EC, Akkus  Z. Cone‑beam dental
accuracy and reliability of preoperative radiographs play computerized tomography for evaluating changes of aging in the
dimensions central superior incisor root canals. Med Oral Patol Oral Cir
an essential role in evaluating root canal morphologies in Bucal 2011;16:e463‑6.
order to avoid iatrogenic errors. 18. Aboshi  H, Takahashi  T, Komuro  T. Age estimation using microfocus
X‑ray computed tomography of lower premolars. Forensic Sci Int
2010;200:35‑40.
Acknowledgment 19. Porto  LV, Celestino da Silva Neto  J, Anjos Pontual  AD, Catunda  RQ.
The authors wish to thank Dr. Thanapat Sastraruji for his Evaluation of volumetric changes of teeth in a Brazilian population
by using cone beam computed tomography. J  Forensic Leg Med
assistance in the statistical analysis. 2015;36:4‑9.
20. Gani  OA, Boiero  CF, Correa  C, Masin  I, Machado  R, Silva  EJ, et al.
Morphological changes related to age in mesial root canals of permanent
Financial support and sponsorship mandibular first molars. Acta Odontol Latinoam 2014;27:105‑9.
Nil. 21. Nitzan DW, Michaeli Y, Weinreb M, Azaz B. The effect of aging on tooth
morphology: A study on impacted teeth. Oral Surg Oral Med Oral Pathol
1986;61:54‑60.
Conflicts of interest 22. Pilo  R, Shapenco  E, Lewinstein  I. Residual dentin thickness in
bifurcated maxillary first premolars after root canal and post
There are no conflicts of interest. space preparation with parallel‑sided drills. J Prosthet Dent
2008;99:267‑73.
23. Lim  SS, Stock  CJ. The risk of perforation in the curved canal:
REFERENCES Anticurvature filing compared with the stepback technique. Int Endod J
1987;20:33‑9.
1. Abuaffan  AH, Hayder  S, Hussen  AA, Ibrahim  TA. Prevalence of dental 24. Ikebe  K, Matsuda  K, Kagawa  R, Enoki  K, Okada  T, Yoshida  M, et al.
caries of the first permanent molars among 6‑14  years old Sudanese Masticatory performance in older subjects with varying degrees of tooth
children. Indian J Dent Educ 2018;11:13‑6. loss. J Dent 2012;40:71‑6.

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