'Fit for school' - a school-based water, sanitation and hygiene programme to improve child health: Results from a longitudinal study in Cambodia, Indonesia and Lao PDR.

BACKGROUND: The Fit for School (FIT) programme integrates school health and Water, Sanitation and Hygiene interventions, which are implemented by the Ministries of Education in four Southeast Asian countries. This paper describes the findings of a Health Outcome Study, which aimed to assess the two-year effect of the FIT programme on the parasitological, weight, and oral health status of children attending schools implementing the programme in Cambodia, Indonesia and Lao PDR. METHODS: The study was a non-randomized clustered controlled trial with a follow-up period of two years. The intervention group consisted of children attending public elementary schools implementing the FIT programme, including daily group handwashing with soap and toothbrushing with fluoride toothpaste, biannual school-based deworming; as well as construction of group handwashing facilities. Control schools implemented the regular government health education curriculum and biannual deworming. Per school, a random selection of six to seven-year-old grade-one students was drawn. Data on parasitological infections, anthropometric measurements, dental caries, odontogenic infections and sociodemographic characteristics were collected at baseline and at follow-up (24 months later). Data were analysed using the χ2-test, Mann Whitney U-test and multilevel logistic and linear regression. RESULTS: A total of 1847 children (mean age = 6.7 years, range 6.0-8.0 years) participated in the baseline survey. Of these, 1499 children were available for follow-up examination - 478, 486 and 535 children in Cambodia, Indonesia and Lao PDR, respectively. In all three countries, children in intervention schools had a lower increment in the number of decayed, missing and filled permanent teeth between baseline and follow-up, in comparison to children in controls schools. The preventive fraction was 24% at average. The prevalence of soil-transmitted helminth infection (which was unexpectedly low at baseline), the prevalence of thinness and the prevalence of odontogenic infections did not significantly differ between baseline and follow-up, nor between intervention and control schools. CONCLUSIONS: The study found that the FIT programme significantly contributed to the prevention of dental caries in children. This study describes the challenges, learnings and, moreover, the importance of conducting real-life implementation research to evaluate health programmes to transform school settings into healthy learning environments for children. The study is retrospectively registered with the German Clinical Trials Register, University of Freiburg (Trial registration number: DRKS00004485, date of registration: 26th of February, 2013).

Associations between oral health-related impacts and rate of weight gain after extraction of pulpally involved teeth in underweight preschool Filipino children.

BACKGROUND: Severe dental caries in young children is associated with underweight and failure to thrive. One possible mechanism for severe caries affecting growth is that the resulting pain and discomfort influences sleeping and eating, and that affects growth and weight. The objective of this study was to assess whether rate of weight gain after extraction of severely decayed teeth in underweight preschool Filipino children was related to reductions in oral health-related impacts and dental pain from severe dental caries affecting eating and sleeping. METHODS: Data are from the Weight Gain Study, a stepped wedge cluster randomized clinical trial where underweight Filipino children with severe dental decay had their pulpally involved teeth extracted. Day care centers were randomly divided into two groups; A and B. Group A children received treatment first and Group B children were treated four months after Group A. Clinical oral examinations used WHO criteria and the pufa-index. Self-reported oral health-related impacts and anthropometric measurements were collected for both groups at baseline, four months after treatment of Group A children and four months after treatment of Group B children. Weight-for-age z-scores were calculated using 2006 and 2007 WHO standards. Data were converted to a one-group pre-test post-test study design, where all children received treatment. Associations between changes in oral health-related impacts and weight-for-age z-scores after dental treatment were assessed. RESULTS: Data on 145 children (mean age 61.4 months) were analyzed. There was a significant association between oral health-related impacts and rate of weight gain after extraction of pulpally involved teeth (p=0.02). Children free of impacts on sleeping related to having severely decayed teeth extracted gained significantly more weight compared to children who reported sleeping problems after dental treatment (p<0.01). CONCLUSIONS: After extraction of severely decayed teeth in underweight Filipino children, levels of oral health-related impacts were associated with rate of weight gain. Decreases in oral health impacts on sleeping appeared to be most strongly associated with weight gain. TRIAL REGISTRATION: ISRCTN: ISRCTN90779069.

Childhood stunting and caries increment in permanent teeth: a three and a half year longitudinal study in Peru.

BACKGROUND: Malnutrition has been consistently associated with caries in primary teeth, although an effect on permanent teeth has not been established because of the few longitudinal studies. AIM: To explore the association between stunting and caries increment in permanent teeth over 3.5 years. DESIGN: In 2003, 121 children aged 7-9 years were randomly selected from nine underserved communities in Lima (Peru). Parents provided demographic information and a food diary for their children. Clinical examinations included assessments of height, weight, oral hygiene, and dental caries. Stunting was defined using the 2000 CDC and 2007 WHO standards. In 2006, 83 children were re-examined, and the 3.5-year net DMFS increment was calculated. The association between stunting and net DMFS increment was assessed using negative binomial regression. RESULTS: Stunting was related to net DMFS increment after adjustment for sex and age, oral hygiene, sugary snacks between meals, and caries experience in primary and permanent teeth. Consistent results were found when using either the 2000 CDC (incidence rate ratio: 1.61; 95%CI: 1.07, 2.44) or 2007 WHO standards (IRR: 1.79; 95%CI: 1.28, 2.51). CONCLUSION: Stunting was a significant risk factor for caries increment in permanent teeth over a 3.5-year period, independent of other well-known risk factors for caries development.

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.

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.

Dental caries in adolescents from public schools in Maputo, Mozambique.

AIM: To assess dental caries prevalence in adolescents at urban and sub-urban areas of Maputo-City, Mozambique and to identify its relationship with dental fluorosis, dental plaque, nutritional status, frequency of sugar consumption and the concentration of fluoride in public water supply. METHODS: Subjects (n=601) were randomly selected from five urban schools and five sub-urban schools. Clinical examinations were performed under standardised conditions by a trained examiner using DMFT index, SiC index, fluorosis index, PHP, BMI, a sugar consumption questionnaire and water supply analysis. The bivariate analysis and Pearson correlation was used (p < 0.05). RESULTS: The mean (DMFT) was 0.9 (+/- 1.65 SD). Children in urban schools showed less dental caries (0.8 +/- 1.49 SD) than children in sub-urban schools (1.1 +/- 1.80 SD, p = 0.03). Only 8.15% had very mild to moderate fluorosis but most presented poor oral hygiene. Cases of malnutrition were found in more sub-urban schools (n=109; 36.22%) than in urban schools (n=66; 22.00%) (p = 0.03). The frequency of sugar consumption was higher among urban children compared to suburban schools (p < 0.00). The level of fluoride in water consumption in urban schools was 0.4 ppmF, above the level of fluoride in sub-urban schools, 0.2 ppmF. CONCLUSION: Dental caries should not be considered a major oral health problem in Maputo at the moment. However the data suggest the implementation of a population strategy to reduce dental caries rates, in children of both urban and sub-urban areas, in Maputo.

Using an oral health-related quality of life measure in three cultural settings.

AIM: To assess the application of the Oral Impacts on Daily Performances (OIDP) index for use in three different language and cultural settings; OBJECTIVES: To develop a Spanish and Afrikaans version of the OIDP for use in the USA and South Africa and to assess its reliability and validity in three counties: UK, USA and South Africa. DESIGN: Co-ordinated pilot studies using the OIDP questionnaire and clinical examination using WHO criteria in the three countries using cross-sectional convenience samples of children. SETTINGS: Two populations in each country: relatively well-off and more socially disadvantaged in three age groups 40 years+, 15-16 and 11-12 year-olds. RESULTS: 525 volunteers participated in the study; 154 in Texas, 177 in Bristol and 194 in Cape Town, the majority being females. The prevalence of oral impacts on daily performances varied between the three sites, with the sample in Bristol showing lower prevalence of 28.8% reporting at least one oral impact in the past six months. Difficulty eating was a common impact in all three sites, reported by 22.7% of the Texas sample, 18.6% of the Bristol sample and 33.0% of the Cape Town sample. Criterion and construct validity: the OIDP performed consistently well in all three sites. The combined dental caries status of the two lower age groups (12- and 16-year-olds) varied by site: Texas had the highest overall mean DMFT of 4.31, then Bristol with 3.07 and Cape Town the lowest at 2.89. CONCLUSIONS: The OIDP index had excellent psychometric properties in the Cape Town and Texas samples and had an overall good performance in the Bristol sample. Potentially the index can be used for oral health needs assessment and planning services. Further studies using larger samples might provide information relevant to the revision of existing oral health care systems.

Poverty, social exclusion and dental caries of 12-year-old children: a cross-sectional study in Lima, Peru.

BACKGROUND: Socioeconomic differences in oral health have been reported in many countries. Poverty and social exclusion are two commonly used indicators of socioeconomic position in Latin America. The aim of this study was to explore the associations of poverty and social exclusion with dental caries experience in 12-year-old children. METHODS: Ninety families, with a child aged 12 years, were selected from 11 underserved communities in Lima (Peru), using a two-stage cluster sampling. Head of households were interviewed with regard to indicators of poverty and social exclusion and their children were clinically examined for dental caries. The associations of poverty and social exclusion with dental caries prevalence were tested in binary logistic regression models. RESULTS: Among children in the sample, 84.5% lived in poor households and 30.0% in socially excluded families. Out of all the children, 83.3% had dental caries. Poverty and social exclusion were significantly associated with dental caries in the unadjusted models (p = 0.013 and 0.047 respectively). In the adjusted model, poverty remained significantly related to dental caries (p = 0.008), but the association between social exclusion and dental caries was no longer significant (p = 0.077). Children living in poor households were 2.25 times more likely to have dental caries (95% confidence interval: 1.24; 4.09), compared to those living in non-poor households. CONCLUSION: There was support for an association between poverty and dental caries, but not for an association between social exclusion and dental caries in these children. Some potential explanations for these findings are discussed.

Increasing prevalence of emergency department visits for pediatric dental care, 1997-2001.

BACKGROUND: Hospital emergency department (ED) visits for non-urgent care have been increasing since the late 1950s. This study investigated the prevalence and characteristics of pediatric ED visits for dental problems during a five-year period. METHODS: This retrospective study included newborns through 17-year-olds with dental complaints identified from the electronic register of the ED of Texas Children's Hospital, Houston, between January 1997 and December 2001. The authors described patient characteristics, diagnoses, factors associated with ED use for nontraumatic problems and annual changes in ED visits for dental and nondental complaints. RESULTS: Of the 1,102 subjects, 809 (73.4 percent) had nontraumatic and 293 (26.6 percent) had traumatic dental complaints. The study revealed a 121 percent increase in ED visits for dental complaints and a 66-fold increase in admissions between 1997 and 2001. Of the inpatient admissions, 68 percent were the result of caries and its sequelae. CONCLUSIONS: This study revealed a substantial increase in ED visits and hospital admissions for dental problems during the study period. The majority of dental problems were nontraumatic in nature. PRACTICE IMPLICATIONS: Dental care experts should be available in ED settings in which increases in such visits are seen. Studies must be conducted to explore ways of keeping patients from seeking care in EDs inappropriately.

Teledentistry and its use in dental education.

BACKGROUND: Teledentistry is a relatively new field that combines telecommunication technology and dental care. Most dentists and dental educators are unaware that teledentistry can be used not only for increased access to dental care, but also for advanced dental education. TYPE OF STUDIES REVIEWED: The authors describe teledentistry as it is applied worldwide, as well as its uses in education. Teledentistry in education can be divided into two main categories: self-instruction and interactive videoconferencing. Both of these methods have been used in several studies and countries. RESULTS: The type of network connectivity used greatly affects the feasibility of teledentistry education. Furthermore, no optimal type exists, but health care professionals should choose the mode based on budget, geography and technical support available. Of the two main categories of teledentistry in education, the interactive videoconferencing method has had better results because of its ability to provide immediate feedback. CLINICAL IMPLICATIONS: Teledentistry can extend care to underserved patient populations, such as those in rural areas, at a reasonable cost. Teledentistry provides an opportunity to supplement traditional teaching methods in dental education, and will provide new opportunities for dental students and dentists.

Dental practice implications of prion diseases.

This review article discusses dental practice implications of prion diseases, including Creutzfeldt-Jakob disease. The current universal precautions used for infection control in dentistry do not inactivate infectious prions. There is a theoretical, yet real risk of prion disease transmission through dental treatment, although the magnitude of that risk has not yet been determined. Medical, family, and travel histories can demonstrate the need for implementing improved levels of infection control. Best practices include the following: For certain cases, single-use disposable dental instruments should be used. Those instruments that are not disposable, should have a thorough physical cleaning, be soaked in hot 1N sodium hydroxide solution for 1 hour, and then autoclaved in a vacuum or porous-load autoclave at 134 degrees C to 138 degrees C for 18 to 20 minutes. Dental and other health care professionals need to understand prion diseases, and for best practice, consider implementing recommended changes to infection-control measures, since current practices do not destroy infectious prions.

Relationship between Untreated Dental Caries and Weight and Height of 6- to 12-Year-Old Primary School Children in Bangladesh.

Background. Children in low-income developing countries are likely to suffer from undergrowth. Dental caries is another common problem in these countries. Aim. To examine the association between untreated dental caries in primary and permanent teeth with age-adjusted height and weight among 6-12-year-old children in Bangladesh. Design. Social, behavioural, and clinical data were collected from 1699 children in nine different randomly selected primary schools in socially deprived areas of Bangladesh. The associations of age-adjusted weight and height and being underweight with dental caries were examined adjusting for sex, area of residence, socioeconomic position, skipping meals, tooth cleaning, and doctor visits. Results. 26% of the children were underweight and 55% had untreated dental caries. Children with at least one decayed tooth were significantly underweight with odds ratios 1.6 (95% CI 1.1, 2.3) and 1.5 (95% CI 1.1, 2.0) for 6-8-years and 9-12-year-old children, respectively, in the adjusted model. The number of decayed teeth was inversely and significantly associated with the standardized age-adjusted weight. Conclusions. The findings highlight the association between untreated dental caries and being underweight in primary school children in socially deprived areas in low-income developing countries and emphasize the need to integrate oral and general health policies with social policies.

Sugar consumption and preference among Mexican, Chinese, and Nigerian immigrants to Texas.

This pilot study investigated the relationship between sugar consumption/ preference and the length of residence in the U.S. among certain immigrant groups. The study sample consisted of 213 volunteers from community organizations and church groups, of Nigerian (45%), Mexican (31%), and Chinese (24%) descent. Data were collected on demographics, sugar consumption/preference (24-hour dietary recall), and oral health status. The age of respondents varied from 18 to 93 years with a mean age of 37.0 ± 11.7 years. The mean length of residence was 9.2 ± 7.2 years, and the mean sugar consumption was 122.4 ± 114.6 g/day. Immigrants from Mexico and Nigeria reported consuming more servings of sweets per day than the Chinese (p= .006); Mexican immigrants had the highest level of sugar preference (p= .001). No significant differences were observed between the length of residence and either sugar consumption or sugar preference. Greater availability of sugar and sweet snacks does not always result in increased sugar consumption or sugar preference.

Is income inequality related to childhood dental caries in rich countries?

BACKGROUND: The aim of this study was to assess the correlates of income and income inequality with dental caries in a sample of all countries, as well as in rich countries alone. METHODS: In this ecological study, the authors analyzed national data on income, income inequality and dental caries from 48 countries. Of them, 22 were rich countries (according to World Bank criteria). The authors determined income by gross national income (GNI) per capita (formerly known as gross national product) and income inequality by the Gini coefficient (a measure of income inequality on a scale between 0 and 1). They assessed dental caries according to the decayed, missing, filled teeth (dmft) index in 5- to 6-year-old children. The authors used Pearson and partial correlation coefficients to examine the linear associations of income and income inequality with dental caries. RESULTS: GNI per capita, but not the Gini coefficient, was inversely correlated with the dmft index in the 48 countries. However, the results showed an opposite pattern when analyses were restricted to rich countries (that is, the dmft index was significantly correlated with the Gini coefficient but not with GNI per capita). CONCLUSION: These findings support the income inequality hypothesis that beyond a certain level of national income, the relationship between income and the population's health is weak. Income inequality was correlated more strongly with dental caries than was income in rich countries. CLINICAL IMPLICATIONS: Among rich countries, income inequality is a stronger determinant of childhood dental caries than is absolute income.