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INTRODUCTION

orld Health Organization regards dental cariesand periodontal disease as two most importantglobal, oral health burdens. In most developed

countries, dental caries affects 60-90% of schoolchildrenand the vast majority of adults.1 Dental caries is amultifactorial disease, its initiation, development andprogression is influenced by numerous factors, such asthe patient's health, diet, presence of bacteria in the oralcavity, salivary parameters and fluoride exposure.2-6 The

distribution, severity andrisk for caries development varysignificantly for different age groups, individuals, teethand teeth surfaces. Thus, caries preventive measuresshould be based on sound knowledge and understandingof the predicted risk.2

Historically, caries was considered as a progressivedisease which ultimately destroyed the tooth unless dentistperformed surgical intervention.7 But with new evidence-based research leading to better understanding of cariesprocess a paradigm shift from curative to preventivedentistry has taken precedence. Nowadays, managementof caries is more directed towards identification of riskindicators, which are the existing signs that the diseaseprocess has occurred and modification of risk factors,which are the attributes or exposuresignificantly associatedwith the development of a disease.8, 9 This change ofparadigm shift is in accordance with the National Instituteof Healthconsensus statement10 which outlines methodsfor theidentification, modification and/or elimination of

JPDA Vol. 24 No. 03 July-Sep 2015129

CARIES RISK ASSESSMENT IN ADULT POPULATIONUSING AMERICAN DENTAL ASSOCIATION MODEL

OBJECTIVE: To conduct caries risk assessment in adult population using American Dental Association (ADA)model.METHODOLOGY: A cross-sectional study was conducted at the Diagnostic department of Operative Dentistryat the dental section of Dow International Medical College, Karachi from 15th November 2014 till 24th December2014. The survey was conducted on a random sample of 50 adults who reported to the diagnostic department at thedental section of Dow International Medical College. A questionnaire(modified model of ADA caries risk assessmentform) was filled which included variables like fluoride exposure, diet, previous dental care records, medical historyand a clinical examination.Descriptive data analysis including frequencies, percentages and means were calculatedusing SPSS version 16.RESULT: Fifty adults consisting of 13 males and 37 females, aged 18-60 years with a mean age of 32.36 yearswere examined. Three risk categories were measured and scored. Patients were recorded, as low risk 0%, Moderaterisk 34% and High risk 66 %.CONCLUSION: The modified ADA questionnaire we able to assess caries risk in adult population. It is ourrecommendation that this model be used in routine clinical practice to help identify the risk factors.KEY WORDS: Caries risk assessment, Adult population, American Dental Association model, RiskCategories,Pakistan.HOW TO CITE: Akhtar H, Naz F, Waseem FS, Shahnawaz D. Caries risk assessment in adult population usingamerican dental association model. J Pak Dent Assoc 2015; 24(3):129-135.Received: September 24 2015, Accepted: October 26, 2015

1. Lecturer, Operative Dentistry, Dental section, Dow International Medical College,Dow University of Health Sciences2. Associate Professor, Operative Dentistry, Dental section, Dow International MedicalCollege, Dow University of Health Sciences. Consultant Dental Surgeon (part time) inOperative dentistry, Section of Dentistry, Department of Surgery, The Aga Khan Universityand Hospital, Karachi, Pakistan.3. Assistant Professor, Department of Oral Biology, Dental section, Dow InternationalMedical College, Dow University of Health Sciences4. Lecturer, Operative Dentistry Dental section, Dow International Medical College,Dow University of Health SciencesCorresponding author: “Dr. Hira Akhtar” < [email protected] >

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Hira Akhtar1 BDSFarah Naz2 BDS, FCPSFarzeen Shafiq Waseem3 BDS, MphilDanish Shahnawaz4 BDS

ORIGINAL ARTICLE

JPDA Vol. 24 No. 03 July-Sep 2015 130

all associated risk indicators and factors for improvedcaries diagnostic, preventive and treatment strategies.

Caries risk assessment determines the probability ofcaries incidencei.e., the number of new cavities or incipientlesions 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 determininga patient's risk.11 Numerousmodels have beendevelopedbyAmerican Academy of Pediatric Dentistry11, Cariesmanagement by risk assessment (CAMBRA)11,Cariogram12 and American Dental Association.11

The American Dental Association (ADA)hasdeveloped two forms: one for patients 0-6 years old, andother for patients older than 6 years.13 ADA periodicallyupdates these forms, on the basis of feedback regardingtheir usefulness by its members and advancements inscience. These form measure patients at low, moderateor high risk of caries by using a scoring system.All positiveresponses in the low risk column carry a score of 0.Responses in the moderate risk column hold score of 1each and responses in the high risk column carry scoreof 10 each. An overall score of 0 indicates patient haslow risk for development of caries. A single high factor,or score of 10 or above places the patient at high risk andscore in between 1 and 9 indicates the patient at moderaterisk for caries development.14

Although extensive research has been conducted toassess caries risk in children; there is scarce evidenceavailable for risk assessment on the global adult andelderly population.7,9,15,16 Also no previous evidence isavailable regarding caries risk assessment involvingPakistani adult population. The presence of this researchgap has led towards difficulty for the dental practitionersin the application of caries risk assessment models on theadult and elderly population.This article emphasizes onthe importance of conducting of caries risk in adults asa prerequisite for appropriate caries preventive andtreatment decisions.The objective of this study was toconduct caries risk assessment in the adult population.

METHODOLOGY

A cross sectional study was conducted in the diagnosticdepartment of Operative dentistry at the dental sectionof Dow International Medical College. Sample size wascalculatedusing 2 proportion formula17 with 99%confidence interval and 95% power of test. 19% proportionof low and very low risk patients16, 81% proportion of

moderate and high risk patients16, the sample sizecalculated was 11 in each risk categories and the totalsample size determined was 44.

For this study non- probability, purposive samplingwas applied. Data was collected over a period of 01month. Patients aged between 18 to 60 years, who werepermanent residents of Pakistan, agreed to sign a consentform, completed the risk questionnaire and dentalexamination and previously did not have caries riskassessment done were included in the study. Whereas,patients who were not fitting within the age range, declinedto sign the consent form or previously had risk assessmentdone and thus, received any preventive and therapeutictreatment were excluded from this study.

Total sample of 50 patients, fitting the inclusioncriteria were selected. After obtaining a signed informconsent from each patient, a modified version of AmericanDental Association risk assessment form18(Annex I) wasfilled. Dental examination was conducted. The overall,caries risk of the each patient was calculated. Resultswere conveyed to the patient. Diet counseling andsubsequent treatment plan was advised to the patient.

Statistical Package for Social Sciences (SPSS) Version16 was used to enter and analyze data. Descriptive dataanalysis including frequencies, percentages and meanswere calculated in the study.

RESULTS

A total sample of 50 patients was recorded. The samplecomprised 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 and66% patients at high risk [Figure2].A vast majority ofpatients were recorded at high risk [Figure 2]. When riskpercentages were compared on the basis of gender,

Caries risk assessment in adult populationAkhtar H / Naz F /Waseem FS / Shahnawaz D

Caries risk assessment in adult population using american dental association model


increased percentages (26%) of females were recordedat high risk whereas males had almost equal distributionamong moderate and high risk categories [Figure 4]. Themajor contributing factors towards increased risk were:presence of three or more active carious lesions, extractiondue to caries in the past 36 months and absence of aregular dental care system [Figure3].

DISCUSSION

Early detection of carious lesion along withincorporation of a preventive protocol regime is the centralaim towards maintenance of a good oral health status.Caries risk assessment procedure can aid the dentist inachieving these goals. An ideal risk assessment modelshould be inexpensive, easy to use and time efficient witha high degree of accuracy in caries predictive value.8 Inthe present study, ADA risk assessment model was usedto determine caries risk in the adult population.Thisstructured form was simple to adapt on our adultpopulation, cost effective and the results were easilytranslated to the patient. Most importantly, this model wascapable in correctly identifying the high risk patients inour population.

In the present study majority of the patients wererecorded at high caries risk [Figure 2].When riskpercentages were compared on the basis of gender,increased percentage (26%) of females were recorded athigh risk whereas males had almost equal distributionamong moderate and high risk categories [Figure 4].Giacaman ARsupports the results of our study,theyconducted caries risk assessment in Chilean adolescentsand 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 Chinaby Wei Xu19 and Turkey by Go¨kalp SG20, have concludedthat females had higher DMFT scores and higherprevalence of dental caries compared to males, theseresults are consistent with the findings in our study.

In this study the main contributing factors towardsincreased caries risk were the presence of three or moreactive caries lesion at the time of examination,teethextracted due to caries in the past 36 months and absenceof a regular dental care system [Figure 3]. Maher Rconducted a national pathfinder study in all 4 provincesin Pakistan on 1146 individuals, which documented that55% children(aged12-15years) and in 78% adults (aged35-65 years) had active caries lesions and frequency ofmissing tooth in adult was recorded at 82%.21 Anothercross sectional study conducted by Siddiqui TM establishedthat 52.7% rural and 47.3% of urban adult population inKarachi suffers from active dental caries.22 These studiessupport the high prevalence of active carious lesion amongadult population that was determined in our study. HaseebM23 determined the causes of tooth extraction at a tertiarycare center in Pakistan, they reported that 63.1% of alldental

Akhtar H / Naz F /Waseem FS / Shahnawaz D

Caries risk assessment in adult population


extractions were due to advanced dental caries, followedby 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 ismost common contributing factor that leads to dentalextraction.

An important contributing factor determined in ourstudy was that 0% of patients had a regular dental caresystem[Figure 3]. Oral diseases like caries and periodontitisare preventable but results of this study show that anincrease 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 dentalawareness and a general disregard towards dental care.Majority of Pakistani population visits dentist only as alast resort; as a result of which 90% of oral diseases remainundiagnosed.24 Waseem FS observed that almost 48% ofPakistani population had never visited a dentist and 51%of the population visited the dentist only when theyhad a complaint.25 Asadi SGR reported that 8% adultPakistani population never cleaned their teeth while only36% cleaned their teeth every day.26 To counteract thesemeasures oral health programs should be arranged toeducate and promote good oral hygiene habits and regularrecall programs should be instilled in clinical practice andpatients should be kept on follow ups.

Caries risk assessment of communities allowsidentification of high caries risk group and determinesspecific treatment therapies and preventive applicationsthat need to be carried out.5 Cariogram is a computerizedsoftware that uses an algorithm to determine caries riskof an individual and then presents it graphically in theform of a pie chart.27 It is an objective and quantitativemethod for predicting caries risk of a patient. In many ofthe researches conducted Cariogram is chosen as tool ofchoice, because the results can be saved, printed, easilydocumented and clearly explained to the patients. Reportedbarrier towards using this model is inclusion of chair sidesalivary testing with microbial cultures.28 These proceduresare costly, time consuming and can delay the processuntil the culture results are provided by the laboratory.28

When determining caries risk in children the mostcommonly used risk assessment tool is CAMBRA. Theform employs an evidence-based approach to prevent ortreat the cause of dental caries at the earliest stages beforeirreversible damage to the tooth takes place11. Applicationof CAMBRA allows early intervention and theestablishment of a dental home that could reduce the risk

of early childhood caries and improve child`s oral andoverall health.29 Although no particular risk assessmentmodel has been proven to be superior compared to others,scientific evidence claims that a structured multifactorialor a computer based model provides the best clinicalpractice and patient care.30

Limitations of this workinclude, being a cross sectional,single centre study with a small sample size but theinformation revealed in this research is alarming.It is ourrecommendation that further longitudinal studies beconducted on a larger scale in order to obtain a baselinedata, as no statistical information regarding caries riskassessment is available on Pakistani population.

CONCLUSION

1. This study was performed using a modified version ofAmerican Dental Association caries risk assessment modelin an effort to overcome the data insufficiency of cariesrisk 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 thereforeaid in reducing the high burden of caries in our adultpopulation.

Paperpresented at 12thInternational and 32nd NationalPDA congress, held at Expo Centre Karachi, from January23rd - 25th, 2015.

Author Contribution: HA conceived the idea and designedthe study, recorded, analysed and interpreted the data andis responsible for the accuracy of the results and integrityof the research. Also wrote the manuscript and along withother authors was involved in critical review and finalapproval of the manuscript. FN supervised the project andalong with Akhtar H was involved in the designing of thestudy, Critical review and final approval of the manuscript.FSW and DS along with the other authors were involvedin the final approved version of the manuscript.Disclosure: None disclosed

REFERENCES

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to oral health. Bull world health org. 2005;83:661-669.2. Basavaraj P, Khuller N, Khuller RI, Sharma N. Cariesrisk assessment and control. J Oral Health Comm Dent.2011;5:58-63.3. Celik EU, Gokay N, Ates M. Efficiency of caries riskassessment in young adults using Cariogram. Eur J Dent.2012;6:270.4. Sheiham A, James WPT. A new understanding of therelationship between sugars, dental caries and fluorideuse: implications for limits on sugars consumption. PubHealth 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 populationusing a computer-based risk assessment model(Cariogram). J Dent Sci 2012;7:99-104.6. Guo L, Shi W. Salivary biomarkers for caries riskassessment. 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 andManagement. In: Heymann H, Ritter A, Swift E, editors.Sturdevant's Art and Science of Operative Dentistry. 6thed. Canada: Mosby; 2012. p.64-70.9. Fontana M, Gonzalez-Cabezas C. Minimalintervention dentistry: part 2. Caries risk assessment inadults. British Dental journal. 2012;213:447-451.10. Diagnosis and Management of Dental CariesThroughout Life NIH Consensus Statement 2001 March26-28; 18:1-2411. Hurlbutt M. CAMBRA: Best Practices in DentalCaries Management. Academy of Dental Therapeuticsand Stomatology. 2011.12. Alian AY, McNally ME, Fure S, Birkhed D.Assessment of caries risk in elderly patients using theCariogram model. J Can Dent Assoc. 2006;72(5):459.13. http://www.ada.org/~/media/ADA/Science%20and%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 AdultsPatients Attending University Malaya Dental Clinic. Listof conferences, seminars, lectures and workshops 38.16. Giacaman RA, Miranda Reyes P, Bravo León V.

Caries risk assessment in chilean adolescents and adultsand its association with caries experience. Brazilian oralres. 2013;27:7-13.17. Pocock SJ. Clinical Trials Of Practical Approach18. http://www.ada.org/~/media/ADA/Public%20Programs/Files/topics_caries_educational_over6.ashx.19. Xu W, Lu H-X, Li C-R, Zeng X-L. Dental cariesstatus and risk indicators of dental caries among middle-aged adults in Shanghai, China. J Dent Sci. 2014;9:151-157.20. Gökalp S, Dogan BG, Tekçiçek M, Berberoglu A,Unlüer S. National survey of oral health status of childrenand adults in Turkey. Community Dent Hlth. 2010;27:12-17.21. Maher R. Dental disorders in Pakistan-A nationalpathfinder study. J Pak Med Assoc. 1991;41:250-252.22. Siddiqui TM, Wali A, Siddiqui SH, Heyat U, NadeemM, Shamim M. An Epidemiological Study of Prevalenceof Dental Caries and Periodontal Disease among Adultsin Deprived Areas-Karachi. J Oral Hlth Res. 2013;4:3-7.23. Haseeb M, Ali K, Munir MF. Causes of toothextraction at a tertiary care centre in Pakistan. JPMA-Journal of the Pak Med Assoc.2012;62:812.24. Harchandani N. Oral Health Challenges In PakistanAnd 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. PakOral Dent J. 2015;35(01).26. Asadi SGR, Asadi ZG. Chewing sticks and the oralhygiene habits of the adult Pakistani population.International dental journal. 1997;47:275-278.27. Ruiz Miravet A, Almerich Silla JM. Evaluation ofcaries risk in a young adult population. Medicina Oral,Patología Oral y Cirugía Bucal (Internet). 2007;12:412-418.28. http://www.aapd.org/assets/1/7/riskbasedtechbrief.pdf.29. Ramos-Gomez F, Ng M-W. Into the future: keepinghealthy teeth caries free: pediatric CAMBRA protocols.J Canadian Dent Assoc. 2011;39(10):723.30. Twetman S, Fontana M, Featherstone JD. Riskassessment-can we achieve consensus? Community DentOral Epidemiol. 2013;41(1):e64-e70.


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ANNEX 1

1. Caries risk assessment can be defined as the probability of caries incidence over a given period of time.

a. True

b. 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.

a. True

b. False

3. Risk indicators are not the direct causal factor of the disease but, merely the existing signs that the disease

process has occurred.

a. True

b. False

4. The most common risk assessment tool, which is used to determine caries risk especially in children, is

CAMBRA

a. True

b. False

Key:

1. True

2. False

3. True

4. True

CONTINUING EDUCATION




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