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Dental Caries Experience and Oral Health Practice among 12-Years-Old Schoolchildren
Int J Clin Prev Dent 2022;18(1):1-7
Published online March 31, 2022;  https://doi.org/10.15236/ijcpd.2022.18.1.1
© 2022 International Journal of Clinical Preventive Dentistry.

Eman K. M. Mansur1, Halima A. Ayyad1, Raga A. Elzahaf2,3

1Community and Preventive Department, Faculty of Dentistry, University of Benghazi, Benghazi, 2Public Health Department, College of Medical Technology, Derna, Libya, 3Middle East and North Africa Research Group
Correspondence to: Eman K. M. Mansur
E-mail: emanmansur80@gmail.com
https://orcid.org/0000-0002-4540-9120
Received January 27, 2022; Revised March 15, 2022; Accepted March 18, 2022.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Objectives: To assess the experience of dental caries and practice of oral health preventive measures.
Methods: This was a secondary data study extracted from primary data through a cross-sectional study of a random sample of two hundred and forty-six 12 years-old Libyan schoolchildren (in 2019). Children underwent clinical examinations for dental caries experience. Then, they asked to complete a self-administrated questionnaire that designed to evaluate the oral health practices. The collected data were analysed using SPSS for Windows, version 25. The alpha value was 0.05.
Results: The prevalence of dental caries, for the total sample, was 80.5% and the mean Decayed, Missing and Filled Teeth index (DMFT) was 2.4 (SD, 1.7). A clear gradient in the DMFT means with statistically significant was observed only across the categories of frequency of toothbrushing and frequency of sugary foods and drinks consumption in between meals. In addition, statistical significant was found for using fluoridated toothpaste.
Conclusion: Dental caries in children aged 12 years old was prevalent in this study. The present survey provided an overview of practice of oral health preventive measures of participants, as the differences in these practices have influenced the DMFT values and provided knowledge about the disease experience.
Keywords : children, cross-sectional studies, dental caries, oral health, infectious disease, risk factors
Introduction

Dental caries is a multifactorial disease, as plaque bacteria, fermentable carbohydrates and a susceptible tooth surface are basic requirements to its occurrence, and these factors are influenced by other variables including socio-economic status [1]. Dental caries is a preventable infectious disease, as early identification of risk factors and implementation of oral health preventive measures at a young age can reduce or even avoid this lesion progression [2]. Oral health preventive practice consists of two sets of activities, the first one is the utilization of dental services including; regular dental checkup: oral health promotion: getting preventive treatment. The second one is the self-care practice including; restriction of sugar intake: tooth brushing: dental flossing: application of fluoride [3]. Therefore, maintaining a good oral health can be achieved by restricting refined carbohydrate consumption especially in-between meals, toothbrushing at least twice daily, interdental cleaning by using dental floss, using fluoridated toothpastes and mouthwashes, and keeping regular dental checkups [4].

Despite the fact that dental caries is a preventable disease, it is still recognized as a major public health issue and the most widespread chronic disease [5]. Dental caries affected about 60% to 90% of schoolchildren and in several developing countries the prevalence rates are increasing [6], which results in negative impacts on quality of life and the academic performance at school [7]. In the developed countries, improved socio‑economic conditions, adopted oral health preventive care programs, changes in dietary habits, and use of fluorides have contributed in the decline in dental caries prevalence. Conversely, the increase in dental caries in the developing countries has been credited to unhealthy dietary habits, limited use of fluoride and poor access to oral health services [8]. Concerning Libyan children, 84.8% experienced dental caries with much of it untreated [9]. However, until now less is known about the extents of dental caries and oral care practices in most parts of the country.

Accordingly, to provide a baseline data for planning and evaluation of oral health promotion programmes, this study was designed and conducted to assess the experience of dental caries and practice of oral health preventive measures in a random sample of 12 years-old Libyan schoolchildren in Benghazi.

Materials and Methods

1. Study population

The data used for this study was secondary data extracted from primary data that was collected through a cross-sectional study of a random sample of two hundred and forty-six 12 years-old Libyan schoolchildren from the seventh grade of eight public elementary schools in the city of Benghazi, along with their parents. Four female schools and four male schools were randomly selected from all 63 public elementary schools in the city, and then, children were selected randomly from those schools. The study was conducted from October to December 2019, and only children with no systemic and/or mental developmental disorders participated. Details of the primary study have been reported by Mansur and Thomson [10].

2. Methods of data collection

The child’s socio-economic status was assessed by using the information from the parent’s questionnaire that was used in the primary data, which included questions about the mother’s and father’s educational levels and current employment that were developed from the literature. For assessing the highest level of education received, the following response options were used: primary school, secondary school, or post-secondary education. The current employment was assessed using the response options of employed and unemployed.

Children were asked to complete a self-administrated questionnaire in the classrooms on the day of the dental examina-tion. After questionnaire distribution, the children received a short explanation and instructions on how to complete it. Only those children were examined who filled the questionnaire completely. The structure of the questionnaire was based on research literature and adapted to the objectives of the study [7,11-13]. The questionnaire included 7 items designed to evaluate the oral health practices included; dental clinic attendance in the last 12 months: toothbrushing frequency: usage of fluoridated toothpaste: usage of fluoridated mouthwash: receiving oral hygiene advice: frequency of consump-tion of sugary foods and drinks: usage of dental floss. These questions were asked along with information on the child’s gender. Pre-tests of the questionnaire were performed with 20 participants who did not participate in the study, in order to determine acceptability and clarity of our questionnaire, and to confirm validity as well. Then, the necessary adjustments on the questionnaire were done for an improved understanding of the participants. All parents and all children understood Arabic.

3. Dental caries examination

Two experienced dentists, who had been calibrated before the examinations started, conducted the clinical examinations. The inter-and intra-examiner tests (using repeat examinations on 15 children) showed kappa statistics ranging from 0.81 to 0.96. The clinical dental examination was conducted during daytime hours in a private room at each school. In order to reduce the risk of cross-infection, a disposable diagnostic kit was used for each child, and the examiner used disposable masks and gloves. Participants were examined for dental caries using the decayed, missed, and filled teeth index (DMFT), with a full-mouth examination using a dental mirror and no probing, according to World Health Organization (WHO) methods [14].

4. Ethical approval

The study received ethical approval from the Faculty of Dentistry, Benghazi University. Permission to conduct the study was also gained from each head of school. The parents signed informed consent forms.

5. Statistical analyses

The collected data were analyzed using SPSS for Windows, version 25.0 (SPSS Inc., Armonk, NY, USA). Socio-demographic information and data from the questionnaire were summarised using numbers and percentages, DMFT scores were described in terms of means and standard deviations (SD), and the parametric tests were performed for comparative analysis (t‑test or chi-square tests, as appropriate). The alpha value was 0.05.

Results

A total of 246 schoolchildren filled in the questionnaires and underwent clinical examinations. More than half of the participants were boys (52.4%). For mothers, 53.3% had post- secondary education and 53.3% were employed. Regarding fathers, 38.2% had post-secondary education, and the majority (79.7%) were employed. The prevalence of dental caries, for the total sample, was 80.5% and the mean DMFT was 2.4 (SD, 1.7). The means DMFT for girls (2.5), unemployed mothers (2.5) and unemployed fathers (2.5) were slightly higher than those for boys (2.2), employed mothers (2.2) and employed father (2.3), respectively. Mothers with secondary education and fathers with primary education had the highest DMFT means, with 2.6 for each. However, all the differences were not statistically significant (Table 1).

Table 1 . DMFT summary data, by socio-demographic characteristics of participants

CharacteristicN (%)DMFT
Mean (SD)
Sex
Male129 (52.4)2.2 (1.7)
Female117 (47.6)2.5 (1.8)
Maternal education
Primary60 (24.4)2.5 (1.7)
Secondary55 (22.4)2.6 (1.7)
Post-secondary131 (53.3)2.2 (1.8)
Maternal occupation
Unemployed115 (46.7)2.5 (1.7)
Employed131 (53.3)2.2 (1.7)
Paternal education
Primary71 (28.9)2.6 (1.6)
Secondary81 (32.9)2.5 (1.8)
Post-secondary94 (38.2)2.1 (1.7)
Paternal occupation
Unemployed50 (20.3)2.5 (1.5)
Employed196 (79.7)2.3 (1.8)
All combined246 (100)2.4 (1.7)

DMFT: Decayed, Missing and Filled Teeth index, N: number, (%): percentage, SD: standard deviation.



Out of all responding 45.5% did not visit the dentist in the last 12 months, with a mean DMFT of 2.6 (SD, 1.7). More than half (50.8%) did not receive an advice on maintaining a good oral hygiene from dentist, with a mean of 2.5 (SD, 1.7). A clear gradient was observed in the DMFT means across the categories of frequency of toothbrushing, with statistically significant. As, 24.8% of the participants brushed their teeth twice or more daily, with a mean of 1.6 (SD, 1.7), and just 2.0% never brushed their teeth with a mean of 3.8 (SD, 2.1). The majority of respondents never used dental floss (86.2%), with a mean of 2.5 (SD, 1.7). However, a clear, but not statistically significant, gradient was observed in the DMFT means across the frequency of dental floss uses categories. About the half of the participants (51.2%) used fluoridated toothpaste and the majority (83.3%) did not use fluoridated mouthwash, with DMFT means of 1.8 and 2.4, respectively. However, statistical significant was found for using fluoridated toothpaste, only (Table 2).

Table 2 . Oral health practices among participants and associated caries experience

Practice of oral health preventive measuresN (%)DMFT
Mean (SD)
How many times did you visit your dentist in the last 12 months?
More than twice29 (11.8)2.5 (1.9)
Twice44 (17.9)2.2 (1.6)
Once61 (24.8)2.0 (1.7)
I did not112 (45.5)2.6 (1.7)
Have you received an advice on maintaining a good oral hygiene from your dentist?
Yes121 (49.2)2.3 (1.7)
No125 (50.8)2.5 (1.7)
How many times a day do you brush your teeth?
Twice or more/day61 (24.8)1.6 (1.7)a
Once/day73 (29.7)2.2 (1.6)
Sometimes107 (43.5)2.8 (1.6)
Never5 (2.0)3.8 (2.1)
How many times a day do you use dental floss?
Twice/day10 (4.1)1.5 (2.0)
Once/day24 (9.8)1.7 (1.7)
Never212 (86.2)2.5 (1.7)
Do you use fluoridated toothpaste?
Yes126 (51.2)1.8 (1.7)a
No59 (24.0)2.8 (1.5)
Do not know61 (24.8)3.0 (1.6)
Do you use fluoridated mouthwash?
Yes17 (6.9)2.1 (1.7)
No205 (83.3)2.4 (1.7)
Do not know24 (9.8)2.4 (1.7)

DMFT: Decayed, Missing and Filled Teeth index, N: number, (%): percentage, SD: standard deviation.

ap<0.05, obtained from chi-square test.



Around one third of the participants (33.7%) reported that they sometimes consume sugary foods and drinks. A clear gradient was observed in the DMFT means across these categories without statistical significant. More than half of the respondents (53.7%) consume sugary foods and drinks in between meals once daily, with a mean of 2.3. A clear gradient was observed in the DMFT means across the categories of frequency of sugary foods and drinks consumption in between meals, with statistically significant (Table 3).

Table 3 . Participants dietary habits and associated caries experience

N (%)DMF
Mean (SD)
How many times a day do you consume sugary foods and drinks?
Once/day61 (24.8)2.2 (1.7)
Twice/day48 (19.5)2.3 (1.7)
Three times or more/day54 (22.0)2.7 (1.8)
Sometimes83 (33.7)2.3 (1.7)
How many times of them in between meals?
Never45 (18.3)1.9 (1.9)a
Once/day132 (53.7)2.3 (1.6)
Twice/day45 (18.3)2.5 (1.6)
Three times or more/day24 (9.8)3.5 (1.6)

DMFT: Decayed, Missing and Filled Teeth index, N: number, (%): percentage, SD: standard deviation.

ap<0.05, obtained from chi-square test.


Discussion

This study assessed the experience of dental caries and practice of oral health preventive measures in a random sample of 12 years-old Libyan schoolchildren. The prevalence of dental caries, for the total sample, was 80.5% and the mean DMFT was 2.4 (SD, 1.7). The present survey provided an overview of practice of oral health preventive measures of the participants, and the differences in these practices have influenced the DMFT values and provided knowledge about the disease experience. However, statistical significant was found for frequency of toothbrushing, using fluoridated toothpaste, and frequency of sugary foods and drinks consumption in between meals, only.

This study observed high prevalence of dental caries that confirms previously reported findings of Libyan studies by Kabar et al. [15] in 2019 (74.7%) and Mansur et al. [9] in 2021 (84.8%). However, this result was higher than the findings of another previous Libyan study by Huew et al. [16] in 2012 (57.8%), Italian study in 2010 (47.1%), Iranian study in 2015 (49.4%), and Nigerian study in 2018 (12.2%) [11,12,16,17]. The WHO specified the global average for caries experience in 12-year-olds should not be higher than 1.0 for the year 2010 [18]. The results of the current study are far from these global goals, as the mean value of DMFT among the participants was found to be 2.4±1.7. These results was slightly less than the results of Italian study in 2010 (2.88±0.16), but higher than the findings of previous Libyan study by Huew et al. [16] in 2012 (1.68±1.86) [11,16]. Comparing with the findings of Sudanese study in 2009 (0.42±0.92), Libyan study in 2019 (0.882±1.68), and Egyptian study in 2019 (1.04±1.56), the findings of this study indicate a need for dental care and a lack of control over the disease [13,15,19].

Investigating the effect of gender on dental caries, the present study revealed that the mean DMFT of females was higher than that of males. This can be explained by that girls usually more concern about their general appearance, bad breath, and tooth colour than boys [20]. This finding is in accordance with previous Libyan studies by Huew et al. [16] in 2012 and Kabar et al. [15] in 2019, where dental caries was more prevalent amongst girls than boys are. However, in variance with the findings of previous Libyan studies, these differences were not statistically significant for the current study [15,16]. On the contrary, these findings were in variance with Egyptian study in 2019, as caries was more prevalent amongst boys than girls [13]. This variation could be attributed to the differences in age groups and the geographical locations studied in the surveys.

Socio-economic background was the most important predictor of caries after age, and a more powerful predictor of caries experience than was oral hygiene habits [11]. Parental education level and occupation status are important markers of socio-economic condition, which greatly affect the child’s oral health [21]. The effect of this social determinants on caries level is reported for all countries, but it was found to be particularly significant when the disease prevalence was high [11]. While the caries prevalence was high in the current study, the impact of parental education level and occupation status on children’s caries experience was not reported. This is in variance with previous studies [13,22,23]. However, most of studies reported this correlation in early years of child's life, as the child grows the parental impact decreases and parents may totally lose their control on the child’s dietary habits and oral hygiene measures [13]. This may explain the non-significant differences in the mean DMFT across the categories of parental educational levels and occupation status, in the present study.

Approximately, half of the participants visit the dentist in the last 12 months at least once, these findings were much better than those came from Indian study by Kabasi et al. [5], in 2021, as the majority of 12‑year‑old schoolchildren in Moradabad city have never been seen by the dentist. However, these findings were less than that reported in Saudi study by Jamjoom [24] in 2001, as 69.8% of the respondents visit the dentist in the last 12 months. It was reported that routine annual dental check-ups are common in industrialized countries, but they are not affordable to most people in developing countries, as a result children are only taken to a dentist as a last resort when they have pain [7]. Many studies found that children who had experience with dental visits reported to have good oral health more often than their counterparts with no dental visits [19,25]. However, in the current study there was not significant difference or even a clear gradient in caries experience across the categories of annual dentist visit. Moreover, half of the participants did not receive an advice on maintaining a good oral hygiene from their dentists, but this can be explained by that just half of the participants in the current study visited the dentist in the last 12 months at least once. Also, it was reported that the dentists may not get time to offer advice, and/or they think oral health education is not necessary to be administered because they feel it is not beneficial [25].

A correlation between an irregular brushing, the lack of using dental floss daily and a greater risk for dental caries development is evidenced by many studies [26]. In the present study, it was observed that as the frequency of toothbrushing and dental floss use increased, the DMFT mean decreased. As, a clear gradient was observed in the DMFT means across the categories of frequency of toothbrushing, with statistically significant. However, a clear, but not statistically significant, gradient was observed in the DMFT means across the frequency of dental floss uses categories. This can be attributed to that, the majority of the participants (86.2%) never used dental floss, and just 2% never brushed their teeth. These findings were in agreement with the study of Nurelhuda et al. [19], in 2009, however in variance with some previous studies [11,12].

About half of the participants (51.2%) used fluoridated toothpaste and the majority (83.3%) did not use fluoridated mouthwash, and statistical significant was found for using fluoridated toothpaste, only. In contrast, the study of Obregón- Rodríguez et al. [27] in 2019 observed no association between toothbrushing with fluoridated toothpaste and dental caries experience in 12-15 age children. However, the findings of the current study may prone to be overestimated or underestimated as the "do not know" responses were 24.8% for using fluoridated toothpaste.

The role of sugar in development of dental caries is well established, and the correlation between sugar consumption and caries prevalence increases with increasing sugar exposure [1]. In the current study, a clear gradient was observed in the DMFT means across the frequency of sugary foods and drinks consumption categories without statistical significant. These findings are in accordance with the study of Gao et al. [28] in 2014, but in contrast with other previous studies [12,13,27]. However, a clear gradient was observed in the DMFT means across the categories of frequency of sugary foods and drinks consumption in between meals, with statistically significant. As, the majority of respondents consume sugary foods and drinks in between meals at least once daily. This finding was on the contrary of that of Iraqi study by Ahmed et al. [8] in 2007, as about the third of participants consume sugary foods and drinks in between meals.

In view of the study’s limitations, this study used a secondary data as the sample size was not calculated to meet its aim. Furthermore, the data was collected by means of self‑administered questionnaire, which may prone the results to information bias. As, practices of oral hygiene habits and frequency of dental visits has assumed to be over-reported, however the consumption of sugary foods and drinks has probably been under‑reported [29]. In addition, recall bias should be considered with respect to consumption of sugary foods and drinks [30]. Considering the study’s strengths, at the age of 12 years, children identify themselves and increase their self‑ awareness that lead to make them more independent with less family supervision. As a result, appropriate data on oral health behaviour could be collected [5]. Furthermore, the data are from a random sample that makes the findings generalizable to the wider population, as well as the sample consisted of a single ethnic group (Libyans).

Conclusion

Dental caries in children aged 12 years old was prevalent in this study. The present survey provided an overview of practice of oral health preventive measures of participants, as the differences in these practices have influenced the DMFT values and provided knowledge about the disease experience. However, statistical significant was found for frequency of toothbrushing, using fluoridated toothpaste, and frequency of sugary foods and drinks consumption in between meals, only. Therefore comprehensive and effective school-based oral health promotion programmes are needed to tackle the burden of this disease. These programmes should intend to help children adopt lifelong healthy behaviors and to improve knowledge and healthy attitudes towards the practice of proper oral hygiene care, the reduction of the frequency and quantity of consumption of sugary foods and drinks, the benefit of F and the adoption of a regular dental visit routine.

1. Why this paper is important for paediatric dentists?

∙This study assessed the experience of dental caries and practice of oral health preventive measures, which can be useful for providing a baseline data for planning and evaluation of oral health promotion programmes.

∙This study strengthens evidence that the differences in oral health practices have influenced the DMFT values and provided knowledge about the disease experience.

∙The findings of the current study emphases the need to comprehensive and effective school-based oral health promotion programmes to tackle the burden of dental caries.

Acknowledgements

The authors thank the children and their parents for their participation in the study.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

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