ABSTRACT
Objectives: The
aim of this study was to evaluate oral hygiene, gingival status and
prevalence of dental caries among 12 to 15 year old schoolchildren in Al Karak
governorate, Southern Jordan. Oral health
knowledge among the study population was assessed through a questionnaire.
Methods: A cross sectional study was conducted among
730 pupils from the 12 to 15 year old age group. Of those there were
263 (36%) males and 467 (64%) females from sixth, seventh, eighth and ninth grades. All participants were examined for oral hygiene,
gingival condition and dental caries experience, using the Silness and Löe Plaque Index (PI), Löe and Silness Gingival Index (GI), and Decayed (D), Missing (M) and Filled
(F) teeth (DMFT) codes respectively. The examiner evaluated oral health
knowledge among the study population through a special questionnaire designed
for this purpose.
Results: Regarding oral hygiene, the mean PI of
the total subjects was 1.33. With regard to gender variation, results showed that the mean PI for
males was 1.38 but for females it was 1.30. The difference was statistically
non-significant, (p=0.126). The mean GI of the total subjects was 1.40.
For males it was 1.55 but for females it was 1.32. The difference was statistically
significant (p<0.001). Regarding caries
prevalence, 25.8 % of the study population were caries free. The mean DMFT
index of the total subjects was 2.82, with a mean DMFT value of 2.62 for males and
2.91 for females. The difference was statistically non-significant (p=0.110).
Regarding oral health knowledge, 55.2% of all study population knew that
gingival bleeding means gingivitis, 35.5% of participants knew that brushing
and flossing are used to prevent gingivitis, and only 28.5% of the sample knew
the meaning of dental plaque.
Conclusions: Regarding oral hygiene, the results of this study showed that males
had non-significant higher plaque index and significantly higher gingival index
than females, but with regard to caries prevalence, females had non-significant
higher DMFT scores than males. However, the values of these clinical
scores were lower than those results previously reported from other places in Jordan. This
study indicated that oral health awareness level among public schoolchildren in
Jordan
is still poor and needs to be improved. Long-term school based oral health
education programme is highly recommended.
Key words: Caries prevalence,
Gingival conditions, Oral health knowledge, Oral hygiene, Schoolchildren
JRMS December 2012; 19(4): 31-36
Introduction
Good oral hygiene is a basic factor for good oral
health. Poor oral hygiene leads to dental plaque accumulation, which among
other factors may lead to gingivitis, periodontitis and dental caries.(1,2)
Epidemiological data from Jordan regarding oral hygiene status and dental caries
prevalence among schoolchildren mainly described the oral hygiene status of
schoolchildren in Northern Jordan, whether in Irbid (3-6) or
Jerash governorates.(7) For example, these studies showed
that dental caries experience, as measured by Decayed (D), Missing (M), and Filled
(F) teeth (T) (DMFT) index.(8) was found to be between 3 and
5 for the 12-16 year old schoolchildren age group.(3-7,9)
These values are relatively high as compared with the declining DMFT values in
most industrialized countries.(10-11) A study about oral
health trends in Jordanian schoolchildren (5) concluded that
oral hygiene, gingival conditions and dental caries have improved since 1993. A recent study of the prevalence of dental
caries experience in 12-13 year old Jordanian students in Irbid showed that the
mean DMFT index was 2.51.(12)
None of the previous studies were related to oral hygiene and dental
caries in schoolchildren in Al Karak governorate.(13) Therefore, there is a shortage of this
necessary information. Collecting and analyzing epidemiological data regarding
prevalence of caries and oral hygiene status is important. These
epidemiological data can be used to help in reducing the prevalence of these
diseases, by giving data to public health administrations to plan their future
preventive oral health programs and developing dental services. Also, such data
can be used to compare the results of future studies with baseline data
obtained here and to monitor oral health changes. Another
important aim in this work was to assess oral health knowledge among schoolchildren.
Assessing oral health knowledge and improving it among schoolchildren, will
lead to improving gingival conditions and reduce dental caries among them,
because schools are a commonly used setting for dental health education, health
promotion and intervention with preventive agents.(14)
The aims of the present study were to:
1-
Evaluate oral hygiene status
2-
Evaluate the gingival condition
3-
Assess the prevalence of dental caries
and
4-
Assess oral health knowledge among
12-15 year old schoolchildren in Al Karak, Jordan.
Methods
Prior to commencing the study, ethical approval by the
Human Research Ethics Committee at the Royal Medical Services was obtained.
Approval of the directorate of education in Karak governorate was obtained. In
this study, we included 3 male and 4 female public schools attending the sixth,
seventh, eighth and ninth grade classes (12-15 year old pupils). The subjects were examined for dental and
periodontal health status by one examiner during the period from February to
May 2009. A letter was sent to the children's parents informing
them of the study and asking for their consent. Parents’ approval and participant’s
consents were obtained for 730 students. Of those, there were 263 (36%) males
and 467 (64%) females.
The children were examined for oral
hygiene status, gingival conditions and dental caries while seated on a chair
beside the classroom’s windows utilizing day light and room artificial light.(7)
Oral hygiene was evaluated by examining the dental plaque present on the inner
and outer aspects of the six index teeth, using the criteria of the Plaque
Index of Silness and Löe.(15) The six indexed teeth are: upper
right first molar, upper right lateral incisor, upper left first premolar, the
lower right first premolar, the lower left lateral incisor and first molar. Missing
teeth are not substituted. The gingival condition was determined for the same
teeth using the criteria of the Gingival Index of Löe and Silness.(16)
Dental caries was diagnosed by visual examination using dental mirror
and probe utilizing the criteria recommended by the World Health Organisation.(8) One examiner did the clinical
examination which took place in the classroom. No radiographs were taken.
Examiner reliability was tested by duplicate examination for 20 subjects for
plaque, gingival and DMFT indices, which revealed a 90% of same readings of
plaque and gingival indices, and 95% for DMFT index among the 20 duplicate
schoolchildren.
Table I. Means (M) and standard deviations (SD) of
Plaque Index and Gingival Index scores for all subjects and among males and
females of the study population (n=730)
|
Variables
|
All subjects
|
Males
|
Females
|
p-value*
|
|
Plaque
index (M±SD)
|
1.33±0.65
|
1.38±0.55
|
1.30±0.70
|
0.126
|
|
Gingival
index (M±SD)
|
1.40±0.70
|
1.55±0.67
|
1.32±0.69
|
<0.001
|
*Independent-Samples
T Test
Table II. Means and standard
deviations of decayed (D), missing (M) and filled (F) teeth (DMFT) scores of
all subjects and for males and females of the study population (n=730)
|
Variables
|
Decayed
teeth
(D)
|
Missing
teeth
(M)
|
Filled
teeth
(F)
|
DMFT±SD*
|
|
All
subjects
|
1.98
|
0.26
|
0.58
|
2.82±1.96
|
|
Male
|
2.04
|
0.24
|
0.34
|
2.62±1.69
|
|
Female
|
1.93
|
0.26
|
0.72
|
2.91±2.09
|
|
p-value
(ANOVA)
|
0.377
|
0.768
|
<0.001
|
0.110
|
*Standard
Deviation
Table
III. Frequency and percentages of answered oral health knowledge questions
by gender
|
Knowledge
questions
|
All subjects (n=730)
|
Male ( n= 263)
|
Female (n=467)
|
|
1-Gingival
bleeding means:
|
|
|
|
|
Healthy
gingiva
|
32 (4.4)
|
10 (3.8)
|
22 (4.7)
|
|
Gingivitis
|
403 (55.2)
|
126 (47.9)
|
277 (59.3)
|
|
Gingival
recession
|
95 (13)
|
52 (19.8)
|
43 (9.2)
|
|
I
don’t know
|
200 (27.4)
|
75 (28.5)
|
125 (26.8)
|
|
2-How to prevent gingivitis?
|
|
|
|
|
Soft food
|
54 (7.4)
|
21 (8.0)
|
33 (7.1)
|
|
Vitamin C
|
225 (30.8)
|
63 (24.0)
|
162 (34.7)
|
|
Brushing and flossing
|
259 (35.5)
|
108 (41.1)
|
151 (32.3)
|
|
Don’t know
|
192 (26.3)
|
71 (27.0)
|
121 (25.9)
|
|
3-What does plaque mean?
|
|
|
|
|
Soft deposits on teeth
|
208 (28.5)
|
92 (35.0)
|
116 (24.8)
|
|
Hard deposits on teeth
|
78 (10.7)
|
29 (11.0)
|
49 (10.5)
|
|
Tooth discoloration
|
73 (10.0)
|
31 (11.8)
|
42 (9.0)
|
|
Don’t know
|
371 (50.8)
|
111 (42.2)
|
260 (55.7)
|
*The correct answer is given in
bold.
Following examination, the second part of the study
consisted of filling a questionnaire. This questionnaire included questions
regarding oral health knowledge. Filling of the questionnaire was carried out in
the classroom by the pupils themselves under the direct supervision of
researchers and the teacher of the 12-15 year old schoolchildren. The questions
were in simple Arabic language. All questions were of multiple choice type. The
students were asked to make a tick or circle around the answer. Questions were adopted
from Peterson et al.(17) and Stenberge et al.(18)
Only three questions regarding oral health knowledge were used in this study.
These questions were also used in other studies assessing oral health knowledge
among schoolchildren in Northern Jordan.(19,
20)
Statistical Analysis
The data were analyzed using computerized
Statistical Package for Social Sciences 15 for windows (SPSS Inc, Chicago, IL,
USA).
Means, standard deviation and frequency
distribution were calculated. An independent samples T-test was used to compare
the means of two variables, while ANOVA test was used to compare the means of
multiple variables. The level of statistical significance was chosen at p<
0.05.
Results
The total number of participants in this study was 730,
of those 263 (36%) were males and 467 (64%) were females. The results of the Mean Plaque and Gingival scores for the total subjects and for both males and females are given in Table I. The results showed
that the mean plaque index of the total subjects was 1.33. Regarding
gender variations, the mean plaque index of the males was 1.38 but for females
it was 1.30. The difference was statistically non-significant,(p=0.126).
Also Table I showed that the mean gingival index of the total subjects was
1.40. For males it was 1.55 but for females it was 1.32. The difference was
statistically significant (p<0.001).
Regarding caries prevalence among the study population,
25.8% were caries free and a range of DMFT between 0 and 10 was scored. The results of the Means
and standard deviations of decayed (D), missing (M) and filled (F) teeth (DMFT)
of the total subjects and for both sexes are given in Table II. The mean DMFT index of the
total subjects was 2.82, with a mean of 1.98 for the D-component, 0.26 for the
M-component, and 0.58 for the F-component. With regard to gender variation in
caries prevalence, results showed that the mean DMFT value for males was 2.62
but for females it was 2.91. The difference was statistically non-significant (p=0.110).
The D-component
was higher in males while the F-component was significantly higher in females.
According to Table III which demonstrate frequency and percentages of answered
oral health knowledge questions, it’s observed that 55.2% of all study
population knew that gingival bleeding means gingivitis; 35.5% of study group knew
that brushing and flossing are used to prevent gingivitis; 28.5% of the sample
knew the meaning of dental plaque, while the rest did not know or reported
wrong answers.
Discussion
Most epidemiological oral health surveys conducted in
schoolchildren in Jordan
focused on oral hygiene status and prevalence of dental caries among
schoolchildren in the northern governorates or the capital Amman. None of these studies were related to
schoolchildren in Al Karak governorate.
This study
revealed that the mean plaque index for the total subjects was 1.33. Regarding
gender variations, Plaque Index for males was 1.38 but for females it was 1.30.
The difference was statistically non-significant, (p=0.126). The mean
gingival index of the total subjects was 1.40. For males it was 1.55 but for
females it was 1.32. The difference was statistically significant (p<0.001). This study reveals a mean plaque index of
1.33 for total subjects. This finding disagreed with earlier studies in 13-14 year
old Northern Jordanian schoolchildren that reported plaque index scores were
1.82 and 1.63 during 1993 and 1999 respectively.(5) Furthermore,
gingival index scores reported in the same study(5) were 1.89
in 1993 and 1.67 in 1999 which were also higher than the figure found in this
study which was 1.40. A more recent study
took place in 2006 for 14-15 year old schoolchildren in Jerash district and
reported a plaque index score of 1.46 and gingival index score of 1.56. But
these results are still higher than results obtained in this study. Regarding
gender variations, these
findings agreed with a previous study(5) that described
trends in oral health in Jordanian male and female schoolchildren, where it
showed that boys had higher plaque and gingival scores than girls within this
age group. This gender difference with regard to plaque and gingival scores may
be related to the patterns of personal oral hygiene, hormonal changes occurring
during puberty and grooming effect at this age.(7) Another study
found that girls scored more favourably on behavioural measures, showed more
interest in oral health, and perceived their own oral health to be good to a
higher degree than did boys.(21)
With regard to hormonal changes occurring during puberty
that affect the gingiva, several cross-sectional studies have demonstrated
an increase in gingival inflammation without an accompanying increase in plaque
levels during puberty.(22) This gingivitis manifests as
marginal and interdental gingival enlargement found primarily on the facial
surfaces, with the lingual surfaces remaining relatively unaltered. This
finding was included in the 1999 International Workshop Classification for Periodontal
Diseases, with a Section specific to endogenous female sex steroid hormones as
puberty associated gingivitis.(23)
This study revealed a direct relationship between
plaque index and gingival index scores. This finding agreed with the general
view that gingivitis is related to plaque deposits. A study of oral
health trends in Jordanian schoolchildren.(5) concluded that
oral hygiene, gingival conditions and dental caries have improved since 1993.
This finding agreed with other studies from developed countries that showed
decline in the occurrence of dental caries, gingivitis and an improvement in
oral hygiene.(11,24)
This
study revealed that the mean DMFT index of the total subjects was 2.82, with a
mean of 1.98 for the D-component, 0.26 for the M-component, and 0.58 for the F-
component. With regard to gender variation in caries prevalence, results showed
that the mean DMFT value for males was 2.62 but for females it was 2.91. The
difference was statistically non-significant (p=0.110).
The DMFT value for
the total subjects in this study was 2.82. This finding disagreed with other
studies that reported a DMFT score of 3.26(5) in
12-15 year old Northern Jordanian schoolchildren. Also the caries prevalence in this study was slightly
less than results obtained from studies in other Arab countries.(25-27)
This lower caries prevalence among this study group may be due to better oral
hygiene habits, better dietary habits and widespread use of fluoridated
toothpastes than other places in Jordan. Also in this study radiographs
were not taken, which will underestimate caries prevalence for the presence of
inter-proximal caries. However there is no obvious cause that can explain
results disparities between the results of this study and with other places in Jordan
or other countries in the world.
Regarding gender variations in caries prevalence, this study showed that caries
experience as measured by DMFT was more among females than males, and mostly
due to the F-component. This finding agreed with previous study from Northern Jordan.(5) This may be due to better awareness of oral
health among females, or may be due to better use for governmental dental
services.
According to Table
III the frequency and percentages of answered questions regarding oral hygiene
knowledge among study population was poor. Oral health knowledge is part of the
more general term, that is, oral health attitude. According to Myers(28)
a person’s attitude is defined by cognitive, affective, and behavioural
components. The cognitive component represents the person’s beliefs and
knowledge, the affective component the strength of their beliefs, and the
behavioural component their readiness to act to a certain object or situation.
In this study the percentages of
schoolchildren who correctly answered the first two questions was less than the
percent from other study of Northern schoolchildren.(19) but
regarding the last question which was about definition of dental plaque, the
percentage was higher.
This study showed that the highest percent of
correctly answered questions was that gingival bleeding reflects gingivitis. This
finding agreed with other studies from Jordan.(20,29) There
was an obvious variation in the percentage of correctly answered questions
according to the gender of the study population. This variation agreed with
other studies from the world that found that gender is an important factor
regarding oral health knowledge.(25,30)
Conclusions
Regarding oral
hygiene, the results of this study showed that males had non-significant higher
plaque index and significantly higher gingival index than females, but with
regards to caries prevalence, females had non-significant higher DMFT scores
than males. However, the values of these clinical scores were
lower than those results previously reported from other places in Jordan.
Also this study indicated that oral health awareness
level among public schoolchildren in Jordan is still poor and needs to
be improved. A long term school based oral health education programme is highly
recommended.
References
1.Jenkinson HF,
Dymock D.
The Microbiology of Periodontal Disease. Dent Update 1999; 26: 191-197
2.Heloe LA,
Haugejorden O. The rise and fall of dental caries: some global aspects of
dental caries epidemiology. Community Dentistry Oral Epidemiology 1981; 9:
244–299.
3.Quteish Taani
D
.Dental health of 13-14-year-old Jordanian school children and its relationship
with socio-economic status. International Journal of Paediatric Dentistry
1996; 6: 183-1 86.
4.Quteish Taani
D. Relationship
of socioeconomic background to oral hygiene, gingival status, and dental caries
in children. Quintessence Int 2002.33:195-198
5.Quteish Taani
D.
Trends in oral hygiene, gingival status and dental caries experience in
13–14-year-old Jordanian school children between 1993 and 1999. Int Dent J
2001; 51: 277–281.
6.Quteish Taani
D.
Caries prevalence and periodontal treatment needs in public and private school
pupils in Jordan.
Int Dent J 1997 47: 100-104.
7.El-Qaderi
SS, Quteish Taani D. Dental plaque, caries prevalence
and gingival conditions of 14–5-year-old schoolchildren in Jerash District, Jordan.
Int J Dent Hygiene 2006; 4: 150–153
8.World Health
Organization. Oral health surveys. Basic methods. 4th edition. Geneva: WHO, 1997
9. Leous P. Oral health in Jordan. Assignment report. Geneva, 1984
10.Marthaler
T.M.. Changes in Dental Caries 1953–2003. Caries Res 2004; 38:173–181.
11.Cahen PM, Obry
Musset AM, Grange D, Frank RM. Caries prevalence in 6–15 years–old
French children based on the 1987 and 1991 national Surveys. J Dent Res 1993; 72: 1581–1587.
12.Albashaireh Z,
Hamasha AA. Prevalence of dental caries in 12-13-year-old Jordanian
students. South Afr Dent J 2002 57: 89-91.
13.Quteish Taani
D. Oral
health in Jordan.
International Dental Journal 2004; 54, 395–400 14.
14.Pine CM. Designing school programmes to be
effective vehicles for changing oral hygiene behaviour. International Dental
Journal 2007; Vol.
57/No.5 (Supplement 1).
15.Silness J, Löe
H.
Periodontal disease in pregnancy ii. correlation between oral hygiene and
periodontal condition. Acta Odontologica Scandinavica 1964; 22:121-135
16.Löe H, Silness
J. Periodontal
disease in pregnancy I prevalence and severity. Acta Odontologica
Scandinavica 1963; 21:533-551.
17.Peterson PE,
Aleksejuniene J, Christensen LB, et al. Oral health behaviour and attitudes of
adults in Lithuania.
Acta Odontol Scand 2000; 58:243-8.
18. Stenberg P,
Hakansson J, Akerman S. Attitudes to dental health and care among 20 to 25-year-old
Swedes: results from a questionnaire. Acta Odontol Scand 2000; 58:102-106.
19.Al-Omiri
M K, Al-Wahadni A, Khaled NS. Oral health
attitudes, knowledge, and behavior among school children in North
Jordan. Journal of Dental Education 2006; 70: 179-187
20.SS-El-Qaderi.
DQ Taani. Oral health knowledge and dental health practices among schoolchildren
in Jerash district/ Jordan.
Int J Dent Hygiene 2004; 2: 78-85
21.Kalsbee
H, Truin G-J, Poorterman J HG, et al. Trends in
periodontal status and oral hygiene habits in Dutch adults between 1983 and
1995. Community Dent Oral Epidemiol 2000; 28: 112-118
22.Mariotti
A. Sex steroid hormones and cell dynamics in the periodontium. Crit
Rev Oral Biol Med 1994: 5: 27–53.
23.Armitage
G. Development of a classification system for periodontal diseases and
conditions. Ann Periodontol 1999: 4: 1–6.
24.Ostberg AL,
Halling A, Lindblad U. Gender differences in knowledge, attitude, behavior and
perceived oral health among adolescents. Acta Odontol Scand 1999; 57:
231-6.
25. Behbehani
JM, Scheutz F. Oral health in Kuwait. International
Dental Journal 2004; 54, 401–408
26.Beiruti
N, Helderman VP. Oral health in
Syria.
International Dental Journal 2004; 54, 383–388
27.Al-Ismaily
M, Al-Busaidy K, Al-Khussaiby A. The progression of dental disease in
Omani schoolchildren. International Dental Journal 2004; 54, 409–410 28.
28.Myers
DG. Social psychology, 6th ed. Boston: McGraw-Hill College 1999.
29.Taani
DQ, Alhaija ES. Self-assessed bleeding as an indicator of gingival health among
12-14- year-old children. J Oral Rehabil 2003; 30:78-81.
30.Al-Omary QD,
Hamasha A. Gender-Specific oral health attitudes and behavior among dental
students in Jordan.
The Journal of Contemporary Dental Practice 2005; 6:1-6