Caries prevalence and experience of 12-year-old children in Montserrat

Coretta E. Fergus

Introduction

The primary aim of this study was to conduct an epidemiological survey of all 12 year olds on Montserrat in order to:

1. Determine the caries experience measured by the DMFT index and Oral Health Related Quality of Life (OHRQoL) of 12 year olds
2. To explore the differences in caries experience by gender, and socioeconomic status

No previous data could be found on the oral health status of Montserratian people and the oral data bank compiled by World Health Organisation (WHO) is devoid of any oral health data for the island. With inadequate previous data this investigation may be timely as it will provide some baseline data for measurement of effectiveness of interventions to reduce caries in 12 year olds and could influence policy makers in the development of new oral health policies.

Methods

Preliminary planning

Permission for conducting the survey was sought and granted by the Ministry of Education (MOE) in Montserrat and also from the principal of the Montserrat Secondary School. Consent letters were distributed to the relevant children on behalf of the researcher.

Training and calibration

Separate training and calibration were carried out in line with BASCD guidelines for the conduct of surveys of child dental health [1] and [2]. [These numbers refer to the numbered list of references.] The calibration was conducted at the Lister Primary Care Centre in Peckham where inter-examiner reliability between the Author and the benchmark BASCD examiner was measured.

For the fieldwork the recorder was trained in recording data by the Author who conducted all examinations. An assistant was responsible for co-ordinating the children.

Subjects Study Population

All 12 yr olds in Montserrat were invited to be part of the survey which was carried out on 14th March 2006. In total there were 46 pupils who all attended the only secondary school on the island. Positive consent was sought 2 days prior to examination and 32 students responded positively. The remaining students failed to return consent forms from parents and were therefore not permitted by the school authority to take part. This was in accordance with exclusion criteria of the study.

Equipment

• CPITN probe Disposable non-latex gloves
• Sterile cotton gauze Data recording sheets
• Mouth mirror, Plane No.4 Desk
• Dental face shield Standardized light source

Examination procedure

Children presented to examination room in no particular order. They were first asked to complete the “Child Oral Health Questionnaire”. The assistant recorded name, date and parental occupation on data forms. Each child was given a data form and directed to the examination. Data forms were handed to recorder who then went on to record data as instructed by examiner.

Each child was asked to lie on the desk in a supine position with examiner positioned directly behind. A Tikka Petzl (3LED) head lamp was used for a light source. Examination packs consisting of a sterile CPITN probe and sterile gauze and disposable mirrors were unwrapped by dentist for each child.

Tooth surfaces were dried with sterile cotton gauze and examined in a standard order as specified by the study protocol. Following the examination all instruments were placed in a “dirties” container and gloves disposed of in a clinical waste bag. No radiographs were taken.

Any child requiring treatment was identified and parent informed and advised by letter to seek appointment at the local dental clinic.

Cross infection control

A standard cross infection prevention protocol was followed. The examiner wore a face shield through out the examination and gloves were changed after each patient.

Intra-examiner reliability

Five subjects were re-examined and statistical test applied to determine intra-examiner reliability.

Data analysis

Data were processed using Dental Survey Plus 2 version 2.1 and Statistical Package for Social Sciences (SPSS version 14) software for the purpose of obtaining descriptive statistics.

Results

Calibration of examiners

High levels of agreement were recorded (Kappa = 0.81) between the BASCD ‘gold standard’/benchmark examiner and the Author (Fergus CE). Five child subjects were examined and scored using the DMFT Index and the BASCD caries criteria.

Characteristics of the sample

Of the 46 twelve-year-olds in Montserrat 32 participated in the survey. This gave a response rate of 69%. A description of the participants by gender and parental occupation is given in Table 1. There were slightly more boys than girls.

Caries experience

The sample of 12 year olds had a mean DMFT of 1.91 (C.I. 1.05 to 2.76), (Table 2). Fifty-nine percent had experience of decay in one or more teeth (DMF>0) (See Figure 1). Conversely only 41% of the children were caries free. One child recorded with a DMFT of 11 (Table 3). All children with caries experience were seen to have active, untreated caries (D>0) and therefore normative treatment need. Few restorations were recorded deriving a Care Index of 16%. Very few extractions had taken place. The participants had an average of 25.69 (C.I. 24.8 to 26.58) sound teeth.

Caries experience and socio-demographic characteristics

Tables 4 and 5 show the breakdown of caries experience according to gender of the child, (Table 4) and the occupation of the father, (Table 5). In both cases numbers of children in the survey are too small for significance testing. However, there does not appear to be any difference in overall caries experience between males and females, but there is a trend towards greater caries experience in non-professional groups. Three children did not give a paternal occupation (Table 1).

Quality of life data

Table 7 shows the distribution of some responses to individual items on the Child Perceptions Questionnaire for the 32 children surveyed. Most children (78%) rated their oral health as “good” or better. The worst commonly reported items were breathing through the mouth, slow eating, food sticking between teeth, feeling upset or nervous about appearance of teeth, difficulty doing homework because of problems with the mouth or teeth and difficulty drinking or eating foods. A lower score represents a lesser impact on QoL than a higher score.

Measurement of examiner reliability

A randomly selected 5 of the 32 subjects were re-examined at the completion of the main survey. Kappa was used to determine intra-examiner reliability. The result of the Kappa test was a score of 1, perfect agreement

Discussion

Caries Experience

The results of the study indicate that the sample of 12 year olds examined have a mean DMFT of 1.91. This indicates that Montserrat has achieved the oral health goal set by WHO of reaching a mean DMFT score of ≤3 by 2000 (Fédération Dentaire Internationale, 1981; WHO, 1988).

The mean number of Decayed teeth being 1.53 (CI 0.75 to 2.31) contributes the highest proportion of the total figure (D=1.53, M=0.06, F=0.31). The sample of 12-year-old children had on average in excess of one an a half teeth with an untreated cavity. The majority of children examined (59% with D>0) were experiencing some form of active decay thus requiring (professionally judged) treatment. Active caries (D component) was measured at an advanced stage of the carious process when there was clear visual dentinal involvement. This does not relate to treatment need directly. There is recognised large underscoring in converting the ‘D’ component, in epidemiological studies, to actual treatment need [3]. The indication is that there were quite high levels of untreated decay amongst this population of children examined and consequently high normative needs. This may imply that current services are failing to meet this need.

The filled component of the DMFT score was also fairly small at, 0.31 (0.64) and this was also reflected by a low Care Index of 16%. The Care Index measures the number of filled teeth in relation to dental disease and can therefore gives an idea of the level of restorative care or treatment services being provided. The Care Index is comparatively low when set against the same age group in the UK. The 2000/01 BASCD study of 12 year olds in England reported a Care Index was 48%. It can be argued that it is inappropriate to compare a developing island state with a developed country but this comparison gives an indication of the standard that Montserrat should aim at. The other reality is that there is a lack of regional data which goes beyond quoting DMFT to actually examining the amount of care and describing treatment needs and amount of care being delivered. Based on the information collected, that there was high active caries and little restorative care in the children examined, it is reasonable to presume that the free government service in Montserrat may be being underutilized.

The mean number of Missing (extracted due to caries) teeth was the lowest component, being less than 1. This may reflect the following: 1) children are retaining their teeth 2) children are not having extractions as a treatment for dental decay which may be because much of the decay could be restored. 3) children are not accessing dental care and receiving treatment.

Gender Distribution

It is difficult to determine from this small sample size whether the higher DMFT scores observed in females was statistically significant. Nonetheless in the studies that observe a higher caries experience among girls they tend to attribute it to females having a greater propensity for sweet foods or poorer dietary habits [4]. The explanation put forward by the author is only speculative and may not be scientifically supported. No significant differences in the dentinal caries experience of boys and girls were reported in the Child Dental Health Surveys, UK, 2003 [5]. However girls were more likely to brush twice a day than boys [6]. Such findings have implications for how dental health interventions are delivered.

Socioeconomic Status

The father’s occupation was used as an indirect measure of child socioeconomic status. Montserrat does not have distinct social class system so this proxy measure was used. The occupation classification was based on the International Standard Classification of Occupations (ISCO88) which classifies jobs into occupational groups according to the similarity in the skill level and the skill specialisation of the tasks and duties performed. For convenience purposes the “Major” ISCO grouping was used which is quite broad. It merges many occupations together and doubtlessly conceals many important details.

The father’s occupation was chosen because father is often regarded as the head of household. However, there are many single parent families in Montserrat where the mother is the sole provider. Omitting the mother’s occupation may exclude relevant information and introduce bias [7]. In this study the children of professional fathers had lower caries prevalence than children of non-professional fathers (Table 5). Socioeconomic status has been linked with oral health status and indeed there is evidence that persons of lower socioeconomic status often have worse health than persons of higher socioeconomic status [8].

This introduces the concept of a social gradient in health that has been expressed by many researchers. It refers to the fact individuals at the top of the social strata have better health than those immediately below them on the next strata and this continues down the social scale or employment hierarchy [9 Sheiham and Watt 2000].

These authors reported that from 1978-1988 the mean number of decayed teeth in social classes IV and V in the UK was 1.8 compared with 0.8 in the upper social classes.

This disparity in caries experience between children from higher and lower socioeconomic households although not quite marked should be monitored or explored further. It is important that any gap be closed and that those at the lower end are not disadvantaged by inequalities.

Quality of Life

The quality of life data showed most children regarded their oral health as “good” or better. They also reported a low level of oral symptoms despite having increased levels of functional limitations. This was interesting to note. One explanation could be that the children did have significant oral symptoms but had managed to cope with them. Blaxter reported that 71% of persons with health problems described their health as good or excellent in the National Health and Lifestyles Survey [10 Blaxter 1990].

Social determinants/Inequalities

Many researchers now focus on social determinants. It is thought that the broader determinants such as economic and environmental factors have far reaching influence ultimately affecting individual habits and behaviours. Good oral hygiene habits and dietary practices will flourish in a supportive environment, where such practices are the norm, where family and community networks can shape habits and persons have access to essential service and goods necessary for maintaining acceptable standards of living and sustaining the good habits [11 Watt 2005].

Poor living conditions, lack of housing, unemployment, educational attainment are all causes of health disparities. While it was not the aim of this study to explore the reasons for the differences in oral health the following are points for consideration:

• There has been severe economic downturn coupled with a rising cost of living following the volcanic disaster.
• Many persons are still facing housing concerns having lost homes or having been forced to abandon homes
• Small numbers of persons are living in volcanic housing developments which are in need of restoration.

However, it can be argued that area deprivation is not a valid indicator as the entire population is now dwelling or living in a more defined area of the country which can be regarded as more homogenous. The essential action is to unearth the “causes of the causes” [12 Sheiham and Watt 2003].

Oral health data from a study in New Zealand revealed significant association between higher caries experience of an individual at age 26 and low paternal socioeconomic position [13 Poulton et al. 2002]. This shows that adverse events in childhood can have the impact later in life [14 Bartley et al. 1997]. Equally an argument can be made for positive interventions early in life with the aim that later outcomes should be positive.

Significance of CPQ

The other concerns of the children such as difficulty eating, being self conscious about appearance should be considered. At face value they may not be regarded as life threatening and could easily be dismissed by health planners particularly when compared with conditions such as diabetes melitus and cardiovascular disease. Quite a high percentage of children reported feeling upset or nervous but these concerns are more personal in nature and do not necessarily have a major impact on the society. Health planners are challenged with convincing relevant authorities that these valid concerns requiring attention. In fact they are all components of the pubic health problem of dental caries. The challenge comes with attempting to quantify, directly measure or assign a value or weight to such concerns for the benefit of funding agencies or financial departments who evaluate things in dollars and cents. Perhaps if these concerns are quantified in terms of days lost from school, or in the case of an adult days lost from work then the threat to economic stability can be better assimilated or judged by those in authority.

While lowering the DMFT will be desirable and will provide a global indicator of the health status it maybe of more value to the patients being served to be painfree, to be able to eat without difficulty and to be able to work well in school. These results can inform planning goals, objectives or more specifically become outcome indicators.

Those children with higher caries experience reported a greater impact on their QoL. This difference was almost twice as much than those who were caries-free. Although no significance testing was performed these results are similar to the findings of other studies which highlight the impact of oral disease on daily activities. Older adults in South Australia reported greater levels of social impact on quality of life as a result of being edentulous [15 Slade and Spencer 1994] .

Public Health Strategies

The success of salt fluoridation in Jamaica [16] and proven effectiveness of water fluoridation [17] lend support to adopting these options in Montserrat. However, with a mean DMFT score of 1.91 at age 12, it may not be justifiable to implement these programmes without further detailed cost benefit analysis. It maybe equally worthwhile to evaluate current oral health interventions, make modifications which are scientifically sound before implementing these population based strategies. A combination of oral health promotion activities (dental education, toothbrushing campaigns) and restorative care for all, together with services directed at those children at higher caries risk could be implemented.

A valid and feasible strategy for tackling this problem and convincing financial bodies whether governmental or non-governmental is to implement the Common Risk Factor Approach (CRFA) [9]. In this way several public health diseases are simultaneously targeted by dealing with a few common risk factors. In this instance diet is the risk factor for dental caries as well as for diabetes mellitus, cardiovascular disease. Such a strategy involves collaborative partnerships with other health and governmental departments.

Study Limitations

A response rate of 69% was achieved in this study. A better response rate would have been more desirable given the small population size. However, study criteria regarding consent had to be adhered to. Omitting the 14 children who failed to return consent letters would likely result in omission of important details and introduce bias. The small numbers also made it difficult to perform any meaningful statistical analysis. Using occupation as a measure of socioeconomic status could have been limiting as it fails to acknowledge other dimensions (educational level, income).

Conclusion

It is difficult to compare Montserrat’s DMFT of 1.93 with that of regional islands as the data was collected at different periods (Refer to Table 1). Many of the islands have scores range from 0-6 suggesting that Montserrat is not differing greatly or experiencing greater disparity than its regional neighbours. It is important not to fall behind. Despite this there is no place for complacency as high levels of untreated decay exist amongst 12-year-olds in Montserrat. This indicates that there is a need for restorative care from the professionals as well as an existing need for care by the individual. This gap between the professional need and patient need needs to be bridged. The barriers preventing this must be identified. It could be something easily identifiable such as fear, issues of accommodation or something more complex as patient perception of illness and disease.

The low Care Index suggests that the current service is falling short in their mission of providing health to the community. Remuneration is via a salaried payment system and one of the faults of such a system is under-treatment. This is just one of many possible explanations being proffered.

Small numbers make it difficult to ascertain any differences between male and female oral health but this can be monitored to ensure that no inequalities are created.

It is not apparent what role, if any, the social and environmental determinants within the community are playing in disease causation. It is also not certain whether economic downturns and housing issues are factors but further research will have to be done on this.

Children are experiencing significant disadvantage as a result of oral conditions or disease. This should not be ignored or trivialised. Inequalities between children of different socioeconomic status is evident from the study but difficult to determine significance.

Recommendations

Montserrat should aim to develop a comprehensive oral health policy as a matter of priority. Special emphasis could be given to oral health of young persons. Current oral health practices and policies need to be evaluated and modified where necessary. The community, general health departments and other stakeholders should be engaged in the policy development. The benefit of conducting a health needs assessment should not be ignored provided resources are available. The results of this study can serve as a foundation for persuading health authorities to give oral health greater priority and can guide general and local clinic policy development or decisions. Additional surveys of children should be performed for 5 and 15 year olds to get a more balanced representation of the state of children’s health. A move towards more evidenced-based dentistry is necessary. Broad areas for attention include diet, dental education and toothbrushing programmes in supportive environment. Urgent attention needs to be given to children with active caries. This could be part of a targeted approach discussed earlier. Adopting a CRFA toward health is highly recommended and this necessitates collaborative partnerships with health departments. In the long-term dental health providers should work with other governmental departments to influence school nutrition policies, food importation and production regulations and consumer education with respect to healthy food choices. The government has a responsibility to ensure and maintain acceptable living standards by reducing social, economic and environmental and inequalities. Health is political.

References

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Acknowledgements

I am indebted to the students who participated and their parents who consented.

The support and assistance of the principal and staff of the Montserrat Secondary School and the Ministry of Education Health and Community Services were beyond expectation.

Special thanks to the staff of the St. John’s Dental Clinic who assisted ably and efficiently with examinations.

Thanks to Supervisors Dr Nick Kendall, Prof. Tim Newton and Dr. Blanaid Daly whose combined input was invaluable and greatly appreciated.

© Coretta E. Fergus

HTML last revised 18th June, 2009.

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