PERIODONTAL HEALTH STATUS OF SCHOOL CHILDREN IN ST. VINCENT AND THE GRENADINES

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1 PERIODONTAL HEALTH STATUS OF SCHOOL CHILDREN IN ST. VINCENT AND THE GRENADINES OLUSEGUN K. ALONGE AND SENA NARENDRAN INTRODUCTION Saint Vincent and the Grenadines (SVG) is an eastern Caribbean island nation. SVG is made up of the main island of St. Vincent and about 30 islands and islets of the Grenadines, and is located in the Lesser Antilles. Grenada is south of SVG, while St. Lucia is to the north and Barbados is on the east. SVG provides universal and free medical care, inclusive of dental services, to its citizens. In addition to dentists, the dental services utilise dental nurses who provide care mainly to children, including school visits and health education/health maintenance. The first national oral health survey of school children in St. Vincent and the Grenadines (SVG) was conducted in 1991, using World Health Organisation s (WHO) Pathfinder method (WHO, 1987). This paper reports the periodontal findings from this survey. Prior to this study there were no national studies on oral health of SVG children. Studies on periodontal diseases in the Caribbean nations using the Community Periodontal Index of Treatment Needs (CPITN), have been reported only for Jamaica (Cutress, 1986), Anguilla (who, 1994) and Antigua (Vignarajah, 1994). In order for health administrators to judiciously allocate limited resources to oral health, they will need information on disease prevalence and severity as well as treatment needs of the population. The main purpose of this study was to determine the pattern and severity of the periodontal diseases in SVG children, using the CPITN. Another objective was to determine factors that may be associated with periodontal diseases and estimate treatment needs, and thus provide information for health planners. This study also provided data to be compiled in WHO s Global Oral Data Bank (WHO, 1994). Department of Dental Public Health Dental Branch - University of Texas Health Sciences Centre Houston 6516 John Freeman, Suite Houston, TX Correspondence to: Dr. 0. K. Monge, Department of Dental Public Health, Dental Branch, University of Texas Health Sciences Centre Houston, 6516 John Freeman, suite 212, Houston, TX MATERIALS AND METHODS A national survey of SVG school children was conducted during The study population consisted of 1646 school children, aged 7-19 years old, from 20 schools representative of all schools and all 11 school administrative districts in SVG. Approval was obtained from the schools through the ministry of education. Modified systematic, multistage sampling was done using the SVG schools directory (1989/90) as sampling frame. In the directory, schools were listed according to administrative districts, and grouped into primary or secondary schools. A total of 20 schools, one fourth of all schools, were selected with all 11 districts adequately represented. The final sample from each school was weighted, based on its population relative to the overall sample size. At each school the students were selected randomly from the classroom. The standardised WHO oral health assessment form (1986) was used for data collection (WHO, 1987). The examinations were performed outside the school building using daylight. Three calibrated examiners, each assisted by a recorder, were involved in data collection. The WHO criteria for diagnosis of periodontal disease and the CPITN (WHO, 1987), were used. In children up to 19 years of age, only six index teeth, 16, 11, 26, 36, 31 and 46 were examined. This modification was necessary to avoid misclassification of false pockets associated with tooth eruption, as periodontal pockets. For this reason WHO does not recommend pocket recording in children below 15 years of age. The periodontal examination in this study included bleeding and calculus, as well as pocketing (in children older than 15 years of age) as recommended by WHO (WHO, 1987). The percentage of children, according to the highest CPITN score was used to estimate prevalence of various periodontal conditions. The severity of the periodontal condition was estimated by the mean number of sextants affected per person, as recommended by Cutress and colleagues (1987). For international comparisons the ages are grouped as single years up to age 14, and years. Differences in periodontal condition between urban and rural locations, and between gender were also examined. Chi-square tests were carried out to assess

2 différences in frequencies between groups, with level of significance, alpha set at RESULTS Prevalence of periodontal indicators of the study population by age is displayed in Table 1. The percentage of subjects with healthy periodontal conditions decreased with increase in age, from a maximum of 51 perc e n t among seven year olds, to a minimum of 12 perc e n t among year olds. Bleeding appears to be associated with age, younger children having higher bleeding scores than older children. The youngest age groups, seven and eight year olds had the highest proportion of sextants with bleeding as the worst score, 23 and 24 percent respectively. The proportion with calculus as worst score, also tend to increase with age, from a low of 26 percent among seven year olds to a maximum of 83 percent among year olds. Among children nine years of age or older, 60 percent or more had calculus as their worst score. The seven year olds on average had approximately five healthy sextants, and less than one sextant with calculus or bleeding as the worst score (Table 1). The oldest group, year olds, had three healthy sextants on average and three sextants with bleeding or calculus as the worst score. A large proportion of children in each age group required scaling (prophylaxis) and oral hygiene instructions (OHI) except for the seven- year- olds, among whom approximately 25 percent needed scaling and about 50 p e rcent needed OHI (Table 1). An increasing trend in both types of treatment (OHI and prophylaxis) with age was observed. Also, the mean number of sextants (MNS) requiring prophylaxis increased from less than one sextant among seven-year-olds, to three sextants in the oldest group (Table 1). Table 1 : Prevalence, severity of Periodontal conditions and treatment needs among SVG school children. Age Number of Percentage of subjects with various periodontal Treatment needs (Percentage) (years) subjects conditions.as highest score Total Healthy (MNS) Bleeding or worse (MNS) Calculus (MNS) OHI Prophylaxis % (MNS) (4.7) 23 (1.3) 26 (0.5) (0.5) (4.2) 20 (1.8) 42 (1.0) (1.0) (3.5) 11 (2.5) 64 (1.7) (1.7) (3.7) 9 (2.3) 64 (1.7) (1.7) (3.5) 7 (2.5) 66 (1.9) (1.9) (3.2) 6 (2.8) 74 (2.1) (2.1) (3.0) 8 (3.0) 73 (2.3) (2.3) (2.9) 1 (3.1) 81 (2.6) (2.6) (2.8) 5 (3.3) 83 (2.7) (2.7) Total 1646 MNS : Mean number of sextants All sextants were healthy among 51 percent of seven year olds compared to 12 percent of the year olds (Table 2). Only one percent of seven-year-olds had no healthy sextant compared to 12 percent of year olds. The 13-year-old group, however, had the highest proportion with no healthy sextants, 14 percent. Age Table 2 : Distribution of subjects with healthy sextants (score = 0) Percentage of subjects by number of healthy sextants

3 Table 3 : Prevalence of Periodontal conditions and treatment needs among year olds in selected Caribbean countries. Periodontal conditions (%) Treatment needs (%) Country year Sample size H B C PD 4-5 PD >6 TNI TN2 (MNS) TN3 Anguilla NA NA NA Antigua Jamaica (3.4) 37 SVG (2.7) 0 NA = not available PD 4-5 = 4-5 mm periodontal pocket TNI = oral hygiene instructions B = bleeding PD 6 = 6 mm periodontal pocket TN2 = prophylaxis H = healthy TN3 = complex C = calculus No difference in prevalence of periodontal conditions was observed between boys and girls. Generally, the prevalence of calculus and bleeding was about the same for both rural and urban locations. No difference in severity of periodontal conditions was observed between the two location types. DISCUSSION This study reports a high prevalence of calculus and bleeding among SVG school children, and the findings are similar to those from other Caribbean as well as developing countries (CUTRESS,1986 ; WHO, 1994; Vignarajah, 1994; Adegbembo et al., 1995; Lopez et al., 1996; Arvidson-Buffano et al., 1990). SVG s study finds high treatment needs among the study population, more than 70 percent of the children required oral hygiene instructions (TN1), except among the seven and eight year olds. Also, more than 60 percent of the children required prophylaxis (TN2). This high treatment needs are similar to the findings in other developing countries using the CPITN (WHO, 1994, VIGNARAJAH, 1994; ADEGBEMBO and al., 1995; Lopez et al., 1996). However, unlike in most developing countries where prophylaxis (TN2) is usually the most prevalent treatment need (HOLMGREN, 1994), in this study, oral hygiene instruction (TN1) was the most prevalent need. The treatment needs, however, should not be accepted at face value. In fact, part of the criticisms directed at the CPITN is that the interpretation of treatment needs generated is beyond the capacity of most developing countries. In a Ta n z a - nian study, MUMGHAMBA and colleagues (1996) remarked that the estimated treatment needs in that country were beyond the capacity of the countries dental services. The authors therefore questioned whether all persons with a CPITN treatment need score should be treated, and suggested that there may be a more practical approach through other models which are yet to be developed. CUTRESS and colleagues (1987) as well as BARMES (1994) have cautioned that the CPITN treatment need indicators should not be literally interpreted. The treatment indicators are only intended to serve as a guide regarding the quantity and complexity of periodontal care needed. The most prevalent periodontal indicators in the present study were bleeding and calculus, which are comparable to that of Antiguan school children (VIGNARAJAH, 1994). On the contrary, ANGUILLA (WHO, 1994) and Jamaica (CUTRESS, 1986) reported pocketing as the most prevalent condition. The present study is in agreement with the other studies in the Caribbean and other developing nations; prophylaxis and OHI are the most prevalent treatment needs among adolescents. It is surprising that among Anguillian and Jamaican children, there was no child with a healthy score. Whereas, in Antigua and SVG healthy score was the second most prevalent after calculus, and bleeding the least prevalent. The findings among 12-year-olds from SVG were similar to Antiguans, except that SVG children had more calculus but less bleeding. In contrast, almost all 12-yearold Jamaican children required OHI and prophylaxis, compared to 80 percent or less in SVG and Antigua. Jamaica is the only Caribbean country that reported pocketing among 12 year-olds. The potential for recording false pockets associated with tooth eruption in this age group, as periodontal pockets also exists. In compliance with WHO guidelines we did not score pockets in children less than 15 years old. Pocketing was the most prevalent condition in Jamaica and Anguilla, but in Antigua only few children had pockets, and SVG did not score pockets. Among all Caribbean countries, a 20

4 high prevalence of periodontal indicators has been reported, and a majority of children needed OHI and prophylaxis, with very few requiring complex periodontal treatments. In light of the problems regarding unrealistic treatment needs scores generated by the CPITN, authors of the present study agree that these scores only serve as a guide to the real periodontal treatment needs of the population. The data obtained should help planners and administrators to set their own priorities and design strategies, considering the amount of available resources. In fact, the main focus should be on health promotion and education, as the first level of intervention (Pilot et al. 1994). The second level that involves prophylaxis should follow the first one, hopefully subsequent to the improvement in the population s oral hygiene. The second level of treatment should only be undertaken after consideration of government s oral health priorities, and the resources that are available for implementation of such a program. A more accurate periodontal predictor of treatment needs still need to be developed. CONCLUSIONS This study reports a high prevalence of calculus and bleeding, especially among older children of SVG. The proportion of children with healthy periodontium ranged from 51 percent among seven-year-olds to 12 percent of year old. Calculus was the most prevalent condition, particularly among older children. Oral hygiene instructions, however, was the most prevalent treatment need followed by prophylaxis. This study recommends primary prevention programs in the form of health education and health promotion as the first step towards reducing the periodontal problems, and secondary prevention programs be introduced later depending on the availability of resources for oral health. ACKNOWLEDGMENT The support of the SVG Ministries of Health and Education, PAHO and Oral Health, Geneva are appreciated. Special thanks to the teachers and school children of St. Vincent and The Grenadines. SUMMARY A national oral heath survey of school children was conducted in October through November The objective was to determine the periodontal status of school children in St. Vincent and The Grenadines (SVG), the pattern and severity of periodontal disease, estimate treatment needs and provide information for health planners. The study had a cross-sectional design, and 1646 schoolchildren representing all school districts were selected via multistage, systematic sampling. Examinations were conducted by three examiners using CPITN probe. Periodontal indicators and treatment needs were determined using the CPITN index. Calculus was the most prevalent condition with values ranging from 26 to 83 percent, bleeding was the least prevalent condition, while children with healthy indicator were intermediate in prevalence. Subjects with healthy indicators ranged from a low of 12 percent among year olds, to a high of 51 percent among seven-year-olds. The mean number of healthy sextants varied from three to five, and mean number of sextants with bleeding or calculus varied from one to three. Oral hygiene instruction (OHI) was the most common treatment need, ranging from 49 to 88 percent. The need for prophylaxis was associated with increase in age, with the highest prohylaxis treatment needs of 83 percent, among year olds. No significant differences were observed in periodontal status between gender, and also between urban and rural children. A high prevalence of calculus and bleeding was observed among SVG school children. Study recommends initiation of primary prevention programs in form of health promotion and health education. Key words : St. Vincent, school children, periodontal status, CPITN. REFERENCES 1 - ADEGBEMBO A.0., EL-NADEEF M.A.I. National survey of periodontal status and treatment need among Nigerians. International Dental Journal 1995, 45 : ARVIDSON-BUFANO U.B., HOLM A. K. Public health in urban and rural areas of central and western Bangladesh. Odonto- Stomatologie Tropical 1990, 13 :

5 3 - BARMES D. CPITN-A WHO initiative. International Dental Journal 1994, 44 : CUTRESS T.W. Periodontal health and periodontal disease in young people : global epidemiology. International Dental Journal 1986, 36 : CUTRESS T.W., AINAMO J., SARDO-INFIRRI J. The community periodontal index of treatment needs (CPITN) procedure for population groups and individuals. International Dental Journal 1987, 37 : HOLMGREN C.J. CPITN-Interpretations and limitations. International Dental Journal 1994, 44 : LOPEZ N. J., RIOS V., FERNANDEZ 0. Periodontal conditions in year-old Chileans. International Dental Journal 1996 ; 46 : MUMGHAMBA E.G, MARKKANEN H.A., HONKALA E. Periodontal status and treatment needs in a rural area of Ukonga, Tanzania. International Dental Journal 1996, 46 : PILOT T., MIYAZAKI H. Global results : 15 years of CPITN epidemiology. International Dental Journal 1994, 44 : SAINT VINCENT AND THE GRENADINES, MINISTRY OF EDUCATION Directory of schools and colleges (1989/90) VIGNARAJAH S. Periodontal treatment needs in 12 and 15 to 19-year-old school children in the Caribbean island of Antigua, Journal of Periodontal Research 1994 ; 29 : WORLD HEALTH ORGANIZATION Oral Health Surveys, Basic Methods, 3rd ed. WHO Geneva WORLD HEALTH ORGANIZATION Periodontal profiles : an overview of CPITN data in the WHO Global Oral Data Bank, periodontal conditions at age years, WHO