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ORIGINAL ARTICLE
Year : 2022  |  Volume : 40  |  Issue : 2  |  Page : 132-139
 

Assessing consequences of untreated dental caries using pufa/PUFA index among 6–12 years old schoolchildren in a rural population of Kerala


Department of Pedodontics and Preventive Dentistry, Azeezia College of Dental Sciences and Research, Kollam, Kerala, India

Date of Submission26-Sep-2021
Date of Decision19-May-2022
Date of Acceptance24-May-2022
Date of Web Publication15-Jul-2022

Correspondence Address:
Dr. Santhosh Kumar Vasavan
Mangalathu Puthen Veedu, Mulavana P.O., Kundara, Kollam - 691 503, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisppd.jisppd_342_21

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   Abstract 


Context: Dental caries is the most common dental disease of childhood. India with a population of more than 135 crores accounts for a high proportion of dental morbidity. Poor oral health has a significant impact on quality of life, especially in rural areas. The consequences of untreated dental caries include pain, abscess, and space infections which may lead to loss of function and school hours. These consequences are of utmost important while planning a community dental care program. Aims: To assess the prevalence of dental caries, caries experience, and severity of dental caries among 6–12 years old schoolchildren in the rural areas of Kollam District, Kerala State. Settings and Design: A community school-based, descriptive, cross-sectional study in the rural areas of Kollam District. Materials and Methods: A cross-sectional study was carried among 2194 schoolchildren in the rural areas of Kollam District in the age group of 6–12 years. Children from eight randomly selected schools were examined for pufa/PUFA and dmf/DMF indices. Statistical Analysis Used: SPSS version 17.0, Mann-Whitney, t-test, KruskalWallis test. P < 0.05 was considered statistically significant. Results and Conclusions: Overall caries prevalence among the total population was found to be 74%. The prevalence of caries in the deciduous dentition was 61% and a mean decayed, missing, filled teeth value of 2.74 ± 3.200 and for the permanent dentition the caries prevalence of 26.8% and a mean Decayed, Missing, Filled Teeth of 0.66 ± 1.360 were observed. The prevalence of untreated dental caries (pufa/PUFA) was 40.8%. The pufa prevalence in deciduous dentition was 38.3% with a mean pufa of 0.99 ± 1.679. Moreover, the PUFA prevalence in permanent dentition was 4.1% with a mean PUFA of 0.06 ± 0.349. The highest prevalence of untreated dental caries (pufa/PUFA) was found in the 7 years' age group (52%) and the lowest in 12 years' age group (22.4%).


Keywords: Children, dental caries, decayed, missing, filled teeth/Decayed, Missing, Filled Teeth, pufa/PUFA, untreated dental caries


How to cite this article:
Vasavan SK, Retnakumari N. Assessing consequences of untreated dental caries using pufa/PUFA index among 6–12 years old schoolchildren in a rural population of Kerala. J Indian Soc Pedod Prev Dent 2022;40:132-9

How to cite this URL:
Vasavan SK, Retnakumari N. Assessing consequences of untreated dental caries using pufa/PUFA index among 6–12 years old schoolchildren in a rural population of Kerala. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Oct 5];40:132-9. Available from: http://www.jisppd.com/text.asp?2022/40/2/132/351050





   Introduction Top


Oral health is an integral part of general health status, and it significantly affects the quality of life of an individual. Oral diseases assume public health significance, as they are preventable to a large extent by oral hygiene technique, diet counseling, and fluoride therapy. Socioeconomic factors are recognized as being the key determinants of oral health. Apart from gender, race and ethnicity also influence the prevalence of oral diseases.

Dental caries and gingivitis are the two most common dental diseases affecting the children of all regions and society in the world. Due to the change in dietary habits and increased consumption of sugar and its related products, the prevalence of dental caries is increasing continuously. Even though dental caries is not a life-threatening disease, it can be of painful, disfiguring, and expensive to manage. In addition to financial burden, numerous study hours and school days are lost in connection with that.

Dental caries is the most common ailment among children around the world.[1] It has a large impact not only on individual but also on society in terms of discomfort, social as well as functional limitations and quality of life. Although dental caries has affected humans since prehistorical times, the prevalence of this disease has greatly increased in these modern times on a global basis. Contrasting reports of caries are reporting across the world, where caries prevalence is dropping in industrialized countries, increasing in less developed ones, and epidemic in emerging economies.

This decrease in caries prevalence has been linked to a more reasonable approach to sugar consumption, improved oral hygiene habits, fluorides in toothpaste, topical fluoride application, fluoride rinsing, and water fluoridation in developed countries. Furthermore, school-based preventative care and oral health education programs have been established in various countries. However, the rapid increase in caries prevalence in developing nations is mostly due to the fact that these countries' oral health care systems are primarily focused on curative care, rather than systematically implemented community-based prevention and oral health promotion.[2]

A number of literature exist on the status of dental caries in the Indian population. Even after several attempts to cure and prevent the disease, its prevalence has increased over the last two decades. These changing trends in the prevalence of dental caries need continuous monitoring and investigation. Thus, the review of the past and prediction of the future is the prime requisite; at present. Early detection of the disease is of great importance in the present scenario.

During the past decades, the Decayed, Missing, Filled Teeth/decayed, missing, filled teeth index (DMFT/dmft) had been used extensively to assess the dental caries experience of the communities worldwide. The drawback of this index is that it fails to record the clinical consequences of untreated dental caries such as pulpal involvement and dental sepsis. A deep carious lesion with pulpal involvement is still considered as “caries in dentin” and pulpal involvement is not included in the caries scoring system even in the latest edition of WHO-Oral Health Surveys-Basic Methods.[3]

In order to improve the accuracy of the caries diagnosis, Monse et al.[4] introduced a new index which could quantify the various advanced stages of a carious lesion, namely “PUFA” index. This index records (P - Pulpal involvement, U - Ulceration, F - Fistula and A - Abscess). pufa/PUFA is an index, which is used to assess the presence of oral conditions arising from untreated dental caries. Despite the fact that a vast number of surveys on schoolchildren in India have been done to study the frequency of dental caries and caries experience,[5],[6],[7] data on the severity and clinical effects of untreated dental caries are comparatively scarce. Moreover, geographical location plays a great role in caries prevalence; it varies with the change in location such as urban and rural. There are few studies done in school children in the urban area, but studies related to rural areas are scarce.

The aim of the present study was to determine the prevalence of dental caries and untreated dental caries among schoolchildren in the rural areas of Kollam District, Kerala, India and to collect the basic data on clinical consequences of untreated dental caries among them using pufa/PUFA index.


   Materials and Methods Top


A community school-based, descriptive, cross-sectional study was conducted at the Department of Pedodontics and Preventive Dentistry, Azeezia College of Dental Sciences and Research, Kollam. 2194 schoolchildren in the age group of 6–12 years, studying in the rural areas of Kollam District were the sampling units. The ethical approval for this study (AEC/REV/2017/28) was obtained from the Institutional Ethics Committee. Written informed consent was obtained from the parents and an assent from the child was also obtained before the survey. A cluster sampling strategy was adopted in the study for the sample selection

The study area was divided into four zones and two schools from each zone were randomly selected and each school represented a cluster. Even though, the estimated sample size was 1803, in order to avoid discrimination among students, all the students of the age group 6–12 years in a school were included in this study, and as a result, the final sample size became 2194.

Organization of the survey

A written permission was obtained from school authorities before the commencement of the study. In the beginning of the survey, intraexaminer variability was measured by carrying out a reproducibility test. A group of 20 children were examined twice and the results of two examinations were compared and achieved an acceptable consistency by 90% agreement for the majority of assessments. Information regarding oral examination was given to both the children and their parents, and written consent was obtained. Caries was recorded for both primary and permanent teeth in terms of dmft/DMFT, using World Health Organization recommendations for Oral Health Surveys (2013)[3] and the severity of untreated caries was assessed using the pufa/PUFA index, as recommended by Monse et al. (2010).[4]

For the survey purpose, the entire Kollam District was divided into four zones, viz., North East, North West, South East, and South West, and from each zone, at least two schools (one Government school and one Government Aided school) were randomly selected and on the whole about eight schools were selected from above-mentioned area. All students in the age group of 6–12 years who were studying in those schools situated in the rural areas of Kollam District were included in this study. Data collection was carried out by a single trained and calibrated investigator.

Indices used in this study

In this study, both traditional dmft/DMFT and more recent pufa/PUFA indices were used. pufa/PUFA is an index used to assess the presence of oral conditions resulting from untreated dental caries. The index is recorded separately from the dmft/DMFT and the pufa/PUFA scores represent either a visible pulp, ulcerations of the oral mucosa due to sharp root fragments, a fistula or an abscess. Visual assessment was done without the use of any instrument. Only one score is assigned per tooth. During the examination, if there is any doubt regarding the extent of odontogenic infection, the basic score (p/P for pulpal involvement) is given. If the primary tooth and its permanent succedaneous tooth are present and both of the teeth present stages of odontogenic infection, both of them will be scored. Upper case letters are used for denoting the permanent dentition and lower case letters are used for the primary dentition. The pufa/PUFA score of the child is computed in the same cumulative way as for the dmft/DMFT and represents the number of teeth that meet the pufa diagnostic criteria. The pufa for primary teeth and the PUFA for permanent teeth are reported separately.

The codes for pufa/PUFA index are as follows

p/P: Pulp involvement is recorded when there is a visible opening of the pulp chamber or when the coronal tooth structures have been destroyed by caries and only root stumps are left.

u/U: Ulceration due to trauma is recorded when the sharp edges of a badly mutilated tooth with pulp involvement or root fragments have caused traumatic ulceration of the adjacent soft tissues, like tongue or buccal mucosa.

f/F: Fistula is scored when a pus discharging sinus tract related to a tooth with pulp involvement is present.

a/A: An abscess is scored when a pus-filled swelling associated with a tooth with pulpal involvement.

The prevalence of pufa/PUFA is calculated as the percentage of the population with a pufa/PUFA score of more than one. The pufa/PUFA experience for a population is calculated as a mean figure and can therefore have decimal values. The untreated caries, pufa ratio is calculated as (PUFA + pufa)/(D + d) × 100.

Data collection

This cross-sectional study was conducted among 2194 primary school children of 6–12 year old, in the rural areas of Kollam District. Before conducting the examination, training and calibration of the examiner for recording indices were completed. Standard infection control guidelines were followed. A clinical examination was conducted in the premises of each school under artificial illumination by using LED headlight. Children were examined for dental caries and untreated dental caries while seated on a chair upright. Mouth mirror and explorer are used for oral examination and the findings were recorded in a pro foma adopted from the WHO. The clinical consequences of untreated dental caries were visually assessed and recorded by using pufa/PUFA index. During the examination of schoolchildren, a questionnaire was used to fill out personal data such as name, age, gender, previous dental visits, oral hygiene methods and brushing frequency, and diet chart of the child and occupation, educational status, and income status of the parent as well.

Statistical analysis

All the data collected were entered into Microsoft Excel datasheet and were analyzed by using SPSS for Windows (Statistical Presentation System Software, (2010), IBM Corp, Armonk, NY) version 19.0. The mean and standard deviation were used to describe continuous data. The Chi-square test was used for count variables. MannWhitney t-test was used for comparing two continuous variables and Kruskal-Wallis test was used for comparing more than two continuous variables. After assuming all the rules of statistical tests, P value (Probability that the result is true) of < 0.05 was considered statistically significant.


   Results Top


A total of 2194 schoolchildren in the age group of 6–12 years were surveyed, among whom 1146 (52.2%) were male and 1048 (47.8%) females [Figure 1]. Sample distribution based on zones and schools is shown in [Table 1].
Figure 1: Sample distribution based on gender

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Table 1: Sample distribution based on zones and schools

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The overall prevalence of dental caries in deciduous and permanent dentition was 74%. Out of the total population, 26% children were caries-free. The highest caries prevalence was found in the 8 years' age group (78.6%) and the lowest in 11 years' age group (65.4%). The caries prevalence in deciduous dentition was 61%. The highest prevalence (dmft) of caries was found in the 8 years' age group (81.6%) and the lowest in 12 years' age group (23.0%). In primary dentition, the highest mean dmft was recorded in 8 years (4.12 ± 4.080) and the lowest mean dmft was recorded in 12 years (0.56 ± 1.312). The prevalence of dental caries in permanent dentition was 26.8%. The highest prevalence (DMFT) of caries was found in the 12 years' age group (51.1%) and the lowest in 6 years' age group (3.3%). In permanent dentition, the highest mean DMFT was recorded in 12 years (1.47 ± 1.920) and the lowest mean DMFT was found in the 6 years (0.07 ± 0.460) [Table 2].
Table 2: Prevalence of caries percent based on age

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The mean caries experience based on age in primary dentition is shown in [Figure 2].
Figure 2: Mean caries experience based on age in primary dentition

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The mean caries experience based on age in permanent dentition is shown in [Figure 3].
Figure 3: Mean caries experience based on age in permanent dentition

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The overall prevalence of untreated dental caries (pufa/PUFA) among primary and permanent dentition was 40.8%. The highest prevalence of untreated dental caries was found in the 7 years' age group (52.0%) and the lowest in 12 years' age group (22.4%). The prevalence of untreated dental caries (pufa) in deciduous dentition was 38.3%. The highest prevalence of untreated dental caries (pufa) was found in the 7 years' age group (51.3%) and the lowest in 12 years' age group (15.3%). In the primary dentition, the highest mean pufa was recorded in 7 years (1.45 ± 1.972) and the lowest in 12 years (0.25 ± 0.691). The overall prevalence of untreated dental caries (PUFA) in permanent dentition was 4.1%. The highest prevalence of untreated dental caries (PUFA) was found in the 12 year age group (8.2%) and the lowest in 6 years age group (0.3%). In the permanent dentition, the highest mean prevalence of PUFA was recorded in 12 years (0.11 ± 0.388) and the lowest in 6 years (0.00 ± 0.055) [Table 3].
Table 3: Prevalence of pufa/PUFA (n %) based on age

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The prevalence, mean and standard deviation of pufa/PUFA and their individual components are shown in [Table 4]. Age-wise comparison of dental caries was done in primary dentition, there was no statistically significant gender difference, except for the 7-year-olds which is statistically significant (P = −0.003) [Table 4].
Table 4: Gender wise distribution of caries status and pufa/PUFA status (mean and standard deviation)

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Age-wise comparison of dental caries was done in permanent dentition, there was no statistically significant gender difference, except for the 8-year-olds which is statistically significant (P = −0.009) [Table 5]. The overall caries experience was 70.4% in deciduous dentition with “d” component was the majority of 61%. and the overall mean dmft index was 2.74 ± 3.2. The prevalence of dental caries in permanent dentition was 26.8% and mean DMFT.66 ± 1.360 [Table 6].
Table 5: The prevalence and experience of dental caries (dmft) and the clinical consequences of untreated dental caries (pufa) (mean and standard deviation) based on gender in primary dentition

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Table 6: The overall caries experience

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The overall pufa experience was 43.1% in deciduous dentition with “p” component was the majority of 38.5% and the overall mean pufa index was 0.99 ± 1.679 [Table 7].
Table 7: pufa/PUFA experience

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The overall prevalence of untreated dental caries (pufa/PUFA) was 40.8%. The overall pufa/PUFA ratio in the entire population found was 21.86%.


   Discussion Top


Dental caries is the most common childhood disease that affects 60%–90% of children worldwide. Due to the change in dietary habits and increased consumption of sugar and its related products, the prevalence of dental caries is increasing continuously. In the Global Burden of Disease Study 2010, the untreated decay of primary dentition was mentioned as the 10th most prevalent condition worldwide.[8]

The present study was conducted to assess the prevalence and severity of dental caries among 2194 schoolchildren of 6–12 year old in the rural areas of Kollam District, by using two indices viz., dmft/DMFT and pufa/PUFA. Overall caries prevalence in the total population was found to be 74%. However, in a study conducted by Retnakumari,[1] the overall caries prevalence reported was 68.5% among primary schoolchildren of Varkala, Thiruvananthapuram. However, Ramazani and Rezaei[9] reported a high caries prevalence of 93% in 6–12 years' age group in Iranian children. Christian et al.[10] found caries prevalence of 77% in 6-year-old children and 44% and in 12-year-old children among children residing in orphanages in Kerala.

In the current study, the caries prevalence in deciduous dentition was 61%. The highest caries prevalence was seen in 8 years' age group (81.6%), while the caries prevalence in permanent dentition was 26.8% where the highest prevalence was found in 12 years' age group (51.1%). A similar result was obtained in a study by Reddy et al.[11] where they had reported a caries prevalence of 64.2% in deciduous dentition and 26.6% in permanent dentition. The higher prevalence of dental caries in deciduous dentition compared to permanent dentition can be due to the lower calcium content of deciduous teeth and structural differences that may increase caries susceptibility as reported by Saravanan et al.[12]

The overall prevalence of untreated dental caries (pufa/PUFA) was 40.8% in this study. This number is higher than that found in studies by Murthy et al.[13] among 12-15 year old schoolchildren in Bangalore city (19.4%) and Figueiredo et al.[14] on 5-6 year old Brazilian children (23.7%), but lower than that found in a study by Monse et al[4]. in the Philippines (85%) and Baginska et al[15] among Polish children (43.4%). The prevalence of untreated dental caries (pufa) in deciduous dentition was 43.1% and in permanent dentition was 4.1%. In the 6–12 years' age group, Ramazani and Rezaei[9] found a 30% prevalence of untreated dental caries. The prevalence of untreated dental caries in deciduous dentition was 25.9% and permanent dentition was 3.8%.

Manivannan and Geo Mani[16] reported a pufa prevalence of 72.6% in 6–10 years old children in Chennai and they also had found that the “p” component was the only component prevalent in their population, which is also in accordance with the current study.

In the present study, the mean dmft/DMFT value in 6–12 years' group was 2.74 and 0.66, respectively, and the mean pufa/PUFA was 0.99 and 0.06 respectively. In a study conducted by Oziegbe and Esan,[17] the mean dmft/DMFT value in 7–12 years' group was 0.14 and 0.06, respectively, and the mean pufa/PUFA was 0.03 and 0.02, respectively. The higher caries experience in the current study may be due to the lack of oral health awareness programs at the school level in Kollam District. Similar results were reported by Singhal and Singla[18] among 6–15 year-old schoolchildren of Uduppi Taluk and their 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% clinical consequences of untreated caries (mean pufa score: 1.30 ± 1.9, mean PUFA score: 0.03 ± 0.2) and 26.8% reported pain.

Mehta and Bhalla[19] reported an overall mean pufa value was 0.9 ± 1.93 and prevalence of 38.6% with major contribution from “p” component of index, among 5–6 year old schoolchildren in Chandigarh. Untreated caries ratio was 35%, suggesting that more than one-third of the developed carious lesions cause adverse events in a population. Similar findings were reported by Sudan et al.[20] among 5, 12, and 15-year-old school children in Ambala district, caries prevalence was 58.4% while the prevalence of odontogenic infections was 45.3%. Among children aged 5, 12, and 15 years, the untreated caries pufa/PUFA ratio was 44.58%, 38.33%, and 36.18%, respectively.

Gurunathan and Shanmugaavel.[21] conducted a study in Chennai to assess dental neglect among 3–12 year old children and found a significantly higher dental neglect score among parents who live in the suburbs (P = 0.001), have a secondary education (P = 0.001), and have not had any dental service for more than 3 years (P = 0.001). The higher dental neglect group had significantly higher DMFT (P = 0.003), deft (P = 0.001), pufa (P = 0.011), and debris index (P = 0.002) scores.

In this study, the children with primary dentition have shown a high prevalence of dental caries and associated pulpal pathology when compared with their permanent counterpart. To improve preventive dental behavior and attitudes in children, and to educate the children as well as parents regarding the brushing methods, and usage of pit and fissure sealants, dental health education and school dental health programs should be organized in the Kollam district.


   Conclusion Top


A total of 2194 children were examined in the age group of 6–12 years. This age group faces the ill effect of adverse oral environment on all primary teeth and permanent teeth. The deciduous teeth are essential in the oral cavity up to the age of 12 years for function and space maintenance. Moreover, the WHO has also recommended this index age group for oral health assessment of primary dentition in their basic oral health survey methodology.[3] This is the first study that has been undertaken in Kollam which focused into the clinical consequences of untreated dental caries.

In this study, the overall prevalence of untreated dental caries (pufa/PUFA) among primary and permanent dentition was 40.8%. In this study, there was no statistically significant difference between pufa/PUFA of boys and girls (P = 0.745 and P = 0.954, respectively). The overall pufa/PUFA ratio in the entire population was found to be 21.86%, which means nearly 1/4th of the decayed teeth are having pulpal pathology, which is an alarming situation.

The presence of large untreated carious lesions in the children of the present study is an indication of a lack of awareness, not only among children, but also in their parents, and teachers regarding the importance of good oral health. This study indicates an urgent need to plan a dental caries preventive program for school children in Kollam.

”pufa”/PUFA index along with dmf/DMFT index can act as an excellent epidemiological and educational tool for reporting consequences of untreated carious lesions in a population. As the present study is a baseline one, further studies are required to find out the reasons for the high prevalence of pufa scores in these children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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