Caries Prevention in Children - The Indian Challenge
In the modern society, the human life expectancy is
showing an upward trend ,thanks to the improved health care, nutrition , sanitation, and
relief from communicable diseases. In 1982, Keki Mistry1 reported that the relative
improvement in general health was in glaring contrast to the deteriorating situation in
oral and dental health in developing countries.
The cause of deterioration in dental health seems readily
apparent. Increasing industrialisation is invariably linked to rising levels of sugar
consumption and inevitable breakdown of the dentition. This process merely mirrors similar
changes in developed countries during the industrial revolution two hundred years ago.
The scenario in India, a subcontinent in the continent of
Asia, is changing. India accounts for only 2.4% of the world area i.e., 3.28 million sq.
km and has 15% of the world population. There is an effective control in child mortality
and life expectancy has increased from 32 years in the fifties to 54 years in the
nineties. The literary level has increased. At the economic level, the per capita income
is on the rise. To-day, our country is progressing in all fields, leading to changes in
the individual’s life- style.
Improved marketing strategies and increased transport
facilities have brought food materials like bread and chocolates to even the remotest
villages. Children who consume these sticky food stuffs are not trained to clean the teeth
properly afterwards. Moreover, such items are freely consumed as in between snacks.
In 1979, the World Health Assembly adopted a resolution
calling for attainment of "Health for all" by the year 2000. In line with this,
the FDI recommended the establishment of specific oral health schedule on the time scale.
Of the WHO goals for global oral health, the first goal is that 50% of 5-6 years old
children should be caries free and the second goal is that the global average should not
be more than 3 decayed, missing, or filled teeth at 12 years of age.
By early 1980 s many industrialised countries had
achieved the second goal. By contrast, the developing countries showed increasing DMF
values at this time.
Epidemiological studies conducted in the community of
Jonkoping, Sweden, by Anders Hugoson and others2 in 1973 and 1983 revealed an increase in
the number of teeth in different age groups. In the 20 year olds, the mean number of DS
was 6.5 in 1973 and 4.5 in 1983. An analysis of the carious lesions showed that 86% of the
lesions were restricted to the enamel. According to recent data for 5-6 year old group,
the percentage of caries free children in Sweden is 72. 3
[The recent data for 5-6 year old children indicate a
mean dmft value of 2.0 in the USA, and the percentage of caries free children is 50 3..]
On the other hand, dental caries is highly prevalent in
India, which is influenced by the lack of dental awareness among the public at large.
Epidemiological survey conducted by Ramachandran and others4 during 1966-68 in Tamil Nadu,
a south Indian state, revealed a caries prevalence of 66.2% in urban population and 47.8%
in rural population.
We conducted a survey on a section of Belgaum population
5 to evaluate the trends in caries in different age groups and the influencing factors for
its causation and prevention. This study revealed a DMF/ dft score of 4.61 in the 6-11
years of age group, with a DMFS score of 9.21. In this age group, 88% of the children
suffered from dental caries.
So when I say caries prevention in children, the image
that conjures up in your minds is entirely different from the picture in my mind.
The 20th century has given tremendous knowledge in the
understanding of oral diseases and possibilities for preventing and treating these
diseases. This knowledge cannot be put into action in a developing country like India due
to financial constraints and lack of man power.
In a country where 70% of population inhabit the villages the dentist population ratio is 1: 35,000,
and only one out of five dentists return back to the rural area to serve,
prevention of caries will be a much more viable option than rendering restorative treatment
Let me just outline the problems we have to face while streamlining a caries prevention programme in India.
1. First of all, in villages where 70% of the population
live, there is no communal water supply. So fluoridation of water supply, the most
cost effective and a very efficient method of caries prevention will remain an elusive
dream for majority of people.
2. Even in urban areas there is no attempt at fluoridating the water supply. There are areas where local water contains high level of
fluoride. So unless a fluoride mapping of the entire country is completed, national
fluoridation programme cannot be implemented. This involves two hurdles. One is the cost
factor. Then there is a strong anti-fluoride lobby in India which widely publicizes that
fluoride is a dangerous element which can cause fluorosis of teeth, bones etc., They
oppose even topical fluoride applications and usage of fluoride tooth pastes with the
contention that even from the tooth paste, the soft tissues absorb fluoride, which will
have cumulative effect over a period of time, leading to fluorosis of bones.
3. Indians by nature are highly tolerant. Even when teeth
are affected by caries, a good number of them wait till the last stage when the
excruciating pain forces them to the dentist. In such a scenario, to make them visit a
dentist for measures at prevention demands high motivation. Widespread and intense
measures at public awareness are needed to bring dental health to a priority level .
Routinely, dental health occupies a very low priority as compared to the general health.
Many of them do not hesitate to come and demand extraction of an offending tooth.
4. The cost involved in assessing the high caries risk
group by S-mutans test and other methods in Indian situations is so high that it cannot
become a routine procedure in the near future.
So you can see, in the existing situation in India, it
calls for real dedicated and strenuous effort to implement caries prevention programmes.
Western Methods for caries prevention as such will not be
successful here and they need to be modified to suit the local needs and habits.
New methods of identifying caries risk groups should be
formulated
One fourth of the country’s population is below the
age of 14 years. To persuade the children to modify or start any new habit, it is very
important to gain their parent’s co-operation. So any nationwide policy should have a
two pronged approach.
1. Community based programmes.
2. School based programmes.
One basic myth that has to be eradicated from the minds
of majority of Indians is that the milk teeth are not important because they will be
replaced by another set of teeth later. Since the first molars erupt when deciduous teeth
are still present, very often they suffer the consequences of neglect.
A recent survey of North London boroughs by Rambohul and
Karmi has revealed an increased prevalence of dental caries on pre-school South Asian
children . They reported that the disparity in dental health between Asians and others
seems to disappear after the second dentition is established.
Controlled studies have to be planned to monitor the
blood level rise of fluoride after topical application. It has to be conclusively proven
that topical fluoride application will not lead to cumulative fluoride accumulation in
blood, resulting in fluorosis of bones, as claimed by the antifluoride lobby.
Coming to the school based activities, regular oral
health programmes should be conducted in schools, to reach large number of children. At
the beginning teachers need to be trained intensely for proper implementation. These
programs should be based on fluoride rinsing, topical fluoride applications, supervised
tooth brushing, professional tooth cleaning, occlusal sealants, health education and
dietary advice. There is acute need for simple, robust, easy to service and inexpensive
equipment for use in rural surroundings.
The development of glass ionomer sealants will make
sealant application more practical due to the cost factor and their low technique
sensitivity as compared to the resin sealants.
Application of antimicrobial varnish should be a viable
option if it can be made cost effective. Fluoridated varnishes (Durafluor/ Duraphat or
Fluor Protector) have been proven to be effective in preventing carious lesions on smooth
surfaces7,8. The application sequence suggested by Dr. Lars Petersson 9 where the varnish
is applied to clean, isolated and dried quadrants three times weekly, once a year will be
very suitable for the Indian situation.
Oral hygiene methods
The knowledge of the importance of oral hygiene is not
recent for Indians. The dental fiber pencil was used by the Indians long before as
described by the great physician and surgeon Susruta, who lived in the 6th century B.C10.
The Hindu vedas contain descriptions of oral hygiene procedures, which are advised to be
performed twice a day. Hindus used various Ayurvedic preparations made specifically for
dental application10,11. They cleaned their teeth with the twigs of various aromatic
shrubs frayed at the end. These twigs are called Datuns.
In 1984, we conducted a study on oral health status of
young adults using indigenous oral hygiene methods12. Indigenous materials used for
maintenance of oral hygiene can be classified into three main groups.
1. Plants and parts.
A. Leaves
Mango (Mangifera indica)
Cashew (Anacardium occidentale)
Coconut (Cocos nucifera)
B. Twigs and Stems
Babul (Acasia arabica)
Neem (Azadiarchita indica)
Banyan (Ficus bengalens)
C. Fruits and its parts
Coconut
D. Barks Walnut (Juglans regia)
2. Charcoal from burnt...
A. Rice husk
B. Walnut shell
C. Almond shell
D. Coconut shell and its sheath
E. Wood
F. Coal (ash)
G. Dried cowdung cake
3. Powders etc.,
A. Sand
B. Common salt (powder and crystalline)
C. Brick and tile powder
D. Tobacco
E. Arecanut
F. Different types of indigenous tooth powders
In the southern Karnataka state of India, the mango leaf
is widely used13. A fresh mango leaf is washed and the midrib is removed. The leaf is then
folded lengthwise with glossy surfaces facing each other. It is rolled into a cylindrical
pack. One end of this pack is bitten off 2-3mm to create a raw surface which is rubbed on
the teeth. The pack is held between the thumb and the index finger. At the end, the
midrib, which was first removed, is used as a tongue cleaner.
We evaluated the efficacy of mango leaf as an oral
hygiene aid and got some interesting findings. Despite having higher soft deposit scores
in the group that used mango leaf, the caries experience in this group was similar to the
group that used tooth brush. Mangiferin, a compound present in mango leaves has been
reported to have significant antibacterial property against certain strains of
Pneumococci, Streptococci, Staphylococci, and Lactobacillus acidophilus.
Recently, Saimbi and co-workers14, tested the antiplaque
efficacy of Neem extract , Ayurvedic tooth powders and commercial tooth pastes. The Neem
extract came out on top and commercial tooth pastes were the last.
| Substances tried |
Antiplaque efficacy % |
| 1% Neem extract |
71.4 |
| 0.5% Neem extract |
69.61 |
| 5% Neem extract |
54.9 |
| Ayurvedic tooth powder A |
43.0 |
| Ayurvedic tooth powder B |
37.5 |
| Commercial tooth paste |
29.8 |
Tooth brush is not commonly used by the rural folk. As
compared to food, they find the cost of tooth brush and paste to be expensive. A tooth
brush costs Rs. 11/-, 200 gm tooth paste costs Rs.30/- and a loaf of bread costs Rs.5/-.
The oral health of the community can be improved by
understanding the cultural attitudes, changing the beliefs of the people and modifying
their habits.
Intensive research need to be done on how to modify their
traditional oral hygiene methods as to make them more effective. Research on mango leaf
and neem extract will definitely yield positive results. Notwithstanding the advice given
in the ancient books for cleaning the teeth twice a day, it is difficult to understand why
Indians have restricted their oral hygiene practices once a day in the morning. The habit
of night brushing has to be reinstated.
Manufacturers should be encouraged to
develop clinically proven and affordable tooth paste formulations for use15. Role of diet.
Traditional Indian food is very much balanced with lots
of fibrous components. Industrialisation has brought in increased sugar consumption and
availability of refined carbohydrate foodstuffs. The consumption of western type food
including "junk food" is rapidly increasing. In the vicinity of schools, vendors
await school children who consume sugar candies and chocolates bought with their pocket
money.
We, Indians are habituated to drinking lot of water.
Consumption of sweetened, aerated beverages is replacing the water intake in the younger
generations. What implications this would have in future has to be observed.
Education of school children with
audiovisual aids on the extreme harmful effects of these in between snacks is highly
necessary. Components in traditional diets that may favor oral health have to be
identified and propagated.
Conclusion
India is a vast country with limited resources and man
power .
Western Methods for caries prevention as such will not be
successful here and they need to be modified to suit the local needs and habits.
New methods of identifying caries risk groups should be
formulated.
Caries preventive programmes should have a
two pronged approach- Community based and school based. References.
References
1. Keki Mistry: Establishment of community dental health
units in developing countries. JIDA 1982 54(10):361-366.
2. Anders Hugoson et al: Caries prevalence and
distribution in individuals aged 20-80 years in Jon Koping, Sweden 1973 & 1983. Swed
Dent J 1988 12:133-140 3. Murray J J: Comments on
results reported at the Second International Conference "Changes in Caries
Prevalence". Int Dent J 1994 44: 457-458.
4. Ramachandran et al: Epidemiological studies of dental
disorders in Tamil Nadu population. Prevalence of dental caries and periodontal disease.
JIDA 1973 45(4):65-70.
5. Asha John: Trends in caries in different age groups in
Belgaum population - Master thesis for MDS, 1994. 6.
Bratthal Douglas: Caries, Views and Perspectives. Scand J Dent Res 1992 100:47-51.
7. Clark D, Stamm J, Robert G, Tessier C: Results of a 32
month fluoride varnish study in Sherbrook & Lac-Megantic, Canada. JADA 1985
111:949-953.
8. Von Lieser O, Scmidt H: Caries preventive affect of
fluoride lacquer after several years’ use in children. Deutch Zahnarztl Z 1978
33:176-178.
9. Petersson L et al: Caries inhibiting effect of
different modes of Duraphat varnish reapplication- a three year radiographic study. Caries
Res 1991 25:70-73.
10. Emslie R D: The value of oral hygiene. BDJ 1964
117:373.
11. Meenakshy Shetty, Bhat J V: Indigenous dentifrices
and oral hygiene. JADA 1949 21:1.
12. Sumant Goel, Beena R Goel, Bhongade M L: Oral Health
status of young adults using indigenous oral hygiene methods. Stomatologica India 1992
5(1):17-23.
13. Nagaraja Rao et al: Oral health status of 500 school
children of Udupi. JIDA 1980 52: 367-370
14. Saimbi C S et al: The efficacy of neem extract
-reported in Jeevaniya Health Care magazine.
15. Blinkhorn A S and Davies R M: Caries Prevention A
continued need worldwide. Int Dent J 1996 46: 119-125.
16. Rambohul V, Karmi G: Dental health and ethnic
minority children. London: NE/NW Thames Regional Health Authorities, 1992. Sited from:-
17. Karmi G: Migration and health. Int Dent J 1996
46(Supplement 1), 181-187.
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