gudinofernadezetal

INTRODUCTION

Dental caries is a multifactorial disease, showing the interrelation between biological and social factors (1). Biologically, dental caries is characterized by a dysbiotic process produced when the dental biofilms move from a balanced and diverse microorganism of low cariogenicity, to a high cariogenicity population of microorganisms (2). This can result in an increased production of organic acids, promoting a hard tissue net mineral loss. The first carious lesion is not clinically visible, nevertheless, if the intraoral buffer mechanisms do not break the demineralization process, it can continue to a incipient enamel lesion (3).

Socially, more than a half of the world’s population is affected by untreated oral conditions (4), being caries in permanent teeth the most prevalent condition evaluated between 1990 to 2015 (5). Additionally, dental decay touches primarily the most disadvantage populations (6), showing a strong social gradient, both between and within countries (7,8). Thus, it continues to represent a public health challenge, particularly for low- and middle-income countries (LMIC’s) (9). Previous studies have shown that dental caries prevalence is increasing in the developing world (9), particularly due to the growing availability and consumption of industrialized sugars (10).

Another limitation regarding LMIC’s, is the lack of reliable information, especially in specific risk population subgroups. This is particularly the case for adolescents and young adults. A 2019 WHO & UNICEF report on youth health stated that “most countries do not know the magnitude of the disease burden, health needs and barriers to services” (11). Indeed, compared to other range age, studies in young people remain rare (12) and are conducted mainly in high income countries. Evidence from industrialized economies have shown that, while the prevalence of untreated caries lesions and the number of decayed, filled, or missing teeth (known as caries experience) have been, in average, declining in children (13) and adolescents (14), this progress has been accompanied by an increase of the social gradient of inequality (15). However, limited information is available regarding dental caries prevalence in Latin American young people, with the exception of Brazil (16). Two previous studies have assessed dental decay in young individuals in Costa Rica. One of them was conducted in 1986, and focused on access to health care (17). The second one (2017), evaluated dental caries in 201 children and adolescents in government’s foster-care institutions (18). Costa Rica’s last representative survey was conducted in 1999, among 12-year-old (19), reporting a caries experience prevalence of 71.9%, and a mean number of Decayed / Filled / Filled and Decayed / Missed for dental caries (DMFT -WHO) (20) of 2.46 (19).

Costa Rica has a national health care system, constitutionally conceptualized as universal, mandatory and solidarity for all citizens (21). Although, the health system includes some aspects of dental health, it remains quite limited. For instance, WHO estimations from 2013, indicated that only 600 state-employed dentists were in charge of attending all public dental needs in the country (22). These leaves the great majority of dental services to private practice (23), since we account for nearly 5446 dentists in Costa Rica, for a variable dentists-to-population ratio of 11 for 10000 inhabitants (24), doubling the average density in the Organization for Economic Cooperation and Development (OECD) member countries (6.1/10000 inhabitants). Disadvantaged Costa Ricans, and particularly young people, are often excluded from the universal health coverage (11), increasing their vulnerability.

This study aims to assess the prevalence and severity of dental caries among Costa Rican male students aged 12-22 years using ICDAS-II. This is the first study conducted exclusively in young students using a standardized caries indicator in Costa Rica, and could be useful to better implement and guide future public dental health policies and interventions.

METHODS

Study design and participants

A cross-sectional study was performed using data from Costa Rican male students aged 12-22 years, who attend a nonprofit social welfare school run by the Order of Augustinian Recollects called “Ciudad de los Niños” (Children’s City). This organization was originally created to receive street children, coming from urban and rural areas, such as, indigenous areas, or those whose parents cannot take care of them. The institution functions as a boarding school, and receives partial financial support by the Costa Rican government, allowing students to receive an economic incentive during the academic cycle and technical capacitation in automotive mechanics, electromechanics, precision mechanics and agroindustry.

All teenage high school students without orthodontic appliances were invited to participate in the study, representing an initial population of 499 persons in 2019. Thirty-one persons decided not to participate in the study, forty were excluded, either for orthodontic reasons or because they were not present at the moment of data collection (N=71). The final sample size included 428 persons, representing 86% of the original population.

Data collection was carried out during two weeks in February 2019 on site. Previous to the clinical examination, participants were asked to clean their teeth with a new tooth brush under supervision. Dental school students reinforce individual dental brushing and flossing to ensure that tooth surfaces were clean. The participants completed a self-reported questionnaire and were clinically examined for caries detection using three portable dental units, equipped with individual lamps. The examination was performed at the same hours in the morning in a well-ventilated and well-illuminated large room. The examiners systematically dyed the dental surfaces with sterile gauze, and performed dental examination using a sterile mouth mirror. All instruments used were sterilized following the infections protocol control of the University of Costa Rica Dentistry Faculty, using external and internal controls in each cycle of sterilization. The subjects with dental emergencies were immediately referred to the Dentistry Faculty for the needed dental care.

ICDAS system and researcher’s calibration

The clinical data was collected following the International Caries Detection and Assessment System (ICDAS-II), derived from the International Caries Classification and Management System ICCMS (25). The system has been recommended for clinical practice, research and development of public health programs. ICDAS-II allows a clinical and visual method for caries detection from the earliest states, allowing an assessment of both severity and level of activity of the caries lesions. It comprises 7 codes according to the caries lesion severity, being code 1 the first clinical observed change of disturbance in the enamel, and 7 the most severe caries lesion (Table 1) (26). ICDAS-II is considered as a robust scoring system to assess the severity and activity of coronal caries lesions, showing a strong correlation with histology, and allows a substantial level of reproducibility and accuracy for assessing primary coronal caries lesions (16). When including the level of activity (27), two additional codes were added for codes 1 and 2 (1 active, 1 inactive / 2 active, 2 inactive) (Table 1). The WHO 11.5 metallic ball- ended probe was only used in case of a diagnostic uncertainty.

Mesial and distal surfaces were not systematically recorded, since the clinical examination was only based on the examiner’s observations, and a radiographic study was not ran.

Three examiners (KMC, SGF, AGF) were previously calibrated on ICDAS, and underwent a recalibration process with the University of Bergen, Norway given by a professor in Pediatric Dentistry. Timepoint 1: the three examiners underwent a theoretical training session according to ICDAS II criteria. The examiners underwent a laboratory practice session with clinical pictures and previously diagnosed extracted teeth affected by different degrees of caries severity. Then, the clinical calibration exercises took place and the scoring results of each examiner were compared to the gold standard. This part of the calibration process was performed during a time period of a week. Timepoint 2: Finally, 10 days later a re-assessment of some clinical pictures and results of the children caries exam by surfaces of each examiner were compared with those previously achieved at Timepoint 1. Test 1 (inter-examiner) showed a mean weighted Cohen’s kappa of 0.84 (individual weighted Cohen’s kappa: KMC: 0.85, SGF: 0.82, AGF: 0.84). The mean weighted Cohen’s kappa for Test 2 (intra-examiner) was 0.90 (individual weighted Cohen’s kappa: KMC:0.94, SGF:0.81, AGF:0.97).

Ethics and data

Written informed consent was obtained from the boarding school Principal, as the general proxy and legal representative of all students. Participants read and signed the informed consent form and to ensure the wiliness and autonomy to participate in the study, voluntary abstention was considered for exclusion. A second written informed consent was completed by each participant directly, for both minors and adults. The ethical approval was given by the Institutional Science and Ethics Committee of the University of Costa Rica (VI-5629-CEC-0008-2018), in conformity to recognized international standards, the Declaration of Helsinki and according to the national law of biomedical research.

Measurements

Prevalence of dental caries experience in the sample

Represents the percentage of the population with untreated caries lesions, filled, decayed, lost and healthy. Prevalence of dental caries experience was calculated dividing the total number teeth filled / filled & decayed / decayed / lost by the total number of participants (428).

The statistical unit used is the individual (Table 2).

Prevalence of dental caries experience according to total teeth

Represents the percentage of the total number of teeth filled / filled & decayed / decayed / lost, divided by the total of theoretical teeth that should be present (28 teeth per person, excluding 68 temporary teeth). The statistical unit used is the tooth (Table 3).

Prevalence of dental caries in the teeth sample using ICDAS

Classification according to the caries severity and caries level of activity, using the ICDAS codes (see Table 1 and Table 4).

Most affected teeth

We assessed highest caries experience by teeth (Table 5).

Mean number of Decayed, Missing, and Filled Permanent Teeth (mean DMFT) in the sample

The mean number of DMFT is the sum of individual DMFT values divided by the sum of the population.

We calculated the DMFT indicator following the WHO recommendations (taking into account only cavitated caries lesions) and taking the ICDAS codes as threshold (taking into account incipient caries lesions) (Table 6).

Statistical analyses

Descriptive statistics were carried out using STATA V14.

RESULTS

Table 1 presents the description if ICDAS codes used in this study. Table 2 shows the results of the prevalence of dental caries experience in the sample. This study examined 428 young male students aged 12-22 with mean age of 15 years old. The total average prevalence of dental caries was found to be 83%, 15% of the study sample have lost a tooth due to dental decay, 61% of the sample have at least one filled tooth, 36% of the population have at least one filled and decayed tooth, 4% of the population have at least 1 missing tooth for causes other than dental caries Finally, 6% of the population was classified as completely “healthy”, having all their teeth classified as sound. Table 2 also shows the prevalence by age range, being those in the 18-22 category the most affected by all the caries experience assessed.

Table 3 shows the prevalence of dental caries experience taking as a statistic unite the tooth. In total 11984 teeth were examined; temporary teeth were excluded from the analyses (n=84). The final sample represented 11916 permanent teeth, of which, 71.4% were classified as sound, 8.2% filled, 2.1% filled and decayed, 17.0% decayed, 1.0% absent due to caries, and 0.2% were lost for other reasons than caries. On average, from 28 teeth present in the mouth, 8.3 had some kind of caries experience.

Table 4 indicate the prevalence of dental caries using ICDAS classification. The most frequent caries lesion found in the sample is codes 2-Inactive (46.7%), followed by code 1-Inactive (23.8%). In general, codes 1 and 2 represent the large majority of dental decay observed in the sample, counting for 83% of all dental caries lesions. The most severe caries lesions found are also the least frequent (code 5: 5.6% and code 6: 0.9%).

Table 5 shows the impact of dental experience according to two-digit notation codes for the adult dentition based on the World Dental Federation (FDI) nomenclature (28). The group of teeth more impacted by caries experience are the lower and upper first permanent molars in the next order: 46 (79.8%), 36 (78.9%), 16 (69.6%) and 26 (69%), followed by the second lower and upper permanent molars of each arch: 37 (62.9%), 47 (58.4), 27 (47.9%) and 17 (43.2%). The third group of teeth more impacted are the first upper premolars: 24 (36.7%), 14 (34.9%), followed by the lower second premolars: 45 (30%), 35 (26.5%). The least impacted are the lower permanent incisors.

Table 6 presents the DMFT-WHO indicator calculated using ICDAS codes. According to WHO, the criteria to record carious crown is “an unmistakable cavity, undermined enamel, or a detectably softened floor or wall” (29). The equivalency point between these two systems was at score 3 of the ICDAS II in this particular study. If we use the code 3 to identified only cavitated caries, DMFT indicator drops to 3.94 from 7.89, mean index considering a caries lesion from ICDAS code 1.

Table 7 shows the distribution of the mean number of caries lesions by age according to ICDAS codes 1 to 6 among the studied population, that reflects the natural history of the disease, the higher mean was identified in the 18 years old and over, (11.5;CI [10.3-12.6]), and the lowest mean number in the 12-13-year-old group (6.1; [CI 5.3-6.9]).

DISCUSSION

This study showed that prevalence of dental caries was 83% among young male from a boarding school in Costa Rica, while only 6% was classified as completely healthy. Additionally, when calculating DMFT-WHO indicator, the mean index using ICDAS-II 1-6>0 codes was estimated at 7.89 (using ICDAS code 1 as threshold). However, for ICDAS-II 3-6>0 (threshold considered at 4, following WHO definitions of caries), the index decreases to 3.94. Finally, we revealed that ICDAS-II codes 1 and 2 represented the large majority of dental decay lesions, and the most affected teeth were the lower and upper first permanent molars.

The prevalence of dental caries and mean DMFT index found in this study, is higher compared to certain international investigations conducted in children and adolescents. For instance, in a 2010 study in children and adolescents aged 5, 12 and 15 in Denmark (30), the DMFT index in was estimated at 2.2. A study in France estimated prevalence of dental caries in young students at 43% (31). However, these findings are difficult to compare, since the indicators and methodology used are not equivalent. There are relatively few studies using ICDAS-II among adolescents or young adults. Arangannal et al., presented, using ICDAS-II, that children and adolescents in India had an average prevalence of 68.8% (32). In Spain, a study indicated that prevalence using caries lesions ICDAS-II 1-6>0 as threshold for 15-year-old was 84.8%, quite similar to the findings in our study (33). Only one study has used ICDAS-II in Costa Rica, and it showed that caries prevalence among foster-care children aged between 2 and 17-year-old was estimated at 96.35% (18). Sugar availability and cultural-related factors, such as health behaviors, can explain the differences average prevalence found between countries (34). However, regarding Costa Rican’s studies, differences can be partially explained by the existence of social inequalities in oral health. It is not surprising to find the highest caries prevalence in adolescents in foster-care, being an extremely vulnerable group cumulating several social and health risks. Our study sample represents as well a vulnerable population, coming mainly from socioeconomically disadvantaged areas and families. Thus, prevalence differences can be found if diverse socioeconomic groups are analyzed. The existence of a strong social gradient in oral health in Costa Rica was already been suggested in previous studies (35,36).

Regarding the caries experience–from an incipient carious lesion to the filled teeth–this study showed the least fillings (47%) to be found on the youngest population (12-13 years old). The group between 18-22 years exhibited the highest number of cavities (92%), and the largest number of teeth with fillings (80%). This can probably relate to an existent, but delayed, access to health care when it comes to dental treatments, strongly suggested by the relation to the percentage of participants that received dental care, which increases according to age. Of all examined teeth with history of disease, 39.9%, were restored or extracted, consistent with previous literature where the history of dental decay increases with age (33). According to Shulman and Cappelli: “the longer a tooth is exposed to the oral environment, the more time for the caries process to work. Although DMFT index increases with age, the contribution of decay decreases and that of the filled and missing components increases”(37).

Previous epidemiological surveys using ICDAS-II on adolescents in disadvantaged communities have revealed a higher prevalence of codes 1 and 2 compared to the other codes (38). In our study, the activity of dental caries was only evaluated at the initial stages, demonstrating that carious lesions can often become inactive and stop its advance. This indicates that oral health education and access to topical and community fluoridations (39), are essential to intervene in the natural progress of the disease avoiding severe stages (40).

We additionally showed that the lower and upper first permanent molars are the group of teeth more impacted with caries lesions. Due to the mean age of the participants, they had a higher number of permanent molars and premolars in active eruption process. In this process, the “groove-fossa system” is under greater risk by the thick biofilm accumulation (41). There is also evidence that proper oral hygiene on the occlusal surface of partially erupted teeth is difficult (42), and there is a significant reduction in detectable dental biofilm in fully erupted teeth, compared to the partly erupted; because mechanical oral function of partially erupted teeth is limited (43,44). Matching with our results, it has already been reported that occlusal molars surfaces are the most caries susceptible of all. From the most susceptible to the least susceptible surfaces, it can be cited: occlusal surface of the four first molars, occlusal surface of the lower second molars, occlusal surface of the upper second molars, mesial surface of the upper first molars (45-47).

The main limitation of this study relates to the non-representative sample of young people. It was conducted in a sample with only young males, coming from socially deprived groups compared to the general population. However, the sample comprises individuals from all the national territory, and allowed to validate a study design for future epidemiological studies. It generates valuable data to present before financial institutions for future research projects. Future studies should be based in a representative sample of young individuals representing both sex/gender and all social groups in the country.

Despite these limitations, this study presents several strengths. It is the first research in Costa Rica adapting a study protocol exclusively for young individuals with a significant sample. We ran this study using a validated methodology such as ICDAS-II, with three calibrated examiners, producing robust and reproductible results.

CONCLUSION

These findings have shown that dental caries experience continues to represent one of the main public health burdens in Costa Rica. Our study shows dental decay as the most prevalent disease in young male in socially and economically deprived groups. This justifies the need for new oral health promotion approaches, considering health and disease social determinants. Oral health education, preventive and not invasive dental treatments, such as timely and appropriate fluoride applications at the individual and community level, are to be considered. Finally, our study shows the urgency for the social security system to prioritize real access to healthcare for young people and adolescents in the country.

References

Gomaa N., Glogauer M., Tenenbaum H., Siddiqi A., Quiñonez C. Social-Biological Interactions in Oral Disease: A ‘Cells to Society’ View. Divaris K, editor. PLoS One [Internet]. 2016 Jan 11; 11 (1): e0146218. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709106/
Kilian M., Chapple I.L.C., Hannig M., Marsh P.D., Meuric V., Pedersen A.M.L., et al. The oral microbiome - an update for oral healthcare professionals. Br Dent J. 2016; 221 (10): 657-66.
Fejerskov O., Larsen M.J. Demineralization and remineralization: the key to understanding clinical manifestations of dental caries. In: Kidd E, Fejerskov O, Edwina BN, editors. The Disease and Its Clinical Management. Third Edit. Oxford: Wiley-Blackwell; 2015. p. 155-70.
World Health Organization. Oral Health [Internet]. Available from: https://www.who.int/news-room/fact-sheets/detail/oral-health
Kassebaum N.J., Smith A.G.C., Bernabé E., Fleming T.D., Reynolds A.E., Vos T., et al. Global, Regional, and National Prevalence, Incidence, and Disability-Adjusted Life Years for Oral Conditions for 195 Countries, 1990-2015: A Systematic Analysis for the Global Burden of Diseases, Injuries, and Risk Factors. J Dent Res [Internet]. 2017; 96 (4): 380-7. Available from: https://doi.org/10.1177/0022034517693566
FDI World Dental Federation. The Challenge of Oral Disease-A call for global action. The Oral Health Atlas. 2nd ed. Geneva; 2015. 120 p.
Kwan S., Petersen P.E. Equity, social determinant and public health programmes. Blas E., Kurup A.S., editors. Geneva; 2010. 293 p.
Schwendicke F., Dörfer C.E., Schlattmann P., Page L.F., Thomson W.M., Paris S. Socioeconomic inequality and caries: A systematic review and meta-analysis. J Dent Res. 2015; 94 (1): 10-8.
Petersen P.E. The World Oral Health Report 2003 WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003; 31 Suppl 1: 3-23.
Masood M., Masood Y., Newton T. Impact of national income and inequality on sugar and caries relationship. Caries Res. 2012; 46 (6): 581-8.
WHO & UNICEF. Adolescent Health: the Missing Population in Universal Health Coverage [Internet]. 2019. p. 32. Available from: https://www.who.int/pmnch/media/news/2018/Adolescent-Health-Missing-Population-in-UHC.pdf?ua=1
Warren J.J., Van Buren J.M., Levy S.M., Marshall T.A., Cavanaugh J.E., Curtis A.M., et al. Dental caries clusters among adolescents. Community Dent Oral Epidemiol [Internet]. 2017/07/03. 2017 Dec; 45 (6): 538-44. Available from: https://pubmed.ncbi.nlm.nih.gov/28671327
Santamaria R.M., Basner R., Schüler E., Splieth C.H. Inequalities in dental caries experience among 6-year-old German children after the caries decline. Acta Odontol Scand [Internet]. 2015 May; 73 (4): 285-291. Available from: https://doi.org/10.3109/00016357.2014.939711
Marthaler T.M. Changes in dental caries 1953-2003. Caries Res. 2004; 38 (3): 173-81.
Petersen P.E., Bourgeois D., Ogawa H., Estupinan-Day S., Ndiaye C. The global burden of oral diseases and risks to oral health. Bull World Health Organ. 2005; 83 (9): 661-9.
Gimenez T., Bispo B.A., Souza D.P., Viganó M.E., Wanderley M.T., Mendes F.M., et al. Does the Decline in Caries Prevalence of Latin American and Caribbean Children Continue in the New Century? Evidence from Systematic Review with Meta-Analysis. PLoS One [Internet]. 2016 Oct 21; 11 (10):e0164903-e0164903. Available from: https://pubmed.ncbi.nlm.nih.gov/27768737
Brenes W., Sosa D. Epidemiología bucal y accesibilidad a los servicios adontológicos de un grupo de adolescentes. Rev costarric cienc méd [Internet]. 1986; 1 (1): 331-7. Available from: https://www.binasss.sa.cr/revistas/rccm/v7n4/art5.pdf
Solis-Riggioni A., Gallardo-Barquero C., Chavarria-Bolanos D. Prevalence and Severity of Dental Caries in Foster-Care Children and Adolescents. J Clin Pediatr Dent. 2018; 42 (4): 269-72.
Tere Salas M., Solórzano I., Chavarría P. Documento técnico #6 - Encuesta Nacional de Salud Oral - Caries Dental [Internet]. San José, Costa Rica; 1999. Available from: http://www.binasss.sa.cr/opac-ms//media/digitales/Encuesta nacional de salud oral 1999.pdf
WHO. Mean number of Decayed, Missing, and Filled Permanent Teeth (mean DMFT) among the 12-year-old age group [Internet]. Available from: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/3812
Herrero R., Ortíz Barboza A., Muñoz G., Torres G., Guevara M., Vargas R.M., et al. Costa Rica. In: Curado MP, Edwards B, Shin HR, Storm H, Ferlay J, Heanue M, et al., editors. Cancer incidence in five continents: vol IX. Lyon; 2007. p. 961.
WHO. Dentistry personnel [Internet]. Global Health Observatory data repository. 2013. Available from: https://apps.who.int/gho/data/node.main.HWF2
Peraza-Valverde J., Vega-Espinoza A. Estudio de oferta de servicios odontológicos 2012-2014. Rev Científica Odontológica. 2014; 10 (1): 9-22.
Barboza-Solís C., Brenes-Gómez W., Brenes-Vásquez L. Evolution of the demographic characteristics of the population of dental professionals in the college of dental surgeons of Costa Rica between 1951-2017. Rev Científica Odontológica. 2019; 15 (1): 1-9.
Pitts N.B., Bds F., Rcs F.D.S., Fds E., Edin R.C.S., Uk F., et al. ICCMS TM Guide for Practitioners and Educators.
Ismail A.I., Sohn W., Tellez M., Amaya A., Sen A., Hasson H., et al. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol. 2007 Jun; 35 (3): 170-8.
Dikmen B. ICDAS II CRITERIA (International Caries Detection and Assessment System). J Istanbul Univ Fac Dent [Internet]. 2015; 49 (3): 63-72. Available from: http://dx.doi.org/10.17096/jiufd.38691
FDI World Dental Federation. FDI Two-Digit Notation [Internet]. Available from: https://web.archive.org/web/20070401074213/http://www.fdiworldental.org/resources/5_0notation.html
World Health Organization. Mean number of Decayed, Missing, and Filled Permanent Teeth (mean DMFT) among the 12-year-old age group [Internet]. Available from: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/3812
Christensen L.B., Petersen P.E., Hede B. Oral health in children in Denmark under different public dental health care schemes. Community Dent Health. 2010 Jun; 27 (2): 94-101.
FEUR E., LABEYRIE C., BOUCHER J., EID A., CABUT S., DIB S., et al. Indicateurs de santé chez les collégiens et lycéens du Val-de-Marne, France, en 2005: excès pondéral, atteinte carieuse et risque de dépression. Bull épidémiologique Hebd [Internet]. 2007;1 (4): 29-33. Available from: http://www.refdoc.fr/Detailnotice?idarticle
Arangannal P., Mahadev S.K., Jayaprakash J. Prevalence of dental caries among school children in Chennai, based on ICDAS II. J Clin Diagnostic Res. 2016; 10 (4): ZC09-12.
Almerich-Silla J-M, Boronat-Ferrer T, Montiel-Company J-M, Iranzo-Cortes J-E. Caries prevalence in children from Valencia (Spain) using ICDAS II criteria, 2010. Med Oral Patol Oral Cir Bucal. 2014 Nov;19 (6): e574-80.
Macgregor I.D., Balding J., Regis D. Toothbrushing schedule, motivation and “lifestyle” behaviours in 7,770 young adolescents. Community Dent Health. 1996 Dec; 13 (4): 232-7.
Barboza Solís C., Fantin R. The Role of Socioeconomic Position in Determining Tooth Loss in Elderly Costa Rican: Findings from the CRELES Cohort . Vol. 19, Odovtos International Journal of Dental Sciences . scielo ; 2017. p.79-94.
Fantin R., Delpierre C., Kelly-Irving M., Barboza Solis C. Early socioeconomic conditions and severe tooth loss in middle-aged Costa Ricans. Community Dent Oral Epidemiol. 2018 Apr; 46 (2):178-84.
Shulman J.D., Cappelli D.P. Epidemiology of Dental Caries. In: Cappelli DP, Mobley C.C., editors. Prevention in Clinical Oral Health Care. Elsevier; 2008. p. 2-13.
Melgar R.A., Pereira J.T., Luz P.B., Hugo FN, Araujo FB de. Differential Impacts of Caries Classification in Children and Adults: A Comparison of ICDAS and DMF-T. Braz Dent J. 2016; 27 (6): 761-6.
Hobbs M., Wade A., Jones P., Marek L., Tomintz M., Sharma K., et al. Area-level deprivation, childhood dental ambulatory sensitive hospitalizations and community water fluoridation: evidence from New Zealand. Int J Epidemiol [Internet]. 2020; Available from: https://doi.org/10.1093/ije/dyaa043
de Amorim R.G., Figueiredo M.J., Leal S.C., Mulder J., Frencken J.E. Caries experience in a child population in a deprived area of Brazil, using ICDAS II. Clin Oral Investig. 2012 Apr;16 (2): 513-20.
Ekstrand K.R., Ricketts D.N., Kidd E.A. Occlusal caries: pathology, diagnosis and logical management. Dent Update. 2001 Oct; 28 (8): 380-7.
Pitts N.B., Zero D.T., Marsh P.D., Ekstrand K., Weintraub J.A., Ramos-Gomez F., et al. Dental caries. Nat Rev Dis Prim. 2017 May; 3:17030.
Carvalho J.C., Ekstrand K.R., Thylstrup A. Dental plaque and caries on occlusal surfaces of first permanent molars in relation to stage of eruption. J Dent Res. 1989 May; 68 (5): 773-9.
Carvalho J.C. Caries process on occlusal surfaces: evolving evidence and understanding. Caries Res. 2014; 48 (4): 339-46.
Hannigan A., O’Mullane D.M., Barry D., Schafer F., Roberts A.J. A caries susceptibility classification of tooth surfaces by survival time. Caries Res. 2000; 34 (2): 103-8.
Carlos J.P., Gittelsohn A.M. Longitudinal studies of the natural history of caries. II. A life-table study of caries incidence in the permanent teeth. Arch Oral Biol. 1965; 10 (5): 739-51.
Batchelor P.A., Sheiham A. Grouping of tooth surfaces by susceptibility to caries: a study in 5-16 year-old children. BMC Oral Health. 2004 Oct; 4 (1): 2.