Prevalence of Common Oral Diseases Among ...

Philippine Journal of Health Research and Development

Prevalence of Common Oral Diseases Among Children Aged 3-5 years in San Juan, Batangas Province, Philippines Angelina A. Atienza*1, Dianne Angeli A. Austria1, Hannah Mae M. Navarro1 *Corresponding author’s email address: [email protected] 1

College of Dentistry, University of the Philippines Manila, Pedro Gil corner Taft Avenue, Ermita, Manila 1000

R E S E A R C H

A R T I C L E

Abstract Background and Objectives: Dental caries is an overlooked affliction among children, affecting a child's wellbeing and creating substantial economic cost both on the family and community. Scarcity of data on the oral health status of Filipino children was the reason for this study. The present study, therefore, aimed to describe the common oral diseases afflicting school children aged 3-5 years old in San Juan, Batangas. Methodology: Using a descriptive cross-sectional study design and purposive sampling, data were collected from children (n=324) aged 3-5 years old in 5 public day care centers in San Juan, Batangas. Data collection involved oral examination of children, distribution of self-administered questionnaires to parents/caregivers, and interview of teachers as key informants. Collected data were summarized as percentages and mean values. Results: Overall prevalence for dental caries is 94.13%, 8.86 mean dmft and 3.0 mean pufa. As the children got older the prevalence and mean for both dmft and pufa likewise increased. Boys showed higher prevalence and mean scores in their dmft and pufa. Dental caries, pulpitis, periapical disease and the presence of ulcerations were the most common oral manifestations. The overwhelmingly poor oral health conditions of the children appear to affect their school attendance. Conclusion: The children in the selected day care centers in San Juan, Batangas manifest severe early childhood caries and a relatively high-unmet treatment needs. We recommend, therefore, the institution of preventive oral health policies and strategies for children 0-6 (age 5) [1]. Dental caries is a public health concern in both developed and developing countries and undoubtedly represents the most common chronic transmissible [1,2] overlooked affliction in children. If left untreated, it can lead 30

to other odontogenic or systemic conditions, such as pulpitis, dental abscess, traumatic ulcerations, fistulous tracts, cellulitis and possible tooth loss, for which seeking treatment becomes more costly. Other consequences reported include occurrences of pain, inability to eat, inability to sleep, and dysfunction [3,4]. The management of pain associated with ECC becomes a growing issue while excessive administration of medication creates another concern as it can lead to serious liver problems [5]. ECC is likewise considered a manifestation of child neglect [6]. SECC, on the other hand, is a potential risk-marker for malnutrition and iron deficiency anemia that can affect children's growth and development [7]. It has been demonstrated that after undergoing dental rehabilitation, children with ECC have marked improvement in their body Phil J Health Res Dev June 2015 Vol.19 No.2, 30-40

Prevalence of Common Oral Diseases

weight and have a catch-up growth [8]. Thus, dental caries not only affects a child's overall development, well-being, and quality of life, but also creates significant economic cost on the family and the community [4,5,9,10,11]. The etiology of dental caries is regarded as multifactorial and the determinants which influence its development in young children may include: low socioeconomic status (SES) (e.g., maternal level of education, income) [2,11,12,13,14,15,16], dietary behavioral habits (e.g., bottle feeding, use of sweeteners, frequency of intake) [11,13,15,16,17,18,19], oral hygiene practices (e.g., adult supervision, frequency of toothbrushing, use of fluoride dentifrice, presence of visible plaque) [11,13,15,16,20], presence of enamel defects [15,16] and early colonization and presence of Streptococcus mutans [1,15,16,21]. A multi-level conceptual model considering the child, family and community has been proposed to explain disparities that exist [5]. Prevalence of ECC worldwide ranges from 6% to over 90% [22]. In developed countries, such as the United Kingdom, it varies from 6.8%-18% with a mean decay of 1.3 [14,23,24]; North America ranges from 11%-53.1% and dmft of 0.3-2.7 [15,23], and in Australia 34% prevalence and 1.4 mean dmft [13]. In India, various literature have pegged prevalence at 19.2%-69% and 2.7-2.85 mean dmft [18,23,25,26,27]. In the Middle East from 31.3%-78% and 2.92-5.28 mean dmft [24,28] while in Asia (China, Taiwan and South Korea), prevalence ranges from 56%-90.8% and 5.37-6.92 mean dmft [17,20]. In the Caribbean region, the reported prevalence was 21%-29% and 1.4 mean dmft [22] while in Brazil, SECC has a prevalence of 36% [29]. A study in the northern Philippines reported that the prevalence of dental caries among three-year old children was 85% and 7.42 dmft, while for four-year olds, about 90% prevalence and 8.84 dmft, and finally for the five-year age group, there was 94% prevalence and 9.78 dmft. It also showed that 59% of the children had lesions extending to the pulp and that there was an early manifestation of dental caries as indicated by the 50% prevalence among the two years of age [30]. There is still a scarcity of data on the oral health status of Filipino preschool children. Thus, the present study aimed to contribute knowledge on the most common oral conditions and caries-associated risk factors that afflict Phil J Health Res Dev June 2015 Vol.19 No.2, 30-40

Filipino children aged 3-5 years old. Results of the study will hopefully supplement and provide broader baseline data to aid in the development of early preventive oral health policies and strategies. The institution of a national oral health program will then hopefully translate to a significant reduction in the dental caries and oral infection index among Filipino pre-school children.

Methodology Participants The study was conducted in San Juan, Batangas, a first class municipality comprised of 42 barangays, predominantly agricultural and approximately 120 km south of Metro-Manila. Based on the 2010 census of the National Statistics Office, it has a population of 94,291 [31]. The University of the Philippines Manila Research Ethics Board approved the research protocol. Approval from the local government officials, municipal health officers, school authorities and teachers of the public day care centers and informed consents from the parents/caregivers were sought prior to the start of the study. The teachers were requested to distribute the informed consent forms to the parents/caregivers prior to the scheduled oral examination. Using purposive sampling, only the top five with the most number of enrolled students were considered as the sampled day care centers. Inclusion criteria were healthy children 3-5 years old (36-71 months) at the time of the oral examination, with all the primary teeth erupted and no permanent teeth present, and with no congenital or systemic disease. Furthermore, included in the study were children who were compliant and had signed the consent forms. Data Collection A cross-sectional design method of data collection was used, which included an oral examination of the 3-5 years (36-71 months) old children, a self-administered questionnaire to the parent/caregiver, and a scheduled interview of the teachers. To identify the presence of the common oral conditions among the children, the dmft and pufa indices were utilized. The dmft index is the universal system for determining the prevalence of caries, restorative and surgical treatment, whereby d represents decay, m for missing and ft for filled teeth. The pufa index is used as a determinant for the presence of oral conditions as a 31


consequence if caries is left untreated. In the pufa index, p is occurrence of dental pulp involvement, u is presence of soft tissue ulceration as a result of traumatic injury from sharp tooth edges or root fragments, f is presence of a fistula or a parulis accompanying a dental abscess, and a is presence of dental abscess [34]. In this study a tooth rated as p was considered to have a pulpal disease and an f or a rating to have a periapical disease. The study, however, did not distinguish from reversible or irreversible pulpitis, and a necrotic pulp from acute or chronic apical abscess or periodontitis. The World Health Organization (WHO) Oral Assessment form (1997) was used for the oral examination. Oral examinations were held within the day care center premises, during school hours and in the presence of the teacher and parents/caregivers. Children were examined using a mouth mirror, dull probe and a small auxiliary headlamp. Teeth were not air-dried or cleaned prior to the examination and no x-rays were taken. Both non-cavitated and cavitated teeth were considered as decay. A single examiner performed the oral examination to prevent examiner bias. The oral examiner was not involved in either the administration of the questionnaires and in the interview of the teachers and vice versa. The self-administered questionnaire was utilized to capture the following data: socio-demographic profile and socio-economic status (SES), dietary habits, oral hygiene practices, fluoride exposure, and whether having any dental problems has affected the child's school attendance. The scheduled interview of the teachers was to determine the presence and extent of any oral health program within the day care centers.

Data Analysis Data was analyzed through cross tabulation of the dependent variables against the independent variables. Considered dependent variables were the dmft, pufa scores and school attendance, while the independent variables included SES, dietary habits, and oral hygiene practices of the children. Mean and percentages of those with and without dmft and pufa were computed.

Results A total of 389 children aged 3-5 years from the five sampled day care centers in the municipality of San Juan, 32

Batangas were examined and 324 (83.3%) qualified into the inclusion criteria. Males made up 52%, while 48% were females. Children aged 4 and 5 years old comprised 95% of the participants with a mean age of 4.37 years. Mothers who are 20-30 years of age made up 76% (218) of the respondents to the self-administered questionnaire. As to their level of education, 17% finished elementary grades, 54% have reached high school, and 21% entered college. Sixty five percent (65%) are unemployed and majority belong to a single-employed household (64%). Slightly more than half (54%) have a monthly family income of Php 5000-below, 23% with Php 6000-10,000/month, 8% with Php 11,000-15,000/month, and 7% with a monthly income of Php 16,000-above. Overall prevalence for dental caries was 94.13%, 8.86 mean dmft and 3.0 mean pufa. In terms of age, the prevalence for dental caries was 84.6% for the 3 years old, 93% for the 4 years old and 96.4% for the 5 years old, and that 60.5% of the children had lesions extending to the pulp. Results also showed that the mean indices for both dmft and pufa increased with age (Figure 1). Decayed teeth contributed largely to the mean dmft, whereas pulpally involved teeth for the mean pufa index. By gender, the males showed higher mean scores in their dmft and pufa indices (Figure 2) and higher dental caries prevalence, 96.4%, as compared to 91.6% amongst the females. Likewise, 67% of the males had lesions involving the pulp compared to 53.5% of the females. Figures 3 and 4 show the prevalence for the most common diseases/conditions by age and gender respectively. Ranking and overall prevalence of the most common diseases/conditions among 3-5 years old children is presented in Table 1. Factors that may influence the occurrence of dental caries, such as SES, dietary habits, oral hygiene practices and fluoride exposure were likewise investigated. Only 304 parents/caregivers returned their self-administered questionnaire with some who did not reply to some of the variables. Of those who responded, Table 2 presents by SES category the percentage of children with and without dmft and pufa. Although not predictive, results showed that the prevalence of children with dmft and pufa was lower when parents have either a college level of education and/or belong to a higher income bracket. As to the children's dietary habits, it appears that only the non-use of sweeteners consistently reduced the prevalence of both the dmft and pufa. Likewise, having less Phil J Health Res Dev June 2015 Vol.19 No.2, 30-40


Table 1. Ranking and prevalence of the common oral diseases/conditions among 3-5 years old children Oral Diseases/ Conditions Dental Caries

Ranking

Overall Prevalence (%)

1

94.13

Pulpal Disease

2

60.50

Periapical Disease

3

26.86

Ulcerations

4

3.10

Figure 1. Mean decayed, missing, filled teeth (dmft) and pulpal involvement, ulceration, fistula, abscess (pufa) indices by age

than daily consumption of cariogenic food reduced the percentage of children with pufa. Otherwise, no discernible trends can be gathered from the other variables (Table 3). It was reported that all the children use fluoridated toothpaste. Source of drinking water was either tap, deep well, or commercial water stations. It was not known whether the community water contains any natural fluoride. None of the vitamins reported taken by the children contained any fluoride. Majority of the children (83%) brushed by themselves and were just watched over. Results of the study showed that brushing two times or more a day decreased the percentage of children with dmft and pufa, whereas, delaying the practice of tooth brushing after age 1 year increased it (Table 4). General and oral health education is taught in the 1st quarter of the school year. All the sampled day care centers Phil J Health Res Dev June 2015 Vol.19 No.2, 30-40

have a daily feeding program that is presumably followed by a tooth brushing drill after the meal. The students provide their own toothbrush and toothpaste, although one day care center was given a one-year supply of toothpaste by the Governor's office. There are no school visits by any barangay health workers or by the municipal dentist. At the time of data collection, only 24% of the children have had some dental visit. The most common reasons for not seeing a dentist were: parents felt no need to visit, financial constraints, unavailability of someone to bring the child to the dentist, and lack of dentists within the area. Data showed a very marginal difference in the prevalence of children with dmft who have had some dental visit over those who have not, whereas there appears to be more children with pufa who have visited a dentist than their counterpart (Table 5). 33


Table 2. Socioeconomic status (SES) and prevalence of children with and without dmft and pufa SES Level of Education Elementary High School College Vocational Total Respondents No Answer Total (n) Employment Employed Unemployed Total Respondents No Answer Total Income = -5,000 Php 6-10Th Php 11-15Th Php 16Th Php-above Total Respondents No Answer Total (n)

% w/ dmft (n)

% w/o dmft (n)

96 (49) 98 (159) 87 (55) 90 (17) 96 (280)

Total (n)

% w/ pufa

% w/o pufa

Total (n)

4 (2) 2 (4) 15 (8) 11 (2) 5 (16)

51 163 63 19 296 8 304

59 (30) 69 (112) 41 (26) 68 (13) 61 (181)

41 (21) 31 (51) 59 (37) 32 (6) 39 (115)

51 163 63 19 296 8 304

95 (103) 94 (182) 94 (285)

5 (5) 6 (12) 6 (17)

108 194 302 2 304

61 (66) 61 (118) 61 (184)

39 (42) 39 (76) 39 (118)

108 194 302 2 304

97 (158) 94 (68) 88 (22) 89 (17) 95 (265)

3 (5) 6 (4) 12 (3) 11 (2) 5 (14)

163 72 25 19 279 25 304

64 (104) 61 (44) 52 (13) 58 (11) 172

36 (59) 39 (28) 48 (12) 42 (8) 107

163 72 25 19 279 25 304

* Total observations are less than 304 as there are respondents who did not answer the variable.

Twenty four percent (24%) of the children were reported to have been absent from school due to dental problems, with toothache or the presence of a swelling as the primary reasons. Of those who reported having absences from school, all exhibit having dmft and a large percentage are afflicted with pufa (Table 6).

Discussion There are a number of studies that give credence to the results of this study that as the child advances in age, the decay prevalence and dmft index both increase [12,14,17,20,21,24,25,26] and that boys have a higher decay experience and dmft scores [12,13,25,26,27]. It has been stated that previous caries experience in the primary dentition is a good predictor of the disease developing in the permanent dentition [24,26,30]. There are, however, different opinions on what constitutes risks based on dmft scores. There is a view that children under the age of five with previous caries experience should be automatically 34

classified as high risk for future decay [15]. It has also been suggested that decay on maxillary deciduous incisors alone or having a