Abstract
Introduction: Dental caries is considered the most prevalent
chronic disease in the world, which affect individual from all ages.
Host
acceptability, cryogenic bacteria, fermentable carbohydrates and time
are the four elements that are essential for the caries to start. dmft
index
is a measurement used to determine the degree of caries in any given
population, in which it could help in setting aims and strategies to
reduce
and prevent this disease.
Aim: The aim of this study was to estimate the caries
prevalence and the value of the dmft index of 3 to 5 year old children
of Dubai private
schools and its association with demographic factors as age and gender.
Methods and Materials: The study was a cross-sectional survey,
which examined 3 to 5 year old children, for the presence of caries in
their primary dentition. The survey was conducted by three calibrated
dentist, who examined the children in the participating schools, in a
school class setting using natural light and dental mirrors. Caries were
recorded for each primary tooth, following WHO 1987 criteria. dmft and
Significant Caries (SiC) Indices were calculated by age, gender and
country of origin. Statistical analysis of the data obtained using
parametric
tests (t-test and ANOVA), to determine the presence of statistical
significant differences.
Results: Two thousand nine hundred fifty-seven children were
included in the study. 1527 males and 1430 females, in the male group
134
children were in the 3 year age group, while 630 and 763 children were
in the four and five year old age group. The females group consisted of
139 children at 3 year of age, 575 in the four year age group and lastly
716 in the 5 year old age group. Caries prevalence was found to be
25.6%,
36.8% and 42.2% for the three age groups respectively. Dmft value was
found to be 0.90, 1.50 and 1.72 for the 3, 4 and 5 year old age groups,
with a dmft value of 1.55 for the total surveyed sample.
Conclusion: Caries prevalence in three, four and five year old
children was 25.6%, 36.8% and 42.2%, respectively. Mean dmft score was
1.55 for the total sample, with a breakdown for each group to be: three
year old group 0.90, four year old group 1.50 and five year old group
1.72. The SiC was found to be 2.07, 4.45 and 5.06; for the three age
groups while the SiC of the total sample found to be 4.55. Comparison
between the age groups showed that the caries prevalence and the SiC
index increased as the age increased. The last national survey in 2001
had higher dmft for the 5 year old children in the state of Dubai
Introduction
Dental caries is the most prevalent chronic disease globally
with multi-factorial etiology and pathogenesis WHO.int. Petersen
[1,2].
It affects more than 5 billion people of total global population
[24]. Children and adults could suffer dental caries at any time;
once the oral hygiene measures are compromised, and the
contributing factors are met together in specific condition and over
a period of time [28,31]. Calling dental caries as a multifactorial,
makes.com think about the elements responsible for such a disease
formation. Tooth surface as a host, cryogenic bacteria, fermentable
carbohydrates and time are the necessary elements. When they
meet in the appropriate proportions formation of the disease will
start. Characteristics of the tooth as a host such as, size, structure,
anatomy and position of the tooth have an important impact in
the progression of the caries and the rate of it. This could explain
why the primary teeth are more susceptible to dental caries,
having a wider proximal contact surface instead of contact point in
permanent teeth [62,63,64,65,73].
Progression of the dental caries is faster which is sent back
to the dental tubules arrangement, which is found as S-shaped
course in permanent teeth and straight course in the primary teeth
[27]. If dental caries are left untreated, then the general health of
the individual is at risk. As a multifactorial disease, elimination of
the cause will aid in the prevention of the disease. Alteration of a
causative factor can be another way to prevent the disease. Dental
caries is suggested to have big impacts on the person’s life, as it could
impair the social function, self-esteem and psychological status
Caries prevalence is another measurement, which represents the
percentage of the affected population by dental caries at any given
time [53]. One of the most important goals regarding global oral health was set by the World Health Organization (WHO) in 1979
is to reduce caries prevalence worldwide [2]. Repeated campaigns
are designed to fulfil this goal. Most of these campaigns mainly
focused on permanent teeth and few were exclusively targeted
to the primary dentition using the dmft tool. Prevalence of dental
caries among children from 0-5 year had been reported, as part of
the WHO goal. Many studies have been conducted in UAE, the Gulf
countries and the rest of the World to calculate the prevalence of
the dental caries in primary dentition [45,16,33].
The caries prevalence’s for 5 years old children worldwide
varied from 19.9% to 94%, while dmft score for the same age group
varied from 0.87(1.16) to 9.8(5.5). In regard to the children aged 3
and 4 years old, little studies was conducted; which has results for
the caries prevalence in 3 year old children between 19.4% and 85%
and for the 4 year old it was between 23.8% and 90%. On the other
hand the dmft scores worldwide was found to be 0.41(1.16) and
0.72(1.62) as lowest findings and 7.4(5.5) and 8.8 (5.6) as highest
finding for the two age groups respectively [51,54,57,59,71,72].
Aim and Objectives
The aim of this study was to estimate the caries prevalence
and the value of the dmft index of 3 to 5 year old children of Dubai
private schools and the association of them with demographic
factors as age and gender. The objectives were to compare the
caries experience between the 3 age groups, to compare the caries
experience between genders and to investigate possible association
of the caries prevalence and demographic factors such as age and
gender.
Methods and Materials
This study was part of European University College Oral Health
Campaign in Dubai - United Arab Emirates. All the licenses needed
for conducting this campaign were obtained from the Ministry of
Higher Education and the Ethics committee of European University
College that approved the project. Permission for participation
in the study was granted from the public and private schools.
Written explanation of the aim of the study and request for consent
forms were given to the parents, in Arabic and English about the
study. Sample From the list provided by the European University
College Oral Health Campaign, three schools enrolled preschool
and kindergartens children and were included in this study. Data
were collected during the academic year 2012-2013. Recruitment
was based on the age and the positive parental written informed
consent. The age of children recruited was between 3 and 5 year
old, starting at the day of their 3rd birthday up to the day before
their 6th birthday date. The date of birth was obtained from the
school files and entered into the computer program.
Procedure
Children of the chosen age groups were screened for
dmft according to WHO 1987 criteria, for caries detection [1].
Examination was performed by three licensed dentist, who were
calibrated based on the WHO 1987 criteria, for intra and inter
liability score of k was 0.80 and 0.78 respectively, based on images
of sound and carious teeth.
All children were examined at their school classroom under
room lighting conditions. Gloves and sterile protocols were used, as
well as tongue depressor, which aided in retraction of the tongue,
lips and cheeks for better visibility of the teeth. Examination
was done by dental mirror only, no dental probes were used. For
moisture control and removal of plaque, cotton rolls and gauze
were used. According to the WHO 1987 criteria, diagnosis of all
primary teeth is based on the presence or absence of the caries.
dmft was recorded for decayed, missing (due to caries) and filled
teeth. The data from every child were recorded in individual
charts. Each chart had an illustration of full primary dentition. The
examiners were marking each tooth as decay (dt), missing (mt) or
filled (ft). Mean dmft was calculated for the entire sample, as well
as individually for each age and gender group separately. Standard
deviation (SD) for the dmft was also calculated. Significant caries
index (SiC) which represents the mean dmft of the one third of the
sample with the highest caries score was also calculated for the
total sample as well as for each age group and gender. SiC index
gives an indication of the severity of the caries of the most affected
part of the population and also illustrates in combination with dmft
the distribution pattern of caries in this population [3].
Statistical Analysis
Data were statistically analyzed and compared between each
age group as well as within each age group by gender. In order to
statistically analyze the data of this study, t–test, ANOVA (Analysis
of variance) and LSD (least square difference) tests were used at a
level of significance p<0.05. ANOVA and t-test were used to identify
differences between the means of dmft, dmft components and SiC index
from different groups. When ANOVA detected a difference between groups
then LSD was used to detect which groups were different.
Table 1:
* Indicates statistical significant difference.
Results
The sample consisted of two thousands nine hundreds fiftyseven
child (Table 1). 1527 males (51.6%) and 1430 females
(48.4%), 273 (9.2%) in the 3 year old group and 1205 (40.8%) and
1479 (50.0%) in the 4 and 5 year old group, respectively. 3 year old
children group consisted of 273 children, 134 (49.1%) males and
139 (50.9%) females, there were 203 (74.4%) caries free children.
Of the male sample 104 children (77.6%) were caries free while
of the females 99 children (71.2%) were free of caries for the 3
year old sample. Mean dmft (SD) was 0.90 (2.18) and dt = 0.83
(2.09), mt = 0.02 (0.27) and ft = 0.03 (0.19). Comparing the caries
experience between males and females the result showed that
males have lower dmft values, with a mean dmft (SD) of 0.69 (1.71),
while for the females the mean dmft (SD) was 1.09 (2.53). Similarly,
all of the dmft components in the male group presented lower
values as compared to females; dt 0.67 (1.69), mt 0.02 (0.27) and
ft 0.02 (0.14) for the males and dt 1.00 (2.41), mt 0.02 (0.27) and ft
0.04 (0.23) for the females. Differences in the means between the
two genders were explored with ANOVA which did not show any
statistically significant difference between the means of dmft (F=
1.52), dt (F= 1.30), mt (F= 1.51) and ft (F= 0.86). Moreover there
were more males without caries (77.6%) compared to females
(71.2%).
SiC value for the males was 2.07 (2.45) which are lower than
the females 3.23 (3.50). 4 year old children group this age group
included 2015 children, 630 (52.3%) were males and 575 (47.7%)
females. There were 761 (63.2%) caries free children, 382 (60.6%)
of the males and 379 (65.9%) of the females. The dmft values were
found to be 1.50 (2.73) for the total sample, with dt = 1.28 (2.48),
mt = 0.02 (0.23) and ft = 0.20 (0.72). It was also observed that dmft
value for the males was 1.54 (2.69), with dt= 1.33 (2.69), mt= 0.03
(0.30) and ft= 0.19 (0.71), while for the females the respective
values were, dmft = 1.45 (2.77), dt= 1.45 (2.77), mt= 0.01 (0.12)
and ft= 0.21 (0.74). The mean dmft and dt was higher in the male
group than the female group while females had higher dt and ft
values. SiC value for the 4 year old sample was found to be 4.40
(3.11), while the SiC values for males and females were 4.44 (2.99)
and 4.33 (3.25), respectively 5 year old children group The 5 year
old group consisted of 1479 children, 763 (51.5%) males and
716 (48.5%) females. The mean dmft value of the total sample
was 1.72 (2.99), with dt = 1.41 (2.55), mt = 0.03 (0.26) and ft =
0.29 (0.95). Comparing males to females in the caries experience
within this group showed that the males had higher dmft value
1.85 (2.99) while the females had 1.59 (2.69). In regard to the dmft
component, dt, mt and ft values; it was 1.53 (2.73), 0.04 (0.23) and
0.28 (0.87) for the males, and 1.28 (2.34), 0.04 (0.29) and 0.31
(1.04) for the females, respectively. Significant Caries index SiC for
the total sample in this age group was 4.86 (2.97). Males presented
statistically significant higher SiC 5.02 (3.05) than females 4.51
(2.82) using Student’s t-test (t= 5.11).
Comparing between the three age groups (3, 4 and 5 year old)
The sample consisted of 1138 (38.5%) children with caries and
1819 (61.5%) caries free children. Caries prevalence for the 3 year
old group was 25.6% (70 children) and 36.8% (444 children) and
42.2% (624 children) for the 4 and 5 year old group respectively.
The mean dmft value was increasing as the age of the sample was
increasing. The lowest dmft value was observed for the 3 year
old group 0.90 (2.18) and then it increased for the 4 year old
1.50 (2.73) and the highest value was observed for the 5 year old
children 1.72 (2.85). Regarding the dmft components, dt (decayed
teeth) ranged between 0.84 (2.09) and 1.41 (2.55) and dt was the
component with the higher contribution to the dmft index while the
component with the lowest contribution was the ft which ranged
between 0.03 (0.20) and 0.29 (0.95). ANOVA showed that among
the three age groups there was statistically significant difference
in the mean dmft (F= 10.81), dt (F= 6.16) and ft (F= 13.14) values,
while there was no statistical significance difference in mt (F= 2.74)
component. LSD test was used to explore the differences between
the means that ANOVA suggested. LSD test showed that there was
statistically significant increase of the mean dmft and dt values as
the age of the children progressed. It was also found that only the
three year old mean value of the dt component was different from
the means of the other ages which had no significant difference.
Comparing dmft and its component between the three age
groups showed that 5 year old children had higher value 0.9 (2.18),
as compared with the 3 and 4 year old groups with 1.5 (2.73)
and 1.72 (2.85), respectively. About the dmft components, dt was
highest among the 5 year old group 1.41 (2.55) followed by the 4
year dmft 1.28 (2.48) and the 3 year old 0.84 (2.09). mt component
was also highest among the 5 year old group 0.04 (0.26), the lowest
was 4 year old children 0.02 (0.23), 3 year old group scored 0.03
(0.28). The values for ft was 0.03 (0.2) for the 3 year old group, 0.2
(0.72) for the 4 year old and 0.29 (0.95) for the 5 year old group.
Dental caries formation in primary dentition increases with age,
as the primate spaces and the physiological spaces reduces. Lack
of hygiene and interproximal cleaning, aids in the increase of
proximal caries as well the flat contact surfaces, which increase
the progress of these kinds of caries. ANOVA was also used to test
the difference of the dmft values between the males and females
among the different age groups. Statistically significant difference
was found between the different mean dmft male values (F=10.19)
and LSD showed that the difference existed between all the three
groups. Statistically significant difference was also observed in the
dt and ft components of the dmft (F=6.71 and 7.10). LSD showed
that males had statistically significant differences in dt and ft values
among all three age groups. In female groups mean dmft did not
have statistically significant difference, the only observation with
statistically significant difference was seen in the mean dmft
component, specifically ft value (F= 6.17). LSD test showed that
all the three means in the ft females component were statistically
significant different .
Discussion
United Arab Emirates has improved in many aspects regarding
the dental health and the dental awareness of the population. Never
the less through the few last year dental caries are still considered
a national health problem among adult and children. Previously
conducted National Survey in 2001 by El Nadeef et al. [4] studying
dental caries among children, found dmft in 5 year old children 5.1, and
specifically 6.6 for the state of Dubai. In this study 5 year
old children dmft score was found to be 1.72. This is showing a
decline of the dmft value as a result which could be attributed to the
increase awareness in regard to dental health and the development
of the dental care facilities. In this survey it is interesting to note
the
large drop of the dmft scores compared to previous studies. This
big difference was primarily due to a substantial decrease of the dt
components suggesting a drop in caries presence in the population.
Despite this drop dt still remains the major contributing factor of
the dmft index suggesting that even today caries are left untreated
in children. Probably this reflects an attitude among the parents
not identifying caries of primary teeth as a disease which needs
treatment. In the past years there have been many awareness
programs and educational campaigns conducted in the UAE trying
to change this attitude. Towards the same direction this study
shows also a slight increase in the ft component between the two
studies. The awareness of the public regarding caries and caries
prevention cannot therefore explain the substantial drop of the
dmft values. Most likely this drop should be attributed to other
confounding factors like wider use of fluoridated toothpaste and
fluoridated products or healthier eating habits.
For the three and four year old group no studies were performed
in Dubai, thus no data were available previously for the state of
Dubai at the time of conducting this study. The results obtained from
this study are the first data for this age group in Dubai, although
the sample was not representative of the total population, the data
may be considered as a pilot sample for an upcoming thorough
investigation. AlHosani, Rugg-gunn 1998 conducted a study which
included 4 and 5 year old children, in the western part of the UAE,
AbuDhabi, AlAin and The West region. Prevalence of caries in the
four year old children was ranging between 71-86%, while for the
five year old it was between 82-94%. dmft was found to be 8.4 in
AbuDhabi, 8.6 in AlAin and 5.7 in The West region. Comparing this
result to the result obtained from this study, we can conclude that
the dmft value in the state of Dubai is lower than the other UAE
regions. Another study by Hashim R 2006 [6] in the city of Ajman
found dmft in 5 year old children 4.0 (4.1), with caries prevalence
of 72.9%, while in this study the prevalence was found to be 42.2%.
Comparing the present findings to those conducted in the Middle
East countries, findings suggest that this study is having lower dmft
and caries prevalence than those conducted in the last decade. Paul,
2003 found in KSA caries prevalence of 83.5% and dmft of 7.1 (6.1)
Paul 2003 [52]; Salem, Holm 1985 [7] had mean dmft 1.2 (0.08) for
children age 3-5 year old in KSA, Morris et al. 1999 [8] had 19%
dental prevalence in 18-48 months old children in Kuwait, also in
Kuwait in 1993, Martomaa H found 22% prevalence in 3-7 year old
children in Kuwait 1993 and Wyne, AH, 2008 found mean dmft 6.1
(3.9) for 3-5 year old children [70].
Among the 3 year old children the lowest dental caries (19.4%)
was experienced in India 2001 [61], while the highest (85%) was
in Philippines 2003 [26]. The result of this study falls in between
this range, close to the lower end being 26%. There are no previous
surveys conducted in the UAE for this age group in order to
compare the result of this study. The only possible comparison can
be done with surveys conducted in other countries of the world.
We can only have an approximate comparison with other studies
of the Gulf region since they report dmft and prevalence values for
a range of ages that include the three year group making a direct
comparison impossible. Viewing the previous studies conducted
for the 3 year old children worldwide and comparing those findings
with the finding of this study, we could conclude that the dmft score
of this age group for the city of Dubai is being the lowest compared
to other studies conducted in other countries in the world. The
highest dmft value 7.4 (5.5) was reported in the Philippines 2003
[26], followed by 5.5 (4.5) in China 2002 [38]. dmft value in India
varied between 0.41 (1.16) in 2001 [61] and 4.43 (2.33) in 2009
[65]. Brazil’s dmft values reported in 2009 were the lowest 1.13
(1.90) for 3 year old children [29], while in 2004 it was 2.10 [66].
For four years old children group the highest caries prevalence
was found to be between 71% and 86% in AbuDhabi 1996 [5] which
is very high compared to 37% in this study. In India (2001) [61], the
reported caries prevalence was the lowest 28.2% [34], followed by
Brazil 2007 with 23.8%. Philippines 2003 had the highest caries
prevalence of 90% for this age group [26].
Comparing to the previous studies from different regions of the
world, it could be noticed that dmft of this study falls in the lowest
range of all dmft values of this age group. Australia 2002 [36] and
Brazil 2009 [29] had the lowest dmft values 1.29 (2.74) and 1.42
(3.11), respectively. Next comes the dmft value of this study 1.50
(2.73).
Most of the dmft studies are conducted for 5 year old children.
After the announcement of WHO goal for the year 2000, of having
caries prevalence to be less that 50% for 5 year old children,
many studies have been conducted all over the world to have this
baseline and efforts have been put together afterwards to achieve
the goal in that period. It worth mentioning that these efforts had
been successfully noticed as dmft values had been significantly
decreasing . In the UAE, significant decrease in the dmft value could
be noticed between 1996 and 2001, and even further decrease could
be noticed in dmft value of this study. Even though this decrease
is obvious, the WHO target of having dmft score below 3 for the 5
year old children, haven’t been achieved yet. KSA 2000 [19], have
achieved WHO target by having 0.95 (2.03) in a specific population.
Other countries like India 2001 [61], Australia 2002 [36], India
2006 [44], Brazil 2007 [34], China 2008 [42], Brazil 2009 [29], Italy
2009 [14], Norway 2010 [74] and Greece 2011 [67] had also reach
the target goal but after the set date. Highest dmft value could be
observed for Philippines 5 year old children 2003 [26], followed by
KSA 2008 [70] and FYROM 2014 [12] with same dmft value of 6.1.
In regard to the caries prevalence in the 5 year old children, the
highest prevalence could be observed in the Philippines 2003 [26]
(94%) and in UAE 1996 [5] (94%).
The lowest prevalence was reported by Ferreira et al., Italy
2007 [34] (19.9%). It worth mentioning here that India 2001
[61], Kuwait 2002 [21], Brazil 2004+2007+2009 [66+34+29], UK 2006 [55], Italy 2009 [14], Norway 2010 [74] and Greece
2011 [50] all had caries prevalence that falls below 50%, which
is the goal set by WHO in 2000 Khan 2014 [9] had reported a
systemic review of the dmft in the Arab world for children aged
between 3 and 10 year of age, for the period from 2000 to 2012.
In this report Kingdom of Saudi Arabia in 2000 [19] reported the
lowest dmft values 0.95 while in 2007 [52], dmft value was the
highest 7.1. These studies were conducted in different places in
KSA, follow up studies worth to be conducted in the same places
to have a frank comparison between the new and old obtained
dmft values. According to the finding results in this study, and
due to the selection of the sample, which was drawn mainly from
private schools and the fact that those children are from a medium
socioeconomic status families, the result are not representative to
the children population in the city of Dubai. Furthermore, the three
examiners were calibrated through photographs, which may have
contributed to some bias for caries underestimation. Also the caries
were scored according the 1987 WHO caries criteria which does
not account for caries with underlining dark shadow from dentin,
lesions that are usually accounted in WHO 1997 criteria, used by
most of the epidemiological studies [15,25,30,32,40,41,46,49,56,
58,60,68,69]. Since the introduction of dmft and SiC indices 1938
[35], it was considered as ideal indices, as they met a number of
criteria, which made them useful epidemiological indicators. These
criteria included simplicity, reliability versatility and statistical
manageability [17,18,20,22,23,37,43,47]. dmf describes the mean
experience of dental caries in specific population, without giving
any information about the level of the dental caries in the most
affected population. On the other hand significant caries index
(SiC), does represent the mean dmft in the highest one third of
the population with the highest dmft scores giving a picture of the
severity of the disease in the most affected portion of the sample.
The SiC index indicated that the study sample had a score of
2.07 (2.45) for the 3 year old group, 4.45 (2.99) for the 4 year old
group and 5.06 (3.13) for the 5 year old group. The SiC score for
the 5 year old children is considered of lower score compared to
the SiC indices from other part of the world, for example in SiC
score of 5 year old children in Greece 2011 was 5.01 [50], while
In Sri Lanka 2012 5.84 for 4 and 5 year old children [11]. In the
Republic of FYROM, SiC index was found to be 8.83 [12] found
SiC in Turkish children to be of 7.75 [13] and according to in Italy,
SiC for 5 year children was 5.32 [14]. Recommendations since the
National survey of dental caries in United Arab Emirates is almost
fifteen year old, efforts have to be put together in a governmental
and personal level to update this important data, which will aid
in thorough prevention of the problem. Health education of the
parents and the children has to start as early as possible, which will
aid in prevention and detection of the problem at its initial stages.
Dental visits have to be scheduled annually for routine checkups.
Parent’s education regarding the importance of the primary teeth
to the child’s overall health has to be emphasized; this important
information will result in maintaining healthy children .
Conclusion
Caries prevalence in three, four and five year old children were
found to be 25.6%, 36.8% and 42.2%, respectively. Mean dmft
score for the total sample was 1.55 (2.75), with a breakdown for
each group to be: three year group 0.90 (2.18), four year group 1.50
(2.73) and five year old group 1.72 (2.85). The SiC was found to be
2.07 (2.45), 4.45 (2.99) and 5.06 (3.13); for the three age groups,
3, 4 and 5 year old children, respectively [61-68]. The SiC for the
total sample was found to be 4.55 (3.12). Comparison between the
age groups showed that the caries prevalence and the SiC index
increased as the age increased. The last national survey in 2001
had higher dmft for the 5 year old children in the city of Dubai.
The prevalence of primary dental caries is greater in 5 year old
children, especially in male children. Dental caries formation in
primary dentition increases with age, as the teeth are exposed to
the cariogenic bacteria for longer time. The sample consists of only
private schools in Dubai; dmft scores are lower than the previous
national survey which was conducted at public schools. Dental
awareness is still minimum among the population new national
survey has to be conducted to update the previous data [69-73].
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