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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 86-95

Reliability of Kvaal's and Cameriere's methods of age estimation in a specific populace in central India


1 Department of Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital and Post-Graduate Research Institute, Parbhani, India
2 Consultant Oral Medicine and Radiologist, Bangalore, Karnataka, India
3 Department of Oral and Maxillofacial Surgery, VYWS Dental College and Hospital, Amravati, Maharashtra, India
4 Consultant Oral and Maxillofacial Pathologist, Amravati, Maharashtra, India
5 Consultant Oral and Maxillofacial Surgeon, Amravati, Maharashtra, India

Date of Web Publication19-Dec-2016

Correspondence Address:
Abhishek Singh Nayyar
44, Behind Singla Nursing Home, New Friends' Colony, Model Town, Panipat - 132 103, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2393-8692.196121

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  Abstract 

Context: Comparison between antemortem and postmortem dental records and radiographs produces results with a high degree of reliability and relative simplicity. Kvaal et al. introduced an age estimation method by indirectly measuring secondary dentin deposition on radiographs. Cameriere et al., later, put forth a method based on radiographic estimation of pulp/tooth area ratio (AR) in canines. The purpose of the present study was to assess the reliability of various teeth in Kvaal's and Cameriere's methods of age estimation in a specific populace in Central India. Materials and Methods: One hundred and ten patients aged between 15 and 75 years were selected, and the variables P = complete pulp length/root length (from enamel-cementum junction [ECJ] to root apex), r = complete pulp length/complete tooth length, a = complete pulp length/root width at ECJ level, b = pulp/root width at midpoint level between ECJ level and mid-root level, and c = pulp/root width at mid-root level and pulp/tooth AR were recorded as devised in Kvaal's and Cameriere's methods of age estimation, respectively. Statistical Analysis: Statistical analysis was performed with SPSS (version 10.5) package. Mean comparison of morphological variables was carried out using Student's t-test. Intra- and inter-observer reproducibility of measurements was studied using the concordance correlation coefficient. Results: Comparing between Kvaal's and Cameriere's methods, results of the latter method were found to be more accurate in predicting age. Conclusion: Kvaal's method showed varying results for different teeth, but Cameriere's method was more consistent, accurate and showed less variability.

Keywords: Age estimation, Cameriere′s method, Kvaal′s method


How to cite this article:
Nayyar AS, Gayitri H C, Naphade MV, Naphade UM, Qureshi AQ, Siddiqui FI, Anwar SS, Shroff PR. Reliability of Kvaal's and Cameriere's methods of age estimation in a specific populace in central India. Indian J Oral Health Res 2016;2:86-95

How to cite this URL:
Nayyar AS, Gayitri H C, Naphade MV, Naphade UM, Qureshi AQ, Siddiqui FI, Anwar SS, Shroff PR. Reliability of Kvaal's and Cameriere's methods of age estimation in a specific populace in central India. Indian J Oral Health Res [serial online] 2016 [cited 2019 Nov 20];2:86-95. Available from: http://www.ijohr.org/text.asp?2016/2/2/86/196121


  Introduction Top


Aging refers to irreversible and inevitable changes that occur with time, which encompasses all aspects of human life, namely, anatomic, physiologic, and psychological. [1] Aging, in forensic context, is necessary both for the dead and the living. For the dead, it is principally to aid in the identification process by creating a biological profile which can, then, be compared to missing individuals while in case of the living, the aim is to solve judicial or, civil problems concerning age of minors in questions of adoption and/or, immutability and for adults, to solve judicial or, civil problems for individuals lacking valid documents for identification. [2] Although several parts of the body can be used for age estimation, the poor condition of the remains, particularly, in severe crashes or, fires, in cases of those recently dead, and due to moisture and burial conditions, in cases of historic subjects, make, many parts of the body, unusable. [3] Despite these problems, in the last few years, the literature has provided several skeletal and dental methods for assessing age. Most of them apply many age indicators related to degenerative changes in the skeleton. [4] Teeth can survive in most of the conditions, encountered at death, and during decomposition, even when the body is exposed to extreme forces and/or temperatures. [5] The specific composition and shape of teeth are a source for many different hereditary and acquired characteristics. Thus, they can serve as reliable biomarkers of aging. It is also observed that tooth development is not perceptibly affected by diseases, drugs, as well as the endocrine status as compared to the bones, consequently making them the preferred tissue in forensic and archaeological investigations. [5] Once a tooth is fully mineralized and erupted, it forms a very stable entity. Both the developmental and regressive changes affecting the teeth can be related to chronological age of the individual. In the last few years, forensic odontology has shown increasing interest in search for optimal age estimation methods in individuals using dental tissues/teeth as evidence. These methods are broadly classified as morphologic and radiologic methods. The former are further subclassified as clinical, histologic, and biochemical methods which include methods analyzing the various forms of tooth modification such as wear, dentin transparency, tooth cementum annulations, racemization of aspartic acid, and apposition of secondary dentin. [3] However, all these methods have one or the other limitation restricting their usage on a mass scale. Furthermore, radiography, being a nondestructive method, plays a vital role in forensic odontology to uncover the hidden facts, which cannot be seen by means of physical examination. Dental examination and comparison between antemortem and postmortem dental records and radiographs produce results with a high degree of reliability and relative simplicity. [6],[7] Radiographic age estimation, using teeth, relies on developmental stages of teeth especially in children, while in adults, continuous deposition of secondary dentin throughout the life depicted by reduction in pulp area can be employed. Several age estimation methods exploit changes undergone by the teeth during the lifetime, but most are destructive warranting extraction of teeth. These methods, therefore, cannot be used in living individuals and in cases where it is not acceptable to extract teeth for various reasons. [8] Radiography, thus, plays an important role in such cases. [9] Dental pulp is a mesenchymal tissue surrounded by a pulp canal. Outside the pulp, there are some odontoblastic lines, which release dentin during the subject's life and reduce the size of the pulp canal. Changes in its size caused by the apposition of secondary dentin are the best morphometric parameters for estimating age in adult subjects as it is a continuous process that takes place throughout the life of an individual. This apposition of secondary dentin can be indirectly measured by the reduction in pulp size on the radiographs. In 1925, Bodecker established that the apposition of secondary dentin correlated with age. [10] Kvaal et al. introduced an age estimation method by indirectly measuring secondary dentin deposition on radiographs and proposed a number of length and width measurements of tooth and pulp. [6] Cameriere et al., later, put forth a similar method based on radiographic estimation of pulp/tooth area ratio (AR) in canines. [7] The purpose of the present study was to assess the reliability of various teeth in Kvaal's and Cameriere's methods of age estimation in a specific populace in Central India.


  Materials and methods Top


Source of data

A total number of 110 patients, 59 males and 51 females, aged between 15 and 75 years, were selected from the outpatient department. Seven age groups (Group I-VII) were formed with both males and female patients. Group I consisted of 15 patients with age between 15 and 20 years, Group II (age 20-30 years) with 47 patients, Group III (age 30-40 years) with 23 patients, Group IV (age 40-50 years) with 15 patients, Group V (age 50-60 years) with 3 patients, Group VI (age 60-70 years) with 4 patients, and Group VII (age 70-75 years) with 3 patients. The permission to conduct the present study was obtained from the Institutional Ethics Committee. All the patients gave an informed consent prior to being included into the study.

Selection criteria

Inclusion criteria

  • Patients aged between 15 and 75 years
  • The selected teeth were the right or left maxillary central incisor, lateral incisor, and second premolar and right or left mandibular lateral incisor, canine, and first premolar which had fully erupted into the oral cavity
  • The roots of the teeth were fully formed
  • Individuals were of ethnic origin from Central India (history confirmed up to two generations).


Exclusion criteria

  • Teeth with any pathology, such as caries or periodontitis or periapical lesions, that would alter the surface area of the tooth
  • Patients with a history of trauma with or without fracture of teeth
  • Teeth with any prosthetic rehabilitations and orthodontic appliances
  • Fractured teeth
  • Severely attrited teeth secondary to parafunctional habits
  • Teeth with any developmental anomaly.


After clinical examination, patients who fitted into the inclusion criteria were subjected to digital intraoral radiographs.

Methodology

Intraoral radiography

Patients were selected according to the decided inclusion and exclusion criteria. After selection of the patients, their consent was taken for radiographic examination. All the guidelines were followed as per the ALARA principle while subjecting the patients to digital intraoral radiographs. The radiographic examination was carried out with the help of X mind X-ray system, 70 kv, 8 mA, 0.425 kVA, 2 mm aluminum filter manufactured by SATELEC (India) Private Limited; DIGORA Optime DXR-50 5001, Digital Imaging System with Windows 2.8 Digital Imaging Program. PSP Digital Sensor (DIGORA Optime DXR-50 5001, Digital Imaging System) with size 2 sensor (31 mm × 41 mm) and Film holding instrument: RINN-Greene Stabe Disposable Film Holder were used with AutoCAD 2007 software (Autodesk Inc., San Rafael, CA, USA) for taking digital intraoral radiographs.

Positioning of the patient

  • For maxillary teeth: The patient's head was positioned upright with the sagittal plane vertical and the occlusal plane horizontal
  • For mandibular teeth: The patient's head was tilted back slightly to compensate for the change in occlusal plane, when the mouth was opened.


Measurement of teeth by Kvaal's method is shown in [Figure 1] wherein the following morphological variables were recorded.
Figure 1: Measurement of teeth by Kvaal's method

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p = complete pulp length/root length (from enamel-cementum junction [ECJ] to root apex)

r = complete pulp length/complete tooth length

a = complete pulp length/root width at ECJ level

b = pulp/root width at midpoint level between ECJ level and mid-root level

c = pulp/root width at mid-root level.

Measurement of teeth by Cameriere's method is shown in [Figure 2] wherein the pulp/tooth area ratio (AR) was recorded.
Figure 2: Measurement of teeth by Cameriere's method

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Measurements were made by a second observer to prevent any inter-observer bias. The morphological variables, chronological age, and subject's gender were entered in a Microsoft Excel Spreadsheet for use as predictive variables for age estimation. Correlation coefficients were evaluated between chronological age and morphological variables. Estimated age was obtained using morphological variables for each tooth.

Statistical analysis

Statistical analysis was performed with SPSS (version 10.5, SPSS Inc., Chicago, USA) package. Mean comparison of morphological variables was carried out using Student's t-test. Intra- and inter-observer reproducibility of measurements was studied using the concordance correlation coefficient.


  Results Top


The chronological age of adults was estimated based on the measurements of the different said variables of the various teeth including maxillary central incisor, lateral incisor, and second premolar and mandibular lateral incisor, canine, and first premolar which were numbered 1-6, respectively, on images of digital intraoral radiographs from derived regression equations. The demographic data of the patients are presented in [Table 1] and [Graph 1 [Additional file 1]]. There was no significant difference observed between morphological variables amongst the males and females indicating gender did not influence the estimation of chronological age [Table 2],[Table 3],[Table 4],[Table 5] and [Table 6]. In Tooth # 4 (mandibular lateral incisor), however, morphological variables, b = pulp/root width at midpoint level between ECJ level and mid-root level and width (W), showed a weakly positive correlation between gender and chronological age [Table 7]. Comparison of the readings of the two observers did not reveal any statistical significance [Table 8]. Karl Pearson's correlation coefficients between age and morphological variables showed that the variables P = complete pulp length/root length (from ECJ- root apex), r = complete pulp length/complete tooth length, mean (M), length (L) and pulp/tooth area ratio (AR) correlated significantly with age with variable P = complete pulp length/root length (from ECJ- root apex) correlating the best amongst them. The ratios between width measurements (a = complete pulp length/root width at ECJ level, b = pulp/root width at midpoint level between ECJ level and mid-root level, and c = pulp/root width at mid-root level) correlated least with age and were not found to be statistically significant and therefore excluded from further statistical analysis. Variable P = complete pulp length/root length (from ECJ to root apex) had highest P value of − 0.920 for central incisor and − 0.951 for mandibular first premolar [Table 9]. The scatter plot graph between predicted age and chronological age showed that the resultant values were equally distributed along the line. Comparing between Kvaal's and Cameriere's methods, results of the latter method were found to be more accurate in predicting age. The scatter plot graph between predicted versus estimated age showed better distribution in Cameriere's method than Kvaal's method [[Graph 2 [Additional file 2]],[Graph 3 [Additional file 3]] and [Graph 4 [Additional file 4]]; with Graph 2 showing comparative analysis between Kvaal's and Cameriere's methods, Graph 3 for Kvaal's method, and Graph 4 for Cameriere's method].
Table 1: Distribution of the study sample by age groups and gender

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Table 2: Comparison of the morphological variables among males and females

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Table 3: Comparison of the morphological variables among males and females

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Table 4: Comparison of the morphological variables amongst males and females

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Table 5: Comparison of the morphological variables among males and females

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Table 6: Comparison of the morphological variables among males and females

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Table 7: Comparison of the morphological variables amongst males and females

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Table 8: Comparison of inter - observer observations

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Table 9: Correlation between age and morphological variables

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  Discussion Top


In 1995, Kvaal et al. [6] presented a method for age estimation which was based on investigation of periapical radiographs while Paewinsky et al. [11] verified the applicability of this method on orthopantomographs. Cameriere et al., in 2004, for the first time conducted a preliminary study to evaluate the variations in pulp/tooth AR as an indicator of age and their method of age estimation seemed promising. [7] While the authors obtained high levels of accuracy in age prediction, they advised that future research should investigate "the effect of race and culture in model parameters." Indeed, other researchers have, also, advocated the verification of age estimation methods on independent samples and some have concluded that best results are derived when population-specific formulas are used. Babshet et al. found that Cameriere's formula, based on the Italian population, is not as applicable to the Indian population as was the case of naive population. [12] The purpose of the present study was to assess the reliability of various teeth in Kvaal's and Cameriere's methods of age estimation in a specific populace in Central India based on the relationship between chronological age and measurement of different variables, as used in Kvaal's and Cameriere's methods, of selected teeth, using digital intra-oral periapical radiographs (IOPARs). The study sample included, 110 patients aged between 15-75 years, only of Central India origin with atleast last two generations residing in the location of the study. This was done to ensure ethnic uniformity of the study sample, considering that the development of teeth varies among populations and that it is genetically determined. Digital radiography was selected because of less radiation exposure than the conventional film-based radiography. Since Kvaal et al. did not find significant differences between teeth from the left and the right side of the jaw, [6] teeth from either left or right side were processed depending on whichever were best suited for measurements. Ratios between the teeth and pulp size were calculated. This procedure helped to reduce the effect of the possible variation in magnification and angulation of the intraoral radiographs. The present study revealed that gender had no significant influence on the morphological variables of teeth, except for morphological variables, b = pulp/root width at midpoint level between ECJ level and mid-root level and width (W), which showed a weakly positive correlation between gender and chronological age for mandibular lateral incisor, similar to the findings of the studies conducted by Kvaal et al. [6] and Cameriere et al. [7] Few other studies by Jeevan et al. [13] and Cameriere et al., [14],[15] also, showed similar results. In the present study, width ratios (a = complete pulp length/root width at enamel-cementum junction (ECJ) level, b = pulp/root width at midpoint level between ECJ level and mid-root level and c = pulp/root width at mid-root level) did not show significant correlation with age. In addition, there were no significant differences between inter- and intra-observer measurements in the present study, similar to the studies, conducted by Kvaal et al., [6] Cameriere et al., [7],[14],[15] Paewinsky et al., [11] Jeevan et al., [13] and Zaheer et al. [16] In the present study, Pearson's correlation coefficients between chronological age and morphological variables showed that the variables P = complete pulp length/root length (from ECJ to root apex), r = complete pulp length/complete tooth length, length (L), and pulp/tooth AR correlated well with the chronological age. Using Cameriere's method, it was found that the morphological variable pulp/tooth AR contributed significantly to the chronological age estimation in contrast to the findings of the study conducted by Saxena. [3] Similarly, contrasting results were found with the studies conducted by Kvaal et al. [6] and Bosman et al., [17] which showed better correlation of chronological age with morphological variables associated with width ratios (a = complete pulp length/root width at ECJ level, b = pulp/root width at midpoint level between ECJ level and mid-root level, and c = pulp/root width at mid-root level) rather than length ratios (p = complete pulp length/root length [from ECJ to root apex] and r = complete pulp length/complete tooth length). The results of the present study were in slight disagreement with the findings of the studies conducted by Meinl et al. [9] and Kanchan-Talreja et al., [18] with the variations observed explained on the basis of the diversity in the ethnicity of the population under study. The scatter plot graph between predicted age and chronological age showed that the resultant values were equally distributed along the line. Comparing between Kvaal's and Cameriere's methods, results of the latter method were found to be more accurate in predicting age. The scatter plot graph between predicted versus estimated age showed better distribution in Cameriere's method than Kvaal's method [Graphs 2-4; with Graph 2 showing comparative analysis between Kvaal's and Cameriere's methods, Graph 3 for Kvaal's method, and Graph 4 for Cameriere's method]. To conclude, based on these variables, chronological age could be determined with an accuracy of 81.90% with Kvaal's and 93.50% with Cameriere's methods.


  Conclusion Top


In the present study, individual teeth correlated best with chronological age than all the teeth taken together. In addition, statistical analysis indicated that gender did not show any correlation with chronological age. Of all the morphological variables, variables P = complete pulp length/root length (from ECJ to root apex), r = complete pulp length/complete tooth length, mean (M), length (L), and pulp/tooth AR correlated significantly with age with variable P = complete pulp length/root length (from ECJ to root apex) correlating the best among them. Variables associated with width ratios (a = complete pulp length/root width at enamel-cementum junction (ECJ) level, b = pulp/root width at midpoint level between ECJ level and mid-root level and c = pulp/root width at mid-root level) rather than length ratios (p = complete pulp length/root length (from ECJ- root apex) and r = complete pulp length/complete tooth length) correlated best with chronological age in the selected populace of Central India origin. To conclude, although both Kvaal's and Cameriere's methods were found suitable for age estimation in Central India Population but Cameriere's method, in particular, was found to be more consistent and reliable.

Limitations of the study

  • Though the results of the study are promising, they cannot be generalized to other populations. Therefore, separate regression equations were formulated;
  • Rotated teeth, decayed teeth or, teeth with any prosthesis were excluded from the study. If the individual has any of the mentioned conditions, then this method cannot be employed to estimate the age, as these conditions alter the tooth surface area.


Need for future studies

  • The efficacy of these methods should be further confirmed or validated using a larger sample size from population of different racial and ethnic origin;
  • Future studies can be taken up to estimate the age using other single rooted teeth and multirooted teeth to determine the completeness of these methods.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Saxena S. Age estimation of Indian adults from orthopantomographs. Braz Oral Res 2011;25:225-9.  Back to cited text no. 3
    
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Cameriere R, De Luca S, Alemán I, Ferrante L, Cingolani M. Age estimation by pulp/tooth ratio in lower premolars by orthopantomography. Forensic Sci Int 2012;214:105-12.  Back to cited text no. 4
    
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Eckert William G. Introduction to Forensic Science. 2 nd ed. Dunfermline, United Kingdom: Better World Books Ltd., CRC Press Inc.; 1997.  Back to cited text no. 5
    
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Kvaal SI, Kolltveit KM, Thomsen IO, Solheim T. Age estimation of adults from dental radiographs. Forensic Sci Int 1995;74:175-85.  Back to cited text no. 6
    
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Cameriere R, Ferrante L, Cingolani M. Variations in pulp/tooth area ratio as an indicator of age: A preliminary study. J Forensic Sci 2004;49:317-9.  Back to cited text no. 7
    
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Meinl A, Huber CD, Tangl S, Gruber GM, Teschler-Nicola M, Watzek G. Comparison of the validity of three dental methods for the estimation of age at death. Forensic Sci Int 2008;178:96-105.  Back to cited text no. 9
    
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Drusini AG. The coronal pulp cavity index: A forensic tool for age determination in human adults. Cuad Med Forense 2008;14:235-49.  Back to cited text no. 10
    
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Paewinsky E, Pfeiffer H, Brinkmann B. Quantification of secondary dentine formation from orthopantomograms - A contribution to forensic age estimation methods in adults. Int J Legal Med 2005;119:27-30.  Back to cited text no. 11
    
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Babshet M, Acharya AB, Naikmasur VG. Age estimation in Indians from pulp/tooth area ratio of mandibular canines. Forensic Sci Int 2010;197:125.e1-4.  Back to cited text no. 12
    
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Jeevan MB, Kale AD, Angadi PV, Hallikerimath S. Age estimation by pulp/tooth area ratio in canines: Cameriere′s method assessed in an Indian sample using radiovisiography. Forensic Sci Int 2011;204:209.e1-5.  Back to cited text no. 13
    
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Cameriere R, Cunha E, Sassaroli E, Nuzzolese E, Ferrante L. Age estimation by pulp/tooth area ratio in canines: Study of a Portuguese sample to test Cameriere′s method. Forensic Sci Int 2009;193:128.e1-6.  Back to cited text no. 14
    
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    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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