ARTÍCULOS ORIGINALES
Dental status and dental treatment demands in preschoolers from urban and underprivileged urban areas in Mendoza city, Argentina
Claudia N. Fernández1, Aldo Squassi2, Noemí Bordoni3
1 Department of Pediatric Dentistry I. School of Dentistry, National University of Cuyo. Master in Oral Health Services and Systems Management, National University of Cuyo.
2 Department of Preventive and Community Dentistry; School of Dentistry, University of Buenos Aires.
3 Institute for Research in Public Health, University of Buenos Aires
CORRESPONDENCE Dra.Claudia N. Fernandez Facultad de Odontologia. Unversidad Nacional de Cuyo. Centro Universitario. Parque Gral San Martin (s/n). Mendoza- Rep.Argentina. CP 5500 e-mail: claudia.n.fdz@gmail.com
The aim of this study was to establish the association between dental status and demand for dental care in preschoolers at urban and underprivileged urban schools in the city of Mendoza. Dental status was diagnosed in a purposive sample of preschoolers at urban schools (Group U: n = 148) and underprivileged urban schools (Group UnU: n = 155) in Greater Mendoza city, by determining the following indicators: (a) caries-free children (%), and (b) dmft/DMFT and its discriminated components, including active non-cavitated enamel caries. The characteristics of demand for care were determined using an ad hoc structured questionnaire. The following were determined: frequency distributions and confidence intervals for categorical variables, measures of central tendency and dispersion, tests for differences in means (Student's t test), association (chi squared) and correlation among variables (Pearson's r), at a significance level p<0.05. Comparison of dental status variables between groups showed significantly higher values in group UnU for: d+D tooth (ẋ = 5.4} 3.8; t = 2.887; p = 0.004); dmft+DMFT (ẋ = 5.7}4.1; t = 0.466; p = 0.020); d+D surface (ẋ = 7.62} 6.2; t = 0.956; p = 0.014); f+F surface (ẋ = 0.12}4.5; t = 2.71; p = 0.007) and percentage of caries-free children (x2= 25.377; p= 0.018). The following trends were found in this group: higher demand on the government subsystem, fewer visits to the dentist (x2 = 7.02, p = 0.008) and greater difficulty in getting appointments (x2 = 19.91, pẋ0.001). Frequency of visits was associated to the severity of dental status (x2 = 19.412; pẋ0.001), but no correlation was found between frequency of visits during the past year and dmft+DMFT (Pearson's r coefficient = 0.091; p = 0.0426) Group U showed preferential demand for the private or "obra social" (trade union managed health insurance) systems (x2 = 78.85 p = 0.00) and there was no statistically significant association between visits to the dentist and dmft+DMFT categories (x2 = 2.781; p = 0.427), although there was direct correlation between frequency of visits during the past year and dmft+DMFT (Pearson's r coefficient = 0.486, p = 0.000). Preschoolers at UnU schools had higher caries indicators than preschoolers at U schools. For UnU the demand for care was related to the severity of dental status and situations of urgency, while U preschoolers demanded dental care in both health and disease, with a tendency to greater adherence to treatment. Actions to promote oral health in preschoolers should take into account both internal and external barriers to access to and use of oral health services.
Key words: Dental caries; Dental health services; School age populations; Access to health care.
RESUMEN
Estado dentario y demanda de atención odontológica en preescolares de areas urbanas y urbano-marginales en Mendoza, rep. Argentina
El objetivo de este estudio fue establecer la asociacion existente entre el estado dentario y la demanda de atencion en alumnos de nivel inicial asistentes a escuelas del ambito urbano y urbano-marginal de la ciudad de Mendoza. Material y metodos: Sobre una muestra intencionada de alumnos/ as asistentes a cuatro escuelas de nivel inicial de ambito urbano (Grupo AU: n=148) y de ambito urbano-marginal (Grupo AUM: n=155) del Gran Mendoza, se realizo el diagnostico del estado dentario determinando los siguientes indicadores: (a) ninos libres de caries (%), (b) ceod/CPOD y sus componentes discriminados, incluyendo caries adamantinas activas no cavitadas. Las caracteristicas de la demanda de atencion fueron establecidas mediante una encuesta estructurada ad hoc. Se establecieron distribuciones de frecuencias e intervalos de confianza para varaibles categoricas, medidas de tendencia central y dispersion, pruebas de diferencias de medias (t de Student), de asociacion (chi cuadrado) y de correlacion entre las variables (r de Pearson), con un nivel de significacion de p<0.05. Resultados: Al comparar las variables del estado dentario entre ambos grupos se encontraron valores significativamente mayores en el grupo AUM para: c+C diente (ẋ=5,4} 3,8; t= 2,887; p=0,004); ceod+CEOD (ẋ=5,7} 4,1; t=0,466; p=0,020); c+C superficie (ẋ=7,62} 6,2; t=0,956; p= 0,014); o+O superficie (ẋ=0,12} 4,5; t=2,71; p=0,007) y porcentajes de ninos libres de caries (x2= 25,377; p= 0,018). En este grupo, se registraron las siguientes tendencias: mayor demanda al subsistema estatal, menor asistencia a la consulta dental (x2=7.02, p= 0,008) y mayor dificultad para obtener turno (x2=19,91, pẋ0,001). La frecuencia de las consultas estuvo asociada con la gravedad del estado dentario (x2=19,412; pẋ0,001), pero no se registro correlacion entre la frecuencia de las consultas durante el ultimo ano y ceod+CPOD (coeficiente r de Pearson =0,091; p=0,0426) El grupo AU demando preferentemente en los subsistemas privado o de seguridad social (x2=78,85 p=0,00) y no existio asociacion estadisticamente significativa entre la concurrencia del nino a la consulta odontologica y las categorias de ceod+CPOD (x2=2,781; p=0,427), pero si correlacion directa entre la frecuencia de consulta durante el ultimo ano y el ceod+CPOD (coeficiente r de Pearson =0,486, p=0,000). Los preescolares asistentes a escuelas de AUM presentaron indicadores de caries mas elevados respecto a los encontrados en el grupo AU. La demanda de atencion para AUM se relaciono con la gravedad del estado dentario y con situaciones de urgencia. Los preescolares de AU demandaron atencion dental tanto en salud como en enfermedad, con tendencia a mayor adherencia al tratamiento. Las acciones tendientes a promover la salud bucal en los preescolares deberan tomar en cuenta tanto las barreras internas como las externas en el acceso y utilizacion de los servicios de salud bucal.
Palabras clave: Caries; Servicios de salud bucal; Poblaciones escolares; Acceso al cuidado dental.
INTRODUCTION
Early childhood caries (ECC) was defined by the
American Academy of Pediatric Dentistry (AAPD)
as the presence of one or more decayed, missing
(due to caries) or filled tooth surfaces in any primary
tooth in a child 71 months of age or younger.
Severe early childhood caries is the presence of any
sign of softening of tooth surfaces in children under
3 years of age or the presence of one or more decayed,
missing (due to caries) or filled primary anterior teeth
from ages 3 through 5, dmfs = 4 at 3 years, 5 affected
surfaces at 4 years or 6 surfaces affected at 5 years
of age 1.
ECC is currently recognized as a public health problem
with defined biological, social and behavioral
etiological components 2. Its impact is higher when
recurrence of caries in children who have had them
previously is analyzed. Approximately 40% of children
who have been treated for ECC develop new
lesions within a year of completing the treatment 3,4.
Family and community socio-economic variables
act as potentiating factors for the severity and progression
rate of the caries process in early infancy.
Milnes5 reports that in developed countries, prevalence
was 1% to 12%, but in developing countries
and within disadvantaged populations in developed
countries, it was as high as 70%. These findings
have been confirmed by different studies 6.
One model explaining the etiology of early childhood
caries attributes it to family stress caused by
joint socio-economic variables, particularly in
mothers, leading to dysfunctional parenting behaviors
and thus greater risk of caries in children 7. In
developing countries, studies on the prevalence of
early childhood caries and caries in preschoolers
match the association found between high caries
experience and disadvantaged socio-economic
status 8-12.
Ly et al.13 in Xiamen, China, studied a population
of 1570 children under 5 years of age and found that
56.8% to 78.31% were affected, and evidence of
increasing tendency with age. These findings were
confirmed by Karla et al.14 in a study in Gurgaon,
Haryana (India) on 600 preschoolers of middle
socio-economic class, where caries prevalence was
68%, with mean dmft 2.85, and increasing values
with age. Pridaryarshini et al.15 found caries prevalence
of 37.3% among low income preschoolers in
the city of Bangalore, India, of whom 94.3% had
high levels of untreated disease. Ramirez et al.16 analyzed a sample of 659 individuals and found that
67% were affected by dental caries according to
ICDAS II criteria.
An increase in prevalence of ECC has been found
even in developed countries. The US 2007 national
health survey showed that caries prevalence is on
the rise and that 28% of 2- to 5-year-olds have caries
experience 17.
Previous studies 18 showed that preschoolers in
Greater Mendoza city have high levels of caries,
which are significantly higher in children who
attend underprivileged urban schools, with a high
level of decayed component (d) indicators and indication
of extraction (ie). This background justifies
the importance of this study, the aim of which was
to analyze the characteristics of demand for care
and the dental care itself, discriminating the differences
between socio-economically distinct groups,
and to advocate the adoption of evidence-based
policies.
MATERIALS AND METHODS
This was a cross-sectional correlational descriptive
epidemiological study on a cluster sample of
preschoolers from 2 schools in an underprivileged
urban area (School No. 17 Silvia Puebla and School
No. 18 Xumec) and 2 urban schools (Hipolito
Yrigoyen and Manuel Belgrano Schools) located in
Greater Mendoza (n=155 and n=148, respectively).
Demographics at the schools were established
according to the criteria of the General Directorship
of Schools of the Government of Mendoza, based
on percentages of families with unmet basic needs.
This was used to include children either in group U
(urban environment, with basic needs satisfied) or
group UnU (underprivileged urban environment,
with unmet basic needs).
The parents or legal guardians of the children at all
four schools were informed about the study and
they provided written consent for children's participation.
All children in the sample were provided
with a preventive program at which oral hygiene
techniques were taught and 1.2% acidulated sodium
fluoride, pH 3.5 was applied professionally.
An oral clinical examination was performed by two
calibrated examiners (inter-judge Kappa index =
77%). The caries category included the white spot
lesion category (ICDAS II criterion 2) 19. The
indices dmft, dmfs, DMFT and DMFS were calculated
20. "Caries free" was used to describe children
with dmft plus DMFT equal to 0.
Data were grouped into four ordinal categories
according to the severity of the variable "sum of
dmft+DMFT":
a) dmft+DMFT = 0.
b) dmft+DMFT = 1 to 3.
c) dmft+DMFT = 4 to 6.
d) dmft+DMFT = 7 or higher
An ad hoc structured survey (Fig. 1) was used to collect data about demand for dental care. It was answered by the parents of the preschoolers included in the study, administered by the teachers from each class.
Fig. 1: Model of the survey used for classifying
demand for dental care.*"centro de salud" refers to a government-
run community health center. **"obra social" refers to
a trade union-managed health insurance plan.
The survey asked about whether the child had ever
visited a dentist (Question 1). If the answer was
‘yes', the following information was requested:
a) which subsector care was requested at,
b) number of visits to the dentist in the past year,
c) whether they were satisfied with the care
received, and
d) whether it was difficult to get an appointment.
The category "Demand according type of school"
was established by associating school setting to the
yes/no variable (has/has not visited a dentist).
To establish the association between dental status
and demand for care in each group, we used:
• the ordinal categories according to severity
(dmft + DMFT), and
• the answers to survey questions 2, 3 and 4.
The data were processed with SPSS 18.0 software.
The following were determined at a significance
level smaller than 0.05:
• Frequency distribution and confidence intervals
for each variable,
• Measures of central tendency and its dispersal,
and
• Comparison between groups (Student's t-test, chi
square and Pearson's r correlation coefficient).
RESULTS
Dental status
Caries experience was 85.8% for children from
underprivileged urban schools (UnU) and 75% for
children from urban schools (U). The percentage of
caries-free children was significantly lower in
group UnU (14.2%) than in group U (25%) (x2=
25.377; p= 0.018).
A comparison of the groups revealed significantly
higher values in children from UnU schools for the
following indicators (Table 1):
• d+D tooth (ẋ = 5.4} 3.8; t = 2.887; p = 0.004 );
• dmft+DMFT (ẋ = 5.7} 4.1; t = 0.466; p = 0.020);
• d+D surface (ẋ = 7.62} 6.2; t = 0.956; p = 0.014), and
• fewer filled surfaces than children from U (f +
F surface: ẋ = 0.12} 4.5; t = -2.71; p = 0.007).
Table 1: Association tests for dental status variables and percentage of caries-free children from each school environment (Student's t-test for independent samples and chi-squared).
When mean dmft+DMFT was discriminated according to grouped categories, distribution was more homogeneous among preschoolers from in the U group, with 52.7% corresponding to the sum of classes 0 and 1/2/3. In children from the UnU group, the problem was more serious: the sum of children with class 0 and 1/2/3 was 34.2% while 41.9% had dmft+DMFT equal to or higher than 7 (Table 2).
Table 2: Contingency table for dmft+DMFT categories for each Type of school.
Demand for dental care
The answers to ‘yes/no' question No. 1: "Has your
child ever visited a dentist?" differed significantly
according to school setting (x2 with Yates' correction
= 7.022; p = 0.008), with 55% of the "yes"
answers corresponding to U and 63% of the "no"
answers to UnU (Figure 2, Table 3).
Fig. 2: Percentages of answers to the ‘yes/no' question "Has
your child ever visited a dentist?" according to type of school.
Table 3: Frequency distribution and association test for answers to the ‘yes/no' question "Has your child ever
visited a dentist?" according to type of school (Chi squared).
For the cases that answered "yes" (n = 180) there
was association between type of school and place
where the visit to the dentist took place (x2 = 78.851;
p = 0.000):
• For U, 85.6% of the answers were "obra social"
(health insurance managed by trade unions) and
"others", whereas
• for UnU 80.3% of the answers were "centro de
salud" (government-run community health centers)
and "public hospital" (Figure 3).
Fig. 3: Percentages of use of oral health subsystems according
to type of school.
No significant difference was found between groups for:
• type of school and average number of visits to the
dentist during the past year (ẋUnU = 1.82}1.5;
ẋU = 2.07}2.1; t = -0.865; p = 0.394);
• school setting and satisfaction with dental care
received (x2 with Yates' correction =1.368;
p=0.242).
Among participants from the underprivileged urban group (UnU), 64% said they had encountered difficulty in getting an appointment for the visit to the dentist, while among participants from the urban group (U), 71% said they had not had difficulty (x2 with Yates' correction = 19.910; p = 0.000).
Severity of dental status and demand
for dental care
To establish possible associations between severity of
dental status and demand for dental care, we analyzed
frequency distribution between the dmft+ DMFT ordinal
categories and the ‘yes/no' question about visiting
the dentist (Question 1) for each type of school. To
establish whether there was a pattern in demand for dental
care related to caries severity indicators, the correlation
between number of visits in the past year (Question
2b) and dmft+DMFT categories was analyzed.
For children from schools there was association
between visits to the dentist and dmft+DMFT categories
(x2 = 19.412; p = .000). A high percentage of
preschoolers whose parents answered "yes" to survey
Question 1 about going to the dentist corresponded
to the category dmft+DMFT = 7 or higher
(59.3%), whereas among children without caries
experience, only 9.9% answered ‘yes' (Table 4). No
correlation was found between frequency of visits
to the dentist during the past year and dmft+DMFT
(Pearson's r coefficient = 0.091; p = 0.0426), as
shown in Table 5. Children from the UnU group
with more severe dental status had visited a dentist,
but not as frequently or as regularly as required by
their diagnosed dental status. Most children without
caries experience had never visited a dentist, i.e.
they had not been to preventive visits.
Table 4: Contingency table for the ‘yes/no' question "Has your child ever visited a dentist?" according to dmft+DMFT categories and type of school.
Table 5: Association and correlation tests for questions 1 and 2 regarding demand for dental care according
to severity of dental status at schools in urban and underprivileged urban settings (Chi squared and
Pearson's correlation coefficient).
In children from urban (U) schools, no evidence was found of association between the child visiting the dentist and dmft+DMFT categories (x2 = 2.781; p = 0.427). However, direct correlation was found between frequency of visits during the past year and dmft+DMFT (Pearson's r coefficient = 0.486; p = 0.000), (Table 5). Children from urban schools visited the dentist in both health and disease, but there was a tendency to increasing the frequency of visits to the dentist when the severity of the dental status was higher.
DISCUSSION
Caries experience in both the populations of children
that were studied in Mendoza is high, in agreement
with studies on caries prevalence in preschoolers in
other developing countries.13-17 Early childhood caries in preschoolers in the study
sample seems to be influenced by multiple factors
related to socio-economic status. Dental status in
children from underprivileged urban schools corresponded
to high degrees of ECC severity and
was worse than in children from urban schools.
However, despite the prevalence of caries, only
47% of those children had ever demanded dental
care, and the frequency and consistency of the visits
were not sufficient to ensure the resolution of
these dental problems. Kopycka-Kedzierawski
and Billings 21 reported similar results in Rochester
(USA), finding that in a population of 246 children
aged 1 to 4 years at child care centers, 28%
had caries, but only 39% of them had demanded
dental care.
Another important finding is that the demand for
dental care due to caries problems in preschoolers
from the underprivileged urban group was not
related to the number of visits completed, from
which it may be inferred that there was little adhesion
to treatment and that the demand was related
to urgencies. This agrees with a study conducted in
New York (USA) by Uargarkar et al.,22 who analyzed
the demand and gradual increase in costs of
care for children under 6 years old, which they
claim is due to an increase in caries in low income
sectors, the existence of physical barriers, lack of
health insurance, lack of knowledge in parents and
care givers, and the limited number of dentists willing
to attend to preschoolers or who have contracts
with the health insurance system in force (Medicaid
in this case).
The health sub-system primarily used by the sample
from UnU schools was the government system,
which involved difficulty in getting appointments.
This constitutes a real barrier to access to oral
health care. To make matters worse, oral health is
undervalued compared to other health needs, particularly
in low income populations. This points to
the need to deal with oral health problems by
means of policies involving both clients and health
care providers 23.
An outstanding study with regard to this issue was
conducted by Grembosky et al.24 on the oral health
status of children from low income families, showing
that children whose mothers had a regular source
of dental care were healthier than children whose
mothers did not have that benefit.
In our study, preschoolers from the urban setting
enjoyed a better socio-economic status, which was
related to access to trade union-managed health
insurance (obra social) or private subsystems. They
tended to demand dental health care for both healthy
and diseased status. Correlation tests showed that
the more often they had visited the dentist, the higher
was the dental status indicator (dmft+DMFT), and
vice versa. This may be interpreted as higher adherence
to treatment and it may be assumed that treatment
was completed.
The association between school setting (defined by
unmet basic needs in the school population) and dental
status may be considered upon establishing subpopulations
at risk of the disease. This concept is
supported by studies such as Da Rosa et al., reporting
a direct association between school deprivation
indices and dental status in preschoolers in Quebec
(Canada) 25. Muirhed et al. also propose school socioeconomic
context as an adequate indicator for mean
dmft values in preschoolers 26.
It would be helpful to explore whether the results
of this study are attributable to:
• Different perceptions in the families regarding
the impact of oral status on the child's quality
of life
• Structure and dynamics of the health care
system fostering or hindering the entry and
engagement of socially deprived population
groups
• The current health care system, which does
not focus on risk in individual or group
programs.
Awareness needs to be created regarding the problem of early childhood caries and severe early childhood caries. It should be prioritized by political decision makers as a real and urgent public health problem in order to establish strategies for preventive and curative intervention, with the participation of human resource training institutions, so that they will be prepared to deal with the situation 27.28,22.
CONCLUSIONS
• Preschoolers from underprivileged urban settings
had higher caries indicators than preschoolers
from urban settings, although this was not reflected
by higher demand for dental care.
• Preschoolers from underprivileged urban settings
tended to demand dental care only for more
severe dental problems, and the severity of their
status was not related to the number of visits
demanded. It may be inferred that demand was
for urgencies.
• Children from urban schools demanded dental
care for both healthy status and diseased status,
and were more likely to adhere to the treatment.
• Action to promote oral health in preschoolers
should take into account internal and external barriers
against access to and use of oral health care
services.
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