ORIGINAL Rajab ARTICLE et al
Oral Health Status Among 6- and 12-year-old Jordanian Schoolchildren Lamis Darwish Rajaba/Poul Erik Petersenb/Zaid Baqainc/Ghazi Bakaeend Purpose: No nationwide oral health survey has previously been carried out in Jordan. The aims of the study were to assess the burden of dental caries and gingival health among children aged 6 and 12 years in relation to sociodemographic factors and to ascertain the trend over time in the occurrence of caries and the need for dental care. Materials and Methods: A cross-sectional epidemiological survey was carried out which included 2496 children aged 6 years and 2560 children aged 12 years selected by stratified cluster sampling. Children were examined in schools and data comprised information about caries and gingival health status. WHO methodology and criteria were applied. Structured questionnaires were used to collect information about oral hygiene, dental visits, consumption of sugars and parents’ level of education. Results: The caries prevalence rates were 76.4% in 6-year-olds and 45.5% in 12-year-olds, and caries experience was 3.3 dmft and 1.1 DMFT, respectively. The prevalence of caries varied significantly by sex and geographical region. In both age groups, children of the social low and middle groups had significantly higher levels of caries experience, more untreated decayed teeth and fewer filled teeth than did children of the upper socioeconomic group. Multivariate regression analysis showed that social class was the most important independent variable for caries. The results from 2005 were compared with similar data collected in the capital, Amman, in 1993. For all social classes, the mean caries experience and the amount of untreated dental caries increased over time. Moreover, 17.7% of 6-year-old children and 49.1% of the 12-year-olds had gingival bleeding. Significant differences in gingival health were found by sex, location, geographical areas and socioeconomic group. Conclusion: Oral disease is a significant public health problem in Jordan. Strengthening of the school oral health programme is needed for effective prevention and control of caries and promoting gingival health. A systematic school oral health programme including oral health promotion should be established. Key words: dental caries, gingival health, Jordan, social inequality, trends in dental caries Oral Health Prev Dent 2014;2:99-107
Submitted for publication: 27.03.12; accepted for publication: 01.02.13
doi: 10.3290/j.ohpd.a31220
O
ver the past two decades, remarkable changes in the oral health status of children have been globally observed. While oral health problems have grown in several low- and middle-income countries, a reduction in the burden of oral disease is shown a
Professor, Department of Paediatric and Preventive Dentistry, Faculty of Dentistry, University of Jordan, Amman, Jordan.
b
Professor, World Health Organization, Global Oral Health Programme, Chronic Disease and Health Promotion, Geneva, Switzerland.
c
Professor, Department of Oral and Maxillofacial Surgery, Oral Medicine, Oral Pathology, and Periodontology, Faculty of Dentistry, University of Jordan. Amman, Jordan.
d
Former Professor, Department of Oral and Maxillofacial Surgery, Oral Medicine, Oral Pathology, and Periodontology, Faculty of Dentistry, University of Jordan, Amman, Jordan.
Correspondence: Professor Lamis D. Rajab, P.O. Box 13595, 11942 Amman, Jordan. Tel: +962-6-535-5000 (ext. 23623), Fax: +962-6-5300844. Email: [email protected]
Vol 12, No 2, 2014
for the child population of several high-income countries (World Health Organization, 2003; Petersen, 2008). This epidemiological transition is observed concurrently with improved socioeconomic conditions, changing lifestyles, self-care practices, use of fluorides and effective use of preventive oral health services (Bratthall et al, 1996; Bratthall et al, 2006; Petersen, 2008). In certain high-income countries, priority in public health care is given to the child population through the establishment of health education programmes or systematic school-based oral health services (Wang et al, 1998; Källestaal et al, 1999; Petersen and Torres, 1999; Kwan et al, 2005). In low- and middle-income countries, the health authorities give little attention to oral health care beyond the control of pain and other symptoms. A number of studies carried out in the Middle East (Al-Khateeb et al, 1990; Al-Ismaily et al, 1996; Al-
99
Rajab et al
Tamimi et al, 1998; Al-Shammery 1999; Abdellatif, 2004; Al-Ismaily et al, 2004; Beiruti et al, 2004; Pakshir, 2004; Zusman et al, 2005; Al-Mutawa et al, 2006; Al-Sadhan et al, 2006; Meyer Lueckel et al, 2006; Ahmed et al, 2007) indicated that the prevalence of caries among children was low to moderate (World Health Organization, 2003; Petersen, 2008). In Jordan, a study of schoolchildren conducted in 1993 in the capital, Amman (Hamdan and Rock, 1993), showed that the caries prevalence rate was 63% at age 6 and 41% at age 12. The mean caries experience was 2.2 dmft for 6-year-olds and 1.0 DMFT for 12-year-olds; however, some socioeconomic variation in caries prevalence was found in a study carried out in 2000 among 12-year-old schoolchildren in northern Jordan (Irbid area) (Albashaireh and Hamasha, 2000), where the caries prevalence rate was 73% while the mean DMFT index was 2.5. In Jordan, the School Oral Health Services Department of the Ministry of Health is responsible for the organisation of oral health programmes for children. All schoolchildren must have their teeth examined regularly and parents receive a report of their child’s oral health status. Parents are encouraged to seek a dentist for any necessary dental care for their child, either a private dental practitioner or a dentist working in the public health care sector. Since an oral health survey carried out in 1993 (Hamdan and Rock, 1993), the Ministry of Health established a fluoride mouth-rinsing programme targeting elementary schoolchildren (grades 2–4), in which children rinse once a week with a sodium fluoride solution (0.1 %). Teachers at primary schools have been trained in the administration of fluoride. Unfortunately, no surveillance studies have been undertaken to investigate the effectiveness of this school health programme. The present study was designed to provide nationwide information on the oral health status of Jordanian schoolchildren. The specific objectives of the study were: 1) to assess the burden of caries and to describe the gingival health status of children aged 6 and 12 in relation to gender, urbanisation, geographic location and socioeconomic status and 2) to ascertain the trend over time in the level of caries and the need for dental care based on studies of children carried out in identical settings. The intentions of the survey were to provide data for the surveillance of oral health and monitoring of oral health promotion programmes for schoolchildren in the country as well as to assist Jordanian health authorities in making appropriate adjustments to oral health interventions.
100
MATERIALS AND METHODS Study area The country of Jordan covers an area of 89,342 square kilometres and numbers an estimated 6 million inhabitants. The population is young, i.e. 59% are under 25 years of age (Department of Statistics 2003, 2004). In total, 83% of the population live in urban centres and 40% reside in the capital of Amman. The dentist to population ratio is 1:1800. There are two kinds of schools, government and private; 80% of children attend government schools, and school is compulsory for children aged 6–14. Jordan is divided into 12 administrative regions. Three geographically dispersed regions were identified as settings for the present survey in order to obtain nationally representative samples of 6- and 12-year-olds, i.e. the northern part (the Irbid area), the central part (the capital of Amman and environs) and the southern part of the country (the Alkarak area).
Study population and sampling procedure In this study, children were chosen from a representative sample of primary and secondary schools for boys and girls using stratified cluster sampling. The schools were selected to include urban and rural areas. Moreover, within the capital of Amman, three different areas were identified; children were selected with a view to balancing the sample by socioeconomic criteria. Children were classified into socioeconomic (SE) groups according to the standard of schools: the upper SE group covered children from private schools; the middle SE group comprised children from state schools, while the low SE group included children from schools located in deprived areas and refugee camps. In all, 103 schools for boys and girls were selected; geographically, 51 schools were chosen in the central region of the country, 20 schools were in the north and 32 in the south. As to location, 57 schools were in urban and 46 in rural areas. As a guideline, the number of children estimated for the sample was set at 2000 in grade 1 (approximately 6 years of age) and 2000 in grade 6 (approximately 12 years of age) in accordance with prior power analysis. After implementation of the survey, the final study population comprised 2496 children aged 6 and 2560 children aged 12; 48% were boys and 52% were girls. All children in
Oral Health & Preventive Dentistry
Rajab et al
the classrooms were targeted and the survey response rate was about 99%.
northern area, from 0.43 to 0.55 mg/l (mean = 0.48 mg/l) in the central area and from 0.43 to 0.46 mg/l (mean = 0.44 mg/l) in the south.
Data collection The survey design was planned jointly with the WHO Global Oral Health Programme, Geneva, including the planning of clinical procedures and calibration trials. Among children, caries and poor gingival health are the major oral health conditions relevant to public health intervention. Clinical examinations of oral health status were conducted in 2005 and clinical data were collected according to the standardised criteria of the WHO (World Health Organization, 1997). Children were examined in classrooms under artificial light using dental mirrors and the WHO CPI periodontal probe. Thus, as recommended by the WHO survey methodology, the examination included recording caries at the cavity level, whereas the Community Periodontal Index (CPI) criteria were used for assessment of gingival health status (score 0: healthy; score 1: gingival bleeding; score 2: calculus). Probing of pocket depth was not performed. Prior to the clinical study, the clinical examiners (10 dentists) were trained in field work and calibrated against an international epidemiologist (PEP). At least 85% consistency in recording caries was achieved and Kappa scores were higher than 0.8, which are the levels recommended by the WHO (1997). During the survey, double examinations of approximately 10% of the children were performed in order to assess intra- and inter-examiner variability in the use of diagnostic criteria. The Kappa statistics obtained on intra- and inter-examiner consistency in the diagnosis of caries were 0.92 and 0.89, respectively. Prior to the clinical examination, information about age, gender, location, SE group, parents’ level of education, dental visits, oral hygiene habits and consumption of sugars (frequency) was collected based on self-administered structured questionnaires addressed to the parents. SE group was classified by type of school and setting.
Data analysis Processing and analysis of data were carried out using the Statistical Package for the Social Sciences (SPSS, PC Version 16.0; Chicago, IL, USA). The caries occurrence was expressed by the prevalence rate and standard indices of caries for deciduous (dmft) and permanent teeth (DMFT). Frequency distributions and dmft/DMFT means were computed for the univariate and bivariate analyses. Student’s t-test or ANOVA was applied for the statistical evaluation of differences in caries means whereas proportions were compared using the chisquare test. Moreover, multivariate analyses were performed by linear regression of the dependent variables dmft/DMFT, and logistic regression included the calculation of odds ratio (OR) for presence of caries (Armitage and Berry, 1994). The association between caries experience and sociobehavioural variables was then explored. The original responses to the questions on dental visits, toothbrushing habits, supervision of toothbrushing and level of education of parent(s) were used in the multivariate analyses. Variables on consumption of sugary drinks and sweets were: high = ‘once or more a day’, moderate = ‘several times a week’, low = ‘sometimes or never’. Regression coefficients were evaluated by the t-test, while the chi-square test was used for OR as estimated by logistic regression analysis. The CPI data were analysed according to WHO recommendations, whereby participants were categorised by maximum CPI score and the mean number of sextants with certain gingival conditions was computed. The chi-square test was used in the statistical analyses of CPI maximum scores, while ANOVA was applied for evaluation of the number of CPI sextants.
RESULTS Fluoride analysis Caries Information on fluoride in drinking water is available from routine evaluations carried out by the Ministry of Environment. The mean fluoride level ranged from 0.43 to 0.55 mg/l (mean = 0.48 mg/l) in the
Vol 12, No 2, 2014
Table 1 shows the prevalence rates and caries experience of children. The d/D-component of the caries indices was dominant in both age groups. At
101
Rajab et al
Table 1 Caries prevalence rate (%) and mean caries experience of Jordanian children aged 6 (dmft) and 12 years (DMF-T) according to gender
60 50 DMFT – 12 years
Indicator
Boys
Girls
Total
6 years
(n=1229)
(n=1267)
(n=2496)
Caries prevalence
79.0
dt
3.0*
74.0
76.4
2.6
2.8
40 %
30 20
dmft – 6 years
10
mt
0.3
0.2
0.2
ft
0.2
0.3
0.3
dmft
3.5*
3.1
3.3
12 years
(n=1209)
(n=1351) 50.6***
(n=2560)
Caries prevalence
39.9
DT
0.7
1.0
0.9
MT
0.0
0.0
0.0
FT
0.1
0.2
0.2
DMFT
0.9
1.2***
1.1
0
0
2
4
6 8 dmft/DMFT
10
12
Fig 1 Distribution (%) of Jordanian children aged 6 and 12 years by caries experience (dmft or DMFT).
45.5
* P < 0.05, *** P < 0.001.
the age of 6, boys had more caries experience than girls. For 12-year-olds, the mean caries experience as well as the caries prevalence rate was high among girls, as confirmed by the t-test (P < 0.001). Figure 1 demonstrates the distribution of children according to the absolute value of caries experience; 32.9% of the 6-year-olds had five or more primary teeth affected by caries and 16.8% of the 12-year-olds had 3 or more permanent teeth with caries. Table 2 illustrates the level of caries of children according to geographical/administrative area. The caries prevalence rate was significantly higher among 6-year-olds living in the north than in the central or southern geographic areas (chi-square, P < 0.05). The amount of untreated caries was high for children living in the north. The occurrence of caries was about the same among children living in rural and urban locations. In both age groups, the level of caries was significantly higher among children of the low and middle social classes than among children from the upper social class. Further, children of the low and middle social classes had more untreated decayed teeth and fewer filled teeth than did children of the upper class. Figure 2 illustrates this situation among the 6-year-olds examined in Amman, which confirms a similar pattern observed in 1993.
102
Multivariate analyses of caries Multivariate analyses of caries experience were undertaken for 6- and 12-year-olds separately (Table 3). Consistent with the bivariate analyses, social class was the most important independent variable for caries. In 6-year-olds, caries experience (dmft) was significantly lower for children of the upper class (` = -0.73, P < 0.01) than for children of the low class; in parallel, upper-class children had a lower caries risk (OR = 0.48, P < 0.01). Corresponding results were noted for DMFT among 12-year-olds; the regression coefficients for upperclass children were ` = -0.65 (P < 0.01) and OR = 0.52 (P < 0.01). At age 6, children of parents with high education had a lower caries experience (` = -0.63, P < 0.05) and a lower risk estimate (OR = 0.54, P < 0.05) when compared to children of parents with low education. No statistically significant associations were found as regards caries and the behavioural variables. Among 6-year-olds, however, caries experience and the odds ratio of caries tended to be somewhat higher in children with frequent consumption of sweets and sugary drinks. For both age groups, it was noted that caries was not associated with the variable ‘dental visits within the past 12 months’.
Oral Health & Preventive Dentistry
Rajab et al
Table 2 Caries prevalence rate (%) and mean caries experience of Jordanian 6-year-olds (dmft) and 12-year-olds (DMFT) according to geographic area and urbanisation Geographic area
Urbanisation
Indicator
Central
North
South
Total
Urban
Rural
Total
6 years
(n = 1267)
(n = 612)
(n = 617)
(n = 2496)
(n = 1583)
(n = 913)
(n = 2496)
Caries prevalence
74.5
dt
2.6
mt
73.7
76.4
77.0
75.5
76.4
3.4***
2.7
2.8
2.7
3.0
2.8
0.2
0.3
0.2
0.2
0.3
0.2
0.2
ft
0.3
0.2
0.2
0.3
0.3
0.2***
0.3
dmft
3.2
3.9***
3.0
3.3
3.3
3.4
3.3
12 years
(n = 1238)
(n = 602)
(n = 2560)
(n = 1658)
(n = 902)
(n = 2560)
Caries prevalence
45.9
83.2*
(n = 720) 49.6
40.0
45.5
45.1
46.3
45.5
DT
0.8
1.1***
0.8
0.9
0.8
0.9
0.9
MT
0.0
0.0
0.0
0.0
0.0
0.0
0.0
FT
0.2
0.1
0.0
0.2
0.2
0.1***
0.2
DMFT
1.5
1.2
0.9
1.1
1.1
1.0
1.1
* P < 0.05, *** P < 0.001.
Gingival health
DISCUSSION The present survey was undertaken to provide nationwide information on the oral health status of Jordanian schoolchildren aged 6 and 12 years; these are standard age groups recommended by WHO for intra- and inter-country comparisons. It is a disadvantage that a national sample cannot be drawn automatically as there is no census list of
Vol 12, No 2, 2014
3
f-t m-t d-t
2.5 2 dmft
The WHO CPI system is based on frequency distributions of individuals by maximum CPI scores and the mean number of sextants with specific CPI scores. The information on the outcome of CPI recordings is shown in Table 4a for 6-year-olds and in Table 4b for 12-year-olds. In all, 82% of 6-year-old children had a maximum CPI score of 0 (i.e. healthy gingival conditions). The percentage of individuals affected by gingival bleeding was relatively high for children of rural areas, the southern region and the low social class. About half of the 12-year-olds had maximum CPI scores of 1 and 2 (i.e. gingival bleeding). Similarly, the figures for gingival bleeding were relatively high among rural children, children of the south, low social class and boys.
3.5
1.5 1 0.5 0
1993 2005
1993 2005
1993 2005
1993 2005
High
Middle
Low
Total
Fig 2 Mean caries experience (dmft) in 6-year-olds in the capital of Amman by social group in 1993 (Hamdan and Rock, 1993) and 2005.
the population in Jordan. However, the school system provides an effective frame for sampling of children and the high response rates obtained in the survey imply that the final sample should be considered relevant for the purpose of the study. The clinical examination of caries and gingival health was conducted in accordance with WHO
103
Rajab et al
Table 3 Multivariate analysis of caries experience in Jordanian children aged 6 and 12 years 6 years Independent variable
12 years
Category
dmft (`)
OR
Male
0.26
1.30
DMFT (`) -0.31**
OR 0.54*
Gender Female Socioeconomic group
Dental visits
Brushing
Consumption of sweets
Parents’ educational level
Brushing supervised by parent R
-
-
-
Upper
-0.73**
0.48**
-0.65**
0.52**
Middle
-0.08
0.93
-0.28
0.75
Low
-
-
-
-
Within the last 12 months
0.29
1.33
-0.13
0.88
Irregular dental visit
0.08
1.09
0.04
1.04
Never been to a dentist
-
Twice a day or more
-0.09
0.92
0.01
1.01
Once a day
0.36
1.43
0.33
1.39
Less often than daily Consumption of sugary drinks
-
-
-
-
-
-
-
-
High
0.20
1.23
0.06
1.06
Moderate
-0.03
0.97
0.28
1.32
Low
-
-
-
-
High
0.57
1.71
0.13
1.14
Moderate
-0.27
1.31
-0.05
0.95
Low
-
-
-
-
High
-0.63*
0.54*
-0.41
0.66
Intermediate
-0.22
0.80
-0.41*
0.67**
Low
-
Yes
-0.10
No
-
2
0.92 -
0.05
-0.26 -
0.77 -
0.05
Dependent variables in the linear regression are dmft or DMFT (regression coefficient `), while in the logistic regression, odds ratio (OR) is calculated from presence/absence of caries. *P < 0.05, **P < 0.01.
guidelines for oral health surveys (World Health Organization, 1997) and successful calibration of examiners was carried out by the WHO prior to the final data collection. This study of schoolchildren demonstrated that caries is a significant public health problem in Jordan. Nearly half of the 12-year-olds and 75% of the 6-year-olds were affected by caries, and the distributions of caries experience were highly skewed to the right for both age groups. The level of caries among 6-year-old children was very high compared to the global goal set by the WHO for the year 2000, i.e. at least 50% of 6-year-old children should be free of caries (World Health Organization, 1982). Meanwhile, the level of caries in children aged 12 years
104
was well below the WHO global goal set for the year 2000, i.e. no more than 3 DMFT (World Health Organization, 1982). A comparison with recent findings from studies carried out in Mediterranean countries indicates that the caries experience of 12-year-old children in Jordan was lower than figures observed for neighbouring countries (Al-Tamimi and Petersen, 1998; Al-Shammery, 1999; Beiruti, 2004; Zusman et al, 2005; Ahmed et al, 2007). Nevertheless, it is worth noting that in all countries, the D-component was the major contributor to total caries index. The caries occurrence varied between the three geographic areas, while the caries prevalence rate as well as the mean caries experience was very similar for urban and rural children. It should be
Oral Health & Preventive Dentistry
Rajab et al
Table 4a Percentages of Jordanian children aged 6 (n = 2496) with specific CPI maximum scores and the mean number of sextants with CPI scores according to urbanisation, gender, geographic/ administrative area and social class CPI max % 6 years
Score 0 (healthy)
Score 1 (bleeding)
Urban
87.5*
11.5
Rural
73.5
Total
Mean no. of sextants Score 2 (bleeding and calculus)
Score 0 (healthy)
Score 1 (bleeding)
Score 2 (bleeding and calculus)
1.0
5.5
0.5
0.0
23.4*
1.1
4.9
1.0
0.1
82.4
15.9
1.8
5.3
0.7
0.0
Boys
80.7
17.2
2.0
5.3
0.7
0.0
Girls
84.0
14.5
1.5
5.3
0.7
0.0
Total
82.4
15.9
1.8
5.3
0.7
0.0
Central
88.9*
10.5
0.6
5.6
0.4
0.0
North
79.2
19.1
1.6
5.2
0.8
0.0
South
72.1
23.7*
4.2*
4.7
1.2
0.1
Total
82.4
15.9
1.8
5.3
0.7
0.0
97.9*
1.8
3.0
5.9
0.1
0.0
Middle
94.2
5.8
0.0
5.8
0.2
0.0
Low
81.0
17.8*
1.2
5.3
0.7
0.0
Total
88.9
10.5
0.6
5.6
0.4
0.0
Socioeconomic group High
(+) Children in Amman; *P < 0.001.
mentioned that due to the greater availability of dental services in urban areas, the f/F component of the caries index was higher in urban than rural children. The effect of sociobehavioural factors on disease patterns is universal (Petersen, 2005; Kwan and Petersen, 2010). Among the children investigated in Jordan, consumption of sweets and sugary drinks presumably played a role in caries; however, the associations of caries with behavioural factors were not statistically significant. Meanwhile, the relationship between social inequality and caries was profound. The total amount of caries was substantially higher in children of the low and middle SE groups than in children of the upper SE group. In addition, the d/D and f/F components differed considerably between the various social groups. Children of the upper SE group had higher numbers of filled teeth than children of the low SE group; on the other
Vol 12, No 2, 2014
hand, children of the low SE group had a relatively high value OR and a relatively high level of untreated caries. In parallel to this pattern, poor gingival health varied by SE group, urbanisation, geographical location and sex. The oral disease profile outlined possibly relates to differences in self-care practices, dietary habits, access to and use of dental services, social norms and dental attitudes, as well as the lack of a regular dental care tradition. The data make it possible to assess the trend over time in caries of Jordanian children. In Amman, an oral health survey of children aged 6 and 12 years was conducted by Hamdan and Rock (1993); the same settings of that survey were included in the present study. In addition, WHO criteria (1997) were used in the recording of caries in both studies. The analysis based on the two surveys illustrates important changes over time in the level of caries. Together, the two surveys also dem-
105
Rajab et al
Table 4b Percentages of Jordanian children aged 12 (n = 2560) with specific CPI maximum scores and the mean number of sextants with CPI scores according to urbanisation, gender, geographic/administrative area and social class CPI max % 12 years
Score 0 (healthy)
Score 1 (bleeding)
Urban
55.9*
34.3
Rural
41.8
Total
Mean no. of sextants Score 2 (bleeding and calculus)
Score 0 (healthy)
Score 1 (bleeding)
Score 2 (bleeding and calculus)
9.8
4.4
1.5
0.1
47.5*
10.8
3.5
2.3
0.2
50.9
38.9
10.2
4.1
1.8
0.1
Boys
42.5
44.2*
13.3
3.8
2.0
0.2
Girls
58.5*
34.2
7.3
4.3
1.6
0.1
Total
50.9
38.9
10.2
4.1
1.8
0.1
Central
56.5
34.8
8.7
4.4
1.5
0.1
North
54.2
36.1
9.7
4.3
1.6
0.1
South
35.7*
50.7*
13.6*
3.3
2.5
0.2
Total
50.9
38.9
10.2
4.1
1.8
0.1
77.3*
19.1
3.6
5.4
0.6
-
Middle
61.5
30.2
8.3
4.7
1.2
0.1
Low
42.4
45.8*
11.8*
3.6
2.2
0.2
Total
56.5
34.8
8.7
4.4
1.5
0.1
Socioeconomic group High
(+) Children in Amman; *P < 0.001.
onstrate the persistence of social inequality in caries; it should be pointed out that the social gap in the amount of untreated caries has widened over this time period. Thus, as emphasised by the WHO (Kwan and Petersen, 2010), it is of utmost importance that public health intervention be oriented towards the root causes of oral diseases. While this study reported a low prevalence of gingival bleeding among the 6-year-old children, poor gingival health was significant among the 12-yearold children. These findings are similar to national data available from the region included in the WHO Global Oral Health Data Bank (World Health Organization, 2010). Boys, rural children, those from the low SE group and from the southern area are particularly in need of oral hygiene instruction.
106
CONCLUSION The oral health situation of children in Jordan is far from under control; in particular, the burden of oral disease is prominent among children with a low socioeconomic background. The trend of caries over time indicates that the poor oral health status of young children and the social inequality observed may worsen unless oral health intervention is intensified. The present fluoride administration (0.1 % F) seems inadequate for prevention and control of caries. It is a challenge for the Ministry of Health as a matter of urgency to ensure effective application of fluoride and to establish systematic school health services. The existing school oral health programme is rather passive and the screening system with referral of children to dentists is seemingly insufficient. In addition to resolving the considerable dental care needs, the survey results provide support for the introduction of systematic
Oral Health & Preventive Dentistry
Rajab et al
health promotion. In line with the WHO Health Promoting Schools concept (Rajab et al, 2002; World Health Organization, 2003), health intervention must target young schoolchildren, pre-school children, parents and the wider community. It is vital that community- and family-oriented health promotion emphasise environmental risk factors and the importance of healthy lifestyles, i.e. balanced diet, restriction of the consumption of sugars and improvement of oral hygiene practices.
ACKNOWLEDGEMENTS The study was funded by the Higher Council for Science and Technology and supported by the World Health Organization (research grant number 1-2-1-2081).
REFERENCES 1. Abdellatif A. Oral health in Tunisia. Int Dent J 2004;54: 389–394. 2. Ahmed NA, Astrøm AN, Skaug N, Petersen PE. Dental caries prevalence and risk factors among 12-year old schoolchildren from Baghdad, Iraq: a post-war survey. Int Dent J 2007;57:36–44. 3. Albashaireh Z, al-Hadi Hamasha A. Prevalence of dental caries in 12–13-year-old Jordanian students. SADJ 2000;57:89–91. 4. Al-Ismaily M, Al-Busaidy K, Al-Khussaiby A. The progression of dental disease in Omani schoolchildren. Int Dent J 2004;54:409–410. 5. Al-Ismaily M, Al-Khussaiby A, Chestnutt IG, Stephen KW, Al-Riyami A, Abbas M, Knight M. The oral health status of Omani 12-year-olds – a national survey. Community Dent Oral Epidemiol 1996;24:362–363. 6. Al-Khateeb TL, Darwish SK, Bastawi AE, O’Mullane DM. Dental caries in children residing in communities in Saudi Arabia with differing levels of natural fluoride in the drinking water. Community Dent Health 1990;7:165–171. 7. Al-Mutawa SA, Shyama M, Al-Duwairi Y, Soparkar P. Dental caries experience of Kuwaiti schoolchildren. Community Dent Health 2006;23:31–36. 8. Al-Sadhan SA. Dental caries prevalence among 12–14 year-old schoolchildren in Riyadh: A 14 year follow-up study of the Oral Health Survey of Saudi Arabia Phase I. Saudi Dent J 2006;18:2–7. 9. Al-Shammery AR. Caries experience of urban and rural children in Saudi Arabia. J Public Health Dent 1999;59:60–64. 10. Al-Tamimi S, Petersen PE. Oral health situation of schoolchildren, mothers and schoolteachers in Saudi Arabia. Int Dent J 1998;48:180–186. 11. Armitage P, Berry G. Statistical methods in medical research. London: Blackwell Scientific Publications, 1994. 12. Beiruti N, van Palenstein Helderman WH. Oral health in Syria. Int Dent J. 2004;54(suppl 1):383–888. 13. Bratthall D, Hansel-Petersson G, Sundberg H. Reasons for the caries decline: what do experts believe? Eur J Oral Sci 1996;104:416–422.
Vol 12, No 2, 2014
14. Bratthall D, Petersen PE, Stjernswärd JR, Brown J. Chapter 38: Oral and craniofacial diseases and disorders. In: Jamison DT, Breman JG, Measham AR, et al (eds). Disease control priorities in developing countries. New York: World Bank Health and Oxford University Press, 2006:723–736. 15. Department of Statistics 2003. Analytical report of multipurpose household survey 2003, Amman, Hashemite Kingdom of Jordan. 16. Department of Statistics 2004. Population and housing census 2004, Hashemite Kingdom of Jordan. 17. Hamdan MAM, Rock WP. Dental caries experience in Jordanian and English schoolchildren. Community Dent Health 1993;10:151–157. 18. Källestaal C, Wang NJ, Petersen PE, Arnadottir IB. Caries preventive methods for children and adolescents in Denmark, Iceland, Norway and Sweden. Community Dent Oral Epidemiol 1999;27:144–151. 19. Kwan S, Petersen PE. Oral health: equity and social determinants. In: Blas E, Sivansankara Kurup A (eds). Equity, social determinants and public health programmes. Geneva: WHO, 2010:159–176. 20. Kwan SY, Petersen PE, Pine CM, Borutta A. Health-promoting schools: an opportunity for oral health promotion. Bull World Health Organ 2005;83:677–685. 21. Meyer-Lueckel H, Paris S, Shirkhani B, Hopfenmuller W, Kielbassa AM. Caries and fluorosis in 6- and 9-year-old children residing in three communities in Iran. Community Dent Oral Epidemiol 2006;34:63–70. 22. Pakshir HR. Oral health in Iran. Int Dent J 2004;54(suppl 1):367–372. 23. Petersen PE. Oral health. Int Encyclop Public Health 2008;1:677–685. 24. Petersen PE. Socio-behavioural risk factors in dental caries–international perspectives. Community Dent Oral Epidemiol 2005;33:274–279. 25. Petersen PE, Torres AM. Preventive oral health care and health promotion provided for children and adolescents by the Municipal Dental Health Service in Denmark. Int J Paediatr Dent 1999;9:81–91. 26. Rajab LD, Petersen PE, Bakeen G, Hamdan MA. Oral health behaviour of schoolchildren and parents in Jordan. Int J Paediatr Dent 2002;12:168–76. 27. Wang N, Källestaal C, Petersen PE, Arnadottir IB. Caries preventive services for children and adolescents in Denmark, Iceland, Norway and Sweden. Community Dent Oral Epidemiol 1998;26:263–271. 28. World Health Organization. Global goals for oral health in the year 2000. Int Dent J 1982;32:74–77. 29. World Health Organization. Oral health surveys – basic methods, ed 4. Geneva: WHO, 1997. 30. World Health Organization. Oral health promotion: an essential element of a health promoting school. WHO information series on school health (document 11). Geneva: WHO, 2003. 31. World Health Organization. The world oral health report 2003: continuous improvement of oral health in the 21st century – the approach of the WHO Global Oral Health Programme. Geneva: WHO, 2003. 32. World Health Organization. Periodontal profiles: an overview of CPITN data in the WHO Global Oral Data Bank. Geneva: WHO, 2010. 33. Zusman SP, Ramon T, Natapov L, Kooby E. Dental health of 12-year-olds in Israel-2002. Community Dent Health 2005;22:175–179.
107
Oral Health Status Among 6- and 12-year-old Jordanian Schoolchildren Lamis Darwish Rajaba/Poul Erik Petersenb/Zaid Baqainc/Ghazi Bakaeend Purpose: No nationwide oral health survey has previously been carried out in Jordan. The aims of the study were to assess the burden of dental caries and gingival health among children aged 6 and 12 years in relation to sociodemographic factors and to ascertain the trend over time in the occurrence of caries and the need for dental care. Materials and Methods: A cross-sectional epidemiological survey was carried out which included 2496 children aged 6 years and 2560 children aged 12 years selected by stratified cluster sampling. Children were examined in schools and data comprised information about caries and gingival health status. WHO methodology and criteria were applied. Structured questionnaires were used to collect information about oral hygiene, dental visits, consumption of sugars and parents’ level of education. Results: The caries prevalence rates were 76.4% in 6-year-olds and 45.5% in 12-year-olds, and caries experience was 3.3 dmft and 1.1 DMFT, respectively. The prevalence of caries varied significantly by sex and geographical region. In both age groups, children of the social low and middle groups had significantly higher levels of caries experience, more untreated decayed teeth and fewer filled teeth than did children of the upper socioeconomic group. Multivariate regression analysis showed that social class was the most important independent variable for caries. The results from 2005 were compared with similar data collected in the capital, Amman, in 1993. For all social classes, the mean caries experience and the amount of untreated dental caries increased over time. Moreover, 17.7% of 6-year-old children and 49.1% of the 12-year-olds had gingival bleeding. Significant differences in gingival health were found by sex, location, geographical areas and socioeconomic group. Conclusion: Oral disease is a significant public health problem in Jordan. Strengthening of the school oral health programme is needed for effective prevention and control of caries and promoting gingival health. A systematic school oral health programme including oral health promotion should be established. Key words: dental caries, gingival health, Jordan, social inequality, trends in dental caries Oral Health Prev Dent 2014;2:99-107
Submitted for publication: 27.03.12; accepted for publication: 01.02.13
doi: 10.3290/j.ohpd.a31220
O
ver the past two decades, remarkable changes in the oral health status of children have been globally observed. While oral health problems have grown in several low- and middle-income countries, a reduction in the burden of oral disease is shown a
Professor, Department of Paediatric and Preventive Dentistry, Faculty of Dentistry, University of Jordan, Amman, Jordan.
b
Professor, World Health Organization, Global Oral Health Programme, Chronic Disease and Health Promotion, Geneva, Switzerland.
c
Professor, Department of Oral and Maxillofacial Surgery, Oral Medicine, Oral Pathology, and Periodontology, Faculty of Dentistry, University of Jordan. Amman, Jordan.
d
Former Professor, Department of Oral and Maxillofacial Surgery, Oral Medicine, Oral Pathology, and Periodontology, Faculty of Dentistry, University of Jordan, Amman, Jordan.
Correspondence: Professor Lamis D. Rajab, P.O. Box 13595, 11942 Amman, Jordan. Tel: +962-6-535-5000 (ext. 23623), Fax: +962-6-5300844. Email: [email protected]
Vol 12, No 2, 2014
for the child population of several high-income countries (World Health Organization, 2003; Petersen, 2008). This epidemiological transition is observed concurrently with improved socioeconomic conditions, changing lifestyles, self-care practices, use of fluorides and effective use of preventive oral health services (Bratthall et al, 1996; Bratthall et al, 2006; Petersen, 2008). In certain high-income countries, priority in public health care is given to the child population through the establishment of health education programmes or systematic school-based oral health services (Wang et al, 1998; Källestaal et al, 1999; Petersen and Torres, 1999; Kwan et al, 2005). In low- and middle-income countries, the health authorities give little attention to oral health care beyond the control of pain and other symptoms. A number of studies carried out in the Middle East (Al-Khateeb et al, 1990; Al-Ismaily et al, 1996; Al-
99
Rajab et al
Tamimi et al, 1998; Al-Shammery 1999; Abdellatif, 2004; Al-Ismaily et al, 2004; Beiruti et al, 2004; Pakshir, 2004; Zusman et al, 2005; Al-Mutawa et al, 2006; Al-Sadhan et al, 2006; Meyer Lueckel et al, 2006; Ahmed et al, 2007) indicated that the prevalence of caries among children was low to moderate (World Health Organization, 2003; Petersen, 2008). In Jordan, a study of schoolchildren conducted in 1993 in the capital, Amman (Hamdan and Rock, 1993), showed that the caries prevalence rate was 63% at age 6 and 41% at age 12. The mean caries experience was 2.2 dmft for 6-year-olds and 1.0 DMFT for 12-year-olds; however, some socioeconomic variation in caries prevalence was found in a study carried out in 2000 among 12-year-old schoolchildren in northern Jordan (Irbid area) (Albashaireh and Hamasha, 2000), where the caries prevalence rate was 73% while the mean DMFT index was 2.5. In Jordan, the School Oral Health Services Department of the Ministry of Health is responsible for the organisation of oral health programmes for children. All schoolchildren must have their teeth examined regularly and parents receive a report of their child’s oral health status. Parents are encouraged to seek a dentist for any necessary dental care for their child, either a private dental practitioner or a dentist working in the public health care sector. Since an oral health survey carried out in 1993 (Hamdan and Rock, 1993), the Ministry of Health established a fluoride mouth-rinsing programme targeting elementary schoolchildren (grades 2–4), in which children rinse once a week with a sodium fluoride solution (0.1 %). Teachers at primary schools have been trained in the administration of fluoride. Unfortunately, no surveillance studies have been undertaken to investigate the effectiveness of this school health programme. The present study was designed to provide nationwide information on the oral health status of Jordanian schoolchildren. The specific objectives of the study were: 1) to assess the burden of caries and to describe the gingival health status of children aged 6 and 12 in relation to gender, urbanisation, geographic location and socioeconomic status and 2) to ascertain the trend over time in the level of caries and the need for dental care based on studies of children carried out in identical settings. The intentions of the survey were to provide data for the surveillance of oral health and monitoring of oral health promotion programmes for schoolchildren in the country as well as to assist Jordanian health authorities in making appropriate adjustments to oral health interventions.
100
MATERIALS AND METHODS Study area The country of Jordan covers an area of 89,342 square kilometres and numbers an estimated 6 million inhabitants. The population is young, i.e. 59% are under 25 years of age (Department of Statistics 2003, 2004). In total, 83% of the population live in urban centres and 40% reside in the capital of Amman. The dentist to population ratio is 1:1800. There are two kinds of schools, government and private; 80% of children attend government schools, and school is compulsory for children aged 6–14. Jordan is divided into 12 administrative regions. Three geographically dispersed regions were identified as settings for the present survey in order to obtain nationally representative samples of 6- and 12-year-olds, i.e. the northern part (the Irbid area), the central part (the capital of Amman and environs) and the southern part of the country (the Alkarak area).
Study population and sampling procedure In this study, children were chosen from a representative sample of primary and secondary schools for boys and girls using stratified cluster sampling. The schools were selected to include urban and rural areas. Moreover, within the capital of Amman, three different areas were identified; children were selected with a view to balancing the sample by socioeconomic criteria. Children were classified into socioeconomic (SE) groups according to the standard of schools: the upper SE group covered children from private schools; the middle SE group comprised children from state schools, while the low SE group included children from schools located in deprived areas and refugee camps. In all, 103 schools for boys and girls were selected; geographically, 51 schools were chosen in the central region of the country, 20 schools were in the north and 32 in the south. As to location, 57 schools were in urban and 46 in rural areas. As a guideline, the number of children estimated for the sample was set at 2000 in grade 1 (approximately 6 years of age) and 2000 in grade 6 (approximately 12 years of age) in accordance with prior power analysis. After implementation of the survey, the final study population comprised 2496 children aged 6 and 2560 children aged 12; 48% were boys and 52% were girls. All children in
Oral Health & Preventive Dentistry
Rajab et al
the classrooms were targeted and the survey response rate was about 99%.
northern area, from 0.43 to 0.55 mg/l (mean = 0.48 mg/l) in the central area and from 0.43 to 0.46 mg/l (mean = 0.44 mg/l) in the south.
Data collection The survey design was planned jointly with the WHO Global Oral Health Programme, Geneva, including the planning of clinical procedures and calibration trials. Among children, caries and poor gingival health are the major oral health conditions relevant to public health intervention. Clinical examinations of oral health status were conducted in 2005 and clinical data were collected according to the standardised criteria of the WHO (World Health Organization, 1997). Children were examined in classrooms under artificial light using dental mirrors and the WHO CPI periodontal probe. Thus, as recommended by the WHO survey methodology, the examination included recording caries at the cavity level, whereas the Community Periodontal Index (CPI) criteria were used for assessment of gingival health status (score 0: healthy; score 1: gingival bleeding; score 2: calculus). Probing of pocket depth was not performed. Prior to the clinical study, the clinical examiners (10 dentists) were trained in field work and calibrated against an international epidemiologist (PEP). At least 85% consistency in recording caries was achieved and Kappa scores were higher than 0.8, which are the levels recommended by the WHO (1997). During the survey, double examinations of approximately 10% of the children were performed in order to assess intra- and inter-examiner variability in the use of diagnostic criteria. The Kappa statistics obtained on intra- and inter-examiner consistency in the diagnosis of caries were 0.92 and 0.89, respectively. Prior to the clinical examination, information about age, gender, location, SE group, parents’ level of education, dental visits, oral hygiene habits and consumption of sugars (frequency) was collected based on self-administered structured questionnaires addressed to the parents. SE group was classified by type of school and setting.
Data analysis Processing and analysis of data were carried out using the Statistical Package for the Social Sciences (SPSS, PC Version 16.0; Chicago, IL, USA). The caries occurrence was expressed by the prevalence rate and standard indices of caries for deciduous (dmft) and permanent teeth (DMFT). Frequency distributions and dmft/DMFT means were computed for the univariate and bivariate analyses. Student’s t-test or ANOVA was applied for the statistical evaluation of differences in caries means whereas proportions were compared using the chisquare test. Moreover, multivariate analyses were performed by linear regression of the dependent variables dmft/DMFT, and logistic regression included the calculation of odds ratio (OR) for presence of caries (Armitage and Berry, 1994). The association between caries experience and sociobehavioural variables was then explored. The original responses to the questions on dental visits, toothbrushing habits, supervision of toothbrushing and level of education of parent(s) were used in the multivariate analyses. Variables on consumption of sugary drinks and sweets were: high = ‘once or more a day’, moderate = ‘several times a week’, low = ‘sometimes or never’. Regression coefficients were evaluated by the t-test, while the chi-square test was used for OR as estimated by logistic regression analysis. The CPI data were analysed according to WHO recommendations, whereby participants were categorised by maximum CPI score and the mean number of sextants with certain gingival conditions was computed. The chi-square test was used in the statistical analyses of CPI maximum scores, while ANOVA was applied for evaluation of the number of CPI sextants.
RESULTS Fluoride analysis Caries Information on fluoride in drinking water is available from routine evaluations carried out by the Ministry of Environment. The mean fluoride level ranged from 0.43 to 0.55 mg/l (mean = 0.48 mg/l) in the
Vol 12, No 2, 2014
Table 1 shows the prevalence rates and caries experience of children. The d/D-component of the caries indices was dominant in both age groups. At
101
Rajab et al
Table 1 Caries prevalence rate (%) and mean caries experience of Jordanian children aged 6 (dmft) and 12 years (DMF-T) according to gender
60 50 DMFT – 12 years
Indicator
Boys
Girls
Total
6 years
(n=1229)
(n=1267)
(n=2496)
Caries prevalence
79.0
dt
3.0*
74.0
76.4
2.6
2.8
40 %
30 20
dmft – 6 years
10
mt
0.3
0.2
0.2
ft
0.2
0.3
0.3
dmft
3.5*
3.1
3.3
12 years
(n=1209)
(n=1351) 50.6***
(n=2560)
Caries prevalence
39.9
DT
0.7
1.0
0.9
MT
0.0
0.0
0.0
FT
0.1
0.2
0.2
DMFT
0.9
1.2***
1.1
0
0
2
4
6 8 dmft/DMFT
10
12
Fig 1 Distribution (%) of Jordanian children aged 6 and 12 years by caries experience (dmft or DMFT).
45.5
* P < 0.05, *** P < 0.001.
the age of 6, boys had more caries experience than girls. For 12-year-olds, the mean caries experience as well as the caries prevalence rate was high among girls, as confirmed by the t-test (P < 0.001). Figure 1 demonstrates the distribution of children according to the absolute value of caries experience; 32.9% of the 6-year-olds had five or more primary teeth affected by caries and 16.8% of the 12-year-olds had 3 or more permanent teeth with caries. Table 2 illustrates the level of caries of children according to geographical/administrative area. The caries prevalence rate was significantly higher among 6-year-olds living in the north than in the central or southern geographic areas (chi-square, P < 0.05). The amount of untreated caries was high for children living in the north. The occurrence of caries was about the same among children living in rural and urban locations. In both age groups, the level of caries was significantly higher among children of the low and middle social classes than among children from the upper social class. Further, children of the low and middle social classes had more untreated decayed teeth and fewer filled teeth than did children of the upper class. Figure 2 illustrates this situation among the 6-year-olds examined in Amman, which confirms a similar pattern observed in 1993.
102
Multivariate analyses of caries Multivariate analyses of caries experience were undertaken for 6- and 12-year-olds separately (Table 3). Consistent with the bivariate analyses, social class was the most important independent variable for caries. In 6-year-olds, caries experience (dmft) was significantly lower for children of the upper class (` = -0.73, P < 0.01) than for children of the low class; in parallel, upper-class children had a lower caries risk (OR = 0.48, P < 0.01). Corresponding results were noted for DMFT among 12-year-olds; the regression coefficients for upperclass children were ` = -0.65 (P < 0.01) and OR = 0.52 (P < 0.01). At age 6, children of parents with high education had a lower caries experience (` = -0.63, P < 0.05) and a lower risk estimate (OR = 0.54, P < 0.05) when compared to children of parents with low education. No statistically significant associations were found as regards caries and the behavioural variables. Among 6-year-olds, however, caries experience and the odds ratio of caries tended to be somewhat higher in children with frequent consumption of sweets and sugary drinks. For both age groups, it was noted that caries was not associated with the variable ‘dental visits within the past 12 months’.
Oral Health & Preventive Dentistry
Rajab et al
Table 2 Caries prevalence rate (%) and mean caries experience of Jordanian 6-year-olds (dmft) and 12-year-olds (DMFT) according to geographic area and urbanisation Geographic area
Urbanisation
Indicator
Central
North
South
Total
Urban
Rural
Total
6 years
(n = 1267)
(n = 612)
(n = 617)
(n = 2496)
(n = 1583)
(n = 913)
(n = 2496)
Caries prevalence
74.5
dt
2.6
mt
73.7
76.4
77.0
75.5
76.4
3.4***
2.7
2.8
2.7
3.0
2.8
0.2
0.3
0.2
0.2
0.3
0.2
0.2
ft
0.3
0.2
0.2
0.3
0.3
0.2***
0.3
dmft
3.2
3.9***
3.0
3.3
3.3
3.4
3.3
12 years
(n = 1238)
(n = 602)
(n = 2560)
(n = 1658)
(n = 902)
(n = 2560)
Caries prevalence
45.9
83.2*
(n = 720) 49.6
40.0
45.5
45.1
46.3
45.5
DT
0.8
1.1***
0.8
0.9
0.8
0.9
0.9
MT
0.0
0.0
0.0
0.0
0.0
0.0
0.0
FT
0.2
0.1
0.0
0.2
0.2
0.1***
0.2
DMFT
1.5
1.2
0.9
1.1
1.1
1.0
1.1
* P < 0.05, *** P < 0.001.
Gingival health
DISCUSSION The present survey was undertaken to provide nationwide information on the oral health status of Jordanian schoolchildren aged 6 and 12 years; these are standard age groups recommended by WHO for intra- and inter-country comparisons. It is a disadvantage that a national sample cannot be drawn automatically as there is no census list of
Vol 12, No 2, 2014
3
f-t m-t d-t
2.5 2 dmft
The WHO CPI system is based on frequency distributions of individuals by maximum CPI scores and the mean number of sextants with specific CPI scores. The information on the outcome of CPI recordings is shown in Table 4a for 6-year-olds and in Table 4b for 12-year-olds. In all, 82% of 6-year-old children had a maximum CPI score of 0 (i.e. healthy gingival conditions). The percentage of individuals affected by gingival bleeding was relatively high for children of rural areas, the southern region and the low social class. About half of the 12-year-olds had maximum CPI scores of 1 and 2 (i.e. gingival bleeding). Similarly, the figures for gingival bleeding were relatively high among rural children, children of the south, low social class and boys.
3.5
1.5 1 0.5 0
1993 2005
1993 2005
1993 2005
1993 2005
High
Middle
Low
Total
Fig 2 Mean caries experience (dmft) in 6-year-olds in the capital of Amman by social group in 1993 (Hamdan and Rock, 1993) and 2005.
the population in Jordan. However, the school system provides an effective frame for sampling of children and the high response rates obtained in the survey imply that the final sample should be considered relevant for the purpose of the study. The clinical examination of caries and gingival health was conducted in accordance with WHO
103
Rajab et al
Table 3 Multivariate analysis of caries experience in Jordanian children aged 6 and 12 years 6 years Independent variable
12 years
Category
dmft (`)
OR
Male
0.26
1.30
DMFT (`) -0.31**
OR 0.54*
Gender Female Socioeconomic group
Dental visits
Brushing
Consumption of sweets
Parents’ educational level
Brushing supervised by parent R
-
-
-
Upper
-0.73**
0.48**
-0.65**
0.52**
Middle
-0.08
0.93
-0.28
0.75
Low
-
-
-
-
Within the last 12 months
0.29
1.33
-0.13
0.88
Irregular dental visit
0.08
1.09
0.04
1.04
Never been to a dentist
-
Twice a day or more
-0.09
0.92
0.01
1.01
Once a day
0.36
1.43
0.33
1.39
Less often than daily Consumption of sugary drinks
-
-
-
-
-
-
-
-
High
0.20
1.23
0.06
1.06
Moderate
-0.03
0.97
0.28
1.32
Low
-
-
-
-
High
0.57
1.71
0.13
1.14
Moderate
-0.27
1.31
-0.05
0.95
Low
-
-
-
-
High
-0.63*
0.54*
-0.41
0.66
Intermediate
-0.22
0.80
-0.41*
0.67**
Low
-
Yes
-0.10
No
-
2
0.92 -
0.05
-0.26 -
0.77 -
0.05
Dependent variables in the linear regression are dmft or DMFT (regression coefficient `), while in the logistic regression, odds ratio (OR) is calculated from presence/absence of caries. *P < 0.05, **P < 0.01.
guidelines for oral health surveys (World Health Organization, 1997) and successful calibration of examiners was carried out by the WHO prior to the final data collection. This study of schoolchildren demonstrated that caries is a significant public health problem in Jordan. Nearly half of the 12-year-olds and 75% of the 6-year-olds were affected by caries, and the distributions of caries experience were highly skewed to the right for both age groups. The level of caries among 6-year-old children was very high compared to the global goal set by the WHO for the year 2000, i.e. at least 50% of 6-year-old children should be free of caries (World Health Organization, 1982). Meanwhile, the level of caries in children aged 12 years
104
was well below the WHO global goal set for the year 2000, i.e. no more than 3 DMFT (World Health Organization, 1982). A comparison with recent findings from studies carried out in Mediterranean countries indicates that the caries experience of 12-year-old children in Jordan was lower than figures observed for neighbouring countries (Al-Tamimi and Petersen, 1998; Al-Shammery, 1999; Beiruti, 2004; Zusman et al, 2005; Ahmed et al, 2007). Nevertheless, it is worth noting that in all countries, the D-component was the major contributor to total caries index. The caries occurrence varied between the three geographic areas, while the caries prevalence rate as well as the mean caries experience was very similar for urban and rural children. It should be
Oral Health & Preventive Dentistry
Rajab et al
Table 4a Percentages of Jordanian children aged 6 (n = 2496) with specific CPI maximum scores and the mean number of sextants with CPI scores according to urbanisation, gender, geographic/ administrative area and social class CPI max % 6 years
Score 0 (healthy)
Score 1 (bleeding)
Urban
87.5*
11.5
Rural
73.5
Total
Mean no. of sextants Score 2 (bleeding and calculus)
Score 0 (healthy)
Score 1 (bleeding)
Score 2 (bleeding and calculus)
1.0
5.5
0.5
0.0
23.4*
1.1
4.9
1.0
0.1
82.4
15.9
1.8
5.3
0.7
0.0
Boys
80.7
17.2
2.0
5.3
0.7
0.0
Girls
84.0
14.5
1.5
5.3
0.7
0.0
Total
82.4
15.9
1.8
5.3
0.7
0.0
Central
88.9*
10.5
0.6
5.6
0.4
0.0
North
79.2
19.1
1.6
5.2
0.8
0.0
South
72.1
23.7*
4.2*
4.7
1.2
0.1
Total
82.4
15.9
1.8
5.3
0.7
0.0
97.9*
1.8
3.0
5.9
0.1
0.0
Middle
94.2
5.8
0.0
5.8
0.2
0.0
Low
81.0
17.8*
1.2
5.3
0.7
0.0
Total
88.9
10.5
0.6
5.6
0.4
0.0
Socioeconomic group High
(+) Children in Amman; *P < 0.001.
mentioned that due to the greater availability of dental services in urban areas, the f/F component of the caries index was higher in urban than rural children. The effect of sociobehavioural factors on disease patterns is universal (Petersen, 2005; Kwan and Petersen, 2010). Among the children investigated in Jordan, consumption of sweets and sugary drinks presumably played a role in caries; however, the associations of caries with behavioural factors were not statistically significant. Meanwhile, the relationship between social inequality and caries was profound. The total amount of caries was substantially higher in children of the low and middle SE groups than in children of the upper SE group. In addition, the d/D and f/F components differed considerably between the various social groups. Children of the upper SE group had higher numbers of filled teeth than children of the low SE group; on the other
Vol 12, No 2, 2014
hand, children of the low SE group had a relatively high value OR and a relatively high level of untreated caries. In parallel to this pattern, poor gingival health varied by SE group, urbanisation, geographical location and sex. The oral disease profile outlined possibly relates to differences in self-care practices, dietary habits, access to and use of dental services, social norms and dental attitudes, as well as the lack of a regular dental care tradition. The data make it possible to assess the trend over time in caries of Jordanian children. In Amman, an oral health survey of children aged 6 and 12 years was conducted by Hamdan and Rock (1993); the same settings of that survey were included in the present study. In addition, WHO criteria (1997) were used in the recording of caries in both studies. The analysis based on the two surveys illustrates important changes over time in the level of caries. Together, the two surveys also dem-
105
Rajab et al
Table 4b Percentages of Jordanian children aged 12 (n = 2560) with specific CPI maximum scores and the mean number of sextants with CPI scores according to urbanisation, gender, geographic/administrative area and social class CPI max % 12 years
Score 0 (healthy)
Score 1 (bleeding)
Urban
55.9*
34.3
Rural
41.8
Total
Mean no. of sextants Score 2 (bleeding and calculus)
Score 0 (healthy)
Score 1 (bleeding)
Score 2 (bleeding and calculus)
9.8
4.4
1.5
0.1
47.5*
10.8
3.5
2.3
0.2
50.9
38.9
10.2
4.1
1.8
0.1
Boys
42.5
44.2*
13.3
3.8
2.0
0.2
Girls
58.5*
34.2
7.3
4.3
1.6
0.1
Total
50.9
38.9
10.2
4.1
1.8
0.1
Central
56.5
34.8
8.7
4.4
1.5
0.1
North
54.2
36.1
9.7
4.3
1.6
0.1
South
35.7*
50.7*
13.6*
3.3
2.5
0.2
Total
50.9
38.9
10.2
4.1
1.8
0.1
77.3*
19.1
3.6
5.4
0.6
-
Middle
61.5
30.2
8.3
4.7
1.2
0.1
Low
42.4
45.8*
11.8*
3.6
2.2
0.2
Total
56.5
34.8
8.7
4.4
1.5
0.1
Socioeconomic group High
(+) Children in Amman; *P < 0.001.
onstrate the persistence of social inequality in caries; it should be pointed out that the social gap in the amount of untreated caries has widened over this time period. Thus, as emphasised by the WHO (Kwan and Petersen, 2010), it is of utmost importance that public health intervention be oriented towards the root causes of oral diseases. While this study reported a low prevalence of gingival bleeding among the 6-year-old children, poor gingival health was significant among the 12-yearold children. These findings are similar to national data available from the region included in the WHO Global Oral Health Data Bank (World Health Organization, 2010). Boys, rural children, those from the low SE group and from the southern area are particularly in need of oral hygiene instruction.
106
CONCLUSION The oral health situation of children in Jordan is far from under control; in particular, the burden of oral disease is prominent among children with a low socioeconomic background. The trend of caries over time indicates that the poor oral health status of young children and the social inequality observed may worsen unless oral health intervention is intensified. The present fluoride administration (0.1 % F) seems inadequate for prevention and control of caries. It is a challenge for the Ministry of Health as a matter of urgency to ensure effective application of fluoride and to establish systematic school health services. The existing school oral health programme is rather passive and the screening system with referral of children to dentists is seemingly insufficient. In addition to resolving the considerable dental care needs, the survey results provide support for the introduction of systematic
Oral Health & Preventive Dentistry
Rajab et al
health promotion. In line with the WHO Health Promoting Schools concept (Rajab et al, 2002; World Health Organization, 2003), health intervention must target young schoolchildren, pre-school children, parents and the wider community. It is vital that community- and family-oriented health promotion emphasise environmental risk factors and the importance of healthy lifestyles, i.e. balanced diet, restriction of the consumption of sugars and improvement of oral hygiene practices.
ACKNOWLEDGEMENTS The study was funded by the Higher Council for Science and Technology and supported by the World Health Organization (research grant number 1-2-1-2081).
REFERENCES 1. Abdellatif A. Oral health in Tunisia. Int Dent J 2004;54: 389–394. 2. Ahmed NA, Astrøm AN, Skaug N, Petersen PE. Dental caries prevalence and risk factors among 12-year old schoolchildren from Baghdad, Iraq: a post-war survey. Int Dent J 2007;57:36–44. 3. Albashaireh Z, al-Hadi Hamasha A. Prevalence of dental caries in 12–13-year-old Jordanian students. SADJ 2000;57:89–91. 4. Al-Ismaily M, Al-Busaidy K, Al-Khussaiby A. The progression of dental disease in Omani schoolchildren. Int Dent J 2004;54:409–410. 5. Al-Ismaily M, Al-Khussaiby A, Chestnutt IG, Stephen KW, Al-Riyami A, Abbas M, Knight M. The oral health status of Omani 12-year-olds – a national survey. Community Dent Oral Epidemiol 1996;24:362–363. 6. Al-Khateeb TL, Darwish SK, Bastawi AE, O’Mullane DM. Dental caries in children residing in communities in Saudi Arabia with differing levels of natural fluoride in the drinking water. Community Dent Health 1990;7:165–171. 7. Al-Mutawa SA, Shyama M, Al-Duwairi Y, Soparkar P. Dental caries experience of Kuwaiti schoolchildren. Community Dent Health 2006;23:31–36. 8. Al-Sadhan SA. Dental caries prevalence among 12–14 year-old schoolchildren in Riyadh: A 14 year follow-up study of the Oral Health Survey of Saudi Arabia Phase I. Saudi Dent J 2006;18:2–7. 9. Al-Shammery AR. Caries experience of urban and rural children in Saudi Arabia. J Public Health Dent 1999;59:60–64. 10. Al-Tamimi S, Petersen PE. Oral health situation of schoolchildren, mothers and schoolteachers in Saudi Arabia. Int Dent J 1998;48:180–186. 11. Armitage P, Berry G. Statistical methods in medical research. London: Blackwell Scientific Publications, 1994. 12. Beiruti N, van Palenstein Helderman WH. Oral health in Syria. Int Dent J. 2004;54(suppl 1):383–888. 13. Bratthall D, Hansel-Petersson G, Sundberg H. Reasons for the caries decline: what do experts believe? Eur J Oral Sci 1996;104:416–422.
Vol 12, No 2, 2014
14. Bratthall D, Petersen PE, Stjernswärd JR, Brown J. Chapter 38: Oral and craniofacial diseases and disorders. In: Jamison DT, Breman JG, Measham AR, et al (eds). Disease control priorities in developing countries. New York: World Bank Health and Oxford University Press, 2006:723–736. 15. Department of Statistics 2003. Analytical report of multipurpose household survey 2003, Amman, Hashemite Kingdom of Jordan. 16. Department of Statistics 2004. Population and housing census 2004, Hashemite Kingdom of Jordan. 17. Hamdan MAM, Rock WP. Dental caries experience in Jordanian and English schoolchildren. Community Dent Health 1993;10:151–157. 18. Källestaal C, Wang NJ, Petersen PE, Arnadottir IB. Caries preventive methods for children and adolescents in Denmark, Iceland, Norway and Sweden. Community Dent Oral Epidemiol 1999;27:144–151. 19. Kwan S, Petersen PE. Oral health: equity and social determinants. In: Blas E, Sivansankara Kurup A (eds). Equity, social determinants and public health programmes. Geneva: WHO, 2010:159–176. 20. Kwan SY, Petersen PE, Pine CM, Borutta A. Health-promoting schools: an opportunity for oral health promotion. Bull World Health Organ 2005;83:677–685. 21. Meyer-Lueckel H, Paris S, Shirkhani B, Hopfenmuller W, Kielbassa AM. Caries and fluorosis in 6- and 9-year-old children residing in three communities in Iran. Community Dent Oral Epidemiol 2006;34:63–70. 22. Pakshir HR. Oral health in Iran. Int Dent J 2004;54(suppl 1):367–372. 23. Petersen PE. Oral health. Int Encyclop Public Health 2008;1:677–685. 24. Petersen PE. Socio-behavioural risk factors in dental caries–international perspectives. Community Dent Oral Epidemiol 2005;33:274–279. 25. Petersen PE, Torres AM. Preventive oral health care and health promotion provided for children and adolescents by the Municipal Dental Health Service in Denmark. Int J Paediatr Dent 1999;9:81–91. 26. Rajab LD, Petersen PE, Bakeen G, Hamdan MA. Oral health behaviour of schoolchildren and parents in Jordan. Int J Paediatr Dent 2002;12:168–76. 27. Wang N, Källestaal C, Petersen PE, Arnadottir IB. Caries preventive services for children and adolescents in Denmark, Iceland, Norway and Sweden. Community Dent Oral Epidemiol 1998;26:263–271. 28. World Health Organization. Global goals for oral health in the year 2000. Int Dent J 1982;32:74–77. 29. World Health Organization. Oral health surveys – basic methods, ed 4. Geneva: WHO, 1997. 30. World Health Organization. Oral health promotion: an essential element of a health promoting school. WHO information series on school health (document 11). Geneva: WHO, 2003. 31. World Health Organization. The world oral health report 2003: continuous improvement of oral health in the 21st century – the approach of the WHO Global Oral Health Programme. Geneva: WHO, 2003. 32. World Health Organization. Periodontal profiles: an overview of CPITN data in the WHO Global Oral Data Bank. Geneva: WHO, 2010. 33. Zusman SP, Ramon T, Natapov L, Kooby E. Dental health of 12-year-olds in Israel-2002. Community Dent Health 2005;22:175–179.
107
