Original Article Caries status of school children in Jazan city, KSA and its relation with dental literacy of their parents Abdulaziz M Zailai,* Mir Faeq Ali Quadri, Maryam Nayeem, Aadil Inamdar, Santosh Tadakamadla.# * Consultant, Department of Restorative Dentistry, Ministry of Health, Jazan, KSA; Lecturer, College of Dentistry, Jazan University, Jazan, KSA; Lecturer, College of Pharmacy, Jazan University, Jazan, KSA; Assistant Professor, College of Dentistry, Jazan University, Jazan, KSA; #PhD Student, Griffith University, Australia. Abstract Introduction: Dental caries is the single-most common childhood oral disease. Parental education may play a key role in predicting caries in the primary dentition of the child. The aim of the study was to assess the relation between caries experience in primary school children and dental literacy among their parents. Materials and Methods: A random sample of 165 children aged 6-12 years was recruited from six schools. Caries was examined using the dft/dmft indices respectively. A document with a set of 10 questions using the words from the REALD-30 was used to assess the literacy level of parents. A score of 80% was used as a cutoff to categorize parents as having low or high dental literacy. Fishers test, as well as multiple regression analysis was done to analyze different correlations. Results: High caries prevalence was observed in both male (89.4%) and female (93.9%) children. Parents of 116 school children had high dental health literacy score (70.7%) while 48 (29.3%) had a low score. Children for parents with higher dental literacy had significantly more permanent filled teeth (p = 0.04) and significantly less (marginally) permanent missing teeth (p=0.07). Conclusion: Parents dental literacy seems to influence dental caries treatment choice (filling vs. extraction), but not caries prevention per se. This however, may not be applicable to other population. Tailored education programs targeting both children and parents are required. Keywords Caries, School children, Dental literacy, Prevention *Author for correspondence: Mir Faeq Ali Quadri, Lecturer, College of Dentistry, Jazan University, Jazan, KSA. +966 59 89 59 409, faeq_ali@yahoo.com
Introduction Oral health is a component of overall health and wellbeing of an individual (1). Tooth decay, gum inflammation and tooth loss are a few of the oral diseases which occur in children (2). Among these, tooth decay, otherwise termed as dental caries, is the single-most common childhood oral disease prevalent among various nations across the world (3). The prevalence rate of dental caries in developing countries is 60-90% among the school going children (4). In fact, there is no geographical location which does not exhibit some or the other form of evidence of dental caries (5). One study done in Jazan, Saudi Arabia showed high caries experience among children aged between 6-8 years with a significant difference in regards to socio economic status and gender (p = 0.007) (6). Prevention of dental caries is being given utmost importance, especially among the school going children. Simple measures need to be followed by the individuals or the community as a whole. Risk factors such as unhealthy dietary habits, limited use of fluoride, low socio economic status and poor access to service providers are greatly talked about and are proven to be associated with high rate of dental caries (7); and strategies like water fluoridation, use of fluoride toothpaste and oral health education sessions focusing on the maintenance of good oral hygiene are used in the developed countries to tackle dental caries (8). The role of dental literacy in preventing dental caries is lacking sufficient evidence and is still a subject of discussion. One systematic review concludes that parental education could be a vital factor in predicting caries in primary teeth (9). A study undertaken among the Iranian population showed the importance of having good oral health literacy in preventing oral cancer (10) thus indicating that high dental literacy level can be considered as a primary step in preventing oral diseases if sufficient level of association is established. This study aims at assessing caries experience of school children in Jazan, which is a small city located at the southern tip of Saudi Arabia and to see its relationship with the dental literacy of their parents. Methods Ethical considerations and questionnaire. This cross-sectional study was approved by the research committee at the Faculty of Dentistry in Jazan University. Permission to conduct the study in primary schools was obtained from the Regional Education Office. Parents were asked to sign a written consent form for their participation in the study. The questionnaire was based on a prevalidated instrument Rapid Estimate of Adult Literacy in Dentistry (REALD) (11). To measure oral health literacy, Richman and his colleagues developed this instrument to which, Lee et al introduced and validated a shorter version termed as REALD-30 (12). A bilingual native Arabic speaking dentist translated the words from REALD to Arabic. Another independent bilingual dental professional was asked to perform a reverse translation and no discrepancies were observed. The questions were designed to check literacy levels and words such as sugar, fluoride, brushing, halitosis, caries etc; were incorporated. A score of 80% was used as a cutoff to categorize parents as having low or high dental literacy. Clinical examination School children were examined under LED light implementing standard infection control measures such as use of gloves, mask and disposable diagnostic instruments. Examiners were blinded to the study objectives. Caries were examined using the dft (decayed-filled-teeth) and DMFT (decayed-missing-filled-teeth) method (13). The children obtaining a dft/dmft score of 2
zero were termed as caries-free and who are having 4 or more carious teeth were termed as caries active. Statistical analysis The demographic and the clinical data were summarized as means±sd (Standard Deviation) or percentages as appropriate. Correlation with caries scores (dft, DMFT, and their components) and knowledge score (high/low) was tested with multiple linear regression, respectively. Age, gender, and oral hygiene status were included in both models as covariates. Coefficient of correlation (r) was obtained for significant differences. The values of P of 0.05 were considered as significant. Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS). Results Response rate and demographic characteristics Parents of 165 children out of 270 gave a positive consent to participate in the study and had completed the questionnaire. The calculated response rate was 61.1%. Forty percent of these were males and 60% were females. The mean age of the sample was calculated as 9.57 + 1.83. Caries Status All the 165 children were examined for oral health status and thirteen of the children (7.8%) were caries free while the rest (92.2%) were caries active. There were significantly more caries free subjects in the males than in the females (10.6% vs. 6.1%, Table 1). The dft/dmft and their components scores are presented in Table 2. The mean D and d scores accounted for 92% and 96% of the mean DMFT and dft scores respectively, while the mean F and f scores accounted for only 6% and 3%, respectively. Age was seen to be negatively correlated with d scores while positively correlated with D scores (r = - 1.92 and 0.48, respectively; p < 0.01). Males had significantly higher decay in primary teeth whereas females had higher decay in the permanent teeth. Table 1: Caries prevalence among the study sample Caries Caries free n (%) active n (%) Male 7 (10.6%) 59 (89.4%) Gender Female 6 (6.1%) 93 (93.9%) LS 5 (5.8%) 81 (94.2%) OHLL HS 8 (10.1%) 71 (89.9%) Fisher s exact test; LS-Low Score, HS-High Score, OHLL-Oral Health Literacy Level. Table 2: Caries scores (mean±sd) by gender Gender Over Component Male Female P* all (N=16 (n=66) (n=99) 5) 1.92 ± 1.63 ± 2.11 ± DT 0.01 1.95 1.77 2.05 MT FT DMFT dt ft dft 0.04 ± 0.40 0.13 ± 0.56 2.08 ± 2.04 3.84 ± 3.27 0.12 ± 0.51 3.96 ± 3.26 0.01 ± 0.12 0.03 ± 0.17 1.68 ± 1.74 4.38 ± 3.43 0.03 ± 0.25 4.41 ± 3.49 0.05 ± 0.50 0.20 ± 0.69 2.34 ± 2.18 3.49 ± 3.12 0.18 ± 0.62 3.67 ± 3.08 0.07 0.04 0.001 0.04 0.05 0.09 * Stepwise multiple linear regression model, adjusting for age, oral hygiene and knowledge score. Parents knowledge and its relation to caries. Almost 70% (116) of parents scored less than 8 out of 10 while 29.3% (48) scored 8 or more. The dft/dmft and their 3
components scores by parent s dental literacy status are presented in Table 3. No significant difference was observed in children s caries experience (d and D scores) for parents with high and low literacy scores. However, children for parents with high score had more filled permanent teeth (F), while children for parents with low score had more missing teeth (M), although the difference was only close to being significant (P= 0.07). Table 3: Caries scores (mean±sd) by knowledge level Component Knowledge Overall LS HS P* (N=165) (n=48) (n=116) DT MT FT DMFT dt 1.92 ± 1.95 0.04 ± 0.40 0.13 ± 0.56 2.08 ± 2.04 3.84 ± 3.27 1.83 ± 2.21 0.12 ± 0.73 0.001 ± 0.001 1.93 ± 2.24 3.85 ± 3.19 1.96 ± 1.85 0.001 ± 0.001 0.19 ± 0.66 2.15 ± 1.96 3.80 ± 3.29 NS 0.07 0.04 NS 0.49 ft 0.12 ± 0.08 ± 0.13 ± 0.51 0.40 0.55 0.54 dft 3.96 ± 3.93 ± 3.93 ± 3.26 3.25 3.26 NS *Stepwise multiple linear regression model, adjusting for age, oral hygiene, and gender. NS-not significant, LS-Low Score, HS-High Score. Discussion Children acquire most of their knowledge thorough their parents. The process of incorporating this knowledge to develop multiple skills begins at home. An understanding of 'oral health' among parents is essential when it comes to teaching healthy habits to their children (14). This study can safely generalize that there is a high prevalence of caries among school children in Jazan, Saudi Arabia. Interestingly, the dental literacy rate calculated in this study is in contradiction to the previous study done in Saudi Arabia which showed a positive understanding among the parents of having a good oral health status for their children (15). Literacy level in general is usually associated with barriers like verbal and oral communication dissonance (16). Any improvement in the dental literacy gives the parents an understanding of various preventive measures associated with dental caries. It also increases their ability to make appropriate decisions regarding the different treatment modalities available for their children (17). Dental literacy levels may also be an indicator of parent s abilities, their understanding of different skills necessary to learn and demonstrate positive oral self-care behaviors, contacting the service provider and complying with the prescribed medications while attending follow-up appointments (18). It is observed in this study that most of the parents with low literacy score had more number of extracted or missing teeth in their children suggesting that parents were not aware of the advances in dentistry to preserve the tooth structure. The confounding factor here could be a missed opportunity by the service provider, to educate the patient. Parents with high literacy score had children with more number of filled teeth, their approach seemed to favor saving the permanent teeth. This study reflects on the fact that parents who realize the importance of good oral hygiene, preservation of primary and permanent teeth, incorporation of healthy habits in early childhood, would normally have a good oral health literacy score and vice-versa. This study adds to the evidence that having good oral health literacy is important to improve an individual s own oral health outcomes and also that of their children (19). 4
Conclusion Parents dental literacy seems to influence dental caries treatment choice (filling vs. extraction) but not caries prevention per se. Need of the hour is to reduce the rate of caries incidence among children in Jazan and to improve their oral health status. The basic oral health literacy has to be improved among the adult population by initiating future communitybased dental health promotion and oral health education programs. Dental service utilization among the population of Jazan, Saudi Arabia needs to be addressed. Further investigations are required for better understanding of association between oral health literacy and caries status. Acknowledgement We are most thankful to the team of dental students who helped in data and sample collection. References 1. World Health Organization. Oral health in ageing societies: Integration of oral health and general health. 2013. 2. Petersen PE. Strengthening the prevention of oral cancer: the WHO perspective. 3. Community dentistry and oral epidemiology. 2005;33:397-9. 4. United States. Dept. of Health and Human Services. Healthy people 2010 : understanding and improving health. Washington, DC: U.S. Dept. of Health and Human Services : For sale by the U.S. G.P.O., Supt. of Docs.; 2000. 5. Joyson Moses BNR, Deepa Gurunathan. Prevalence Of Dental Caries, Socio- Economic Status And Treatment Needs Among 5 To 15 Year Old School Going Children Of Chidambaram. Journal of Clinical and Diagnostic Research. 2011;5(1):146-51. 6. Peterson P. The World Oral Health Report: continuous improvement of oral health in the 21st century-the approach of the WHO Global Oral Health Program. Community Dental and Oral Epidemiology. 2003;31(1):3-23. 7. Dosari A Al AH, Refai A Al. Oral health status of primary dentition among 551 children aged 6-8 years in Jazan, Saudi Arabia. Saudi Dental Journal. 2000. 8. Research NIoDaC. Chapter 7: Community and Other Approaches to Promote Oral Health and Prevent Oral Disease. 2013. 9. Burt BA. Prevention policies in the light of the changed distribution of dental caries. Acta Odontologica Scandinavica. 1998;56(3):179-86. 10. Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicators of risk in caries management. J Dent Educ. 2001 Oct;65(10):1126 32. 11. Motallebnejad. M. M AMK, R. AND Dabbaghian. I. Community survey of knowledge about oral cancer in Babol: effect of an education intervention. Eastern Mediterranean Health Journal. 2009;15:1489. 12. Richman JA, Lee JY, Rozier RG, Gong DA, Pahel BT, Vann WF, Jr. Evaluation of a word recognition instrument to test health literacy in dentistry: the REALD- 99. J Public Health Dent. 2007 Spring;67(2):99-104. 13. Lee JY, Rozier RG, Lee SY, Bender D, Ruiz RE. Development of a word recognition instrument to test health literacy in dentistry: the REALD-30--a brief communication. J Public Health Dent. 2007 Spring;67(2):94-8. 14. World Health Organization. oral health surveys basic method:4th edition, Geneva, WHO 1987:760-871 15. Anonymous. The invisible barrier: literacy and its relationship with oral health. A report of a workgroup sponsored by the National Institute of Dental and Craniofacial Research, 5
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