Caries Control throughout life in Asia
International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
International Dental Conference
on “Caries Control throughout life in Asia”
Organized
by
Dental Innovation Foundation under Royal Patronage (DIF)
Ministry of Public Health (MOPH)
Dental Association of Thailand (DAT)
International Co-sponsored
by
World Health Organization (WHO)
World Dental Federation (FDI)
International Association for Dental Research (IADR)
November, 20-22, 2013
@ Beyond Resort Krabi, Krabi, Thailand
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
Editors
Yupin SONGPAISAN
Khun Mettachit NAWACHINDA
Chantana UNGCHUSAK
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
TABLE OF CONTENTS
Page
TABLE OF CONTENTS
3
WELCOME MESSAGES
Mr
THEINTONG
Vice-Minister
Ministry of Public Health
8
Prof Thanpuying Petchara TECHAKUMPUTCH
President
Dental Innovation Foundation under Royal
Patronage (DIF)
10
Dr. Porntep SIRIWANARANGSUN
Director-General,
Department of Health
Ministry of Public Health
13
Prof Lt Gen Phisal THEPSITHAR
President
Dental Association of Thailand
14
Prof Poul Erik PETERSEN
Chief, Oral Health,
World Health Organization (WHO)
16
Dr Tin Chun WONG
President
FDI World Dental Federation
18
Prof Helen WHELTON
President
International Association for Dental Research
(IADR)
20
SCIENTIFIC PROGRAM
25
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
Page
GUEST LECTURES
29
Global oral health inequalities
- the need for public health strategies in disease
prevention and restorative dental care
PE PETERSEN
World Health Organisation (WHO)
31
FDI World Dental Federation: A Focus on Prevention
TC WONG
President
International Dental Federation (FDI)
39
Global Caries Perspective: the Research Agenda
ECM LO
Treasurer
International Association for Dental Research
(IADR)
55
Cariology Research Update
D ZERO
Professor, Indiana University, USA
59
Cariology Education in Dental School
JC LLODRA
Professor, Granada University, Spain
FDI – Public Health Committee, Chair
Dental Caries Control in Children
ECM LO, D DUANGTHIP
Professor, University of Hong Kong, HK-SAR;
Nutrition and Oral Health
A RUGG-GUNN, P MOYNIHAN
Professor, University of New Castle, UK;
WHO-Collaborating Centre for Nutrition and
Oral Health
Dental Caries Control In Elderly
H OGAWA
Assoc/Professor, Niigata University, Japan;
WHO–Collaborating Centre for Translation of
Oral Health Science
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
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COUNTRY REPORT
Bhutan
Sonam NGEDUP
Dorji PHURPA
Brunei Daressalam
Mary Cheong Poh HUA
Hong Kong, SAR
Frankie HC SO
Joseph CY CHAN
India
Naseem SHAH
Indonesia
Dewi Kartini SARI
ZAURA Kiswarina Anggraeni
Japan
Masaki KAMBARA
Korea
Deok-Young PARK
Lao PDR
Khamhoung PHOMMAVONGSA
Sakpaseuth SENESOMBATH
Malaysia
KHAIRIYAH Abd. Muttalib,
WAN MOHD NASIR bin Wan Othman,
YAW Siew Lian
Norliza ISMAIL
Myanmar
AYE AYE MAW
MYINT MYINT SAN
SAW TUN AUNG
Nepal
Shaili PRADHAN
Philippines
Maria Liza C CENTENO
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
Page
Singapore
Eu Oy CHU
Taiwan
Lin-Yang CHI
Lih-Jyh FUH
Thailand
Sutha JIENMANEECHOTECHAI,
Chantana UNGCHUSAK,
Supranee DALODOM
Piyada PRASERTSOM,
Oranart MATANGKASOMBUT
Vietnam
Trinh Dinh HAI
Ngo Dong KHANH
Organizing Committee & Editors
Map of the workshop venue
Notes
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
WELCOME MESSAGES
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
???
Vice Minister,
Ministry of Public Health
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
On behalf of the organizers of the International Dental Conference on
“Caries Control throughout life in Asia”, it is my great honor to
welcome you to the Conference.
This event is organized by the Dental Innovation Foundation under
Royal Patronage (DIF), which is a section of His Majesty the King’s
Dental Service Unit, in conjunction with the Ministry of Public Health
and the Dental Association of Thailand. The conference is cosponsored by the World Health Organization, the International
Association for Dental Research and the World Dental Federation.
It is the belief of the Dental Innovation Foundation that dental caries
is a preventable and controllable disease. Dental caries management
procedures may be different in each country based on the availability
of dental man- power and resources. We believe that resources can be
better optimized by the sharing of learning and experiences amongst
member countries.
The objectives of this Conference are, therefore, to
1.
2.
3.
Share and exchange experiences in caries prevention and control,
Apply new development in appropriate dental caries prevention for
future success,
Discuss the implementation of the Minamata Global Convention
on phasing down of dental amalgam,
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On behalf of the Dental Innovation Foundation, I would like to extend
my appreciation to the resource persons and international experts
from WHO, FDI and IADR for their expertise and valued time to
exchange their knowledge and experiences with the participants.
I wish all success and fruitful benefits for this Conference
Sincerely,
Professor Thanpuying Petchara Techakampuch
President
Dental Innovation Foundation under Royal Patronage (DIF)
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
Department of Health, Ministry of Public Health honor to organize the
“International Dental Conference on Caries control throughout life in
Asia” during 20-22 November 2013 in cooperation with Dental
Innovation Foundation under Royal Patronage (DIF) and The Dental
Association of Thailand (DAT) with support from the World Health
Organization (WHO), International Association for Dental Research
(IADR), and World Dental Federation (FDI).
The Department of Health has a policy to promote health of Thai
people in all age groups. Oral health related quality of life has also
been prioritized and implemented all over the country in Thailand.
Dental caries problem in all age groups has been solved at the
individual level: an early detection and specific prevention, and
community level: Sweet Enough Network, Oral Health School Network,
Non-carbonated soft drink in school and Oral health network in
Elderly Club, but dental caries still be a problem in some areas. This
meeting will give us an opportunity to learn from other countries and
create cooperation among Asian countries to work together on
management of dental caries in all age groups in the future.
Dr. Porntep Siriwanarangsun
Director-General
Department of Health
Ministry of Public Health
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
Dear All Participants
The Dental Association of Thailand would like to welcome you to
Thailand and enjoy one of the best tourist attractions of Thailand,
Krabi. We appreciate your efforts in spending your prestigious time to
make this congress a success.
The Dental Association of Thailand has fully supported this congress
of “Caries Control throughout Life in Asia” aiming that all the experts
and authorities will together summarize the modalities that enable the
very fundamental Oral Health Issue of the World, especially in Asia:
Dental Caries and its control.
For the passing half century, The Dental Association of Thailand has
dedicated in both clinical means and public health to promote various
technologies and health promotional schemes for improving the Oral
Health of Thais. We have collaborated with the private enterprises and
government agencies to create the awareness of the importance of
Good Oral Health through the “Thai Smiles”. Make sure that every
single Thais would want to have those attractive appearances till the
very last day of life. Today we have a new generation of kids that is
caries free and the percentage is increasing by all the helps and
supports from both the private and government sectors.
With the changes in filling material which bases heavily on the
environmental perspective, not on the practical Scientific Evidence
Base, we wish all Thais still receive best dental treatments without
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
sacrificing the standard and safety they used to. Turning to the new
softer, unproven longevity and short lasting material should not be
unseen risks to Thais and all mankind.
On behalf of the Dental Association of Thailand, I would like to
express my sincere gratitude to all of you that make this event
happen, success and be another initiative for good quality of life. This
event would not have happened if we do not have the input from all of
those who dedicated their times and efforts, not wanting to be named
and get recognition. Thanks again. We really appreciated your kind
consideration.
Sincerely,
Professor Lt. Gen. Phisal Thepsithar
President
The Dental Association of Thailand
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
In 2010, the World Health Organization published an important
report on “Equity, Social Determinants and Public Health
Programmes”. It takes the challenges to public health several steps
forward, with the aim of translating knowledge into concrete,
workable actions. The four main criteria in identifying priority public
health conditions were:
1)
2)
3)
4)
they represent a large aggregate burden of disease;
they display large disparities across and within
populations;
they disproportionately affect certain populations or
groups within populations, and
they are emerging or epidemic prone.
The burden of oral disease matches these four main criteria of critical
public health conditions. In particular, oral diseases are most
prevalent non-communicable diseases (NCDs) worldwide. They cause
much suffering, such as pain and discomfort, and they are a
considerable economic burden to people and society. Moreover, oral
diseases are linked to major chronic diseases, i.e. cardio-vascular
diseases, cancer, and chronic respiratory diseases. Poor diet, tobacco
use, and excessive use of alcohol are shared risk factors. The World
Health Assembly Resolution on Oral Health (WHA60.17) specifies both
the need for prevention and control of oral diseases. Dental caries is
major disease burden in all countries around the globe. Integrated
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disease prevention must be strengthened; however, many people still
require restorative dental care, especially the poor and disadvantaged
population groups. Primary Health Care (PHC) addresses both disease
prevention and disease control. The challenges to PHC are evident to
low- and middle income countries as these countries continue to have
limited capacity in oral health care. The WHO highly welcomes the
Thailand Krabi meeting “Caries control throughout life” which will
consider the achievement of better health for all through the
integration of primary prevention, secondary disease prevention, and
tertiary intervention.
Dr Poul Erik Petersen
World Health Organization (WHO)
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Caries management and a focus on prevention
It gives me great pleasure to welcome delegates to this important
conference on dental caries, the most pervasive medical condition in
the world. Dental caries afflicts 90% of the world’s population and, as
a disease that causes pain and discomfort, its social and economic
impact is significant, especially in developing countries. If a child is in
pain, he or she cannot go to school. The same applies to the working
population who have to take time off work.
This conference will provide a huge opportunity to focus on this
important issue, exchange ideas, discuss solutions and recommend
actions. Let me remind you briefly of the objectives:
To share and exchange experiences in caries prevention and
control in Asia;
To assess the applicability of dental caries intervention
programmes from industrial countries;
To apply novel development in appropriate dental caries
prevention for future success;
To discuss the implementation of the Minamata Global
Convention of phasing down of dental amalgam: The WHO –
UNEP Initiative.
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In the end, the debate about caries is all about prevention; in the end,
this is one of the few viable options if our goal is to increase access to
oral health since access to treatment is, for many in this world,
geographically or financially impossible.
This is all the more important since the dental materials we use for
our restorative work are increasingly coming under the critical eye of
groups concerned with health and the environment. Just over a
month ago, I was in Japan to observe the proceedings of the
‘Conference of Plenipotentiaries on the Minamata Convention on
Mercury. As you are probably aware, this Convention contains special
provisions for dental amalgam, one of dentistry’s most clinically
proven, safe and cost-effective restorative materials.
During the negotiation process, there was a view that it should be
subject to a phase-out, leading ultimately to a ban. Effective advocacy
from FDI working its partners at the World Health Organization
(WHO), the International Association for Dental Research (IADR) and
International Dental Manufacturers managed to turn that into a
‘phase-down’, which means that it can continue to be used – for the
moment.
In return, however, the dental sector made a certain number of
commitments on prevention, research and implementing best
management practice for dental waste. Now it is up to us to deliver. In
this sense, this International Dental Conference on “Caries Control
throughout life in Asia” is part of the process of developing strategy in
one of those key areas, prevention.
I very much look forward to giving my own presentation during the
course of this event. FDI has a unique voice and message in the world
and I am delighted to be, as President, that voice communicating that
message. I am also, naturally, looking forward with keen interest to
what my colleagues from Thailand, elsewhere in Asia and from
around the world have to say on the subject of caries control.
I wish you all an excellent conference!
Dr Tin Chun Wong
President
FDI World Dental Federation
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
Dear Conference Delegates,
As the president of the International Association for Dental Research
(IADR), it is my pleasure to welcome you to the 2013 International
Conference on "Caries Control Throughout Life in Asia." I am
appreciative to the Dental Innovation Foundation under Royal
Patronage, the Ministry of Public Health and the Dental Association of
Thailand for organizing this meeting, along with the World Dental
Federation and the World Health Organization for co-sponsoring it
with IADR.
IADR’s three-pronged mission is to advance research and increase
knowledge for the improvement of oral health worldwide; to support
and represent the oral health research community; and to facilitate
the communication and application of research findings. Preceded by
the 2011 International Conference themed “Effective Use of Fluoride
in Asia,” this year’s meeting aligns well with the IADR mission in its
effort to improve oral health. Following the success of the 2011
meeting, this one will bring attention to the global oral disease burden
and allow us to work together to find a solution.
We know that oral diseases are among the most common chronic
diseases, affecting in excess of 3.9 billion people worldwide. The
recently adopted Minamata Convention includes a provision for dental
amalgam that sets national objectives aiming at dental caries
prevention and health promotion, thereby minimizing the need for
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dental restoration. Although dental caries is preventable in many
populations, it is still intractable in many others. Expansion of the
benefits of prevention of this disease to all people, including those
with the greatest need, will require a multisectoral and
interdisciplinary approach.
Everyone who attends this meeting has a direct responsibility to
increase awareness of the importance of oral health and contribute to
the improvement of the global oral disease burden. Your attendance
at this meeting takes us a step closer to solving this problem and
raising the global profile of oral health.
While I regret that I cannot attend personally, I look forward to
hearing about the discussions that will take place at this meeting and
the positive outcomes that will be produced.
Sincerely,
Helen Whelton, BDS, MDPH, FFD, PhD, FFPHM
President, International Association for Dental Research
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SCIENTIFIC PROGRAM
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
International Dental Conference on “Caries Control throughout life in Asia”
Organized
by
Dental Innovation Foundation under Royal Patronage (DIF)
Ministry of Public Health (MOPH)
Dental Association of Thailand (DAT)
International Co-sponsored
by
World Health Organization (WHO)
World Dental Federation (FDI)
International Association for Dental Research (IADR)
November, 20-22, 2013
@ Beyond Resort Krabi, Krabi, Thailand
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
Wednesday, November 20, 2013
09.00-09.30
Opening Ceremony
- Report by Organizing Chair
- Opening by Minister of Public Health, Thailand
- Address by Representatives from WHO, FDI and
IADR
09.30-10.00
Break and poster viewing
10.00-10.30
11.30-12.00
Global oral health inequalities - the need for public
health strategies in disease prevention and restorative
dental care
Prof PE PETERSEN
WHO, Switzerland
FDI World Dental Federation: A Focus on Prevention
Dr TC WONG
President FDI, Switzerland
Global caries perspective: the research agenda
Prof. ECM LO
Treasurer IADR, Hong Kong SAR
Discussion
12.00-13.00
Lunch break
13.00-13.45
16.45-17.30
Cariology Research Update
Prof D ZERO
Indiana University, USA
Cariology Education in Dental School
Prof JC LLODRA
Granada University, Spain
FDI – Public Health Committee, Chair
Dental Caries Control in Children
Prof ECM LO*, Dr Duangporn DUANGTHIP
University of Hong Kong, HK-SAR;
Nutrition and Oral Health
Prof A RUGG-GUNN*, Prof P MOYNIHAN
University of New Castle, UK
WHO - Collaborating Centre for Nutrition and Oral
Health
Dental Caries Control In Elderly
Prof H OGAWA
Niigata University, Japan
WHO–Collaborating Centre for Translation of Oral
Health Science
Discussion
19.00-21.00
Welcome reception
10.30-11.00
11.00-11.30
13.45-14.30
14.30-15.15
15.15-16.00
16.00-16.45
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International Dental Conference on “Caries Control throughout Life in Asia”
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Thursday, November 21, 2013
09.00-09.15
09.15–10.30
11.00-12.30
Summary of Day 1
Success story in Asia: Examples from
China
Prof. Tao XU
School of Stomatology
Peking University
Korea
Prof. PARK Deok-young
College of Dentistry
Gangneung-Wonju National University
Malaysia
Dr KHAIRIYAH bt abd Muttalib
Division of Oral Health
Ministry of Health
Singapore
Dr Eu Oy CHU
School Dental Services
Department of Health
Thailand
Dr. Sutha JIENMANEECHOTECHAI
Department of Health
Ministry of Public Health
Group Discussion: First round
Group 1: Dental Education and Research in Cariology
(ECM LO, C FOX & JC LLODRA)
Group 2: Caries Control in Children & Elderly
(PE PETERSEN, A RUGG-GUNN, & H OGAWA)
Group 3: Home Care Caries Prevention
(D ZERO, TC WONG & P PHANTUMVANIT)
12.30-13.30
Lunch break
13.30-15.00
15.00-16.30
18.00-19.00
Group Discussion: Second round
Group Discussion: Third round
Special session:
Future Use of Materials for Dental Restoration
Summary of Minamata Convention on Global
Reduction of Mercury
Prof PE PETERSEN, WHO
19.00-21.00
Dinner
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International Dental Conference on “Caries Control throughout Life in Asia”
November 20-22, 2013, Krabi, Thailand
Friday, November 22, 2013
09.00-10.30
10.30-11.30
11.30-12.30
12.30-13.00
Group Reports
Discussion
Next Steps and Networking
Summary
13.00-14.00
Lunch break
14.00
Meeting adjourn
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GUEST LECTURES
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GLOBAL ORAL HEALTH INEQUALITIES
THE NEED FOR PUBLIC HEALTH STRATEGIES
IN DISEASE PREVENTION AND
RESTORATIVE DENTAL CARE
Poul Erik PETERSEN
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GLOBAL ORAL HEALTH INEQUALITIES
THE NEED FOR PUBLIC HEALTH STRATEGIES
IN DISEASE PREVENTION AND RESTORATIVE DENTAL CARE
Poul Erik PETERSEN1
Dental caries is still a major public health problem in countries across
the world as the disease affects 60-90% of school-aged children and
the vast majority of adults. At present, the distribution and severity of
dental caries vary in different parts of the world and within the same
region or country (1). According to the WHO Global Oral Health Data
Bank (2), the global dental caries index among children aged 12 years
is 1.7 teeth on average, however, there are marked differences in
severity amongst regions. The disease level in children of this age is
relatively high in the Americas and in the European region; the index
is low among children of the African and Western Pacific regions,
while at the moment dental caries severity is moderate in countries of
South East Asia and in the Eastern Mediterranean regions. The WHO
Global Oral Health Data Bank also provides information on the time
trends in dental caries experience of children. In most low and middle
income countries, dental caries levels were low until recent years
whereas dental caries prevalence rates and dental caries experience
have tended to increase rapidly with changing lifestyles and growing
consumption of sugars, inadequate exposures to fluoride, and lack of
national programmes for prevention of oral disease (1,2). In contrast,
a decline in dental caries prevalence has been observed in most high
income countries over the past 20 years or so. This pattern is seen as
the result of a number of public health measures, including effective
use of fluoride, coupled with changing living conditions, lifestyles and
improved self-care practices, and establishment of school oral health
programmes (1,2).
For the child population of the several countries the amount of
untreated dental caries (dt/DT) contributes significantly to the total
caries experience, as measured by the dmft and DMFT indices. This
pattern is documented for countries within each of the WHO Regions
World Health Organization, Oral Health Programme, Prevention of Non-communicable
Diseases, Geneva, Switzerland. Email: Poul Erik Petersen <petersenpe@who.int>
1
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and Figure 1a-b present selected data for those standard age groups
of children recommended by WHO.
Worldwide, dental caries prevalence is high among adults as the
disease affects nearly 100% of the population in the majority of
countries (1). Most high income countries and some countries of Latin
America show high DMFT values (i.e. 14 teeth affected by caries or
more at the age of 35-44 years) while dental caries experience levels at
present are lower in the low income countries of Africa and Asia. The
pattern of disease in adults is illustrated in Figure 1c.
Mean dental caries experience in primary teeth (dmft)
among 5-6-year-olds across WHO regions
USA
Brazil
South Africa
Madagascar
Qatar
Kuwait
Hungary
Denmark
Thailand
Indonesia
China
Japan
0
1
2
3
dt
4
mt
5
6
7
8
ft
Figure 1a: Mean dental caries experience in populations of
selected countries as measured by the dmft or DMFT
indices at age 5-6 years (2).
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International Dental Conference on “Caries Control throughout Life in Asia”
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Mean dental caries experience in permanent teeth (DMFT)
among 12-year-olds across WHO regions
USA
Brazil
Madagascar
Burkina Faso
Qatar
Kuwait
Hungary
Denmark
Thailand
Indonesia
Japan
China
0
1
2
DT
MT
3
4
FT
Figure 1b: Mean dental caries experience in populations of selected
countries as measured by the dmft or DMFT indices at
age 12 years (2).
Mean dental caries experience (DMFT) among 35-44-yearolds of selected countries across WHO regions
USA
Brazil
Burkina Faso
Madagascar
Kuwait
Iran
Hungary
Denmark
Indonesia
Thailand
China
Japan
0
5
10
DT
MT
15
20
FT
Figure 1c: Mean dental caries experience in populations of selected
countries as measured by the dmft or DMFT indices at
age 35-44 years (2).
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Universally, the burden of disease is high among the poor and
disadvantaged people compared to wealthy population groups (3). In
addition, underprivileged population groups are less likely to visit a
dentist if available and often have unhealthy habits, or knowledge and
attitudes to oral health. The social consequences or the impact of illhealth on daily life of people are notable. Poor oral health could
threaten job security and economic productivity that in turn may
exacerbate adverse social, psychological and economic circumstances.
In several high income countries, older people often have had their
teeth extracted early in life because of pain or discomfort, leading to
reduced quality of life (3). The proportion of edentulous adults aged 65
years or more is still high in many countries; meanwhile, in
industrialized countries there has been a positive trend of reduction
in tooth loss among older adults in recent years. In parallel, an
increase in the proportion of adult people with functional dentition (i.e.
20 teeth or more) reflects the growing use of preventive oral health
services available (1,2).
THE NEED FOR PREVENTIVE DENTAL CARE
There is a tremendous need for prevention of dental caries and
consideration should be given to the fact that tooth extraction equals
to failure. The efficiency of dental caries prevention methods has been
substantiated in several countries around the world; however, despite
this knowledge, not all countries have or will implement such public
health programmes in the near future and many people that have
suffered from dental caries need their teeth restored to normal
function; failure to do this will undoubtedly result in loss of teeth.
Population oriented oral disease prevention programmes and health
promotion do not exist in many low and middle income countries, and
oral health services may only provide emergency care aiming at relief
of pain. Such care mostly implies tooth extraction which is most
simple and less expensive form of treatment.
THE NEED FOR RESTORATIVE DENTAL CARE
In spite of success in the prevention of dental caries, caries in need of
restoration still occur. Unless the access to dental restorative
treatment is further upgraded, the growing burden of dental caries in
low and middle income countries will result in even higher numbers of
people becoming edentulous in the near future. Dental amalgam has
been used for dental restoration over the past 150 years and is
considered to be safe. Providers of oral health care in most countries
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consider dental amalgam of relevance in serving their patients.
Meanwhile, over the past 10 years or so, the awareness and
recognition of the environmental implications of mercury has
increased and dentistry being a source to contamination of the
environment has gained further attention. In general, the quality of
materials alternative to dental amalgam is limited. There is an urgent
need to strengthen research into the long-term performance, possible
adverse effects, and viability of alternative materials. In addition,
some countries require systems for waste management to prevent
release of mercury to the environment.
WHO AND THE ENVIRONMENT
WHO and the United Nations Environment Programme (UNEP) have
strengthened the work for reduction of the mercury releases and
usage. UNEP was mandated to elaborate legally binding instrument
on a ban of mercury; the work commenced in 2010 with the goal of
completing it prior to the UNEP Governing Council/Global Ministerial
Environment Forum in 2013. This so-called Minamata treaty will have
a significant impact on delivering oral health care worldwide and
includes the following elements(3): Setting national objectives aiming
at dental caries prevention and health promotion, thereby minimizing
the need for dental restoration; (ii) Setting national objectives aiming
at minimizing its use; (iii) Promotion of the use of cost-effective and
clinically effective mercury-free alternatives for dental restoration; (iv)
Promotion of research and development of quality mercury-free
materials for dental restoration; (v) Encouraging representative
professional organizations and dental schools to educate and train
dental professionals and students on the use of mercury-free dental
restoration alternatives and on promotion of best management
practices; (vi) Discouraging insurance policies, and programmes that
favour dental amalgam use over mercury-free dental restoration; (vii)
Encouraging insurance policies and programmes that favour the use
of quality alternatives to dental amalgam for dental restoration; (viii)
Restricting the use of dental amalgam to its encapsulated form; and
(ix) Promotion of the use of best environmental practices in dental
facilities to reduce releases of mercury and mercury compounds to
water and land.”
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REFERENCES
1.
Petersen PE (2008). Oral Health. In: Kris Heggenhaugen and
Stella Quah, Editors. International Encyclopedia of Public Health,
Volume 4, San Diego: Academic Press, pp. 677-685
2.
World Health Organization. WHO Global Oral Health Data Bank
(2011). WHO, Geneva.
Petersen PE (2005). Socio-behavioural risk factors in dental
caries - international perspectives. Community Dentistry Oral
Epidemiology 33:274–9.
3.
4.
Rekow ED, Fox CH, Petersen PE, Wattson T (2013). Innovations
in materials for direct restoration. Why do we need innovations?
Why is it so hard to capitalize on them? Journal Dental
Research 92: 945-947
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FDI WORLD DENTAL FEDERATION:
A FOCUS ON PREVENTION
Tin Chun WONG
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FDI WORLD DENTAL FEDERATION:
A FOCUS ON PREVENTION
Tin Chun WONG2
First of all, thank you for the kind invitation to speak here today. I am
delighted to be present at this important event. Caries control is a
particularly important theme for the FDI World Dental Federation. I
will come to the question of ‘why?’ later in my presentation.
But first, a little background information on FDI World Dental
Federation. It was set up over 110 years ago as a forum for dentists
around the world together to share views and experiences. Its
continued existence today implicitly recognizes that the profession
needs an international voice to defend its positions and promote its
views. Thus, FDI speaks and acts internationally on behalf of dentists
worldwide.
FDI is now headquartered in Geneva, in close proximity to
international partners such as the World Health Organization and
other agencies of the United Nations. It represents some 200 national
dental associations and specialist groups around the world. FDI can
therefore claim to be the authentic international ‘voice’ of around 1
million dentists with a mission to ‘lead the world to optimal oral
health’.
DIRECT IMPACT OF FDI
Although the perspective of an international organization such as FDI
may seem distant from the reality of people’s lives, its activities and
decision can frequently have a direct impact on people’s lives in a
number of quite specific ways. These include dental materials, dental
practice and ethics, dental waste management as well as guidelines,
the good practice recommendations and public information messages.
All of these together have a tremendous impact on health
professionals - but on also patients, both directly and indirectly.
President of FDI World Dental Federation, World Dental Federation, Tour de Cointrin, Avenue
Louis Casai 84, Case Postale 3, 1216 Genève - Cointrin SWITZERLAND. www.fdiworldental.org
2
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FDI Policy Statements are of particular significance to the work of the
dentist. These are declarations of current thinking on various
significant issues related to oral health, oral health policies and the
dental profession. They are put together by FDI’s Science Committee
in collaboration with partners such as the World Health Organization
(WHO), the International Association for Dental Research (IADR), and
the International Organization for Standardization (ISO), through
intensive discussion, the consensus among leading dental experts
from around the world and wide consultation with all national dental
associations.
For example, as a result of the 2013 General Assembly, five new
Policy Statements have been adopted and issued in key fields of
public health, oral health and dentistry. The subjects covered include
Non-communicable Diseases (NCDs); Oral Health and the Social
Determinants of Health; Oral Infection/Inflammation as a Risk Factor
for Systemic Diseases; Salivary Diagnostics; and Bisphenol-A in
Dental Restorative and Preventive Materials.
They will be published in the December 2013 edition 1 of the
International Dental Journal along with an editorial by FDI Science
Committee Chair and my compatriot Prof Lijian Jin. The Policy
Statement on Noncommunicable Diseases has particular resonance
for FDI’s work in the field of oral disease prevention and control.
VISION 2020
Today, more than ever before, the practice and art of dentistry are
called upon to meet new and urgent demands. In response to this—
and FDI considers this a positive step—the scope of dental medicine is
expanding way beyond operative and restorative dentistry and into
the important fields of education and prevention.
In its role of ‘thought leadership’, FDI is responding to the expanded
role for the dental profession with a strategy for the coming decade.
Two strong values have emerged. The first is that oral health should
be considered a fundamental right, along with the right to health. The
‘right to health’ was first articulated in the founding documents of the
World Health Organization.
The second value is ‘oral health in all policies’. This notion derives
from the Adelaide Statement on Health in all Policies 2, a WHO report
published in 2010.
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These values are integrated into FDI Vision 20203, document drafted
by an FDI Task Team and adopted by the General Assembly in Hong
Kong in 2012. This Vision being articulated through five basic
approaches, focusing on prevention, the dental workforce, access to
oral care and the promotion of technology and research and the move
towards green dentistry.
The fifth basic approach is education, which includes patient
education and oral health literacy for prevention.
IMPLEMENTING VISION 2020
Two aspects of Vision 2020 are now in the process of implementation:
one of these is to generate data and information achieve two goals:
one is to update FDI’s landmark Oral Health Atlas, the only one of its
kind in existence but, with figures from as far back as 1997, not a
reflection of oral health today. The other goal is to develop a global
observatory whose principal aim would be as a tool to measure oral
health in the world.
The other aspect of Vision 2020 in the process of implementation is
interprofessional collaborative practice (ICP), one of the major themes
among members of the medical professions today. From the
perspective of the healthcare professional, the focus should be on the
contribution of ICP to patient care and rehabilitation. But the sub-text
of collaborative practice for governments is as a means of cutting
waste and improving efficiency in the health service.
I cannot go into too much detail at this stage since the project was
only recently launched. We will, naturally, be liaising closely with our
colleagues in other medical professions, in particular the physicians,
nurses, pharmacists and physical therapists with whom we are in
partnership in the World Health Professions Alliance WHPA 4.
In this, dentists have some unique points to make not only from the
perspective of health care providers within the health service but also,
for many of us, as heads of our own small business, that is, our
dental practice. We understand better than most the need to ensure
that we are working well, effectively and economically.
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THE THEME OF PREVENTION
Today, prevention is an important theme, reflecting the tendency
among dentists to always have an eye on the future. It is essential to
the well-being of our profession: we have worked with an ever-evolving
technology and are always on the lookout for the best, most solid and
aesthetically pleasing materials in our restoration.
We also have an eye to the future when it comes to prevention:
dentists probably entered this domain well in advance of other
professions and, with our partners in industry, have been key in
helping develop the tools of prevention. We constantly remind our
clients and patients of the importance of brushing their teeth daily
with fluoride toothpaste to prevent caries and tooth decay.
Dental caries in young people age 6-19 (% affected-highest value, latest
data available 1982-2008. Source: WHO)
In fact, FDI’s flagship prevention programme Live.Learn.Laugh. 5 (LLL),
carried out in partnership with Unilever Oral Care, has already been
running for nine years—phase I from 2005 to 2009, phase II 20102013—with phase III about to begin. The basic LLL message is one of
prevention. Its goal is to measurably improve oral health through
encouraging twice daily brushing with a fluoride toothpaste.
Where public funds are lacking, like in many
prevention is the best, and in some cases, the
Much of what is termed ‘prevention’ focuses
individual behaviour. We estimate that the
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developing countries,
only option available.
on encouraging good
eleven LLL projects
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underway in Asia will reach at least 10,700 children and patients. We
are looking forward to seeing a change in oral health habits of the
populations. I think all involved can take immense pride in being part
of an effort to raise awareness.
GLOBAL CARIES INITIATIVE: A FOCUS ON PREVENTION
LLL is taking place at a time when the dental profession is
implementing a shift toward a prevention-based model of oral-health
care. This transformation will, over time, become the most robust and
long-term strategy to address the issue of dental restorative materials,
including dental amalgam.
With limited funds available for restorative care in many countries, an
essential part of FDI’s work is to raise awareness of the importance of
oral health and focus its projects and activities on prevention
strategies. This, for example, is the key message of the landmark
Global Caries Initiative6, GCI for short. It is a profession-led "call to
action" to implement a new paradigm for caries management, disease
prevention and health promotion, thus improve the oral and general
health of populations globally by the year 2020.
Age-standardized disability-adjusted life year (DALY) rates from dental
caries by country (per 100,000 inhabitants)- (Source: WHO 2004)
The GCI vision is based on our current knowledge of the disease
process and its prevention, so as to deliver optimal oral and thus
general health and well being to all peoples. The GCI aims to establish
a broad alliance of key influencers and decision-makers from
research, education, clinical practice, public health, government, and
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industry to bring about fundamental change in health systems and
individual behaviour.
Within the context of GCI has now developed an overarching Global
Oral Health Improvement Matrix (GOHIM)7 to integrate oral health
into health, thereby establishing a collaborative, prevention-oriented
model of oral health care.
Figure 1: The FDI World Dental Federation Caries Matrix.
It consists of three tiers, one above the other. The extent of the caries
lesion and pathology is depicted on the horizontal axis. The top tier
(level 1) represents the World Health Organization8 Basic Methods
(Decayed, Missing, Filled Teeth [D3MFT]/Decayed, Missing Filled
Surfaces [D3MFS]) system. The bottom tier (level 3) is the full
International Caries Detection and Assessment System (ICDAS), 9
which provides the most detailed level of information and allows for
an expanding degree of detail. The middle tier (level 2) seeks to
describe the D1MFT threshold, the American Dental Association
(ADA) Caries Classification System (D.M. Meyer, DDS, written
communication, April 2012) and the collapsed ICDAS detection, as
well as other systems. The middle tier (level 2) of the FDI Caries
Matrix makes differentiations between cavitated and noncavitated
enamel that correspond to ICDAS but do not correspond to all the
named systems. Note that even for the sound/decayed interface at
level 1 (WHO Basic Methods), there are a range of regional variations
in the conventions used for exact positioning of the vertical lines that
subdivide the extent of caries. Future harmonization of these
conventions is highly desirable. The + and − symbols indicate the
activity of caries lesions as defined in the glossary of terms for caries
by Longbottom and colleagues. 13 The FDI World Dental Federation
Caries Matrix as illustrated does not address surface origin of the
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caries. F: Filled. M: Missing. PUFA: Pulpal involvement (P/p),
ulceration caused by dislocated tooth fragments (U/u), fistula (F/f)
and abscess (A/a).24.
MANAGING CARIES RISK AS AN INTEGRAL PART OF GLOBAL HEALTH
Through the GCI, FDI is seeking to expand the role of dental medicine
within the field of healthcare. It has the support of the World Health
Organization Oral Health Programme, which has recognized the
importance of promoting “a new paradigm among dental practitioners,
shifting from a restorative to preventive/health promotion model”. 8
It is important to be clear that the vision of the GCI is not simply to
move from a surgical and a restorative model of care to a preventive
one, i.e. replacement. Rather it seeks encompass appropriate
restorative care within a prevention based model of oral health to
expand value and contribute to health outcomes.
As WHO highlighted “different approaches to dental caries
management in countries need to be considered in oral health policy,
development and planning of public health programmes. Implications
for training of dental personnel and costs to society as well as the
individual are significant” 9
Figure 2: Oral diseases share common risk factors with
noncommunicable diseases.
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ORAL HEALTH and NCDs
This expansion of the role of dentists can also be seen in FDI’s focus
in recent times on NCDs or ‘chronic diseases’. They include
cardiovascular disease, cancer, chronic respiratory disease and
diabetes, among others and are responsible for 60% of deaths
worldwide, in both industrialized and developing countries.
In 2011, FDI and its partners succeeded in having a specific reference
to oral diseases included in the United Nations Political Declaration
on the Prevention and Control of Non-communicable Diseases
(2011)10 and the ‘common risk factor approach’ described in Article
19.
There, governments recognize “that renal, oral and eye diseases pose
a major health burden for many countries and that these diseases
share common risk factors and can benefit from common responses
to non-communicable diseases;”
Dental practitioners are in a unique position when it comes to
detecting risk factors. They are one of the few medical professions to
see patients who are not actually ill but just there for a check-up.
Furthermore, many behaviours are immediately visible during the
course of a dental check-up, so dentists are well placed to launch
discussion on risks.
PREVENTION AND CONTROL
With the common risk factor approach to disease control and
prevention now inscribed in UN principle, the FDI Policy Statement on
‘Non-communicable Diseases’ takes the recognition of the impact of
oral health on general health one step further.
This Statement advocates incorporating oral health prevention and
control strategies into the NCD agenda, interventions, programmes
and campaigns. It calls on FDI and its member national dental
associations to make governments, policy makers and community
leaders more aware of the great importance of major common risk
factors affecting both oral health and other NCDs.
The common risk factor theme also emerges in the FDI Policy
Statement ‘Oral Health and the Social Determinants of Health’, which
sees the dentists worldwide aligning with other health care
professionals to deplore “the structural determinants and conditions
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of daily life responsible for a major part of health inequities between
and within countries”.
Among other things, the Statement calls on FDI to engage with key
partners, notably WHO and the IADR, to develop an integrated
approach to reducing oral health inequalities globally. It further calls
upon oral health care professionals, in the interest of oral health in all
policies, to engage with leaders and policy-makers of government and
NGOs, locally, nationally, regionally and globally.
CREDIBILITY
FDI’s credibility has been particularly crucial in defining FDI as a key
partner in major international initiatives and ensuring its place at the
negotiating table. I was able to view the result of that early in October,
when I attended the Conference of Plenipotentiaries on the ‘Minamata
Convention on Mercury’.
It was a proud moment. In the run-up to the final FDI had with its
partners in the WHO Oral Health Programme and the International
Association for Dental Research (IADR), had been in the vanguard of
advocacy to defend the right of dentists around the world to continue
to exercise their freedom in the choice of the materials they use for
restorative work.
The Convention’s provisions for dental amalgam make it highly
relevant to the dental profession. Dental amalgam is clinically proven,
safe and cost effective restorative material, in use for over 150 years
in the fight against dental caries, the cause of tooth decay, which
afflicts 90 percent of the world's population.
However, it is also, within the terms of the Minamata Convention, a
mercury-added product, containing 50% mercury. FDI’s goal during
the negotiations was to ensure that discussions were based on the
best available science. In this respect, the GCI also proved useful as
an example of a system for managing caries risk as an integral part of
global health.
It was during the fifth and final negotiation session (INC5) in January
2013 that consensus built around a phase-down approach to dental
amalgam advocated by the FDI, the International Association for
Dental Research (IADR) and the World Health Organization (WHO) 11.
Thus, efforts by a team representing the international dental and oralhealth sector succeeded in ensuring that dental practitioners would
continue to have access to dental amalgam.
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OPPORTUNITIES FOR THE PROFESSION
The phase-down approach—versus a ban (phase-out)—advocated by
FDI calls for increased research and development on alternatives and
the implementation of the best management techniques for amalgam
waste.
It also calls for a greater focus on dental prevention and health
promotion. Ideally, use of dental amalgam will fall due to a reduction
in demand created by more effective prevention strategies. Dental
professionals living in a country that has ratified the Convention need
to be aware of the direct impact this will have on their profession. In
addition, national dental associations, their partners and individual
dental professionals have a critical role to play in ensuring that the
impact is positive.
This entails taking an active role by helping inform governments
about opportunities to improve health and protect the environment
within the context of the Convention without diminishing the
importance of safe, effective and affordable oral-health care.
CONVENTION PROVISIONS ON DENTAL AMALGAM
The Minamata Convention contains nine provisions for dental
amalgam, with ratifying countries under and obligation to implement
at least two. The fall into five thematic groups, as follows:
Disease prevention and health promotion
i.
Setting national objectives aiming at dental caries prevention
and health promotion, thereby minimizing the need for dental
restoration;
ii.
Setting national objectives aiming at minimizing its use;
Research on alternative materials
iii.
Promoting the use of cost-effective and clinically effective
mercury-free alternatives for dental restoration;
iv.
Promoting research and development of quality mercury-free
materials for dental restoration;
Education
v.
Encouraging representative professional organizations and
dental schools to educate and train dental professionals and
students on the use of mercury-free dental restoration
alternatives and on promoting best management practices;
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Financial incentives
vi.
Discouraging insurance policies, and programmes that favour
dental amalgam use over mercury-free dental restoration;
vii.
Encouraging insurance policies and programmes that favour
the use of quality alternatives to dental amalgam for dental
restoration;
Best management practice
viii.
Restricting the use of dental amalgam to its encapsulated form;
ix.
Promoting the use of best environmental practices in dental
facilities to reduce releases of mercury and mercury
compounds in water and land.
IMPLEMENTATION
The Convention enters into force once it has been ratified by 50
countries, but only in the ratifying countries. The next few years will
see the implementation stage (2014 to 2017), to be monitored by what
the Convention calls the ‘Conference of the Parties’. Article 4, item 8,
calls for a review of progress within a period of 2014-2017.
It is now up to the members of the oral-health profession to develop
ways and means to demonstrate their understanding of the issues
and commit to its undertakings in the field of prevention, research
and the development of new materials as outlined in the treaty.
Recommended actions include:
•
Implementing a preventive based model of oral health care;
increased emphasis on health promotion, risk assessment,
disease prevention and surveillance
•
Establishing a comprehensive global research agenda,
including both public and private sectors, to develop and
commercialise quality mercury-free materials for dental
restoration, alongside expanded preventive approaches
•
Developing and delivering education for health care providers
on the safe handling, effective waste management and
appropriate disposal of dental restorative materials and
environment.
•
Adopting environmentally sound lifecycle management of all
dental materials, including dental amalgam.
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CONTINUING EDUCATION
Once a year, FDI holds its Annual World Dental Congress: in 2014 it
will be in New Delhi. In 2015, the congress will be kindly hosted in
Bangkok by our friends at the National Dental Association of
Thailand. Today, the FDI Congress is not only one of the key global
sources of Continuing Education; it is also rapidly becoming the key
place to debate issues of political and strategic concern for the dental
profession.
For example, the 2013 congress in Istanbul saw a number of World
Oral Health Forums where important issues of public health issues
were discussed including one entitled ‘How might the Minamata
Convention on Mercury Change Dentistry. A second World Oral
Health Forum took up the theme again under the title: ‘Addressing
Oral Health into the Global Noncommunicable Diseases Initiative: A
focus on the opportunities provided by such integration at regional
and country level.
These are important debates for all of us and I do encourage you to
join us in September 2014 to pursue these and other debates on
issues of concern, in particular caries management and oral health
promotion and disease prevention.
WORLD ORAL HEALTH DAY 2014
We all know and understand the importance and effectiveness of
public service messages about prevention and caring for your mouth,
teeth and gums. Perhaps we also have memories of some of the
messages we heard as children about brushing your teeth after each
meal. That is why I would also very much encourage your
participation in World Oral Health Day 2014 either as an individual
dentist—example, by having a poster or logo on the wall of your dental
practice—or through an event organized by the local branch of your
national dental association.
Projects and events vary from country to country and from culture to
culture but they all have important messages to communicate about
oral and dental health and the individual’s role in securing his or her
own oral health and preventing oral disease. This year’s theme is
‘celebrating healthy smiles’ – and I hope I can count on all present
here today to join FDI in, using the words of this year’s theme
‘celebrating healthy smiles’ on 20 March 2014.
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CONCLUSION
The activities and policies outlined in this paper demonstrate FDI’s
commitment to oral health promotion and disease prevention. It is a
key part of its vision, as described in FDI Vision 2020. It plays a
pivotal role in FDI’s Live.Learn.Laugh. Programme. Furthermore,
FDI’s Global Caries Initiative is predicated on a preventive model of
oral care and the key to its approach to the prevention and control of
oral diseases within the context of NCDs.
The concept of caries prevention permeates key FDI documents,
notably its most recent Policy Statements. Its landmark GCI was
central to the negotiation strategy of FDI and its partners during all
five sessions Intergovernmental Negotiating Committee (INC) on
Mercury, which led ultimately to the Minamata convention and its
provisions for dental amalgam.
REFERENCES
1.
FDI Policy Statements ‘Non-communicable Diseases (NCDs)’;
‘Oral Health and the Social Determinants of Health’; ‘Oral
Infection/Inflammation as a Risk Factor for Systemic Diseases’;
‘Salivary Diagnostics’; and ‘Bisphenol-A in Dental Restorative
and Preventive Materials’. International Dental Journal 63, no. 6
(2013):
2.
Future Use of Materials for Dental Restoration’, WHO, 2009.
3.
Da Silva, Orlando Monteiro, and Michael Glick. “FDI Vision 2020:
a Blueprint for the Profession.” International Dental Journal 62,
no. 6 (2012): 277–277. doi:10.1111/idj.12011. and Glick,
Michael, Orlando Monteiro da Silva, Gerhard K. Seeberger, Tao
Xu, Gilberto Pucca, David M. Williams, Steve Kess, Jean-Luc
Eiselé, and Tania Séverin. “FDI Vision 2020: Shaping the Future
of Oral Health.” International Dental Journal 62, no. 6 (2012):
278–291. doi:10.1111/idj.12009.
4.
WHPA: World Medical Association (WMA), International Council
of Nurses (ICN), International Pharmaceutical Federation (FIP)
and the World Confederation of Physical Therapy (WCPT)
5.
Pine CM, Dugdill L. Analysis of a unique global public-private
partnership to promote oral health. Int Dent J. 2011;61:11–21.
and Cohen LK. Live.Learn.Laugh.: A Unique Global Public-Private
Partnership to Improve Oral Health. Int Dent J. 2011;61:1–1.
6.
Fisher J, Johnston S, Hewson N, van Dijk W, Reich E, Eiselé J-L,
et al. FDI Global Caries Initiative; implementing a paradigm shift
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in dental practice and the global policy context. Int Dent J.
2012;62(4):169–74.
7.
Fisher, Julian, BDS, MSc,MIH; Glick, Michael, DMD;for the FDI
World Dental Federation Science Committee. ‘A new model for
caries classification and management. The FDI World Dental
Federation Caries Matrix’. Journal of the American Dental
Association (JADA). JADA 143(6) http://jada.ada.org June
2012, 546-551.
8.
‘Future Use of Materials for Dental Restoration’, WHO, 2009.
9.
‘Future Use of Materials for Dental Restoration’, WHO, 2009.
10.
For explanations of the contents of the UN Political Declaration
on Noncommunicable Diseases, consult the FDI publication ‘Oral
Health and the United Nations Political Declaration on NCDs: a
guide to advocacy’, online at
www.fdiworldental.org/media/9465/oral_health_and_un_politic
al_dec_on_ncds.pdf.
11.
In particular ‘Future Use of Materials for Dental Restoration’,
WHO 2010.
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GLOBAL CARIES PERSPECTIVE:
THE RESEARCH AGENDA
Edward CM LO
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GLOBAL CARIES PERSPECTIVE: THE RESEARCH AGENDA
Edward CM LO3
The International Association for Dental Research (IADR) is the largest
international organization of dental researchers, with more than
11,500 members worldwide. Its mission is: (1) to advance research
and increase knowledge for the improvement of oral health worldwide;
(2) to support and represent the oral health research community; and
(3) to facilitate the communication and application of research
findings.
IADR recognizes that there is marked social gradient in oral health
and that there are global inequalities in oral health, both between and
within different regions and societies. Dental caries is among the most
prevalent oral diseases of concern. Despite having much research into
the biological and social determinants of oral health, including dental
caries, there has been limited success in translating research into
effective action to promote global oral health and improve on the
dental caries inequality situation. Earlier this year, the IADR Global
Oral Health Inequalities Research Agenda (IADR-GOHIRA®) was
published (Sgan-Cohen et al., 2013). This calls for coordinated action
and strategy to address the prioritized research agenda so as to close
the knowledge gaps in different aspects of reducing inequalities in oral
health.
The overall aim of the IADR-GOHIRA is to focus attention on the need:
(1) for better understanding of the full range of oral health
determinants; (2) to promote research on social and physical
environments, across the social gradient, with emphasis on
marginalized and vulnerable communities; (3) to focus on research
strategies that can better serve to reduce existing oral health
inequalities, within and between countries; and (4) to develop and
maintain usable resources for compiling evidence-based systematic
reviews and guidelines on methods and strategies to address the
inequalities in oral health.
3
Treasurer, International Association for Dental Research. Edward LO <hrdplcm@hku.hk>
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REFERENCES
Sgan-Cohen HD, Evans RW, Whelton H, Villena RS, MacDougall M,
Williams DM, and IADR-GOHIRA Steering and Task Groups (2013).
IADR Global Oral Health Inequalities Research Agenda (IADRGOHIRA®): a call to action. J Dent Res 92:209-211.
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CARIOLOGY RESEARCH UPDATE
Dominick T ZERO
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CARIOLOGY RESEARCH UPDATE
Dominick T ZERO4
4
Professor, Indiana University, USA. Email: Dominick T Zero <dzero@iupui.edu>
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CARIOLOGY IN DENTAL EDUCATION
Juan Carlos Llodra CALVO
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CARIOLOGY IN DENTAL EDUCATION
Juan Carlos Llodra CALVO5
First of all, thank you for the kind invitation to speak here today.
I have been asked to prepare a lecture about Cariology in Dental
Education. Therefore, I’m going to present the results “of a joint
workshop of the European Organization for Caries Research (ORCA)
together with the Association for Dental Education in Europe (ADEE),
which was held in Berlin from 27 to 30 June 2010.”
The European Core Curriculum in Cariology can be divided into 5
domains (Figure 1)




The knowledge base
The risk assessment and diagnosis
The clinical decision making (preventive non-surgical therapy
and surgical therapy)
Evidence-based cariology
Figure 1: The European Core Curriculum in Cariology.
Preventive and Community Dentistry. University of Granada. Spain; FDI Public Health
Committee Chair. Email: Juan Carlos Llodra <jllodra@hotmail.com>
5
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DOMAIN I: THE KNOWLEDGE BASE(1)
The domain knowledge base includes not only the traditional fields of
basic sciences such as anatomy and histology but propose to include
emerging sciences such as molecular biology, nanotechnology,
behavioural sciences fields and research methodology. This also
includes all aspects relating to prevention.
It is very important that the future dentist learn to make a clear
distinction between dental caries as symptomatic process such as
caries lesion and caries disease with all its etiological connotations
stemming from it. Furthermore, we believe that we must insist on the
evolution of the dental caries concept, from a merely surgical therapy
to preventive option in order to avoid or reduce those aggressive
therapies.
We cannot forget the dynamic and reversible concept of the process of
caries. This includes an analysis of pathological and protective
factors.
DOMAIN II: RISK ASSESSMENT, DIAGNOSIS AND SYNTHESIS(2)
Three major competencies were identified: Risk Assessment –
competent at identifying and estimating the probability for a patient of
developing new caries lesions or progression of existing lesions during
a specified period of time; Diagnosis – competent through collecting,
analysing and integrating data on signs and symptoms of dental
caries and assess activity status of a lesion on a tooth surface to
arrive at an identification of past or present occurrence of the disease
caries; and Synthesis – competent at synthesising all relevant
information by combining and interpreting findings from: risk
assessment and diagnostic processes; from patients’ needs,
preferences and best interests; and from monitoring, review and reassessment findings, when available.
All these concepts must be translated into an educational process in
which the future dentist knows to integrate all matters relating to risk
assessment on one hand, and on the other, the current concepts of
caries diagnosis with the aim of being able to achieve a synthesis
based on scientific evidence. To accomplish this educational goal, a
number of terms, which are often confusing and used in a wrong and
inappropriate way for the dental community, should be clarified. The
terms of lesion detection, lesion assessment and caries diagnosis
should be clearly defined from the beginning of the educational
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process.
As previously mentioned, in this process should be a distinction
between the risk assessment performed at the tooth surface level and
that performed at the patient level. (Fig.2). All this information
subsequently allows the development of a right treatment plan for the
patient in order to avoid a merely technical vision of caries disease.
Figure 2: Framework for ICDAS-enabled, patient-centred caries
management.
Regarding diagnosis, the International Caries Detection and
Assessment System (ICDAS) is currently proposed for several reasons:





It employs an evidence-based and preventively oriented
approach,
Is a detection and assessment system classifying stages of the
caries process
Provides all stakeholders with a common caries language
Has evolved to comprise a number of approved, compatible
‘formats’
Supports decision-making at both individual and public health
levels.
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ICDAS system is extremely versatile and it is very useful not only in
the education field but also in the dental practice, research and public
health fields. This system has also the ability, in those situations that
require it, to incorporate the PUFA index which includes pulp
problems (such as ulceration, fistula and abscesses)
Domains III and IV are dedicated to Caries Management. Domain III
corresponds to the preventive and non-surgical therapy while domain
IV is reserved for surgical therapy.
DOMAIN III. DECISION MAKING AND PREVENTIVE NON-SURGICAL
THERAPY(3)
Traditionally, the dental curriculum usually prevail surgical therapy.
One factor that is essential in the provision of a preventive, nonsurgical approach is that of communication with the patient. However,
this unfortunately takes less space in the dental curricula compared
with technical skills aimed at restorative procedures; this weighting
needs to be more equally balanced.
The teaching of these competencies to undergraduate dental students
and the application of these competencies in clinical situations
require not only a thorough understanding of the caries process
according to the best evidence but also acceptance of moving away
from a surgical-only model of dental care. The latter has to be
accepted not only by all branches of the dental profession but also by
patients and healthcare institutions.
For this reason, dental student must correctly handle all the available
preventive tools and learn the basic notions of communication with
patients. For dental students to become competent in the assessment
of caries activity and preventive strategies, early patient contact is
essential so that these students can follow up patients long enough to
establish the outcome of their assessment and management.
To fulfil this approach, it is extremely important the students know
the effectiveness of the different prevention methods and its health
economic aspects. Teaching prevention should not focus in an isolated
way on aspects related to Cariology. It must be integrated into a global
prevention in the field of dentistry in order to avoid conflicting
messages. Furthermore, because many active practitioners graduated
some decades ago, the new message that caries treatment does not
consist of operative treatment alone needs to be disseminated.
Continuing education is a good way to reach these practitioners.
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DOMAIN IV. DECISION MAKING AND SURGICAL THERAPY(4)
Domain IV focuses on surgical therapy aspects, defined as “any step
undertaken by the dentist, or other qualified personnel to
intentionally remove dental hard tissue and includes treatment
options such as cavity preparation to place a restoration”. It is
unanimously agreed that surgical therapy was not reasonably
balanced regarding the preventive aspects. In any case, the long-term
results of surgical therapy will largely depend on preventive measures
implanted.
Undergraduate education should be able to prepare students in the
manual skills of quality in surgical therapy of dental caries. That
includes a good knowledge of the effectiveness and longevity of the
different treatments available, the cost of them and ethical
considerations in order to provide the best treatments available to the
patient.
In this decision-making of surgical therapy a number of factors need
to be considered. These factors include patient’s needs, preventive
strategies, tooth preservation, short and long term results of
treatments and the cost of them. It is obvious that the best training in
this field, the better the results in the medium and long term.
Regarding
identified:







the
caries
process,
numerous
variables
have
been
Misperception of caries: Caries is still perceived by dentists and
patients as a disease that can be ‘cured’ by drilling and filling
Lack of patient and professional education: Preventive concepts
do not lead to instant results
Lack of integration: Usually dental education and educators are
organised, think and act in divisions (e.g. operative, restorative,
preventive departments)
Lack of evidence base: Most decisions in dental practice are
based on low evidence levels
How to increase acceptability of less invasive treatment:
prevention and risk assessment must be worthwhile for the
patient, dentists, insurers and politicians.
Remineralisation therapies are evidence-based standard
methods to treat carious lesions, and the benefits over
restorative approaches are well accepted.
Inverse teaching approach: In most dental schools students
learn initially the skills of cavity preparation and restoration
with phantom-heads and subsequently with patients. Only at a
later stage in the course will preventive treatment options be
taught and practised on the clinic.
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Regarding to the caries removal two aspects have been identified:


The existence of a very high level of variability at the time of
removal of caries based on the classical criteria (dentin
hardness, its colour, etc.)
The maximum preservation of dental hard tissues should be
considered a priority (minimal dentistry intervention).
Regarding to the cavity restoration, a number of relevant aspects must
also be highlighted:



Lack of patient education: many patients prefer immediate and
tangible results instead of waiting for possible intangible
benefits of longer-term prevention. The time value is very
important, especially nowadays. In this sense, the patients
prefer a quick restoration and not having to go through
repeated preventive treatments that take much longer.
Lack of dentist and educator motivation: the student’s own
assessment is usually based on the tangible number of
therapeutic acts carried out: number of filling, number of
crowns, etc. However, other treatments such as those related to
minimal intervention therapies, are not evaluated with the
same intensity probably because its difficult to assess them.
Lack of long-term effectiveness: the average life of restorative
treatment depends on several factors.
In dentistry rerestorations are usually after a certain period of time, which
means an increase of dental treatment cost for patients.
In relation to financial considerations in most models of dental care
around the world, surgical treatments are more important than
preventive treatments. These are not usually reimbursed and
therefore suffer severe discrimination that determines, in part, the
way to practice dentistry. We thus come to a dangerous vicious circle
in which dentist assumes that prevention do not compensate because
they are not going to be paid for it. On the other hand, the patient also
assumes that will not pay for prevention if dentist have not really
done anything tangible. It is obvious that only through the
undergraduate educational process, these false axioms could be
gradually changed (Figure 3).
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Figure 3: The vicious circle of prevention.
In short, at the end of their undergraduate education, the future
dentist should be prepared to make the best treatment decisions
possible, providing the most benefit to the patient with the best
available scientific evidence. This also includes a good training in
manual skill in order to provide the best treatments, being aware of its
longevity, its costs, and its potential adverse effects in terms of
repercussions in oral and global health. The future dentist should
have training in relation to the importance of the preservation of
dental hard tissues and the relevance of health promotion. All this
goes through a proper knowledge and manual skills training, properly
balanced throughout the whole curriculum, and if possible, from the
beginning of it.
DOMAIN V. EVIDENCE-BASED DENTISTRY IN CLINICAL AND PUBLIC
HEALTH PRACTICE(5)
Domain V focuses on the study of evidence-based cardiology in
clinical and public health practice. The Berlin Workshop recommends
“On graduation, a dentist must understand the benefits of practicing
in an evidence-based manner at both individual and public health
levels, and have good knowledge and skills in these areas, and apply
them to the fields of caries”.
To conclude, The European Core Curriculum in Cariology, proposed
by the European Organization for Caries Research (ORCA) together
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with the Association for Dental Education in Europe (ADEE) is based
on 5 domains interrelated with each other. It is a versatile proposal
based on the available scientific evidences. Its main objective is
helping the future dentist not only to be able to do things right, but
also to be able to do the right things.
REFERENCES
1.
P. Anderson, J. Beeley, P. Manarte Monteiro, H. de Soet, S.
Andrian, B. Amaechi and M.-C. D. N. J. M. Huysmans. A
European Core Curriculum in Cariology: the knowledge base.
Eur J Dent Educ 2011; 15(Suppl 1): 18-22
2.
N. Pitts, P. Melo, S. Martignon, K. Ekstrand and A. Ismail. Caries
risk assessment, diagnosis and synthesis in the context of a
European Core Curriculum in Cariology. Eur J Dent Educ 2011;
15(Suppl 1): 23-31
3.
P. Bottenberg, D. N. J. Ricketts, C. Van Loveren, C. Rahiotis and
A. G. Schulte. Decision-making and preventive non-surgical
therap in the context of a European Core Curriculum in Cariology.
Eur J Dent Educ 2011; 15(Suppl 1): 32-39
4.
W. Buchalla, A. Wiegand and A. Hall. Decision-making and
treatment with respect to surgical intervention in the context of a
European Core Curriculum in Cariology. Eur J Dent Educ 2011;
15(Suppl 1): 40-44
5.
Ch. H. Splieth, N. Innes and A. Söhnel. Evidence-based cariology
in clinical and public health practice as part of the European
Core Curriculum in Cariology. Eur J Dent Educ 2011; 15(Suppl
1): 45-51
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DENTAL CARIES CONTROL IN CHILDREN
Edward CM LO
Duangporn DUANGTHIP
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DENTAL CARIES CONTROL IN CHILDREN
Edward CM LO6
Duangporn DUANGTHIP 7
Dental caries is one of the most common childhood diseases
worldwide, including in Asia. To plan and implement the effective
caries control program in children, one should have good knowledge
of the causes of and factors associated with dental caries in children.
In a systematic review of the literature on the risk factors for dental
caries in young children, Harris et al. (2004) identified 106 factors
which were significantly related to the prevalence or incidence of
caries. Among these factors, the ones that are more important for
planning caries prevention programs include reduction in the
frequency of sugary food/drink intake, good or supervised
brushing/cleaning of teeth, and less use of feeding bottle especially
when going to bed at night. The above should be included in the key
messages in ORAL HEALTH EDUCATION programs for parents and
caretakers of young children. However, evidence showing effectiveness
of oral health education in preventing dental caries in young children
is limited (Ammari et al., 2007). Despite this, oral health education for
children and their parents should still be an important component of
the dental caries control program for children as it can help to raise
the participants’ awareness of good oral health, increase their dental
health knowledge and improve their attitudes (Kay & Locker, 1998).
USE OF FLUORIDE
Besides oral health education there should be other preventive
measures for dental caries control. From the extended host-agentenvironment disease causation model for dental caries (Ten Cate,
2009), the use of fluorides appears to be one of the most important
factors for caries prevention. Fluoride acts on the tooth surface to
reduce demineralization and to promote remineralization of dental
hard tissues, and it also has antimicrobial actions such as
suppressing the production of acids by plaque bacteria (Buzalaf et al.,
2007). Fluorides can be administered through community-based
6Faculty
7
of Dentistry, University of Hong Kong. Email: Edward Lo <hrdplcm@hku.hk>
Faculty of Dentistry, University of Hong Kong. Email: Duangporn <dduangporn@yahoo.com>
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delivery program, applied topically by professionals or through the
use of self-care products. Among the various fluoride delivery
methods, fluoridation of the community drinking water supply has
the longest history which is over 60 years. The dental caries
preventive effect of water fluoridation is clearly shown in the
systematic review of the literature conducted by McDonagh et al.
(2000). Two-thirds of the 30 included studies in the review showed a
significant increase in the proportion of children without dental caries
experience after water fluoridation was introduced compared to the
situation when there was no water fluoridation. There was also a
decrease in the mean number of decayed, missing, and filled
primary/permanent teeth (dmft/DMFT) in the range of 0.5 to 4.4
teeth. Water fluoridation is probably the most cost-effective
community-based dental caries prevention method for children. It is
recommended by both the World Health Organization (WHO) and the
World Dental Federation (FDI). In situations where water fluoridation
cannot be implemented, salt fluoridation and milk fluoridation are
feasible alternatives. These programs have been implemented
successfully in some countries in Asia (Petersen et al., 2012).
Results from numerous studies have shown that topical fluorides can
effectively prevent dental caries in children, with a pooled prevented
fraction of 26% of DMFS scores (Marinho et al., 2003). The most
commonly used topical fluoride agents is fluoride toothpaste. A recent
Cochrane systematic review confirmed that the effectiveness of
fluoride toothpaste in preventing dental caries in children increased
with the fluoride concentration and supervision of tooth brushing
(Walsh et al., 2010). Besides promoting the use of fluoride toothpaste
at home, regular tooth brushing with fluoride toothpaste in
kindergarten or school can be a good program for dental caries control
in children when indicated. The conventional concentration of fluoride
ion in toothpaste is around 1000 parts per million (ppm). For better
control of dental caries in older children who do not have significant
risk for developing dental fluorosis, for example those older than 6
years, higher concentration fluoride toothpaste would be appropriate.
However, there are different views on the appropriate use of fluoride
toothpaste in the very young children. On one hand, there may be an
increased risk of development of mild dental fluorosis when a child
starts to use fluoride toothpaste at or before 12 months of age (Wong
et al., 2011). On the other hand, the use of toothpaste with a fluoride
concentration at around 500 ppm or below may not be effective in
preventing dental caries (Walsh et al., 2010). When balancing the risk
and benefit of using fluoride toothpaste in young children, in most
cases the need for preventing dental caries outweighs the possibility
of a minor cosmetic side effect of mild fluorosis. It has been proposed
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that reducing the amount of toothpaste applied onto a toothbrush
would be a better strategy than using low fluoride concentration
toothpaste, and that a thin smear to a small pea size amount of
toothpaste be used for children under the age of 6 years (Zero et al.,
2012).
Another effective topical fluoride agent is fluoride mouthrinse. Sodium
fluoride rinse used daily at a lower concentration (around 0.05%) or
used weekly at a higher concentration (at around 0.2%) has been
found to have a caries preventive effect in children with limited
background fluoride exposure but its additional effect in children with
daily use of fluoride toothpaste is questioned (Twetman et al., 2004).
Use of fluoride mouthrinse is generally recommended for children
starting from age 6 years but it can also be used safely for children 45 years old under close supervision (Zero et al., 2012).
Fluoride gel/foam and fluoride varnish are both used by dentists in
the private sector and in public services in Asian countries and both
are effective in preventing dental caries in children (Lo et al., 2012).
Compared to fluoride gel, fluoride varnish has the advantage of more
targeted application onto the tooth surfaces which require protection
against caries and the amount of fluoride used in each application is
less and well controlled by the operator. The latter advantage is of
particular importance when used in young children as the risk of
fluoride toxicity due to ingestion would be much reduced. In the
systematic review on fluoride varnish conducted by Marinho et al.
(2002), the reported pooled prevented fraction for the DMFS and the
dmft scores were 46% and 33%, respectively. The frequency of fluoride
varnish application should be based on the dental caries risk of the
children and 2 to 4 times a year has been suggested (American Dental
Association Council on Scientific Affairs, 2006).
PREVENTION OF PRE-CAVITATED DENTAL CARIOUS LESION
Other than the use of fluorides, placement of sealants on the pits and
fissures of permanent teeth has been found to be very effective in
preventing dental caries. The 3-year pooled risk for developing dental
caries in the sealed sites of first permanent molars is only 30% of that
of unsealed sites (Ahovuo-Saloranta et al., 2008). The traditional
fissure sealants use resin-based material, and good moisture control
and use of dental equipment is needed for successful placement. In
the last two decades, glass ionomer materials suitable for use as
sealants have been developed and their application is technically less
demanding. A systematic review by Beiruti et al. (2006) found no
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clinical evidence supporting that either resin-based or glass ionomer
sealant material was superior to the other in preventing dentin caries
lesion development in pits and fissures over time. Notwithstanding
that dental sealants are highly effective in preventing pit and fissure
caries in permanent teeth, evidence showing their effectiveness in
primary teeth is very limited.
It should be noted that the use of the above-mentioned dental caries
preventive methods can be combined to achieve a better outcome.
There is good evidence of the complementary efficacy of preventive
strategies such as using fissure sealants and fluoride varnish, as well
as toothbrushing with fluoride toothpaste and dietary counseling
(Azarpazhooh & Main, 2008). Use of fluoride mouthrinse, gel or
varnish in combination with fluoride toothpaste can result in a pooled
prevented fraction of around 10% in DMFS score in children
compared to using fluoride toothpaste alone (Marinho et al., 2004).
Thus, when planning dental caries prevention programs for children,
the use of complementary strategies should be considered.
Besides preventing the development of new dental caries, a good
caries control program for children should also include component
which can prevent or halt the progression of existing non-cavitated
and cavitated carious lesions. It has been documented that daily
brushing with fluoride toothpaste can arrest active carious dentin
lesion in the primary teeth of preschool children (Lo et al., 1998). The
active dentin caries lesion will become dark in color with a shiny
appearance when arrested and the surface of the arrested lesion is
hard on gentle probing. There is no pain or discomfort from the
arrested lesions which had not previously progressed into the dental
pulp. Whether an arrested caries lesion needs to be restored depends
to a great extent on the wish of the child/parent and the availability of
resources. Clinical studies have found that repeated applications of
sodium fluoride varnish or silver fluoride solution can arrest active
dentin caries in young children, with the latter being more effective
(Rosenblatt et al., 2009). With regular applications of silver diammine
fluoride solution over 2 years, up to 90% of the cavitated dentin caries
lesions in primary teeth can be arrested while removal of the
superficial soft carious dental tissues by using hand instruments can
speed up the process of complete caries arrest (Wong et al., 2005).
Fissure sealants with a good seal can also stop the progression of
early dental caries. A review of the literature on the effect of dental
sealants on bacteria levels in caries lesions by Oong et al. (2008)
found sealing caries in teeth was associated with a drastic reduction
in the number of viable bacteria in the lesions and that the concerns
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about poorer outcomes associated with inadvertently sealing caries
was not supported. A recent report of the American Dental
Association Council on Scientific Affairs also supports the use of
fissure sealants to prevent the initiation and progression of dental
caries in children (Beauchamp et al., 2008).
PREVENTIVE RESTORATION OF CAVITATED DENTAL CARIOUS LESION
Traditionally, cavitated dental carious lesions in vital teeth have been
treated using a restorative approach. Placement of amalgam or resin
composite into a surgically prepared cavity in a dental clinic setting
has been a common practice by dental professionals for restoring the
function of a decayed tooth. However, placement of dental fillings in
young children is not easy and challenging for many dentists. In
many places, most of the decayed primary teeth in preschool children
are unfilled. Furthermore, the success of dental restorations placed in
primary teeth is highly variable and is significantly affected by the
operator. In a recent systematic review on the survival of Class II
amalgam restorations placed in primary molars, a wide range of
failure rates from 0 to 58% was reported (Kilpatrick & Neumann,
2007). Another systematic review conducted by Hickel et al. (2005) on
the longevity of different restorations placed in stress-bearing cavities
of primary molars reported annual failure rates of 0-15% for resin
composite restorations.
The use of glass ionomer material in restoring cavities in stressbearing areas in teeth is relatively new. This was prompted by the
introduction of the atraumatic restorative treatment (ART) which was
developed in response to a need to provide effective preventive and
restorative treatment in underserved communities where running
water and electricity was not easily available. Nowadays, high
viscosity glass ionomer restorative materials are marketed by various
dental material manufacturers for use in both clinical and field
settings. A recent systematic review on the survival of ART sealants
and restorations placed using high-viscosity glass ionomers reported
2-year survival rates of 93% and 62% for single-surface and multiplesurface ART restorations in primary teeth, respectively (de Amorim et
al., 2012). These rates are comparable to those of the traditional
amalgam or resin composite restorations. With its fluoride releasing
property, secondary caries around glass ionmer restortaions is
uncommon and it can help to remineralize the underlying soft dentin
left behind when treating a deep carious cavity (Massara et al., 2002).
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CONCLUSION
In summary, there are a number of effective primary and secondary
prevention methods available for use in dental caries control
programs for children. The notable ones include the use of fluorides
and fissure sealants. Careful assessment of the situation and the
caries risk of the children should be undertaken before deciding on
the most appropriate method to be used. Combination of different
complementary strategies is feasible and should be considered when
planning dental caries control programs. The use of fluoride releasing
adhesive material for restoring cavitated lesions seems promising.
Caries arrest treatment is a viable alternative to the traditional
restorative approach in treating dentin caries, especially in the
primary teeth of young children. More clinical trials on the
effectiveness of various methods in preventing and arresting dental
caries, especially those using a combination strategy and those for
use in preschool children, are needed.
REFERENCES
Ahovuo-Saloranta A, Hiiri A, Nordblad A, Makela M, Worthington HV
(2008). Pit and fissure sealants for preventing dental decay in the
permanent teeth of children and adolescents. Cochrane Database Syst
Rev Issue 4: CD001830.
American Dental Association Council on Scientific Affairs (2006).
Professionally applied topical fluoride: evidence-based clinical
recommendations. J Am Dent Assoc 137:1151-1159.
Ammari JB, Baqain ZH, Ashley PF (2007). Effects of programs for
prevention of early childhood caries. A systematic review. Med
Principles Prac 16:437-42.
Azarpazhooh A. Main PA (2008). Fluoride varnish in the prevention of
dental caries in children and adolescents: a systematic review. J Can
Dent Assoc 74:73-79.
Beauchamp J, Caufield PW, Crall JJ, et al. (2008). Evidence-based
clinical recommendations for the use of pit-and-fissure sealants: a
report of the American Dental Association Council on Scientific Affairs. J
Am Dent Assoc 139:257-268.
Beiruti N, Frencken JE, van 't Hof MA, van Palenstein Helderman WH
(2006). Caries-preventive effect of resin-based and glass ionomer
sealants over time: a systematic review. Community Dent Oral
Epidemiol 34:403-409.
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Buzalaf MA, Pessan JP, Honório HM, ten Cate JM (2011). Mechanisms
of action of fluoride for caries control. Monogr Oral Sci 22:97-114.
de Amorim RG, Leal SC, Frencken JE (2012).Survival of atraumatic
restorative treatment (ART) sealants and restorations: a meta-analysis.
Clin Oral Investig 16:429-441.
Harris R, Nicoll AD, Adair PM, Pine CM (2004). Risk factors for dental
caries in young children: a systematic review of the literature.
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Hickel R, Kaaden C, Paschos E, Buerkle V, Garcia-Godoy F, Manhart J
(2005). Longevity of occlusally-stressed restorations in posterior
primary teeth. Am J Dent 18:198-211.
Kay E, Locker D (1998). A systematic review of the effectiveness of
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Kilpatrick NM, Neumann A (2007).Durability of amalgam in the
restoration of class II cavities in primary molars: a systematic review of
the literature. Eur Arch Paediatr Dent 8:5-13.
Lo ECM, Schwarz E, Wong MCM (1998). Arresting dentine caries in
Chinese preschool children. Int J Paed Dent 8:253-260.
Lo ECM, Tenuta LMA, Fox CH (2012). Use of professionally
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Marinho VCC, Higgins JPT, Logan S, Sheiham A (2002). Fluoride
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Marinho VCC, Higgins JPT, Sheiham A, Logan S (2004). Combinations
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adolescents. Cochrane Database Syst Rev Issue 1: CD002781.
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treatment: clinical, ultrastructural and chemical analysis. Caries Res 36:
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McDonagh MS, Whiting PF, Wilson PM et al. (2000). Systematic review
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Oong EM, Griffin SO, Kohn WG, Gooch BF, Caufield PW (2008). The
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the evidence. J Am Dent Assoc 139: 271-278.
Petersen PE, Baez RJ, Lennon MA (2012). Community-oriented
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NUTRITION AND ORAL HEALTH
Andrew RUGG-GUNN
Paula MOYNIHAN
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NUTRITION AND ORAL HEALTH
Andrew RUGG-GUNN8
Paula MOYNIHAN8
INTRODUCTION
Nutrition is a major influence on growth, well-being, and the presence
and absence of disease. Nutrient deficiency diseases used to be
common – causing failure to thrive, death, and increased
susceptibility to infections. In developed countries they still exist but
are now much rarer, overtaken in importance by diseases related to
food intake which is both excessive and badly balanced. In the 20
countries of interest at this conference, both problems exist – undernutrition, and excessive and badly balanced nutrition, contributing,
in turn, to a rise in non-communicable diseases – cardiovascular
diseases, diabetes, cancer and chronic respiratory diseases, to name
but a few. Non-communicable diseases are now responsible for 63% of
total world mortality: nearly 80% of this disease burden is in low- and
middle-income countries [1]. They are now the most frequent cause of
death in South-East Asia. These non-communicable diseases share
many risk factors, including imbalanced nutrition. Most oral diseases
fit within this group, being due, in a large part, to badly balanced diet.
WHO projections show that NCD mortality will rise in South-East Asia,
2010 to 2020, by over 20%, while no increase is expected in Europe.
In parallel with these changes in disease profile have been changes in
diet. In many countries, there has been a change from traditional
diets to fast-foods and sugared drinks aggressively marketed by
multinational companies.
ORAL DISEASES
The oral diseases that will be considered are: dental caries,
periodontal disease, cancer, and dental fluorosis. The importance of
oral diseases from medical, social and economic viewpoints is
considerable. According to WHO, oral disease is the fourth most
expensive disease to treat [2]. Dental caries remains the most
WHO Collaborating Centre for Nutrition and Oral Health, Professor, Newcastle University, UK.
Email: Andrew Rugg-Gunn <andrew@rugg-gunn.net>,
Paula Moynihan <p.j.moynihan@newcastle.ac.uk>
8
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prevalent and economically important oral disease. In the 20 Asian
countries being considered, there is a mixed picture. In some, dental
caries severity is decreasing, in others, severity is increasing, and in
others there has been little change over recent years. The South-East
Asia Consultation on Oral Health in 2008 reported caries prevalences
of 50% to 80% at age 6 years, with mean DMFT at age 12 years
varying between 0.5 and 2.2 [3]. The WHO collaborating centre at
Niigata has been coordinating data on periodontal disease
[www.dent.niigata-u.ac.jp/prevent/perio/contents.html]. The incidence
of oral cancer varies widely within Asia. Globally, it is the seventh
most prevalent cancer, while in south-central Asia, it is the third,
affecting more than 150 thousand Indians each year [4].
Although there are major challenges in improving oral health, there
are many building blocks in place which could lead to considerable
reduction in the burden of oral disease. First, information on the
occurrence of oral diseases within each country is much improved.
Second, information about nutrition and diet within countries is also
improving. Third, our knowledge of the relation between nutrition,
diet, and health and disease is now very well documented. Fourth,
much of these chronic, non-communicable diseases are preventable.
Fifth, the realisation that good nutrition is fundamental to health is
now influencing policy within Regions, within countries, within
communities, and is understood by individuals: the goals set are
achievable. This is well-illustrated by looking through the Agendas for
the World Health Assembly for recent years and the web-pages for
SEARO and WPRO. I wish now to consider the third point above – the
relation between nutrition, diet and oral health.
EVIDENCE FOR THE RELATION BETWEEN NUTRITION, DIET AND ORAL
DISEASE
The book ‘Nutrition and dental health’, published in 1993, is 470
pages long and contains some 1,500 references [5]. This is evidence of
the vast amount of information published on this subject. Since then,
other reviews have been published but the conclusions have not
changed significantly. The evidence will not be discussed in detail but
reference will be made to the most authoritative, recent review – the
WHO Technical Report 916 ‘Diet, Nutrition and the Prevention of
Chronic Diseases’, 2003 [6]. It is a report of a joint WHO/FAO Expert
Consultation. There were 30 members and each draft underwent
intense external scrutiny. Dental disease was one of six chronic
diseases considered because of their public health importance and the
many common risk factors.
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Nutrition and dental disease. Nutritional status affects teeth preeruptively, although this influence is much less important than the
post-eruptive local effect of diet on teeth. Deficiencies of vitamins D
and A, and protein-energy malnutrition have been associated with
enamel hypoplasia and salivary gland atrophy, so that undernutrition
coupled with a high intake of sugars may exacerbate the risk of dental
caries. There is some evidence to suggest that periodontal disease
progresses
more
rapidly
in
undernourished
populations.
Undernourishment exacerbates the severity of oral infections – for
example, acute necrotizing gingivitis and, more severely, noma. To
complete the picture, it is well known that excessive ingestion of
fluoride during tooth formation results in dental fluorosis.
Regarding dietary sugars and dental caries, to quote the WHO report:
“there is a wealth of evidence from many different types of
investigation, including human studies, animal experiments and
experimental studies in vivo and in vitro to show the role of dietary
sugars in the aetiology of dental caries.” “Sugars are undoubtedly the
most important dietary factor in the development of dental caries”.
There are some aspects of sugars consumption which need to be
considered.
First, frequency and amount of sugars consumed. There are studies
showing that both are important – some studies measured frequency
and showed this to be important, and others measured amount and
showed this to be important. Likewise, in animal experiments, both
increasing frequency and increasing amount of sugars intake have
been positively related to caries development. In free-living people,
there is a close correlation between frequency of sugars intake and
amount of sugars consumed. It is, therefore, good advice to decrease
both frequency and amount. Which takes preference will depend on
the situation: when giving personal advice, people understand the
concept of frequency well; on the other hand, national guidelines and
goals must be given in terms of amount, as this is the method used
for all other nutrients.
Second, different types of sugar. Summarising quite a quantity of
information from several types of study – lactose is less cariogenic
than other sugars, and there is little difference in cariogenicity
between the other dietary sugars.
Third, the potential impact of reducing sugars consumption on the
rest of the diet. This has centred on the issue – ‘would intake of fats
rise as sugar intake falls?’ This was mentioned in the WHO trs 880,
published in 1998 [7]. This is incorrect and was corrected in WHO trs
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916, 2003 [6]. I quote: “There is, however, a growing body of evidence
from studies over time that shows that changes in intake of fat and
free sugars are not inversely related, and that reductions in fat intake
are offset by increases in intakes of starch rather than free sugars.”
“Overall, dietary goals that promote increased intake of wholegrain
staple foods, fruits and vegetables and reduce consumption of free
sugars are thus unlikely to lead to an increased consumption of fat.”
Fourth, the influence of fluoride. Does fluoride do the job of
preventing dental caries so well that there is no need to reduce sugars
consumption? This view was also included in the WHO trs 880, 1998,
mentioned previously [7]. Again, this view is incorrect. Fluoride
reduces caries development but does not eliminate it. Several reviews
have stated that the gain in sugars restriction is reduced when
fluoride is used appropriately, but is still significant. As Marthaler [8]
concluded in his review: “...in industrialised countries where there is
adequate exposure to fluoride, no further reduction in the prevalence
and severity of dental caries will be achieved unless the intake of
sugars is reduced.” WHO trs 916, 2003, concludes: “Thus, restricting
sugars consumption still has a role to play in the prevention of caries
in situations where there is widespread use of fluoride but this role is
not as strong as it is without exposure to fluoride.”
A view put forward, particularly by the sugar-related industries, is
that all carbohydrates cause dental caries. This would remove the
spotlight from sugars alone. This is not true, as several reviews have
shown, including WHO trs 916 [6]. This document states that the
evidence that starch intake has no relation with dental caries risk is
‘convincing’; in contrast, the evidence was also ‘convincing’ that
‘amount of free sugars’ and ‘frequency of free sugars’ increases risk. A
worrying trend is for food manufacturers to include a number of
oligosaccharides into products. Limited evidence indicates that these
are not free of cariogenic risk [9].
Are fruit and vegetables caries risks? After all, they both contain
sugars. A number of reviews, including WHO trs 916, conclude “No
risk” [6]. The level of evidence in this report was that it was ‘probable’
that there was no relation between ‘whole fresh fruit’ and caries risk,
but that evidence was ‘insufficient’ that ‘whole fresh fruit’ decreased
caries risk.
Is milk a caries risk? Again, reviews conclude “No”. WHO trs 916
states that the evidence that milk decreases caries risk as ‘possible’
[6]. This refers to cow’s milk (or ‘bovine’ milk). Soy milk is marketed as
an alternative to bovine milk but it cannot be considered safe for teeth.
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Soy milks contain sugars other than lactose, which are well
recognised as being more cariogenic than lactose [5]. Although the
calcium contents of bovine and soy milk are similar, calcium in soy
milk is not so available. A recent publication from Australia and
Singapore concluded “... that soy beverages have a higher potential
acidogenicity than bovine milk beverages due to the relatively higher
rates of organic acid production by bacterial fermentation. The soy
beverages also contained relatively low bioavailable calcium
concentrations and low buffering capacity. These results may indicate
that soy beverages have a higher cariogenic potential than bovine milk
beverages and therefore this potential should be investigated further”
[10].
A brief word about ‘probiotics’ and oral health. They could be termed
‘dietary supplements’. They are living micro-organisms added to food
which beneficially affect the host by improving microbial balance.
There is some evidence that they have an inhibitory effect on dental
caries but this evidence is not extensive [11]. There are, though, two
recent studies from Sweden showing that a combination of fluoride
and probiotics added to milk prevented caries development – the
effects appear to be additive [12,13].
Thus, restriction of sugars consumption and increasing consumption
of staple starchy foods, fresh fruit and vegetables will decrease risk of
dental caries [5,6,14].
As far as periodontal disease is concerned, evidence of the effect of
nutrition and diet is less and conclusions must be tentative. Four
possible effects are worth comment. First, protein-energy
undernutrition has been associated with periodontal disease -- WHO
trs 916 gave the level of evidence for ‘undernutrition’ increasing risk
of periodontal disease as ‘possible’ [6]. There is growing evidence that
obesity is associated with risk of periodontal disease [15] and of the
protective roles of dietary anti-oxidant vitamins [16] and omega-3 fatty
acids [17]. Although scurvy, with destruction of periodontal tissues, is
a severe deficiency disease, it is rare and not of public health
importance. There is no evidence of benefit from vitamin C intakes
above the Dietary Reference Intake, which is achieved in most
populations [6]. Although dietary calcium intake affects bone density,
there is insufficient evidence to make any recommendation [6].
It is important to include oral cancer in any review of nutrition, diet
and oral disease. The most authoritative review is the World Cancer
Research Fund document; the most recent edition was published in
2007 [18]. First, regarding alcohol, the report concluded: “There is
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ample and consistent evidence, both from case-control and cohort
studies, with a dose-response relationship. There is robust evidence
for mechanisms operating in humans. The evidence that alcoholic
drinks are a cause of mouth, pharynx, and larynx cancers is
convincing. Alcohol and tobacco together increase the risk of these
cancers more than either acting independently. No threshold was
identified.” No differences in risk were reported for different types of
alcoholic drink. Second, fruit and vegetables probably have a
protective role. These three statements are from the WCRF document
[18]: “Non-starchy vegetables probably protect against mouth,
pharynx, and larynx cancers.” “Foods containing carotenoids probably
protect against mouth, pharynx, and larynx cancers.” “Fruits
probably protect against mouth, pharynx, and larynx cancers.” There
is growing evidence that ‘Body fatness’ is a risk factor for several types
of cancer and that physical exercise is protective – this was a new
addition to this WCRF document. It concluded that ‘energy-dense
foods’, ‘fast-foods’, and ‘sugary drinks’ where probable risk factors for
weight gain. Thus, there is good reason to restrict consumption for
sugary foods and drinks to reduce cancer risk.
It is right to mention dental fluorosis. This is a public health issue
affecting many people in SE Asia. Although appearance is adversely
affected, it is not classed as a disease. There is evidence that undernutrition while teeth are forming increases the severity of dental
fluorosis, but more information is needed on this topic [5]. Prevention
is seemingly simple – reduce fluoride intake during childhood – but
we all know that this is very hard to achieve in endemic areas. Dental
erosion is not considered a public health issue and dietary
recommendations [5] will not be included here.
In conclusion, nutritional guidelines to improve oral health are: avoid
energy/protein under-nutrition; low sugars intake; majority of intake
should be staple starchy foods, fresh fruit and vegetables; low to zero
consumption of alcoholic drinks. All of these will benefit general as
well as oral health.
GUIDELINES FOR HEALTHY EATING
As there are differences between countries in nutritional intake and
dietary habits, wealth, customs, and agriculture, it is sensible for
each country to decide their own nutritional guidelines. Looking at the
literature, much progress has been made in this area. Most these
guidelines are ‘food-based dietary guidelines’, or FBDG for short. It is
worth a few moments to comment on ‘nutrient guidelines’ and food-
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based guidelines. Nutrient guidelines are well established in many
countries. They almost always give recommendations for specific ages
and special groups – for example, pregnant women – usually as
‘Recommended Dietary Allowances’ or Dietary Reference Values’ [19].
Nutrition surveys (eg. recording all dietary intake for a number of
days) will indicate whether the population is receiving adequate and
appropriate nutrition. But it is well understood that people eat ‘foods’
not ‘nutrients’, and understand dietary advice when given in terms of
foods. Therefore, it is not surprising that countries have opted to give
guidelines in terms of foods. Formulating food based dietary
guidelines is not easy as they must take into account: nutrient
content of foods; availability and price of foods; cultural preferences;
cooking habits; and foods eaten by vulnerable groups. Very often,
national advice is given in terms of foods and nutrients – for example,
‘eat plenty of fruit’ and ‘need for adequate calcium intake during
adolescence’.
In 1998, WHO produced a document ‘Preparation and use of foodbased dietary guidelines’ (trs 880), based on a meeting held in 1995
[7]. It describes the process of developing FBDGs. Unfortunately, the
consideration given to oral health in this document is slightly and
incorrect. There was only one dental person referenced – Konig – and
his views were not mainstream. There was no expert on oral health on
the panel drawing up the document. This highlights an important
point: at all levels of discussion and decision-making, you must
ensure that there is an expert in oral health. This was corrected in the
2003 WHO document ‘Diet, Nutrition and the Prevention of Chronic
Diseases’ (trs 916), where advice is evidence-based and much more
balanced [6]. Within a country, to avoid conflicting advice and ensure
progress, it is essential that guidelines are agreed by medical, dental
and dietetic professions. Following on from the earlier (1998) WHO
document [7], SEARO published an 18 page document ‘Development
of food-based dietary guidelines for the Asian region’ [20]. It is a
balanced document and contains 10 ‘Core Guidelines’. I mention just
three. ‘Eat plenty of vegetables and fruits regularly’: in Thailand, this
could mean increasing intake from 150 to 200 grams per day, and in
India, from 50 to 100 grams per day. Consumption of dietary fat in
the Region is 20 to 30 percent of energy and “maintenance at this
level was compatible with good health”. Regarding sugars intake,
written in 1998, it recommended: “Despite the generally low
consumption levels of sugar in this region, with increasing prevalence
of obesity sugar consumption levels of populations in the Asian region
should not increase beyond present levels and hence this could be a
specific guideline.”
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A more comprehensive document was published by SEARO in 2011:
‘Regional
Nutrition
Strategy:
addressing
malnutrition
and
micronutrient deficiencies (2011-2015)’ [21]. This 56 page document
pointed out that “about one fourth of the global population lives in the
Region”, but it “contains over 70% of the world’s malnourished
children”, and, “over the last decade, countries in this region have
also witnessed a relative rapid increase in overnutrition and obesity”.
It noted that countries “have abundant vegetables and fruits, many of
which are not expensive.” “The increase in vegetable consumption in
developing countries, especially Asian countries, has been nearly twofold while consumption in developed countries remained unaltered.”
However, it noted that “the increase has mainly occurred in the
middle and high-income groups while the consumption patterns
among the poorest segments of population remains low as before.”
This current Regional Nutrition Strategy has four core elements: (1)
Developing
a
country-driven,
outcome-oriented
integrated
multisectoral nutrition policy and plan of action; (2) Addressing
malnutrition and micronutrient deficiencies through a multisectoral
approach and involvement of all relevant sectors; (3) Addressing
obesity and dietary prevention of chronic diseases; and (4) Developing
effective and functional nutrition surveillance systems.
GUIDELINES IN SOME COUNTRIES IN SOUTH AND SOUTH-EAST ASIA
Countries in south and south-east Asia have published food-based
dietary guidelines, and I will mention a few. Many of these have been
published in the Asia Pacific Journal of Clinical Nutrition.
First, Thailand [22-24]. The FBDGs promote nine dietary guidelines:
(1) Eat a variety of foods from each the five food groups and maintain
proper weight; (2) Eat adequate rice, or alternate carbohydrate; (3) Eat
plenty of vegetables and fruits regularly; (4) Eat fish, lean meats, eggs,
legumes and pulses regularly; (5) Drink sufficient amount of milk
every day; (6) Take moderate amounts of fat; (7) Avoid excessive
intake of sweet and salty foods; (8) Eat clean and uncontaminated
foods; and (9) Avoid or reduce consumption of alcoholic beverages.
The five food groups mentioned in (1) above have been increased to
six: cereal, meat, vegetable, fruit, milk, and fat, oil and sweet. These
apply to age 6 years and over. There are specific guidelines for infants
and young children. Much thought has been given to their promotion.
Importantly, they were launched by the Prime Minister. Two food
guide models were considered – a ‘folding fan’ and a ‘hanging flag’ (the
‘Nutrition Flag’). In an article in 2008 [22], the same authors
mentioned “Some activities related to Thai FBDG”. These included:
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campaign programme for lowering sugar consumption through the
‘Sweet enough campaign network’ since 2002; Thai FDA passed a law
prohibiting sugar addition in follow-on formula for infants in
November 2004; Health snacks for children with friendly nutrition
labelling; School lunch program – menu development; Nutrition
education training for teachers and health volunteers. A publication
this year stated: “Thailand is known for its successful nationwide
community-based nutrition program implemented during the 1980s
to mid-1990s” [24]. Undernutrition has reduced markedly since the
first national nutrition survey in 1960, but the recent rise in obesity is
of considerable concern.
FBDGs are a crucial tool for nutrition education and communication
in Vietnam [25]. There have been three versions since the first was
launched by the Prime Minister in 1995. Vietnam has chosen the
‘Food Guide Pyramid’ and ‘Food Square’ as nutritional education tools.
I mention three aspects related to oral health: (1) Use iodized salt. Do
not consume too much salt; (2) Eat less sugar. Children and adults
should not eat cake, candy, soft drinks before a meal. One person
should consume only 500g sugar per month on average; (3) Drink soy
milk. Increase consumption of the calcium-rich foods such as milk,
dairy products, and small fish. I mention (1) because there is now
fluoridated salt in Vietnam. Second, 500 grams of sugar per month
equates to 17 grams per day, which is a wonderfully low amount.
Third, I have mentioned previously the uncertainty as to whether soy
milk is dentally safe [10]. Meals are provided in nearly all
kindergarten and elementary schools [26].
The Malaysian Dietary Guidelines (MDG) were first published in
1999. The 2010 version contains 14 key messages and 55
recommendations – physical activity was included for the first time
[27]. The graphic display is a food pyramid. In Singapore, the latest
Dietary Guidelines were published in 2011, using results from the
National Nutrition Survey the year before [28]. Guidelines are given
for various groups such as children and adolescents, adults, and
older persons. The latest Diet Pyramid appeared in 2009; but
consideration is being given to replacing this with a ‘Healthy Lifestyle
Graphic’ which will include physical activity. There is a major ‘Healthy
Eating in Schools’ programme [29].
In South Korea, the body responsible for nutritional guidelines is the
Korea Food and Drug Administration (KFDA) [30]. Guidelines are
given for various age groups and include advice on physical activity
[31]. The KDFA also advises on nutrition labelling and the National
School Lunch Program [32]. School lunches have been provided since
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1953 and coverage is now virtually 100%. Nutrition surveys indicate
the traditionally high vegetable consumption, which has been
maintained despite changes to lifestyle and eating habits (158 gram
vegetables per capita per day in 2009) [33]. In contrast, there was an
unwelcome 50% increase in sugar-sweetened beverage intake in
adolescents from 1998 to 2009 [33].
In Japan, ‘Healthy Japan 21’ was launched in 2000 [34]. In 2005, a
graphic model was introduced called ‘Japanese Food Guide Spinning
Top’ (JFG-ST). The idea is intriguing – first, if the balance of foods is
wrong, the top falls over, and, second, the spinning evokes the idea of
exercise. Also, in 2005, ‘Shokuiku’ was introduced (Shoku = diet, iku
= growth and education) [34,35]. This health and well-being concept is
broad-based, incorporating principles of healthy eating. School-based
Shokuiku programmes were established in 2007 [35]. A study
published this year showed that students with better knowledge of
Shokuiku had less dental caries than students with less knowledge
[36]. In Japan, not only is there concern about an increase in obesity
in men and children, but there is also concern about underweight
girls.
In China, nutrition surveys from 1991 to 2009 show a growth in
snacking, intake of cereals has decreased and consumption of
beverages has increased [37]. The proportion of energy provided by
drinks increased three-fold during this time period. FBDGs were first
introduced in 1989 [38,39]. In 2011,’ Healthy China 2020’ was
launched, choosing the Food Guide Pagoda (FGP) to convey
nutritional guidelines. To the side of the pagoda is a walker and cup
of water [39].
In Taiwan, FBDGs have existed since the early 1980s [40]. Recent
guidelines list 8 key points, including eat less sugar and drink more
water. A study of over two thousand Taiwanese children revealed that
poor performance at school was related to unhealthy eating patterns
including high sugar foods and drinks [41]. In the Philippines,
Nutritional Guidelines for Filipinos (NGF) have been published – the
latest in 2000 [42]. In Indonesia, FBDGs were launched in 1995,
containing 13 messages [43]. Food based dietary guidelines exist in
India, containing 6 goals and 14 dietary guidelines [44]. There is
concern in the Philippines, Indonesia and India about the high and
persistent prevalence of undernutrition and the growing consumption
of nutritionally poor quality snacks and increasing burden of obesity
[45].
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ISSUES RELATED TO THE GUIDELINES
There are a number of bright spots in this review. First, all countries
appear to have nutritional guidelines. In this, SEARO leads the world
[46]. For a review of progress in developing national nutrition policies,
by WHO Regions, this 122-page document published earlier this year
is recommended [46]. Second, in several countries in SEA, FBDGs
have been launched at the highest level of government. They are
reviewed frequently and effectiveness has been evaluated in some
countries. Third, most of the committees developing guidelines have
been multisectoral, since it is important that there is agreement
across government departments – health, education, agriculture and
industry. There is growing belief that policies should be
‘environmentally sensitive’ [47]. There appears to be an apparent
absence of advice from specialists in oral health and nutrition when
guidelines were being developed. Were they involved? If I am wrong,
please correct me, for I am well aware that I am presenting an
external view. I have emphasised before the importance of ensuring
that committees developing nutritional guidelines include expertise on
oral health. At risk of self-advertising, I comment that there is a WHO
Collaborating Centre for Nutrition and Oral Health, and the present
Director (Professor Paula Moynihan) would be very prepared to assist
people with access to these committees with evidence and other
related matters. Fourth, although the need to restrict sugar
consumption is mentioned – sugars were at the smallest end of the
pyramid and hanging flag (sugars did not seem to be present in the
‘pagoda’) – it appears that targets for sugar consumption were seldom
given.
So what effect will these food based dietary guidelines have on oral
health in south and south-east Asia? It should be favourable. After
all, guidelines emphasise the need for restricted sugar consumption;
to drink water instead of sugared drinks; need for continued high
consumption of vegetables and fruit, and staple starchy foods; and
the need to restrict alcohol consumption. This is, of course, in line
with WHO recommendations, aimed at improving general health
including oral health [6]. For me, one of the uncertainties is the role of
SEARO and WPRO. They issue guidelines, but are there experts on
oral health active in these committees? I have emphasised this point
rather heavily. You may think that, since the broad principle of sugar
restriction is present in guidelines, a high level of expertise in
nutrition and oral health is not needed. My experience is that this is
not so. There are powerful multinational companies that will oppose
restrictions in sugar and alcohol consumption [48], and government
departments and committees will expect those that advise them on
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nutrition and oral health to have a thorough knowledge of the
literature and the ability to present their case effectively. This is
necessary at a Regional level and National level.
An increasing population, the move from rural to urban living, the
almost universal viewing of television with greater exposure to
commercial advertising, and advances in technologies of food
production, have meant that our choice of food purchase is now much
governed by a powerful food industry [48]. It must be understood that
their motivation is profit; their loyalty is to their shareholders. There
will be opportunities to make profits from marketing healthy foods –
that should be encouraged. But it is the marketing of sugar and
sugar-containing foods and drinks, alcoholic drinks, and tobacco,
which adversely affect oral health most [6,18].
Manufacturers of sugar-containing drinks and foods have been
aggressive in their marketing and you should understand the
methods they use. First, their large budgets allow extensive and
sophisticated advertising. Second, they will lobby decision-makers.
These decision-makers are unlikely to be experts in nutrition and oral
health, and will rely on you to provide detailed counter-arguments.
Third, they may find some professional prepared to support their
views: in which case, they will announce that professional opinion is
divided, so no decisions on sugar restriction should be made. This is
thoroughly unfair as the vast majority of professional opinion is
united in their call for sugar restriction. Fourth, they may fund
scientific institutions. I give as an example the ‘International Life
Sciences Institute’ which active in most regions of the world. This
institute has funded several dental conferences and people may well
attend not knowing that ILSI is largely funded by industry. In India
and Korea, for example, funders include Coca-Cola, Mars, and
PepsiCo. That does not mean that such conferences do not contain
good science, but we cannot be certain that they are free of
commercial pressures.
But there is much going in your favour. First – health. People prefer
health to disease. Second, governments understand this, and
appreciate that prevention is usually cheaper than cure. Third,
scientific literature is firmly on your side. Fourth, because of the
important health issues I have discussed, and the strength of the
scientific literature, the highest health authorities have issued
unequivocal guidelines on nutrition and health. Fifth, medical, dental
and dietetic opinion is united on scientific advice and the need to act
to improve diet and nutrition.
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Regrettably, in order to assist people, particularly children, in
choosing a better diet, it has proved necessary to legislate. I will
mention three areas. First -- advertising. In many countries there are
restrictions on advertising: advertisements should not encourage
frequent eating of high sugar foods and drinks, and not encourage
their consumption before bedtime; such advertisements are banned
from TV during children’s peak viewing times. Second -- labelling of
foods and drinks. Nutrient labelling should display sugars content
[49]. To help the food purchaser and consumer, traffic-light guidance
is put on the front of packs – red for high sugar content etc. Third,
food and drink in the school environment. There has been great
progress in providing nutritious meals in schools – these may be
provided free or at a subsidised cost. The sugared drinks industries
were aggressive at putting drinks vending machines into schools and
sponsoring school activities such as provision of sports kits [50].
Such activities are now banned in many countries: vending machines
in school can only provide water, milk, and pure fruit juice [51]. It is
important that these health-promoting initiatives are evaluated so
that authorities and the public can be aware of the benefits, although
the nutritional benefits of school meals are pretty well documented.
Public opinion is very powerful – it should be measured, and used
appropriately to encourage further progress. This article from
Australia is one example [52]. Lastly, a tax on sugar-containing
beverages is being considered in some countries [53-55].
SUMMARY
So, in summary, much progress has been made. There are big
challenges ahead but the rewards in reducing the burden of oral
disease are considerable. The causes of the major oral diseases are
very well known. Much of oral disease is preventable through
improved nutrition and diet. The risk factors for oral diseases are
common to most chronic lifestyle diseases, which should strengthen
the case for prevention. It is essential that those advising government
and other public authorities know the scientific literature so that
guidelines, policies and educational programmes are soundly based.
Lastly, I am very aware that I present an ‘outside view’ of nutrition
and oral health in south and south-east Asia. I hope that you will
have the opportunity to put forward your view on this topic.
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China. Obes Rev 12:552-559.
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food guide pagoda. Asia Pac J Clin Nutr 20:439-446.
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the Taiwanese experience. Asia Pac J Clin Nutr 17(suppl 1):5962.
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42.
Tanchoco CC. (2011) Food-based dietary guidelines for Filipinos:
retrospects and prospects. Asia Pac J Clin Nutr 20:462-471.
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Sekiyama M, Roosita K, Ohtsuka R. (2012) Snack foods
consumption contributes to poor nutrition of rural children in
West Java, Indonesia. Asia Pac J Clin Nutr 21:558-567.
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guidelines in India. Asia Pac J Clin Nutr 17(suppl 1):66-69.
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WHO. (2013) Global nutrition policy review: what does it take to
scale up nutrition action? Geneva: World Health Organization.
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mild and body. Asia Pac J Clin Nutr 22:504.
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Brownell KD, Warner KE. (2009) The perils of ignoring history:
Big Tobacco played dirty and millions died. How similar is Big
Food? Milbank Q 87:259-294.
49.
Roodenburg AJ, Popkin BM, Seidell JC. (2001) Development of
international criteria for a front of package food labelling system:
the international choices programme. Eur J Clin Nutr 65:11901200.
50.
Maliderou M, Reeves S, Noble C. (2006) The effect of social
demographic factors, snack consumption and vending machne
use on oral health of children living in London. Br Dent J
201:441-444.
51.
Loughridge JL, Barratt J. (2005) Does the provision of cooled
filtered water in secondary school cafeterias increase water
drinking and decrease the purchase of soft drinks? J Hum Nutr
Dietet 18:281-286.
52.
Pettigrew S, Pescud M, Rosenberg M, Ferguson R, Houghton S.
(2012) Public support for restrictions on fast food company
sponsorship of community events. Asia Pac J Clin Nutr 21:609617.
53.
Claro RM, Levy RB, Popkin BM, Monteiro CA. (2012) Sugarsweetened beverage taxes in Brazil.
Am J Public Health
102:178-183.
54.
Uutela A. (2013) Health in all policies: a call for effective
governance for health and equity. Presented at the World
Congress on Preventive Dentistry, Budapest, 9-12 October.
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55.
Hackett A, Rugg-Gunn A, Moynihan P. (2007) Nutrition, dietary
guidelines and food policy. In: Community Oral Health. (eds.
Pine C, Harris R.) 2nd edit. London: Quintesscence. pp 333-356.
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CARIES CONTROL IN ELDERLY
Hiroshi OGAWA
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CARIES CONTROL IN ELDERLY
Hiroshi OGAWA9
INTRODUCTION
The world population is rapidly aging. Between 2000 and 2050, the
proportion of the world's population over 60 years will double from
about 11% to 22%. The absolute number of people aged 60 years and
over is expected to increase from 605 million to 2 billion over the
same period. Asia’s elderly population is projected to reach 922.7
million by the middle of this century. As a result, Asia is on track in
the next few decades to become the oldest region in the world (WHO
2011).
Figure 1: Proportion of elderly population by some selected countries.
Associate Professor, Faculty of Dentistry, Niigata University, Japan.
Email: Hiroshi Ogawa <ogahpre@dent.niigata-u.ac.jp>
9
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Figure 2: Total population aged 60 or more.
PREVALENCE
Dental caries is one of the most significant health problems facing
older adults. More than half of the elderly who are dentate are affected
with either coronal or root caries, and caries are the primary cause of
tooth loss in this population. Over the past two decades, 13 studies
conducted in nine countries (i.e., the United States, Canada, Brazil,
Germany, Finland, Sweden, Japan, India and Sri Lanka) have
reported a relatively wide range of root caries prevalence in older
adults ranging from 29 to 89%, with most of those studies reporting
within the narrower prevalence range of 30–60%. Annual root caries
increments of 0.47–1.0 surfaces per year per adult with a prevalence
rate of ∼45% suggests that the prevention of root caries in adults
should be a high national oral health priority (Gluzman et al., 2013).
The available data shows that dental caries is closely linked to social
and behavioural factors. The pattern is mostly that persons of low
income, those who do not visit a dentist regularly, do not brush their
teeth frequently, consume many sugars and smoke, tend to suffer
from dental caries (Petersen et al., 2005). For institutionalized elderly,
the oral health status is generally poorer, with high levels of untreated
dental caries (Chalmers et al., 2002; Lo et al., 2004; Simunkovic et al.,
2005). There is a need to prevent caries among elderly people,
especially those who are in long-term care facilities (Tan et al., 2010).
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DIAGNOSIS OF ROOT CARIES
The diagnosis of the present root caries is not usually difficult, as the
condition often presents at exposed root sites where gingival recession
has taken place and so may be directly visible. The diagnosis can,
however, sometimes be difficult at inaccessible sites such as posterior,
interproximal areas and lingually on the lower molars. Vertical
bitewing radiographs can aid diagnosis at interproximal sites. The
decision as to whether a root caries lesion is active or arrested can be
problematic. Lesion colour could be a poor indicator of root caries
lesion activity (Lynch et al.,1994, Curzon et al., 2004).
ETIOLOGY OF ROOT CARIES
The primary factors involved in root caries are the same as for any
caries process. These are the factors that must be present in order for
the condition to be initiated and are plaque bacteria, a tooth (root)
surface, ingested fermentable carbohydrate and time. Certainly,
plaque removal is often a difficulty in elderly patients, due to a lack of
manual dexterity (especially in cases of rheumatoid arthritis and
stroke).
Elderly people may also have difficulty in comprehending oral hygiene
advice and a loss of muscle tone around the oral musculature may
also contribute to food and plaque stagnation. Poorly designed or illfitting partial dentures will not help the oral hygiene of an elderly
patient and so may contribute to the caries risk.
For the specific condition of root surface caries, the pre-diagnosing
factor of periodontal disease must be present in order for the process
to be initiated. Root caries is most commonly seen at sites of gingival
recession. If loss of periodontal attachment can be prevented, then
root caries will, by definition, also be prevented.
The most important secondary factors that govern the rate which a
root caries lesion may progress are saliva and fluoride. It has been
said that saliva is a much neglected medium, in terms of how it is
regarded in its importance to oral health. This is most dramatically
appreciated in cases of xerostomia. The number of elderly individuals
suffering from some degree of dry mouth appears to be increasing.
This is most significantly due to the fact that several hundred
regularly prescribed medications have the potential side effect of
causing reduced salivary flow (Sreebny et al., 1997). In addition, more
elderlies are under polypharmacy regimes, such that they have many
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medications to take each day, thus increasing the risk of druginduced hyposalivation. The anti-caries properties of saliva are well
known and include acid and sugar clearance action, buffering
systems and fluoride, calcium and phosphate content. When saliva
flow is reduced, the effect on caries rates can be dramatic, especially
on susceptible root surface sites, where carious lesions can progress
with alarming rapidity.
The importance of the topical effects of fluoride on the enamel carious
lesions is generally accepted. There is now evidence that topical
fluoride may also have potential remineralization promoting and
demineralization inhibiting effects on root dentine (Curzon et al.,
2004).
OTHER RISK FACTORS
Diet
Diet is a very important factor in preventing caries since certain
foods and snacks can greatly increase the number of bacteria
that forms the decay-causing plaque. The more sweetened
snacks consumed and the more frequently they are consumed
increase the risk for developing caries. The frequency of sugar
intake is more important than the amount of sugar consumed
in the development of caries (Burt et al., 1988). Therefore,
minimizing snacking is recommended since snacking creates a
continual supply of nutrition for acid-creating bacteria in the
mouth. Also, chewy and sticky foods (such as dried fruit or
candy) tend to adhere to teeth longer and consequently are best
eaten as part of a meal.
It is beneficial to look at other factors such as diet, which
together with decreased salivary flow make one more
susceptible to root caries. When dietary habits, microbial
factors, and salivary factors were analyzed together in older
adults who had root caries compared to adults who did not
have root caries, individuals with root caries ate a greater
number of meals a day and had a higher sugar intake (Finn et
al., 1992). Root caries subjects had significantly higher
lactobacilli counts and less salivary buffering capacity
suggesting that higher microbial counts and less salivary flow
may be risk factors associated with root caries in older adults.
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Bacteria
Plaque consists of bacteria and an extracellular matrix that
contains lipids, proteins, and polysaccharides. Teeth are more
vulnerable to an increase in bacterial plaque when
carbohydrates in the food are left on teeth after every meal. In
the presence of sugar and other carbohydrates, bacteria in the
mouth produce acids that can demineralize enamel, dentin,
and cementum. The more frequently teeth are exposed to this
environment, the more likely caries are to occur. The bacterial
profiles associated with root caries in the elderly subjects
exhibit reduced diversity (Preza et al., 2008). Certain bacterial
species appear to be strongly associated with health, as they
are rarely detected or are absent from root caries carriers but
are commonly found in healthy subjects. In root caries,
Veillonella parvula, Veillonella dispar, Selenomolas noxia,
Campylobacter gracilis, Streptococcus mutans, Selenomonass
putigena, and Fusobacterium nucleatum are found at high
levels. Lactobacilli appears to be associated with the disease, as
they are common in carious lesions, while rare or absent in
healthy teeth. In individuals with no caries, Streptococcus
mutans are less common and lactobacilli are absent, while for
individuals with root caries, levels of Streptococcus mutans
and lactobacilli are increased.
The prevalence of Streptococcus mutans alone or in
combination with lactobacilli is similar in root caries lesions.
Lactobacilli are absent in healthy subjects but highly present
in carious dentin, supporting the suggestion that lactobacilli
might play a significant role in the progression of root caries.
Bacterial species typically associated with root caries can be
detected, such as Streptococcus mutans, lactobacilli, and
Actinomyces (Preza et al., 2008).
Oral Hygiene
Oral hygiene is a major component of oral disease
susceptibility. The relationship between oral health and oral
behaviors is widely recognized (Levin et al., 2004). Although
many variables influence the production and progression of
oral disease, the one variable that shows an immediate and
long lasting significant effect on one’s oral health is oral
hygiene. The purpose of oral hygiene (brushing and flossing
daily) is to minimize, remove, and prevent the formation of
plaque. Efficient oral hygiene practices have positive effects on
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root caries (Nyvad et al., 1986).
Systemic Diseases
One of the most groundbreaking studies of oral disease today is
examining the associations between oral and systemic diseases.
Data showed that individuals with rheumatoid arthritis,
diabetes, or a liver condition were twice as likely to have an
urgent need for dental treatment (Griffin et al., 2009). The data
also showed that arthritis, cardiovascular diseases, diabetes,
emphysema, hepatitis C, obesity, and stroke were all
associated with dental disease. Unmet dental care needs were
observed among participants with chronic diseases. These
results suggested that some chronic diseases increase the risk
of developing dental disease. Others may interpret this
association as meaning that those with systemic disease tend
to neglect their oral health and so show a higher incidence of
oral disease.
Cardiovascular diseases have also been associated with higher
caries experience, particularly in individuals 80 years or older
(Holm-Pedersen et al., 2005). Individuals with three or more
active root caries lesions have more than twice the odds of
cardiac arrhythmias than ones without active root caries.
These results did not notably change after adjusting for age,
medications that reduce saliva, and number of teeth. The
findings indicate that there may be a link between active root
caries and cardiac arrhythmias in those aged 80 and older.
One explanation for these findings is that both cardiac
arrhythmias and caries are simply markers of declining general
health (Gati et al., 2011).
CLINICAL INTERVENTION
As for other age groups, use of fluoride is effective in prevention of
dental caries in elderly. Topical fluoride applications are shown to
reduce the number of root surface caries lesions, both in active oldage people (Wallace et al., 1993) and in seniors in long-term care
facilities (Wyatt et al., 2004). Fluoride containing dentifrices is also
effective in preventing both coronal and root surface caries (Jensen et
al., 1988). Topical application of fluoride can additionally prevent
tooth mortality in older people when combined with chlorhexidine
rinsing (Wyatt et al., 2004). Rinsing with a chlorhexidine solution
tends to reduce gingival inflammation, pocket depth, and incidence of
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denture stomatitis (Persson et al., 1991). The addition of
chlorhexidine rinses to usual dental care resulted in a 15% reduction
in tooth mortality in a group of older people (Hujoel et al., 1997).
Clinical studies suggest that oral health education for elderly patients
is effective (Schou, 1995). A randomized clinical trial for older patients
revealed that group-based behaviour modification intervention helped
patients improve their self-care skills such as brushing and flossing
(Little et al, 1997).
COMMUNITY-BASED
PREVENTION
HEALTH
PROMOTION
AND
ORAL
DISEASE
Oral health programmes have been designed to improve the oral
health status of the institutionalized elderly. For example, an oral
health care programme which was established for residents of nursing
homes or long-term care facilities, provided oral examination, dental
treatment, oral prophylaxis, and instructions to both nursing staff
and residents and the programme demonstrated a reduction in the
number of teeth with decay and prevalence of denture stomatitis, and
improved denture hygiene (Vigild et al., 1998, Budtz-Jørgensen et al.,
2000). Toothbrushing by nurses and caregivers combined with
professional oral care by dentists or dental hygienists were associated
with decreased pneumonia, febrile days, death from pneumonia and
improved daily living activities and cognitive functions of
institutionalized older people (Yoneyama et al., 2002).
RECOMMENDATION FOR THE PREVENTION OF ROOT CARIES FOR
ELDERLY
According to a systematic review on the effectiveness of the seven
leading preventive agents for root caries, specifically: fluoride,
chlorhexidine, xylitol, amorphous calcium phosphate, sealants,
saliva stimulators, and silver diamine fluoride (Table 1), four agents
(fluoride, chlorhexidine, amorphous calcium phosphate and silver
diamine fluoride)
in various
either formulations
or/and
concentrations or/and various routes of administration have been
found to be effective in the primary prevention of root caries and can
be recommended for use with all older adults (Tan et al., 2010,
Gluzman et al., 2013).
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Table1: Abbreviations and brand names of effective agents or
combination of agents for Root Caries Prevention
(Extracted Gluzuman et al., 2013)
Table 2: Recommendations for use of the effective root caries
preventive agents or combination of agents in elderly
population in ascending order of effectiveness (Extracted
Gluzuman et al., 2013)
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Table 2 shows that use of CHX varnish, a 22,500 ppm NaF varnish, a
1100 ppm NaF toothpaste, and a 38% solution of SDF (the first four
listed in the table) resulted in reductions of 41–57%, 56–64%, 67%,
and 72%, respectively, as compared to a placebo group. The two most
effective agents or combination of agents for the primary prevention of
root caries incidence were a 1110 ppm NaF+ triclosan toothpaste selfapplied daily and a ACP + 250 ppm NaF toothpaste applied daily, both
of which nearly doubled the reduction of root caries when compared
to an already proven effective root caries prevention products.
Only fluoride in two concentrations and in different routes of
administration was found to be effective in the secondary prevention
of root caries: a 4,500–5,000 ppm NaF toothpaste gel self-applied
daily and a 22,500 ppm NaF varnish professionally applied every 1–3
months. While the range reported for arresting lesions was similar
(52–100% for the self-applied NaF toothpaste and 54–95% for the
professional applied NaF varnish with or without supplementation of
NaF toothpastes and rinses), the mean reported arrested lesion rate
was higher for the NaF varnish (78% vs. 64%) (Gluzuman et al., 2013).
RECOMMENDATION FOR THE PREVENTION OF ROOT CARIES FOR
INSTITUTIONALIZED ELDERLY
Table 3: Recommendations for use of root caries preventive agents
or combination of agents in institutionalized elderly
(Extracted Gluzuman et al., 2013).
Table 3 shows the recommended choices for use with particular
attention to vulnerable elderly and introduces the consideration of
feasibility for use of these effective agents or combination of agents
within a vulnerable population, that is, the required frequency of
application and the capability of vulnerable elderly to self apply. For
the primary prevention of root caries the recommended“best choice”
agent is the 38% SDF solution professionally applied annually. If no
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professional application is possible, the recommendation for “best
alternative” for the primary prevention of root caries is the use of a
self-applied ACP + 250 ppm NaF toothpaste daily.
For the secondary prevention of root caries (i.e., arresting lesions), the
recommended “best choice” is fluoride in a form of 22,500 ppm NaF
varnish professionally applied every 3 months. If no professional
application is possible, the recommendation for “best alternative” for
the secondary prevention of root caries is the use fluoride, as well, but
in a form of a 4,500–5,000 ppm NaF toothpaste/gel self-applied daily
(Gluzuman et al., 2013).
CONCLUSION
As the global population ages, and more teeth are retained, there will
be a higher prevalence of root caries and untreated dental decay.
Therefore, the demand for dental services in the population of the
oldest elderly people is likely to increase. There are a wide variety of
risk factors associated with the development of caries, and although
there are differences of opinion regarding the cause of the increase in
caries it should be agreed upon that public health strategies are
needed to renew the fight against caries and promote prevention of
future oral disease. Awareness and promotion of fluoride applications,
emphasis on proper tooth brushing with a fluoride dentifrice, flossing,
a proper diet, and regular dental office visits can hinder the
progression of future caries and can result in an increase in the oral
health of all elders.
REFERENCES
Budtz-Jørgensen E, Mojon E, Rentsch A, Deslauriers N: Effects of an
oral health program on the occurrence of oral candidosis in a long-term
care facility. Community Dent Oral Epidemiol 28: 141-149, 2000.
Burt BA, Eklund SA, Morgan KJ: The effects of sugars intake and
frequency of ingestion on dental caries increment in a three-year
longitudinal study. J Dent Res 67: 1422-1429, 1988.
Chalmers JM, Hodge C, Fuss JM, Spencer AJ, Carter KD: The
prevalence and experience of oral diseases in Adelaide nursing home
residents. Aust Dent J 47: 123-130, 2002.
Curzon ME, Preston AJ: Risk groups: nursing bottle caries/caries in the
elderly. Caries Res 38 (Suppl1): 24-33, 2004.
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Faine MP, Allender D, Baab D, Persson R, Lamont RJ: Dietary and
salivary factors associated with root caries. Spec Care Dentist 12: 177–
182,1992.
Gati D, Vieira AR: Elderly at greater risk for root caries: a look at the
multifactorial risks with emphasis on genetics susceptibility. Int J Dent
647168, 2011.
Gluzman R, katz RV, Frey BJ, McGowan R: Prevention of root caries: a
literature review of primary and secondary preventive agents. Spec
Care Dentist 33(3): 133-140, 2013.
Griffin SO, Barker LK, Griffin PM, Cleveland JL, Kohn W: Oral health
needs among adults in the United States with chronic diseases. JADA
140: 1266–1274, 2009.
Holm-Pedersen P, Avlund K, Morse DE: Dental caries, periodontal
disease, and cardiac arrhythmias in community-dwelling older persons
aged 80 and older: is there a link?. J Am Geriatr Soc 53: 430–437,
2005.
Hujoel PP, Powell LV, Kiyak HA: The effects of simple interventions on
tooth mortality: findings in one trial and implications for future studies.
J Dent Res 76: 867-874,1997.
Jensen ME, Kohout F: The effect of a fluoridated dentifrice on root and
coronal caries in an older adult population. J Am Dent Assoc 117: 829832, 1988.
Levin L, Shenkman A: The relationship between dental caries status
and oral health attitudes and behavior in young Israeli adults. J Dent
Educ 68: 1185–1191, 2004.
Little SJ, Hollis JF, Stevens VJ, Mount K, Mullooly JP, Johnson BD:
Effective group behavioral intervention for older periodontal patients. J
Periodont Res 32: 315-325,1997.
Lo EC, Luo Y, Dyson JE: Oral health status of institutionalized elderly
in Hong Kong. Community Dent Health 21: 224-226, 2004.
Lynch E and Beighton D: A comparison of primary root caries lesions
classified according to colour. Caries Res 28: 233-239, 1994.
Nyvad B, Fejerskov O: Active root surface caries converted into inactive
caries as a response to oral hygiene. Scand J Dent Res 94: 281–
284,1986.
Persson RE, Truelove EL, Leresche L, Robinovitch R: Therapeutic effects
of daily or weekly chlorhexidine rinsing on oral health of a geriatric
population. Oral Surg Oral Med Oral Pathol 72: 184-191,1991.
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Petersen PE and Yamamoto T: Improving the oral health of older people:
the approach of the WHO Global Oral Health Programme. Community
Dent Oral Epidemiol 33: 81–92, 2005.
Preza D, Olsen I, Aas JA, Willumsen T, Grinde B, Paster BJ: Bacterial
profiles of root caries in elderly patients. J Clin Micro 46: 2015–
2021,2008.
Schou L: Oral health, oral health care, and oral health promotion among
older adults: social and behavioral dimensions. In: Cohen LK, Gift HC,
editors. Disease Prevention and Oral Health Promotion. Copenhagen:
Munksgaard; 1995.
Simunkovic SK, Boras VV, Panduric J, Zilic IA: Oral health amomg
institutionalized elderly in Zagreb, Croatia. Gerodontology 22: 238-241,
2005.
Sreebny LM, Schwartz SS: A reference guide to drugs and dry mouth-2nd edition. Gerodontology 14: 33-47, 1997.
Tan HP, Lo EC, Dyson JE, Luo Y, Corber EF: A randomized Trial on root
caries prevention in elders. J Dent Res 89: 1086-1090, 2010.
Vigild M, Brinck JJ, Hede B: A one-year follow-up of oral health care
programme for residents with severe behavioural disorders at special
nursing homes in Denmark. Community Dent Health 15: 88-92, 1998.
Wallace MC, Retief H, Bradley EL: The 48-month increment of root
caries in an urban population of older adults participating in a
preventive dental program. J Public Health Dent 53: 133-137,1993.
World Health Organization The World Health Report 2011. Geneva,
Switzerland: WHO; 2011.
Wyatt CCL, MacEntee MI: Caries management for institutionalized
elders using fluoride and chlorhexidine mouthrinses. Community Dent
Oral Epidemiol 32: 322-328, 2004.
Yoneyama T, Yoshida M, Ohrui T, Mukaiyama H, Okamoto H, Hoshiba
K: Oral care reduces pneumonia in older patients in nursing homes. J
Am Geriatr Soc 50: 430-433, 2002.
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COUNTRY REPORT
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BHUTAN
Sonam NGEDUP
Dorji PHURPA
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
BHUTAN
Sonam NGEDUP10
Dorji PHURPA10
Introduction
Bhutan, a small landlocked country measuring 38,394 square
kilometers in area is situated between China and India. It is mostly
mountainous and heavily forested with 70.5% vegetation cover. The
country was in self imposed isolation for centuries when it ushered
modern development in 1960s as five-year- development plan was
launched. The current population is 740,431 derived from 1.8%
growth rate of 634,982 counts as baseline in 2005 when
internationally accepted census method was adopted for the first
time. The life expectancy is 69-years for males and females
respectively. About 25% of the populations are youth below 25 years
of age. The hydropower export fuelled rapid economic achievement
and presently has one of the highest per capita income in SouthAsia
region1-2.
The health coverage in Bhutan is 90% and the doctor to patient ratio
is 3:10,000. There is acute shortage of health professional across all
categories, including dental. The oral health situation, therefore, is
unexplored and uncared for as the authorities struggle to fight
infectious diseases similar to many developing countries in the region.
However, health being a social sector, advancement of modern health
care services gives great importance. The annual health budget has
been increasing exponentially over the years in terms of fiscal outlay 34
Department of Dentistry, Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan.
Email: sonam ngedup <gortshom@gmail.com>; Dorji Phurpa <dorjiphurpa21@gmail.com>,
10
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DENTAL CARIES EPIDEMIOLOGY
The dental caries prevalence has been declining in most of the
developed countries because of the use of various fluoride products.
But the same trend is not true for many developing countries,
including Bhutan, due to meal component transition to the western
form of diets and vigorous campaign by junk food manufacturers that
flood the market targeted to vulnerable groups such as children 5-9.
The caries situation in the general Bhutanese population especially
for adults is not available. The past few studies were conducted in
schoolchildren in various age groups. In 1985, the caries prevalence
in Thimphu and Paro for the urban and rural areas among 15-19year-old children was 73% and 76% respectively 10. The WHO goal of
2000 for 12-year olds with 1.4 DMFT had already been achieved 15
years before and still was without significant change at mean 1.2
DMFT in 200811 after more than two decades of socioeconomic
development that was associated with changes in all aspects of
lifestyle including diet. In that study by Singh et al, dietary habits,
chewing of betel leaves and Areca nut, irregular tooth brushing
habits, poverty and lack of knowledge of oral health were some of the
attributed contributing factors for poor oral health.
Ngedup S. et al (2008)11 did a cross-sectional study in capital city
Thimphu among 461 12-year-olds schoolchildren and found 57.9%
caries prevalence. Other details of the findings are presented in Table
1.1 and 1.2
Table 1.1: Percent caries affected and DMFT for different age
groups
Age
Group
inyears
(N)
12
(461)
%
affected
DMFT
D
M
F
Year
58.0
1.2
1.1
0.1
0.1
2008**
15-19
73.0
2.5
na
na
na
1985*
15-19
76.0
2.6
na
na
na
1985*
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Source
Thimphu
City
Urban
(Thimphu
& Paro)
Rural
(Thimphu
& Paro)
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Table 1.2: Fluoride levels in some Thimphu drinking waters.
Sl/No.
1
2
3
4
Source of Water
samples
Dechenchholing
(North Thimphu)
Taba
Babesa
Changzamtog
Fluoride
Concentration (ppmF)
0.02
0.06
0.06
0.04
Table 1.3 shows details of the study 12 outcome for Loselling Meddle
Secondary School, Thimphu, which was carried out as part of the
school oral health program and detected high caries prevalence.
Descriptive analysis showed 79% caries in 6-8-year-old and 43%
among 13-16-year olds. The caries prevalence was less among older
children.
Table 1.3: Caries prevalence with mean DMFT in Loselling Middle
Secondary School, Thimphu, 2010.
Age
group
in years
(N)
6-8
(247)
9-12
(458)
13-16
(339)
%
Caries
affected
%
Caries
free
Decayed
(D)
Missin
g
(M)
Filled
(F)
DMFT
79.3
20.7
3.1
0.1
0.4
3.6
68.3
31.7
1.5
0.1
0.4
2.0
43.4
56.6
3.1
0.1
0.4
3.6
In 2010, Wangchuk S.R et al13 initiated a three year longitudinal three
pronged study on effectiveness of sodium fluoride mouth rinses,
brushing with fluoridated toothpaste and oral health education on
caries experience among pre-primary schoolchildren. The study
subject comprised 684 5-6 and 7-8-year-old kindergarten children in
Thimphu, Zhemgang and Trashing that represents western, central
and eastern regions respectively. The study group was 317 (46%)
kindergarten children; 367 (54%) grade two children served as
controls. The interventions were supervised fluoride mouth rinsing
along with brushing (in the presence of the trained health teacher)
and a half hour oral health education lecture delivered in the
classroom for the intervention group every alternate week for 36
months.
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Table 1.4: Regional Mean, SD, decayed, missing filled, dmft and
significances
Assessment
Status
Pre-intervention
(Age 6 years)
Post-intervention
(Age 8 years)
Sample (n)
130
88
decayed (Mean), dt
6.0
0.2
Missing, mt
0.2
2.1
Filled, ft
0.1
0.7
dmft
6.3
3
19
(14.6)
21
(23.9)
p <0.02
p <0.002
Sample(n)
93
60
decayed (Mean)
2.4
1
missing
0.2
0.08
filled
0
0.05
dmft
2.6
1.1
31
(33.3)
29
(48.3)
p <0.002
p <0.04
Sample(n)
132
82
decayed (Mean)
4.7
0.2
missing
0.2
2.7
filled
0.2
0.3
dmft
5.1
3.2
17
(12.9)
p <0.001
16
(19.5)
p <0.001
Western Region
Total caries free
[% children (%)]
Significance
Central Region
Total caries free
[% children (%)]
Significance
Eastern Region
Total caries free
[% children (%)]
Significance
After three years, the authors found a less caries incidence among the
study group compared to controls from the baseline. Thimphu and
Trashigang children had more caries than those from the central
region, hypothetically due to exposure to refined diets and parental
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affordability for pockets money to children than better oral hygiene
measures or more regular dental visits while the central region
children had more traditional form of diets, other factors being the
same. Table 1.4 represents the overall data of the study.
The oral health scenario for the elderly at the national level is again
missing. A slightly bizarre finding from the “Free Health Checkup for
the Elderly” conducted in the street in 2012 for 328 elderly, only 9%
had normal dentition. Thus it is demonstrated that geriatric dental
problems exist among those 65-years and older14.
The caries data for primary dentitions (dmft) among 5-6-year-old
children is not available presently. But the caries reports for some
years are alarming as shown in Tabel.1.5 and Figure 1.1. An initiative
has been taken towards that end and a proposal for a nationwide oral
health survey would come to realize by the coming year if the Borrow
Foundation accepts for funding the project proposal. As of now, only
clinical experience shows that the majority of children visiting for
dental services have rampant caries. It is anticipated that the planned
survey data would show the real caries status among children in this
age group15-16.
Table 1.5: Age specific dental caries for 2010.
Age Group
(Years)
Male
Under 1
Female
Total
29
39
68
599
735
1,334
5-14
4,202
4,154
8,347
15-49
9,101
11,797
20,898
50-64
2,140
2,014
4,164
955
690
1,645
1-4
Above 65
Total
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Figure 1.1: Annual dental caries cases
COMMUNITY DENTAL CARIES PREVENTION PROGRAM
Dental caries is one of the top ten most common diseases in
Bhutan21. The burden of dental diseases in the country is high and
expensive. The reported caries cases have been on a gradual rise since
2005 as illustrated in Figure 1.2. Dental caries associated pain,
swelling, dysfunction of dietary intakes, missed work or school days
still not documented could be enormous.
The need of exposure to 1 ppm of fluoride in public drinking water
supplies in temperate climate countries has been shown to reduce
dental caries experience, especially in children by approximately 50%
in several communities22-24.
In a similar context, the WHO has suggested fluoride levels of 0.5-1.0
ppmF for best cariostatic effects in hot and cold climates for lower and
upper limits respectively25
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Figure 1.2: Dental caries related treatments 2005-2011.
The oral health program was started in 1988. Schools were annually
screened of dental caries and other oral problems, mostly by dental
hygienists. Extractions of grossly decayed and primary mobile teeth
were extracted after the oral health talk to students. This program
still continues today but the regional discrepancy in school visits and
lack of monitoring and evaluation of the activity is the hallmark 26
The comprehensive school health program jointly conducted and
monitored by the education and health ministry was initiated in 1998.
But oral health topics are hardly covered to indicate indifference to
oral health. Although no health topics including that of oral were
there in the old curriculum, it is has now become essential for
children to learn health chapters in their sciences and social study
books. It is also a universal practice for schools to have a health
teacher each who are trained in basic health care and they teach and
look after the health issues of the school as a whole or have the
authority for referral to hospitals26.
Two successive drinking water fluoride mapping was done in 2013.
While the study by Dorji C et al covered all the towns in the country
for both wet and dry seasons, the dental team survey of fluoride
covered entire urban and semi-urban areas and most villages,
including samples from major rivers of Bhutan. Some of the fluoride
level data are shown in Figures 1.3 and 1.4. Both studies had found
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very low fluoride levels in drinking water across the country in
different seasons. The studies have concluded that dental caries levels
be high in light of negligible protection from water fluoride and less
number of oral health workers27-28.
Figure 1.3: Fluoride concentration in major river waters in Bhutan
Figure 4.3: Fluoride level in village drinking waters of twenty
districts
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HOME CARE FOR DENTAL CARIES CONTROL
A study by Ngedup S et al (2008) 11 found 95% use of fluoride
toothpastes among the participants. The type of toothpastes and their
fluoride concentrations were not ascertained. The same study also
found that only 40% visited the dentist within the past twelve months,
the reasons being toothaches. Less than 50% had the tendency of
brushing less than twice a day and before bedtime brushing was done
by 40% children. The first ever oral health study in the country by
Singh et al. (1985)12 had also ascribed to poor oral behaviour and low
education as the reasons for both poor dental and gingival health.
The use of in-office fluoride is erratic and is practiced at high end
clinics in Thimphu only. Even though, 2% acidulated phosphate
fluoride (APF) has recently begun to be used for patients, the
noncompliance and poor record keeping factors could prove harmful
for children. There is no fluoride varnish as well and could be better
for the same reasons. Fluoride mouth rinses are hardly prescribed or
found in the pharmacy shops unlike antiseptic mouthwashes which
are frequently prescribed but not available in the hospital
pharmacy29.
While various brands of nylon toothbrushes are vague in towns, more
remote areas also use traditional forms of oral cleaning like using
charcoal, earth or just chew sticks alone.
CARIOLOGY EDUCATION IN DENTAL SCHOOL
Until 1950s monastic schools were the only form of education with
schools in Paro, Haa and Bumthang, and still today it plays an
important role in preserving and promoting the tradition and culture
of the country. Bhutan’s tryst with organized modern education
started in 1961when the development plan was launched. Today there
are more than 500 schools including private, vocational and colleges
under the Royal University of Bhutan (RUB)1,17.
Construction of a medical university named-University of Medical
Sciences of Bhutan (UMSB) is in the advanced stage and would be
opened by 2014. When it becomes functional, all the health related
studies will be conducted within the country, bringing an end to
decades of sending all health professionals for training outside the
country. In 1972 the first health school was established in Thimphu:
National Health School. It was planned to train national paramedics.
The school was renamed as the Royal Institute of Health Sciences
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(RIHS) in 1984. Although the school was originally meant to train
basic health care workers like health assistants (HA), nurses, basic
health workers (BHW), other categories of health professionals were
inducted. A two year duration certificate level dental hygiene course
was first started in 1984. Two years later, the same duration dental
technician course was also inducted 18 The present dental
professionals strength in the country is indicated in Table1.6.
Table 1.6: Bhutan Dental Healthcare personnel
Dental Health
Professional
Pediatric Dentist
Orthodontist
Oral Surgeon
Prosthodontist
Dental Surgeon
Dental Hygienist
Dental Technician
Dental Assistant
Number
of staff
1
1
1
1
5
57
32
2
Working Hospital
Thimphu
Thimphu
Thimphu
Thimphu
Thimphu & Districts
Thimphu (21)
Thimphu(17)
Thimphu
The dental hygiene course entails a wholesome curriculum including
basic sciences and some important tenets of major dental specialty
topics. Great care is taken to inculcate among hygienists the sense of
prevention and promotion of oral health for the masses. A three year
diploma in dental therapy is proposed that would come through once
the medical university starts its academic session in the future 18-19
Higher education for health professionals like doctors including
dentists were until now trained in foreign countries viz. India, Sri
Lanka, Myanmar, Nepal and Thailand among others. Presently
Bhutan has 57 dental hygienists, 32 dental technicians and 2 dental
assistants. On the other hand, the number of dentist is just 9,
including a specialist each in oral surgery, orthodontics,
prosthodontics and pediatric density. In having the first national
dentist in 1986, it has been a dismal increase to its present number 20.
CONCLUSION
Dentistry in Bhutan has made great strides since the first expatriate
dentist in 1970 and a national dentist in 1986. The low dentist counts
could be numbered when a number of privately sponsored young
graduates studying outside the return for practice within a decade
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from now. On the other hand, the upgraded diploma in dental hygiene
course could make a positive difference as the dental workforce. As
the national electrification is complete, dental technology will be used
in every nook and corner of the country in delivering oral health
services to people.
The present poor oral health attitude of people would likely change for
the better as the literacy and globalization impacts their lives. The
dental professionals should provide effective oral health messages
through various media especially target to children who are easily
misled into accepting refined sugar forms that are detrimental to oral
health. The final message is that drinking water fluoride
concentration is very low and hence the use of fluoridated toothpastes
should be encouraged for all.
REFERENCES
1.
National Statistics Bureau (2012). Statistical Year Book, Royal
Government of Bhutan.
2.
Population and Housing census of Bhutan (2005). Royal
Government of Bhutan.
3.
9th FYP document for the Health Sector (2002-2007). Ministry of
Health. Royal Government of Bhutan.
4.
Annual Health Bulletin (2012). Ministry of Health, Thimphu,
Bhutan.
5.
Petersen PE (2003). The World Oral Health Report: continuous
improvement of oral health in the 21st century – the approach of
the WHO Global Oral Health Programme. Community Dent Oral
Epidemiol. 31(Suppl. 1):3–24.
6.
Petersen PE, Hoerup N, Watanapa A (2001). Oral health status
and oral health behavior of urban and rural schoolchildren in
Southern Thailand. Int Dent Journal 51:95-102.
7.
Koirala S, David J, Khadka R et al.(2003) Dental caries
prevalence, experience and treatment needs of 5-6 years old and
12-13 years old and 15 years old school children of Sunsari
district, Nepal. Journal of the Nepal Dental Association 5:12-24.
8.
Ulla M.S., Aleksejuniene,J., Eriksen,H.M.(2002). Oral health of
12-year-old
Bangladeshi
children.
Acta
Odontologica
Scandanivica 60: 117-122.
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9.
Teng O.(2001). Factors affecting oral health status among 12year-old children in primary school participating in oral health
preventive program in Phnom Penh City, Cambodia [MSc. Thesis,
Mahidol University] Thailand.
10.
Singh D.(1985). Dental caries and
prevalence in schoolchildren of Bhutan.
11.
Ngedup S, Leelatataweewud P, Lexomboon D.(2009) Oral health
status and associated factors in 12 years old children in
Thimphu city, Bhutan. Int Dent J Paed Dent 9 (suppl.1): 36.
12.
Ngedup S., Phurpa D., Karchu (2011). Prevalence of dental caries
among children in Loselling Middle Secondary School, Thimphu,
Bhutan.
13.
Wangchuk SR, Phurpa D, Dorji T et al.(2012). Effectiveness of
supervised fluoride mouth rinse and oral health education on
caries incidence among kindergarten pupils in three regions of
Bhutan: a Pilot Project.
14.
Department of Dentistry (2012). Jigme Dorji Wangchuk National
Referral Hospital, Thimphu.
15.
Ngedup S, Phurpa D. (2013). Oral Health Survey in 6- and 12year-old Bhutanese schoolchildren: A proposal for Borrow
Foundation, USA.
16.
Dental Monthly Report (2012). Department of Dentistry, Jigme
Dorji Wangchuk National Referral Hospital, Thimphu.
17.
Education in Bhutan. Full version at:
http://countrystudies.us/bhutan/29.htm. (Accesses on October
9, 2013).
18.
Tamang S Pratap. (1990). Dental Hygiene and Technician
Certificate Course Curriculum, Royal Institute of Health Sciences,
Thimphu.
19.
Ngedup S, Phurpa D, Jamtsho L.(2012). Dental Hygiene and
Technician Diploma Course Curriculum, Department of Dentistry,
Jigme Dorji Wangchuk National Referral Hospital, Thimphu.
20.
Master Plan (2012). Human Resources Division, , Ministry of
Health, Thimphu.
21.
Dental Services (2012). Annual Health Bulletin, A window to
health Sector Performance. Ministry of Health, Bhutan.
22.
Dean HT, Arnold FA, Evolve E.(1942). Domestic water and dental
caries. V. Additional studies of the relation of fluoride in
domestic water to dental caries experience in 4,425 white
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disease
International Dental Conference on “Caries Control throughout Life in Asia”
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children aged 12 – 14 years, of 13 cities in 14 states. Public
Health Reports 1155–1179.
23.
Murray JJ, Rugg-Gunn AJ.(1982). Fluoride in Caries Prevention.
Dental Practitioner's Handbook No. 20.2nd edition. Boston:
Wright PSG; Modes of action of fluoride in reducing caries; pp.
222–223.
24.
O'Mullane DM, Clarson J, Holland T et al. (1988). Effectiveness
of water fluoridation in the prevention of dental caries in Irish
children. Community Dental Health 5:331–334.
25.
World Health Organization (1994). Expert Committee on Oral
Health Status and Fluoride Use, author. Fluorides and Oral
Health. Geneva: World Health Organization. WHO Technical
Report. Series No. 846.
26.
Oral Health Program (1990). Ministry of Health, Thimphu
Bhutan.
27.
Dorji C, Wangchuk R. (2012). Fluoride mapping of drinking water
in urban and suburban areas in Bhutan, Water Quality Section,
Public Health Laboratory, Ministry of Health, Bhutan.
28.
Ngedup S, Phurpa D. (2013). Fluoride mapping for dental caries
prevention. Oral Health Program, Ministry of Health, WHO
support.
29.
Standard Treatment Guide (2012). Department of Medical
Servicers, Ministry of Health, Thimphu Bhutan.
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BRUNEI DARUSSALAM
Mary Cheong Poh HUA
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
BRUNEI DARUSSALAM
Mary Cheong Poh HUA11
DENTAL CARIES EPIDEMIOLOGY
-
Data from Dental screening in schools and “Parents and young
children programme” 2012
Caries free 5 year old 41% (1999 caries free11%)
Caries free 3 year old 60.8%
Dmft 5 year olds 3.9 (1999 dmft 7) d=3.7, m=0.06, f=0.05
dmft 3 year olds 2 (d=2, m=0,f=0)
DMFT 12 year olds 0.6 (1999 DMFT 5)
COMMUNITY DENTAL CARIES PREVENTION PROGRAMME
Current programmes and activities conducted by Oral Health
Promotion Division
1.
Water Fluoridation


2.
almost 100% supply /coverage from water treatment
plants
2012 fluoride level in water 0.5 to 0.7 ppm
Oral Health Promotion through television promotion



Infant diet – promoting breastfeeding, stopping bottle
feeding with infant formula, prevent sweet snacking
Oral hygiene – toothbrushing education
Prevention of cross infection from mother to child
Department of Dental services, Ministry of Health, Brunei Darussalam.
Email: Mary Cheong <markusdawat@yahoo.com>
11
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
3.
Antenatal programmes




4.
Comprehensive dental treatment
Oral health education for mother and infant to be born
Oral health promotion booklet and pamphlet
2012 data showed coverage of 25% of antenatal mothers
Parents and Young Childrens Oral Health Promotion and
Prevention programme for 5 year olds and below in community
health centres providing:4.1
4.2
4.3
5.
2012 study showed 7% of mothers who watched the
promos have started brushing their childrens’ teeth with
fluoridated toothpaste.
Oral health education.
Fluoride varnish 2x a year until 5 years old.
Interventive oral health promotion programme for 9
months old babies

Giving of a bag with fluoridated toothpaste,
toothbrush, feeder cup and oral health education
booklet and pamphlets.

Follow up every 6 months - giving toothbrush and
fluoridated toothpastes) till 5 years of age.

Collection of data for 5 year olds and below –
caries free % for 3, 5 year olds, dmft for 3,5 year
olds.

Percentage of total number of 9 months old babies
attended was 24%.

Percentage of total number of children under 5
year olds attended was 98%.
Health Promoting School Programme



Collaboration with Department of Schools, Ministry of
Education.
Teams from various Departments inspect schools &
monitor all health aspects of schools (Medical; Dental;
Sick bay; hygiene and cleanliness of school premises,
compound, toilets, drains; nutrition and healthy diet in
canteen/tuckshop, food brought from home.)
All schools visited once a year and reports given
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6.
Daily Fluoridated Tooth Brushing Programme





7.
Introduced in Government primary schools (Total 119)
Tooth brushing activity is carried out 10 min before the
end of break, by the whole school under teachers’
supervision, every school day.
1 toothbrush per year and Pollypaste (1450 ppmF) are
provided by the Ministry of Health
Conducted by Oral Health Promotion Division.
All government primary schools visited by oral health
promotion division 2x a year.
National Dental Song Competition for all primary
schoolchildren aged 6-9 years old.

58 primary schools competed in 2012
8.
National Tooth brushing Competition for Primary
schoolchildren to be conducted in 2014.
9.
Current programs & activities conducted by School Dental
Services Division







10.
Static Dental Clinics
45 dental surgeries in schools throughout the country
Mobile Dental Squads
Started in 2007 where teams of 2-6 dental nurses
treating school children using portable equipment
Move to another school upon 80% completion
Currently ⇨ 12 Mobile Dental Squads
2012: 99 schools covered
Current programs & activities conducted by Paediatric
Dentistry Unit


A Special Oral Health Promotion programme in schools
to both children with special needs & their carers.
Paediatric Dental Specialists & Therapists also provide
specialised & comprehensive dental care for children
with special needs & medically compromised.
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HOME CARE FOR DENTAL CARIES CONTROL
Fluoridated toothpaste – 1450ppm fluoride.
CARIOLOGY EDUCATION IN DENTAL SCHOOL




No dental school at present.
2014 September starting dental school education at the
University of Brunei twinning with UK University.
Cariology teaching and learning and clinical practice in
Diploma in Dental Hygiene and Therapy course conducted by
the Department of Dental Services, Ministry of Health with
King’s College, London.
Contents : Dental Caries – Aetiology and microbiology of dental
caries in relation to dental plaque; the epidemiology of caries;
features of enamel, dentine and root caries (both
microscopically and macroscopically); Diagnostic methods of
dental caries; management of dental caries; histopathology of
pulpitis; abscess formation.
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CAMBODIA
Sopharith SOEUN
Callum DURWARD
Sithan HAK
Tepirou CHHER
Chhnoeum TIENG
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
CAMBODIA
Sopharith SOEUN12
Callum DURWARD13
Sithan HAK12
Tepirou CHHER12
Chhnoeum TIENG14
INTRODUCTION
Oral health is now accepted as being an important part of general
health. Not only can poor oral health lead to pain and infection, but it
can also have an adverse effect on a person’s general health and
quality of life. Studies have shown an association between oral health
and conditions such as cardiovascular disease, premature birth, and
diabetes (Barnett, 2006).This report will describe the dental health
status of Cambodians from ages 6 to over 60 years, the teaching of
Cariology in the undergraduate curriculum, public health measures
to address the problem of dental caries, and preventive dental
products available in Cambodia.
DENTAL CARIES EPIDEMIOLOGY
Unfortunately, most Cambodians experience dental problems from an
early age. This is evidenced in several studies that have been
conducted on the epidemiology of dental caries in Cambodia since
1990 (Durward et al., 1991; Todd et al., 1994; Shidara et al., 2007;
Chu et al., 2008; Teng et al., 2004). The most recent national oral
health survey shows high levels of dental caries in all age groups,
although caries in children is more severe (Table 1) (Ministry of Health,
2011a). The mean dmft of 6 year old children was 9.0, with very few
Oral Health Office, Preventive Medicine Department, Ministry of Health, Cambodia.
Email: Sopharith Soeun <rithisambath@yahoo.com>; Sithan Hak <sithan_hak@yahoo.com>;
Tepirou Chher <tepirou@yahoo.com>
13
Faculty of Health Sciences, University of Puthisastra, Cambodia, Email: Callum Durward
<callumspencerdurward@gmail.com>
14 Cambodian Dental Association. Email: Chhnoeum Tieng <chhnoeum@yahoo.com>
12
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primary teeth having been restored or extracted. Only 6.9% of these
children were caries-free. The mean pufa (pulpally involved, ulceration
due to trauma, fistula or abscess) index (Monse et al., 2010a) was 2.7.
This indicates that an average of almost 3 teeth had deep decay
affected the dental pulp. In addition, 60% of mothers of the children
in the 6 year old age group indicated that their child had suffered
from dental pain in the past 6 months. The mean DMFT for the 12
year old age group was 3.5, with few permanent teeth having been
restored or extracted, and with a mean PUFA score of 0.9. Only 21.7%
of 12 year olds were caries-free. The adolescent group (aged 14-15)
had a mean DMFT of 4.2, with little evidence of treatment, and a
caries-free rate of only 20.9%. In the 35-44 year old age group, the
DMFT was 5.6, with almost half of the affected teeth being either
restored or extracted. 28.9% of this age group was caries-free. And in
the over 60 years group, the DMFT rose to 8.1, and the PUFA score
was 2.6.
Table 1: Dental caries epidemiology in Cambodia.
Age
Grp
Caries
free
(%)
5-6
6.9
12
1415
3544
>60
dt
mt
8.9
0.1
21.7
-
-
20.9
-
28.9
31.7
ft
dmft
pufa
DT
9.0
2.7
0.2
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
0.0
MT
0.0
FT
DMFT
0.0
0.2
PUFA
-
3.4
0.1
0.1
3.5
0.9
3.8
0.1
0.2
4.1
0.9
3.8
1.3
0.5
5.6
1.9
3.9
4.1
0.1
8.1
2.6
COMMUNITY DENTAL CARIES PREVENTION PROGRAMS
1.
Community fluoride administration in Cambodia
So far, although most water supplies in Cambodia are deficient
in fluoride, there have been no community fluoride
administration programs. The Oral Health Office, Preventive
Medicine Department, Ministry of Health (MOH), has
investigated salt and water fluoridation, but these have not
been implemented due to technical challenges, and resistance
from some stakeholders. However, the Oral Health Office is
continuing to promote fluoridation as a safe and cost-effective
means of caries prevention. In the meantime, the Oral Health
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Office has focused on promoting the use of fluoride toothpastes,
and ensuring that all toothpastes have adequate levels of
fluoride. In January 2007, a meeting was organized by the
MOH on the topic “The Future Direction for Fluoride
Toothpaste in Cambodia” (Ministry of Health, 2007b). All
importers of toothpaste were invited to attend (presently
Cambodia has no local toothpaste manufacturers).
The objectives of this first meeting were: to provide information
on the effectiveness and affordability of fluoride toothpaste; to
present the situation of fluoride toothpaste in some ASEAN
countries and Cambodia; and to draft a strategic plan aimed at
improving the quality and affordability of fluoride toothpaste in
Cambodia.
1200
1000
800
600
400
200
0
Pepsodent
Evafresh
Darlie
Darlie(double…
Forament BI…
Oral B(Sensitive…
Foramen Junior…
Bamboo Salt
Hi-herb
Ioderm (herb)
Colgate (double…
Herbal
Colgate (fresh…
Dental Academy…
Perl Drop (Arctic…
Median Clinic n
Median White E
Calgate (proven…
2080 Dental…
Close Up
Pepsodent (Anti-…
This was followed by two other meetings on “Fluoride Levels in
Good Quality Toothpaste” in June 2010 and May 2011. The
objectives of these meetings were: to give information to the
toothpaste import companies on the level of the fluoride in
toothpaste which can prevent tooth decay; to give information
on the resultsof fluoride toothpaste analysis; to discuss ways of
improving of quality of toothpaste in the Cambodian market
and achieve international standards of fluoride; and to increase
the cooperation between Preventive Medicine Department,
Ministry of Health, other public partners, and private
companies, with the aim of improving the oral health of all
Cambodians (Ministry of Health, 2010 and 2011 b).
Figure 1: Fluoride content of selected toothpaste samples in
Cambodia 2004.
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As part of this project, the Oral Health Office carried out
several surveys of toothpastes available in the Cambodian
market. Only very few brands of toothpaste had fluoride levels
close to international recommendations. However, over time
there has been an improvement in this situation (Figures 1, 2,
3) (Ministry of Health, 2004, 2008 and 2013).
1200
1000
800
600
400
200
0
Free F
1400
1200
1000
800
600
400
200
0
Darlie All Shiny white…
Darlie Fresh in brite
Pepsodent Herbal…
Colgate Total…
Systema Lion
Salz Lion
Darlie All Shiny white…
Darlie All Shiny white…
Colgate Doule Cool…
Colgate Great Regular…
Colgate Salt Herbal
Colgate Max Fresh
Close Up New…
Colgate Sensitive
Colgate Whitening
Perl Drops
Darlie Double action
Colgate Provent…
Pepsodent + 50%…
Pierrot Aloe Vera
Figure 2: Fluoride content of selected toothpaste samples in
Cambodia in 2008.
Figure 3: Fluoride content of selected toothpaste samples in
Cambodia in 2013.
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2.
Community oral health programs for caries prevention in
children.
Cambodia has several community oral health programs for
caries prevention in children. These include:
Bright SmilesBright Futures (BSBF)
Since 2008, BSBF has operated in Cambodia with the support
ofthe Colgate Palmolive Company. The program in Cambodia
includes the provision of toothpaste, toothbrushes, and
educational materials (eg. tooth brushing models and posters)
to approximately 500 primary schools. BSBF is a collaboration
between: the Oral Health Office, Preventive Medicine
Department, Ministry of Health; the School Health Department,
Ministry of Education Youth and Sport; and the Colgate
Palmolive Company. The program started in Phnom Penh, but
has now spread to 10 provinces. It focuses mainly on children
in Grades 3 and 4 with brushing instruction and oral health
education. Apart from the preventive dental interventions, the
BSBF also includes hand-washing instruction. These activities
are introduced through a “train the trainers” (TOT) approach
involving schoolteachers and health workers. To date over
300,000 children have participated in this program.
Fit for School (FFS)
Fit for School is a program which focuses on improving both
general and oral health. It originated in the Philippines, and is
now also operating as a pilot project in Cambodia, Laos and
Indonesia. The FFS Essential Health Care Package (EHCP)
consists of three components: daily hand washing with soap;
daily tooth brushing with fluoride toothpaste; and biannual deworming. Both hand hygiene and tooth brushing are carried
out as group activities so that children will develop both good
habits and a good attitude toward their health. The toothpaste
used in this program has 1450ppm fluoride (Monse et al.,
2010b).
One of the key elements of the program is to create a
supportive environment through:
1)
Improving access to water- Schools which implement the
program need to have running water for students to do
hand washing and tooth brushing. If there is no water
system, schools can use simple water containers to
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make running water for students to use. The amount of
water that is used is approximately half a liter per child
per day.
2)
The construction of handwashing and toothbrushing
facilities - The words “Fit for School” do not only imply
good health for school children, but also that the
program “fits” to the real context of the school’s situation.
So building hand washing and tooth brushing facilities
must “fit” to the situation of the school and the
community, no matter how rich or how poor they are. If
the school Principal and Parent Teacher Association are
willing to help, the facilities can be built and the
program supported on an ongoing basis.
In some
situations, not only the school children but also other
children in the community can use the facilities to wash
their hands while playing in the school grounds.
3)
Tippy tap wash stations–FFS includes daily group hand
washing and tooth brushing at school, and building a
“tippy tap” wash station is very useful for group
activities. Moreover, they are designed is to save water
from dripping or being used in a wasteful way.
4)
Health corner- within to the policy of the Ministry of
Education Youth and Sport called “Child Friendly
Schools”, the third component focuses on Health, Safety
and Child Protection, and promotes the concepts of
Good Eating, Good Drinking, and Good Living(Ministry
of Education, Youth and Sport, 2007). The FFS Health
Corner therefore supports “Child Friendly Schools”
policy. This corner is designed to keep students’
toothbrushes, toothpaste, and soap, along with other
items such as first aid kits and analgesics.
The FFS program is a collaboration between the Oral Health
Office, Preventive Medicine Department, Ministry of Health, the
School Health Department, Ministry of Education Youth and
Sport, Parent Teacher Association (PTA), local authorities, and
the German International Cooperation (GIZ) based in Phnom
Penh, Cambodia.
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Seal Cambodia
Seal Cambodia is a 3-year school-based project to protect the
teeth of 60,000 Grade 2 children by placing GIC fissure
“sealants” (Fuji VII) on their first permanent molars (Durward,
2013). The project also aims to: demonstrate how partner
organizations (including NGOs) can work together in a dental
public health program, to improve child oral health;
demonstrate the success of the project through a longitudinal
prospective research study.
The local partners of this project are: the Oral Health Office of
the Ministry of Health; the School Health Department of the
Ministry of Education Youth and Sport; the Cambodian Dental
Association; the Faculty of Dentistry, International University;
the Dental Nurses School at the Regional Training Center,
Kampong Cham province; the NGO Cambodia World Family;
the NGO One-2-One Cambodia; and the NGO Cambodia
Buddhist Library Project.The project is primarily sponsored by
the Global Child Dental Fund (GCDF), CamKids–the
Cambodian Children’s Charity, and GC (Asia).
In the first 7 months of the project, over 11,000 Grade 2
children were sealed on-site at the primary schools. A very
basic set of dental instruments and materials is used, and
children usually lie on a school table to be sealed. In addition
to the local Cambodian teams, a number of overseas volunteer
dental personnel and dental students are involved. It is
expected that the research will demonstrate a very large
reduction in dental caries in the first permanent molars.
Cambodia Smile
This is a One2One Cambodia (NGO) initiative focusing on
mothers and pre-schoolers. An initial baseline survey of several
hundred infants and caregivers showed that caries was
prevalent in most preschool children. A number of risk
indicators were identified, including: lack of oral hygiene; lack
of fluoride exposure; and almost universal night-time ondemand breast-feeding often continuing for several years.
Interventions are being developed which will focus on a
common risk factor approach, and will include: health and oral
health education for mothers, early introduction of brushing
with a fluoride toothpaste, intermittent topical fluoride
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applications, the use of silver diamine fluoride to arrest caries,
de-worming, nail clipping, hand washing, and de-licing.
Live Learn Laugh (LLL)
This is a unique global partnership between Unilever Oral Care
and the FDI World Dental Federation aims to measurably
improve oral health on a global scale through encouraging
students to brush their teeth twice a day with fluoride
toothpaste. The Cambodian Dental Association was one of the
National Dental Associations' partners that has run this project
in Cambodia since the beginning of the phase I in 2005. The
project is running well until now, however Live Learn Laugh
(LLL) is restricted to 8 primary schools in Phnom Penh.
3.
Oral Health Office (OHO), Preventive Medicine Department,
MOHInitiatives
The MoH has developed a policy to integrate the activities of the
OHO with other areas of health, particularly Maternal Child
Health programs. This has included conducting training about
oral health for nurses and midwives who work in the public
sector. These health workers should now be capable of
transmitting important oral health messages to people living in
their communities, focusing especially on pregnant women and
mothers of young children.
Table 2: Tooth brushing habits of primary school children
Tooth brushing
Frequency
%
Never
53
6.6
<1 time per day
53
6.6
1 time per day
151
18.8
twice per day
322
40.3
>twice per day
222
27.8
Total
801
100
The Oral Health Office has also produced flip charts and
leaflets promoting oral health. The staff of the OHO takes these
educational resources to the field and use them when training
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the health workers. Thou has also produced a second flip chart
targeting school children which focuses on the importance of
good oral health for general health. The staff of the OHO also
has its own school oral health program targeting children’s oral
hygiene, hand washing, and dietary habits. As part of the
school program, the OHO conducted a survey to investigate
primary school children’s attitudes and practices relating to
toothbrushing. The results are shown in Table 2.
4.
Home care for dental caries control
The NOHS (Ministry of Health, 2011) found that at the age of 6,
28% of children had still not started to brush, and by age 1,
only 3% were brushing (Table 3). This is far below international
recommendations.
Table 3: The age of commencement of tooth brushing (NOHS,
2011).
N
%
3
0.7
At age 1
10
2.5
At age 2
32
7.9
At age 3
57
14.1
At age 4
52
12.9
At age 5
64
15.9
At age 6
72
17.9
Not yet brushing
113
28.0
Total
403
100
When teeth first erupted
However, almost all (97%) of the children in the older age
groups brushed their teeth. 22% brushed once a day, and 72%
two or more times per day (Table 4).
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Table 4: Distribution of children’s habit of their daily frequency of
tooth brushing (NOHS, 2011).
Frequency of
daily tooth
brushing
Never
Less than once
a day
Age group
15-17
12-13
N
%
N
%
All
N
%
15
3.6
12
3.0
27
3.3
12
2.9
6
1.3
18
2.1
Once a day
117
28.3
65
16.0
182
22.2
Twice a day
200
48.4
241
59.2
441
53.8
69
16.7
83
20.4
152
18.5
3 times or
more/day
Total
413
407
820
Among the two adult age groups, 2% of the 35-44 year olds,
and 9% of the over 60 year olds said they brushed less than
once per day (Table 5).
Table 5: Frequency of daily tooth brushing by age group (NOHS,
2011).
Age group
Over 60
N
%
Frequency of
daily tooth
brushing
Less than once
a day
N
9
2.3
31
9.5
40
5.5
Once a day
103
25.9
97
29.7
200
27.6
Twice a day
237
59.5
171
52.3
408
56.3
49
12.3
28
8.5
77
10.6
3 times or
more/day
Total
35-44
%
398
327
All
N
%
7250
These data from the recent National Oral Health Survey
indicate that for many people, home care for dental caries
control is less than optimal. The Oral Health Office, Preventive
Medicine Department, Ministry of Health of Cambodiahas
recommended that the appropriate fluoride concentration in
toothpaste is 1000-1500ppm, and that teeth should be
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brushed at least two times per day. For preschool children, a
smear of adult toothpaste is recommended. The use of
children’s toothpastes with a lower fluoride concentration is not
recommended. However, Cambodia has a free market which
permits private companies to import many brands of
toothpaste.As previously mentioned, the Oral Health Office has
analysed the concentration of fluoride in toothpastes sold in
Cambodia since 2004, and the situation is improving thanks to
good communication with the companies, and their
understanding of what levels of fluoride are recommended by
the Ministry of Health.
In addition to fluoride toothpastes, there are many different
types of preventive agents available in Cambodia at the present
time. These include:
Fluoride tablets and drops (NaF)
These are usually available through some pharmacies, but are
not widely used. This is probably because most people are not
aware of the benefits of fluoride supplements, and many would
not be able to afford to purchase them.
Fluoride varnish (NaF)
Fluoride varnish is generally not used by Cambodian dentists
to prevent dental caries. Until recently fluoride varnish could
not be purchased locally, and the product has only recently
been approved for sale by the government. One dental school
and some NGOs currently use a lot of fluoride varnish in their
work with children, thanks for donations from abroad. At a
conference for Cambodian dentists in September 2013 the use
of fluoride varnish was promoted in a lecture by the Head of
the Oral Health Office of the MOH. One company has recently
started selling fluoride varnish to dentists, and Colgate
Palmolive hope to be selling Duraphat by the end of 2013. The
cost is still prohibitive for most dentists and patients.
Fluoride mouthrinse (0.05% NaF)
This dental caries prevention agent was introduced to
Cambodian schools around 1991 by the NGO “World Concern”
working in the collaboration with the Faculty of Dentistry,
University of Health Science. Today the school daily mouth
rinsing program no longer exists, however fluoride mouth
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rinses can be purchased by the public from supermarkets in
the larger cities.
Chlorhexidine mouthwash
Private companies sell chlorhexidine mouth rinse in Cambodia,
and some dental clinics also sell it to patients.
Resin sealants
These are seldom used in Cambodia, and most dental supply
companies do not sell resin sealants to dentists.
GIC for fissure protection
This is the most popular type of “fissure sealant”. It is used in
the SEAL CAMBODIA project, in some NGO projects, at the
dental schools, and in many private clinics.
Tooth mousse (CCP / ACP)
This is available in some private dental clinics, and is
purchased by the more affluent patients.
Traditional medicines are sometimes used to treat dental
problems, however these are becoming less popular over time.
CARIOLOGY EDUCATION IN DENTAL SCHOOLS
In Cambodia there are four dental schools, and one school for dental
nurses. The oldest dental school is the Faculty of Odontostomatology,
University of Health Sciences, which is a governmental school. There
is also the Faculty of Dentistry, Health and Science Institute of the
Royal Cambodian Armed Forces (established in 2012), and two private
dental schools -the Faculty of Dentistry at International University
(established in 2004), and the Department of Dentistry of the
University of Puthisastra (established in 2011). The dental nurse
school was established in late 1996 in Kampong Cham province. It
trains a unique type of bi-functional dental/general nurse, who can
carry out ART restorations, extract teeth, and provide basic
periodontal and preventive care.
None of the dental schools have a Cariology department. Cambodia
lacks expertise in this area, and so far there are no Cambodian
specialists in Cariology, Restorative Dentistry, Pediatric Dentistry or
Endodontics.There are however specialists in Dental Pubic Health
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(13), Prosthodontics (2), Orthodontics (8), and Oral Maxillofacial
Surgery (2). There are also several Cambodian postgraduate students
currently studying in Japan, Korea and Thailand, as well as
postgraduate students studying in Cambodia in Endodontics, OMF
Surgery and Orthodontics. There are approximately 700 universitytrained dentists in Cambodia, and probably and equal number of
traditional dentists, who have no formal training.
All dental schools in Cambodia must follow a National Dental
Curriculum, and Cariology is part of this curriculum (Ministry of
Health, 2007a).
Cariology Teaching
University of Health Science (UHS): Cariology is mainly taught in
Oral Biology, Community Dentistry, Operative Dentistry,
Paediatric Dentistry and Dental Pathology. Clinical teaching in
Cariology takes place in the appropriate clinical departments.
International University (IU): This is a one department private
university in which Cariology is taught mainly in Oral Biology,
with some lectures in Dental Pathology and Community
Dentistry. Applied Cariology is taught in Operative Dentistry,
Pediatric Dentistry, Radiography and Endodontics. All clinical
treatment is provided in the one general practice dental clinic
at IU.
University of Puthisastra (UP): This new private University
presently has students studying in years 1-3. A dental clinic is
under construction and will be ready for the students to begin
their dental practicum in late 2014.The University of
Puthisastra has no Cariology Department. Cariology is mainly
taught in Oral Biology, with some lectures in Dental Pathology
and Community Dentistry. Applied Cariology will be taught in
Operative Dentistry, Pediatric Dentistry, Radiography and
Endodontics.
Military Dental School: This government school is one
department within the Military Institute of Health and Science.
The curriculum and teaching of cariology is the same as at the
University of Health Science.
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CONCLUSIONS
Dental caries is very prevalent in all age groups in Cambodia, but is
especially severe among children. Early Childhood Caries is almost
universal, possibly related to a lack of oral hygiene in preschoolers,
and the almost universal practice of on-demand night-time breastfeeding which often continues for several years. A range of schoolbased dental public health programs have been implemented by the
Ministry of Health, NGOs and dental companies to address the
problem, however these do not have universal reach, and cannot
address the rampant decay in the primary dentition which develops
before the children reach school. There are presently no community
fluoride programs in Cambodia, although the MOH has had some
success in promoting the sale of fluoride toothpastes through its
advocacy with toothpaste importers. As a developing country with
limited resources and a limited workforce, preventive dental programs
are the only sensible way to address the significant public health
problem of dental caries in Cambodia.
REFERENCES
Barnett ML. (2006): The oral-systemic disease connection, J Am Dent
Assoc137(suppl 2):5S–6S.
Chu CH; Wong AWY; Lo ECM, Courtel F. (2008): Oral health status and
behaviours of children in rural districts of Cambodia. International
Dental Journal58:15-22.
Durward CS (2013). NGO Initiatives and Impacts on the Oral Health of
School Children in SE Asia. The 7 th Asian Conference of Oral Health
Promotion for School Children, Sept 12-14, 2013, Bali, Indonesia, pp 50.
Durward CS; So PK, Cheng S, Kiet S, Uy KC, Im P. (1991).Cambodian
National Oral Health Survey 1991, in Report of the Cambodian National
Conference on Oral Health, September 1991.
Ministry of Education Youth and Sport (2007): “Child Friendly Schools”
the third component.
Ministry of Health (2004).Preventive Medicine Dept, Oral Health Office.
Ministry of Health, Cambodia (2007 a). National Program of Doctor of
Dental Surgery, Department of Human Resource Development.
Ministry of Health, Cambodia (2007 b). Report of meeting on “The Future
Direction for Fluoride Toothpaste in Cambodia”, Oral Health Office,
Preventive Medicine Department.
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Ministry of Health (2008). Preventive Medicine Dept, Oral Health Office.
Ministry of Health, Cambodia (2010, 2011 b): Minutes of Meetings on
“Fluoride Levels in Good Quality Toothpaste”.
Ministry of Health, Cambodia (2011 a). National Oral Health Survey,
2011.
Ministry of Health (2013). Preventive Medicine Dept, Oral Health Office.
Monse B, Heinrich-Weltzien R, Benzian H, Holmgren C, van PalensteinHelderman W. (2010), PUFA – An index of clinical consequences of
untreated dental caries. Community Dent Oral Epidemiol 38:77-82.
Monse B, Naliponguit E, Belizario V, Benzian H, van PalensteinHelderman W. (2010). Essential health care package for children - the
‘Fit for School’ program in the Philippines. International Dental Journal
60:85–93.
Shidara EK, McGlothlin JD, Kobayashi S. (2007). A vicious cycle in the
oral health status of schoolchildren in a primary school in rural
Cambodia. International Journal of Dental Hygiene5:165-173.
Teng O, Narksawat K, Podang J, Pacheun O. (2004). Oral health status
among 12-year-old children in primary schools participating in an oral
health preventive school program in Phnom Penh City, Cambodia, 2002.
Southeast Asian Tropical Medicine and Public Health 35:458-462.
Todd RV, Durward CS, Chot C,So PK, Im P. (1994): The dental caries
experience, oral hygiene and dietary practices of preschool children of
factory workers in Phnom Penh, Cambodia. International Journal of
Paediatric Dentistry 4: 173-178.
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CHINA
Xiangyu SUN
Yan SI
Xuenan LIU
Shuguo ZHENG
Tao XU
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
CHINA
Xiangyu SUN15
Yan SI15
Xuenan LIU15
Shuguo ZHENG15
Tao XU15
DENTAL CARIES EPIDEMIOLOGY
According to the latest data in the third national epidemiological
survey in China, the caries prevalence rate of 5 and 12 year-oldchildren, adult and senior population were 66.0%, 28.9%, 88.1% and
98.4%, respectively.
In this survey, the mean dmft value of 5-year-old children was 3.50,
and the average dt, mt and ft value was 3.39, 0.02 and 0.10,
respectively.
The mean DMFT value of 12, 35-44 and 65-74 years-old population
was 0.54, 4.51 and 14.65, separately. And the average DT, MT and
FT value was 0.48, 0.00 and 0.06 in 12-year-old group, while in 3544 year-old group this data was 1.53, 2.60 and 0.38, whereas in 6574 year-old group the datum was 3.34, 11.03 and 0.29 respectively.
Data related to Mean dmft/DMFT et al were shown in Table 1.
Currently, the fourth national oral health survey is being considered
potential in the next few years.
Department of Preventive Dentistry, Peking University School of Stomatology, Beijing 100081,
P.R.China. Email: Xiangyu Sun <allon627@163.com>, Yan Si <siyanyy@163.com>,
Xuenan Liu <lxn1968@163.com>, Shuguo Zheng <zhengsg86@gmail.com>,
Tao Xu <taoxu@bjmu.edu.cn>.
15
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Table 1: Prevalence of dental caries and the mean of caries
components by age group, the 3 rd National Oral Health
Survey, 2005
Age
Group
(year)
5
12
35-44
65-74
%
Prevalence
66.0
28.9
88.1
98.4
dmft/
DMFT
dt/DT
mt/MT
3.50
0.54
4.51
14.65
3.39
0.48
1.53
3.34
0.02
0.00
2.60
11.03
ft/FT
0.10
0.06
0.38
0.29
COMMUNITY DENTAL CARIES PREVENTION PROGRAM
The guidelines of oral health care were that “prevention is priority,
integrate of prevention and treatment” in China. The models of oral
health care were “supported by government, cooperated by specialists,
joined by the public”. Here we established the “National Teeth Love
Day”, which was a campaign program of oral health education held
annually since September 20th, 1989.
In order to promote caries prevention, we had applied comprehensive
oral health intervention program for children in central and western
regions of China in recent years. The technical methods included
fissure sealing for first molars in school-age population and topical
fluoride application for primary dentition in pre-school-age population.
By the year 2012, this program was carried out in 392 cities with the
government investment up to 137.25 million Chinese Yuan, and the
total of 4.8 million first molars in 2 million children were fissuresealed for free Some relevant data from this program were shown in
Table 2.
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Table 2: The national comprehensive oral health intervention
program in China.
Caries
preventive
methods
Fissure
sealing
Fluoride
application
Year
2008
2009
2010
2011
2012
2012
National
investment
(Chinese Yuan)
8,800,000
10,000,000
33,480,000
33,480,000
46,490,000
5,000,000
Number of
cities
involved
80
112
267
297
392
72
Number of
teeth
projected
528,000
586,000
1,860,000
1,860,000
2,305,000
200,000
children
Furthermore, national dental health education and promotion were
developed in many areas in China, and the awareness of oral health
care habit and knowledge was increasing in most of the population.
Moreover, many people could also benefit from regular oral-health
examination.
HOME CARE
CONTROL
AND
PROFESSIONAL
CARE
FOR
DENTAL
CARIES
In China, alternative fluoride using for a diverse population had been
performed. In most of the Chinese population, toothpastes with
fluoride were used in daily oral health care individually. The 1000
ppm fluoride toothpastes were used for adults and the 500 ppm
fluoride toothpastes were used for adolescents and children.
Besides brushing with fluoride toothpaste at home, professionally
applied topical fluoride was also carried out in many kindergartens
and elementary schools by dental professionals. The same application
was also conducted after clinical procedures in many dental clinics
and hospitals in China.
CARIOLOGY EDUCATION IN DENTAL SCHOOL
There were 286 specialized hospitals of Stomatology in China by 2009.
Most of the general hospitals also had the department of stomatology,
and some traditional Chinese medical hospitals were also planning to
establish the department of Stomatology. The number of dental health
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personnel was 136,520 and there was 1 dentistry personnel per
10,000 populations in China (2000-2009), while the proportion was
only 1:25,000 in 2002.
The teaching of Cariology theory course mainly contained
microbiology and pathology of caries, while some parts of the course
were included in the teaching of oral medicine such as Endodontics,
Pediatric Dentistry and Preventive Dentistry. Clinical practice was
also done in the department of Endodontics, Pediatric Dentistry and
Preventive Dentistry.
In addition, Chinese WHOCC in preventive dentistry played a
significant role and led the responsibility to do more in the field of
prevention and oral health promotion by training of professionals in
dental public health in China.
REFERENCES
Xiaoqiu Qi, Boxue Zhang, et al. Report for the third national
epidemiological investigation in China. Beijing, People's Medical
Publishing House, 2008.
Shuguo Zheng, Yan Si, Tao Xu. Oral Health Status and Oral Health
Care Model in China.
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HONG KONG, SAR
Frankie HC SO
Joseph CY CHAN
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“Caries Control throughout Life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
HONG KONG, SAR
Frankie HC SO16
Joseph CY CHAN16
DENTAL CARIES EPIDEMIOLOGY
In the early days, dental surveys in Hong Kong were focused on
primary school children mostly due to the ease in sampling (Chan et
al., 1997; Medical and Health Department, 1960; 1962; 1980; Wong,
1968). With the standardisation and specification by the World Health
Organization, more recent dental surveys focused on the 5 and 12
year old children (Department of Health, 2002) as well as adults and
older persons (Department of Health, 2002; Lind et al., 1987; Lo and
Schwarz, 1994). Due to variations in samples and methods, direct
comparison of results may not be possible but the declining trend of
dental caries level over time can still be observed. The Department of
Health has completed another Oral Health Survey in 2011 and the
final report will be published at the end of this year.
Dental caries among children and adult age groups has been slowly
declining during the period 1968 to 2001. This may be attributed to
the increased awareness in dental care due to the establishment of
the Faculty of Dentistry in the University of Hong Kong, and the Oral
Health Education Unit (OHEU) and School Dental Care Service (SDCS)
under the Department of Health.
1.
Caries in primary dentition among 6 to 8 year old children
There was more than 50% reduction in the mean number of
primary teeth affected by caries among 6 to 8 year old children
from 1960 to 1995 as a result of the community water
fluoridation started in 1961 (Table 1). The Oral Health Survey
conducted in 2001 targeted at 5 year old children. The mean
dmft in 2001 was 2.3 (dt=2.1, mt=0.0, ft=0.2) and the
16
Department of Health, The Government of Hong Kong Special Administrative Region.
Email: Frankie HC SO <Frankie_so@dh.gov.hk>; Joseph CHAN <joseph_chan@dh.gov.hk>
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percentage of children with dmft >0 was 51%. The caries level
of 5 year old children in 2011 will be published soon but no
dramatic change is anticipated.
Table 1: Dental caries epidemiology of primary teeth of 6 to 8 year
old children in Hong Kong
Year
Percentage
with dmft >0
1960
97
1962
96
1980
77
1986 *
63
1995 *
66
* 6-year old children only
2.
dmft
9.2
8.4
5.0
3.1
3.0
dt
mt
ft
8.0
7.4
4.7
2.4
2.3
1.2
1.0
0.2
0.1
0.2
0.0
0.0
0.1
0.7
0.5
Caries in permanent dentition among 9 to 11 year old children
Table 2: Dental caries epidemiology of permanent teeth of 9 to 11
year old children in Hong Kong
Year
Percentage
with DMFT >0
1960
93
1962
90
1980
52
1986 *
54
* 11-year old children only
DMFT
DT
MT
FT
4.4
3.5
1.3
1.2
4.1
3.3
1.2
0.3
0.1
0.1
0.0
0.0
0.1
0.1
0.1
0.9
There was also more than 50% reduction in the mean number
of permanent teeth affected by caries among 9 to 11 year old
children from 1960 to 1980 (Table 2). The mean DMFT of 12
year old primary school children in 1995 was 1.0 (DT=0.2,
MT=0.0, FT=0.7) and the percentage of children with DMFT > 0
was 48%. The DMFT of this age group declined further to 0.8
(DT=0.1, MT=0.1, FT=0.6) in 2001 and further reduction is
anticipated at the Oral Health Survey conducted in 2011.
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3.
Caries in 35 to 44 year old adults
Table 3: Dental caries epidemiology of permanent teeth of 35 to 44
year old children in Hong Kong
Year
Percentage
DMFT
DT
with DMFT >0
1984 *
90
7.3
1.0
1991
98
8.7
1.0
2001
98
7.4
0.7
* used a different diagnostic criteria for MT
MT
FT
2.7
4.5
3.9
3.5
3.2
2.8
Table 3 should be interpreted with caution as the diagnostic
criteria for missing teeth was different in the dental survey
conducted in 1984. If the same method used in 1991 and 2001
was used, the prevalence of caries and the mean DMFT should
be higher and the downward trend of dental caries among the
adult population would be more obvious.
4.
Caries in 65 to 74 year old non-institutionalised older persons
Table 4: Dental caries epidemiology of permanent teeth of 65 to 74
year old children in Hong Kong
Year
1991
2001
Percentage
with DMFT >0
100
99
DMFT
DT
MT
FT
18.9
17.6
1.4
1.3
17.0
15.1
0.5
1.2
Only two representative oral health surveys on the noninstitutionalised older person group were conducted. No
dramatic change should be expected as older persons in the
same age group in 2011 were all born before the start of water
fluoridation.
COMMUNITY DENTAL CARIES PREVENTION PROGRAMME
1.
Community water fluoridation
The introduction of water fluoridation was proposed during the
early 1950s and the Hong Kong Government allocated funds for
the installation of fluoridation facilities in 1957. The domestic
water supplies in the major metropolitan areas were fluoridated
during 1961 and practically all other urban areas were
supplied with fluoridated water soon afterwards (Evans et al.,
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1987).
The fluoride concentration was originally set at 0.9 ppm during
the cooler months and at 0.7 ppm during the summer. There
was some concern that these levels were sub-optimal. The
fluoride level was increased to 1.0 ppm in May 1967 on a year
round basis. In June 1978, the fluoride level was reduced to
0.7 ppm on a year round basis in response to the emergence of
signs of dental fluorosis. With substantial decrease in the
extent and severity of dental caries in the population after 25
years of water fluoridation, the water fluoride level was further
reduced in 1988 to 0.5 ppm throughout the year.
A Water Fluoridation Monitoring Committee was set up in the
Department of Health to closely monitor the caries and
fluorosis levels after the lowering of water fluoride level. Since
its formation, the volume of water treated, the weight of
chemical applied and the average fluoride concentration in
water samples at all 19 water treatment stations were
scrutinized on a monthly basis. The caries status and level of
dental fluorosis are being monitored by representative surveys
in 1995, 2001 and 2011.
2.
School Dental Care Service (SDCS)
The SDCS is a primary dental health care programme
administered by the Department of Health for all primary
school children in Hong Kong. Children receive service at one of
our eight school dental clinics near their schools. A group of
dedicated and well-trained dental therapists provide the service
under the direct supervision of government dental officers. It
has a 24-hour interactive voice response system and homepage
(www.schooldental.gov.hk) to provide information on SDCS and
oral health care for the general public.
The objectives of the SDCS are to promote good oral hygiene
and prevent common dental diseases. The service emphasizes
on yearly dental check-up, oral health education, and
preventive dental treatment such as pit and fissure sealant.
3.
Oral Health Education Unit
OHEU promotes oral health to all sectors of the community by
producing oral health education materials and organising
publicity campaigns, and engaging in collaborative projects
with non-governmental organisations and professional bodies.
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In addition to supporting other health service units, OHEU
continues the Oral Health Promotion Programmes for
kindergarten children, primary students, secondary students
and students with mild and moderate intellectual disabilities.
There is also an ‘Oral Health information Hotline’ and a website
(www.toothclub.gov.hk) to provide information on oral health
care for the general public.
HOME CARE FOR DENTAL CARIES CONTROL
The Department of Health promotes the use of fluoride toothpaste
in daily toothbrushing for people of all ages except the very young
children who are not yet able to spit. However, the use of a
mouthrinse including fluoride mouth rinse should only be used
under the instruction of dentists.
CARIOLOGY EDUCATION IN DENTAL SCHOOL
There is only one dental school in Hong Kong under the University
of Hong Kong (HKU), which was established in 1982. Cariology has
been incorporated in the teaching of undergraduate students by
various disciplines including Paediatric Dentistry, Dental Public
Health and Operative Dentistry. There is a recent update of the
teaching of Cariology to the second year dental student (at HKU the
dental students have clinical teaching from second year onwards) by
introducing a series of lecture/presentations by experts, in addition
to the PBL tutorials, on the following topics: basics of dental caries
and the ICDAS recording system; caries risk assessment; patterns
of caries in the population; home/self-care in caries prevention; and
root caries. In addition, there are practical sessions on the following
activities: ICDAS learning program; plaque disclosure and tooth
brushing; saliva tests; and use of Cariogram.
ACKNOWLEDGEMENT
The authors are grateful to Prof Edward Lo for providing comments
and input on Cariology education in dental school.
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REFERENCES
Chan JCY, So FHC, Yu YSH (1997). Oral health survey on primary
school children in Hong Kong. Hong Kong: Department of Health.
Department of Health (2002). Oral health survey 2001. Common dental
diseases and oral health related behaviour Hong Kong: Department of
Health, Hong Kong.
Evans RW, Lo ECM, Lind OP (1987). Changes in dental health in Hong
Kong after 25 years of water fluoridation. Comm Dent Health 4:383394.
Lind OP, Holmgren CJ, Evans RW, Corbet EF, Lim LP, Davies WIR
(1987). Hong Kong survey of adult oral health. Part 1. Clinical findings.
Comm Dent Health 4:351-356.
Lo ECM, Schwarz E (1994). Tooth and root conditions in the middleaged and the elderly in Hong Kong. Community Dentistry and Oral
Epidemiology 22(5):381-385.
Medical and Health Department (1960). Report on the 1st (prefluoridation) dental survey of primary school children in Hong Kong.
Medical and Health Department (1962). Report of the 2nd fluoridation
dental survey of school children in Hong Kong.
Medical and Health Department (1980). Final report on the fluoridation
dental survey of primary school children in Hong Kong.
Wong KK (1968). Report of a dental survey in Hong Kong 1968. Hong
Kong: the Government Dental Service and the World Health
Organization.
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INDIA
Naseem SHAH
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
INDIA
Naseem SHAH17
INTRODUCTION
Dental caries is universal, affecting all regions, both sexes and all agegroups, though the prevalence and severity of disease may vary from
region to region. There are several factors that affect caries experience
of an individual, society or a nation: i) heredity (ii) structure,
morphology and alignment of teeth, iii) dietary and iv) oral hygiene
practices etc. Apart from these, the determinants of health, such as
socio-economic status, cultural and religious beliefs, water, soil and
vegetation quality, sanitation, awareness regarding health and
diseases and accessibility to health care facility. Dental caries is
therefore, to a large extent, a lifestyle related disease and preventable
to a large extent.
The dental caries activity also differs in different age-groups. Teeth,
immediately after the eruption in the oral cavity, are not fully
mineralized and the enamel is porous. As it ages in the mouth, it
acquires minerals from saliva. Hence, tooth susceptibility to caries is
more, immediately after the eruption, both in deciduous and
permanent teeth. Very young children in the age range of 2-5 years
are
affected
with
early
childhood
caries.
(ECC)
Caries
susceptibility/experience is high till the age of 12-15 years i.e. in
mixed dentition and till the completion of permanent dentition in the
mouth. Thereafter, it slows down, to again increase in 35 and above
age group and later in 60 + age group, when the prevalence of root
caries is more due to concurrent periodontal disease, gingival
recession and cervical defects caused by abrasion, erosion and
abfraction. WHO has therefore given index ages at which dental caries
should be measured. It coincides with dental caries experience at
Professor & Head, Department of Conservative Dentistry & Endodontics and Chief, Centre for
Dental Education & Research, All India Institute of Medical Sciences, New Delhi, INDIA.
Email: Naseem Shah <naseemys@gmail.com>
17
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these specified age groups and also allows comparison of data from
across the globe.
Control of dental caries, therefore, demands measures to be taken
throughout life. However, in all the countries of the world, the
maximum emphasis is to prevent caries in children. As the population
ageing is a trend observed in all the countries of the world, oral health
issues of the elderly have now gained importance and attention of
policy makers and dental professionals.
Dental caries is one of the major causes for tooth loss with various
adverse negative impacts on physical and psychological well-being of
persons. It is therefore imperative that caries preventive measures are
taken in all age groups.
EPIDEMIOLOGY OF DENTAL CARIES IN INDIA
India is a vast country of over 1.24 billion people. It has 28 states and
6 union territories. More than 72% of its population reside in rural
areas. In terms of religion, culture, languages, India shows vast
diversity. Geographically, its terrain as well as weather conditions are
vastly different from region to region.
As an emerging economic state, India faces many challenges. In the
Health Sector, the major challenges include sanitation, drinking water
infections and communicable diseases are emerging epidemic of noncommunicable diseases. Its infant and maternal mortality rates are
high in comparison to many other developing countries. Against these
challenges, India spends a meager 1.4% of its GDP on health which is
very low in comparison to developed country. In this scenario, it is
natural that Oral Health receives the least attention of the
government and attracts only a paltry budget to finance oral health,
which is mainly utilized for health care delivery and school oral health
care programme.
Systemic epidemiological studies on a vast population of India, added
to the vast diversity of its terrain and people is a gigantic task and
would require a huge budget, which in the given scenario of
government priority on other health issues, appears to be very
difficult. Isolated studies from different parts of the country, reported
on different age group of population cannot be relied on to project the
dental caries prevalence of the country. Therefore, an attempt was
made to pool-in all available studies on dental caries in the specified
age group of the Indian population as recommended by WHO and
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bring out the average figures for the prevalence of dental caries in the
country. This work was commissioned by the National Commission on
Macro-economics and Health under the Ministry of Finance and
Ministry of Health, Government of India in 2005. This is presented in
Table 1.
Table 1: Prevalence of dental caries in different age groups
Age group
(years)
5-6
12
15
30-35
60-75
Urban
Rural
67.23
57.94
55.97
46.21
79.40
Average
46.22
36.90
43.28
39.27
61.90
56.72
47.39
49.69
42.24
70.65
DMFT
2.1
1.6
1.37
1.39
Based on this data, a statistical model was prepared to predict the
burden of dental caries by 2015, which is 6231.8 lakh by 2015, if
caries prevalence in all age-groups combined is taken as 50%.
In 2007, a Government of India – WHO collaborative project was
undertaken to study the magnitude of various oral and dental
problems at seven representative Centres in India namely – Delhi,
Mumbai, Cuttack, Pondicherry, Jaipur, Lucknow and Arunachal
Pradesh. The proper sampling methodology was used and sample size
was calculated. Four index age groups, as recommended by WHO (12,
15, 35-44 and 65-74 yrs age groups) equally distributed in urban and
rural areas were selected. (n=3200/Centre, Total=22,400). Modified
Oral Health Survey Proforma 2004 and Modified Questionnaires on
Oral Health for children and adult population (WHO) were used. The
data thus generated was arranged and analyzed for prevalence of oral
diseases and oral health attitude, practices and behavior. Though the
data was specific for each state and there were wide variations
between the dental caries prevalence between different states and
they could not be pooled together for statistical analysis, they were
combined and average and mean was calculated to indicate the trend
of dental caries prevalence in the country. The result of pooled data is
given below in Table 2.
Table 2: Dental caries prevalence and DMFT scores
Age
12
15
35-44
65-74
Range
23.0-71.5
24.3–83.4
48.1–86.4
51.6–95.1
Average
48.7
53.9
72.25
67.88
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DMFT
1.33
1.79
3.53
6.14
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The data from both the above review indicate similar trends, except
for 35-44 year age group. A very wide variation was found for average
prevalence of dental caries as well as DMFT score of 35-44 year age
group in these two analyses, which is difficult to explain.
COMMUNITY DENTAL CARIES PREVENTION PROGRAM
1.
Fluoride administration in the country
Fluoride as a trace element is established for its caries
preventive effect since 1930s. There are many success stories
of fluoridation of drinking water with fluoride supplement to
bring it to an optimal level of 1 ppm, ranging from 0.7-1.1.
However, India has endemic zones of high fluoride, spread over
220 districts of the total 609 districts. It is estimated that high
fluoride level affects approximately 6% of the population.
Therefore, there is strong opposition to use of systemic fluoride
in the country. Also, there are several other reasons for not
adopting fluoridation programme in the country as follows.
As mentioned earlier, over 70% of the population resides in
rural India, where pipe water supply is not available. Even
among the urban area, it is not uniformly available. In the
absence of such supply, it is not possible to fluoridate the
water supply. Fluoridation of water supply is considered a
violation of ethics as it is construed as forced medication,
without the consent of the consumer. Though other form of
systemic administration of fluoride such as fluoride tablets,
drops, milk and salt fluoridation are available, these also meet
with stiff resistance, besides involving cost and other logistic
issues.
2.
Community oral health program for caries prevention in
children and in elderly
India has a very strong, wide-reaching network of public health
delivery system. From the village level upwards, it has subcenters, PHCs, CHCs, sub-district and district level hospitals.
There are more than 320 medical colleges and 294 Dental
colleges for tertiary care provision. Moreover, in the recent past,
a large number of private, corporate hospitals have been
started which provide world-class tertiary care not only to
Indians but also attract foreign nations (medical tourism).
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In 1999, the GOI launched a pilot project on “National Oral
Health Care Programme” for which, All India Institute of
Medical Sciences at Delhi was made the Nodal agency. The
programme aimed to create oral health awareness through
development of IEC materials, training of the trainers and
dissemination till the grass-root level, utilizing the existing
health manpower of the public health delivery network as
outlined above. The programme was conducted successfully in
12 states of the country for 6 years.
In 2005, the GOI launched National Rural Health Mission
(NRHM) with the aim of providing basic health care to all,
especially to the rural masses and to improve the reach,
integrate various system of medicine. The oral health
programme was merged with NRHM. For this, literate women
from the community, after training was made ASHA (accredited
social health activist) for door-to-door health care surveillance
and carrying health information and awareness generation.
These ASHAs report to male and female health care workers
and health guides, which in turn report to PHCs, (which is the
first contact point with a medical doctor). These trained
workforces carry health promotive and disease preventive
messages to the community, including oral health messages,
i.e. oral hygiene maintenance and ill-effects of tobacco and
alcohol consumption etc.
Under school health programme, there is an oral health
component. The school dental health programme runs in major
cities and at district level; however, at village level, it has
almost no presence, where over 70% of the population reside.
The major effort towards community health programme for
children and elderly in recent years can be attributed to the
department of Public Health Dentistry in over 290 dental
schools across the country. As a mandatory requirement for
training, both graduate and postgraduate students in the
Public Health subject, each dental school must have a mobile
dental van which has to go to the community in remote, underserved areas and conduct dental camps and provide services to
the population at their doorstep. Many dental schools in semiurban areas adopt 2-5 villages and provide oral care on a
regular basis. Another initiative by the DCI which will have an
impact on community dental and oral health is mandatory 3
months’ rural posting during the internship of graduate
students.
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In addition to the above, few individual efforts from different
parts of the country towards the provision of oral health care
are reported from time to time. Few of these are listed below:
3.
Indian Dental Association:
A professional National body of registered Dentists conducts
various oral health activities at regional, state and national
level. IDA represents more than 50,000 dental professionals
and has 30 state and 350 local branches. It collaborates with
multinational companies to conduct various oral health care
related activities, such as create awareness regarding oral
health and hygiene maintenance. It also runs a Rural Oral
Health programme through mobile dental vans to provide free
oral health care services to rural populations and to train
primary health care workers. October month every year is
observed as Oral Health month, during which rallies, folk
dances, exhibitions, smile contest, free dental checkups etc.
are conducted through a vast network of volunteer dental
surgeons.
Its school health programme, which it conducts in
collaboration with Colgate is very popular. In this, IDA
conducts free dental checks, distributes free toothpaste and
toothbrush and educational leaflets on oral health among
school children between 9-14 years of age. It also conducts
training programme on oral health for teachers and parents.
4.
Aurovillae Oral Health Project:
This project has been in operation since 1996. It runs a dental
clinic at the health centre located in Aurovillae, which is a local
community residing at Pudducherry in South India. It runs
outreach services in 10 sub-centres, where oral health
education and ART for treatment and prevention of dental
caries are being provided to local school children with minimal
equipment. The manpower for this is women selected from the
local community, who are trained for 3 weeks in caries
diagnosis and technique of ART. It is a unique and very
effective community-based programme for control of dental
caries.
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5.
Chitrakut Health Project:
It is a charity project aimed at providing health care services to
the under-privileged population. It is located at the border of
MP and UP, where the socio-economic condition of its
population is very low and health care facility is almost nonexistent. There are around 500 villages to which this project
caters to. Volunteers for this project include University
Professors, NHS Consultants, Harley Street Practitioners and
Royal College of Surgeons Tutors. Various services are provided,
including cleft lip and palate surgery. It also provides treatment
for dental caries at the health centre as well as through mobile
vans.
HOME CARE FOR DENTAL CARIES CONTROL
In urban India, the usage of toothpaste and toothbrush is the most
common practice of oral hygiene. However, brushing twice /day is less
common than once/day. However, even in urban areas, use of
indigenous methods of oral hygiene, such as tooth-powder, use of
bark of various trees, tobacco, charcoal etc. are also observed in
about 20% of the population. In rural area, where >72% of the
population reside, use of toothpaste and a toothbrush is much lower
than in rural areas, though the trend is now changing with increasing
awareness through radio and television. Almost 50% of rural
population use toothpaste and brush.
The use of toothpaste consumption in India was calculated and
compared with the developed world. It was found that use of
toothpaste/person/year in India was just 190 gms, whereas in
developed countries such as USA and other European countries, the
toothpaste usage was 375 gms/person/year.
CARIOLOGY EDUCATION IN DENTAL SCHOOLS
India has 294 Dental Schools, the highest in the world. Of these, only
35 are government-run, rest all are run by private players. Most of
these dental schools have 100 annual admissions; making a total of
more than 25,000 admissions/year. Of these, over 150 dental schools
run postgraduate MDS degree programme of 3 years’ duration in all
or multiple disciplines of dentistry, making over 1500 seats available
in a Postgraduate (PG) degree programme. The Government of India
estimates that dental manpower, including specialists, needs to be
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increased, to improve the dentist: population ratio in the country, to
provide oral health care to its people, especially in rural areas. Hence
in the past 5 years, PG seats have been increased exponentially in
various institutions, mostly in the private sector (which suits their
commercial interest).
There is no separate department of Cariology in the country. Cariology
is taught under the discipline of Oral Pathology, Oral Medicine and
Radiology, Pediatric and Preventive Dentistry and Public Health
Dentistry but most importantly, under the discipline of Conservative
Dentistry and Endodontics. Pediatric Dentistry and Conservative
Dentistry provide comprehensive promotive, preventive and curative
treatment for dental caries and its sequelae in clinical settings, while
the discipline of Public Health Dentistry provides services using the
community approach for dental caries prevention and control at the
community level. Oral health promotion and prevention of dental
caries measures, which can be instituted at both clinical and
community level include i) Health education, including diet counseling
and use of fluoridated toothpaste and correct method and frequency
of tooth brushing, flossing, inter-dental brushing, use of mouth
washes etc. ii) topical application of fluoride or chlorhexidine varnish
or silver diamine fluoride, iii) pit and fissure sealing and vi)
Atraumatic Restoration Treatment (ART).
CONCLUSIONS
Tooth loss and dental caries related pain, loss of productive man-days
and other morbidities are high in India. Due to the size of the
population, in actual number, the treatment needs for dental caries is
enormous and not practical to meet. The total budget allocation for
health is meager and for oral health it is only a fraction of the total
health budget. There is as yet no oral health policy adopted by the
government of India. There is no policy for systemic use of fluoride; in
fact, there are several misconceptions and opposition to use of
fluoride in the country.
Improved socio-economic status in urban India with expendable
income has led to increased consumption of junk foods, sweets, colas
etc., increasing the caries susceptibility. On the other hand, people in
lower socio-economic status and lower literacy level, due to low
awareness regarding oral health and health care facilities also suffer
from increased caries susceptibility. Use of toothpaste and toothbrush
in rural area is low as compared to urban areas. For people with low
income, toothpaste and toothbrush is not affordable as these
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products are categorized under cosmetic products and hence levied
higher tax.
As health is a state subject, each state makes its own policies and
programmes and hence there is a lack of uniformity. There are no
well-planned systematic, community-based programmes for dental
caries prevention and early intervention.
In view of all above, there is an urgent need to adopt and integrate
national oral health policy into the Health policy of India. All-out effort
needs to made to curtail the burden of dental caries in all age-groups
to prevent the morbidity and tooth loss and improve the productivity
and QOL of people.
REFERENCES
Report of the Steering Committee on Health for 12 th Five-year Plan.
Health Division, Planning Commission, February, 2012
Shah N. Oral and Dental Diseases: Causes, prevention and treatment
strategies. In Burden of Disease in India. National Commission on
Macroeconomics and Health, Ministry of Health & Family Welfare &
Ministry of Finance, Government of India, 2005
Shah N, Pandey RM, Duggal R, Mathur VP and Rajan K. “Oral Health in
India: a report of the multicentre study” Directorate General of Health
Services, Ministry of Health & Family Welfare. Govt. of India & World
Health Organization Collaborative Program Dec. 2007.
Toothpaste Industry: An Overview.
http://www.allprojectreports.com/MBA-Projects/Marketing-ProjectReport/consumer-buying-behaviour-toothpaste-brands/toothpasteindustry-in-india-an-overview.htm (accessed on 23-09-2013)
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INDONESIA
Dewi Kartini SARI
ZAURA Kiswarina Anggraeni
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
The Upstream and Downstream Perspectives
of Caries Control Efforts in INDONESIA
Dewi Kartini SARI18
ZAURA Kiswarina Anggraeni19
INTRODUCTION
The success of the caries intervention in a country depends very
much on the upstream efforts beginning of the understanding of the
science of Cariology and the technology of caries treatment, as well as
the downstream efforts being the clinical and community preventive
and curative programs for individuals and the community at large.
This paper discusses the above mentioned topic in a systematic
presentation of the profile of the caries problem in Indonesia, the
profile of Dental Schools, the distribution of dental graduates, the
teaching and learning process of Cariology, as well as an overview of
dental caries prevention program in Indonesia.
THE PROFILE OF CARIES PROBLEM IN INDONESIA
Being the 1th most experience health problems suffered by the
Indonesian community, oral health problem has also become a major
health burden globally. Since 1995, national dental researches were
done periodically every 5 years by the National Oral Health Research
Center. Data of the latest national survey year 2013 as a part of a
comprehensive National Basic Health Research (NBHR), are still in the
process of analysis. Therefore, the data presented in this paper were
taken from the year 2007 National Basic Research (NBHR, 2007). The
DMF-T score by age group is shown on Table 1.
The average national score of DMFT for all age groups is 5.42;
comprising of score of Decay index 1.24; Missing index 4.1; Filled
Ministry of Health, Republic of Indonesia. Email: Dewi Kartini Sari <sariaswin@yahoo.com>
Indonesia Dental Association. Professor, Faculty of Dentistry, University of Indonesia.
Email: Zaura Rini Anggraeni <rinizaura@yahoo.com>
18
19
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index was 0.08. However, the profile of DMF-T index score by age
groups can be seen in the following Tables.
Table 1: DMFT by age groups, Indonesia, 2007
Age group
D
M
F
DMFT
12
0.56
0.32
0.01
0.88
15
0.75
1.23
0.02
2.00
35-44
1.45
2.82
0.08
4.35
65+
1.22
17.05
0.15
18.42
(WHO)/years
DMFT score for the in 12 years old group was found to be less than 1
DMF-T was perceived as an underestimation due to the clinical
competence of the survey examiner being non-dental manpower. The
D was recorded as obvious decayed teeth.
Further data were collected as active caries (untreated caries) and
caries history (treated/filled teeth or extracted tooth due to caries
(Table 2).
Active Caries and Experience Caries Prevalence
Table 2: Prevalence of active caries and caries experience by age
groups, Indonesia, 2007
Age group
Active caries
Caries experience
(WHO)/years
(%)
(%)
12
29.3
36.0
15
36.5
62.1
18
41.9
53.0
35-44
54.3
81.4
65+
34.2
95.7
Reference: Kristanti ChM, Hapsari D, Sintawati FX, Jovina TA
(2012); Mapping on Oral Health Status in Indonesia – Ministry of
Health of Republic of Indonesia
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COMMUNITY DENTAL CARIES PREVENTION PROGRAM
1.
Community fluoride administration in the country
Indonesia has a diversity geographic condition, although
Indonesia has many volcanoes, Kalimantan (Borneo) has none.
A research done in late 80’s on fluoride content in Indonesia,
few areas in Borneo have zero fluoride content in water. In
early 2000’s South Kalimantan government establish a water
fluoridation program, but it has to stop due to the lack of
budgeting.
The most effective fluoride administration in Indonesia is daily
tooth brushing using fluoride containing toothpaste. Ministry
of Health Republic of Indonesia has adopted Basic Package of
Oral Care to a national guidance of oral health services in
Primary Health, one of the obligatory statements is affordable
fluoride toothpaste.
2.
Community oral health program for caries prevention in children
Daily toothbrushing using fluoride toothpaste and fissure
sealant in school is amongst the main activities of School
Dental Health Program. Since (year) West Java Province is the
first pilot project of Fit For School which one of the program is
daily tooth brushing in school. On September 2013, SD 3
Legian in Bali became one of the schools visited by delegates
from 21 countries that attended Asian Conference of Oral
Health Promotion for School Children.
3.
In elderly the prevention program are screening and guidance to
brushing properly.
HOME CARE FOR DENTAL CARIES CONTROL
Fluoride toothpaste used, percentage, formula, how to use
effectively
More than 90% of toothpaste in Indonesia’s market contained
fluoride, the fluoride content is varied between 1,000 to 1,600
ppm and free Fluoride range between 338 to 995 ppm. Ministry
of Health Republic of Indonesia and other stake holder
(toothpaste company) continues to campaign daily tooth
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brushing twice a day for two minutes, after breakfast and
before bedtime.
CARIOLOGY EDUCATION IN DENTAL SCHOOL
Dental School in Indonesia
Sulawesi, 3
Kalimantan,
1
Bali, 1
16
14
12
10
8
6
4
2
0
Sumatera, 6
Java, 16
7
3
9
3
2
1
1
Sumatera
Java
Kalimantan
Faculty of Dentistry
1
Sulawesi
Bali
Dental Study Program
Figure 1: Data Distribution of Faculty of Dentistry and Dental
Study Program in Indonesia
Until today Indonesia own 15 universities with faculty of dentistry as
well as 12 Dental Study Program (source: Indonesian Dental
Collegian)
DATA DISTRIBUTION OF
DENTIST
NAD :
149 drg
Dentist ratio ± 1 : 12.000 penduduk
SUMUT :
1.226 drg
Riau :
371 drg
Kepri :
106 drg
SUMBAR :
481 drg Jambi :
132 drg BABEL :
51 drg
Bengkulu :
64 drg
SUMSEL :
215 drg
Lampung :
234 drg
Banten :
971 drg
13 FKG
13 Prodi KG
Kaltim :
310 drg
Kalbar :
142 drg
Kalteng :
66 drg
DKI :
4.420 drg Jateng :
Jabar :
3.179 drg
Yogyakarta:
789 drg
Malut :
20 drg
Papua Barat :
20 drg
Sulbar :
24 drg
Kalsel :
143 drg
1.321
drg
Sulut :
76 drg
Gorontalo:
25 drg
Bali :
597 drg
Sultra :
71 drg
Sulsel :
976 drg
NTB :
127 drg
Jatim :
3.225 drg
Dentist ratio = 8 : 100.000 people
TARGET 2010 = 11 : 100.000 (MOH RI)
Maluku :
34 drg
Papua :
79 drg
Sulteng :
63 drg
NTT :
87 drg
Dentist Total : 22.941
(Data KKI Sept 2012)
(Sumber : DIV REG KKG-KKI, 2010)
DR.Laksmi Dwiati, drg. MM, MHA
Figure 2: Data Distribution of Dentist
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The disparity of distribution is significantly contributed by uneven of
dental school by region in Indonesia that condition has an impact to
unequal availability of dental service and dental care in the country.
Therefore caries as major oral health problem together with
periodontal disease was not to able optimal control.
On the other side in the context of the upstream profile of dental
education, especially the topic of caries and the dental aspect of caries
has not fully standardize within the curriculum. Related to condition,
the Indonesian Dental Association through collegian dentistry is
making is the process of stabilization in as curriculum of dental
education in Indonesia. In the area downstream Indonesia Dental
Association have a responsibility to carry out competency examination
that is compulsory for all dental graduates from all dental school in
Indonesia as a mechanism to obtain standardize quality of dentist
from every dental school. This role and function is mandatory by law
under the dental act of the Republic of Indonesia under the Medical
Practice Act No. 29 year 2004 the ultimate goal is to give quality
insurance of dental graduate of lifelong quality control for every
dentist who practice in Indonesia. The teaching and learning
Cariology should the standardize.
Caries management education in Indonesia is given in various
departments, not specified in a single department as Cariology
department. Teaching material limitations of each department to
some extent influenced by the level of therapy based on the formation
and development of caries severity. As an illustration, when viewed by
age, related teaching materials in primary teeth given in Pedodontia
Department while the permanent teeth are given in the department of
Conservation. Meanwhile society preventive and promotive approach
were given more focus in public health departments, although
individual approach given in the Conservation Department.
Clinical practice with Cariology teaching material covering the stages
of caries diagnosis, treatment planning for hard and soft tissue of
dental and periapical tissues, as well as the management of the
reference made in the Conservation Department.
Competency Base Curriculum was done by using the tutorial where a
thorough and comprehensive examination conducted by each student
for each patient under faculty lecturer supervision and assessment.
The examination results are discussed in the teaching groups.
Improving skills through clinical practice given in each laboratory
department. These could be either graduate education levels or
professions, and also specific caries management teaching material
given in specialist levels at the Department of Conservation. In the
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Base Curriculum Competency assessment it is done in terms of
cognitive, affective and psychomotor.
Promotion and prevention in individual and society oral health
improvement done through Public Health teaching in the classroom
as well as direct practice on the field. Content of public health
teaching includes health-related knowledge and demography, practice
management, individual and community approaches, ethics, and so
forth. More specific clinical material provided through program
specialist in the department of Conservation. In Department of
conservation there are three subspecialist or specialist consultant
such as Cariology, restoration and endodontic. Specialist consultant
in Cariology is awarded to those who hold a PhD in Cariology.
CONCLUSION
Active caries prevalence shows that the estimated need of total dental
treatment in Indonesia is still high. Decaying Teeth in Indonesia are
correlated with tooth extraction because of the late treatment.
The uneven distribution of dentist is among one of the causes of
incapability of handling early detection of caries. This is also caused
by limited dental health appliances and dental material as Indonesia
is an archipelago country which accessibility to dental health sources
is limited in the remote regions.
One of the easiest ways to control caries, easy to distribute, affordable
and accessible is to utilize fluoride toothpaste. Empowerment of tooth
brushing habit as a fluoridation program in a community with a
program target is for children since their earliest age.
REFERENCES
Benzian H, Holmgren C, Buijs M, Vab Loveren C, Van der Weijden F,
Helderman, WP (2012). Total and free available fluoride in toothpastes
in Brunei, Cambodia, Laos, the Netherlands and Suriname.
International Dental Journal 62: 213-221.
Kristanti ChM, Hapsari D, Sintawati FX, Jovina TA, Mapping on Oral
Health Status in Indonesia - Ministry of Health of Republic of Indonesia,
Jakarta, 2013.
Laskmi Dwiati, Division Registration of Council of Dentistry, Jakarta
2012.
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Ministry of Health Republic of Indonesia, Basic Health Research 2007,
Jakarta, 200.
Ministry of Health Republic of Indonesia, Guidance of school dental
health program, Jakarta, 2012.
Sinthawati, Evaluation of study water fluoridation at Banjarmasin<
South Kalimantan, Center of Health Research and Development,
Jakarta, 2003.
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JAPAN
Masaki KAMBARA
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
JAPAN
Masaki KAMBARA20
DENTAL CARIES EPIDEMIOLOGY
1.
Caries free at 3, 6 and 12 years old children
Table 1: Caries free at 3, 6 and 12 years old children
Age Group
(yrs)
Year
% Caries free
2010
78.5
2011
75.0
2012
49.4
6
2011
57.9

2012
57.2
12
2011
57.9
Source:  Statistical Survey of Maternal and Child Health;

Report on the Survey of Dental Diseases (2011)
3
2.
dmft at 3, 6(5) years old children, with d,m,f component
breakdown
Table 2: dmft at 3, 6(5) years old children
Age
Group
(yrs)
Year
dmft
dt
mt
2010
0.80
2011
0.63
0.63
0
5
2011
2.77
1.53
0

6
2011
1.84
0.89
0
Source:  Statistical Survey of Maternal and Child Health;

Report on the Survey of Dental Diseases (2011)
3
ft
0
1.23
0.95
Professor, Osaka Dental University Faculty of Dentistry, Department of Preventive and
Community Dentistry. Email: Masaki Kambara <kambara@cc.osaka-dent.ac.jp>.
20
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3.
DMFT at 12, 15, 35-44, >60 years population, with D,M,F
component breakdown
Table 3: DMFT at 12, 15, 35-44, >60 years population
Age
Group
(yrs)
12
15
35-44
≥60
Source:
Year
DMFT
DT
MT
2011
1.35
0.32
0
2011
2.96
1.50
0
2011
12.28
0.95
0.64
2011
17.91
1.03
10.4

Report on the Survey of Dental Diseases (2011)
FT
1.03
1.46
10.68
9.50
COMMUNITY DENTAL CARIES PREVENTION PROGRAM
1.
Community fluoride administration in the country
by Ministry of Health, Labour and Welfare
2.
Community oral health program for caries prevention in children,
in elderly
In children: annual oral examination by the law of school health
In elderly: oral examination by the law of health promotion and
oral health
Success story of the community caries prevention in the country
3.
Oral health system through life
HOME CARE FOR DENTAL CARIES CONTROL
1.
Fluoride toothpaste used, percentage, formula, how to use
effectively
Fluoride toothpaste is used over 95% in Japanese market.
Several types of formula are there. Any usage of tooth paste is
available.
2.
Fluoride mouth-rinse used, children or school, adult or elderly,
how to use
Fluoride mouth wash is used in many elementary schools.
DMFT at 12 years of age in the prefecture with F mouth wash
school showed a quarter compared to prefecture without F
mouthwash. There is big inequality. There are two types of F
mouth wash daily and once per week.
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3.
Any other home care dental caries control in children, adult
and elderly
Use of Fluoridated dentifrice in the house is available in all
generations. Times of brushing per day increase from one to
two or three, therefor it increase the contact to fluoride with
dentifrice.
CARIOLOGY EDUCATION IN DENTAL SCHOOL
1.
Number of dental schools in the country
There are 29 dental schools in the country.
2.
Cariology department in dental school
There is Cariology Deparmtent in dental school.
3.
Cariology teaching and learning
Cardiology teaching is in the following department: Preventive
and Community Dentistry, Operative Dentistry, Biochemistry,
Bacteriology and Biomaterials
4.
Cariology contents
These are history of cariology, epidemiology, cause of dental
caries, the risk factor of dental caries, prevention, fluoride,
preventive treatment, instruction of oral health, index,
brushing, dentifrice, preventive methods by generation, oral
examination, strategy for caries prevention in public health,
oral health system through life
5.
Cariology in clinical practice
Cariology practice is in the Operative Department.
6.
Speciality or specialist in Cariology
Authorization by Japanese Society for Oral Health and
Japanese Society of Conservative Dentistry.
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REFERENCES(Japanese)
Statistical Survey of Maternal and Child Health, Ministry of Health,
Labour and welfare. http://www.mhlw.go.jp/stf/shingi/
2r9852000001oujo-att/2r9852000001oumv.pdf
Report on the survey of dental diseases (2011), Japanese Society for
Oral Health. http://www.mhlw.go.jp/toukei/list/dl/62-23-02.pdf
Statistical Survey of School Health (2012), Ministry of Education,
Culture, Sports, Science and Technology.http://www.e-stat.go.jp/
SG1/estat/List.do?bid=000001046936&cycode=0
National health and nutrition survey 2009, Ministry of Health, Labour
and Welfare. http://www.mhlw.go.jp/bunya/kenkou/eiyou/dl/ h21houkoku-01.pdf
Statistical Survey of School Health (2012), Ministry of Education,
Culture, Sports, Science and Technology.
http://www.estat.go.jp/SG1/estat/List.do?bid=000001046937&cycode=0
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KOREA
Deok-Young PARK
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
KOREA
Deok-Young PARK21
DENTAL CARIES EPIDEMIOLOGY
1.
2
Source of National Data: The national data is comprised of two
surveys.
a.
National Oral Health Survey (NOHS)
This survey is being done in every 3 years under the
legislative support by “Oral Health Act”. This was started
from 2000. Until now, there have been 5 surveys (2000,
2003, 2006, 2010, 2012). This survey mainly focuses on
surveying children’s oral health status. The sampling frame
is a school (primary, middle, high) and kindergarten-based.
b.
Korean National Health and Nutrition Examination Survey
(KNHANES)
This survey is conducted every year under the legislative
support by “National Health Promotion Act”. The three-year
result is grouped as 1 period. Oral Examination was
included from year 2007. Sampling is based on a household.
Four trailers with the dental unit chair are moving to
sampled town in every week. About 200 towns are sampled
in a year.
Caries free rate of Korean children
Although dft index of-5 year-olds is decreasing, rate of 5-yearolds who never experienced caries, is showing a somewhat
static trend recently. This implies there are needs to develop an
oral health program for children aged 5 years or under. Until
now, the main focus of an oral health program for caries
Professor, Department of Preventive and Public Health Dentistry, College of Dentistry,
Gangneung-Wonju National University, Korea. Email: Deok-Young Park <jguitar@gwnu.ac.kr>
21
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prevention is on primary schools. Compared to deciduous teeth,
rate of caries-free 12-year-olds is increasing continuously.
Table 1: The percentage of caries-free 5-year-olds in Korea, 20002012.
Year
Total
Boys
Girls
2000
16.71
17.46
15.86
2003
22.70
22.41
23.00
2006
32.30
29.70
35.50
2010
38.47
36.52
40.57
2012
37.78
36.48
39.14
Source: National Oral Health Survey 2000-2012
Table 2: The rate of caries-free 12-year-olds in Korea, 2000-2012.
Year
Total
Boys
Girls
2000
22.86
25.29
20.19
2003
24.12
30.00
18.18
2006
38.90
43.10
34.20
2010
39.53
44.22
34.22
2012
42.67
46.53
38.44
Source: National Oral Health Survey 2000-2012
3
dft index of Korean children
Table 3: Mean (SE) of dt, ft and dft index of 5 year-olds children in
Korea, 2000-2012.
dt
ft
dft
Year
N
2000
202
2.57
2.91
5.48
2003
599
1.57
2.55
4.12
2006
151
0.89
0.11
1.95
0.16
2.85
0.20
2010
6,255
1.13
0.04
1.86
0.05
2.99
0.06
2012
4,800
0.97
0.08
1.83
0.08
2.79
0.09
Mean
SE
Mean
SE
Source: National Oral Health Survey 2000-2012
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SE
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Caries experience of deciduous teeth is decreasing, but the
slope of decreasing is getting somewhat flattened recently. A
birth rate of Korea is decreasing continuously, and caregivers
are giving more attention and concern to their children’s overall
health. Access to dental care is getting better and better by
increased number of dentists and dental clinics. Market share
of fluoride toothpaste went up over 90% in middle 1990s, and
popular toothpastes didn’t contain fluoride before then.
Because oral health program related to caries prevention of
deciduous teeth is not that prominent compared to that of
permanent teeth, those factors may have taken important roles
in reduction of dft index.
4
DMFT index of Korean
Table 4: Mean (SE) of DT, MT, FT and DMFT index of 12 yearolds in Korea, 2000-2012.
Year
N
DT
MT
FT
DMFT
2000
1,203
1.01
0.03
2.26
3.30
2003
597
1.53
0.02
1.72
3.25
2006
1,755
0.58
(0.10)
0.01
(0.01)
1.58
(0.15)
2.17
(0.17)
2010
6,251
0.43
(0.03)
0.01
1.64
(0.05)
2.08
(0.06)
2012
5,222
0.21
(0.02)
0
1.63
(0.08)
1.84
(0.08)
Source: National Oral Health Survey 2000-2012
Table 5: Mean (SE) of DT, MT, FT and DMFT index at 35-44 yearolds in Korea, 2000-2012.
Year
N
DT
MT
FT
DMFT
2007
589
0.96
(0.09)
0.86
(0.08)
3.72
(0.18)
5.52
(0.19)
2011
1,190
0.68
(0.06)
0.77
(0.06)
4.03
(0.15)
5.45
(0.15)
Source: Korean National Health and Nutrition Examination Survey
(yearly)
Dental caries of the permanent teeth has been reduced
dramatically during the last decade. DMFT index of 12-year-
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olds was reduced its value more than 1.0 during 2000 to 2010.
Compared to 2000, DMFT index in 2012 is reduced more than
40%. Compared to 12-year-olds, DMFT index of adults is not
showing significant reduction. This implies school-based oral
health programs for children were effective, and reduction of
DMFT index for adults would take significant time unless oral
health programs for them are developed.
Table 6: Mean (SE) of DT, MT, FT and DMFT index at >60 yearolds in Korea, 2000-2012.
Year
N
DT
MT
FT
DMFT
2007
937
0.84
(0.06)
5.82
(0.39)
1.79
(0.11)
8.43
(0.37)
0.66
5.82
2.19
8.66
(0.05)
(0.31)
(0.10)
(0.30)
Source: Korean National Health and Nutrition Examination Survey
(yearly)
2011
2,067
COMMUNITY DENTAL CARIES PREVENTION PROGRAM
1.
Community fluoride administration in the country
Community water fluoridation started in the year 1984 as a
pilot program. It was suggested by professionals in preventive
dentistry field and was driven by government level. However,
this pilot program was not expanded for 10 years. In year 1994,
one city was fluoridated by a citizen’s petition.
In late 1997, Department of Oral Health was founded in the
Ministry of Health and Welfare. According to this
administrative achievement, ‘Oral Health Act’ was legislated,
and water fluoridation with various oral health programs was
promoted.
After middle of 2000s, anti-fluoridation activists’ activities were
strengthened and water fluoridation went into static phase.
Administrative system changed from centralism to the local
autonomous system from 1990s, and the central government’s
will to promote water fluoridation became more difficult to be
accepted from local government.
Also, Department of Oral Health was merged with another
department and lost its independent function in late 2000s,
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and this makes expansion of the water fluoridation program
more difficult.
Table 8: Water fluoridation in Korea
Area
number
(N)
Water
purification
Plant
(N)
1984
1
1
120,000
0.3
1985
2
3
310,000
0.8
1994
2
3
260,000
0.6
1995
2
3
260,000
0.6
1996
4
5
520,000
1.1
1997
9
11
1,380,000
3.0
1998
13
18
2,990,000
6.5
1999
26
30
3,380,000
7.3
2000
30
35
3,660,000
7.8
2001
31
36
4,430,000
9.4
2002
32
36
4,250,000
8.9
2003
30
34
3,840,000
8.0
2004
24
27
2,810,000
5.8
2005
22
25
2,780,000
5.6
2006
21
24
2,770,000
5.6
2007
19
23
2,290,000
4.4
2008
21
26
2,970,000
6.9
2009
21
26
3,090,000
6.3
2010
20
25
3,080,000
6.3
2011
23
25
3,080,000
6.3
2012
22
24
3,220,000
6.4
Year
Benefited Population
(N)
(%)
Source: Report from Korea Health Promotion Foundation
2.
Community oral health program for caries prevention in childre
n and elderly
Community oral health programs are being done by
Community Health Centers. Oral health programs are more
actively implemented in rural areas because there are more
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dental hygienists or public dental health practitioners
compared to urban areas. The list of programs is as follows.
•
Oral health education program in schools
- Mainly for primary school students
•
School-based Fluoride mouth rinsing program
•
•
-
The 1st and 2nd graders of primary schools in the area
where water fluoridation is not being implemented.
-
One time/day with 0.05% Sodium fluoride solution or
one time/week with 0.2% Sodium fluoride solution.
-
Sodium fluoride powder is stored by dental hygienists
working in community health center and delivered to
schools. Fluoride solution is distributed by a nurseteacher in a school for students.
Fluoride Topical Application program
-
For children aged 15 or younger.
-
Priority of benefit is given to children in poor family, with
high caries risk, and who have multiple caries lesions
-
Fluoride gel or varnish is used
Pit and Fissure Sealing program for children in poor
families
-
•
•
•
Pit and fissure sealing for permanent 1 st and 2nd molars
are covered by National Health Insurance with some outof-pocket money. But, children in poor family have the
benefit of this program for free.
School oral health care center program for primary schools
-
The dental unit chair is installed in primary schools and
various oral health programs are being done in this
facility.
-
There are 468 schools with this facility in 2012.
School oral health care center program in schools for
handicapped students
-
The dental unit chair is installed and oral examination,
fluoride topical application, pit and fissure sealing, and
extraction of deciduous teeth is being provided.
-
There are 51 schools with this facility in 2012.
School tooth brushing facility installation program
-
Facility with washbasin, water and sewage, mirror is
installed in primary schools to promote tooth brushing
after lunch
-
There are 61 primary schools with this facility in 2012.
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•
•
3.
Oral examination program for primary school students
-
Students are required to visit the nearby dental clinic
and get examination periodically.
-
Examination fee for some designated ages is paid by
National Health Insurance, and others are paid by the
schools.
Fluoride Topical application and scaling program for elderly
-
For the aged 65 or older
-
Priority of benefit is given to poor persons
Success story of the community caries prevention
Dental caries of 12-year-olds has been decreased more than 40%
during the past decade like as shown in the following graph.
6
4
DMFT12
dft5
2
0
2000
2003
2006
2010
2012
Figure 1: Reduction trend of dental caries in Korea
4.
What made this caries reduction possible?
Decreased birth rate and increased concern and care for
children with their caregivers may be possible reasons for this
phenomenon. Increased access to dental care by increased
number of dentists and dental clinics also may be a possible
reason. However, it is unreasonable to think that these reasons
are main causes regarding the magnitude and duration of
caries reduction. Korean professionals agree that the most
important impact came from active oral health programs being
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implemented.
To understand the phenomenon, giving attention to
administrative change in Korea is needed. Department of Oral
Health in Ministry of Health and Welfare was founded in late
1990. Before then, there was no independent department
taking charge of oral health existed in government. With the
foundation of the department, coordinated efforts and
systematic evaluation of community health centers’ programs
started. Especially, strengthening reporting and evaluation
process for community health centers make them try to
maximize their output of programs.
Water fluoridation program was promoted under the direction
of the Department of Oral Health, and this may have taken
some role for the success, but the beneficiary of the
fluoridation program is still under 10% of the total population.
Thus, main reason should be found from other reasons.
School-based pit and fissure sealing program implemented by
community health center is supposed to be the most important
reason for this success. With the foundation of the Department
of Oral Health, every dental staffs in community health centers
were required to promote pit and fissure sealing program with
various oral health programs. Active implementation of schoolbased pit and fissure sealing program, especially in rural areas,
gave significant impact on increasing the rate of experience of
pit and fissure sealing. The impact in rural areas could be
proven by the result of the National Oral Health Survey.
School-based fluoride mouth rinse is the second most
important program for caries reduction. With pit and fissure
sealing program, this program was main contents of
community oral health programs implemented by health
centers. Those two wheels, pit and fissure sealing and fluoride
mouth rinsing, both were rolled simultaneously in primary
schools are leading contributors of caries reduction.
According to the evidence of the reduction of caries prevalence
and proven role of pit and fissure sealing, government included
pit and fissure sealing of permanent molars in a coverage area
of National Health Insurance since December 2009. However,
this may act as a threat for dental caries prevalence. With
inclusion into National Health Insurance, school-based pit and
fissure sealing program has to be stopped. With this policy,
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accessibility of pit and fissure sealing may be lowered because
children should visit the dental clinic instead of being treated
in their daily living school, and also students should pay some
out-of-pocket money. Impact of this change from school-based
program system to insurance coverage system should be
assessed later.
As a summary, existence of central administration and policy,
the existence of local resources (health centers and human
resources like dental hygienists and public dental health
practitioners) with powerful oral health programs like schoolbased pit and fissure sealing and school-based fluoride mouth
rinsing made caries reduction possible for the short period of
time.
HOME CARE FOR DENTAL CARIES CONTROL
1.
Fluoride toothpaste used, percentage, formula, how to use effec
tively
More than 90% of market share of toothpaste is occupied by
Korean domestic companies (LG Household and Healthcare,
Amore Pacific Corporation, Aekyung Industry, Bukwang
Pharma, Yuhan Corporation), and most of their products
contain fluoride.
Fluoride concentrations of all toothpastes are below 1,000 ppm
F by the regulation.
Toothpastes with no fluoride comprise less than 5% of total
toothpaste market share.
Fluoride
used
in
toothpastes
is
mainly
Sodium
monofluorophosphate, and some toothpastes use Sodium
fluoride.
From July of 2009, Korean Food and Drug Administration
made a regulation to mark a note of attention to the packing of
toothpastes made for children as follows.
•
Content of Fluoride in this toothpaste is OOO ppm. (Total
contents should be under 1,000 ppm)
•
When a child, aged 6 or younger, is using this paste, make
him/her use pea sized toothpaste per a time, and let him/her
use under the management of caregiver to prevent sucking or
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swallowing.
2.
•
If a child aged 6 or under swallowed considerable amount of
toothpaste, consult to the doctor or dentist immediately
•
Keep the toothpaste away from the hands of a child aged 6
or under to use.
Fluoride mouth-rinse used, children or school, adult or elderly,
how?
Ready-made fluoride mouth rinse products are on the market.
Usually, fluoride concentration of fluoride mouth rinse in the
market is 0.02% Sodium fluoride. There are many mouth rinse
products that are lack of fluoride. Companies producing mouth
rinse solution advertise their product is effective in prevention
of dental caries by antibacterial efficacy even in absence of
fluoride. It is not easy for people to know whether the product
contains fluoride or not unless they check contents printed on
the package intentionally.
Besides school-based public mouth rinsing program, private
use of mouth rinse is not that popular in Korea, and mouth
rinse solution is mainly being used by young generation with
the purpose of masking mouth odor, so far.
Status of utilization of oral hygiene products surveyed by
KNHANES in 2011 is as follows.
Table 9: Percentage of persons using oral hygiene products by age
in 2011.
Age
Mouth
rinse
Dental
Floss
Interdental
brush
Powered
Tooth
brush
12-14
1.1
0.9
1.0
3.1
15-18
4.1
3.9
0.9
1.5
19-29
8.0
12.1
4.7
2.3
30-39
7.2
21.7
10.6
5.1
40-49
5.2
13.4
11.0
5.0
50-59
2.1
6.9
12.9
3.1
60-69
1.3
4.4
8.6
1.5
>70
0.9
1.1
1.7
0.8
Source: Report of Korean National Health and Nutrition Examination
Survey 2011
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CARIOLOGY EDUCATION IN DENTAL SCHOOL
1.
Number of Dental schools
Table 7: Dental schools of Korea and number of students per year
Name of school
Seoul National University
National/
Private
National
Students
/year
90
Gangneung-Wonju National University
National
40
Chonbuk National University
National
40
Kyungpook National University
National
60
Pusan National University
National
80
Chonnam National University
National
70
Yonsei University
Private
60
Kyunghee University
Private
80
Dankook University
Private
70
Wonkwang University
Private
80
Chosun University
Private
80
There are 11 dental schools in Korea. Among them, 6 schools
are National and 5 schools are private. The number of dental
schools has not been increased since 1992. An accreditation
system for dental schools has just started recently which will
be difficult to establish a new dental school. Approximately,
there are 750 students graduate every year.
2.
Cariology department in dental school
Every dental school have the department named ‘Preventive
dentistry’ or ‘Preventive and Public Health Dentistry (a few
school use the name as ‘Social Dentistry’ also)’. These
departments play major role in Cariology education.
3.
Cariology teaching and learning
Most schools have the subject as ‘Cariology’. Sometimes it is
taught in the subject named ‘Preventive dentistry’. Contents
are etiology, histology, epidemiologic characteristics, risk
assessment, caries activity tests, methods of prevention
(Fluoride, Sealant), social approaches (Community water
fluoridation, Fluoride use, education, various oral health
programs), and so forth.
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4.
Cariology in clinical practice
Caries treatment is being taught in the Department of pediatric
dentistry, and in the Department of Operative (or Conservative)
dentistry. Oral health education in clinics, and every preventive
therapies and caries risk assessment is done in Department of
preventive dentistry (among 11 dental schools, 3 schools’
hospitals have Preventive clinic), or Department of pediatric
dentistry.
5.
Specialty or specialist in Cariology
There are overall 10 Specialists in dentistry by the law in Korea.
These are ‘Oral and maxillofacial surgery’, ‘Prosthetic dentistry’,
‘Orthodontics’, ‘Preiodontology’, ‘Operative (Conservative)
dentistry’, ‘Pediatric dentistry’, ‘Oral medicine’, ‘Oral pathology’,
‘Oral radiology’, and ‘Preventive dentistry’ As mentioned above,
in the viewpoint of treatment, caries is dealt in ‘Operative
(Conservative) dentistry’ and ‘Pediatric dentistry’. But,
epidemiology, prevention, community programs are in the area
of ‘Preventive Dentistry’.
REFERENCES
Ministry of Health and Welfare. National Oral Health Survey Report
2000. Apr. 2001.
Ministry of Health and Welfare. National Oral Health Survey Report
2003. Dec. 2003.
Ministry of Health and Welfare. National Oral Health Survey Report
2006. Aug 2007.
Ministry of Health and Welfare. National Oral Health Survey Report
2010. Sep 2010.
Ministry of Health and Welfare. National Oral Health Survey Report
2012. Mar 2013.
Ministry of Health and Welfare and Korean Centers for Disease Control
and Prevention. National Health Statistics 2007: Report of the 1st year
of KNHANES IV. Dec 2008.
Ministry of Health and Welfare and Korean Centers for Disease Control
and Prevention. National Health Statistics 2011: Report of the 2nd year
of KNHANES V. Dec 2012.
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Ministry of Health and Welfare and Korea Health Promotion Foundation.
Education material for Water Fluoridation 2012 (electronic data).
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Lao, PDR
Khamhoung PHOMMAVONGSA
Sakpaseuth SENESOMBATH
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
Lao, PDR
Khamhoung PHOMMAVONGSA22
Sakpaseuth SENESOMBATH23
DENTAL CARIES EPIDEMIOLOGY
According to the last Lao National Oral Health Survey conducted in
2010, the dental caries status of Lao people as shown in the following
tables.
1.
Caries in primary dentition among 3 to 6 year old children
Table 1: Percentage of caries free children (3, 6 year olds) and
mean number of teeth with active caries, filled and
missing.
Age
(year)
3
6
Percentage of
caries free
children
(dmft=0)
21.1
11.4
dmft
5.91
7.95
dt
mt
5.91
7.95
0
0.03
ft
0
0
President, Lao Dental Association, Chief Dental Officer, Mohosod Hospital, Vientiane, Lao
PDR. Email: Khamhoung Phommavongsa <laodentist@gmail.com>
23 Secretary General, Lao Dental Association, Dental Officer, Mohosod Hospital, Vientiane, Lao
PDR. Email: Sakpaseuth Senesombath <sakpaseuthkeo@yahoo.com>
22
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2.
Caries in permanent dentition
Table 2: Percentage of population with caries and mean number of
teeth with caries, filled and missing.
Age
(year)
12
15
35-44
60+
Percentage
with DMFT >0
72.9
79.9
76.8
85.1
DMFT
2.18
3.20
3.65
7.10
DT
MT
FT
1.50
2.06
1.97
2.80
0.05
0.14
1.25
3.99
0.63
1.00
0.43
0.22
NATIONAL/COMMUNITY DENTAL CARIES PREVENTION PROGRAM
The community fluoride administration in the country operated under
the Salt Fluoridation project since 2011. In 2014, another salt factory
will be operated.
The community oral health program for caries prevention in children
has carried on as follows.
 The activities Simplified and Modified Atraumatic Restorative
Treatment (SMART) for caries program has been provided for
two for young school children in Vientiane Capital. In 2014, the
project will expand to other two provinces.
 Prevention program in primary school children activities such
as fluoride APF GEL, Fluoride Ion Tophoresis, toothbrushing
with fluoride toothpaste.
Success story of the community caries prevention


97.2% of adult knew that tooth brushing or cleaning can
prevent the teeth from decay.
93.4 % of adult think that go to the dentist prevent from teeth
problem.
HOME CARE FOR DENTAL CARIES
Individual home care for dental caries is by tooth brushing with
fluoride toothpaste 2 times or more per day.
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CARIOLOGY EDUCATION IN DENTAL SCHOOL
There is one dental school in Lao PDR. There is no specific Cariology
education per se in the country. However, the etiology, treatment and
prevention of dental caries are taught and included in the subject of
community dentistry, restorative dentistry and pediatric dentistry.
REFERENCE
Jin BH, Paik DI, Phommavongsa K, Sensombath S, Khounsiri V,
Songpaisan Y, Phantumvanit P (2011). A Report on The 2 nd Lao PDR
National Oral Health Survey 2009.
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MALAYSIA
KHAIRIYAH Abd. Muttalib
WAN MOHD NASIR bin Wan Othman
YAW Siew Lian
Norliza Ismail
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
MALAYSIA
KHAIRIYAH Abd. Muttalib24,25
WAN MOHD NASIR bin Wan Othman26
YAW Siew Lian27
Norliza Ismail28
There is generalised caries decline in all age groups in Malaysia. Over a 10year period from 1995 to 2005, caries–free 5-year-old children increased
from 12.9% to 23.8%, with a slight decrease in dft of 5.8 to 5.5. Comparing
findings from schoolchildren surveys in 1997 and 2007, caries-free children
increased in all three age groups; 6-year-olds: 19.1% to 25.5%, 12-year-olds:
39.1% to 58.5% and 16-year-olds: 24.5% to 40.4%. The mean dft of 6-yearolds decreased from 4.1 to 3.6 while the DMFT of 12- and 16-year-olds
decreased from 1.9 to 1.1 and 3.3 to 2.1 respectively. There is also caries
decline among adults in Malaysia but this has been very slow. There has
been an overall decrease in caries prevalence from 94.6% (1990) to 88.9%
(2010). Overall mean DMFT, however, show slow decline from 13.2
(1974/75) to 11.7 in 2010.
Factors attributed to the caries decline have been the national water
fluoridation programme covering 77.7% of the Malaysian population in 2012,
the extensive coverage of children under the School Incremental Dental Care
Programme and the use of fluoridated toothpaste. In addition, this paper
discusses the political will and government support for oral health in the
country that have made possible the large oral health workforce, the
outreach delivery, the extensive network of dental facilities, the referral
system and the partners in oral health within the oral health programme of
Principal Director for Oral Health Programme, Ministry of Health, Malaysia. Email: Khairiyah
Abd. Muttalib <drkay@moh.gov.my>
25 Corresponding Author, Oral Health Division, Ministry of Health Malaysia, Level 5, Block E 10,
Parcel E, Precinct 1, 62590 Putrajaya, Malaysia. +603 8883 4229.
26 Dean, Faculty of Dentistry, Islamic Science University of Malaysia. Email: Wan Mohd Nasir
bin Wan Othman <ddwan818@yahoo.com>
27 Deputy Director and Head, Section on Oral Health Research & Epidemiology, Oral Health
Division, Ministry of Health, Malaysia. Email: Yaw Siew Lian <slyaw@moh.gov.my>
28 Senior Principal Assistant Director, Unit for Oral Health Policy, Oral Health Division, Ministry
of Health Malaysia. Email: Norliza Ismail <norlizaismail@moh.gov.my>
24
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the Ministry of Health Malaysia. In spite of these enabling factors, there is
still a continuing need to engage the public on the use of fluorides for caries
prevention and control.
INTRODUCTION
Dental caries is a preventable disease despite its multi-factorial and
complex aetiology. Globally, it remains as a public health issue and a
continuing burden despite the wide use of fluoride and other
preventive approaches in the management of the disease at both the
individual and community level. Over the last few decades, there has
been a generalised caries decline in Malaysia in all age groups,
particularly among the schoolchildren. However, the disease burden
remains substantial among the preschool children and adults. The
need to monitor disease trends continue and national oral health
surveys are conducted by the Oral Health Division, Ministry of Health
Malaysia every ten years, separately for preschool children,
schoolchildren and the adult population.
As recommended by the World Health Organisation (WHO),
epidemiological data for caries in Malaysia are collected for the index
ages of 5-6, 12, 15, 35-44 and 65-74years (WHO, 1997). The first few
surveys of schoolchildren in Malaysia included all school-going ages of
6 to 18 years. From 1988 onwards, surveys have focused on ages 6,
12 and 16. With concerns for the oral health status of very young
children, the Ministry of Health Malaysia embarked on surveys on 5year-olds in 1995 (Dental Services Division, 1995). In Malaysia, 5year-olds are captive in preschool institutions while 6-year-olds enter
First Year in primary schools. The country does not have caries data
for 3-year-olds.
DENTAL CARIES EPIDEMIOLOGY
1.
Caries in 5- and 6-year-olds
Among 5- and 6-year-olds, the rates of caries decline are slower
compared to 12- and 16-year-olds. In spite of the decline, there
are concerns for younger children who have higher caries
experience in deciduous teeth. The majority is the only captive
in preschool institutions from age 4 upwards. Hence,
population strategies in the country in the last 4 years have
increasingly focused on younger children in the community.
Two national surveys on 5-year-olds in Malaysia in 1995 and
2005 (Dental Services Division, 1995, Oral Health Division,
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2007) show a twofold increase in caries-free percentages over
the 10-year period from 12.9% (1995) to 23.8% in 2005 (Table
1). Mean dft scores declined from 5.8 (1995) to 5.5 (2005). The
‘f’ component remained low over the 10-year period, indicating
an unmet caries treatment need in relation to the high ‘d’
component.
Table 1: Dental Caries among 5- and 6-year-olds
Variables
5-year-olds
6-year-olds
1995
2005
1997
2007
12.9
23.8
19.1
25.5
Mean dft
5.8
5.5
4.1
3.6
Mean dmft
na
5.6
na
3.9
d
5.7
5.3
3.7
3.2
m
f
na
0.2
0.1
0.2
na
0.5
0.3
0.5
na
na
na
0.1
*% Caries-free
Mean DMFT
Source: Oral Health Division, 2007 and 2009
na = not available
*6-year-olds, caries-free is dmft 0 and DMFT 0
Surveys on 6-year-olds are separate. There have been two
national surveys on 6-, 12- and 16-year-olds in 1997 and 2007
(Oral Health Division 1998, Oral Health Division, 2009, Oral
Health Division, 2010a, Oral Health Division, 2010b). Earlier
surveys were conducted by regions.
For 6-year-olds, caries-free percentages (dmft=0, DMFT 0) rose
25% from 19.1% (1997) to 25.5% (2007) (Table 1). Mean dft
dropped 12% over the same period. The most recent 2007
findings still show the decayed (d) component as still the
highest at 3.2 (Table 1).
2.
Caries Status of 12 year-olds
From 1997 to 2007 (Oral Health Division, 2010a) there was a
32% increase in caries-free children among 12-year-olds (Table
2). Overall mean DMFT reduced 42% over the 10-year period.
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Table 2: Dental Caries among 12-year-olds
Variable
Caries-free
1997
39.1%
2007
58.5%
1.9
1.10
0.6
0.1
1.2
0.40
0.03
0.70
3.0
1.6
D
1.1
0.6
M
0.3
0.1
F
1.9
0.9
Mean DMFT
D
M
F
Mean DMFS
Source: Oral Health Division, 2010
The World Health Organisation classifies caries rate of 12-yearolds into five categories (Table 3). Malaysia improved from ‘low’
to ‘very low’ caries rate for 12-year-olds from 1997 to 2007.
Table 3: WHO Caries Rate Classification of 12-year-olds
Caries Rate Category
Very Low
Low
Moderate
High
Very High
Mean DMFT
<1.2
1.2 – 2.6
2.7 2.7– 4.4
4.5 – 6.5
> 6.5
Source: World Health Organisation Country Profile. Information
3.
Caries Status in 16-year-olds
In Malaysia, children aged 16 years are proxy for the WHO
index age of 15. The choice of 16-year-olds is to avoid a
national examination that 15-year-olds have to sit in.
Therefore, in the Malaysian context, 16-year-olds represent
those leaving organised dental care in schools.
From 1997 to 2007 (Oral Health Division, 2010b) caries-free
16-year-olds increased from 24.5% (1997) to 40.4% (Table 4).
The mean DMFT dropped from 3.3 to 2.1.
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Table 4: Dental Caries among 16-year-olds
Variable
Caries-free
1997
24.5%
2007
40.4%
Mean DMFT
3.3
2.1
D
M
F
Mean DMFS
D
M
F
1.1
0.3
1.9
5.9
2.2
1.3
2.4
0.8
0.1
1.2
3.5
1.3
0.6
1.6
Source: Oral Health Division, 2010
For the period 2000 to 2010, Malaysia set National Oral Health
Goals, in which the country set targets for caries for 2010
(Table 5). Findings from 1997 were used as baseline for 6-, 12and 16-year-olds. Since then, the standards for caries targets
have been raised for the newer NOHP 2011-2020 (Oral Health
Division, 2011).
Table 5: National Oral Health Plan Goals for Malaysia, 2010 and 2020
Age
group
6
12
16
6
12
16
Goal
2007
dft <2
3.6
DMFT <1.5
1.1
DMFT <2.5
2.1
% person with Caries free
30
25.5
60
58.5
40
40.4
Goals for 2020
dft ≤2
DMFT ≤1
DMFT ≤2
50
70
50
Source: Oral Health Division, 2011
Overall, for Malaysia, there has been much improvement in
caries status among children from the early days of regional
surveys begun in 1970. These improvements have been
especially marked among the 12- and the 16-year-olds.
However, in spite of caries decline, the rates of improvement
have been much slower among the younger children, leading to
policies of the Ministry of Health to focus more on prevention
activities for toddlers and preschool children.
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Seen in greater detail, there is better oral health among
children in urban areas than in rural, higher caries experience
in females in the 12 and 16 age groups, but not in younger
children, inverse association of caries experience with
Education Level and Monthly Household (HH) Income. Malaysia
is a plural society, there is interest in the community for
information
by
ethnic
group.
As
a
group,
the
Indians/Pakistanis persistently exhibited the lowest levels of
caries in Malaysia, a phenomenon yet to be explored.
4.
Caries among Adults
There have been four adult surveys in Malaysia since 1974
(Dental Division, MOH, 1977, Dental Division, MOH, 1993,
Oral Health Division, MOH 2004, Oral Health Division, 2013a).
However, national surveys only began in 1990.
There is also caries decline among adults in Malaysia but this
has been very slow. There has been an overall decrease in
caries prevalence from 94.6% (1990) to 88.9% (2010) (Table 6).
Overall mean DMFT, however, show slow decline from 13.2
(1974/75) to 11.7 in 2010.
Table 6: Caries Status in Malaysian Adults
Year of Survey
1974
1990
2000
2010
% Caries
Prevalence
95.0
94.6
90.3
88.9
Mean DMFT
13.2
12.9
11.3
11.7
Source: Oral Health Division, 2013
The highest proportions of caries-free adults are among those
aged 30 years and below, best shown graphically (Figure 1).
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15-19
20-24
25-29
30-34
35-44
45-54
55-64
65+
1974/75
11.8
6.5
2.8
3.5
3.6
1.5
2.9
1.6
1990
13.9
8.2
6.9
4.6
3.3
1.9
1.2
0.9
2000
29.5
18.1
9
5.5
3.9
3
3.7
5
2010
41
30.3
16.4
4.3
2.8
0.9
0.4
0.1
Figure 1: Prevalence of Caries-free Adults by Age Group (1975,
1990, 2000, 2010)
Mean DMFT
Again, substantial decreases in mean DMFT scores were
observed among those aged 30 years and below (Figure 2).
15-19
20-24
25-29
30-34
35-44
45-54
55-64
65+
1974
6.2
8.8
11.5
12.1
14.5
17.8
20.7
25.2
1990
4.6
6.9
9.1
10.9
12.9
15.4
20.3
22.8
2000
2.9
4.4
6.1
8.6
12.5
15.9
20.2
23.6
2010
2.3
3.1
4.8
7.8
10.7
16.2
20.8
25.4
Figure 2: Mean DMFT by Age Group (1974/75, 1990, 2000, 2010)
From the 2010 survey, the largest component was ‘M’ (8.3),
showing the magnitude of missing teeth. The ‘F’ component
was the highest in DMFT score for the youngest age group of
15-19, while ‘M’ was the highest component for the 35-44 and
65-74 age groups (Table 7).
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Table 7: Mean DMFT and Components Index Age Groups
Age Group
Mean DMFT and Components (95% CI)
D
M
F
DMFT
15-19
0.9
0.2
1.2
2.3
35-44
2.1
6.4
2.3
10.7
65-74
1.6
22.1
0.7
24.4
Source: Oral Health Division, 2013
From the caries perspective in Malaysia, there are substantial
improvements in oral health of children in schools and these
have translated into better oral health of younger adults below
the age of 30 as these children leave school into the
community. This gradual development has led the Ministry of
Health Malaysia to now focus more on addressing oral health
issues in toddlers and preschool children and older adults aged
60 and above.
Oral health policies in Malaysia see the Ministry of Health
Malaysia bearing responsibility for oral healthcare of the
younger generation in preschools and schools, antenatal
mothers, the elderly, those with special needs, marginalized
groups and those who are deemed ‘socially-disadvantaged’.
While the Ministry renders oral healthcare to adults who
actively seek care at its facilities, there is no structured
programme for any other adult group aside from those
mentioned above. However, there are programmes rendered on
a ‘community’ basis, almost always as outreach services that
covers all who seek care in such communities. These are,
however, planned according to the local capacity of service
providers.
COMMUNITY DENTAL CARIES PREVENTION PROGRAMME
Established fluoridation programmes in several states demonstrate
continuing low caries experience among schoolchildren. The water
fluoridation programme in Malaysia is considered the cornerstone of
the dental public health programmes in the country. Water
fluoridation was given Cabinet Committee approval in 1972 following
the recommendations of a Commission to institute water fluoridation
in Malaysia (Dental Division 1971). The optimal fluoride level was
accepted at 0.7 ppm for the years 1972 to 2004, but was
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subsequently adjusted to 0.5 ppm in 2004, taking into cognisance
other fluoride sources from toothpastes and foods in the country (Tan,
2003) as well as various studies on enamel opacities in the country
(Oral Health Division, 2013b). Seen against the global picture for
fluoridation, the decision by government in 1972 was bold and
sentinel as many countries were still hesitant at the time.
Hence, much of the caries decline is attributed to this nationwide
water fluoridation program that now covers 77.7% of the Malaysian
population (Oral Health Division, 2013c). There were some setbacks
in the 1990s when water fluoridation ceased in some states due to
changes in state water management. This led to constraints in
achieving optimum coverage and optimum fluoride level of 0.5 ppm at
reticulation points in these states. But there has been a turn around
of policy decisions in these states since then, due to obvious rising
caries among children over the period of fluoridation cessation.
In East Malaysia, more positive government support for the
fluoridation program in Sarawak has demonstrated caries severity
being twofold higher in Sabah which did not enjoy the same (Mean
DMFT 2.93) compared to Sarawak (Mean DMFT 1.4) (Health
Informatics Centre, MOH, 2012).
While the majority of children enjoy better oral health, disparities
remain among children from different states and socioeconomic
backgrounds. However, in spite of the disparities, all states still
exhibit a caries reduction.
At the same time, the Ministry of Health Malaysia instituted a
comprehensive incremental dental care programme begun in schools
in the 1980s. This programme sees the bulk of school services
shouldered by dental nurses (therapists) that now account for 2,574
staffs compared to 2,461 dental practitioners in the Ministry. The
improvement in dental nurse in children numbers from 1 in 17,855
(1995) to 1 in 3,654 (2012) has seen many states achieving more than
95% coverage of schoolchildren.
Much of this care is rendered on an outreach basis, which sees oral
healthcare brought to schools and the community using portable
equipment in mobile teams or as ‘itinerant’ facilities in the form of
mobile dental clinics. Undertaking care on an outreach basis has
been instrumental in expanding the capacity of the Ministry to
increase coverage.
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Such structured programmes are reported under the Health
Information Management System (HIMS) of the Ministry. HIMS data
reports 32% caries-free 6-year-olds (Year 1) in schools 2012, which
indicate that ground situation is on track with survey findings of
25.5% caries-free in 2007. HIMS also reports 64.7% of 12-year-olds
(Year 6) caries-free with a mean DMFT of 1.1 and 54.6% of 16-yearolds (Fourth Form) caries-free with mean DMFT of 1.4 in 2012 (Oral
Health Division b, 2013). The reports seem to be on track for 6- and
12-year-olds albeit a bit optimistic for the 16-year-olds, of which
coverage of the latter at about 85% in 2012 is not as good as for
primary schoolchildren.
Embodied in the Ministry of Health is also a referral system that
enables any child who needs more complex care to be referred by the
dental nurse to dental officers to reach dental specialists if there is a
need.
As members of the dental team, dental officers and nurses function
on a multitasking basis, covering all age groups, and encompassing
promotion, prevention and treatment (and rehabilitation for officers)
as a continuum of activities that fit their job scope.
There is a need to understand the political will and government
support for oral health in Malaysia. Establishment of new facilities,
upgrading of current dental facilities, and procurement of materials
and equipment are assured over Five-Year Malaysia Plans. The
government has ensured policies that support oral healthcare under
the Ministry of Health Malaysia. In 2012, more than RM 538 Million
in operating expenses and RM 27 Million in development funds were
expended for oral health to cover programmes supported by the
Ministry of Health for a workforce that now touches on 14,000
comprising close to 10,000 for the dental team (from dentists to
dental surgery assistants), and almost 4,000 more of health
attendants, clerical staff and drivers. Very few countries have such a
system borne by government.
Health Ministry primary care facilities have template designs that
cover different sizes and facilities befitting the local population size
and needs. Past 5-year Malaysia Plans and now into the 10 th Malaysia
Plan (2011-2015), Category 1 to 5 health clinics are designed and
built with integrated dental components to have 12-chair, 8-chair, 5chair, 3-chair and 1-chair dental facilities. Mobile dental teams and
mobile dental clinics operate out from these ‘base’ dental clinics to
bring oral healthcare into the community.
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The widespread school dental service has additionally served as the
vehicle for an integrated fissure sealant programme begun in 1999.
This followed recommendations of the survey in 1997 and further
addressed caries in pits and fissures (Oral Health Division, 2003).
Several guidelines have been formulated for toddlers, preschool
children, schoolchildren, antenatal, trainee teachers, ‘special needs’
groups and the elderly. Malaysia shared these guidelines on its
webpage www.ohd.moh.gov.my.
At the same time, the country is mindful of the impact of fluoride use.
This year 2013 sees the formulation of a protocol and training of
examiners for a study on fluoride enamel opacities among 16-year-old
children. With this generalised caries decline among children, the
Ministry of Health is also considering embarking on a pilot to test
variable recall periods for children considered ‘low-risk’. While open to
the suggestion, it is a project that has to be approached with caution
due to the difficulty of determining who constitute ‘low-risk’ children.
The Health Ministry also enjoys a long-standing collaboration with the
Ministry of Education (MOE) Malaysia and the dental industry. The
industry provided oral healthcare kits to Year 1 children in primary
schools, while the MOE provides rich ground for the implementation
of various collaborative efforts such as the ‘Doktor Muda’ Programme
(literally ‘young doctors’, a peer-led programme for health)
While one might argue that some of the above are adjuncts to the core
caries prevention strategies, they help to flesh out the scenario of
political will and government support for oral health within the
country that have made possible many oral health population
strategies.
HOME CARE FOR DENTAL CARIES CONTROL
Past studies in the 1990s reported that 74% of the toothpaste
available in the Malaysian market contained fluoride (Musa and Saub,
1998). Another found that fluoride levels in toothpaste in the local
market ranged from 20 to 1,970 ppm (Abdul-Kadir and Abdol-Latif,
1998).
In the 2010 survey of adults in Malaysia (Oral Health Division,
2013a), the majority of dentate adults in Malaysia used toothpaste
when brushing their teeth (98.9%). Of these, the majority (93.7%) was
found to use fluoridated toothpaste, while 5.1% claimed to use nonfluoridated toothpaste. A very small proportion did not use toothpaste
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(1.1%). A small proportion (0.1%) did not know whether their
toothpaste contained fluoride. The use of fluoridated toothpaste did
not differ significantly between urban and rural adults or by gender.
In a study among Malaysian Territorial Army personnel (Jasmin &
Jaafar, 2011), 82.0% used fluoridated toothpaste all the time while
4.9% claimed using it ‘sometimes’. About 2.1% of the respondents
used non-fluoridated toothpaste and about 10.9% were unsure about
their use of fluoridated toothpaste.
Among those using fluoridated toothpaste, 53.8% perceived they were
using fluoridated toothpaste, 3.5% perceived they were using nonfluoridated toothpaste and 42.7% did not know whether their
toothpaste contained fluoride. Among those who used non-fluoridated
toothpaste, 20.5% perceived they were using fluoridated and 33.5%
knew they were using non-fluoridated toothpaste, while 46.0% did not
know whether their toothpaste contained fluoride.
The two most recent studies on fluoride toothpastes serve to show
how fluoridated toothpastes have infiltrated the market in Malaysia,
and are now accessible to the majority of Malaysians. However, the
misperceptions reported from the studies also show that there is still
a need to engage and educate the public on the benefits of fluoridated
toothpaste and proper home care for caries prevention and control.
Based on concerns for younger preschool children, to this end, the
Malaysian oral health programme has formulated guidelines for
‘anticipatory guidance’ for parents/carers of very young children (Oral
Health Division, 2008). Much time has also been put into a pilot on
use of fluoride varnish for caries control in young children based on
current evidence. This initiative involves individual intervention
requiring identification of children ‘at-risk’ with the attendant
difficulties of assessing caries risk. This is new; we are not able at this
time to report on its implementation.
CARIOLOGY EDUCATION IN DENTAL SCHOOL
The problem of dental caries has shown significant reduction in
prevalence and severity among school children in Malaysia but it
continues to remain relatively high among pre-school children, adults
and elderly. A number of concerted effort have been put in place to
address the problem of dental caries and its impact on health, social,
economic and quality of life of the people. This role has principally
been the domain of the Ministry of Health Malaysia. Lately, the rapid
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increase in dental schools and the number of potential graduates that
will be produced, provide an avenue to contribute to a caries-free
future through collaboration between the Ministry of Health and
dental schools in Malaysia.
1.
Number of Dental Schools
Malaysia experienced a phenomenal growth in the number of
dental schools and enrollment of students since 2006. Within a
period of seven years (2006 to 2013), 12 dental schools were
established. This resulted in a total of 15 dental schools in
Malaysia, serving a population of 29 million. As of current,
these schools are in various stages of development. Graduates
from these dental schools and others who registered with the
Malaysian Dental Council (MDC) have to serve in the public
service for two years as required by the Dental Act 1971. These
newly appointed dental officers have to deal with a number of
dental public health issues, particularly dental caries and its
sequelae. Preventive and restorative therapy for caries will
continue to be important tasks for them.
2.
Department of Cariology and Speciality in Cariology
None of these 15 dental schools in the country have a
Department of Cariology. Nevertheless, the concern for dental
caries and the preparation of their graduates to overcome this
problem effectively remain high on the agenda of these dental
schools.
At present, speciality or specialists in clinical dentistry are
confined to the traditional discipline of Oral Surgery,
Orthodontics,
Periodontics,
Paediatric
Dentistry,
Oral
Pathology and Oral Medicine and Restorative Dentistry. There
is no specialist or speciality in Cariology. Taking into
cognizance that cariology is a multidisciplinary and
interdisciplinary subject, issues or problems related to
cariology are referred to the relevant speciality or specialists.
Teaching-learning activities related to cariology are mainly
carried
out
by
three
(3)
departments,
namely
Restorative/Conservative Dentistry, Paediatric Dentistry and
Dental Public Health/Community Dentistry. Certain topics
related to Cariology are also considered in courses such as
Microbiology, Biochemistry, Oral Pathology and Oral Biology.
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3.
Content
The content may differ in depth and extensiveness among
dental schools. Essentially it includes the basic science aspects
of cariology, diagnosis, management and prevention of dental
caries and to a certain extent the behavioral intervention and
related issues in increased risks of dental caries among certain
groups of population.
4.
Philosophy of Cariology
The Oral Health Division, Ministry of Health Malaysia takes a
conservative approach in the control and management of
dental caries. It adopts the philosophy of “when in doubt,
review”; minimal intervention and minimally invasive dentistry;
the application of a preventive strategy in clinical care; and the
use of “orally fit” as an outcome measure. These philosophies
were incorporated in the design of the curriculum of dental
schools in Malaysia. It provides a smooth transition for the
graduates from Malaysian dental schools to implement the
philosophies of these caries control measures from the dental
school environment to the field environment.
5.
International Caries Development and Assessment System
An interesting development recently is the interest of dental
schools in Malaysia in the International Caries Development
and Assessment System (ICDAS). The strategy is to train a core
group of faculty members from each dental school who will
spearhead the development and implementation of this System
in their respective schools. This augurs well with the effort in
ensuring a uniform approach in caries diagnosis and
management that will strengthen the present oral health care
programme in the country. The Deans’ Caucus of Dental
Schools in Malaysia will play a major role in this initiative. The
close collaboration between the Deans’ Caucus and the Oral
Health Division, Ministry of Health Malaysia is envisaged to
lead to a seamless implementation of the ICDAS in the
diagnosis, control and prevention of dental caries.
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CONCLUSION
The caries decline in Malaysia can be largely attributed to the wide
coverage of the water fluoridation programme, the extensive network
of incremental oral healthcare for schoolchildren and the widespread
use of fluoridated toothpaste. Additionally, strong political will and
government support, and the increasing momentum of collaborative
partnerships with other stakeholders are enabling factors in
improving the caries profile of the country. Despite the generalized
decline in caries, epidemiological evidence is in support of dental
caries as a public health challenge, particularly among the very young
children and the adult population.
Future perspectives for further improvement of the caries situation in
Malaysia needs to be considered. These include the continuing
engagement and empowerment of the population for good oral health,
further development of cariology in the dental curriculum and the
adoption of the ICDAS in the diagnosis and management of dental
caries. These upstream investments will play a major role in bringing
about positive trends in the caries profile of Malaysians.
REFERENCES
Abdul-Kadir R, Abdol-Latif L (1998). Fluoride level in dentifrices. Annals
Dent Univ Malaya 5:2-5.
Dental Division, Ministry of Health Malaysia (1971). Report of the
Committee appointed to inquire into and report upon the fluoridation of
public water supplies in West Malaysia.
Dental Division, Ministry of Health Malaysia (1993). Dental
Epidemiological Survey of Adults in Malaysia, 1990. Percetakan
Nasional Malaysia Berhad.
Dental Services Division, Ministry of Health Malaysia (1995). Dental
epidemiological survey of preschool children in Malaysia 1995.
Dental Division, Ministry of Health, Malaysia (1997). Dental
Epidemiological Survey of Adults in Peninsular Malaysia, September
1974-April 1975. Ketua Pengarah Percetakan, Kuala Lumpur
Health Informatics Centre, Ministry of Health Malaysia (2012). Health
Information Management System, Dental Subsystem 2011.
Jasmin B, Jaafar N (2011). Dental caries and oral health behaviour in
the Malaysian Territory Army Personnel. Arch Orofac Sci 6: 19-25
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Oral Health Division, Ministry of Health Malaysia (1998). National Oral
Health Survey of School Children 1997 (NOHSS ’97). MOH/GIG/6.98
(RR).
Oral Health Division, Ministry of Health Malaysia (2003). Guidelines:
School-based fissure sealant programme. Second edition.
Oral Health Division, Ministry of Health Malaysia (2004). National Oral
Health Survey of Adults 2000 (NOHSA 2000), MOH/K/GIG 13.2004
(RR), November.
Oral Health Division, Ministry of Health Malaysia (2007). National Oral
Health Survey of Preschool Children 2005 (NOHPS 2005): Oral health
status and treatment needs. MOH/K/GIG 1.2007 (RR).
Oral Health Division, Ministry of Health Malaysia (2008). Guidelines
Early childhood oral healthcare. Never too early to start.
Oral Health Division, Ministry of Health Malaysia (2009). National Oral
Health Survey of Schoolchildren 2007 (NOHSS 2007): 6-year-olds.
August.
Oral Health Division, Ministry of Health Malaysia (2010a). National
Oral Health Survey of Schoolchildren 2007 (NOHSS 2007): 12-yearolds. August.
Oral Health Division, Ministry of Health Malaysia (2010b). National
Oral Health Survey of Schoolchildren 2007 (NOHSS 2007): 16-yearolds. November.
Oral Health Division, Ministry of Health Malaysia (2011). National Oral
Health Plan for Malaysia 2011-2020 MOH/K/GIG/7.2011 (BK).
Oral Health Division, Ministry of Health Malaysia (2012). Oral Health
Status, 2011
Oral Health Division, Ministry of Health, Malaysia (2013 a). National
Oral Health Survey of Adults 2010 (NOHSA 2010). In print.
Oral Health Division, Ministry of Health Malaysia (2013 b). Protocol :
Fluoride enamel opacities among 16-year-old schoolchildren. In print
Oral Health Division, Ministry of Health Malaysia (2013 c). Preliminary
draft for Facts that Figure 2012.
S Musa, R Saub (1998). Toothpaste available in the Malaysian market.
Annals Dent Univ Malaya 5: 45-48.
Tan BS (2003). Fluorosis and fluoride exposure among Malaysian
schoolchildren. Thesis in fulfilment of the requirement for the degree of
Doctor of Philosophy, Department of Community Dentistry, Faculty of
Dentistry, University of Malaya.
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World Health Organisation (1997). Oral health survey: Basic methods.
Fourth edition. WHO, Geneva.
World Health Organisation. Country Profile.
http://www.whocollab.od.mah.se (accessed 2009)
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MYANMAR
AYE AYE MAW
MYINT MYINT SAN
SAW TUN AUNG
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“Caries Control throughout Life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions (1)
MYANMAR
AYE AYE MAW29
DENTAL CARIES EPIDEMIOLOGY
A representative national oral health survey data is not available in
Myanmar. Nevertheless, dental caries status data in Yangon Division
are shown in Table 1.
Table 1: Dental caries status (% prevalence, mean dmft/DMFT) in
Yangon Division representative from Five projected
townships
Year
2001
1993
1999
Age group
(year)
6
12
12 (Urban)
12 (Rural)
%
Prevalence
84.6
dmft
DMFT
4.17
37.7
0.83
0.65
1.13
NATIONAL/COMMUNITY DENTAL CARIES PREVENTIVE PROGRAM
Tooth brushing with efficacious fluorides toothpaste is most
preventive measure for Myanmar Population. Toothpaste is the most
practical self-care measure to control dental caries.
Fluoride varnish and mouth rinsing is limited used.
In collaboration with school health program and UNICEF, Oral Health
Unit had developed and integrated oral health news, reduction of
29
Consultant Dental Surgeon, Nay Pyi Taw General Hospital 1000 Bedded, Myanmar.
Email: Aye Maw <aye2maw.mmr@gmail.com>
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sugar for prevention of dental caries and self-care oral hygiene
measure into the school curriculum of primary and middle standard
school children.
Primary oral health care (POHC) project jointly sponsored by the
Ministry of Health and Oral Health Organization. Bright Smile Bright
Future Project is starting now.
In Myanmar, with the aim to active and healthy aging, health care of
the elderly project was implemented since 1992, 1993. It has been
implemented in over 90 townships, where the townships and station
hospital & rural health centre open clinic for older people every
Wednesday. Based on the concept of active and healthy ageing, the
project mainly focused on preventive & promotive aspects.
HOME CARE FOR DENTAL CARIES CONTROL
Most of people used fluoride toothpaste various kinds of toothpaste
are distributed in Myanmar market, commonly used 17 toothpaste
(11 for adults & 6 for children) have up till now examined.
Tooth brushing with fluoride toothpaste is home care dental caries
control in children elderly.
Mouth-rinsing is rare.
CARIOLOGY EDUCATION IN DENTAL SCHOOL
There are two dental universities in Myanmar, Yangon and Mandalay.
Another military dental university is present but intake is rare. Dental
school has Cariology Department. Conservative Department,
Paedodontic Department and PCD Department are teaching and
learning Cariology education.
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“Caries Control throughout Life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions (2)
Caries prevention in Myanmar
MYINT MYINT SAN 30
LOCATION OF MYANMAR
The Republic of the Union of Myanmar (formerly Burma) is the
westernmost and largest country in mainland South East Asia with a
total land area of 676,578 square kilometers, stretches 2200
kilometers from north to south and 925 kilometers from east-west at
its widest point. It is approximately the size of France and England
combined. It is bounded on the north and northeast by the people’s
Republic of China, on the east and southeast by the Lao People’s
Democratic Republic and the Kingdom of Thailand, on the west and
south by the Bay of Bengal and Adman Sea, on the west by the
09•32’N and 28•31’ N latitudes and 92•10’E and 101•11’ E longitudes.
30
Professor, Department of Conservative Dentistry, University of Dental Medicine, Yangon,
Myanmar. Email: Myint San <myintmyintsanmya@gmail.com>
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INTRODUCTION
Myanmar was known as the Golden Land in ancient and mediaeval
times for the wealth of its agriculture and minerals. It has a
population of 60 million and situated between two world's great
civilizations, China and India. There was no dental public health
service in Myanmar before the Second World War. There were a few
foreign and local dentists practicing dentistry on a private basis.
Nowadays, over 2000 dentists received a BDS degree and nearly half
of them practicing in the public health sector such as hospitals and
school health teams.
Estimate population (in million) and its structure are shown in
Table.1. Table 2, 3 and 4 are the number and distribution of dental
professionals in Myanmar.
1.
Demography
Table 1: Estimate population (in million) and its structure in (Tin
Wai, 2013).
Age
2000-01
2010-11
2011-12
group
Estimate
0-14
16.43
32.77
17.06
29.44
17.62
29.19
15-59
29.72
59.29
36.94
61.79
37.45
62.01
3.98
7.94
5.24
8.77
5.31
8.8
50.13
100
59.78
100
60.38
100
≥60
Total
%
Estimate
%
Estimate
%
Source: Population Department, Ministry of Immigration and Population,
2013.
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Table 2: Estimate population (in million) and its structure
(Ministry of Immigration and Population, 2013).
Estimate population in million (%)
Population
Age group
1990-
2000-
2009-
2010-
2011-
(years)
1991
2001
2010
2011
2012
14.70
16.43
18.84
17.60
17.62
(36.05)
(32.77)
(31.86)
(29.44)
(29.19)
23.47
29.72
35.06
36,94
37.45
(57.55)
(59.29)
(59.29)
(61.97)
(62.01)
2.61
3.98
5.23
5.24
5.31
(6.4)
(7.94)
(8.85)
(8.77)
(8.80)
40.78
50.13
59.13
59.78
60.38
20.57
25.22
29.73
30.06
30.53
(50.28)
(50.31)
(50.28)
(50.28)
(50.56)
20.21
24.91
29.40
29.72
29.85
(49.72)
(49.69)
(49.72)
(49.72)
(49.44)
98.25
98.77
98.89
98.87
97.77
0-14
15-59
≥60
Total
Female
Male
Sex Ratio
(M/100F)
Table 3: Oral Health Manpower in Myanmar (Tin Wai, 2013)
Dentist
Registered
Number
3,372
Under Department of Health (DoH)
512
University of Dental Medicine (Mandalay)
54
University of Dental Medicine (Yangon)
71
Other Ministries
15
Registered dentist/Pop Ratio
Public sector dentist/Pop ratio
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Table 4: Number and distribution of dental professionals in
Myanmar (Tin Wai, 2013)
Health facility
No. of dentists
Central Unit
4
Hospitals
420
Urban Health Centre
39
School Health Teams
49
Prison Department
3
Railway Department
3
Workers’ Hospital
3
YCDC
1
UDNR
1
MOGE
1
Others
3
Total
2.
527
Role of Dental Universities
Being aware of the need for dental health care of the
community, the Ministry of Health and Ministry of Education
launched the development of the College of Dental Medicine in
Yangon in 1964, which was upgraded into University in 1974.
The second Dental University was opened in the second city
Mandalay in 1999. The dental public health subject was
included in the core curriculum of basic degree (BDS) course,
taught in year 4 and year 5 as preventive and community
dentistry, division of the Dental Health Department.
In year 4, basic oral health survey methods (WHO, 1997) and
the principles and practice of oral health education topics were
taught and students were sent to the sub-urban and rural
areas annually for 7 days to get exposure for community dental
care (Table. 5).
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Table 5: Data collection in PCD trip yearly
Division/
District
Townships
State
Bago
Pyae
Padaung
Manadalay
Myingyan
Myingyan,
Mean
Collection
DMFT
Date
0.45
Oct, 1999
0.7
Nov, 1999
1.05
Apr, 2000
1.5
Apr, 2001
1.28
Nov, 2002
1.11
Nov, 2003
Taungthar,
NgaHtoeGyi
Ayeyarwaddy
MyaungMya
MyaungMya,
WaKha Ma
Mandalay
Pyin Oo
Pyin Oo Lwin
Lwin
Shan (South)
TaungGyi
TaungGyi,
NyaungShwe
Pindaya
Rakhine
Than Twe
Than Twe,
TaungGoke,
Gwae
Shan (North)
Kyauk Mae
Kyauk Mae,
Lasho,
Thipaw
Magway
Minbu
Minbu,
Salin,
Sin PhyuKyun
Tennimtharyi
Dawei
Dawei
Apr, 2004
Lectures on oral hygiene, indices epidemiology, prevention,
fluoride, ethics and management were taught in both years.
Year 5 students need to participate in the school based oral
health promotion training program. Presentations of regional
oral health data as well as oral health education poster were
part of the duty of house surgeon.
Department of preventive and community dentistry taught
dental public health not only to dental students but also to
undergraduate medical students, health assistants and nurses.
Master degree (MDSc) 2 years course was opened in 1992 and
one to two candidates a year submit a dissertation on the
dental public health subject. Some titles related are:
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-
-
Relationship between dental fluorosis and intelligence of
children in Myinmu township
Prevalence of traumatic injuries to the permanent incisors
among schoolchildren aged 7 – 12 years in Yangon Division
Epidemiological Characteristics of Dental Caries and
Treatment Need among 14-Year-Old Schoolchildren using
DMF-T and DMF-S Indices. (Table 9,10,11,12)
Oral health status of school children and oral health
knowledge and awareness of school children and their
mothers.
One year Diploma course was started in 2000 for general
practitioners and which also include lectures and practical
presentation on the dental public health subject. Dr Dent Sc.
(Dental Public Health) was started in year 2011.
3.
Role of dental health department of Ministry of Health
In order to give oral health care to the grass root level,
department of health appointed dentists in township level
hospitals and school health teams all over the country. In
addition, the department of health in collaboration with the
World Health Organization has started Primary Oral Health
Care (POHC) project in 1992. The main objective was to
develop township oral health personal and basic health
personal to perform POHC care services which include giving
oral health education, emergency and self care to the
community. It also comprises a referral system as well as after
lunch tooth brushing drill in primary schools. Now POHC is
extended to 120 townships all over Myanmar.
For dissemination of oral health awareness in the community,
oral health unit of the department of health produce oral
health education pamphlet and oral health education video
programs were telecast on the national TV program. Oral
health messages are included in the school textbooks for
primary school children. Moreover "Best smile" award was
contested in Yangon and other cities in collaboration with the
Myanmar Dental Association (MDA) around oral health day, on
12th September.
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Fluoride related Activities of DOH (Tin Wai, 2013)
-
4.
Invitation meeting on Fluoride Exposure for Oral Health in
Myanmar- 2002
Distribution of compatibility of fluoride and abrasive system
and user-instruction to local toothpaste manufacturers,
2006-07
World Oral Health Day , fluoride symposium-2008
Fluorosis Project
Role of Myanmar Dental Association in collaboration with
International organizations
The Myanmar Dental Association was established in 1979 in
which both governmental and private dentists were actively
participated. The Dental public health unit is one of the
branches of MDA and it organized dental public health
activities such as oral health survey and oral health education
in schools and communities. e.g. Field trips in Seasaing,
Hopone and Thone kwa.
Dentists from MDA also organized meetings and forum in
collaboration with the Myanmar Academy of Medical Sciences
(MAMS) to assess and promote the use of fluoride among
Myanmar people. Affordable fluoridated toothpaste and fluoride
mapping (assessment of fluoride content in drinking water in
Myanmar) projects are underway in planning. MDA
collaborates with FDI - published oral health care handbook of
live, learn and laugh and "Best smile" award contest in Yangon
and other cities in collaboration with the Myanmar Dental
Association (MDA) around oral health day, 12th September.
International organizations such as JICA, JAICOH, IADR,
APDF, AAPD, AOHPF and MDA jointly carried out dental public
health activities in Myanmar. The dental public health unit has
a plan to carry out National Oral Health survey in future.
Therefore, dentists from MDA and Dental Universities
organized pathfinder survey in 2006 and 2007 which was
sponsored by Asia Oral Health Promotion Fund (AOHPF). The
survey team was trained and calibrated in Yangon Dental
University and collected oral health data in 4 geographical
areas with large city. Summary of oral health status data were
presented in Table 6, 7, 8 and 9.
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Table 6: Mean DMFT, Prevalence of dental caries by age group
(Myanmar Pathfinder Oral Health Survey, 2006–2007).
Year
Age
group
5
2006
12
35-44
5
2007
12
35-44
Mean
%
DMFT
Prevalence
Gender
N
Male
381
5.27
83.6
Female
398
5.14
79.8
Male
389
1.39
52.2
Female
404
1.37
51.7
Male
379
2.29
63.3
Female
404
3.62
75.7
Male
424
4.41
66.1
Female
368
3.84
69.6
Male
429
0.61
27.3
Female
395
0.50
25.9
Male
367
1.82
49.5
Female
433
3.29
77.8
Table 7: Caries free rate (%) and dmft (Myanmar Pathfinder Oral
Health Survey, 2006–2007).
Age
% Caries
year olds
free
2006
3
dmft
2007
2006
2007
n.a
n.a
n.a
n.a
18.3
32.15
5.26
4.13
12
48.05
73.4
1.38
0.56
15
n.a
n.a
n.a
n.a
35-44
n.a
n.a
3.96
2.56
>60
n.a
n.a
n.a
n.a
5 (6)
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Table 8: Prevalence of dental caries (%) and mean DMFT
(Myanmar Pathfinder Oral Health Survey, 2006–2007).
2006
Age
% dental
Group
caries
5
12
35-44
DMFT
81.7
5.21
51.95
1.38
69.5
2.96
% dental
Gender
N
Male
381
83.6
5.27
Female
398
79.8
5.14
Male
389
52.2
1.39
Female
404
51.7
1.37
Male
379
63.3
2.29
Female
404
75.7
3.62
Male
424
66.1
4.41
Female
368
69.6
3.84
Male
429
27.3
0.61
Female
395
25.9
0.50
Male
367
49.5
1.82
Female
433
77.8
3.29
caries
DMFT
2007
5
12
35-44
67.85
4.13
26.6
0.56
63.65
2.56
Table 9: SEARO Oral Health Indicators, Myanmar 2010.
Mean DMFT
12 yrs
35-44 yrs
2.3
6.0
% caries free
(5-6 yrs)
5.0
% edentulous
65-74 yrs
n.a.
The national representative data is still unknown and no
relevant data on dmft component break-down.
Table 10: Epidemiological characteristics of dental caries and
treatment need among 14 year-old school children
using DMFT and DMFS indices, Relationship between
Gender and DMF-S (N=740), (Thein Tun Oo, 2010)
Gender
Male
Female
Total
%
Caries
28.5
34.3
31.2
DT
MT
FT
0.47
0.55
0.51
0.01
0.03
0.02
0.04
0.09
0.06
DMFT
0.52
0.66
0.59
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DS
0.73
0.83
0.78
MS
0.01
0.04
0.02
FS
0.07
0.13
0.1
DMFS
0.8
1.0
0.90
International Dental Conference on “Caries Control throughout Life in Asia”
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Table 11: Epidemiological characteristics of dental caries and
treatment need among 14 year-old school children using
DMFT and DMFS indices, Relationship between locality
and DMF-T (N=740), (Thein Tun Oo, 2010).
Locality
Urban
Rural
Total
%
Caries
0.52
0.49
0.51
DT
MT
FT
0.52
0.49
0.51
0.02
0.02
0.02
0.13
0.00
0.06
DMFT
0.66
0.51
0.59
DS
0.86
0.69
0.78
MS
0.02
0.03
0.02
FS
0.19
0.00
0.1
DMFS
1.07
0.72
0.90
The Myanmar Pathfinder Oral Health Survey was conducted in
2006–2007. Nationally representative data is still unknown
and no relevant data on dmft component break down.
Table 12: Dental caries status, Myanmar Pathfinder Oral Health
Survey, 2006-2007
Status
% Caries free
deft
DMFT
Age
(yrs old)
3
5
3
5
12
15
35-44
≥60
2006
18.3
5.21
1.38
3.96
-
2007
32.15
4.13
0.56
2.56
-
COMMUNITY DENTAL CARIES PREVENTION PROGRAM
1.
Fluoridation in Myanmar
Pipe public water system- None
Affordable tooth paste
Mouth rinse- No special program school children, adult
and elderly
Topical – professional/ homecare (no special program)
2.
Community oral health program for caries prevention in
children
-
School health teams-examination, basic treatment,
referral to appropriate centre, Health education
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-
3.
Community oral health program for caries prevention in elderly
-
-
4.
Directorate of Health (Myanmar) collaborate with
Colgate-Pulmolive (Thailand)
Bright Smile- Bright Future Program on Grade 4
students (started from1991-92)
POHC services ion project, effective fluoride tooth paste
and brush, distribution of IEC materials
Routine oral health care delivery in fixed stations
Outreach activities corporate with Myanmar Dental
Council, Myanmar Dental Association, Myanmar
Maternal and Child-care Welfare Association , NonGovernment Association
New approach to oral health care system for Elderly-oral
health survey for elderly on selected townships
Success story of community caries prevention in country
After pilot project (after 18 months) - 40% less new carious
teeth, 60% less caries progression (reduction in pulp
involvement)
In 2008, 76% of local brands are effective after advocacy
processes (Ko Ko Maw, 2008)
Advocacy process
Not concern with toothpaste, distribution of fluoride
water in some region
Assessment of free ionizable F in toothpaste in Myanmar
market (result- N=21,both import and local, 38% less
than 700ppm, 71% less than 700ppm free ionizable
F(Ko Ko Maw & Wim van Palenstein Helderman, 2004)
Fluoride toothpaste used - 26% of local brands showed
desirable efficacy (>700ppm free available fluoride)
Production and marketing of fluoride toothpaste from
the factory of the Ministry of Industry 1 (Myanmar),
Pepsodent with fluoride, free ionizable 780ppm (Ko Ko
Maw, 2004)
2006, Consultative advocacy meeting for development of
affordable and effective fluoride toothpaste for Myanmar
(local/international, Dental, Medical, Health, MDA, local
manufacturers)
Distribution of user instruction in Myanmar
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5.
Other activities
-
-
-
-
Oral health education pamphlet and oral health
education video programs were telecast on the national
TV program.
Oral health messages are included in the school
textbooks primary school children.
Dental public health activities of the dental public
health unit (branch of MDA) did oral health survey and
oral health education in schools and communities.
National Oral Health survey in future of the dental
public health unit
Joint dental public health activities in Myanmar with
International organizations such as JICA, JAICOH,
IADR, APDF, AAPD, AOHPF
Signal and FDI programs in school children to promote
health education such as live, learn and laugh program,
day and night tooth brushing program
HOME CARE FOR DENTAL CARIES CONTROL
1.
Instruction of fluoride toothpaste used in schools and
community
Fluoride tooth paste- locally available
•
Colgate- Active ingredient
•
Sodium Fluoride 0.24% (0.14% W/V), Triclosum
0.30%
•
Fresh up- SMFP 0.76%, Potassium Nitrate- 5%
•
Signal- SMFP 1450 ppm
•
Pepsodent- free ionisable fluoride-780 ppm (Ko Ko
Maw, 2004)
How to use effectively
A.
Health Education
•
teach tooth brushing technique in simple
way, use fluoride toothpaste twice a day,
before immediately bed time and after meal
at morning,
•
Amount of F toothpaste: 6 mo – 2 yr: half
pea size, 2 – 6 yr: pea size or width of
toothbrush, 6 and older: full length of
toothbrush.
•
Brushing Time – Minimum of two minutes
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Post brushing behaviors – Spit out the
toothpaste and minimize rinsing behaviors
with water.
Community service
•
school oral health care service should be
done frequently and at least three times a
year
•
corporation of parents in oral health care
and should participate in taking record of
good oral health behavior
•
motivation of good oral habit in children
by corporation of teachers and parents
•
B.
2.
Fluoride mouth rinse used- No history and no relevant data
-
3.
Children or school
Adult or elderly
How to use
Any other home care caries control in children, adult and
elderly
-
No specific home care
CARIOLOGY EDUCATION IN DENTAL SCHOOL
Dental schools- Two Universities, one in Yangon, one in Mandala
Cariology Department- No separate department
Cariology teaching and learning under –
Department of Conservative Dentistry
Content- Definition of dental caries, Etiology, Classification,
Diagnosis of dental caries, Treatment
Department of Preventive and Community Dentistry
Content- Epidemiology and prevention of dental caries
Department of Paedodontics
Content- Microbiological aspect, caries activity tests, Caries
risk assessment, saliva and dental caries and Management of
dental caries in children
Department of Oral Medicine
Content- Histo-pathology and sequelae of dental caries
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Cardiology in clinical practice
Department of Conservative Dentistry- Caries management- Curative
and ART, and prevention- fissure sealant
Department of Paedodontic Dentistry- Curative
prevention- Fluoride modalities, Fissure sealant
and
Specialty or specialist in Cariology
none
REFERENCES
Department of Preventive and Community Dentistry, Data collection in
PCD trip yearly.
Ko Ko Maw & Wim van Palenstein Helderman,(2004), Assessment of
free ionized/ionisable F in toothpaste from Myanmar market, 20012002.
Ko Ko Maw (2004) Invitational meeting on Fluoride exposure and Oral
Health Care for Myanmar, July -2002.
Pathfinder oral health survey (2006–2007), Myanmar, Caries free rate
(%), Prevalence of Dental Caries and Mean DMFT, and Periodontal
disease.
Population Department, Ministry of Immigration and Population (2013),
Estimate population and its structure.
Prathip Phantumvanit (2013) SEARO oral Health Indicators, Myanmar
2013- Myanmar Dental Conference, 2012.
Thein Tun Oo (2010) Epidemiological characteristics of Dental Caries
and Treatment Need among 14 year-old school children using DMFT
and DMFS indices, Dissertation.
Tin Wai (2013) Quality care of Myanmar, Presentation, 27th August
2013.
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“Caries Control throughout Life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions (3)
Fluoride and current caries situation
in some portions of Myanmar
SAW TUN AUNG31
INTRODUCTION
Myanmar, located in South East Asia, is developing country.
According to the current socio-economical situation, 12 year old
DMFT, an indicator not only for dentition status, but also for the over
all oral health status in Myanmar varies in the regions of the country.
Such variables, mainly depends upon changing lifestyle. However,
another factor like fluoride should also be studied, for the influential
role in the caries prevalence.
Caries are common in the developed countries, where high sugar
content westernized foodstuffs are available. Instead of being that
purpose, the caries rate drastically declines in those countries, within
several late decades of the previous century. Experts highlighted, after
doing some reviews, the widely utilization of fluoridated toothpaste in
those countries, is the main reason.
Among the various fluoride usages of caries prevention, water
fluoridation, professional application methods, fluoride supplements
are still not available in Myanmar. The most common sources of
fluoride in Myanmar are mainly based upon the drinking water.
Generally, there are 3 categories of fluoride levels (0, 0.1-1.5 and
above 1.5 mg/L) in Myanmar drinking water. Apart from the drinking
water, some fluoridated toothpaste distributed in Myanmar market is
another source. In some mountainous region, the tradition of drinking
plain tea, in which optimal level of fluoride is contained, can also give
the effectiveness of fluoride, in caries prevention.
In this paper, the role of fluoride on caries, in some portions of
Myanmar, i.e. two from upper part of the country, where fluoride level
is more than 1.5 mg/L and another one from lower portion, where
31
Professor/Head, Department of Preventive & Community Dentistry, University of Dental
Medicine, Yangon, Myanmar Email: Saw Tun Aung <dr.sawhtunaung@gmail.com>
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fluoride level is less than 1.5 mg/L is studied. At the same time, the
effect of fluoridated toothpaste is also study, for the purpose of dental
caries prevention.
MATERIALS AND METHOD
The study areas of this paper are based upon Myingyan, Shwebo and
Nyaungdon. First two townships are situated in the Mandalay and
Sagaing division and the last one is the township of Ayeyarwady
division. Mandalay and Sagaing are the divisions of Upper Myanmar
and Ayeyarwady is located in the Lower Myanmar. According to the
previous research, the fluoride content of drinking well water of
Mandalay and Shwebo divisions is more than 1.5 mg/L and the
drinking water of Ayeyarwady division is less than 1.5 mg/L.
The sample size of the study is 352. Sample size was determined by
using the formula of Swanga and Lemeshow, WHO, Geneva, 1991.
The type of study is descriptive, cross sectional and non-intervention
in design. In this study, the fluoride content of the toothpastes,
occupied the majority share of market, were collected to confirm the
real component. At the same time, the frequency of tooth brushing,
caries prevalence and mean DMFT of 12 year old school children were
also collected. The DMFT of 12 year old school children were selected
to know not only the dentition status, but also the global oral health
situation, in this study.
Simultaneously, the relationship between drinking water fluoride
component and dentition status of the study areas, and fluorosis
situation were also examined. Study period is one year (from August
2011 to August 2012)
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RESULTS
The table shows that all toothpastes from Myanmar market have
below 1000 ppm of fluoride.
Table 1: Fluoride content in the common toothpaste
No.
Code no.
1
2
3
4
5
6
7
8
9
10
TP1
TP2
TP3
TP4
TP5
TP6
TP7
TP8
TP9
TP10
Fluoride component
ppm
968.00
968.00
968.00
934.00
634.0833
634.0833
634.0833
827.500
699.200
760.000
Table 2: Previous 12 year old DMFT among Myanmar people
Age group
Author
Year
DMFT
10-12
Menezes et.al
1972
12
WHO(4)
1977
12
Valentine
et.al
WHO (6)
1982
Oral Health
Unit (7)
1996
2.38
(Low)
0.80
(Very low)
1.30
(Low)
1.10
(Very low)
0.83
(Low)
12
12
1993
Above table shows DMFT of 12 year old in some portion of Myanmar
is just between very low and low.
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Table 3: Mean 12 year old DMFT of study area
Location
Mean DMFT
Shwebo
Standard
Deviation
0.95
0.39
(Very low)
0.2
(Very low)
2.18
(Low)
Myingyan
Nyaungdon
0.58
0.75
ANOVA p<0.01; (Highly significant)
According to the table, 12 year old DMFT for those areas of fluoride
level of drinking water (>1.5 mg/L) are very low.
Table 4: Number of children aged 12 year olds with their
toothbrushing practice by the study locations.
Location
Shwebo
Myingyan
Nyaungdon
Total
No. of children
Tooth brushing Tooth brushing
≥2 times
2 times
81
45
51
49
68
58
200
152
Total
126
100
126
352
X2=4.76; p>0.05 Non Significant
Tooth brushing frequencies between three townships show non
significant.
Table 5: Effect of frequency of tooth brushing (12 year)
Frequency
<2 times
≥2 times
Mean DMFT
0.98
0.97
Unpaired t test: t=0.165, p>0.05
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Standard Deviation
2
1.5
International Dental Conference on “Caries Control throughout Life in Asia”
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Table 6: Population affective by fluoride in drinking water (>1.5
mg/L)
City
Sagaing
Mandalay
Ayeyarwady
Source of
water
Dug well
Tube well
Other
Dug well
Tube well
Other
Dug well
Tube well
Other
Population
149,000/5,500,000
55,000/5,500,000
0/5,00,000
148,000/7,058,00
185,000/7,058,000
0/7,058,000
0/7,065,000
0/7,065,000
0/7,065,000
DISCUSSION
According to Table 1, fluoride content in the top 10 toothpastes in
Myanmar market, is no more than 1000 ppm. In Table 2, 12 year old
mean DMFT, collected from 1972, 1977, 1983, 1993, 1996, have
shown that it varies between very low and low. However, since these
were the data collected randomly in the convenient areas, it does not
represent the national level. At the same time, the data collected in
2012, presented in table (3), shows the various 12 year old DMFT in
the study area, it can be noticed the varieties of results. Among the
first 12 year old two townships, resided in the high fluoride level
(>1.5mg/L) in drinking water, have a very low 12 year old DMFT. In
the same table, it can be seen, low 12 year old DMFT, in Nyaungdon
Township, located in Ayeyarwady division, where fluoride level is less
than 1.5 mg/L in drinking water (See Table 6).
Table 4 and 5 indicated that the dentition status is not affected by
fluoridated toothpastes. Community’s oral hygiene care should be
promoted by using strategies of oral health promotion. The behavior
and awareness of positive oral hygiene care should be changed to
promote the dentition status, whether they use fluoridated
toothpastes or not.
In this study, it can be concluded that only fluoride from drinking
water effect positively on dentition status. However, the problem, i.e.
fluorosis should be taken care, in the other hand.
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REFERENCES
Bratthall D et.al. Reasons for the caries decline: what do the experts
believe? Eur J Oral Sci 1996; P 416-422.
Gunshima Y et.al The Effects of Fluorides in the Prevention of Caries in
Adults: Dentistry in Japan, Volume 34, 1998, p 84-6.
Peterson PE. The Effective Use of Fluorides in Public Health, The
Workshop on “Effective Use of Fluoride in Asia” Phang-Nga, Thailand,
March 22-24, 2011, p 22-30.
World Health Organization. Inadequate or Excess Fluoride: A Major
Public Health Concern, The Workshop on “Effective Use of Fluoride in
Asia”. Phang-Nga, Thailand, March 22-24, 2011. p 13-17.
World Health Organization Expert Committee on Oral Health Status and
Fluoride Use, Fluorides and Oral Health; WHO Technical Report Series,
846, 1994.
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NEPAL
Shaili PRADHA
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
NEPAL
Shaili PRADHA 32
DENTAL CARIES EPIDEMIOLOGY
Dental caries is considered a major public health problem globally
due to its high prevalence and significant social impact. It is one of
the commonest oral problems affecting children and elderly globally
involving the people of all regions and society. It can be seen in all age
groups involving both deciduous and permanent teeth. Treatment of
dental caries involves restorative or pulp therapy which is not only
expensive but also painful.
The 2004 National Pathfinder Survey shows that 58% of 5-6 year old
school children suffer from dental caries (Yee and Mishra 2006). With
this high prevalence, dental caries is more prevalent than
malnutrition that affects 49% of the child population (Ministry of
Health annual report 2009/10). The Survey reported pain and
discomfort due to untreated dental caries in 18% of 5-6 year olds and
64% in older adults. Adolescent school children reported inability to
eat followed by inability to speak properly. The survey reported that in
5-6 years old, dental caries prevalence was 57.5%, mean dmfs was
5.47 and the mean dmft was 2.70. 5-6 year old school children from
urban schools had significantly higher mean dmfs and dmft than
their counterparts attending rural schools. Total no of sample size
was 1027, 5.27 had ds, 0.19 had ms and 0.03 had fs component in 56 yr old.
In total of 1047, 12-13 year old age group, the dental caries
prevalence was 25.6%, mean DMFS was 0.74 and the mean DMFT
was 0.50. DT was 0.45, MT was 0.01 and FT was 0.03. In total of
1074 15-16 year old children, dental caries prevalence was 25.6%,
mean DMFS was 0.74 and DMFT was 0.50. DT was 0.52, MT was
Professor, Coordinator, MDS Periodontology and Oral Implantology, National Academy of
Medical Sciences and Chief, Oral Health Focal Point, Department of Health Services, Ministry of
Health and Population. Email: Shaili Pradhan <shaili_p@yahoo.com>
32
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0.04 and FT was 0.07. In the age group 34-49, with sample size 603,
prevalence of dental caries was 57.5% and mean DMFT of this study
group was 2.71. D component was 66.4%, M was 28.4% and F was
5.2%. DT was 1.80, MT was 0.77 and FT was 0.16.
In a total of 616 for older adults aged 50-99 yrs, prevalence of dental
caries and mean DMFT was 69.6% and 6.40, while DT was 3.65, MT
was 2.69 and FT was 0.06. After 2004 there is no national survey or
data on oral conditions, however, there are some published reports of
academic institutions which adopt certain districts for teaching
learning purposes.
In a total of 2,177 of 5-6 year old and 3,323 of 12-13 year old school
children from urban and rural areas, the caries prevalence and mean
dmft score of 5-6 year olds was 67% and 3.3. Similarly the caries
prevalence and mean DMFT score of 12-13 year olds was 41% and
1.1 (Yee and McDonald 2002).
In a study of 638 school children, 325 of age 12-13 years and 313 of
age group 5-6 years, conducted in Kathmandu valley, dmfs and caries
prevalence was 3.79 and 69%, similarly in 12–13 year age
group,DMFS and caries percentage was found to be 1.6 and 53.23%
(Subedi B et al 2011).
In a study conducted in a study population of 3174 school going
children of 5-14 years old, the prevalence of dental caries was found
to be 47.1%, mean DMFT in 5-7 year old was 1.96 and 11-14 years
was 1.84 (Adhikari, Malla and Bhandari 2012).
In another study conducted on 361 school age children by age group
from 5-16 years, caries prevalence and mean dmft/DMFT score of 5-6
years old and 12-13 years old was 52%, 1.59 and 41%, 0.84
respectively (Dixit et al 2013).
COMMUNITY DENTAL CARIES PREVENTION PROGRAMME
Nepal does not have any community fluoride administration in the
country, as there is no sufficient regular water supply to every
household from the Government. People depend on boring water
supply and well water for daily household work. In 1995, an attempt
was made to lobby for salt fluoridation as there is one door system for
salt in the whole country through a salt trading corporation which
supplies salt to almost 90% of the houses in the country. However, it
could not materialize because of some unavoidable circumstances.
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Government through Oral health focal point does have regular
community oral health program for caries prevention in children and
in elderly. This is conducted every year as per the budget allocated.
Though few in numbers, community oral health program for caries
prevention in children is carried out every year in the form of
orientation on oral health to school children and teachers and
Atraumatic Restorative Treatment by Government. Such programs
are also conducted by academic institutions and NGOs regularly as
part of their curriculum. As for elderly, there is no separate program
for caries prevention. However, a few messages are aired regularly
through the radio on oral health. Some NGOs do fluoride varnish
application on school children.
There is no official document exactly whether caries prevalence, dmft
has reduced or not after 2004, no national survey has been
conducted in the country,. However, there is a published report on
gains in oral health and improved quality of life of 12-13 year old
Nepali school children five and six years after the introduction of
fluoride toothpaste in 1991 (Yee, McDonald and Helderman 2006).
There was a 26.6% decline in caries prevalence and 38.0% decrease
in 12-13 year old DMFT. There is also increasing in tendency to have
dental checkup, which may be attributed to the dental camps
organized by Government and private sector, oral health education,
orientation and awareness programs in schools, radio and TV both by
the Government as well as private sector.
HOME CARE FOR DENTAL CARIES CONTROL
Nepalese population totally rely on fluoridated tooth paste for dental
caries control. Ninety five % of the toothpastes available in the market
are fluoridated and is easily available to all the population, as it is
manufactured in Nepal. Most of the Nepalese people brush
immediately after waking up, before breakfast and we need to bring
change in this behaviour and they are not aware about not to rinse
thoroughly after brushing and most people brush once a day only.
Purely fluoride mouth rinse is not available in the country; however
anti plaque mouth washes mixed with fluoride are available. Fluoride
is
available
in
the
form
of
sodium
fluoride,
sodium
monofluorophosphate in the tooth paste in 1000 ppm. Some private
clinics do offer fluoride varnish and gel applications, however it is
quite expensive.
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CARIOLOGY EDUCATION IN DENTAL SCHOOL
History of dental education in the country is very recent. The first
dental college was started in Nepal by the private sector in 1999. At
present there are 12 dental schools with five dental colleges having
both undergraduate and postgraduate courses and 2 institutes
having only postgraduate courses, rests have only undergraduate
courses.
In Nepal Cariology is not a separate department; it is incorporated in
Conservative and Endodontics department. However, Cariology
subject is introduced to undergraduates from 1 st year as introductory
classes, it is also covered in 2 nd and 3rd year and in the final year, it
dealts in detail. Cariology covers all the aspects of dental caries
including etiology, classification, prevention, treatment and
maintenance.
In clinical practice, Cariology is taught by Conservative and
Endodontics department and contents are theory as well as practical.
In practical classes students learn to detect caries as well as
management of dental caries. In preclinical classes which are
incorporated in 1st and 2nd year classes, students initially learn about
caries and cavity preparation in cast and phantom head in laboratory
till 2nd year and from 3rd year onwards they learn in human subjects
regarding diagnosis of dental caries and preparation of different
cavities for the management of dental caries.
There are very few specialized dental surgeons in all aspects of
dentistry. Thus our country lacks specialist in Cariology till date.
REFERENCES
Adhikari RB, Malla N and Bhandari PS (2012). Prevalence and
treatment needs of dental caries in school going children attending
dental outpatient department of a tertiary care centre in western region
of Nepal, National journal of medical sciences 2012;1(2):115-8
Dixit LP et al (2013). Dental Caries prevalence, oral health knowledge
and practice among indigenous Chepang school children of Nepal, BMC
Oral Health 2013,13:20
Ministry of Health and Population (2011): Department of Health
Services Annual Report 2066/2067 (2009/2010)
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Subedi B et al (2011). Prevalence of Dental Caries in 5-6 years and 1213 years age group of school children of Kathmandu valley, J Nepal
Med Assoc 2011;51(184):176-81
Yee R and McDonald N (2002). Caries experience of 5-6 year old and
12-13 year old school children in central and western Nepal. Int Dent J
2002;52:7-10
Yee R, Mishra P (2006). Nepal Oral National Pathfinder Survey 2004
Yee R, McDonald N and Helderman VP (2006). Gains in oral health and
improved quality of life of 12-13 year old Nepali school children:
outcomes of an advocacy project to fluoridate toothpaste. Int Dent J
2006;56:196-202.
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PHILIPPINES
Maria Liza C CENTENO
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
PHILIPPINES
Maria Liza C CENTENO 33
DENTAL CARIES EPIDEMIOLOGY
The prevalence of dental caries in the Philippines has remained high
for several decades now. There are several efforts to address this
problem. The programs are offered on a national scale by several
agencies both by the government and private sectors, however, these
programs have remained fragmented across the nation, which has
made the impact less significant.
The following data were gathered from the latest report released
August 2013 by the Department of Health-National Center for Disease
Prevention and Control, this concluded the nationwide dental survey
conducted in 2011 by the National Monitoring and Evaluation Dental
Survey (NMEDS), in collaboration with the University of the
Philippines, National Institutes of Health.
Source: NMEDS, 2011
Philippine Pediatric Dental Society, Inc., Pediatric Dentistry Center.
Email: Maria Liza Centeno <lizacenteno@yahoo.com>
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1.
Caries free at 3, 6 and 12 years old children
The NMEDS 2011 report gathered the dmft and DMFT in its
sample population and the data showed that dental caries in
children has lowered but is still by far high in comparison to
that of the region. While there is no data specific for 3 years
old, the survey included children aged 5 and 12 years old.
Average decayed and filled temporary teeth were 5.6, which
were mostly decayed. Only 6 of the 586 subjects had filled
teeth. Missing teeth are not included since these could either
be unerupted or extracted early due to caries (NMEDS, 2011).
Source: NMEDS, 2011
2.
dmft at 3, 6(5) years old children, with d,m,f component
breakdown
Overall, prevalence of dental caries in temporary teeth was 87.7%
from among five hundred eighty six (586) 5-year old children,
which is HIGH according to the severity classification of
diseases. Males have higher prevalence at 88.9% compared to
the females at 86.4%. The urban children obtained a very high
prevalence at 90.8% while the rural children was at a high
84.1%.
3.
DMFT at 12, 15, 35-44, >60 years population, with D, M, F
component breakdown
Source: NMEDS, 2011
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4.
Prevalence in Permanent Teeth
By age, the prevalence of dental caries is HIGH for the 12, 1519 and 35-44 year age groups and Very High for the 65-74
years age group.
By gender and residence, the prevalence of dental caries is
HIGH for both female and male. It is also MEDIUM for both
urban and rural areas.
5.
Average Decayed Missing Filled Teeth (XDMFT)
The average decayed, missing, filled teeth were highest since
65-74 years age group at an average of 22.87 and 3.25 for 12
years age group. The occurrence of XDMFT was also higher in
urban areas when compared with rural areas.
6.
Prevalence of Missing Teeth
Females (70.9%) have a higher prevalence of missing teeth
compared to males (53.9%). The prevalence of missing teeth is
VERY HIGH for 65-74 years and 35-44 year age groups at
98.8% and 94.9%, respectively.
7.
Average Missing Teeth
The average number of missing teeth was higher in females at
8.39 compared to males at 4.44. By age, 12 years age group
received the lowest number of missing teeth at an average of
0.69, while the 65-74 years age group showed a high 21.03
missing teeth.
COMMUNITY DENTAL CARIES PREVENTION PROGRAM
The Dental Services of the Department of Health (DOH) was
reorganized in the early nineties and simultaneously the devolution of
the local government was implemented. This political reorganization
created a significant impact on the oral health programs in the
country and for a time, the regions, provinces and municipalities
provided mostly curative services until the DOH came up with its Oral
Health Policies, Guidelines and Programs in 2005. The “Orally Fit
Child Program” for under 6-year old children of the DOH and the Oral
Health Program ‘Fit for School Program’ of the Department of
Education (DEPED) contributed greatly to the improvement of the oral
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health status of children specifically for oral hygiene as evidenced by
the majority (93.3%) of the study population brushing their teeth.
This may be the reason for the high decrease in periodontal disease.
However, the same cannot be said for dental caries status. To meet
the WHO Goals, both government agencies still have to do more.
(NMEDS, 2011)
1.
Community fluoride administration in the country
At present, water fluoridation or any means of public health
fluoride administration in the country has not been restored.
Water Fluoridation in Metro Manila lasted for 3 years, from
1983-1986, however, the program did not continue after the
supply was consumed. There are no immediate plans for the
implementation of any form of public health fluoridation
program in the country.
2.
Success story of the community caries prevention in the
country
There are isolated programs in several regions where oral
health awareness is being advocated. Most of it are being
successfully implemented but since there is no centralized
agency monitoring the programs, there are no data to
statistically prove its significant impact to the community.
HOME CARE FOR DENTAL CARIES CONTROL
Toothbrushing remains to be the main means of controlling
dental caries in the Philippines. A great majority of the subjects
(93.3%) cleaned their teeth with toothbrush in all regions
examined and only 2.4% used other methods while 3.2% didn’t
clean their teeth at all. (NMEDS, 2011) However, the survey did
not ask if the respondents used toothpaste for brushing nor
were their brushing habits asked. It also did not inquire
frequency and time of toothbrushing. While it is customary for
Filipinos to use toothpaste for tooth brushing, there remains
insufficient proof of the use of Fluoridated toothpaste.
Interestingly, the survey also revealed that almost half (48.4%)
of the respondents went to a dentist to get a free toothpaste
(NMEDS, 2011). Whether there is actual toothbrushing or use
of Fluoridated toothpaste, it is worthy to note that most of the
respondents know that toothbrushing is an essential part of
hygiene.
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In 2011, the Philippine Pediatric Dental Society, Inc. released
the Fluoride Guidelines on the use of toothpaste, mouthwashes
and fluoride supplements. Below is the summary tabulating
the recommendations.
Philippine Pediatric Dental Society, inc. Fluoride guidelines 2011
Fluoride Vehicle
Water
fluoridation
Fluoride
toothpaste
- frequency
- concentration
- amount
Fluoride
mouthrinse
- frequency
-
time
- amount
Fluoride
Supplements
Fluoride Gel
Fluoride Varnish
6 months to
2 years
2 to 6 years
6 years and
above
0.5–1 ppm
0.5–1 ppm
0.5–1 ppm
Twice a day
Twice a day
Twice a day
1000 ppm
smear
1000 ppm
pea size
none
When able to
spit
Daily
1500 ppm
10 mm and
above
Daily
Caries risk
assessment
2-4x a year
for 30
seconds
10 ml
Caries risk
assessment
2-4x a year
For 30
seconds
10 ml
1 mg
2-4x a year
2-4x a year
While dental caries remains to be high, there are concerted
efforts in the private sector to curb its prevalence. Several nongovernment organizations have coalesced to create a unified
advocacy and programs for the benefit of the oral health of the
entire Philippines. The absence of measures emanating from
the Department of Health has prompted several nongovernment organizations, such as the Philippine Dental
Association, the Philippine Pediatric Dental Society, the
University of the Philippines Alumni Association and the
University of the Philippines College of Dentistry to coalesce
and have a unified advocacy and programs for the benefit of
the oral health of the entire Philippines.
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CARIOLOGY EDUCATION IN DENTAL SCHOOL
There are 27 dental schools all over the Philippines, the subject on
Cariology is included in Restorative Dentistry subjects. There is no
separate department dedicated to Cariology alone. At present, there is
no specialty group or research department intended for Cariology.
REFERENCES
National Monitoring and Evaluation Survey 2011 Final Report.
Department of Health-National Center for Disease Prevention and
Control. Released August 2013.
4th National Monitoring and Evaluation Dental Survey 1998. Dental
Health Service Department of Health.
National Monitoring Evaluation Dental Survey Dental Health Service
Implementation Support Division, Dental Research Publication
Department of Health 1992.
RA9484 “The Philippine Dental Act of 2007”.
Philippine Pediatric Dental Society, Incorporated. Guidelines on the Use
of Fluoride 2011.
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SINGAPORE
Eu Oy CHU
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
SINGAPORE
Eu Oy CHU34
DENTAL CARIES EPIDEMIOLOGY
The School Dental Service (SDS) provides comprehensive oral health
care to primary and secondary school children. In June 2006, it rolled
out a fully integrated computer system, Integrated Dental Electronic
Assessment for Students (IDEAS), which performs roles ranging from
front desk patient management to management of clinical records.
IDEAS allows more than 200 clinicians who are situated at the School
Dental Centre (SDC) in Health Promotion Board (HPB) and 230 dental
clinics island-wide in real-time accessing and capturing of student
records. Access to the system is done either through school and
government networks or 3.5G wireless network. The use of
odontogram charting, treatment planning and treatment execution
facilitate data capture and provides a useful guided clinical approach
to the management of the patients. The design of the odontograms
also facilitates the capture of structured data for analysis and
research.
The data in this report pertain to 7, 12 and 15 year olds in the year
2011 and was generated from the IDEAS system. Table 2 shows the
demographic profile of pupils examined for the period from January
2011 to December 2011. Table 1 shows that the majority of the
children stayed in 4-5 room flats.
Table 1: Percentage of children stayed in different room size.
Year
2011
1-3 Room
15
Percentage of children per room size
4-5 Room
Executive
Private
60
9
17
Others
3
Senior Deputy Director, School Dental Service, Health Promotion Board, Singapore Email: Oy
Chu EU (HPB) <EU_Oy_Chu@hpb.gov.sg>
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Table 2: Demographic profile of pupils examined for the period
from January 2011 to December 2011.
Total no of local children
examined
7
31,746
Age (yrs old)
12
38,628
15
33,093
Ethnic Groups (%)
Chinese
69.5
70.0
73.0
Malay
13.8
14.0
12.6
Indonesian
6.0
6.0
5.3
Eurasian
0.4
0.5
0.4
Indian
8.7
8.3
7.8
Others
1.6
1.2
0.9
Male
51.3
52.0
51.0
Female
48.7
48.0
49.0
Gender (%)
1.
Primary Dentition: Oral health status of 3 year olds
The results of the latest study of pre-schoolers were published
in 2009. 1,782 children aged 3-6 years were examined. The
caries status was evaluated using WHO examination
procedures and diagnostic criteria. It was found that about
40% of the children (26%, 37%, and 49% in 3-4, 4-5, and 5-6
year-olds, respectively) were affected by caries. The mean (sd)
dmft and dmfs were 1.54 (2.75) and 3.30 (7.49), respectively.
About 90% of the affected teeth were decayed teeth. The study
revealed a significantly skewed distribution of caries lesions,
indicating that 16% children with high caries activity (dmft≥4)
were carrying 78% lesions. Rampant caries, defined as caries
affecting the smooth surfaces of two or more maxillary incisors,
were found in 16.5% of children. About 61% of affected
surfaces were smooth surfaces. Demographically, Malay
children and boys tended to have more rampant caries. Higher
caries severity and treatment needs were found among Malays
and children in the low socio-economic group (Gao et al., 2009).
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2.
Oral health status of 7 year olds (Charts 1-4)
Of the 31,746 pupils aged 7 examined in the year 2011, 49.5%
of the children were affected by dental caries. The mean dmf of
the primary teeth was 2.09. The main contributory factor to the
dmft index was the filled (f) component (mean=1.58) (Figure 1).
In terms of severity of caries experienced, about one-fifth of the
children (20.1%) had dmft ≥4.
Malay children had a higher deciduous dmft (2.47) as
compared to Chinese (2.06) and Indians (1.60) (Figure 2). Like
the 3 year olds, the Malays and the boys tended to have higher
caries experience (Figure 3).
Figure 1
Figure 2
Figure 3
Figure 4
Housing types of the children were recorded and used as a
gauge of the socioeconomic status of the children. A higher
percentage of children who stayed in 1-3 room flats had caries
compared to children who stayed in private apartments or
properties (Figure 4).
Amalgam was once the main material for use in filling, its
utilization rate has dropped from 60% of restorations in 2007
to 33% of restorations in 2011.
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3.
Permanent Dentition: Oral health status for 12 and 15 year
olds
In the year 2011, a total of 38,628 12 year olds and 33,093 15
year olds were examined respectively. About 29.4% of the 12
year olds and 40.0% of the 15 year olds had dental caries. The
mean DMF teeth for these age groups were 0.56 and 1.04 with
the filled (F) component being the major contributory factor to
the indices (Charts 5, 6).
Figure 5
Figure 6
Figure 7
Figure 8
In both age groups, the girls had a higher mean DMFT
compared to the boys across all ethnic groups. At age 12, the
Malay children had a higher mean DMFT as compared to
Chinese and Indian children. But by age 15, the Chinese
children had the highest DMFT compared to the other ethnic
groups (Charts 7, 8).
In summary, the prevalence of dental caries in children has been
shown to be influenced by ethnicity, educational level and
socioeconomic standards. There is a disparity in the burden of disease
within the community.
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4.
Adult population
Table 3: The distribution of caries free and DMFT according to
gender, age group, ethnicity and education is shown in
the table below.
Overall
s.d.
Gender
Female
Male
Age Group
20–24
25–34
35–44
45–54
55
Ethnicity
Chinese
Malay
Indian
Others
Education
Primary &
Below
Secondary
Tertiary
Caries
Free (%)
Mean no. of Teeth
MT
FT
DT
9.9
—
0.9
1.5
3.1
6.4
4.1
4.2
8.1
7.1
58.6
41.5
0.9
1.0
2.9
3.4
4.5
3.3
8.3
7.7
30.3
29.0
17.8
11.8
11.2
0.5
0.9
1.0
1.1
0.9
0.1
0.3
1.1
3.6
8.8
1.8
3.2
5.3
4.4
3.7
2.4
4.3
7.4
9.1
13.4
56.6
13.8
26.3
3.3
0.8
1.4
1.0
1.1
3.6
2.1
1.3
0.9
4.6
2.6
2.5
3.7
9.0
6.1
4.8
5.7
13.8
1.1
7.1
3.2
11.4
44.1
42.1
1.0
0.6
2.1
0.7
4.5
4.1
7.6
5.4
DMFT
The last adult survey was conducted in 2003. It found that
9.9% of the adult population was caries free. The mean DMFT
among the population surveyed was 8.1
The distribution of caries free and DMFT according to gender,
age group, ethnicity and education is shown in the Table 3.
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COMMUNITY DENTAL CARIES PREVENTION PROGRAMME
1.
Water Fluoridation
Singapore adopted water fluoridation in 1954 after a careful
review of the benefits of fluoridation, its effectiveness in
reducing dental caries and that the fluoride level in the tap
water was safe when consumed.
Since 1957, the entire water supply of Singapore was
fluoridated at 0.7 mg/l. In the same year, a ten-year study was
conducted to compare the prevalence rate of dental caries
among children in Singapore against that of Malacca in
Malaysia, where the water was not fluoridated. The study
showed that fluoridation of drinking water in Singapore had
lowered the prevalent rate of dental caries by 30% among our
children. There was no corresponding fall in the prevalence rate
of dental caries among children of Malacca.
In the light of an increase availability of multiple forms of
fluoride, the “optimal” fluoride concentration of drinking water
was reduced to 0.6 mg/l in January 1992. The current
fluoridation level of 0.4 to 0.6 mg/l in our tap water is well
within the latest (2004) World Health Organization (WHO)
guidelines of 1.5 mg/l and is not expected to have any adverse
health concerns.
Today, fluoride in drinking water has contributed to Singapore
having one of the lowest DMFT index for 12 year olds.
2.
School Dental Service: Dental Services to Primary Schools
The School Dental Service (SDS) was introduced in 1948. The
first school dental clinic was set up in an operating theatre at
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the Tan Tock Seng Hospital with just 1 school dental officer.
Over the years, dental clinics were built in primary schools in
tandem with the Ministry of Education’s school development
plan. The mission was to provide on-site, free basic oral health
care services, health promotion and education to the children.
Dental Nurses (now known as Dental Therapists) were deployed
to provide the services.
Today, the services are provided to all primary school children
(including children with special needs) via 185 school dental
clinics. The services can be broadly divided into curative,
preventive care and oral health promotion. Curative services
include fillings, pulpal therapy, and extractions. Scaling,
polishing, application of fluoride therapy and fissure sealants
on permanent teeth as well as interceptive orthodontic therapy
constitute the main preventive services. Annually, staff is
audited on caries management to ensure that the services,
especially the preventive services, are properly and timely
executed. In addition, tooth brushing is taught and reinforced
throughout the primary school years and dental health talks
are conducted to empower the children with the skills and
knowledge to take care of their own teeth.
3.
Extension of dental services to all secondary schools
To build on the good results of the dental programme for
primary school children, the Government extended the free onsite dental services to all secondary school children in 2002.
Unlike the delivery of services to the primary school children,
the secondary school children are provided with readily
available, accessible and comprehensive basic oral health care
services via 20 school dental clinics and 27 mobile dental
clinics.
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Each mobile dental clinic visits 4-5 secondary schools in a year
and spends 2-3 months in each school to render the secondary
school children dentally fit for the year before moving off to the
next school.
4.
Services to Preschoolers
Every year, the dental therapists will visit kindergartens and
deliver an oral health promotion programme to the preschoolers. Through interactive activities and presentations, the
pre-schoolers are taught the importance of oral health and how
to prevent dental caries. Parents are also provided with dental
health education resource materials – My Toothbrushing Diary
and stickers are distributed to complement what the pre-school
children have learnt in schools.
Pre-school children who require dental care could seek dental
treatment at School Dental Centre. They charge a
concessionary rate that takes into account a 75% subsidy from
the Government. Permanent residents get 25% subsidy.
5.
Programme for Low Social Economic Status (SES) preschool
children
In 2012, SDS and a Family Service Centre (FSC) initiated a
programme for the low SES pre-schoolers. The children were
referred from the FSC to School Dental Centre and to 3 of the
field dental clinics for dental screening and treatment during
the school holidays. It was found that about 30 per cent of the
children had rampant caries and they required several visits to
complete treatment. Fees were waived for these children.
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The children were accompanied by their parents who were
taught how to take on an active role at home for their
child/children’s oral health.
6.
Caries Risk Assessment
In Jan 2005, Caries Risk Assessment (CRA) was introduced in
SDS. Colour-coded stickers were first used on treatment charts
to identify the caries risk status of all the primary school pupils
enrolled in SDS programme.
With the introduction of IDEAS, factors like past caries
experience, number of white spot lesions and oral hygiene
status were input into the system to identify and track the
patients’ caries risk, electronically. Originally, only pupils in
Primary 5 identified as low caries risk were exempted from
screening. It was later extended to 2 levels of pupils: pupils in
Primary 3 identified as low caries risk were also exempted from
screening.
The application of the CRA has reduced the number of dental
therapists required to manage the Primary School Oral Health
Programme.
7.
Community Service for the needy, elderly
Adult dental services are rendered at Government polyclinics
and mainly at private dental clinics.
Since 2004, during the school holidays in June and December,
MDCs manned by dental officers and oral health therapists
have been deployed to community centres and nursing homes.
There, they attended to the elderly needy in the community and
to the residents of the nursing homes at subsidized rates. Most
of the treatment provided was scaling, fillings and extractions.
For patients who required follow up treatment, they were
provided with a list of private dental clinics under the
Community Health Assist Scheme (CHAS) where they could
attend and continue to enjoy government subsidies for basic
dental care.
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HOME CARE FOR DENTAL CARIES CONTROL
Plaque Disclosing Programme
SDS collaborated with Oral Kare in the development of a plaque
disclosing toothpaste to help children develop proper brushing habits
and to help them improve their oral hygiene. The toothpaste was
introduced into the Primary 3 oral health promotion programme.
Pamphlets were distributed for the children to bring home to their
parents for the continuation of the programme at home.
A survey was conducted to evaluate the impact of the plaque
disclosing programme among the Primary 4 pupils who had
participated in the programme the previous year when they were in
Primary 3.
30% of the pupils showed improvement in their oral health status as
compared to the previous year and 53% increased knowledge on the
causes and effects of dental diseases and the reasons for brushing
their teeth. Hands-on teaching on the use of disclosing toothpaste
created a “seeing is believing”
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CARIOLOGY EDUCATION IN DENTAL SCHOOL
The Faculty of Dentistry (FOD), National University of Singapore (NUS)
is currently the only dental school in Singapore.
Cariology education is taught throughout the four years of the dental
undergraduate curriculum. The academic aspects of cariology (i.e.
aetiology, pathogenesis, fluorides, and caries preventive programmes)
are covered in the first year. This is taught by staff from the Discipline
of Oral Sciences (Dental Public Health) and Paediatric Dentistry. To
complement this, staff from the Discipline of Restorative Dentistry
teach the undergraduates about the management of dental caries in
the pre-clinical Operative Technique curriculum.
The students will then apply the knowledge and skills acquired in the
pre-clinical years when they enter clinics in their third and final years
as part of the Operative/Restorative Dentistry, Paediatric Dentistry,
and Special Needs Dentistry clinics. Apart from providing curative
treatment for the management of caries, the students are also taught
to perform Caries Risk Assessments for their patients where they
assess dietary intake, use of fluoride, bacteria count (Strep Mutans,
Lactobacillus), saliva pH/buffering capacity and flow rates etc.
REFERENCES
Gao XL, Hsu CYS, Loh T, Koh D, Hwarng H.B, Xu Y. Dental caries
prevalence and distribution among pre-schoolers in Singapore.
Community Dental Health (2009) 26, 12–17.
School Dental Service, IDEAS System.
Adult Oral Health Survey 2003.
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TAIWAN, REPUBLIC OF CHINA
Lin-Yang CHI
Lih-Jyh FUH
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
TAIWAN, REPUBLIC OF CHINA
Lin-Yang CHI35
Lih-Jyh FUH36
DENTAL CARIES EPIDEMIOLOGY
According to the national survey results, dental caries prevalence for
5-6 year-old children decreased from 89.38% (1997) to 79.32% (2011)
(Figure 1). In the meantime, deft index decreased from 7.31 to 5.44
(Figure 2). It is clear that much more efforts are indicated to meet the
target for the year 2000 set by WHO for the 5-year-old that caries
prevalence should be less than 50%.
Figure 1: Secular trend of prevalence of dental caries among
preschool children in Taiwan, 1997-2011.
Associate Professor, Department of Dentistry, National Yang-Ming University, Taipei, Taiwan.
Email: Lin-Yang CHI <chily@ms.ym.edu.tw>
36 President, Association for Dental Sciences, R.O.C., Professor & Director, Department of
Prosthodontics, School of Dentistry, China Medical University Taichung, Taiwan.
Email: ljfuh <ljfuh@mail.cmu.edu.tw>
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Figure 2: Secular trend of deft among preschool children in Taiwan,
1997-2011.
Table 1: DMFT and DMFS of schoolchildren in Taiwan, 2006
Age (year)
DMFT index
DMFS index
6
0.25
0.33
7
0.48
0.60
8
0.94
1.18
9
1.07
1.50
10
1.33
1.88
11
2.00
2.79
12
2.58
3.91
While the WHO goal for 12-year-old in 2000 was DMFT less than 2.0,
schoolchildren in Taiwan did not meet that goal in 2006. The DMFT of
12-year-old in Taiwan was 2.58 and DMFS 3.91 in 2006 (Table 1). It
should be noted that DMFT is a composite index and changes in its
value need to be interpreted cautiously. For example, Taiwan had its
National Health Insurance launched in 1995, which provided most
dental services, including operative dental services, to more than 98%
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of its 23 million population. While the decrease in total DMFT was not
satisfactory, the significant increase in F (Filling) component needs to
be taken into consideration (Table 2).
Table 2: DMFT and its components of 12-year-old in Taiwan,
2000-2012
Year
DMFT
2000
3.31
2006
2.58
2013*
2.50
DT
MT
FT
1.35
(41%)
1.15
(45%)
0.03
(1.0%)
0.12
(5.0%)
1.93
(58%)
1.31
(51%)
0.82(33%)
0.01 (0.4%)
1.67(67%)
* preliminary results
Source: YH Huang (2013)
Table 3: Prevalence of dental caries and DMFT among people aged
18+ in Taiwan, 2004 (N=2660)
Gender
Male
Female
Age group
18-34
35-44
45-49
50-64
65-74
75+
Area
Metropolitan
City
County
Mountainous
village
Total
n
Prevalence
%
p-value
mean
DMFT
SD
p-value
1145
1196
84.64 <0.0001
91.46
7.1
9.73
6.94 <0.0001
6.84
842
397
405
488
150
59
83.63 <0.0001
90.91
88.94
92.48
92.41
82.47
6.59
7.27
7.85
9.99
15.81
15.45
7.93 <0.0001
6.01
7.14
6.49
5.3
5.68
184
393
1724
94.24 <0.0001
95.55
85.79
9.20
8.90
8.25
5.19
7.18
7.96
40
90.1
6.49
2.08
2341
87.99
8.39
7.01
Source: YH Yang (2006)
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Prevalence of dental caries among elderly people (65 years old and
over) in Taiwan was 89.36% in 2004, with mean±SD of DMFT index as
15.71±5.43. There was significant urban-rural difference as 9.20±5.19
and 6.49±2.08, respectively (P<0.0001) (Table 3).
While women had a higher prevalence (61.24%) of filling for dental
caries than men (47.87%), men had in average more remaining teeth
(24.03±6.41 teeth) than women (22.41±6.70 teeth) (p<0.0001). Those
aged 65+ had a lowest filling rate (43.55%) and least remaining teeth
(14.35±5.65 teeth) among all age groups (both p<0.0001).
Table 4: Prevalence of filling for dental caries and the number of
remaining teeth among people aged 18+ in Taiwan, 2004
(N=2660)
Prevalence of Filling
mean
SD
p-value
Gender
Male
Female
Age group
18-34
35-44
45-49
50-64
65-74
75+
Area
Metropolitan
City
County
Mountainous
village
Total
No. of remaining teeth
mean
SD
p-value
47.87
61.24
40.16 <0.0001
35.91
24.03
22.41
6.41 <0.0001
6.70
56.28
57.01
58.08
52.09
46.33
36.50
58.56 <0.0001
38.75
43.66
31.65
21.40
18.01
25.70
24.58
23.65
21.00
14.31
14.43
6.06 <0.0001
4.73
6.05
6.09
5.69
5.60
39.64
58.85
56.09
26.68 <0.0001
43.81
42.48
24.77
22.75
23.17
4.26
7.34
7.51
23.54
13.73
23.86
1.67
54.70
38.46
23.23
6.62
0.004
Source: YH Yang (2006)
As far as living area was concerned, people living in the mountainous
areas had a lowest filling rate (23.54%), while people living in cities
had least remaining teeth (22.75±7.34 teeth) (p<0.0001 and p=0.004,
respectively) (Table 4). Women had a higher prevalence of edentulism
(2.2%) than men (1.2%) (p=0.067). As would be expected, those aged
65+ had the highest prevalence of edentulism (13.6%) among all age
groups (p<0.0001). Adult inhabitants living in metropolitans had a
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higher prevalence of edentulism (2.6%) than those living in
mountainous villages, but the difference was not statistically
significant (P=0.67) (Table 5).
Table 5: Prevalence of edentulism among people aged 18+ in
Taiwan, 2004 (N=2660).
Gender
Age
group
Area
Male
Female
18-34
35-44
45-49
50-64
65-74
75+
Metropolitan
City
County
Mountainous
village
Total
n
1353
1307
1007
437
455
527
163
72
195
411
2009
Edentulism
case
%
17
1.2
28
2.2
0
0
1
0.2
5
1.1
8
1.5
19
11.7
13
18.1
5
2.6
8
2.0
32
1.6
45
0
0.0
2660
45
1.69
p-value
0.067
<.0001
0.67
Source: YH Yang (2006)
Table 6: Oral health status of disabled people in Taiwan, 2005
FT
%
Caries
%
Filling
0.39
0.80
69.43
35.93
3.98
0.58
2.04
87.89
36.06
10.31
4.67
3.29
2.35
93.27
32.86
17.68
4.68
11.50
1.50
98.73
20.70
Age
DMFT
DT
12
3.14
1.95
13-18
6.60
19-44
>44
MT
Source: National oral health survey of disabled people in Taiwan (2005)
There were 953,214 registered disabled people in 2006, which
accounted for 4.2% of the total population. The DMFT of the 12-yearold disabled people were 3.14, in which DT was 1.95 (62.1%) – both
were significantly higher than their counterparts in the non-disabled
population. However, the FT component was 0.80 (25.5%) and
significantly lower than the nondisabled population (1.17 and 45.3%),
indicating that there was a disparity in oral health services provided
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to and/or used by the disabled population (Table 2, 6 and 7).
Table 7: Oral health status between disabled and non-disabled
people aged 6-18 in Taiwan, 2005.
Age
DMFT
DT
MT
FT
ND
D
ND
D
ND
D
ND
D
6
0.20
0.21
0.12
0.18
0.00
0.01
0.09
0.02
9
1.36
1.64
0.52
1.11
0.06
0.17
0.78
0.37
12
2.58
3.14
1.20
1.95
0.13
0.39
1.17
0.80
15
4.67
6.22
2.39
3.79
0.19
0.58
2.09
1.84
18
4.92
7.44
1.87
4.19
0.30
0.69
2.75
2.57
Source: National oral health survey of disabled people in Taiwan (2005)
COMMUNITY DENTAL CARIES PREVENTION PROGRAM
Topical fluoride application has been one of the most effective
measures to prevent dental caries. Fluoride varnish, used by
dentists to prevent caries for more than three decades, has been
shown to reduce caries in the permanent dentition by 46% and
primary
dentition
33%.
Taiwan
Health
Promotion
Administration (THPA), Ministry of Health and Welfare, has
provided topical fluoride application service to all children aged
5 years or less twice a year since 2004, extended to those aged
6 years or less in 2013.
Figure 3: Utilization rate of topical fluoride application service
among preschool children in Taiwan, 2007 -2011
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For children of special need, including those of low -income
families, indigenous areas, remote areas, and those disabled,
the service has extended to 12-year-old and four times a year.
The utilization rate increased from 11.4% in 2007 to 20.1% in
2011 (figure 3), and THPA expected to significantly improve the
utilization rate by sending dentists into the kindergartens/
nurseries since 2013.
Studies have shown that more caries happened in occlusal
surface of posterior teeth than on smooth surfaces. Pit & fissure
sealant (PFS) has been regarded as a more effective measure to
prevent occlusal caries than fluoride-containing materials.
Traditionally public PFS programs have been offered to targeted
groups of high risk in developing dental caries, partly due to its
relatively high cost. THPA launched a free PFS service to the
underprivileged schoolchildren since 2010, and is preparing to
extend the service to all first-grade schoolchildren (around
195,000 children) in Taiwan starting from 2014.
Being unable to fluoridate drinking water, Taiwan Dental
Association (TDA)
has chosen to promote fluoridated
mouthwash in primary schools as an alternative strategy to
prevent dental caries since 1997 with sponsorship from the
government. An earlier pilot study carried out by Taiwan
Academy of Pediatric Dentistry showed that daily use of 0.05%
NaF mouthwash had a better effect of caries reduction (44%)
than weekly use of 0.2% NaF mouthwash (36%). However, the
later scheme was chosen due to administrative considerations.
For the past 16 years more than 98% of Taiwan’s 1.9 million
schoolchildren used 10c.c. mouthwash containing 0.2% NaF
after lunch weekly during school days (Table 8).
In fact, TDA has done a lot in oral health education. National
oral hygiene skill competition of schoolchildren had been one of the
major yearly events to promote schoolchildren’s motivation of oral
hygiene from 1993 to 2004. The competition grinded to a halt due to
shortage of government budget and changes in health promotion
strategy.
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Table 8: Coverage rate of NaF mouthwash program of
schoolchildren, 1997-2004.
Year
No. of
Counties
& Cities
1997
10
34
40,640
2.1
1998
13
48
52,281
2.7
1999
16
368
457,773
23.8
2000
21
1,959
1,414,000
73.4
2001
25
2,429
1,819,495
94.5
2002
25
2,632
1,903,357
98.0
2003
25
2,627
1,883,509
98.2
2004
25
2,638
1,882,186
98.4
No. of
Schools
No. of
Students
Coverage
rate (%)
The Ministry of Education (MoE) launched Health Promoting
School (HPS) program in 2005, and ‘oral health’ has been listed
as one of nine optional themes. More than one third of the HPSs
chose oral health as their focus in 2006. MoE tried to establish
a network of school dentists in 2009, which ended up with less
than 20% of the 2500 primary schools did find a school dentist,
and the program is practically suspended now.
HOME CARE FOR DENTAL CARIES CONTROL
A national campaign ‘National Oral Health Week’ will take place
during the last week of October since 2010. The national associations
of dentists join forces with TPHA to provide the latest information of
the epidemiology of oral diseases and methods of prevention. In
addition to brushing teeth regularly with fluoridated toothpaste,
people are also advised to use dental floss to promote periodontal
health. Bass method has been chosen as the ‘standard method’ of
brushing teeth. However, people are also encouraged to visit dentists
every 6 months to discuss the best way to keep their oral hygiene in a
high standard. It should be noted that Taiwan’s national health
insurance provide most of dental services free of charge to about 98%
of the national population except the prosthetic and orthodontic
treatment.
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Figure 4: Percentage of people brushing their teeth before sleep by
age group in Taiwan, 2001and 2005 (source: TPHA)
According to a national survey carried out by TPHA in 2005, about
one quarter of the population went to bed in the night without
brushing their teeth. Compared to the survey results in 2001, there
was a significant improvement in the percentage of people brushing
their teeth every day (98.2% in 2005), mean number of toothbrushing
per day (1.87 times in 2005), and the percentage of people using
dental floss regularly (17.8% in 2005). The improvement was most
obviously among those aged 12 and less. Females performed better
than males and the better the education the better the oral hygiene
practice.
Times
Figure 5: Percentage of people brushing their teeth everyday by age
group in Taiwan, 2001and 2005. (source: TPHA)
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Figure 6: Mean number of toothbrushing per day by age group in
Taiwan, 2001and 2005 (source: TPHA)
Figure 7: Percentage of people flossing their teeth every day by age
group in Taiwan, 2001and 2005 (source: TPHA)
DENTAL EDUCATION IN CARIOLOGY IN DENTAL SCHOOL
There are 7 universities in Taiwan boast a department of dentistry – 5
of them have a school of dentistry/Stomatology. Most of the
undergraduate students came from local high schools, and studied for
6 years (including 1-year internship) before graduation. Cariology is
not offered as an independent course but instead the relevant
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knowledge and discussion are disseminated into many required
courses such as: oral histology, oral pathology, oral radiation,
operative dentistry, endodontics, and dental public health. Almost
every dental department in Taiwan offers postgraduate course – most
of them focus on specialties of clinical dentistry, and some of them
have an independent institute of oral medicine/biology for studying
basic dental sciences.
REFERENCES
Chen HS et al. National oral health survey for the disabled people in
Taiwan, 2005.
Yang YH et al. National oral health survey for adults and elderly people,
2006.
Huang ST et al. National oral health survey for children and
adolescents in Taiwan, 2006.
Huang ST et al. National oral health survey for preschool children aged
less than 6 years old, 2012.
Chiou YC et al. Report on the National Fluoridated Mouthwash Anticaries program for schoolchildren, 2012.
Huang YH et al. National oral health survey for children and
adolescents in Taiwan, 2013 (preliminary report).
Administration of Health Promotion, Ministry of Health and Welfare,
http://www.hpa.gov.tw/BHPNet/Web/HealthTopic/TopicArticle.aspx?
No=200811210013&parentid=200811100003, visited on 2013.10.25
Administration of Health Promotion, Ministry of Health and Welfare,
http://www.hpa.gov.tw/BHPNet/Web/HealthTopic/TopicArticle.aspx?
No=200811210014&parentid=200811100003, visited on 2013.10.25
Administration of Health Promotion, Ministry of Health and Welfare,
http://www.hpa.gov.tw/BHPNet/Web/HealthTopic/TopicArticle.aspx?
No=201212170001&parentid=201003040001, visited on 2013.10.25
Administration of Health Promotion, Ministry of Health and Welfare,
http://www.hpa.gov.tw/BHPNet/Web/HealthTopic/TopicArticle.aspx?
No=200811210016&parentid=200811100003, visited on 2013.10.25
Administration of Health Promotion, Ministry of Health and Welfare,
http://www.bhp.doh.gov.tw/BHPNet/Web/HealthTopic/TopicBul
letin.aspx?id=201305210001&parentid=200712250070, visited on
2013.10.25
Administration of Health Promotion, Ministry of Health and Welfare,
http://www.hpa.gov.tw/BHPNet/Web/HealthTopic/TopicBulletin
.aspx?No=201203140001&parentid=201003040001 , visited on
2013.10.25
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Administration of Health Promotion, Ministry of Health and Welfare,
http://www.hpa.gov.tw/BHPNet/Web/HealthTopic/TopicBulletin
.aspx?No=201203140002&parentid=201003040001 , visited on
2013.10.25
Administration of Health Promotion, Ministry of Health and Welfare,
http://www.hpa.gov.tw/BHPNet/Web/HealthTopic/TopicArticle.
aspx?No=201011180001&parentid=200811100002, visited on
2013.10.25
Administration of Health Promotion, Ministry of Health and Welfare,
http://www.hpa.gov.tw/BHPNet/Web/HealthTopic/TopicArticle.
aspx?No=201011180001&parentid=200811100002, visited on
2013.10.25
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THAILAND
Sutha JIENMANEECHOTECHAI
Chantana UNGCHUSAK
Supranee DALODOM
Piyada PRASERTSOM
Oranart MATANGKASOMBUT
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
THAILAND
Sutha JIENMANEECHOTECHAI37
Chantana UNGCHUSAK37
Supranee DALODOM37
Piyada PRASERTSOM37
Oranart MATANGKASOMBUT38
ORAL HEALTH STATUS
For over 20 years since 1977, the Bureau of Dental Health has been
responsible for the national oral health survey in every 5 years to
acquire important dental health status of Thai people. The survey
data have been used for planning, evaluation, service provision, and
adjusted operational strategies. In addition to the national survey, the
Department of Health support for provincial-based oral health survey
as a baseline for setting priorities and adjusted operational plan in the
areas.
The results of the suggested that dental caries status of Thai people
tends to improve slightly over the past decade, i.e. reduced tooth
decay in children, increased functional teeth in adults and elderly,
and reduced tooth loss.(Table 1, 2, Figure 1-3) Regarding the
prevalence of dental fluorosis, data revealed 5.8 % in 12 years old.
The level of severity was very mild and mild level according to Dean’s
index (Table 2). The major sources of over fluoride consumption is
underground water. There was 0.9 % of drinking water sources
containing fluoride more than 4 milligrams per liter.
Bureau of Dental Health, Department of Health, Ministry of Public Health, Nontaburi.
Email: Sutha Jienmaneechotechai <suthajien@gmail.com>,
Chantana Ungchusak <uchantana@gmail.com>,
Supranee Dalodom <supranee.d@anamai.mail.go.th>,
Piyada Prasertsom<pprasertsom@gmail.com>
38 Faculty of Dentistry, Chulalongkorn University,
Email <Oranart Matangkasombut@ <noon.oranart@gmail.com>
37
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Table 1a: Oral health status of Thai population by prevalence of
dental caries (%), National oral health survey 19842012.
Age
(yrs)
% Prevalence of dental caries
1984
1989
1994
2001
2007
2012
Primary teeth
3
-
66.5
61.7
65.7
61.3
51.7
5
-
-
-
-
80.6
-
71.6
-
-
87.4
-
78.5
-
83.1
85.1
-
-
-
12
45.8
49.2
53.9
57.3
56.9
52.3
15
-
-
-
62.1
66.3
62.3
18
63.1
63.3
-
-
-
-
17-19
-
-
63.7
-
-
-
35-44
80.2
76.8
85.7
85.6
89.6
86.7
≥60
95.2
93.9
-
-
-
-
--
-
95.0
95.6
96.1
97.1
5-6
6
Permanent teeth
60-74
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Table 1b: Oral health status of Thai population by mean no. of
decay, missing and filled teeth, National oral health
survey 1984-2012.
Age
(yrs)
Mean no. of decay, missing and filled teeth
1984
1989
1994
2001
2007
2012
Primary teeth
3
-
4
3.4
5
-
-
-
3.2
2.7
5.4
-
4.9
-
-
6
-
4.4
-
5.6
5.7
-
-
-
12
1.5
1.5
1.6
1.6
1.6
1.3
15
-
-
-
2.1
2.2
1.9
18
3.0
2.7
-
-
-
-
17-19
-
-
2.4
-
-
-
35-44
5.4
5.4
6.5
6.1
6.7
6.0
16.3
16.2
-
-
-
-
-
-
15.8
14.4
15.8
14.9
5-6
6
3.6
Permanent teeth
≥60
60-74
Table 2: Mean decayed (dt, DT) missing (mt, MT) and filled (ft, FT)
teeth by indexed age group, 2012.
3
No. of
teeth
present
19.93
5
Age
(yrs)
Decayed
dt, DT
Missing
mt, MT
Filled
ft, FT
DMFT,
dmft
2.57
0.05
0.06
2.68
20.04
3.98
0.13
0.26
4.37
12
26.16
0.55
0.04
0.72
1.34
15
27.70
0.89
0.09
0.97
1.95
35-44
28.27
0.77
3.69
1.57
6.04
60-74
18.81
1.41
13.19
0.44
15.03
80-89
8.92
1.24
23.08
0.09
24.41
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100
90
80
70
60
50
40
30
20
10
0
66.5
65.7
61.7
61.3
51.7
1989
1994
2001
2007
2012
Figure 1: Trend of dental caries in 3 years old children, National
oral health survey 1994-2012
100
90
80
70
60
50
40
30
20
10
0
45.8
49.2
1984
1989
53.9
57.3
56.9
1994
2001
2007
52.3
2012
Figure 2: Trend of dental caries in 12 years old children, National
oral health survey 1994-2012
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Table 4: Prevalence of dental fluorosis in 12 years old children
1984-2012
Year
Region
1984
Urban
1989
1994
2001
2007
2012
8.8
4.7
13.7
11.2
6.1
12.4
Rural
18.7
9.4
18.6
10.4
5.6
7.2
Country
16.8
8.2
17.0
11.6
5.8
9.2
Tooth loss is the main problem in adult and elderly. WHO has set “20
functional teeth” as the key indicator of oral health in these groups.
National data revealed that more than 90% of Thai adults had at least
20 teeth in their mouth but half of the teeth were rapidly lost in
elderly. However, the situation became better in each survey (Figure
4). Although, tooth loss situation was gradually declined, there was
still a group of edentulous mouth in elderly requiring rehabilitation
for their quality of life improvement (Figure 5).
100
90
80
70
60
50
40
30
20
10
0
91.9
47.7
96.2
92.3
49
54.8
97.8
57.7
Adult
Elderly
1994
2001
2007
2012
Figure 4: Percentage of adult and ederly with 20 functional teeth,
1994-2012.
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Pecent
20
18
16
14
12
10
8
6
4
2
0
16.3
10.5
8.2
1994
2001
7.2
2007
2012
Figure 5: Percentage of Thai Elderly with edentulous mouth
MAJOR ORAL HEALTH PROMOTION AND PROVENTION PROGRAMS
1)
Promotion and prevention programs for pregnant women and
children 0-5 years
The Thai government has major concerned with addressing the
tooth decay problem among children as it may pose adverse
effect on children’s oral health, general health and
development. The intervention to control dental caries in
primary teeth was initiated as a part of the Dental Health
program in the 1992–1996 National Health Development Plan
with subsequent intervention programs/projects every 3 – 5
years. In 2013, the Ministry of Public Health announced a
policy to prevent and control tooth decay among the childhood.
The national indicator was set and targeted to reduce
prevalence of dental caries in primary teeth. The indicator is
"By 2014, no more than 57% of early childhood (3 years old)
having tooth decay”. In line with this, dental care services were
identified which include oral cavity check-up; skill trainings on
tooth brushing for caregivers; children with high risk of tooth
decay receiving fluoride varnish application or other suitable
forms.
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Major activities for this target group include:
1)
Promotion and prevention service for pregnant women.
Pregnant women are entitled to receive a periodontal
examination and oral hygiene instruction, as well as an
essential treatment according to the benefit package of
the Universal Health Care Coverage. These services are
integrated into ANC clinic.
2)
Promotion and prevention service for children 0-2 years.
The service is integrated into the well-child clinic.
Children
receiving
immunization
program
are
transferred for further oral health check-up for hygiene
and early stage tooth decay, with a plan for continuous
service and care. Parents will be advised and trained
how to brush the child’s teeth. Children with any tooth
decalcification (white spot) found will receive locally
application of fluoride such as fluoride varnish or other
suitable forms, with follow-up appointments up until 3
years old.
3)
Promotion and prevention service for children 3–5 years.
Dental health promotion service is incorporated into
other health care in the day care center for early
childhood or pre-school children. The service activities
include daily tooth brushing after lunch, control of
sugary diets, and oral health checkup by dental
personnel for 2 times a year.
4)
Set up a community-based surveillance for primary tooth
decay
In addition to institutionalized services, Thailand makes
use of village health volunteers (VHVs) to help monitor
tooth decay among children at family and community
levels. The VHVs serve to locate potential children at
high risk of tooth decay, and inform parents for early
prevention by brushing teeth with fluoridated
toothpaste. Oral health check up is combined with other
health care activities such as weigh measuring to
monitor nutritional status. (For details, see section 4.5
on Village Health Volunteers).
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5)
Communication campaigns on "Good teeth begins at first
tooth"
Due to the high rate of primary tooth decay and parents’
lack of understanding and concern of primary teeth
care, educational campaigns are conducted to create
social trends through various forms of media so as to
raise awareness on dental care by starting from the first
erupted tooth. The campaigns are undertaken in
collaboration of the Department of Health, the National
Health Security Office, and the Thai Health Promotion
Foundation.
2)
School oral health promotion and preventive dentistry.
Figure 6: Thailand School Oral Health Program Strategies
Oral health prevention and promotion in school-age children
has long been implemented continuously for more than three
decades. During the first decade (1977-1987), the focus was on
the incremental dental care by school dental nurse. However,
because of less coverage of care, the second decade (19881998) had introduced the school-based dental health
surveillance by utilizing available data to solve dental health
problem on school own effort, along with improving skills in
oral health care. During the third decade up until the present,
under the framework of “health promoting school to promote
healthy behaviors among Thai children”, the programs on tooth
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brushing, proper diets (reduced flour and sugar) and enhanced
health literacy for children have been undertaken using 3 key
strategies. They are after lunch tooth brushing with fluoridated
toothpaste in school; food environmental management in
school’ and organizing curriculum-based learner development
activities (Figure 6).
1)
Development of school network of Thai healthy teeth
student.
It aims to establish a school network to carry out dental
health promotion in school. The high potential school
serves as a host school and advocates surrounding
schools to work together to promote school dental health
by involving teachers, parents, students, and the
communities. In each year, there are learning and
sharing activities in the school- network with successful
experience, as the learning source for other schools.
2)
Campaigns and policy recommendations for "No-Soda
School"
In order to reduce risks of obesity and oral health
problem, campaigns have been conducted to encourage
schools to stop selling carbonated drinks, sugared
drinks, and crunchy snacks in school by urging through
the education area offices to take action so that all
schools in their respective areas become ‘No-Soda
Schools’ (More details in section 5.4 on Sweet Enough).
3)
Collaborative work with the private sector (Public-private
mix)
The school dental health promotion program is operated
with the cooperation from the Colgate-Palmolive,
Thailand to initiate the “Bright Smile Bright Future”
project, for which materials/media, toothbrushes and
toothpastes are supprted by the private sector.
4)
Fluoridated milk for preventing dental caries
It was started in the year 2000 as a collaborative project
between the Department of Health, the Royal Chitralada
Projects, the World Health Organization, and the Borrow
Foundation. Fluoride is added to milk provided under
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the school supplementary food (milk) project in order to
prevent tooth decay in children 4-12 years. Evaluation of
early phrase in Bangkok reported that among children
who drink fluoridated milk for 5 consecutive years, the
effect on reducing permanent tooth decay is 34.4%
higher than among children who did not drink
fluoridated milk. Based on this, the project has then
been expanded to the provincial level in Chumphon,
Khon Kaen, Surat Thani, Sa Kaeo, Chonburi, Krabi and
Phatthalung, covering approximately 954,901 children
within 13 years. Moreover, this project also serves to
help develop the fluoridated milk project in foreign
countries such as Korea, Malaysia, Brunei and
Mongolia.
3)
Oral health promotion program in elderly
Thailand is moving toward an aging society and expected to be
aged society in 2025. Nowadays, the number of older people 60
years and more is 9.5 million persons or 14.7 percent which
increase about 200,000 persons every year. A higher proportion
of elders cause higher prevalence of Chronic Diseases, such as
diabetes, hypertension and oral diseases with common risk
factors and need more complexity care than the younger.
Tooth loss is the main oral health problem in aging population
especially complete tooth loss that related to eating, chewing
and swallowing abilities, affected to poor nutrition, unhealthy
and low quality of life. The 7th National oral health survey in
2012 reported that the elders who have at least 20 functional
teeth is increased from 49% in 2001 to 58% in 2012 but there
were still 8.2% who lost all of their teeth and 2.5% or 250,000
older people needed Complete dentures. Moreover, oral hygiene
behavior is less effective to prevent tooth loss. Bureau of Dental
Health has launched Oral Health Programs since 2005 to
improve their oral health by increasing proper functional teeth
(at least 20 permanent teeth or 4 posterior occlusal pairs).
Networking co-operation, oral health services system towards
Comprehensive care, Building the capacity of health personnel
and key persons in the community, National policy and
Campaign to advocate social response, Model development and
knowledge management, were used as Basic strategy. Oral
Health Programs related to the Quality of Life for Aging
Population are as follows.
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1)
The Royal denture project.
To celebrate on the auspicious occasion of His Majesty
the King, oral health promotion and rehabilitation
service for Thai elderly was initiated. This program
correspond to the King’s speech that concerning on oral
health issue of Thai people “Persons who lose their
teeth, it’s difficult to enjoy food, which make them feel
unhappy, mental health is ill and becomes weakened”.
The objectives of the program are to provide more
coverage in the complete denture service and to develop
proper promotion & prevention model for Thai elders.
Since 2005, complete denture service covers more than
300,000 elders all over the country or 35,000 persons
each year.
2)
Elderly club for oral health promotion.
In 2006, the Bureau of Dental Health offered a
development program for elderly club to arrange the
activities for oral health promotion of members. Initially,
32 model clubs were developed and have been
progressively expanded up until today with 2,620 clubs
nationwide, covering more than 500,000 older people.
3)
Promotion and prevention services by District health
promoting hospital.
In 2008, the Bureau of Dental Health mobilized the
district-based services of oral health promotion and
prevention among the elderly group. The activities
included oral health examination and risk group
screening, oral hygiene instruction, plaque control,
fluoride application to prevent root caries, cleaning and
polishing to prevent acute periodontal disease. In 2012,
the project covered 970 District health promoting
hospital.
4)
Integration with health promotion for the elders.
The Department of Health, Bureau of Health promotion,
has set 5 standards of healthy elder which include a)
physical, mental, and social well-being; b) 20 functional
teeth or 4 posterior occlusal pairs; c) BMI in the normal
range; d) regular physical activities and e) Activities of
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daily living indicated that they can live by themselves. In
2010, oral health prevention and promotion had been
expanded to the subdistrict level as an activity
integrated with health promotion for the elders such as
long-term care activities, health promoting temple
aiming at achieveing healthy elder.
5)
National Geriatric dentistry plan 2014-2021.
In 2012-2013, the National Geriatric dentistry plan had
been formulated as a collaborative plan between the
Ministry of Public Health, the King’s Dental Innovation
foundation, and the Ministry of Education. The plan
consists of:
Strategy 1: development of model, system and quality of
comprehensive oral health care;
Strategy 2: research and development of innovations for
geriatric oral health care;
Strategy 3: geriatric dentistry courses or special training
for health personnel and
Strategy 4: management, including monitoring and
evaluation system.
The National Geriatric Dentistry Plan will improve the
following status: tooth loss, untreated dental caries
including coronal and root caries, periodontal disease
and poor oral hygiene, oral cancer and mucosal lesions,
attrition, xerostomia and other condition related to non
chronic disease.
4)
Campaigns for policy movement to reduce consumption of
sweet diet (Sweet Enough)
The database suggested that in 2002, Thai people consumed
sugar 3 times higher than that of WHO’s recommendation.
Based on this situation, a number of dentists, pediatricians
and academicians of various disciplines who are concerned
with the adverse health effect on Thai children due to excessive
consumption of sugar, had joined together and run the
campaign for policy movement to reduce consumption of sweet
diets. The campaign took various forms to raise Thai social
awareness and to invoke policy and legal movement to reduce
over sugar consumption habits among Thai children. The
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operation received support from the Department of Health and
the Thai Health Promotion Foundation (ThaiHealth).
Operation strategies: Based on the mountain-moving-triangle
concept initiated by Prof. Emeritus Dr. Prawet Wasi, relevant
knowledge and information are utilized for this movement.
1)
Creating and management of knowledge.
The operations of networks was focused on the search of
knowledge and to propose policy issues that would affect
reduced sugar consumption in children; survey of main
food sources of sugar and amount received by children;
opinion survey among dentists and pediatricians toward
the campaign to reduce sweet consumption in children;
review of knowledge on measures to reduce sugar
consumption in oversea countries; and research &
development of implementation model to reduce sugar
consumption in different settings (e.g. schools, child
development centers, hospitals, local administrative
organization, etc.)
2)
Campaign among children using the
procedures (Wisdomization with imagination)
alternative
This includes the trial of campaign model focussing on
the participation of target groups, along with the social
marketing process; attending lectures offered by various
organizations; campaigns at both the national and local
levels. The modes of the campaign include displays,
public information programs through local media (cable
TV, newspapers, radio)
3)
Policy Pressure
This is to explore relevant proclaimations/laws/
ministerial regulations that should be revised to
facilitate reduced sugar consumption, for example:
a)
The Ministry of Public Health’s Notification No. 286,
287: In 2004, it was proposed that the MOPH’s
regulations be revised to prohibit sugar adding in
the follow-up formula milk, which was resulted in
the change in 2006 approving the revision of
ministerial’s regulations as stated in its
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notifications No.156 and 157 to No.286 and 287
that prohibit sugar adding in the follow-up
formula milk.
b)
No-Soda School: It was proposed that the Ministry
of Education announces the No-Soda School
policy, and as a result, the education area offices
throughout the country were informed to
implement No-Doda School by discontinuing the
sale of soda drinks, chunky snacks and highsugared drinks.
c)
Healthy meetings: The MOPH and WHO Thailand
collaborated in the research study and
recommended that proper food for meeting’s
breaks should be provided together with the body
stretching during the meetings. Accordingly, there
were organizations and hotels that made an
agreement as a model to adopt the healthy
meeting approach and serve fruits/low calorie
food.
4)
Ministry of Public Health’s Notification No. 305: On the
suggestion that the Food and Drug Administration
defines a simple food label spelling out the content of
sugar, fat, energy, and sodium, the Ministry of Public
Health’s Notification No. 305, B.E. 2550 (2007) provided
that 5 categories of snacks, i.e. fried or baked potato,
popcorn, crisp rice or crunchy/extruded snacks,
crackers or biscuits and assorted wafer require a
nutrition label with warning "Consume less and exercise
for health"
5)
Building an area-based campaign network: It was aimed
to develop campaigns that suit the economic and social
context in a particular area and to bring about
movement of on-going implementation. It encourages
area-based model development. For example No Sugar
Day: Snacks, drinks or sugar condiment is not allowed
to be sold in schools for one campaign day in a week.
Reducing sugar supply in the school’s kitchen: Schools
have a policy to reduce the purchase of sugar for
school’s cooking and in turn reduced consumption of
sugar and expenses. Changing the expenses into savings:
Schools encourage students to save their money for
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snacks and eat less snacks while practicing money
saving, and coordinate with the local banks to support
student activities.
The campaign network for less sugar consumption in Thai
children employed the key strategy of policy process developed
from major problem issues as the causes of excessive sugar
consumption among children; developed the models,
innovations and media promote health literacy and change the
mindset of thai people to practice proper consumption
behavior; and conduct research & development to offer
snacks/drinks alternatives to the society.
5)
Village health volunteers (VHVs) and dental health work.
The VHVs are those with voluntary spirits to assist in
community health care. They are selected by the villagers and
attended basic training program arranged by the Ministry of
Public Health. At present, there are totally 980,000 VHVs all
over the country of which 10–20 VHVs are located in each
village. The VHVs play vital roles as change agents of health
behavior, convey health information, give advice and
disseminate knowledge, plan and coordinate public health
development activities. They also provide health services such
as health promotion, disease surveillance and prevention, first
aid and primary care, provide drugs and supplies as defined
by the Ministry of Public Health, refer cases for services and
rehabilitation, and organize public sector’s heath activities in
the village/community.
The scope of work engaged by VHVs covers 14 elements
including:
1)
Nutrition,
2)
Health education,
3)
Treatment and care,
4)
Provision of essential drugs,
5)
Sanitation and clean water supply,
6)
Maternal and child health and family planning,
7)
Local
communicable
disease
control
and
prevention,
8)
Immunization promotion,
9)
Dental health promotion,
10)
Mental health promotion,
11)
Environmental health promotion,
12)
Consumer protection,
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13)
14)
Prevention and control of accidents, disasters,
and non-communicable diseases, and
AIDS
In 2012, VHVs’capacity building was implemented by offering
VHVs specialized training programs. These programs were
intended to be conducted by the provincial health offices to
correspond their local problem situation. In 2013, the dental
health specialized program was added and the training has
been extended to improve VHVs’ knowledge, skills, and
expertise in dental health promotion. This is a part of the
movement to promote people’s good oral health and their
capability to take care of themselves and family members
especially children and the elderly to change health behavior.
Finally, social measures were collectively established and
management mechanism was in place to facilitate better
community health care system.
HOME CARE FOR DENTAL CARIES CONTROL
Fluoride tooth paste is common among Thai. Most of toothpastes in
the market are fluoridated. The fluoride content in tooth paste
normally sale in Thailand is 1000 ppm according to FDA regulation.
Data from the recent survey reported that most of Thais used fluoride
toothpaste in their daily life. There were 91.4% of school children
used fluoride toothpaste. The figure decreased with age. There were
89.5% in adolescent (15 yrs), 81.0% and 80.7% in adult and elderly
respectively. Mouth-rinsed was not common among Thai people,
especially commercial mouth-rinse. There was 27.2% and 14.6% of
adult and elderly in the recent survey reported to use mouth-rinse in
their daily self-cleansing.
The major problem of home care is the effectiveness of tooth brushing.
Although toothbrushing twice daily is common knowledge among
people but there were approximately 5% of people who didn’t brush
their teeth daily. Moreover the quality of tooth brushing is not clean
enough for disease prevention. The Bureau of Dental Health has
established self-care empowerment program in community level.
There are manuals and leaflets distributed in villages. Mass media i.e;
newspaper, radio, and television are also more frequent used to raise
perception and concern in the oral health of Thai people.
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CARIOLOGY EDUCATION IN DENTAL SCHOOL
Table 5: Cariology in dental curricula in Thailand
University
Dedicated
Cariology
courses
No. or
credits
Year
offered
Chulalongkorn
Yes
(I, II, III)
Mahidol
Chiangmai
Prince of
Songkhla
Khon Kaen
Srinakarinwirote
Thammasat
Naresuan
Rangsit
Western
3
2nd, 3rd
Yes
(I and II)
3
2nd
and
3rd
Yes
(I and II)
2
2nd
and
3rd
2
2nd
Integrated
in “Dental
and
periodont
al health
and
diseases”
No (part of
2 courses:
I. Oral
biology II.
Preventive
Dentistry)
Integrated
in “Caries
and
periodont
al
diseases”
course
Yes
Responsible
departments
Multiple departments
a) Microbiology &
Biochemistry
b) Operative
c) Pediatric
Multiple departments
(Coordinator: Oral
Biology)
Multiple departments
I. Oral diagnostics
II. Orthodontics
&Pedodontics
Oral Biology and
Conservative Dentistry
(with lecturers from
multiple departments)
~1
3rd
3 (1 on
caries)
3rd
Oral biology and
Pediatric (with
lecturers from
Diagnostic,
Restorative, and
Community Dentistry)
Operative,
Endodontics,
Pathology, and
Microbiology
3rd
2nd
and
3rd
3rd
2nd
(summ
er)
Oral Biology
Operative, Oral
Biology, Community
Dentistry
Operative Dentistry
Multiple departments
(Currently by external
lecturers)
3
No
~2
Yes
2
Yes
3
There are 10 dental schools in Thailand; 7 are public and 2 private.
Although none has a dedicated Cariology department, most schools
offer Cariology as integrated multidisciplinary courses with lecturers
from several departments (see Table 5).
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The majority offers 2-3 credits of Cariology courses in the 2 nd and 3rd
years of the 6-year curricula. These courses cover both basic and
clinical sciences related to Cariology including Biochemistry,
Microbiology, Immunology, Operative, Endodontics, Pedodontics, and
Community Dentistry. In all schools, Cariology-related clinical
practices are supervised by the departments of Operative,
Pedodontics, and Community Dentistry.
REFERENCES
Bureau of Dental Health, Department of health, Ministry of Public
Health. National Oral Health Survey, Thailand 2012. 1 st ed., Office of
The War Veterans Organization of Thailand Printing. Bangkok. 2013.
Dental Health Division, Department of health, Ministry of Public Health.
Thailand Oral Health Goal 2020. Office of The War Veterans
Organization of Thailand Printing. Bangkok. 2007.
Prasertsom P, Jirapongsa W, Changban P, Luengvara P,
Rattanarungsima K, Rityue A. 37 Years of Experience of Oral Health
Promotion in schoolchildren. Thailand Journal of Health Promotion and
Environmental Health. 2009; 32: 24-33.
Ungchusak C, Jienmaneechotechai S, Jirapongsa W, Prasertsom P,
Visalseth W, Dalodom S, Bangkerdsing W. The 5th Asian Conference of
Oral Health Promotion for School Children. Thailand Journal of Health
Promotion and Environmental Health. 2009; 32: 34-40.
Dental Health Division, Department of health, Ministry of Public Health.
Guideline for oral health promotion program. Fiscal Year 2013. Office of
The War Veterans Organization of Thailand Printing. 2013
Bureau of Dental Health, Department of health, Ministry of Public
Health. Oral health surveillance in village: Manual for Village Health
Volunteer. 2nd, Office of The War Veterans Organization of Thailand
Printing. Bangkok. 2013.
Bureau of Dental Health, Department of health, Ministry of Public
Health. Training Curriculum of Village Health Volunteer for Oral Health
Promotion 2013. 1st ed, Office of The War Veterans Organization of
Thailand Printing. Bangkok.
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VIETNAM
Trinh Dinh HAI
Ngo Dong KHANH
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“Caries control throughout life in Asia”
Country Report on Dental Caries Epidemiology
and Relevant Interventions
VIETNAM
Trinh Dinh HAI39
Ngo Dong KHANH40
INTRODUCTION OF VIETNAM
Vietnam, officially the Socialist Republic of Viet Nam, is the
easternmost country on the Indochina Peninsula in Southeast Asia.
With a population of over 90 million, Vietnam is the 13th most
populous country in the world. The population density is 260 people
per square kilometer, with most (69.6%) of the population living in
rural areas. Over the past few years, Vietnam has witnessed a gradual
change in its population structure. In 2008, the percentage of the
population aged 0 -14 was 25.1%, a decrease of 5.9% compared with
2000. However, the percentage aged over 64 years increased rapidly
(by 0.6 %) over the same seven-year period. This shows that fertility
has continued to decline in recent years, while the number of elderly
people has been increasing gradually.
Vietnam has 54 different ethnic groups, with the Kinh representing
87% of the total population. The rest are ethnic minorities scattered
all over the country, mostly in mountainous and remote areas.
Vietnam is divided into 58 provinces and 5 centrally-governed cities,
which exist at the same level as the provinces. Hanoi is the capital
city. The government often groups the various provinces into eight
regions: Northwest, Northeast, Red River Delta, North Central Coast,
South Central Coast, Central Highlands, Southeast, and Mekong
River Delta.
Assoc Prof, Director of the National Hospital of Odonto Stomatology in Hanoi; President,
Vietnam Odonto Stomatology Association (VOSA).
Email: Trinh Dinh HAI <haitdnhos@yahoo.com>.
40 President, HoChiMinh city Odonto Stomatological Association (HOSA), Vice Dean, Faculty of
Odonto Stomatology in HoChiMinh City. Email: Ngo Dong KHANH <ngodongkhanh@ymail.com>.
39
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HEALTH SERVICE SYSTEM IN VIETNAM
The Ministry of Health is the government agency that exercises state
management in the field of people’s health care, including preventive
medicine; consultation and treatment; rehabilitation; traditional
medicine; pharmaceuticals, including vaccine production; hazardous
effects of cosmetics on human health; food hygiene and safety;
medical equipment; health facilities; population and family planning;
and health system development and management.
The health system is a mixed public-private provider system, in which
the public system plays a key role in health care, especially in terms
of policy, prevention, research and training. The private sector has
grown steadily since the ‘reform’ of the health sector in 1989, but it is
mainly active in outpatient care. Inpatient care is provided entirely
through the public sector.
The health care network is organized under state administrative units
at the central, provincial, district, commune and village levels, with
the Ministry of Health at the central level. In the public sector, there
are 774 general hospitals, 136 specialized hospitals and 11,576
primary health care centers. The establishment of the grassroots
health care network (including the commune and district levels) as
the foundation for health care has yielded many achievements,
especially that of contributing toward the attainment of national
health care goals for the entire population.
The health stations in communes provide primary health care
services,
including
consultation,
outbreak
prevention
and
surveillance, treatment of common diseases, maternal and child
health care, family planning, hygiene and health promotion. Health
care is further strengthened by the implementation of national health
care programs to deal with diseases and health issues that are of
important public health concern. For example, the tuberculosis
control program has made every effort to maintain- over many years-a
high implementation rate, with DOTS (Directly Observed Treatment
Short course) now covering 100% of the affected population. The WHO
has highly commended the program and has ranked it as being on
par with those countries that have achieved the highest standards in
the world.
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DENTAL CARIES IN VIETNAMESE POPULATION
1.
The situation and developing tendency of dental caries in
school children.
In 1991, Vo The Quang reported the situation of dental caries by
the First National Oral Health Survey. The results showed that
from 1983 to 1991, the dental caries had an increasing tendency
in caries rate as well as the average DMFT. The results of the
First Oral Health Survey were presented in Table 3.1.
Table 3.1: Dental caries experience in Vietnamese children (1983–
1991)
Age
1983
12
1984
12
15
1991
12
15
Dental caries experience in Vietnamese children
HoChiMinh
Vietnam
North of VN
South of VN
City
%
%
%
%
DMFT
DMFT
DMFT
DMFT
caries
caries
caries
caries
-
-
19.30
0.40
76.29
2.51
-
-
-
-
-
-
-
-
77.90
83.95
3.27
3.40
57.33
60.00
1.82
2.16
43.33
47.33
1.15
1.38
76.33
82.99
2.93
3.59
-
-
In 2002, The Second Oral Health Survey was conducted by the
National Institute of Odonto-Stomatology Hanoi and
HoChiMinh City (National Hospital of Odonto-Stomatology
Hanoi and HoChiMinh City presently). The results of the
Second Oral Health Survey showed that the caries experience
of children had increased compared to the results of the First
Survey and were presented from Table 3.2 to Table 3.4.
Table 3.2: Caries experience in deciduous dentition in Vietnam
(2002)
Age
6-8
9-11
%
caries
dt
84,9 5.07
56.3 1.85
dmft
mt
ft
0.31 0.02
0.10 0.01
dmft
5.40
1.96
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dmfs
ds
ms
fs
11.5 1.37 0.02
4.12 0.47 0.01
dmfs
12.98
4.60
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The result from table 3.2 showed that the prevalence of dental
caries in deciduous dentition in school children at age 6-8 was
84.9% with the average dmft of 5.1. Especially, each school
child in this age group had average nearly 13 surfaces
destroyed by caries. Deciduous caries in school children had
reflected the potential of risk factors of dental caries. The fish
portion of dmfs index was only 0.02. This situation suggested
that the majority of caries in surfaces did not treat.
Table 3.3: Caries experience in permanent dentition (2002)
Age
6-8
9-11
12-14
15-17
%
caries
25.4
54.6
64.1
68.6
DT
0.47
1.15
1.96
2.12
DMFT
MT
FT
0.00 0.01
0.02 0.02
0.05 0.04
0.15 0.13
DMFT
0.48
1.19
2.05
2.40
DS
0.59
1.60
3.10
3.26
DMFS
MS
FS
0.00 0.01
0.08 0.03
0.24 0.05
0.73 0.17
DMFS
0.60
1.71
3.39
4.16
Prevalence of caries in permanent dentition as well as DMFT
index was increased 25.4% of school children in the age group
6-8 had experienced dental caries with the average DMFT of
0.48 when at age group 15–17, the prevalence of dental caries
was 68.6% with the average DMFT of 2.40. The increasing in
dental caries rate in school children had reflected the potential
of risk factors of dental caries as well.
Table 3.4: Dental caries experience in key age group in Vietnam
(2002)
Age
(yrs)
6
12
15
%
caries
83.7
dt
5.88
56.6
67.6
DT
1.83
2.03
dmft
mt
ft
0.24 0.03
DMFT
MT
FT
0.01 0.03
0.12 0.01
dmft
6.15
ds
12.99
DMFT DS
1.87 2.93
2.16 3.10
dmfs
ms
fs
dmfs
1.13 0.03 14.15
DMFS
MS
FS DMFS
0.05 0.04 3.02
0.59 0.02 3.71
The result from Table 3.4 showed that the prevalence of
deciduous caries was very high in school children at age 6 with
average dmfs of 14.15. The caries rate in permanent dentition
was increasing with age, that was 56.6% and 67.6% at age 12
and 15, respectively.
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Deciduous caries experience by age group and area is shown in
table 3.7. Most areas had mean scores of near six for younger
children except the Red River Delta and Central Highland
which had mean scores between 3.0 and 3.5.
Table 3.5: Deciduous caries experience by age and urban/rural
locality (2002)
Age
(yrs)
6-8
9-11
Area
n
Urban
Rural
Urban
Rural
403
303
408
283
%
caries
84.4
85.1
51.
57.6
dt
4.98
5.10
1.60
1.93
dmft
mt
ft
dmft
0.31 0.08 5.37
0.31 0.00 5.41
0.18 0.02 1.80
0.08 0.00 2.01
Table 3.6: Permanent caries experience by age and urban/rural
locality (2002)
Age
(yrs)
6-8
9-11
12–14
15-17
Area
n
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
403
303
408
283
392
303
385
285
%
caries
24.6
25.6
50.8
55.8
68.4
63.0
78.3
65.8
DT
0.40
0.49
1.15
1.15
1.70
2.03
2.56
1.43
DMFT
MT
FT DMFT
0.00 0.03 0.43
0.00 0.00 0.49
0.00 0.06 1.12
0.02 0.01 1.18
0.05 0.14 1.89
0.05 0.01 2.09
0.26 0.33 3.15
0.05 0.02 1.50
Table 3.5 and 3.6 showed that deciduous caries experience
varied little by urban/rural location and age group.
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Table 3.7: Primary caries by geographic area (2002)
Area
Age
n
Northern
Highland
Red River
Delta
North Central
Coast
South Central
Coast
Central
Highland
North East
South
Mekong River
Delta
6-8
9-11
6-8
9-11
6-8
9-11
6-8
9-11
6-8
9-11
6-8
9-11
6-8
9-11
98
99
97
104
99
93
10
96
96
106
96
90
96
90
%
caries
80.7
74.5
72.3
53.2
83.7
50.9
91.6
53.3
71.1
38.3
88.2
54.0
93.7
51.1
dt
6.43
2.44
3.41
1.68
5.61
2.32
4.82
1.73
3.04
1.25
5.12
1.52
5.71
1.65
dmft
mt
ft
0.06 0.00
0.02 0.00
0.01 0.03
0.00 0.01
0.34 0.00
0.03 0.00
0.31 0.00
0.09 0.00
0.18 0.00
0.10 0.00
0.56 0.03
0.33 0.02
0.59 0.04
0.18 0.02
dmft
6.49
2.46
3.45
1.69
5.95
2.35
5.13
1.82
3.22
1.35
5.71
1.87
6.34
1.85
Table 3.8: Permanent caries by geographic area (2002)
dmft
Area
Age
n
%
caries
dt
mt
ft
dmft
Northern
Highland
6-8
9-11
12-14
15-17
98
99
108
101
19.3
43.5
77.2
65.7
0.43
0.78
2.17
1.88
0.00
0.00
0.03
0.11
0.00
0.02
0.00
0.02
0.43
0.80
2.21
2.01
Red River
Delta
6-8
9-11
12-14
15-17
97
104
104
101
10.3
50.7
43.9
32.3
0.15
0.81
0.92
0.89
0.00
0.00
0.03
0.02
0.00
0.00
0.02
0.02
0.15
0.81
0.97
0.93
North Central
Coast
6-8
9-11
12-14
15-17
99
93
100
106
31.6
61.8
65.2
67.2
0.70
1.54
2.33
1.96
0.00
0.02
0.05
0.15
0.00
0.00
0.05
0.15
0.70
1.56
2.43
2.26
South Central
Coast
6-8
9-11
12-14
110
96
99
43.5
68.0
81.9
0.96
1.90
2.73
0.00
0.01
0.07
0.02
0.03
0.03
0.98
1.94
2.83
15-17
87
92.0
4.02
0.18
0.16
4.36
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Table 3.9: Permanent caries by geographic area (2002) (cont.)
dt
0.25
0.58
1.03
2.08
dmft
mt
ft
0.00 0.00
0.00 0.01
0.03 0.00
0.17 0.06
dmft
0.25
0.59
1.06
2.31
27.3
56.4
64.5
88.2
0.44
0.12
1.57
2.31
0.00
0.03
0.08
0.34
0.04
0.09
0.17
0.45
0.48
1.24
1.82
3.10
29.3
61.7
70.9
86.3
0.44
1.38
2.36
2.71
0.00
0.04
0.06
0.18
0.00
0.00
0.03
0.13
0.44
1.42
2.45
3.02
96
106
83
90
%
caries
18.2
32.4
48.2
68.1
6-8
9-11
12-14
15-17
110
103
91
88
6-8
9-11
12-14
15-17
96
90
110
97
Area
Age
n
Central
Highland
6-8
9-11
12-14
15-17
North East
South
Mekong River
Delta
Permanent caries experience by age and geographic area is
shown in table 3.8 and 3.9. Highest mean DMFT scores in the
oldest age group were found in South Central Coast with lowest
scores in the Red River Delta.
In 2007, in order to get data base for the Salt Fluoridation
project to prevent caries for community, National Hospital of
Odonto-Stomatology in Hanoi conducted the Survey on dental
caries, dental fluorosis of children in Hanoi and LaoCai
province. The results of this survey were presented from table
3.10 to Table 3.14.
Table 3.10: Caries experience in deciduous dentition in Hanoi and
Laocai province (2007)
Age
Hanoi
6–8
9-11
Lao cai
6–8
9-11
dmft
mt
ft
n
%
caries
dt
116
123
92.2
67.5
5.4
2.9
0.15
0.1
0.11
0.06
110
146
90.9
61.0
6.05
2.36
0.03
0.01
0.03
0.01
dmft
5.7
3.0
ds
dmfs
ms
fs
dmfs
12.25 0.04
5.8
0
0.16 12.05
0.07 5.72
6.07 12.44 0.06
2.38 4.75 0.07
0.00 12.49
0.03 4.86
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Over 90% of school children in the age group 6-8 in Hanoi and
Lao CAI province had experienced deciduous caries and each
child had approximately six teeth affected by caries and more
than 12 surfaces destroyed by caries by mean.
Table 3.11: Caries experience in permanent dentition in Hanoi and
LaoCai Province (2007).
Age
Hanoi
6–8
9–11
12-14
15-17
Lao cai
6–8
9-11
12-14
15-17
%
caries
DMFT
MT
FT
DT
18.2
39.0
43.1
47.1
0.30
0.79
1.08
1.24
0.00
0.00
0.02
0.01
18.2
39.0
39.0
47.1
0.30
0.79
0.79
1.24
0.00
0.00
0.00
0.01
DMFS
MS
FS
DMFT
DS
DMFS
0.00
0.01
0.02
0.04
0.30
0.80
1.12
1.29
0.39
1.01
1.56
1.64
0.00
0.00
0.00
0.01
0.00
0.01
0.02
0.04
0.39
1.02
1.58
1.68
0.00
0.01
0.01
0.04
0.30
0.80
0.80
1.29
0.39
1.01
1.01
1.64
0.00
0.00
0.00
0.01
0.00
0.01
0.01
0.04
0.39
1.02
1.02
1.68
Permanent caries status in school children in Hanoi and
LaoCai province was increasing in caries rate and in mean
DMFT/DMFS as well. One important problem was the low rate
of filling teeth (ft component) compared with high rate of decay
teeth (dt component).
Table 3.12: Caries experience in permanent dentition in Hanoi and
LaoCai Province (2007).
Age
Hanoi
6-8
9-11
12-14
15-17
Lao Cai
6-8
9-11
12-14
15-17
%
caries
DMFT
MT
FT
DT
18.2
39.0
43.1
47.1
0.30
0.79
1.08
1.24
0
0
0.02
0.01
18.2
39.0
39.0
47.1
0.30
0.79
0.79
1.24
0
0
0
0.01
DMFS
MS
FS
DMFT
DS
0
0.01
0.02
0.04
0.30
0.80
1.12
1.29
0.39
1.01
1.56
1.64
0
0
0
0.01
0
0.01
0.02
0.04
0.39
1.02
1.58
1.68
0
0.01
0.01
0.04
0.30
0.80
0.80
1.29
0.39
1.01
1.01
1.64
0
0
0
0.01
0
0.01
0.01
0.04
0.39
1.02
1.02
1.68
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The permanent caries rate in school children in Hanoi and
LaoCai Province was slightly increasing by age. This situation
is shown in table 3.12.
Table 3.13: Dental caries in key age groups in LaoCai province
(2007)
Age
n
6
37
12
15
48
63
%
caries
91.9
dt
6.27
dmft
mt
ft
0.00 0.00
39.6
60.3
DT
0.88
1.35
MT
0.02
0.00
FT
0.00
0.00
dmfs
dmft
ds
ms
fs
6.27 11.89 0.00 0.00
DMFT DS
0.90 1.23
1.35 1.79
MS
0.00
0.00
dmfs
11.89
FS DMFS
0.00 1.23
0.00 1.79
Table 3.13 and 3.14 showed that over 90% of 6 years old
children in Hanoi and LaoCai had experienced deciduous
caries. The prevalence of permanent caries at age 12 and 15
was high too.
Table 3.14: Dental caries in key age groups in Hanoi (2007)
Age
n
6
38
12
15
2.
36
55
dmft
Dmfs
%
caries dt mt
ft
dmft ds ms Fs
97.4 6.05 0.11 0.11 6.27 13.4 0.1 0.1
52.8
63.6
dmfs
13.1
DT MT FT DMFT DS MS FS DMFS
1.4 0.0 0.2
1.6 1.9 0.0 0.3
2.1
2.4 0.02 0.07 2.5 3.1 0.0 0.07 3.2
Dental caries change in Vietnamese children from 1999 to
2007
Between 1999 and 2007 the deciduous caries experience in 6-8
year olds increased significantly in Hanoi (23% increase in
caries prevalence and 50% increase in dmfs) and slightly in
LaoCai (11% increase in caries prevalence and 9% increase in
dmfs). There were similar to the 1999 survey national average
levels (national 1999 – 12.98 dmfs, Hanoi 2007 – 12.25 dmfs,
LaoCai 2007 – 12.49 dmfs). This situation is presented in
Figure 3.1.
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Figure 3.1: Deciduous caries experience (dmft) and caries
prevalence (%) in Hanoi and Lao Cai 6–8 year olds in
1999 and 2007
Over the same period, permanent caries experience in 12-14
year olds remained at similar levels in Hanoi (3% decrease in
caries prevalence and 9% increase in DMFS), and decreased
markedly in LaoCai (41% decrease in caries prevalence and
13.4% in DMFS). Both Hanoi and LaoCai caries experience
for this age group were below the 1999 national survey
average (national 1999 – 3.39 DMFS, Hanoi 2007 – 2.60
DMFS, LaoCai 2007 – 1.58 DMFS). This situation is shown in
Figure 3.2.
Figure 3.2: Permanent caries experience (DMFT) and prevalence
(%) in Hanoi and Lao Cai 12–14 year olds in 1999 and
2007.
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3.
Dental caries experience in Vietnamese adults
Table 3.15: Dental caries experience by age group
Age
18
18-34
35-44
45+
n
63
1013
1160
999
%
caries
87.5
75.2
83.2
89.7
DT
2.28
2.31
2.35
2.14
DMFT
MT
FT
0.52
0.04
0.77
0.21
2.10
0.25
6.64
0.15
DMFT
2.84
3.29
4.70
8.93
Dental caries experience increased with age from a mean of
2.84 teeth in 18 year olds to 8.93 in those 45 years and older
(Table 3.15). Over 75% of adults in each age group had caries
experience. Untreated decay accounted for 80% of the caries
experience in 18 year olds and declined to 24% in those 45
years and older. The mean number of missing teeth increased
across age groups from 0.52 in 18 year olds to 6.64 in those 45
years and older. There were very few filled teeth in all age
groups.
Table 3.16 shows the caries experience by sex for each age
group. In each age group males had less disease than females.
This was apparent for all components of the DMFT score as
well as for the total score.
Table 3.16: Dental caries experience by age and sex
Age
18-34
35-44
45+
Gender
n
Male
Female
Male
Female
Male
Female
374
639
442
718
436
563
%
caries
74.8
74.7
89.7
88.5
88.0
84.3
DT
2.30
2.33
1.82
2.83
1.63
2.54
DMFT
MT
FT
0.53
0.11
1.00
0.30
1.87
0.14
2.31
0.36
6.10
0.12
7.06
0.17
DMFT
2.94
3.63
3.83
5.50
7.84
9.77
Table 3.17 shows caries experience by urban or rural locality
for each age group. Generally, in each age group urban persons
had more caries experience than rural persons. This is
particularly evident in the percentage of a percentage of
persons with caries experience.
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Table 3.17: Dental caries experience by age and urban/rural
Age
18-34
35-44
45+
Location
Urban
Rural
Urban
Rural
Urban
Rural
n
643
370
753
407
625
374
%
caries
88.1
61.4
95.3
82.9
93.7
78.6
DT
2.49
2.26
2.20
2.39
2.23
2.12
DMFT
MT
FT
1.02
0.43
0.69
0.14
2.78
0.59
1.92
0.16
8.07
0.40
6.22
0.07
DMFT
3.94
3.09
5.57
4.47
10.70
8.41
DENTAL NETWORK IN VIETNAM
The dental health care network in Vietnam is still too small.
Currently, two thirds of the districts in the country do not have dental
physicians, those being mainly in mountainous areas. Departments of
Odonto-Stomatology in many province hospitals are still limited and
are unable to meet the needs of people.
One dentist in Vietnam serves 20,000 people on average, while in
developed countries, the rate is one dentist per 1.000 to 2.000 people.
On the other hand, although the Ministry of Health has focused on
the oral health promotion program for school children, until now, the
program has only been adopted in eight provinces (Ninh Binh, Nam
Dinh, Hai Duong, Thai Nguyen, Thua Thien Hue, Da Nang, Lang Son
and Tuyen Quang). The number of provinces that take part in the oral
health promotion program is 58 (92.1%). There are 5 provinces that
still do not offer the oral health promotion program (Ha Giang, Vinh
Phuc, Thanh Hoa, Lai Chau and Hoa Binh). Although most provinces
offer the oral health promotion program, only about 6 out of 12
million school children are receiving regular dental care at school.
At the national level: There are two National Hospitals of
Odonto-Stomatology, one hospital is in Hanoi and the other is
in HoChiMinh City. Of these two hospitals, the hospital in
Hanoi is the leading hospital, and it offers the following services:
Supplying dental services for the community, Training in
dentistry and maxillofacial surgery, Managing the dental
network at the national level, Conducting research in dentistry
and related issues, Conducting the prevention of oral diseases
for children and communities throughout the country.
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At the provincial level: There are five Dental Hospitals and three
Dental Centers in big cities (Hanoi, Ho Chi Minh City, Hue, Da
Nang and Can Tho). Additionally, in all of the other provinces,
there is a dental department that belongs to the provincial
general hospital.
At the district level: About 30% of the districts in the country
have a small dental department that belongs to the district
medical center, with dentists and/or dental nurses and simple
dental equipment.
At the commune/ward level: There is no dental clinic in most
communes or wards.
Private dental system: Developed in a short amount of time,
this system considerably contributes to dental service for
people, especially in big cities and towns.
The School based Dental Program (SDP) is significant in creating
opportunities for school children to access dental care services and to
learn about preventative dental care measures.
The dental care network at the ward and the district levels is still
insufficient and weak. School children in most rural and
mountainous areas have difficulty accessing dental care and dental
advice services.
ORAL HEALTH PROMOTION IN VIETNAM
1.
Vietnamese Governmental Policies
In 1987, Viet Nam’s Prime Minister requested the Ministry of
Health and the Ministry of Education to issue policies on the
development and implementation of the School based Dental
Program (SDP) with the aim of promoting dental health care for
school children. Under the supervision of the Prime Minister,
on 21 st October 1987, the two ministries issued an interministerial circular No. 23 on the missions and
implementation of the SDP. Then on 19th September 1994, the
two ministries issued an inter-ministerial circular No. 14, which
provides guidance on the implementation of voluntary health
care insurance for school children. Accordingly, part of the
funding was allocated for the SDP.
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On 1st March 2000, the two ministries issued Circular No.3
(2000), which provides guidance on the implementation of
school based health care and supplements the ongoing
regulations for school-based health care, including the School
based Oral Health Care Program.
2.
Oral Health promotion for school children
2.1
Implementing and
Program (SDP)
managing
School
based
Dental
Management System of the SDP
Ministry of
Education and Training
Ministry of Health
National Hospital of Odonto - Stomatology
Local Health Department
Local Education
Department
Primary schools all over the country
Conducting activities of SDP
2.2
The component of SDP:
The SDP consist of four components: Oral Health
education, fluoride mouth rinsing and tooth brushing,
clinical prevention and fissure sealants.
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The 1st component: Oral Health Education
Oral health education is an important component of the
SDP. Teachers and school dental workers (dental
therapists) are trained in oral health education and
received the training materials for giving dental
education to primary school children.
The most important skill that these teachers and
therapists teach school children is how to brush their
teeth properly. Additionally, the teachers highlight the
importance of oral health for students and give them
basic knowledge about how to protect themselves
against dental diseases by practicing oral healthcare
activities, such as having a healthy diet, getting periodic
oral examinations, etc.
The 2nd component: Mouth rinsing with a 0.2% sodium
fluoride weekly at school and tooth brushing with fluoride
toothpaste
The primary school managing board organizes mouth
rinsing with a 0.2% sodium fluoride for school children
weekly at schools, under the supervision of teachers and
dental therapists. Tooth brushing with fluoride
toothpaste after lunch carried out at kindergartens and
primary schools.
The 3rd component: Clinical prevention
Clinical preventive activities consist of periodic
examinations and early treatment for common oral
diseases. In order to implement clinical preventive
dentistry, the dental clinics at schools require dental
equipment for operated by dental therapist. Dental
clinical preventive activities include: Periodic oral
examinations to find early signs of common oral
diseases, such as dental caries, gingivitis, etc., and to
evaluate oral hygienic status individually. Providing
early treatments, such as deciduous teeth extraction,
atraumatic filling, scaling calculus, gingivitis treatment
and introduction for school children to control dental
plaque, in the dental clinics at schools.
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The 4th component: Pit and fissure sealants
Filling pits and fissures on tooth surfaces with resins or
Glass ionomer Cement (GIC) to prevent dental caries in
the occlusal surface of permanent molars.
2.3
The public use of fluoride to prevent dental caries for
school children in Vietnam
Using fluoride to prevent dental caries has been
implemented in Vietnam for several decades, and it has
brought a considerable benefit to reducing the
prevalence of caries and the average DMFT. Fluoride
regimens used in Vietnam focus on target groups,
including
-
The community: water fluoridation, salt fluoridation.
Individual consumers: tooth brushing with fluoride
toothpaste and fluoride mouth rinsing.
2.3.1 Water fluoridation
Water fluoridation is the systemic fluoride method
that has been applied in Viet Nam until present.
Water fluoridation has been implemented in Ho
Chi Minh City since 1989 with the original
concentration of 0.70 ppm in the first stage; it is
now at 0.50 ppm. Currently, the water
fluoridation network covers 20/24 districts in Ho
Chi Minh City and one city in Dong Nai province,
with a total of about 10 million citizens.
After 10 years of fluoride supplementation in tap
water, caries prevalence of 12-year-old children
decreased from 87% to 45%, and the DMFT is <2
for this age group.
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33
%
40
37.7
30
16
20
10
0
6.11
5.9
Non - Fluoridated
Area
3.13
1989
Baseline
data
1995
After 5 years
F+ 0.7 ppm
Fluoridated Area
2010
Year
After 15 years
F+, 0.5 ppm
Figure 6.1: Proportion of caries free in 5 year old children between
Fluoridated and Non–Fluoridated area in HoChiMinh
City
53.6
%
60
50
40
30
20
10
0
22.4
19.8
1989
Baseline
data
24.9
27.1
Fluoridated Area
18.8
1995
After 5 years
F+, 0.7 ppm
Non - Fluoridated
Area
2010
Year
After 15 years
F+, 0.5 ppm
Figure 6.2: Proportion of caries free in 12 year old children between
Fluoridated area and Non – Fluoridated area in HoChiMinh
City
In Ho Chi Minh City, after 20 years of conducting
water fluoridation, the percentage of caries-free in
5-year-old, as well as 12-year-old, children clearly
increased. This means that the dental caries
experience in deciduous dentition as well as in
permanent dentition was remarkably reduced.
The implementation of water fluoridation in Ho
Chi Minh City has obviously been very effective
in preventing dental caries, even with the
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fluoride concentration in the water level at 0.5
ppm. There was a similar result in the mean
DMFT for 5-year-old and 12-year-old children.
These results are presented in Figure 6.3 and 6.4.
dmft
Water fluoridation is the most effective method for
caries prevention, but it covers only a small area
where people have a tap water network. More
than 70% of Vietnamese people, especially in
rural areas, who do not have tap water will not be
able to benefit from this program.
10
8
6.7
8.4
6.5
6
8
4
2
Fluoridated Area
3.1
3.4
1995
2010
0
1989
Baseline
data
After 5 years
F+, 0.7 ppm
Non - Fluoridated
Area
Year
After 15 years
F+, 0.5 ppm
DMFT
Figure 6.3: dmft in 5 year old children between Fluoridated area
and Non – Fluoridated area in HoChiMinh City
4
3
3.1
2.9
3.6
2.7
2.5
2
1
1.2
Fluoridated Area
0
1989
Baseline
data
1995
After 5 years
F+, 0.7 ppm
2010
Year
After 15 years
F+, 0.5 ppm
Figure 6.4: DMFT in 12 year old children between Fluoridated area
and Non–Fluoridated area in HoChiMinh City
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2.3.2 Mouth rinsing with Sodium Fluoride
Mouth rinsing with a 0.2% sodium fluoride weekly
for children in primary schools was implemented
in HoChiMinh City in 1980, and it expanded to
many provinces in Vietnam quickly. Mouth
rinsing with a 0.2% sodium fluoride weekly has
been one important part of the school based oral
health promotion program, and more than five
million school children have benefited from this
program since 2004. Today, mouth rinsing with a
0.2%
sodium fluoride
weekly
has been
implemented widely throughout Vietnam and has
proven to reduce dental caries in children
effectively.
2.3.4 Tooth brushing with fluoride toothpaste
According to the results of the National Oral
Health Survey in 2002, more than 90% of
children and adults brush their teeth and use
toothpaste when brushing in Vietnam. Since that
time, the awareness of the community about
tooth brushing to prevent caries increased
considerably, and most Vietnamese people now
brush their teeth every day. Most toothpaste
available on the Vietnamese market is fluoridated
toothpaste now.
2.3.5 Fluoridated salt
According to the Second National Oral Health
Survey (2002), 84.9% of children in Vietnam are
affected by dental caries in the primary dentition.
The lack of fluoride in most drinking water
sources leads to the low concentration of fluoride
in people’s oral cavities, which has been shown to
prevent caries. The risk of dental caries is growing
in the country, due to the growing consumption of
sugars, though many prevention programs have
been carried out.
In 2006, the World Health Organization (WHO)
recommended that salt fluoridation should be
implemented urgently to prevent caries for
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communities in Vietnam. The recommended
dosage now is at the level of 250 ppm fluoride.
With technical and financial support from the
World Health Organization in Vietnam, the pilot
phase of salt fluoridation program has been
implemented, with the following activities:
-
-
-
-
Epidemiology
surveillance
on
caries
prevalence, DMFT, fluorosis in the region
where fluoridated salt is being distributed.
Salt consumption and dietary habits also
are being investigated.
A map of fluoride concentration in natural
drinking water in this area was developed.
Set up procedure of fluoridated salt
production and control the quality of salt
under supervision of WHO’s experts
Produce 20 tons of fluoridated salt and
transport to Lao Cai province
Make plans for the communication
campaign to raise social acceptance
Make plans for delivery of fluoridated salt
to Lao CAI province, which serves over 20
million people
Make plans to monitor the program
Fluoridated salt will be delivered at Bat Xat
district, Lao CAI province by the end of
2011 to prevent dental caries for
communities and especially for children
under the supervision of the National
Hospital of Odonto-Stomatology in Hanoi
and the World Health Organization in
Vietnam.
DENTAL EDUCATION IN VIETNAM
Education is provided through kindergartens, primary schools,
secondary schools, high schools and various tertiary institutions. All
citizens attending government schools have free education. The non–
government schools charge a fee to their students irrespective of
whether they are citizens or not.
Currently, there are 7 public dental schools, 5 public and private
dental nurse schools. The number of dentists who graduated from
dental school increased from 2,345 in 2000 to 4,650 in 2012.
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The core curriculum for the training of doctoral degree in OdontoStomatology was approved by the Ministry of Health in 2009 and its
implementation will provide a common platform for each dental school
to be evaluated.
A recent revision of the curriculum structure in faculty, to suit the
core curriculum, has led to a better integration and harmonization of
the teaching of undergraduate and graduate students.
The undergraduate curriculum for doctor degree in OdontoStomatology was first revised as mentioned in the last reports, the
former one covered up to 6 years, with the first 2 years majoring in
general knowledge, fundamental sciences and part of health sciences,
and the last four years focusing in knowledge and skills in dental
disciplines. The new curriculum has been modified since the last
academic year, the new one has maintained the 6-year program, with
3 first years majoring in basic health sciences as well as general
medicine and the last three years of knowledge and skills in dental
disciplines. It is known as the “3 plus 3 curriculum for doctoral
degree in Odonto-Stomatology”.
The reasons why the Faculty increased the number of credits in basic
health sciences are to promote a closer integration between dentistry
and medicine and provide dental students with a better knowledge of
the health care system.
The Faculty has also reformed the graduate curriculum since the end
of the last academic year. The graduate division of the Faculty is
dedicated to training competent specialists in various fields of
dentistry. All applicants are recruited upon entrance examination,
they can choose one of 2 following programs: (1) one for dental
practitioners leading to the 1st and 2nd degree of specialty (under the
Ministry of Health); or (2) the other leading to the Master and the
Ph.D degree (under the Ministry of Education).
In the former program, whatever the graduate course, the learners
will be provided with foundation core courses, basic dental sciences,
and advanced technical competencies in a group of dental clinical
disciplines depending on the field of practice they selected such as:
(1) Exodontics, Minor oral surgery, Oral pathology; (2) Conservative
dentistry, Periodontology, Prosthodontics; (3) Or Orthodontics,
Pediatric dentistry, Dental Public Health.
In the new one, the learners will be provided with foundation core
courses which are common to all groups, they will follow the modules
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of theory and clinical practice according to the competencies they
have selected at the entrance. The new curriculum has been
established in 3 specialties oriented groups which are related to the
surgical and pathological Dentistry including Exodontics, Minor oral
surgery, Oral pathology; and Restorative Dentistry including
Conservative
dentistry,
Periodontology,
Prosthodontics;
and
Preventive and Developmental Dentistry comprise meaning
Orthodontics, Pediatric dentistry and Dental Public Health. The new
program has been applied since the beginning of this academic year.
CONCLUSION
The prevalence of dental caries is very high in Vietnamese school
children. Dental Caries’ status in permanent dentition is increasing
with age. Nearly 85% of school children from ages 6-8 have caries in
deciduous dentition, and each student has more than 6 teeth and 12
surfaces affected by caries per person. In the past ten years, there has
been a tendency to increase in dental caries in this age group, which
demonstrates that there is a potential for the risk factor of dental
caries in Vietnam to increase further. The analysis of thousands of
drinking water samples collected from many provinces across the
country over a long period of time shows that the majority of
Vietnamese school children has used drinking water sources that are
decreased or totally lacking in fluoride. This is one of the potential
risk factors of dental caries; therefore, conducting preventive
strategies is urgent.
Apart from the deficiency of fluoride in natural drinking water sources
for communities, the increase in sugar consumption is a severe risk
factor that requires more interest from the community than in the
past two decades. There are a considerable percentage of
schoolchildren who have never made a dental visit and do not brush
their teeth every day, which shows the lack of interest of some parents
and schools in oral health care for children. The oral hygiene status of
many students is at an unacceptable level.
The leaders of the Government, the Ministry of Health, the Ministry of
Education and the Vietnamese Dental Profession have paid more
attention to oral health promotion for school children (OHPSC). Oral
health promotion is presented through instructive policies for the
implementation of OHPSC in Vietnam, which has been enforced since
1987. OHPSC in Vietnam has been greatly effective in dental caries
prevention, while risk factors are increasing. Especially in areas where
OHPSC has been strictly implemented over the past five years, an
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ideal oral health status of school children reaches the World Health
Organization’s targets. In Vietnam, as well as for many other
countries in the world, there has to be an interest taken in OHPSC
before it can promote oral health for the community. It is necessary to
extend, sustain and develop the OHPSC program to offer oral health
care coverage for all Vietnamese schoolchildren frequently and stably.
The OHPSC program in Vietnam has been financially effective for the
community as well.
It is necessary for the dental profession of Vietnam to stimulate
collaboration and sharing of information with other countries in the
region and the entire world for the purpose of school-based oral
health promotion. This will be helpful in enhancing oral health for
general health and well-being, and it will have a significant impact on
the quality of people’s lives.
REFERENCES
Robert-Thomson KF, Spencer AJ, Hai TD et al. "The second National
Oral Health Survey of Vietnam, 1999: Backgraound and
methodology.
Loc G.D, Spencer AJ, Hai TD, et al. “Oral Health status of
Vietnamese children: Findings from the National Oral Health Survey
of Vietnam 1999”, Asia Pacific Journal of Public Health, Vol 23,
Number 2, March 2011.
Truong TV, Hai TD et al. National Oral Health Survey of Vietnam
2001. Medical Publishing House. Hanoi, Vietnam 2002.
Hai TD (2005). “Dental caries prevention”, Medical Publishing House,
2004.
Hai TD, Minh NTH et al. Survey on Fluoride concentration in drinking
water sources and dental caries, dental fluorosis situation in
children in Hanoi and LaoCai province. Report of Ministry of Health’s
study. 2010.
Khanh ND. The School Oral Health Promotion Program; Succes Challenges and Solution. The Scientific Proceeding of the
6 th
ACOHPSC, Hanoi, 2011.
Khanh ND, Hai HD, Hung HT et al. "Effect of water fluoridation of
HoChiMinh city after 20 years". The National Scientific Proceeding,
2010.
Quang VT. “Fluoride in caries prevention”, Medical Publish House,
1985.
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Quang VT. “Dental caries status in Vietnam and the Oral Health
approach to the year. 2000”, Hospdent (Tokyo). 1992, 4(1), 20 -21.
World Health Organization. Oral Health Surveys (Basic methods) 4 th
Ed. Geneva, WHO, 1977.
World Health Organization, “WHO information series on School
Health Oral Health Promotion: An essential elements of a Health
Promoting School”, Document eleven, WHO, Geneva, 2003.
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, 2003.
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ORGANIZING COMMITTEE
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LOCAL ORGANISING COMMITTEE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Assoc/Prof Khun Mettachit NAWACHINDA
Vice President
Dental Innovation Foundation under Royal Patronage
Assoc/Prof Prathip PHANTUMVANIT
Director, National Dental License Examination Board
Thailand Dental Council
Dr Sutha JIENMANEECHOTCHAI
Director
Bureau of Dental Health, Ministry of Public Health
Dr Chantana UNGCHUSAK
Bureau of Dental Health, Ministry of Public Health
Dr Supranee DALODOM
Bureau of Dental Health, Ministry of Public Health
Assoc/Prof Araya PHONGHANYUDH
Faculty of Dentistry, Mahidol University
Dr Piyada PRASERTSOM
Bureau of Dental Health, Ministry of Public Health
Assoc/Prof Oranart MATANGKASOMBUT
Faculty of Dentistry, Chulalongkorn University
Assoc/Prof Waranuch PITIPHAT
Faculty of Dentistry, Khon Kaen University
Assoc/Prof Siriruk NAKORNCHAI
Faculty of Dentistry, Mahidol University
Dental Association of Thailand
Dr Thanya SITTHISETTPHONG
Faculty of Dentistry, Thammasat University
Dr Kornkamol NIYOMSILP
Bureau of Dental Health, Ministry of Public Health
Mr Worawut KULKAEW
Dental Innovation Foundation under Royal Patronage
Dr Woranuch CHETPAKDEECHIT
Faculty of Dentistry, Thammasat University
Mr Pongthon HAEMAOUPATHOM
Dental Innovation Foundation under Royal Patronage
Miss Winapha CHANSUD
Dental Innovation Foundation under Royal Patronage
Mr Khachen KHEOBAINGAM
Dental Innovation Foundation under Royal Patronage
EDITORS
Dr Yupin SONGPAISAN
Dr Khun Mettachit NAWACHINDA
Dr Chantana UNGCHUSAK
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Chair
Co-chair
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
International Dental Conference on “Caries Control throughout Life in Asia”
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Map of the workshop venue
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Map
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