| Abstract|| |
Background: Dental caries is a major chronic noncommunicable disease affecting whole of mankind. Nontreatment of caries can have severe consequences such as pain, abscess formation, space infection, etc., which leads to loss of function, working hours or absence from school in children. These consequences are equally important, while planning dental care program for a community.
Aim: The aim of this study is to assess the prevalence and severity of consequences of untreated carious lesions using pufa index that is, pulpal involvement, and ulcer due to root fragments, fistula, and abscess index among 5-6 year old school children in an urban Indian population.
Materials and Methods: A cross-sectional survey was conducted on 603 school going children of 5-6 year age group in mainly an urban Indian population. Children from 12 randomly selected schools were examined for pufa and decayed extracted filled indices.
Results and Conclusions: Overall mean pufa value was 0.9 ± 1.93 and prevalence was 38.6% with major contribution from P component of index. Untreated caries ratio was 35%, suggesting that more than one-third of the developed carious lesions cause adverse events in a population. This study emphasis the need for treating dental caries at its earliest possible stage to avoid severe consequences. The pufa index can be used as tool to highlight these adverse consequences to dental professionals and health authorities.
Keywords: Decayed extracted filled index, pufa index, school children, untreated caries, urban population
|How to cite this article:|
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
Oral diseases, such as dental caries, periodontal diseases, tooth loss, oral mucosal lesions, oropharyngeal cancers and orodental trauma, are a serious public-health problem. The impact on individuals and communities in terms of pain and suffering, impairment of function and reduced quality-of-life, is considerable. The current pattern of oral diseases reflects distinct risk profiles across countries related to living conditions, behavioral and environmental factors, oral health systems and implementation of schemes to prevent oral disease. 
|How to cite this URL:|
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 [serial online] 2014 [cited 2019 Jun 27];25:150-3. Available from: http://www.ijdr.in/text.asp?2014/25/2/150/135906
Dental caries is a major oral health problem around the world, affecting 60-90% of schoolchildren and the vast majority of adults. In many developing countries, access to oral health services is limited and teeth are often left untreated or are extracted because of pain or discomfort. 
For the last 70 years, data on prevalence of dental caries have been collected worldwide using the Decayed, Missing, Filled Teeth (DMFT)/decayed extracted filled teeth (deft) index. This classical index provides information on caries as well as its restorative and surgical treatment, but it fails to provide information on the clinical consequences of untreated dental caries, such as pulpal abscess, which may be more serious condition than the carious lesions themselves. A deep carious lesion with pulpal involvement is usually considered under the code "caries of dentin" and pulpal involvement is not mentioned at all in the caries scoring system in the latest edition of WHO - Oral Health Surveys-Basic Methods.  Some limited information might be obtained on the severity of advanced caries lesion by the scoring of "teeth indicated for extraction" under treatment needs, but this code does not give the precise reason for extraction. For example, "indicated for extraction" could be for reasons other than the consequences of untreated dental caries, e.g. as a sequel to trauma, for orthodontic or cosmetic reasons, or in preparation for a prosthesis. Moreover, "treatment needs" for extraction are rarely reported in the literature and the consequences of untreated dental caries are hardly ever mentioned. 
In order to improve oral health care facilities, there is a need of a diagnostic index that presents an accurate picture of consequences of advanced stages of dental caries to the authorities. An index called as "pufa" index (i.e., pulpal involvement, ulcer due to root fragments, fistula and abscess) is developed by Monse et al.  This new index attempts to compliment and increase the sensitivity of original DMF (def) index and to record consequences of a carious lesion. Data collected through this index can have impact on decision taken by authorities regarding oral care, which is not possible with DMF index.
This study was conducted with an aim of assessing prevalence and severity of oral conditions related to untreated caries lesions using pufa index among 5-6 years old school children of Chandigarh city.
| Materials and methods|| |
A cross-sectional survey was conducted on 603 school going children of 5-6 year age group in mainly an urban Indian population.
Study area and sample size calculation
Chandigarh is capital of states of Punjab and Haryana in North India and is a Union Territory. It has a population of 900,635, making for a density of about 7900 persons/km 2 . Males constitute 56% of the population and females are 44%. Chandigarh has an average literacy rate of 81.9%, higher than the national average of 64.8%. 
The dentist population ratio of city is 1:3000 and water fluoride level is 0.3 ppm. 
There are around 100 government aided and 50 private schools in Chandigarh,  the total population of 5-6 year old school going children would be around 30,000 and considering prevalence rate of dental caries to be 70%,  the sample size required was 379 at 95% confidence level. We end up examining more subjects than required sample size in order to give equal representation to different schools like government and private schools and location of school in an urban and suburban area. In total 603 children from 12 schools were examined. The study area was divided into four zones and three schools, that is, one private, one government, and one school from suburban area was randomly selected from each zone.
Organization of survey
A pilot survey was conducted on 30 school children of each age for calibration and training of examiners. Attempt was made to diagnose all variables of the index that is, p, u, f, a, but there was no case of ulcer (u) in the pilot sample. Inter - examiner reliability (two examiners) was assessed using kappa statistics. The kappa value was 0.78, which denotes substantial level of agreement between the examiners.
Data for main survey was collected over a period of 2 months. All the children were examined in school premises under natural light using mouth mirror and CPI probe (used only for recording def index). Institutional ethical clearance was obtained before proceeding with data collection. Permission to examine school children was taken from principals of selected schools. Informed consent was obtained from parents/guardian of the examined subjects.
The pufa index
pufa (PUFA) is an index used to assess the presence of oral conditions resulting from untreated caries. The index is recorded separately from the DMFT/deft and scores the presence of either a visible pulp, ulceration of the oral mucosa due to root fragments, a fistula or an abscess. The assessment is made visually without the use of an instrument. Only one score is assigned per tooth. In case of doubt concerning the extent of odontogenic infection, the basic score (P/p for pulp involvement) is given. If the primary tooth and its permanent successor tooth are present and both present stages of odontogenic infections, both teeth will be scored. Upper case letters are used for the permanent dentition and lowercase letters used for the primary dentition. The pufa score per person is calculated in the same cumulative way as for the def and represents the number of teeth that meet the pufa diagnostic criteria. The PUFA for permanent teeth and pufa for primary teeth are reported separately. Thus, for an individual person the score can range from 0 to 20 pufa for the primary dentition and from 0 to 32 PUFA for the permanent dentition.
The prevalence of pufa is calculated as percentage of the population with a pufa score of one or more. The PUFA/pufa experience for a population is computed as a mean figure and can therefore have decimal values. The untreated caries, pufa ratio is calculated as PUFA + pufa/D + d ×100. 
The sample size and collected data were analyzed using SPSS version 17 (IBM software company). Mean and standard deviations were calculated to express the mean def and pufa values. The statistical significance was determined by the Chi-square test, and level of significance was set at P < 0.05.
| Results|| |
A total of 603 school children were surveyed, among whom 300 (49.8%) were males and 303 (50.2%) females. There was no significant difference in the sample size of males and females (P > 0.05) [Table 1].
Overall pufa codes prevalence was 38.6%, the "p" component formed majority of the pufa codes (34.6%) and abscess formation due to periapical infection was second most frequent finding. There were only 2 cases of ulcer formation due to root fragment and sharp edges of pulpally involved tooth and 4 cases of fistula formation were recorded [Table 2]. The overall mean pufa index was 0.9 ± 1.93 and mean def was 2.54 ± 2.4 [Table 3]. Prevalence of dental caries in the study population was 69.5%. The untreated caries ratio was found to be 35.3% which can be inferred as that more than one-third of decayed component progressed to pulpal involvement. Males were having significantly higher individual P and a values in pufa index and e value in def index when compared with females [Table 4] and [Table 5]; Chi-square test, P < 0.05].
| Discussion|| |
In this study, 603 children of 5-6 year age group were assessed for their dental caries status and its consequences using pufa and def indices. This age group covers effect of adverse oral environment on all primary teeth. The deciduous teeth are essential in oral cavity up to the age of 12 years for space and function hence, it is important to assess their future prognosis. WHO has also recommended this index age group for oral health assessment of primary dentition in their basic oral health survey methodology. 
In our study, sample prevalence of pufa codes was 38.6%, this percentage is higher when compared to study conducted by Figueiredo et al.  on 5-6 years old Brazilian children (23.7%), but lesser to the study by Monse et al.  in Philippines (85%) and Bagiρska et al.  among Polish children (43.4%). "p" component of pufa formed majority of the total score, that is, 34.7%, this finding is comparable to other comparable studies. , Very few cases of other components of pufa were observed especially the u (ulceration) component, suggesting the need to modify the index by eliminating u and combining f and a components.  We felt further studies are required to substantiate such modifications.
Frencken et al. has suggested some modifications and purposed a new index altogether called as caries assessment spectrum and treatment (CAST) index. This index was developed because of the need to find a reliable, pragmatic cohesive, and easy to read reporting system, which is based on the strengths of PUFA and ICDAS-II indices and provide a link to the widely used DMF index (M and F components). It covers the total dental caries spectrum-from no carious lesion, through caries protection (sealent), and caries cure (restoration) to carious lesions in enamel and dentine, and the advanced stages of caries lesion progression in pulpal and tooth surrounding tissue. It doesn't record active and inactive carious lesions.  The CAST index has not been validated, nor has its reliability been tested. Furthermore, pufa index is suggested as a complimentary index to the dmf index not as its replacement. 
Dental caries prevalence was 69.5% in studied sample, which is comparable to other studies conducted in the same city. , Mean pufa value is 0.94, which is higher than as reported by Figueiredo et al.  and Oziegbe and Esan  but lesser than in studies by Monse et al.  and Baginska et al.  Gender comparison of mean pufa and def scores shows a significant difference between the two (P < 0.05) with females having lesser pufa scores as compared with males. Untreated caries ratio was 35.3% which is slightly less than as reported by Monse et al.  and Murthy et al.,  but higher than study done on Nigerian children.  This ratio provides an opportunity for the dental healthcare workers to explain the health authorities about the adverse consequences of dental caries on teeth.
Dental caries is a multifactorial disease with various social, cultural, and economic factors playing an important role in its etiology. One of the limitations of our study was not considering the above factors, while recording dental caries although, we have tried to represent various clusters present in the city by giving adequate representation to urban and periurban areas in order to limit the effect of these confounding factors.
| Conclusion|| |
Large majority of untreated carious lesions in the children is evident in the results of present study, suggesting lack of awareness among children, their parents, and teachers regarding importance of good oral health. Therefore, there is an urgent need to plan a dental caries preventive and curative program for school children in Chandigarh.
"pufa" index along with def index can act excellent epidemiological and educational tool for reporting consequences of untreated carious lesions in a population. This a baseline study, further studies are required to find out the reasons why there is high prevalence of pufa scores in this population.
| References|| |
|1.||Petersen PE. World Health Organization global policy for improvement of oral health - World Health Assembly 2007. Int Dent J 2008;58:115-21. |
|2.||Petersen PE. The World Oral Health Report 2003: Continuous improvement of oral health in the 21 st century - The approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003;31 Suppl 1:3-23. |
|3.||World Health Organization. Oral Health Surveys-Basic Methods. 4 th ed. Geneva: WHO; 1997. |
|4.||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. |
|5.||Official Website of Chandigarh Administration. Available from: http://www.chandigarh.nic.in. [Last accessed on 2013 Mar 15]. |
|6.||Goyal A, Gauba K, Chawla HS, Kaur M, Kapur A. Epidemiology of dental caries in Chandigarh school children and trends over the last 25 years. J Indian Soc Pedod Prev Dent 2007;25:115-8. |
|7.||Official Website of Department of Education, Chandigarh Administration. Available from: http://www.educhandigarh.gov.in. [Last accessed on 2013 Mar 15]. |
|8.||Figueiredo MJ, de Amorim RG, Leal SC, Mulder J, Frencken JE. Prevalence and severity of clinical consequences of untreated dentine carious lesions in children from a deprived area of Brazil. Caries Res 2011;45:435-42. |
|9.||Bagiñska J, Rodakowska E, Wilczyñska-Borawska M, Jamio³kowski 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. |
|10.||Frencken JE, de Amorim RG, Faber J, Leal SC. The caries assessment spectrum and treatment (CAST) index: Rational and development. Int Dent J 2011;61:117-23. |
|11.||Chawla HS, Gauba K, Goyal A. Trend of dental caries in children of Chandigarh over the last sixteen years. J Indian Soc Pedod Prev Dent 2000;18:41-5. |
|12.||Oziegbe EO, Esan TA. Prevalence and clinical consequences of untreated dental caries using PUFA index in suburban Nigerian school children. Eur Arch Paediatr Dent 2013;14:227-31. |
|13.||Murthy AK, Pramila M, Ranganath S. Prevalence of clinical consequences of untreated dental caries and its relation to dental fear among 12-15-year-old schoolchildren in Bangalore city, India. Eur Arch Paediatr Dent 2014;15:45-9. |
Departments of Public Health Dentistry, Faculty of Dentistry, Jamia Millia Islamia, New Delhi
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]