pufa/PUFA index–a new index to assess caries activity

Abstract

Purpose: to present general data on the pulp involvement index – pufa / PUFA and to assess complicated caries in a group of preschool children using this index.

Material and method: descriptive observational retrospective study on dental files of 161 children (91 boys) aged 5, examined and treated in the Pedodontics Department, Carol Davila University Bucharest during 2001-2020.Data about the dental status of primary teeth (PT) existing on the arch at the time of first examination were obtained from the dental files.Caries prevalence index (Ip), carious experience indices (dmft/s) and pufa index were calculated, the dmft-pufa ratio was assessed and the caries distribution was analyzed.Statistical analysis was performed with SPSS 20.0, using ANOVA, t-test and Pearson correlation (p=0.05).

Results: Ip=97.51%; dmft=5.49±3.96; dmfs=11.08±10.67. Out of 3202 examined PT, 232 (7.24%) had complicated caries: 50 (21.55%) with pulpitis and 182 (78.44%) with pulp necrosis. pufa index=1.45±1.58; pufa_boys=1.53±1.62; pufa_girls=1.35±1.51(p=0.473); p=0.82±1.34; u=0.01±0.13; f=0.37±0.64; a=0.22±0.46. The”p” component accounted for 56.72% of the whole pufa index.

Conclusions: 1) The pufa index is an essential completion to the classical indices, allowing the assessment of the complicated caries. 2) High carious experience in primary dentition was noticed in this study sample, more than two thirds (69.56%) of the examined children having at least one tooth with pulp involvement (pufa index>0). 3) Based on pufa index, future epidemiological studies can be initiated and they are even recommended to be performed on large population groups, allowing comparisons also regarding complicated caries, thus providing data much closer to the real situation.

Key words: preschool children, complicated caries, pufa index

Introduction

Dental caries continue to be a public health problem, especially in underdeveloped or developing countries [1,2]. Even in developed countries where in recent years noncavitated caries have become more common than cavitated lesions [3], there are still population groups, especially those with a low socio-economic level, which have an increased caries risk [1]. In this context, it is still necessary to carry out epidemiological studies to assess caries experience in large samples and in relation to different factors, the assessment of carious activity being done by different methods.

Until recently, only the classic indices were used: dmft/DMFT, SiC and ICDAS. A disadvantage of these indices has always been the fact that they register decayed, missing or treated teeth without providing information about pulp damage. Therefore, it has become necessary to identify an index to quantify the clinical consequences of untreated caries. To date, global data about the prevalence of cases with pulp damage is scarce and, even if it exists, it has been difficult to make comparisons as a standardized system could not be used.

Thus, in 2010 Monse et al. [4], with the approval of World Dental Federation (FDI), introduced a new index – the pufa/PUFA index. It complements the classical indications by providing additional information on the clinical consequences of untreated caries, in this case on pulp involvement, for the primary dentition using the term “pufa” and for the permanent “PUFA”. The index has 4 components: component p/P – records teeth with carious lesions that open the pulp chamber or teeth in the form of root debris, component u/U – records traumatic ulcerations that occur on the soft tissues (oral mucosa, jugal mucosa, tongue) due to the sharp edges of teeth with complicated caries, including root debris, component f/F shows the fistulas near the teeth with pulp damage, component a/A – records the abscess with the starting point of the teeth with pulp involvement [4].

The pufa/PUFA index is a cumulative score, being calculated for each patient in the same way as the dmft/DMFT index, namely: the number of teeth corresponding to the pufa/PUFA diagnostic criteria is added together.Permanent teeth and primary teeth are assessed separately.The maximum score for a patient can vary between 0 and 20 for primary dentition and between 0 and 32 for permanent dentition [4].

In this context, the aim of the paper has been to assess the damage caused by complicated caries in a group of preschool children using the pufa index.

Material and method

A descriptive observational retrospective study was conducted on the dental files of 161 children (91 boys) aged 5, examined and treated in the Pedodontics Department, Bucharest, during 2001-2020.The inclusion criteria were: non-syndromic patients, aged between 60 and 71 months, with completed and accurate dental files.The exclusion criteria were: age less than or older than 5 years, children with chronic diseases, incomplete dental records. Data on dental status were selected: caries free, teeth with uncomplicated or complicated carious lesions, treated or untreated. Caries prevalence index (Ip), dmft/dmfs indices and pufa index were calculated, the dmft-pufa ratio was assessed and the caries distribution was analyzed. Statistical processing was performed with SPSS 20.0, using ANOVA, t-test and Pearson correlation (p=0.05).

Results

            The caries prevalence in the studied group was 97.51%: 97.80% in boys and 97.14% in girls, the differences between the two sexes being notstatistically significant (p>0.05).

Of the 3202 teeth examined, 77.27% were caries free, 25.4% had untreated carious lesions and 1.77% had fillings. Of the untreated carious lesions, 71.64% were uncomplicated and 28.36% were complicated. The distribution of teeth with complicated carious lesions is shown in Figure 1.

The mean values of the carious experience indices were: dmft = 5.29±3.96 and dmfs = 11.08±10.67. The mean value of pufa index was 1.45±1.58 (with values ranging from 0 to 8). According to gender, the pufa index was 1.53±1.62 in boys and 1.35±1.51 in girls, the differences being notstatistically significant (p=0.473). The analysis by components showed that ”p” component – simple pulp damage predominated, representing 56.72% of the entire index (Table I.).

Table I. pufa index by components

The distribution of the pufa index components relative to the two arches shows that in the upper arch pulp damage predominated in the incisors, while in primary molars, both in the maxilla and in the mandible there was an equal proportion of both pulp damage and involvement of surrounding tissues (Figs. 2, 3). Analyzing by gender, it was found that boys had more complicated pulp necrosis with externalized periodontitis than girls (Fig. 4).

Analyzing the relationship between dmft indices and pufa, it was noticed that as the dmft index increased, so did pufa index, with a positive and strong relationship between the two indices (r=0.9661). Table II and figure 5 show the range of values in which the dmft index varies for a certain value of the pufa index for the study group.

Table II. pufa scores and mean dmft values

Discussions

Early childhood caries is a common condition in preschool children in Romania (Munteanu et al., 2010) [5]. Untreated caries of primary teeth can lead to pain, discomfort, sleep and nutrition disorders, thus affecting the quality of life of children (Gudipaneni et al, 2020) [6]. Therefore, in this study, the complications of caries in the primary dentition were analyzed, using the pufa index, and also a correlation between the caries experience indices and pufawas made. The 5-year-old age group was chosen because it is a Word Health Organization (WHO) reference group and because caries experience in primary dentition is an important predictor of caries experience in permanent dentition.

The caries prevalence in primary dentition in children aged 5 years examined at the PedodonticDepartment, Faculty of Dentistry, Carol Davila University, Bucharest between 2001-2020 was 97.51%, which means that only 4 patients were caries free (dmft=0), while most of children already had at least one carious lesion by the age of 5. Table III compares the values ​​obtained in the present study with those reported in similar studies conducted in various countries.

Table III. Caries prevalence index for 5 year old children – comparative data

Regarding the assessment of pulp damage, it was found that more than two thirds (69.56%) of children aged 5 at the time of examination had at least one tooth with complicated caries (pufa index>0), so that for the whole group the pufa scorewas 1.45±1.58.This value is comparable to those reported in other studies (Table IV).

Table IV.pufa index for 5 year olds from the general population – comparative data

The largest component was the pulp damage component p – 56.72%. Thus, the p component was 0.82±1.34, followed by the fistula component f = 0.37±0.64, the abscess component a = 0.22±0.46 and the ulceration component u = 0.01±0.13.Similar results were obtained in other studies (Table V).

Table V.pufa components for 5 year old children – comparative data

Related to gender, it was found that 58.3% of boys had at least one tooth with pufa, thus obtaining a higher index value of 1.53±1.62, compared to that of girls -1.35±1.51.However, the difference was not statistically significant (p=0.473). Grund et al. (2011) also noted a higher mean value of pufa in boys (0.1±0.7) than in girls (0.0±0.2) [12]. Compared to present study, higher values ​​of pufa were calculated for Polish children examined by Bagińska et al. (2011): pufa_boys=2.73±3.82, pufa_girls=1.55±2.77 [11].

In the present study, the most affected teeth and those with the highest values ​​of the pufa index were lowersecond molars, followed by lower first molars and upper first molars. The lowest values ​​were recorded in the lower front group. Table VI shows the percentage distribution of the pufa index on groups of teeth compared to the values ​​obtained by Grund et al. [12].

Table VI.pufaindex distribution by dental group – comparative data

There was a positive and strong correlation between dmft and pufa indices, so that for a number between 9 and 19 decayed teeth, 8 had complicated caries. A positive correlation was found by both Grund et al. (2011) [12] and Bagińska et al. (2011) [11]. The analysis of the relationship between dmft and pufa must be viewed from several angles. First, the pufa index can never be higher than the carious experience index for the same person or group of people analyzed. It can be at most equal to dmft. Second, there is an upward trend in dmft as the pufa index score increases, so the higher the pufa index, the higher the mean value of dmftindex. However, this connection is not the other way around, so there may be a case where a person/ group of people has a high dmft value even when the mean value of pufa index is 0, as there are only uncomplicated caries.

Over time, however, there have been reactions to the pufa index. In 2013, the Polish authors Baginska and Stokowska [13], starting from the pufa index, proposed a new index – the prs/PRS index (pulpal involvement – roots – sepsis index). In addition, to assessing the clinical consequences of untreated caries, it also sets out the treatment requirements for each stage, as shown in Table VII [13].

Table VII. prs/PRS index (by Baginska&Stokowska [13])

The authors also established a relation between the two indexes (tab.VIII) [13].

Table VIII. PUFA-PRS relation (as perBaginskaandStokowska [13])

On the other hand, Frigueiro et al. [14] and Murthy et al. [15] suggested that “f” and “a” codes of the pufa index should be merged because they refer to the same inflammatory process of the bone and represent only different stages of inflammation. In this context, it should be considered that the pufa index was not designed to serve as an index of the need for treatment, but to quantify the severity of dental caries and to assess the presence of dental infections [16].

CONCLUSIONS

1) The pufa index is an essential completion to the classical indices, allowing the assessment of the complicated caries.

2) High carious experience in primary dentition was noticed in this study sample, more than two thirds (69.56%) of the examined children having at least one tooth with pulp involvement (pufa index>0).

3) Based on pufa index, future epidemiological studies can be initiated and they are even recommended to be performed on large population groups, allowing comparisons regarding also complicated caries, thus providing data much closer to the real situation.

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