Key words:
Assessment - caries - Caries Assessment Spectrum and Treatment - index - permanent
- primary - teeth
INTRODUCTION
Dental caries remains a major public health problem on the community level and continues
to be a source of pain, suffering and low quality of life on an individual level.[1]
[2] The dynamic nature of the disease manifests it in different shapes, depths, sizes,
and colors of lesions which is reflected on the wide spectrum of different strategies
available to control it ranging from remineralization, fluoride application, atraumatic
restorative treatment to extensive cavity preparation, pulp therapy, and full coverage.[3]
[4]
To help dental practitioners and dental program planners develop effective caries
control measures, many tools for the assessment of dental caries have been presented.
Among these, the most widely used was the decayed, missing and filled teeth index
(DMFT), recommended by the World Health Organization (WHO). Even though the index
had its strengths, yet the D-component showed a wide range of variation. The need
to monitor and assess the severity of the D-component of the DMFT index in recent
decades was the main reason for researchers to develop the International Caries Detection
and Assessment System (ICDAS).[4]
[5] The ICDAS system had an advantage of helping to distinguish three stages of caries
severity in enamel, but it required complete dryness of the tooth surface using dry
air and double checking which rendered surveys to be time and money consuming.[6] Later, two indices were developed to assess the severe course of untreated dental
caries, the Pulpal Involvement-Ulceration-Fistula-Abscess and the Pulpal Involvement-Roots-Sepsis
but their disadvantage is that they do cover a limited area of the wide range of caries
process letting them act complementary to DMFT and ICDAS. From the clinical perspective
as well as the epidemiological point of view, it is always advantageous to implement
a single simple index to monitor the whole spectrum of a disease.[7]
In 2011, Frencken et al .[3] developed the Caries Assessment Spectrum and Treatment (CAST) index. An advantage
of CAST is that it counts successfully restored teeth as sound teeth which is an epidemiologically
acceptable concept of health. It covers also the whole spectrum of dental caries starting
from sound, preventive, restorative, to caries in enamel and dentin, reaching to the
advanced stages of untreated lesions of pulpal involvement and surrounding tooth structures
up to eventual tooth loss. CAST codes follow a hierarchical manner describing the
increased caries severity and additionally contain all the WHO caries assessment criteria;
it eliminates the need for drying the tooth surface making it a straightforward, practical
and easy to implement system.
Through the years, the hypothesis that teeth get decayed in a random manner was rejected.
It is observed that dental caries follows some universal patterns, for example, symmetrical
distribution around the midline as well as between upper and lower jaws. In 2004,
Batchelor and Sheiham[8] demonstrated that a true symmetry of dental caries does not exist, but there are
certain groups of teeth that share the same caries susceptibility.
Most of the literature on patterned dental caries adopted the DMF and DMFT indices.
Recently, the ICDAS tool was used to assess the patterned occurrence of dental caries.
However as CAST is gaining more acceptances worldwide, it might have a potential to
be a useful tool for planning caries control programs on both individual and community
levels.
The aim of this study is to demonstrate the use of CAST tool in monitoring patterns
of dental caries among primary and permanent molars and to evaluate integrating the
tool into the patient health information (PHI) system of a teaching dental hospital.
MATERIALS AND METHODS
Dental records of 348 children, aged 7–9 years (n = 167 boys, and n = 181 girls) attending University Dental Hospital Sharjah (UDHS) from February to
December 2016 for routine checkup and treatment as part of a school dental program
arranged by the University of Sharjah, United Arab Emirates.
After obtaining parents or caregivers approval according to the institution’s policy,
charting was done on the hospital’s PHI system (axiUm® Exan division of Henry Schein Co.). Dental examination and data entry into axiUm® was done by students on patients seated on dental chairs under supervision of pediatric
dentist faculty members using plane mirrors and sharp explorers. Routine orthopantomogram
was taken and stored into another separate computer software module other than/axiUm®.
On time/while the study was conducted, axiUm® records were examined retrospectively where both pre- and post-treatment health status
for each individual tooth was translated into CAST codes.
To achieve a reliable translation to CAST codes, every clinical side note, as well
as every pretreatment panoramic radiograph, was examined by two pediatric dentists
who had to agree on the designated code for each tooth. The unweighted kappa value
for the interexaminer reliability was 0.97 for second primary and 0.95 for first permanent
molars. The same two pediatric dentists performed the translation to CAST for all
the records included in the study. If two conditions were present on the same tooth
or tooth surface, the condition with the higher score was counted. All the children’s
records included in the study had four first permanent molars erupted. We excluded
records with any of the premolars erupted to avoid confusion related to whether the
primary molar was lost due to caries or was normally exfoliated.
For the purpose of our study, CAST codes 1, 2 were considered healthy, 3 were considered
as premorbid, 4–7 for morbidity, and 8 for mortality. CAST codes for primary and permanent
molars were tabulated and recorded for statistical analysis. For statistical analysis,
the nonparametric Mann–Whitney U-test was used to test the difference in the distribution
of CAST codes in evaluated second primary molar and first permanent molar according
to age and gender. Spearman’s Correlation Coefficient was used to assess the correlation
between caries status of second primary molar and permanent first molars. The statistical
significance was set at 0.05.
RESULTS
Dental records of a total of n = 348 children, aged between 7 and 9-years (n = 167 boys, and n = 181, girls) were examined in this study. The recorded dental status of the second
primary and first permanent molars were evaluated and translated into CAST codes.
[Table 1] represents the distribution of each CAST code separately for evaluated primary and
permanent molars.
Based on the epidemiological concept of health and disease, proposed by Frencken et al.,[4] healthy dentition status is represented by codes 0–2. In our study, CAST codes 0–2
were observed only in about 3% primary and almost 5% in permanent dentition, respectively.
The prevalence of children with diseased first permanent molar is almost 67% (codes
4–7). While in second primary molars, the recorded prevalence is over 70% for representing
teeth with morbidity and severe morbidity.
With regards to second primary molars, over one-third of the teeth had pulpal involvement
(code 6-serious morbidity). Caries in first permanent molars was mostly evaluated
and recoded as the dentinal lesions, with morbidity codes 4 (discolored dentin visible
through enamel, with or without enamel breakdown) or code 5 (distinct cavitation into
dentine), with the prevalence of over 50%. Tooth extracted due to caries (code 8),
was found to be more prevalent (almost 10%) in primary molars versus 1% in first permanent
molar, represented in [Figure 1]
Figure 1: Distribution of evaluated second primary and first permanent
molar teeth according to the concept of health and different disease
stages
Table 1:
Distribution of Caries Assessment Spectrum and Treatment codes in primary and permanent
molar teeth
|
Tooth No
|
Code 0
|
Code 1
|
Code 2
|
Code 3
|
Code 4
|
Code 5
|
Code 6
|
Code 7
|
Code 8
|
|
16
|
1.7
|
1.1
|
9.2
|
18.2
|
21.8
|
30.7
|
12.1
|
2.6
|
2.6
|
|
26
|
1.8
|
1.2
|
9.5
|
17.1
|
21.3
|
31.3
|
12.4
|
4.3
|
1.1
|
|
36
|
2.5
|
3.6
|
7.3
|
21.2
|
17.3
|
27.1
|
19.2
|
1.6
|
0.2
|
|
46
|
2.3
|
0.7
|
10.8
|
20.5
|
19.8
|
26.7
|
17.6
|
1.2
|
0.4
|
|
55
|
1.3
|
0
|
5.6
|
8.6
|
8.3
|
21.4
|
40.6
|
4.1
|
10.1
|
|
65
|
1.5
|
0
|
5.1
|
7.5
|
8.3
|
22.1
|
42
|
3.8
|
9.7
|
|
75
|
0.8
|
0
|
4
|
10.3
|
8.9
|
21.6
|
37.2
|
8.2
|
9
|
|
85
|
2.5
|
0
|
6.3
|
15.8
|
7.3
|
22.1
|
26.7
|
9.1
|
10.2
|
A strong correlation was found between caries stages of lower right and neighboring
first permanent molars r = 0.69, and lower left second primary and permanent dentition r = 0.64 [Figures 2]
[3]. All the correlations between primary and permanent molars in the lower jaw reached
high statistical significance (P = 0.001). With regard to the teeth in the upper arch, both right and left second
primary molar revealed moderate correlation r = 0.435 (P ≤ 0.05), between disease stages with their neighboring permanent first molars, [Figures 4]
[5].
Figure 2: Correlation of Caries Assessment Spectrum and Treatment
codes between tooth 46 and 85
Figure 3: Correlation of Caries Assessment Spectrum and Treatment
codes between tooth 36 and 75
Figure 4: Correlation of Caries Assessment Spectrum and Treatment
codes between tooth 26 and 65
Figure 5: Correlation of Caries Assessment Spectrum and Treatment
codes between tooth 16 and 55
[Table 2] demonstrates the hierarchical structure in CAST codes which follows severity of
the consequences of disease stages, with increasing codes before provision of treatment.
Following caries treatment, a restored tooth is considered functional and healthy
and therefore, these codes were changed from diseased to healthy status. Moreover,
as many as 16.5% of lower first permanent molar were lost due to extraction, while
only an average of 2.9% could have been saved after endodontic treatment for teeth
categorized as code 6 or 7
Table 2:
Frequency distribution of status of teeth before and after comprehensive care according
to Caries Assessment Spectrum and Treatment codes
|
Tooth No. CAST Codes
|
Status of teeth acc. to CAST codes
|
Percentage distribution of teeth acc. to CAST codes before treatment
|
Type of Treatment provided
|
CAST codes after treatment
|
Status and Percentage distribution of teeth acc. to
CAST codes after treatment
|
|
Tooth No. 16
|
|
|
|
|
|
|
Code 3
|
Pre-morbidity
|
18.2
|
Sealant/PRR/Restorative care
|
3→1 or 2
|
Healthy (18.2)
|
|
Code 4/5
|
Morbidity
|
52.5
|
Restorative care/IPT
|
4/5→2
|
Healthy (52.5)
|
|
Code 6
|
Morbidity
|
12.1
|
Pulp treatment/Extraction
|
6→2 or 8
|
Healthy (2.3) &
|
|
Code 7
|
Morbidity
|
2.6
|
Extraction
|
7→8
|
Mortality (9.8)
|
|
Code 8
|
Mortality
|
2.6
|
|
|
Mortality (2.6)
|
|
Tooth No. 26
|
|
|
|
|
|
|
Code 3
|
Pre-morbidity
|
17.1
|
Sealant/PRR/Restorative care
|
3→1 or 2
|
Healthy (17.1)
|
|
Code 4/5
|
Morbidity
|
52.6
|
Restorative care/IPT
|
4/5→2
|
Healthy (52.6)
|
|
Code 6
|
Morbidity
|
12.4
|
Pulp treatment/Extraction
|
6→2 or 8
|
Healthy (2.7)
|
|
Code 7
|
Morbidity
|
4.3
|
Extraction
|
7→8
|
Mortality (9.7)
|
|
Code 8
|
Mortality
|
1.1
|
|
|
Mortality (4.3)
|
|
Tooth No. 36
|
|
|
|
|
|
|
Code 3
|
Pre-morbidity
|
21.2
|
Sealant/PRR/Restorative care
|
3→1 or 2
|
Healthy (21.2)
|
|
Code 4/5
|
Morbidity
|
44.4
|
Restorative care/IPT
|
4/5→2
|
Healthy (44.4)
|
|
Code 6
|
Morbidity
|
19.2
|
Pulp treatment/Extraction
|
6→2 or 8
|
Healthy (5.2)
|
|
Code 7
|
Morbidity
|
1.6
|
Extraction
|
7→8
|
Mortality (14)
|
|
Code 8
|
Mortality
|
0.2
|
|
|
Mortality (1.6)
|
|
Tooth No. 46
|
|
|
|
|
|
|
Code 3
|
Pre-morbidity
|
20.5
|
Sealant/PRR/Restorative care
|
3→1 or 2
|
Healthy (20.5)
|
|
Code 4/5
|
Morbidity
|
46.5
|
Restorative care/IPT
|
4/5→2
|
Healthy (46.5)
|
|
Code 6
|
Morbidity
|
17.6
|
Pulp treatment/Extraction
|
6→2 or 8
|
Healthy (1.4)
|
|
Code 7
|
Morbidity
|
1.2
|
Extraction
|
7→8
|
Mortality (16.2)
|
|
Code 8
|
Mortality
|
0.4
|
|
|
Mortality (1.2)
|
DISCUSSION
Dental caries is a major oral health problem worldwide. WHO, 2005 bulletin reports
caries the prevalence of 60%–90% among school-aged children and the vast majority
of adults in the majority of countries.[9] In this study, a high prevalence of carious first permanent molars in over 65% of
children was observed, which is in agreement with the previously reported data from
a Saudi study among children aged-9–12-years.[10]
Several studies[11]
[12]
[13] documented that dental caries in deciduous dentition is a strong predictive factor
of a high caries increment in the permanent dentition, especially in the first permanent
molars. Neglect in dental care related to deciduous dentition is obvious with the
prevalence of over 70% for codes 4–7 representing teeth with morbidity and severe
morbidity. This could be strongly correlated to high caries prevalence in first permanent
molars, as observed in this study. Mandatory dental screenings should be initiated
at the age of 5 years, and periodic follow-ups for another 5–6 years. This will help
identify children with high caries risk and for the provision of preventive care such
as dental sealants to high-risk group. Results from the present study indicated an
extremely low percentage of pit and fissure sealants in the permanent teeth and negligible
in the primary molars. Considering number of factors such as age, early eruption,
anatomy, large crown size, position in the oral cavity, and makes first permanent
molars highly susceptible to caries.[14]
[15] Sealants are strongly recommended for susceptible tooth surfaces in high-risk population
employing appropriate material and technique.[16]
[17]
At UDHS, we follow comprehensive care in our undergraduate and postgraduates-teaching
clinics. Using radiographic records retrieved from PHI system (axiUm®) we translated different disease stages of caries into CAST morbidity codes (codes
4–7). Formulated treatment plan for comprehensive care entered in the system was based
on the diagnosis explaining caries types (primary caries, arrested caries), etc.,
only. It was quite tedious for us to relate radiographic records, clinical notes supporting
the diagnosis, treatment plan and treatment rendered especially for caries involving
enamel and dentine with no pulpal involvement. Documentation in clinical notes of
the stages of carious lesions both for early and for more severe levels using caries
assessment criteria is necessary for learning and periodic follow-up of the high-risk
patients.
Among many systems, the CAST instrument is a promising tool which gives a full spectrum
of the clinical picture of dental caries from enamel and dentine carious lesions to
advanced stages of caries, involving pulp, and surrounding tissue.[4]
[7]
[18] Utilizing/employing the CAST tool, a simple numerical value can reflect/reflects
the precise stage of caries evaluated clinically or through radiographs which can
easily be documented in the clinical notes of the patient. This can bridge any gaps
in the existing PHI system. It will then become easier for future caregivers to have
complete picture of the progression of caries stages for the follow-up patients.
This caries assessment tool might provide undergraduates with a structural guidance
to formulate and document an effective treatment plan for comprehensive care in the
PHI system. Undergraduates can have better understanding of assessing and documenting
the presentation of premorbidity stage with a numerical value that only needs preventive
care. Furthermore, codes 4/5 can help them distinguish carious lesion in dentine,
which either can be restored or require more complicated treatment beyond restoration.
Moreover, through a comprehensive assessment of the disease stages, it may give an
insight into the consequences of untreated caries. In addition, based on the assessed
health, premorbid and morbid status of the tooth, students can properly select treatment
modalities that can effectively change the health status from morbid to health using
CAST tool.
So far, this is the first work/study where CAST tool is used on retrospective patient
records. Despite this fact, the results are in agreement with other studies done by
Baginska et al .,[7] where CAST tool was used during the actual clinical examination. This agreement
reflects the strength and reliability of CAST as an epidemiological and clinical assessment
tool.
In a teaching hospital as UDHS, it is very common that service providers (the undergraduate
dental students) do alternate during provision of a certain services especially when
the service requires multiple visits. This is sometimes inevitable due to events related
to the learning environment, for example, graduation of students and study breaks.
Our study recommends the integration of CAST tool in the PHI system where a simple
numerical value can express clinical progress, overcome interruptions of treatment,
and ensures continuity of patient care.
CONCLUSION
CAST tool is a valuable caries index that expresses the severity of caries and the
clinical progress and outcome of management. our study recommends the integration
of CAST tool in the patient health information system where a simple numerical value
can express clinical progress, overcome interruptions of treatment and ensures continuity
of patient care in teaching hospitals
Financial support and sponsorship
Nil.
