ASSESSMENT OF DENTAL ANODONTIA AMONG FERDINAND I MILITARY TECHNICAL ACADEMY STUDENTS IN ROMANIA

Background / Aim. Data regarding tooth absence among Romania military personnel are lacking. The purpose of this study was to determine the prevalence of dental anomalies among military students at a military technical academy in Bucharest, Romania. Methods. A cohort of 318 military students enrolled the study. Each participant underwent an extensive evaluation of their oro-dental health status based on guidelines of the EGOHID II (European Global Oral Health Indicators Development II Project). Results. Anodontia was discovered in 6/318 participants (prevalence rate, 1.9%), namely 4 women (prevalence among women, 4.6%) and 2 men (prevalence among men, 0.87%). Five of the six patients were previously undiagnosed. The most commonly affected teeth were second premolars (n = 8), followed by first premolars (n = 4) and second permanent molars (n = 2). Premolar anodontia was equally common in the maxilla and the mandible; both instances of molar anodontia were in the mandible. None of the participants with anodontia had remaining temporary teeth. A brief overview of the case of two of the presently diagnosed patients, who presented with inferior bilateral second molar anodontia and quadruple canine inclusion and a quadruple second premolar anodontia, is included. Conclusion. Military students in Romania would benefit from systematic dental evaluation and long-term monitoring prior to the enrollment the Military Academy.


Introduction
Romania, being a strategic partner of NATO, is an active participant in peacekeeping operations that require Romanian military troops to remain combat ready.
Military readiness depends on physical training, mental training, and health, including orodental health. 1,2,3 Specialized dental emergency care cannot be administered to personnel located in isolated areas for combat missions or combat exercises. Moreover, the medical evacuation of a soldier in the event of such an emergency requires substantial logistical and human resources. Hence, it is important to monitor the oro-dental health status of troops.
To this end, NATO has published military oral health standards for NATO member states with a dental fitness classification system. 4 Data regarding tooth loss among Romania military personnel are lacking. Teeth can be missing for a variety of reasons, including extraction due to caries, trauma, or anodontia. 5,6 Incomplete dentition can disrupt patients' quality of life due several functional impacts, including impaired masticatory and phonetic function, as well as psychosocial impacts, due to discomfort, pain, or shame related to a poor aesthetic. 7 It is important that oro-dental disease be timely diagnosed to enable provision of appropriate interdisciplinary treatments that can correct functional and aesthetic deficiencies.
Individuals may have anodontia of both temporary and permanent teeth, 8,9,10 or may, more commonly, have anodontia of a permanent tooth despite having had complete temporary dentition. 11,12,13,14,15 Ideally, anodontia should be recognized early in children's radiographs. However, many young adults joining the Romanian military may not have received regular dental care during childhood. Thus, it is likely that there are military academy students with undiagnosed congenital anodontia or with missing teeth due to trauma or tooth decay. The aim of the present study was to assess the oral health status of Romanian military students, with particular attention to identification of missing teeth due to anodontia.

Participants
Appropriate enrolment to achieve a representative sample was estimated to be 261 participants in Open-Epi, version 2.3, 16  were invited to participate in this study. Because participation in the study was voluntary, following random selection, the sample should be considered a sample of convenience. The inclusion criteria in this study were: (1) being a year 1, 2, or 3 student at the academy; (2) and completing the informed consent form to participate in the study. Before being asked for consent, prospective participants were informed of the purpose and stages of the study, potential study benefits for participants and for medical research, and implications of providing informed consent to participate in the study.

Clinical Evaluation
Participating students were subjected to an examination in the academy's dental office between March and May of 2019. Prior to clinical evaluation, the following information was recorded for each participant: age, gender, time since last dental examination, time it takes to get to the dentist, use of fluoride toothpaste, typical number of snacks between main meals, tobacco and alcohol consumption, type of high school graduated (military or civilian), and environment of origin (urban or rural). For each clinical examination, a dental mirror, dental probe, dental tweezer, light, air spray, cotton rolls, cotton balls, toothbrushes, and possibly dental floss were used.
Before their examinations, subjects were asked to remove any removable braces or dentures. The examiner made sure that the teeth to be examined were clean, intervening where necessary by cleaning teeth with a dry toothbrush. Floss was used to remove interdental bacterial plaque. To perform a thorough examination, the teeth were dried for 5 seconds with air spray or a cotton ball, and the teeth were illuminated with a light source from the dental unit.
The examiner searched for signs of oro-dental disease and dental anomalies, according to the EGOHID II Dental Disease Assessment form, similar to the sample form shown in the European Global Oral Health Indicators Development Project Report. 17 Causes of missing teeth were coded in accordance with EGOHID II guidelines outlined in the aforementioned report as follows: CODE 97, extracted due to caries; CODE 98, missing for any other reason; and CODE 99, unerupted (visible in an x-ray). Additionally, missing teeth that had been rehabilitated with an implant were noted with CODE P. Dental sites of anodontia were identified according mouth quadrant (1-4, upper right and left, lower right and left, respectively) and dental site within the quadrant (numbered from central incisor backward). When anamnesis indicated that a missing tooth were never present in the arch, a radiological evaluation was performed or was presented by the patient to confirm or rule out anodontia. Third molars were not considered in this study. The clinical examinations took, on average, 12 minutes per patient (range, 10~15 minutes).

Participants
Of the 805 students invited to participate, 318 students gave informed consent and

Dental Findings
Cohort Anodontia was observed in 6 of the 318 participants (1.88%), including 4 women (prevalence among women, 4.6%) and 2 men (prevalence among men, 0.87%). The most affected teeth were the second premolars (n = 8), followed by the first premolars (n = 4) and permanent molars (n = 2). There were six absent premolars from the maxilla, and six absent premolars from the mandible. The sites of both anodontia-affected permanent molars were located in the mandible. None of the participants had a temporary molar corresponding to the premolar(s) affected by anodontia. The dental sites affected by anodontia are summarized in table 1.
Notably, five of the six participants in whom anodontia was discovered received their diagnosis of anodontia for the first time in the course of this study. Only one of them had been receiving ongoing dental monitoring and the rest of them had not heard of this type of abnormality.

Treated Case
Teeth surrounding sites affected by anodontia often exhibited inter-dentition tremas and dental rotations that would be expected to disrupt optimal dento-maxillary functioning.

Figure 1
The coexistence of anodontia together with dental inclusions can affect the positioning of patients' teeth in both arches. Notably, this patient presented with excessive tremas in both arches together with a midline maxillary diastema, which were corrected by orthodontic treatment. No skin, hair, nails, eyes, or bone abnormalities were observed during her clinical examinations, indicating that her anodontia was non-syndromic.
Because the patient was adopted and not in contact with her biological family, it could not be determined whether she may have inherited the observed dental abnormalities.

Untreated Case
Another example is of a 19 years old female participant that had anodontia at the level of all four second premolars (D.A.I., images in Fig. 2). In this case, the radiograph was performed four years before the clinical examination, but shows the absence of premolars. Also in this case there was a non-syndromic anodontia. This patient did not benefit of orthodontic treatment.

Discussion
The prevalence of anodontia observed in the present study cohort (1.88%) was within the range of previously reported anodontia incidence rates (0.15-13.4%), 8,10,18,19,20,21,22,23 while being slightly lower than that reported in a prior study conducted in Romania in the period of 2008-2015 (3%). 24 Although women constituted only 27.4% of our cohort, women accounted for two-thirds of the anodontia cases observed, consistent with prior studies reporting a higher risk of anodontia in females than males. 8,10,12 The predominance of second premolars being affected by anodontia in our study is consistent with prior studies reporting that second premolars and upper lateral incisors were the teeth most often affected by anodontia 25,26 with the most often affected teeth within series of like-type teeth being the distal tooth in each series (i.e. lateral incisor, second premolar, third molar). 8,27,28 We observed bilateral, rather than unilateral, anodontia of the second premolars, more frequently than has been reported in previous studies. 10,29 In general population, anodontia of the second molars is quite rare, with reported prevalence rates ranging from 0% to 3.4%; 19,21,22,30,31 in our study, we observed a 0.31% (N = 1) prevalence. Previously, anodontia of the second permanent molars has been reported to be accompanied by other dental anomalies. 10 In the case observed here, the patient presenting with anodontia of the permanent lower second molars had comorbid inclusion of all four permanent canines.
Only one of the six patients diagnosed in our study had received a prior diagnosis of anodontia. Of the six patients in whom anodontia was identified, only one elected to proceed with orthodontic treatment. That patient had anodontia of the second permanent molars of the lower arch (V.E.C. shown in Fig. 1). None of the patients in whom anodontia of the premolars was discovered accepted to receive specialized therapy to correct associated dento-maxillary dysfunctions.
There are two major limitations of this study. First, the study focused on a single military academy with young adult students in Romania. Thus, the findings may not reflect the general population. Second, the sample of anodontia cases discovered was small. Given that data regarding the oral health status of Romanian military students and personnel are lacking, a similar analysis should be conducted for the Romanian armed forces at large.
Furthermore, a longitudinal study conducted with periodic evaluations would be warranted to reveal how the treatment needs of military personnel changes over time, and thus to provide information regarding the logistical and human resources that should be involved.

Conclusions
prevalence of almost 1 in 50. Second premolars were the most common teeth affected, followed by first premolars and second permanent molars. Both arches and both sides were affected at similar rates. The participants' lack of prior knowledge of their diagnoses indicates that the dental needs of members of the Romanian military academy are not yet being well met. The lack of early treatment for dental anomalies that impair dentomaxillary function, such as anodontia, can result in worsening of oro-dental status over time, and thus more costly corrective treatment. 32 Timely therapeutic intervention may be facilitated by widespread early dental evaluations.