METHODS OF MEASURING DENTAL CARIES Measurements of the intensity of dental caries, such as the proportion of first molars lost

through caries and the percentage of permanent teeth affected, have been used since the early 20th century. Both of these methods were useful when there was little information of any kind about the disease, but they were not sensitive. At the other extreme, the Bodeckers' index, described in 1931, was sensitive but complicated. Dean and his colleagues used a systematic approach to counting the numbers of teeth in the mouth visibly affected by caries in their pioneering studies of the caries-fluoride relationship. The first description of what is now known as the DMF index is usually attributed to Klein, Palmer, and Knutson in their studies of dental caries in Hagerstown, Maryland, in the 1930s. Since then, the DMF index has received practically universal acceptance and is probably the best known of all dental indexes. The DMF, an irreversible index, is applied only to permanent teeth. As originally described, D was for decayed teeth; M, teeth missing due to caries; and F, teeth that had been previously filled. Filled teeth were assumed to have been unequivocally decayed prior to restoration. The DMF score for any one individual can range from 0 to 32, in whole numbers. A mean DMF score for a group, being the total of individual values divided by the number of subjects examined, can have fractional values. The DMF index can be applied to whole teeth (designated as DMFT) or to surfaces (DMFS). Modifications can be made to the index for such factors as teeth that have been filled and have redecayed, secondary caries, crowned teeth, bridge pontics, and any other particular attribute required for a study. To save time in a large survey, DMF can be used half-mouth, applied to opposite diagonal quadrants and the score doubled, an approach that assumes the bilateral nature of caries. The DMF index for permanent teeth is always signified by uppercase letters; the equivalent index for the primary dentition is the def and its modifications, signified by lowercase letters. As originally defined, d stood for decayed teeth, e meant indicated for extraction, and f was filled teeth. In the def index, teeth missing for caries are not recorded because of the frequent difficulty of distinguishing between extracted and naturally exfoliated primary teeth. Modifications of this index are

(a) dmf for use in children before ages of exfoliation, (b) dmf applied only to the primary molar teeth, and (c) the df index in which missing teeth are ignored. Values for df and def should be numerically the same; def allows for two grades of caries and neither index counts missing teeth. Both def and df may therefore understate the true extent of the carious attack, though the greater reliability gained by ignoring missing teeth is often seen as a net benefit. Other methods of measuring dental caries using a different philosophical base from that of the DMF index have been suggested ' One is Grainger's hierarchy, an ordinal scale designed to simplify the recording of the caries status of a population, which uses five zones of severity of the carious attack. It has been shown to be valid, but has received little further use, probably because of low sensitivity. The DMF index, in fact, has received remarkably little challenge over more than 50 years of life, probably because it has proven so versatile for studying dental caries throughout the world. Limitation of the DMF index No index is perfect, however, and even the venerable DMF has its limitations. The principal ones are these: 1. DMF values are not related to the number of teeth at risk. A DMF score for an individual is a simple count of those teeth that in the examiner's judgment have been affected by caries; it has no denominator. A DMF score thus does not directly give an indication of the intensity of the attack in any one individual. A seven-year-old child with a DMF score of 3.0 may have only 9 permanent teeth in the mouth; thus, one third of these teeth have already been attacked by caries in a short space of time. An adult may have a DMF score of 8.0 from a full complement of 32 teeth; thus, over a longer period of time only one quarter of the teeth have been affected. DMF scores therefore have little meaning unless age is also stated. 2. The DMF index can be invalid in older adults because teeth can become lost for reasons other than caries. Although caries appears to be the greatest single

global reason for tooth loss, many teeth are also extracted for other reasons. This is especially the case in adults aged 60 or older, among whom the M component of a DMF score is not a valid reflection of teeth lost because of caries. 3. The DMF index can be misleading in children whose teeth have been extracted for orthodontic reasons. In some child populations there is heavy loss of bicuspids in the course of orthodontic treatment. Their inclusion in the M component of the DMF score would obviously be invalid. The same line of thought applies to extracted third molars in young adults, given that removal of a symptomatic third molars is common. 4. The DMF index can overestimate caries experience in teeth with "preventive restorations," or where treatment services are intense. Some dentists place restorations in teeth that, although not yet carious, they think may decay in the future. In an epidemiological survey, such teeth must be included in the F component of DMF, although had they not been filled in the first place they might have been diagnosed as sound teeth. Where this practice is common, DMF scores will be inflated. 5. DMF cannot be used for root caries. Root caries begins below the cementoenamel junction following recession of the gingivae. Prevalence measures are useful, but if intensity is to be measured the number of lesions should be related to the root surfaces at risk (i.e., exposed to the oral environment), rather than to the number of teeth present. Because it occurs at a different period of life from most corona caries lesions, and because teeth with root lesions often already have coronal lesions, root caries needs to be measured separately from coronal caries. 6. DMF cannot account for sealed teeth. Sealants did not exist in 1938, so are obviously not included in the description of the index. Here is where the DMF index shows its age; sealants and other composite restorations for cosmetic purposes have to be dealt with separately. There are two plausible approaches to dealing with sealants in the DMF index. One says that the sealed tooth is not restored in the classic sense and should therefore be considered sound. The

other says that it has required hands-on, one-to-one dental attention, and so should be considered a filled tooth. Probably the best way to deal with sealed teeth is to put them in a category by themselves, S for sealed. The DMFS index would then become DMFSS. Composite restorations judged to have been placed only for cosmetic reasons should not be included in DMF, though they are a measure of dental treatment received. They too need separate consideration. With modern preventive and restorative technology, DMF is becoming outdated. The unquestioned assumption at the time of its inception was that restored teeth represented caries, an assumption that cannot be accepted so readily today. It is philosophically questionable to use an index for a disease that is so dependent on the treatment judgments of many practitioners for its quantification. A measure of caries activity would be preferable for many purposes, but until such a measure arrives DMF will continue to be used. The results of its use, however, should always be interpreted thoughtfully. Criteria for Diagnosing Coronal Caries There are no globally accepted criteria for diagnosing dental caries, despite a vast quantity of words on the subject. Different traditions about defining a lesion in the gray area", where it is difficult to tell whether the disease is irreversibly established or not, have grown up and are still adhered to. It is known that by the time caries can be clinically detected by either visual or radiographic methods, a lesion is histologically well established. Diagnosis of a sound tooth is not difficult, nor is diagnosis of an obvious lesion. The disease process in between, however, requires carefully defined criteria and an examiner who can adhere to them during many examinations. The cost of using unequivocal criteria, however, is that some real or suspected lesions can be misclassified. Criteria for diagnosis of caries used in North America, Britain, and the other English-speaking countries tend toward the dichotomous (yes-no) variety, whereas some European investigators use much stricter criteria in which grades of carious lesions are diagnosed. Use of the European criteria requires a longer, more meticulous

survey examination and could lead to a greater degree of examiner inconsistency because of the increased number of diagnostic decisions that have to be made. Like many research planning decisions, trade-offs are required here: the European criteria should give a more accurate estimate of disease progression, though at the risk of greater examiner inconsistency (or greater demands on examiner standardization). As always, choices are often dictated by the reasons for collecting the data. Trade-offs are also required when the use of radiographs is being considered in a caries study. The greater diagnostic sensitivity they provide can be outweighed by the necessity for yet another set of diagnostic decisions that require their own criteria; additional risk of inconsistency is thus added. (There are other factors in the use of radiographs as well, such as the ethical issues of exposing participants to radiation unnecessarily. A study sample can become biased through the refusal of some participants to be radiographed. There is also the cost and logistics of using radiographs in a caries field study to be considered.) In the 1990s, radiographs are not usually used in caries clinical trials. Root Caries As suggested earlier, the DMF index is not designed for use with root caries. Useful information has come from expressing a simple prevalence of the condition, meaning the proportion of a defined population or subgroup with at least one root lesion, and from the mean number of carious or restored lesions per person. For many purposes, these measures are sufficient The criteria most frequently used to diagnose root caries were first described by Banting and his colleagues for a Canadian study in 1980. The clinical examination was carried out after a thorough prophylaxis, after which root caries was diagnosed according to the criteria shown in Table. These criteria have proved to be versatile. Root lesions, however, are becoming increasingly difficult to detect because they are more commonly found as small, discrete lesions on a single root surface rather than circumscribing a root. While most lesions occur on exposed root surfaces, 10.0% and 12.5% of all root lesions detected have been found on teeth without gingival recession.

Inability to sometimes detect the cementoenamel junction, either because of obliteration by restorations or calculus adds to the difficulties.

Table. Criteria for diagnosing root surface caries 1. There is a discrete, well-defined, and discolored soft area. 2. The explorer enters easily and displays some resistance to withdrawal. 3. The lesion is located either at the cementoenamel junction or wholly on the root surface. 4. Restored root lesions are counted only if it is obvious that the lesion originates at the cementoenamel junction or is confined to the root surface completely. The Root Caries Index (RCI), also first described in 1980, was intended to make the simple prevalence measures more specific by including the concept of teeth at risk (in contrast to the DMF usage). As described by Katz, a tooth is considered to be at risk of root caries if enough gingival recession has occurred to expose part of the cemental surface to the oral environment. The RCI is computed by scoring root lesions and restorations and noting teeth with gingival recession, according to the following formula:

Root surfaces: (decayed + filled) Root surfaces: (decayed + filled + sound)

100

The index can be computed for an individual, for particular tooth types, or for a population at large. A community RCI of 6.9% means that of all teeth with gingival recession, 6.9% were decayed or filled on the root surfaces. (As with the use of any index scores, results are most useful if a measure of distribution of the condition is also presented, since means can be unduly weighted by a small number of individuals with severe disease.) In his description of the RCI, Katz acknowledged the chances of underestimation brought on by gingival overgrowth subsequent to the loss of periodontal attachment.

Because he considered this occurrence to be unusual, Katz decided to leave the criteria for the index as stated. As noted above, however, 10% or more of all root lesions recorded are of this type. In a later discussion, Katz noted that there still was not a working definition of root caries, and that until one was adopted it would be difficult to standardize the collection of root caries data. Caries Treatment Needs At first glance, assessment of a group's treatment needs by epidemiological survey seems simple enough. In fact, it becomes more complicated because A. B. the criteria used to diagnose caries in a survey are not necessarily those used by practitioners when examining their patients; perceived needs, dental awareness, and ability or willingness to pay all C. D. a practitioner has to look at a patient's long-term needs, whereas a influence treatment carried out; survey does not; and treatment philosophy can change quite rapidly with expanding knowledge and Because surveys are usually conducted under less than ideal conditions, relative to the dental office, it would be expected that surveys detect fewer needs than practitioners do. Although that has been shown to be true, it begs the question of which assessment is "correct." Field surveys can miss incipient lesions, but practitioners can also over diagnose. In addition, treatment plans for the same patients have been shown to vary drastically from dentist to dentist. The World Health Organization (WHO), however, includes a subjective treatment-need assessment by the examiner as part of its Pathfinder survey method. The difficulties in determining treatment need by survey have been illustrated by a fascinating series of reports from Scotland. They began with the 1978 national dental survey in Britain, in the course of which 720 dentate adults in Scotland agreed to permit their dental records to be followed over sub sequent years. After three years, records showed that while 863 teeth in this group had been assessed as needing restorative care in the survey, 3,108 actually had been restored. That could perhaps be technological developments.

explained by lesions missed under the poorer survey conditions, but if that explanation is accepted then the next finding has no logic: of the 863 teeth classified as needing restorative treatment in the survey, only 271 (31%) were in the 3,108 restored (115). This shows that the care carried out, rather than being an extension of the survey results, in fact bore no relation to them. There were similar findings with prosthetic treatment (49). "Dental needs" were assessed by examiners in the first National Health and Nutrition Examination Survey (NHANES I) of 1971-1974, and 65% of the population were judged as being in need of care. A similar assessment was made with the first national survey of schoolchildren in 1979 1980, when 37% of schoolchildren were judged to be in need of restorative care. The validity of these figures is debatable, and they also have received little use. In more recent national surveys, treatment need assessments were not carried out.