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Year : 2021  |  Volume : 19  |  Issue : 2  |  Page : 104-108

Comparison of caries assessment spectrum and treatment needs index with def index in measuring dental caries among 2–6-year-old schoolchildren: A descriptive cross-sectional survey

1 Department of Paediatric and Preventive Dentistry, GSL Dental College and Hospital, Rajahmundry, Andhra Pradesh, India
2 Department of Paediatric and Preventive Dentistry, Vishnu Dental College and Hospital, Bhimavaram, Andhra Pradesh, India
3 Department of Paediatric and Preventive Dentistry, Meghna Institute of Dental Sciences, Nizamabad, Telangana, India

Date of Submission06-Jun-2020
Date of Decision11-Feb-2021
Date of Acceptance02-Jun-2021
Date of Web Publication2-Aug-2021

Correspondence Address:
Charan Teja Vemagiri
D. NO: 2-49, Near ZP Elementary School, Diwancheruvu, Rajanagaram Mandal, East Godavari District, Rajahmundry - 533 296, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_113_20

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Background: Decayed, missing, and filled teeth and def indices are the preferred choices for dental caries quantification. Lacunae in earlier caries indices led to Caries Assessment Spectrum and Treatment Needs Index (CAST) development. CAST index measures caries experience of a single tooth and overall dentition in a hierarchical level of caries severity. Aim: This study aimed to compare CAST and def indices in measuring dental caries among 3–6-year-old school children in and around Bhimavaram town, Andhra Pradesh, India. Material and Methods: A descriptive cross-sectional survey was conducted. A single examiner conducted survey among 898 3–6-year-old school children at randomly selected schools. Caries experience was recorded in a structured pro forma using CAST and def indices. Descriptive statistical analysis was done. Inter- and intragroup comparisons were made by Kruskal–Wallis ANOVA and Mann–Whitney U–tests, respectively. Correlation between def and CAST indices was explored by Spearman's rank correlation coefficient. Results: Caries prevalence with CAST index (45.7%) was marginally higher compared with def index (44.7%). No statistically significant difference was found between mean deft scores measured with CAST and def index (P = 0.87). High statistically significant difference in mean def scores with def index and def component of CAST index for 3-, 4-, 5-, and 6-year age groups was observed (P < 0.001). A strong correlation in measuring dental caries (P < 0.001) and similar percentage of agreement for application (98.5%) was observed between both the indices. Conclusion: No statistically significant difference was found in measuring caries experience indicating the similarity between CAST and def indices in quantifying dental caries. CAST index provides more detailed information of caries prevalence, experience, and severity compared with def index.

Keywords: Caries Assessment Spectrum and Treatment Needs index, def index, dental caries

How to cite this article:
Vemagiri CT, Uloopi K S, Chandrappa V, Ch A, Pavitra J, Chowdary P B. Comparison of caries assessment spectrum and treatment needs index with def index in measuring dental caries among 2–6-year-old schoolchildren: A descriptive cross-sectional survey. J Indian Assoc Public Health Dent 2021;19:104-8

How to cite this URL:
Vemagiri CT, Uloopi K S, Chandrappa V, Ch A, Pavitra J, Chowdary P B. Comparison of caries assessment spectrum and treatment needs index with def index in measuring dental caries among 2–6-year-old schoolchildren: A descriptive cross-sectional survey. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2022 Aug 15];19:104-8. Available from: https://www.jiaphd.org/text.asp?2021/19/2/104/322851

  Introduction Top

Dental indices are widely used for quantifying dental caries.[1] Among numerous indices available, decayed, missing, and filled teeth and def indices[1] are commonly used. However, the paradigm shift in curative to preventive dentistry[2] and management protocols led to development of new indices named International Caries Detection and Assessment System,[3] pulpal involvement-ulceration-fistula-abscess (PUFA/pufa),[4] and pulpal involvement-root sepsis[4] indices. However, none of these indices gained attention globally.[2],[3]

No index available described the total picture of caries progression which is beneficial for epidemiological surveys.[5] Hence, to visualize the entire caries spectrum, Caries Assessment Spectrum and Treatment Needs (CAST) index was developed which unfolds caries in an increasing level of severity.[6]

A paucity of literature is evident regarding the characteristics of CAST index, its diagnostic precision, and its reliability for use in different populations. Hence, the present study was designed with a primary objective to compare the CAST index with def index in measuring dental caries among 3–6-year-old schoolchildren. The secondary objective was to measure the complete range of carious lesions using CAST index. It was null hypothesized that CAST index was inferior to def index in detailing the caries spectrum, while the alternate hypothesis was kept as CAST index gives a more detailed picture of dental caries than def index.

  Materials and Methods Top

The present descriptive cross-sectional study was conducted among 3-6-year-old schoolchildren in and around Bhimavaram, Andhra Pradesh, India, between December 2014 and July 2015 for a period of 8 months. The study was approved by the Institutional Ethical Review Board (IEC/IRB NO: VDC/IEC/2014-16). The purpose and nature of the study were explained and prior permission from school authorities and written informed consent from their parents were obtained. Selection of schools was done randomly based on availability of children with only fully erupted deciduous dentition on the day of examination. Children with erupted first permanent molar, congenital missing teeth, and who require special health care needs were excluded from the study.

Prior to the original research, the investigator was trained and calibrated for a period of 2 weeks, recording “def” and “CAST” indices under the guidance of the staff incharge to assess the intraexaminer variability. The investigator had first carried out oral examination on twenty subjects with dental caries. Then, the same subjects were reexamined after 2 days and the results of two examinations were compared to assess intraexaminer variability. The Cohen's kappa coefficient (κ) value for intraexaminer agreement for both the indices was established at 0.93 (95% confidence interval [CI = 0.791–0.968], Z = 1.96), (P < 0.001) and the percentage of agreement for application of indices by the investigator was about 98.5%.

Based on the prevalence (46.21%) obtained in the pilot study, minimum sample size was estimated to be around 398 using the formula (Z2α/2 × p × [1 − p])/E2 taking 95% CI for which the value of Z2α/2 = 1.96 and marginal error 0.05. However, considering CAST index can estimate a rage of carious lesions and based on the availability of children from schools in and around Bhimavaram during study period, 898 schoolchildren of various socioeconomic status were allocated into the study by simple random sampling (lottery) method. Ten percent of the sample was re-examined to assess intraexaminer variability and found to be having good agreement (κ =0.917).

The clinical examination was performed at predecided dates under sufficient daylight making children sit in an upright position with plane mouth mirror and WHO periodontal probe under strict aseptic conditions. The data regarding caries experience were recorded in a specially designed pro forma. Examination was limited to ten subjects per day and the average time spent for each child was approximately 15 min. Children who required any invasive dental procedures were referred to college for the needful.

Statistical analysis

Statistical analysis was done using IBM Statistical Package for Social Sciences 17.0 (Armonk, NY, USA). The intraexaminer reliability was determined by the unweighted Cohen's kappa coefficient values. The Spearman's rank correlation coefficient ® explored the correlation between “def” index and “CAST” index. Inter- and intragroup comparisons were made using Kruskal–Wallis ANOVA and Mann–Whitney U-tests, respectively. For all the tests, P value was set ≤ 0.05.

  Results Top

Around 898 schoolchildren, 474 males (52.78%) and 424 females (47.22%), with the mean age of 4.79 years were examined in the present study. Both age and gender show almost equal in its distribution.[Figure 1] The unweighted kappa value for intraexaminer consistency of measuring dental caries with def and CAST indices was established at 0.93 (95% CI = 0.791–0.968), Z = 1.96). The spearman rank correlation coefficient showed a highly significant strong agreement between CAST and def indices for all age groups (P < 0.001) [Table 1].
Figure 1: Distribution of study participants according to age and gender

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Table 1: Correlation between decayed extracted and filled index and Caries Assessment Spectrum and Treatment Needs Index according to age and gender

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The CAST index presented 45.7% caries prevalence among the study subjects which was marginally higher and statistically insignificant (P = 0.87) compared with deft index (44.7%) [Figure 2].
Figure 2: Comparison of “def” index and “Caries Assessment Spectrum and Treatment Needs” index in measuring the prevalence of dental caries

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The difference observed on comparison of overall mean score for d, e, and f component of CAST index (2.19 ± 3.30) with def index (2.16 ± 3.30) was statistically insignificant (P = 0.87) [Table 2].
Table 2: Intergroup comparison of mean decayed extracted and filled scores between different age groups

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A significant increasing trend of mean deft score was observed in both the indices as the age increased from 3 to 6 years [Table 2]. However, intergroup comparison of mean def scores of different age groups between both the indices showed no statistically significant difference (P = 0.819 for 3 years, P = 0.913 for 4 years, P = 0.937 for 5 years, P = 0.874 for 6 years) [Table 2].

Around 88.2% of the examined teeth were found to be sound, whereas 2.46% presented a distinct visual change in enamel. 2.30% and 2.28% of teeth had noncavitated and cavitated dentinal lesions, respectively. The teeth with pulpal involvement and with abscess formation were 2.87% and 0.62%, respectively. Sealed tooth component was 0.001% and 0.65% of examined teeth represented restored (0.15%), lost (0.21%), and other components (0.27%) of the index [Table 3].
Table 3: Prevalence of total spectrum of dental caries according to Caries Assessment Spectrum and Treatment Needs Index

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  Discussion Top

Data collected by dental indices are reliable and help in prevention and treatment of dental caries.[6] Since eight decades, def (decayed extracted and filled teeth) index has been frequently used for caries measurement of primary teeth in a given population.[1],[2] However, it fails in recording the early white spot lesions, thereby underestimating the prevalence and severity of caries lesions.[1] Therefore, its use is only limited to those populations who have high caries prevalence.[2] Nevertheless, assessing carious lesions in both enamel and dentine has become vital in recent times.[7]

To combat with the changing ideology to minimal invasive dentistry, CAST index which describes the complete range of carious lesions in a hierarchical manner was developed.[8],[9] Although CAST index was validated for face content and construct,[7] a few studies are reported in the literature regarding its usage in populations of different age groups and backgrounds in various countries. Hence, the present study was designed.

The present study included 3 to 6-year age group children because the primary dentition eruption completes by around 33 ± 6 months and also it was difficult to get large sample at a single place below 3 years.[10]

def index was compared since it is most frequently used for dental caries quantification in primary dentition.[1],[2] Examination and cavitation confirmation were done by the WHO periodontal probe as the children are of very young age.[3],[8] Furthermore, the child's cooperation with examination in turn a positive dental behavior was achieved. Besides, literature reveals the usage of explorer probe disrupts surface layer and prevents the possibility of re-mineralization.[11],[12]

The study reveals that the caries prevalence was marginally higher with CAST index (45.7%) compared to def (44.7%) similar to Baginska et al. and de Souza et al. studies.[13],[14] CAST index records initial enamel decalcifications, while def index ignores them thus underestimating the prevalence rate.[11] High caries prevalence in the present study population was also in similarity to that reported in Brazil (46%) in 2000,[15] Nigeria (40%) in 1985,[16] and Aurangabad (47.8%) in 1992.[17]

The kappa coefficient and Spearman's rank correlation coefficient values in the present study revealed perfect intraexaminer reliability and strong correlation in measuring dental caries between CAST and def indices for all the age groups and for both genders. This was in agreement with the study conducted by Baginska et al.[13]

No statistically significant difference was found in overall mean deft scores and deft scores for different age groups indicating that caries prevalence and experience recorded by CAST and def indices were similar for all age groups. This result coincides with that of de Souza et al.[14]

The mean deft scores were significantly different between different age groups with CAST (0.86, 1.60, 2.15, and 3.27) and def (0.79, 1.58, 2.17, and 3.22) indices which suggests an increase in caries experience as the age increases with both the indices. A similar finding was also reported by Das et al. and Shankar et al.[1],[18]

CAST index criterion presents 0–9 codes in a hierarchical pattern of caries progression, out of which codes 3, 4, and 5 report carious experience representing enamel and noncavitated and cavitated dentinal caries, respectively. The remaining six codes demonstrate the sealed (code 1), restored (code 2), caries severity (code 6 and 7), and lost/missing status (code 8).[2]

In the present study, a high proportion of children having teeth with pulpal involvement (2.87%) was observed, implying that availability of dental treatment services in the present population is lower. This, in turn, led to the high incidence of caries severity (0.62%). High enamel caries lesions (2.46%) indicate the requirement of immediate restorations, dental health education, and continuous follow-up. Furthermore, codes 4 and 5 percentage (4.76%) depicts a portrait of the amount of curative care required for the schoolchildren. Lack of awareness among parents could be known by the low proportion of sealants (0.01%) and restorations (0.15%) in the present study population.

Quantification of deft scores from CAST index is possible which infers that caries prevalence and experience recorded with CAST index can be compared with def index and other caries assessment criteria.[7] Furthermore, reporting of progression of caries on a single tooth can be possible with CAST but not with def index.[14] In addition, CAST index details initial distinct visual changes in enamel as well as noncavitated and cavitated dentinal lesions based on which appropriate treatment plan can be designed which was not possible with def index. For collecting complete caries prevalence and experience in a population, CAST index is advantageous because deft scores do not have to be complimented with pufa/PUFA index as that with def index.[5]

Measurement of dental caries with both CAST and def indices was found to be similar in the present study population. CAST coding criterion will differentiate preventable and restorable carious lesions, which were just recorded as cavities in epidemiological studies till date with def index. Furthermore, CAST index also details the untreated caries consequences which were omitted using def index.[2],[3],[4]

Despite immense training, the intraobserver bias may occur since only a well-trained eye can visualize caries in the superficial brilliance of the enamel even while using an air syringe. Hence, the investigator might have underestimated the actual caries status as caries was diagnosed entirely on visual examination. Moreover, the relative lack of discoloration of an early lesion would have also contributed to the underestimation of caries by investigator.

Certain limitations pertaining to the CAST codes observed during the present study also need to be addressed such as where should a carious tooth with developmental disturbance of enamel and dentin is to be coded. The investigator moreover finds difficulty in distinguishing dentinal caries lesions with cavitation just only on visual discoloration without the radiographs, especially in proximal regions. It was also observed that code 8 can be misinterpreted as tooth lost should be recorded exclusively on proper history and tooth can be lost due to various other reasons such as periodontal problems, trauma, and orthodontic reasons. Furthermore, code 9 does not detail what other dental disease conditions apart from dental caries have to be included. Time consumed for recording caries experience with CAST codes in comparison with def index will also be a challenge if used in an epidemiological research.

CAST index was more advantageous and delivered a detailed picture of caries experience than def index in primary dentition of the present study population, thus satisfying the alternate hypothesis. However, further studies with equally distributed sample size in different populations of the globe need to be carried out for the acceptance of CAST as a reliable index.

  Conclusion Top

Based on the findings from this cross-sectional study, the following conclusions were drawn.

  • Dental caries prevalence and experience measured with CAST index were marginally higher compared with def index, but the difference was statistically not significant
  • Similar caries experience was provided by both CAST and def indices for different age groups
  • CAST index has the potential for detecting the whole spectrum of dental caries more precisely compared with def index.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Tiwari S, Dubey A, Singh B, Avinash A. Clinical consequences of untreated dental caries evaluated with the pulpal involvement-roots-sepsis index in the primary dentition of school children from the raipur and durg districts, Chhattisgarh State, India. Med Princ Pract 2014;24184-8.  Back to cited text no. 4
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  [Table 1], [Table 2], [Table 3]


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