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: dinon25@gmail.com
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: WKHLRPMedknow_reprints@wolterskluwer.com
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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


which is often attributed to advanced age, is a degenerative
change of pulp‑dentin complex caused by secondary dentin
deposition, which is formed throughout life after completed
root formation.[3,5] The relationship between secondary
dentin deposition and age was examined and used for age
estimation using dental radiographs. Several researchers
have found that the pulp/tooth area ratio (PTAR) decreased
with aging; however, the majority of the previous studies
used single‑rooted teeth.[6‑8]
Strip perforation is another complication that can lead to
the failure of endodontic treatment.[9] This is often caused
by overinstrumentation at the furcation area, known as a
danger zone.[10] In mandibular first molar, the distal wall
of mesial root has limited dentin thickness  (DT), around
2–4 mm under the furcation.[11‑14] Data remain lacking in
terms of the correlation of DT and aging.
Cone‑beam computed tomography (CBCT), which has the
ability to create accurate three‑dimensional images, could
be a powerful tool in endodontic treatment. CBCT provides
accurate information of internal root canal anatomy.[15]
Moreover, CBCT imaging can overcome problems related
to the superimposition of image from crowding of the
teeth, providing axial images traditional radiographs
cannot.[8,16] Thus, this study aimed to compare PTAR and
DT in mandibular first molars in different age groups using
CBCT imaging.
SUBJECTS AND METHODS
Subjects
This study was approved by the Human Experimentation
Committee of the Faculty of Dentistry, Chiang Mai
University, Thailand (Clearance#26/2019). One hundred
CBCT images were retrospectively collected from patients,
aged 20–85 years old (mean = 44.72 ± 15.692), which were
taken for the purpose of routine therapeutic and clinical
evaluation from 2012 to 2019. All images were obtained
using DentiScan  (NSTDA, Bangkok, Thailand), which had
good quality for diagnosis. The images were categorized
into five groups (n = 20); age 20–29, 30–39, 40–49, 50–59,
and 60 years old and older.
The inclusion criteria were right/left fully erupted
mandibular first molar with complete root formation. The
outline of the roots and pulp must be clearly seen with no
radiopaque restorative or endodontic filling. Meanwhile,
the exclusion criteria were as follows: those with large
dental caries or restorative filling, excessive tooth wear,
presence of periapical lesion or other odontogenic or
nonodontogenic pathology, presence of root canal filling
or post or crown restoration, and presence of two root
canals of distal root.
Journal of Conservative Dentistry | Volume 24 | Issue 2 | March-April 2021
Chaleefong, et al: Pulp/tooth area ratio and dentin thickness
Axial cone‑beam computed tomography
image acquisition
CS 3D imaging software (Version 3.7.1, Carestream Dental,
Rochester, New York, USA) was used. The axial images were
obtained at three levels of each root; Level A (furcation),
Level B (between Levels A and C), and Level C (half distance
between the furcation and apex of the root) to measure
the PTAR and at 2 and 3 mm under furcation to measure
DT. Then, the axial images were exported to ImageJ
software  (Version  1.50i, National Institutes of Health,
Bethesda, Maryland, USA). The contrast and brightness of
the images were adjusted to achieve optimal visualization.
Methods
Pulp and tooth area analysis
According to the axial images at Levels A, B, and C, twenty
points of tooth outline and ten points of pulp outline were
created[7] using polygon selection. The areas of pulp and
tooth were measured thrice, and the mean values were
recorded. The PTAR of each level was calculated for each
sample.
Dentin thickness analysis
According to the axial images at 2 and 3 mm under
furcation, the DT of distal wall of mesiobuccal  (MB) and
mesiolingual  (MLi) canals and mesial wall of distal canal
was measured by calculating the minimum distance from
the edge of the root canal to the external surface of its
root.[11] The values were measured thrice, and the mean
values were recorded.
Before measurement, the calibration was performed
by an examiner and an experienced oral radiologist. To
test the intraexaminer reproducibility, ten samples were
re‑examined after an interval of 2 weeks using intra‑class
correlation coefficient  (ICC). ICC for intraobserver
agreement of PTAR was 0.816 and for DT was 0.909.
Statistical analysis
Statistical Package for the Social Sciences, version 23 (IBM
Company, Chicago, IL, USA), was used for data analysis.
One‑way analysis of variance was used to determine
significant difference among age groups and least
significant difference test was performed to determine
which pair was different. The significant level was set at
P < 0.05.
RESULTS
Pulp/tooth area ratio
The PTAR reduced as one’s age increased. The morphological
changes of PTAR are shown in Figure 1. The means of PTAR
of each group is shown in Table 1. Significant differences
were found among age groups in each level (P < 0.05).
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
changes of DT are shown in Figure 2. The average of DT of each
group is shown in Table 2. Significant differences were found
in distal DT of MB and MLi canal at 2 and 3 mm (P < 0.05)
among age groups. No statistical difference was found in
mesial DT of distal canal among age groups.
DISCUSSION
Understanding the internal anatomy of the teeth plays a
significant role in the success of endodontic and restorative
treatments.[15] Increasing age has been observed to change
of pulp‑dentin complex due to the physical deposition of
secondary dentin, which results in the reduced size of pulp
chamber and root canal diameter.[5,11,17]
To explore the change of PTAR among different age groups,
we selected the coronal part of the root because the
deposition of secondary dentin in multirooted tooth begins
at the floor of the pulp chamber following the coronal part
and then the apical part of the root.[5] The change of pulp
space at the coronal part is strongly correlated with age
than at the apex of root.[18]
PTAR has been observed to be inversely correlated with age.
The mean values of PTAR showed significant differences
who examined CBCT images obtained from maxillary
central incisors, they reported that pulp/tooth volume
varies among age groups. Kaya et al.[17] also reported the
difference of pulp width of the maxillary central incisor
between age groups.
At Levels A and B, a significant reduction of the PTAR was
determined between 40 and 49 years old and 50–59 years
old in both roots. Kaya et al.[17] reported that the greatest
decrease in the pulp width of the maxillary central incisor
was determined in the age group of 45–54  years. In
premolars, the steepest reduction of pulp/tooth volume
was in the age group of 20–50  years.[18] Therefore, this
reduction could be attributed to varying tooth types and
genetic and other environmental factors that may affect
secondary dentin deposition.
At Level C, PTAR was observed to decline with increasing
age, which is deemed similar to other levels. However, its
pattern of significant difference among age groups was
different from those at the Levels A and B. The possible
reason could be the difficulty to clarify the boundary of the
root canal.[6] Lee et al.[8] also reported that PTAR at cervical
area has shown strong correlation with age than other
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
calcified canals are practical challenges during endodontic
treatment in patients with advanced age. Thus, endodontic
treatment in older patients is more likely to be complicated
than in younger patients.
At distal root, our study showed no significant difference in
the mesial DT of distal canal among age groups. We found
that 30–39  years old had the smallest DT. However, the
data in terms of DT and the correlation with aging of distal
root remain to be limited.

Understanding DT, especially in the danger zone, plays an
important role in successful endodontic and restorative
treatments. The DT reduction during root canal and post
space preparation is a crucial point that can lead to strip
perforation.[10] As per our findings, the mean distal DT of
mesial root ranged from 0.765 to 0.821 mm, while the
mesial DT of distal root ranged from 0.850 to 0.952 mm.
Previous studies have reported that the distal DT in mesial
roots ranged from 0.789 to 1.27 mm,[12] whereas the mesial
DT of distal root was at 1.3 mm.[13] The mean values could
vary for many reasons, for example, usage of different
measurement methods, range of the danger zone location,
races, and the age of patients.
According to our study, the distal DT at two and three
mm below the furcation of mesial roots was significantly
different among age groups. These results were consistent
with the study of Zhou et al.,[11] which examined the axial
CBCT images obtained from a Chinese population. This
study reported that distal DT of MB and MLi canal had
significantly increased with age in every age groups.
In this study, DT increased with age particularly between
30 and 39 years old and 40–49 years old. In accordance
with the study of Gani et al.,[20] who examined root canal
morphology of mandibular first molars, they reported that
the root canals in adults over 40 years were sharply defined
and narrow compared to others. Nitzan et al.[21] reported
that secondary dentine has significantly increased after the
age of 39. Based on these findings, it can be indicated that
younger patients have larger canal and thinner root canal
wall compared to older patients.
This study showed that distal DT of the mesial root was
smaller in comparison with the mesial DT of the distal
root. It was affirmed that the mesial root is prone to strip
perforation and crack formation during root canal and
post space preparations.[11‑14] The lowest recommended
residual DT of 1 mm is generally accepted to avoid the risk
of jeopardizing root integrity.[22] However, the minimum
DT after root canal instrumentation should be at least
0.2–0.3 mm in order to withstand compaction force
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
radiographs should be taken into account to help
evaluate root anatomy before any treatment. Dentists may
consider using CBCT imaging as it reveals more accurate
three‑dimensional information compared to traditional
radiographs.[15]
Based on the results of PTAR and DT, we have determined
that a decrease in PTAR corresponds to the increase in the
DT with increasing age. It was confirmed that pulp‑dentin
complex changes over time due to the deposition of
secondary dentin, which contributes to the narrowing of
root canal and increasing DT around root canal. However,
the deposition of secondary dentin was not consistent.
Besides aging process, the dentin deposition may be
influenced by several other factors such as tooth loss or
occlusal contact.[24] Further study may be needed to explore
factors related to the deposition of secondary dentin in
advanced ages.
Although the sample size calculation was done and
achieved, limited sample sizes might be a limitation of this
study. Thus, it would be great to obtain more samples to
determine the relationship between age and the changes
of PTAR and DT.
CONCLUSIONS
The PTAR was found to reduce; meanwhile, the DT was
found to increase with age. Clinically, the calcified canals
and thin furcation area have been identified to be practical
challenges in endodontic and restorative treatments. Thus,
accuracy and reliability of preoperative radiographs play
an essential role in evaluating root canal morphologies in
order to avoid iatrogenic errors.
Acknowledgment
The authors wish to thank Dr. Thanapat Sastraruji for his
assistance in the statistical analysis.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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