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Assessment of periodontal status and treatment needs among 12 and 15 years old school children in Udaipur, India.

Introduction

Periodontal disease has been defined as "a group of lesions affecting the tissues surrounding and supporting the teeth in their sockets." The majority of periodontal diseases can be classified as either gingivitis or periodontitis which occur as a result of bacterial plaque or calculus present on supra-gingival or sub-gingival tooth surfaces. It is generally accepted that periodontal diseases begin as gingivitis, which in some individuals may progress to periodontitis [Carranza, 2006].

Children are more predisposed to gingivitis due to special conditions of the periodontium and poor oral hygiene (OH) [Pourhashemi et al., 2007]. A systematic literature review indicated that in the majority of studies, improvements in gingival conditions were obtained in the short term by oral health promotion initiatives [Watt and Marinho, 2005]. However, for appropriate planning of Public Dental Health Services, the knowledge of dental treatment needs of populations with different characteristics is important. The

Community Periodontal Index of Treatment Needs (CPITN) developed and proposed by WHO, has been widely used to determine needs [Cutress et al., 1987]. The CPITN has proven to be a useful tool for evaluating changes in the periodontal status of a given population after a program implementation [Dini et al., 1997].

Periodontal disease is one of the most widespread diseases in the world [World Health Organization, 1978] and is more prevalent in developing countries [Waerhaug, 1967; Baelum et al., 1988; Rahimah, 1994]. The disease has been reported to appear at an early age in developing countries (as with gingivitis) and progress with age to periodontitis.

Owing to a dearth of literature on the prevalence and severity of periodontal disease among Indian school children, this study was conducted to assess and compare the periodontal status and treatment needs among school children aged 12 and 15 years in public and private schools of Udaipur, (India) and also to establish reliable baseline data for planning and development of national or regional OH programs.

Materials and methods

A cross sectional descriptive study was conducted among the school going children aged 12 and 15 years in the city of Udaipur, Rajasthan, India. Children with systemic diseases and on antibiotic therapy in the previous six months were excluded from the study.

Official permission, ethical clearance and informed consent. The study protocol was reviewed by the local Institutional Review Board and was granted ethical clearance. Official permission was obtained from the Director of Education, Udaipur, India. Written informed consent was obtained from the parents of all children who fulfilled the eligibility criteria and were willing to participate in the survey.

Training and calibration. Before the commencement of the study, training and intra-examiner calibration was performed in the Department of Public Health Dentistry (kappa value = 90%).

Pilot survey. A pilot study was carried out among 50 children, 12 and 15 years old from one private and one public school to determine the feasibility of the study. Depending on the prevalence obtained (31%), 95% confidence level and 10% allowable error, the sample size was determined to be 855 which was rounded up to 900.

Sampling technique. The sample frame consisted of middle and high schools (public and private) in Udaipur, obtained from the District Education Office. The study sample was recruited by a two-stage cluster sampling technique. For study purposes, Udaipur city was arbitrarily divided into 4 geographical regions and schools from each region were randomly selected to obtain the desired sample size, such that there was an equal representation from each of the four zones. Out of the total number of public (32) and private schools (58), 8 public and 12 private schools were randomly selected. In the second stage, eligible schoolchildren were stratified according to age and gender, and randomly selected in proportion to the total number of 12 and 15 years old students enrolled in each school to reach the sample of about 900.

Methodology. Data collection was carried out by a single investigator (RN) who was assisted by a recording assistant. Data regarding general information, OH practices were obtained through interview and recorded on a proforma. The periodontal examination of the subjects was performed as per Community Periodontal index of Treatment needs (CPITN) [Ainamo et al, 1982]. The periodontal indicators assessed were gingival bleeding and calculus. Periodontal pockets were not measured as those are indicated for above 15 years of age. Code 0 [Treatment Need (TN-0)] was used to designate a sextant as healthy and no treatment is required. Code = X indicated missing sextant. In case of gingival bleeding without calculus, it was recommended to improve the OH [Code 1 (TN-1)]. If calculus was detected, OH instructions were provided and professional cleaning was carried out [Code 2 = (TN-2)].

Statistical analysis. The data was compiled and entered onto a spreadsheet (Microsoft Excel 2007) and exported to a data editor page of SPSS version 11.5 (SPSS Inc., Chicago, IL, USA). Descriptive statistics included computation of percentages, means and standard deviations. Chi-square test (x2) and student's t-test were used and confidence intervals and p-values were set at 95% and < 0.05 respectively.

Results

Of the total study population, 66.6% were males and 33.4% were females. Nearly 46.9% participants belonged to the 12 years age group (44.8% public; 55.2% private) and 53.1% were aged 15 years (41.6% public; 58.4% private) (Table 1).

Table 2 shows the distribution of study subjects according to OH practices. Toothbrush and toothpaste were the most common means of cleaning teeth among 97.6% and 97.2% of 12 years old children, and among 99.4% and 98.3% of 15 years old children respectively. All the children in private schools used toothbrush and toothpaste as compared to public schools (96.6% used toothbrush and 95.1% used toothpaste) and this difference was statistically significant, p<0.001. Among all participants, 42% of subjects brushed twice daily. The frequency of brushing twice a day was significantly higher in private schools than public schools.

At the age of 12 years, healthy periodontal tissues existed only in 15.4% of subjects. Gingival bleeding was highly prevalent indicating the need for oral hygiene instructions (74.2%). Among 15 year old children 19.9% had healthy periodontia. Bleeding gums (63.6%) requiring OH instructions and calculus (16.5%) with need of professional cleaning was also observed among these children. A statistically significant difference was found in the CPITN scores in terms of gender (p<0.05) at the age of 12 years. Healthy sextants were found to be more frequent in females than males in both the age groups. Higher percentages of children had healthy periodontia in private schools as compared to public schools. Calculus was more frequently present in 12 years old public school children as compared to private school children which was statistically significant (p<0.001). However, 15 year old children private school children had more calculus, although this difference was not significant (p>0.05) (Table 3).

The mean scores for the bleeding component were higher than that of calculus. Children aged 15 years had a better mean healthy periodontal score (3.33[+ or -]1.96) when compared with 12 years group (p<0.05). The mean number of healthy sextants was higher in children who brushed twice a day when compared to those who brushed once a day in both the age groups. The difference elicited a significant association between frequency of brushing and CPITN scores among the 15 years of age group whereas 12 year old children showed a significant association between gender and CPITN scores (Table 4).

Discussion

This cross sectional study was carried out among two age groups (12 and 15 years) to assess the prevalence and treatment needs of periodontal disease among school children in Udaipur, India. The 12 and 15-year-old cohorts were chosen in accordance with the WHO index age groups used for international comparisons and monitoring of disease trends. Data for the 15-year-old cohort was more meaningful as it can be compared with the data for 12 year-olds to provide an estimate of the increase in prevalence and severity of periodontal disease. Moreover, the two cohorts were selected to help develop a plan for school health services and baseline data for a national survey which should include more age groups. The present study sample consisted of school children from both public and private schools in order to have representation of children from all the social, economic and cultural communities. Two recent studies in Europe conducted in Greece have also used these age groups. Firstly, the Greek national pathfinder study identified several socio-demographic and behavioural determinants for dental caries, OH and periodontal health of Greek children and adolescents [Vadiakas et al., 2011] and secondly, dental and oral health conditions were factors found to impact on the quality of life of Greek adolescents [Papaioannou et al., 2011].

Unlike other studies [Hussein et al., 1996; Sanei and Nasrabadi, 2005], 82.2% of the study population herein was affected by periodontal disease. The proportion of children with periodontal disease among the 12 year-old group (74.2%) was higher than those among 15 year-old group (63.6%). This finding is in contrast to the studies of Leung and Chu [2003] as well as to the findings of National Oral Health Survey and Fluoride Mapping of India [Bali et al., 2004a] and Rajasthan [Bali et al., 2004b]. Recently, similar results were also reported in a study of Nepalese children [Yeel et al., 2009]. This difference in the findings may be due to a higher proportion of public school children among the 12 year-old age group as compared to the 15 year-old age group. The overall high prevalence of gingivitis in both the age groups may be attributed to ineffective oral hygiene measures which can be due to inadequate brushing time, improper brushing technique or both factors. Further, it may also be possible that some of the children did not actually brush their teeth although they claimed to.

The higher proportion of gingival bleeding might be due to the mixed dentition period, shedding of primary teeth and pubertal changes in girls. A significant male preponderance was also depicted for periodontal disease prevalence among 12 year-old children which is in accordance with other studies [Mahesh Kumar et al., 2005; Sanei and Nasrabadi, 2005; Saied-Moallemi et al., 2009; Elamin et al., 2010]. This can be explained by females being more conscious of their appearance; including their OH. The present study recorded the same finding with an increase in frequency of tooth brushing among females than males.

The prevalence of calculus among 12 year-olds was found to be significantly higher in public school children when compared to private school children. This observation is analogous to the reported unhealthy periodontal status among children aged 12-13 and 15-16 years where studying in public school was determined as an indicator for this status [Yeel et al., 2009].

Little difference was evident in OH practices according to age groups, but the public school children showed a significantly poorer practice in comparison to private school children. This may be attributed to factors such as lower socio-economic background as well as lower education levels and awareness of parents. All of the private school children used toothbrush and toothpaste but only about half of them brushed twice daily. This clearly indicates their awareness about OH. At the age of 12 years, most of them (65.8%) brushed once a day which is less than required as compared to the findings of Petersen [Petersen et al., 2001]. The frequency of brushing twice a day was commoner in private schools as compared to public schools which is in accordance to other reports [Petersen et al., 2001; Mahesh Kumar et al., 2005]. Moreover, an inverse relationship was observed between frequency of toothbrushing and the prevalence of periodontal disease which can be explained on the basis of a correlation between plaque retention and gingival inflammation [Alonge and Narendran, 1999].

Motivation about OH maintenance was found to be the most prevalent treatment need in the study population signifying a need for school based oral health education programs. The age group of the study favours the early inculcation of OH habits in response to an effective educational effort. A study among school children in St. Vincent and Grenadines (West Indies) also recommended initiation of primary prevention programs in the form of health promotion and health education [Alonge and Narendran, 1999].

In the present study, it was found that the children in private schools had a significantly higher proportion of healthy gingiva as compared to public schools at 12 years. This has probably attributed to the parents positive attitude and greater dental awareness which was reflected in the child's oral health maintenance. Parents and teachers training programs provide a useful insight into improving the oral health of children and also moving closer to WHO goals of oral health [Sanei and Nasrabadi, 2005].

Conclusion

There was a high prevalence of periodontal disease (71.1%) in a sample of Indian children which needs to be dealt with a systematic preventive approach. Although, private school children had a higher prevalence of healthy periodontal tissues as compared to public schools, the periodontal treatment need encompassed more than half of the private school children. Sequentially to improve the periodontal health of children in Udaipur, a systematic endeavour to enhance the preventive approach as a component of oral health promotion programmes should be undertaken.

References

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Alonge OK, Narendran S. Periodontal health status of school children in St. Vincent and the Grenadines. Odontostomatol Trop 1999; 22:18-22.

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Bali RK, Mathur VB, Talwar PP, et al. Jain J. National Oral Health Survey and Fluoride Mapping 2002-2003 Rajasthan. Dental Council of India and Ministry of Health and Family Welfare (Public of India), 2004b.

Carranza FA. Classification of diseases of the periodontium. In: Carranza FA and Newman MG (10th ed). Clinical Periodontology. Philadelphia: W B Saunders Company; 2006. Pg: 58-81.

Cutress TW, Ainamo J, Sardo-Infirri J. The Community Periodontal Index of Treatment Needs (CPITN) procedure for population groups and individuals. Int Dent J 1987; 37:222-233.

Dini EL, Foschini AL, Brandao IM. Periodontal conditions in a 7-19-year-old student population in Araraquara, Sao Paulo, Brazil, 1995. Cad Saude Publica 1997; 13:321-324.

Elamin AM, Skaug N, Ali RW, Bakken V, Albandar JM. Ethnic disparities in the prevalence of periodontitis among high school students in Sudan. J Periodontol 2010; 81:891-896.

Hussein SA, Doumit M, Doughan B, El Nadeef M. Oral health in Lebanon: a pilot pathfinder survey. Eastern Mediterranean Health Journal 1996; 2:299-303.

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Mahesh Kumar P, Joseph T, Varma RB, Jayanthi M. Oral health status of 5 years and 12 years school going children in Chennai city--an epidemiological study. J Indian Soc Pedod Prev Dent 2005; 23:17-22.

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Pourhashemi SJ, Motlagh MG, Khaniki GRJ. Prevalence and intensity of gingivitis among 6-10 years old Elemantary School Children in Tehran, Iran. Journal of Medical Sciences 2007; 7:830-834.

Rahimah AK. Profile of periodontal conditions in selected West Malaysian adults. Singapore Dent J 1994; 19:4-7.

Saied-Moallemi Z, Virtanen JI, Vehkalahti MM, Tehranchi A, Murtomaa H. School-based intervention to promote preadolescents' gingival health: a community trial. Community Dent Oral Epidemiol 2009; 37:518-526.

Sanei AS, Nasrabadi AN. Periodontal health status and treatment needs in Iranian adolescent population. Arch Iranian Med 2005; 8:290-294.

Vadiakas G, Oulis CJ, Tsinidou K, Mamai-Homata E, Polychronopoulou A. Socio-behavioural factors influencing oral health of 12 and 15 year old Greek adolescents. A national pathfinder survey. Eur Arch Paediatr Dent 2011; 12:139-145.

Waerhaug J. Prevalence of periodontal disease in Ceylon. Association with age, sex, oral hygiene, socio-economic factors, vitamin deficiencies, malnutrition, betel and tobacco consumption and ethnic group. Final report. Acta Odontol Scand 1967; 25:205-231.

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R. Nagarajappa *, M. Kenchappa **, G. Ramesh ***, S. Nagarajappa ****, M. Tak *

Departments of * Public Health Dentisty, *** Oral and Maxillofacial Pathology, Pacific Dental College and Hospital, Udaipur, Rajasthan, India. ** Department of Paedodontics and Preventive Dentistry, Darshan Dental College and Hospital, Loyara, Udaipur, Rajasthan, India. **** Department of Public Health Dentisty, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India.

Postal address: Dr R. Nagarajappa, Department of Public Health Dentistry, Pacific Dental College and Hospital, Airport Road, Debari, Udaipur--313024, Rajasthan, India.

Email: rameshpcd@yahoo.co.in
Table 1. Distribution of study subjects according
to age, gender and school in a study on 12 and
15 year old Indian children.

                   Public      Private
Age     Gender     School       School       Total
                   n (%)        n (%)        n (%)

12      Male     130 (47.9)   141 (52.1)   271 (64.2)
        Female    59 (39.1)    92 (60.9)   151 (35.8)
        Total    189 (44.8)   233 (55.2)   422 (46.9)
15
        Male     159 (48.5)   169 (51.5)   328 (68.6)
        Female    40 (26.7)   110 (73.3)   150 (31.3)
        Total    199 (41.6)   279 (58.4)   478 (53.1)
Total
        Male     289 (48.2)   310 (51.8)   599 (66.6)
        Female    99 (32.9)   202 (67.1)   301 (33.4)
        Total    388 (43.1)   512 (56.9)   900 (100)

Table 2. Distribution of subjects according to type
of school, age (years), gender and oral hygiene
practices in a group of Indian children.

                                       Cleaning habits

Variables                   Toothbrush      Finger         Other

School
Public (388)                375 (96.6)    3 (0.8)       10 (2.6)
Private (512)               512 (100)     0 (0)          0 (0)
Age       Gender
12        Male (271)        265 (97.8)    1 (0.4)        5 (1.8)
          Female (151)      147 (97.4)    0 (0)          4 (2.6)
          Total (422)       412 (97.6)    1 (0.2)        9 (2.1)
15        Male (328)        326 (99.4)    2 (0.6)        0 (0)
          Female (150)      149 (99.3)    0 (0)          1 (0.7)
          Total (478)       475 (99.4)    2 (0.4)        1 (0.2)
Total     Male (599)        591 (98.7)    3 (0.5)        5 (0.8)
          Female (301)      296 (98.3)    0              5 (1.7)
          Total (900)       887 (98.5)    3 (0.3)       10 (1.1)

                                        Materials used

Variables                   Toothpaste    Toothpowder      Other

School
Public (388)                369 (95.1)    9 (2.3)       10 (2.6)
Private (512)               512 (100)     0 (0)         0 (0)
Age       Gender
12        Male (271)        263 (97.0)    5 (1.8)       3(1.1)
          Female (151)      148 (98.0)    1 (0.7)       2 (1.3)
          Total (422)       411 (97.2)    6 (1.4)       5 (1.2)
15        Male (328)        322 (98.2)    2 (0.6)       4 (1.2)
          Female (150)      148 (98.7)    1 (0.7)       1 (0.7)
          Total (478)       470 (98.3)    3 (0.6)       5(1.1)
Total     Male (599)        585 (97.7)    7(1.2)        7 (1.2)
          Female (301)      296 (98.3)    2 (0.7)       3 (0.9)
          Total (900)       881 (97.9)    9 (1.0)       10 (1.1)

                                       Frequency of brushing

Variables                      Once          Twice         Never

School
Public (388)                281 (72.4)    107 (27.6)    0 (0)
Private (512)               241 (47.1)    271 (52.9)    0 (0)
Age       Gender
12        Male (271)        191 (70.5)     80 (29.5)    0 (0)
          Female (151)       87 (57.6)     64 (42.4)    0 (0)
          Total (422)       278 (65.8)    144 (34.1)    0 (0)
15        Male (328)        180 (54.9)    148 (45.1)    0 (0)
          Female (150)       64 (42.7)     86 (57.3)    0 (0)
          Total (478)       244 (51.1)    234 (48.9)    0 (0)
Total     Male (599)        371 (61.9)    228 (38.1)    0 (0)
          Female (301)      151 (50.2)    150 (49.8)    0 (0)
          Total (900)       522 (58)      378 (42)      0 (0)

Statistical tests: Chi square test; p<0.05 considered
statistically significant. p-value for public and
private schools: Cleaning habits: <0.001, Materials
used: <0.001; Frequency of brushing:< 0.001

Table 3. Periodontal status and treatment needs
among study population in relation to age, gender
and type of school in Indian children.

Variables                       CPITN score

                         0--Healthy     1--Bleeding
                        (No need of    (Oral hygiene
Age     Gender           treatment)    instructions)

12      Male (271)        32 (11.8)      202 (74.5)
        Female (151)      33 (21.9)      111 (73.5)
        Total (422)       65 (15.4)      313 (74.2)

15      Male (328)        58 (17.7)      212 (64.6)
        Female (150)      37 (24.7)       92 (61.3)
        Total (478)       95 (19.9)      304 (63.6)

Age     School

12      Public (189)      20 (10.6)      123 (65.1)
        Private (233)     45 (19.3)      190 (81.5)
        Total (422)       65 (15.4)      313 (74.2)

15      Public (199)      15 (7.5)       150 (75.4)
        Private (279)     80 (28.7)      154 (55.2)
        Total (478)       95 (19.9)      304 (63.6)

Total   900              160 (17.8)      617 (68.6)

Variables                        CPITN score

                        2--Calculus             p
                        (Professional         value
Age     Gender            cleaning)

12      Male (271)        37 (13.7)
        Female (151)        7 (4.6)           <0.05
        Total (422)       44 (10.4)

15      Male (328)        58 (17.7)
        Female (150)      21 (14.0)           >0.05
        Total (478)       79 (16.5)

Age     School

12      Public (189)      24 (12.7)
        Private (233)      20 (8.6)          <0.001
        Total (422)       44 (10.4)

15      Public (199)      34 (17.1)
        Private (279)     45 (16.1)           >0.05
        Total (478)       79 (16.5)

Total   900              123 (13.7)

Statistical tests: Chi-square test;
p<0.05 considered statistically significant.

Table 4. Mean score of the sextants for each periodontal
indicator according to age (years) and brushing frequency.

                                        CPI score

                            0-Healthy           1--Bleeding
Variables               (Mean [+ or -] SD)   (Mean [+ or -] SD)

Age     Gender

12      Males (271)     3.12 [+ or -] 1.8    2.55 [+ or -] 1.7
        Females (151)   2.99 [+ or -] 1.7    2.95 [+ or -] 1.9
        Total (422)     3.01 [+ or -] 1.86   2.61 [+ or -] 1.80

15      Males (328)     3.31 [+ or -] 2.1    2.8 [+ or -] 1.92
        Females (150)    3.4 [+ or -] 1.5    2.3 [+ or -] 1.77
        Total (478)     3.33 [+ or -] 1.96   2.52 [+ or -] 1.86

Total   Males (599)     3.12 [+ or -] 1.3    2.88 [+ or -] 1.9
        Females (301)   3.18 [+ or -] 1.9    2.42 [+ or -] 1.77
        Total (900)     3.15 [+ or -] 1.8    2.57 [+ or -] 1.88

Age     Frequency/day

12      Once (278)      3.01 [+ or -] 1.91   2.71 [+ or -] 1.84
        Twice (144)     3.82 [+ or -] 1.76   2.01 [+ or -] 1.73

15      Once (244)      3.11 [+ or -] 1.98   2.63 [+ or -] 1.87
        Twice (234)     3.67 [+ or -] 1.91   2.15 [+ or -] 1.83

                                         CPI score

                           2--Calculus            p value
Variables               (Mean [+ or -] SD)

Age     Gender

12      Males (271)     0.22 [+ or -] 0.58
        Females (151)   0.09 [+ or -] 0.41         <0.05
        Total (422)     0.11 [+ or -] 0.56

15      Males (328)     0.41 [+ or -] 0.55
        Females (150)   0.23 [+ or -] 0.72         >0.05
        Total (478)     0.31 [+ or -] 0.65

Total   Males (599)     0.3 [+ or -] 0.44
        Females (301)   0.11 [+ or -] 0.66         >0.05
        Total (900)     0.22 [+ or -] 0.63

Age     Frequency/day

12      Once (278)      0.11 [+ or -] 0.56         >0.05
        Twice (144)     0.18 [+ or -] 0.55

15      Once (244)      0.41 [+ or -] 0.68         <0.05
        Twice (234)     0.31 [+ or -] 0.61

Statistical tests: t-test; p<0.05 considered
statistically significant.
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Author:Nagarajappa, R.; Kenchappa, M.; Ramesh, G.; Nagarajappa, S.; Tak, M.
Publication:European Archives of Paediatric Dentistry
Article Type:Report
Geographic Code:9INDI
Date:Jun 1, 2012
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