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ORIGINAL ARTICLE
Year : 2006  |  Volume : 24  |  Issue : 3  |  Page : 146-151
 

Oral cleanliness of 12-13-year-old and 15-year-old school children of Sunsari District, Nepal


1 Department of Health Service, Ministry of Health, His Majesty's Government, Nepal
2 Oral Health Researcher, Institute of Oral Sciences - Pedodontics and Centre of International Health, University of Bergen, Norway
3 Department of Oral and Maxillofacial Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal

Correspondence Address:
J David
Institute of Oral Sciences - Pedodontics, Arstadveien 17, No - 5009, Bergen, Norway

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.27896

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   Abstract 

The aim of the study was to evaluate the oral cleanliness of school children in the District of Sunsari, Nepal. A multi-stage random sampling oral epidemiological survey was conducted in private and government, urban, rural town and rural village schools in 15 illakas of Sunsari District, Eastern Nepal. A total of 600, 12-13-year-old and 600 15-year-old school children were examined by trained examiners using the simplified oral hygiene index (OHI-S). The average age-group, debris and calculus index scores were combined to obtain the simplified oral hygiene index (OHI-S). The mean OHI-S scores were compared and evaluated using the parametric t-test for two independent samples. The mean OHI-S for urban 12-13-year-old school children was 0.98 compared to 1.34 for school children of rural towns and 1.44 for school children of rural villages and these differences in mean OHI-S were statistically significant ( P <0.005). In the 15-year-old age group, urban school children had a mean OHI-S score of 1.00 compared to 1.37 for rural towns and 1.43 for rural villages. The variance in the mean OHI-S scores were statistically significant ( P <0.005). The overall level of cleanliness in the school children surveyed was good. Children of urban schools had the lowest scores followed by school children from rural towns and then rural villages. When the mean OHI-S scores were compared with the DMFT scores, there was an inverse relationship between oral cleanliness and dental caries. Frequency of sugar consumption and the availability and affordability of fluoridated toothpaste may be important factors in the development of dental caries than oral cleanliness.


Keywords: Nepal, oral hygiene index - simplified, school children


How to cite this article:
Yee R, David J, Khadka R. Oral cleanliness of 12-13-year-old and 15-year-old school children of Sunsari District, Nepal. J Indian Soc Pedod Prev Dent 2006;24:146-51

How to cite this URL:
Yee R, David J, Khadka R. Oral cleanliness of 12-13-year-old and 15-year-old school children of Sunsari District, Nepal. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2019 Jul 23];24:146-51. Available from: http://www.jisppd.com/text.asp?2006/24/3/146/27896



   Introduction Top


Sunsari district in the Terai region of eastern Nepal has a total population of 6,28, 405 (males: 3, 15, 819; females: 3, 12, 586).[1] Life expectancy of this area averages 60.5 years, which is above the national average for Nepal. Adult literacy rate is 45.18% and the per capita income is 8,130 Nepali rupees.[2] The prominent castes in this district include Tharus, Muslims, Brahmin Pahadis, Chettris, Rais, Yadavs, Newars and Mushers.

An emerging health problem amongst the child population in Nepal is dental caries. A series of cross sectional surveys conducted on school children by the united mission to Nepal Oral Health Programme between the period of 1999 and 2000 in Central and Western Nepal show that the caries prevalence and mean dmft score of 5-6-year-olds (n=2, 177) was 67% and 3.2 while the caries prevalence and mean DMFT score of 12-13-year-olds (n=3, 323) was 41% and 1.1.[3] A recent district-wide survey of Sunsari reveals that the caries prevalence and mean DMFT score of 12-13-year-olds and 15-year-olds was 24% and 0.49; and 26% and 0.67, respectively.[4]

Very little information is available concerning the oral cleanliness of children and adults on a national and the district level. With the trend towards increasing prevalence and severity of dental caries[5] and a concern for the periodontal health of young adults, information concerning the oral hygiene status of young children would assist in the development of oral health policies, strategic plans, monitoring and surveillance systems for oral health.

The aim of the study was to gain information concerning the oral cleanliness of children as it is lacking at a district level throughout Nepal. Collection of such data in the district of Sunsari serves as a baseline to monitor the impact of oral health activities carried out by the College of Dental Surgery at the B. P. Koirala Institute of Health Sciences in Dharan, Sunsari. The aim of this study was to describe and analyze the level of debris and calculus in the permanent dentition of 12-13-year-old and 15-year-old school children in the District of Sunsari.


   Materials and Methods Top


Multi-stage random sampling method was used to select the subjects for the survey. The study population was selected from government schools and private (boarding) schools from each of the 15 illakas in Sunsari. The first stage units were all the government schools and private schools from each illaka. From the two separate lists, one government school and one private school were selected at random from each illaka. When private schools were not available in an illaka, private schools were randomly selected from another illaka. The second stage units were three separate lists of students of the age groups of interest from each of the selected government schools and a similar list compiled from each of the selected private schools. The required number of school children in each of the interested age groups were then selected at random by lottery system. For each of the government schools and private schools there were three separate draws, one for each age group.

The same subjects surveyed in a previously reported study[4] were examined for debris and calculus prior to examination for dental caries.

In that study the sample size for each age group was calculated using the following formula:

Sample size = p(1-p)/e 2

p = prevalence of disease in the population

e = required size of standard error = 0.02

Calculation of the sample size for the 12-13-year-old population was based on the average prevalence of dental caries in the respective populations found in recent surveys conducted by the UMN Oral Health Programme[3] and by Petersen, Mohr and Geddes.[6] Sample size for the 15-year-old population was based on the average prevalence of disease in the 12-13-year-old population. It was assumed that the prevalence of dental caries in the 15-year-old population would be similar to that in the 12-13-year-old population. Prevalence (p) used for the calculation of sample size for the both 12-13-year-olds and 15-year-olds was 40%. Calculated sample size for each of the two age groups was 600. From each of the 15 government schools and each of the 15 boarding schools, 20 children from each of the three age groups were randomly selected.

Dental examinations were carried out by two dentists (JD and RK) from the College of Dentistry, B. P. Koirala Institute of Health Sciences. Children between the age of 12-13 years and at 15 years were examined in school during class hours in an orderly fashion. Students were positioned supine on a bench or table and were examined by the gloved and masked dental examiners using torchlight. All instruments were brought back to the dental college, washed and sterilized in an autoclave. A trained assistant recorded the data on a standardized form.

Training of the dentists using school children was accomplished over a two-day period in the B. P. Koirala Institute of Health Sciences prior to the survey. The examiners were trained to use the criteria for debris and calculus outlined in the Simplified Oral Hygiene Index (OHI-S).[7] Oral debris and calculus was estimated by running the side of an explorer along the tooth surfaces examined. The surfaces and teeth examined were the buccal aspects of the upper first molars (16, 26), the lingual aspects of the lower first molars (36, 46) and the labial aspects of the upper right (11) and lower left (31) incisors. Procedure for quick selection and screening of the study subjects for entry into the study was also conducted. Inter-examiner and intra-examiner calibration was not feasible for the OHI-S Index. The survey was completed over six months (April-September, 2001). Consent for the survey was gained through the District education officer of Sunsari and the individual head masters of the selected schools.

Data entry and data analysis was performed with SPSS version 10.0. Plaque and calculus are graded on a numeric scale from 0 to 3, depending on the severity and extent of the deposits. The debris scores are totaled and divided by the number of surfaces scored for each individual, which provided the debris index. The same methods were used to obtain the calculus index. The average age-group debris and calculus index scores were combined to obtain the simplified oral hygiene index (OHI-S). The OHI-S values range from 0 to 6 and the scores are categorized as follows:

Good: score 0.0 to 1.2

Fair: score 1.3 to 3.0

Poor: score 3.1 to 6.0

The mean OHI-S scores were compared and evaluated using the parametric t-test for two independent samples with the level of statistical significance set at P <0.05.


   Results Top


A total of 324 males and 276 females in age group 12-13 years and 362 males and 238 females in age group 15-years were examined in 15 private and 15 government schools located in urban centers, rural towns and rural villages. Private schools were situated mainly in urban settings and rural town settings. Rural towns are situated along paved roads while rural villages are accessed via dirt roads.

[Table - 1][Table - 2][Table - 3][Table - 4][Table - 5][Table - 6] display the mean debris, calculus and OHI-S for each of the index teeth as well as the mean score for debris and calculus and the mean OHI-S of the school children surveyed. The order of the index teeth with the highest total score to the lowest total score was consistent: 46, 36, 26, 16, 31, 11. All mean OHI-S scores were normally distributed. Debris scores were consistently higher than calculus scores for all index teeth.

In both age groups, the mean debris, calculus and OHI-S for the index teeth and for the mean scores was higher in school children of government schools than in private schools [Table - 1][Table - 2] and the differences in mean OHI-S were statistically significant ( P < 0.005). Males and females of 12-13-year-olds had a comparable mean OHI-S (1.24 and 1.17) and this was not statistically significant [Table - 3]. However, the mean OHI-S was higher in males (1.29) compared to females (1.11) in the 15-year-old age group and this was statistically significant ( P <0.005) [Table - 4]. Results of 12-13-year-old school children of urban schools, rural towns and rural villages are displayed in [Table - 5]. Children of urban schools had the lowest scores followed by school children from rural towns and then rural villages. The mean OHI-S for urban school children was 0.98 compared to 1.34 for school children of rural towns and 1.44 for school children of rural villages and these differences in mean OHI-S were statistically significant ( P <0.005). This trend was also evident in the 15-year-old school children where urban school children had a mean OHI-S score of 1.00 compared to 1.37 for rural towns and 1.43 for rural villages [Table - 6]. The variance in the mean OHI-S scores were statistically significant ( P <0.005). The proportion of the school children with good, fair and poor hygiene is presented for both age groups in [Table - 7]. In both age groups a greater proportion of females had good hygiene compared to males of the same age group.


   Discussion Top


The simplified oral hygiene index (OHI-S) has been widely used to evaluate the level of oral cleanliness in epidemiological studies. OHI-S is easy to use since the criteria are objective, the examinations can be carried out quickly and a high level of reproducibility is possible with minimum training. For these reasons OHI-S was chosen for this study. The disadvantage of OHI-S is that the index is not used internationally like the Community Periodontal Index (CPI) and opportunities for international comparison of results is limited. However, CPI is an index for assessment of periodontal status and does not provide information on the level of debris. CPI measures the outcomes of accumulated plaque: gingival inflammation and periodontal pockets.

Higher OHI-S scores were noted in the molar index teeth (46>36>26>16) followed by the incisor index teeth (31>11). This may be a reflection of the greater difficulty in cleaning the surfaces of posterior teeth relative to the anterior teeth. A toothbrush with a smaller head would aid in gaining access to the lingual surfaces of the lower molars and the buccal surfaces of the upper molars for the removal of plaque.

The overall OHI-S score for both 12-13-year-olds (1.21) and 15-year-olds (1.22) in the District of Sunsari were almost identical and are indicative of good oral hygiene. However, a close examination of the OHI-S scores based on the type of school attended by the children shows statistically significant differences in mean OHI-S scores for both age groups ( P <0.005). For children of government schools the oral hygiene status can be rated as 'fair' compared to 'good' for children attending private schools. A better level of oral cleanliness amongst children enrolled in boarding (private) schools may be associated with a higher standard of education and higher standard of living since upper class and middle class families are more financially able to enroll their children in private schools. This finding is consistent with other countries such as the United States where a higher level of education and standard of living is associated with a better level of oral cleanliness.[8]

When the mean OHI-S scores are compared between males and females the scores were not statistically different in the 12-13-year-old age group. In the 15-year-old age group, females had better oral hygiene (OHI-S of 1.11) than males (OHI-S of 1.29) and this was statistically significant ( P <0.005). A greater proportion of females in the 12-13-year-old age group (55.1% scored 'good') and the 15-year-old age group (56.7% scored 'good') had good hygiene compared to 51.2% and 45.3% of the males respectively. Proportion of school children with poor hygiene was nil. Females have better oral hygiene and the variation between sexes may be attributed to behavioral differences.[8]

School children in both age groups enrolled in urban schools had better oral cleanliness (good) than their counterparts in both rural towns (fair) and villages (fair) and the differences in OHI-S were statistically significant ( P <0.005). Although village school children had the highest OHI-S scores, the difference from the OHI-S score of rural town school children was not statistically significant. The variance noted between these groups based on location may be due to socio-economic factors and the availability and affordability of toothbrushes and fluoridated toothpaste.

Statements concerning any differences in oral cleanliness of school children of various ethnic groups are difficult to formulate since the data collected for some of the ethnic groups was small and not amenable to analysis.

Some dentists in Nepal have speculated that the major reason for the increase in dental caries in Nepal has been due to poor oral hygiene practices and that mere mechanical removal of plaque is sufficient to prevent dental caries. Oral cleanliness may not be as significant as the frequency of sugar consumption and use of fluoridated toothpaste in the development of dental caries in the school children of Sunsari District. The same school children surveyed for oral cleanliness were also examined for dental caries and the results were reported in a recent article.[4] When the mean 12-13-year-old DMFT and mean 15-year-old DMFT is compared with OHI-S, an inverse relationship is noted. School children of these two age groups attending private schools had lower OHI-S scores than their counterparts attending government schools but they had a higher mean DMFT. In the case of 15-year-olds, the mean DMFT was significantly higher ( P <0.001) in private schools (mean DMFT = 0.80) than in government schools (mean DMFT =0.54). Similarly, 15-year-old females (mean DMFT = 0.86) had a significantly higher mean DMFT than males (mean DMFT = 0.55), but their oral hygiene was significantly better. This inverse relationship was also noted in school children attending urban schools, rural town schools and village schools. Urban school children had statistically significant lower OHI-S scores but recorded significantly higher mean DMFT in 12-13-year-old and 15-year-old children.

The multifactorial relationship of plaque, sugar consumption, tooth susceptibility and time has been demonstrated in Tristan de Cunha[9],[10] and Hopewood House.[11],[12] The children and adults of these communities had poor oral hygiene and heavy plaque accumulation but remained relatively caries free as long as daily sugar consumption was low. Once the daily average consumption of sugar and refined carbohydrates increased, there was a corresponding increase in dental caries. Cross-sectional and prospective studies have also shown a weak positive association between plaque and dental caries[13] and this has led some dentists to challenge the intrinsic value of oral hygiene practices in the prevention of dental caries.[14],[15] A Canadian Task Force[15] reported on evidence-based treatment for dental caries in 1994 and concluded that brushing without fluoridated toothpaste to remove plaque was not cariostatic but brushing was essential for the application of fluoridated toothpaste and the prevention of gingivitis. In a systematic review and up-date of the effectiveness of mechanic oral hygiene practices, Brothwell et al[16] reported that there was good evidence to recommend tooth brushing twice daily with a fluoride toothpaste in the prevention and control of gingivitis and dental caries. The fluoride in toothpaste contributed largely to caries reduction. There is also evidence to show that brushing with non-fluoridated toothpaste is ineffective in reducing dental caries.[13],[17] Controlling the frequency and amount of sugar consumed as well as fluoridation of the teeth are more important preventive measures than mere mechanical plaque control. Oral health education should emphasize brushing twice a day with fluoridated toothpaste and reducing the frequency of consumption of sugar between meals. The following conclusions can be drawn from this evaluation of oral cleanliness in 12-13-year-old and 15-year-old school children in the District of Sunsari:

  • Overall, the oral hygiene of these two age groups is good.
  • 15-year-old females have significantly better OHI-S scores than their male counterparts.
  • School children attending private schools have significantly better OHI-S scores than children attending government schools.
  • Urban school children have significantly better OHI-S scores than rural school children of the same age.
  • The differences in OHI-S of children attending private schools versus government schools may be due to socio-economic status.
  • The variation in the OHI-S scores of urban and rural children may also be related to socio-economic status or the availability and affordability of toothbrushes.


When data from this study is analyzed in light of the data concerning prevalence and experience of dental caries in the same subjects in the District of Sunsari[4] the following conclusions and recommendations can be made:

  • Urban school children, 12-13-years and 15-years, have better oral cleanliness but experience more dental caries than rural school children.
  • 15-year-old female school children have significantly cleaner teeth than males of the same age, but they also experience more decay.
  • Even though 12-13-year-old and 15-year-old school children of private (boarding) schools have significantly better oral hygiene than their counterparts attending government schools, they experience relatively more decay.



   Acknowledgement Top


Our sincere thanks to the office of the World Health Organization, Nepal for funding the study

 
   References Top

1.Central Bureau of Statistics. Preliminary Results of Population Census 2001. His Majesty's Government of Nepal: Kathmandu; 2001.  Back to cited text no. 1    
2.Nepal South Asia Centre. Nepal Human Development Report 1998. Nepal South Asia Centre: Kathmandu; 1998.  Back to cited text no. 2    
3.Yee R, McDonald N. Caries experience of 5-6-year-old and 12-13-year-old school children in central and western Nepal. Int Dent J 2002;52:453-60.  Back to cited text no. 3    
4.Koirala S, David J, Khadka R, Yee R. Dental caries prevalence, experience and treatment needs of 5-6-year-old, 12-13-year-old and 15-year-old school children of Sunsari District, Nepal. J Nep Dent Assoc 2003;5:12-24.  Back to cited text no. 4    
5.van Palenstein Helderman W, Groeneveld A, Jan Truin G, Kumar Shrestha B, Bajracharya M, Stringer R. Analysis of epidemiological data on oral diseases in Nepal and the need for a national oral health survey. Int Dent J 1998;48:56-61.  Back to cited text no. 5    
6.Petersen PE, Mohr A, Geddes D. Epidemiology data on Nepal children of ages 6 and 12 and oral health knowledge and attitudes of primary school teachers (unpublished report). University of Copenhagen: Copenhagen; 2001.  Back to cited text no. 6    
7.Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.  Back to cited text no. 7    
8.Grant DA, Stern IB, Listgarten MA. In : Periodontics in the tradition of Gottlieb and Orban. C.V Mosby Company: Washington, DC USA; 1988. p. 232-3.  Back to cited text no. 8    
9.Fisher FJ. A field survey of dental caries, periodontal disease and enamel defects in Tristan da Cunha. Br Dent J 1968;125: 447-53.  Back to cited text no. 9    
10.Holloway PJ, James PM, Slack GL. Dental caries among the inhabitants of Tristan da Cunha. (d). The last count. R Soc Health J 1962;82:139.   Back to cited text no. 10    
11.Sullivan HR, Harris R. The biology of children of Hopewood House, Bowra NSW. 2. Observations on oral conditions. Aust Dent J 1958;3:311-7.  Back to cited text no. 11    
12.Gillham J, Lennon D. The biology of the children of Hopewood House, Bowral, N.S.W. II. Observations extending over five years (1952-1956 inclusive). 4. Dietary survey. Aust Dent J 1958;3: 378-82.  Back to cited text no. 12    
13.Sutcliffe P. Oral cleanliness and dental caries. In : Murray JJ. 3rd ed. Oxford University Press: Oxford; 1996. p. 68-77.  Back to cited text no. 13    
14.Bibby BG. Do we tell the truth about preventing caries? J Dent Child 1966;33:269-79.  Back to cited text no. 14    
15.Lewis DW, Ismail AI. Prevention of periodontal disease. The clinical guide to preventive health care, the Canadian task force on periodic health examination. Minister of supply and services: Ottawa; 1994.  Back to cited text no. 15    
16.Brothwell DJ, Jutai DK, Hawkins RJ. An update of mechanical oral hygiene practices: Evidence-based recommendations for disease prevention. J Can Dent Assoc 1998;64:295-306.  Back to cited text no. 16    
17.Koch G. Long-term study of effect of supervised tooth brushing with a sodium fluoride dentifrice. Caries Res 1970;4:149-57.  Back to cited text no. 17    


    Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7]


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