RESEARCH ARTICLE
Dental Caries Status and Oral Health Behavior Among Civilian Pilots Xi Chen, Yang Liu, Qing Yu, Liwei Zheng, Xiao Hong, Feifei Yan, and Haiyang Yu CHEN X, LIU Y, YU Q, ZHENG L, HONG X, YAN F, YU H. Dental caries Dental caries have been shown to be related to one’s status and oral health behavior among civilian pilots. Aviat Space lifestyle and behavior, including dietary habits (conEnviron Med 2014; 85:999–1004. sumption of carbohydrates, sugar intake, etc.), oral beObjectives: This study was aimed at investigating the caries status of havioral factors (tooth brushing, use of dental floss, Chinese civilian pilots and the relationship between caries and oral health behaviors, including sugar intake, smoking, alcohol consumpdental check-up, etc.), tobacco consumption (1,29,30), tion, tooth brushing, and dental check-up attendance. Methods: This and so on. Numerous studies over the past 50 yr have cross-sectional investigation enrolled pilots from Shenzhen Airline. A confirmed the relationship between dietary sugars and questionnaire was used to collect general information and oral health dental caries (20), and demonstrated sufficient evidence behaviors. The Decayed, Missing, and Filled Teeth (DMFT) Index, International Caries Detection and Assessment Delivered System (ICDAS) II, caries to: University by Ingenta Florida showing anofassociation between a high sugar intake and prevalence, and rate of missing teeth were via oral examinaIP:recorded 37.230.212.20 On: Sun,increased 26 Jun 2016 risk 08:27:00 of dental caries (30). Moreover, an investition. Rank correlation was used to reveal the correlation between caries Copyright: Aerospace Medical gation Association of Brazilian schoolchildren found that rational and oral health behavior. Results: All of the pilots were men ages 21–58 use of sugar is a factor in caries prevention (11). Smokyr (mean, 31.48 6 7.20). In the caries group (CG), the frequency of tooth brushing and flossing was a little higher; more subjects had already ing is an exogenous factor related to dental caries. Studgiven up smoking; more subjects had higher alcohol consumption; the ies had been done to reveal the relationship between sugar intake index (SII) was a little bit higher; and the last dental attensmoking and caries, but the results varied. Several early dance time (LDAT) was shorter than that in the noncaries group (NCG). studies showed that smoking helped to reduce dental A total of 211 pilots (37.95%) had caries and 85 (15.29%) had missing teeth. The average DMFT was 2.19, while the mean ICDAS was 0.72. caries (22). However, a study of professional truck drivThe frequency of sugary beverage consumption was negatively correers in Mexico reported that smokers tend to show the lated with caries (r 5 20.088), while a positive relationship was found greatest numbers of large cavities and missing teeth (1). between LDAT and caries (r 5 0.094). Conclusions: Chinese civilian piAircraft pilots must pass periodic medical examinalots have relatively good oral hygiene behavior and dental health. A relationship was found between sugary beverage consumption/LDAT and tions and are required to maintain eligible mental and caries. physical health status to ensure flight safety (10). While Keywords: sugar consumption index, caries prevalence, DMFT, flying, pilots are exposed to risks of dental damage cross-sectional study.
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HE MOST COMMON chronic oral disease is dental caries, showing localized destruction of hard dental tissues caused by bacterial acidic by-products (16). Caries prevalence and status varies worldwide. Studies have shown that the frequency of dental caries in adult populations is approximately 5–10 teeth per individual and comprises the most significant cause of adult tooth loss (18,21). Americans had 10 teeth and 30 tooth surfaces decayed, filled, or even missing during 1999–2004 (4). Over recent decades, a fall in the prevalence and severity of caries in permanent teeth has been seen in many developed countries (9,12). Although the caries prevalence and severity has declined in developed countries, it remains an issue of concern in developing countries. The mean decayed, missing, and filled teeth (DMFT) index of Jewish adults in Jerusalem was 10.59; as much as 93.2% of their population was affected by caries (29). In China, the third national survey investigated 23,538 adults (35–44 yr old) across the country and found that 88.1% had caries with a mean DMFT of 4.51 (14).
caused by the aviation environment. In-flight barodontalgia may be caused by deep caries, pulpitis, or other dental diseases (28). Phenomena caused by atmospheric pressure changes are called dental barotrauma; one example is barometric pressure-induced tooth fracture (26). Dental barotrauma could compromise a pilot’s operative fitness, dramatically jeopardizing safety (27). Currently, the caries status in Chinese aircraft pilots remains unknown. This study aimed to investigate the caries status among civilian pilots, provide preventive dental education, and develop a professional prevention protocol for civilian pilots. The relationship between
From the State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan Province, China. Xi Chen and Yang Liu are co-first authors. This manuscript was received for review in December 2013. It was accepted for publication in July 2014. Address correspondence and reprint requests to: Prof. Haiyang Yu, 14 S. Renmin Rd. 3rd sec., Chengdu, Sichuan Province 610041, China; [email protected]. Reprint & Copyright © by the Aerospace Medical Association, Alexandria, VA. DOI: 10.3357/ASEM.3951.2014
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DENTAL CARIES & CIVILIAN PILOTS—CHEN ET AL. never. LDAT was classified as within the past 6 mo, 1 yr, 2 yr, or never. Frequency and percentages about general information and oral health behavior were also calculated. METHODS In this study, the evaluation of sugar intake was different from that of the Sugar Consumption Index (SCI) This cross-sectional study was approved by the in(7) and the results were not categorized according to the stitutional review board (West China Hospital of StoWorld Health Organization (WHO) recommendations matology, Sichuan University; IRB 2,011,090) and carried (25). We adopted the SCI from the TNESOH. One reason out at the Medical Center of Shenzhen Airline (Shenzhen, is that Chinese diet patterns are entirely different from China) between June 2012 and April 2013. All subjects western diets. Based on the sweets, sugar, soft drinks, were on-duty civilian pilots from Shenzhen Airline. Since and sweet pastries of the SCI by Laurikainen (7), the nathere are no female pilots in the company, inclusion critional survey added several kinds of sugary foods that teria for this study were male civilian pilots under an Chinese people often eat, such as pastries. Moreover, it obligatory annual medical examination. Exclusion cridetailed the categories of the sugary foods, like sugary teria were civilian pilots who suffered from systematic beverages and sodas, both of which belong to the soft diseases such as diabetes or hypertension. Foreign pilots drinks category of the SCI. Most Chinese adults do not were excluded. Domestic pilots who failed to accomhave sugary foods at a frequency of three or four times a plish either the oral examination or the questionnaire day according to the TNESOH result, so we categorized survey were also excluded. the results into once per day or more, once per week or Informed consent was acquired from each participant. more, and hardly ever. They were asked to come for the examination in the Dentition status was evaluated using two systems. morning. The questionnaire of the Third National EpiIngenta University of Florida the DMFT index was used to calculate the number demiological Survey of Oral Health Delivered (TNESOH)by(14 ) was to: First, IP: 37.230.212.20 On: Sun, 26 Jun 2016 08:27:00 of permanent teeth used. General information includedCopyright: age, totalAerospace flying Medical Associationwith caries lesions, that had been extracted due to caries, or that had fillings or crowns actime, last-year flight time, and aircraft type. Oral health cording to the WHO criteria (24). The DMFT value was behaviors included tooth brushing frequency, use of the sum of the three figures. Dental caries experience dental floss, sugar intake, smoking, alcohol consumpwas divided into caries (DMFT . 0) and noncaries tion, and last dental attendance time (LDAT, defined as (DMFT 5 0). Then, the second digits of ICDAS scores (3) the time since the last dental check-up). In the questionwas also used to describe the caries status. Each subnaire, sugar intake included consumption of sweets/ ject’s mean score was calculated. When the pilots scored chocolate, desserts, fresh fruits, pastries, sodas, sugary 3 or higher in the examination, they were considered to beverages, and dairy products, just the same as the have caries according to the ICDAS II (23). The mean TNESOH questionnaire. Each subject completed the DMFT and ICDAS II values were calculated. questionnaire under the guidance of a well-trained All data were subjected to statistical analysis using investigator. the SPSS software package (Statistical Package for Social The examination was performed by a single trained dentist at a dentist’s office. The number of existing teeth Sciences version 17; IBM Inc., Chicago, IL). To discover was calculated (the maximum number was 32). The the factors that may cause the different caries status DMFT index and the International Caries Detection and among civilian pilots, the Chi-squared or t-test was used Assessment System (ICDAS) II were used to assess the to investigate the difference between the caries group caries severity. Radiography was not applied. (CG) and the noncaries group (NCG). The Chi-squared In the questionnaire, the answers on sugar intake test was applied for count data, while the t-test was used were scored from 1 to 6: 1 5 never or less than once per for measurement data. Rank correlation was used to remonth; 2 5 1–3 times per month; 3 5 once a week; 4 5 veal the correlation between caries and oral health be2–6 times a week; 5 5 once per day; and 6 5 twice a day havior and explore whether it affected dental status or more. The sugar intake index was the sum of these among civilian pilots. figures. The frequency of tooth brushing and flossing was also scored from 1 to 6: 1 5 never or less than once RESULTS per month; 2 5 1–3 times per month; 3 5 once a week; 4 5 2–6 times a week; 5 5 once per day; and 6 5 twice Of the 617 pilots in the airline company, 556 individua day or more. Tobacco and alcohol consumption was als were enrolled and 61 were excluded. All of the pilots evaluated by five grades: 1 5 every day; 2 5 every week; were men ages 21–58 yr (mean, 31.48 6 7.20); 72.12% 3 5 rarely; 4 5 never; and 5 5 former user. LDAT were were ,32 yr of age. A comparison of the oral health bescored as: 1 5 within 6 mo; 2 5 6–12 mo; 3 5 1–2 yr; 4 ⱖ havior between the CG and NCG is shown in Table I. A 2 yr; and 5 5 never. Tooth brushing frequency was cattotal of 381 (68.77%) pilots brushed their teeth twice a day egorized as twice a day or more, once a day, or less than or more. A total of 479 (86.46%) of the subjects never used once a day. Flossing frequency was categorized as every dental floss. The frequency of tooth brushing and flossing day, often, or hardly ever. Sugar intake was classified as in the CG was a little higher than that in the NCG. once a day or more, once a week or more, or hardly ever. In the CG, more subjects smoked little or had already Smoking status was categorized as current, former, or given up smoking. A total of 455 (81.98%) subjects rarely caries development and pilots’ oral health-related behaviors was also evaluated.
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DENTAL CARIES & CIVILIAN PILOTS—CHEN ET AL. TABLE I. DIFFERENTIATION OF ORAL HEALTH BEHAVIORS BETWEEN CARIES GROUP AND NON-CARIES GROUP PILOTS.
Tooth brushing Twice per day or more Once per day Less than once per day Dental floss Every day Often Hardly ever Sugar intake Fresh fruits Once per day or more Once per week or more Hardly ever Desserts Once per day or more Once per week or more Hardly ever Sweets/chocolate Once per day or more Once per week or more Hardly ever Pastries Once per day or more Once per week or more Hardly ever Sodas Once per day or more Once per week or more Hardly ever Sugary beverage Once per day or more Once per week or more Hardly ever Sugary dairy products Once per day or more Once per week or more Hardly ever Smoking Current Rarely/never Former Alcohol consumption Every day Every week Rarely Never Former LDAT Within six months Within a year Within two years Never
Total N (%)
Caries (DMFT .0)
Non-Caries (DMFT 5 0)
381 (68.77) 152 (27.44) 21 (3.79)
210 (72.66) 71 (24.57) 8 (2.77)
171 (64.53) 81 (30.57) 13 (4.91)
35 (6.32) 40 (7.22) 479 (86.46)
18 (6.21) 24 (8.28) 248 (85.52)
17 (6.44) 16 (5.52) 231 (87.50)
257 (46.73) 264 (48.00) 29 (6.27)
132 (45.67) 144 (49.83) 13 (4.50)
125 (47.89) 120 (45.98) 16 (6.13)
66 (12.00) 273 (49.64) 211 (38.36)
37 (12.80) 139 (48.10) 113 (39.10)
29 (11.11) 134 (51.34) 98 (37.55)
40 (7.32) 179 (32.78) 327 (59.89)
22 (7.72) 99 (34.74) 164 (57.54)
18 (6.90) 80 (30.65) 163 (62.45)
41 (7.51) 157 (28.75) Delivered 348 (63.74)by
22 (7.72) 85 (29.82) University of Florida 178 (62.46)
Ingenta to: IP: 37.230.212.20 On: Sun, 26 Jun 2016 08:27:00 53 (9.72) Aerospace Medical Association 28 (9.82) Copyright:
19 (7.28) 72 (27.59) 170 (65.13)
226 (41.47) 266 (48.81)
119 (41.75) 138 (48.42)
25 (9.62) 107 (41.15) 128 (49.23)
68 (12.48) 242 (44.40) 235 (43.12)
40 (14.04) 134 (47.02) 111 (38.95)
28 (10.77) 108 (41.54) 124 (47.69)
91 (16.67) 261 (47.80) 194 (35.53)
51 (17.89) 136 (47.72) 98 (34.39)
40 (15.33) 125 (47.89) 96 (36.78)
182 (32.79) 327 (58.92) 46 (8.29)
91 (31.27) 170 (58.42) 30 (10.31)
91 (34.47) 157 (59.47) 16 (6.06)
4 (0.72) 96 (17.30) 406 (73.15) 39 (7.02) 10 (1.80)
1 (0.34) 50 (17.24) 213 (73.45) 21 (7.24) 5 (1.72)
3 (1.13) 46 (17.36) 193 (72.83) 18 (6.79) 5 (1.89)
173 (31.17) 166 (29.91) 117 (21.08) 99 (17.84)
80 (27.49) 87 (29.90) 67 (23.02) 57 (19.59)
93 (35.23) 79 (29.92) 50 (18.94) 42 (15.91)
consumed alcohol or were former drinkers, and more alcohol consumption was found in the CG than in the NCG. A total of 173 (31.17%) pilots had visited a dentist within the past 6 mo, whereas 216 (38.92%) had not visited a dentist for at least 2 yr. The LDAT in the NCG was longer than that in the CG. Sugar intake frequency is detailed in Fig. 1. The sugar intake index (SII) was 7–42 (mean, 20.41 6 6.64). The SII of the CG was a little bit higher (20.50) than that of the NCG (19.94). Duplicate examinations were conducted in 10% of the examined pilots approximately halfway through the survey (kappa value 5 0.91) and at the end of the survey (kappa value 5 0.88). The number of existing teeth was 24–32 (mean, 29.35 6 1.59). Except for the unerupted
third molars, 85 (15.29%) of the subjects had at least one missing tooth. The mean DMFT was 2.19 (6 3.37). The average decayed, missing, and filled values were 1.44 (6 2.67), 0.09 (6 0.44), and 0.66 (6 1.83), respectively. Among the subjects, 265 (47.66%) were caries free; 211 (37.95%) had one or more decayed teeth [138 (65.40%) never sought treatment]; and 46 (8.27%) had missing teeth due to caries. The mean ICDAS value was 0.72 (6 0.70) and 409 (73.56%) subjects were considered to have dental caries (ICDAS score ⱖ 3). Differences were evaluated between groups and relationships were measured between caries and age, flying time, tooth brushing frequency, use of dental floss, sugar intake, smoking, alcohol consumption, and LDAT. There
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Fig. 1. Differentiation in sugar intake between civilian pilots and national average. *CP, mean of civilian pilots; NL, mean of national male level.
Fig. 2. Difference in oral health behaviors between the national average and civilian pilots. *TNESOH, Third National Epidemiological Survey of Oral Health.
was no difference found between the two groups. The frequency of sugary beverage consumption was negacaries susceptibilities. Many twin studies have provided Delivered by aIngenta Universitythat of Florida tively correlated with caries (r 5 20.088), while posi- to: evidence individual genes may provide multiple IP: 37.230.212.20 On: Sun, 26 Jun 2016 08:27:00 tive relationship was found between LDAT and caries proteins, protein variations can contribute to the susCopyright: Aerospace Medical Association (r 5 0.094). No other significant relationship was found ceptibility to dental caries, and evidence supports the (P , 0.05). linkage of altered dental enamel development with inDISCUSSION Aviation exposes civilian pilots to hazards like hypoxia, acceleration forces, disorientation, and pressure and temperature alterations, which could hamper tissue or organ function. An oral cavity can be affected by the aviation environment (27); as such, attention should be paid to pilots’ oral health. However, little is known about this issue. Literature review was not able to reveal any prior work about Chinese civilian pilots’ oral health status. These results could contribute to dental disease prevention and the development of treatment protocols and screening standards for civilian pilots. A comparison of the oral health behavior between the national average (14) and civilian pilots is detailed in Fig. 2. The figure shows that the oral hygiene habits of civilian pilots are generally better than those of the national average. Comparison of the pilots’ dental status and the national averages is shown in Table II. According to Table II, the tooth missing rate and missing tooth value of civilian pilots were lower, indicating better tooth preservation among the pilot population. Caries prevalence and DMFT values were also lower among civilian pilots; the damaged tooth value of civilian pilots was a little higher than the national average. It showed that approximately one-third of the pilots had caries, however, with a more severe status than the national average. This indicated that civilian pilots are polarized on dentition status. One explanation for this feature could be that individuals have different caries susceptibility. Accumulating documents show that caries susceptibility varies among people. Multiple factors contribute to a person's risk for caries. One group (8) believes that diverse morphological tooth types show differing 1002
creased susceptibility to dental caries (17). Furthermore, environmental factors such as salivary ingredients and cariogenic bacteria also contribute to differing susceptibilities (15,19). Oral hygiene behaviors were compared between the CG and NCG. An interesting result was that pilots in the CG brushed their teeth more often than those in the NCG. One explanation for this result was that pilots with caries paid more attention to caries prevention; as such, they brushed their teeth more frequently. An improper tooth brushing method may also be one of the reasons. Among the two groups, CG and NCG, a positive relationship was found between LDAT and caries (r 5 0.094), showing that the span of time between our study and the last dental visit had a relationship with caries, i.e., the longer the amount of time, the more caries will develop. It can be deduced that visiting a dentist regularly could help reduce dental caries and it showed the importance of dental visits and motivation.
TABLE II. DIFFERENTIATION OF DENTAL STATUS BETWEEN CIVILIAN PILOTS AND NATIONAL AVERAGE.
Caries prevalence Tooth-missing rate DT MT FT DMFT
Civilian Pilots
TNESOH Average*
37.95% 15.29% 1.44 6 2.67 0.09 6 0.44 0.66 6 1.83 2.19 6 3.37
84.9% 37.0% 1.14 6 1.90 2.40 6 2.66 0.24 6 0.79 3.79 6 3.57
* TNESOH: the Third National Epidemiological Survey of Oral Health. DT 5 damaged teeth; MT 5 missing teeth; FT 5 filled teeth; DMFT 5 Damaged, Missing, and Filled Teeth Index.
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DENTAL CARIES & CIVILIAN PILOTS—CHEN ET AL. decision to publish, or manuscript preparation. The authors would In this study, the frequency of sugary beverage conlike to thank Duanjing Chen, Lu Xie, Haili Huang, Xingyuan Wang, sumption was negatively correlated with caries (r 5 and the staff of the Medical Center of Shenzhen Airlines for their assis20.088); namely drinking sugary beverages on more tance with this study. Authors and affiliations: Xi Chen, M.D.S., Ph.D. candidate, Yang days per week had a consistent relationship with eleLiu, M.D.S., Ph.D., Qing Yu, M.D.S., Ph.D. candidate, Liwei Zheng, vated numbers of caries. We can deduce that the more Ph.D., Assistant Professor, Xiao Hong, Ph.D., Assistant Professor, and sugary beverages one consumes, the greater the possiHaiyang Yu, D.D.S., Ph.D., State Key Laboratory of Oral Disease, West bility that one will develop dental caries. All carbohyChina Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China; and Feifei Yan, D.D.S., Director, Medical Center, Shenzhen drates have the potential to promote dental caries Airlines, Bao'an District, Shenzhen, Guangdong, China. because they can be fermented by microorganisms in the mouth that produce acid on the tooth surfaces (5). It is generally believed that desserts, sweets, sodas, and sugary beverages can cause caries. However, sugary REFERENCES beverages were found to be the most cariogenic sub1. Aguilar-Zinser V, Irigoyen ME, Rivera G, Maupomé G, SánchezPérez L, Velázquez C. Cigarette smoking and dental caries stances among civilian pilots in this study. As sugary among professional truck drivers in mexico. Caries Res 2008; beverages are not as sweet as sweets (which remain in 42:255–62. the mouth for long periods of time and/or adhere to 2. Assaf AV, de Castro Meneghim M, Zanin L, Tengan C, Pereira AC. 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Dental Caries Status and Oral Health Behavior Among Civilian Pilots Xi Chen, Yang Liu, Qing Yu, Liwei Zheng, Xiao Hong, Feifei Yan, and Haiyang Yu CHEN X, LIU Y, YU Q, ZHENG L, HONG X, YAN F, YU H. Dental caries Dental caries have been shown to be related to one’s status and oral health behavior among civilian pilots. Aviat Space lifestyle and behavior, including dietary habits (conEnviron Med 2014; 85:999–1004. sumption of carbohydrates, sugar intake, etc.), oral beObjectives: This study was aimed at investigating the caries status of havioral factors (tooth brushing, use of dental floss, Chinese civilian pilots and the relationship between caries and oral health behaviors, including sugar intake, smoking, alcohol consumpdental check-up, etc.), tobacco consumption (1,29,30), tion, tooth brushing, and dental check-up attendance. Methods: This and so on. Numerous studies over the past 50 yr have cross-sectional investigation enrolled pilots from Shenzhen Airline. A confirmed the relationship between dietary sugars and questionnaire was used to collect general information and oral health dental caries (20), and demonstrated sufficient evidence behaviors. The Decayed, Missing, and Filled Teeth (DMFT) Index, International Caries Detection and Assessment Delivered System (ICDAS) II, caries to: University by Ingenta Florida showing anofassociation between a high sugar intake and prevalence, and rate of missing teeth were via oral examinaIP:recorded 37.230.212.20 On: Sun,increased 26 Jun 2016 risk 08:27:00 of dental caries (30). Moreover, an investition. Rank correlation was used to reveal the correlation between caries Copyright: Aerospace Medical gation Association of Brazilian schoolchildren found that rational and oral health behavior. Results: All of the pilots were men ages 21–58 use of sugar is a factor in caries prevention (11). Smokyr (mean, 31.48 6 7.20). In the caries group (CG), the frequency of tooth brushing and flossing was a little higher; more subjects had already ing is an exogenous factor related to dental caries. Studgiven up smoking; more subjects had higher alcohol consumption; the ies had been done to reveal the relationship between sugar intake index (SII) was a little bit higher; and the last dental attensmoking and caries, but the results varied. Several early dance time (LDAT) was shorter than that in the noncaries group (NCG). studies showed that smoking helped to reduce dental A total of 211 pilots (37.95%) had caries and 85 (15.29%) had missing teeth. The average DMFT was 2.19, while the mean ICDAS was 0.72. caries (22). However, a study of professional truck drivThe frequency of sugary beverage consumption was negatively correers in Mexico reported that smokers tend to show the lated with caries (r 5 20.088), while a positive relationship was found greatest numbers of large cavities and missing teeth (1). between LDAT and caries (r 5 0.094). Conclusions: Chinese civilian piAircraft pilots must pass periodic medical examinalots have relatively good oral hygiene behavior and dental health. A relationship was found between sugary beverage consumption/LDAT and tions and are required to maintain eligible mental and caries. physical health status to ensure flight safety (10). While Keywords: sugar consumption index, caries prevalence, DMFT, flying, pilots are exposed to risks of dental damage cross-sectional study.
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HE MOST COMMON chronic oral disease is dental caries, showing localized destruction of hard dental tissues caused by bacterial acidic by-products (16). Caries prevalence and status varies worldwide. Studies have shown that the frequency of dental caries in adult populations is approximately 5–10 teeth per individual and comprises the most significant cause of adult tooth loss (18,21). Americans had 10 teeth and 30 tooth surfaces decayed, filled, or even missing during 1999–2004 (4). Over recent decades, a fall in the prevalence and severity of caries in permanent teeth has been seen in many developed countries (9,12). Although the caries prevalence and severity has declined in developed countries, it remains an issue of concern in developing countries. The mean decayed, missing, and filled teeth (DMFT) index of Jewish adults in Jerusalem was 10.59; as much as 93.2% of their population was affected by caries (29). In China, the third national survey investigated 23,538 adults (35–44 yr old) across the country and found that 88.1% had caries with a mean DMFT of 4.51 (14).
caused by the aviation environment. In-flight barodontalgia may be caused by deep caries, pulpitis, or other dental diseases (28). Phenomena caused by atmospheric pressure changes are called dental barotrauma; one example is barometric pressure-induced tooth fracture (26). Dental barotrauma could compromise a pilot’s operative fitness, dramatically jeopardizing safety (27). Currently, the caries status in Chinese aircraft pilots remains unknown. This study aimed to investigate the caries status among civilian pilots, provide preventive dental education, and develop a professional prevention protocol for civilian pilots. The relationship between
From the State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan Province, China. Xi Chen and Yang Liu are co-first authors. This manuscript was received for review in December 2013. It was accepted for publication in July 2014. Address correspondence and reprint requests to: Prof. Haiyang Yu, 14 S. Renmin Rd. 3rd sec., Chengdu, Sichuan Province 610041, China; [email protected]. Reprint & Copyright © by the Aerospace Medical Association, Alexandria, VA. DOI: 10.3357/ASEM.3951.2014
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DENTAL CARIES & CIVILIAN PILOTS—CHEN ET AL. never. LDAT was classified as within the past 6 mo, 1 yr, 2 yr, or never. Frequency and percentages about general information and oral health behavior were also calculated. METHODS In this study, the evaluation of sugar intake was different from that of the Sugar Consumption Index (SCI) This cross-sectional study was approved by the in(7) and the results were not categorized according to the stitutional review board (West China Hospital of StoWorld Health Organization (WHO) recommendations matology, Sichuan University; IRB 2,011,090) and carried (25). We adopted the SCI from the TNESOH. One reason out at the Medical Center of Shenzhen Airline (Shenzhen, is that Chinese diet patterns are entirely different from China) between June 2012 and April 2013. All subjects western diets. Based on the sweets, sugar, soft drinks, were on-duty civilian pilots from Shenzhen Airline. Since and sweet pastries of the SCI by Laurikainen (7), the nathere are no female pilots in the company, inclusion critional survey added several kinds of sugary foods that teria for this study were male civilian pilots under an Chinese people often eat, such as pastries. Moreover, it obligatory annual medical examination. Exclusion cridetailed the categories of the sugary foods, like sugary teria were civilian pilots who suffered from systematic beverages and sodas, both of which belong to the soft diseases such as diabetes or hypertension. Foreign pilots drinks category of the SCI. Most Chinese adults do not were excluded. Domestic pilots who failed to accomhave sugary foods at a frequency of three or four times a plish either the oral examination or the questionnaire day according to the TNESOH result, so we categorized survey were also excluded. the results into once per day or more, once per week or Informed consent was acquired from each participant. more, and hardly ever. They were asked to come for the examination in the Dentition status was evaluated using two systems. morning. The questionnaire of the Third National EpiIngenta University of Florida the DMFT index was used to calculate the number demiological Survey of Oral Health Delivered (TNESOH)by(14 ) was to: First, IP: 37.230.212.20 On: Sun, 26 Jun 2016 08:27:00 of permanent teeth used. General information includedCopyright: age, totalAerospace flying Medical Associationwith caries lesions, that had been extracted due to caries, or that had fillings or crowns actime, last-year flight time, and aircraft type. Oral health cording to the WHO criteria (24). The DMFT value was behaviors included tooth brushing frequency, use of the sum of the three figures. Dental caries experience dental floss, sugar intake, smoking, alcohol consumpwas divided into caries (DMFT . 0) and noncaries tion, and last dental attendance time (LDAT, defined as (DMFT 5 0). Then, the second digits of ICDAS scores (3) the time since the last dental check-up). In the questionwas also used to describe the caries status. Each subnaire, sugar intake included consumption of sweets/ ject’s mean score was calculated. When the pilots scored chocolate, desserts, fresh fruits, pastries, sodas, sugary 3 or higher in the examination, they were considered to beverages, and dairy products, just the same as the have caries according to the ICDAS II (23). The mean TNESOH questionnaire. Each subject completed the DMFT and ICDAS II values were calculated. questionnaire under the guidance of a well-trained All data were subjected to statistical analysis using investigator. the SPSS software package (Statistical Package for Social The examination was performed by a single trained dentist at a dentist’s office. The number of existing teeth Sciences version 17; IBM Inc., Chicago, IL). To discover was calculated (the maximum number was 32). The the factors that may cause the different caries status DMFT index and the International Caries Detection and among civilian pilots, the Chi-squared or t-test was used Assessment System (ICDAS) II were used to assess the to investigate the difference between the caries group caries severity. Radiography was not applied. (CG) and the noncaries group (NCG). The Chi-squared In the questionnaire, the answers on sugar intake test was applied for count data, while the t-test was used were scored from 1 to 6: 1 5 never or less than once per for measurement data. Rank correlation was used to remonth; 2 5 1–3 times per month; 3 5 once a week; 4 5 veal the correlation between caries and oral health be2–6 times a week; 5 5 once per day; and 6 5 twice a day havior and explore whether it affected dental status or more. The sugar intake index was the sum of these among civilian pilots. figures. The frequency of tooth brushing and flossing was also scored from 1 to 6: 1 5 never or less than once RESULTS per month; 2 5 1–3 times per month; 3 5 once a week; 4 5 2–6 times a week; 5 5 once per day; and 6 5 twice Of the 617 pilots in the airline company, 556 individua day or more. Tobacco and alcohol consumption was als were enrolled and 61 were excluded. All of the pilots evaluated by five grades: 1 5 every day; 2 5 every week; were men ages 21–58 yr (mean, 31.48 6 7.20); 72.12% 3 5 rarely; 4 5 never; and 5 5 former user. LDAT were were ,32 yr of age. A comparison of the oral health bescored as: 1 5 within 6 mo; 2 5 6–12 mo; 3 5 1–2 yr; 4 ⱖ havior between the CG and NCG is shown in Table I. A 2 yr; and 5 5 never. Tooth brushing frequency was cattotal of 381 (68.77%) pilots brushed their teeth twice a day egorized as twice a day or more, once a day, or less than or more. A total of 479 (86.46%) of the subjects never used once a day. Flossing frequency was categorized as every dental floss. The frequency of tooth brushing and flossing day, often, or hardly ever. Sugar intake was classified as in the CG was a little higher than that in the NCG. once a day or more, once a week or more, or hardly ever. In the CG, more subjects smoked little or had already Smoking status was categorized as current, former, or given up smoking. A total of 455 (81.98%) subjects rarely caries development and pilots’ oral health-related behaviors was also evaluated.
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DENTAL CARIES & CIVILIAN PILOTS—CHEN ET AL. TABLE I. DIFFERENTIATION OF ORAL HEALTH BEHAVIORS BETWEEN CARIES GROUP AND NON-CARIES GROUP PILOTS.
Tooth brushing Twice per day or more Once per day Less than once per day Dental floss Every day Often Hardly ever Sugar intake Fresh fruits Once per day or more Once per week or more Hardly ever Desserts Once per day or more Once per week or more Hardly ever Sweets/chocolate Once per day or more Once per week or more Hardly ever Pastries Once per day or more Once per week or more Hardly ever Sodas Once per day or more Once per week or more Hardly ever Sugary beverage Once per day or more Once per week or more Hardly ever Sugary dairy products Once per day or more Once per week or more Hardly ever Smoking Current Rarely/never Former Alcohol consumption Every day Every week Rarely Never Former LDAT Within six months Within a year Within two years Never
Total N (%)
Caries (DMFT .0)
Non-Caries (DMFT 5 0)
381 (68.77) 152 (27.44) 21 (3.79)
210 (72.66) 71 (24.57) 8 (2.77)
171 (64.53) 81 (30.57) 13 (4.91)
35 (6.32) 40 (7.22) 479 (86.46)
18 (6.21) 24 (8.28) 248 (85.52)
17 (6.44) 16 (5.52) 231 (87.50)
257 (46.73) 264 (48.00) 29 (6.27)
132 (45.67) 144 (49.83) 13 (4.50)
125 (47.89) 120 (45.98) 16 (6.13)
66 (12.00) 273 (49.64) 211 (38.36)
37 (12.80) 139 (48.10) 113 (39.10)
29 (11.11) 134 (51.34) 98 (37.55)
40 (7.32) 179 (32.78) 327 (59.89)
22 (7.72) 99 (34.74) 164 (57.54)
18 (6.90) 80 (30.65) 163 (62.45)
41 (7.51) 157 (28.75) Delivered 348 (63.74)by
22 (7.72) 85 (29.82) University of Florida 178 (62.46)
Ingenta to: IP: 37.230.212.20 On: Sun, 26 Jun 2016 08:27:00 53 (9.72) Aerospace Medical Association 28 (9.82) Copyright:
19 (7.28) 72 (27.59) 170 (65.13)
226 (41.47) 266 (48.81)
119 (41.75) 138 (48.42)
25 (9.62) 107 (41.15) 128 (49.23)
68 (12.48) 242 (44.40) 235 (43.12)
40 (14.04) 134 (47.02) 111 (38.95)
28 (10.77) 108 (41.54) 124 (47.69)
91 (16.67) 261 (47.80) 194 (35.53)
51 (17.89) 136 (47.72) 98 (34.39)
40 (15.33) 125 (47.89) 96 (36.78)
182 (32.79) 327 (58.92) 46 (8.29)
91 (31.27) 170 (58.42) 30 (10.31)
91 (34.47) 157 (59.47) 16 (6.06)
4 (0.72) 96 (17.30) 406 (73.15) 39 (7.02) 10 (1.80)
1 (0.34) 50 (17.24) 213 (73.45) 21 (7.24) 5 (1.72)
3 (1.13) 46 (17.36) 193 (72.83) 18 (6.79) 5 (1.89)
173 (31.17) 166 (29.91) 117 (21.08) 99 (17.84)
80 (27.49) 87 (29.90) 67 (23.02) 57 (19.59)
93 (35.23) 79 (29.92) 50 (18.94) 42 (15.91)
consumed alcohol or were former drinkers, and more alcohol consumption was found in the CG than in the NCG. A total of 173 (31.17%) pilots had visited a dentist within the past 6 mo, whereas 216 (38.92%) had not visited a dentist for at least 2 yr. The LDAT in the NCG was longer than that in the CG. Sugar intake frequency is detailed in Fig. 1. The sugar intake index (SII) was 7–42 (mean, 20.41 6 6.64). The SII of the CG was a little bit higher (20.50) than that of the NCG (19.94). Duplicate examinations were conducted in 10% of the examined pilots approximately halfway through the survey (kappa value 5 0.91) and at the end of the survey (kappa value 5 0.88). The number of existing teeth was 24–32 (mean, 29.35 6 1.59). Except for the unerupted
third molars, 85 (15.29%) of the subjects had at least one missing tooth. The mean DMFT was 2.19 (6 3.37). The average decayed, missing, and filled values were 1.44 (6 2.67), 0.09 (6 0.44), and 0.66 (6 1.83), respectively. Among the subjects, 265 (47.66%) were caries free; 211 (37.95%) had one or more decayed teeth [138 (65.40%) never sought treatment]; and 46 (8.27%) had missing teeth due to caries. The mean ICDAS value was 0.72 (6 0.70) and 409 (73.56%) subjects were considered to have dental caries (ICDAS score ⱖ 3). Differences were evaluated between groups and relationships were measured between caries and age, flying time, tooth brushing frequency, use of dental floss, sugar intake, smoking, alcohol consumption, and LDAT. There
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Fig. 1. Differentiation in sugar intake between civilian pilots and national average. *CP, mean of civilian pilots; NL, mean of national male level.
Fig. 2. Difference in oral health behaviors between the national average and civilian pilots. *TNESOH, Third National Epidemiological Survey of Oral Health.
was no difference found between the two groups. The frequency of sugary beverage consumption was negacaries susceptibilities. Many twin studies have provided Delivered by aIngenta Universitythat of Florida tively correlated with caries (r 5 20.088), while posi- to: evidence individual genes may provide multiple IP: 37.230.212.20 On: Sun, 26 Jun 2016 08:27:00 tive relationship was found between LDAT and caries proteins, protein variations can contribute to the susCopyright: Aerospace Medical Association (r 5 0.094). No other significant relationship was found ceptibility to dental caries, and evidence supports the (P , 0.05). linkage of altered dental enamel development with inDISCUSSION Aviation exposes civilian pilots to hazards like hypoxia, acceleration forces, disorientation, and pressure and temperature alterations, which could hamper tissue or organ function. An oral cavity can be affected by the aviation environment (27); as such, attention should be paid to pilots’ oral health. However, little is known about this issue. Literature review was not able to reveal any prior work about Chinese civilian pilots’ oral health status. These results could contribute to dental disease prevention and the development of treatment protocols and screening standards for civilian pilots. A comparison of the oral health behavior between the national average (14) and civilian pilots is detailed in Fig. 2. The figure shows that the oral hygiene habits of civilian pilots are generally better than those of the national average. Comparison of the pilots’ dental status and the national averages is shown in Table II. According to Table II, the tooth missing rate and missing tooth value of civilian pilots were lower, indicating better tooth preservation among the pilot population. Caries prevalence and DMFT values were also lower among civilian pilots; the damaged tooth value of civilian pilots was a little higher than the national average. It showed that approximately one-third of the pilots had caries, however, with a more severe status than the national average. This indicated that civilian pilots are polarized on dentition status. One explanation for this feature could be that individuals have different caries susceptibility. Accumulating documents show that caries susceptibility varies among people. Multiple factors contribute to a person's risk for caries. One group (8) believes that diverse morphological tooth types show differing 1002
creased susceptibility to dental caries (17). Furthermore, environmental factors such as salivary ingredients and cariogenic bacteria also contribute to differing susceptibilities (15,19). Oral hygiene behaviors were compared between the CG and NCG. An interesting result was that pilots in the CG brushed their teeth more often than those in the NCG. One explanation for this result was that pilots with caries paid more attention to caries prevention; as such, they brushed their teeth more frequently. An improper tooth brushing method may also be one of the reasons. Among the two groups, CG and NCG, a positive relationship was found between LDAT and caries (r 5 0.094), showing that the span of time between our study and the last dental visit had a relationship with caries, i.e., the longer the amount of time, the more caries will develop. It can be deduced that visiting a dentist regularly could help reduce dental caries and it showed the importance of dental visits and motivation.
TABLE II. DIFFERENTIATION OF DENTAL STATUS BETWEEN CIVILIAN PILOTS AND NATIONAL AVERAGE.
Caries prevalence Tooth-missing rate DT MT FT DMFT
Civilian Pilots
TNESOH Average*
37.95% 15.29% 1.44 6 2.67 0.09 6 0.44 0.66 6 1.83 2.19 6 3.37
84.9% 37.0% 1.14 6 1.90 2.40 6 2.66 0.24 6 0.79 3.79 6 3.57
* TNESOH: the Third National Epidemiological Survey of Oral Health. DT 5 damaged teeth; MT 5 missing teeth; FT 5 filled teeth; DMFT 5 Damaged, Missing, and Filled Teeth Index.
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DENTAL CARIES & CIVILIAN PILOTS—CHEN ET AL. decision to publish, or manuscript preparation. The authors would In this study, the frequency of sugary beverage conlike to thank Duanjing Chen, Lu Xie, Haili Huang, Xingyuan Wang, sumption was negatively correlated with caries (r 5 and the staff of the Medical Center of Shenzhen Airlines for their assis20.088); namely drinking sugary beverages on more tance with this study. Authors and affiliations: Xi Chen, M.D.S., Ph.D. candidate, Yang days per week had a consistent relationship with eleLiu, M.D.S., Ph.D., Qing Yu, M.D.S., Ph.D. candidate, Liwei Zheng, vated numbers of caries. We can deduce that the more Ph.D., Assistant Professor, Xiao Hong, Ph.D., Assistant Professor, and sugary beverages one consumes, the greater the possiHaiyang Yu, D.D.S., Ph.D., State Key Laboratory of Oral Disease, West bility that one will develop dental caries. All carbohyChina Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China; and Feifei Yan, D.D.S., Director, Medical Center, Shenzhen drates have the potential to promote dental caries Airlines, Bao'an District, Shenzhen, Guangdong, China. because they can be fermented by microorganisms in the mouth that produce acid on the tooth surfaces (5). It is generally believed that desserts, sweets, sodas, and sugary beverages can cause caries. However, sugary REFERENCES beverages were found to be the most cariogenic sub1. Aguilar-Zinser V, Irigoyen ME, Rivera G, Maupomé G, SánchezPérez L, Velázquez C. Cigarette smoking and dental caries stances among civilian pilots in this study. As sugary among professional truck drivers in mexico. Caries Res 2008; beverages are not as sweet as sweets (which remain in 42:255–62. the mouth for long periods of time and/or adhere to 2. Assaf AV, de Castro Meneghim M, Zanin L, Tengan C, Pereira AC. 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