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ORIGINAL ARTICLE
Year : 2016  |  Volume : 8  |  Issue : 2  |  Page : 115-119

Assessment of dental caries in primary dentition employing caries assessment spectrum and treatment index


Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Date of Web Publication16-Dec-2016

Correspondence Address:
Karthik Anchala
Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Chintareddypalem, Nellore, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-8844.195913

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  Abstract 

Background: Caries assessment spectrum and treatment (CAST) index was developed as an innovative instrument for evaluating dental caries in epidemiological studies. Aim: The aim of the study was to assess the usefulness of CAST in evaluating caries prevalence and treatment needs among children in primary dentition stage. Materials and Methods: Children in the age range of 5-6 years were selected and their caries status, along with the treatment needs, was recorded using CAST index. The differences in caries status between maxillary and mandibular arches, right and left quadrants as well as boys and girls were assessed using Mann–Whitney U test with the level of significance set at 0.05 and correlation of the distribution of CAST codes among the evaluated teeth was explored through Spearman's rank correlation coefficient. Results: A strong correlation was found between the status of the teeth from the right and left sides of the oral cavity. The correlation coefficient (r) for neighboring maxillary anteriors was 0.67 and 0.57, whereas 1 for all mandibular anteriors (P < 0.001). The correlation coefficient (r) for neighboring maxillary posteriors was <0.3, whereas it was 0.48 and 0.18 for mandibular posteriors (P < 0.001). Correlations were found to be weak (r 0.07-0.29) between maxillary and mandibular arches. Conclusions: In the evaluated population, the strongest correlation was found for the distribution of caries stages in primary incisors as well as molars on the right side of the mouth and the percentage of molars with carious lesions was especially high for second primary molars.

Keywords: Caries pattern, caries assessment spectrum and treatment (CAST) index, children, primary dentition


How to cite this article:
Anchala K, Challa R, Vadaganadham Y, Kamatham R, Deepak V, Nuvvula S. Assessment of dental caries in primary dentition employing caries assessment spectrum and treatment index. J Orofac Sci 2016;8:115-9

How to cite this URL:
Anchala K, Challa R, Vadaganadham Y, Kamatham R, Deepak V, Nuvvula S. Assessment of dental caries in primary dentition employing caries assessment spectrum and treatment index. J Orofac Sci [serial online] 2016 [cited 2017 Apr 27];8:115-9. Available from: http://www.jofs.in/text.asp?2016/8/2/115/195913


  Introduction Top


Dental caries is an active disease that manifests as lesions of different extents in the enamel and dentine.[1] It is considered as one among the major public health problems that may cause pain, suffering, and a decrease in a person's quality of life.[2] Various caries control measures can be used to curb progression of the carious lesion rate. It is widely believed that carious lesions in the enamel and dentine can be arrested can be arrested. If caries control measures are applied, further progression and damage can be prevented.[1] Caries is a preventable and controllable disease; hence, there is a requisite of reliable caries index in a given population.[3]

For the assessment of dental caries, a variety of tools has been presented in the literature, among which the most recognized and frequently used is the decayed, missing, and filled teeth (DMFT) index and also other indices such as International Caries Detection and Assessment System (ICDAS) I, ICDAS II, and Pulp Involvement-Ulceration-Fistula-Abscess (PUFA) index.[2]

Although the DMFT index has advantages, these are outweighed by its weaknesses because the consequences of untreated cavitated dentine lesions and carious lesions in the enamel are not recorded in this index. Due to this, the prevalence and severity of caries are underestimated.[2]

A new visual and tactile dental caries detection system was established for international practice known as the ICDAS to overcome the difficulties experienced with DMFT index that also combines other caries assessment indices.[4],[5] This index was meant to be used in clinical practice as well as education, research, and epidemiological purposes. A few changes were made in this original index by the ICDAS Coordinating Committee and it was finally named as ICDAS II.[6]

Nevertheless, the ICDAS II two-digit coding system is complex for use in a caries epidemiological study. This system encumbers data analysis and makes it difficult to present results in a meaningful and easy-to-read method.[7],[8],[9] Furthermore, application of the system requires the use of an air compressor for drying each tooth surface, which necessitates additional financial resources and a source of electricity.[9]

For the populations with a high frequency and a severe path of caries, tools such as PUFA and pulpal involvement-roots-sepsis (PRS) for the recognition of consequences of untreated dental caries index were recommended.[10],[11] Even though PUFA and PRS arouse great attention, their drawback is that they cover only a portion of the extensive range of caries stages and they only supplement the DMFT or ICDAS.

As the need to find a consistent, sensible, organized, and easy-to-read reporting system for presenting results obtained using both ICDAS II and PUFA indices continued, a new index was proposed known as caries assessment spectrum and treatment (CAST) index.[12] This index has been developed with a view to overcome the disadvantages of both the abovementioned systems. It describes the wide range or spectrum of carious states in a hierarchical manner, from the absence of carious lesions to the presence of sealants or restorations, initial lesions in the enamel or dentine, deep lesions involving the pulp and tissue surrounding the tooth (abscess/fistulae), and loss of teeth. This approach implies that a high CAST score suggests a severe condition, which demands prompt treatment.[2],[12] Moreover, this index can be used in epidemiological surveys as the assessment can be performed visually and does not require the use of compressed air.[2],[13]

Most of the studies in the literature utilized DMFT for evaluation of the caries pattern. However, one study analyzed the caries distribution and correlation in primary dentition employing ICDAS,[8] whereas another study evaluated dental caries in primary and permanent molars in 7-8-year-old schoolchildren using CAST index.[14]

No report on caries pattern covering the full spectrum of the disease in primary dentition could be found in the literature. Hence, the present study was undertaken to evaluate caries in primary teeth of 5-6-year-old children using the CAST index and to find whether there was any correlation between the caries stages.


  Materials and Methods Top


Sample

The present cross-sectional study was conducted in the Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India to evaluate the caries status in primary teeth using CAST index. A total of 465 children living in the urban area who were between 5 years and 6 years of age were examined and the study was conducted from March 2014 to August 2014 after obtaining approval of the institutional ethical committee. Children with a complete set of primary dentition and low socioeconomic status were included in the study. Children with any of the permanent molars erupted and with any systemic disease were excluded. Following these criteria, 113 children were excluded and the study was completed in 352 children (217 of 5 years-old and 135 of 6-years-old children).

The dental examination was performed by one of the examiners and the teeth were evaluated according to the CAST recommendations mentioned in [Table 1]. The examination was performed outside the classrooms of the schools using CAST criteria; children cleaned their teeth before examination, and a dental mirror and a periodontal probe were used to check the status of each tooth surface. The examination was conducted for all the teeth present in the child's mouth and the score was recorded in an index form, which was developed separately for this study. If two conditions were present on the same surface, that is, superficial lesion in one pit and a deep one in another, the higher score were recorded. At the end of each session, about 5% of the evaluated population was reexamined to determine the intraexaminer reliability.
Table 1: Description of CAST codes

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Statistical analysis

Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 17 (SPSS Statistics for Windows, Version 17.0. Chicago, SPSS Inc.) with the level of significance set at 0.05. Intergroup comparisons of ordinal variables were made with the help of nonparametric Mann–Whitney U test. The Spearman's rank correlation coefficient was used to explore the correlation of the distribution of CAST codes between neighboring teeth, teeth on the right and left sides of the dental arch, and the teeth located in the opposite jaws. The intraexaminer reliability was determined by the unweighted kappa coefficient.

Sample size determination

Based on the data obtained from the pilot study (conducted on 120 children), taking alpha error as 0.05, power of 95%, and considering 10% for errors, a total sample size of 347 was determined.


  Results Top


A total of 352 school children [189 boys (53.7%) and 163 girls (46.3%)] were examined using CAST index. The unweighted kappa value for the intraexaminer reliability was established at 0.90. Significant difference was observed in CAST codes distribution between 5 years and 6 years of age in all the second molars. However, no significant difference was observed in the distribution of the CAST codes between boys and girls.

Most of the evaluated primary teeth were found to be healthy (codes 0-2). Carious lesions were most frequently recorded as noncavitated dentine lesion with distinct visual changes in the enamel and discoloration in the dentine (codes 3 and 4) for both first and second primary molars. Among primary anteriors, it was noted as sound and with distinct changes in the enamel (codes 0 and 3) for maxillary anterior teeth and as code 0 for mandibular anteriors.

Distinct cavitation into the dentine and involvement of the pulp chamber (codes 5 and 6) were found to be prevalent in the first molars followed by second molars in the maxillary arch. In contrast, it was frequent in second molars compared to first molars in the mandibular arch. No score was recorded from categories 8 and 9. Mann–Whitney U test findings showed no difference in the distribution of CAST codes with respect to age and gender.

[Table 2] shows the results of the Spearman correlation test with correlation coefficient and P values. The analysis of distribution of CAST codes in complete primary dentition revealed a strong correlation between the right and left sides. The rank correlation coefficient was moderate for all the molars, whereas it showed a strong correlation for the incisors and canines.
Table 2: Correlations of CAST codes in evaluated primary teeth

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The correlation status of the central and lateral incisors was stronger for the right side compared to the left side of the mouth; r was 0.67 and 0.57 in the maxilla, whereas, 1 and 1 in the mandible (P< 0.001) for the central and lateral incisors, respectively. For the neighboring first and second molars, r values were lower than 0.3, which meant a weak correlation (r 0.2 and 0.23 in the maxilla and 0.48 and 0.18 in the mandible) (P< 0.001). With regard to the teeth situated in opposite jaws, the study revealed that the correlations were weak (r 0.07-0.29).


  Discussion Top


CAST, a new caries assessment and treatment index was developed based on the strengths of the ICDAS II and PUFA indices and provides a link to the widely used DMF index.[1],[12] Various advantages of CAST index have been reported in the literature; it provides information regarding the number of noncavitated and cavitated lesions, reports the consequences of the untreated lesions by recording pulpal involvement and the presence of fistula and abscess due to the caries process, and the incorporation of the lost and restored components makes the outcomes obtained through CAST easily comparable to those derived using DMFT index.[13] The reproducibility of the CAST instrument for use in the primary dentition is substantial to almost perfect, whereas in permanent dentition it is almost perfect.[15]

CAST is considered as an important dental epidemiological tool because the outcomes obtained through CAST are easily comparable to those derived from surveys using DMFT index. However, prerequisites of a survey such as cost-effectiveness and time-consumption compared to the other indices need to be proven in further studies.[13]

In the present study, no significant relationship between the prevalence of dental caries and gender was found, which is in contrast to the findings of a longitudinal study,[16] which stated gender to be a dental caries predictor with boys being more affected than girls. A large proportion of first and second molars with carious lesions at different stages of progression remained untreated.[17] The percentage of molars with carious lesions was high, particularly for second primary molars in the mandibular arch, which was similar to some cross-sectional studies.[14],[18],[19] Possible causes for the difference in caries prevalence between the first and second molars are that the second primary molars erupt 10-12 months later than the first primary molars at an age of 24-30 months, based on which one could assume that the first primary molar has more caries due to a longer presence in the oral cavity,[14] which is not supported by the literature. Only in special cases [early childhood caries (ECC)], teeth are attacked in the sequence of eruption.[20] Brushing the second primary molar is difficult compared to brushing the first primary molar and natural cleaning is probably better on the first primary molar. Other reasons such as anatomy of the tooth and developmental disturbances also favor the difference in caries prevalence between the first and second molars.[14]

Maxillary central incisors were the teeth with highest carious lesions among the anterior teeth in the present study and this was similar to the findings of other studies.[18],[21] The probable reason for high caries prevalence in these teeth could be the close interproximal contact, direct exposure during intake, and pooling of cariogenic fluids around these teeth.[18] In the present study, the mandibular incisors were unaffected, which was comparable to the results of other studies.[21],[22] The reason could have been due to the protection by the tongue and the opening of major salivary ducts near the lower incisors.[19]

The present study found a strong correlation between the status of contralateral teeth except for the first molars where the correlation was moderate. In this study, the correlations between CAST categories found in neighboring primary teeth were stronger for the right side of the mouth, both in the maxilla and mandible, which was in contrast to the another study.[17] Furthermore, the pulpal involvement was found to be the most serious stage in 15.6% of the evaluated primary teeth.

It was observed that the percentage of teeth with enamel lesions was at a different level for second and first molars. The presence of precavitated lesions is a predisposing factor for cavity development. A low number of sound primary molars was the best and most consistent predictor of high caries increment.[23] Caries observed in more than two surfaces of primary second molars may be a clinically useful predictor at 5 years of age for future caries development in the next 5 years on permanent incisors, and/or on mesial surfaces of permanent first molars, and/or as a whole develop an extensive amount of lesions in permanent teeth.[24] The combination of quicker lesion progression in the primary enamel, its relative lack of thickness, and the proximity of the relatively larger pulp chamber could be the probable risk factors when compared to permanent teeth.[25]

Hence, the present study showed the usefulness of the CAST index but the generalizability is limited as the disease prevalence and treatment needs were assessed in a local city population.


  Conclusion Top


In the evaluated population, a strongest correlation was found for the distribution of caries stages in primary incisors as well as molars on the right side of the mouth and the percentage of molars with carious lesions was especially high for second primary molars. Hence, the present study proves the usefulness of CAST index in primary teeth as well as epidemiological surveys.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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