A silent public health crisis: untreated caries and dental infections among 6- and 12-year-old children in the Philippine National Oral Health Survey 2006.

The oral health status of 6- and 12-year-old Filipino children was assessed in a representative national sample of 2030 6-year-old and 2022 12-year-old children, using WHO Basic Methods for Oral Health Surveys (4th edition, 1997) and the PUFA (pulpal involvement [P/p], ulceration caused by dislocated tooth fragments [U/u], fistula [F/f], and abscess [A/a]) index. A subsample of 242 12-year-old children was included to assess backward comparability between the 1998 Oral Health Survey that used WHO Basic Methods (3rd edition, 1987). The results showed that 97% of 6-year-old children had caries (mean dmft 8.4), 85% showed dental infection (mean pufa 3.4), 20% reported pain when examined. In all, 82% of 12-year-old children had caries (mean DMFT 2.9), 56% prevalence of pulp involvement (mean PUFA 1.0), and 16% reported pain when examined. Differences in methodology between the 1998 and the 2006 surveys are likely to have had an effect on the observed reduction in DMFT, indicating that the real caries prevalence had not changed much and remains very high.

The Fit for School Health Outcome Study - a longitudinal survey to assess health impacts of an integrated school health programme in the Philippines.

BACKGROUND: Child health in many low- and middle-income countries lags behind international goals and affects children's education, well-being, and general development. Large-scale school health programmes can be effective in reducing preventable diseases through cost-effective interventions. This paper outlines the baseline and 1-year results of a longitudinal health study assessing the impact of the Fit for School Programme in the Philippines. METHODS: A longitudinal 4-year cohort study was conducted in the province of Camiguin, Mindanao (experimental group); an external concurrent control group was studied in Gingoog, Mindanao. The study has three experimental groups: group 1-daily handwashing with soap, daily brushing with fluoride toothpaste, biannual deworming with 400 mg albendazole (Essential Health Care Program [EHCP]); group 2-EHCP plus twice-a-year access to school-based Oral Urgent Treatment; group 3-EHCP plus weekly toothbrushing with high-fluoride concentration gel. A non-concurrent internal control group was also included. Baseline data on anthropometric indicators to calculate body mass index (BMI), soil-transmitted helminths (STH) infection in stool samples, and dental caries were collected in August 2009 and August 2010. Data were analysed to assess validity of the control group design, baseline, and 1-year results. RESULTS: In the cohort study, 412 children were examined at baseline and 341 1 year after intervention. The baseline results were in line with national averages for STH infection, BMI, and dental caries in group 1 and the control groups. Children lost to follow-up had similar baseline characteristics in the experimental and control groups. After 1 year, group 1 showed a significantly higher increase in mean BMI and lower prevalence of moderate to heavy STH infection than the external concurrent control group. The increases in caries and dental infections were reduced but not statistically significant. The results for groups 2 and 3 will be reported separately. CONCLUSIONS: Despite the short 1-year observation period, the study found a reduction in the prevalence of moderate to heavy STH infections, a rise in mean BMI, and a (statistically non-significant) reduction in dental caries and infections. The study design proved functional in actual field conditions. Critical aspects affecting the validity of cohort studies are analysed and discussed. TRIAL REGISTRATION: DRKS00003431 WHO Universal Trial Number U1111-1126-0718.

Caries preventive efficacy of silver diammine fluoride (SDF) and ART sealants in a school-based daily fluoride toothbrushing program in the Philippines.

BACKGROUND: Occlusal surfaces of erupting and newly erupted permanent molars are particularly susceptible to caries.The objective of the study was to assess and compare the effect of a single application of 38% SDF with ART sealants and no treatment in preventing dentinal (D3) caries lesions on occlusal surfaces of permanent first molars of school children who participated in a daily school-based toothbrushing program with fluoride toothpaste. METHODS: The prospective community clinical trial in the Philippines was conducted over a period of 18 months and included 704 six- to eight-year-old school children in eight public elementary schools with a daily school-based fluoride toothpaste brushing program. Children were randomly assigned for SDF application or ART sealant treatment. Children from two of the eight schools did not receive SDF or ART sealant treatment and served as controls. SDF or ART sealant treatment was applied on sound occlusal surfaces of permanent first molars. Surfaces that were originally defined as sound at baseline but which changed to dentinal (D3) caries lesions were defined as surfaces with new caries (caries increment). Non-compliance to the daily toothbrushing program in three schools offered the opportunity to analyze the caries preventive effect of SDF and sealants separately in fluoride toothpaste brushing and in non-toothbrushing children. RESULTS: In the brushing group, caries increment in the SDF treatment group was comparable with the non-treatment group but caries increment in the sealant group was lower than in the non-treatment group with a statistically significant lower hazard ratio of 0.12 (0.02-0.61). In the non-brushing group, caries increment in the SDF treatment group and the sealant group was lower than the non-treatment group but the hazard ratio was only statistically significant for the sealant group (HR 0.33; 0.20-0.54). Caries increment was lower in toothbrushing children than in non-toothbrushing children. Hazard ratios reached statistical significance for the non-treated children (HR 0.43; 0.21-0.87) and the sealant-treated children (HR 0.15; 0.03-0.072). CONCLUSIONS: A one-time application of 38% SDF on the occlusal surfaces of permanent first molars of six- to eight-year-old children is not an effective method to prevent dentinal (D3) caries lesions. ART sealants significantly reduced the onset of caries over a period of 18 months. TRIAL REGISTRATION NUMBER: German Clinical Trial Register DRKS00003427.

The effects of extraction of pulpally involved primary teeth on weight, height and BMI in underweight Filipino children. A cluster randomized clinical trial.

BACKGROUND: Severe dental caries and the treatment thereof are reported to affect growth and well-being of young children. The objective of this study was to assess the effects of extraction of severely decayed pulpally involved primary teeth on weight and height in underweight preschool Filipino children. METHODS: Underweight preschool Filipino children with severe dental decay had their pulpally involved primary teeth extracted during a stepped wedge cluster randomized clinical trial. Day care centers were randomly divided into two groups; children from Group A day care centers received treatment as soon as practical, whereas children from Group B day care centers were treated four months after Group A. Clinical oral examinations using WHO criteria and the pufa-index were carried out. Anthropometric measurements were done on both groups immediately before treatment of Group A and at follow-up four months later. Height and weight z-scores were calculated using 2006 and 2007 WHO Growth Standards. Multilevel analysis was used to assess the effect of dental extractions on changes in anthropometric measurements after dental treatment. RESULTS: Data on 164 children (85 in Group A and 79 in Group B), mean age 59.9 months, were analyzed. Both groups gained weight and height during the trial period. Children in Group A significantly increased their BMI (p < 0.001), and their weight-for-age (p < 0.01) and BMI-for-age z-scores (p < 0.001) after dental treatment, whereas untreated children in Group B did not. Children in Group A had significantly more weight gain (p < 0.01) compared to untreated children in Group B. However, children in Group A had an inverse change in height gain (p < 0.001). Adjustment for the time interval between the two visits had little effect on the results. CONCLUSIONS: The extraction of severely decayed primary teeth resulted in significant weight gain in underweight Filipino children. Untreated dental decay should be considered an important co-factor affecting child growth and should be considered when planning for interventions to improve child growth. TRIAL REGISTRATION: ISRCTN90779069 http://www.controlled-trials.com/isrctn/isrctn_loa.

Total and free available fluoride in toothpastes in Brunei, Cambodia, Laos, the Netherlands and Suriname.

OBJECTIVES: This study assessed total and free fluoride concentrations in samples of toothpaste from Brunei, Cambodia, Laos, the Netherlands and Suriname, and investigated the labelling practices of the respective manufacturers. MATERIALS AND METHODS: Convenience samples were bought in the five countries and sent for analysis to the Netherlands. Levels of total and free available fluoride were measured. Details of the information declared on the packaging about type of fluoride and abrasives were recorded, and manufacturing and expiry dates were noted. RESULTS: A total of 119 samples of toothpaste were analysed. With one exception, all samples from the Netherlands complied with ISO (International Organisation for Standardisation) labelling requirements and there were no differences between the fluoride content declared and that found to be present on analysis. In samples purchased in the other countries, sodium monofluorophosphate (SMFP) toothpastes predominantly showed a low percentage of free available fluoride and the majority of toothpastes did not follow standard labelling guidelines. DISCUSSION: This study is not representative of any of the brands analysed, yet it highlights problematic discrepancies in products across countries. These may be related to the lack of a generally accepted methodology for analysing total and free fluoride content, absence of an agreement on the minimum concentration of fluoride required to ensure efficacy, weak regulating institutions that are unable to control labelling and consumer information, as well as a possible influx of counterfeit low-quality toothpaste. CONCLUSIONS: Renewed international focus should be directed towards closing gaps in guidelines and standards. Consumers should use only non-expired toothpaste, which should preferably be silica-based fluoride toothpaste that does not include abrasives containing calcium and that is properly labelled.

Untreated severe dental decay: a neglected determinant of low Body Mass Index in 12-year-old Filipino children.

BACKGROUND: Dental decay is the most common childhood disease worldwide and most of the decay remains untreated. In the Philippines caries levels are among the highest in the South East Asian region. Elementary school children suffer from high prevalence of stunting and underweight.The present study aimed to investigate the association between untreated dental decay and Body Mass Index (BMI) among 12-year-old Filipino children. METHODS: Data collection was part of the National Oral Health Survey, a representative cross-sectional study of 1951 11-13-year-old school children using a modified, stratified cluster sampling design based on population classifications of the Philippine National Statistics Office. Caries was scored according to WHO criteria (1997) and odontogenic infections using the PUFA index. Anthropometric measures were performed by trained nurses. Some socio-economic determinants were included as potential confounding factors. RESULTS: The overall prevalence of caries (DMFT + dmft > 0) was 82.3% (95%CI; 80.6%-84.0%). The overall prevalence of odontogenic infections due to caries (PUFA + pufa > 0) was 55.7% (95% CI; 53.5%-57.9%) The BMI of 27.1% (95%CI; 25.1%-29.1%) of children was below normal, 1% (95%CI; 0.5%-1.4%) had a BMI above normal. The regression coefficient between BMI and caries was highly significant (p < 0.001). Children with odontogenic infections (PUFA + pufa > 0) as compared to those without odontogenic infections had an increased risk of a below normal BMI (OR: 1.47; 95% CI: 1.19-1.80). CONCLUSIONS: This is the first-ever representative survey showing a significant association between caries and BMI and particularly between odontogenic infections and below normal BMI. An expanded model of hypothesised associations is presented that includes progressed forms of dental decay as a significant, yet largely neglected determinant of poor child development.

Political priority of global oral health: an analysis of reasons for international neglect.

Global Oral Health suffers from a lack of political attention, particularly in low- and middle-income countries. This paper analyses the reasons for this political neglect through the lens of four areas of political power: the power of the ideas, the power of the issue, the power of the actors, and the power of the political context (using a modified Political Power Framework by Shiffman and Smith. Lancet370 [2007] 1370). The analysis reveals that political priority for global oral health is low, resulting from a set of complex issues deeply rooted in the current global oral health sector, its stakeholders and their remit, the lack of coherence and coalescence; as well as the lack of agreement on the problem, its portrayal and possible solutions. The shortcomings and weaknesses demonstrated in the analysis range from rather basic matters, such as defining the issue in an agreed way, to complex and multi-levelled issues concerning appropriate data collection and agreement on adequate solutions. The political priority of Global Oral Health can only be improved by addressing the underlying reasons that resulted in the wide disconnection between the international health discourse and the small sector of Global Oral Health. We hope that this analysis may serve as a starting point for a long overdue, broad and candid international analysis of political, social, cultural, communication, financial and other factors related to better prioritisation of oral health. Without such an analysis and the resulting concerted action the inequities in Global Oral Health will grow and increasingly impact on health systems, development and, most importantly, human lives.

Illegal oral care: more than a legal issue.

Affordable, safe and appropriate oral care, including preventive services, is not available for large parts of the world's population. In many low- and middle-income countries patients have to rely on a range of illegal oral care providers who are often socially accepted and part of the cultural context. Although filling a gap in service provision for poor populations, illegal provision of oral care is a serious public health problem, resulting in situations of low-quality care and risks for patients. It is a complex phenomenon going far beyond the legal context. It should be seen as a symptom of underlying health system and society deficits, ranging from lack of access to care and health inequities to problems of governance and law-enforcement. This paper analyses the problem based on the country case of Guyana, explores the public health, legal, professional, social, economical and ethical dimensions of the problem and proposes a differential view on illegal practice by grouping illegal oral care situations in four broad categories; each of them requiring different solutions to tackle underlying issues leading to the problem of illegal oral care.

Black stain and dental caries in Filipino schoolchildren.

UNLABELLED: Black stain is defined as dark pigmented exogenous substance in lines or dots parallel to the gingival margin and firmly adherent to the enamel at the cervical third of the tooth crowns in the primary and permanent dentition. OBJECTIVES: This study was conducted to assess the prevalence of black stain on teeth of Filipino children and to determine a possible association between black stain and caries levels. The study was designed to test the following hypotheses: (i) the prevalence of black stain does not differ between children from schools with oral health intervention programs and those from schools without an intervention program, (ii) the prevalence of black stain does not differ in children attending easily accessible and remote schools, (iii) caries prevalence and caries experience do not differ in children with and without black stain and (iv) the caries distribution at the surface level does not differ in children with and without black stain. METHODS: In total, 32 elementary schools were included. 19 schools with a comprehensive school-based preventive oral health program, seven schools with a basic preventive program and six control schools. All sixth graders of these schools (n=1748) aged 11.7+/-1.1 years were clinically examined for black stain. DMFT was assessed in 1121 children by seven calibrated dentists using WHO criteria. DMFS was scored in 627 children by two calibrated dentists. RESULTS: Black stain was found in 16% of this population. The prevalence of black stain did not differ significantly between children attending schools with different oral health intervention programs. Thus, hypothesis 1 was accepted. The prevalence of black stain was significantly higher (P<0.05) in remote than in more accessible schools. Thus, hypothesis 2 was rejected. Children with black stain had significantly lower (P<0.05) caries prevalence and caries experience than children without black stain. Thus, hypothesis 3 was rejected. No difference was found in the DMFS pattern of occlusal, smooth and proximal surfaces between children with and without black stain. Thus hypothesis 4 was accepted. CONCLUSIONS: The presence of black stain is associated with lower levels of caries, but a difference in the distribution of caries in black stain children was not noticed. The interplay between black stain, caries, oral microflora and diet remains unclear and urges further research.

Comparison of the use of different modes of mechanical oral hygiene in prevention of plaque and gingivitis.

BACKGROUND: The objective of this study was to evaluate the effect of an oscillating/rotating/pulsating powered toothbrush on plaque and gingivitis prevention over a 9-month period. METHODS: The study had an examiner-masked, randomized, three-group parallel design. A total of 122 subjects >or= 18 years of age in good general health and with at least five teeth per quadrant and no pockets >or= 5 mm were included. A 3-week preexperimental period of extensive oral home care, including rinses, was started to improve gingival health. Professional oral hygiene instruction with a manual brush was provided. At baseline, subjects were assigned to one of three regimens: twice daily brushing with a manual toothbrush, a manual toothbrush and the use of floss, or a powered toothbrush. Subjects were professionally instructed in their regimen and given a prophylaxis. Two weeks later, oral hygiene reinforcement was provided. Gingival bleeding, plaque, staining, and gingival abrasion were assessed during the preexperimental period and at baseline, 10 weeks, and 6 and 9 months. RESULTS: There was a significant reduction in plaque and gingivitis from the preexperimental period to baseline. At 10 weeks and 6 and 9 months, the level of plaque was statistically significantly lower with the powered toothbrush versus the other two regimens (P

Situational analysis of dental caries and existing oral health care of children and adolescents in Hubei Province, People's Republic of China: implications for change.

PURPOSE: (1) To evaluate trends in dental caries of children and adolescents of Hubei Province and Wuhan Municipality over the last two decades. (2) To conduct a situational analysis of existing oral health care and to recommend changes to improve this care for children. MATERIALS AND METHODS: An analysis was performed on data from national oral health surveys carried out in China at the provincial level, and data on 12-year-old children of Wuhan Municipality. A review of the literature was conducted on available and utilised oral health care facilities by children. RESULTS: In 1983, the mean decayed, missing and filled teeth (DMFT) of 12-year-olds in Hubei Province was 1.0, and in 1995 it was 0.6. The studies in Wuhan Municipality in 1993-1995 among 12-year-olds reported DMFT values ranging from 0.7-1.5, however different methods of caries assessment were performed in the various studies making comparisons difficult. The caries prevalence and the mean dmft score of 5-year-old children in 1995 in Hubei Province were 69% and 3.6, respectively. The percentage of untreated caries for all age groups in Hubei Province was very high. CONCLUSIONS: Analysis of epidemiological information over the last two decades does not provide any conclusive evidence supporting either an increasing or decreasing trend of dental caries in the child and adolescent population of Hubei Province and Wuhan Municipality. There is, however, a clear need to prevent the incidence of dental caries from increasing and to provide care to address the treatment needs of pre-school and school-age children. The promotion of twice-daily tooth brushing with fluoride toothpaste at maternal and child health care centres, and the establishment of daily tooth brushing with pea-size amounts of fluoride toothpaste in the pre-school and primary school setting are recommended preventive strategies. Establishment of school-based oral health promotion should be accompanied with the provision of Atraumatic Restorative Treatment (ART) sealants and ART restorations which can be provided by dental nurses at dramatically lower costs than the traditional high-tech approach.

Six-year follow up of atraumatic restorative treatment restorations placed in Chinese school children.

OBJECTIVES: This study aimed to evaluate the clinical performance of atraumatic restorative treatment (ART) restorations placed in school children in China over a 6-year period. METHODS: This study was implemented in 1996 and 294 ART restorations were placed in 197 children aged 12-13 years by five assistant dentists in four schools. Standard ART procedures and instruments were used combined with a high-strength glass-ionomer restorative material. One examiner evaluated the restorations annually using the ART criteria while at 5 years an independent external examiner used US Public Health Service (USPHS) criteria. RESULTS: Fifty-eight per cent of the restorations were followed for 6 years. At the 6-year evaluation examination, 76% and 59% of the small and large restorations respectively were present and were without major wear or defect (P < 0.01). Similar results were obtained when using the USPHS criteria. Results of a multilevel survival analysis show that the correlation between restoration failure and operator was small but failure of restorations placed in the same child was substantial. Net wear of the small and large restorations after 6 years were 176 and 172 microm respectively (P > 0.05). CONCLUSION: The 6-year survival rate of the class I ART restorations in this study, especially the smaller ones, was satisfactory. This suggests that the ART approach can be used in the school setting to improve the oral health of large populations of underserved children.

Chlorhexidine varnish for preventing dental caries in children, adolescents and young adults: a systematic review.

This systematic review aimed to determine the caries-inhibiting effect of chlorhexidine (CHX) varnishes on the permanent dentition of children, adolescents and young adults, and to explore two possibly related factors, namely application frequency and the time between evaluation and the last application. The literature search identified 14 publications of randomized controlled trials or controlled clinical trials where the effect of CHX varnish was compared with placebo controls or controls that received no preventive treatment. To obtain uniform outcome effects, the prevented fraction and 95% confidence intervals of caries increment were calculated. Owing to insufficient data presentation, only eight publications were included. Another two publications were included after receiving additional data from the authors. This systematic review did not result in a meta-analysis as an overall prevented fraction could not be computed because of the large variation of outcome results. The variation could not be explained by the time between evaluation and last application but might be explained by application frequency. It is tentatively concluded that CHX varnish has a moderate caries-inhibiting effect when applied every 3-4 months. However, this effect seems to have diminished by around 2 yr after the last application. There is no evidence for a caries-inhibiting effect of CHX varnish with longer intervals between applications.

The atraumatic restorative treatment (ART) approach for managing dental caries: a meta-analysis.

The number of publications reporting on the survival of ART sealants and ART restorations has increased considerably in recent years. A systematic investigation of their longevity is therefore warranted. Based on three exclusion criteria, a literature search in the electronic libraries Pubmed and Medline revealed 28 eligible publications for inclusion in a meta-analysis. High mean survival rates for single-surface ART restorations using high-viscosity glass-ionomer in primary dentitions over 3 years were found (95% after 1 year to 86% after 3 years). These rates were statistically significantly higher than for those of multiple-surface ART restorations in primary dentitions (p<0.0001). High mean survival rates for single-surface ART restorations using high-viscosity glass-ionomer in permanent dentitions over 6 years were found (97% after 1 year to 72% after 6 years). The mean annual failure rates for single-surface ART restorations using high-viscosity glass-ionomer in primary and permanent dentitions and for multiple-surface ART restorations in primary dentitions are 4.7%, 4.7% and 17%, respectively. The number of studies reporting on the retention and caries preventive effect of ART sealants was low. It is concluded that single-surface ART restorations using high-viscosity glass-ionomer in both primary and permanent dentitions show high survival rates. Medium-viscosity glass-ionomer should not be used for ART restorations.

Guidance for the planning, implementation and evaluation of oral health care demonstration projects for under-served populations.

Recently, it has been proposed that in planning oral health care services in non-established market economy (non-EME) countries, and for under- served communities throughout the world, high priority be given to a basic package of oral care (BPOC). This package contains three key components: emergency care (oral urgent treatment--OUT), exposure to appropriate fluoride (affordable fluoride toothpaste--AFT) and appropriate treatment technology (atraumatic restorative treatment--ART). These three components are embedded in the supporting context of oral health promotion (OHP). There is a lack of experience in implementing BPOC and besides, there is not much known about the effectiveness, efficiency and sustainability of the proposed components of BPOC, either individually or as a package, under local conditions. An effective approach in one setting may not be successful in another setting due to many factors such as a lack of acceptability by the community or local government or because of insufficient financial and human resources. It is therefore recommended to consider small scale demonstration projects for effectiveness, efficiency and sustainability assessments of the various components of BPOC before embarking on large scale programmes. The purpose of this paper is to highlight the different aspects related to the planning, implementation and evaluation of oral health demonstration projects for under-served communities.