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DENTAL CARIES PREVALENCE WITH ICDAS CRITERIA AND ASSOCIATED FACTORS IN COLOMBIAN CHILDREN WITH PRIMARY DENTITION



Authors
Farith González Martínez1
Luis Carmona Arango2
Edwin Puello Del Rio3

 

1Professor and Head Research Department College of Dentistry University of Cartagena. Cartagena, Colombia.
2Professor Clinical of Child, College of Dentistry, University of Sinú and University of Cartagena. Cartagena, Colombia.
3Manager, Academic Coordinator University of Cartagena. Cartagena, Colombia.

Recibido 24 de Junio 2013/Enviado para modificación 03 de Agosto 2013/Aceptado 24 de Agosto 2013



ABSTRACT

Objective. Describes the prevalence and severity of dental caries in Colombian preschool children with primary dentition. Methods. Cross-sectional study, using a random sample by clusters of 336 children between 3 and 5 years of age, examined during 2010. Dental caries lesion detection was carried out by visual criteria (ICDAS). A questionnaire was answered by the parents. Examiner´s calibration in ICDAS assessment method was carried out with a benchmark examiner, and the inter-examiner and intra-examiner reliability was calculated. The association exploration was analyzed parting from the prevalence ratio (PR; 95 percent confidence interval CI). The multivariate analysis was done using poisson regression model, obtaining adjusted values by age and gender. Results. Dental caries prevalence was 88.9 %, (51.4 % for experience and 37.5 % for non cavitated lesions). The average dmf-t was 1.7 +/-2.5. The most commonly present lesions were non cavitated, being the smooth surfaces in cervical area the most affected. For caries experience there was significance with a cariogenic diet, tooth brushing parent supervision and the use of a high fluoride content toothpaste, while the severity of dental caries was associated with dental consultations per year, mother´s schooling and school behavior. Conclusions. The dental caries prevalence and severity  was associated with different risk factors (weekly cariogenic diet consumption, no parental tooth brushing supervision, use of high fluoride content toothpaste, visit to the dentist less than one/year, mother schooling less than high school and inadequate school behavior), which at this age can be oriented by parents through a change in behavior. 

Key words:
dental caries; prevalence; primary dentition.



INTRODUCTION


Dental caries in Colombia is considered a public health problem according to indicators reported in the last oral health national study (54.8% was found in five year old children). These data demonstrate that for the primary dentition the goals established by the World Health Organization (WHO) (1), for the year 2000, were not accomplished. In preschool children is necessary to evaluate other risk indicators that increase the evidence in this topic to advance in the prevention of dental caries. Besides, using ICDAS dental caries detection system can reduce underreporting of dental caries in the deciduous dentition, successfully intercepting the problem from the initial stages. The ICDAS index is comparable to standard criteria (WHO) and that it is intended to be feasible for use in epidemiological surveys and to detect cavitated and non-cavitated stage lesions with acceptable reliability (2).

The Colombian Caribbean, is characterized by sub-populations with a diverse ethnic origin. These individuals are influenced by a lot of social factors, which are responsible for the heterogeneous epidemiologic distribution of oral alterations. Several studies carried out in different population groups in the Cartagena city have provided certain evidence to demonstrate the advance of this problem. González et al. (3), reported, in Colombia´s continental population, results of dental caries in five year old children of 74% and, in children younger than five years old, a prevalence of 55%. Likewise, Diaz et al. (4), found in school children, 51% caries prevalence in the age group between four and five years of age.

These results are still insufficient to understand the distribution and etiology of dental caries in early ages, especially when the interest of health institutions has been focused on the five year old population and older, leaving aside the  preschoolers, whose children have primary dentition and different exposures to dental caries risk factors (5). This population is exposed, since a very early age, to a series of factors associated with the disease, whose specific weight as indicators, within the determinist caries model, is unknown, and this is why preventive actions cannot be adhered. Also, any Colombian study reported the prevalence of dental caries considering earlier stagies and any study to evaluate the association of risk factors considering cavitated and non-cavitated caries lesions.

This study describes the prevalence and severity of dental caries in a Colombian preschool population with primary dentition.

MATERIALS AND METHODS
Sample

This cross-sectional study was carried out in a sample of 326 children between the ages of 3 and 5 years, representative of the urban area of the Cartagena City Colombia for the year 2010. The participants were selected through a randomized sample by clusters, including the child day care centers of the Instituto Colombiano de Bienestar Familiar de la Ciudad de Cartagena de Indias (ICBF).
The calculation of sample size was estimated, assuming a 5% type I error,  power 80% and a expected estimator reported in the literature for the factors in the study (PR=1,5), for a total sample size of 326 subjects.

The children who participated in the study all had primary dentition and no systemic diseases; their parents had to be residents of the Cartagena City and they accepted to answer a questionnaire, obtaining their written informed consent based on the Helsinki declaration. The protocol of study was approved by the Ethics Committee University of Cartagena.

The clinical measurements were done using the parameters of the visual criteria of the International Caries Detection and Assessment System (ICDAS) (6). Clinical examinations were conducted in standard dental chairs under calibrated light, using a plane buccal mirror, air and moisture on tooth surfaces to detect non cavitated lesion, and direct vision for cavitated lesions. To measure the factors associated to dental caries, a structured questionnaire was applied to the children mothers, considering the explanatory variables. 

Clinical examination
Examiners calibration in ICDAS was carried out with a benchmark examiner and calculation of inter-examiner and intra-examiner reliability. For the selection of the best examiner, an agreement degree between 0.75 and 0.80 was accepted using the weighted kappa coefficient for evaluation of ICDAS criteria with ordinal assessment indicators, obtaining as a result two examiners who met these parameters (0.78 and 0.79). The calibration process was performed initially with exfoliated primary teeth, and later with clinical examination, to evaluate the concordance between detection of non-cavitated carious lesions and cavitated or dentinal carious lesions. The calibration for the oral hygiene index (7), was done out with two examiners and the intraclass correlation coefficient. At the end of the standardization, were considered values the correlation coefficient (r= 0.75-0.80). For all the inter-examiner and intra-examiner analyses, the plaque index operators obtained values above this parameter.

The field examinations was initiated with a professional prophylaxis with rotary brush and prophylactic paste, which permitted the detection of color changes or dental opacities. The prevalence of dental caries experience was expressed at the dichotomy level (dmf-t =0 and dmf-t > 0). For the extent of dental caries two indicators (dmf-t=1 and dmf-t >1) were used. In order to assesses the dental surfaces, the ICDAS modified clinical diagnostic criteria was used considering the following indicators: code 0= sound surface; code 1= first visual change in the enamel (seen only after prolonged air drying restricted to within the confines of a pit or fissure); code 2= distinct visual change in the enamel; code 3= localized enamel breakdown (without clinical visual signs of dentinal involvement); code 4= underlying dark shadow from dentin; code 5= distinct cavity with visible dentine; code 6= extensive distinct cavity with visible dentin.
For the oral hygiene index a hematoxiline/eosin two tone plaque disclosing solution (red/blue) was used. 55 dental surfaces located on the buccal, lingual, occlusal and palatal sides were evaluated, and the six palatal surfaces of the upper incisors as well as all interproximal surfaces were excluded. Each one of the dental surfaces were stained using a cotton tip on the tooth clinical crown; afterwards, the teeth were rinsed with water and the presence of dental plaque in each surface was registered, taking into consideration only those areas stained with blue, which reflects the stage of maturity of the biofilm. In order to obtain the general readings, the number of blue stained surfaces was divided by the number of evaluated surfaces. The categorization for the analysis was as follows: (code1; 31-100 percent; deficient oral hygiene; code 2=16-30 percent; moderate oral hygiene; code 3=0-15 percent; good oral hygiene).

Questionnaire
A validated structured questionnaire for the explanatory variables was designed and directed to the children mothers, with 23 questions. The categories and codes used for each one of the variables were the following: demographic variables: age (years) (1=three; 2=four; 3=five), gender (1=male; 2=female). Parents´ school level: (1=less than high school; 2=graduated from high school; 3=college degree or higher. Oral Hygiene: tooth brushing frequency (1=once a day; 2=twice a day; 3=three or more times a day), tooth brushing supervision (1=tooth brushing not supervised; 2=tooth brushing supervised by parents or caregivers), type of toothpaste used during tooth brushing (1=fluoride content in PPMs equal or less than 500; 2=fluoride content in PPMs in a range between higher than 500 and less than 1200; 3=fluoride content in PPMs equal or higher than 1200, 4=toothpaste without fluoride; 5=does not use toothpaste). Access to dental services: last visit to the dentist (1=one year ago or more; 2=six months ago; 3=three or four months ago; 4=none), chief complaint (1=emergency treatment only; 2=preventive and restorative treatment; 3=prevention only 4=none); fluoride application during the appointment (1=never had a fluoride application; 2=at least once a year; 3=two or more during the year). Sugar consumption in the diet (whose indicators were taken from parameters of the last Nutritional Situation National Study ENSIN-Colombia 2005): carbohydrate  daily consumption (1=three or more times; 2=two times; 3=one time; 4=occasionally; 5=never), frequency and type of foods consumed during the day (1=sugars and sweets; 2=fats and oils; 3=cereals, roots, tubercles and plantains; 4= meats, eggs, dry leguminous, mixed vegetables; 5= dairies (milk, cheese), 6=fruits; 7= produce, vegetables, green leguminous), soda consumption during the day (1=three or more times; 2=twice a day; 3=once; 4=occasionally; 5=never); sweet snack consumption during the day (1=three or more times; 2=twice a day; 3=once ; 4=occasionally; 5=never). Family life: person in charge of the child during the day (1=maid; 2=close family members; 3=one of the parents), parents informed about children´s oral hygiene needs (1=no; 2=yes).

Prior to the recollection of the data, this format was evaluated by three expert judges in order to verify its appearance validity and a reliability-stability, test-retest was used and applied to a pilot group of volunteer mothers at two different moments and correlating the two sets of data obtained. All interviewers were trained to administer their assigned questionnaires. Also, the questionnaires were tested before the initiation of the study and went through auditing and monitoring phases including the review by investigators to evaluate the adherence to protocols. During the data collection the mothers in each selected child care center were summoned and the questionnaire was applied, the guidance researchers provided orientation to complete the questionnaire, in order to guarantee for non-response or losses.

Data Analysis
The statistical analyses were performed using the STATA® (Stata Corp. LP, College Station, TX, USA), calculating the estimators to the sampling design. Two outcomes were used in this study: prevalence of caries experience (dmf-t > 0) and severity of dental caries (dmf-t > 1). Poisson regression analyses taking into account the clusters sampling were performed to assess the association between the independent variables and the outcomes. The regression analysis considering the cut off code 3 of ICDAS, in this cut off point the ICDAS is comparable with WHO criteria in the analyses. We calculated the prevalence ratio (PR; 95 percent confidence interval CI) to assess the caries experience and its severity or not, who were considered as the dependent variables, because the odds ratio overestimate the prevalence ratio in cross-sectional studies (8). A backward stepwise procedure was used to include or exclude explanatory variables in the fitting of models. Explanatory variables were selected for the final models only if they had a P-value < 0.05 after adjustment. The interactions between variables were explored using Likelihood-ratio test.

RESULTS

840 children were invited to participate in the study, 480 did not have the selection criteria and 34 mothers refused to participate. The 326 children participating in the study had an average age of 3.8 years (SD=0.74), of which the highest frequency corresponded to 4 year old group with 42.6%. Regarding gender, the males participated with 55.5% and the females with 44.5%. 

The prevalence of dental caries experience in the subjects of the study was 88.9% (dmf-t > 0, including cavitated treated and untreated lesions and non cavitated lesions); regarding cavitated lesions considering the cut off code 3 of ICDAS, the prevalence was a 51.4%, being similar for age, gender and location. In reference to the dmf-t, the mean of teeth was 1.7 (table 1).

Table 2 shows the severity of caries lesions in accordance with ICDAS criteria. Regarding the location of the caries lesions, most of them were found in smooth surfaces in cervical area; buccal and labial (2.76) and lingual/palatal (0.45;SD=1.06;CI;0.33-0.57), followed by the occlusal surface with 1.3 (SD=1.69). The dental areas with the lowest average for caries lesions were the interproximal surfaces (mesial=0.19+/-0.44 and distal= 0.2+/-0.55). In reference to the dmf-s, the media of surfaces was 4.9).

The dental caries associated factors with the highest occurrence were: moderate/deficient oral hygiene index 80.9%;CI;76.6-85.3, daily consumption of sweets 69.9%;CI;64.9-74.9, visits to the dentist less than one per year 68.6%;CI;63.2-74.0, delegation of responsibility of child care in persons different from family members 64.2%;CI; 58.6-69.8, no parental tooth brushing supervision 47.5%; CI;42.1-53.2, use of high fluoride content toothpaste (47.3%;CI;41.5-53.1), father schooling lower than high school with  45.9%;CI;40.2-51.7 and mother schooling lower than high school (45.8%;CI;40.0-51.5).

At the bivariate level with estimators adjusted by age, for the dental caries experience, there was a statistically significant relationship with six variables. When interactions were explored, there was no increase in the strength of association for any of these variables. Through the multivariate analysis, the best model was obtained by associating three variables (χ2=31.6; p=0.000) (table 3). For dental caries severity, there was a statistically significant relationship with nine variables. Through the multivariate analysis, the best model showed significance with three variables; (χ2=9.02; p=0.02) (table 4).


DISCUSSION

This  study took into account behavioral, social and dietary risk indicators related with the life styles of the mother-child dyade, which have been evaluated through validated questionnaires in several studies reported in the literature for these ages (1-2). The researchers assumed that, being this cross sectional study that uses questionnaires to explore associations with determinants, the results could have some limitations such as underestimation of some exposures that change with time and also, the effect of time on the memory of the subjects evaluated.  Besides, there are other biological risk indicators that have been associated with dental caries in the primary dentition which were not considered in this study, this must be evaluated in future studies to supplement the information obtained. The use of the dental caries visual criteria parameters ICDAS, permitted us to see aspects of the disease related to its natural history, making it possible to design a preventive approach model and intercept the development of this event from its early stages, something that is not considered viable when using WHO´s dental caries criteria (3-5).

According to the results obtained, the prevalence of caries experience, including treated and non treated cavitated lesions, was 51.4%, however, when non cavitated lesions are added, prevalence increases to 88.9%. This finding demonstrates that just by observing the cavitated lesions within a diagnosis of dental caries, any population estimator is underestimated. Presently, any prevalence higher than 50% is considered high. This finding is probably due to the fact that at early ages the child is exposed to factors such as sweets consumption and  parents delegating in them responsibility of tooth brushing as a measure to generate autonomy and stimulate interest in oral hygiene.   

The mean for decayed teeth was 1.68; this finding is within the criteria established by WHO (1), for these ages. In Latin America, Cook et al.(9), in children of Mexican populations found an average of caries lesions of 12.5 in the deciduous dentition. This findings permit to assume that in the City of Cartagena, although there are a high proportion of children with at least one caries lesion, the severity is not very alarming. 
The most frequently found lesions in this study were non cavitated, (white lesion; mean=3.18) located on smooth surfaces cervical area, however, many proximal lesions are missed by visual inspection and therefore, radiographic evaluation is necessary. Certainly, interproximal surface caries can be present more often than non-cavitated caries lesions in smooth surfaces. These findings are similar to those reported in several regional studies of the City of Cartagena (3,4). When comparisons were made with other Colombian populations, Saldarriaga et al. (10), in the city of Medellin, Colombia observed higher frequency of dental caries for smooth surfaces, very similar to what is reported in this study. From this perspective it is important to consider that children in this age group do not have the required skills to perform an adequate removal of the dental plaque deposited in these areas (11). When using (ICDAS), is possible to find a larger number of initial lesions per tooth (2). Besides, it was possible to identify a larger number of initial lesions compared with other national studies (ENSAB III) that only reported cavitational lesions.

The poisson regression analysis helped find an explanation for dental caries due to exposure to a cariogenic diet for more than three moments a week, in this regard it was found that the children who presented dental caries were consuming a diet rich in tuberous plants, carbohydrates, sweetened soda pops and candies between meals and low fruit and vegetables consumption. Hashim et al. (12), found in preschool children of the Arab Emirates, that the increase in consumption of snacks, sweetened soda pops and cookies between meals increase the risk of dental caries in these ages. Likewise, Pienihäkkinen et al. (13), in Finnish children, reported that the combination between incipient caries lesions and sweets consumption could have a predictive value for the clinical implications of this alteration (14).

Another factor with statistical significance in this study was tooth brushing supervision by parents. Declerck et al. (15), found that the children who rarely receive help during tooth brushing have four times more risk of developing dental caries than those whose tooth brushing is supervised daily. Also, the benefits provided by supervised oral hygiene programs have been proposed, especially when they are supervised by an adult at home or school, during daily tooth brushing activities (16-18).

Regarding the use of low fluoride content tooth pastes in the primary dentition, the best current available evidence indicates that the most effective preventive approach against dental caries is using fluoride dentifrice with concentration of fluoride with 1000 ppm and above (19). According to this study, the use of low fluoride content tooth paste was a protective factor. These results are contrary to those reported for other populations, with the hypothesis that a high (>/=1500ppm) or lower (1000-1250 ppm) fluoride content tooth paste permits a better remineralization (20,21). Notwithstanding, the current tendency is to use tooth pastes with a lower fluoride content at these ages, besides they have good flavor and color, which is probably better tolerated by the children (22).
Regarding the severity of dental caries, as it refers to parents schooling, which was the one with the highest statistical power in this study, some of the reviewed current studies did not find significant differences, being this event similar in those children whose parents had a low schooling level in comparison with the parents with a high schooling level (15). However, Piovesan et al. (23), using poisson regression found association between mother’s and father’s level of education with the dental caries experience. In this study the association could have happened because in the target population, which consisted mainly of African descendant population belonging to social low strata, the behavioral and socio-cultural aspects are closely related with the educational level of the individuals, relationship that is not as evident in developed countries (21,10). Also, the dental examination of the child at an early age has been considered an important habit to prevent new lesions. Eckert et al. (24), found that having access to the dentist at early ages is related to a lesser risk of having dental caries, but regular visits during the year have no significance. In this sense other authors have established that visiting the dentist for control visits prevents the progress of new lesions (25).

The results found in this study can serve as a guideline to review the public policy of the district to oral health, which in turn can turn around the philosophy with which preventive programs are designed at the health institutions taking care of this population.
In conclusion, the high prevalence of dental caries in primary dentition children is associated by different risk indicators, both for the experience (weekly cariogenic diet consumption, no parental tooth brushing supervision and use of high fluoride content toothpaste) as for the severity (visit to the dentist less than one/year, mother schooling less than high school and inadequate school behavior), which at this age can be oriented by parents through a change in behavior. These risk indicators can vary from one population to another if they appear in different circumstances and moments and they would provide a new interpretation of the etiology of this important public health event. In this manner it is considered relevant to institute preventive programs with an adequate knowledge of the individual dental prevention and treatment needs of the participants through the implementation of standardized visual detection criteria, where besides the traditional dmf-t (OMS), initial caries lesions and their relationship with habits and other socials aspects of the child are included.

Acknowledgements. University of Cartagena and University of Sinú, for their contribution at the development of this study.


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