Oral health status of 5 years and 12 years school going children in Chennai city - An epidemiological study

in Chennai city - An epidemiological study MAHESH KUMAR P. a, JOSEPH T. b, VARMA R. B. c, JAYANTHI M. d ISSN 0970-4388 Abstract India, a developing country, faces many challenges in rendering oral health needs. The majority of Indian population resides in rural areas of which more than 40% constitute children. The purpose of this study was to assess the oral health status of 5 years and 12 years school going children in Chennai city. The study population consisted of 1200 school children of both the sexes (600 private and 600 corporation school children) in 30 schools, which had been selected randomly. The survey is based on WHO, 1999 Oral Health Assessment, which has been modified by including gingival assessment, enamel opacities/ hypoplasia for 5 years. Evaluation of the oral health status of these children revealed, dental caries is the most prevalent disease affecting permanent teeth, more than primary teeth and more in corporation than in private schools, thereby, correlating with the socioeconomic status. It may be concluded that the greatest need of dental health education is at an early age including proper instruction of oral hygiene practices and school based preventive programs, which would help in improving preventive dental behaviour and attitude which is beneficial for life time. Key words: Dental Caries, Dental Treatment Needs, Prevalence, Simplified OHIS in Five Years Introduction Dental Caries is the most prevalent dental affliction of childhood. Despite credible scientific advances and the fact that caries is preventable, the disease continues to be a major public health problem. In developing countries changing life-styles and dietary patterns are markedly increasing the caries incidence. [1] This epidemiological study was planned as very few studies have been conducted in Chennai city. This study was undertaken with the following aims and objectives: 1. To assess the dental caries, oral hygiene, enamel opacities and malocclusion in children of corporation and private schools. 2. To correlate socio-economic status with oral hygiene practices, and OHIS, caries and malocclusion. 3. To assess treatment needs and suggest any possible remedial measures for planning of oral health programs. Materials and Methods The study was carried out to assess oral health status of 5 and 12 years old school going children of Chennai city. 1. Study population consisted of thirty schools which had been selected randomly in Chennai city which included fifteen corporation schools and fifteen private schools. 2. 40 children in each school were examined. Out of 40, 20 were 5 years old and 20 were 12 years old. The total a Lecturer, b Former Professor and Head, c Professor, d Reader, Ragas Dental College and Hospital, East Coast Road, Uthandi, Chennai - 600 119, India number of children examined were 1200. 600 each in 5 and 12 years age group. 3. The annual income of parents was recorded from school register and it was grouped as I to V, according to modified proposed classification by Sogi and Basker 1997 [2] and from this classification we have modified Group I as high income group. Group II and III middle income group. Group IV and V as low income group. 4. The survey was based on WHO oral health assessment, which has been modified by including gingival assessment, enamel opacities / hypoplasia for 5 years. The survey was carried out between the months of December 2002 and February 2003. Results A total number of 1200 school going children in the age group of 5 years and 12 years of Chennai city were studied. Among the 5 year age group examined, 53.8% were boys and 46.2% were girls (Table 1). In the 12 years age group 52.8% were boys and 47.2% were girls. Children studying in the corporation schools were generally from the low income groups like daily wage earners, labourers, and coolies. While children in private school were from high-income groups (Table 2). There is statistically significant difference in the economic status between corporation and private school children (P<0.001). Table 3 shows the gingival assessment using Green and Vermillion index modified for 5 years age group. Above 80% were having good oral hygiene and 20% were with poor 17 J Indian Soc Pedo Prev Dent - March 2005

Table 1: Age and sex distribution of subjects Age in Male Female Total years No. % No % No % 5 323 53.8 277 46.2 600 50 12 317 52.8 283 47.2 600 50 Total 640 53.8 560 46.7 1200 100 Table 2: Distribution of SES by schools for 5 years and 12 years 5 years 12 years SES Corporation Private Corporation Private School School School School I - - 278 92.6% - - 282 94% II 8 2.7% 22 7.3% 6 2% 18 6% III 200 66.7% - - 196 65.3% - - IV 80 26.7% - - 83 27.7% - - V 12 4% - - 15 5% - - Total 300 300 300 300 P < 0.001 P < 0.001 I. Per Month Rs. 7501 and above II. Rs. 6001-7500 Group I - High income III. Rs. 4001-6000 Group II and III Middle income IV. Rs. 2501-4000 Group IV and V - Low income V. Below Rs. 2500 oral hygiene. Boys exibited poor oral hygiene as compared to girls, which was statistically significant, (P=0.01). There was no statistically significant difference between Corporation and Private School (P=0.44). This could be attributed to their healthy oral hygiene practices irrespective of the socio economic status. Table 4 shows the gingival and periodontal assessment using CPI for 12 years age group. The boys were affected more than girls showing statistical significance (P=0.008). It was also observed that higher percentage of corporation school children had gingival and periodontal problems than private school children. It was seen that oral hygiene score showed increase with age and boys were affected more. This observation is in contradiction with findings of Saha and Sarkar 1996. [3] The reason could be that the present study was carried out in mixed dentition period, and due to varied food habits, shedding of primary teeth, improper and unsupervised oral hygiene practices and pubertal changes in girls. Table 5 shows the Dental caries assessment of 5 and 12 years. In 5 years boys dmft was 3.53±3.07, girls was 3.49±2.83. In 12 years the DMFT for boys was 3.80±3.43, girls 4.11±2.98. There was no statistically significant difference between dmft / DMFT of boys and girls in both age groups. It was observed that caries prevalence of 12 years age group was higher as compared to the 5 years age group in both sexes. Similar findings were seen in a study conducted by Retnakumari in 1999. [4] She reported the high level of caries experience in permanent dentition at the age of 12 years. Table 6 shows prevalence of malocclusion in 12 years age group, taken according to the WHO criteria 1997. [5] It was observed that Diastema, Maxillary and Mandibular overjet and antero posterior relationship showed a statistical significance. The other criteria of malocclusion like crowding, spacing, maxillary and mandibular irregularity and open bite did not show any statistical significance. The overall prevalence of malocclusion in both private and corporation school showed mild to moderate degree of malocclusion. Table 7 shows prevalence of enamel opacities in 5 years and 12 years. In 5 years it was 28.3% and 12 years 23.3%. Mean value was 0.5±1.35 for 5 years and 0.7±1.3 for 12 years. This observation showed statistical significant difference in 5 years, between boys and girls (P=0.02) and schools (P=0.04). There was no statistically significant difference between age groups and schools for 12 years. The reason for this could be attributed to the fact that enamel hypoplasia and opacities occur as result of disruption in enamel development. Environmental and genetic factors could be a contributory factor. Other factors could be the malnourishment, trauma and lack of prenatal care due to lack of awareness and low literacy level. Table 8 shows the prevalence of dental fluorosis in 5 and 12 year group. 2.5% of 12 year group and 1% in the 5 year group showed dental fluorosis. From this survey it was noted that dental fluorosis was not significant among the 5 years and 12 years age group. This can be attributed to the fact that Chennai city does not belong to the endemic zone of fluorosis. Table 9 shows the relationship between OHI-S and oral hygiene practices of 5 years. The table depicts the corporation school girls showed more gingival bleeding (using finger) as compared to those using tooth brush which was a statistically significant (P=0.04). The corporation school boys using tooth powder and charcoal showed the higher gingival bleeding than tooth paste users. This observation showed statistical significance (P=0.03). When frequency of brushing habits in private school boys and girls was taken, it was seen that those children who brush once daily had more calculus as compared to those children brushing twice a day. This observation shows statistically significant between boys (P=0.03), and girls (P<0.001). Table 10 shows the relation between CPI and oral hygiene practice of 12 years. In private school boys using finger showed more gingival bleeding as compared to those using toothbrush. This observation shows a statistical significance (P=0.0007). Private schools, boys using tooth powder showed higher gingival bleeding than toothpaste users. This observation showed statistically significant difference (P=0.0001). When frequency of brushing habits in private school boys and girls was noted, it was concluded that those children who brushed once daily had more calculus as compared to those brushing two times a J Indian Soc Pedo Prev Dent - March 2005 18

Table 3: Gingival assessment green and vermilion OHIS modified - (5 years) (Chi square test) Score Males Females Total P value Corporation Private Total P value No. % No. % No. % -- No. % No. % No. % 0.1-1.2 273 84.5 251 90.6 524 87.3 258 86 266 88.6 524 87.3 1.3-3.0 32 9.9 10 3.6 42 7 25 8.3 17 5.6 42 7 3.1-6.1 18 5.5 16 5.7 34 5.6 P= 0.1 17 5.6 17 5.6 34 5.6 Total 323 277 600 300 300 600 P=0.44 0.1-1.2 Good, 1.3-3.0 Fair, 3.1-6.0 Poor Table 4: Gingival and peridontal assessment by using CPI scores - (12 years) Score Males Females Total P value Corporation Private Total P value No. % No. % No. % -- No. % No. % No. % 24 7.5 43 15.1 67 11.2 45 15 22 73 67 11.2 164 51.7 114 50.8 308 51.3 109 36.3 199 66.3 308 51.3 129 40.6 96 33.9 225 37.5 146 48.6 79 26.3 225 37.5 Total 317 283 600 P=0.008 300 300 600 P<0.001 0 - healthy, 1 - bleeding, 2 - calculus Table 5: Dental caries assessment in 5 and 12 years Sex No. of Caries Caries Free 5 Years Decayed Missing Filled Mean P value Children Affected dmft Teeth Teeth Teeth n % n % n % n % n % Male 323 279 86 44 14.0 1139 1121 98.4 18 1.5 0 0 3.53 + 3.07 Female 277 219 79 58 21 966 940 97.3 26 2.69 0 0 3.49 + 2.83 0.87 Total 600 498 83 102 17 2105 2061 97.9 44 2.09 0 0 3.51 + 2.96 Sex No. of Caries Caries Free 12 Years Decayed Missing Filled Mean P value Children Affected DMFT Teeth Teeth Teeth n % n % n % n % n % Male 317 243 76.6 74 23.3 1203 1194 99.2 8 0.66 1 0.08 3.80 + 3.43 Female 283 237 83.7 46 16.2 1163 1152 99.05 11 0.94 0 0 4.11 + 2.98 Total 600 480 80 120 20 2366 2346 99.1 19 0.8 1 0.047 3.94 + 3.23 0.23 Mean DMFT 5 years 3.51±2.96 Mean DMFT 12 years 3.94±3.23 Table 6: Prevalence of malocclusion School Crowding Spacing Diastema Maxillary Mandibular Maxillary Mandibular Openbite APR Irregulartity Irregulartity Overjet Overjet n % n % n % n % n % n % n % n % n % Corporation 77 25.7 56 18.7 20 6.7 40 13.3 50 16.7 28.3 94.3 5 1.7 27 9 289 96.3 Private 95 31.7 45 15 39 13 47 15.7 57 19 267 89 21 7 38 12.7 193 64.3 P value 0.12 0.28 0.01 SIG 0.49 0.52 0.03 SIG 0.003 SIG 0.19 <0.0001 SIG Table 7: Prevalence of enamel opacities in 5 years and 12 years 5 Years 12 Years Sex Total No. of % Unaff % Mean P Total No. of % Unaff % Mean P No. of cases ected value No.of cases ected value cases affected cases affected Male 317 98 30.9 19 69 0.9+1.5 323 81 25 242 74.9 0.7+1.3 Female 283 72 25.4 211 74.5 0.4+1.0 277 59 21.2 218 78.7 0.6+1.2 Total 600 170 28.3 430 71.6 05.+1.3 0.02 600 140 23.3 460 76.6 0.7+1.3 0.37 Sig Corporation 300 88 29.3 212 70.6 0.4+1.1 300 56 29.3 244 70.6 0.7+1.3 Private 300 82 27.3 218 72.6 0.5+1.3 300 84 27.3 216 72.6 0.7+1.3 Total 600 170 28.3 430 71.6 0.5+1.3 0.04 600 140 23.3 460 76.6 0.7+1.3 1.0 Sig Table 8: Dental fluorosis Age Overall % 5 years <1 12 years 2.5 day. This observation was statistically significant (Boys P=0.007, Girls P=0.05). In corporation school, neither boys nor girls showed any statistically significant difference. 19 J Indian Soc Pedo Prev Dent - March 2005

Table 9: Relationship of OHIS with oral hygiene practices (5 years) Method Materials Frequency Sex School Tooth Mean±SD P Tooth Mean±SD P Once Mean±SD P Value Value Value Male Corporation Tooth brush 1.0±0.2 Tooth paste 1.0±0.2 Once daily 1.06±0.23 Finger 1.1±0.2 Tooth powder 1.1±0.3 Twice daily 1.04±0.14 0.16 Any 1.5±0 0.03 0.95 other SIG Private Tooth brush 1.1±0.3 Tooth paste 1.1±0.3 Once daily 1.08±0.25 Finger 1.0±0 Tooth powder 1.1±0.2 0.84 Twice daily 1.16±0.24 0.07 More than 1.0±0 0.03 twice SIG Female Corporation Tooth brush 1.1±02 Tooth paste 1.1±0.3 Once daily 1.07±0.24 Finger 1.1±0.3 Tooth powder 1.1±0.2 0.88 Twice daily 1.08±0.33 N.S. 0.04 Any other 1.0±0 0.45 SIG Private Tooth brush 1.0±02 Tooth paste 1.0±02 Once daily 1±0.02 Tooth powder 1.0±0 Twice day 0.98±0.09 More than 2±0 <0.001 twice SIG Table 10: Relationship of OHIS with oral hygiene practices (12 years) Method Materials Frequency Sex School Tooth Mean±SD P Tooth Mean±SD P Once Mean±SD P Value Value Value Male Corporation Tooth brush 1.4±0.7 Tooth paste 1.4±0.2 Once daily 1.43±0.69 Finger 1.5±0.7 Tooth powder 1.4±0.7 Twice daily 1.23±0.69 0.26 Any other 1.4±0 0.17 0.15 Private Tooth brush 1.2±0.5 Tooth paste 1.25±0.5 Once daily 1.31±0.55 Finger 2.0±0 Tooth powder 1.7±0.5 0.0001 Twice daily 1.0±0.00 SIG Any 1.0±0 0.007 0.007 other SIG SIG Female Corporation Tooth bruth 1.2±0.8 Tooth paste 1.2±0.8 Once daily 1.24±0.74 Finger 1.5±0.6 Tooth powder 1.3±0.7 0.22 Twice daily 1.42±0.84 N.S. 0.08 Any other 2.0±0 0.08 Private Tooth brush 1.1±0.6 Tooth paste 1.1±0.6 Once daily 1.1±0.6 Finger 1.0±0 Tooth powder 1.1±0.3 0.89 Twice daily 1.08±0.56 0.70 More Than 2±0 0.005 twice SIG Table 11: Percentage of teeth needing treatment for dental caries among 5 year old Age in No. of No. of teeth 1 surface 2 Pulp Extraction Other Years teeth requiring treatment Surface Restoration Care 5 Years examined treatment treatment Corporation Male 3200 591 422 58 81 17 13(0.40%) (18.46%) (13.18%) (1.9%) (2.53%) (0.53%) Female 2800 526 371 55 63 21 8 (18.78%) (13.25%) (1.96%) (2.25%) (0.75%) (0.25%) Private Male 3260 212 159 4 45 4 0 (6.5%) (4.87%) (0.12%) (1.38%) (0.12%) Female 2740 297 259 1 35 0 2 (10.83%) (9.45%) (0.036%) (1.27%) (0.07%) Table 11 shows percentage of teeth needing treatment for dental caries in 5 years. In Corporation act of school 3200 teeth examined in boys; 591 (18.46%) teeth required treatment. Out of 591, 422 (13.18%) required one surface restoration, 58 (1.9%) required two surface restorations, 81 (2.53%) required pulp treatment, 17 (0.53%) required extraction and 13 (0.40%) required other care. In girls 2800 teeth were examined out of which 526 (18.78%) required treatment. Out of 526, 371 (13.25%) required one surface restoration, 55 (1.96%) required two surface restoration, J Indian Soc Pedo Prev Dent - March 2005 20

Table 12: Percentage of teeth needing treatment for dental caries among 12 year old Age in No. of No. of teeth 1 2 Pulp Extraction Other Years teeth requiring surface Surface Restoration Care 12 Years examined treatment treatment treatment Corporation Male 3839 676 631 7 41 14 10(0.26%) (17.60%) (16.43%) (0.18%) (0.36%) (0.26%) Female 3733 667 628 4 14 10 11 (17.86%) (13.25%) (1.10%) (0.37%) (0.26%) (0.29%) Private Male 4184 626 603 4 19 0 0 (14.96%) (4.87%) (0.09%) (0.45%) (0.12%) Female 3524 549 535 5 7 1 1 (15.57%) (9.45%) (0.14%) (0.19%) (0.02%) (0.02%) 63 (2.25%) required pulp restoration, 21 (0.75%) required extraction and 8 (0.25%) required other care. In private school, children out of 3260 teeth examined in boys. 212 (6.5%) required treatment. Out of 212, 159 (4.87%) required one surface restoration, 4 (0.12%) required two surface restoration, 45 (1.38%) required pulp restoration, 4 (0.12%) required extraction. In girls, 2740 teeth were examined out of which 297 (10.83%) required treatment. 259 (9.45%) required one surface restoration, 1 (0.036%) required two surface restoration, 35 (1.27%) required pulp restoration, 2 (0.07%) required other care. Table 12 shows percentage of teeth needing treatment in 12 years old. In corporation school out of 3839 teeth examined in boys, 676 (17.60%) required treatment. 631 (16.43%) one surface restoration, 7 (0.18%) required two surface restorations required, 14 (0.36%) required pulp restoration, 14 (0.36%) required extraction and 10 (0.26%) required other care. In girls out of 3733 teeth examined. 667 (17.86%) teeth required treatment. Out of 667, 628 (16.82%) required one surface restoration, 4 (0.10%) required two surface restorations, 14 (0.3s 7%) required pulp restoration, 10 (0.26%) required extraction and 11 (0.29%) required other care. In private school, out of 4184 teeth examined in boys. 626 (14.96%) teeth required treatment. Out of 626, 603 (14.41%) required one surface restoration, 4 (0.09%) required two surface restoration, 19 (0.45%) required pulp restoration. In girls, 3524 teeth were examined. 549 (15.57%) teeth required treatment. Out of 549, 535 (15.18%) required one surface restoration, 5 (0.14%) required two surface restoration, 7 (0.19%) required pulp restoration, 1 (0.02%) required extraction and 1 (0.02%) required other care. Discussion By assessing the treatment needs for Dental disease, among 5 years and 12 years the greatest need was for one surface restorations followed by two surface restorations, pulp restorations, extractions and other care. Caries is the most prevalent dental disease both in the primary and the permanent dentition. In this study it was concluded that caries rate is high in permanent dentition than in primary dentition and more in children studying in Corporation schools than in Private schools. The reason could be due to fact that permanent teeth are exposed to cariogenic diet from the time of eruption till the teeth are in situ. Five year old boys and girls showed good oral hygiene than 12 years old. In twelve year olds gingival bleeding was noticed in both sexes. This could be due to the mixed dentition period, shedding of primary teeth, ineffective maintenance of oral hygiene and pubertal changes in girls. A few cases of enamel opacities and enamel hypoplasias have been detected in five and twelve year groups. The reason for this, could be attributed to disruption in enamel development. A few cases of fluorosis have been reported as questionable which was not significant among five and twelve years. The prevalence of malocclusion was high in both groups. When dental caries was correlated with malocclusion it was noted that private school children had more caries. The correlation between modified Green and Vermillion OHIS score with dental caries for five years showed that boys had a high OHI with increased caries rate when compared to girls. The correlation of CPI versus dental caries for twelve years revealed that girls showed increased dental caries when compared to boys. Correlating all the above findings with the SES, it was found that irrespective of the SES, oral hygiene was good amongst both private and corporation school children. With dental caries high amongst corporation school children. By assessing the treatment needs for Dental disease, amongst 5 years and 12 years the greatest need was for one surface restorations followed by two surface restorations, pulp restorations, extractions and other care. 21 J Indian Soc Pedo Prev Dent - March 2005

A study on oral health assessment and dental health education of children at an early age helps in improving preventive dental behaviour and attitudes, which is beneficial for a lifetime. This can be achieved by educating the uneducated parents about dental health through school dental health program. For the benefit of a community a dental health programmes have to be conducted repeatedly in order to reach the goals of WHO. Parents should be made aware of the brushing methods, and usage of pit and fissure sealants and importance of preventive measures for the children. The rationale of school dental health programme is to improve and motivate the parents and children regarding their dental health and treatment needs. References 1. Rao A, Sequeira SP, Peter S. Prevalence of dental caries among school children of Moodbidri. J Indian Soc Pedo Prev Dent 1999;17:2:45-8. 2. Sogi GM, Bhaskar DJ. Dental caries and oral hygiene status of school going children in Davangere related to their socio economic levels - An epidemiological study. J Indian Soc Pedo Prev Dent 2002;20:152-7. 3. Saha, Sarkar. Prevalence and severity of dental caries and oral hygiene status in rural and urban areas of Calcutta. J Indian Soc Pedo Prev Dent 1996;14:17-20. 4. Retnakumari N. Prevalence of dental caries and risk assessment among primary school children of 6-12 years in the Varkala municipal area of Kerala, J Indian Soc Pedo Prev Dent 1999;17:4:135-42. 5. World Health Organization, Oral Health survey, Basic methods, 4 th Ed. Geneva: WHO; 1999. Reprint requests to: Dr. Balagopal Varma Ragas Dental College and Hospital, East Coast Road, Uthandi, Chennai - 600 119, India J Indian Soc Pedo Prev Dent - March 2005 22