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Differential Impacts of Caries Classification in Children and Adults: A Comparison of ICDAS and DMF-T

Differential Impacts of Caries Classification in Children and Adults: A Comparison of ICDAS and... Brazilian Dental Journal (2016) 27(6): 761-766 ISSN 0103-6440 http://dx.doi.org/10.1590/0103-6440201600990 ¹Faculty of Dentistry of Universidad Differential Impacts of Caries Peruana Cayetano Heredia, Lima, Peru University Center of Serra Classification in Children and Adults: Gaúcha, Caxias do Sul, RS, Brazil and UFRGS - Federal University of Rio Grande do Sul; Pediatric A Comparison of ICDAS and DMF-T Dentistry, Porto Alegre, RS, Brazil 3UFRGS - Federal University of Rio Grande do Sul, Pediatric Dentistry, Porto Alegre, RS, Brazil Rosa Ana Melgar¹, Joanna Tatith Pereira², Patrícia Blaya Luz , Fernando UFRGS - Federal University of Rio Grande do Sul, Center Neves Hugo , Fernando Borba de Araujo of Community Dental Health Research, Porto Alegre, RS, Brazil Correspondence: Professora Joanna The aim of this study was to describe and compare findings regarding the prevalence and Tatith Pereira, Rua São Manoel severity of dental caries when using ICDAS and DMFT/dmft in an epidemiological study 1411/402 90620-110, Porto Alegre, with children and their mothers. This cross-sectional study evaluated 150 preschoolers RS, Brazil. Tel: +55-51-981714591. and their mothers. Data were collected with ICDAS and then transformed into DMFT/dmft. e-mail: [email protected]. ICDAS scores related to caries were analyzed according to three different cut-off-points: CP1 (0-healthy/1-6-caries), CP2 (0-1-healthy/2-6-caries) and CP3 (0-2-healthy/3-6- caries), representing the D/d of DMFT/dmft. ICDAS codes regarding restorations, except sealants, were considered the F/f and the code 97 as the M/m of DMFT/dmft index. Prevalence of caries and its severity with ICDAS were 92%, 84% and 31.3% in children and 97.3%, 96.6% and 80% in adults according to CP1/CP2/CP3, respectively. Admitting CP3 as the standard for data transformation of ICDAS in DMFT/dmft, it was observed that DMFT/dmft index would underestimate 60% of non-cavitated lesions in children and 16.6% in adults. The DMFT/dmft underestimated the presence of disease to disregard non-cavitated lesions for the pediatric population evaluated. The choice of which is the best index for epidemiological surveys will depend on the purpose of the research and the target population: if it is to estimate the needs of the population to determine clinical care in children and adults, the DMFT/dmft may be sufficient. However, if the objective is to have a more comprehensive diagnosis of caries at the population level in Key Words: dental caries, order to develop preventive strategies, to halt and reverse the disease, the detection of epidemiological survey, ICDAS, non-cavitated-lesions becomes important, mainly in young children. DMFT/dmft, caries detection. Introdution Dental caries is the most common chronic disease of the system was feasible for epidemiological research with an oral cavity, which affects the population in general, from acceptable degree of reliability to detect non-cavitated and children to adults and seniors (1,2). Several epidemiological cavitated lesions (7-9). The most commonly used detection population-based studies have demonstrated a significant criteria recommended by the World Health Organization decrease in caries worldwide, a fact that is not demonstrated (WHO), the DMF index, is used worldwide in dental research, when the object of the study are preschool children (3). but is unable to provide accurate data about lesions in the Well-designed epidemiological studies provide a picture early stages (10). of the population and are important tools in defining the Based on the minimal intervention concept, as well as distribution of funds for oral health programs and the in the possibility of paralyzing and reversing dental caries implementation of preventive policies by stakeholders (4). in the early stages, one should not restrict the detection of Based on current knowledge of cariology and on disease to cavitated lesions (5). Thus, the use of a method the principles of minimal intervention, the treatment of capable of identifying spot lesions and their progression carious lesions in the early stages occurs in a non-operative over time in an epidemiological level may be relevant manner, avoiding the need for more complex and costly considering the objective to be achieved in a study. The treatments (5). For this purpose, the choice of a criterion need for operative treatment at the population or individual of caries detection that includes non-cavitated lesions level may be measured by the DMF index (11-13). While this and detect early injuries could increase sensitivity, mainly information is in itself important, when evaluated alone, it in populations with low prevalence of the disease, in perpetuates the over past concept that the caries process which carious lesions have a low progression rate and are should be treated by restorations and extractions only. commonly found in the initial stages (6). Thus, the contemporary needs for planning, delivery and In 2004, a new system for the visual detection of caries monitoring of oral health care services at the population lesions was developed for use in clinical practice and in level are not fulfilled (13). clinical and epidemiological research - ICDAS (7). This Studies that have evaluated the magnitude of Braz Dent J 27(6) 2016 the differences between ICDAS and DMFT/dmft at to the various stages of carious lesion progression (codes the population level are rare, and to our knowledge, range from 0-6). Four special codes can also be found (96 these studies are focused only in children population - tooth surface cannot be examined; 97 - tooth missing (14). Although fewer in number compared to the child because of caries; 98 - tooth missing for other reasons; population, some researchers have accessed caries using 99 - unerupted) (7). ICDAS in clinical and epidemiological studies involving adults (15,16). To our knowledge, no study has brought Epidemiological Survey and Data Collection this aspect of comparison to epidemiological studies of Examinations were conducted within a 12-month period the adult population, which should also have the diagnosis and each children’s mother signed an informed consent. All of caries and its treatment based on the philosophy of data collection was performed at the participant´s house. minimal intervention. A phone call previously set the appointment. Families that The aim of this study was to describe and compare phone numbers did not match were directly visited. This findings regarding the prevalence and severity of dental procedure was repeated at least 3 times before family was caries when using the ICDAS and DMFT/dmft in an considered a non-response. epidemiological study with children and their mothers. According to ICDAS protocol, all examinations in children and adults were performed with the dental surface clean Material and Methods and dry (19). After that, dental examination was conducted Study Design and Sample Selection using house facilities and portable resources: air compressor The survey was conducted in twelve primary care (Nevoni, São Caetano), suction device (Ssplus, São Paulo), services (PCS) belonging to a hospital group in Porto Alegre, head light, WHO probe (Fava, São Paulo), tweezers (Fava, São Rio Grande do Sul, Brazil. This study is part of a larger Paulo), dental mirror (Sylkap, Curitiba) and cotton rolls. All research on early childhood caries and the influence of personal protective equipment was used. Examination was social, psychological and behavioral variables, which was performed in children and their mothers. For each dental approved by the Research Ethics Committee of Hospital surface, a code for dental condition and a code for caries Group Conceição (GHC), reference CEP-GHC/11-196. status were recorded; afterwards, the caries conditions of All 674 children born in 2008 (3-4 years-old) and the teeth were categorized according to the worse surface registered in one of the PCS were eligible, as were their code. The authors did not assess the activity of the lesions. mothers. The GHC is part of the Brazilian Ministry of Health, In addition, mothers were interviewed and the following and provides access to care under Brazil’s Public Health information was collected: age (in years), education of System. The GHC has an organized register of users which mothers (years of study), marital status, family monthly is considered a reference for Brazilian public health services. income (in Reais), child gender, number of sons and number A required sample size of 173 children was based on of people living in the house. an estimated caries prevalence of 31% (using data from a neighboring city) (17), bidirectional alpha of 0.05 and beta Statistical Analyses of 0.10. Assuming a 20% non-response rate, the sample All collected data were inserted into a data entry size was set in 208 dyads of mother-child. The sample programme specially designed for the epidemiological selection was randomly performed using a table with survey. The two-digits codes from ICDAS were collected and random numbers maintaining the proportion of children recorded by surfaces, and after, the codes were converted born in each PCS. into the components of dmf-t/DMF-T index, in order to calculate caries experience in the following ways in both Training and Calibration of Examiners adults and children. Three examiners performed oral examinations using When the surface condition had code 3 or higher ICDAS criteria for caries detection. They were already from ICDAS digit I, it was considered that the tooth was familiar with ICDAS, and were trained previously using restored (the f/F component from dmf/DMF). In relation an E-learning Program (18). Calibration was performed at to dental caries, after evaluation by surface, each tooth the Pediatric Dentistry Ambulatory of Federal University received the worst ICDAS code for one of its five surfaces. of Rio Grande do Sul. Ten children were examined and re- Regarding the literature (9,14,20), it was used codes 3-6 to examined two weeks later. Tooth surface was considered transform ICDAS to dmf/DMF – d/D. Code 97 from ICDAS as the unit analysis for Kappa calculation. was computed like the m/M component of dmf/DMF. dmf/ ICDAS consists of a two digits coding system, the first DMF-T was obtained by adding ICDAS codes transformed digit refers to the presence of sealants or any kind of to D, M, and F. All the analysis (both ICDAS and DMF-T) restorations (codes range from 0-8), and the second digit, was done at the tooth level. R. A. Melgar et al. Braz Dent J 27(6) 2016 A descriptive analysis was performed for the variable amalgam, 11% composite resin and 25% temporary or frequency of caries lesions in both groups (mothers and faulty restorations). Concerning teeth extracted due to children) for cut-off points CP1, CP2 and CP3 from ICDAS. caries, 25.4% of the mothers had at least one tooth lost Scores of ICDAS related to caries were analyzed according and molars were the most frequently extracted. to three different cut-off points: CP1 (code.0: healthy, code In children, using ICDAS code CP1 as the cut-off point 1-6: caries), CP2 (code 0-1: healthy, code 2-6: caries) and (≥1: presence of disease), 92% presented some clinical CP3 (code 0-2: healthy, code 3-6: caries). The frequency sign of disease. Using code CP2 as the cut-off point (≥2: of caries by DMFT, dmft and ICDAS, presented by mean, presence of disease), 84% presented carious lesions. When standard deviation, minimum and maximum values were using score 3 as the cut-off point (code CP3), this number presented. To compare the prevalence of dental caries in reduces to 31%, showing that most of the children had only the group of children and mothers in cut-off points CP1 non-cavitated lesions (61%). Regarding the mothers, there and CP3 of ICDAS, the Fisher’s exact test was used. The is no difference between the cut-off points CP1 and CP2 tests were worked on a significance level of 5 %. (97.3% e 96.6%, respectively). At the cut-off point CP3, the prevalence reduces 17.3%, indicating that 80% of mothers Results had at least one cavitated lesion in the mouth. In relation The sample comprised 300 participants, 150 children to restorations, 9% of children had some sort of restoration and 150 mothers. The mean inter-examiner Kappa value (code 3 or >); that number increased considerably when was 0.67 (ranged from 0.64 to 0.73). Description of the mothers were examined (86%). Regarding teeth extracted sample and sociodemographic characteristics can be found due to caries, 25.4% of adults had at least one tooth missing in Table 1. due to caries, while no child had lost any teeth because of It was observed that no child presented teeth extracted it. When transforming these data to the DMFT index (using due to caries; in those who had some type of restoration a cut-off 3-ICDAS), 34% of children would present dmft (9%), 73% were in primary molars, especially in the lower ≥1 (p<0.001), as well as 98% of adults (p=1.000) (Table 2 one, and with tooth-colored restorations. Regarding the and 3). Differences between different ICDAS cut-points mothers, 86% had at least 1 type of restoration (39% and DMF-T are presented in Tables 2 and 3. Discussion The traditional DMFT index (10) bases the detection Table 1. Description of the sample of caries at the cavitated level only and considers that its Children (n=150) Mean (± SD) treatment should be based on fillings and extractions. The main and original finding of our study was that, in adult Age 3.34 (±0.5) populations, the use of ICDAS added new information Male (n=70; 46.66%) - about non-cavitated lesions, but showed no statistically Female (n=80; 53.33%) - significant difference when compared with the DMFT index, Mothers (n=150) - since most mothers already had teeth with cavitated lesions, that had been restored or extracted due to caries. Also, the Age 33.66 (±7.6) detection of non-cavitated lesions significantly influenced Years of study 5.32 (±2.07) the findings in relation to caries when compared with the Family income R$ 2,240.08 (±R$ 1,980.83) dmf/DMF findings in preschool children. In this context, Number of people one should evaluate the purpose of the study in the adult 4.68 (± 4.50) living in the house population and the cost-effectiveness of using a more Number of children time-consuming method like the ICDAS. Moreover, the 2.22 (± 1.27) living in the house Table 2. Prevalence of dental caries in children and mothers, according to ICDAS and DMFT index CP1 - ICDAS-1 CP2 - ICDAS-2 CP3 - ICDAS-3 Restoration Extraction DMF-T /dmf-t or > 1 or > 2 or > 3 presence duo to caries p value > or = 1 N (%) N (%) N (%) N (%) N (%) Children (n=150) 138 (92%) 126 (84%) 47 (31.3%) 14 (9.3%) 0 (0%) 51 (34%) P< 0.001a Mothers (n=150) 146 (97.3%) 145 (96.6%) 120 (80%) 129 (86%) 38 (25.4%) 147 (98%) P = 1.000 Fisher’s exact test (between CP1 and CP3). Children versus adults: ICDAS or DMF-T Braz Dent J 27(6) 2016 DMF-T index underestimates the presence of the disease Other finding of the present paper was that the in children evaluated, as it ignored the most prevalent detection of non-cavitated lesions was suitable and reliable clinical presentation of caries found in the studied sample, when performed under field conditions. Some studies non-cavitated lesions. (22,23) support the use of a modification of WHO index This study shows that the criteria recommended by WHO allowing the detection of non-cavitated lesions; however, can be used for adults without losing much information. the most current version of the WHO manual gives no However, in children, a relevant amount of information information or reference about these changes (10). Knowing in estimating disease burden is lost, and for those who that obtaining good conditions for conducting a detailed make decisions on health it is essential. This may lead to an clinical examination in the context of an epidemiological underestimation of caries in populations, primarily children, study is a challenge, this study described a methodology and result in changes in the implementation of caries to collect data with sufficient flexibility to be used in a prevention actions by stakeholders. It can be considered variety of settings and situations in the field. Concerning that the non-cavitated lesions are very common but they the reliability of the diagnosis of non-cavitated lesions in have a low rate of progression (21), without ignoring the epidemiology studies, the values obtained were compatible differential impact of “untreated” initial caries and “actual with substantial agreement. burden of caries - cavities”, especially when considering the Any method that aims to register non-cavitated implementation of politic measures to control the disease. lesions requires more time for the clinical examination to Research in epidemiology has an objective of making be performed when compared to the traditional system a population diagnosis, which is important for decision recommended by the WHO. This statement is in accordance making in health and should therefore be able to generate with the literature, which showed that the choice of a accurate estimates of disease burden. These accurate method to detect non-cavitated lesions may take twice estimates are also important because, in order to develop as long (9, 24). It is important to take into account the and plan effective health actions, one cannot work with experience of examiners, since the knowledge and previous diagnostic criteria that only account for the disease at a training positively influences the time of data collection cavitation level, looking for all of the knowledge that has (18). The ICDAS website provides an e-learning Program for been accumulated regarding caries disease to date. prior training (www.icdas.org). The information obtained We must, therefore, consider the meaning of through the detection of non-cavitated lesions should, in epidemiological investigation. If it is of interest that the one way or another, compensate the extra time during oral health care planners to estimate dental caries figures the fieldwork if this information was essential to meet the for the purpose of determining clinical care and treatment objective of the research. needs, the DMF-T index may be sufficient. On the other To control biases in the study, three experienced, trained hand, if the action also has the objective of stalling and and calibrated examiners performed the data collection; reversing the carious process through population-based, when 50% of the sample was reached, a new calibration prevention oriented actions, one has to consider whether was performed by reviewing 10% of the sample. All it is important to estimate the lesions at an earlier stage. collected data were recorded by an undergraduate student As some studies raise difficulties regarding the use of who was unaware of the value of each code. This random ICDAS because it is time-consuming, adding relevant sample is representative of Northern District of the City costs to survey implementation, this should be prioritized of Porto Alegre/Brazil. Additional studies are needed to in epidemiological surveys focused on the pediatric extrapolate these findings. A limitation of the study is that population. the examination was not carried using the traditional index Table 3. Severity distribution of caries (ICDAS digit I) in children and mothers, according to ICDAS and DMFT index Non-cavitated lesions Cavitated lesions Mean ICDAS (± SD) Mean DMF-T /dmf-t (± SD) (ICDAS 1-2) (ICDAS 3-4-5-6) Female children 49 (32%) 25 (16.6%) - - Male children 42 (28%) 22 (14.6%) - - Total of children 91 (60%) 47 (31.3%) 2.52 (± 1.53) 1.39 (± 2.73) Mothers 25 (16.6%) 121 (80.6%) 4.04 (± 1.60) 9.03 (± 4.90) R. A. Melgar et al. Braz Dent J 27(6) 2016 prevalência e severidade da cárie dentária ao utilizar ICDAS e CPOD/ recommended by WHO with the objective of comparing the ceod em um estudo epidemiológico com crianças e suas mães. Este estudo transversal avaliou 150 pré-escolares e suas mães. Os dados foram accuracy of the methods discussed. However, the literature coletados utilizando-se o ICDAS e depois transformados em CPOD/ceod. brings findings in this direction and guides the best cut-off Os códigos do ICDAS relacionados à cárie foram analisados de acordo point to be made to transforming the data collected with com três diferentes pontos de corte: CP1 (0-hígido/1-6-cárie), CP2 (0-1 hígido/2-6-cárie) e CP3 (0-2 hígido/3-6-cárie), representando o D/d do the ICDAS in DMFT/dmft. When we started planning the índice CPOD/ceod. Os códigos do ICDAS referentes às restaurações, exceto survey, ICDAS did not advocate activity assessment of the selantes, foram considerados o O/o e o código 97 do ICDAS como o P/e do disease, the reason we did not asses it. índice CPOD/ceod. A prevalência de cárie e sua severidade com o ICDAS foram de 92%, 84% e 31,3% em crianças e 97,3%, 96,6% e 80% em Each epidemiological index has particular characteristics adultos de acordo com o CP1 / CP2 / CP3, respectivamente. Admitindo o that also influence the choice of which index to use. The ponto de corte CP3 como o padrão para a transformação de achados do ICDAS, based on best available evidence for detecting ICDAS em CPOD/ceod, foi observado que o índice CPOD/ceod subestimaria 60% das lesões não cavitadas em crianças e 16,6% em adultos. O CPOD/ early and later stage caries severity, have different scores ceod subestima a presença da doença ao desconsiderar as lesões não for surface and caries evaluation and should lead to the cavitadas na população pediátrica avaliada. A escolha de qual é o melhor acquisition of better quality information which could then índice para levantamentos epidemiológicos vai depender do propósito da pesquisa e da população-alvo: se o objetivo for estimar as necessidades be used to inform decisions about appropriate diagnosis, da população para determinar cuidados clínicos em crianças e adultos, prognosis, and clinical management of dental caries at o CPOD/ceod pode ser suficiente. No entanto, se o objetivo for ter um both the individual and public health levels. The WHO diagnóstico mais abrangente da doença ao nível da população, a fim de desenvolver estratégias preventivas, para paralisar e reverter a doença, recommended index, DMFT/dmft, is used worldwide to a detecção de lesões não cavitadas torna-se importante, principalmente measure the prevalence of dental caries based on decayed, em crianças pequenas. missing and filled teeth due to caries. It has the advantage of not requiring prior prophylaxis, lighting and drying of the dental element. However, it only recognizes one condition References 1. Constante HM, Souza ML, Bastos JL, Peres MA. Trends in dental caries by surface reducing the sensitivity of the method and among Brazilian schoolchildren: 40 years of monitoring (1971-2011). therefore its application in planning and health promotion. Int Dent J 2014;64:181-186. As well as ICDAS being a coding classification there are 2. Misra S, Tahmassebi JF, Brosnan M. Early childhood caries - a review. 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Caries decline in the Ethics Committee on Research Hospital Group Conceição (GHC-CEP) on primary dentition of Belgian children over 15 years. Community Dent 09/11/2011, with the number of 11-196 process, and financed with funds Oral Epidemiol 2004 Aug;32:277-282. granted by the Universal Notice “National Counsel of Technological and 13. Pitts NB. Modern concepts of caries measurement. J Dent Res 2004;83 Scientific Development” 479894 / 2010-8 and Notice Researcher Gaucho Spec No C:C43-C47. Support of the State of Rio Grande do Sul Research Foundation 11 / 1368-4. 14. Clara J, Bourgeois D, Muller-Bolla M. DMF from WHO basic methods to ICDAS II advanced methods: a systematic review of literature. Odontostomatol Trop 2012;35:5-11. Resumo 15. Carta G, Cagetti MG, Cocco F, Sale S, Lingström P, Campus G. 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Received April 25, 2016 Accepted August 1, 2016 21. Guedes RS, Piovesan C, Floriano I, Emmanuelli B, Braga MM, Ekstrand KR, et al. Risk of initial and moderate caries lesions in primary teeth to progress to dentine cavitation: a 2-year cohort study. Int J Paediatr Dent 2016;26:116-124. R. A. Melgar et al. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Brazilian Dental Journal Unpaywall

Differential Impacts of Caries Classification in Children and Adults: A Comparison of ICDAS and DMF-T

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Brazilian Dental Journal (2016) 27(6): 761-766 ISSN 0103-6440 http://dx.doi.org/10.1590/0103-6440201600990 ¹Faculty of Dentistry of Universidad Differential Impacts of Caries Peruana Cayetano Heredia, Lima, Peru University Center of Serra Classification in Children and Adults: Gaúcha, Caxias do Sul, RS, Brazil and UFRGS - Federal University of Rio Grande do Sul; Pediatric A Comparison of ICDAS and DMF-T Dentistry, Porto Alegre, RS, Brazil 3UFRGS - Federal University of Rio Grande do Sul, Pediatric Dentistry, Porto Alegre, RS, Brazil Rosa Ana Melgar¹, Joanna Tatith Pereira², Patrícia Blaya Luz , Fernando UFRGS - Federal University of Rio Grande do Sul, Center Neves Hugo , Fernando Borba de Araujo of Community Dental Health Research, Porto Alegre, RS, Brazil Correspondence: Professora Joanna The aim of this study was to describe and compare findings regarding the prevalence and Tatith Pereira, Rua São Manoel severity of dental caries when using ICDAS and DMFT/dmft in an epidemiological study 1411/402 90620-110, Porto Alegre, with children and their mothers. This cross-sectional study evaluated 150 preschoolers RS, Brazil. Tel: +55-51-981714591. and their mothers. Data were collected with ICDAS and then transformed into DMFT/dmft. e-mail: [email protected]. ICDAS scores related to caries were analyzed according to three different cut-off-points: CP1 (0-healthy/1-6-caries), CP2 (0-1-healthy/2-6-caries) and CP3 (0-2-healthy/3-6- caries), representing the D/d of DMFT/dmft. ICDAS codes regarding restorations, except sealants, were considered the F/f and the code 97 as the M/m of DMFT/dmft index. Prevalence of caries and its severity with ICDAS were 92%, 84% and 31.3% in children and 97.3%, 96.6% and 80% in adults according to CP1/CP2/CP3, respectively. Admitting CP3 as the standard for data transformation of ICDAS in DMFT/dmft, it was observed that DMFT/dmft index would underestimate 60% of non-cavitated lesions in children and 16.6% in adults. The DMFT/dmft underestimated the presence of disease to disregard non-cavitated lesions for the pediatric population evaluated. The choice of which is the best index for epidemiological surveys will depend on the purpose of the research and the target population: if it is to estimate the needs of the population to determine clinical care in children and adults, the DMFT/dmft may be sufficient. However, if the objective is to have a more comprehensive diagnosis of caries at the population level in Key Words: dental caries, order to develop preventive strategies, to halt and reverse the disease, the detection of epidemiological survey, ICDAS, non-cavitated-lesions becomes important, mainly in young children. DMFT/dmft, caries detection. Introdution Dental caries is the most common chronic disease of the system was feasible for epidemiological research with an oral cavity, which affects the population in general, from acceptable degree of reliability to detect non-cavitated and children to adults and seniors (1,2). Several epidemiological cavitated lesions (7-9). The most commonly used detection population-based studies have demonstrated a significant criteria recommended by the World Health Organization decrease in caries worldwide, a fact that is not demonstrated (WHO), the DMF index, is used worldwide in dental research, when the object of the study are preschool children (3). but is unable to provide accurate data about lesions in the Well-designed epidemiological studies provide a picture early stages (10). of the population and are important tools in defining the Based on the minimal intervention concept, as well as distribution of funds for oral health programs and the in the possibility of paralyzing and reversing dental caries implementation of preventive policies by stakeholders (4). in the early stages, one should not restrict the detection of Based on current knowledge of cariology and on disease to cavitated lesions (5). Thus, the use of a method the principles of minimal intervention, the treatment of capable of identifying spot lesions and their progression carious lesions in the early stages occurs in a non-operative over time in an epidemiological level may be relevant manner, avoiding the need for more complex and costly considering the objective to be achieved in a study. The treatments (5). For this purpose, the choice of a criterion need for operative treatment at the population or individual of caries detection that includes non-cavitated lesions level may be measured by the DMF index (11-13). While this and detect early injuries could increase sensitivity, mainly information is in itself important, when evaluated alone, it in populations with low prevalence of the disease, in perpetuates the over past concept that the caries process which carious lesions have a low progression rate and are should be treated by restorations and extractions only. commonly found in the initial stages (6). Thus, the contemporary needs for planning, delivery and In 2004, a new system for the visual detection of caries monitoring of oral health care services at the population lesions was developed for use in clinical practice and in level are not fulfilled (13). clinical and epidemiological research - ICDAS (7). This Studies that have evaluated the magnitude of Braz Dent J 27(6) 2016 the differences between ICDAS and DMFT/dmft at to the various stages of carious lesion progression (codes the population level are rare, and to our knowledge, range from 0-6). Four special codes can also be found (96 these studies are focused only in children population - tooth surface cannot be examined; 97 - tooth missing (14). Although fewer in number compared to the child because of caries; 98 - tooth missing for other reasons; population, some researchers have accessed caries using 99 - unerupted) (7). ICDAS in clinical and epidemiological studies involving adults (15,16). To our knowledge, no study has brought Epidemiological Survey and Data Collection this aspect of comparison to epidemiological studies of Examinations were conducted within a 12-month period the adult population, which should also have the diagnosis and each children’s mother signed an informed consent. All of caries and its treatment based on the philosophy of data collection was performed at the participant´s house. minimal intervention. A phone call previously set the appointment. Families that The aim of this study was to describe and compare phone numbers did not match were directly visited. This findings regarding the prevalence and severity of dental procedure was repeated at least 3 times before family was caries when using the ICDAS and DMFT/dmft in an considered a non-response. epidemiological study with children and their mothers. According to ICDAS protocol, all examinations in children and adults were performed with the dental surface clean Material and Methods and dry (19). After that, dental examination was conducted Study Design and Sample Selection using house facilities and portable resources: air compressor The survey was conducted in twelve primary care (Nevoni, São Caetano), suction device (Ssplus, São Paulo), services (PCS) belonging to a hospital group in Porto Alegre, head light, WHO probe (Fava, São Paulo), tweezers (Fava, São Rio Grande do Sul, Brazil. This study is part of a larger Paulo), dental mirror (Sylkap, Curitiba) and cotton rolls. All research on early childhood caries and the influence of personal protective equipment was used. Examination was social, psychological and behavioral variables, which was performed in children and their mothers. For each dental approved by the Research Ethics Committee of Hospital surface, a code for dental condition and a code for caries Group Conceição (GHC), reference CEP-GHC/11-196. status were recorded; afterwards, the caries conditions of All 674 children born in 2008 (3-4 years-old) and the teeth were categorized according to the worse surface registered in one of the PCS were eligible, as were their code. The authors did not assess the activity of the lesions. mothers. The GHC is part of the Brazilian Ministry of Health, In addition, mothers were interviewed and the following and provides access to care under Brazil’s Public Health information was collected: age (in years), education of System. The GHC has an organized register of users which mothers (years of study), marital status, family monthly is considered a reference for Brazilian public health services. income (in Reais), child gender, number of sons and number A required sample size of 173 children was based on of people living in the house. an estimated caries prevalence of 31% (using data from a neighboring city) (17), bidirectional alpha of 0.05 and beta Statistical Analyses of 0.10. Assuming a 20% non-response rate, the sample All collected data were inserted into a data entry size was set in 208 dyads of mother-child. The sample programme specially designed for the epidemiological selection was randomly performed using a table with survey. The two-digits codes from ICDAS were collected and random numbers maintaining the proportion of children recorded by surfaces, and after, the codes were converted born in each PCS. into the components of dmf-t/DMF-T index, in order to calculate caries experience in the following ways in both Training and Calibration of Examiners adults and children. Three examiners performed oral examinations using When the surface condition had code 3 or higher ICDAS criteria for caries detection. They were already from ICDAS digit I, it was considered that the tooth was familiar with ICDAS, and were trained previously using restored (the f/F component from dmf/DMF). In relation an E-learning Program (18). Calibration was performed at to dental caries, after evaluation by surface, each tooth the Pediatric Dentistry Ambulatory of Federal University received the worst ICDAS code for one of its five surfaces. of Rio Grande do Sul. Ten children were examined and re- Regarding the literature (9,14,20), it was used codes 3-6 to examined two weeks later. Tooth surface was considered transform ICDAS to dmf/DMF – d/D. Code 97 from ICDAS as the unit analysis for Kappa calculation. was computed like the m/M component of dmf/DMF. dmf/ ICDAS consists of a two digits coding system, the first DMF-T was obtained by adding ICDAS codes transformed digit refers to the presence of sealants or any kind of to D, M, and F. All the analysis (both ICDAS and DMF-T) restorations (codes range from 0-8), and the second digit, was done at the tooth level. R. A. Melgar et al. Braz Dent J 27(6) 2016 A descriptive analysis was performed for the variable amalgam, 11% composite resin and 25% temporary or frequency of caries lesions in both groups (mothers and faulty restorations). Concerning teeth extracted due to children) for cut-off points CP1, CP2 and CP3 from ICDAS. caries, 25.4% of the mothers had at least one tooth lost Scores of ICDAS related to caries were analyzed according and molars were the most frequently extracted. to three different cut-off points: CP1 (code.0: healthy, code In children, using ICDAS code CP1 as the cut-off point 1-6: caries), CP2 (code 0-1: healthy, code 2-6: caries) and (≥1: presence of disease), 92% presented some clinical CP3 (code 0-2: healthy, code 3-6: caries). The frequency sign of disease. Using code CP2 as the cut-off point (≥2: of caries by DMFT, dmft and ICDAS, presented by mean, presence of disease), 84% presented carious lesions. When standard deviation, minimum and maximum values were using score 3 as the cut-off point (code CP3), this number presented. To compare the prevalence of dental caries in reduces to 31%, showing that most of the children had only the group of children and mothers in cut-off points CP1 non-cavitated lesions (61%). Regarding the mothers, there and CP3 of ICDAS, the Fisher’s exact test was used. The is no difference between the cut-off points CP1 and CP2 tests were worked on a significance level of 5 %. (97.3% e 96.6%, respectively). At the cut-off point CP3, the prevalence reduces 17.3%, indicating that 80% of mothers Results had at least one cavitated lesion in the mouth. In relation The sample comprised 300 participants, 150 children to restorations, 9% of children had some sort of restoration and 150 mothers. The mean inter-examiner Kappa value (code 3 or >); that number increased considerably when was 0.67 (ranged from 0.64 to 0.73). Description of the mothers were examined (86%). Regarding teeth extracted sample and sociodemographic characteristics can be found due to caries, 25.4% of adults had at least one tooth missing in Table 1. due to caries, while no child had lost any teeth because of It was observed that no child presented teeth extracted it. When transforming these data to the DMFT index (using due to caries; in those who had some type of restoration a cut-off 3-ICDAS), 34% of children would present dmft (9%), 73% were in primary molars, especially in the lower ≥1 (p<0.001), as well as 98% of adults (p=1.000) (Table 2 one, and with tooth-colored restorations. Regarding the and 3). Differences between different ICDAS cut-points mothers, 86% had at least 1 type of restoration (39% and DMF-T are presented in Tables 2 and 3. Discussion The traditional DMFT index (10) bases the detection Table 1. Description of the sample of caries at the cavitated level only and considers that its Children (n=150) Mean (± SD) treatment should be based on fillings and extractions. The main and original finding of our study was that, in adult Age 3.34 (±0.5) populations, the use of ICDAS added new information Male (n=70; 46.66%) - about non-cavitated lesions, but showed no statistically Female (n=80; 53.33%) - significant difference when compared with the DMFT index, Mothers (n=150) - since most mothers already had teeth with cavitated lesions, that had been restored or extracted due to caries. Also, the Age 33.66 (±7.6) detection of non-cavitated lesions significantly influenced Years of study 5.32 (±2.07) the findings in relation to caries when compared with the Family income R$ 2,240.08 (±R$ 1,980.83) dmf/DMF findings in preschool children. In this context, Number of people one should evaluate the purpose of the study in the adult 4.68 (± 4.50) living in the house population and the cost-effectiveness of using a more Number of children time-consuming method like the ICDAS. Moreover, the 2.22 (± 1.27) living in the house Table 2. Prevalence of dental caries in children and mothers, according to ICDAS and DMFT index CP1 - ICDAS-1 CP2 - ICDAS-2 CP3 - ICDAS-3 Restoration Extraction DMF-T /dmf-t or > 1 or > 2 or > 3 presence duo to caries p value > or = 1 N (%) N (%) N (%) N (%) N (%) Children (n=150) 138 (92%) 126 (84%) 47 (31.3%) 14 (9.3%) 0 (0%) 51 (34%) P< 0.001a Mothers (n=150) 146 (97.3%) 145 (96.6%) 120 (80%) 129 (86%) 38 (25.4%) 147 (98%) P = 1.000 Fisher’s exact test (between CP1 and CP3). Children versus adults: ICDAS or DMF-T Braz Dent J 27(6) 2016 DMF-T index underestimates the presence of the disease Other finding of the present paper was that the in children evaluated, as it ignored the most prevalent detection of non-cavitated lesions was suitable and reliable clinical presentation of caries found in the studied sample, when performed under field conditions. Some studies non-cavitated lesions. (22,23) support the use of a modification of WHO index This study shows that the criteria recommended by WHO allowing the detection of non-cavitated lesions; however, can be used for adults without losing much information. the most current version of the WHO manual gives no However, in children, a relevant amount of information information or reference about these changes (10). Knowing in estimating disease burden is lost, and for those who that obtaining good conditions for conducting a detailed make decisions on health it is essential. This may lead to an clinical examination in the context of an epidemiological underestimation of caries in populations, primarily children, study is a challenge, this study described a methodology and result in changes in the implementation of caries to collect data with sufficient flexibility to be used in a prevention actions by stakeholders. It can be considered variety of settings and situations in the field. Concerning that the non-cavitated lesions are very common but they the reliability of the diagnosis of non-cavitated lesions in have a low rate of progression (21), without ignoring the epidemiology studies, the values obtained were compatible differential impact of “untreated” initial caries and “actual with substantial agreement. burden of caries - cavities”, especially when considering the Any method that aims to register non-cavitated implementation of politic measures to control the disease. lesions requires more time for the clinical examination to Research in epidemiology has an objective of making be performed when compared to the traditional system a population diagnosis, which is important for decision recommended by the WHO. This statement is in accordance making in health and should therefore be able to generate with the literature, which showed that the choice of a accurate estimates of disease burden. These accurate method to detect non-cavitated lesions may take twice estimates are also important because, in order to develop as long (9, 24). It is important to take into account the and plan effective health actions, one cannot work with experience of examiners, since the knowledge and previous diagnostic criteria that only account for the disease at a training positively influences the time of data collection cavitation level, looking for all of the knowledge that has (18). The ICDAS website provides an e-learning Program for been accumulated regarding caries disease to date. prior training (www.icdas.org). The information obtained We must, therefore, consider the meaning of through the detection of non-cavitated lesions should, in epidemiological investigation. If it is of interest that the one way or another, compensate the extra time during oral health care planners to estimate dental caries figures the fieldwork if this information was essential to meet the for the purpose of determining clinical care and treatment objective of the research. needs, the DMF-T index may be sufficient. On the other To control biases in the study, three experienced, trained hand, if the action also has the objective of stalling and and calibrated examiners performed the data collection; reversing the carious process through population-based, when 50% of the sample was reached, a new calibration prevention oriented actions, one has to consider whether was performed by reviewing 10% of the sample. All it is important to estimate the lesions at an earlier stage. collected data were recorded by an undergraduate student As some studies raise difficulties regarding the use of who was unaware of the value of each code. This random ICDAS because it is time-consuming, adding relevant sample is representative of Northern District of the City costs to survey implementation, this should be prioritized of Porto Alegre/Brazil. Additional studies are needed to in epidemiological surveys focused on the pediatric extrapolate these findings. A limitation of the study is that population. the examination was not carried using the traditional index Table 3. Severity distribution of caries (ICDAS digit I) in children and mothers, according to ICDAS and DMFT index Non-cavitated lesions Cavitated lesions Mean ICDAS (± SD) Mean DMF-T /dmf-t (± SD) (ICDAS 1-2) (ICDAS 3-4-5-6) Female children 49 (32%) 25 (16.6%) - - Male children 42 (28%) 22 (14.6%) - - Total of children 91 (60%) 47 (31.3%) 2.52 (± 1.53) 1.39 (± 2.73) Mothers 25 (16.6%) 121 (80.6%) 4.04 (± 1.60) 9.03 (± 4.90) R. A. Melgar et al. Braz Dent J 27(6) 2016 prevalência e severidade da cárie dentária ao utilizar ICDAS e CPOD/ recommended by WHO with the objective of comparing the ceod em um estudo epidemiológico com crianças e suas mães. Este estudo transversal avaliou 150 pré-escolares e suas mães. Os dados foram accuracy of the methods discussed. However, the literature coletados utilizando-se o ICDAS e depois transformados em CPOD/ceod. brings findings in this direction and guides the best cut-off Os códigos do ICDAS relacionados à cárie foram analisados de acordo point to be made to transforming the data collected with com três diferentes pontos de corte: CP1 (0-hígido/1-6-cárie), CP2 (0-1 hígido/2-6-cárie) e CP3 (0-2 hígido/3-6-cárie), representando o D/d do the ICDAS in DMFT/dmft. When we started planning the índice CPOD/ceod. Os códigos do ICDAS referentes às restaurações, exceto survey, ICDAS did not advocate activity assessment of the selantes, foram considerados o O/o e o código 97 do ICDAS como o P/e do disease, the reason we did not asses it. índice CPOD/ceod. A prevalência de cárie e sua severidade com o ICDAS foram de 92%, 84% e 31,3% em crianças e 97,3%, 96,6% e 80% em Each epidemiological index has particular characteristics adultos de acordo com o CP1 / CP2 / CP3, respectivamente. Admitindo o that also influence the choice of which index to use. The ponto de corte CP3 como o padrão para a transformação de achados do ICDAS, based on best available evidence for detecting ICDAS em CPOD/ceod, foi observado que o índice CPOD/ceod subestimaria 60% das lesões não cavitadas em crianças e 16,6% em adultos. O CPOD/ early and later stage caries severity, have different scores ceod subestima a presença da doença ao desconsiderar as lesões não for surface and caries evaluation and should lead to the cavitadas na população pediátrica avaliada. A escolha de qual é o melhor acquisition of better quality information which could then índice para levantamentos epidemiológicos vai depender do propósito da pesquisa e da população-alvo: se o objetivo for estimar as necessidades be used to inform decisions about appropriate diagnosis, da população para determinar cuidados clínicos em crianças e adultos, prognosis, and clinical management of dental caries at o CPOD/ceod pode ser suficiente. No entanto, se o objetivo for ter um both the individual and public health levels. 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Received April 25, 2016 Accepted August 1, 2016 21. Guedes RS, Piovesan C, Floriano I, Emmanuelli B, Braga MM, Ekstrand KR, et al. Risk of initial and moderate caries lesions in primary teeth to progress to dentine cavitation: a 2-year cohort study. Int J Paediatr Dent 2016;26:116-124. R. A. Melgar et al.

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Published: Dec 1, 2016

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