SRM Journal of Research in Dental Sciences A Publication of SRM Dental College, Ramapuram Campus, SRM University, Chennai

ISSN 0976-433X Volume 6 / Issue 1 / Jan-Mar 2015 SRM Journal of Research in Dental Sciences A Publication of SRM Dental College, Ramapuram Campus, SRM University, Chennai www.srmjrds.in

Original Article Screening for caries activity among preschool children of Anganwadi centers in a North Indian City Sonika Raj, Sonu Goel 1, Vijay Lakshmi Sharma, Naveen Krishan Goel 2 Centre for Public Health, Panjab University, 1 School of Public Health, Post Graduate Institute of Medical Education and Research, 2 Department of Community Medicine, Government Medical College and Hospital, Sector 32, Chandigarh, India ABSTRACT Introduction: The incidence of dental caries is as high as 70% among preschool children. There are various screening tests used globally in different settings to diagnose caries activity among preschool children. Snyder test is one such test, which is sufficiently accurate and sensitive for estimation of caries activity in field settings. Objective: The aim was to assess the change in caries activity level of preschool children by Snyder test after providing oral hygiene training to Anganwadi workers (AWWs). Materials and Methods: This before and after comparison study was conducted in year 2010 among Anganwadi centers (AWCs) of Chandigarh, a North Indian City. A total of 495 children aged 3-6 years from 21 AWCs were randomly selected. The prevalence of dental caries was recorded based on decayed, missing, filled teeth index using codes and criteria as described by WHO. The saliva samples (0.2 ml) of children were taken in tubes with Snyder media to detect caries activity. The readings were taken at 24, 48 and 72 h to detect the color change in media. AWWs were provided with oral hygiene training who then educated children and their parents. Post training data regarding caries activity using Snyder test was again collected after 3 months. Results: Caries activity among children decreased from 48.2% pretraining to 31.2% posttraining. The positive caries activity level at 48 and 72 h showed statistically significant decline after training when compared to the baseline level. Prevalence of caries based on WHO criteria (48.3%) was in concordance to Snyder test results (48.2%) at the end of 72 h. Conclusion: Snyder test could be used to detect the caries activity of children in field settings. Snyder test will diagnose highly susceptible children for caries that in-turn will assist in prioritizing the dental care and management. Key words: Anganwadi workers, dental caries, decayed, missing, filled teeth index, Snyder test, training INTRODUCTION Address for correspondence: Dr. Sonika Raj, Panjab University, Chandigarh, India. E-mail: sonikagoel007@yahoo.com Access this article online Quick Response Code: Website: www.srmjrds.in DOI: 10.4103/0976-433X.149551 Dental caries is an important public health problem and is the most prevalent oral disease in the world. [1] The incidence of dental caries is as high as 70% among children and ranges from 40% to 60% in adults across various states of India. [2,3] It affects children as early as 6 months of age and often carries itself throughout the life of an individual. Globally, there are many caries activity tests (viz. lactobacillus colony count test, calorimetric swab test, enamel solubility test, salivary reductase test, dip slide method, Alban test etc.) which measures the level of caries activity or development of new and recurrent carious lesions over a period of 1

time. [4,5] They measure degrees at which the dietary and other contributing factors affects the microbial growth and metabolism. However, none of them possesses all the qualities of being sufficiently accurate, cost-effective, simple and applicable in field settings. [4,5] Snyder test is one such test, which is sufficiently accurate and sensitive for estimation of caries activity in field settings. Its accuracy for the estimation of caries activity has shown to be almost equal to the standard lactobacillus count. [6] Snyder test is a calorimetric caries activity test which measures the ability of salivary microorganisms (lactobacillus) to form organic acids from a carbohydrate medium. [7] It is a simple tool which can even be performed by a basic level health worker with minimum training. This test can also be used during mass surveys in field settings. The test finding provides insight to individual patient s oral activity through longitudinal charting and in-turn assist the dentist in planning case management. This test requires minimum laboratory facilities, easy to perform, easy to read and interpret, capable of being handled in large volume, economical in cost and does not require strict cold chain conditions. [4,5,8] However, it requires cooperation of children while spitting. Few studies have been conducted across world among children to determine caries activity using Snyder test. [9-11] Studies have shown a positive association between dental caries (using decayed, missing, filled teeth [dmft] index) and caries activity (using Snyder test). [12,13] A study by Sánchez- Pérez et al. on a cohort of 6-year-old Mexican children found that Snyder test had a strong association with caries increment. The study concluded that Snyder test is a useful predictor for caries and may be useful in targeting caries prevention efforts in developing countries. [13] However, there is limited literature available about use of Snyder test to determine caries activity in field settings. Further, very few studies have been conducted to find out the concordance of caries activity using Snyder test with dental caries using dmft index. Therefore, the present study was conducted to assess the change in caries activity level of preschool children in Anganwadi centers (AWCs) by Snyder test after providing oral hygiene training to Anganwadi workers (AWWs). The study will also assess the concordance of caries activity with dental caries among preschool children. MATERIALS AND METHODS This before and after comparison study was conducted in 2010 among AWCs of Chandigarh, a North Indian City. Chandigarh has an estimated population of around one million. Around the 35,000 preschool children are enrolled in 423 AWCs in Chandigarh. The AWCs are administratively divided into three projects which are looked after by Project Officer, Integrated Child Development Scheme (ICDS). [14] One AWW looks after an AWC. The sample size for the study was determined using Centers for Disease Control (CDC) EPI-INFO-7 for Windows. A total of 495 children aged 3-6 years from 21 AWCs were randomly selected. Assuming that an AWC will contain around 20-25 children in the age group of 3-6 years, a total of 21 AWCs were included in the study. Simple random sampling technique was used for selection of AWCs from 3 projects, 7 from each project (n = 21). All the children aged 3-6 years attending the AWC on the date of visit, whose parents consented for the study were included. The children absent on the day of the visit or those <3 years or >6 years or whose parents denied consent were excluded from the study. The prevalence of dental caries was recorded based on dmft index using codes and criteria as described by WHO. [15] The saliva samples (0.2 ml) of children were taken in tubes with Snyder media to detect caries activity and then tubes were transported to laboratory and incubated at 37 C. The readings were taken at 24, 48 and 72 h to detect the color change in media. [7] Baseline data collection was done in the month of October, 2010. The AWW was provided with oral hygiene training by principal author of the study. The training includes power point presentation on oral hygiene practices, tooth friendly diet, brushing and flossing; a poster on tooth friendly diets and brushing technique; and a story on oral hygiene. [16] The AWW later provided training to mothers and children in their respective AWCs on a weekly basis. A total of 12 training sessions were held by each AWW at their respective AWC. The trainings were provided by principal researcher and monitored by team from Department of Health and Family Welfare, UT Chandigarh. The saliva samples of children in the selected AWCs were again collected after 3 months of providing training to AWW in February 2011. The consent of the Project Officer, ICDS; Medical Officer, ICDS, Chandigarh; AWWs and parents of the children was obtained. Data were analyzed using the software IBM Statistical Package for Social Science-version 16 (SPSS-16) using proportions and Chi-square test. RESULTS A total of 534 and 538 children aged 3-6 years were examined before and after providing oral hygiene training to AWWs. There was no significant difference in the demographic profile of children before and after the training. Almost half children were from urban areas (48.3%) and were in the age group of 3-4 years (48.5%). Boys (50.7%) and girls (49.3%) were almost equally distributed in the study population. Majority (78%) of them belonged to upper lower socioeconomic status. The prevalence of dental caries was found to be 48.3% (n = 258). The mean dmft score was 2.11 ± 3.12. There were no cases of filled teeth in any of the children examined. 2

The caries activity of children was determined using Snyder test before and after the oral hygiene training to AWWs. The baseline caries activity level was 48.2% (n = 241) which decreased to 31.2% (n = 168) after the training. A statistically significant change in negative Snyder test results after 72 h was observed in age group, whereas, there was no significant change in gender, socio-economic status and residence of study population [Table 1]. The positive caries activity level at 48 and 72 h showed statistically significant decline after training when compared to the baseline level [Figure 1]. The prevalence of caries based on WHO criteria (48.3%) was in concordance to Snyder test results (48.2%) at the end of the 72 h. Table 1: Level of caries activity before and after oral hygiene training using Snyder test Demographic variables Negative Snyder test results after 72 h Before training (n = 258) After training (n = 370) Chisquare Age group (in years) 3-4 144 (55.8) 252 (68.1) 10.24 0.005 # 4-5 80 (31) 87 (23.5) 5-6 34 (13.2) 31 (8.4) Gender Female 109 (42.2) 180 (48.6) 2.51 0.11 Male 149 (57.8) 190 (51.4) Socioeconomic status * Upper 1 (0.4) 3 (0.8) 5.13 0.27 Upper middle 9 (3.5) 18 (4.9) Lower middle 46 (17.8) 77 (20.8) Upper lower 194 (75.2) 251 (67.8) Lower 8 (3.1) 21 (5.7) Residence Urban 134 (51.9) 172 (46.4) 1.98 0.37 Slum 59 (22.9) 99 (26.8) Rural 65 (25.2) 99 (26.8) * Kuppuswamy socioeconomis status, # P value significant at 0.05 level Figure1: Level of caries activity at different time intervals before and after oral hygiene training P DISCUSSION The present study showed a prevalence of dental caries as 48.3% in preschool children of AWCs of Chandigarh. Studies conducted among preschool children in India have shown similar findings as the present study. The National Oral Health Survey conducted in 2004 in India has shown the prevalence of dental caries as 50.0% in 5-year-old children. [2] A study by Mandal et al. in urban areas of West Bengal, Orissa and Sikkim (Eastern states of India) showed the prevalence of 52.4%, 56.0%, and 61.8% respectively in 5-6-year-old children. [3] A study in Hubli - Dharwad city showed the prevalence of dental caries as 54.1% in the age group of 3-5 years. [17] The prevalence of dental caries among 5-year-old children of urban Pondicherry was 44.4%. [18] However, few studies in India have shown a higher prevalence of dental caries in preschool children. A study done among children aged 3-5 years of Anganwadis in Mangalore showed a higher prevalence of dental caries as 81.4%. [19] In Karnataka, prevalence of dental caries was found to be higher (81.2%) among 5-6-year-old children. [20] The prevalence of dental caries was found to be 61.4% in children aged 5-6 years of Akola city, Maharashtra. [21] The higher prevalence of dental caries among preschool children in the present study may be due to lack of awareness about importance of oral health and also due to unavailability and nonafford ability of dental services. The present study found that caries activity level among preschool children by Snyder test was 48.2% (n = 241). This finding was in concordance with the prevalence of caries (48.3%) by dmft index. Similar results were found in a study conducted in Turkey by Tanboga et al. among children aged 4-6 years wherein, around 46% of the children had positive results at the end of the 48 h and the results were in accordance with prevalence of caries in the group. [9] Other studies conducted globally have also shown the concordance between caries activity and prevalence of caries. [10-12] Ali et al. in their study found a definite correlation between caries status, colony forming units of Streptococcus mutans and Snyder caries activity test. [10] Studies have also demonstrated that tooth morphology and Snyder test are useful predictors for caries. [13] In addition to present findings, authors have also found that oral hygiene training package imparted to AWWs have led to improving oral hygiene of preschool children. [16] The present study is one of the very few studies which document the high level of agreement between caries activity using Snyder test and incidence of caries using WHO index. The strengths of the study include larger sample size, representative sampling and assessing feasibility of utilizing AWW in diagnosing caries activity among preschool children. However, the study could have tested feasibility of other simple caries activity tests and compared them with each other for their effectiveness. Further limitations include limited generalizability of study findings and shorter duration of the study. 3

CONCLUSION AND RECOMMENDATIONS The present study revealed that preschool children have not only high incidence of caries but also have high caries activity. There was a high level of concordance in level of caries activity and dental caries. Hence, Snyder test, which is a simple and cost-effective test to determine the caries activity among children, can be introduced as a part of routine dental assessment of preschool children. However, the findings of the present study need to be generalized by conducting large-scale similar study in different settings. This will assist in diagnosing highly susceptible children for prioritizing the dental care and management. ACKNOWLEDGMENTS We acknowledge the support of National Rural Health Mission, Chandigarh for providing financial support. REFERENCES 1. World Health Organization. Global Oral Health Data Bank. Geneva: WHO; 2001. Available from: http://www.who.int/oral_health/media/ en/orh_report03_en.pdf. [Last accessed on 2014 Jul 15]. 2. National Oral Health Survey and Flouride Mapping, 2002-2003. Vol. 32. New Delhi: Dental Council of India, Ministry of Health and Family Welfare, Govt. of India; 2004. p. 67-78. 3. Mandal KP, Tewari AB, Chawla HS, Gauba KD. Prevalence and severity of dental caries and treatment needs among population in the Eastern states of India. J Indian Soc Pedod Prev Dent 2001;19:85-91. 4. Peter S. Caries activity tests. In: Peter S, editor. Essentials of Preventive and Community Dentistry. 1 st ed., Ch. 8. India: Arya (Medicine) Publishing House; 1999. p. 337-366. 5. Marwah N, editor. In: Textbook of Paediatric Dentistry. 2 nd ed. India: Jaypee Brothers; 2009. 6. Snyder ML. Correlation and comparison of laboratory findings with the clinical evidence of caries in a group of sixty-six children J Am Dent Assoc 1942;29:2001-11. 7. Snyder ML, Arbor A. A simple colorimetric method for diagnosis of caries activity. J Am Dent Assoc 1941;28:44-9. 8. Rao A. Principles and Practice Pedodontics. 2 nd ed. India: Jaypee Brothers; 2008. p. 179-86. 9. Tanboga I, Alaçam R, Batirbaygil Y, Korten G. Determination of caries activity levels in children aged 4-6 years by the modified Snyder test. Mikrobiyol Bul 1987;21:194-9. 10. Ali YA, Chandranee NJ, Wadher BJ, Khan A, Khan ZH. Relationship between caries status, colony forming units (cfu) of Streptococcus mutans and Snyder caries activity test. J Indian Soc Pedod Prev Dent 1998;16:56-60. 11. Ramesh K, Kunjappan S, Ramesh M, Shankar S, Reddy S. Comparative evaluation of predictive value of three caries activity tests-snyder, lactobacillus count and cariostat in mixed dentition children with and without caries. J Pharm Bioallied Sci 2013;5: S63-8. 12. Ansai T, Yamashita Y, Shibata Y, Katoh Y, Sakao S, Takamatsu N, et al. Relationship between dental caries experience of a group of Japanese kindergarten children and the results of two caries activity tests conducted on their saliva and dental plaque. Int J Paediatr Dent 1994;4:13-7. 13. Sánchez-Pérez L, Golubov J, Irigoyen-Camacho ME, Moctezuma PA, Acosta-Gio E. Clinical, salivary, and bacterial markers for caries risk assessment in schoolchildren: A 4-year follow-up. Int J Paediatr Dent 2009;19:186-92. 14. Project-Wise/Anganwadi Centre-Wise Location of Anganwadi Centres in the Chandigarh. Available from: http://www.chandigarh. gov.in/pdf/anganwadi-centres.pdf. [Last accessed on 2010 Aug 10]. 15. World Health Organization. Oral Health Surveys. Basic Methods. 4 th ed. Geneva, Switzerland: WHO; 1997. 16. Raj S, Goel S, Sharma VL, Goel NK. Short-term impact of oral hygiene training package to Anganwadi workers on improving oral hygiene of preschool children in North Indian City. BMC Oral Health 2013;13:67. 17. Mahejabeen R, Sudha P, Kulkarni SS, Anegundi R. Dental caries prevalence among preschool children of Hubli: Dharwad city. J Indian Soc Pedod Prev Dent 2006;24:19-22. 18. Saravanan S, Madivanan I, Subashini B, Felix JW. Prevalence pattern of dental caries in the primary dentition among school children. Indian J Dent Res 2005;16:140-6. 19. Shenoy R, Sequeira PS, Rao A, Rao A, Pai D. Dental caries experience of pre-school children in Mangalore, India. J Nepal Dent Assoc 2009;10:25-30. 20. Goel P, Sequeira P, Peter S. Prevalence of dental disease amongst 5-6 and 12-13 year old school children of Puttur municipality, Karnataka State-India. J Indian Soc Pedod Prev Dent 2000;18:11-7. 21. Ali YA, Chandranee NJ, Khan A, Khan ZH. Prevalence of dental caries in nursery school children of Akola city. J Indian Soc Pedod Prev Dent 1998;16:21-5. How to cite this article: Raj S, Goel S, Sharma VL, Goel NK. Screening for caries activity among preschool children of Anganwadi centers in a North Indian City. SRM J Res Dent Sci 2015;6:1-4. Source of Support: The support of National Rural Health Mission, Chandigarh for providing financial support. Conflict of Interest: None declared 4