Assessing consequences of untreated carious lesions using pufa index among 5-6 year old school children in an urban population
Abstract
Dental caries is a major chronic non-communicable disease affecting whole of mankind. Non-treatment of caries can have severe consequences like pain, abscess formation, space infection etc. leading to loss of function, working hours or absence from school in children. These consequences are equally important while planning dental care programme for a community. Despite this, none of the currently available caries indices record these events. The pufa index is first attempt to record such consequences. Hence the aim of this study was to assess prevalence and severity of consequences of untreated carious lesions using pufa index among 5-6 year old school children in an urban Indian population. 603 children from 12 randomly selected schools were examined for pufa and dmf index. Overall mean pufa value was 0.9 +/- 1.93 and prevalence was 38.6% with major contribution from p component of index. Untreated caries ratio was 35%, suggesting that more than one-third of the developed carious lesions causes adverse events in a population. Therefore this study emphasis the need for treating the caries at it earliest possible stage. The pufa index can be used as tool to highlight any adverse consequence that occur due to lack of treatment of caries for dental professionals and health authorities.
Key words: untreated caries, school children, pufa index, dmf index
Introduction
Oral diseases, such as dental caries, periodontal disease, tooth loss, oral mucosal lesions, oropharyngeal cancers and orodental trauma, are a serious public-health problem. There impact on individuals and communities in terms of pain and suffering, impairment of function and reduced quality of life, is considerable. The current pattern of oral diseases reflects distinct risk profiles across countries related to living conditions, behavioral and environmental factors, oral health systems and implementation of schemes to prevent oral disease 1.
Dental caries is a major oral health problem around the world, affecting 60-90% of schoolchildren and the vast majority of adults. In many developing countries, access to oral health services is limited and teeth are often left untreated or are extracted because of pain or discomfort. 2
For the last 70 years, data on prevalence of dental caries have been collected worldwide using the DMFT/dmft index. This classical index provides information on caries as well as its restorative and surgical treatment but fails to provide information on the clinical consequences of untreated dental caries, such as pulpal abscess, which may be more serious than the carious lesions themselves. A deep carious lesion with pulpal involvement is usually considered under the code 'caries of dentin' and pulpal involvement is not mentioned at all in the caries scoring system in the latest edition of WHO - Oral Health Surveys-basic methods 3. Some limited information might be obtained on the severity of advanced caries lesion by the scoring of 'teeth indicated for extraction' under treatment needs but this code does not give the precise reason for extraction. For example,' indicated for extraction' could be for reasons other than the consequences of untreated dental caries, e.g. as a sequel to trauma, for orthodontic or cosmetic reasons, or in preparation for a prosthesis. Moreover, 'treatment needs' for extraction are rarely reported in the literature and the consequences of untreated dental caries are hardly ever mentioned 4.
In the low and middle income countries like India where people have little access to oral health care there is a need for a diagnostic index that addresses the advanced stages of untreated caries lesions so that caries data collected should have impact on health decision makers, which is not possible with DMF index. The PUFA index is an attempt to compliment and increase the sensitivity of DMF index and to record consequences of a carious lesion.
Hence the present study was conducted with an aim of assessing prevalence and severity of oral conditions related to untreated caries lesions using pufa index among 5-6 year old school children of Chandigarh city. The other objective of the study was to provide relevant information to authorities on consequences of dental caries in the population complimentary to DMF index.
Materials and method
The present study was conducted on 603 school going children of 5-6 year age group in mainly urban Indian population.
Sample size calculation
There are around 100 government and 50 private schools in Chandigarh 7, the total population of 5-6 year old school going children will be around 30000 and considering prevalence rate of dental caries to be 70% 8, the sample size required was 379 at 95% confidence level. We end up examining more subjects than required sample size in order to give equal representation to different schools like government and private schools and location of school like urban and suburban. In total 603 children from 12 schools were examined. The study area was divided into 4 zones and 3 schools i.e. one private, one government and one school from suburban area was randomly selected from each zone.
Organization of survey
A pilot survey was conducted on 30 school children of each age for calibration and training of examiners. Attempt was made to diagnose all variables of the index i.e p,u,f,a but there was no case of ulcer (u) in the pilot sample. Inter- examiner reliability was assessed using kappa statistics. The kappa value was 0.78 which denotes substantial level of agreement between the examiners.
The data for main survey was collected over a period of two months. All the children were examined in school premises under natural light using mouth mirror and CPI probe. Ethical clearance for the study was obtained by institutional ethical committee. Permission to examine school children was taken from Principals of selected schools.
The PUFA index
PUFA is an index used to assess the presence of oral conditions resulting from untreated caries. The index is recorded separately from the DMFT/dmft and scores the presence of either a visible pulp, ulceration of the oral mucosa due to root fragments, a fistula or an abscess. The assessment is made visually without the use of an instrument. Only one score is assigned per tooth. In case of doubt concerning the extent of odontogenic infection, the basic score (P/p for pulp involvement) is given. If the primary tooth and its permanent successor tooth are present and both present stages of odontogenic infections, both teeth will be scored. Upper case letters are used for the permanent dentition and lowercase letters used for the primary dentition. The PUFA/pufa score per person is calculated in the same cumulative way as for the DMFT/dmft and represents the number of teeth that meet the PUFA/pufa diagnostic criteria. The PUFA for permanent teeth and pufa for primary teeth are reported separately. Thus, for an individual person the score can range from 0 to 20 pufa for the primary dentition and from 0 to 32 PUFA for the permanent dentition.
The prevalence of PUFA/ pufa is calculated as percentage of the population with a PUFA/ pufa score of one or more. The PUFA/pufa experience for a population is computed as a mean figure and can therefore have decimal values. The untreated caries, PUFA ratio is calculated as PUFA+pufa/ D+d X100. 4
Statistical analysis
The collected data was analyzed using SPSS version17. Mean and standard deviations will be calculated to express the mean def and pufa values. The statistical significance was determined by the chi-square test, and level of significance was set at p< 0.05.
Results
A total of 603 school children were surveyed, among whom 300 (49.8%) were males and 303 (50.2%) females. There was no significant difference in the sample size of two genders (p > 0.05). There was also no significant difference between numbers of 5 and 6 year old, it was also decided not to compare index scores for age because of close proximity of the ages and lack of proper age reporting of children by schools or parents (Table-1).
Overall pufa codes prevalence was 38.6%, the "p" component formed majority of the pufa codes (34.6%) and abscess formation due to periapical infection was second most frequent finding. There were only 2 cases of ulcer formation due to root fragment and sharp edges of pulpally involved tooth and 4 cases of fistula formation were recorded (Table-2). The overall mean pufa index was 0.9 +/- 1.93 and mean dmf was 2.54+/- 2.4 (Table-3). Prevalence of dental caries in the study population was 69.5%. The untreated caries ratio was found to be 35.3% which can be inferred as that more than one-third of decayed component progressed to pulpal involvement. Males were having significantly higher def as well as pufa values compared to females (chi square, p<0.05).
Discussion
603 children of 5-6 year age group were assessed for their dental caries status and its consequences using pufa and def indices. This age group covers effect of adverse oral environment on all primary teeth, some of these teeth are required in oral cavity upto the age of 12 years for space and function hence it is important to assess their future prognosis. WHO has also recommended this index age group for oral health assessment of primary dentition in their basic oral health survey methodology. 3
Prevalence of pufa codes was 38.6%, this is higher when compared to study conducted by Figueiredo MJ etal 9 on 5-6 year old Brazilian children (23.7%) but lesser than as Monse B etal 4 in Philippines (85%) but the caries prevalence was also high in this population (97%). Majority of this percentage was from 'p' component of pufa (34.7%) , this finding is comparable to other similar studies.4,9 Very few cases of other components were observed especially the u (ulceration) component, suggesting the need to modify the index by eliminating u and combining f and a components.9 We felt further studies are required to substantiate such modifications. Frencken JE etal has suggested these modifications and purposed a new index altogether called as CAST (caries assessment spectrum and treatment) index. This index was developed because of the need to find a reliable, pragmatic cohesive and easy to read reporting system which is based on the strengths of PUFA and ICDAS- II indices and provide a link to the widely used DMF index (M and F component). It covers the total dental caries spectrum - from no carious lesion, through caries protection (sealent) and caries cure (restoration) to carious lesions in enamel and dentine, and the advanced stages of caries lesion progression in pulpal and tooth surrounding tissue. It doesn't record active and inactive carious lesions.10 The CAST index has not been validated, nor has its reliability been tested. Also pufa index is suggested as a complimentary index to the dmf index not as its replacement.
Dental caries prevalence was 69.5% in studied sample which is comparable to other studies conducted in the same city. 8,11 Mean pufa value of 0.94 was higher than as reported by Figueiredo MJ etal 9 but lesser than as Monse B etal. 4 Gender comparison of mean pufa and def scores shows a significant difference between the two (p<0.05) with females having lesser scores as compared to males. Untreated cares ratio was 35.3% which is slightly less than as reported by Monse B etal. 4 This ratio provides an opportunity to explain the health authorities about the adverse consequences of dental caries on teeth of small children, if there are no preventive programme for them both at primary and secondary level of prevention. Untreated caries and its consequences have been found to be associated with negative impact on overall quality of life. 12
Large majority of untreated carious lesions as evident in the results of this study suggests lack of awareness among children, their parents and teachers regarding importance of good oral health. Therefore, there is an urgent need to plan a dental caries preventive and curative programme for school children in Chandigarh. Pufa index along with def index can act excellent epidemiological and educational tool for reporting consequences of untreated carious lesion in a population.
References: Dental Journal (2008) 58, 115-121
1. Petersen PE, World Health Organization global policy for improvement of oral health - World Health Assembly 2007 World Health Organization Int Dent J 2008;58:115-21
2. Petersen PE, World Oral Health Report 2003- Continuous improvement of oral health in the 21st century - the approach of the WHO Global Oral Health Programme, Community Dent Oral Epidemiol 2003; 31 (suppl.1): 3-24
3. World Health Organization. Oral Health Surveys- Basic Methods 4th edition Geneva,WHO;1997
4. Monse B, Heinrich-Weltzein R, Benzian H, Holmgren C, van Palenstein Helderman W. PUFA- an index of clinical consequences of untreated dental caries Community Dent Oral Epidemiol 2010;38: 77-82
5. Bratthall D. Introducing the Significant Caries Index together with a proposal for a new global oral health goal for 12-year-olds. Int Dent J 2000; 50: 378-84.
6. Broadbent JM, Thomson WM. For debate: problems with the DMF index pertinent to dental caries data analysis. Community Dent Oral Epidemiol 2005; 33: 400-9.
7. Official Website of Department of Education, Chandigarh administration, http:// www.educhandigarh.gov.in. Accessed on: March 15th 2012
8. Goyal A, Gauba K, Chawla HS, Kaur M, Kapur A. Epidemiology of dental caries in Chandigarh school and trends over the last 25 years; Journal of Indian Society of Pedodontics and Preventive Dentistry September 2007: 115-118
9. Figueiredo MJ, de Amorim RG, Leal SC, Mulder J, Frencken JE. Prevalence and severity of clinical consequences of untreated dentine carious lesions in children from a deprived area of Brazil. Caries Res. 2011;45(5):435-42.
10. Frencken JE, de Amorim RG, Faber J, Leal SC. The caries assessment and spectrum and treatment(CAST) index: rational and development Int Dent J 2011;61:117-23
11. Chawla HS, Gauba K, Goyal A. Trends of dental caries in children of Chandigarh over last sixteen years. J Indian Dent Assoc 2000;18:41-45
12. Leal SC, Bronkhorst EM, Fan M, Frencken JE. Untreated cavitated dentine lesions: impact on children's quality of life. Caries Res. 2012;46(2):102-6.
Tables:
Table-1: Distribution of subjects according to age and gender
Age
Gender
5
6
Male
female
Total (n=603)
270
333
300
303
Table-2: Prevalence of pufa index codes
Frequency
Percentage
p
209
34.6
u
2
0.003
f
4
0.006
a
18
0.02
Total
233
38.6
Table 3: Mean pufa and dmf values
Mean value (SD)
Mean value (SD)
p
0.84(1.5)
D
2.08 (2.3)
u
0.001(0.05)
M
0.45 (1.1)
f
0.01(0.08)
F
0.01 (0.2)
a
0.5(0.3)
Total
2.54 (2.4)
Total
0.9 (1.93)
