Oral Health Indices and Obstacles to Dental Care Related to Demographic Features in Bosnian Children Aged Six.
Original scientific paper
Oral Health Indices in Bosnian Children Aged Six.
Muratbegović A1, Marković N1, Zukanović A1, Kobašlija S1, Selimović Dragaš M1 and Jurić H2.
1 Department of Preventive and Paediatric dentistry, Faculty of Dentistry, University of Sarajevo, Bosnia and Herzegovina.
2 Department of Pediatric Dentistry, School of Dental Medicine, University of Zagreb, Zagreb, Croatia.
The main aim of this paper is to present epidemiological indicators of oral health among six-year olds in Bosnia and Herzegovina (BH) and to analyze values of dmft index and dental treatment needs in order to identify differences in access to health care in different parts of the country. Another aim is to identify the needs from the public oral health care system in Bosnia and Herzegovina related to early permanent dentition by analyzing the condition of first permanent molars (FPM) as an indicator of oral health of permanent dentition. Survey was carried out in 2004 in 8 cantons of the Federation of BH (FBH) and in the Republic of Srpska (RS). Final sample included 560 examinees aged six. One dental team clinically examined all examinees according to WHO methodology and criteria. The parameters used were: dmft index, DMFT index of first permanent molars (FPM), presence of sealants and treatment needs. A questionnaire about oral health habits had been administered. Dmft was 6.71 in that the d-component constituted the major part of the index. DMFT index of FPM was 0.61 (SD±1.08). Percentage of caries free examinees aged 6 was 6.8%.Average number of FPM with fissure sealents in BH was 0.25 (SD±0.78). Significant demographic differences in dmft index, DMFT FPM and treatment needs were identified. Most examinees (48.5%) had their first dental visit between the ages of five and seven. National oral health goal for Bosnia and Herzegovina should be to develop and implement disease prevention programs based on education of both parents and dental practitioners. It is necessary to improve access to dental care and shift focus from curative to preventive procedures. It is also necessary to set real goals for improvement of oral health which can be achieved within a desired time frame, as well as to precisely define measures to be taken. Key words: dmft, first permanent molars, children, oral health, Bosnia and Herzegovina
Introduction Accurate data about oral health of Bosnia and Herzegovina’s children aged six, as standardized group for oral health monitoring in primary dentition, suggested by World Health Organization (WHO), are so far unavailable. In the former Yugoslavia in 1986, the dmft index was 7.41. Ivankovic’s 1997 research, conducted in some parts of Bosnia and Herzegovina (BH), pointed to dmft 4.8 in children aged six 2. Previous studies suggested children of BH to be at medium risk for dental caries development due to bad oral hygiene maintenance, lack of preventive programs, inadequate diet content and frequency, occasional usage of topical fluoridation and changes in living conditions 3.
Epidemiological data about the oral health status that our country currently lacks are prerequisite for improvement of oral health. Therefore, it was necessary to conduct a study to gather epidemiological data about the oral health in Bosnia and Herzegovina.
Subjects and Methods Study area
Bosnia and Herzegovina is made up of two entities (Federation of Bosnia and Herzegovina, Republic of Srpska) and one district (Brčko). Federation of Bosnia and Herzegovina (FBH) is further divided into 10 cantons. It covers an area of some 51,128 km2, and has population of 3,717,130 people. Bosnia and Herzegovina is an area with low natural fluoride content in the drinking water (less than 0.1 ppm). Fluoride-toothpastes are available in BH.
Study population and sampling procedure
Sample stratification was done by size of community and by administrative areas (regions) according to relevant WHO recommendations4. Eight studied cantons from FBH were represented by a sample of examinees from one location namely: Sarajevo, Tuzla, Sanski Most, Visoko, Goražde, Vitez, Široki Brijeg and Mostar. Republic of Srpska (RS) was represented by a sample of examinees from Banja Luka. Education ministries provided us with the lists of all public primary schools (386 in FBH, 170 in RS and in Brčko District 12). Survey was conducted in public schools as the number of private schools was too low to be significant. In locations chosen by stratification schools were randomly selected from the list. Granted permissions for the research by all respective ministries and other relevant authorities was obtained, and we directly contacted all 14 schools to set up the precise dates of visits and other organizational and administrative elements of the research. In each of the 14 schools the first classroom was chosen (designated A or 1), and children from the next class (designated B or 2) were included if necessary. Children born in 1997 and 1998 were included in the study. In each primary school 40 subjects were examined. The final sample included 560 examinees aged six.
Assessment of oral health
One dental team visited primary schools and clinically examined all subjects in line with WHO methodology and criteria, using dental mirrors and standard CPI/WHO periodontal probe, under natural light 4. When necessary, gross plaque or food debris was removed with cotton-rolls prior to examination. The parameters used to measure oral health status were: dmft index, DMFT index of first permanent molars (FPM) and presence of sealants. Treatment needs (TN) of primary and permanent teeth were assessed as well. Clinical examination for recording dental caries was carried out in schools by one investigator, previously trained in using the dmft index on twenty-five examinees aged six not included in final sample. Kappa statistics was used to test the intra-investigator reliability. The kappa values estimated from repeat examination for the intra-consistency of the fieldwork investigator was k=0.89.
Survey questionnaire was completed by parents/ foster parents one day prior to the examination. Questionnaires were returned at school along with a granted consent that data from clinical examinations could be used for the study. The questionnaire included questions about oral hygiene habits, diet contents and frequency, reasons for and frequency of dental visits.
The findings were coded, noted on a data sheet and later saved electronically. The Statistical Package for Social Science - SPSS for Windows, version 15.0 (SPSS Inc. Chicago, Ill., USA) was used. Mean values, standard deviations and frequency distributions, correlations and factorial analysis of variance - ANOVA were computed.
Results In 6-year-olds the dmft was 6.71 in that the d-component constituted the major part of the index (88.79%), followed by extracted teeth (8.89%) and a small percentage of filled teeth (2.32%) Percentage of caries free examinees aged 6 was 6.8%. Different values of dmft and its components were registered in survey locations (Table 1, Graph 1). ANOVA statistical analyses revealed significant differences between different survey locations in terms of dmft index (p=0.005, F=2.75), dt (p=0.001, F=3.36) and ft (p=0.017, F=2.35). Differences were noticed in needs for preventive dental treatment (p=0.016, F=1.16), one-surface and multi-surface fillings (p=0.016, F=2.38 and p=0.021, F=2.27), pulp treatment and extraction (p=0.004, F=2.82 and p=0.001, F=3.33). The values of all parameters registered in examinees’ deciduous dentition were compared with those obtained for Sarajevo (Table 2).
Average number of first permanent molars among examinees was 3.63 (SD±0.95) and varied between 3.58 (SD±0.95) in Sarajevo and 3.14 (SD±1.43) in Banja Luka. DMFT index of FPM was 0.61 (SD±1.08). First permanent molar status was analyzed and significant demographic differences were noticed for all components, DMFT (p=0.000; F=2.75), DT (p=0.024; F=2.22), MT (p=0.003; F=3.00) and FT (p=0.000; F= 4.27). Average number of FPM with fissure sealant in BH was 0.25 (SD±0.78) with highest values in Široki Brijeg 0.85 (SD±1.47) followed by Sarajevo and Mostar (0.45, SD±0.95 and 0.42 SD±1.03). Demographic differences related to FPM treatment needs were evaluated using ANOVA and post-hock LSD test for multiple comparisons. There were significant only for extraction (p=0.001, F=3.48) and fissure sealent need (p=0.000; F=10.88). Values of parameters registered for FPM were compared with values for Sarajevo (Table 3).
Total number of the 560 issued questionnaires were returned. But, 344 were filled out to a satisfactory level (response rate of 61.4%). Descriptive statistics (mean values and frequency distribution) indicated that examinees had an average of 4 to 5 meals per day (61.3% of examinees), one serving of sweets per day (45%) and that they toothbrush teeth twice daily (60.5%). Most examinees (48.5%) had their first dental visit between the age of five and seven. The main reason for the first dental visit was dental checkup (43%). Although, most of children visit dentists (86.3%), 49% of them had not a regular dentist. The most frequent reason for dental visits was dental checkup (38.5%).
Spearman’s correlation was conducted between dmft index and number of meals per day, sweets intake, and number of tooth brushing per day, frequency of dental visits, accessibility of dental care, age at first dental visit, reasons for first dental visit, and most frequent reason for dental visits. Weak correlation was found between sweets intake and dmft index (correlation coefficient 0.13, p=0.013) and between dental visits and dmft index (correlation coefficient 0.13, p=0.13).
Discussion and Conclusion
Among children aged five in eight European countries dmft index varies from 0.8 in Sweden to 3.06 in Scotland5. In the former Yugoslavia in 1986, the dmft index for the same age group was 7.4 1 and in Bosnia and Herzegovina, according to Ivankovic’s study, it was 4.8 in 19972. In our study, first one conducted in BH according to WHO recommendations, dmft was 6.71 in that the d-component constituted the major part of the index, which is comparable with values in Croatia (7.7) in younger age group6.
Comparisons of dmft index values by separate survey locations reveal differences, with the highest values registered in Gorazde (8.63), Banja Luka (7.06) and Vitez (7.00) and the lowest in Mostar (5.05). Established differences in the presence of diseases in different survey locations were expected due to differences in organization, development and accessibility of oral care as well as different geographic characteristics of specific regions (climate, altitude, quality of drinking water etc.). However, this can also be due to different socio-economic factors3 , not analyzed in this study.
Results obtained for values of dmft index, DMFT FPM and dental treatment needs were compared with relevant values for Sarajevo because the capital city has the greatest number of preventive and pediatric dentists (Table 4.). High dmft values were registered among examinees in Sarajevo. Results also show that the need for fissure sealing and the number of fissure sealants on FPM was higher in Sarajevo than in any other survey location other than Siroki Brijeg where the number of fissure sealants was significantly higher than those in Sarajevo. For better understanding of the above, it is necessary to mention that Sarajevo Canton has the highest number of registered dental care users. In Mostar, which is the representative of the Herzegovina-Neretva Canton, we registered a significantly lower value of dmft index along with a significantly lower number of caries-affected teeth, as well as high number of filled teeth which can be explained by the number of general and paedodontic dentists available there. Mostar had the highest number of deciduous teeth in need of preventive treatment. In Gorazde, which has the least number of dentists, we registered the highest number of caries-affected teeth and highest dmft values. The fact that we had not come across any filled deciduous teeth in Gorazde and that the DMFT values on FPM (1.33 ± 1.30) were higher than anywhere else in BH are reasons for concern. Further on, not a single examinee in Gorazde had a sealed permanent molar and the need for extraction of permanent molars was significantly higher in Gorazde than elsewhere. Tuzla as a representative of the Tuzla Canton, has the second highest number of paediatric dentists and also the second lowest value of dmft index (after Mostar), but it also had a high frequency of caries-affected and extracted deciduous teeth (90% and 9% respectively). Results for Široki Brijeg, representative of the Herzegovina-Neretva Canton, revealed the highest percentage of extracted deciduous teeth without any presence of fillings in deciduous teeth. It holds the second place in terms of DMFT FPM, but at the same time has the highest number of sealed FPM (0.85±1.47), that clearly requires deeper consideration. Banja Luka had the lowest values of DMFT FPM, but in interpreting these findings one must keep in mind that the number of present FPM was the lowest among examinees there.
The care for primary teeth in our country is neglected. The pattern of percentual share of specific components of dmft index (decayed, missing, filled teeth) is unsatisfactory in the whole of Bosnia and Herzegovina. There are probably numerous reasons for this, but most importantly, the difference is due to absence of oral disease prevention and oral health promotion programs in BH which are standard in most developed European countries that also have well-organized system of dental protection. Limiting factors include fragmented health care system in Bosnia and Herzegovina, and curative rather than preventive approach to health care. Analyses have shown that most of our examinees had their first dental visit between the ages of five and seven, rather than at the recommended age of one year, which points to a low level of awareness among parents in BH about the importance of deciduous teeth health. In most surveyed cantons, the responsibility for dental care of children had been given to general dentists. Some studies indicate that our dentists know about the basic principles of preventive dental care, but are not giving it sufficient attention in general treatment of their patients. Instructions for oral hygiene are the only preventive measure used by private general dentists in the Sarajevo Canton while professional local fluoridation is provided by under a half of them and that mainly to children7. Fissure sealing is an efficient preventive measure, but in contrast to the finding of the above mentioned research that as many as 72% of dentists are using it our study has shown that it is poorly used in all parts of BH.
Sealants are effective in preventing caries, although their efficacy may be related to the background caries prevalence in the population8. Opinions about effectiveness of sealants in population such as BH are confusing. Some studies consider it of value while other don’t and recommend combination with other preventive measures to reduce caries activity9-12.
WHO global goals for the year 2000 was that 50% of children aged five to six is caries free, and for the twelve year olds DMFT should not be higher than 313. In this study, percentage of caries free examinees was 6.8. The average DMFT of children aged twelve in 2004 was 4.16±2.92 (9% caries free)14. Our national goals must be less ambitious than those currently promoted by WHO and FDI, because oral health of our children is much worse than that of the children in most other European countries.
Bosnian national oral health goal should be development and implementation of a disease prevention programs, based on education of parents and dental practitioners as well. It is necessary to improve access to dental care and shift focus from curative to preventive procedures. Realistic goals for improvement of oral health should be set, that can be implemented within desired time frame, as well as to precisely define measures to be taken.
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Address for correspondence:
Department of Preventive and Paediatric dentistry, Faculty of Dentistry, University of Sarajevo, Bolnička 4a, 71000 Sarajevo, Bosnia and Herzegovina
Demographic values of dmft index and first permanent molars status (DMFT, sealants present and indicated) of examinees aged six in Bosnia and Herzegovina
First permanent molars
TN* fissure sealant
*TN – treatment need
Demographic differencies in dmft index and tretment needs
One surface filling
Multi surface filling
Demographic differencies in DMFT index and tretment needs of first permanent molars (FPM)
Multi surface filling
Fissure sealing 2.01 (±1.48)
*FPM- first permanent molar
Demography of dental care in eight cantons of FBiH and RS.