Fifteen Years of the PUFA Index in Oral Epidemiology: A Systematic Review of Global Application and Reporting.

Abstract

The PUFA index records the presence of pulpal involvement, ulceration, fistula, and abscess to quantify the clinical consequences of untreated dental caries. The PUFA index captures the prevalence and severity of oral conditions, making it useful for surveillance, research, and advocacy. After 15 years of global use, this systematic review synthesises how the PUFA index has been applied and reported. Following PRISMA 2020 guidelines, seven databases were searched: PubMed, Embase, Scopus, Web of Science, CINAHL, Global Health, and Google Scholar. Eligible studies were published between 2010 and 2025 and reported original epidemiological data using the PUFA index. Data extraction captured study design, population, dentition type, PUFA reporting formats, examiner details, and use of complementary indices. Descriptive synthesis was performed with high inter-rater reliability among reviewers (96.5%). Out of 4438 records, 260 studies from 53 countries met the inclusion criteria. PUFA was predominantly applied in low- and middle-income countries across the life course, but with a focus on children and adolescents. Nearly half of the studies (48.8%) examined associations between PUFA and health outcomes, and over one-third (37.7%) applied PUFA in population surveillance. Reporting practices varied, and examiner type was specified in about half of the studies (47.3%), with dentists being the most common (82.9%). While methodological rigour was generally good, there were inconsistencies in reporting formats and limited availability of inter- and intra-examiner reliability data. The PUFA index is a recognized oral health index that has shown steady adoption across numerous studies and diverse populations. Its global credibility has positioned it for integration into modern surveillance frameworks, including the updated WHO STEPS Oral Health Module. Future priorities include standardizing reporting, strengthening integration into surveillance systems, and exploring how the PUFA index can be used in program evaluation to better inform policy and reduce oral health inequities.