Ethnic Variability in the Prevalence
of Submerged Primary Molars
E. KOYOUMDJISKY-KAYE* and S. STEIGMAN
Department of Orthodontics, Hebrew University-Hadassah School of Dental Medicine, t Jerusalem, Israel
Dental submergence, linked primarily with tooth ankylosis, has been
reported to have a possible genetic predisposition. The submergence
of primary molars was examined in a sample of 1530 children,
2.5-13.5 yr old, appertaining to seven ethnic groups living in Israel.
It was found that the frequency of submergence varied among the
ethnic groups, and that, on the whole, it was considerably higher
than that in North American children.
J Dent Res 61(12):1401-1404, December 1982
Introduction.
The exact causative factor of dental submersion has not, as
yet, been determined, although histological examinations of
submerged human teeth,1-3 substantiated by experimental-
ly induced submerging,4 demonstrated the association be-
tween the apparent tooth submergence and ankylosis.
Various studies, and especially those done on siblings,
indicated a possible genetic predilection.5-8 Thus, the great
variability in the frequency and distribution of submerged
teeth as reported in the literaturel,7l11 may also be due to
the different genetic backgrounds of the investigated popu-
lations.
The establishment of the State of Israel in 1948 enabled
the ingathering of complete Jewish communities, widely
dispersed geographically and culturally, following the
destruction of the First [586 B.C.E. (Before Common Era)]
and Second [70 C.E. (Common Era)] Temples. Each of these
communities had undergone considerable changes during
the many centuries of exile, as evidenced, for example, by
differences in appearance, in cephalofacial, in dental and
dental arch dimensions.12415 Their resettlement in separate,
predominantly rural communities greatly diversified the
overall population of Israel and created a natural laboratory
for the study of genetic variability.
The specific objectives of the present study were to
determine and to compare the rate of occurrence of sub-
merged primary teeth in seven of these ethnic groups.
Materials and methods.
The study was carried out on 1530 children, aged 2.5-
13.5 yr, appertaining to five Jewish ingathered groups -
Kurds, East Europeans, North Africans, Cochins, and
Yemenites and two non-Jewish endemic groups - Druse
-
and Circassians.
The two-stage sampling method allowing for ethnic
purity and socio-economic comparability has been described
in detail elsewhere.18 The children were almost equally
distributed among the ethnic and age groups and between
the sexes.
Submergence of primary molars was determined from
plaster study models obtained from each child. A tooth was
Received for publication March 9, 1982
Accepted for publication June 9, 1982
*Postal address: Department of Orthodontics, POB 1172, Jer-
usalem 91010, Israel
tFounded by Alpha Omega Fraternity, Jerusalem, Israel
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considered submerged if its intact marginal ridges were
more than 0.5 mm below the intact marginal ridges of the
adjacent normal teeth. Teeth whose marginal ridges were
obliterated by caries or by plaster defects were excluded
from the study. The following parameters were checked:
the number of children with one or more submerged teeth;
the frequency, distribution, and location of submerged
primary molars; and the degree of tooth submersion -
mild, moderate, or severe - as defined by Brearly and
McKibben.7
Analysis of the data was completed on a high-speed
digital computer.$ Ethnic variability was estimated in per-
centages. Differences between sex and age groups were tested
for each ethnic group by the X2 test. Data were analyzed
for age groups: 4.6-7.5 yr, 7.6-10.5 yr, and 10.6-13.5 yr -
the lowest age group (2.6-4.5) being too small for statistical
analysis. More detailed information relating to the investi-
gated parameters is available upon request.
Results.
The prevalence of children with submerged deciduous
molars in the various ethnic groups ranged from 14.23% to
35.27%, with considerable differences among some of the
groups (Table 1). Most affected were the Kurds. Only small
differences appeared among the East Europeans, Druse,
Circassians, and North Africans; all of those had a much
larger number of children with submerged teeth than did
the Cochins and Yemenites. These last two groups exhibited
the lowest percentage of submergence the Yemenites
even lower than the Cochins. A similar pattern was apparent
in the percentage of submerged primary molars out of the
total number of primary molars at risk.
Submergence tended to be more frequent in females in
the Kurds, East Europeans, and Circassians, while in the
Druse, North Africans, and Yemenites, the trend was higher
in males. Only in the Cochins was submerging significantly
higher in females (p < 0.05).
Three distinct patterns of differences between age
groups were depicted (Table 2). In the East Europeans,
Druse, and Yemenites, both the percentage of affected
children and the percentage of submerged molars rose in
the group aged from eight to ten yr, as compared to the
from-four-to-seven-yr group, significantly so in East Euro-
peans (p < 0.001) and Yemenites (p < 0.01), and thereafter
declined again in the from-ll-to-13-yr group. In Kurds,
Cochins, and Circassians, the number of affected children
decreased steadily with age; only in Kurds was the difference
between the various age groups statistically significant (p <
0.05). However, in these three ethnic groups, the percen-
tage of submerged primary molars, out of all primary
molars present, increased with age. In North Africans, both
parameters increased significantly with age (p < 0.02).
In all ethnic groups, the most frequently affected tooth
was the lower first primary molar (Table 3), usually followed
tCyber 74, Hebrew University Computation Centre, Jerusalem,
Israel
1401
1402 KO YOUMDJISKY-KA YE & STEIGMAN J Denzt Res December 1 9827

TABLE 1
PREVALENCE OF SUBMERGING PER ETHNIC GROUP AND SEX
Total Affected Children Affected Teeth
No. of No. of
Ethnic Group Children Teeth at Risk N % N %
Kurds male 114 633 38 33.33 75 11.85
female 110 653 41 37.27 98 15.01
total 224 1286 79 35.27 170 13.22
East male 110 537 28 25.45 61 11.36
Euro- female 80 403 30 37.50 54 13.40
peans total 190 940 58 30.53 115 12.23
Druse male 97 519 31 31.96 46 8.86
female 104 514 24 23.08 40 7.78
total 201 1033 55 27.36 86 8.33
Circas- male 99 423 25 25.25 44 10.40
sians female 61 270 18 29.51 36 13.33
total 160 693 43 26.88 80 11.54
North male 133 771 37 27.82 79 10.25
Afri- female 130 802 30 23.08 60 7.48
cans total 263 1573 67 25.48 139 8.84
Cochins male 104 616 12 11.54 19 3.08
female 103 614 23 22.33 49 7.98
total 207 1230 35 16.91 68 5.53
Yeme- male 127 595 19 14.96 31 5.21
nites female 112 594 15 13.39 24 4.04
total 239 1189 34 14.23 55 4.63

TABLE 2
ASSOCIATIONS BETWEEN SUBMERGING AND AGE
Age 4.6-7.5 Yr 7.6-10.5 Yr 10.6-13.5 Yr
Total % Total % Total %
Ethnic Group Sample Affected Sample Affected Sample Affected
East Europeans, C 235 20.85 290 26.90 105 19.05
Druse, Yemenites T 1459 5.35 1362 11.09 341 7.92
Kurds, Cochins, C 192 30.73 256 26.17 143 21.68
Circassians T 1333 9.08 1378 10.38 488 11.07
North Africans C 105 18.10 120 26.67 38 42.11
T 754 5.44 678 9.29 141 24.82
C, number of children.
T, number of teeth.

by the lower second primary molar. Only in Yemenite and
Druse boys did the percentage of submerged upper primary
first molars exceed that of the lower second molar. In the
two above-mentioned groups, as well as in the Circassian
and Cochin groups, no submerged upper second primary
molars were found.
In all ethnic groups, the majority of submerged teeth
were located in the lower arch only (p < 0.01), either in
one or in both its quadrants (Table 4). In East Europeans,
Kurds, and North Africans, submersion in the upper arch or
both arches, in three or four dental quadrants, was also
found in a relatively large percentage of the sample. In
these three ethnic groups, multiple submerging of primary
molars (Table 5) and a severe degree of submersion (Table
6) were present as well.
Out of the 46 children aged 2.6-4.5 yr, eight (17.39%)
had a total number of 13 submerged lower first primary
molars. No affected second primary molars were detected
in this age group. Four of the affected young children were
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Cochins, two were Kurds, and the other two were East
Europeans.
Discussion.
Previous epidemiologic surveys, in urban as well as in
rural settlements, reported a very high occurrence of
submerged primary molars in Israeli children.10,ll,17
Of all epidemiologic surveys cited in the literature,
Brearly and McKibben7 found the highest prevalence
(6.9o%) in North American children; in Israeli children of
mixed ethnic descent, it reached 24.8%. Although the
considerable discrepancy may partly be explained by our
very minimal definition of submergence, the results of the
present study reveal that this discrepancy evidently cannot
be solely attributed to this factor. The frequency of sub-
mergence varies considerably between the different ethnic
groups -- the frequency for the Kurds being about three-
fold that of the Yemenites. Nonetheless, even in Yemenites,
Vol. 61 No. 12 SUBMERGED PRIMARY MOLARS 1403

TABLE 3
DISTRIBUTION OF SUBMERGED PRIMARY MOLARS PER ETHNIC GROUP AND SEX
Lower M1 Lower M2 Upper M1 Upper M2
Ethnic Group T S T S T S T S
Kurds male 126 31.75 184 11.96 139 7.91 184 1.09
female 146 42.47 178 10.11 149 9.40 180 0.56
East male 90 24.44 136 13.97 133 12.03 178 2.25
Europeans female 75 36.00 93 11.83 104 14.42 131 0.76
Druse male 119 25.21 146 6.16 107 6.54 147
female 112 19.64 148 8.11 96 6.25 158
Circas- male 88 28.41 142 11.97 69 2.90 124
sians female 54 40.47 81 13.58 53 5.66 82
North male 164 25.00 232 12.07 165 4.85 210 0.95
Africans female 166 21.08 220 6.82 186 4.84 230 0.43
Cochins male 117 9.40 165 3.64 149 1.34 185
female 123 27.64 164 6.10 143 3.50 184
Yeme- male 96 19.79 167 2.99 144 4.86 188
nites female 116 12.93 155 3.23 131 3.05 192
M1, primary first molar; M2, primary second molar.
T, number of teeth at risk.
S, percentage of affected teeth.

TABLE 4
DISTRIBUTION ACCORDING TO LOCATION OF SUBMERGED TEETH
A. Dental Arches
Affected Lower Arch Upper Arch Both
Ethnic Group Children Only % Only % Arches %
Kurds 79 76.54 11.11 12.35
East Europeans 58 55.00 28.33 16.67
Druse 55 80.00 18.18 1.82
Circassians 43 86.05 4.65 9.30
North Africans 67 74.63 5.97 19.40
Cochins 35 82.05 7.69 10.26
Yemenites 34 76.47 17.65 5.88
B. Dental Quadrants
Affected One Both Quadrants One Quadrant Three or Four
Ethnic Group Children Quadrant % in One Arch % in Each Arch % Quadrants %
Kurds 79 33.33 54.32 2.47 9.88
East Europeans 58 48.34 35.00 5.00 11.66
Druse 55 52.73 45.45 1.82
Circassians 43 46.51 46.51 4.66 2.32
North Africans 67 43.28 37.31 2.98 16.43
Cochins 35 33.33 56.41 5.13 5.13
Yemenites 34 52.94 41.18 5.88

submerging occurs in a much higher percentage than in
North American children.
The different age changes detected in the various ethnic
groups might possibly be related not only to the genetic
predisposition to submerging, but also to the inception of
this condition and the exfoliation time of the submerged
tooth. Normal root resorption and exfoliation of submerged
primary teeth have already been established.7,18,19 It is
feasible that in East European, Druse, and Yemenite
groups, there is an initial increase of the frequency of
submersion due to excessive accumulation of affected
teeth, and, after the age of ten yr, a normal shedding process,
especially of the first primary molars, decreases the fre-
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quency. In Kurd, Cochin, and Circassian groups, the percen-
tage of affected teeth increases with age, despite the decrease
in number of affected children. In a longitudinal study of
113 children with submerged teeth, Brearly and McKibben7
found that, during a four-year follow-up, in 29.2% of the
children from one to five additional teeth became affected.
Although the present findings are based on a cross-sectional
study, similar events may be responsible for the trend in the
above-mentioned ethnic groups, as witnessed by the high
percentage of multiple submerging found in these children.
The pattern of the North African group, in which the num-
ber of affected children, as well as the number of submerged
teeth, increased with age, could be attributed to a late onset
1404 KOYOUMDJISKY-KA YE & STEIGMAN J Dent Res December· 1 982

TABLE 5 TABLE 6
DISTRIBUTION OF AFFECTED CHILDREN (%) PER NUMBER SEVERITY OF SUBMERSION IN AFFECTED TEETH
OF SUBMERGED TEETH IN EACH CHILD
Submersion
No. of Number of Submerged Teeth No. of
Affected Ethnic Group Affected Teeth Mild Moderate Severe
Ethnic Group Children 1 2 3 4 5-6
Kurds 170 84.97 13.29 1.74
Kurds 79 29.63 48.15 6.17 13.58 2.47 East Europeans 115 84.03 12.61 3.36
East Europeans 58 43.33 35.00 10.00 6.67 5.00 Druse 86 86.05 9.30 4.65
Druse 55 52.73 40.00 5.45 1.82 Circassians 80 82.50 17.50
Circassians 43 41.86 37.21 13.95 6.98 North Africans 139 84.17 10.79 5.04
North Africans 67 43.28 28.36 11.94 11.94 4.48 Cochins 68 96.00 4.00
Cochins 35 30.77 53.85 7.69 7.69 Yemenites 55 85.45 14.55
Yemenites 34 52.94 35.29 8.82 2.94

of the condition. 8. VIA, W.F.: Submerged Deciduous Molars: Familial Tendencies,

Other obvious differences in sex predilection and loca-
tion, multiplicity, and severity of submersion are apparent
(Tables 3-6), although it is difficult to assign genetic affinity
among certain groups appearing with similar trends, since
these are different in the various distributions.
The data presented in this study supplement the suppo-
sition that genetic predisposition may play a role in the
frequency of submersion. Both the Jewish and non-Jewish
groups investigated from this area have an obviously higher
tendency to submersion than reported in epidemiologic
studies from the North American Continent.
A close affinity in anthropometric parameters,12 as well
as in blood group distributions,20-23 has been found between
the investigated groups and their host populations. A con-
siderable gene flow must have been responsible for this
affinity. From the historic background of these ethnic
groups,16 it can be surmised that the East Europeans,
Druse, Circassians, and North Africans each have a highly-
mixed origin, while the Kurds, Yemenites, and Cochins have
admixtures predominantly from the host populations.
Epidemiologic studies of submersion in the latter may
present an additional aspect of how dispersion has affected
the variability of these groups.
Conclusions.
The findings in the present study support the proposition
of a genetic predisposition being involved in dental sub-
mergence. It is suggested that epidemiologic surveys in
additional countries may contribute further knowledge on
the subject.
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