ORAL HEALTH CARE IN MALAYSIA A REVIEW

ORAL HEALTH CARE IN MALAYSIA A REVIEW 1 ANDALEEB UMER 2 AFSHEEN UMER SUMMARY This paper reviews oral health status of population of Malaysia. A computer based search was made on 136 articles from eight journals. Indicators were selected according to CDC (Centre for Disease Control and Prevention) to explain oral health care in Malaysia. Oral diseases are mostly preventable. Nevertheless dental caries continue to be a significant public health problem in Malaysia. Studies among children found caries prevalence to be 75.5%. A school based sealant programme was implemented in 1999 as preventive strategy for caries. In adults caries figure was estimated to be 80%. About half of adults were found to have visited dentists more than two years ago. Oral cancer was found to be fifth most common cancer in Malaysia. Tobacco use and quid chewing habit contributed to oral cancer. Fluoridation of public water is a great step in control of caries. So improving oral health is a multi prong attack. Lack of resources and dental staff was also contributing factor in oral health problems. A National Oral Health Plan 2010 based on four oral health conditions, i.e. dental caries, periodontal conditions, dental injuries and oral malignancies has been launched. Targets are set up for improvement of these conditions. Oral health education is recognized as cornerstone in improvement of oral health of individuals and communities. Key words: Oral. Healthcare, Malaysia, Review INTRODUCTION Malaysia is situated in South East Asia and abuts the neighbouring countries Indonesia, Singapore and Thailand. Malaysia is made up of two geographical wings namely, Peninsular Malaysia and East Malaysia, which is composed of the states of Sabah and Sarawak. The beauty of Malaysia lies in its multiethnic culture. The ethnic breakdown is comprised of Malays 54.1%, Chinese 25.4%, Indians/ Pakistani 7.5%, Indigenous groups 11.7% and others 1.3%. The historical record of dentistry in Malaysia can be traced back to 1869, when first practitioner named Cheong Chun Tin started private practice. Oral Health is being considered as an integral part of general health. Oral healthcare was given considerable importance in Malaysia during the last decade. This paper gives an overview about oral healthcare in Malaysia. Following indicators about oral healthcare are taken from CDC to explain oral healthcare programme: Caries Experience, Dental Sealants use in children Dental Visit and Teeth Cleaning among Adults aged 18 years and above Complete Tooth Loss and Loss of 6 or more teeth in Old Age group of 65 years and above Cancer of the Oral Cavity and Pharynx Fluoridation Status. Percentage of people served fluoridated water through public water systems ORAL HEALTH CARE FOR CHILDREN IN MALAYSIA 1 Demographic Profile of Dental Caries among School Children in Malaysia Caries control in children continues to be a big challenge. Various National epidemiological surveys were done to assess the prevalence of dental caries among children in Malaysia. The Malaysian Oral Health Survey on 5-years old children carried out in 2005 showed caries prevalence was 75.5%. Mean dmft was 5.57. 1 Dental epidemiological study showed that 95.4% of 6 years old children had carious primary teeth in Peninsular Malaysia. 2 This figure dropped to 88.6% in 1988, and by 1997 a further reduction to 80.6% was 1 Provincial Health Services Academy Peshawar, Pakistan 2 Khyber Medical University, Peshawar, Pakistan 141

reported. 3.4 Studies in Sarawak found 91.7% caries prevalence in 6 years old children. 5 In 1994, this prevalence dropped to 88.2% while in 1997 prevalence was 79.6%. 4.6 In a pre-school survey in Sarawak, caries prevalence of 5 years old children was estimated to be 85.5%. 7 Among the states, Sabah reported highest caries prevalence among 6 years old, which was 96.9% in 1985 and 94.7% in 1997. 4 There was little decline of 2.2% in 12 years. This gives an idea about high level of unmet treatment needs. Similar conclusion was drawn in a study in Petaling Jaya, where only 15.4% of 5 years old and 14.8% of 6 years old were found caries free. 8 The mean dft was 5.5 for 5 years old and 5.9 for the 6 years old children. 9 As a part of National Oral Health Survey of Pre-School Children (NOHPS), 2005, survey in Johor 10 gave an insight idea about caries prevalence in children. A sample of 1,929 children were examined, out of whom 61% were found to have caries. Mean dmft was 3.46, with decayed teeth ratio being the highest i.e. 3.27. About 72.1% children were reported with clean teeth, 25.9% had little plaque while 2.2% had greater amount of plaque. A scientific research study 11 was conducted in Seberang Marang to find an association between caries prevalence and negative attitude to oral hygiene practice. Simple random sampling of 206 school children was selected. 50% of children were diagnosed with caries. The results revealed a significant association between caries prevalence and attitude towards oral hygiene habits. 2. Dental Services for School Children Children under 18-years make up 50% of population in Malaysia and as evident from figures, their oral health is a serious consideration and so dental services specific for school children are need of time. In 1948, the school dental services were launched in Malaysia. In 1952, there were 19 dental school clinics operating. By 1957 there were 55 dental school centres and 40 school based dental clinical units managed by dental nurses. By the year 2000 the figure increased more than eight fold, whereby 787 school dental clinics were in function with 21 dental centres. Mobile dental units increased from 13 in 1970 to 407 in 2007. School Based Fissure sealant Programme is a preventive project with main objective to prevent dental caries. In 1999 it was implemented nationwide. In this project, fissure sealants are applied to permanent molars in children who are found to be at risk for occlusal caries. In 2003 program was reviewed and further guidelines were set for more accelerated achievement of goals. 12 ORAL HEALTH CARE FOR ADULTS In Malaysia, multiple oral health surveys were carried out about oral health of adults, namely the Dental Epidemiological Survey of Adults in Peninsula Malaysia 1974/1975 13 and the Dental Epidemiological Survey of Adults in Malaysia 1990. 14 The estimated results of the latter provided a baseline data for caries and periodontal conditions of the adult population. The Oral Health Survey of Malaysian Adults 2000 15 was a ten yearly survey, and findings provided a comparison in adult oral health profile since 1990. The main objective of this survey was to determine oral health conditions, effects and treatment needs of 15 years and above, and to assess their utilization of dental services. In this survey a sample of 10,891 adults was selected and examined, of which 87.2% belonged to Peninsula Malaysia, 5.2% from Sabah and 7.6% from Sarawak. 55.9% were females and 60.2% were urban population. There was no edentulous case among those aged 15-29 years. Prevalence of edentulism increased with increasing age from 30 years and above. Utilisation of dental care services can be seen in Fig 1. Table 1 tells about the reasons for seeing dentists. Caries prevalence by age groups is shown in Fig. 2. A survey 16 was conducted on 537 adults, aged 15 years and above, about oral hygiene practices. About 89.7% adults reported that they brushed their teeth, 68% used tooth paste having fluoride, but only 8.4% reported about use of floss. Better tooth cleaning habits were observed with higher socio-economic class. ORAL HEALTH CARE IN OLD AGE GROUP (65 YEARS AND ABOVE) According to Malaysian Demographic profile, 2011, elder population comprise about 5% of population. These numbers have increased considerably from 2000. By the year 2020, when the nation is expected to achieve status of a developed nation, it is assumed that this population will be increased to 12.0% of total population. This rapid ageing necessitates economic and social strategies while controlling health problems of old age. In National Oral Health Survey 2000 15 about 39.1% cases were found to be edentulous in age group 65-74 years. A study 17 was carried out in Kelantan to analyze dentition status of elder population. A cross sectional designed study was done taking a sample of 369 adults. Majority of subjects were found to be edentulous (81.0%). The mean number of natural teeth, functional natural teeth, decayed teeth (D), missing teeth (M) and 142

Fig 1: Utilisation of dental care services (Source: Oral Health Division, Ministry of Health Malaysia) Fig 2: Caries prevalence by Age group. (Source: Oral Health Division, Ministry of Health Malaysia) TABLE 1: REASONS FOR VISIT TO DENTIST WITHIN THE LAST TWO YEARS Reasons for Visit No. of responses (%) Something wrong 2,653 (51.2%) Time for examination / 651 (12.6%) cleaning Reminded by dentist 29 (0.6%) Part of school health 968 (18.7%) programme Part of treatment series 548 (10.6%) Part of ante natal 148 (2.9) examination Referred 179 (3.5%) Others 1 (0.0%) Total 5,177 (100%) Source: Oral Health Division, Ministry of Health Malaysia teeth indicated for extraction (X) were 3.22 (SD 7.54), 2.75 (SD 6.70), 0.06 (SD 0.48), 28.80 (SD 7.51) and 0.41 (SD 1.60) respectively. Among 70 dentate subjects, the mean number of natural teeth, functional natural teeth, occluding pair of functional natural teeth, decayed teeth (D), missing teeth (M), teeth indicated for extraction (X) and DMFX(T) index were 17.1 (SD 8.00), 14.5 (SD 8.11), 6.3 (SD 4.22), 0.3 (SD 1.06), 15.1 (SD 8.20), 2.2 (SD 3.14) and 17.6 (SD 8.08) respectively. Another study 18 was carried out in Kota Bharu, Kelantan about prevalence of edentulisn in elder population. The prevalence of edentulism was 55.9%. Females were found to be more edentulous than males. CANCER OF ORAL CAVITY Oral cancer is the sixth common cancer in the world. 19 In India, Pakistan and Bangladesh, oral cancer is the most common cancer. 20 In Malaysia it is the fifth 143

Fig 3: Proportion of population receiving fluoridated and non-fluoridated water supply TABLE 2: TOOTH MORTALITY IN OLD AGE GROUP Age Group Number of Missing Teeth 65-74 years 21.1 75+ years 22.2 Source : National Oral Health Survey of Adults (NOHSA 2000), Oral Health Division, Ministry of Health, Malaysia, 2004. Oral Health status Malaysian Adults most common cancer. 21 In Malaysia one of the characteristics features of oral cancer is that its prevalence is noted higher among Malaysians of Indian origin. About 60% of cases of oral cancer are reported in Indian population 22 although they make up only 8% of population. FLUROIDATION STATUS IN MALAYSIA Fluoridation of water supplied in Malaysia is the keystone of the dental public health programme and represents one of three national primary preventive projects of the Oral Health Division. When the Cabinet gave permission for this project, at that time recommended optimum level was 0.7 parts per million (ppm). Later it was changed to 0.5 ppm in 2004, based on studies among school children in Malaysia. Currently about 69% of community gets benefitted from this project. 23 As more than 95% of community get public TABLE 3: NUMBER OF DIFFERENT ORAL HEALTH PROFESSIONALS Category Total Number Dentists (whole country) 3 165 Dental therapists 2 271 Chair side assistants 2 567 Dental Laboratory Technicians 653 Source: Malaysian Dental Council water supply, fluoridation is most suitable public health strategy for control of caries. 24 The first fluoridation survey in Johor Baru reported an overall decline of 44.8% caries, with 60.1% in permanent dentition and 29.4% in deciduous dentition. A survey 25 was done to assess the impact of fluoride mouth rinsing on caries in school children three years after implementation in Malaysia. A caries reduction of 47.6% was found in test subjects. DENTAL HUMAN RESOURCE IN MALAYSIA ORAL HEALTH PLAN The government has set a target to achieve a developed nation status by year 2020. It is from Vision 2020 that National Oral Health Plan for the year 2010 was developed. There has been considerable improvement in oral health status of Malaysians for the past 50 years. The main focus of the National Oral health Plan was to improve oral conditions of public health significance. Four oral conditions were identified for this purpose i.e. dental caries, oral malignancies, dental injuries and periodontal conditions. CONCLUSION There has been tremendous improvement in the oral health of Malaysians over the past 50 years. However, there still exist areas with major oral health problems and inadequate resources availability. Dental caries continue to be a major problem amongst children. National Oral Health Survey 2005 among children showed caries prevalence was 75.5%. Adult Survey 2000 showed caries prevalence around 80%. Oral cancer is the fifth most common cancer in Malaysia. 69% of population is being supplied with fluoridated water. Oral health education is recognised as the key element in the empowerment of individuals and families towards achieving their health potential. 144

TABLE 4: DENTIST: POPULATION RATIO MALAYSIA, (1970-2007) Region/Year 1970 1980 1990 2000 2007 Peninsular Malaysia Population 8,819,928 11,188,100 14,667,000 17,670,092 24,769,500 Dentist 259 592 1,289 1,967 2,866 Ratio 1:34,186 1:18,899 1:11,379 8,983 1:8,582 Sabah Population 654,943 1,003,847 1,479,000 2,519 906 3,063,600 Dentist n.a. 19 49 79 134 Ratio n.a. 1:52,815 1:30,184 1:31,897 1:22,863 Sarawak Population 977,438 1,249,846 1,807,353 2,012,616 2,404,200 Dentist n.a. 35 63 98 145 Ratio n.a. 1:36,996 1:28,688 1:20,536 1:16,581 Malaysia Population 10,452,309 13,486,433 17,953,353 22,202,614 27,173,700 Dentist n.a. 645 1,401 2,144 3,165 Ratio n.a. 1:20,877 1:12,815 10,356 1:8,586 n.a. = Not available Source : Oral Health Division Malaysia REFERENCES 1 Muttalib K.A. et al. Caries in 5-year-olds in Malaysia. World Congress on Preventive Dentistry; 2009. http://iadr.confex. com/iadr/wcpd2009/webprogram/paper124198.html. DOA : 9/06/2011. 2 Dental Services Division, Ministry of Health Malaysia. Dental epidemiological survey of school children in West Malaysia 1970-71. Kuala Lumpur, Government Printer, 1972. 3 Dental Services Division, Ministry of Health Malaysia. Dental epidemiological survey of school children in Peninsular Malaysia 1988. Kuala Lumpur, Government Press, 1990. 4 Oral Health Division, Ministry Of Health Malaysia. National Oral Health Of School Children Survey 1997. (NOHSS 97). MOH/K/GIG/6.98 (RR). 5 Dental Services Division, Ministry of Health Malaysia. Dental epidemiological survey of school children in Sarawak 1981. Kuala Lumpur, Government Printer, 1982. 6 Dental Services Division, Ministry of Health Malaysia. Dental epidemiological survey of school children in Sarawak 1994. Kuala Lumpur, Government Printer, 1994. 7 Dental Services Division, Ministry of Health Malaysia. Dental epidemiological survey of pre-school children in Sarawak 1995. Kuala Lumpur, Government Printer, 1995. 8 Dental Services Division, Ministry of Health Malaysia. Dental epidemiological survey of school children in Sabah 1985. Kuala Lumpur, Government Press, 1986. 9 Dental Services Division, Ministry of Health Malaysia. Dental epidemiological survey of pre-school children in Malaysia 1995. Kuala Lumpur, Government Printer, 1995 10 Meon R., Nik Hussein NN. Dental decay in pre-school Chinese children aged 3-6 years in Petaling Jaya. Dent J Malaysia 1985; 8: 9-12. 11 Nik Hussein NN, Meon R. The prevalence of dental caries in pre-school children in Kuala Lumpur, Malaysia. Sing Dent J 1985; 10: 5-7. 12 Tan EH, Ramalingam SR, Wan MN, A Hamid M, Khairiyah AM. Johor. Oral health status of 5-year-old pre-school children in Johor. Johor Tech Rep 2005;p 59-70. 13 Haszelini H, Farah Salwa Ar. Caries Prevalence In Association With Oral Hygiene Practice And Sugar Consumption Among Students In Smk Seberang Marang. Project reported to the Oral Health Division, Ministry of Health, 2007. 14 http://ohd.moh.gov.my/modules/xt_conteudo/index.php? id=99. 15 Dental Services Division, Ministry of Health Malaysia. Dental epidemiological survey of adults in Peninsular Malaysia, September 1974-April 1975. Ketua Pengarah Percetakan, Kuala Lumpur : 1977. 16 Dental Services Division, Ministry of Health Malaysia. Dental epidemiological survey of adults in Malaysia 1990. Percetakan Nasional Malaysia Berhad : 1993. 17 http://www.whocollab.od.mah.se/wpro/malaysia/data/ oral_health_status-malaysian_adults.pdf 18 Esa R, Razak IA, Jallaudin RL, Jaafar N. A survey on oral hygiene practices among Malaysian adults. Clin Prev Dent. 1992 Jan-Feb;14(1):23-27. 19 Seman Ka, Abdul Manaf Hb, Ismail Arc. Dental caries experience of elderly people living in Pondok in Kelantan. Archives of Orofacial Sciences (2007) 2; 20-25. 20 Shamdol Z. Ismail N.M., Hamzah N.T., Ismail A.R. Prevalence and Associated Factors of Edentulism among Elderly Muslims in Kota Bharu, Kelantan, Malaysia. JIMA: 2008; 40: 143. 21 Parkin DM, Laara E, Muir CS. Estimates of the Worldwide Frequency of Sixteen Major Cancers in 1980. Int J Cancer 1988;41:184-97. 22 World Health Organisation. Control of Oral Cancer in Developing Countries. Bulletin WHO 1984;62:817-30. 23 Preliminary Annual Report 2005 on Fluoridation Programme 2005, Oral Health Division Ministry of Health 24 The Economic Planning Unit, Prime Minister s Department. Ninth Malaysia Plan 2006-2010. The Economic Planning Unit, Prime Minister s Department Putrajaya 2006 Chapter 18 p 387. 25 Chen CJA, Ling KS, Yaw SL, Chia JC, Eddy A, Chu GT, Esa R. A School-Based Fluoride Mouth Rinsing Programme In Sarawak: A 3-Year Nonrandomized Field Study. Paper submitted to the Director General of Health, 2007 145