Original Article Caries Risk Assessment In Adult Population Using American Dental Association Model

Hira Akhtar¹                                                                           BDS

Farah Naz²                                                                             BDS, FCPS

Farzeen Shafiq Waseem³                                                 BDS, Mphil

Danish Shahnawaz³                                                           BDS, Mphil

INTRODUCTION

World Health Organization regards dental caries and periodontal disease as two most important global, oral health burdens. In most developed countries, dental caries affects 60-90% of schoolchildren and the vast majority of adults.¹ Dental caries is a multifactorial disease, its initiation, development and progression is influenced by numerous factors, such as the patient’s health, diet, presence of bacteria in the oral cavity, salivary parameters and fluoride exposure.^1-6 The distribution, severity andrisk for caries development vary significantly for different age groups, individuals, teeth and teeth surfaces. Thus, caries preventive measures should be based on sound knowledge and understanding of the predicted risk.²

Historically, caries was considered as a progressive disease which ultimately destroyed the tooth unless dentist performed surgical intervention.⁷ But with new evidencebased research leading to better understanding of caries process a paradigm shift from curative to preventive dentistry has taken precedence. Nowadays, management of caries is more directed towards identification of risk indicators, which are the existing signs that the disease process has occurred and modification of risk factors, which are the attributes or exposuresignificantly associated with the development of a disease.^{8, 9} This change of paradigm shift is in accordance with the National Institute of Healthconsensus statement¹⁰ which outlines methods for theidentification, modification and/or elimination of all associated risk indicators and factors for improved caries diagnostic, preventive and treatment strategies.

Caries risk assessment determines the probability of caries incidencei.e., the number of new cavities or incipient lesions over a given period of time.⁷ Over the past years, various caries risk assessment tools have been developed, modified and adapted toassist clinicians in determining a patient’s risk.¹¹ Numerousmodels have beendeveloped byAmerican Academy of Pediatric Dentistry¹¹, Caries management by risk assessment (CAMBRA)¹¹, Cariogram¹² and American Dental Association.¹¹

The American Dental Association (ADA)has developed two forms: one for patients 0-6 years old, and other for patients older than 6 years.¹³  ADA periodically updates these forms, on the basis of feedback regarding their usefulness by its members and advancements in science. These form measure patients at low, moderate or high risk of caries by using a scoring system.All positive responses in the low risk column carry a score of 0. Responses in the moderate risk column hold score of 1 each and responses in the high risk column carry score of 10 each. An overall score of 0 indicates patient has low risk for development of caries. A single high factor, or score of 10 or above places the patient at high risk and score in between 1 and 9 indicates the patient at moderate risk for caries development.¹⁴

Although extensive research has been conducted to assess caries risk in children; there is scarce evidence available for risk assessment on the global adult and elderly population.^7,9,15,16 Also no previous evidence is available regarding caries risk assessment involving Pakistani adult population. The presence of this research gap has led towards difficulty for the dental practitioners in the application of caries risk assessment models on the adult and elderly population.This article emphasizes on the importance of conducting of caries risk in adults as a prerequisite for appropriate caries preventive and treatment decisions.The objective of this study was to conduct caries risk assessment in the adult population.

METHODOLOGY

A cross sectional study was conducted in the diagnostic department of Operative dentistry at the dental section of Dow International Medical College. Sample size was calculatedusing 2 proportion formula¹⁷ with 99% confidence interval and 95% power of test. 19% proportion of low and very low risk patients¹⁶, 81% proportion of moderate and high risk patients¹⁶, the sample size calculated was 11 in each risk categories and the total sample size determined was 44.

For this study non- probability, purposive sampling was applied. Data was collected over a period of 01 month. Patients aged between 18 to 60 years, who were permanent residents of Pakistan, agreed to sign a consent form, completed the risk questionnaire and dental examination and previously did not have caries risk assessment done were included in the study. Whereas, patients who were not fitting within the age range, declined to sign the consent form or previously had risk assessment done and thus, received any preventive and therapeutic treatment were excluded from this study.

Total sample of 50 patients, fitting the inclusion criteria were selected. After obtaining a signed inform consent from each patient, a modified version of American Dental Association risk assessment form¹⁸(Annex I) was filled. Dental examination was conducted. The overall, caries risk of the each patient was calculated. Results were conveyed to the patient. Diet counseling and subsequent treatment plan was advised to the patient.

Statistical Package for Social Sciences (SPSS) Version 16 was used to enter and analyze data. Descriptive data analysis including frequencies, percentages and means were calculated in the study.

RESULTS

A total sample of 50 patients was recorded. The sample comprised more female (76%) than male patients (24%) [Figure1].The mean age was determined as 32.36 years. Caries risk assessment percentages were recorded as: 0% patient at low risk, 34% patients at moderate risk and 66% patients at high risk [Figure2].A vast majority of patients were recorded at high risk [Figure 2]. When risk percentages were compared on the basis of gender,

increased percentages (26%) of females were recorded at high risk whereas males had almost equal distribution among moderate and high risk categories [Figure 4]. The major contributing factors towards increased risk were: presence of three or more active carious lesions, extraction due to caries in the past 36 months and absence of a regular dental care system [Figure3].

DISCUSSION

Early detection of carious lesion along with incorporation of a preventive protocol regime is the central aim towards maintenance of a good oral health status. Caries risk assessment procedure can aid the dentist in achieving these goals. An ideal risk assessment model should be inexpensive, easy to use and time efficient with a high degree of accuracy in caries predictive value.⁸ In the present study, ADA risk assessment model was used to determine caries risk in the adult population. Thisstructured form was simple to adapt on our adult population, cost effective and the results were easily translated to the patient. Most importantly, this model was capable in correctly identifying the high risk patients in our population.

In the present study majority of the patients were recorded at high caries risk [Figure 2].When risk percentages were compared on the basis of gender, increased percentage (26%) of females were recorded at high risk whereas males had almost equal distribution among moderate and high risk categories  [Figure 4]. Giacaman ARsupports the results of our study, theyconducted caries risk assessment in Chilean adolescents and adults, 0.016%adults were recorded at low risk,21.6% at moderate risk and 59.4%adults at high caries risk.¹⁶ Caries risk assessment studies conducted in adults in China by Wei Xu¹⁹ and Turkey by Go¨kalp SG²⁰, have concluded that females had higher DMFT scores and higher prevalence of dental caries compared to males, these results are consistent with the findings in our study.

In this study the main contributing factors towards increased caries risk were the presence of three or more active caries lesion at the time of examination,teeth extracted due to caries in the past 36 months and absence of a regular dental care system [Figure 3]. Maher R conducted a national pathfinder study in all 4 provinces in Pakistan on 1146 individuals, which documented that 55% children(aged12-15years) and in 78% adults (aged 35-65 years) had active caries lesions and frequency of missing tooth in adult was recorded at 82%.²¹ Another cross sectional study conducted by Siddiqui TM established that 52.7% rural and 47.3% of urban adult population in Karachi suffers from active dental caries.²² These studies support the high prevalence of active carious lesion among adult population that was determined in our study. Haseeb M²³ determined the causes of tooth extraction at a tertiary care center in Pakistan, they reported that 63.1% of alldental extractions were due to advanced dental caries, followed by periodontitis (26.2%),restoration failure (4.6%), trauma (3.2%) and miscellaneous local pathologies (2.9%) supporting the result of the present study that caries is most common contributing factor that leads to dental extraction.

An important contributing factor determined in our study was that 0% of patients had a regular dental care system[Figure 3]. Oral diseases like caries and periodontitis are preventable but results of this study show that an increase percentage of our adult population is at high risk. This can be accredited to factors such as poor oral hygiene, change in dietary habits, low literacy rate, lack of dental awareness and a general disregard towards dental care. Majority of Pakistani population visits dentist only as a last resort; as a result of which 90% of oral diseases remain undiagnosed.²⁴ Waseem FS observed that almost 48% of Pakistani population had never visited a dentist and 51% of the population visited the dentist only when they had a complaint.²⁵ Asadi SGR reported that 8% adult Pakistani population never cleaned their teeth while only 36% cleaned their teeth every day.²⁶ To counteract these measures oral health programs should be arranged to educate and promote good oral hygiene habits and regular recall programs should be instilled in clinical practice and patients should be kept on follow ups.

Caries risk assessment of communities allows identification of high caries risk group and determines specific treatment therapies and preventive applications that need to be carried out.⁵ Cariogram is a computerized software that uses an algorithm to determine caries risk of an individual and then presents it graphically in the form of a pie chart.²⁷ It is an objective and quantitative method for predicting caries risk of a patient. In many of the researches conducted Cariogram is chosen as tool of choice, because the results can be saved, printed, easily documented and clearly explained to the patients. Reported barrier towards using this model is inclusion of chair side salivary testing with microbial cultures.²⁸ These procedures are costly, time consuming and can delay the process until the culture results are provided by the laboratory.²⁸

When determining caries risk in children the most commonly used risk assessment tool is CAMBRA. The form employs an evidence-based approach to prevent or treat the cause of dental caries at the earliest stages before irreversible damage to the tooth takes place¹¹. Application of CAMBRA allows early intervention and the establishment of a dental home that could reduce the risk of early childhood caries and improve child`s oral and overall health.²⁹ Although no particular risk assessment model has been proven to be superior compared to others, scientific evidence claims that a structured multifactorial or a computer based model provides the best clinical practice and patient care.³⁰

Limitations of this workinclude, being a cross sectional, single centre study with a small sample size but the information revealed in this research is alarming.It is our recommendation that further longitudinal studies be conducted on a larger scale in order to obtain a baseline data, as no statistical information regarding caries risk assessment is available on Pakistani population.

CONCLUSION

1. This study was performed using a modified version ofAmerican Dental Association caries risk assessment model in an effort to overcome the data insufficiency of caries risk in our population.
2. This model has successfully identified that our adultpopulation is at high caries risk.
3. Caries risk assessment can serve as an importantdiagnostic tool to identify the risk factors and therefore aid in reducing the high burden of caries in our adult population.

Paperpresented at 12thInternational and 32nd National PDA congress, held at Expo Centre Karachi, from January 23rd – 25th, 2015.

Author Contribution: HA conceived the idea and designed the study, recorded, analysed and interpreted the data and is responsible for the accuracy of the results and integrity of the research. Also wrote the manuscript and along with other authors was involved in critical review and final approval of the manuscript. FN supervised the project and along with Akhtar H was involved in the designing of the study, Critical review and final approval of the manuscript. FSW and DS along with the other authors were involved in the final approved version of the manuscript.

Disclosure: None disclosed

REFERENCES

1. Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bull world health org. 2005;83:661-669.
2. Basavaraj P, Khuller N, Khuller RI, Sharma N. Caries risk assessment and control. J Oral Health Comm Dent. 2011;5:58-63.
3. Celik EU, Gokay N, Ates M. Efficiency of caries risk assessment in young adults using Cariogram. Eur J Dent. 2012;6:270.
4. Sheiham A, James WPT. A new understanding of the relationship between sugars, dental caries and fluoride use: implications for limits on sugars consumption. Pub Health Nutri. 2014;17:2176-2184.
5. Peker I, Mangal T, Erten H, Alp G, Avci E, Akca G. Evaluation of caries risk in a young adult population using a computer-based risk assessment model (Cariogram). J Dent Sci 2012;7:99-104.
6. Guo L, Shi W. Salivary biomarkers for caries risk assessment. J Cali Dent Assoc 2013;41:107.
7. Fontana M, Zero DT. Assessing patients’ caries risk. J Am Dent Assoc. 2006;137:1231-1239.
8. Ritter A, Eidson R, Donovan T. Dental Caries: Etiology, Clinical Characteristics, Risk Assessment and Management. In: Heymann H, Ritter A, Swift E, editors. Sturdevant’s Art and Science of Operative Dentistry. 6th ed. Canada: Mosby; 2012. p.64-70.
9. Fontana M, Gonzalez-Cabezas C. Minimal intervention dentistry: part 2. Caries risk assessment in adults. British Dental journal. 2012;213:447-451.
10. Diagnosis and Management of Dental Caries Throughout Life NIH Consensus Statement 2001 March 26-28; 18:1-24
11. Hurlbutt M. CAMBRA: Best Practices in Dental Caries Management. Academy of Dental Therapeutics and Stomatology. 2011.
12. Alian AY, McNally ME, Fure S, Birkhed D. Assessment of caries risk in elderly patients using the Cariogram model. J Can Dent Assoc. 2006;72(5):459.
13. http://www.ada.org/~/media/ADA/Science%20 and%20Research/Files/topic_caries_over6.ashx.
14. http://www.nysdental.org/img/uploads/file/topics _caries_over6.doc.
15. Asma M, Ho S, Yong J, Nor N, Yusof Z, editors. Developing A Caries Risk Assessment Model For Adults Patients Attending University Malaya Dental Clinic. List of conferences, seminars, lectures and workshops 38.
16. Giacaman RA, Miranda Reyes P, Bravo León V. Caries risk assessment in chilean adolescents and adults and its association with caries experience. Brazilian oral res. 2013;27:7-13.
17. Pocock SJ. Clinical Trials Of Practical Approach
18. http://www.ada.org/~/media/ADA/Public%20 Programs/Files/topics_caries_educational_over6.ashx.
19. Xu W, Lu H-X, Li C-R, Zeng X-L. Dental caries status and risk indicators of dental caries among middleaged adults in Shanghai, China. J Dent Sci. 2014;9:151157.
20. Gökalp S, Dogan BG, Tekçiçek M, Berberoglu A, Unlüer S. National survey of oral health status of children and adults in Turkey. Community Dent Hlth. 2010;27:1217.
21. Maher R. Dental disorders in Pakistan-A national pathfinder study. J Pak Med Assoc. 1991;41:250-252.
22. Siddiqui TM, Wali A, Siddiqui SH, Heyat U, Nadeem M, Shamim M. An Epidemiological Study of Prevalence of Dental Caries and Periodontal Disease among Adults in Deprived Areas-Karachi. J Oral Hlth Res. 2013;4:37.
23. Haseeb M, Ali K, Munir MF. Causes of tooth extraction at a tertiary care centre in Pakistan. JPMA-Journal of the Pak Med Assoc.2012;62:812.
24. Harchandani N. Oral Health Challenges In Pakistan And Approaches To These Problems Pak Oral Dent J. 2012;32(3).
25. Waseem FS, Hussain A, Maqsood A, Sultan M. Socioeconomic Status And Oral Health Care Attitudes: A Snapshot Of Karachi Based Teaching Hospital. Pak Oral Dent J. 2015;35(01).
26. Asadi SGR, Asadi ZG. Chewing sticks and the oral hygiene habits of the adult Pakistani population. International dental journal. 1997;47:275-278.
27. Ruiz Miravet A, Almerich Silla JM. Evaluation of caries risk in a young adult population. Medicina Oral, Patología Oral y Cirugía Bucal (Internet). 2007;12:412418.
28. http://www.aapd.org/assets/1/7/riskbasedtechbrief.pdf.
29. Ramos-Gomez F, Ng M-W. Into the future: keeping healthy teeth caries free: pediatric CAMBRA protocols. J Canadian Dent Assoc. 2011;39(10):723.
30. Twetman S, Fontana M, Featherstone JD. Risk assessment-can we achieve consensus? Community Dent Oral Epidemiol. 2013;41(1):e64-e70.

CONTINUING EDUCATION

1. Caries risk assessment can be defined as the probability of caries incidence over a given period of time.
   1. True
   2. False
2. The distribution, severity and risk for caries development do not vary significantly for different age groups, individuals, teeth and teeth surfaces therefore, universal preventive strategies can be applied to all individuals.
   1. True
   2. False
3. Risk indicators are not the direct causal factor of the disease but, merely the existing signs that the disease process has occurred.
   1. True
   2. False
4. The most common risk assessment tool, which is used to determine caries risk especially in children, is CAMBRA
   1. True
   2. False

Key:

1. True
2. False
3. True
4. True

1. Lecturer, Operative Dentistry, Dental section, Dow International Medical College, Dow University of Health Sciences
2. Associate Professor, Operative Dentistry, Dental section, Dow International Medical College, Dow University of Health Sciences. Consultant Dental Surgeon (part time) in Operative dentistry, Section of Dentistry, Department of Surgery, The Aga Khan University and Hospital, Karachi, Pakistan.
3. Assistant Professor, Department of Oral Biology, Dental section, Dow International Medical College, Dow University of Health Sciences
4. Lecturer, Operative Dentistry Dental section, Dow International Medical College, Dow University of Health Sciences
Corresponding author: “Dr. Hira Akhtar” < hira.akhtar@duhs.edu.pk >