THE DYNAMIC EVOLUTION OF ORAL HEALTH STATUS OF
SCHOOLCHILDREN IN IASI UNDER THE IMPACT OF THE NATIONAL
PREVENTION PROGRAM
Livia BOBU1, Carina BALCOŞ2 , Adriana BĂLAN3
1 Univ. Assist., PhD, Oral and Dental Prevention, Faculty of Dental Medicine, „Gr. T. Popa” U.M.Ph. of Iaşi, Romania 2 Univ. Assist., PhD, Oral and Dental Prevention, Faculty of Dental Medicine, „Gr. T. Popa” U.M.Ph. of Iaşi, Romania 3 Assoc. Prof., PhD, Pedodontics, Faculty of Dental Medicine, „Gr. T. Popa” U.M.Ph. of Iaşi, Romania
Corresponding author: carinutza2005@yahoo.com
Abstract
In most of the developing countries, dental caries continues to represent a major issue of public health. In Romania, the National Program for Oral and Dental Diseases Prevention, implemented between 1999-2010 and addressed to children attending primary school, consisted of of weekly mouthrinses with a 0.2% NaF solution. In the present study, the dynamics of oral health status of schoolchildren aged 6-12 years in Iasi, under the impact of this program, was analyzed. The results showed a
decreasing trend in the prevalence and incidence of dental caries, a constant decrease of caries experience indices,
DMFT and DMFS, and, within them, the increasing trend of fillings index, FS, and the decrease of deep lesions weight. The conclusion is that tooth decay has declined in
schoolchildren in Iasi during the development of the National Prevention Program.
Keywords: mouthrinses, schoolchildren, fluoride, DMFT,
DMFS.
1. INTRODUCTION
In spite of the obvious improvement in oral health status of the population worldwide, oral diseases continue, however, to represent a major public health issue.
In the last 20 years, most of the industrialized countries have experienced a significant decrease of dental caries prevalence in children, which is mainly attributed to changing conditions and
lifestyle. Such positive trends have been seen in
some Eastern European countries, too, but, for most of the developing countries, the prevalence of dental caries in children continues to be high.
This is because of the economic and political characteristic situation that affects health systems and, consequently, oral health systems.
In Romania, the National Program for Oral and Dental Diseases Prevention (program P 1/5, observation 4), consisting in weekly mouthrinses with a 10 ml Fluorostom solution (0.2% NaF), for 1 min, was implemented in 1999. The program targeted primary schoolchildren and was implemented in four major urban centers in the country, including the city of Iaşi. In the year 2000, the Program included 8,000
children, their number increasing progressively up to 12,800 in the year 2005, after which, as a result of the rising costs of the necessary kits, the number of children began to decrease, up to
9,000 in 2007. In the year 2010, as a result of the
lack of financial funds, the Program was
suspended.
The aim of the present study was to analyze the dynamic evolution of oral health status of schoolchildren in Iaşi, under the impact of the National Prevention Program.
2. MATERIAL AND METHODS
A clinical longitudinal study was conducted between 2003-2007. The study sample was selected according to the following criteria:
children aged 6 to 12 years, attending schools in various districts of Iasi and presenting various
socio-economic levels; schools that have a dental office. The sample was selected using the probabilistic method, through stratification. The
size of the study group was established taking into account the prevalence of dental caries in
in the population the sample had been extracted from. A minimum of 600 children aged 6-12 years were evaluated yearly.
The applied method involved calculation of the morbidity indices of dental caries. Clinical examinations were performed in the dental offices of schools. All examiners were previously calibrated according to the W.H.O. methodology [1], by means of post-university perfecting courses. In order to determine the repeatability index, 8% of the records of 6 year-old children and 5% of the records of 12 year-old children were re-examined, resulting in a Kappa index with values ranging between 0.73 and 0.84.
Recording of oral health status of children made use of a W.H.O. recording form, filled in according to the WHO methodology, so that it could meet each standard criterion for the
evaluation of oral health status [2].
Registration of dental health status followed the WHO pattern, based on codes from 0 to 8, the
present study referring to data corresponding to
permanent teeth. Also recorded was the type of
carious lesion, as a function of its depth and of the
affected dental tissues, according to the WHO codification system: D1 – lesion in enamel, clinically detectable, with intact surface (non-cavitary lesion); D2 – lesion in enamel, clinically
detectable, cavitary; D3 – lesion in dentin, clinically detectable; D4 – lesion affecting the pulp.
Recording of these codes involved exclusively
clinical considerations (inspection, palpation
with dental probe), with no use of complementary means.
SPSS 14.0 was used for statistical analysis of data. The statistical significance cut-off point p
was set at 0.05 and the t test was used for data
comparison.
Written parental consent for children participation in the study was first obtained.
Children also had the opportunity to accept or refuse participation.
Data privacy as well as the impossible identification of subjects in the case the results are published were ensured.
3. RESULTS
Dental caries prevalence increased gradually,
with increasing age (table 1). However, a downward trend in dental caries prevalence was
noted during the study, in all age groups. In 7
year-old children, prevalence decreased from 18.4% in 2003 to 13.7% in 2007, while in 12 year-old children a decrease from 75.6% in 2003 to 68.4% in 2007 was recorded.
Table 1. Dental caries prevalence (%) in permanent teeth
Age
(years)
Year of examination
2003 2004 2005 2006 2007
6 16.2 15 13.7 12.5 12.5
7 18.4 16.2 15 15 13.7
8 28.6 27.6 25 23.7 22.5
9 43.2 41.8 39.8 38.7 37.5
10 61 59 56.1 55.1 53.7
11 67.1 65 61.4 59.2 58.2
12 75.6 74.1 72 70.4 68.4
Dental caries incidence presented a gradual
increase with increasing age, too (table 2). However, similarly with the prevalence, an improving trend was observed, namely a
constant decrease of caries incidence during the
Table 2. Dental caries incidence (‰) in permanent teeth
Age (years) Year of examination
2004 2005 2006 2007
7 200.00 187.50 175.00 162.50
8 204.08 200.00 187.50 175.00
9 214.29 204.08 200.00 187.50
10 261.36 234.69 224.49 212.50
11 300.00 284.09 275.51 265.31
12 317.65 310.00 306.82 295.92
Dental caries structure indicators increased
with increasing age. In 2007, the DMFS index (table 3) was 0.16 at the age of 6 years, 1.22 at
Table 3. DMFS and DMFT indices (mean values and standard deviation)
Age (years)
DMFS DMFT
2003 2004 2005 2006 2007 2003 2004 2005 2006 2007
6 0.25 (0.66) 0.21 (0.56) 0.19 (0.50) 0.18 (0.49) 0.16 (0.46) 0.25 (0.66) 0.21 (0.56) 0.19 (0.50) 0.18 (0.49) 0.16 (0.46)
7 0.36 (0.85) 0.30 (0.77) 0.26 (0.72) 0.24 (0.64) 0.22 (0.63) 0.33 (0.75) 0.25 (0.62) 0.21 (0.56) 0.20 (0.51) 0.19 (0.50)
8 0.79 (1.53) 0.62 (1.15) 0.58 (1.06) 0.54 (1.12) 0.52 (1.14) 0.64 (1.12) 0.54 (0.95) 0.48 (0.88) 0.45 (0.94) 0.42 (0.89)
9 1.35 (1.88) 1.29 (1.87) 1.27 (1.83) 1.25 (1.78) 1.22 (1.90) 1.02 (1.27) 0.86 (1.16) 0.82 (1.12) 0.79 (1.12) 0.76 (1.18)
10 2.48 (2.64) 2.45 (2.71) 2.41 (2.60) 2.38 (2.55) 2.35 (2.64) 1.55 (1.55) 1.45 (1.43) 1.37 (1.37) 1.35 (1.36) 1.32 (1.45)
11 3.13 (2.86) 3.11 (2.94) 3.07 (3.05) 3.04 (3.02) 3.01 (2.99) 1.98 (1.58) 1.84 (1.61) 1.76 (1.61) 1.74 (1.63) 1.72 (1.63)
12 3.93 (3.52) 3.89 (3.31) 3.83 (3.27) 3.80 (3.51) 3.76 (3.49) 2.40 (1.87) 2.35 (1.61) 2.29 (1.74) 2.27 (1.83) 2.24 (1.87) the age of 9 years and 3.76 at the age of 12. The
DMFT index in the same age groups was 0.16,
0.76 and 2.24, respectively.
However, a constant decreasing trend of caries indices was observed during the study, in all age groups. In 10 year-old children, the DMFS index decreased from 2.48 in 2003 to 2.41 in 2005 and
2.35 in 2007.
Dental caries structure indicators presented
different trends. Decayed teeth index, DS, (table
Table 4. DS, MS and FS indices (mean values and standard deviation)
Age
(years) 2003 DS 2007 2003 MS 2007 2003 FS 2007
6 (0.60)0.24 (0.45)0.15 (0.00)0.00 (0.00)0.00 (0.11)0.01 (0.11)0.01
7 (0.84)0.34 (0.50)0.15 (0.00)0.00 (0.00)0.00 (0.14)0.02 (0.34)0.08
8 (1.52)0.74 (0.65)0.28 (0.00)0.00 (0.00)0.00 (0.24)0.04 (0.66)0.25
9 (1.88)1.30 (1.57)0.91 (0.00)0.00 (0.00)0.00 (0.35)0.06 (0.72)0.31
10 (2.63)2.36 (2.55)2.02 (0.00)0.00 (0.00)0.00 (0.38)0.12 (0.75)0.32
11 (2.91)2.76 (2.57)2.35 (0.54)0.06 (0.00)0.00 (0.61)0.31 (1.32)0.66
12 (3.52)3.33 (2.98)2.69 (0.90)0.17 (0.50)0.05 (0.88)0.43 (1.75)1.01
Assessment of the newly developed carious lesions depending on their depth showed an increase
of the percentage of deeper lesions with increasing age (table 5). In 2004, non-cavitary enamel lesions (stage D1) represented 58.5% of the newly developed lesions in 7 year-old children and 27.8% in 12 year-old children; cavitary dentine lesions (stage D3) represented 41.4% of the newly developed lesions in 12 year-old children and only 5% in 7 year-year-old children. At the same time, lesions affecting the pulp (stage D4) were observed only starting with the age of
11 years.
A decrease in the percentage of deeper lesions
was observed in all age groups during the study, along with an increase in the percentage of non-cavitary lesions, which became of majority in 2007. In 7 year-old children, the newly developed caries were limited to enamel and 65.7% of them were non-cavitary lesions. In 12 year-old children, lesions in stage D1 represented 44.8% of the newly developed lesions, followed by lesions in stage D2 (28.1%) and lesions in stage D3 (27.1%). Lesions affecting the pulp were no longer observed in any of the studied age groups.
Table 5. Distribution of newly developed lesions depending on depth (%)
Age
(years)
Evolution stage
D1 D2 D3 D4
2004 2007 2004 2007 2004 2007 2004 2007
7 58.5 65.7 36.5 34.3 5 0 0 0
8 50.4 60.1 35.7 33.2 13.9 6.7 0 0
9 43 57.3 34.3 32.8 22.7 9.9 0 0
10 39.1 55.4 33.4 30.6 27.5 14 0 0
11 30 49.2 32 28.5 34.6 22.3 3.4 0
4. DISCUSSION
The profile of oral diseases has experienced
marked changes over the last 50 years. The effects of fluoridation, the change in dietary habits and oral health behavior have influenced the overall
picture of oral health [3].
Most of the studies assessing oral health of the
population refer to children oral health because
it represents an indicator of the health of the
community [4,5].
In Romania, data from the study conducted in
1986 is a reference point in what concerns oral health of schoolchildren in the communist regime [6]. The research was resumed in 1992 and 2000, the results obtained reflecting the manner in which changes in many fields have contributed
to changing oral health of children.
The results of the present study evidence a
trend of improving oral health of schoolchildren, as caries prevalence in 2007 decreased with 16.7% in 6 year-old children and 24.8% in 12 year-old children, compared to the values
registered in 1992.
At the same time, a decreasing trend of caries experience indices was observed. The DMFS index decreased with 68% and the DMFT index decreased with 60% in 6 year-old children. In 12 year-old children, the DMFT index increased with 24.4% (from 3.1 to 4.1) between 1986-1992; subsequently, the DMFT index tended to decrease,
reaching to 3.4 in 1995 and to 2.7 in 2000. In the
present study, the DMFT index was 2.40 in 2003 and 2.24 in 2007, for 12 year-old children.
This means a decrease of 17% of the DMFT index, in 12 year-old children, when compared to the value in 2000, of 34.1% compared to the value in 1995 and of 45.3% compared to the value
in 1992.
A separate analysis of dental caries structure
indicators in permanent teeth evidences a decrease of the caries index DS, compared to the values in 1992, but also between 2003-2007. In the present study, the DS index was 0.24 in 2003 and 0.15 in 2007 for 6 year-old children, while in 1992 the reported value was 0.40. The decrease of the DS index in the mentioned period is obvious in 12 year-old children, too; the DS index was 5.0 in
1992 in this age group, while in the present study the DS index was 3.33 in 2003 and 2.69 in 2007.
The same decreasing trend was also observed, during the study, for the missing teeth index MS, although this index increased from 0.10 in 1992 to 0.17 in 2003, in 12 year-old children, most probably due to the social health insurances, namely full deduction of dental treatments provided for children with ages up to 18 years [7]. However, the MS index was 0.05 in 2007, which is half of the value recorded in 1992.
Moreover, at the end of the present study, the
only age group that still presented permanent teeth extractions was 12 years.
The fillings index FS presented one of the most important evolution trends. In 2003, the FS index was 0.43 in 12 year-old children, meaning 52.2% lower than the value in 1992 (0.9). In 2007 the FS index increased up to 1.01, meaning 2.34 times higher than the value in 2003.
The factors that may explain these changes in oral health status of children aged 6-12 years in Iasi are multiple.
Firstly, one of the factors having intervened
between 1992 and 2003 is the implementation
of the National Program for Oral and Dental
Diseases Prevention, addressed to primary
schoolchildren and consisting in weekly mouthrinses with a 0.2% NaF solution. The role of these preventive programs in improving dental health status of children is very well documented in the literature. The use of fluoride is considered to be the main cause of the marked improvement in oral health status in
industrialized countries in latest generations
[8]. Nowadays, fluoride manners of action are well-known, and the application methods have been extensively tested. Considering that fluoride action is predominantly a post-eruptive one, the main purpose of using fluoride products is to ensure a low, yet constant level in the oral environment to be available for remineralization
processes [9].
The idea to use fluoride mouthrinses for dental caries prevention started to be implemented in 1965, when a study in Sweden reported an approximately 50% decrease in dental caries
The main advantage of using fluoride
mouthrinses is the low cost compared to other methods of prevention, and the fact that it does not require skilled personnel, as supervision can be provided by parents or educators. Anyway, the method is firstly recommended to high-risk population groups, to ensure an optimal
cost-effectiveness ratio.
Another advantage is that such a program may be easily applied in schools.
The efficiency of local fluoridation through mouthrinses was demonstrated in Iasi as early as 1993, in a case-control study which evidenced that caries morbidity, as expressed by caries prevalence, severity and experience indices was lower in children who received local fluoridation compared
to the children in the control group [11,12].
5. CONCLUSIONS
Dental caries declined in all age groups during
the implementation of the National Program for Oral and Dental Diseases Prevention. This can be attributed to fluoride mouthrinses, but some other factors should be considered, too: oral hygiene improvement, increased knowledge level in the population, improved access to dental care.
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