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DOI: 10.17653/2374-9075.SS0005

We hypothesized that there was an association between oral health and overall health. In order to show the association, we present the use of the Decayed Missing and Filled Teeth and Surface (DMFT/S) ratio as an oral health indicator. However, the DMF scores are not often applied in dental practice. The scores have traditionally been used in public health and by dental research settings. To date, most commercially available dental software programs for office practices do not calculate DMF scores.

We measured DMFT/S scores for four groups, children 9 months to 36 months of age, adults living with HIV/ AIDS; children and adults undergoing complex prosthodontic rehabilitation; and healthy young adult dentists. DMFT/S is a ratio of decayed (D), missing (M), and filled (F) teeth (T) or surfaces (S) per a standard number of teeth or surfaces that provides a means for comparing dental health between individuals.1 The purpose of this study was to describe DMFT/S scores in each of the four distinct groups, and determine differences among the groups accounting for age.

Dental caries is a major public health problem in most industrialized countries, affecting 60-90% of school children and the vast majority of adults. 2 Studies have reported that dental caries remains one of most common conditions that affect children in the United States and worldwide. In the United States where dental caries had been on the decline, presently there is resurgence. Dental caries experience in primary teeth for children aged 2-4 years increased 33.3% from 18% in 1988-94 to 24% in1999-2004, moving further away from the Healthy People 2010 target of 11%.3

The associations of oral health to changes in systemic health have been difficult to quantify. Although it would seem obvious that caries, gingivitis and periodontitis could provide an avenue for further disease in an immune compromised person, some published studies have found that there is an ambiguous relationship between Human Immunodeficiency Virus (HIV) / Acquired Immune Deficiency (AIDS) and caries incidence. HIV/AIDS has a strong correlation with other oral diseases not normally found in the general population, and in resource-limited areas these diseases, such as oral candidiasis, Kaposi sarcoma, and oral hairy leukoplakia can be used as markers for AIDS diagnosis and progression. 47 One study did show an association between childhood oral diseases including caries and compromised health. In children with HIV observed from 2003-2009, investigators found a significant decrease in oral disease when children were receiving anti-retroviral medications.8 Several researchers have attempted to correlate standard dental DMFT and DMFS scores with HIV patient immune status, HIV progression and mortality.4,9 However, an association between health status and dental caries using DMFT and/or DMFS scores is not often reported in the literature, and furthermore it is not routinely used in caries risk assessment.

In a study designed to compare standard dental care with enhanced dental care in adults infected with HIV, Brown et al.[4] evaluated gingivitis, oral pain, and used DMFS to measure active decay. They found that while enhanced care, bimonthly protective treatment and twice-daily chlorhexidine rinses, reduced gingivitis compared to standard care, there was equal improvement in DMFS scores in standard and enhanced treatments. The group was unable to show any impact of improved dental health on immune status or disease progression, and theorized that this was due to the use of retroviral therapies.4 A study in India examined DMFT scores in HIV-infected children who were categorized into mild, severe, and advanced disease based on their CD4 counts, and found that in general the children had a high rate of tooth decay, and that the prevalence was even higher in the advanced CD4 group. 9 In another study, primary dentition caries status in HIV-infected children was reported to beconsiderably greater than that for the US pediatric population, and increases with decreasing CD4 percentage and moderate to severe immune suppression.10

Dental caries studies of people without HIV/AIDS have attempted to demonstrate that improved oral health can lead to improved physical and mental health. Malek et al.11 conducted a longitudinal study on 6 year-old children in which DMFT was recorded in deciduous teeth; also recorded were height, weight, with body mass index (BMI) derived before and 6 months after removal of carious teeth. They found during this period, children gained weight and increased BMI, and those children with the lowest initial weights had the most significant gains. Improved oral health has long been associated with improved mental health and improved quality of life.4,5,12 Quality of life can improve overall health. For HIV-infected people, improvement in oral health has the potential to reduce social stigma.6 Some Investigators have looked at the association of dental caries and age.13 However, oral health and the ability to masticate should have a notable impact. Therefore, the relationship of age, oral health, ability to masticate and overall systemic health could be used in an enhanced risk assessment algorithm. Overall, these factors should be used to enhance DMFT/S scores.

The measurement of oral health indicators and its association with overall systemic health is an area of further study. Hence, there is a need for a simplified validated tool to designate individuals’ oral health status that account for age, function and overall systemic health.9,10

In this study, we conducted a longitudinal study of children ages 9 months through 3 years of age, HIV-infected people, and children (12 years) and older patients undergoing complex prosthodontic rehabilitation. The study used retrospective data collected from chart review and radiographs.

The objective of this study is to use a practical DMFT/S score as a measurement for oral health status to determine differences among groups categorized by age and health.


This study includes four groups. Healthy young adults who are dentists (N=16, age: 26 – 33 years, mean/median 27.8/27, standard deviation (SD) 1.9) served to establish a baseline reference for comparison (Table. 01). The three other groups include young pediatric dental patients (N= 317, age: 8 months – 35 months, mean/median: 18.1/18 months, SD 7), patients undergoing complex prosthodontics rehabilitation (N=206, age: 12 – 101 years, mean/median 57.2/60, SD 17.8) and patients with complex comorbidity, i.e.,people living with HIV/AIDS (PLWHA) (N=55, age: 24 – 67 years, mean/median 47.5/48, SD 9.7) (Table. 02, 03 and 04). In addition to HIV/ AIDS, the patients in this group all have other complex medical comorbidities. The demographics were derived from the electronic medical record using Clinical Looking Glass®, a proprietary electronic data mining software program. Socioeconomic Status (SES) was calculated using an algorithm derived by Clinical Looking Glass® that is based on six variables: median household income; median value of housing units; the percentage of households receiving interest, dividend, or net rental income; education (the percentage of adults 25 years of age or older who had completed high school and the percentage of adults 25 years of age or older who had completed college); and occupation (the percentage of employed persons 16 years of age or older in executive, managerial, or professional specialty occupations).14,15

Herein, we modified an oral health index most commonly used in pediatric dentistry. This scoring system can be measured from the electronic dental record to use as one indicator for an individual’s oral health status or caries risk assessment based on the DMFT/S.

Table. 01

Age, months
mean/median 27.8/27
Std. Dev. 1.9
min 26
max 33
mean/median *
Std. Dev. *
min *
max *
Female 8 (50%)
Male 8 (50%)
N/A 0
Hispanic 6 (37.5%)
Black not Hispanic 4 (25%)
White not Hispanic 4 (25%)
Multiracial not Hispanic 0
Asian, Alaskan, Hawaiian, Native American Not Hisp. 2 (12.5%)
N/A 0
Total 16

Demographics for 16 adults Control Healthy Dentists

*equal or same SES based on income above Federal Poverty Level (FPL), same salary, housing conditions, and education as listed previously.14

Table. 02

Age, months
mean/median 18.1/18
Std. Dev. 7
min 8
max 35
mean/median -3.1/-2.5
Std. Dev. 2.5
min -8.6
max 2.2
Female 148 (46.7%)
Male 147 (46.4%)
N/A 22 (6.9%)
Hispanic 131 (41.3%)
Black not Hispanic 67 (21.1%)
White not Hispanic 10 (3.2%)
Multiracial not Hispanic 60 (18.9%)
Asian, Alaskan, Hawaiian, Native American Not Hisp. 16 (5.1%)
N/A 33 (10.4%)
Total 317

Demographics for 317 Pediatric Dental Patients ( 8 months through 35 months old)

Table. 03

Age, months
mean/median 57.2/60
Std. Dev. 17.8
min 12
max 101
mean/median -1.1/-0.4
Std. Dev. 3
min -8.6
max 3.6
Female 122 (59.2%)
Male 79 (38.3%)
N/A 5 (2.4%)
Hispanic 31 (15%)
Black not Hispanic 30 (14.6%)
White not Hispanic 78 (37.9%)
Multiracial not Hispanic 6 (2.9%)
Asian, Alaskan, Hawaiian, Native American Not Hisp. 6 (2.9%)
N/A 55 (26.7%)
Total 206

Demographics for 206 Patients Undergoing Complex Prosthodontic Rehabilitation

Table. 04

Age, months
mean/median 47.5/48
Std. Dev. 9,7
min 24
max 67
mean/median -3.8/-3.6
Std. Dev. 2.7
min -8.3
max 2.2
Female 26 (47.3%)
Male 29 (52.7%)
N/A 0
Hispanic 23 (41.8%)
Black not Hispanic 29 (52.7%)
White not Hispanic 2 (3.6%)
Multiracial not Hispanic 1 (1.8%)
Asian, Alaskan, Hawaiian, Native American Not Hisp. 0
N/A 0
Total 55

Demographics for 55 HIV+ adults living with HIV/AIDS

The indicators of oral health include caries experience as well as management of dental caries including fillings and tooth loss or dental experience. One method of measuring dental caries experience in a person is to examine and count the number of decayed (D), missing (M), filled (F) teeth (T) and or surfaces (S), designated as DMFT or DMFS, respectively. In order to obtain a DMFT score for the patient, three distinct values must be determined: the number of teeth with fillings or crowns, the number of teeth with carious lesions, and the number of missing teeth. Ratio score of 0 would indicate all 32 teeth are intact whereas the ratio score of 1 indicates that all teeth found in an individual patient have dental work done and/or are missing or a combination involving all 32 teeth. The DMFT score can range from 0-64 with a maximum of 64 in the case that no teeth are missing (0) and all 32 teeth are both decayed and filled.

The DMFS scores provide more detailed information about the patient’s oral health. The DMFS score can range between 0-160. In our modification, we assume that each tooth has 5 surfaces, equaling 160 surfaces for a full dentition. For a patient with 6 decayed surfaces, 35 other surfaces either filled or included in a crown, and 4 teeth that are missing, their DMFS score is 45. In this case, 89 surfaces are intact (Table. 05). The DMFS/S ratio (ratio S) will equal 45/160, and like ratio T, the ratio S ranges from 0 to 1. With higher ratio T or S, the dental patient is more likely to experience or manifest more extensive dental problems significant of poor oral health. Dental health professionals chart dental caries by surfaces that require restoration. When charting 5 surfaces, in effect, this describes the condition of each tooth. When we measure DMFS, it provides a more detailed representation of the dental conditions and caries experience of the patient as described above. Hence, DMFS will give a more informative result of caries experience than the DMFT score, alone.However, DMFT is more easily calculated from a dental charting perspective (Table. 05). It is more accurate to measure. For DMFS, the caries/ filled interpretation of each surface is much more subjective depending on the available radiographs and accuracy of recorded hard-tissue charting. Because of the subjective nature of interpretation of caries and filled surfaces of each tooth, it is more difficult and labor intensive to calculate and may be less accurate depending on calibration of operators conducting the assessment.

Table. 05

Total Surfaces 160
Decays -6
Filled or with crowns -35
4 Missing teeth x 5 surfaces -20
Total DMFT 89

Example of how to calculate the DMFT score

The pediatric scores are designed with lower case, DMFT/DMFS, and are scored based on a modification from E. Lo.16 Unlike in adult DMF scores, the score in children accounts for 20 teeth instead of 32. According to Lo, the anterior teeth are only accounted for 4 surfaces and the posterior teeth for 5 surfaces. In our modification, we have taken into consideration 5 surfaces for all teeth. This modification and the problem of counting the number of surfaces that are used in a DMF score is discussed in depth by Broadbent et al.17

To evaluate the variability between the operators, DMF scores were performed by calibrated operators. We had 30 operators read the same set of radiographs and provide individualized DMFT and S scores for comparison. These scores reported in this study were derived from radiographic interpretation at chart review, only. No additional radiographs were taken for the purpose of this study. The project received Institutional Review Board approval as part of an ongoing study on the biomineralization of teeth and caries risk.

Further clarification for how special dental problems are counted includes the following modifications: 1. Endodontically treated teeth with filled root canals were counted as follows: i. Root canal with crown: 1 filled tooth, 5 filled surfaces ii. Root canal with filling: 1 filled tooth, number (#) of filled surface iii. Root canal with decayed retained root: 1 decay, 5 decayed surfaces 2. Retained deciduous teeth (baby teeth) in the adult dentition were counted as follows: i. Missing adult teeth, note made on data sheet for these patients. 3. Supernumerary teeth: i. Designated as a negative integer, -1, for missing teeth.4. Impacted teeth were counted as present adult teeth with a note made on the data sheet for these patients. Exclusions: DMFT/S for adult and pediatric dentitions out of different maximum values (adult: 64, 360 and pediatric: 40, 200); Mixed dentition patients were excluded. 5. Not all clinic patients had bite wing radiographs which we acknowledge are the standard radiographic view for caries interpretation. Bitewing radiographs were not consistently available. Therefore, there were limitations on caries interpretation from using a panoramic dental radiograph for counting decay on many of these cases. However, part of the usefulness of the modification that we present includes that a range or quartile can be established with this retrospective scoring system that is useful for caries risk assessments.

The sample sizes were based on convenience/availability from patients seen at the clinic from 2012 through 2013. The groups were selected based on an Institutional Review Board (IRB) approved dental caries and biomineralization protocol.The healthy young adults showed little age variation and since they are dentists brought with them a knowledge of oral health and access to care that could be considered a paradigm. Therefore, we believe that the healthy young adults can serve as a comparison group.

Descriptive statistics are presented as means and standard deviations, and medians and ranges. Multiple linear regression analysis was used to determine differences among groups with regard to DMFT/S accounting for age; all interaction terms were assessed and variables in the final model were derived using a monitored backwards stepwise procedure. Variables in the final models were those with resulting p-values < .05. All analyses were performed using SAS Version 9.3, Cary NC.


Sample Patient For Dmft/S Scoring From The Complex Comorbidity Group

Table. 06 The calibrated dentists were asked to score one individual using the same set of radiographs. No clinical examination was done by these dentists. We used the panoramic radiograph below Figure. 01A from a sample patient to measure variability of interpretation.

Table. 06

Group Prosthodontic Patients HIV + Patients Pediatric Patients Healthy Dentists
Avg. DMFT ± SD 23.20 ± 9.14 19.44 ± 9.11 0.32 ± 0.95 7.50 ± 4.92
Avg. DMFT/T ± SD 0.73 ± 0.29 0.61 ± 0.29 0.02 ± 0.05 0.23 ± 0.15
Avg. DMFS ± SD 101.17 ± 50.44 77.13 ± 50.96 0.67 ± 2.35 21.06 ± 11.67
Avg. DMFS/S ± SD 0.63 ± 0.32 0.48 ± 0.31 0.01 ± 0.02 0.18 ± 0.10

Average DMFT or S scores, ratios and standard deviations

The graphs in Figure. 01B below show the subjective bias during interpretation of one sample patient panoramic dental radiograph used during training, scoring and calibration of operators: standard deviation (SD) = 4.2 for DMFT but SD = 23 for DMFS.

There is noticeable discrepancy in the DMFS scores based on interpretations done by multiple calibrated operators (dentists, N = 29). We saw less variation when using DMFT scores when comparing the variability among multiple calibrated operators. Figure. 01C.

We propose the following, as shown in Figure. 01B. Quartiles, designated in the graphs separate the oral health interpretation into units of 16 for DMFT and by 40 for DMFS resulting in the following categories:

The radiograph used for the measurement of variability in interpretation of DMFT/S score is presented to demonstrate the level of difficulty reading this film that was encountered by the dentists who scored the case.

Fig. 1: The radiograph used for the measurement of variability in interpretation of DMFT/S score is presented to demonstrate the level of difficulty reading this film that was encountered by the dentists who scored the case.

Note: This person has poor systemic health is HIV positive and was 53 years of age at the time the radiograph was taken


DMFT: 0-16 excellent to good; 17-32 fair to poor; 33-48 poor; 49-64 extremely poor. DMFS: 0-40 excellent to good; 41-80 fair to poor; 81-120 poor; 121-160 extremely poor

A larger range was selected for the DMFS quartiles due to the larger SD = 23. Therefore, because of variability observed in the DMFS, we report on the DMFT score in the following groups. Overall, using the DMFT score, age was positively associated with DMFT (p > .05)

Healthy Young Adult Dentist Group

The DMFT / DMFS scores among healthy individuals (N: 16) were derived from healthy young dental residents with no known medical comorbidities. The DMFT score ranges from 0-18 (Avg. = 8, SD = 5) the DMFS score ranges between 0-47 (Avg. = 2, SD = 12). The graphs below show that the DMFT score are mostly between the range of 0 and 20 shows that is a strong correlation between oral health and health status. The young healthy dentists DMFT scores fall within the quartile for excellent to good dentition or oral health indicator. However, there is one dentist that had an outlier score of 18. The age range is so narrow, 26 to 33, that there is no correlation with observed by age (R² = 0.00).


Pediatric Dental Patient Group

DMFT scores for pediatric patients between the ages of 8 months to 35 months old, ranges between 0-5.


This group includes children ranging between the ages of 8 month to 35 months which may cause us to over or under estimate the caries score/ dental experience of the child because until the age of 6 the child only has 20 teeth. According to that the maximum DMFT score should be 20 and the DMFS score should be 100. The score is reported In relation to the number of teeth present in the child’s mouth and gives a more accurate representation of the oral health by demonstrating dental caries and dental experience of the child. The graph shows the computed score for this group have experienced dental caries by an early age.

Multivariate Analyses

The first multiple regression analysis involved the comparison between young healthy children and all other groups with regard to DMFT; controlling for age, results indicated that DMFT scores for the Healthy Young Adult (Dentists) group, the HIV+ group and the group with adults and children who received prosthodontics care were significantly greater than those of young children (p <.02). In addition, patients treated with prosthodontics had greater DMFT scores at younger ages and their rate of increase with age was less compared with other subjects. For the second model that compared the Healthy Young Adult (Dentists) group with both the HIV+ group and the group with adults and children who received prosthodontics care, DMFT scores were significantly greater in the Healthy Young Adult (Dentists) group, controlling for age (p <.001). The last analysis compared DMFT scores between the HIV+ group and the group with adults and children who received prosthodontics care, for HIV+ pa- tients had generally lower DMFT scores except for those under 25 and those over 65 (p < .01). In all analyses, older age was independently associated with increased DMFT (p < .0001). Table. 07 below resents results of multivariate models.

Table. 07

Model : Do HIV, Prost-hodontics, and Healthy Young Adult Groups differ from Health Chil-dren? R2= 0.81 Estimate Standard Error P-Value
Intercept 0.08510 0.31129 0.7847
Age Squared* 0.00471 0.00065 <.0001
Healthy Young Adults 3.73651 1.50582 0.0134
HIV + 5.03019 2.12252 0.0181
Prosthodontics 16.51129 0.87390 <.0001
Interaction Prosth & Age2 -0.00289 0.00068 <.0001
Model: Do HIV and Prosthodontics groups differ from Healthy Adults? R2=0.31
Intercept 6.07009 2.04372 0.0032
Age Squared* 0.001849 0.00029 <.0001
HIV + -0.972749 3.70192 0.7929
Interaction HIV+ & Age2 0.00290 0.00100 0.0040
Prosthodontics 10.52612 2.26450 <.0001
Model: Does the HIV Group differ from the Prosthodontics Group? R2=0.22
Intercept 5.09734 3.14101 0.1059
Age Squared 0.00474 0.00097 <.0001
Prosthodontics 11.49901 3.36893 0.0007
Interaction Prosth & Age2 -0.00290 0.00102 0.0047


Herein we propose a modified a DMFT/S scoring system that can be used to measure point prevalence of caries in a dental population. There are not many reports on DMFT or S in adult populations in the literature. Unlike other systems,we used five surfaces for each tooth and counted third molars or wisdom teeth.16,17 Other studies only count for four surfaces for anterior, and disallow the incisal as a surface. Our simplified method can be used to address the variability of patient dentition across age and health status. Even though the groups are of completely different characteristics and background, we would expect their oral health to be different. Moreover, we are not making any comparisons or association among the four . However, the scoring system could be used to separate groups as distinct, which is what they are. In the future, we will be able to use this scoring system for analysis within each group e.g. DMFT/S versus age of children or adults and look for an effect of comorbidity. Using this system, patients in prosthodontic care had in general significantly greater DMFTs than other groups, followed by HIV+, then healthy young adults, with the lowest DMFTs found in children.

Sample Patient For DMF Scoring From The Complex Comorbidity Group

The standard deviation for the test radiograph suggests that the DMFS score is more prone to discrepancy or inaccuracy when used during a radiographic review as shown in Figure. 01B. One possible explanation is that the quality of the radiographs interfered with the dentist’s ability to make accurate diagnosis. The dentists did not have access to a full series of periapical views or traditional bitewing views that are used for caries interpretation. Another explanation is that the score is based on radiographic interpretation retrospectively without a clinical examinations conducted during the interpretation. These include the limitations that can be ascribed to dental radiographs in general.18,19

However, despite variability in the interpretation and limitation on the quality and type of radiographs, the range that the DMFS scores approach stays within a quartile that could be used to represent the oral health status of the patient’s dentition.

Limitations of this modified DMFT/S system include: 1. The can be radiographic interpretation error. 2. The etiology of tooth loss or reason for missing teeth is not accounted for. Tooth loss causes can be caries, trauma, orthodontia, congenitally missing and periodontal tooth loss. Therefore, the score may give a false interpretation that a tooth is lost due to decay and thereby affecting the interpretation of oral health. 3. We cannot account for sealed teeth and veneers or crowns placed for aesthetic reasons. 4. There is no accountability for fractured teeth, attrition, erosion and abrasion facets. 5. The DMFT scoring system does not account for periodontal disease. Periodontal pocket depth charting should be included in a total oral health assessment. 6. There is no accountability for fixed and removable complete and partial dentures or implants. Subjects within groups were chosen based on convenience; this could introduce bias and lack of statistical power. In addition, there was no overlap in age between the young children’s group and other groups, and very little among the older groups.

Healthy Young Adult (Dentist) Group

The healthy young dentist DMFT/S scores fall within the quartile for excellent to good dentition status. Therefore, we establish the baseline upper and lower limits. There is one dentist that had a score of 47. Therefore, the quartile designation for oral health status does not apply (Figure. 02A).


Pediatric Dental Patient Group

Ideally, children should have no caries experience.20 Therefore, the results presented in Figures. 02B, are troubling because they suggest that the pediatric group does have caries experience and at a very young age (8 months to 35 months). It should be noted that the children selected for the purposes of this study are from an inner city, densely populated, lower socioeconomic community, possibly skewing the results because they are at higher risk for dental caries (Figure. 02B).


Prosthodontic Patient Group

The DMFT score shows a dense clustering between of scores above 16 (second quartile).There are many cases that represent edentulous and by chart review have complete dentures. There was correlation with age seen in prosthodontic patients. It is expected because these are older patients who are under treatment for missing teeth and previously had caries experiences (Figure. 02C).


Complex Comorbidities (HIV+) Group

Overall, prosthodontic and HIV+ group graphs when compared to those of the group comprising healthy young dentists and the pediatric group show an increase in caries with age and medical comorbidities. The increase in the DMFT/S scores supports our hypothesis that there is a correlation between age, oral health and overall health. Beena et al,9 reported on the relationship between high caries scores using DMF in children with HIV. However, there are few if any caries studies in HIV+ adults using a scoring system. In the future, it would be of value to compare PLWHA to healthy adults to establish relationship and conditions related to HIV treatment and caries experience (Figure. 02D).


DMFT score for HIV + people by age indicating a positive correlation

Among the primarily adult groups (prosthodontic and PLWHA) there is a small correlation (R= 0.18, with the DMFT score by age, which is not seen in the pediatric group which shows less because of primary dentition teeth are only in the mouth for 6 month to 6 years (average 5 years) years versus adults that hold teeth ideally for 100 years. This means that the adult has more chance to experience caries than the child

Caries Risk and Etiology

Diet, personal oral hygiene, microbiome, fluoride supplementations, medications that induce xerostomia and/or access to dental care are overwhelming and confounding factors that need to be considered.21 Also, other clinical information in addition to the DMFT/S scores such as quantification including periodontal examinations is needed to determine the total oral health status of a person. In the future, a relative value score used with DMFT/S quartiles to assign oral health status may be used to demonstrate the change in trends of dental treatment such as esthetic dentistry, implants and orthodontics. The usefulness of dental caries scoring systems in quality improvement initiatives for dental care should be considered. In conjunction with this scoring system, the etiology of caries risk, periodontal status and the relative value of functional rehabilitation with dental prostheses would provide a total picture for an improved measuring system to demonstrate association of oral health and total health.


The hypothesis that DMFT/S scores should be lower with children and higher with age or decreased health status is supported by the data derived. Further study with increased sample size and multiple scoring by calibrated operators is required to demonstrate precision and variation using this method to identify predisposition to caries for targeting interventions. This system can be used for quick assessment of caries experience and risk with the DMFT/S scoring for a patient, in a dental practice or community health of a population and thereby assist health care planners and third-party payers with actuarial calculations.