Clinical consequences of untreated dental caries in German 5- and 8-year-olds
Grund et al. BMC Oral Health
Clinical consequences of untreated dental caries in German 5- and 8-year-olds
Katrin Grund 0
Inka Goddon 2
Ina M. Schüler 0
Thomas Lehmann 1
Roswitha Heinrich-Weltzien 0
0 Department of Preventive and Paediatric Dentistry, Jena University Hospital , Bachstr. 18, D-07743 Jena , Germany
1 Department of Medical Statistics and Epidemiology, Jena University Hospital , Bachstr. 18, D-07743 Jena , Germany
2 Department of Social Services and Health, Health Services for Children and Adolescents Schwelm , Hauptstr. 92, D-58332 Schwelm , Germany
Background: About half of all carious lesions in primary teeth of German 6- to 7-year-old children remain untreated, but no data regarding the clinical consequences of untreated dental caries are available. Therefore, this cross-sectional observational study aimed to assess the prevalence and experience of caries and odontogenic infections in the primary dentition of 5- and 8-year-old German children. Methods: Dental examinations were performed in 5-year-old pre-school children (n = 496) and in 8-year-old primary school children (n = 608) living in the Westphalian Ennepe-Ruhr district. Schools and preschools were selected by sociodemographic criteria including size, area, ownership, socio-economic status. Caries was recorded according to WHO criteria (1997). The Lorenz curves were used to display the polarisation of dental caries. Caries pattern in 5-year-olds was categorized by Wyne's (1997) definition of early childhood caries (ECC). Odontogenic infections as clinical consequence of untreated dental caries were assessed by the pufa index. The 'untreated caries-pufa ratio' was calculated, and the Spearman's rank correlation coefficient (ρ) was used for evaluating the correlation between dmft and pufa scores. Categorical data were compared between groups using the chi-square test and continuous data were analysed by t-test. Results: Caries prevalence and experience in the primary dentition was 26.2 %/0.9 ± 2.0 dmft in 5-year-olds and 48.8 %/2.1 ± 2.8 dmft in 8-year-olds. ECC type I (22 %) was the prevalent caries pattern in 5-year-olds. About 30 % of the tooth decay was treated (5y: 29.7 %/8y: 39.3 %). The Lorenz curves showed a strong caries polarisation on 20 % of the children. Pufa prevalence and experience was 4.4 %/0.1 ± 0.5 pufa in 5-year-olds and 16.6 %/0.3 ± 0.9 pufa in 8-year-olds. In 5-year-olds 14.2 % and in 8-year-olds 34.2 % of the d-component had progressed mainly to the pulp. A significant correlation between dmft and pufa scores exists in both age groups (5y: ρ = 0.399; 8y: ρ = 0.499). First deciduous molars were most frequently affected by odontogenic infections, presenting virtually all pufa scores (>95 %). Conclusions: Prevalence and experience of odontogenic infections and the untreated caries-pufa ratio were increasing from the younger to the elder children. Dmft and pufa scores in primary teeth predict a higher caries risk in permanent teeth. The pufa index highlights relevant information for decision makers to develop effective oral health care programs for children at high risk for caries.
Children; Odontogenic infections; Primary dentition; pufa index; Untreated dental caries
Dental caries continues to be one of the most widespread
diseases in the world . In particular, children are
predisposed to the development of carious lesions, and their
treatment is not just a problem in low- and middle-income
countries [2, 3]. Even in economically developed countries
such as the United Kingdom, France, Germany, and the
United States, the treatment of decayed primary teeth
remains an on-going public health challenge [4–7].
Severely decayed teeth have an important impact on
children’s general health, nutrition, growth and body
weight [8–10] by causing discomfort, pain, sleeping
problems, learning disorders and absence from school
[11–13]. Furthermore, odontogenic infections as a
consequence of untreated dental caries are the most
frequent reason for the hospitalisation of young children
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[6, 14]. Therefore, oral health fundamentally influences
children’s general health and quality of life [15–17].
The early onset of dental caries is of exceptional concern
since it represents an indicator for missed opportunities
for preventive care and endangers the general health of a
child. Wyne classified dental caries in children aged
younger than 6 years as early childhood caries (ECC) by three
types of severity . Type I has been defined as the
existence of isolated carious lesion(s) on molars and/or incisors,
type II as labiolingual carious lesions on maxillary incisors
and type III as carious lesions on almost all teeth, including
lower incisors . The American Academy of Pediatric
Dentistry (AAPD) defines ECC as the presence of one or
more decayed (non-cavitated or cavitated lesions), missing
(due to caries), or filled tooth surfaces in any primary tooth
in a child under the age of six .
Most epidemiological studies performed in children have
used the dmft index, which provides information on the
caries experience and restorative and surgical treatment,
but fails to contribute data on the consequences of
untreated caries. The diagnosis ‘teeth indicated for extraction’
is a WHO criterion for treatment needs , but does not
give detailed information about the severity of advanced
caries lesions and is rarely used in the literature.
In 2010, Monse et al.  introduced a new clinical
index characterising the consequences of untreated dental
caries in primary and permanent teeth: the pufa/PUFA
index. It is calculated as sum of teeth with four diagnoses
concerning different kinds of odontogenic infections ([p]
pulpal involvement, [u] ulceration, [f] fistula, [a] abscess).
Thus, the pufa index complements the dmft index by
displaying the severity of dental decay and quantifying
odontogenic infections of the pulp and surrounding tissues due
to untreated caries.
Recently, the pufa index was used particularly in
lowand middle-income countries to display the severity of
oral health neglect (Table 1). The pufa prevalence varies
from 24 % in Brazilian 6- to 7-year-olds  up to 85 %
in 6-year-old children from the Philippines ,
indicating a huge dental need. Although Germany is a
highincome country, the treatment of dental decay in the
primary dentition of pre-school children is insufficient.
The last representative study amongst 6- to 7-year-old
German children revealed that almost half of all carious
primary teeth (47.4 %) are untreated . This situation has
been nearly unchanged for more than 10 years . Until
now, the consequences of untreated dental
caries—odontogenic infections—had not been quantified in German
children with the pufa index. Therefore, the aim of this
cross-sectional study was to assess the prevalence and
experience of caries and odontogenic infections in primary
teeth of 5- and 8-year-old German children from the
Westphalian Ennepe-Ruhr District (EN District). The null
hypotheses tested were as follows: 1) there is no difference
in the prevalence and experience of odontogenic
infections between 5- and 8-year-old German children; 2)
untreated dental caries does not correlate with odontogenic
infections; 3) odontogenic infections in 8-year-olds do not
correlate with caries experience in permanent teeth.
Data from oral examinations provided by public health
service between January and December 2011 to 1.104
children aged five (n = 496) and eight (n = 608) years living in
the EN District in Germany were included in this
crosssectional epidemiological study. By the law, free dental
screenings to all children and adolescents attending
preschools and schools are annually offered by the Department
of Social Services and Health, Health Services for Children
and Adolescents of the EN District. The age group of
5year-olds was chosen because of a good comparability to
international studies regarding the pufa index (Table 1) and
the possibility to evaluate ECC. The attendance of
preschools for 5-year-olds is highly recommended by the
German Department of Education. Therefore, the large
majority of 5-year-olds is visiting pre-schools, enabling the
examination of a representative sample of children.
Furthermore, 5-year-olds display the highest stage of the
complete developed primary dentition before the first
permanent teeth are erupting.
At the age of eight, children reveal the end of the
second phase of the mixed dentition—before exfoliation of
the primary molars—and the first permanent molars are
commonly erupted and exposed to the oral environment
since 2 years. Therefore, examination of 8-year-olds
enables to show the influence of caries experience in the
primary dentition on dental health of the permanent
dentition; particularly the first permanent molar.
The EN District is located in the centre of the federal
state North Rhine-Westphalia (NRW) in Western
Germany. NRW experienced high industrialisation and
urbanisation in the early 20th century, becoming the
largest conurbation and centre of coal industry in
Europe. Because of the coal-crisis in the years following
1960, the socio-economic status declined. In 2011 NRW
had an at-risk-of-poverty rate of 14.6 % which is
comparable to Germany (15 %) . The report of poverty
for the EN District in 2010 states that this district is
representative for NRW showing a slightly higher
atrisk-of-poverty rate (16 %) .
The sample size was estimated to the number of children
necessary to obtain statistical significance with 80 % power
and an interval of 5. Targeting the estimated sample size
and following the regional socio-demographic pattern,
21.0 % (34 out of 162) pre-schools and 38.2 % (21 out of
55), primary schools were selected from the different areas.
Selection criteria of the schools/pre-schools included area
Baginska J., et al.
N = 215/ Poland
5.56 ± 4.45 dmft 43.0
Thekiso, M., et al.
N = 800/South Africa
6.69 ± 3.14 dmft 72.0
Table 1 Pufa prevalence and mean pufa index in the primary dentition of children—overview from the literature
Mehta A., Bhalla S.
Age of dmft dmft
Population prevalence (%) (mean ± SD)
N = 603/ Indian
Figueiredo M.J., et al. 2011/2009
N = 835/ Brazil
N = 2030/ Philippines 6 years
(urban/rural and industrialized/middle-class), size (small
and large), ownership (public/private) and socio-economic
status targeting a proportional distribution.
The exclusion criteria for the cross-sectional study
were: 1) absenteeism from school/pre-school 2) child
has a special health care need and 3) refusal of the child
to be examined in the pre-school setting. Eighty per cent
(495 out of 620) of all 5-year-olds attending the selected
pre-schools and 88.9 % (608 out of 684) of all
8-yearolds attending the selected primary schools could be
included in this study.
Prior to the survey, the examiner (I. G.) received 1-day
theoretical and clinical calibration training for using
the dmft and pufa indices. An experienced dentist and
epidemiologist (R. H.-W.) conducted the training. Ten
children were examined in a pre-school and a primary school
not included in this survey, but under the same field
conditions as in the main study. The intra- and
inter-examinerreproducibility was assessed by the kappa (κ) statistics. The
κ values for inter-examiner-reproducibility ranged from
0.90 (I. G.) to 0.92 (R. H-W.) for the pufa index,
demonstrating excellent agreement, and values for inter-examiner
reproducibility for the dmft was in the same range (0.88 I.
G/0.93 R. H-W.). Intra-examiner reproducibility ranged
from 0.89 to 1.00 for the examiner (I. G.) for both indices.
Within the main study, every 20th child was repeatedly
examined. The intra-examiner reproducibility for both
indices ranged between 0.91 and 1.00.
The examinations were performed by one calibrated
dentist in classrooms in each pre-school or primary
school (I. G.). The caries status of the children was
assessed according to WHO criteria  using an
intraoral mouth mirror, a CPI ball-end probe, and a halogen
examination light (Mach 113, Dr. Mach GmbH & Co.
KG, Ebersberg, Germany) after tooth-brushing
supervised by the dental nurse or teacher. Cotton rolls were
used for moisture control. Caries was assessed using the
dmft index and the dmft/DMFT in 8-year olds.
The clinical consequences of untreated caries were
recorded by using the pufa index . The pufa index per
child represents the number of teeth meeting the
following diagnostic criteria: Decayed teeth with visible pulpal
involvement (p) was measured when the open pulp
chamber was visible or the clinical crown was destroyed and
only root fragments were left. Ulceration (u) of the soft
tissue surrounding the tooth was scored when caused by
dislocated tooth fragments. Fistula (f ) was diagnosed when
pus-releasing sinus tract was related to the tooth with
pulpal involvement. Abscess (a) was scored when a
puscontaining swelling was related to the tooth. The diagnosis
of the pufa index was performed visually, without the use
of a dental probe.
Data collection was performed with excel spreadsheets
(Excel 2011 Microsoft Cooperation, Redmond, WA, USA)
and the statistical analysis of the oral health data was
carried out using SPSS 21.0. (IBM Corp, Armonk, NY, USA),
R 3.1.1 (R Core Team, 2014 ). Caries experience was
calculated as mean dmft and the Significant Caries Index
(SiC index) as the mean dmft of one third of the population
with the highest caries scores . ECC in 5-year-olds was
assessed according to the definition of Wyne differentiating
between mild (type I), moderate (type II) and severe caries
pattern (type III) . The Lorenz curve was used to
display the polarisation of dental caries (cumulative disease),
and the extent of inequality was measured by the Gini
coefficient (G) with finite population correction. The range
of the Gini coefficient is 0 ≤ G ≤ 1, with value 0 indicating
equality and value 1 expressing maximal inequality. The
care index was calculated as [ft/dmft] × 100. The
severity of untreated dental caries was recorded by the pufa
index. The ‘untreated caries-pufa ratio’ was calculated
as [pufa/dt] × 100 and describes the percentage of
untreated carious teeth that developed an oral infection.
The correlation between dmft and pufa scores was
computed by the Spearman’s rank correlation coefficient (ρ).
Categorical data were compared between groups using
the chi-square test and continuous data were analysed
by t-test. A binary logistic regression model was fitted
to determine the influence of dmft and pufa on the risk
of developing dental caries in the permanent dentition.
Statistical significance level was set at p ≤ 0.05.
This study was performed in full accordance with ethical
principles and approved by the ethics committee of the
Jena University Hospital (registration number 3660-D1/13).
Four hundred and six 5-year-olds (249 boys) with an
average of 19.4 primary and 0.7 permanent teeth were included
in the analysis. Caries prevalence was 26.2 % and caries
experience was 0.9 ± 2.0 dmft (Table 2). The SiC index
amounted to 2.8 dmft. ECC was distributed to 22 % on
ECC type I, 4 % on type II and 0.2 % on type III. Caries
polarisation is displayed by the Lorenz curve in Fig. 1 and
confirmed by the high Gini coefficient (G = 0.84). The care
index was 29.7 %, indicating that less than one-third of the
dental decay was treated. The prevalence of odontogenic
infections was 4.4 % and exclusively concentrated on pulpal
involvement (p) with a mean pufa of 0.1 ± 0.5 (Table 2).
Boys had a higher pufa (0.1 ± 0.7) than girls did (0.0 ± 0.2,
p = 0.035) and also had a higher untreated caries-pufa-ratio
(boys = 20.4 %, girls = 6.1 %, p = 0.030). First primary
molars were affected most frequently by odontogenic
infections (Fig. 2). Nearly all dental decay (93.6 %) and
odontogenic infections (89.2 %) were concentrated in 20 %
of the children, showing a significant correlation between
high dmft and pufa scores (ρ = 0.399, p < 0.001).
Six hundred eight 8-year-olds (298 boys) with 11.3
permanent and 11.7 primary teeth were examined. Caries
prevalence was 48.8 % in the primary (Table 2) and
3.9 % in the permanent teeth. The caries experience of
the primary teeth was 0.9 ± 2.0 dmft and of the
permanent teeth 0.1 ± 0.4 DMFT. The SiC index amounted to
5.6 ± 1.9 dmft and 0.2 ± 0.7 DMFT, respectively. Caries
2.1 ± 2.8 2.3 ± 2.9 1.8 ± 2.6 0.032*
0.9 ± 1.7 1.1 ± 1.8 0.8 ± 1.6 0.074
0.3 ± 1.0 0.4 ± 1.1 0.3 ± 1.0 0.189
0.8 ± 1.6 0.9 ± 1.7 0.8 ± 1.5 0.348
5.6 ± 1.9 6.1 ± 1.9 5.0 ± 2.0 0.056
39.3 [36.6–42] 37.9 [34.3–41.6] 41.1 [37.1–45.2] 0.302
16.6 [13.9–19.8] 21.2 [16.9–26.1] 11.9 [8.8–16.0] 0.002+
0.3 ± 0.9 0.4 ± 1.0 0.2 ± 0.8 0.008*
0.3 ± 0.9 0.4 ± 1.0 0.2 ± 0.8 0.016*
0.0 ± 0.1 0.0 ± 0.2 0.0 ± 0.0 0.021*
0.0 ± 0.0 0.0 ± 0.0 0.0 ± 0.0
0.0 ± 0.1 0.0 ± 0.0 0.0 ± 0.1 0.158
34.2 [30.4–34.2] 39.3 [34.0–44.8] 27.6 [22.4–33.4] 0.003*
polarisation shown by the Lorenz curve revealed that
66 % of the total caries experience was concentrated on
20 % of the children (Fig. 3). The Gini coefficient was
0.67, showing a lower concentration than in the
population of the 5-year-olds. The care index of the primary
teeth was 39.3 % with no significant difference between
boys and girls.
Pufa prevalence amounted to 16.6 % and the mean pufa
was 0.1 ± 0.5 (Table 2). Pulpal involvement (p) was scored
most frequently (94.8 %). The untreated caries-pufa-ratio
indicates that 34.2 % of the d-component had progressed
mainly to the pulp, indicating a significant correlation
between dmft and pufa scores (ρ = 0.499, p < 0.001). The
prevalence of caries experience and odontogenic infections
Fig. 1 Lorenz curve for the dmft distribution of 5-year-old German children
Fig. 2 Tooth related distribution of the single pufa components in German 5-year-olds
was significantly higher in boys. Almost 40 % of untreated
caries in boys revealed a pufa index >0. Figure 4 presents
the tooth related distribution of single pufa components
in 8-year-olds. Virtually all pufa scores (96.9 %) were
concentrated on primary molars with pulp involvement and
the ulceration of soft tissues. The first primary molars
were the most affected teeth. Twenty-four (3.9 %) of all
examined 8-year-olds revealed caries experience in
permanent teeth (DMFT > 0). Of these children, 41.7 %
also showed a pufa score in the primary dentition (Table 3).
Caries experience in the permanent dentition was
significantly determined by dmft index and the dt and mt
component as well as by pufa index and the p
component (t-test). For each unit increase in dmft and pufa
the risk of caries experience in the permanent dentition
increased by 33.9 % (OR 1.339, p = 0.00) and 34.9 %
(OR 1.349, p = 0.03) (Table 4).
In recent years, epidemiological caries research in
highincome countries like Germany focussed on the
development of more sensitive diagnostic methods to enable the
assessment of initial caries lesions like the International
Caries Detection and Assessment System (ICDAS II)
[28, 29]. This trend results from the decline of cavitated
caries lesions and the development of non-invasive and
preventive interventions requiring a distinction between
different stages of initial caries lesions. In contrast, the
remaining decay is concentrated in a small group of
children with high caries levels and a huge need for treatment
Fig. 3 Lorenz curve for the dmft distribution of 8-year-old German children
. Epidemiological studies have indicated that
socioeconomic conditions are important risk factors for caries
during childhood [30, 31]. Thus, high caries prevalence
and experience in low-income countries  and in
socio-economically disadvantaged groups [33, 34] have
been documented. That polarisation phenomenon is also
present in German children [35–37]. Our findings display
the inequality of caries distribution by the Lorenz curve
(Fig. 1), confirmed by the Gini coefficient. In 5-year-olds,
90 % of the whole caries burden was concentrated in 20 %
of the children, showing a strong polarisation of ECC.
Unfortunately, no data on the children’s ethnical or
socioeconomic background were collected in the examination,
which is a limitation of this survey.
Untreated caries may affect seriously the quality of
children’s life because of pain and discomfort, which could
lead to acute and chronic infections, oral mucosal
conditions and altered eating and sleeping habits [38, 39].
Furthermore, untreated caries in primary teeth can have a
lasting detrimental impact on the permanent dentition by
causing high caries risk  or developmental defects of
the permanent successor tooth . This was
demonstrated in the present study population by the fact that
41.7 % of 8-year-olds with dental decay in the permanent
dentition (DMFT > 0) also presented pufa scores in the
primary dentition (pufa > 0). With this fact the third null
hypothesis that there is no correlation of odontogenic
infections and caries in the permanent dentition of
8-yearolds was rejected (Table 3). Thus, children with pufa
scores should be characterized to be at high caries risk for
early caries onset in permanent teeth. Presenting only
dmft data to decision makers leaves them unaware of the
severity and associated consequences of untreated caries
on general and dental health [10, 42]. Therefore, for the
first time, our study gathered data on odontogenic
infections as consequences of untreated dental caries in 5- and
8-year-old German children by using the pufa index.
About one-third to one-half of Westphalian 5- to
8-yearolds suffered from caries in primary teeth, which is in the
same range (47.3 %) estimated for 6- to 7-year-olds in the
last representative epidemiological German study in 2009
. About one third of all decay was restored (5y: 29.7 %;
8y: 39.3 %), leaving the teeth to development of pulpal
involvement and odontogenic infections. This reflects the
fact, that many German dentists perceive dental treatment
of children as stressful . Commonly, dental school
graduates are insufficiently qualified because of the limited
university education in paediatric dentistry. Furthermore,
for most dentists, it is not attractive to attend a
postgraduate paediatric curriculum, due to inadequate
reimbursement for restorative treatment in small and pre-school
children with limited or lacking capability to cooperate
. But the risk of young children experiencing pain
and sepsis increases with higher caries experience .
Therefore, children at high caries risk would benefit most
from early dental care. On average, every twentieth
5-yearold child (4.4 %) and every sixth 8-year-old child (16.6 %)
had odontogenic infections. Thus, the first the null
hypothesis that there is no difference in the prevalence and
experience of odontogenic infections between 5- and 8-year-old
German children was rejected. In 5-year-olds, nearly all
odontogenic infections (89 %) were concentrated in 20 %
of the children displaying the highest dmft scores. This is
emphasised by the correlation of untreated dental caries
Fig. 4 Tooth related distribution of the single pufa components in German 8-year-olds
and odontogenic infections (ρ = 0.399, p < 0.001). Hence,
the second null hypothesis that untreated dental caries does
not correlate with odontogenic infections was rejected.
Taking into account the different socio-economic
background of the population examined, comparisons with
other countries may be limited. The pufa prevalence of our
population was considerably low (5y: 4.4 %, 8y: 16.6 %)
compared to Filipino 6-year-olds (85 %) , Brazilian
6to 7-year-olds (23.7 %) , South African 4- to 5-year-olds
(33 %) and 6- to 8-year-olds (41 %) , Polish
5-year(43 %) and 7-year-olds (72 %) , and Indian 5- to
6-yearolds (38.6 %) . Solely, the pufa prevalence in 8-year-old
German boys (21.2 %) was in the same range as reported
for Brazilian children  since 40 % of the caries lesions
had progressed to the pulp. Knowing the impact of severe
consequences of untreated dental caries on children’s
general health, these findings should lead to the
development of programs for German children at high caries risk.
Consistent with the studies mentioned, pulp involvement
(p) was the diagnosis most frequently recorded, followed
by ulceration (u) especially in 8-year-olds. This is in
contrast to the findings of Figueiredo et al.  and Baginska
et al. , revealing different patterns of odontogenic
infections in different countries. The fact that primary molars
were the teeth most affected by pulp involvement is
consistent with their high caries susceptibility [45–47]. Possible
causes for children showing more odontogenic infections
in first primary molars are their earlier eruption compared
to the seconds which leads to a longer oral cariogenic
exposure and the potential of lesions development between
eruption and examination time. Furthermore the faster
lesion progression from enamel surface to the dental pulp
Table 3 Dental caries and odontogenic infections in the primary dentition of 8-year-olds with and without caries experience in the
Caries prevalence (%) [95 % CI]
pufa prevalence (%) [95 % CI]
p-value statistically significant (*t-test, +Fisher’s exact test)
due to the lower enamel-dentin-thickness is related to
larger pulp chambers compared to second primary and
permanent molars [48, 49]. Additionally, the early age of
the child at eruption of first primary molars as well as their
posterior position at the dental arches may contribute to
more difficult and less efficient tooth brushing by parents
or care givers. However, there is no consistent evidence
that the first primary molars are more often carious
affected [46, 50] than the second primary molars [51-54].
Frigueiro et al.  and Murthy et al.  suggest that
the codes ‘f ’ and ‘a’ of the pufa index could be grouped
together since they refer to the same inflammatory
process of the jaw bone and are only different stages of
inflammation. Furthermore, the necessity to score these
codes separately was questioned, as the treatment
requested will be the same: endodontic treatment or
extraction [56, 57]. In this context, it should be considered that
the pufa index was not designed to serve as a treatment
need index, but rather as an index to quantify the severity
of untreated dental caries and to assess the presence of
odontogenic infections .
The use of only the dmft/DMFT index may be
misleading the interpretation of caries epidemiological data. That
was shown by the national oral health survey of the
Philippines  reporting 2.9 DMFT in 12-year-olds,
which fulfils the WHO/ FDI goal of 3 DMFT for this age
Table 4 Dental caries and odontogenic infections in the
primary dentition of 8-year-olds as risk factors for dental caries
in permanent teeth
p-value statistically significant (*binary logistic regression analysis)
group in 2000 . However, in reality, 41 % of the decay
component had progressed to odontogenic infections
assessed by the PUFA index, indicating the huge severity
of untreated tooth decay. The dmft/DMFT index fails to
provide information on the clinical consequences of
untreated dental caries, which may be more serious than
the caries lesions themselves. The more meticulous caries
classification system, ICDAS II enables the recording of
different caries progression stages from sound to extensive
decay compared to the dmft/DMFT . However,
scoring of odontogenic infections (pufa/PUFA index) is only
optionally recommended. Until now, German public oral
health services prefer using dmft/DMFT index,
considering ICDAS II too complicated and time consuming. The
new caries assessment spectrum and treatment
(CAST)index was developed combining elements of the ICDAS II
and the pufa/PUFA index with the m- and f-components
of the dmft/DMFT index . It covers the total spectrum
of carious lesion progression, including the advanced stages
of carious lesion progression in the pulpal and tooth
surrounding tissue. De Souza et al. compared the assessment
of dental caries using the CAST instrument and the DMFT
index showing no difference between the recorded caries
prevalence, caries experience and time spent for
examination . Still there is a need to validate the CAST index
more closely before trying to replace any other index.
Dental caries is a multifactorial chronic disease with the
interplay of individual, cultural, social and socio-economic
risk factors. The lack of data regarding these factors is a
limitation of the present cross-sectional study.
Nevertheless, using the pufa index provides a more comprehensive
view on caries pattern in primary teeth of German
children. However, there is a lack of other studies performed
in high-income countries to compare the findings.
This is the first German survey showing prevalence and
experience of odontogenic infections as consequences of
severe untreated dental caries in primary teeth among
German 5- and 8-year-olds by using the pufa index.
Prevalence and experience of odontogenic infections and
the untreated caries-pufa ratio were increasing from the
younger to the elder children. Pufa scores in primary
teeth predict a higher caries risk in permanent teeth.
The pufa index highlights relevant information by
assessing the severity of untreated dental caries for dentists
and decision makers to develop effective oral health care
programs for children at high caries risk.
AAPD: American Academy of Pediatric Dentistry; CAST: Caries assessment
spectrum and treatment; CPI: Community Periodontal Index; DMFT: Decayed,
missing, filled tooth; ECC: Early childhood caries; EN: Ennepe-Ruhr; FDI: World
dental federation; ICDAS II: International Caries Detection and Assessment
System; NRW: North Rhine-Westfalia; PUFA: Pulpal involvement, ulceration,
fistula, abscess; SiC: Significant caries; WHO: World Health Organisation.
RHW and IMSCH conceptualised the paper and reviewed the paper for
content, including the final version of the manuscript. RHW, IMSCH and IG
developed the study design. IG organised and conducted the clinical
examination. KG collected the data, performed the statistical analysis,
conducted the literature review and authored the major portion of the
manuscript. IMSCH and TL contributed towards statistical analysis and data
handling. All authors have read and approved the manuscript.
We acknowledge the support of the headmaster and teachers of all selected
pre- and primary schools during the clinical examination of the children.
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