Caries risk assessment among 12–13 year old school-going children of government and private schools of Tirupur district, Tamil Nadu

Abstract

Background:
Dental caries is as ancient as humankind and has the longest association with the dental profession, an association that is punctuated with agony and ecstasy. The agonizing fact is that despite several efforts toward total eradication, this disease is still prevalent. Nevertheless, an ecstatic success of the profession is the global decline in the incidence compared to the yesteryears' epidemics. Hence, predicting dental caries earlier is a boon. One such model to predict is cariogram developed by Bratthall in 1996.

Aim:
The aim of this study was to assess the caries risk among 12-13 year old school-going children of government and private schools of Tirupur district in Tamil Nadu using cariogram computer model.

Methods:
A cross-sectional survey was carried out among 136 study subjects of 12-13 year of age, who fulfilled the inclusion and exclusion criteria. Data were collected using a predesigned questionnaire and scored according to a standardized protocol. The Chi-square test was used to find differences between caries-related factors and cariogram group. The correlation was acquired using Spearman's correlation.

Results:
Government school study subjects had 56% of chance of avoiding caries whereas the private school study subjects had 66% of chance of avoiding caries in future and the differences were statistically significant (P = 0.001). A negative correlation was observed between the chance to avoid dental caries and cariogram sectors.

Conclusion:
The majority of the study subjects from government school belonged to medium-risk category and private school subjects belonged to low-risk category which inferred that private school students have high chance to avoid dental caries compared to government study subjects.

Full text

© 2016 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
244
ABSTRACT
Background: Dental caries is as ancient as
humankind and has the longest association
with the dental profession, an association that is
punctuated with agony and ecstasy. The agonizing
fact is that despite several efforts toward total
eradication, this disease is still prevalent.
Nevertheless, an ecstatic success of the profession
is the global decline in the incidence compared
to the yesteryears’ epidemics. Hence, predicting
dental caries earlier is a boon. One such model
to predict is cariogram developed by Bratthall
in 1996. Aim: The aim of this study was to assess
the caries risk among 12–13 year old school‑going
children of government and private schools of
Tirupur district in Tamil Nadu using cariogram
computer model. Methods: A cross‑sectional
survey was carried out among 136 study subjects
of 12–13 year of age, who fullled the inclusion
and exclusion criteria. Data were collected using a
predesigned questionnaire and scored according
to a standardized protocol. The Chi‑square test
was used to nd differences between caries‑related
factors and cariogram group. The correlation was
acquired using Spearman’s correlation. Results:
Government school study subjects had 56% of
chance of avoiding caries whereas the private
school study subjects had 66% of chance of
avoiding caries in future and the differences were
statistically signicant (P = 0.001). A negative
correlation was observed between the chance
to avoid dental caries and cariogram sectors.
Conclusion: The majority of the study subjects
from government school belonged to medium‑risk
category and private school subjects belonged
to low‑risk category which inferred that private
school students have high chance to avoid dental
caries compared to government study subjects.
KEYWORDS: Caries risk assessment, caries risk
model, cariogram, Tirupur
Caries risk assessment among 12–13 year old
school‑going children of government and private
schools of Tirupur district, Tamil Nadu
Madhu Mitha M, Nijesh JE, Preetha Elizabeth Chaly, Indra Priyadharshini, Mohammed Junaid,
Vaishnavi S
Department of Public Health Dentistry, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India
Introduction
Dental caries is an important public health predicament.
The unique characteristic of dental diseases is that
they are universally prevalent and do not undergo
diminution or termination if untreated and require
technically demanding expertise and time‑consuming
professional treatment. The risk factors should be
comprehensively studied, tackled, and modied so
that the occurrence of dental caries can be prevented.[1]
The multifactorial etiology of dental caries points to a
risk assessment model that would include the different
Address for correspondence:
Dr. Madhu Mitha M,
Department of Public Health Dentistry, Meenakshi Ammal
Dental College, Alapakkam Main Road, Maduravoyal,
Chennai ‑ 600 095, Tamil Nadu, India.
E‑mail: dr.madhu2090@yahoo.com
How to cite this article: Mitha MM, Nijesh JE, Chaly PE,
Priyadharshini I, Junaid M, Vaishnavi S. Caries risk assessment
among 12–13 year old school-going children of government and
private schools of Tirupur district, Tamil Nadu. J Indian Soc Pedod
Prev Dent 2016;34:244-8.
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Mitha, et al.: Caries risk assessment among 12–13 years old school‑going children
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jul-Sep 2016 | Vol 34 | Issue 3 | 245
factors or parameters that accompany the development
of new carious lesions. Cariogram is one such model
which assesses and illustrates a caries risk prole for
a personage graphically, simultaneously taking into
account the interaction of different caries causing
factors/parameters of the patient.[2,3]
There are two different approaches described for
caries risk assessment models: The risk model and the
prediction model. The risk model is used to determine
the causative caries factors called risk factors, but it
cannot predict the caries outcome. The prediction
model estimates the risk of caries progression in the
future. Cariogram paradigmatic model has both risk
and predictor models in it.[4]
Cariogram software can be downloaded from the
internet. The outcomes are presented graphically to
the patient, indicating the probability of avoiding
new carious lesions. Cariogram is anchored in a set
of pathological and protective factors, namely, caries
experience, systemic diseases, diet contents and
frequency, the amount of plaque, mutans streptococci,
uoride sources, saliva secretion, and buffer capacity
in addition to the professional clinical judgment. As
some other factors are considered more relevant than
others regarding caries development, different weights
are given to different factors.[5,6]
Children have a greater incidence of carious lesions
as they reach school age, mostly due to irregular and
ineffective oral hygiene habits and of course not to say
the least frequent snacking rich in carbohydrate and
sugar. It becomes pragmatic to nd ways to predict
new carious lesions so that we can prevent their
progression and occurrence.[1,7]
In a country like India, which needs the emphasis on
assessing the caries risk and a profound acumen in
identifying high‑risk individuals who will develop caries.
so, that preventive measures can be beleaguered to that
group, thereby not only plummeting the encumbrance of
the restorative care but also eliminating pain and rening
the quality of life. Moreover, preventive measures can
then be beleaguered at this group, thereby not only
plummeting the encumbrance of the restorative care but
also eliminating pain and rening the quality of life.[4,8]
Hence, this study was conducted to assess the caries risk
among 12–13 year old school‑going children in Tirupur
district, Tamil Nadu using cariogram computer model.
Methods
A cross‑sectional survey was carried out among
the 12–13 years old school‑going children in both
private and government schools in Tirupur district,
Tamil Nadu. Only children who were 12–13 years of
age as per school records and present on the day of
the examination were included in the study. Medically
compromised subjects, children who were not present
on the day of examination and uncooperative subjects
were excluded from the study. The nature and purpose
of the study were explained to the Institutional Review
Board (MADC/IRB/2015/103) and ethical clearance
was obtained. The study subjects were then explained
about the purpose and study procedure, following
which informed consent was obtained from them.
A sample size of 130 was determined based on the
comparison of mean values of decayed/missing/
lled teeth (DMFT) obtained from the pilot study. All
the study subjects from both private and government
schools were selected through stratied cluster random
sampling and were recruited for this study resulting in
a sample size of 136.
The clinical examination and laboratory analysis were
carried out by a single examiner. The risk assessment
included (1) a questionnaire, (2) estimation of oral
hygiene, (3) saliva sampling, (4) clinical examination
and (5) creating a risk prole for each child using
a cariogram. Interview‑based Questionnaire was
employed to collect data pertaining to diet, frequency
of eating (snacks/meals) per day, related general
diseases, the use of uoride toothpaste, and other
uoride supplements. The examination was conducted
outside the classrooms of the study subject, (ADA
Specication Type III clinical examination). On an
average, examination was conducted for a maximum
of ten subjects per day. Caries prevalence and DMFT
were recorded using the WHO standard criteria for
oral health status and treatment needs (2013). Oral
hygiene was estimated using plaque index by Silness
P and Loe H (1967).
Simplied techniques of salivary assessments were
used to make them cost effective and applicable for
the eld study. The study subjects were instructed
to place the sterilized rubber band in the mouth and
start chewing it for 30 seconds and stimulated saliva
was collected. All the saliva samples were labeled with
a number before sending them for microbiological
processing. To ensure blinding, the number was given
by an assistant who was unaware of the purpose of the
study. The number given by the assistant ensured that
the investigator who inoculates processes and reads
the plates was unaware of which sample belongs to the
study subjects. Stimulated whole saliva was collected
from all children to measure the
i. Saliva secretion rate (expressed as ml/min)
ii. Buffering capacity of saliva
iii. Lactobacillus and Streptococcus mutans count.
Salivary pH was measured by electronic pH meter.
Assessment of diet frequency was obtained by intake
frequency questionnaire, the interview method (24 h
recall questionnaire).
When all the information was available, they were
scored according to the predetermined scale as
0–2 or 3. The scores were entered into the cariogram
computer program to calculate the “caries risk” and
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Mitha, et al.: Caries risk assessment among 12–13 years old school‑going children
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jul-Sep 2016 | Vol 34 | Issue 3 |
246
conversely “chance of avoidance of caries” for each
child. The subjects were classied into three caries
risk groups according to the percentage shown by the
cariogram: 61–100% ‑ low risk, 21–60% ‑ medium risk
and 0–20% ‑ high risk.
The data so‑obtained were compiled systematically and
analyzed using SPSS (Version 16, SPSS Inc., Chicago,
USA) software. Descriptive statistics were obtained for
all demographic variables. Caries risk prole among
the study subjects was obtained using the Chi‑square
test. The correlation between caries risk and cariogram
sectors was obtained using Pearson’s correlation and
the signicance level was set at P < 0.05.
Results
This study was conducted among 136, 12–13 years old
children comprising 69 males and 67 females [Table 1].
Among the study subjects, the dominant sector
was bacteria sector in both government and private
schools with 18.0725 ± 8.48583 and 13.4776 ± 7.03316,
respectively, and the differences noted between the
two groups were statistically signicant (P = 0.001).
The least sector is circumstance having 6.0580 ± 3.01898
in government sector and 4.4776 ± 2.88863 in
private sector study subjects and the differences
found between the two groups were statistically
signicant (P = 0.002) [Table 2]. The difference noted
between male and female study subjects for average
caries risk prole were not found to be statistically
signicant [Table 3].
The government and private school study subjects
were divided into groups according to the chance
of avoiding caries ranging from high‑ to low‑risk
group. Of 69 government school study subjects,
52.1% (n = 36) belonged to medium‑risk category,
44.9% (n = 31) belonged to low‑risk category, and
2.9% (n = 2) belonged to high‑risk category [Table 4].
Of 67 study subjects among private school,
27.3%(n=19) belonged to medium‑risk category,
72.7% (n = 48) belonged to low‑risk category, and none
of them belonged to high‑risk category. The difference
noted between these two groups were statistically very
highly signicant (P = 0.001) [Table 4].
Chance to avoid dental caries was found to have a
very highly signicant moderate negative correlation
with diet, bacteria, susceptibility and circumstance
[Table 5].
Discussion
The present study was conducted among 12–13 years
old school children of government and private
schools of Tirupur district to compare and evaluate
their caries prole using cariogram model which was
introduced by Bratthall et al. in 1997. Schools were
profoundly selected for this study because it provided
a unique platform for the promotion of oral health
and overall health not only for the students but also
for the benevolent staff, families, and members of the
community as a whole.
The WHO has certain index ages out of which age group
belonging to 12 years is chosen. The WHO considers
12‑years age as the global indicator age for monitoring
dental caries.[6] Children with permanent dentition
were selected to avoid discrepancies between mixed
and permanent dentition with regard to microbial
counts as stated by Schlagenhauf and Rosendahl.[9]
The present study used cariogram, which is considered
one of the most reliable models as reported by many
authors[10‑12] for predicting caries risk in an individual
since it is an amalgamation of objective, quantitative
methods that uses a computer program to calculate
the data, results that can be printed out and saved.
Table 1: Distribution of study subject based on government and
private schools
Gender Government
school (%)
Private
school (%)
Total (%)
Male 34 (50.0) 34 (50.0) 68 (100.0)
Female 35 (51.5) 33 (48.5) 68 (100.0)
Total number
of subjects in
each variable
69 (50.7) 67 (49.3) 136 (100.0)
Table2:Theaveragecariesriskproleof12-13-year-oldstudy
subjects among government and private schools
Mean±SD Signicance
Government
school
Private
school
Susceptibility 7.8116±5.31722 5.8657±4.01473 0.018
Bacteria 18.0725±8.48583 13.4776±7.03316 0.001
Diet 11.5217±6.62573 9.8657±5.89272 0.126
Circumstance 6.0580±3.01898 4.4776±2.88863 0.002
Chance
to avoid
(caries risk)
56.4783±18.97026 66.2836±15.17155 0.001
SD=Standard deviation
Table3:Theaveragecariesriskproleof12-13-year-oldstudy
subjects among male and female study subjects
Mean±SD Signicance
Male Female
Susceptibility 6.1765±4.22127 7.5294±5.26739 0.101
Bacteria 14.7941±7.04476 16.8235±8.98912 0.145
Diet 10.5441±5.47023 10.8676±7.08352 0.766
Circumstance 4.7941±2.78888 5.7647±3.23746 0.063
Chance
to avoid
(caries risk)
63.6176±15.39726 59.0000±19.82084 0.132
SD=Standard deviation
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Mitha, et al.: Caries risk assessment among 12–13 years old school‑going children
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jul-Sep 2016 | Vol 34 | Issue 3 | 247
Another imperative advantage is that it makes a series
of recommendations for preventive action according
to the caries risk. The pie chart presentation with
its different sectors makes it interestingly easier for
patients to understand caries risk prole which can
be effectively used to motivate the patient. When
validated among both children and elderly, cariogram
predicted caries increment more accurately than any
single‑factor model.[1,3,13,14]
The chance to avoid caries was nally grouped into
three levels: Low chance 0–20% (high caries risk),
moderate chance 21–60% (moderate caries risk), and
high chance 61–100% (low caries risk) which was
similar to the study conducted by Kavvadia et al.
among 2–6‑year‑old Greek children.[15]
In the present study, the majority of the study subjects
from government schools belonged to medium risk
category and private school subjects belonged to
low‑risk category which inferred that private school
students have high chance to avoid dental caries
compared to government study subjects. This is due
to the fact that the susceptibility, bacteria, diet, and
circumstances sector were dominant in government
study subjects when compared with private school
study subjects.
Exposure to uoride is one of the most important
protective factors when evaluating caries risk is
the cause of the considerable fall in caries levels in
western countries. None of the children in this study
used uoride supplements, and the only source of
uoride was uoridated toothpastes, use of which
was conrmed by asking the brand name. The
circumstances that lead to an individual caries risk,
according to cariogram, emphasize the experience of
caries and the presence of diseases that may directly
impact on the increase of caries and in the weakness of
the individual. In the present study, no interferences
were observed. All children were found healthy,
without any systemic changes. This is in accordance
with the study conducted by Hebbal et al. among
12‑year‑old children in an Indian city.[3]
Signicant negative correlation was obtained between
the sectors and chance to avoid dental caries. This result
was found to be contrast with the study conducted by
Hebbal et al. among 12‑year‑old children in an Indian
city[3] because correlation was obtained between the
different variables and the risk obtained for each sector.
Petersson et al.[2,13,16,17] expressed the results of their
studies with the cariogram as a chance to avoid
caries which is similar to this study. For statistical
analysis purposes, the results of the present study are
expressed as caries risk, which the authors consider
a more comprehensible and useful value; obtained
by adding up the partial caries risks of susceptibility,
circumstances, bacteria, and diet, it allows correlations
to be established and gives greater scope for analysis.
Three variables of cariogram were not used in this
trial, such as country/area, and groups were scored
as a standard set and clinical judgment was scored
as 1, similar to the previous studies on the efcacy of
cariogram.[18,19] Using these options may increase the
efcacy of this program. Comparison of all results
with other studies was not possible, as the disparity
between the results exists.
Thus, cariogram program is effective and has some
advantages such as making recommendations for
preventive care and increasing patient motivation.
The cariogram model has been evaluated in scientic
studies both children and adult population. It is a useful
pedagogic tool for dentists, dental hygienists, and
assistants in discussion with patients about their caries
risk. The cariogram complements the current trends
toward computerized record keeping and management.
Conclusion
The accuracy of caries prediction in school children
was signicantly impaired when cariogram model
was applied. However, the results of the study will
serve as the baseline data, which will be used to plan a
preventive program for the school children in Tirupur
district.
Table 4: Caries risk among government and private school children made by cariogram
Schools High risk (0‑20%) Medium risk (21‑60%) Low risk (61‑100%) Total Signicant
Government school 2 (2.9) 36 (52.1) 31 (44.9) 69 (100.0) 0.001
Private school 0 (0) 19 (27.3) 48 (72.7) 67 (100.0)
Total number of subjects
in each variable
2 (1.5) 55 (40) 79 (58.5) 136 (100.0)
Table 5: Correlation between caries risk and cariogram sectors among study subjects belonging to both schools
Chance to avoid
dental caries
Diet Bacteria Susceptibility Circumstances
Chance to avoid dental caries 1 −0.771 −0.919 −0.687 −0.764
P‑value ‑ 0.000 0.000 0.000 0.000
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Mitha, et al.: Caries risk assessment among 12–13 years old school‑going children
Journal of Indian Society of Pedodontics and Preventive Dentistry | Jul-Sep 2016 | Vol 34 | Issue 3 |
248
Financial support and sponsorship
Nil.
Conicts of interest
There are no conicts of interest.
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