|Year : 2015 | Volume
| Issue : 2 | Page : 62-65
An Assessment System for the Consequences of Untreated Dental Caries
V Anil Dev Dutt, V Raja Sekhar, Kondala Rao Boddeda
Department of Pedodontics and Preventive Dentistry, GITAM Dental College and Hospital, Visakhapatnam, Andhra Pradesh, India
|Date of Web Publication||17-Dec-2015|
V Raja Sekhar
Department of Pedodontics and Preventive Dentistry, GITAM Dental College and Hospital, Gandhi Nagar Campus, Rushi Konda, Visakhapatnam - 530 045, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Aims and Objectives: To assess the prevalence of caries experience using decay-missing-filled teeth (DMFT)/decayed, extracted, and filled teeth (deft) index and severity of clinical consequences of untreated dental caries (PUFA/pufa index) in the age groups of 6, 12, and 15 years in urban and rural school going children of Visakhapatnam District. Materials and Methods: A cross-sectional study of 689 rural and urban school going children of Visakhapatnam District with the age groups of 6, 12, and 15 years were randomly selected. Intra oral examination was carried out to assess dental caries experience using the World Health Organization criteria. For data collection, DMFT/deft and PUFA/pufa index were used and data collected was tabulated and subjected to statistical analysis. Results: The mean prevalence of caries (DMFT + deft > 0) in rural: 37.37% and urban: 26.28%, and the mean prevalence of clinical consequences of untreated dental caries (PUFA + pufa > 0) in rural: 11.9% and urban: 10.7%. The "untreated caries, PUFA ratio" for 6 years children was found to be 53.33% in rural and 50% in urban, for 12 years children was found to be 41.05% and 16.43%, whereas for 15 years it is 15% and 17.54% in rural and urban children, respectively. Conclusion: The study showed that the prevalence of clinical consequence of the untreated dental caries is high in the rural children of age groups 6 and 12. Hence, the use of PUFA/pufa index as a compliment to the classical caries indices can address the neglected problem of untreated caries and its consequences. Furthermore, PUFA/pufa data may be used for planning, monitoring, and evaluating the treatment plan by the health care providers.
Keywords: Decay-missing-filled teeth/dmft index, PUFA/pufa index, untreated caries PUFA ratio, untreated dental caries
|How to cite this article:|
Dev Dutt V A, Sekhar V R, Boddeda KR. An Assessment System for the Consequences of Untreated Dental Caries. Indian J Oral Health Res 2015;1:62-5
|How to cite this URL:|
Dev Dutt V A, Sekhar V R, Boddeda KR. An Assessment System for the Consequences of Untreated Dental Caries. Indian J Oral Health Res [serial online] 2015 [cited 2019 Jul 21];1:62-5. Available from: http://www.ijohr.org/text.asp?2015/1/2/62/172034
| Introduction|| |
Despite improvements in oral health in high income countries during the last decades, dental caries is still a major global public health problem, as it involves the interaction between genetic and environmental factors in which biological, social, behavioral, and psychological components are expressed in a highly complex and interactive manner. 
The World Health Organization (WHO) has adopted decay-missing-filled teeth (DMFT) index in its oral health assessment form for conducting national oral health surveys.  Although this classical index provides information on caries as well as its restorative and surgical treatment, but it fails to provide information on the clinical consequences of untreated dental caries, such as pulpal involvement and dental abscess, which may be more threatening than the carious lesions themselves.  Hence, in 2007, the WHO World Health Assembly recognized the growing burden of oral diseases worldwide and emphasized the need to scale up action based on comprehensive data collection systems.  An index called as "PUFA" index (i.e. pulpal involvement, ulcer due to root fragments, fistula, and abscess) is developed by Monse et al. in 2010, , which attempts to compliment , and increase the sensitivity of original DMFT (decayed, extracted, and filled teeth [deft]) index and to record consequences of carious lesion. Data collected through this index can have impact on decision making by authorities regarding oral care, which is not possible with DMF index. 
The objective of this study is to assess the prevalence of caries experience using DMFT/deft index and to validate the PUFA/pufa index in assessing the prevalence and severity of oral conditions related to untreated caries in the age groups of 6, 12, and 15 years in urban and rural school going children of Visakhapatnam District.
| Materials and methods|| |
This study was carried out on 689 children in total of 336 rural and 353 urban school going children of Visakhapatnam District and oral examination was carried out by two trained examiners and two recorders, for data collection DMFT/deft (permanent and primary dentition) and the PUFA/pufa indices were used. Institutional ethical clearance was obtained before proceeding with survey. Inter examiner reliability was assessed using kappa statics. The kappa value was 0.78, which denotes substantial level of agreement between the examiners.
The examiners used sterilized mouth mirrors, CPITN-E probes and examined under illumination. According to the WHO criteria of age selection, the school children were separated according to the ages 6, 12, and 15 in rural and urban schools, respectively. Examination and interpretation was done according to the WHO criteria for dental caries. The data collected were tabulated and subjected to statistical analysis.
PUFA/pufa: It is an epidemiological assessment of dentition taking into account the condition of the pulp and periapical tissues and named it as index of clinical consequences of untreated dental caries, Monse et al. have proposed abbreviation PUFA from the first letters of English names of the assessed clinical situations: pulpal involvement, ulceration, fistula, and abscess for primary (pufa) and permanent (PUFA) dentition.
The recordings are generally given in [Table 1]. In case of one that describe the condition of tooth obtains code 1, and a tooth without the above-mentioned symptoms assigned code 0. The PUFA index is calculated similarly to the DMF and it is the sum of teeth with code 1. Thus, for an individual person, the score range from 0 to 20 pufa for the primary dentition and from 0 to 32 PUFA for the permanent dentition.
|Table 1: Description of the clinical situation assigned by individual codes for PUFA according to Monse et al.|
Click here to view
The data were analyzed with SPSS version 17 software (IBM Software Company) and the frequencies of dental caries and consequences of untreated dental caries, i.e., DMFT/deft and PUFA/pufa are calculated for rural and urban of all three age groups individually. The mean prevalence and standard deviation for dental caries (DMFT + deft > 0) and the consequences of untreated caries (PUFA + pufa > 0) were also calculated.
PUFA ratio was calculated for total urban and rural school children for all the three age groups individually using the formula.
| Results|| |
From a total of 689; urban (353) and rural (336) school going children of Visakhapatnam District in the age group of 6, 12, and 15 years were evaluated, the caries experience and frequency in rural and urban areas is shown in [Table 2].
The mean prevalence of caries (DMFT + deft > 0) in rural 37.37% and urban 26.28%, and the mean prevalence of untreated dental caries (PUFA + pufa > 0) in rural 11.9% and urban 10.7% are shown in [Table 3].
|Table 3: Prevalence of DMFT + deft >0 and PUFA + pufa >0 in rural and urban areas|
Click here to view
The "untreated caries, PUFA ratio" for 6 years children was found to be 50% and 53.33% and for 12 years children was found to be 16.438% and 41.05%, whereas for 15 years children in urban and rural was found to be 17.54% and 15%, respectively, as shown in the [Table 4].
The results of the present study showed that the prevalence of caries is higher in rural areas, significantly at the age group of 6 years, whereas there was no statistically significant difference between urban and rural areas, regarding the prevalence of untreated dental caries. The "untreated caries, PUFA ratio" for 6 years children was found to be higher in rural region; whereas, at 15 years, children recorded higher in urban region.
| Discussion|| |
Dental caries is the most common childhood disease and the most frequent noncommunicable disease worldwide (Petersen et al. 2005; Oziegbe et al. 2013).  Most of the dental decay remains untreated with significant impact on general health, quality of life,  productivity, behavior,  development, and educational performance  of children. In this study, 689 school going rural and urban children of Vishakhapatnam for 6, 12, and 15 years of age groups were assessed for their dental caries status and its consequences of untreated dental caries using DMFT/deft and PUFA/pufa indices.
The DMFT index is used worldwide for the collection of data on caries, although it provides limited information on the severity of advanced lesion by scoring of teeth "indicated for extraction," this code does not give precise reason for extraction but fails to provide accurate information on the clinical consequences of untreated dental caries. This might also over estimate or under estimate the present prevalence rate of dental caries as it not only scores decay but also scores missing (M) and filled (F) components. , During the last decade, International Caries Epidemiology had focused on the development of more sensitive diagnostic criteria for assessment of the initial stages of caries in developed nations. ,, However, in developing countries such as India, even though recorded decrease in dental caries, large proportion of caries remains untreated leading to innumerable consequences;  so there is a need for a diagnostic index that addresses the advanced stages of untreated caries lesions.  Hence, in this study, we used "PUFA/pufa" index along with DMFT/deft index which acts as an excellent epidemiological  and educational tool for reporting consequences of untreated carious lesions in a population. This PUFA/pufa index defines four different clinical stages of advanced caries providing "a face of the reality" to the prevailing and often ignored oral conditions which may be more serious than the caries, , and the age groups selected here are the index age groups recommended by the WHO for oral health assessment in their basic oral health survey methodology. 
The prevalence of DMFT/deft in different age groups in this study, being 37.37% and 26.28% in rural and urban children, respectively; this was compared to the studies conducted by Adekoya-Sofowora et al. (10.9%);  Nigerian study by Adeniyi et al. (10.9%);  and Oziegbe and Esan (16.9%).  However, comparisons between studies should be made with caution owing to the lack of uniformity in sample selection, age groups, and examination procedures.
The prevalence of untreated dental caries PUFA/pufa was 11.9% in rural and 10.7% in urban children, which is lower when compared to study conducted by Figueiredo et al. (2011) on 5-6-year-old Brazilian children (23.7%),  Monse et al. in Philippines (85%),  Baginska et al. among Polish children (43.4%),  Monse et al. (56%), Benzian et al. (55.7%),  and Leal et al. (26.2%).  This inconsistency may be attributed to the higher caries prevalence due to variation in their dietary habits, coupled with limited access to dental care.
The prevalence for untreated caries, PUFA ratio (6 years 53.33% and 50%, for 12 years to be 41.05% and 16.43%, in rural and urban children) had greater caries experience in rural areas as compared to urban children, which may be due to the fact that those children living in rural locations are less likely to be benefit from water fluoridation, socioeconomic hardships, physical barriers such as distance and lack of transportation, in proportionate patient/dentist ratio in rural areas (1:250,000), , lower utilization of dental care among preschool children residing in rural than in urban areas (45% vs. 53%; National Health Interview Survey, 1997 and 1998). It is therefore not surprising that children from rural areas have a greater burden of dental disease than do children from urban areas. Whereas for 15 years, it is 15% and 17.54% in rural and urban children, the slight increase in ratio in this age of urban children; as in this age child enter adolescence, changes in dietary habits, increased exposure to foods high in sugar, increased independence and responsibility for oral hygiene often put them at higher risk for dental caries. Among 15-year age, the proportion of adolescence with dental caries increases to 77.9% according to a survey done on the Indian population. 
The association between age and prevalence of dental caries has been reported in many studies. ,, The prevalence rate of caries is high in 6 years age group, which is accordance to many studies and this present study is mainly due to the lack of awareness and negative attitude of parents toward primary teeth; where only 4% of parents had knowledge about primary teeth and 82% of parents consider primary teeth are not important, which might be due to beliefs or cultural based opinions.  According to the National Oral Health Survey, 2002-2003, the mean DMFT/deft is 1.8 in the 12 years of age groups in India (Maru et al., 2012), the prevalence of dental caries of Indian children aged 12-14 ranged from 60.41% to 79.48% (Shanbhog et al., 2013),  and 17.3% among 5-14-year-old to 54.6% in those aged above 55 in rural population of India.  According to the adult dental health survey, 2009; there is 31% increase in prevalence of caries as age increases from 16 to 85 years.  The simple fact that teeth had been exposed to environmental insults for a longer period of time in mouths of older children may indirectly increase the probability of having a more advanced stage in the continuum of dental diseases,  which is significant to our results.
| Conclusion|| |
This new index (PUFA) would provide qualitative and quantitative information about untreated dental caries in an individual or populations based on clinical examination and when used along with the DMFS index, would provide additional data for health planners for effective planning and treatment  for target population. Hence, the use of PUFA/pufa index as a compliment to the classical caries indices can address the neglected problem of untreated caries and its consequences. Furthermore, PUFA/pufa data may be used for planning, monitoring, and evaluating the treatment by the epidemiologist and health care providers.
Large majority of untreated carious lesions in the children is evident in the results of present study, suggesting the lack of awareness among children, their parents and teachers regarding importance of good oral health, due to dental fear. The attention of health care providers and government agencies should be drawn to the PUFA/pufa score rather than the DMFT/dmft scores for planning and allocation of health resources. This is a baseline study; further studies are required to find out the reasons why there is a high prevalence of untreated caries PUFA/pufa ratio in this population.
| References|| |
Shanbhog R, Godhi BS, Nandlal B, Kumar SS, Raju V, Rashmi S. Clinical consequences of untreated dental caries evaluated using PUFA index in orphanage children from India. J Int Oral Health 2013;5:1-9.
Mehta A. Comprehensive review of caries assessment systems developed over the last decade. Rev Sul Bras Odontol 2012;9:316-21.
Mehta A, Bhalla S. Assessing consequences of untreated carious lesions using pufa index among 5-6 years old school children in an urban Indian population. Indian J Dent Res 2014;25:150-3.
Monse B, Heinrich-Weltzien 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.
Murthy AK, Pramila M, Ranganath S. Prevalence of clinical consequences of untreated dental caries and its relation to dental fear among 12-15-year-old schoolchildren in Bangalore city, India. Eur Arch Paediatr Dent 2014;15:45-9.
Oziegbe EO, Esan TA. Prevalence and clinical consequences of untreated dental caries using PUFA index in suburban Nigerian school children. Eur Arch Paediatr Dent 2013;14:227-31.
Nyvad B, Machiulskiene V, Baelum V. Reliability of a new caries diagnostic system differentiating between active and inactive caries lesions. Caries Res 1999;33:252-60.
Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, et al.
The international caries detection and assessment system (ICDAS): An integrated system for measuring dental caries. Community Dent Oral Epidemiol 2007;35:170-8.
World Health Organisation. Oral Health Surveys. Basic Methods. 5 th
ed. Geneva: World Health Organisation; 2013.
Adekoya-Sofowora CA, Nasir WO, Taiwo M, Adesina OA. Caries experience in the primary dentition of nursery school children in Ile-Ife, Nigeria. Afr J Oral Health 2006b; 2:19-25.
Adeniyi AA, Oyinkan O, Ogunbodede EO, Jeboda SO, Sofola OO. Dental caries occurrence and associated oral hygiene practices among rural and urban Nigerian pre-school children. J Dent Oral Hyg 2009;1:64-70.
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;45:435-42.
Baginska J, Rodakowska E, Wilczynska-Borawska M, Jamiolkowski J. Index of clinical consequences of untreated dental caries (pufa) in primary dentition of children from north-east Poland. Adv Med Sci 2013;58:442-7.
Benzian H, Monse B, Heinrich-Weltzien R, Hobdell M, Mulder J, van Palenstein Helderman W. Untreated severe dental decay: A neglected determinant of low Body Mass Index in 12-year-old Filipino children. BMC Public Health 2011;11:558.
Leal SC, Bronkhorst EM, Fan M, Frencken JE. Untreated cavitated dentine lesions: Impact on children′s quality of life. Caries Res 2012;46:102-6.
Tandon S. Challenges to the oral health workforce in India. J Dent Educ 2004;68 7 Suppl: 28-33.
Nagaveni NB, Radhika NB, Umashankar KV. Knowledge, attitude and practices of parents regarding primary teeth care of their children in Davangere city, India. Pesqui Bras Odontopediatria Clin Integr João Pessoa 2011;11:129-32.
US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health. Oral Health in America: A Report of the Surgeon General. Rockville, MD; May, 2000. Available from: . [Last accessed on 2013 Jun 03].
Maru AM, Narendran S. Epidemiology of dental caries among adults in a rural area in India. J Contemp Dent Pract 2012;13:382-8.
Jimmy Steele, Ian O′ Sullivan. Diseases and Related Disorders - A Report from Adult Dental Health Survey; 2009. Available from: [Last accessed on 2013 Nov 27].
Villalobos-Rodelo JJ, Medina-Solís CE, Maupomé G, Lamadrid-Figueroa H, Casanova-Rosado AJ, Casanova-Rosado JF, et al.
Dental needs and socioeconomic status associated with utilization of dental services in the presence of dental pain: A case-control study in children. J Orofac Pain 2010;24:279-86.
[Table 1], [Table 2], [Table 3], [Table 4]