Eur Arch Paediatr Dent
DOI 10.1007/s40368-013-0064-1
ORIGINAL SCIENTIFIC ARTICLE
Prevalence of clinical consequences of untreated dental caries
and its relation to dental fear among 12–15-year-old
schoolchildren in Bangalore city, India
A. K. Murthy • M. Pramila • S. Ranganath
Received: 18 March 2013 / Accepted: 18 June 2013
Ó European Academy of Paediatric Dentistry 2013
Abstract
Purpose To investigate the prevalence of clinical conse-
quences of untreated dental caries and its relation to dental
fear among public schoolchildren in India.
Method A cross-sectional study of 1,452 schoolchildren
aged 12–15-years in Bangalore city using a three-stage
stratified random sample was conducted. Caries was scored
by WHO (World Health Organisation) criteria (1997) and
clinical consequences of untreated dental caries using the
PUFA index. Dental fear was assessed by a single item
dental fear questionnaire.
Results The overall prevalence of caries was 57.9 % and
of untreated dental caries was 19.4 %. Children with high
dental fear had 2.05 times the risk of untreated caries as
compared to children with low fear.
Conclusions This study showed that the prevalence of
clinical consequences of untreated dental caries was low,
and dental fear was shown to be a significant determinant
of clinical consequences of untreated dental caries.
Keywords Consequences of untreated caries  PUFA
index  Schoolchildren  Dental fear
Introduction
Dental caries continues to be a serious public health
problem globally (Figueiredo et al. 2011). This results in an
A. K. Murthy (&)  M. Pramila  S. Ranganath
Department of Public Health Dentistry,
M. R. Ambedkar Dental College, 1/36,
Cline Road, Cooke Town, Bangalore 560006, India
e-mail: archanakm20@gmail.com
inequality of oral health, disadvantaging the poorest pop-
ulation the most. However, in the past two decades, many
developing countries have recorded a decrease in den-
tal caries in children. On the contrary, a large proportion
of caries remains untreated leading to innumerable
consequences.
Untreated dental caries lesions have been shown to
significantly impact on the children’s quality of life by
causing discomfort, pain, dental sepsis (Figueiredo et al.
2011; Finucane 2012), chewing difficulty and also affect
the child’s learning (Leal et al. 2012), sleep and behav-
iour (Gradella et al. 2011). Severely decayed teeth are
known to also adversely affect children’s nutrition,
growth, body weight and their general health (Benzian
et al. 2011).
Despite the fact that the consequences of untreated
dental caries are more detrimental to the child’s general
health and well-being than the carious lesions themselves,
very few studies have recorded these consequences as a
part of caries assessment indices (Monse et al. 2010;
Gradella et al. 2011).
It is known that the currently used caries epidemiolog-
ical indices do not measure untreated dental caries (WHO
1997). Monse et al. (2010) used the PUFA/pufa index to
record untreated dental caries and to complement the
commonly used caries indices.
Although, a large number of surveys have been con-
ducted on Indian children, reporting the prevalence of
dental caries and its associated factors (Dash et al. 2002;
Sudha et al. 2005), data of prevalence of untreated dental
caries are non-existent. Therefore, many researchers have
investigated the prevalence of untreated dental caries and
few have assessed the impact of untreated dental caries on
body mass index (Benzian et al. 2011) and quality of life of
the children (Gradella et al. 2011; Leal et al. 2012).
123

Further, dental fear/anxiety has been recognised as a
significant health issue in many countries. It has therefore
been noticed that people with high levels of fear may avoid
visiting the dentist or when attending dental treatment
display behavioural problems (Bedi et al. 1992; Kruger
et al. 1998; Schuller et al. 2003; Pohjola et al. 2008). Thus
it is often cited as a contributing factor to the development
of poor oral health in children as well as adults (Esa et al.
2010). Studies were carried out on dental fear in relation to
individual perception of oral health status, clinical exami-
nation (Bedi et al. 1992) and radiological examination, and
they showed that dentally anxious subjects were more
likely than non-anxious subjects for need of dental care
(Ng and Leung 2008).
In this context, the present study was conducted to
assess the prevalence and severity of untreated dental
caries and also to explore the role of dental fear as a
determinant of unwanted consequences of untreated dental
caries among 12–15-year-old public schoolchildren. It was
hypothesised that the children with high dental fear were
likely to be affected by untreated dental caries than chil-
dren with low fear.
Materials and methods
This cross-sectional study was carried out among 12–
15-year-old schoolchildren enrolled in public secondary
schools of Bangalore city. According to the list pro-
vided by the Deputy Director of Public Instructions,
Bangalore, the Bangalore city is divided into three
zones. Using a three-stage stratified random sampling
technique, one zone (north zone) was selected that
comprised four blocks. In total, 12 public secondary
schools were selected for the survey, 3 in each block.
In each school, about 125 children aged 12–15 years
were randomly sampled from the list of enrolled
schoolchildren.
A probabilistic sample was calculated with a stan-
dard error of ± 4, 95 % confidence level and a 56 %
prevalence of untreated dental caries among 12-year-old
schoolchildren (Monse et al. 2010). A correction factor
of 2 was applied to increase the precision, as a multi-
stage sampling method was adopted rather than random
sampling. The minimal sample size needed to satisfy
the requirements was estimated at 1,182 children.
However, an additional 20 % was included in the study
(n = 236) in order to compensate for potential refusals.
Ethical approval was obtained from the Institutional
Review Board of M. R. Ambedkar Dental College,
Bangalore. Information about the oral examination was
given to the children and their parents and their consent
was taken.
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Eur Arch Paediatr Dent
Dental fear assessment
The socio-demographic data which included the children’s
age, gender, and year of studying were collected. To assess
dental fear, participants were asked the question ‘Are you
afraid of going to the dentist?’ with four response catego-
ries being ‘1—not at all’, ‘2—a little’, ‘3—yes, moder-
ately’, and ‘4—yes, very’ (Armfield et al. 2007). The
questionnaire was translated into ‘Kannada’, the local
language and then retranslated into English. Any ambigu-
ities were clarified by changing the problematic words
accordingly. The questionnaire was administered in the
classrooms by two investigators. For the analysis of data in
the present study, participants who rated themselves as ‘not
at all’ and ‘a little’ were classified as ‘low fear’ while those
who responded as ‘yes, moderately’ and ‘yes, very’ were
classified as ‘high fear’.
Clinical examination
Following the completion of the questionnaire, the same
investigators examined for dental caries and untreated
dental caries, while the children were seated on a chair with
their heads resting on the back rest. The data collection
included DMFT/dmft scored according to the WHO crite-
ria (1997). In addition to this, to assess the presence of
clinical consequences resulting from untreated dental car-
ies, the PUFA/pufa index was used following standard
procedures (Monse et al. 2010). Intra-examiner and inter-
examiner kappa values for DMFT scores were 0.95 and
0.85, and for PUFA scores, 0.85 and 0.80, respectively.
Statistical analysis was performed using Epi Info, Ver-
sion 3.2 statistical software (Centers for Disease Control
and Prevention, Atlanta, GA, USA). Descriptive statistical
analyses included prevalence and means of caries status and
untreated caries status. For further analysis, the variable
caries status was dichotomised into caries-free children
(DMFT ? dmft = 0) versus children with caries
(DMFT ? dmft [ 0). Similarly, children with untreated
caries were dichotomised into those with untreated caries
versus those without untreated caries. The ‘Untreated Caries,
þ pufa
PUFA Ratio’ was calculated as PUFA Dþd  100. Chi-square
and Mann–Whitney test were used for comparison between
groups. A logistic regression model was used to analyse the
relationship between dental fear and status of caries and
untreated caries.
Results
Of the 1,452, 12–15-year-olds examined, 54.6 and 45.4 %
were boys and girls, respectively, with a mean age of
Eur Arch Paediatr Dent

13.56 ± 1.04 years. The prevalence, median with inter- compared to the low-fear group (p \ 0.001) thus showing
quartile range (IQR) and range of caries and untreated an association between dental fear and untreated dental
dental caries are presented in Table 1. caries.
The overall caries prevalence (dmft ? DMFT [ 0) was When dental fear as an independent variable, and caries
57.9 % with a median (IQR) of 1.0 (3). In both permanent and untreated dental caries prevalence as dependent vari-
and primary dentitions, the decayed (d/D) component ables were introduced into the logistic regression model,
comprised a major portion of total caries experience. children having high dental fear were more likely to have
Likewise, the overall prevalence of untreated dental caries untreated dental caries (PUFA) with an odds ratio of 2.05
(pufa ? PUFA [ 0) was 19.4 % with a median of 0.5 (0), (95 % CI 1.55–2.7, p \ 0.001) as compared to children
while PUFA/pufa = 0 was noticed in the remaining with low dental fear.
80.6 %. Pulpal involvement (code p/P) was the condition
most frequently scored. The ‘Untreated Caries, PUFA
Ratio’ was 21 % indicating that 21 % of the D ? d com- Discussion
ponent had progressed mainly to pulpal involvement.
Though the boys had a significantly higher prevalence of A cross-sectional study was conducted to assess the prev-
caries (62 %) as compared to the girls (53 %), there was no alence of consequences of untreated dental caries and its
significant difference in caries prevalence and median relation to dental fear among schoolchildren aged
scores in relation to age groups (Tables 2 and 3). Similarly, 12–15 years in Bangalore city, India. This is one of the first
the prevalence and median scores of untreated dental caries studies to be conducted in India and in this age group in
were not related to these variables. Figure 1 depicts the this context of untreated dental caries.
frequency distribution of the number of untreated dental The prevalence of untreated dental caries was consid-
caries lesions according to low and high dental fear erably low (19.4 %) despite the high prevalence of carious
categories. lesions (57.9 %), similar to the observations made by
The results of the present study showed that the preva- Figueiredo et al. (2011). On average, every fifth child
lence of caries and also the median caries score were not presented at least some features of untreated dental caries.
associated with dental fear (Tables 2 and 3). On the con- These results reflect that dental caries is still highly pre-
trary, the untreated dental caries prevalence and its median valent in Indian children and a major portion remains
score were significantly greater in the high-fear group as untreated which would warrant extraction or endodontic
treatment. This scenario highlights the fact that the present
oral health promotion and prevention programmes have to
Table 1 Percent prevalence, mean and standard deviation (SD) and
range of dmft/DMFT and pufa/PUFA scores in 12–15-year-old be stepped up in order to deal with this serious problem
schoolchildren (Leal et al. 2012).
Exact comparisons of the results of the present study
Index Prevalence N (%) Mean ± SD Range
with that of others cannot be made as the number of studies
DT 768 (52.9) 1.38 ± 1.8 0–11 that have used PUFA/pufa index is low and the study
MT 31 (2.1) 0.003 ± 0.2 0–3 populations differ in terms of age and social class. How-
FT 14 (0.1) 0.02 ± 0.2 0–6 ever, the prevalence of untreated dental caries in the
DMFT 780 (53.7) 1.42 ± 1.8 0–11 present study was much lower than in the studies by Monse
dt 87 (6) 0.1 ± 0.5 0–5 et al. (2010) (56 %) and Benzian et al. (2011) (55.7 %) and
mt 47 (3.2) 0.05 ± 0.3 0–4 also in the studies on primary dentition by Figueiredo et al.
ft 0 0 0 (2011) (23.7 %) and Leal et al. (2012) (26.2 %). This
dmft 123 (8.5) 0.15 ± 0.6 0–7 inconsistency may be attributed to the higher caries prev-
P 191 (13.2) 0.19 ± 0.6 0–5 alence in the above-mentioned studies.
U 1 (0.1) 0.01 ± 0.03 0–1 The intra- and inter-examiner consistencies using the
F 7 (0.5) 0.01 ± 0.1 0–1 PUFA index were found to be good in the present study.
A 17 (1.2) 0.01 ± 0.1 0–1 This is in line with the studies by Monse et al. (2010) and
PUFA 205 (14.1) 0.21 ± 0.6 0–6 Figueiredo et al. (2011). Further, more studies are required
p 85 (5.9) 0.1 ± 0.5 0–5 to determine the external validity of the PUFA index.
u 0 0 0 The pulpal involvement component (code P/p) was the
f 1 (0.1) 0.01 ± 0.03 0–1 condition most frequently recorded as also reported by
a 1 (0.1) 0.01 ± 0.03 0–1 (Monse et al. 2010; Figueiredo et al. 2011). Taking into
pufa 86 (5.9) 0.1 ± 0.5 0–5
account the results of the present study, it should be reit-
erated that the codes of A/a and F/f could be grouped

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 Eur Arch Paediatr Dent

Table 2 Prevalence (95 % CI) of dmft ? DMFT [ 0 and pufa ? PUFA [ 0 scores in 12–15-year-old schoolchildren in relation to gender, age
and dental fear
Groups (N) DMFT ? dmft [ 0 PUFA ? pufa [ 0
N % (95% CI) Chi square p value N % (95% CI) Chi square p value

Boys (792) 491 62 (58.5–65.4) \0.001 160 20.2 (17.5–23.2) 0.41

Girls (660) 350 53 (49.1–56.9) 122 18.5 (15.6–21.7)
12–13-year-olds (694) 392 56.5 (52.8–60.1) 0.29 136 19.6 (16.8–22.8) 0.87
14–15-year-olds (758) 449 59.2 (55.7–62.7) 146 19.3 (16.6–22.3)
Low fear (1,080) 611 56.6 (53.6–59.6) 0.23 176 16.3 (14.2–18.7) \0.001
High fear (372) 230 61.8 (56.7–66.8) 106 28.5 (24–33.4)
Total (1,452) 841 57.9 (55.3–60.5) 282 19.4 (17.4–21.6)

Table 3 Median (IQR) of

Groups (N) DMFT ? Mann– PUFA ? Mann–
DMFT ? dmft and
dmft Median Whitney pufa Median Whitney
PUFA ? pufa scores in 12–15-
(IQR) p value (IQR) p value
year-old schoolchildren in
relation to gender, age and Boys (792) 1 (3.5) \0.001 0.5 (0) 0.42
dental fear
Girls (660) 1.5 (2) 0.5 (0)
12–13-year-olds (694) 1 (1.5) 0.11 0.5 (0) 0.83
14–15-year-olds (758) 1.5 (3.5) 0.5 (0)
Low fear (1,080) 1.5 (2) 0.18 0.5 (0) \0.001
High fear (372) 1.0 (3) 0.5 (0.5)
Total (1,452) 1.0 (3) 0.5 (0)

progression of the carious process, the treatment aspect will

Fig. 1 Distribution of number of untreated dental caries according to
low- and high-fear groups
together as suggested by Figueiredo et al. (2011) and
Frencken et al. (2011). The present study also showed a
negligible prevalence of ulceration thus doubting the
inclusion of ‘code U/u’ into the PUFA index. When con-
sidering these points, in the studies using the PUFA index,
if only the P/p code contributed significantly, then this code
may be comparable to code D4 (caries involving pulp) in
the Dental Caries Severity Index (Peter 2006) and also
code-6 (pulpal involvement) in the dentition status of Oral
Health Surveys, Basic Methods (World Health Organisa-
tion 1997). In spite of the detailed coding of the
be still limited to two modalities, namely, endodontic
treatment and extraction.
Dental fear has been evidenced to be a predictor of
dental caries, and may be a risk factor for untreated dental
caries incidence (Kinirons and Stewart 1998). Numerous
studies have shown a positive association between DMFT
and dental fear (Bedi et al. 1992; Skaret et al. 1999).
However, in the present study no such correlation was
found as also concurred by Taani and El-Qaderi (2005).
Further, such comparisons should be made cautiously due
to differences in study populations and methodology. The
introduction of PUFA/pufa index in this study examining
possible association between dental decay and fear of
dental treatment, though done for the first time ever,
appeared to be relevant and a positive association between
dental fear and the prevalence of untreated dental caries
was detected. This effect can be explained by the vicious
cycle, wherein the disposition to experience fear in dental
situations leads to avoidant behaviour and, in turn, delays
in receiving adequate preventive care or treatment
(Armfield et al. 2007). Waiting longer for treatment would
result in more extensive and severe decay development,
making it more likely that a decayed tooth would require
extraction or endodontic treatment rather than restoration
(Armfield et al. 2009).

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Eur Arch Paediatr Dent
The cyclical model presented by (Bedi et al. 1992; Ng and
Leung 2008; Armfield et al. 2009) in which increased carious
teeth, missing teeth were accompanied by enhanced dental
fear has received no validation in the present study, whereas
the clinical consequences of untreated dental caries, in par-
ticular, seem to be strongly associated with dental fear.
Hence, these findings suggest that dental fear influences
timely receipt of preventive and treatment services, cul-
minating in the deterioration of oral health and can have
serious consequences on general well-being (Skaret et al.
1999). Also, it is necessary to identify and then effectively
tackle dental fear as an important step in reducing
untreated dental caries.
Conclusion
This is the first ever representative survey showing the
prevalence of untreated dental caries in India and also
assessing the relation between dental fear and untreated
dental caries. The data of this cross-sectional study showed
a moderate prevalence of untreated dental caries in spite of
high prevalence of caries. Children who reported high
dental fear were more likely to have untreated dental caries
as compared to children with low fear. Also the inclusion
of tools that assess severe consequences of the carious
process, such as PUFA/pufa index, would benefit the
understanding of the epidemiology of the disease.
References
Armfield JM, Stewart JF, Spencer AJ. The vicious cycle of dental
fear: exploring the interplay between oral health, service
utilisation and dental fear. BMC Oral Health. 2007;7:1.
Armfield JM, Slade GD, Spencer AJ. Dental fear and adult oral health
in Australia. Community Dent Oral Epidemiol. 2009;37:220–30.
Bedi R, Sutcliffe P, Donnan PT, Barrett N, McConnachie J. Dental
caries experience and prevalence of children afraid of dental
treatment. Community Dent Oral Epidemiol. 1992;20:368–71.
Benzian H, Monse B, Heinrich-Weltzien R, Hobdell M. Untreated
severe dental decay: a neglected determinant of low Body Mass
Index in 12-year-old Filipino children. BMC Public Health.
2011;11:558.
Dash JK, Sahoo PK, Bhuyan SK, Sahoo SK. Prevalence of dental
caries and treatment needs among children of Cuttack (Orissa).
J Indian Soc Pedod Prev Dent. 2002;20(4):139–43.
Esa R, Savithri V, Humphris G, Freeman R. The relationship between
dental anxiety and dental decay experience in antenatal mothers.
Eur J Oral Sci. 2010;118:59–65.
Figueiredo MJ, de Amorin RG, Leal SC, Mulder J, Frencken JE.
Prevalence and severity of clinical consequences of untreated
dentine carious lesions in children from a deprived area of
Brazil. Caries Res. 2011;45:435–42.
Finucane D. Rationale for restoration of carious primary teeth: a
review. Eur Arch Paediatr Dent. 2012;13:281–292
Frencken JE, de Amorim RG, Faber J, Leal SC. The caries assessment
spectrum and treatment (CAST) index: rational and develop-
ment. Int Dent J. 2011;61:117–23.
Gradella CMF, Bernabe E, Bonecker M, Oliveira LB. Caries
prevalence and severity, and quality of life in Brazilian 2- to
4- year-old children. Community Dent Oral Epidemiol.
2011;39:498–504.
Kinirons MJ, Stewart C. Factors affecting levels of untreated caries in
a sample of 14–15-year-old adolescents in Northern Ireland.
Community Dent Oral Epidemiol. 1998;26:7–11.
Kruger E, Thomson WM, Poulton R, et al. Dental caries and changes
in dental anxiety in late adolescence. Community Dent Oral
Epidemiol. 1998;26:355–9.
Leal SC, Bronkhorst EM, Fan M, Frencken JE. Untreated cavitated
dentine lesions: impact on children’s quality of life. Caries Res.
2012;46:102–6.
Monse B, Heinrich-Weltzien R, Benzian H, Holmgren C, van
Palenstein Helderman W. PUFA—An index of clinical conse-
quences of untreated dental caries. Community Dent Oral
Epidemiol. 2010;38:77–82.
Ng SKS, Leung WK. A community study on the relationship of dental
anxiety with oral health status and oral health-related quality of
life. Community Dent Oral Epidemiol. 2008;36:347–56.
Peter S. Essentials of Preventive and Community Dentistry. 3rd ed.
New Delhi: Arya Publishing House; 2006. p. 185–7.
Pohjola V, Lahti S, Vehkalahti MM, Tolvanen M, Hausen H. Age-
specific associations between dental fear and dental condition
among adults in Finland. Acta Odontol Scand. 2008;66:278–85.
Schuller AA, Willumsen T, Holst D. Are there differences in oral
health and oral health behaviour between individuals with high
and low dental fear? Community Dent Oral Epidemiol.
2003;31:116–21.
Skaret E, Raadal M, Berg E, Kvale G. Dental anxiety and dental
avoidance among 12–18 year olds in Norway. Eur J Oral Sci.
1999;107:422–8.
Sudha P, Bhasin S, Anegundi RT. Prevalence of dental caries among
5–13-year-old children of Mangalore city. J Indian Soc Pedod
Prev Dent. 2005;23:74–9.
Taani DQ, El-Qaderi SS, Abu Alhaija ES. Dental anxiety in chil-
dren and its relationship to dental caries and gingival condition.
Int J Dent Hyg. 2005;3:83–7.
World Health Organisation. Oral Health Surveys, Basic Methods. 4th
ed. Geneva: WHO; 1997.
123