Inter and Intra-Examiner Reliability of Pulp Ulcer Fistula Abscess Index in the Representative Sample of Students in Saudi Arabia

Special Article - Dental Public Health

J Dent & Oral Disord. 2016; 2(7): 1037.

Inter and Intra-Examiner Reliability of Pulp Ulcer Fistula Abscess Index in the Representative Sample of Students in Saudi Arabia

Subait AA¹*, Ousaimi MA¹, Shohaib TA¹, Richi HN¹ and El-Metwally A²

¹Department of Public Health, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia

²Department of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia

*Corresponding author: Abeer Al Subait, Department of Public Health, College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Received: May 04, 2016; Accepted: September 27, 2016; Published: October 03, 2016

Abstract

Introduction: No studies have been conducted in Saudi Arabia to assess the reliability of PUFA (Pulp Ulcer Fistula Abscess Index) which is indeed to analyze the functionality and reproducibility for giving a true and unbiased burden of untreated caries.

Methods: This cross-sectional study was conducted at Alnaeem Ibn Hammad Intermediate School from March 1st till 5th. One hundred and forty six students were examined for consequences of caries using PUFA/pufa (permanent/primary) indices. Kappa statistics was calculated for inter and intraexaminer reliability on the same time and for day 1 and 2 in both dentitions.

Results: For day 1 and 2 we found substantial to moderate agreement among two observer for different units of PUFA and pufa scale and for over all scale for primary and permanent dentition. For first observer we found substantial agreement for marking pulpal involvement, fistula, abscess and overall PUFA score. For the second observer we found almost perfect agreement for marking pulpal involvement and overall PUFA score with kappa statistics of 0.90 (CI: 0.82- 0.97 and 0.849 (CI: 0.75- 0.93) respectively. Intra-reliability for first observer had moderate agreement for marking pulpal involvement and overall pufa scores while for second observer we found substantial agreement for marking pulp and overall pufa score with kappa statistics 0.73 (CI: 0.50- 0.96) and 0.66 (CI: 0.41- 0.90) respectively.

Conclusion: Through this study we conclude that PUFA scale is reproducible and functional in determining burden of untreated caries in both primary and secondary dentition as results of over study indicate perfect to fair agreement of inter and intra examiner reliability. Further multicenter studies are recommended to support such findings.

Keywords: Pulp ulcer fistula abscess index; Inter-intra examiner reliability; Saudi Arabia

Introduction

Dental caries; as known; are caused by an imbalance between tooth re-mineralization and demineralization which results in destruction of tooth structure along with having pain and feeling discomfort [1]. In 2007, World Health Organization (WHO) emphasized on promoting new tools for a proper data collection to estimate a true burden of dental caries so that preventive strategies can be formulated [2]. Preventing and controlling dental caries highly depend upon a suitable examinations and correct diagnosis. Thus, it is really important to develop new tools or at least encourage using newly developed ones so a precise assessment of caries can be carried out which is considered very useful for a proper management of caries worldwide [3].

The DMF (Decayed Missing Filled) index which was formulated by Klein, Palmer and Knutson in 1938 has been used long time ago by researchers and clinicians for the assessment of dental caries [4]. The DMF index has many limitations in terms of the scores such as the number of teeth at risk, the assessment is confined on dentinal caries, not valid for elderly people, neither root caries nor progression of these caries can be determined and other few limitations [5,6]. Despite of these limitations, DMF index is still in used because of its validity, reliability and simplicity [3]. To overcome the limitations of DMF, various scales came into existence such as: SC (Significant Caries) index, ICDAS (International Caries Detection and Assessment System), (Specific Caries) index, CAST (Caries Assessment Spectrum and Treatment) index and PUFA (Pulp Ulcer Fistula Abscess) index [3]. The aim of this current article is to validate PUFA scale.

PUFA index was developed to outdo one of the drawbacks of DMF scale and unfortunately, no information is available on the clinical consequences of untreated dental caries, such as pulpal abscess which is considered a serious complication of dental caries [7]. PUFA records show multiple issues such as a visible pulp, oral mucosal ulcerations due to a root fragment or sharp cusp, a fistula and an abscess [3].

Many studies have been conducted in different parts of the world to assess the burden of untreated caries by using PUFA/pufa scores. Recently, a study was conducted in India reported that total 603 students of age 5-6 years old were examined for pufa with mean recorded 0.9 (SD: 1.93) and 38.6% have caries involving pulp. The ratio of untreated caries was 35% concluding that pufa index can be used as a tool to highlight the true burden of untreated dental caries [8]. World-wide different studies have been conducting to document the effectiveness of this scale in terms of assessment of untreated caries [7-12]. However none of the studies have studies the reliability of this tool. The aim of this article is to assess the reliability of PUFA/ pufa score in Saudi Arabia as this tool has shown promising outcomes in other parts of the world. To the best of our knowledge, no studies have been conducted in Saudi Arabia to assess the reliability of PUFA which is indeed an important step to analyze the functionality and reproducibility of such indexes so that can be used in future studies for giving a true and unbiased burden of untreated dental caries.

Materials and Methods

This cross-sectional study was conducted a tone of the National Guard schools; Alnaeem Ibn Hammad Intermediate School from March 1st until March 5th. A convenient sample of 146 intermediate students was examined for consequences of caries using the PUFA/ pufa indices. An approval was obtained from the Ministry of Education’s Office and ethical committee in Riyadh.

Customized Arabic informed consents with codes were given to the principle for distribution. After collecting the consent form an assigned teacher was given the lists of all classes and be requested to bring the students to the examination venue; one class at a time. The students were called by the teacher one after other in the same order written in the lists and any absent student was then highlighted right away.

The list was folded and handed back to the first examiner so that only the students’ codes were visible without knowing their names. Each student was called to be examined by the first examiner. After that, the student was guided to go directly to the adjacent room to be examined again by the second examiner which allows the student to return back to his class once the examination was completed. Absentees in the first and second days were examined in the third day that is March 3rd. All students were reexamined by the same both examiners two days after their first examination except for 10 students who were be absent on that day ending up with a total of 136 students.

Exclusion criteria

Students with special needs were excluded.

Data collection

Each tooth could be scored either as PUFA/pufa, or not scored at all. Then, the number of permanent teeth with pulpal involvement was counted to be recorded as P score, teeth with soft tissue ulceration were counted to be recorded as U score, teeth with a fistula were counted to be recorded as F score and teeth with an abscess were counted to be recorded as a score. The total summation of PUFA was recorded as PUFA score for each case. In the same way, pufa for primary teeth was recorded and the final score were ranged between 0-32 for PUFA index; including the third molars and 0-20 for pufa index.

Calibration

Two examiners were trained well by an experienced oral epidemiologist one week before starting the study to measure PUFA/ pufa indices. The session was lasting for 10 minutes looking at various photos of teeth with pulpal involvement, fistula, abscess, and soft tissue ulceration caused by sharp tooth edges.

Examination

All examinations were carried out by two independent examiners through visual examination using disposable mouth mirror and 2X2 gauze as well. The both examinations; performed by the first examiner and the second examiner were taken place in the library of the school and another room connected to the library respectively. A number of 146 students were examined on the first day by both examiners comparing with 136 students were examined two days later by the same examiners.

Statistical analysis

Data were entered twice using SPSS version 20.Inter and intraexaminer reliability of PUFA/pufa and PUFA/pufa scores were calculated using kappa statistics. Inter-examiner reliability was calculated twice; during the first examination and second examination respectively ended with calculated mean. The mean of all reliabilities was calculated to come up with an overall reliability of PUFA/pufa indices.

Results

Kappa statistics was calculated for inter and intra-examiner reliability of PUFA/pufa, and PUFA/pufa scores on the same day and for day 1 and 2 in permanent and primary dentations. For day 1, a substantial agreement was found between two observers of marking pulpal involvement in permanent dentition with kappa value of 0.75 (CI: 0.64-0.88). Total number of 104 students, were marked as free cavity from both observers. For fistula, a moderate agreement was found in permanent dentition among both observers with kappa statistics of 0.56 (CI: 0.07-1.00). Total number of 141 students, were marked as having no fistula in any tooth by both observers. For abscess, a slight agreement was found among both observers with kappa statistics of 0.19 (CI: 0.00-0.47). For overall PUFA score, a substantial agreement was found among both observers with kappa statistics of 0.70 (CI: 0.52-0.78) (Table 1).