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ORIGINAL Machale ARTICLE et al Assessment of Non-cavitated and Cavitated Carious Lesions Among 12- to 15-year-old Gover...

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ORIGINAL Machale ARTICLE et al

Assessment of Non-cavitated and Cavitated Carious Lesions Among 12- to 15-year-old Government and Private School Children in Pune, Maharashtra, India Priyanka S. Machalea/Sahana Hegde-Shetiyab/Ravi Shirahattic/Deepti Agarwald Purpose: The present cross-sectional study was conducted to assess and compare the mean number of non-cavitated (initial lesions, IL) and cavitated carious lesions (WHO criteria) per child in the permanent dentition and to correlate it with the plaque index among 12- to 15-year-old government and private school children. Materials and Methods: 481 schoolchildren aged 12–15 years were selected randomly by multistage random sampling from two government and two private schools. Demographic details were collected at the time of examination. Baseline plaque scores were recorded using the Silness and Löe plaque index. Immediately after brushing and drying the teeth, cavitated lesions were recorded based on WHO recommendations and non-cavitated lesions were recorded using the IL criteria of Nyvad et al and Fyffe et al. Results: The mean number of surfaces with cavitated and non-cavitated lesions for government school children was 2.13 ± 2.98 and 3.21 ± 2.97, respectively, and 1.24 ± 1.86 and 3.08 ± 2.33 for private school children, respectively. WHO + IL surfaces among private school children were 4.33 ± 3.48 and in government school children 5.35 ± 4.45. There was a positive correlation of plaque score with IL (r = 0.63) and WHO+IL (r = 0.73). Conclusion: Non-cavitated lesions are about twice as common as cavitated carious lesions in school children. Government school children had a higher number of cavitated and non-cavitated carious lesions when compared with private school children. Key words: caries epidemiology, caries risk predictors, early caries, non-cavitated carious lesions, precavitated caries Oral Health Prev Dent 2014;2:117-124

Submitted for publication: 19.12.11; accepted for publication: 24.02.13

doi: 10.3290/j.ohpd.a31659

H

ealth services are still treating dental caries as a patent cavity and not as a multifactorial disease which clinically presents evident initial signs of enamel demineralisation (Ismail et al, 2004; Pitts, 2004). The inclusion of initial lesions (IL) in surveys generates a statistically significant percent

a

Senior Lecturer, Department of Public Health Dentistry. M.G.M. Dental College and Hospital, Mumbai, Maharashtra, India.

b

Professor and Head, Department of Public Health Dentistry, Dr. D. Y. Patil Vidyapeeth Dental College and Hospital, Pune, Maharashtra, India.

c

Reader, Department of Public Health Dentistry, A B S M Institute of Dental Sciences, Mangalore, India.

d

Reader, Department of Public Health Dentistry, Dr. D. Y. Patil Vidyapeeth Dental College and Hospital, Pune, Maharashtra, India.

Correspondence: Dr. Priyanka S Machale, Department of Public Health Dentistry. M.G.M. Dental College and Hospital, Kamothe, Navi Mumbai, Maharashtra, India. Tel: +91-727-624-1433, Fax: +91020-2742-3427. Email: [email protected]

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increase in caries indices, which contributes to obtaining additional information for oral health planning in public services (Assaf et al, 2006). Diagnosis of early carious lesions is a necessary first step for the secondary prevention of caries. Surveys that include IL could be very relevant to show distinct preventive and operative needs of the population (Assaf et al, 2006). It is important to include the non-cavitated lesions in a diagnostic threshold, as the pattern of caries is very relevant not only for clinicians, but also for epidemiologists and oral health service planners (Assaf et al, 2006). Many studies have been carried out to examine the prevalence of non-cavitated and cavitated carious lesions, with result showing that the prevalence of non-cavitated carious lesions was higher than that of cavitated carious lesions (Ismail et al, 1992; Machiulskiene et al, 1998; Assaf et al, 2006). In a developing country like India, data on

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caries prevalence that includes non-cavitated lesions is scarce. A substantial proportion of children in many developing countries are affected by tooth decay, and most decay is left untreated due to limited access to oral health services (WHO, 2003a). Poor oral health in childhood often continues into adulthood, leading to the complicated disease process which in turn leads to time-consuming, expensive operative treatment. School provides an ideal setting for promoting oral health and preventing diseases at an early stage and young age (WHO, 2003a). Therefore, this study was conducted to assess and compare non-cavitated and cavitated carious lesions among 12- to 15-year-old government and private school children and to find the correlation between plaque and initial lesions.

lottery method of simple random sampling based on the roll number of students and those fulfilling the inclusion criteria. If any child was excluded based on exclusion criteria, the next child was selected randomly by using the same criteria. The inclusion criteria were 12- to 15-year-old schoolchildren with all permanent teeth except third molars and for whom parents gave consent. The exclusion criteria were orthodontic treatment in progress, presence of any systemic disease, enamel hypoplasia or opacities, dental fluorosis, developmental enamel defects, intrinsic stains, deciduous teeth and handicaps. Before commencing the study, informed consent was obtained from the schoolchildren’s parents.

Diagnostic Thresholds, Criteria and Codes

MATERIALS AND METHODS A cross-sectional study was carried out for a period of 20 days in June-July 2011. Before commencing, study approval was obtained from the institutional review board and ethics committee of the Dr. D.Y. Patil Dental College and Hospital, Pimpri, Pune, India.

Sampling and inclusion criteria A list of government and private schools was obtained from the local authority. Official permission was obtained from the Education Officer and the school authorities concerned before commencing the study. Four schools (2 government and 2 private) were randomly selected from the list of 57 government and 64 private schools by simple random sampling using a table of random numbers. None of the selected schools reported any previous history of school-based oral health programmes. Sample size was estimated based on the mean number of non-cavitated and cavitated carious lesions from the study by Jain et al (2010). Sample size was estimated using N. Master software, version 1.0 (Christian Medical College; Vellore, India). Considering the relative precision to be 20%, desired confidence level of 0.05 (_ = 0.05) and power of the study 95%, the sample size was derived to be 120. Total study sample was estimated to be 480 (120 x 4 ages = 480). As the study consisted of four schools, 120 children (30 children in each age group) from each of the four schools were examined. Within each age group (12 to 15 years), 30 children were examined from each school using the

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Dental plaque was recorded according to Silness and Löe criteria (Löe, 1967). Two diagnostic thresholds were used to record caries: 1) the WHO threshold (WHO, 1997), i.e. a tooth is considered decayed when a cavitation is present; 2) IL diagnostic threshold, in which active initial lesions are recorded following criteria by Nyvad et al (1999) and Fyffe et al (2000). The following codes and abbreviations were employed: decayed teeth according to WHO criteria: WHO (DT); decayed surfaces according to WHO criteria: WHO(DS); teeth with initial lesions according to Nyvad et al (1999) and Fyffe et al (2000): IL (T); tooth surfaces with initial lesions according to Nyvad et al (1999) and Fyffe et al (2000): IL(S); combination of decayed teeth and teeth with initial lesions: WHO (DT) +IL (T); combination of decayed surfaces and surfaces with initial lesions: WHO(DS) +IL(S).

Training and calibration of examiners The calibration process of the examiners began with a theoretical phase. The training sessions were held as discussions with the benchmark examiner for the purpose of initial standardisation. Calibration for both IL and plaque index was done by examining 10 subjects in the age group of 12 to 15 years, whom examiners and benchmark examiner examined independently. The intraclass correlation coefficient for inter-examiner reliability was 0.98 and 0.80 for both the Silness and Löe plaque index and WHO+IL. The intraclass correlation coefficient value for intra-examiner reliability was 0.99 and 0.86 for both the Silness and Löe plaque index and WHO+IL.

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Machale et al

Table 1

Distribution of study subjects according to age, gender, school type and socioeconomic status (N = 481) Age

12 years

13 years

14 years

15 years

Total

Private school (n)

60

60

60

60

240 (49.89%)

Government school (n)

60

60

60

61

241 (50.10%)

Male (n)

17

25

23

35

100 (41.49%)

Female (n)

43

35

37

25

140 (58.09%)

Male (n)

15

21

27

30

93 (38.58%)

Female (n)

45

39

33

31

148 (61.41%)

7

3

6

2

18 (7.56%)

Upper middle (II)

35

41

51

47

174 (72.50%)

Lower middle (III)

9

12

2

6

29 (12.08%)

Upper lower (IV)

9

4

1

5

19 (7.91%)

Upper middle (II)

2

3

3

3

11 (4.56%)

Lower middle (III)

7

17

8

11

43 (17.84%)

Upper lower (IV)

50

40

49

46

185 (76.76%)

1

0

0

1

2 (0.82%)

Private school

Government school Upper (I) Private school socioeconomic status (SES) according to modified Kuppuswamy’s SES scale for June 2011

Government school SES according to modified Kuppuswamy’s SES scale for June 2011

Lower (V)

Commencement of the study A proforma designed for recording all the relevant data pertaining to demographic information (age, sex, school type, parents’ education, occupation and income) was given to the children from all four schools. Based on demographic information (education, occupation and parents’ income), the socioeconomic status of each child was determined using a modified Kuppuswamy’s socioeconomic status scale (Kumar et al, 2007) for Pune (June 2011). Clinical examinations were carried out in schools using a portable dental chair and artificial overhead light. All the schoolchildren fulfilling inclusion criteria were examined. One day prior to clinical examination, all children were asked to bring their toothbrushes to school. Baseline examination was carried out in order to record the plaque index. Children were asked to brush their teeth according to the Bass technique for a standardised time of 2 min (prior to toothbrushing the Bass technique was demonstrated) under supervision of a qualified dentist. Further examination to record WHO and IL indices was performed under standardised conditions using a portable dental chair, artificial light, mouth mirror and CPI probe. Children were seated in an upright position on the portable dental chair. Prior tooth drying was carried out using three-way syringes during the examinations for about

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5 s per tooth. A recording clerk was trained to record the findings of the Silness and Löe plaque index and WHO and IL thresholds.

Statistical analysis Data were found to be nonparametric. The number of cavitated and noncavitated carious lesions per child was represented as means and standard deviations. The Mann-Whitney U-test was used to compare the cavitated and non-cavitated lesions between government and private school children. Spearman’s correlation was used to check the correlation of plaque index with noncavitated carious lesions [IL(S)] and WHO(DS) + IL(S)]. The significant caries (SiC) index – in which the third of the population with the highest caries score is selected and the mean DMFT for this subgroup calculated (Bratthall, 2000) – was calculated according to individual DMFT values. All the statistical data were analysed using SPSS version 11 (SPSS; Chicago, IL, USA).

RESULTS Table 1 shows that a total of 481 schoolchildren (240 from private schools and 241 from govern-

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Pvt (n = 240) Mean ± SD

Govt (n = 241) Mean ± SD

1.70 ± 2.84

2.10 ± 2.92

2.01 ± 2.98

2.72 ± 3.16

2.13 ± 2.98

0.00*

Age

12 years

13 years

14 years

15 years

Total

P-value

1.69 ± 2.52

1.84 ± 2.71

1.60 ± 2.42)

1.70 ± 2.46

1.61 ± 2.52

Total (N = 481) Mean ± SD

0.35

3.21 ± 2.97

2.96 ± 2.98

2.63 ± 2.69

2.76 ± 2.29

4.51 ± 3.47

Govt (n = 241) Mean ± SD

3.08 ± 2.33

2.81 ± 2.17

2.95 ± 2.12

3.81 ± 3.12

2.76 ± 1.52

Pvt (n = 240) Mean ± SD

IL (S)

3.15 ± 2.67

2.89 ± 2.60

2.79 ± 2.42

3.29 ± 2.77

3.64 ± 2.80

Total (N = 481) Mean ± SD

1.23 ± 1.65

1.18 ± 1.26

1.16 ± 1.37

1.63 ± 1.39

1.30 ± 1.43

12 years

13 years

14 years

15 years

Total

FT

0.05 ± 0.23

0.03 ± 0.27

0.10 ± 0.30

0.03 ± 0.18

0.01 ± 0.12

3.08

0.09 ± 0.32

0.08 ± 0.27

0.06 ± 0.25

0.16 ± 0.41

0.06 ± 0.31

MT

1.46 ± 1.47

1.80 ± 1.50

1.33 ± 1.37

1.38 ± 1.31

1.31 ± 1.65

DMFT

0.94 ± 1.21

0.71 ± 1.15

0.91 ± 1.07

1.08 ± 1.25

1.06 ± 1.33

DT

FT

0.10 ± 0.32

0.08 ± 0.18

0.16 ± 0.41

0.10 ± 0.35

0.10 ± 0.30

2.65

0.02 ± 0.14

0.03 ± 0.18

0.03 ± 0.18

0.01 ± 0.12

0.00 ± 0.00

MT

Private school (n = 240) Mean ± SD

1.06 ± 1.28

0.78 ± 1.15

1.11 ± 1.19

1.20 ± 1.41

1.16 ± 1.35

DMFT

1.12 ± 1.33

1.18 ± 1.35

1.04 ± 1.23

1.13 ± 1.25

1.15 ± 1.49

DT

DMFT = 0.00*, MT = 0.00*, FT = 0.15, DT = 0.00* Government and private school children compared by using Mann-Whitney U-test (*P ≤ 0.05).

Total SiC index

DT

Age

Government School (n = 241) Mean ± SD

Table 3 Mean number of decayed, missing and filled teeth (DMFT) in government and private school children

0.04*

MT

0.07 ± 0.28

0.05 ± 0.23

0.13 ± 0.36

0.06 ± 0.28

2.89

0.05 ± 0.25

0.05 ± 0.23

0.05 ± 0.21

0.09 ± 0.31

0.05 ± 0.23

FT

Total (N = 481) Mean ± SD

4.33 ± 3.48*

3.78 ± 3.16

4.15 ± 3.11

4.85 ± 3.99

4.30 ± 2.95

Pvt (n = 240) Mean ± SD

WHO(DS)+IL(S)

0.03 ± 0.22

5.35 ± 4.45

5.68 ± 4.42

4.65 ± 3.97

5.11 ± 4.44

6.21 ± 5.24

Govt (n = 241) Mean ± SD

Govt: government school; Pvt: Private school. Mann-Whitney U-test to compare between government and private school children. *P 0.73), which it might have been had a more sensitive index been used to record plaque. The mean DMFT of the study population was found to be 1.26 ± 1.39. Mean DT and MT of government school children was significantly higher than that of private school children (Table 3). This shows that the amount of untreated decay was high in government school children, which could be due to lack of oral hygiene awareness, inattentiveness to oral health, low education, occupation and income of parents, low standard of living, lack of affordability of dental treatment. Mean FT was slightly higher in private school than government school children, which shows that the better the socioeconomic status, the higher the filled-tooth component becomes. This can be explained by greater dental health awareness and affordability of dental treatment among private school children. These findings are in agreement with many previous studies (Havold et al,1984; Angulo et al, 1994; Sogi and Bhaskar, 2002). The SiC index of the present study population was as high as 3 (Table 2). With the help of SiC, attention is drawn to the skewed distribution of caries within the study population, indicating that there are large groups of individuals who have considerably more caries than other groups. It has also been proposed that the SiC index for countries should be less than 3 DMFT in 12-year-olds by the year 2015 (Bratthall, 2000). In the present study, the SiC index for 12-year-old schoolchildren was 3.12. Examinations were performed by using a mouth mirror, CPI probe, 3-way syringe and artificial light. As artificial light was used, illumination for posterior teeth was adequate to identify lesions. This eliminated the misleading diagnosis of IL lesions in posterior region. As the data were collected in terms of tooth surfaces, the study results are more sensitive. The information related to socioeconomic status was collected during the examination and could help explain why the government school children had higher caries experience. The inclusion of incipient or noncavitated carious lesions in a criteria system has always been questioned by epidemiologists because of the contention that reliability will suffer. Previous studies have shown that early carious lesions can be measured

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reliably (Pitts and Fyffe, 1988). In this study, the overall reliability coefficients for the IL criteria was good. The limitation of this study was its small sample size, as precision of 20% was considered. The mean number of initial carious lesions [IL(T), IL(S)] was higher in government school children than in private school children but not statistically significant. As the sample size was small, this might be one of the reasons why there was no significant difference between school type in relation to initial lesions [IL(T), IL(S)]. Further studies need to be conducted with a larger sample size. A systematic bias may have occurred in the study as authors asked children to bring their toothbrush. This could have let them to clean their teeth better the day before the examination, influencing plaque index values. In India, there is a lack of school oral health programmes. A National Oral Health Policy was passed by the Ministry of Health and Family Welfare in 1995 and as a part of it, a pilot project for a national oral health programme was implemented in 5 states of India, including Maharashtra. It also included a school oral health programme based on oral health education and preventive strategies. However, progress in implementation has been very slow and variable in different regions, and the goals set by the policy remains on paper. Without action or activities these are unlikely to be achieved. To date, the training of school teachers for health education has been the only activity pursued and there have been no follow-up activities to discern what has been accomplished by the teachers. The exclusive oral health policy is not viable; it has to be an integral part of health policy in principle. The results of the pilot project are eagerly awaited, as then the programme can be expanded to other parts of the country. These results must be shared with various stake holders/sectors on a regular basis and even more so with school children, teachers and parents, whose quality of life and oral health are affected most.

CONCLUSION Inclusion of IL conventional diagnostic criteria showed that total caries experience of the study population was about three times higher than when using conventional diagnostic criteria alone. The government school children had higher caries experience than did private school children; as most of the government school children (95.44%) belonged

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to the low and lower middle class, the high caries experience could be related to SES. The plaque index was highly correlated with surfaces with initial lesions and cavitated lesions. This shows that poor oral hygiene is risk predictor for active enamel lesions and cavitated carious lesions. The results reaffirm the importance of mechanically controlling biofilm to prevent caries development in its initial stage (white lesion).

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