Australian Dental Journal, February, 1975
7
South Australian kindergarten children: Fluoride tablet supplements and dental caries Elluboth A. Fanning Reader in Preventive Dentistry, Department of Dental Health, University of Adelaide K. M. Celiier AND
Maureen M. Leadbeater Division of Mathematical Statistics, C.S.I.R.O., Glen Osmond
C. M. Somwllle A.D.A. Representative to the Pre-School Council of The Kindergarten Union of S.A. Inc.
ABSIRACT-Astudy of 4,278 country and city kindergarten children living in South Australia showed 63 and 59 per cent received fluoride tablets at some time and 17 per cent received daily doses. Lower dmf scores were found in those taking fluoride tablets but of decreasing value in the older children. Where no fluoride was taken zero dmf scores were 41-69 per cent. Protection from fluoride was not found where fluoride was taken for less than two years. Self administration appears to be an unsatisfactory method for fluoride therapy. (Received for publication January, 1974)
Water fluoridation is acknowledged to be the most efficient method for the public to receive the levels of fluoride required for the prevention of dental caries.'. 2 . 3 In Australia, however, many families do not have access to reticulated water systems, or they reside in areas where fluoridation of the communal water supply has not yet been initiated. Consequently, the children of these families have to depend upon fluoride tablets in order to receive the benefits of systemic fluoride. It is essential that children take the tablets regularly on a daily basis from birth to approximately 12 years of age while the teeth are calcifying. This requires early education of the parents, as well as careful supervision and strong motivation on their part. The present study, which was carried out prior to the fluoridation of Adelaide's water supplies, involved children attending city and rural kindergartens in South Australia. The purpose of the study was to assess the extent of fluoride tablet supplementation in children of kindergarten age and to determine the effects of the fluoride supplements on dental caries in the primary teeth.
T. G.-The Hastings Fluoridation Project. V. Dental effects between 1954-1964. N.Z. Dent. J., 61:3, 175-179 (July) 1965. 1 A r o l d . F. A., Likins, R. C., Ruu~11,A. L.. and Scott, D. B.-Fifteenth Year of the Grand Raoids Fluoride Study. J.A.D.A 696 780-785 0s.) 1%2. 3 Ast, D. B., a!d &a=, 'H.C.--The Newburgh-Kingstone Cariss-Fluorine Study. IV. Dental 5ndinga after six years of water fluoridation. Oral Surg.. Oral Med., Oral Path., 6:1, 114-123 (Jan.) 1953. 1 Ludwig,
Materials and methods The data analysed were obtained from a total sample of 4,278 children aged between 3 and 6 years. They comprised 2,842 from 68 kindergartens in the Adelaide metropolitan area and 1,436 from 19 rural kindergartens. Questionnaires completed by parents gave information as to:-whether fluoride tablets had ever been taken; whether the tablets were taken daily or occasionally; the age at which the tablets were commenced; and the length of time they have been taken. An examination of the children's teeth with mirror and explorer only was made by the dentist attending the kindergarten. The clinical findings of the dentist were charted directly on an examinaiton form that used a digit code for each item of information. This allowed direct transfer of the data to punched cards. R.rultS
The pattern of Buoride tablet intake Sixty-three per cent of rural children and 59 per cent of city children, aged 3-6 years, had taken flouride tablets at some time during their lifetime. The pattern of intake was similar in boys and girls and between rural and city children and all the data were pooled for subsequent analysis. Of those children taking fluoride tablets, 84 per cent aged 3-4 years and 78 per cent aged 4-6 years took the tablets daily, while the remainder took them occasionally. The majority of children taking tablets daily had commenced
Australian Dental Journal, February. I975
8
the practice before they were one year old. These comprised 87 per cent of 3-4 year olds and 76 per cent of 4-6 year olds. Some children who took daily fluoride tablets started the practice early and persisted throughout the entire period from birth while others who started early, ceased the practice. Of those children who commenced taking fluoride tablets early, the percentage who persisted throughout life decreased with age from 49 per cent in the 3-4 year old children to 32 per cent in the 4-5 year old and 18 per cent in the 5-6 year old children. Table 1 gives the percentages of children who failed to take fluoride tablets, as well as those in the different tablet categories, averaged over sex, TABLE 1
Fluoride therapy in S . A . kindergarten children aged 3-6 years Percentages in fluoride teblet groups .
No tablets Occasional tablets Daily tablets: periodic lifetime
40 13
30 17
area, and age. Only 17 per cent of the total population of children received the necessary daily dose of fluoride.
The effect of fluoride tablet intake on dental caries The effectiveness of fluoride tablets in reducing dental caries was studied. Appropriate statistical analyses were carried out to determine if there were differences due to sex, age group, location of residence (city and country), and fluoride tablet usage. Since there were n o differences in the findings between sexes or between city and rural children, the results were combined. The mean scores for decayed, missing (extracted) and
filled teeth (dmft) in children grouped according to age and fluoride tablet usage are given in Table 2. TABLE 2
The effects of fluoride tablets as measured by tlw mean dmft in three age groups of children 3-4
No fluoride tablets Total dmft No. of children Mean dmft Fluoride tablets Total dmft No. of children Mean dmft
Age (years) 4-5
5-6
123 90 1.37
2,197 1,036 2.12
1,598 581 2.75
105 182 0.58
2,216 1,586 1.40
1,478 801 1.85
There was a general increase in the mean dmft score with age and a small reduction due to fluoride. The dmft scores showed a preponderance of zeros (between 40 and 80 per cent of subjects within a group) with the remaining scores as high as 17 so that the more detailed examination of the effect of dmft of length of time for which fluoride tablets were taken, was made by comparing the proportion of children with zero dmft in the various tablet groups by means of the xa test. The results are given in Table 3. There was a significant association between length of time of fluoride intake and percentage of zero dmft scores for all age group (p < 0.01 for age 3-4 years; p < 0.001 for ages 4-5 years and 5-6 years). Eighty-nine per cent of children aged 3-4 years, 81 per cent aged 4-5 years and 77 per cent of those aged 5-6 years who had taken daily fluoride tablets throughout life had a zero dmft score. The percentages with a zero score decreased as the length of time tablets were taken became shorter. Children in all age groups who took tablets daily for periods of less than two years failed to derive any protection against dental caries and in the oldest group (5-6 years) no protection was obtained unless tablets had been
TABLE 3
Percentage of children with zero dmft scores grouped according to fluoride tablet intake None taken
Age 3-4 years No. of children Percentage zero dmft Age 4-5 years No. of children Percentage zero dmft Age 5-6 years No. of children Percentage zero dnift
Occasional tablets
n-2
2-3
Daily tablets Years taken 3-4 4-5
90 69
29 59
41 71
23 83
89 88
1.036 49
349 54
339 48
199 59
197 70
504 81
581 41
183 45
141 42
80 46
66 59
185 73
5-6
146 77
9
Australian Dental Journal, February, 1975 TABLE 4
Mean dmft scores of children according to length of time fluoride tablets were taken
-
3-4 vears .............................................. --~ 4-5 years ................................................... 5-6 years ...................................................
None taken
Occasional tablets
0-2
2-3
1.37 2.12 2.75
1.14 1.72 2.85
0.90 2.17 2.77
0.52 1.56 2.59
taken for at least three years. A similar trend was observed in the mean dmft scores which are shown in Table 4. Discussion Approximately 20 per cent of children aged 3-6 years attend kindergartens in South Australia. Therefore, the children in this study belong to an elite group and the findings may not apply to the population at large. In addition, an earlier analysis on the eating habits and dental care of the same children showed a greater dental consciousness in those. families providing fluoride tablets for their children.' Fluoride tablet supplements were associated with a lower frequency of daily sugary snacks between meals. For instance 23 per cent of children taking fluoride tablets had sugary snacks compared with 29 per cent of those who failed to take fluoride tablets. A higher standard of dental care was also associated with fluoride tablet intake in that 51 per cent of children taking fluoride tablets brushed their teeth twice a day compared to 40 per cent of the children not taking fluoride. Furthermore, the children who took fluoride tablets were more likely to receive help with toothbrushing and to visit the dentist more frequently than those who failed to take tablets. Therefore, some of the advantage attributed to fluoride supplementation may have been due to a higher standard of dental care in the families using fluoride tablets. However, the trend whereby the percentage of children with zero dmft increased as the time for which tablets were taken also increased is highly significant and the daily use of fluoride tablets is recommended in those areas where the community water supplies are not fluoridated. It should be emphasized also that the occasional user of tablets received very little protection against dental caries and those who took daily tablets for periods of
4 Fanning, E. A., and Sanerville, C. M.&th
Australian kinderparten children: dental health factors in urban and country families. Austral. D.J. 19:l. 35-38 (Peb.) 1974.
Daily tablets Years taken 34
0.26 1.17 1.44
4-5
56
0.67 0.86
0.71
less than two years failed to receive any protection at all. The results confirm that in some respects selfadministration is an unsatisfactory form of fluoride therapy. Although daily tablets throughout life were shown to be extremely effective in protecting the primary teeth, only 17 per cent of the children received these dose levels. The information obtained from this study accents the need for parents to receive advice on dental health early and for the information to be reinforced from time to time. Summrly The study of 4,278 South Australian kindergarten children revealed 59 per cent of city children and 63 per cent of country children received fluoride tablets at some time during their lives whilst 17 per cent had received daily doses at the required level throughout their lives. When tablets were taken consistently from within the first year 77-88 per cent had zero dmf scores with the lesser level in the 5-6 year old children; similarly when no tablets were taken 41-69 per cent had zero dmf scores. Some improvements in the fluoride group may have been the result of the better standard of oral hygiene in this group. No protection appeared to be gained where tablets were taken daily for less than two years. Self-administration appears to be an unsatisfactory method of fluoride therapy because the majority of parents fail to maintain the daily fluoride supplement for the children. Acknowledgements This study has been mode possible by liaison between The Kindergarten Union of South Australia Incorporated and the Australian Dental Association, South Australian Branch Incorporated. Expenses involved in the study are being met by a grant from Colgate-Palmolive Pty. Ltd. Department of Dental Health, The University of Adelaide, Adelaide, S.A., 5 0 1 .
7
South Australian kindergarten children: Fluoride tablet supplements and dental caries Elluboth A. Fanning Reader in Preventive Dentistry, Department of Dental Health, University of Adelaide K. M. Celiier AND
Maureen M. Leadbeater Division of Mathematical Statistics, C.S.I.R.O., Glen Osmond
C. M. Somwllle A.D.A. Representative to the Pre-School Council of The Kindergarten Union of S.A. Inc.
ABSIRACT-Astudy of 4,278 country and city kindergarten children living in South Australia showed 63 and 59 per cent received fluoride tablets at some time and 17 per cent received daily doses. Lower dmf scores were found in those taking fluoride tablets but of decreasing value in the older children. Where no fluoride was taken zero dmf scores were 41-69 per cent. Protection from fluoride was not found where fluoride was taken for less than two years. Self administration appears to be an unsatisfactory method for fluoride therapy. (Received for publication January, 1974)
Water fluoridation is acknowledged to be the most efficient method for the public to receive the levels of fluoride required for the prevention of dental caries.'. 2 . 3 In Australia, however, many families do not have access to reticulated water systems, or they reside in areas where fluoridation of the communal water supply has not yet been initiated. Consequently, the children of these families have to depend upon fluoride tablets in order to receive the benefits of systemic fluoride. It is essential that children take the tablets regularly on a daily basis from birth to approximately 12 years of age while the teeth are calcifying. This requires early education of the parents, as well as careful supervision and strong motivation on their part. The present study, which was carried out prior to the fluoridation of Adelaide's water supplies, involved children attending city and rural kindergartens in South Australia. The purpose of the study was to assess the extent of fluoride tablet supplementation in children of kindergarten age and to determine the effects of the fluoride supplements on dental caries in the primary teeth.
T. G.-The Hastings Fluoridation Project. V. Dental effects between 1954-1964. N.Z. Dent. J., 61:3, 175-179 (July) 1965. 1 A r o l d . F. A., Likins, R. C., Ruu~11,A. L.. and Scott, D. B.-Fifteenth Year of the Grand Raoids Fluoride Study. J.A.D.A 696 780-785 0s.) 1%2. 3 Ast, D. B., a!d &a=, 'H.C.--The Newburgh-Kingstone Cariss-Fluorine Study. IV. Dental 5ndinga after six years of water fluoridation. Oral Surg.. Oral Med., Oral Path., 6:1, 114-123 (Jan.) 1953. 1 Ludwig,
Materials and methods The data analysed were obtained from a total sample of 4,278 children aged between 3 and 6 years. They comprised 2,842 from 68 kindergartens in the Adelaide metropolitan area and 1,436 from 19 rural kindergartens. Questionnaires completed by parents gave information as to:-whether fluoride tablets had ever been taken; whether the tablets were taken daily or occasionally; the age at which the tablets were commenced; and the length of time they have been taken. An examination of the children's teeth with mirror and explorer only was made by the dentist attending the kindergarten. The clinical findings of the dentist were charted directly on an examinaiton form that used a digit code for each item of information. This allowed direct transfer of the data to punched cards. R.rultS
The pattern of Buoride tablet intake Sixty-three per cent of rural children and 59 per cent of city children, aged 3-6 years, had taken flouride tablets at some time during their lifetime. The pattern of intake was similar in boys and girls and between rural and city children and all the data were pooled for subsequent analysis. Of those children taking fluoride tablets, 84 per cent aged 3-4 years and 78 per cent aged 4-6 years took the tablets daily, while the remainder took them occasionally. The majority of children taking tablets daily had commenced
Australian Dental Journal, February. I975
8
the practice before they were one year old. These comprised 87 per cent of 3-4 year olds and 76 per cent of 4-6 year olds. Some children who took daily fluoride tablets started the practice early and persisted throughout the entire period from birth while others who started early, ceased the practice. Of those children who commenced taking fluoride tablets early, the percentage who persisted throughout life decreased with age from 49 per cent in the 3-4 year old children to 32 per cent in the 4-5 year old and 18 per cent in the 5-6 year old children. Table 1 gives the percentages of children who failed to take fluoride tablets, as well as those in the different tablet categories, averaged over sex, TABLE 1
Fluoride therapy in S . A . kindergarten children aged 3-6 years Percentages in fluoride teblet groups .
No tablets Occasional tablets Daily tablets: periodic lifetime
40 13
30 17
area, and age. Only 17 per cent of the total population of children received the necessary daily dose of fluoride.
The effect of fluoride tablet intake on dental caries The effectiveness of fluoride tablets in reducing dental caries was studied. Appropriate statistical analyses were carried out to determine if there were differences due to sex, age group, location of residence (city and country), and fluoride tablet usage. Since there were n o differences in the findings between sexes or between city and rural children, the results were combined. The mean scores for decayed, missing (extracted) and
filled teeth (dmft) in children grouped according to age and fluoride tablet usage are given in Table 2. TABLE 2
The effects of fluoride tablets as measured by tlw mean dmft in three age groups of children 3-4
No fluoride tablets Total dmft No. of children Mean dmft Fluoride tablets Total dmft No. of children Mean dmft
Age (years) 4-5
5-6
123 90 1.37
2,197 1,036 2.12
1,598 581 2.75
105 182 0.58
2,216 1,586 1.40
1,478 801 1.85
There was a general increase in the mean dmft score with age and a small reduction due to fluoride. The dmft scores showed a preponderance of zeros (between 40 and 80 per cent of subjects within a group) with the remaining scores as high as 17 so that the more detailed examination of the effect of dmft of length of time for which fluoride tablets were taken, was made by comparing the proportion of children with zero dmft in the various tablet groups by means of the xa test. The results are given in Table 3. There was a significant association between length of time of fluoride intake and percentage of zero dmft scores for all age group (p < 0.01 for age 3-4 years; p < 0.001 for ages 4-5 years and 5-6 years). Eighty-nine per cent of children aged 3-4 years, 81 per cent aged 4-5 years and 77 per cent of those aged 5-6 years who had taken daily fluoride tablets throughout life had a zero dmft score. The percentages with a zero score decreased as the length of time tablets were taken became shorter. Children in all age groups who took tablets daily for periods of less than two years failed to derive any protection against dental caries and in the oldest group (5-6 years) no protection was obtained unless tablets had been
TABLE 3
Percentage of children with zero dmft scores grouped according to fluoride tablet intake None taken
Age 3-4 years No. of children Percentage zero dmft Age 4-5 years No. of children Percentage zero dmft Age 5-6 years No. of children Percentage zero dnift
Occasional tablets
n-2
2-3
Daily tablets Years taken 3-4 4-5
90 69
29 59
41 71
23 83
89 88
1.036 49
349 54
339 48
199 59
197 70
504 81
581 41
183 45
141 42
80 46
66 59
185 73
5-6
146 77
9
Australian Dental Journal, February, 1975 TABLE 4
Mean dmft scores of children according to length of time fluoride tablets were taken
-
3-4 vears .............................................. --~ 4-5 years ................................................... 5-6 years ...................................................
None taken
Occasional tablets
0-2
2-3
1.37 2.12 2.75
1.14 1.72 2.85
0.90 2.17 2.77
0.52 1.56 2.59
taken for at least three years. A similar trend was observed in the mean dmft scores which are shown in Table 4. Discussion Approximately 20 per cent of children aged 3-6 years attend kindergartens in South Australia. Therefore, the children in this study belong to an elite group and the findings may not apply to the population at large. In addition, an earlier analysis on the eating habits and dental care of the same children showed a greater dental consciousness in those. families providing fluoride tablets for their children.' Fluoride tablet supplements were associated with a lower frequency of daily sugary snacks between meals. For instance 23 per cent of children taking fluoride tablets had sugary snacks compared with 29 per cent of those who failed to take fluoride tablets. A higher standard of dental care was also associated with fluoride tablet intake in that 51 per cent of children taking fluoride tablets brushed their teeth twice a day compared to 40 per cent of the children not taking fluoride. Furthermore, the children who took fluoride tablets were more likely to receive help with toothbrushing and to visit the dentist more frequently than those who failed to take tablets. Therefore, some of the advantage attributed to fluoride supplementation may have been due to a higher standard of dental care in the families using fluoride tablets. However, the trend whereby the percentage of children with zero dmft increased as the time for which tablets were taken also increased is highly significant and the daily use of fluoride tablets is recommended in those areas where the community water supplies are not fluoridated. It should be emphasized also that the occasional user of tablets received very little protection against dental caries and those who took daily tablets for periods of
4 Fanning, E. A., and Sanerville, C. M.&th
Australian kinderparten children: dental health factors in urban and country families. Austral. D.J. 19:l. 35-38 (Peb.) 1974.
Daily tablets Years taken 34
0.26 1.17 1.44
4-5
56
0.67 0.86
0.71
less than two years failed to receive any protection at all. The results confirm that in some respects selfadministration is an unsatisfactory form of fluoride therapy. Although daily tablets throughout life were shown to be extremely effective in protecting the primary teeth, only 17 per cent of the children received these dose levels. The information obtained from this study accents the need for parents to receive advice on dental health early and for the information to be reinforced from time to time. Summrly The study of 4,278 South Australian kindergarten children revealed 59 per cent of city children and 63 per cent of country children received fluoride tablets at some time during their lives whilst 17 per cent had received daily doses at the required level throughout their lives. When tablets were taken consistently from within the first year 77-88 per cent had zero dmf scores with the lesser level in the 5-6 year old children; similarly when no tablets were taken 41-69 per cent had zero dmf scores. Some improvements in the fluoride group may have been the result of the better standard of oral hygiene in this group. No protection appeared to be gained where tablets were taken daily for less than two years. Self-administration appears to be an unsatisfactory method of fluoride therapy because the majority of parents fail to maintain the daily fluoride supplement for the children. Acknowledgements This study has been mode possible by liaison between The Kindergarten Union of South Australia Incorporated and the Australian Dental Association, South Australian Branch Incorporated. Expenses involved in the study are being met by a grant from Colgate-Palmolive Pty. Ltd. Department of Dental Health, The University of Adelaide, Adelaide, S.A., 5 0 1 .
