DENTAL HEALTH
Factors associated with dental caries experience and oral health status among New South Wales adolescents John Skinner,1,2 George Johnson,1 Anthony Blinkhorn,1 Roy Byun3
R
esearch has shown that there are critical periods in a person’s life where long-term health related behaviours can be established, with one of these crucial periods being adolescence.1,2 An early longitudinal national survey in Finland from 1977–1989 looked at oral health habits of adolescents and dental services via postal questionnaires.3 The study collected clinical and dietary information and identified the consumption of sugary drinks and frequency of tooth brushing as risk factors in oral health.3 A cross-sectional clinical assessment study combined with self-reported questionnaires looked at the relationship between socioeconomic status (SES) and caries experience in adolescents in the US.4 In this study, a random selection of parents completed a questionnaire on SES, exposure to fluoride and dental service visits. The number of decayed (D), missing (M) and filled (F) teeth (T) was used as the measure of caries experience (DMFT) in the permanent teeth of these adolescents. This is an internationally recognised measure of the current dental disease state of an individual,5 but does not measure improvements in oral health. The study reported that lower SES was associated with a higher prevalence of severe caries; however, the authors concluded that the pathways through which SES-associated disparities in oral health occur need to be determined in future research.4 Another crosssectional survey involving 2,662 adolescents in eight Chinese provincial capitals measured the relationship between certain general and oral health-related practices and parents’ level
Abstract Objective: To investigate the potential social and behavioural risk factors influencing the oral health of teenagers aged 14 and 15 years living in New South Wales Australia. Methods: Quantitative and qualitative methodologies were used in this research project. Data were obtained from both the clinical and questionnaire components of the NSW Teen Dental Survey 2010 and were analysed in SAS 9.2. The analyses allowed for various demographic and behavioural risk factors to be assessed using caries experience, severe caries and DMFT (decayed, missing or filled teeth) counts as the key outcome variables. Results: Of the 1,256 14- and 15-year-olds who had a dental examination, 1,199 (95.5%) provided questionnaire data. The clinical examinations found that 44.4% of teenagers overall had caries experience in at least one tooth, while 10.6% of the sample had experienced severe caries. Severe dental caries was found to be significantly related to a variety of factors, including family income, fluoridation status, tooth brushing behaviour and sugary drink consumption. Conclusions: The oral health of 14- and 15-year-olds in NSW is influenced by social and dietary factors as well as access to fluoridated water supplies. There was also a strong relationship between self-rated oral health status with DMFT and with caries experience. Implications: The findings of this study will assist policy makers by highlighting the current caries risk factors that should be part of future health promotion programs. Key words: dental caries, adolescent health, tooth brushing, socioeconomic status, fluoridation
of education and income, school performance and peer relationship.6 They reported significantly higher scores for adolescents on oral hygiene practices with high parental levels of education and income, and also peer relationship.6 In 2001, a review of the effectiveness of oral health education and promotion literature concluded that many current interventions were poorly and inadequately evaluated.7 It stated that scientifically validated evaluation and reporting in health promotion is vital to develop good practice, to provide feedback and to inform policy development.
Quantitative and qualitative methodologies are required in modern health promotion initiatives to effectively evaluate a program with the use of standardised appropriate outcomes.7 In 2012, three successful UK health promotion programs identified risk factors for oral disease as alcohol consumption, smoking, poor dietary habits and chronic diseases such as diabetes and heart disease, and suggested that health promotion programs should be multi-faceted and target these behavioural health risk factors to improve oral and general health.8 The study also
1. Population Oral Health Unit, Faculty of Dentistry, University of Sydney, New South Wales 2. Centre for Oral Health Strategy, New South Wales Ministry of Health 3. Centre for Research, Evidence Management and Surveillance, Sydney and South Western Sydney Local Health Districts, New South Wales Correspondence to: Mr John Skinner, Population Oral Health Unit, Faculty of Dentistry, University of Sydney, 1 Mons Road, Westmead, NSW 2145; e-mail: [email protected] Submitted: September 2013; Revision requested: January 2014; Accepted: March 2014 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2014; 38:485-9; doi: 10.1111/1753-6405.12245
2014 vol. 38 no. 5
Australian and New Zealand Journal of Public Health © 2014 Public Health Association of Australia
485
Skinner et al.
Article
found an association between poor oral health and lower socioeconomic (SES) class9 and this is supported by two further studies that highlight that a low parental SES can influence the oral and general health behaviour of children and adolescents.9,10
years. The teenagers attended metropolitan and non-metropolitan secondary schools under the jurisdiction of the NSW Department of Education and Training, the Catholic Education Commission and Independent Schools.
In Australia, there have been several child and adolescent oral health promotion campaigns since the early 1990s. Two such campaigns in NSW are Life Sux without Teeth11 in 1994 and the Save Our Kids Smiles program, which targeted children in kindergarten, years 2, 4, 6 at primary school and in year 8 (13-14-year-olds) in high schools from 1996 to 2000.12 More recently, the Australian Dental Association recognised the importance of adolescent oral health in NSW by targeting the oral health of teenagers during Dental Health Week in 2006.13 Promotional materials were produced on three main topics: dental erosion, oral piercings and nutrition to help fight dental decay.13
Nineteen calibrated examiners performed 1,269 clinical examinations on 14-15-yearolds at a total of 84 schools. Each examination team included a dental therapist (examiner) and a dental assistant (recorder), with children examined in schoolrooms under standardised conditions using a sterile mirror and dental probe. Dental plaque, caries, trauma and fluorosis scores were recorded directly into a laptop using a Microsoft Access database developed by the Australian Research Centre for Population Oral Health. The examinations were conducted according to a clinical examination and coding protocol based on the NSW Child Dental Health Survey 2007.15
Most dental health surveys involving the oral health of adolescents in Australia and New South Wales have focused on measuring oral health status, and limited data has been collected on the potential risk and protective factors among these groups.14 However, in 2010 the NSW Teen Dental Survey surveyed the oral health status of a random representative sample of year 9 students aged 14-15 years along with a self-reported risk-factor questionnaire. This paper focuses on the self-reported oral health behaviour and identified risk factors from the 2010 NSW Teen Dental Survey, examining the relationship with clinical oral health status. The paper uses the quantitative clinical data and the qualitative social data to explore the major sources of variation in caries experience within the sample of 14-15-year-olds. The hypothesis tested was that mean DMFT, severe caries and simple caries prevalence would each be higher among those teenagers from families with lower income levels and mothers with a lower education level. In addition, the oral health behaviours and prevention interventions of tooth brushing, use of fluoride toothpaste, access to fluoridated water, presence of fissure sealants and a recently reported dental visit is discussed.
Methods Data for the NSW Teen Dental Survey were collected in 2010 from a random sample of year 9 secondary students aged 14 and 15
486
A total of 1,199 of the 14-15 year-olds who had a clinical examination also completed a 17-item questionnaire related to oral hygiene behaviours, perceived oral health status, importance of their dental health, consumption of water and sugary drinks; plus a number of questions about the appearance of their front teeth, how much the condition of their teeth affected their lives, and whether they had ever felt embarrassed about having bad breath. Questions about food consumption and weight were omitted from this current study because there are already regular Child Health Surveys16 and School Students Health Behaviours Surveys17 in NSW covering these issues. The parents of the teenagers included in the survey were asked to answer a 29-item questionnaire in four main sections: nine questions on their child’s use of dental services and family dental insurance cover; eight questions related to eligibility for the Australian Medicare Teen Dental Program and their child’s use of this scheme; three questions related to their child’s general and dental health; and a final section with nine questions that collected household information related to family income, age of parents and highest level of education attained by parents. To allow modelling of the data, and comparison with other surveys, a new variable was created for mother’s highest education level. Data on drink consumption for soft drinks, fruit juice, energy drinks and sports drinks were also combined to allow comparison with the findings of the NSW Child Health Survey 200716 and the NSW
School Students Health Behaviours Survey 2008.17 These variables were used to assess the four distinct oral health behaviours commonly accepted as being valuable in controlling oral diseases: effective oral hygiene, restriction of sugar consumption, use of fluorides and dental attendance.18 Effective oral hygiene was measured by tooth-brushing frequency, sugar consumption in terms of reported soft drink, fruit juice and sports drink use, living in a fluoridated area and a reported dental visit in the past 12 months. Data were weighted to ensure estimates reflect the Estimated Resident population of 14-15-year-olds in NSW, from which participants were selected. Sampling weights were calculated as probabilities of selection, accounting for differential response rates by Local Health District, age and sex. Data were analysed in SAS 9.219 and the questionnaire data were compared with the clinical data using cross-tabulations, chi-square tests and logistic and negative binomial regression. The key dependent variables used in the analyses were severe caries (DMFT>3; Y/N), caries experience (DMFT>0; Y/N) and DMFT counts. Logistic regression was used to determine independent predictors for dichotomous caries outcomes and negative binomial regression for DMFT counts. Potential predictors included water fluoridation, income (Y/N), mother’s education level (completed school/did not complete school), sugary drink consumption (none per day/ one or more per day), reported dental visit in the past 12 months (Y/N) and tooth-brushing frequency (≤once/day, ≥2 times/day). The backward selection method was used to derive the final model. Ethics approval for the Survey was granted by the New South Wales Population and Health Services Research Committee and through the State Education Research Assessment Process of the New South Wales Department of Education and Training. The Catholic Education Commission and Association of Independent Schools gave their permission to involve schools within their jurisdiction.
Results The final sample consisted of 1,199 14-15 year-olds for whom both clinical and questionnaire data were available. The clinical examinations found that 44.4% of teenagers overall had caries experience in at least one
Australian and New Zealand Journal of Public Health © 2014 Public Health Association of Australia
2014 vol. 38 no. 5
Dental Health
Dental caries experiences among NSW adolescents
tooth (DMFT>0), while 10.6% of the sample had experienced severe caries (DMFT>3), see Table 1. The mean DMFT for males was 1.22 and 1.07 for females (Table 1). There was no significant difference in the mean DMFT between the larger group with questionnaire and clinical data and the smaller sample reported elsewhere with clinical data only (χ2=3.33; 1 DF; p=0.068). The majority of teenagers in the survey (63.7%) had visited a dental practitioner within the past 12 months (Table 1) and 65.5% also had a regular visiting pattern of at least one visit every 12 months. More than 80% of the parents reported the primary reason for their child’s last dental visit was for a check-up and in the majority of cases (62.3%) this was to a private dental practitioner. Other common treatments received included a fluoride treatment (32.8%) and cleaning of teeth (50.6%). The reported rates of fillings and extractions were low at 18.8% and 6.5%, respectively. The majority of teenagers (87.0%) had access to the benefits of water fluoridation, 89.4% reported using a fluoride toothpaste, and 56.8% brushed their teeth at least twice a day. This tooth-brushing behaviour was also examined by gender (Table 2) with females brushing significantly more often than males (χ2=40.0; 3 DF; p0 OR (95%CI) 0.66 (0.48-0.91)* 0.59 (0.37-0.94)* 1.89 (1.23-2.92)** 1.91 (1.37-2.68)*** 1.00 (0.70-1.44) 1.22 (0.87-1.71) 0.91 (0.66-1.26)
Severe caries OR (95%CI) 0.52 (0.32-0.86)* 0.60 (0.36-1.01) 1.96 (0.81-4.70) 2.18 (1.29-3.66)** 1.37 (0.78-2.39) 1.20 (0.71-2.04) 0.96 (0.60-1.53)
# Multivariate model for dental caries among teenagers, after weighting and adjusting for all risk factors, age and gender. * p
Factors associated with dental caries experience and oral health status among New South Wales adolescents John Skinner,1,2 George Johnson,1 Anthony Blinkhorn,1 Roy Byun3
R
esearch has shown that there are critical periods in a person’s life where long-term health related behaviours can be established, with one of these crucial periods being adolescence.1,2 An early longitudinal national survey in Finland from 1977–1989 looked at oral health habits of adolescents and dental services via postal questionnaires.3 The study collected clinical and dietary information and identified the consumption of sugary drinks and frequency of tooth brushing as risk factors in oral health.3 A cross-sectional clinical assessment study combined with self-reported questionnaires looked at the relationship between socioeconomic status (SES) and caries experience in adolescents in the US.4 In this study, a random selection of parents completed a questionnaire on SES, exposure to fluoride and dental service visits. The number of decayed (D), missing (M) and filled (F) teeth (T) was used as the measure of caries experience (DMFT) in the permanent teeth of these adolescents. This is an internationally recognised measure of the current dental disease state of an individual,5 but does not measure improvements in oral health. The study reported that lower SES was associated with a higher prevalence of severe caries; however, the authors concluded that the pathways through which SES-associated disparities in oral health occur need to be determined in future research.4 Another crosssectional survey involving 2,662 adolescents in eight Chinese provincial capitals measured the relationship between certain general and oral health-related practices and parents’ level
Abstract Objective: To investigate the potential social and behavioural risk factors influencing the oral health of teenagers aged 14 and 15 years living in New South Wales Australia. Methods: Quantitative and qualitative methodologies were used in this research project. Data were obtained from both the clinical and questionnaire components of the NSW Teen Dental Survey 2010 and were analysed in SAS 9.2. The analyses allowed for various demographic and behavioural risk factors to be assessed using caries experience, severe caries and DMFT (decayed, missing or filled teeth) counts as the key outcome variables. Results: Of the 1,256 14- and 15-year-olds who had a dental examination, 1,199 (95.5%) provided questionnaire data. The clinical examinations found that 44.4% of teenagers overall had caries experience in at least one tooth, while 10.6% of the sample had experienced severe caries. Severe dental caries was found to be significantly related to a variety of factors, including family income, fluoridation status, tooth brushing behaviour and sugary drink consumption. Conclusions: The oral health of 14- and 15-year-olds in NSW is influenced by social and dietary factors as well as access to fluoridated water supplies. There was also a strong relationship between self-rated oral health status with DMFT and with caries experience. Implications: The findings of this study will assist policy makers by highlighting the current caries risk factors that should be part of future health promotion programs. Key words: dental caries, adolescent health, tooth brushing, socioeconomic status, fluoridation
of education and income, school performance and peer relationship.6 They reported significantly higher scores for adolescents on oral hygiene practices with high parental levels of education and income, and also peer relationship.6 In 2001, a review of the effectiveness of oral health education and promotion literature concluded that many current interventions were poorly and inadequately evaluated.7 It stated that scientifically validated evaluation and reporting in health promotion is vital to develop good practice, to provide feedback and to inform policy development.
Quantitative and qualitative methodologies are required in modern health promotion initiatives to effectively evaluate a program with the use of standardised appropriate outcomes.7 In 2012, three successful UK health promotion programs identified risk factors for oral disease as alcohol consumption, smoking, poor dietary habits and chronic diseases such as diabetes and heart disease, and suggested that health promotion programs should be multi-faceted and target these behavioural health risk factors to improve oral and general health.8 The study also
1. Population Oral Health Unit, Faculty of Dentistry, University of Sydney, New South Wales 2. Centre for Oral Health Strategy, New South Wales Ministry of Health 3. Centre for Research, Evidence Management and Surveillance, Sydney and South Western Sydney Local Health Districts, New South Wales Correspondence to: Mr John Skinner, Population Oral Health Unit, Faculty of Dentistry, University of Sydney, 1 Mons Road, Westmead, NSW 2145; e-mail: [email protected] Submitted: September 2013; Revision requested: January 2014; Accepted: March 2014 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2014; 38:485-9; doi: 10.1111/1753-6405.12245
2014 vol. 38 no. 5
Australian and New Zealand Journal of Public Health © 2014 Public Health Association of Australia
485
Skinner et al.
Article
found an association between poor oral health and lower socioeconomic (SES) class9 and this is supported by two further studies that highlight that a low parental SES can influence the oral and general health behaviour of children and adolescents.9,10
years. The teenagers attended metropolitan and non-metropolitan secondary schools under the jurisdiction of the NSW Department of Education and Training, the Catholic Education Commission and Independent Schools.
In Australia, there have been several child and adolescent oral health promotion campaigns since the early 1990s. Two such campaigns in NSW are Life Sux without Teeth11 in 1994 and the Save Our Kids Smiles program, which targeted children in kindergarten, years 2, 4, 6 at primary school and in year 8 (13-14-year-olds) in high schools from 1996 to 2000.12 More recently, the Australian Dental Association recognised the importance of adolescent oral health in NSW by targeting the oral health of teenagers during Dental Health Week in 2006.13 Promotional materials were produced on three main topics: dental erosion, oral piercings and nutrition to help fight dental decay.13
Nineteen calibrated examiners performed 1,269 clinical examinations on 14-15-yearolds at a total of 84 schools. Each examination team included a dental therapist (examiner) and a dental assistant (recorder), with children examined in schoolrooms under standardised conditions using a sterile mirror and dental probe. Dental plaque, caries, trauma and fluorosis scores were recorded directly into a laptop using a Microsoft Access database developed by the Australian Research Centre for Population Oral Health. The examinations were conducted according to a clinical examination and coding protocol based on the NSW Child Dental Health Survey 2007.15
Most dental health surveys involving the oral health of adolescents in Australia and New South Wales have focused on measuring oral health status, and limited data has been collected on the potential risk and protective factors among these groups.14 However, in 2010 the NSW Teen Dental Survey surveyed the oral health status of a random representative sample of year 9 students aged 14-15 years along with a self-reported risk-factor questionnaire. This paper focuses on the self-reported oral health behaviour and identified risk factors from the 2010 NSW Teen Dental Survey, examining the relationship with clinical oral health status. The paper uses the quantitative clinical data and the qualitative social data to explore the major sources of variation in caries experience within the sample of 14-15-year-olds. The hypothesis tested was that mean DMFT, severe caries and simple caries prevalence would each be higher among those teenagers from families with lower income levels and mothers with a lower education level. In addition, the oral health behaviours and prevention interventions of tooth brushing, use of fluoride toothpaste, access to fluoridated water, presence of fissure sealants and a recently reported dental visit is discussed.
Methods Data for the NSW Teen Dental Survey were collected in 2010 from a random sample of year 9 secondary students aged 14 and 15
486
A total of 1,199 of the 14-15 year-olds who had a clinical examination also completed a 17-item questionnaire related to oral hygiene behaviours, perceived oral health status, importance of their dental health, consumption of water and sugary drinks; plus a number of questions about the appearance of their front teeth, how much the condition of their teeth affected their lives, and whether they had ever felt embarrassed about having bad breath. Questions about food consumption and weight were omitted from this current study because there are already regular Child Health Surveys16 and School Students Health Behaviours Surveys17 in NSW covering these issues. The parents of the teenagers included in the survey were asked to answer a 29-item questionnaire in four main sections: nine questions on their child’s use of dental services and family dental insurance cover; eight questions related to eligibility for the Australian Medicare Teen Dental Program and their child’s use of this scheme; three questions related to their child’s general and dental health; and a final section with nine questions that collected household information related to family income, age of parents and highest level of education attained by parents. To allow modelling of the data, and comparison with other surveys, a new variable was created for mother’s highest education level. Data on drink consumption for soft drinks, fruit juice, energy drinks and sports drinks were also combined to allow comparison with the findings of the NSW Child Health Survey 200716 and the NSW
School Students Health Behaviours Survey 2008.17 These variables were used to assess the four distinct oral health behaviours commonly accepted as being valuable in controlling oral diseases: effective oral hygiene, restriction of sugar consumption, use of fluorides and dental attendance.18 Effective oral hygiene was measured by tooth-brushing frequency, sugar consumption in terms of reported soft drink, fruit juice and sports drink use, living in a fluoridated area and a reported dental visit in the past 12 months. Data were weighted to ensure estimates reflect the Estimated Resident population of 14-15-year-olds in NSW, from which participants were selected. Sampling weights were calculated as probabilities of selection, accounting for differential response rates by Local Health District, age and sex. Data were analysed in SAS 9.219 and the questionnaire data were compared with the clinical data using cross-tabulations, chi-square tests and logistic and negative binomial regression. The key dependent variables used in the analyses were severe caries (DMFT>3; Y/N), caries experience (DMFT>0; Y/N) and DMFT counts. Logistic regression was used to determine independent predictors for dichotomous caries outcomes and negative binomial regression for DMFT counts. Potential predictors included water fluoridation, income (Y/N), mother’s education level (completed school/did not complete school), sugary drink consumption (none per day/ one or more per day), reported dental visit in the past 12 months (Y/N) and tooth-brushing frequency (≤once/day, ≥2 times/day). The backward selection method was used to derive the final model. Ethics approval for the Survey was granted by the New South Wales Population and Health Services Research Committee and through the State Education Research Assessment Process of the New South Wales Department of Education and Training. The Catholic Education Commission and Association of Independent Schools gave their permission to involve schools within their jurisdiction.
Results The final sample consisted of 1,199 14-15 year-olds for whom both clinical and questionnaire data were available. The clinical examinations found that 44.4% of teenagers overall had caries experience in at least one
Australian and New Zealand Journal of Public Health © 2014 Public Health Association of Australia
2014 vol. 38 no. 5
Dental Health
Dental caries experiences among NSW adolescents
tooth (DMFT>0), while 10.6% of the sample had experienced severe caries (DMFT>3), see Table 1. The mean DMFT for males was 1.22 and 1.07 for females (Table 1). There was no significant difference in the mean DMFT between the larger group with questionnaire and clinical data and the smaller sample reported elsewhere with clinical data only (χ2=3.33; 1 DF; p=0.068). The majority of teenagers in the survey (63.7%) had visited a dental practitioner within the past 12 months (Table 1) and 65.5% also had a regular visiting pattern of at least one visit every 12 months. More than 80% of the parents reported the primary reason for their child’s last dental visit was for a check-up and in the majority of cases (62.3%) this was to a private dental practitioner. Other common treatments received included a fluoride treatment (32.8%) and cleaning of teeth (50.6%). The reported rates of fillings and extractions were low at 18.8% and 6.5%, respectively. The majority of teenagers (87.0%) had access to the benefits of water fluoridation, 89.4% reported using a fluoride toothpaste, and 56.8% brushed their teeth at least twice a day. This tooth-brushing behaviour was also examined by gender (Table 2) with females brushing significantly more often than males (χ2=40.0; 3 DF; p0 OR (95%CI) 0.66 (0.48-0.91)* 0.59 (0.37-0.94)* 1.89 (1.23-2.92)** 1.91 (1.37-2.68)*** 1.00 (0.70-1.44) 1.22 (0.87-1.71) 0.91 (0.66-1.26)
Severe caries OR (95%CI) 0.52 (0.32-0.86)* 0.60 (0.36-1.01) 1.96 (0.81-4.70) 2.18 (1.29-3.66)** 1.37 (0.78-2.39) 1.20 (0.71-2.04) 0.96 (0.60-1.53)
# Multivariate model for dental caries among teenagers, after weighting and adjusting for all risk factors, age and gender. * p
