Home | About Us | Editorial Board | Current Issue | Archives | Search | Instructions | Subscription | Feedback | e-Alerts | Login 
Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
 Users Online: 311  
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size

  Table of Contents    
Year : 2018  |  Volume : 36  |  Issue : 1  |  Page : 15-20

Assessing clinical sequelae of untreated caries among 5-, 12-, and 15-year-old school children in ambala district: A cross-sectional study

Department of Public Health Dentistry, M.M College of Dental Sciences and Research, Ambala, Haryana, India

Date of Web Publication28-Mar-2018

Correspondence Address:
Dr. Girish Malleshappa Sogi
Department of Public Health Dentistry, M.M College of Dental Sciences and Research, Ambala, Haryana
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_97_17

Rights and Permissions



Background: Dental caries is a public health problem globally, especially in children. Thus, it is important to quantify its clinical consequences in terms of its prevalence and severity. Aim: This study aims to assess the prevalence and severity of oral conditions linked with untreated dental caries using pulp involvement, ulceration, fistula, abscess (pufa/PUFA) index in 5-, 12-, and 15-year-old school children in Ambala district. Settings and Design: This cross-sectional study was conducted among 433 school children of 5-, 12-, and 15-year-old age group in Ambala district. Materials and Methods: In the present study, participants were recruited from randomly selected schools and were examined according to pufa/PUFA index and Oral Health Surveys Dentition Status. Statistical Analysis Used: Data were analyzed using SPSS Software Version 20.0 (Chicago, USA). The statistical significance was determined by Chi-square test, and level of significance was set at P < 0.05. Correlation analysis was expressed in terms of Pearson's correlation coefficient (r). Results: Caries prevalence was reported to be 58.4% while the prevalence of odontogenic infections was 45.3%. Untreated caries pufa/PUFA ratio among 5, 12, and 15 years old was 44.58%, 38.33%, and 36.18%, respectively. The care index among 5, 12, and 15 years old was 0, 3.31%, and 36.18% emphasizing the lack of utilization of dental services by school children. Conclusions: The use of PUFA/pufa index as an adjunct to the classical caries indices can address the neglected problem of untreated caries and its consequences.

Keywords: Care index, dentition status, pufa/PUFA, untreated caries pufa/PUFA ratio

How to cite this article:
Sudan J, Sogi GM, Veeresha L K. Assessing clinical sequelae of untreated caries among 5-, 12-, and 15-year-old school children in ambala district: A cross-sectional study. J Indian Soc Pedod Prev Dent 2018;36:15-20

How to cite this URL:
Sudan J, Sogi GM, Veeresha L K. Assessing clinical sequelae of untreated caries among 5-, 12-, and 15-year-old school children in ambala district: A cross-sectional study. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2022 Dec 4];36:15-20. Available from: http://www.jisppd.com/text.asp?2018/36/1/15/228755

   Introduction Top

Dental caries remains one among the most widespread chronic diseases known to afflict children that results in a compromised quality of life.[1],[2] As per South East Asia Regional Office data (2013), nearly 70%–95% of school children in the region are victimized by dental caries.[3] Dental caries prevalence in India was reported as 51.9%, 53.8%, and 63.1% at ages 5, 12, and 15 years, respectively, as stated in National Oral Health Survey.[4] In spite of improvement in prevention strategies and management modalities, children still bear considerable burden of dental caries.[5] Treatment of caries in young children is nearly nonexistent in low- and middle-income countries.[6] If left unattended, these may cause pain, loss of function, poor appearance, less self-esteem, absenteeism from school or work, and difficulty in concentrating on daily activities.[7] Dental decay when left untreated can adversely affect children's growth and overall well-being.[1],[6],[7],[8],[9]

World Health Assembly in 2007 acknowledged germinating burden of oral diseases around the world and stressed the need to scale up activities based on extensive collection network.[10] Statistics on dental caries has been collected worldwide using the decayed, missing, and filled teeth (DMFT/dmft) index that renders information on overall caries experience but does not furnish any details regarding sequelae of untreated dental caries which have been proven to be serious than the carious lesion itself.[6]

Recently, Monse et al. presented a pulp involvement, ulceration, fistula, abscess (PUFA) index describing the clinical consequences of untreated dental caries.[11],[12] The information is presented in combination with the results of the assessment of dentition by means of the DMF (dmf)[13] index or WHO Oral Health Surveys [14] and attempts to multiply the sensitivity of original DMF (dmf) Index.[6],[10],[11] In a population of high prevalence of dental caries, it is likely that sequelae of untreated caries will also be higher but a critical analysis of the literature revealed a scarcity of studies that assess the clinical consequences of untreated dental caries in school children in India. Therefore, this study aimed to assess the prevalence and severity of oral conditions as a result of untreated dental caries in 5-, 12-, and 15-year-old school children using PUFA/pufa index and correlate the same with the dental caries experience of the sample.

   Materials and Methods Top

This cross-sectional study was carried over a period of 9 months (May 2015 to February 2016). The study abide by the ethical principles and was approved by the Institutional Ethical Committee (Project no. 509). The written permission was obtained from the District Education Officer, Ambala (Haryana) before planning the study. The sample size [15] was estimated using n = 4pq/L2 (n = Estimated sample size; p = Approximate prevalence of the disease; q = 1 – p; L = Permissible error in the estimation of p (at 95% confidence limit with 5% allowable error).

For compensation of possible losses due to incomplete recording of data, 10% of the total sample was added to the original sample size and the final sample constituted of 433 participants.

Sampling strategy

For administrative purpose, Ambala district of Haryana is subdivided into three subdivisions, namely, Ambala, Barara, and Naraingarh. The present study included all the three subdivisions of the Ambala district. A two-phase stratified random sampling method was used for the selection of schools and recruitment of the study participants. In the first phase, all the schools in each subdivision were stratified into government and private schools, and later, two private and two government schools were randomly selected from each subdivision using the lottery method. Principal investigator informed the principals of the selected school regarding the study protocol before data collection. In the next phase, 5-, 12-, and 15–year-old school children were separated from rest of the school children and an effort was made to get equal representation of both the genders. For the recruitment of the individuals, systematic stratified random sampling was done; male and female students were arranged in a line and lottery method was used to pick the first number, and latterly, the sequence was followed. To reach the estimated sample size, 12 participants of each age were randomly chosen from each school and included in the study.

Inclusion and exclusion criteria

All school children who were 5, 12, and 15 years old at their last birthday and for whom assent was obtained from child or consent was obtained legally authorized individuals were included in the study and exclusion criteria were the absenteeism from school and children who could not cooperate because of special health need. However, none of the participants were excluded based on these criteria.

Examiner calibration

Before the fieldwork, principal investigator was subjected to a training and calibration exercise under the supervision of department faculty. Data were recorded by a trained recorder in prestructured format. Intraexaminer reliability for the index was assessed using Kappa statistics,[14] and it revealed almost perfect agreement with value of κ = 0.88.

Oral examination

Type III [16] dental examination was carried out with the individual seated on a stool or chair as per availability in the school premises. Infection control [17] and sterilization measures were observed throughout the study. The waste produced in the course of the study was handled in accordance with Biomedical Waste (management and handling) Rules, 1998 of India.[18] Assessment of dentition status was done according to WHO Oral health Surveys, 2013,[14] and later, DMFT/dmft scores were obtained from the dentition status values. Clinical consequences were assessed using PUFA/pufa using standard procedure.[6] Dental screening was carried out for all the school children, and referral cards were issued to those in need.

Statistical analysis

The data so collected were entered into the Microsoft Excel sheet Version 14.4.7 and analyzed using statistical package for social sciences [19] (SPSS) Software (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp). Caries prevalence, for example, percentage of children with the dmft/DMFT =1 and above was evaluated in the whole sampled population and separately for each group with reference to all children in the particular age group. The prevalence of pufa was calculated the same way. The mean caries experience (DMFT/dmft) and mean pufa/PUFA scores were expressed in terms of mean and standard deviation. The care index was computed as FT (ft)/DMFT (dmft). The percentage of untreated carious teeth that had progressed to an oral infection was narrated in terms of untreated caries-pufa ratio using PUFA + pufa/D + d × 100. The statistical significance was determined by Chi-square test and level of significance was set at P < 0.05. The correlation between dmft/DMFT and pufa/PUFA scores was expressed in terms of Pearson's correlation coefficient (r).

   Results Top

A total of 433 individuals were analyzed in the study. The caries prevalence was 58.4% and prevalence of odontogenic infections was 45.3%.

Five-year-old participants

One hundred and forty four participants (66 males) displayed a caries prevalence of 50.7% [Table 1] and caries experience of 2.31 ± 2.87 dmft [Table 1]. The care index was 0 indicating that dental caries is left untreated in deciduous dentition [Table 2]. The untreated caries ratio was 44.58% [Table 2]. The prevalence of odontogenic infections was 42.4% [Table 3] that absolutely concentrated on involvement of pulp (p), 1.03 ± 1.65 being mean pufa scores [Table 3]. A statistically significant correlation was found between dmft and pufa values (r = 0.81, P ≤ 0.05) [Table 4].
Table 1: Prevalence and experience of dental caries in various age groups

Click here to view
Table 2: Untreated caries-PUFA/pufa ratio

Click here to view
Table 3: Prevalence of odontogenic infections in various age groups

Click here to view
Table 4: Correlation analysis between dmft/DMFT and pufa/PUFA

Click here to view

Twelve-year-old participants

The prevalence of dental caries among 144, 12 year olds (71 males), was 57.6% and caries experience in primary teeth was 0.22 ± 0.64 dft whereas in permanent teeth, it was 1.81 ± 1.94 DMFT [Table 1]. The care index was 3.31% indicating that < 5% dental decay is treated [Table 2]. The prevalence of odontogenic infections was 53.5% with mean score of 0.24 ± 0.77 in primary dentition and 0.69 ± 0.95 in permanent dentition [Table 3]. More than 30% of the decayed component had advanced primarily to pulpal involvement (Untreated Caries Ratio 38.33%) [Table 2]. A statistically significant positive correlation was found between dental caries experience and odontogenic infections (r = 0.49, P ≤ 0.05%) [Table 4].

Fifteen-year-old participants

Out of 145, 15 years old children (72 males), 33.1% were caries free [Table 1]. The caries experience in primary teeth was 0.03 ± 0.22 dft, and in permanent teeth, it was 2.06 ± 2.04 DMFT [Table 1]. The care index was 1.95% that is <2% [Table 2]. The prevalence of odontogenic infections was 40% and mean score being 0.24 ± 0.77 (pufa) and 0.69 ± 0.95 (PUFA) [Table 3]. The untreated caries ratio was 36.18% [Table 2] and a statistically significant positive correlation was found between dental caries experience and odontogenic infections (r = 0.64, P ≤ 0.01) [Table 4].

The prevalence of dental caries and odontogenic infection varied between different age groups (P=0.04)[Table 3].

   Discussion Top

In recent years, focus of caries epidemiology has been on developing a more sensitive diagnostic criteria that detect initial changes of caries process.[6],[20] This could be of more relevance in developed countries where nonoperative and preventive interventions require early detection of carious lesions. However, in underdeveloped countries where population have limited access to even basic form of healthcare, a diagnostic criteria that address the advanced stages of untreated caries lesions will be of utmost relevance.[20]

The way data regarding caries are portrayed can have great influence on oral health planners. For instance, in the present study, caries experience among 12 years old was found to be 1.81 ± 1.94 DMFT that is in accordance with the WHO goal of three DMFT for the year 2000 for 12 years old. This can lead to complacency among health planners that the target has been achieved, but in reality, in this age group, 38.44% of the decayed component has advanced to odontogenic infections or in other words was left untreated as evident by untreated caries ratio of PUFA index. This clearly demonstrates the ambiguous explanatory potential of DMFT and presenting the dental caries scenario in terms of DMFT leave health planners nescient of the real picture.

In this study, the mean caries prevalence (DMFT/dmft > 0) was reported to be 50.7% in 5 years old, 57.6% in 12 years old, and 66.9% in 15 years old, which shows an increase in caries status with the advancing age among 12 and 15 years old. The irreparable nature of carious lesions and longer contact of teeth to harmful oral environment can be a possible explanation of increasing prevalence of caries with age in 12 and 15 years old. This finding is similar to the findings of National Oral Health Survey.[21] The prevalence of odontogenic infections (pufa/PUFA > 0) was found to be 42.4% in 5 years old and the mean score was found to be 1.03 ± 1.65 with majority of the contribution from pulpal involvement (“P”) component; that is similar to findings of an earlier study [10] which necessitates the use of educative and preventive measures for caries prevention in the early stages of life.[22] Five years old revealed highest untreated caries-pufa ratio 44.58% but lowest care index (0). The possible explanation could be discussions in recent years that indicate that most deciduous teeth with untreated caries remain without symptoms until the moment of replacement with a permanent tooth [12] and also partly this could be due to negative attitude of parents toward the primary teeth.[23] This is further supported by the complete absence of “m” missing component and “f” filled component of dmft in this study. The prevalence of “PUFA” was 53.5% in 12 years old and 40% in 15 years old showing a linear increase which is in accordance with an earlier study [23] and comparable to another study done for 12 years old. The simple fact that teeth had been exposed to the oral environment for a longer period of time in mouths of older children may directly increase the probability of having more advanced stage in the continuum of dental disease [23] could be the possible explanation for this finding.

In many low- and middle-income countries like India, even the cavitated teeth are not being managed for a number of reasons such as unawareness, unaffordability, and inaccessibility to basic health services [24] that is clearly reflected in the untreated caries-pufa ratio of 38.33% and 36.18% among 12 and 15 year olds, respectively. Untreated caries can have detrimental effect on children's life because of pain and discomfort along with disturbed eating and sleeping behavior.[25] In addition, untreated caries can increase caries risk or can cause developmental defects of permanent successor tooth.[11] This study presented a complicated mosaic of dental caries in which mean DMFT is relatively low, but the fact that <1 tooth on an average among 12 and 15 years old (0.69 ± 0.95 and 0.72 ± 1.21, respectively) has been considered advanced enough to be assessed as foci of odontogenic infections cannot be overlooked.

Another astonishing revelation of the present study is the negligible care index values of 3.31% and 1.95% for 12 and 15 years old, respectively, which is less than even 5% that insinuates a substantial burden of untreated caries among these age groups which necessitates the exploration of concept that people have regarding oral health. Furthermore, the role of established psychosocial and financial barriers to the use of oral health care services cannot be ruled out in the present study. Issues such as dental anxiety, dependency of children on parents, perception of needs, and lack of access [26] are some of the identified barriers in regular dental care that may be true for the present study also. In a real world, existing disease should be treated rendering the clinical consequences to the minimum. Thus, there is a urgent need of new avenues addressing these barriers to utilization of dental services among these age groups.

A statistically significant correlation between odontogenic infections and dental caries experience of the participants was revealed using Pearson's Correlation analysis that is similar to another study.[27] The data have clearly shown that the neglect to treat caries increases the risk of its clinical consequences.[12]

It should be kept in mind that PUFA/pufa assesses four stages of clinical relevance concerned with untreated caries that sketch the real landscape of dental caries. However, it cannot be ignored that it is not an index of treatment need rather a measure of quantification of clinical sequelae.[28] Treatment decisions are inevitably linked to the available resources and potentials of local health settings. It can help to prioritize treatment by guiding selection of patients with high scores when the resources are scarce but it specifically does not indicate the type of treatment.

The intermittent nature of abscess could have led to the underestimation of “a/A” component in pufa/PUFA in assessment of clinical consequences, which is limitation of our study. Interactions among individual, cultural, social, and socioeconomic factors cannot be overlooked in development of dental caries, so there is need of further research to generate evidence supporting the same.

The present study has shown the pertinence of this newer index in addressing the overlooked problem of untreated caries and its clinical consequences. The use of this index is recommended in view of the ethical mandate of a dental professional to furnish health-care decisionmakers with more relevant data on real clinical picture of the situation that may have a higher potential than other measurements to get oral health into the political agenda.

   Conclusions Top

The data of this cross-sectional study have revealed that more than 40% of dental decay proceeded to odontogenic infections, irrespective of advancements in caries detection and management. The data necessitate the need of oral health prevention and promotion programs that focus on young school children, parents, and wider community by organizing oral health promotion programs regularly. Since schools are the microcosm of the larger community with prevailing structures and systems in place provides, an exquisite scope to integrate oral health into school curriculum, and attempts can be made to influence students' oral health knowledge, beliefs, attitudes, and behavior which change the lifestyle.


The authors have acknowledged the support of District Education Officer (Ambala), Principals of respective schools along with the participants.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Jackson SL, Vann WF Jr., Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children's school attendance and performance. Am J Public Health 2011;101:1900-6.  Back to cited text no. 1
Alsumait A, ElSalhy M, Raine K, Cor K, Gokiert R, Al-Mutawa S, et al. Impact of dental health on children's oral health-related quality of life: A cross-sectional study. Health Qual Life Outcomes 2015;13:98.  Back to cited text no. 2
Yani R. Relationship between dental caries and nutritional status in toddlers at Kaliwates Jember. Int J Sci Basic Appl Res 2015;21:428-33.  Back to cited text no. 3
Pine CM, Harris RV, Burnside G, Merrett MC. An investigation of the relationship between untreated decayed teeth and dental sepsis in 5-year-old children. Br Dent J 2006;200:45-7.  Back to cited text no. 4
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.  Back to cited text no. 5
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.  Back to cited text no. 6
Benjamin RM. Oral health: The silent epidemic. Public Health Rep 2010;125:158-9.  Back to cited text no. 7
Oral Health Worldwide. A Report by FDI World Dental Federation;2013.  Back to cited text no. 8
Mohammadi TM, Jane Kay E. Effect of Dental Caries on Children Growth. In Dr Ming Yu Li. Contemporary Approach to Dental Caries. In Techopen Publications; 2012:379-94.  Back to cited text no. 9
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.  Back to cited text no. 10
[PUBMED]  [Full text]  
Grund K, Goddon I, Schüler IM, Lehmann T, Heinrich-Weltzien R. Clinical consequences of untreated dental caries in German 5- and 8-year-olds. BMC Oral Health 2015;15:140.  Back to cited text no. 11
Baginska J. Evaluation of the status of primary dentition in 6-7 year old children from Bialystok District using the Mean DMF and the index of Clinical Consequences of Untreated Caries (Pufa). Dent Med Probl 2013;50:160-6.  Back to cited text no. 12
Klein H, Palmer CE, Knutson JW. Studies on dental caries Dental status and dental needs of elementary school children. Public Health Rep (Wash) 1938;53:751-65.  Back to cited text no. 13
World Health Organization. Oral Health Surveys Basic Methods. 5th ed. Geneva: WHO; 2013.  Back to cited text no. 14
Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiollogic Statistics for Public Health version. Available from: www.openepi.com. [Last updated on 2013 Apr 06, Last accessed on 2015 Mar].  Back to cited text no. 15
Dunning JM. Surveying. In: Principles of Dental Public Health. Cambridge, Mass: Harvard University Press; 1986.  Back to cited text no. 16
Kohli A, Puttaiah R. Dental Infection Control and Occupational Safety for oral Health Professionals. New Delhi: Dental Council of India;2008.  Back to cited text no. 17
Biomedical Waste (Management and Handling) Rules. Ministry of Forest and Environment, Government of India; 1998. Available from: http://www.CPCB.nic.in. [Last accessed on 2015 Aug 28].  Back to cited text no. 18
Available from: https://www.csun.edu/sites/default/files/statistics20-briefguide-64bit.pdf. [Last accessed on 2015 May 03].  Back to cited text no. 19
Jazrawi KH. Evaluation of the sequelae of Untreated Dental Caries using PUFA Index. Al Rafidain Dent J 2014;14:101-10.  Back to cited text no. 20
Sukhabogi Jr. Shekar C, Hameed Ia, Ramana I, Sandhu G. Oral health status among 12- and 15-year-old children from government and private schools in Hyderabad, Andhra Pradesh, India. Ann Med Health Sci Res 2014;4:S272-7.  Back to cited text no. 21
Jain K, Singh B, Dubey A, Avinash A. Clinical assessment of effects of untreated dental caries in school going children using PUFA Index. Chettinad Health City Med J 2014;3:105-8.  Back to cited text no. 22
Dev Dutt A, Shekhar R, Boddeda KR. An assessment system for the consequences of untreated dental caries. Indian J Oral Health Res 2015;1:62-5.  Back to cited text no. 23
Shanbhog R, Godhi BS, Nandlal B, Kumar SS, Raju V, Rashmi S, et al. Clinical consequences of untreated dental caries evaluated using PUFA index in orphanage children from India. J Int Oral Health 2013;5:1-9.  Back to cited text no. 24
Colak H, Dülgergil CT, Dalli M, Hamidi MM. Early childhood caries update: A review of causes, diagnoses, and treatments. J Nat Sci Biol Med 2013;4:29-38.  Back to cited text no. 25
Freeman R. Barriers to accessing dental care: Patient factors. Br Dent J 1999;187:141-4.  Back to cited text no. 26
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.  Back to cited text no. 27
Holmgren C, van Palenstein Helderman W, Monse B, Heinrich-Weltzien R, Benzian H. Modifications to the PUFA index: Are they justified at this stage? Med Princ Pract 2014;23:292-3.  Back to cited text no. 28


  [Table 1], [Table 2], [Table 3], [Table 4]


Print this article  Email this article


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (451 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

    Materials and Me...
    Article Tables

 Article Access Statistics
    PDF Downloaded353    
    Comments [Add]    

Recommend this journal

Contact us | Sitemap | Advertise | What's New | Copyright and Disclaimer | Privacy Notice
  2005 - Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow 
Online since 1st May '05