Purpose: The preferred epidemiological caries assessment method is the decayed, missing, and filled surfaces (dmfs) score, which records all crowned/missing primary teeth's surfaces as carious. The purpose of this study was to evaluate the dmfs score's accuracy in capturing caries-affected (versus treated) surfaces of crowned/extracted teeth. Methods: A high-caries risk cohort of children, eight to 18 months old at baseline, were recruited from a nonfluoridated, rural, minority, and low-income community. Oral examinations occurred every 12 months for five years, identifying children with at least one caries-related crown/extraction (N equals 45). Observed scoring counted all crowned/extracted surfaces as carious. Private dentists' clinical records were also reviewed to determine how many surfaces were carious at crown/extraction appointments (53 actual scores for n equals 19). Differences in actual and observed scoring were evaluated (sign test; α equals 0.05 with two-tailed P-values). Results: Most children in the study group had more than one crown/extraction. Actual scoring revealed two to three fewer carious surfaces per tooth than observed scoring; cumulatively, observed scoring added two to 27 more surface counts per participant (P<0.001). Conclusions: Observed scoring exaggerated early childhood caries burdens when crowns/extractions were prevalent. Modified dmfs scoring, individualized or population-corrected crown/extraction counts, could more accurately estimate disease.