| Abstract|| |
Context: The widely accepted caries risk assessment tools such as the Cariogram model needs modifications in the scoring of different factors for reliable results. Aims: The study was aimed to report the caries experience in 3-60 years of the Rajasthan population and to apply the newly derived average decayed exfoliated filled teeth/Decayed Missing Filled Teeth (deft/DMFT) scores in the Cariogram model to assess the caries risk. Settings and Design: The cross-sectional study was planned in the Department of Dentistry and a total of 500 participants were equally divided into five groups (3-6, 7-12, 13-30, 31-44, and 45-60 years) were included. Methods and Material: All participants were examined for caries detection using deft/DMFT, ICDAS, and CAST indices according to the predefined protocol. A single examiner evaluated the participants in a dental operatory and data was recorded. Statistical Analysis Used: One-Way ANOVA and Tukey's Post-Hoc tests were used to evaluate the significant difference between the groups of each caries index. Results: A statistically significant difference was observed between the mean deft/DMFT and CAST scores of 3-6, 7-12, and 13-30 age groups with the 45-60 years age group. Caries prevalence was highest (83%) in 31-44 and 45-60 year age groups and lowest (51%) in the 3-6 year age group. Conclusions: Caries experience scores increase as the age increases and the highest scores were observed in 31-44 and 45-60 year age groups and the lowest were observed in the 3-6 year age group. The average ICDAS and CAST scores were higher when compared to the deft/DMFT index.
Keywords: CAST, Cariogram, DMFT, ICDAS, index
|How to cite this article:|
Patnana AK, Chugh A, Chugh VK, Rathore K, Solanki I, Kumar P. Caries experience scores revisited for caries risk assessment using cariogram model – A cross-sectional study. Indian J Dent Res 2022;33:135-40
|How to cite this URL:|
Patnana AK, Chugh A, Chugh VK, Rathore K, Solanki I, Kumar P. Caries experience scores revisited for caries risk assessment using cariogram model – A cross-sectional study. Indian J Dent Res [serial online] 2022 [cited 2022 Nov 29];33:135-40. Available from: https://www.ijdr.in/text.asp?2022/33/2/135/358443
| Introduction|| |
Dental caries is a multifactorial disease caused by interactions between acidogenic bacteria, biofilm, and individual caries risk factors. As dental caries is preventable, Caries Risk Assessment (CRA) is an important tool assisting the dentist in a better understanding of the cariogenic profile of the individual. The Cariogram model is a simple and handy tool for caries risk assessment and can be downloaded from online sources. The caries experience needs to be scored according to the different grades given in the Cariogram manual.
The critical issue in implementing the pre-specified scores in all populations was that these reference scores were calculated from Jönköping's epidemiological survey in 1993. Considering the variability in dietary habits, economic factors, and modified lifestyle patterns in the past two decades, these reference scores cannot be implemented directly to all population groups in the world. Though the Cariogram model is an effective caries risk assessment tool, there is a vital need for modifying certain factors in clinical implementation.
The staging of the caries experience scores in the Cariogram model was derived from the decayed, missing, and filled (DMF) index scores. However, different caries detection measures were proposed with improved efficiency in the past two decades.[5–8] The newer methods such as International Caries Detection and Assessment System (ICDAS) evaluates different levels of caries progression in enamel, whereas Caries Assessment Spectrum and Treatment (CAST) evaluates caries lesions based on different levels of caries progression in enamel and dentine. Though ICDAS and CAST caries detection methods have been evaluated for an appropriate diagnosis in the Indian population,, more studies are warranted to validate the newer caries detection methods for an efficient clinical application.
The primary objective of the study was to derive the past caries experience scores for individuals in the 3 – 60 years age group of the Rajasthan population. The secondary objectives were to apply the newly derived past caries experience scores in the Cariogram model and to report the average scores of ICDAS and CAST caries detection indices in the Rajasthan population.
| Methodology|| |
The present cross-sectional study was done in the Department of Dentistry, AIIMS, Jodhpur from October 2021 to January 2022 after approval from the Institutional Ethical Committee (AIIMS/IEC/2019-20/1016). All the participants visiting the regular dental OPD were screened for inclusion in the present study. The study methodology was explained and only the participants who were willing to participate and signed the consent form were included in the present study. The other inclusion criteria were participants in the age group of 3– 60 years and participants with or without visible dental carious lesions. The exclusion criteria were the special health care need children and patients who need emergency dental care. The participants were divided into five groups 3-6, 7-12, 13-30, 31-44, and 45-60 years, and were evaluated for different caries scoring systems (Phrase sounds grammatically inconsistent. Please consider revising to “…were evaluated using different caries scoring systems”) such as deft/DMFT, ICDAS, and CAST by a single experienced examiner.
The DMFT index is the total number of teeth or surfaces that are decayed (D), missing (M), or filled (F) in permanent teeth. The DMFT index in primary teeth is represented as deft and is expressed as the total number of teeth or surfaces that are decayed (d), indicated for extraction/extracted due to caries (e), or filled (f).
The ICDAS detection codes for coronal caries range from 0 to 6 depending on the severity of the lesion. There are minor variations between the visual signs associated with each code depending on several factors, including the surface characteristics (pits and fissures versus free smooth surfaces), whether there are adjacent teeth present (mesial and distal surfaces), and whether or not the caries is associated with a restoration or sealant. CAST covers the total dental caries spectrum, from no carious lesion, through carious lesion protection (sealant) and carious lesion care (restoration) to carious lesions in enamel and dentine, and the advanced stages of carious lesion progression in pulpal and tooth-surrounding tissue and teeth loss due to caries. The scoring of deft/DMFT, ICDAS, and CAST were done by a single experienced examiner using the reference methodologies published.[11–13]
Dental equipment (dental light, dental chair) and dental instruments (WHO probe and plain dental mirror) were used for examination of the oral cavity of the participants. A compressed air syringe is used to dry the teeth during the application of the ICDAS, which is the only method that requires the use of this resource. The caries scores were recorded as per the protocol and a qualified assistant recorded all the scores in a pre-approved case record form for each participant.
The data regarding the number of participants of different genders, socioeconomic status, and dietary habits in each group were extracted and tabulated. The descriptive statistics of mean and standard deviation values of each caries scoring system were evaluated. One-Way ANOVA and Tukey's Post-Hoc tests were used to evaluate the significant difference between the groups for each caries scoring system.
| Results|| |
The descriptive statistics of participants in each age group were presented in [Table 1]. The mean age of the individuals in the age groups 3-6, 7-12, 13-30, 31-44, and 45-60 years were 4.5 ± 1.11, 8.9 ± 1.81, 23.7 ± 4.06, 36 ± 3.68, and 52.1 ± 5.15 years. The deft/DMFT scores increase as age increases and the highest mean deft/DMFT scores (3.3 ± 2.69) were observed in the 45-60 years age group and the lowest mean deft/DMFT scores (1.9 ± 2.74) were observed in the 3-6 years age group. The highest mean ICDAS scores (9.6 ± 11.61) were reported in the age group of 7-12 years followed by 3-6 and 45-60-year age groups (8.7 ± 13.01 and 8.7 ± 9.35 respectively). The highest mean CAST scores (16.9 ± 14.34) were observed in the 45-60 years age group and the lowest mean CAST scores (9 ± 13.39) were observed in the 3-6 years age group. The comparison of mean deft/DMFT, ICDAS, and CAST scores was done, the results were presented in [Figure 1] and it was observed that the mean ICDAS and CAST scores were higher when compared to the deft/DMFT scores in all the age groups.
|Figure 1: Comparison of deft/DMFT, ICDAS, and CAST scores among different age groups|
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The intergroup comparison of the mean deft/DMFT scores among different age groups was presented in [Table 2]. A statistically significant difference was observed between the mean deft/DMFT scores of 3-6, 7-12, and 13-30 age groups with the 45-60 years age group. The intergroup comparison of the ICDAS scores among different age groups was presented in [Table 3]. No statistically significant difference was observed between the mean ICDAS scores among different age groups. The intergroup comparison of the CAST scores among different age groups was presented in [Table 4]. A statistically significant difference was observed between the mean CAST scores of 3-6, 7-12, 13-30, and 31-45 age groups with the 45-60 years age group.
|Table 2: Mean values of deft/DMFT and statistical analysis with ANOVA and Post-Hoc tests|
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|Table 3: Mean values of ICDAS and statistical analysis with ANOVA and Post-Hoc tests|
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|Table 4: Mean values of CAST and statistical analysis with ANOVA and Post-Hoc tests|
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The prevalence of dental caries among different age groups was presented in [Figure 2]. The caries prevalence was highest (83%) in 31-44 and 45-60 year age groups and lowest (51%) in the 3-6 year age group. The decayed teeth were more when compared to filled and missed teeth in all the groups. Among the different age groups, decayed teeth were highest (216) in 7-12 years, missing teeth were highest (89) in 45-60 years, and filled teeth were highest (68) in the 31-44 years age group. The variations in the observation of decayed anterior, premolars, and molars were presented in [Figure 3]. In all the age groups, the highest number of decayed teeth was molars when compared to anterior and premolar teeth. Next to the molars, anterior teeth were decayed more in the 3-6 year age group and premolars were decayed more in the 31-44 year age group.
|Figure 3: Variations in the number of decayed anterior, premolars, and molars in different age groups|
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The variations in the number of decayed enamel, dentinal and pulpal carious lesions were presented in [Figure 4]. A wide variation in the enamel, dentinal and pulpal carious lesions were observed in different age groups. Carious teeth with dentin involvement were observed highest in the 7-12, 31-44, and 45-60 years age groups. Carious teeth with pulpal involvement were observed highest in the 3-6 years and carious teeth with only enamel involvement were observed in the 13-30 years age group.
|Figure 4: The variations in the observation of enamel, dentin and pulpal carious lesion in different age groups|
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| Discussion|| |
Though there are published reports reporting the mean deft/DMFT scores of different regions in India, the present study was the first among its kind in India. In the present study, the range of different age groups was considered rather than WHO indexed age groups (5, 12, 15, 35-44, and 65-74 years) of participants. The novelty of evaluating the population in age groups range (3-6, 7-12, 13-30, 31-44, and 45-60) allows epidemiologists to apply the average caries experience scores for all individuals rather than only for WHO indexed age groups individuals. The suggested modified caries experience scores for the Rajasthan population allow the clinicians to assess the caries risk for any individual between 3-60 years using the Cariogram model.
Though the newer caries detection systems were advantageous over the deft/DMFT index, a few practical problems were observed while implementing them in the clinical scenario of the present study. It takes more time to completely evaluate the ICDAS scoring system compared to the other two systems. In ICDAS, each tooth surface needs to be dried to evaluate the enamel carious lesions which may increase the time required to complete the scoring and the findings as per the earlier reports. Whereas scoring in the CAST system is quite easy and does not require any dry surfaces to score the caries progression. The ease of use of the CAST system was reported in the literature and one report even mentioned that the CAST scoring system takes only one minute longer than scoring DMFT. Over observation from the authors infer that deft/DMFT and CAST are convenient and time effective when compared to the ICDAS system. Further, the advantages like ease of use and ability to detect caries at different stages made the CAST system a more effective caries detection system than the deft/DMFT index in the present study.
To reduce the sampling errors, a convenient sampling method was employed in the present study and an equal number of participants for each group were recruited in the present study. Though there is no gender difference, other factors such as brushing habits, area of domicile, and eating habits of the included participants vary a lot in the present study. One of the interesting findings observed in the present study was maximum of the participants were from the urban region rather than from rural areas. The study was conducted in a tertiary care government hospital where the services are more targeted toward the rural population and urban populations. However, the number of included participants is more from urban regions which highlights the importance of educating the rural population to consult tertiary care hospitals when they are available in their area of domicile.
The deft/DMFT scores vary significantly between 3-6, 7-12, and 13-30 within 45-60 year age groups, and the possible reason may be an increase in the findings of filled and missing teeth in the higher age group (45-60 year). The increase in mean DMFT scores with age was in accordance with one recently published systematic review of the prevalence of dental caries in India. However, no significant difference was observed between the 3-6, 7-12, and 13-30 year age group participants. The average deft/DMFT scores observed in the present study population differ from the normal caries experience values mentioned in the Cariogram manual. The possible reasons for variations in the average deft/DMFT scores might be because of variations in the population groups evaluated and changes in the approach towards caries management at the community level in recent times around the globe. The clinicians/epidemiologists may consider modifying the reference values for caries experience scores in the Rajasthan population for caries risk assessment using the Cariogram model. The individuals with caries experience scores above the mean values of the present study need to be considered 'worse than normal' and lower than the mean value need to be considered 'better than normal' for caries risk assessment using the Cariogram model.
No significant difference was observed in the ICDAS scores of different age groups in the present study. ICDAS system does not consider either filled or missing teeth in the scoring system, which may be the one factor that equals the caries experience of younger and older participants in the present study. Thus unlike DMFT, ICDAS scores need to be interpreted carefully when compared to the other caries detection systems. The average caries experience scores in the CAST system vary significantly between 3-6, 7-12, 13-30, and 31-44 within 45-60 year age group participants. CAST system includes the component of missing teeth and an increase in the number of missing teeth in older individuals, which may result in higher mean CAST scores when compared to other groups.
The prevalence of caries was highest (83%) in the 31-44 and 45-60 year age groups when compared to other age groups and the present study findings coordinate with the earlier published reports. The lowest (51%) caries prevalence (caries-free children are 49 out of 100) was observed in the 3-6 year age groups when compared to other age groups. Though the observation of caries experience was lowest for 3-6 year age group children, the prevalence of 51% indicates that every second child had caries in the Rajasthan population, which needs to be considered as a critical situation. However, the results cannot be generalized to the whole of Rajasthan population as major data in the present study was collected from the urban population. It was reported recently that the children belonging to rural areas have more caries prevalence scores than those in urban areas. Thus, it can be assumed that the rural population of Rajasthan might have more caries prevalence than the urban population and this critical situation needs to be addressed by the dental professionals in the rural and urban areas.
The inclusion of participants from the out-patient settings could be a possible limitation in the present study. Cross-sectional studies to determine the prevalence of any disease should be planned as an epidemiological study to increase the reliability of the results. In addition, a convenient sample was considered in the present study again limiting the generalizability of the present study results. Thus, future researchers should consider an epidemiological survey with a large sample size to determine the normal caries experience scores.
| Conclusion|| |
The normal past caries experience scores in 3-6, 7-12, 13-30, 31-44, and 45-60 are 1.9, 2.2, 2.3, 2.8, and 3.3 respectively. The mean caries scores assessed using the ICDAS index are 8.7, 9.6, 8, 7.7, and 8.7 respectively. The mean caries scores assessed using the CAST index are 9, 9.8, 9.2, 11.6, and 6.9 respectively. The normal past caries experience scores observed in the present study vary with the values mentioned in the Cariogram manual and clinicians/epidemiologists may consider the newly derived values for caries risk assessment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007;369:51-9.
Alaluusua S, Malmivirta R. Early plaque accumulation - A sign for caries risk in young children. Community Dent Oral Epidemiol 1994;22:273-6.
Bratthall D, Hansel Petersson G. Cariogram-a multifactorial risk assessment model for a multifactorial disease. Community Dent Oral Epidemiol 2005;33:256-64.
Bratthall D, Petersson GH, Stjernswärd JR. Cariogram Manual. Version 2.01. Stockholm: Förlagshuset Gothia; 1997.
Fisher J, Glick M. A new model for caries classification and management. J Am Dent Assoc 2012;143:546-51.
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.
de Souza AL, Leal SC, Bronkhorst EM, Frencken JE. Assessing caries status according to the CAST instrument and WHO criterion in epidemiological studies. BMC Oral Health 2014;14:119.
Monse B, Heinrich-Weltzien R, Benzian H, Holmgren C, van Palenstein Helderman W. PUFA â€“ An index of clinical consequences of untreated dental caries. Community Dent Oral Epidemiol 2010;38:77-82.
Nagarajappa R, Naik D, Satyarup D, Dalai RP. Risk factors and patterns related to dental caries evaluated with caries assessment spectrum and treatment (cast) among schoolchildren of Bhubaneswar, India. RoczPanstwZaklHig 2020;71:113-22.
Henry JA, Muthu MS, Saikia A, Asaithambi B, Swaminathan K. Prevalence and pattern of early childhood caries in a rural South Indian population evaluated by ICDAS with suggestions for enhancement of ICDAS software tool. Int J Paediatr Dent 2017;27:191-200.
Ribeiro APD, Maciel IP, de Souza Hilgert AL, Bronkhorst EM, Frencken JE, Leal SC. Caries assessment spectrum treatment: The severity score. Int Dent J 2018;68:84-90.
Gugnani N, Pandit I. International caries detection and assessment system (ICDAS): A new concept. Int J Clin Pediatr Dent 2011;4:93-100.
Kassawara ABC, Assaf AV, Meneghim M de C, Pereira AC, Topping G, Levin K, et al
. Comparison of epidemiological evaluations under different caries diagnostic thresholds. Oral Health Prev Dent 2007;5:137-44.
Bali RK, Mathur VB, Talwar PP CH. National Oral Health Survey and Fluoride Mapping 2002-03. Dental Council of India; 2004.
Castro ALS, Vianna MIP, Mendes CMC. Comparison of caries lesion detection methods in epidemiological surveys: CAST, ICDAS and DMF. BMC Oral Health 2018;18:122.
Baginska J, Rodakowska E, Milewski R, Kierklo A. Dental caries in primary and permanent molars in 7-8-year-old schoolchildren evaluated with caries assessment spectrum and treatment (CAST) index. BMC Oral Health 2014;14:74.
Janakiram C, Antony B, Joseph J, Ramanarayanan V. Prevalence of dental caries in India among the WHO Index age groups: A meta-analysis. J Clin Dig Res 2018;12:8-13.
Subramaniam P, Surendran R. Oral health related quality of life and its association with dental caries of preschool children in urban and rural areas of India. J Clin Pediatr Dent 2020;44:154-60.
Dr. Pravin Kumar
Professor and Head, Department of Dentistry, All India Institute of Medical Sciences, Jodhpur, Rajasthan- 342005
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]