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Journal of Public Health Dentistry ... Key Words: preventive dental care, children's dental health, health education, .... such as asthma, allergy, or epilepsy.
Journal of Public Health Dentistry

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SCIENTIFIC ARTICLES

Changes in Dental Health and Dental Health Habits from 3 to 5 Years of Age Marja-Leena Mattila, DDS; Paivi Paunio, DDS, PhD; Paivi Rautava, MD, PhD; Ansa Ojanlatva, PhD; Matti Sillanpaa, MD, PhD Abstract Objectives: This study sought to determine how dental health and dental health habits change from3 to 5 years ofage and to consider whetherpreventive dental health care helped in preventing or halting caries in children. Methods: The study included 67 maternity health care clinics, 72 we//-babyclinics, and 69 dental health care clinics. Of the 1,292 newborn children, 1,003 (90.8%)were included in this study. Results: Preventive dental health care contributed to dental caries being halted in only 13.2percent of those children who had enamel caries at 3 years ofage. The dmft index did not increase in 22.6 percent ofthose children who had dentinal caries at 3 years of age. For all others, the disease became

more severe. Toothbrushing habits of 3-year-old children were very consistent over the two years studied. Children were at a risk for caries when their mothers had nine years of basic education, when they already had plaque and caries at 3 years ofage, and when the frequencyof eating sweets increased the most during the two-year study period. Conclusions: Among 3-year-old children, plaque is an indicator of caries risk and therefore should be a key element in health education. Those children who already have evidence of caries at 3 years ofage should be the target ofpreventivedental services because of their increased risk. [J Public Health Dent 1998;58(4):270-41 Key Words: preventive dental care, children’s dental health, health education, quality ofpreventive dental care.

Dental health habits are associated with the dental health status of 3-yearold, first-born children in Finland (1). Paunio et al. (2) found that drinking juice at night and dental cleanliness emerged as statistically significant explanatory factors for dental caries. By the time children in that study reached 3 years of age, regular toothbrushing was associated with other health habits. Kinirons and McCabe (3)found that the ability of parents to take care of their children’s dental health seemed to increase with time because the lowest caries occurrence was in secondand third-born children. A mother’s dental attendance pattern and her anxiety about dental care were important factors affecting a child’s dental

care. In Finland, the provision of pediatric dental care services is concentrated in public clinics. These services are free of charge and individuals receive notification for a visit at regular intervals. The Finnish public dental care system emphasizes the significance of good dental health habits and its mission is based on preventive dental health care. Despite these strategies, toothbrushing practices are not adequate in children. Toothbrushing frequency for 12-year-old Finnish children is the same as for 3-year-old children in many other countries (4,5). The prediction of caries patterns is not easy. A prior history of caries is considered to be a strong predictor (6). Holbrook et al. (7) found baseline car-

ies scores and high consumption of sugar to be the strongest of several prediction variables included in their study. In another study, caries experience in the primary molars at 5 years of age was of value as a predictor for caries in the first permanent molars two years later (8). The purposes of the present study are to describe changes in dental health and dental health habits from 3 to 5 years of age, to explore factors, including a deterioration in dental health habits, that might be associated with any deterioration in dental health, and to consider whether preventive dental health care can prevent or halt caries in chldren.

Methods The present study is part of the Finnish Family Competence Study introduced by staff at the Department of Public Health, University of Turku, in 1985. A stratified probability sample was used to select 11 health authority areas weighted according to the degree of urbanization from the (then) Province of Turku and Pori in southwestern Finland. Nulliparous women who in 1986 made their first visit for their pregnancy to one of 67 maternity health care clinics (MHCCs) in the sample areas composed the sample. Of the 1,582 women who qualified for participation in the study, 1,443 gave informed consent. These women gave birth to 1,292 infants. A detailed description of the original study population is presented elsewhere (9). Mothers completed a pretested questionnaire during their first visit to the MHCCs at about their 10th week of pregnancy, and when their children were seen at 18 months, 3 years, and 5

Send correspondence and reprint requests to Dr. Rautava, Department of Public Health, University of Turku, Le-lkaisenkatu 1,20520 Turku, Finland. E-mail: [email protected]. Dr. Mattila is with the Department of Public Health, University of Turku, and the Dental Health Care C h c of Turku; Dr. Paunio is with the Dental Health Care Clinic of Turku; Drs. Rautava and Qanlatva are with the Department of Public Health, University of Turku; and Dr. Sillanpaa is with the Department of Child Neurology, University of Turku. Manuscript received: 12/31/97; returned to authors for revision: 3/10/98; accepted for publication: 11/25/98.

Vol. 58, No. 4, Fall 1998 years of age at one of 72 well-baby clinics (WBCs)or 69 public dental clinics. The number of returned questionnaires at each of these three follow-up periods was 1,025, 887, and 1,003, respectively. In addition to the questionnaire data being collected on the children at the WBCs, dental examinations were performed by 101 dentistsatthepublic health dental centers. Appointments were not scheduled for purposes of the study; rather, each child was seen during the regularly scheduled dental visit. Deviations from the planned examination times did not exceed two months in any case. Completed dental examinations were available for 1,059 and 828 3- and 5-year-old children, respectively. Examinations for both ages were available for 741 children. Replicate examinations were done for 47 children when they came for their dental visit at 3 years of age. The initial examination was performed by one of the study dentists; the second, by one of the authors (PP). The kappa statistic for these replicate examinations was .64, suggesting a satisfactory level of agreement between the two observers. Examiner reliability was not assessed when children were examined at 5 years of age. In an analysis of any biases resulting from loss of subjects to follow-up, only two statistically significant differences were found. Those mothers who lived in urban areas (Pearson PO,dentinal caries); dmft index (good dental health=O dmft, fairly good dental health=lll dmft, poor dental health=5-9 dmft, and very poor dental health210 dmft); and the actual dmfs score. A second outcome variable used in the analysis was the change in dental health from 3 to 5 years of age measured by changes in the dmf tooth and surface indices. Several independent variables were

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included in the analysis. Sociodemographic variables included: basic education level (9 years); occupational education (none, occupational education ongoing, a course or education at work, occupational institution, college, university); and occupation (using a Finnish classification as reported). Toothbrushing behaviors (a person performing/helping perform toothbrushing and frequency of b r u s h g ) were assessed by questionnaire, and dental cleanliness (no visible plaque, visible plaque on some or all tooth surfaces) was assessed clinically by a dentist along with a designation of the method used in making these assessments (teeth checked with naked eye only, teeth dried or air blown to assist checking, teeth checked without a disclosing solution, all teeth generally checked) (1,lO). Other behaviors affecting dental health included: use of xylitol chewing g u m (daily, sometimes, never), snacking on sweets and frequency of snacking, and drinking something other than pure water at night. A final independent variable captured whether dental habits remained poor or became worse from 3 to 5 years of age. Univariate associations were tested using Pearson’s chi-square, MannWhitney, Kruskal-Wallis, and Wilcoxon signed ranks test (for differences between paired observations). Multivariable associations of explanatory variables with dichotomous measures of dental health at 5 years of age and change in dental health were analyzed using stepwise logistic regression. Associations were quantified with odds ratios (OR) and 95 percent confidence intervals (11).Allcomputations were performed using the BMDP statistical program package (12).P-values of less than .05were considered to be statistically significant. The study was approved by the Ethics Committee of the University of Turku Medical School. Results Dental Caries at 5 Years of Age. Dentinal caries (dmft>O)was found in 230 of the 828 children (27.8%) at 5 years of age. Of the children examined a t this age, 19.8 percent had a dmft value from 1 to 4, 6.3 percent had a value from 5 to 9, and 1.7 percent had a value of 10 or more. The mean dmft and dmfs per child was 1.0 (SD=2.2)

and 1.6 (SD=5.1),respectively. At 5 years of age, 72.2 percent of children h a d n o dentinal caries (dmft=O). Enamel caries alone was found in 15.9 percent (132 of 828) of those without dentinal caries, leaving about 56 percent (466 of 828) with neither enamel nor dentinal caries. No statistically significant differences in mean dmft or dmfs scores were found according to sex or chronic illnesses such as asthma, allergy, or epilepsy. The incidence of chronic illnesses was 19.8 percent (231 of 1,165). Changes in Dental Caries from 3 to 5 Years of Age. At 3 years of age, 81.6 percent (831 of 1,018) of children had caries-free dentitions (dmft=O).Of the 611 children who had no dentinal caries at baseline and were examined at 5 years of age, 408 (66.8%)remained caries free (dmft=O), 16.2 percent (99 of 611) were found to have enamel caries only, and 17 percent (104 of 611) dentinal caries and/or teeth with fillings (dmft>O). Of the children with enamel caries at 3 years of age, 57.4 percent had dentinal caries two years later, and only 13.2 percent were caries free. The dmf index remained the same in only 22.6 percent of these children with enamel caries over the two years in which they were studied. Those children who had dentinal caries (dmft>O) at 3 years of age had an 8.5-fold (950/,CI=4.8, 15.0) increase in risk for caries as compared to those children without dentinal caries at baseline. Altogether, 35 (4.2%) children who had filled teeth at 3 years of age did not have any new caries at the age of 5. Increases in mean dmft and dmfs index values between 3 and 5 years of age were 0.72 (SD=1.56; Wilcoxon P