PRcrrrc HeRr-rs Drnloc Vol 10 No. 1 . 2003 Onrcrrunl Pnpens
Caries prevalence in the secondary dentition
Table 2 reflects DMFT rates which also all exceed the 1987 U.S. national means, however, to a lesser degree than the dft findings.
In this case, the age-weighted DMFT for children ages 5 through 9 were higher on Guam by contrast with palau
In reviewing in the findings presented, consider that the average 6 year old in Guam had over 7 (of a possible 20) primary teeth which were carious, 81.6 percent of children had untreated dental caries, 69.1 percent of all carious t e e t h o b s e r v e d w e r e a c t i v e l y d e c a y e d a n d i n n e e d o f treatment, 8.8 percent of children had no carious primary teeth, 76.7 percent had rampant tooth decay (5 or more d e c a y e d te e t h ) a n d 6 7 . 9 p e r c e n t o f p r i m a r y m o l a r s observed had been damaged by caries.
H a w a i ' i , 1 9 9 9 P a l a u , 1 9 9 9 G u a m , 2 0 0 0
u . s . , 1 g g 7 Age in Years
5
o
8 I 5 through I (Age-Weighted)
Boys 5 through 9
G i r l s 5 through 9
M e a n ( s . d . )
0 . 0 1 9 ( 0 . 2 o 2 ) 0 . 0 0 0 ( 0 . 0 0 0 ) 0 . 0 0 0 0 . 1 0 6 ( 0 . 4 8 3 ) 0 . 1 6 4 ( 0 . 5 4 5 ) 1 . 1 6 7 0 . 2 8 6 ( 0 . 7 5 2 ) 0 . 5 5 2 ( 0 . 9 6 2 ) 1 . 6 4 9 0 . 5 5 3 ( 1 .0 9 0 ) 0 . 9 1 7 ( 1 .2 7 8 \ 1 .9 6 e 0 . 7 6 7 ( 1 . 2 6 3 ) 1 . 4 4 8 ( 1 . 8 3 3 ) 2 . 8 s 6
4 . 2 7 8 ( 0 . 7 9 8 ) 0.767 (1.336) 1.806 o . 2 4 4 ( 0 . 7 4 6 ) 0.705 (1.368) 1.656 0 . 3 1 5 ( 0 . 8 4 9 ) 0 . 8 4 7 ( 1 . 2 9 5 ) 1 . 9 6 7
( 0 . 0 0 0 ) ( 1 . 3 6 2 ) ( 1 . 5 7 3 ) ( 1 . 4 1 4 ) ( 2 . 4 e 0 ) ( 1 . e 0 0 ) ( 1 . 7 7 5 1 ( 2 . 0 1 4 )
0 . 0 5 ( 0 . 5 4 9 ) 0 . 1 0 ( 0 . 7 0 1 ) 0 . 2 9 ( 1 . 2 s 0 ) 0 . 5 1 ( 1 . 6 4 3 ) 0 . 7 7 ( 2 . 1 9 3 ) 0 . 3 8 n a 0 . 3 6 n a 0 . 4 1 n a
na not available
age-weighted means for fhe U. S., 1987 derived f rom calculations based upon published dala sels / H a w a i ' i , n = 2 4 , 7 5 2 P a l a u , n = 5 5 8 G u a m , n = 1 , 5 1 A l J . S . . n = 1 6 . 5 4 7
(p<0.001). Both are significanfly higher than the rate found in Hawai'i. Low or non-existent rates at 5 years of age are n o t u n u s u a l , c o n s i d e r i n g t h a t t y p i c a l l y a c h i l d ' s fi r s t secondary teeth, the first permanent molars, generally do not erupt until about 6 years of age. lf present at age 5,
€XposUr'e to the possibly cryogenic environment of the oral c a v i t y h a s b e e n m i n i m a l .
P r o g r e s s in P a l a u
F i n d i n g s in T a b l e 4 r e f l e c t p r o g r e s s i v e a n d s i g n i f i c a n t improvements in the oral health status of adolescents in P a l a u a s s o c i a t e d w i t h d e n t a l d i s e a s e p r e v e n t i o n strategies targeting young children. Associated the dismal statistical oral health profile that emerged when data was
S a m p l e S i z e
H a w a i ' i 6 , 1 5 2 P a l a u 1 4 0 G u a m 3 0 5
d f t 9 5 % C . t .
4 . 1 6 5 4 . 0 6 5 , 4 . 2 6 5 6 . 9 0 0 6 . 1 5 0 , 7 . 6 5 0 7 . 3 6 4 6 . 8 7 0 , 7 . 8 5 8
Percent of
%d Children
Caries-Free
28.7% 30.1%
8 7 . 7 1 2 . 9 6 9 . 1 8 . 8
Percent of
Children Primary with Unmet Molars
Treatment Which Needs b were
Decayed 3 5 . 8 % 4 3 . 9 %
7 8 . 6 6 4 . 2 8 1 . 6 6 7 . 9 Percent of
Children with Rampant
Caries ' 4 4 . 7 % 7 4 . 3 76.7
a "Rampant Caries" defined as 5 or more carious teeth
b "Unmet Treatment Needs" defined as children with activelv carious teeth
Signifi cant early childhood caries risk
Early caries indicators ambng 6 year olds reflect high c a r i e s r a t e s . T h o u g h t h e s e s t a t i s t i c s ( T a b l e 3 ) demonstrate a severe early childhood caries problem in all three regions, in relative terms, 'caries risk'was found to be highest in Guam and lowest in Hawai'i.
first collected in 1993 and, the Ministry of Health supported a variety of initiatives aimed at preventing and controlling dental disease among young children in Palau.
At various times since, oral health surveys were conducted in monitoring program impact. The experience of B-year- o l d c h i l d r e n i s r e p r e s e n t a t i v e o f t h e i m p a c t o f d i s e a s e prevention and early intervention programs targeting all age groups in Palau. Findings reflect significant reductions
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in caries prevalence in both the primary and secondary d e n t i t i o n s , a s i g n i f i c a n t i n c r e a s e i n s e a l a n t p l a c e m e n t a n d utilization, an increase in the proportion of the population that is free of caries in the secondary dentition, a reduction in the proportion of carious secondary molars within the population and a reduction in the percentage of unmet treatment needs.
dental care services, participation in other dental disease prevention activities, such as targeted sealant programs, dietary counseling, daily home care and regular, periodic professional dental care visits. Nevertheless, the contrast is caries prevalence shown between children with and w i t h o u t d e n t a l s e a l a n t s , in a l l t h r e e c o m m u n i t i e s . i s
S a m p l e d f t S t z e
^.P.:l""nt o.f.. Secondary 9 5 % c . l . D M F T g s % c.l. c h l l d r e n w i t h Molars which
at Least otr€ *ere Decayed S e a l a n t
Percent of C h i l d r e n Caries-free ( S e c o n d a r y
Teeth) 1 0 . 1 %
48.2
Percent of C h i l d r e n w i t h U n m e t
Treatment Needs 98.7%
s 5 . 2 92.1 7 8 . 0
35.3 79.4 P a l a u , 1 9 9 3 7 9
P a l a u , ' 1 9 9 4 8 3 P a l a u , 1 9 9 7 2 4 O P a l a u , 1 9 9 9 1 3 2 B y C o n t r a s t . .
H a w a i i , 1 9 9 9 5 9 7 5 G u a m , 2 0 0 0 1 2 6
8 . 3 2 9 7 . 4 0 0 , 9 . 2 5 8 2 . 8 2 3 2 4 0 4 , 3 . 2 4 2 5 . 9 5 2 5 . 1 4 0 , 6 . 7 6 4 1 . 2 0 5 0 . 8 8 9 , 1 521 s 0 0 8 4 6 1 7 , 5 . 3 9 9 0 . 9 1 7 0 . 7 6 1 , . 1 . 0 7 3 5 . 7 2 0 5 . 1 3 5 , 6 . 3 0 5 0 . 9 1 7 0 . 6 9 9 , 1 . . 1 3 5
3 . 7 8 8 3 . 7 0 8 , 3 . 8 6 8 0 . 5 5 3 0 5 2 5 , 0 5 8 1 5 . 8 1 0 5 . 2 1 0 , 6 . 4 1 0 2 . 0 3 2 1 .7 6 0 , 2 . 3 0 4
1 3 9 % 1 0 . 8 8 1 . 2 8 1 . 1
20.4 6 9 . 0
6 0 . 6 %
1 5 . 5 5 . 2
3 . 1 6 4 3 . 9 4
5 2 5 5 3 . 8
/ J . 3
2 3 8
' Gorrelations with dental sealant utilization
F i n d i n g s s h o w n i n F i g u r e 1 d e m o n s t r a t e a s t r o n g correlation between the utilization of dental sealants and lower caries prevalence among secondary teeth among a d o l e s c e n t s in e a c h o f t h e t h r e e j u r i s d i c t i o n s . C o m p a r a b l e c o r r e l a t i o n s h a v e b e e n f o u n d i n s e v e r a l recent U.S. national and regional cohorts.3,a lt's difficult to attribute the lower caries prevalence demonstrated direcfly t o t h e s e a l a n t s th e m s e l v e s . W i t h o u t evidence to the c o n t r a r y , i t c a n b e a r g u e d t h a t c h i l d r e n w i t h s e a l a n t s m a y b e f r o m m o r e a f f l u e n t a n d r o r f r o m m o r e , d e n t a l l y c o n s c i o u s ' h o m e s , w h i c h m i g h t b e a t l o w e r ri s k fo r caries
s t r i k i n g , w i t h s e a l e d c h i l d r e n h a v i n g s i g n i f i c a n t l y l o w e r DMFT rates than unsealed children in all ages examined.
U.S. national oral health objectives
Oral health indicators (Table 5) associated with the U.S.
National Oral Health Objectives demonstrate poor oral h e a l t h a n d h i g h n e e d s a m o n g a d o l e s c e n t s i n a l l t h r e e jurisdictions.s National Objectives 21 .1b and 20.2b relate primarily to the high early childhood caries experience in t h e p r i m a r y d e n t i t i o n . O b j e c t i v e 2 1 . 8 a o n t h e o t h e r h a n d , i s a p r o x y i n d i c a t o r o f p r e v e n t i v e s e r v i c e s u t i l i z a t i o n targeting caries prevention in the secondary dentition.
f?alau w /o Sealants
Palau w/ Sealants
Guam w /o Sealants
Guam w / Sealants
l-iaw ai i w /o Sealants
F,law ai'iw/ Sealants
d e v e l o p m e n t t h a n c h i l d r e n le s s l i k e l y to h a v e sealants u p o n e x a m i n a t i o n .
Sealant presence, in a broad sense, is reflective of access to and utilization of preventive dental services, which may be influenced by many factors including socioeconomic status, the availability and accessibility of professional
Over the past decade, the Republic of Palau Ministry of Health and Guam Department of Public Health and Social S e r v i c e s h a v e m a d e c o n c e r t e d e f f o r t s t o i n v e s t in prevention in working to break the cycle of dental disease so prevalent among young children in the region. This is reflected in the high sealant rates found among 8 year
o l d s . G i v e n l i m i t e d r e s o r r r . : e s l h a n h e l l a n n e r e m a i n c l n
Figure 1 Variance in DMFTAssociated with Sealant Utilization
Pncrrrc Henrrn DrRloe Vol 10 No. 1 . 2003 ORrcrrunl Pnpens
d e v e l o p a n d i m p l e m e n t e f f e c t i v e s t r a t e g i e s a i m e d a t reducing community caries risk among younger children and provide sufficient treatment services to lower the proportion of children with unmet treatment needs.
however, with the high rates of and the high caries prevalence a p p a r e n t th a t m o r e n e e d s t o childhood caries under control.
unmet treatment needs rates which remain, it's b e d o n e t o b r i n g e a r l y T h e i m p l e m e n t a t i o n a n d
O b j . 2 1 . 1 b . . . t h e p r o p o r t i o n o f 6 through 8 year old children with one or more caries (primary or secondary dentition)
Obj. 20.2b ...the proportion of 6 through 8 year old children with untreated caries (primary and/or s e c o n d a r y d e n t i t i o n )
O b . i . 2 1 . 8 a . . . t h e p r o p o r t i o n o t 8 year old children with at least one secondary molar occlusal s e a l a n t
Y e a r 2 0 1 0 H a w a i ' i ,
Objective 1999
< 40% 74.69% 10.63
< 2 2 % 3 5 . 9 7 1 0 . 7 0
> 70o/o 20.44 l.1.02
Palau, Guam,
1 9 9 9 2 0 0 0 91.13% t2.77 93.05% t1.59
7 9 . 5 6 1 3 . 9 2 8 2 . 6 4 1 6 . 6 1
8 1 . 0 6 i 6 . 6 8 6 9 . 0 5 1 8 , 0 7 U.S.
Baseline 5 2 %
2 S %
23%o
95% C.l. a Source; Healthy People 2010
Discussion
Data presented here reflect findings by age and gender and in some cases, by an age selected as a community b e n c h m a r k . r e p r e s e n t a t i v e o f c h i l d r e n i n t h e i r communities. All data collected demonstrate disease rates w h i c h f a r e x c e e d t h o s e f o u n d o n t h e U . S . m a i n l a n d , t h o u g h in relative terms, children in Guam were found to be the l e a s t h e a l t h y ( h a v e t h e w o r s t o r a l h e a l t h i n d i c a t o r s ) , f o l l o w e d b y P a l a u a n d H a w a i ' i . T h o u g h n o t a n i s s u e in t h e scheme of this project, the authors acknowledge that the disproportionately poor oral health indicators found among G u a m c h i l d r e n b y c o n t r a s t w i t h H a w a i ' i a n d P a l a u , c o u l d be an artifact considering that data was collected utilizing a slightly dlfferent methodology. However, we believe that the data is certainly representative a of significant public health problem. The statistical findings at all three sites c l e a r l y lu s t i f y t h e c o n c e r n s r a i s e d f o r m a n y y e a r s t h r o u g h o u t t h e r e g i o n o v e r t h e a p p a r e n t e a r l y c h i l d h o o d d e n t a l c a r i e s e p i d e m i c w h i c h a f f e c t s s o m a n v o f o u r c h i l d r e n a n d c o m m u n i t i e s .
O r a l d i s e a s e h a s b e e n c a l l e d A m e r i c a ' s " s i l e n t e o i d e m i c "
b y U . S . S u r g e o n G e n e r a l D r . D a v i d S a t c h e r . 6 D e n t a l d i s e a s e i s i n s i d i o u s , p a i n f u l , a s s o c i a t e d w i t h e n h a n c e d r i s k o f c h r o n i c d i s e a s e , c o s t l y a n d d i s f i g u r i n g . . . a n d , f o r t h e m o s t p a r t , c o m p l e t e l y p r e v e n t a b l e . l t ' s n o l o n g e r accepted that tooth decay and other forms of oral disease a r e a n o r m a l p a r t o f c h i l d h o o d a n d a g i n g . P u b l i c p r o g r a m m i n g a i m e d a t e a r l y d e t e c t i o n a n d i n t e r v e n t i o n and the delivery of both preventive and treatment services i s i n o r d e r w h e r e a c c e s s t o p r i v a t e s e c t o r s e r v i c e s is limited. High disease rates are indicative of the need for p r i m a r y , s e c o n d a r y a n d t e r t i a r y p r e v e n t i v e s e r v i c e s . P a r t i c u l a r l y w h e n d e a l i n g w i t h y o u n g c h i l d r e n , n o n e s h o u l d be provided at the exclusion of the others.
The oral health crisis demonstrated by the findings of this project warrant the focused attention of community health p l a n n e r s , p u b l i c a d m i n i s t r a t o r s a n d o u r e l e c t e d representatives. Our findings reflect that progress has b e e n m a d e i n r e c e n t y e a r s w i t h t h e i m p l e m e n t a t i o n o f t a r g e t e d d e n t a l d i s e a s e p r o g r a m s a t P a l a u a n d G u a m ,
m a i n t e n a n c e o f f l u o r i d e s u p p l e m e n t p r o g r a m s , s u c h a s community water fluoridation where feasible, systematic programs of early and periodic dental examinations with treatment targeting pre-school children and school-linked dental sealant and weekly fluoride mouth rinse programs may help lower the caries risk of these communities.
As efforts continue towards the development of a common regional (Pacific basin) data set, we recommend that basic, standardized indicators be utilized which are reflective of disease rates, unmet treatment needs rates and dental sealant utilization rates and that, in the interest of economy, that a few benchmark or proxy ages be identified. With an u n d e r s t a n d i n g o f b a s i c t r e n d s a n d t e n d e n c i e s , d a t a associated with a few, or even single age cohorts, can yield inexpensive, fairly easy to collect, accurate, timely a n d u s e f u l d a t a fo r e s t a b l i s h i n g c o m m u n i t y b a s e l i n e s a n d monitoring of community oral health status.
Acknowledgements
T h e a u t h o r s w i s h t o t h a n k D r . K a r e n l . H u a n d d e n t a l h y g i e n i s t s S u s a n L . T e n g a n a n d J o y c e T . T a k a t a ( H a w a i ' i S t a t e D e p a r t m e n t o f H e a l t h D e n t a l H e a l t h D i v i s i o n ) a n d D r . J o h n B e t z ( U . S . N a t i o n a l H e a l t h S e r v i c e C o r p a s s i g n e e i n P a l a u 1 9 8 8 - 1 9 9 4 ) f o r t h e i r in v a l u a b l e a s s i s t a n c e w i t h this project. We also extend our appreciation to Dr. Bruce S. Anderson, Director of the Hawai'i State Department of H e a l t h , D r . R u b e a n g N g i r u c h e l b a d , D e n t a l C h i e f ( 1 9 8 9 - 1 9 9 4 ) o f t h e P a l a u M i n i s t r y o f H e a l t h , M s . A n g e l i n a M u m m e r t , A d m i n i s t r a t o r f o r t h e G u a m B u r e a u o f C o m m u n i t y H e a l t h S e r v i c e s a n d D r s . C h r i s t i n a R a p a d a s a n d M i c h a e l F e r n a n d e z o f t h e G u a m D e D a r t m e n t o f P u b l i c Health and Social Services for their support of this project a n d p r o g r a m s t a r g e t i n g o r a l d i s e a s e p r e v e n t i o n a n d c o n t r o l .
Reference
1. WB Saunders, Textbook ofPediatrics.'l5th edition, 1996.
2 . G r e e n w a l l , A L e t a l . L o n g i t u d i n a l e v a l u a t i o n o f c a r i e s patterns from the primary and mixed dentition. Pediatr Dent 1990'.12:27 8-282.
