Note: this lecture includes what is mentioned in the lecture summarized by your group and the handouts

METHODS OF MEASURING DENTAL CARIES

Dental caries = a microbial process (infection)

characterized by demineralization of inorganic matter followed by destruction of the organic matter

If we want to measure dental caries among certain population then we can do it in more than one way:

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1. We can measure the number of members having dental caries and divide it by the total number of the population studied 2. We can measure the number of decayed teeth and divide it by the total number of teeth examined

History of dental caries measurement:

- Measurements of the intensity of dental caries in the early 20th century by:

The proportion of first molars lost through caries The percentage of permanent teeth affected

Both of these methods were useful when there was little information of any kind about the disease, but they were not sensitive - Bodeckers' index, described in 1931, was sensitive but complicated - Dean and his colleagues used a systematic approach to counting the numbers of teeth in the mouth visibly

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affected by caries in their studies of the caries - fluoride relationship - The first description of what is now known as the DMF

index is usually attributed to Klein, Palmer, and Knutson

in their studies of dental caries in the 1930s Since then, the DMF index has received practically universal acceptance and is probably the best known of all dental indexes

DMF INDEX:

The DMF is an irreversible index DMF index is applied only to permanent teeth DMF index can be used for an individual or for a DMF index counts number of teeth in the mouth

population at larger

with history of dental caries

DMF index indicates oral hygiene of the patient

D is for decayed teeth, M is teeth missing due

to caries and F is for teeth that had been previously

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filled assuming that these filled teeth were carious prior to restoration

DMF index counts teeth missing as missing

due to caries although they might be missing for something else other than caries such as trauma,
periodontal disease, developmental anomaly and this overestimates the caries risk of the

individual

DMF index counts teeth filled as being filled

due to caries although they might be filled just for cosmetic reasons or for prevention and this again overestimates the caries risk of the individual

The DMF score for any one individual can range

from 0 to 32

The DMF score for one individual is expressed in

whole number integral number " "

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A mean DMF score for a group is

calculated by dividing the total of individual values by the number of subjects examined

DMF score mean of a group can have

fractional values

The DMF index applied to whole teeth is

designated as (DMFT)

The DMF index applied to surfaces of teeth is

designated as (DMFS) We have 32 teeth, each has 5 surfaces, so 32 teeth have 160 surfaces

DMFT counts one tooth as one surface BUT

DMFS counts one tooth as five surfaces, thus DMFS is more sensitive than DMFT

Modifications can be made to the DMF index

to include other situations than those included already in the index, such as: teeth that have been filled and have redecayed secondary caries, crowned teeth,

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bridge pontics, and any other particular attribute required for a study

To save time in a large survey, DMF can be

applied to half mouth or applied to one quadrants and the score is doubled or multiplied by four an approach that assumes the bilateral
nature of caries When we have a patient with DMF of 10, then we

cant tell what has composed this 10 how many teeth with caries?!, how many teeth missing due to caries?!, how many teeth filled due to caries?! We cant actually know!!

The DMF index for permanent teeth is always

signified by uppercase letters

The equivalent index for the primary dentition is

the def that is always signified by lowercase letters

In the def, d stood for decayed teeth, e stood

for indicated for extraction, and f stood for filled teeth

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It is def BUT NOT dmf, why?!

In the def index, teeth missing due to caries are

not recorded because of the frequent difficulty of distinguishing between extracted primary teeth due to caries and naturally exfoliated primary teeth
A.

Modifications of the def index are: dmf for use in children before ages of

exfoliation before 5-6 years old it is supposed

that if any tooth is lost before normal age of teeth exfoliation might be due to caries, and thats why dmf is used and the letter m indicates missing due to caries
B.

dmf applied only to the primary molar teeth

primary molar teeth usually last very long in the arch before exfoliation, so if they are lost sooner than normal, it is supposed that they are lost due to caries and thats why dmf is used and the letter m indicates missing due to caries
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C.

df index in which missing teeth are ignored

because we are NOT sure if this missing tooth

has normally shed or lost due to caries

Values for df and def should be numerically

the same since neither index counts missing teeth

Both def and df may therefore underestimate

the true extent of the carious attack although sometimes ignoring missing teeth is often seen as a net benefit

Grainger's hierarchy = an ordinal scale

designed to simplify the recording of the caries

status of a population
This scale which uses five zones of severity of the

carious attack
It has been shown to be valid, but has received little further use, probably because of low sensitivity
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Limitation of the DMF index No index is perfect and even the DMF index has its
limitations. The principal ones are these:
1.

DMF values are NOT related to the

number of teeth at risk

A DMF score for an individual is a simple count of

those teeth that in the examiner's judgment have been affected by caries and it has no denominator
A DMF score thus does not directly give an

indication of the intensity of the attack in any one individual

-

DMF score of 3.0

Without knowing the age of the patient

and the total number of teeth this patient has

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we may think that this DMF value is small and not important

If this patient is 7 years old only and has 9

permanent teeth in the mouth then this DMF value indicates that one third of these teeth have already been attacked by caries in a short space of time
-

DMF score of 8.0

If this patient is 30 years old and has a full

set of 32 teeth then this DMF value indicates that one quarter of the teeth have been affected over a longer period of time

DMF scores therefore have little meaning unless age and total number of teeth at risk is also stated 2. The DMF index can be invalid in older adults because teeth can become lost for reasons other than caries

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Although caries appears to be the greatest single global reason for tooth loss, many teeth are also extracted for other reasons This is especially the case in adults aged 60 or older, among whom the M component of a DMF

score is NOT a valid reflection of teeth lost because of caries 3. The DMF index can be misleading in children whose teeth have been extracted for orthodontic reasons
In some child populations there is heavy loss of

premolars in the course of orthodontic treatment

In young adults population there is heavy

extraction of 3rd molars especially if they are symptomatic The inclusion of these teeth in the M component of the DMF score would obviously
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be invalid reflection of teeth lost because of caries

4.

The DMF index can overestimate caries

experience in teeth with "preventive restorations" or where treatment services are intense
Some dentists place restorations in teeth that are not carious yet but they think they might get carious in the future In an epidemiological survey, such teeth must be included in the F component of DMF although they had not been filled due to caries and so DMF scores will be overestimating the condition

5.

DMF can NOT be used for root caries

Root caries begin below the cementoenamel junction following recession of the gingivae

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Root caries needs to be measured separately from coronal caries for two reasons:
a.

Root caries occurs at a different period of life

from most coronal caries b.Teeth with root lesions often already have coronal lesions The intensity of root caries is measured by dividing the number of lesions already present by the

number of root surfaces at risk root surfaces

exposed to the oral environment and might get carious in the future, rather than using the number of teeth present
6.

DMF can NOT account for sealed teeth

Sealants and composite restorations for cosmetic reasons are not included in the description of the index Sealants and other composite restorations for cosmetic purposes have to be dealt with
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separately and to be placed in a category by themselves Criteria for Diagnosing Coronal Caries

There are NO globally accepted criteria for

diagnosing dental caries

There is a tradition about defining the carious

lesion in the gray area when it is difficult to tell whether the disease is irreversibly established or not

It is known that by the time caries can be

clinically detected by either visual or radiographic methods, a lesion is histologically well established Diagnosis of a sound tooth is not difficult,

nor is diagnosis of an obvious lesion

The disease process in between requires

carefully defined criteria and an examiner who can adhere to them during many examinations

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Criteria for diagnosis of caries used in North

America, Britain, and the other English-speaking countries tend toward the dichotomous (yes

present/no absent") variety

Following these criteria means caries is either present or absent theres nothing in between

Criteria for diagnosis of caries used in Europe are

much stricter in which grades of carious lesions are

diagnosed
Following these criteria means caries is subclassified into many grades according to its extension and severity

The European criteria should give a more

accurate estimate of disease progression, BUT:

a.

Use of the European criteria requires a longer,

more meticulous survey examination and could lead to a greater degree of examiner inconsistency greater demands on examiner standardization

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because of the increased number of diagnostic decisions that have to be made

b.

Additional risk of inconsistency is also added if

the use of radiographs is being considered in a caries study Radiographs provide us with greater diagnostic sensitivity but at the same time they need another set of diagnostic decisions that require their own criteria

Root Caries

DMF index is not designed for use with root

caries

Most root caries lesions occur on exposed

root surfaces after gingival rescission although some lesions have been found on teeth without gingival rescission!! The most teeth affected by gingival rescission are:
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a. Labial surfaces of upper molars b. Lingual surfaces of lower anterior teeth

The criteria most frequently used to diagnose root

caries were first described by Banting and his colleagues

Criteria for diagnosing root surface caries:

1.

There is a discrete ,well-defined,

and discolored soft area

2.

The explorer enters easily and displays

some resistance to withdrawal

3.

The lesion is located either at the

cementoenamel junction or wholly on the root surface

4.

Restored root lesions are counted only if

it is obvious that the lesion originates at the cementoenamel junction or is confined to the root surface completely

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Root lesions are becoming increasingly

difficult to detect because:

a.

Root caries lesions are more commonly found

as small, discrete lesions on a single root surface rather than circumscribing a root
b.

Inability to sometimes detect the

cementoenamel junction either because of

obliteration by restorations or calculus adds to the difficulties of identifying root caries

Root Caries Index (RCI)

This index was intended to make the simple

prevalence measures of root caries lesions more specific by including the concept of teeth at risk in contrast to the DMF usage

A tooth is considered to be at risk of root

caries if enough gingival recession has occurred to expose part of the cemental surface to the oral environment

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The RCI is measured by scoring root lesions and

restorations and noting teeth with gingival recession, according to the following formula:

Root surfaces: (decayed + filled) 100 Root surfaces: (decayed + filled + sound)

The index can be measured for an individual or for

a population at large

RCI of 7% means = of all teeth with gingival

recession, 7% were decayed or filled on the root surfaces

In the RCI there is chance of underestimation

brought on by gingival overgrowth subsequent to the loss of periodontal attachment

Caries Treatment Needs

Assessment of caries treatment needs by

epidemiological survey seems simple enough. In fact,

it becomes more complicated because:

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1.

The criteria used to diagnose caries in a survey are not necessarily those used by practitioners when examining their patients

2.

Perceived needs, dental awareness, and ability or willingness to pay all influence treatment carried out

3.

A practitioner has to look at a patient's long-term needs, whereas a survey does not

4.

Treatment philosophy can change quite rapidly with expanding knowledge and technological developments

Because surveys are usually conducted under less

than ideal conditions relative to the dental office, it would be expected that surveys detect fewer

treatment needs than practitioners do

Which assessment is correct? Survey or

practitioner?!

Surveys can miss incipient lesions early enamel

lesions but practitioners can also over diagnose. In

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addition, treatment plans for the same patients have been shown to vary drastically from dentist to dentist

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