Evaluation of the Dental Health of the Young Adult Male Population in Turkey

Transcription

1 MILITARY MEDICINE, 169, 11:885, 2004 Evaluation of the Dental Health of the Young Adult Male Population in Turkey Guarantor: Captain Selim Kiliç Contributors: Captain Süleyman Ceylan*; Captain Cengiz Han Açikel ; Captain Kemal Murat Okçu ; Captain Selim Kiliç ; Captain Ö. Faruk Tekbas*; Major Kerim Ortakoğlu This study aimed to determine the prevalence of dental caries in military recruits and to assess the relation of dental caries with socioeconomic and demographic factors, and sugar consumption behavior, and to generalize the findings for the young adult male population to draw a picture of dental health status of this population segment in Turkey. In this crosssectional study conducted between August and October 2000 in a military basic training center in Turkey, 2,766 male recruits of the age of 20 were examined by dental specialists to determine their mean number of decayed, missing, or filled teeth (DMFT) scores and were administered a questionnaire for capturing their demographic characteristics and sugar consumption behavior. The mean DMFT score for the 20-yearold male population in Turkey was found to be DMFT scores were weakly correlated with income level and urbanization. Sugar consumption was strongly correlated with DMFT scores. The mean number of teeth with fillings component was strongly correlated with income level, moderately with the subject s education, and weakly with the mother s education, father s education, and urbanization. DMFT scores for the young adult male population in Turkey were strongly associated with sugar consumption behavior, whereas they were weakly or not at all associated with demographic factors such as education level, income level, and urbanization. Introduction iseases of the teeth and the adjacent structures continue to D be among the most common maladies affecting human beings. Because they are so common and are seldom life threatening, they usually do not receive the attention they deserve, either from those directly affected or from health officials, health planners, or others concerned with improving a population s health status. 1 Oral diseases are important considerations in public health and preventive dentistry for several reasons. First, they are of almost universal prevalence. Rarely if ever does anyone go unaffected by at least one of these diseases, and most people are affected by several during their lifetime. Second, most oral diseases do not undergo remission or termination if left untreated, as do many diseases, but accumulate a backlog of unmet needs that can ultimately end in the loss of teeth. Third, these diseases *Assistant Professor, Public Health Department, Gülhane Military Medical Academy, 06018, Etlik, Ankara, Turkey. Public Health Specialist, Health Division, Turkish General Staff Headquarters, 06010, Bakanlıklar, Ankara, Turkey. Assistant Professor, GMMA, Department of Oral and Maxillofacial Surgery, 06018, Etlik, Ankara, Turkey. Public Health Specialist, GMMA, Department of Epidemiology, 06018, Etlik, Ankara, Turkey. This manuscript was received for review in April The revised manuscript was accepted for publication in September Reprint & Copyright by Association of Military Surgeons of U.S., usually require technically demanding, expensive, and timeconsuming professional treatment. Finally, oral diseases are important for consideration in public health because they are, in large measure, preventable. 2 The World Health Organization (WHO) proposes to use the mean number of decayed, missing, or filled teeth (DMFT) or the mean number of decayed, missing, or filled surface (DMFS) values to assess the prevalence of dental caries. DMFT and DMFS describe the amount the prevalence of dental caries in an individual. DMFT and DMFS are means to numerically express the caries prevalence and they are obtained by calculating the number of decayed (D), missing (M), filled (F), teeth (T), or surfaces (S). Thus, they are used to get an estimation illustrating how much the dentition has become affected by dental caries until the day of examination. 3 A number of studies show that prevalence of dental caries varies by several factors. One of these factors is age. In the United States, although approximately 50% of U.S. schoolchildren are considered to be caries free, by the age of 17 years, only 15% of these young adults have not experienced caries. 4 In a study carried out in the Republic of Niger, although the mean DMFT score of 1.3 was observed among the 12 year olds, the 35 to 44 year olds had an average DMFT score of Among Greek adolescents, it was found that the percentage of caries-free adolescents varied from 24.3 in the age group of 12 to 13 years to 13.2 in the age group 16 to 17 years; mean DMFT values were 3.7 in the younger age group and 5.9 in the older age group. 6 A relationship between a population s level of socioeconomic development and dental caries is often assumed. Caries is a good proxy measure for socioeconomic development. Countries in the throes of socioeconomic transition have the highest DMFT scores. 7 Among the primary school students in United Kingdom, it was found that children in the highest income group had a mean DMFT of 1.83 compared with 2.56 in the middle group, and 3.43 in the lowest income group. 8 Dental caries levels vary by countries in respect to socioeconomic indicators. In a study investigating the association between some factors and caries levels in 109 countries, it was found that the highest correlation coefficients were those between the DMFT and public expenditures, sugar consumption, and urbanization. 9 In some studies, there was an inverse relationship between education level and dental caries. For example, a study conducted among Lithuanian adults reported that participants with more years of education had lower DT and MT values, and higher FT values. 10 In another study from Israel, it was reported that negative associations were detected between education levels and untreated and extracted components, and a positive association was detected between education levels and the 885

2 886 Dental Health in Turkey treated caries component. 11 In addition to this, there are some studies showing that parents education levels are important factors in children s dental caries. In Abu Dhabi, among the preschool children, it was found that higher parental educational attainment was related to a lower number caries. 12 There are different opinions about the effects of sugar consumption on the prevalence of dental caries. In a study examining the data on dental caries among 12-year-old children and sugar consumption of the total population for 90 countries, it was found that there was no evidence of a sugar-caries relationship; the slope of the linear regression line was estimated to be 0.013, not significantly different from zero. 13 However, in a similar study conducted recently based on international data, it was found that sugar consumption had one of the strongest correlations with DMFT. 9 Furthermore, at the national or regional level, there are several studies showing that sugar preferences have strong positive correlations with dental caries. For example, in a study conducted in Iraq, a positive significant correlation between sweet preference and dental caries was found for urban and rural populations, and this relationship was stronger in the rural groups than in the urban groups. 14 In Turkey, according to WHO data, mean DMFT scores were 4.4 for 6 year olds, 5.2 for 7 year olds, 2.7 for 12 year olds, and 11.6 for 35 to 44 year olds. The study providing these findings was conducted in 1988, and DT components were 4.3, 4.8, 2.2, and 3.0, respectively. 15 Data collection on public health status in general and dental health status in particular poses problems for health planners as well as researchers. Military services, with their well-organized medical facilities and medical screening procedures, generally provide a good and reliable environment for accurate collection of such data, although such data are basically limited to a specific population segment such as young adult men, and, in some countries, young adult women as well. In Turkey, military service is compulsory for young adult men from the age of Thus, data on the health status of military recruits can be collected easily and accurately during the initial medical checks or during later periodical medical examinations of these recruits. In several countries, studies have been carried out in military recruits. In Denmark, for example, during the routine medical examinations for recruits in 1972, 1982, and 1993, a total of 4,103 male recruits, age 18 to 25 years, were examined. The findings showed DMFT scores of 16.6 in 1972, 11.8 in 1982, and 6.2 in This study has two purposes: (1) to determine the prevalence of dental caries in military recruits and assess the relation of dental caries with socioeconomic and demographic factors and sugar consumption behavior, and (2) to generalize the findings for the young adult male population to draw a picture of the dental health status of this population segment in Turkey. Methods This was a cross-sectional study conducted between August and October 2000 in the Armor School and Training Division Command (Etimesgut, Ankara, Turkey) by participation of 2,766 new recruits. The study was performed by the examination of the teeth of recruits by two specialist dentists and by the administration of a questionnaire for sociodemographic characteristics, sugar consumption behavior, and oral health status of the recruits. The study was conducted in a military basic training center. Approximately 3,000 to 3,500 new recruits come to this center for their basic military training every 3 months. Upon arrival to this facility, recruits are medically examined by physicians. Their overall health status is recorded. Their periodic examinations are based on these first examinations. In this study, 3,271 recruits in the setting mentioned above were examined in August 2000 for dental caries by two specialist dentists during medical examinations. Dental examinations were done according to the WHO criteria, and DMFT scores were recorded. Because all recruits were examined physically, no sampling was done, and all 3,271 recruits were examined for dental caries. Wisdom teeth records were excluded from the study. All 3,271 recruits were administered a questionnaire consisting of 10 questions designed to capture their sociodemographic characteristics and sugar consumption behavior. Because the dental health status varies with age, we considered and aimed to do statistical analyses of the relation between DMFT scores and related factors for only 20-year-old recruits. For this reason, we excluded recruits older than 20 years from the analyses. The education status of the recruits and their parents were captured as were the number of years of schooling. The income levels of the participants were assessed in respect to monthly income per capita in Turkish liras (TL). The level of 50 million TL reflects the bare subsistence level for an individual living in a family. Based on this number, those earning below the 50 million TL level were considered very poor, those earning between 50 to 99 million TL were considered poor, those earning between 100 to 199 million TL were considered lower middle class, and those earning above 200 million TL were considered middle class. On an informational note, at the time of the study, one U.S. dollar was equal to 635,000 TL on August 1, 2000, and to 676,000 TL on December 31, 2000, with a 6-month average of 650,000 TL. Urbanization status was assessed in respect to the settlement unit where the participant lived longest after the age of 7. To determine sweet preference of the participants, we used a proxy measure to quantify the sugar consumption behavior. In Turkey, the most common type of sugar consumption on an individual level is the sugar used in tea. For this reason, during the first examinations, we asked the participants: How many cups of tea a day have you drunk on average for the last 10 years? and How many cubes of sugar do you add to a cup of tea on average for the last 10 years? For this procedure, we used a standard cup, 200 ml in volume, and a sugar cube that weighs 2 g. According to the answers, sweet preferences were scored from1to5. The definition of the scores regarding dental health used in this study are as follows: 3 DMFT, DT, MT, FT, the percentage of population affected with dental caries (%DMFT), and the percentage with untreated decayed teeth (%D). We recorded and analyzed the data with SPSS for Windows, version 8.0 (SPSS, Chicago, IL). In the analyses, we used oneway analysis of variance, the t test, and correlation analysis.

3 Dental Health in Turkey Results All of the recruits were men. All of the recruits included in analyses were 20 years old. The majority of the recruits were single (87.3%). Only 49 (1.7%) of the recruits were illiterate. Although 4.1% of them had received education of 12 years or more, more than one-half of the participants (70.9%) had 1 to 8 years of education. Of the participants, 42.9% lived in urban centers after the age of 7. Income levels as monthly per capita income in TL earned in the household in which the participants lived ranged from 25 to 375 million TL at the time the study was conducted. The illiteracy rate for the parents of the participants was as follows: 46.8% of the mothers and 11.3% of the fathers were illiterate. For 20-year-old recruits, the distribution of DMFT scores by sociodemographic characteristics was assessed. It was found that married subjects had significantly higher DMFT scores than single subjects, and, similarly, those with illiterate mothers than those with literate mothers, those who after the age of 7 lived in villages longer than those who lived in towns or cities, and those with monthly income of 200 million TL or up than those with less than 200 million TL. Also, illiterate subjects and those with 12 years or more of education had significantly higher DMFT scores than other educational groups. No significant difference was found between the groups in terms of the father s educational level. The distribution of DMFT scores of 20-year-old recruits by various characteristics is shown in Table I. For 20-year-old recruits, the DT was 4.75 (range, 0 16), the TABLE I MEANS OF DMFT SCORES OF 20-YEAR-OLD RECRUITS BY VARIOUS SOCIODEMOGRAPHIC CHARACTERISTICS Characteristics n % DMFT p a Marital status Single 2, Married Years of schooling Illiterate , or more Unit of settlement b Village Town City center 1, Mother s education Illiterate 1, Literate 1, Father s education Illiterate years 2, years or more Income level c 0 49 million TL million TL 1, million TL million TL or more Total 2, a Indicates p for t test and one-way analysis of variance. b Unit of settlement lived longest after age of 7. c As monthly per capita income in Turkish Liras. MT was 0.87 (range, 0 7), the FT was 0.34 (range, 0 5), the mean DMFT score was 5.97 (range, 0 17), %DMFT was 96.6, and %D was Nobody was edentulous. These values are shown in Table II for 20-year-old-recruits. In the final phase of the analyses, correlation between various variables and the DT, MT, FT, and DMFT scores was analyzed. In this analysis, educational levels of the subjects, mothers, and fathers, per capita monthly income in the household where the subject lived, urbanization degree, and the subject s sweet preference level were considered. The strongest positive correlation was between income level and FT score (r 0.568, p 0.01), the next was between sweet preference and DMFT score (r 0.565, p 0.01), and then between sweet preference and DT score (r 0.534, p 0.01). Considerable correlations were found between the subjects educational level and FT score (r 0.431, p 0.01), and sweet preference and MT score (r 0.402, p 0.01). The strongest negative correlation was found to be between the subjects educational levels and DT score (r 0.181, p 0.01). The correlations between various sociodemographic variables and DT, MT, FT and DMFT scores are given in Table III. Discussion One important aspect of this study is that, thus far, it is the largest survey of dental health conducted on the young male population in Turkey. According to WHO data, the DMFT score for 12 year olds in Turkey is 2.7, and 11.6 for the 35- to 44-year-old group. 15 The DMFT score of 5.97 found in this study for the 20-year-old group seems consistent with these data. The DT scores according to the same data are 2.2 and 3.3 for the respective age groups. Although the mean DT score of 4.75 found in our study seems to be somewhat high, the aforesaid finding that losses and filling levels increase by age is confirmed. The MT score according to the same data is 0.2 for the 12-year-old group and 8.1 for the 35- to 44-year-old-group (0.87 for the 20-year-old group in our study), and the FT scores are 0.3 and 0.5 for the respective age groups (0.34 for our study). Married subjects had significantly higher DMFT scores than single ones (7.66 versus 5.73). However, it must be borne in mind that only 12.7% of the subjects in the study group were married. As for the education level, illiterate subjects and those with 12 years or more of education had statistically significant higher DMFT scores (7.71 and 6.49, respectively) than other educational level groups. However, the number of subjects in these two groups makes up only a small portion of the total subjects (1.7% and 4.1%, respectively). We examined the correlation be- TABLE II MEANS OF DMFT SCORES AND ITS COMPONENTS FOR 20-YEAR-OLD RECRUITS Score Mean DT 4.75 MT 0.87 FT 0.34 DMFT 5.97 %DMFT 96.6% %D 95.5% 887

4 888 Dental Health in Turkey TABLE III CORRELATION COEFFICIENTS BETWEEN DMFT SCORES, ITS COMPONENTS, AND VARIOUS SOCIODEMOGRAPHIC CHARACTERISTICS OF 20-YEAR-OLD RECRUITS DT MT FT DMFT Years of schooling a a Income level a a a Mother s education a a Father s education a Sweet preference a a a Urbanization a b b a Correlation is significant at b Correlation is significant at tween the DMFT score and the educational level. As a result of the correlation analysis, a statistically insignificant, negative correlation in the environs of zero was found between the DMFT score and the educational level in years of schooling. On the other hand, a statistically significant positive moderate correlation was found between the educational level and the FT component. Along this line, a statistically significant negative correlation was found between the educational level and the DT component. These findings were consistent with the findings of earlier studies in other countries that reported that the level of treated tooth decay increased as the educational level increased, and the FT component increased as the DT component decreased. 10,11 Those with illiterate mothers had significantly higher DMFT scores than those with literate mothers (6.20 versus 5.77). The fact that only 2.9% of the participants had mothers with 9 years or more of education prevented us from conducting a meaningful correlation analysis. Although this finding was consistent with the findings of earlier studies that having more educated parents was associated with having lower tooth decay level, 12 we should emphasize that in our study, no statistically significant difference was found between the DMFT scores groups with different levels of father s education. Those subjects whose primary place of living after the age of 7 was villages, or in other terms those living in rural areas, had significantly higher DMFT scores than those living in urban areas (towns and cities). However, the significance level of this finding was borderline (p 0.048). On the other hand, the level of urbanization had weak correlations with the DMFT score, with the DT component, the FT component, and the MT component. These findings were not consistent with earlier studies reporting that the urbanization level was strongly associated with tooth decay. 9 When we examine the DMFT scores by income level, which is the basic determinant of socioeconomic status, those with per capita monthly income of 0 to 49 million TL (the lowest income group) had the lowest DMFT score (5.84), and those with per capita monthly income of more than 200 million TL (the highest income group) had the highest DMFT score (7.35). However, considering that highest income group made up only 3.0% of the total subjects, we examined the correlations. Results of the correlation analysis suggested a weak correlation between the income level and the DMFT score. The correlation between the income level and the FT component was strong, and the DT and MT components were weak. These findings could be interpreted that as the socioeconomic level increases, the level of decayed tooth treatment goes up. The consumption of beverages containing sugar, which is an indicator of the sugar consumption reported in some studies, as strongly associated with tooth decay was examined in this study as well. Significant correlations were found between the sugar consumption and the DMFT score, the DT component, and the MT component. However, when interpreting these findings, we should acknowledge that these were based only on the selfreported amount of sugar used in tea drinking. Although food consumption research is tedious, self-reporting must still be the most accurate way of determining individual sugar consumption. Although there are other ways of consuming sugar, the amount of sugar usage with tea, which is a common method of sugar consumption in Turkey, is considered to be a good proxy measure for sugar consumption behavior. An important limitation of this study is that all the subjects were young men. We encourage researchers to conduct similar studies on women in the same age bracket, which should help complete the missing half of the whole picture. We revealed in this study that tooth decay is an important public health problem for the young adult male population in Turkey. It was found that only 1 person out of 30 was not affected by tooth decay. This finding stands out as a concrete indicator of the need for education on oral and dental health. In closing, we should emphasize that the mandatory military service in Turkey and the regular and well-organized medical screenings before and during the service provide excellent opportunities for public health surveys, as well as an important time period for educating the recruits on oral and dental health. Thus, the medical checks during military service can be a remarkable and noteworthy data source to determine the dental health profile of our national young adult population. The data collected in this manner may help the design and development of a national oral health policy in developing countries such as Turkey, where the overall oral health status may not be accurately known. References 1. Green JC: Dental public health. In: Oxford Textbook of Public Health, Ed 3, Vol 3, Chap 7. Edited by Detels R, Holland WW, McEwen J, Omenn GS. Oxford, UK, Oxford Medical Publications, Rozier RG: Dental public health. 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5 Dental Health in Turkey Skudutyte R, Aleksejuniene J, Eriksen HM: Dental caries in adult Lithuanians. Acta Odontol Scand 2000; 58: Sgan-Cohen HD, Horev T, Zusman SP, Katz J, Eldad A: The prevalence and treatment of dental caries among Israeli permanent force military personnel. Milit Med 1999; 164: Al-Hosani E, Rugg-Gunn A: Combination of low parental educational attainment and high parental income related to high caries experience in pre-school children in Abu Dhabi. Commun Dent Oral Epidemiol 1998; 26: Woodward M, Walker AR: Sugar consumption and dental caries: evidence from 90 countries. Br Dent J 1994; 176: Jamel HA, Sheiham A, Watt RG, Cowell CR: Sweet preference, consumption of sweet tea and dental caries: studies in urban and rural Iraqi populations. Int Dent J 1997; 47: Marthaler TM: Caries status in Europe and predictions of future trends: Symposium report. Caries Res 1990; 24: Turkish Military Service Law No [Bin Yüz On Bir Sayılı Askerlik Kanunu]. 17. Antoft P, Rambusch E, Antoft B, Christensen HW: Caries experience, dental health behavior and social status: three comparative surveys among Danish military recruits in 1972, 1982 and Commun Dent Health 1999; 16: 80 4.