|Year : 2018 | Volume
| Issue : 1 | Page : 19-23
Severity and clinical consequences of untreated dental caries using PUFA index among schoolchildren in Udupi Taluk, India
Deepak K Singhal, Nishu Singla
Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Udupi, Karnataka, India
|Date of Web Publication||9-Jul-2018|
Dr. Deepak K Singhal
Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Udupi, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Data on dental decay using the Decayed, Missing, Filled teeth (DMFT/dmft) index provides information on caries and treatment experiences only, but fails to give information on clinical consequences of untreated dental caries. Aim: The aim of the study was to determine the prevalence and clinical consequences of untreated dental caries using Pulp, Ulceration, Fistula, Abscess (PUFA) index among schoolchildren. Materials and Methods: A cross-sectional survey of 957 schoolchildren, aged 6–15 years in Udupi taluk was conducted. Caries experience was evaluated according to World Health Organization (WHO) criteria, 1997 (DMFT/dmft index) and clinical consequences of untreated dental caries by PUFA/pufa index. Results: The results showed that 77.3% of 6–10 years old children had caries (mean dmft score: 3.30 ± 2.9, mean DMFT score: 0.26 ± 0.7), 47.3% showed clinical consequences of untreated caries (mean pufa score: 1.30 ± 1.9, mean PUFA score: 0.03 ± 0.2) and 26.8% reported pain. In 11–15 years old children, 55.6% had caries (mean dmft score: 0.36 ± 0.9, mean DMFT score: 1.04 ± 1.4), 18% showed prevalence of pulpal involvement (mean pufa score: 0.15 ± 0.5, mean PUFA score: 0.14 ± 0.4) and 11.6% reported pain. Statistical analysis revealed a strong relation between DMFT/dmft and PUFA/pufa in both age groups. Conclusion: The present study revealed negligence in the dental treatment of children resulting in pulpal involvement. This index is a valuable measurement tool to record clinical consequences of untreated dental caries.
Keywords: Clinical consequences of untreated caries, dental caries, PUFA index, schoolchildren, untreated caries
|How to cite this article:|
Singhal DK, Singla N. Severity and clinical consequences of untreated dental caries using PUFA index among schoolchildren in Udupi Taluk, India
. J Orofac Sci 2018;10:19-23
|How to cite this URL:|
Singhal DK, Singla N. Severity and clinical consequences of untreated dental caries using PUFA index among schoolchildren in Udupi Taluk, India
. J Orofac Sci [serial online] 2018 [cited 2022 Aug 7];10:19-23. Available from: https://www.jofs.in/text.asp?2018/10/1/19/236209
| Introduction|| |
Dental caries among children still continues to be the most common childhood disease worldwide, despite improvements in oral health during the last few decades. Treatment of dental caries among schoolchildren is almost nonexistent in developing countries. Untreated dental caries is a global public health problem, especially among child population.
For the last 75 years, data on dental decay have been collected worldwide using the DMFT/dmft index, which only provides information on caries and treatment experiences (extraction due to caries and restoration of decayed teeth) but fails to give information on the clinical consequences of untreated dental caries, such as involvement of pulp and dental abscess. Despite this fact that consequences of untreated caries are more serious than caries lesions themselves, very few studies have recorded them in caries assessment indices.,,, Untreated caries have been shown an impact of children’s quality of life by causing pain, discomfort and sepsis, problems in chewing and learning behavior, sleeping and behavior disturbances, children’s nutrition, growth, body mass index, general health, and quality of life.
In order to improve oral health care facilities, especially in low and middle income countries, as well as deprived communities within high income countries, where people have little access even to the most basic forms of dental care, there is a need for a diagnostic index that presents the correct data on the consequences of advanced stages of dental caries to the health care professional and authorities. Monse et al. in 2010 developed the PUFA/pufa index. This new index attempts to compliment and increase the sensitivity of original DMFT (def) index and to record consequences of a carious lesion. Data collected through this index can have impact on decision taken by authorities regarding oral care, which is not possible with the use of DMFT index.
Even though, a large number of surveys have been conducted on schoolchildren in India, reporting the prevalence of dental caries and caries experience,,, but the data on severity and clinical consequences of untreated dental caries are relatively unknown. So the purpose of the present study was to determine the prevalence of dental caries and untreated dental caries among schoolchildren in Udupi taluk, India and to gather basic data on clinical consequences of untreated dental caries among them using PUFA/pufa index.
| Material and Methods|| |
A cross-sectional survey was conducted among 6–15 years old schoolchildren enrolled in schools of Udupi taluk. The sample was collected from six randomly selected schools (three each from rural and urban areas) in Udupi taluk. The ethical approval for this study (IEC: 24/2011) was obtained from the Institutional Ethical Committee on 11 Feb 2011. Before conducting the survey, permission was obtained from school authorities. Information about oral examination was given to the children and their parents, and written consent was obtained. Those children, whose parents did not allow their children to participate, were excluded from the study. The total sample consisted of 957 schoolchildren aged 6–15 years and was divided into two groups according to age; 6–10 years old and 11–15 years old children.
Caries was recorded for both permanent and primary teeth in terms of decayed, missing and filled teeth index (DMFT and dmft), using World Health Organization recommendations for oral health surveys (1997) and untreated caries was assessed using PUFA/pufa index according to the standard procedure recommended by Monse et al.
It is an index used to assess the presence of oral conditions and infections resulting from untreated caries in the primary (pufa) and permanent (PUFA) dentition. 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 permanent dentition, and lowercase letters are used for primary dentition. The index scores denote the presence of either a visible pulp, ulceration of the oral mucosa due to root fragments, a fistula or an abscess. In case of doubt concerning the extent of odontogenic infection, the basic score (P/p for pulp involvement) was given. The lesions in surrounding tissues that are not related to a tooth with visible pulp involvement as a result of caries are not recorded. No instruments are used; only mouth mirror is needed to retract the cheek for better vision. The assessment is made visually, and only one score is assigned per tooth.
The codes for PUFA index are as follows:
Training and calibration of the examiner for recording indices were completed before conducting the examination. Clinical examination was conducted in the premises of each school under natural daylight. All children were advised to brush their teeth prior to examination. Children were examined for dental caries and untreated dental caries while seated on the chair with their heads resting on the back rest.
The PUFA/pufa score per person is calculated in the same cumulative way as for the DMFT/dmft. 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 0–32 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 value and can, therefore, have decimal values. The "Untreated Caries, PUFA ratio” is calculated as: [(PUFA + pufa)/(D + d)] ×100.
The collected data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, United States) version 20.0 software. Descriptive statistical analyses included prevalence and means of caries status (DMFT scores) and untreated caries status (PUFA scores). The statistical significance was determined by using the chi-square test, and level of significance was set at P < 0.05.
| Results|| |
The sample was distributed according to age and gender as shown in [Table 1]. A total sample of 957 schoolchildren consisting of 568 (59.4%) males and 389 (40.6%) females. A total sample of 507 children belonged to 6–10 years age group, while 450 children were in 11–15 years age group.
|Table 1: Distribution of study subjects according to age groups and gender|
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[Table 2] showed that 77.3% of 6–10 years old children had caries, 47.3% showed clinical consequences of untreated caries and 26.8% reported pain when examined. The caries experience in the primary dentition was 3.3 dmft with majority (3.11) on the d component. The permanent dentition presented 0.26 DMFT purely concentrated on the D component (0.25). The pufa index, for the primary dentition was 1.30 and the PUFA index for the permanent dentition was 0.03. The main component of PUFA/pufa was pulpal involvement. The "Untreated Caries PUFA Ratio" was 37.4%, indicating that 37.4% of the D + d component for this age group had progressed to an odontogenic infection [[Table 3] and [Table 4]].
|Table 2: Prevalence (%) of caries (DMFT/dmft) and prevalence (%) of PUFA/pufa of study population/schoolchildren|
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|Table 4: Mean PUFA/pufa experience (SD) of study population/schoolchildren|
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In 11–15 years old children, the overall caries prevalence was 55.6%, while 18% of children present at least one tooth with pulpal involvement and other consequences and 11.6% reported pain [Table 2]. The caries experience in the primary dentition was 0.36 with 0.34 on the d component. The permanent dentition presented 1.04 DMFT with 1.0 D component. The mean pufa index of the remaining primary dentition was 0.16 and the PUFA index for the permanent dentition was 0.14. The "Untreated Caries PUFA Ratio" was 21.4%, indicating that 21.4% of the D + d component for this age group had progressed to an odontogenic infection [[Table 3] and [Table 4]].
A statistical analysis revealed a strong correlation between DMFT/dmft and PUFA/pufa in both age groups [Table 5].
| Discussion|| |
In most epidemiological studies concerning dental caries, the mean DMFT index in relation to whole tooth or their surfaces is used to evaluate tooth decay and to the present day constitutes a basis for the calculations of the prevalence and incidence of dental caries. But during the last decade, this DMF index was not considered sufficient to describe the entire caries spectrum because it did not take into consideration the changes to the enamel without the presence of a cavity and advanced stages of untreated carious lesions.
Recently, the international caries epidemiology has focused on the development of more sensitive diagnostic criteria, International Caries Detection and Assessment System (ICDAS II), to allow for assessment of the initial stages of caries., It is particularly used in epidemiological studies conducted in developed countries, where the incidence of caries is low, as well as in studies evaluating the effectiveness of prevention programs.
Neither the DMFT index nor ICDAS II take into consideration the complications resulting from the lack of treatment of carious teeth. The assessment of the seriousness of a disease is an important element in assessing the treatment. The presence of teeth with advanced caries and odontogenic infections in the oral cavity is a significant clinical problem and has an influence on the quality of life and the general state of health.,,,
By exposing decision makers only to DMFT data, leaves them unaware of the high levels of untreated caries lesions, their severity, associated health, and quality of life consequences. It is the ethical responsibility of the dentist to provide relevant information on disease levels and its advanced stages to the health decision makers and policy makers. The introduction of the PUFA/pufa index provides health planners with relevant information on the number of patients who present for treatment with symptoms that reflect the serious consequence of tooth decay.
The results of the present study showed that prevalence of caries among schoolchildren is high (77% in 6–10 years old and 55.6% in 11–15 years old) and major portion of caries remains untreated which progress into advanced stages involving pulp and causing dental sepsis (47.3% in 6–10 years old and 18% in 11–15 years old). This could be due to lack of awareness of oral health, negligence for dental treatment by parents, and lack of accessibility of oral care.
Despite the high prevalence of dental caries lesions among 6–10 years old schoolchildren, the prevalence of clinical consequences of untreated carious lesions was considered moderate (47.3%), and the severity was considered low in comparison to the findings of Monse et al. (85% in 6-year-old Filipino children) and Bagińska et al. (72.4% in 7-year-old Poland children). The prevalence is higher, when compared to study by Figueiredo et al. (23.7% on 5–6 years old Brazilian children) and Thekiso et al. (41% in 6–8 years old South African children). The "Untreated Caries PUFA Ratio" was 37.4% among 6–10 years old children which is in line with the one reported by Monse et al. (40% in 6-year-old Filipino children).The prevalence of clinical consequences of untreated caries in 11–15 years old schoolchildren was 18%. This finding is similar to reported by Murthy et al. (19.4%, 12–15 years old schoolchildren in Bangalore city, India) but less than reported by Monse et al. (56% in 12-year-old Filipino children).
Among 6–10 years old children, “p” component of pufa in primary dentition formed majority of the total score, followed by abscess, and fistula while the “P” component in permanent dentition constitutes the entire PUFA score. These findings were comparable to other comparable studies., Among 11–15 years old, majority was pulpal involvement (P/p) among the clinical consequences of untreated caries for both primary and permanent dentition. Very few cases of other components of pufa were observed especially the “u” component, suggesting the need to modify the index by eliminating “u” and combining f and a components. Further studies are needed to support these findings with such modifications.
Approximately 21.4% of decayed teeth had signs of odontogenic infection. This "Untreated Caries PUFA Ratio" was less than that reported by Monse et al. (41% in 12-year-old Filipino children).
| Conclusion|| |
The present study revealed negligence in dental treatment of schoolchildren resulting in the pulpal involvement and odontogenic infections. This index is relevant and a valuable measurement tool to address the neglected problem of untreated caries and its consequences. It must be noted that it would be more cost effective to implement preventive strategies to reduce caries prevalence, and to avoid the clinical consequences highlighted by PUFA scores.
We are very grateful to school teachers and children for their kind support, co-operation, and participation during the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Petersen PE. The 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.
Baelum V, van Palenstein Helderman WH, Hugoson A, Yee R, Fejerskov O. A global perspective on changes in the burden of caries and periodontitis: Implications for dentistry. J Oral Rehab 2007;34:872-906.
Klein H, Palmer CE, Knutson JW. Studies on dental caries. 1. Dental status and dental needs of elementary children. Public Health Rep 1938;53:751-65.
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.
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.
Gradella CM, Bernabé E, Bönecker M, Oliveira LB. Caries prevalence and severity, and quality of life in Brazilian 2 to 4-year-old children. Community Dent Oral Epidemiol 2011;39:498-504.
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.
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.
Shetty NS, Tandon S. Prevalence of dental caries as related to risk factors in school children of South Kanara. J Ind Soc Pedo Prev Dent 1988;6:30-7.
Bali RK, Mathur VB, Talwar PP, Chanana HB. National Oral Health Survey and Fluoride Mapping 2002–2003 Karnataka, India. New Delhi: Dental Council of India; 2004.
Dhar V, Jain A, Van Dyke TE, Kohli A. Prevalence of dental caries and treatment needs in the school-going children of rural areas in Udaipur district. J Indian Soc Pedod Prev Dent 2007;25:119-21.
] [Full text]
World Health Organization. Oral Health Surveys. Basic Methods. 4th ed. Geneva: World Health Organization 1997.
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.
Bagińska J, Rodakowska E, Wilczyńska-Borawska M, Jamiołkowski 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.
Thekiso M, Yengopal V, Rudolph MJ, Bhayat A. Caries status among children in the West Rand District of Gauteng Province, South Africa. SADJ 2012;67:318-20.
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.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]