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\def\RunningAuthor{Anjaneyulu K et al.}
\firstPage{578}
\articleType{Original Article}
\receivedDate{30 Sep 2020}
\acceptedDate{20 Dec 2020}
\revisedDate{02 Dec 2020}
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\title{\textbf{Relationship between class 1 dental caries and sextant involving caries among patients visiting the outpatient department of Saveetha Dental College, Chennai, India}}
\author{Ankita~Komal~Labh\textsuperscript{1},  
            Anjaneyulu~K\textsuperscript{*}\textsuperscript{2}, 
            Geo~Mani\textsuperscript{3}~\\[5pt]{\textsuperscript{1}Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai {\textendash} 600 077, Tamil Nadu, India}~\\{\textsuperscript{2}Department of Conservative Dentistry and Endodontics, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai {\textendash} 600 077, Tamil Nadu, India }~\\{\textsuperscript{3}Department of Pedodontics and Preventive Dentistry, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai {\textendash} 600 077, Tamil Nadu, India}}

\begin{abstract}
Depending upon the site of the tooth, accessibility of oral hygiene products like toothbrush, tooth floss etc. different teeth have varying susceptibility to getting infected by cariogenic bacteria. Plaque accumulation, occlusal morphology, oral hygiene practices etc. play an important role in determining the susceptibility of teeth towards caries. A retrospective cross-sectional study was conducted using patient records from the Dental College, Chennai after reviewing and analysing the data of 86000 patients between June 2019 and March 2020. The variables involved were age, gender and site of carious teeth. Data were then exported to the Statistical Package for Social Sciences (SPSS) for Windows (Version 19, 2010) for further analysis. The total sample size was 19014. The sample had a gender distribution of 55.56\% males and 44.44\% females. Class 1 dental caries was found to be most prevalent in sextant 6 that is the lower right posterior teeth region. Least incidence of class 1 DC was noted in sextant 5, which is the lower anterior teeth. Young adults (18-35 years) had the highest incidence of class 1 dental caries (p{\textless}0.05). Among males and females, respectively, class 1 caries was most prevalent in sextant 6 (p{\textless}0.05). Within the limits of the study, it can be concluded that caries experience is highest in mandibular posteriors. There was a slight male predilection in the prevalence of class 1 dental caries. Young adults in the age group, 18-35 years, have the highest incidence of class 1 DC.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Class 1,\newline dental caries,\newline G.V. Black,\newline mandibular posteriors,\newline molars etc.
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Anjaneyulu~K~\\ Phone:\ 9566151527~\\  Email:\ kanjaneyulu.sdc@saveetha.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
Dental caries is one of the most prevalent chronic diseases of people worldwide. Individuals are susceptible to this throughout their lifetime. \unskip~\citep{969346:21096637} It is a cause of great pain and discomfort if left untreated for a long period of time. \unskip~\citep{969346:21096632} Dissolution of tooth structure weakens the crown often resulting in fracture of the tooth. \unskip~\citep{969346:21096622}

The susceptibility of individual tooth surfaces to dental caries varies vastly. \unskip~\citep{969346:21096628} Also, the spread of dental caries varies greatly from tooth to tooth and surface-to-surface. There is evidence that occlusal caries precedes other types of caries in the spread. It has the highest prevalence in molars. \unskip~\citep{969346:21096616}

Caries prevalence also varies based on gender. There is a higher prevalence seen in females due to various factors such as the early eruption of teeth in girls, frequent snacking during food preparation, pregnancy etc. Due to hormonal fluctuations during several events such as puberty, menstruation, pregnancy etc., the oral environment is highly cariogenic in women. \unskip~\citep{969346:21096633}

There are various other factors that may lead to caries. \unskip~\citep{969346:21096623} These include inadequate salivary flow and composition, high numbers of cariogenic bacteria, insufficient fluoride exposure, gingival recession, immunological components, genetic factors, among others. \unskip~\citep{969346:21096637} Host matrix metalloproteinases get activated, leading to dentin matrix breakdown in the course of dental caries. \unskip~\citep{969346:21096620}

Diagnostic tests such as thermal test, electric pulp test, pulse oximeter etc. are employed to check the vitality of the tooth. \unskip~\citep{969346:21096634} Efficient removal of carious lesions is necessary to prevent recurrence of caries. \unskip~\citep{969346:21096618,969346:21096619} The treatment of dental caries depends on various factors such as remaining dentin thickness, pulpal involvement, vitality tests etc. \unskip~\citep{969346:21096615} Commonly used dental materials used for cavity filling are resin composite, flowable composite, GIC, amalgam, gold etc. \unskip~\citep{969346:21096638,969346:21096631} Veneers and laminates can be used for the aesthetic management of caries in anterior teeth. \unskip~\citep{969346:21096624} Traditional medicines such as neem, tulsi, grape seed extract etc. have been advised for the prevention of dental caries. \unskip~\citep{969346:21096630} In the case of the incipient lesion, remineralisation pastes can be used to reverse the cariogenic activity. \unskip~\citep{969346:21096625} Proper brushing technique, frequent usage of floss, chlorhexidine mouthwash should be advised to prevent dental caries. \unskip~\citep{969346:21096617}
    
\section{Materials and Methods}
\textbf{Study design and setting}

This is a retrospective cross-sectional study in which patient records from a Dental College, Chennai were obtained. Data was collected for patients reporting to the Department of Conservative Dentistry and Endodontics after reviewing patient records and analysing the data of 86000 patients from June 2019- April 2020 who had class 1 dental caries.

\textbf{Data Collection}

A total of 19014 cases of class 1 dental caries were identified. Other relevant data such as age, gender, patient ID, patient name etc., were also recorded. Repeated patient data and incomplete records were excluded. Clinical photos and radiographs were used to verify the site of dental caries. Data was also verified by an external reviewer.

\textbf{Statistical analysis}

Data were recorded in Microsoft Excel and later exported to the Statistical Package for Social Sciences for Windows (Version 19, 2010) after proper coding of the variables involved. These variables included were gender (1. Male, 2. Female), age (1. 18-35 years, 2. 36-55 years, 3. {\textgreater}56 years) and site of caries involvement (1. Sextant 1- 18-14, 2. Sextant 2- 13-23, 3. Sextant 3- 24-28, 4. Sextant 4- 38-34, 5. Sextant 5- 33-43, 6. Sextant 6- 44-48). Thereafter, the data were subjected to statistical analysis using the Statistical Package for Social Sciences (SPSS) for Windows (Version 19, 2010). Chi-square test was employed with the level of significance set at p{\textless}0.05. Appropriate graphs, tables and charts were constructed using the same software for a clear representation of the results obtained.
    
\section{Results and Discussion}
The final data consisted of 19014 cases of patients with class 1 dental caries (DC). Gender distribution among the patients was found to be - 55.56\% males and 44.44\% females. (Table~\ref{tw-01c8ea7e0f6c}, Figure~\ref{f-161650a129b2}) Incidence of class 1 DC in the different age groups was 72.6\% in 18-35-year-olds, 25.2\% in 36-55 years olds and 2.2\% in {\textgreater} 56-year-olds. (Table~\ref{tw-68ef4be8a25d}, Figure~\ref{f-cf49f2dfa18f}) The distribution of site of occurrence of class 1 DC in decreasing order of incidence was 31.51\% in sextant 6, 30.95\% in sextant 4, 18.31\% in sextant 1, 18.08\% in sextant 3, 1.09\% in sextant 2 and 0.06\% in sextant 5. (Table~\ref{tw-983102378c95}, Figure~\ref{f-67d28f42792c}) Chi-square test done between gender and site class 1 DC (Table~\ref{tw-51e006331d24}, Figure~\ref{f-e0dc73ba9e47}), and age and site of class 1 DC (Table~\ref{tw-1c01b0a978ef}, Figure~\ref{f-60b4bee3ef69}) had p{\textless}0.05 making the data statistically significant.


\begin{table*}[!htbp]
\caption{\boldmath {Age distribution in patients with Class 1 Dental Caries. 18-35 years (72.6\%), 36-55 years (25.2\%) and 56+ years (2.2\%)} }
\label{tw-68ef4be8a25d}
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\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Age groups & \cAlignHack Frequency  & \cAlignHack Percent \\
\tblmidrule 
\cAlignHack 18-35 years  &
  \cAlignHack 13796 &
  \cAlignHack 72.6\\
\cAlignHack 36-55 years  &
  \cAlignHack 4792  &
  \cAlignHack 25.2 \\
\cAlignHack 56+ years  &
  \cAlignHack 426 &
  \cAlignHack 2.2\\
\cAlignHack Total  &
  \cAlignHack 19014  &
  \cAlignHack 100.0 \\
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\begin{table*}[!htbp]
\caption{\boldmath {Gender distribution among patients with Class 1 Dental Caries. Females 44.4\%, Males 55.6\%} }
\label{tw-01c8ea7e0f6c}
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\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Gender & \cAlignHack Frequency  & \cAlignHack Percent \\
\tblmidrule 
\cAlignHack Male  &
  \cAlignHack 10564 &
  \cAlignHack 55.6\\
\cAlignHack Female  &
  \cAlignHack 8450  &
  \cAlignHack 44.4 \\
\cAlignHack Total  &
  \cAlignHack 19014 &
  \cAlignHack 100.0\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Distribution of site of Class 1 Dental Caries. Sextant 1 (18.31\%), Sextant 2 (1.09\%), Sextant 3 (18.08\%), Sextant 4 (30.95\%), Sextant 5 (0.06\%) and Sextant 6 (31.51\%)} }
\label{tw-983102378c95}
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\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Site & \cAlignHack Frequency   & \cAlignHack Percent \\
\tblmidrule 
\cAlignHack Sextant 1  &
  \cAlignHack 3481 &
  \cAlignHack 18.2\\
\cAlignHack Sextant 2  &
  \cAlignHack 207  &
  \cAlignHack 1.1 \\
\cAlignHack Sextant 3  &
  \cAlignHack 3438 &
  \cAlignHack 18.1\\
\cAlignHack Sextant 4  &
  \cAlignHack 5885  &
  \cAlignHack 31.0 \\
\cAlignHack Sextant 5  &
  \cAlignHack 11 &
  \cAlignHack 0.1\\
\cAlignHack Sextant 6  &
  \cAlignHack 5992  &
  \cAlignHack 31.5 \\
\cAlignHack Total  &
  \cAlignHack 19014 &
  \cAlignHack 100.0\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Cross-tabulation of gender and site of class 1 dental caries (DC)} }
\label{tw-51e006331d24}
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\begin{tabulary}{\linewidth}{p{\dimexpr.1111111111111111\linewidth-2\tabcolsep}p{\dimexpr.1111111111111111\linewidth-2\tabcolsep}p{\dimexpr.1111111111111111\linewidth-2\tabcolsep}p{\dimexpr.1111111111111111\linewidth-2\tabcolsep}p{\dimexpr.11111111111111114\linewidth-2\tabcolsep}p{\dimexpr.10648888888888893\linewidth-2\tabcolsep}p{\dimexpr.11848888888888895\linewidth-2\tabcolsep}p{\dimexpr.1046666666666667\linewidth-2\tabcolsep}p{\dimexpr.11480000000000006\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Gender & \cAlignHack  & \cAlignHack  & \multicolumn{2}{p{\dimexpr(.22222222222222225\linewidth-2\tabcolsep)}}{\cAlignHack Site} & \cAlignHack  & \cAlignHack  & \cAlignHack Total & \cAlignHack P-value\\
\rowcolor{kwdboxcolor}\cAlignHack  & \cAlignHack Sextant 1 & \cAlignHack Sextant 2 & \cAlignHack Sextant 3 & \cAlignHack Sextant 4 & \cAlignHack Sextant 5 & \cAlignHack Sextant 6 & \cAlignHack  & \cAlignHack \\
\tblmidrule 
\cAlignHack Male &
  \cAlignHack 1879 &
  \cAlignHack 130 &
  \cAlignHack 1813 &
  \cAlignHack 3329 &
  \cAlignHack 7 &
  \cAlignHack 3406 &
  \cAlignHack 10564 &
  \cAlignHack \\
\cAlignHack Female &
  \cAlignHack 1602 &
  \cAlignHack 77 &
  \cAlignHack 1625 &
  \cAlignHack 2556 &
  \cAlignHack 4 &
  \cAlignHack 2586 &
  \cAlignHack 8450 &
  \cAlignHack 0.000\\
\cAlignHack Total &
  \cAlignHack 3481 &
  \cAlignHack 207 &
  \cAlignHack 3438 &
  \cAlignHack 5885 &
  \cAlignHack 11 &
  \cAlignHack 5992 &
  \cAlignHack 19014 &
  \cAlignHack \\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{Chi-square test - Gender vs Site of class 1 dental caries. p=0.000. Data is statistically significant}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Cross-tabulation of age and site of class 1 dental caries (DC)} }
\label{tw-1c01b0a978ef}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1111111111111111\linewidth-2\tabcolsep}p{\dimexpr.1111111111111111\linewidth-2\tabcolsep}p{\dimexpr.1111111111111111\linewidth-2\tabcolsep}p{\dimexpr.1111111111111111\linewidth-2\tabcolsep}p{\dimexpr.11111111111111114\linewidth-2\tabcolsep}p{\dimexpr.11204444444444448\linewidth-2\tabcolsep}p{\dimexpr.11200000000000003\linewidth-2\tabcolsep}p{\dimexpr.1046666666666667\linewidth-2\tabcolsep}p{\dimexpr.11573333333333336\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Age & \cAlignHack  & \multicolumn{4}{p{\dimexpr(.44537777777777784\linewidth-2\tabcolsep)}}{\cAlignHack Number of missing teeth} & \cAlignHack  & \cAlignHack Total & \cAlignHack P-value\\
\rowcolor{kwdboxcolor}\cAlignHack  & \cAlignHack Sextant 1 & \cAlignHack Sextant 2 & \cAlignHack Sextant 3 & \cAlignHack Sextant 4 & \cAlignHack Sextant 5 & \cAlignHack Sextant 6 & \cAlignHack  & \cAlignHack \\
\tblmidrule 
\cAlignHack 18-35 years &
  \cAlignHack 2570 &
  \cAlignHack 152 &
  \cAlignHack 2525 &
  \cAlignHack 4241 &
  \cAlignHack 5 &
  \cAlignHack 4303 &
  \cAlignHack 13796 &
  \cAlignHack \\
\cAlignHack 36-55 years &
  \cAlignHack 845 &
  \cAlignHack 46 &
  \cAlignHack 849 &
  \cAlignHack 1504 &
  \cAlignHack 5 &
  \cAlignHack 1543 &
  \cAlignHack 4792 &
  \cAlignHack 0.000\\
\cAlignHack 56+ years &
  \cAlignHack 66 &
  \cAlignHack 9 &
  \cAlignHack 64 &
  \cAlignHack 140 &
  \cAlignHack 1 &
  \cAlignHack 146 &
  \cAlignHack 426 &
  \cAlignHack \\
\cAlignHack Total &
  \cAlignHack 3481 &
  \cAlignHack 207 &
  \cAlignHack 3438 &
  \cAlignHack 5885 &
  \cAlignHack 11 &
  \cAlignHack 5992 &
  \cAlignHack 19014 &
  \cAlignHack \\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{Chi-square test - Age vs Site of class 1 dental caries. p=0.029. Data is statistically significant}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\bgroup
\fixFloatSize{images/d0481648-8c49-483b-8a66-2b59a5249bec-upicture1.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/d0481648-8c49-483b-8a66-2b59a5249bec-upicture1.png}{\includegraphics{images/d0481648-8c49-483b-8a66-2b59a5249bec-upicture1.png}}{}
\makeatother 
\caption{\boldmath {Pie chart showing age distribution in patients with Class 1 Dental Caries. 18-35 years (72.6\%), 36-55 years (25.2\%) and 56+ years (2.2\%).}}
\label{f-cf49f2dfa18f}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/49f9b85d-e6f5-4b32-8638-3d8a7c57603d-upicture2.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/49f9b85d-e6f5-4b32-8638-3d8a7c57603d-upicture2.png}{\includegraphics{images/49f9b85d-e6f5-4b32-8638-3d8a7c57603d-upicture2.png}}{}
\makeatother 
\caption{\boldmath {Pie chart showing gender distribution among patients with Class 1 Dental Caries. Females 44.4\%, Males 55.6\%}}
\label{f-161650a129b2}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/274787cc-f88f-4676-832e-8d917219ca95-upicture3.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/274787cc-f88f-4676-832e-8d917219ca95-upicture3.png}{\includegraphics{images/274787cc-f88f-4676-832e-8d917219ca95-upicture3.png}}{}
\makeatother 
\caption{\boldmath {Pie chart showing distribution of site of Class 1 Dental Caries. Sextant 1 (18.31\%), Sextant 2 (1.09\%), Sextant 3 (18.08\%), Sextant 4(30.95\%), Sextant 5 (0.06\%) and Sextant 6 (31.51\%)}}
\label{f-67d28f42792c}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/7ab425fd-9b7d-4b80-a041-a211e4ef2a21-upicture4.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/7ab425fd-9b7d-4b80-a041-a211e4ef2a21-upicture4.png}{\includegraphics{images/7ab425fd-9b7d-4b80-a041-a211e4ef2a21-upicture4.png}}{}
\makeatother 
\caption{\boldmath {Bar graph showing an association between gender and site of class 1 dental caries}}
\label{f-e0dc73ba9e47}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/56b7b044-51b6-4815-98b4-2e7a94cee683-upicture5.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/56b7b044-51b6-4815-98b4-2e7a94cee683-upicture5.png}{\includegraphics{images/56b7b044-51b6-4815-98b4-2e7a94cee683-upicture5.png}}{}
\makeatother 
\caption{\boldmath {Bar graph showing an association between age and site of class 1 dental caries}}
\label{f-60b4bee3ef69}
\end{figure}
\egroup
From Figure~\ref{f-e0dc73ba9e47}, X-axis denotes gender and Y-axis denotes the site of Class 1 Dental Caries. This graph represents the correlation of gender and site of class 1 dental caries where blue colour denotes sextant 1, and green denotes sextant 2, white denotes sextant 3, purple denotes sextant 4, yellow denotes sextant 5 and red denotes sextant 6. It shows that most Class 1 DC have occurred in sextant 6 in both males and females followed by sextant 4. Least number of Class 1 DC was seen in sextant 5 among both genders. (Chi-square test; p-value=0.000; statistically significant) Data has a statistically significant association.

From Figure~\ref{f-60b4bee3ef69}, X-axis denotes age and Y-axis denotes the site of Class 1 Dental Caries. This graph represents the chi-square analysis of age and site of class 1 dental caries where blue colour denotes sextant 1, and green denotes sextant 2, white denotes sextant 3, purple denotes sextant 4, yellow denotes sextant 5 and red denotes sextant 6. The most common site of class 1 DC among all 3 age groups was sextant 6 followed by sextant 4. Least common sites were sextant 5 and sextant 2 in all age groups. (Chi-square test; p-value=0.029; statistically significant) Data has a statistically significant association.

In the present study, it is revealed that the incidence of class 1 DC is higher in the mandibular posterior region than other areas. When comparing incidence between upper and lower jaws, caries is seen more frequently in the mandible (62.52\%) than the maxilla (37.48\%). Also, caries incidence shows a male predilection. (Table~\ref{tw-01c8ea7e0f6c}, Figure~\ref{f-161650a129b2})

According to a study by Demirci et al., the caries incidence is higher in the maxillary jaw (62.4\%) than the mandibular jaw (37.6\%)\unskip~\citep{969346:21096636}. This contradiction could be due to the high sample size in the present study. However, an interarch analysis of caries revealed that the mandibular arch was more affected by dental caries than the maxillary arch. In the mandibular arch, the molars were most commonly involved. \unskip~\citep{969346:21096635}

In the same study by \unskip~\cite{969346:21096636}, it was reported that caries had a slightly higher female predilection (59.1\%) among genders. The reason for such opposing findings could be the high prevalence of certain oral habits such as tobacco chewing, smoking etc. among males in the Indian subcontinent, which is known to increase the susceptibility of dental caries. \unskip~\citep{969346:21096627}

A study by Chestnutt et al. suggested that molar occlusal surfaces have the highest susceptibility to attack by cariogenic bacteria. Also, the highest incidence of caries in this study was in pit and fissures, which are most commonly found in molars and premolars\unskip~\citep{969346:21096629}. The first molar was reported to be the most commonly affected tooth, followed by the second molar. \unskip~\citep{969346:21096621} These studies are in line with the present study as the incidence of class DC in posterior teeth is 98.95\%. (Table~\ref{tw-983102378c95}, Figure~\ref{f-67d28f42792c})

Hopcraft et al. reported that first molar teeth had the highest caries experience and caries was present more frequently on the occlusal surfaces than on the proximal surfaces. \unskip~\citep{969346:21096626}
    
\section{Conclusion}
Within the limits of the study, it can be concluded that class 1 dental caries is most prevalent in mandibular molars and premolars. There is a male predominance in its occurrence and is seen mostly in the age group of 18-35 years. 

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study.

\textbf{Funding Support}

The authors declare that they have no funding support for this study.
    

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