|Year : 2019 | Volume
| Issue : 4 | Page : 322-327
Dental caries experience using the international caries detection and assessment system among adults, Nellore District, Andhra Pradesh, India: An epidemiological survey
N Sarah Sheela Emerald1, V Chandrasekhar Reddy2, KM Sudhir2, R V. S Krishna Kumar2
1 Department of Public Health Dentistry, CKS Theja Institute of Dental Sciences and Research, Tirupati, Andhra Pradesh, India
2 Department of Public Health Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
|Date of Submission||28-Sep-2018|
|Date of Decision||25-Oct-2019|
|Date of Acceptance||01-Nov-2019|
|Date of Web Publication||12-Dec-2019|
Dr. N Sarah Sheela Emerald
Department of Public Health Dentistry, CKS Theja Institute of Dental Sciences and Research, Renigunta Road, Tirupati, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Objectives: The International Caries Detection and Assessment System (ICDAS-II) is a newly developed system for determining dental caries at both cavitation and noncavitation levels. The present study was conducted to assess the prevalence, severity, and risk indicators of dental caries using ICDAS-II. Methods: Multistage cluster sampling methodology was followed. Data were collected using a questionnaire, and dentition status was recorded according to the ICDAS-II. Multiple linear regression analysis was done to determine the risk factors for caries. The significance level is taken as P < 0.05. Results: In a total sample of 1500 participants, the prevalence of dental caries according to ICDAS-II was highest at the cutoff point 1 in both males (98.2%) and females (99.4%) and was the least at the cutoff point 4 (males [44.8%], females [32.1%]). The risk factors for dental caries in the present study population are age, sex, employment status, socioeconomic status, level of education, systemic diseases, smoking, sugar consumption, last dental visit, self-perception of oral health, pain, and type of material used to clean teeth according to the ICDAS-II. Conclusions: This cross-sectional epidemiological study provides the prevalence, severity, and risk indicators of dental caries in 35–44-year-old adults of Nellore district, Andhra Pradesh, India.
Keywords: Cavitated lesion, dental caries, epidemiology, International Caries Detection and Assessment System, noncavitated lesion
|How to cite this article:|
Emerald N S, Reddy V C, Sudhir K M, Kumar R V. Dental caries experience using the international caries detection and assessment system among adults, Nellore District, Andhra Pradesh, India: An epidemiological survey. J Indian Assoc Public Health Dent 2019;17:322-7
|How to cite this URL:|
Emerald N S, Reddy V C, Sudhir K M, Kumar R V. Dental caries experience using the international caries detection and assessment system among adults, Nellore District, Andhra Pradesh, India: An epidemiological survey. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2022 Jul 6];17:322-7. Available from: https://www.jiaphd.org/text.asp?2019/17/4/322/272784
| Introduction|| |
Dental caries is the most common disease of the oral cavity affecting the entire human race in all ages. Caries prevalence is high worldwide, affecting nearly 100% of the adult population in many countries. India is the second most populous and seventh largest country in the world, with an estimated population of approximately 1.32 billion in 2017, and over 41.08% are adults aged 25–54 years. In proportion to the large population of adults, the number of teeth affected by dental caries is also very large obviously. The poignant issue is that very scanty literature is available regarding the epidemiological pattern of dental caries among adults in India. This is a serious limitation that needs to be addressed.
To identify the presence of dental caries, a number of measurement criteria have been developed. These have only managed to detect whether a tooth is decayed or not, but they could not measure the extent of the decay; therefore, a novel visual caries diagnosis system was proposed to be used for epidemiological purposes, clinical studies, and clinical practices. The new system was named as International Caries Detection and Assessment System (ICDAS) and includes assessment of both noncavitated and cavitated caries lesions. This new system for caries assessment has been developed with codes ranging from the first visual change in enamel to an extensive cavity in dentine (ICDAS II). Caries process starts as a reversible lesion progressing to an irreversible lesion, finally leading to a complete handicap stage meaning the tooth is lost and many more other severe complications. Prevention is better than cure!! To prevent all these difficulties and improve the health status of the teeth, it is better to tackle the problem in the initial stages itself, especially in developing countries such as India, where the common man cannot afford high costs of dental treatments. ICDAS-II provides an excellent platform for solving the above problem.
Targeted healthcare is of significant importance, especially in developing and underdeveloped countries to overcome the increasing healthcare cost burden and resource constraint for the Government. Risk-based management is favored to provide this targeted healthcare in the prevention and treatment of dental caries. This demands the epidemiologists as well as clinical practitioners to identify the specific risk factors. The three main factors in dental caries; diet, microflora, and a susceptible tooth were identified almost 100 years ago. Since that time, a large number of further local and general risk factors have been identified. In fact, the whole socio-cultural environment of the community in which the individual lives may also have an influence on the development of dental caries.
Considering the above facts, an attempt is made here to assess the prevalence, severity, and risk factors, influencing the dental caries and detecting the early lesions among adults to prevent the progression using the more sensitive, recent, internationally accepted, valid, and reliable criteria, the ICDAS-II in Nellore district of Andhra Pradesh.
| Methods|| |
A descriptive cross-sectional study was carried out between the months of April and July 2015 among 35–44-year-old adults in urban and rural areas of Nellore district of Andhra Pradesh in randomly selected community or primary health centers. Written consent was obtained from the respective medical officers. All willing participants at the time of examination were taken for the final inclusion in the sample. Ethical approval for the study was obtained from the Institutional Ethics Committee. An oral informed consent was taken from each member participating in the study.
Training exercises were first carried out in the department of public health dentistry on the outpatients, till the consistent results were obtained by five examiners. An online tutorial was also taken for training and calibration in recording ICDAS-II. Intraclass correlation coefficient (ICC) for intra-examiner repeatability was calculated for the chief examiner and the remaining examiners. It was good, the findings were high (0.91 for ICDAS-II). When ICC for individual score was calculated, ICC was least for score 1 (0.68), highest for scores 5 and 6 (1.0).
The sample size was calculated using the formula N = 4pq/l, where “p” is the prevalence of dental caries in adults of >35 years in India taken from the National oral health survey and fluoride mapping of India, “q” is 1 − p, and “l” is the allowable error or precision. Multi-stage cluster sampling methodology was followed. Data collection was done using a questionnaire on behavioral factors such as oral hygiene, diet, and socioeconomic factors such as income, education, and occupation of the parents apart from general information such as age and sex. ICDAS-II was used for recording caries in permanent teeth.
Strict protocol for infection control was observed constantly throughout the data collection period. The instruments were autoclaved daily, and necessary cold sterilization was performed in the field during the clinical examination. Cold sterilization method was followed using Korsolex ® chemical solution (gluteraldehyde – 7.0 g, 6-dihydroxy 2, 5-dioxahexane – 8.2 g, and polymethylol urea derivatives –17.6 g). One part of Korsolex ® was diluted to nine parts of clean tap water to get 10% solution, into which, prerinsed instruments were immersed for a minimum of 30 min before being reused, if needed.
No continuous variable exhibited a normal distribution (Shapiro–Wilk test). The decayed missing filled tooth surfaces (DMFS) scores were calculated using data obtained by ICDAS-II at four cutoffs: score 1 (scores 1–6 classified as carious); score 2 (scores 0 and 1 classified as sound and scores 2–6 as decayed); score 3 (0–2 sound and 3–6 carious); and score 4 (0–3 sound and 4–6 carious). Caries prevalence using ICDAS-II criteria at different cutoffs was determined. Intra-examiner reproducibility was calculated at tooth surface level using inter-class correlation. Prevalence ratio values (95% confidence interval [CI]) and rate ratio values (95% CI) were obtained by the Poisson regression. Multiple linear regression of dental caries determined by ICDAS-II with various independent variables was also done. Multivariate regression models (negative binomial) were chosen for this analysis because it is an appropriate model for analysis of “overdispersed” counts such as the number of noncavitated, cavitated, filled, or missing tooth surfaces. As the dependent variables represent counts of surfaces with significant dispersion (the variance of the count was larger than the mean), the negative binomial regression model was estimated. Sampling weights and clustering effects caused by sampling were adjusted for when the negative binomial coefficients were computed. The significance level for all analyses is P < 0.05.
| Results|| |
In a total sample of 1500 participants, males comprise 44.9%, and females comprise 55.1%. Urban and rural population were included as per the distribution in Nellore city, that is, 30% and 70% [Table 1]. Of them, 64.9% belonged to the 35–40 years age group, and 35.1% belonged to the 41–44 years age group. Out of them, 89.3% were married, and 10.7% were single (unmarried, divorced, and widowed). Most of them were employed, only 23.4% were unemployed. Majority of the participants belonged to the Prasad's Socioeconomic Class III (33.5%). 23.3% of them were graduates, and 22.5% with an education level of middle school. The prevalence of dental caries according to ICDAS-II was highest at the cutoff point score 1 in both males (98.2%) and females (99.4%) and was the least at the cutoff point score 4 (males [44.8%], females [32.1%]). According to the ICDAS prevalence ratio values (95% CI) obtained by Poisson regression using participants with caries, as the outcome with cutoff points scores 1, 2, 3, and 4 shows that age and level of education (only in some categories) have significant association (P < 0.05) at noncavitated threshold alone. Marital status showed significant association with dental caries at the only initial caries lesion threshold alone. Systemic diseases, smoking, sugar consumption, employment status, last visit to the dentist, self-oral health perception, and type of material used for cleaning teeth were significantly associated (P < 0.05) with adults with caries assessed by ICDAS-II at both the cavitated and noncavitated thresholds.
Rate ratio values (95% CI) were obtained by the Poisson regression using DMFS values as the outcome according to the International Caries Detection and Assesment System (ICDAS) with cutoff points scores 1, 2, 3, and 4; some explanatory variables show that age, geographic distribution, level of education, sugar consumption, smoking, systemic diseases, last visit to the dentist, self-oral health perception, and type of cleaning had significant association (P < 0.05) with DMFS in adults at the cavitated threshold level. Age, geographical distribution, marital status, smoking, systemic disease, and self-oral health perception showed significant association with DMFS at the noncavitated threshold level when observed using ICDAS-II. DMFS values observed using ICDAS-II showed significant association (P < 0.05) with age, geographic distribution, sugar consumption, systemic diseases, smoking, and self-oral health perception at both cavitated and noncavitated thresholds. Level of education and socioeconomic status were significantly associated with DMFS values, but only in some categories.
[Table 2] presents the findings of multivariate regression models (negative binomial) for five dental outcomes (noncavitated [D1, D2], cavitated [D3], total decay [D1–6], or filled tooth surfaces [F] and missing teeth [M], and risk indicators). Multiple linear regression analysis was done to assess the impact of various independent variables on dental caries determined by ICDAS-II [Table 3].
|Table 2: Multivariate regression model (negative binomial) coefficients and standard errors for four dental outcomes (noncavitated [D1, D2], cavitated [D3], total decay [D4-6], or filled tooth surfaces [F], and missing teeth [M]) and risk indicators|
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|Table 3: Multiple linear regression of dental caries determined by the International Caries Detection and Assessment System-II with various independent variables (only caries considered)|
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| Discussion|| |
This cross-sectional epidemiological study provides the latest picture of dental caries experience in 35–44-year-old adults of Nellore district, Andhra Pradesh, India. The prevalence of dental caries according to ICDAS-II in the present study is 98.8%. It is far higher than the prevalence obtained using the WHO criteria in other studies. Whereas the mean DMFS was 13.04 among 31–35-years and 24.35 among 36–51-years in Australian army recruits in 2002–2003, the mean DMFS according to ICDAS-II in 35–44-year-old African–Americans in Detroit (2002–2003) was 69.7. The National Health Survey conducted in 2004 throughout India presented 80.2% prevalence of dental caries in adults aged 35–44-years, and the mean DMFS was 13.8 among 189 participants aged 18–91 in a rural village of Bidada, Kachchh, India, in 2012.
The differences observed between the results of this study, and those of other investigations may be explained by two main factors. First, a WHO criterion for dental caries was used in many of the other studies, and second, if and when ICDAS-II was used, it was used to measure the caries prevalence and determination of risk factors in primary or mixed dentition. It is difficult to compare the results of other prevalence studies in such circumstances.
Multiple linear regression showed gender as a significant risk factor, when dental caries was measured using ICDAS-II criteria. In this study, females show a higher prevalence of dental caries when compared to males (M = 98.2%, F = 99.4%). Similar results were found in some other studies.,,,, Higher caries prevalence among females is often explained by one of three factors: teeth erupt earlier in girls resulting in a longer cariogenic oral environmental exposure, frequent snacking during food preparation, and pregnancy. Hormonal changes also have a striking effect on the oral health of women, and constitute an important contributory factor in explaining sex differences in caries rates.
In the present study, age is a significant risk indicator for dental caries. Similar results were obtained in another study done by Costa et al. in 2012, where age exerted a significant influence over the severity of caries. Marital status was dichotomized into yes or no. Unmarried, divorced, widowed, and separated were all included under not married. Participants who were not married had a high prevalence of dental caries as well as high mean DMFS, similar results were obtained in another Indian study conducted in Pondicherry. This can be explained by the fact that married people have a better quality of life and thus a better oral health.
Dental caries prevalence is more in the urban population when compared to rural population in the present study. Similar results were obtained in some other studies.,, The reason for the greater prevalence of dental caries in urban population maybe due to the difference in their dietary habits and increased intake of cariogenic food and more refined sugars, which promote dental caries. Socioeconomic status of the study population is determined using modified BG Prasad's Classification for 2013, as this can be applied to assess the socioeconomic status in both rural and urban areas of India. In the present study, socioeconomic status is a significant risk factor for dental caries. Other studies also show socioeconomic status as a significant risk factor,,,, but they have taken different classifications of socioeconomic status. Level of education also is a significant risk. Negative binomial regression showed significant value in the missing surfaces component among the illiterates; this might be because they do not have enough knowledge regarding restorative procedures for dental caries and they go for extraction of the tooth rather than restoration.
The role of sugar as a risk factor in the initiation and progression of dental caries is overwhelming. This study took into consideration, the frequency of sugar consumption, as many studies point to the frequency of eating sugars to be of a significant etiological importance for caries than the total consumption of sugars. The primary evidence comes from the Vipeholm study. Sugar consumption is indeed a significant risk factor for dental caries in the present population. Similar results were seen in other studies.,,,, The prevalence of current smokers in the study population is less (18.5%) but the prevalence of dental caries is more in the smokers (99.3%) when compared to nonsmokers (98.8%), which is a significantly associated risk factor for dental caries in the present study. Studies conducted by Golpasand Hagh et al., 2013 and Vellappally et al., 2008 showed similar results., The reason for the increase in dental caries among smokers might be attributed to the fact that daily smoking is associated with increased use of sugar in tea or coffee and with more frequent alcohol consumption.
Self-reported oral health and last visit to the dentist are significant risk factors in the present study population for dental caries, as their self-perception of their oral health degraded their dental caries prevalence and mean DMFS increased. Similar results were observed in a study done by Armfield et al., in 2004–2006 in Australia. Many studies show the similar result that those who visited the dentist frequently and have visited the dentist in the past 2 years have a significant less carious teeth when compared to those who did not visit the dentist frequently and to those who have never visited the dentist ,,,, proving that regular dental attendance is associated with better oral health outcomes.
Oral hygiene practice is also a significant risk indicator. Those who used datun (neem stick) to clean their teeth had the least prevalence of dental caries when compared to those who cleaned their teeth using a toothbrush or finger. It might be due to the medicinal properties of neem as well as the abrasive action of the stick which removes plaque and calculus which are the main etiologic factors for dental caries. Similar results were seen in the study conducted by Varenne et al., in 2006, in Africa where people use traditional chewing sticks to clean their teeth. The dental caries experience was significantly low in those who used these sticks to clean their teeth.
| Conclusions|| |
This study concludes that the prevalence of dental caries among 35–44-years of Nellore district, Andhra Pradesh, India, is 98.95% when dental caries were measured using ICDAS-II. The risk factors for dental caries in the present study population are age, sex, employment status, socioeconomic status, level of education, systemic diseases, smoking, sugar consumption, last dental visit, self-perception of oral health, pain, and type of material used to clean teeth according to the ICDAS-II.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Peterson PE. Oral Health in the Developing World: Global Oral Health Programme Chronic Disease and Health Promotion. Geneva: World Health Organization; 2009.
Available from: https://www.statista.com/statistics/263766/total-population-of-india/. [Last accessed 2018 Jun 23].
Available from: https://www.indexmundi.com/india/demographics_profile.html. [Last accessed on 2018 Jun 23].
Mendes FM, Braga MM, Oliveira LB, Antunes JL, Ardenghi TM, Bönecker M, et al.
Discriminant validity of the International Caries Detection and Assessment System (ICDAS) and comparability with World Health Organization criteria in a cross-sectional study. Community Dent Oral Epidemiol 2010;38:398-407.
de Amorim RG, Figueiredo MJ, Leal SC, Mulder J, Frencken JE. Caries experience in a child population in a deprived area of Brazil, using ICDAS II. Clin Oral Investig 2012;16:513-20.
Sugandhi A, Mangal B, Mishra AK, Sethia B. To explore and develop a model to maintain and build upon a dental clinic open for all in developing regions, with a primary focus on India. World J Clin Cases 2014;2:439-47.
Hunter PB. Risk factors in dental caries. Int Dent J 1988;38:211-7.
Hopcraft MS, Morgan MV. Pattern of dental caries experience on tooth surfaces in an adult population. Community Dent Oral Epidemiol 2006;34:174-83.
Burt BA, Kolker JL, Sandretto AM, Yuan Y, Sohn W, Ismail AI. Dietary patterns related to caries in a low-income adult population. Caries Res 2006;40:473-80.
Bagramian RA, Garcia-Godoy F, Volpe AR. The global increase in dental caries. A pending public health crisis. Am J Dent 2009;22:3-8.
Maru AM, Narendran S. Epidemiology of dental caries among adults in a rural area in India. J Contemp Dent Pract 2012;13:382-8.
Namal N, Can G, Vehid S, Koksal S, Kaypmaz A. Dental health status and risk factors for dental caries in adults in Istanbul, Turkey. East Mediterr Health J 2008;14:110-8.
Demirci M, Tuncer S, Yuceokur AA. Prevalence of caries on individual tooth surfaces and its distribution by age and gender in university clinic patients. Eur J Dent 2010;4:270-9.
Lee HY, Choi YH, Park HW, Lee SG. Changing patterns in the association between regional socio-economic context and dental caries experience according to gender and age: A multilevel study in Korean adults. Int J Health Geogr 2012;11:30.
Nguyen TC, Witter DJ, Bronkhorst EM, Truong NB, Creugers NH. Oral health status of adults in Southern Vietnam – A cross-sectional epidemiological study. BMC Oral Health 2010;10:2.
Bhardwaj VK, Veeresha KL, Sharma KR. Impact of socioeconomic status on Decayed, Missing, Filled Teeth (DMFT) among state government employees in Shimla city, Himachal Pradesh. J Cranio Max Dis 2012;1:74-8. [Full text]
Lukacs JR, Largaespada LL. Explaining sex differences in dental caries prevalence: Saliva, hormones, and “life-history” etiologies. Am J Hum Biol 2006;18:540-55.
Costa SM, Vasconcelos M, Haddad JP, Abreu MH. The severity of dental caries in adults aged 35 to 44 years residing in the metropolitan area of a large city in Brazil: A cross-sectional study. BMC Oral Health 2012;12:25.
Jagadeesan M, Rotti SB, Danabalan M. Oral health status and risk factors for dental and periodental diseases among rural women in Pondicherry. Indian J Community Med2003;25:1-10.
Eustaquio MV, Montiel JM, Almerich JM. Oral health survey of the adult population of the Valencia region (Spain). Med Oral Patol Oral Cir Bucal 2010;15:e538-44.
Dudala SR, Arlappa N. An Updated Prasad's socio economic status classification for 2013. Int J Res Dev Health 2013;1:26-8.
Chandra Shekar BR, Reddy C. Oral health status in relation to socioeconomic factors among the municipal employees of Mysore city. Indian J Dent Res 2011;22:410-8.
] [Full text]
Hudson K, Stockard J, Ramberg Z. The impact of socioeconomic status and race-ethnicity on dental health. Sociol Perspect 2007;50:7-25.
Gupta P, Gupta N, Pawar AP, Birajdar SS, Natt AS, Singh HP. Role of sugar and sugar substitutes in dental caries: A review. ISRN Dent 2013;2013:519-21.
Krasse B. The vipeholm dental caries study: Recollections and reflections 50 years later. J Dent Res 2001;80:1785-8.
Varenne B, Petersen PE, Ouattara S. Oral health behaviour of children and adults in urban and rural areas of Burkina Faso, Africa. Int Dent J 2006;56:61-70.
Golpasand Hagh L, Zakavi F, Ansarifar S, Ghasemzadeh O, Solgi G. Association of dental caries and salivary sIgA with tobacco smoking. Aust Dent J 2013;58:219-23.
Vellappally S, Jacob V, Smejkalová J, Shriharsha P, Kumar V, Fiala Z. Tobacco habits and oral health status in selected Indian population. Cent Eur J Public Health 2008;16:77-84.
Armfield JM, Mejía GC, Jamieson LM. Socioeconomic and psychosocial correlates of oral health. Int Dent J 2013;63:202-9.
Brennan DS, Spencer AJ, Roberts-Thomson KF. Caries experience among 45-54 year olds in Adelaide, South Australia. Aust Dent J 2007;52:122-7.
Thomson WM, Williams SM, Broadbent JM, Poulton R, Locker D. Long-term dental visiting patterns and adult oral health. J Dent Res 2010;89:307-11.
[Table 1], [Table 2], [Table 3]