Abstract
Objectives:
This paper demonstrates International Caries Detection and Assessment System (ICDAS) training procedures and inter/intra-examiner reliability for lesion severity, activity, and filling criteria in an elementary school setting.
Methods:
ICDAS training was conducted in December 2021 prior to a school-based cluster-randomized controlled trial. A total of 59 children (6–8 years old) in grades 1–2 from one school in Houston, Texas were recruited. Two licensed dentists received a five-day training from an ICDAS trainer at the participating school. Thirty-eight children were evaluated at least once by each dental trainee, and 18 had repeat examinations. The ICDAS criteria were used to classify dental caries lesion severity (0–6), lesion activity (active/inactive), and filling material (0–9) of all visually available primary and permanent tooth surfaces. Inter and intra- examiner reliability between each dental trainee and the “gold standard” trainer was evaluated using Kappa statistics.
Results:
For lesion severity, the examination indicated an inter-rater weighted Kappa of 0.77 (95% CI 0.71–0.82) and 0.82 (95% CI 0.77–0.87) for each trainee examiner compared to the gold standard examiner. The Kappas increased slightly from the first to second examinations (lesion-weighted Kappa: 0.77 to 0.84 and 0.82 to 0.84). The intra-rater reliability indicated excellent reliability for lesion and filling (0.83 to 0.94) and moderate for activity (0.58).
Conclusions:
ICDAS training/calibration were essential to ensure accuracy and reliability of dental caries measurements. The study demonstrated that ICDAS training of dentists with no prior criteria experience is feasible in a community setting and can lead to high reliability and repeatability.
Keywords: community-based study, ICDAS, caries, dental examiners, reliability
Introduction:
In the United States (US), dental caries is one of the most common chronic diseases among children, affecting 50% of children aged 6–8 years.1 The prevalence of dental caries varies across states, as it disproportionately affects low-income and minority children in prevalence and severity.2,3 In the state of Texas (2017–2019), 53% of kindergarteners and 67% of third graders were reported to be affected by dental caries.4
The International Caries Detection and Assessment System (ICDAS) was developed to provide a validated, uniform system to measure dental caries in clinical practice, dental educational settings, and dental public health research.5 The utilization of the ICDAS detection criteria offers notable benefits for public health research in children. Firstly, it enables the identification of dental caries lesions at an early stage, prior to cavitation, providing valuable insight into the current disease status. This early detection allows for timely interventions, thereby enhancing the potential impact of educational and behavioral measures. Secondly, the adoption of ICDAS facilitates the observation of subtle intervention effects, allowing researchers to discern nuanced changes resulting from the interventions.6,7 Others have also argued for more sensitive measures for prevention and health promotion, particularly to observe trends over time and so that actions taken are as minimally invasive as possible.8,9 Compared to the World Health Organization (WHO) DMFT/dmft classification system, ICDAS was estimated to detect 50% to 58% higher caries prevalence rates in children, highlighting the advantage of ICDAS as a sensitive outcome measure in public health programs and research aiming to prevent and control disease progression.10
The CATCH Healthy Smiles cluster randomized controlled trial (RCT) aims to determine the efficacy of a school-based behavioral intervention targeting oral health in reducing the incidence of dental caries among children enrolled in low-income elementary public schools (grades K-2) within the Greater Houston Area (2021–2026). As part of this clinical trial, we are using ICDAS to conduct visual dental examinations to determine caries incidence longitudinally within each child across a three school-year period starting kindergarten through grade 2. Details regarding the CATCH Healthy Smiles study design are presented elsewhere.11
While ICDAS has been used successfully in community-based studies as a gold standard measure of dental caries incidence and prevalence, to our knowledge there is no literature describing ICDAS training and calibration procedures, including coding systems, or have reported on the reliability and validity of ICDAS to measure caries incidence in young children with mixed dentition in school or community settings.12 These data are important for replication of methods by other researchers conducting studies in similar populations using these measures. The purpose of this paper is to demonstrate ICDAS training procedures and the calculation of inter-and intra-examiner reliability in diagnosing lesion severity, activity, and filling criteria of the ICDAS in a school setting among elementary school children ages 6 to 8 years.
Methods:
This study was conducted as part of the ICDAS training for the CATCH Healthy Smiles cluster RCT.11 For this ICDAS training, a convenience sample of one elementary school was recruited to participate in the study, and reflected the general characteristics of the schools for the larger trial including, located in the Greater Houston, TX metropolitan area, at least 75% of the student body enrolled in the national free/reduced school lunch program (a proxy for lower socioeconomic status), and the school enrolls children in grades K, 1st or 2nd. The ICDAS training was conducted in December 2021 over a five-day period. Consent forms were sent home to parents of students in the 1st and 2nd grades in the participating school to allow their child to participate in the ICDAS training. Students were excluded from the study if the parent indicated on the consent form that the child had any congenital dental conditions (cleft palate, enamel hypoplasia, or severe fluorosis) or special needs identified by the school. Written consent was obtained from the parent and verbal assent was obtained from the child at the time of measurement. The age and gender of children were collected.
A total of 63 children aged 6 to 8 years in grades 1st and 2nd were recruited, of which 59 met the inclusion criteria (Figure 1). The study protocol and recruitment material were approved by the Institutional Review Board Committee for the Protection of Human Subjects at the University of Texas Health Science Center at Houston. A report of the dental assessment was sent home to the child’s parent after the assessments. The report included information on the child’s tooth health status and community dental clinics.
Figure 1.
Flow chart of participants examined during the training
The ICDAS training and related protocol development were conducted by an ICDAS trainer (Trainer A). The ICDAS trainer is a licensed and practicing dentist, has conducted over 5000 dental examinations using ICDAS, and has conducted trainings for clinical trials and observational research studies using ICDAS for over a decade. ICDAS training was provided to two practicing public health dentists (Trainees B and C) who are co-investigators on the CATCH Healthy Smiles trial. Additionally, study staff were trained as dental recorders tasked to record ICDAS scores on the dental case report form.
The training and calibration occurred over five days and combined didactic sessions and clinical practice. Days 1 and 2 of the training consisted of a 4-hour didactic session each day plus 8 hours of practice examinations over the two-day period (Supplementary Material). The training was conducted at the school in a designated area (i.e. classroom) during regular school hours. The didactic portion of the training focused on reviewing the examination procedure and the detection and recording of dental caries using the ICDAS criteria, followed by a practice examination of 27 children (Figure 1), not using any extracted teeth. Examiners reviewed the clinical procedures, communicated with recorders, and examined subjects. Scoring differences between the trainee examiners and the gold standard examiner were identified and discussed. Days 3 to 5 of the training consisted of a series of assessments where the three examiners (trainer and trainees) independently examined each child at least once (n=38), of which 18 were assessed twice by each examiner (a total of six assessments for each child to assess whether the agreement improved upon re-assessing the child after calibration). Repeat examinations were conducted at least 30 minutes after the initial examination, with some re-assessments conducted the next day. The calibration and repeated examinations assessed the lesion severity, lesion activity, and the restorative status of each tooth surface to determine if the subjects had received treatment/restorative care. Data from the calibration and repeated exams on days 3–5 were used in the study analysis.
Training and assessments were conducted using portable dental units and included a portable patient chair, dental LED light, and dental tray. Participants were seated in the dental chair in a reclined position. Children participating in the study were brought to the classrooms for their dental examination five at a time. Three children were examined, while coloring material was provided to children in the room waiting their turn. Due to COVID-19 concerns, air syringes were not used for examinations during this training; instead, disposable dental exam mirrors, disposable dull-end explorer/probes, disposable cotton pliers, and gauzes for drying tooth surfaces were used. A full description of training setting is described in Supplementary Material.
Teeth examination and coding system using ICDAS
All teeth were examined regardless of their condition and included in the calibration. A standardized visual examination was completed for each subject by examining teeth in a clockwise manner, starting from the upper right quadrant and then towards the upper left, lower left, and lastly, lower right quadrant. Each tooth type (primary vs. permanent) and surface (occlusal, buccal, lingual, mesial, and distal) of the erupted tooth were examined, coded, and recorded. Subsequently, a tooth status code was given for each tooth examined and included a code for unerupted teeth (Table 1). All codes were called out by the dental examiner to the trained study recorder, who recorded the scores/codes on a specifically designed case report form (Supplementary Figure).
Table 1.
Lesion and filling codes for ICDAS II and tooth surface code
| A. Lesion and filling codes for ICDAS II | |
|---|---|
| Lesion Codes | |
| 0 | Sound tooth surface. No or questionable change in enamel translucency after prolonged air drying (>5s). Artifacts such as hypoplasia, fluorosis, wear, and stains must be avoided. |
| 1 | First visual change in enamel. Opacity or discoloration not visible on the wet surface, but distinctly visible after air drying. Lesion is less than 1 mm wide |
| 2 | Distinct visual change in enamel. Opacity or discoloration distinctly visible on a wet surface. Lesion is more than 1 mm wide |
| 3 | Initial breakdown in enamel due to caries with no visible dentin |
| 4 | Underlying dark shadow from dentin with or without localized enamel breakdown |
| 5 | Distinct cavity with visible dentin exposed at the base of the cavity |
| 6 | Extensive distinct cavity with visible dentin. |
| Filling Codes | |
| 1 | Sealant, partial |
| 2 | Sealant, full |
| 3 | Tooth-colored restorations |
| 4 | Amalgam restoration |
| 5 | Stainless steel crown or metal/acrylic crown on primary tooth |
| 6 | Crown, gold, porcelain or MCC |
| 7 | Lost restoration |
| 8 | Temporary restoration |
| 9 | Other |
| Lesion Activity Codes | |
| 1 | Non-Active |
| 2 | Active |
| B. Tooth Status Codes | |
| S | Sound |
| U | Unerupted (primary teeth are not being scored in this study) |
| X | Extracted, presumed for the reasons of caries |
| Y | Extracted for other reasons, e.g. orthodontic reasons (if any doubt that extraction was performed for reasons other than caries) |
| N | Not gradable, e.g. for reasons of trauma |
| C | Caries or caries-related events such as fillings or sealants |
| E | Exfoliated |
| P | Pulp tissue visible |
| F | Fistula (gum boil) |
| A | Abscess |
| L | Cellulitis |
Tooth type
We used either an international or universal system for this training according to the examiners’ preferences. For the universal system, primary teeth were referred to using an alphabet naming system (A-T), and permanent teeth were referred to by numbers (3–30). Teeth were classified as either primary or permanent.
Surface code
Surfaces of all erupted anterior (incisal, lingual, mesial, and distal) and posterior (occlusal, buccal, lingual, mesial, and distal) teeth were examined. The ICDAS criteria were used in this study, and a separate score was used for lesion severity, lesion activity, and the presence and type of filling materials presented (Table 1).
Tooth status code
Once the examination of all tooth surfaces was completed, the tooth status code was graded by the trained dentist (Table 1).
Defining dental caries incidence
The primary outcome of the CATCH Healthy Smiles trial is child dental caries incidence measured longitudinally at the primary tooth surface level (dfs) from Kindergarten through 2nd grade (baseline and three follow up measures per child). The secondary outcomes are to determine the impact of CATCH Healthy Smiles on the incidence of dental caries at the tooth level for permanent teeth (DFT and DFS) and tooth level for the primary teeth (dft) from Kindergarten through 2nd grade. To capture the dental caries experience, using the ICDAS 0–6 criteria presented in Table 1, the lesion coding was adapted to the d’ component of the WHO dfs/DFS and dft/DFT index configuration. A priori, we decided the categorization of a lesion at each surface/tooth (the “d” component) would be either a cutpoint of >2 or >1 for the ICDAS lesion coding, depending on the Kappa results for inter and intra-rater reliability in this analysis. A positive lesion in the parent study will be defined as a decay/lesion code of either ≥3–6 or ≥2–6, with an activity code of 2 (active). The “f/F” component corresponds to a permanent or temporary filling or when a filling is defective but not decayed. Teeth that are restored for reasons other than dental caries are not counted as an “f.” A filled surface will use ICDAS filling codes 3–9, while codes 1–2 will not be considered filled.
Although the longitudinal primary outcome for the parent study was a modified crude caries increment (mCCI), similar to that described in Broadbent and Thomson (2005),12 in the current ICDAS assessment study, we considered a cross-sectional measurement of dfs. Missing tooth was not considered as an event since the reason for a missing tooth cannot be determined with a visual examination only, and missing teeth were expected to naturally exfoliate due to the age range of the children assessed.
Statistical Analyses
The primary analysis to determine adequate reliability was the pairwise comparisons of each examiner’s first assessment of the 38 children that were assessed at least once by three examiners. If a child was assessed twice by the same examiner, only the first assessment was compared to the gold standard trainer’s first assessment. For the subset with a repeat assessment after calibration (n=18, a subset of the primary analysis), the first assessment was compared to the second assessment, by examiner.
Inter-examiner reliability between each dental examiner (trainees B and C) and the Trainer A and intra-examiner reliability were evaluated using Kappa statistics for lesion severity, activity, and filling and weighted Kappa using Fleiss-Cohen weights for lesion severity.13 Kappa provides a scale of −1 to +1, displaying the degree of agreement, corrected for chance, where a positive value indicates a better-than-chance agreement. Kappa values 0–0.2 indicate none to a slight agreement, 0.21–0.40 as fair, 0.41–0.60 as moderate, 0.61–0.80 as substantial, and 0.81–1.00 as almost perfect agreement. No adjustment was made to account for the correlation of the teeth within the same child in the calculation of confidence intervals. Analyses were conducted using R, version 4.2.0 (R Foundation for Statistical Computing).
Results
A total of 59 children aged 6–8 years were recruited for this study and were examined by each dentist at least once. Eighteen children were examined twice by each dentist (Trainer A, Trainees B and C). The race/ethnicity distribution of the participating school consisted of 97.5% Hispanic/Latino. Participating children were on average 7.1 years of age (range 6.3–8.6), and 57.9% were female. Figure 2 shows the distribution of examiner A’s (trainer) first examination assessment of the number of surfaces (Figure 2a) and teeth (Figure 2b) with tooth decay using either lesion score >1 (first row) or >2 thresholds (second row). The prevalence of tooth decay in the cohort of participating children was 74% (using a lesion score >1 for at least one surface/tooth) and 61% (using a lesion score >2 for at least one surface/tooth).
Figure 2.
Distribution of the number of decayed surfaces and teeth in the cohort as assessed by the trainer
Agreement of tooth type between Examiners A versus B was 99%, and A versus C was 98% (Supplemental Table 2). Table 2 displays the cross-tabulations between the lesion severity for Examiners A versus B, and A versus C. This resulted in a weighted Kappa=0.77 (95% CI 0.71–0.82) for Examiner A versus B, and a weighted Kappa=0.82 (95% CI 0.77–0.87) for Examiner A versus C (Table 3). Comparing the lesion severity score by Examiner A to the first and second examinations of the trainers, the Kappas increased from 0.76 to 0.84 for examiners A versus B, and from 0.82 to 0.84 for examiners A versus C. The intra-rater reliability for lesion and filling ranged from 0.83 to 0.94, indicating excellent reliability. The intra-rater reliability was moderate for activity at 0.58 for both trainee dentists (Table 4).
Table 2.
Grading of lesion severity for each surface
| Examiner A | ||||||||
|---|---|---|---|---|---|---|---|---|
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | ||
| Examiner B | 0 | 3451 | 19 | 28 | 6 | 6 | 15 | 0 |
| 1 | 0 | 2 | 3 | 1 | 0 | 0 | 0 | |
| 2 | 7 | 3 | 1 | 3 | 2 | 0 | 0 | |
| 3 | 2 | 1 | 2 | 7 | 0 | 2 | 1 | |
| 4 | 4 | 0 | 0 | 1 | 3 | 0 | 0 | |
| 5 | 11 | 1 | 5 | 3 | 4 | 31 | 12 | |
| 6 | 0 | 0 | 0 | 0 | 1 | 6 | 8 | |
| Examiner C | 0 | 3479 | 20 | 26 | 7 | 10 | 4 | 1 |
| 1 | 5 | 0 | 4 | 0 | 0 | 0 | 0 | |
| 2 | 7 | 4 | 6 | 1 | 1 | 0 | 0 | |
| 3 | 9 | 2 | 5 | 10 | 3 | 2 | 0 | |
| 4 | 2 | 0 | 0 | 0 | 1 | 0 | 0 | |
| 5 | 6 | 0 | 0 | 3 | 1 | 43 | 12 | |
| 6 | 2 | 0 | 0 | 0 | 0 | 5 | 8 | |
Table 3.
Agreement and Inter-rater reliability of lesion severity score, activity, and filling between trainee examiners (B and C) and gold standard examiner
| Examiner B | Examiner C | |||||
|---|---|---|---|---|---|---|
|
| ||||||
| Agreement % | Kappa | 95% CI | Agreement % | Kappa | 95% CI | |
| Comparison of the first assessment by each examiner (N=38) | ||||||
| Lesiona, b | 95.92 | 0.77 | 0.71–0.82 | 96.15 | 0.82 | 0.77–0.87 |
| Activity | 87.38 | 0.07 | −0.18–0.31 | 82.88 | 0.15 | −0.09–0.39 |
| Fillingb | 96.96 | 0.91 | 0.90–0.93 | 96.72 | 0.91 | 0.89–0.92 |
| First Examination in subset of 18 children with repeat examinations | ||||||
| Lesiona, b | 93.50 | 0.76 | 0.69–0.83 | 94.03 | 0.82 | 0.76–0.88 |
| Activity | 86.3 | 0.09 | −0.21 – 0.39 | 85.90 | 0.19 | −0.12–0.50 |
| Fillingb | 97.26 | 0.92 | 0.89–0.94 | 96.42 | 0.89 | 0.87–0.92 |
| Second examination in subset of 18 children with repeat examinations | ||||||
| Lesiona, b | 93.04 | 0.84 | 0.79–0.89 | 93.80 | 0.84 | 0.79–0.89 |
| Activity | 91.95 | 0.18 | −0.19–0.55 | 90.91 | 0.51 | 0.21–0.80 |
| Fillingb | 95.21 | 0.85 | 0.82–0.88 | 96.9 | 0.91 | 0.89–0.93 |
Weighted Kappa
Excludes non-available coding
Table 4.
Agreement and Intra-rater reliability of lesion severity score, activity, and filling score
| Examiner A | Examiner B | Examiner C | |||||||
|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||
| Agreement % | Kappa | 95% CI | Agreement % | Kappa | 95% CI | Agreement % | Kappa | 95% CI | |
| Lesiona,b | 96.23 | 0.94 | 0.91–0.96 | 97.25 | 0.83 | 0.77–0.90 | 97.3 | 0.87 | 0.82–0.93 |
| Activity | 96.12 | 0.76 | 0.56–0.96 | 92.86 | 0.58 | 0.25–0.91 | 91.90 | 0.58 | 0.28–0.88 |
| Fillingb | 97.36 | 0.92 | 0.90–0.94 | 96.57 | 0.89 | 0.86–0.92 | 96.86 | 0.91 | 0.88–0.93 |
Weighted Kappa
Excludes non-available coding
Kappas for both cutpoints of >2 or >1 for the ICDAS lesion coding indicated greater agreement for >2 cutpoint (Kappa=0.72 and 0.77 for the two examiners, Table 5).
Table 5.
Kappa statistics of agreement between trainee examiners (B and C) and the gold standard examiner for lesion severity using cut-off scores greater than 1 or greater than 2
| Lesion Severity | Examiner B | Examiner C | ||
|---|---|---|---|---|
|
| ||||
| Kappaa | 95% CI | Kappaa | 95% CI | |
| Lesion Severity score >1 (0–1 versus 2–6) |
0.66 | 0.60 – 0.73 | 0.70 | 0.63 – 0.76 |
| Lesion Severity score >2 (0–2 versus 3–6) |
0.72 | 0.65 – 0.79 | 0.77 | 0.71 – 0.83 |
Unweighted Kappa
Discussion:
Overall, our paper provides a detailed description of the ICDAS training protocol, coding, and analysis procedures, establishing the reliability and validity of conducting these measures among young children ages 6–8years in school settings. Our results showed that the prevalence of dental caries in the participating children was high, ranging from 61% to 74%, with cut-off criteria of >2 and >1 for the ICDAS lesion score, respectively. This prevalence is similar to that seen across Texas for the same age group.4 The high rates of dental caries prevalence underscores the need to have a sensitive measure of dental caries incidence and progression, such as ICDAS, particularly in longitudinal studies to monitor lesion incidence and progression. While the ICDAS criteria is considered to be a sensitive measure to lesion detection, specifically in pediatric populations,6 there is still a need to train and calibrate dental examiners to ensure a standardized assessment with high reliability of outcome over time.
The ICDAS training was conducted over five days and required a significant amount of time and investment to secure the training/assessment study population with similar characteristics to the clinical trial. Nonetheless, this training was crucial to ensure a continuum of consistency and reliability of dental caries measurements over the study period. Findings from this study indicated good-to-excellent inter-rater reliability (0.77–0.82) for lesion severity in the overall assessment. Repeating measures in the second assessment resulted in a slight increase in the weighted kappa scores for trainee B (from 0.76 to 0.84) and trainee C (from 0.82 to 0.84) for lesion severity which was not clinically significant. The inter-reliability kappa scores reported in this study were similar to a previous study (0.69–0.81) that conducted ICDAS training in a pediatric dental and endodontic clinic in a university institution,10 a finding similar to prior studies.14
We observed moderate consistency among examiners in identifying lesion activity with the ICDAS trainer. Training of lesion activity scoring should be emphasized in future training. We observed good-to-excellent inter-reliability weighted kappa scores for the filling. Similar excellent kappa scoring was reported for the intra-rater reliability for both the lesion and filling scores. Trainee examiners showed a moderate kappa score for activity. Findings were similar to a study by Nelson et al., 2011 reporting high intra-rater reliability for filling, indicating that dental examiners participating in observational longitudinal or clinical trial studies with no experience in ICDAS criteria can be trained and calibrated.10 The current study considered a younger age group (6–8 years) than those in the baseline assessments in Nelson et al (8–16 years) and water and air syringes were not used in our study.10
This study has many strengths being one of the first studies to our knowledge reporting the training procedures and calibration of ICDAS in a community-based setting where trainee examiners obtained pragmatic training in a population with criteria similar to that of the parent study. Several studies have discussed the challenges with conducting calibration of dental examinations in children and in schools due to it being demanding on the child, lack of cooperation, frequent movement, difficulty in keeping the teeth dry, and demanding on the examiners.7,8,15 We were able to overcome these challenges to successfully conduct this training and calibration exercise, showing that these studies are feasible in 6–8-year-old children in a school setting. The lesion code weighted Kappas in the current study (0.77–0.82) were similar or higher than a similar study conducted in adults (0.42–0.83).16
This study was also subject to several limitations. The ICDAS scoring consisted of the dentist verbally calling the score to the recorder, who would then write the scores in the designated field on the case report form. This could lead to recording errors which was not measured during training. Restrictions on using air syringes (due to the COVID-19 pandemic) may have caused difficulties in identifying certain stages of tooth fillings, such as partial sealant and tooth-colored fillings. The Kappas may be higher if we had been able to use air syringes or water to clean the teeth. Finally, the study sample size was small, which could affect the statistical precision of the Kappa confidence intervals.
Lastly, the ICDAS training was cross-sectional whereby prevalence of dental caries was estimated. The cluster RCT is longitudinal to estimate change in caries incidence at the tooth and tooth surface level within each child. To that end, as part of the overall trial, in addition to conducting reliability assessment on 10% of the study sample, we have established additional protocols to ensure validity and reliability of the data collected over time. For example, we have implemented an extensive set of data validation queries within the database system, comparing the longitudinal forms to ensure that coding is biologically plausible and accurate (e.g. a lesion code of 3 or more at baseline should not be coded as 0 indicating sound tooth at follow up).
In conclusion, our paper describes ICDAS training and calibration protocols and procedures, including results of our calibration, to measure caries in young children in community settings which is relevant for future studies in these populations.
Supplementary Material
Acknowledgements
The authors would like to acknowledge the UTHealth Michael and Susan Dell Center for Healthy Living, CATCH Global Foundation, participating school, and Harris County Public Health for their support on the project
Funding
This study was funded by the National Institutes of Health/National Institute for Dental and Craniofacial Research (NIDCR) [Grant Number: 4UH3DE029213 - 02]. Study investigators have no have financial or competing interests.
Footnotes
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper
Data Availability
This research was conducted with the understanding and consent of each participant, and in accordance with the ethical guidelines and principles outlines in Community Dentistry and Oral Epidemiology’s Author Guidelines. The data that support the findings of this study are available from the University of Texas Health Science Center at Houston School of Public Health. Restrictions apply to the availability of these data.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
This research was conducted with the understanding and consent of each participant, and in accordance with the ethical guidelines and principles outlines in Community Dentistry and Oral Epidemiology’s Author Guidelines. The data that support the findings of this study are available from the University of Texas Health Science Center at Houston School of Public Health. Restrictions apply to the availability of these data.