LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

MEDICAL ACADEMY

FACULTY OF PUBLIC HEALTH

DEPARTMENT OF PREVENTIVE MEDICINE

SHILPA G.MIRAJKAR

THE RELATIONSHIP BETWEEN DIET AND DENTAL CARIES

AMONG SCHOOL CHILDREN

IN THE CITY OF CHENNAI, INDIA

Master Thesis

Thesis Supervisor

Professor Apolinaras Zaborskis

KAUNAS, 2014

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SUMMARY

The Relationship between Diet and Dental Caries among School Children in the city of

Chennai, India

Shilpa.G.Mirajkar

Academic supervisor Prof. Apolinaras Zaborskis.

Lithuanian university of Health Sciences, Faculty of Public Health, Department of Preventive

Medicine. Kaunas:2014

AIM. The aim of the present study was to determine the relationship between diet and dental

caries among adolescent school children, between the age group of 13 to 14 years in the city

of Chennai, India

OBJECTIVES. To find out the characteristics of diet pattern among school children; to

analyze the prevalence of dental caries among school children; to determine the association

between of diet and dental caries.

METHODS. The survey was conducted in the city of Chennai, India. A total of 200 children

participated in the survey between the age groups of 13 to 14 years from private and public

schools. In each of these age groups an attempt was made to include equal number of male

and female subjects. Questionnaires were filled by the children and dental examination was

done by dental surgeon with help of two assistants, which were recommended by WHO oral

health assessment. Statically data was analyzed using the statistics packages spss17.0for

windows.

RESULTS. The diet pattern of Indian school going children aged between 13 to 14 years was

not healthy among the boys and girls. Children under the poor socio-economic category

consumed more healthy diet followed by the rich and average socio-economic group and

consumption of unhealthy diet was more among the rich socio-economic group followed by

average and poor socio-economic group. Children in the public school consumed healthy

food more frequently than children from the private school (51.2% and 45.3% respectively).

Prevalence dental caries was more among the boys when compared to girl (54.0% and

46.0%). The children belonging to the low socio-economic status had higher caries

prevalence than those belonging to the high socio-economic status (58.1%vs43.2%). Caries

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prevalence was more among the public school children when compared to private school

(53.0% and48.0%). Caries prevalence was lower among healthy diet patterns. A correlation

was seen between unhealthy diet consumption and caries, with the prevalence of dental caries

increasing with increasing exposure to unhealthy food. The unhealthy food consumption was

found to have a highly significant relation with the socio-economic status.

CONCULSION. Nutrition habits of the majority children did not meet the recommendations

for the healthy nutrition. Nutrition education and counseling for the purposes of reducing

caries in children is aimed at teaching the children and their parents the importance of

reducing the frequency of exposures to unhealthy diet.

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CONTENTS

INTRODUCTION…………………………………………………………………………….5

1. THE AIM AND THE OBJECTIVES………………………………………………………..7

2. LITERATURE REVIEW………………………………………………………………….. 8

2.1 The dental caries process………………………………………………………............9

2.2 Effects of dental caries………………………………………………………………..10

2.3 Dietary Factors in the Initiation and Progression of Dental Caries…………………...11

2.4 Types of Food Products which play a main role in the development of

Dental caries………………………………………………………………………..12

2.5 Eating Between Meals……………………………………………………………….....15

2.6 Dietary fluoride and water fluoridation……………………………………………….15

2.7 DMF Index…………………………………………………………………………....16

2.8 Prevalence of Dental Caries among School Children in India……………………….18

2.9 Socioeconomic factors responsible for the prevalence of

Dental caries among school children…………………………………………… ……….18

2.10 The impact of dental caries on quality of life………………………………… ……19

3. MATERIAL AND METHODS

3.1 Research design and sampling ………………………………………………………..21

3.2 Organizing the survey…………………………………………………………………21

3.3 Implementing the survey……………………………………………………................22

3.4 Measurement criteria…………………………………………………………………..23

3.5 Statistical analysis…………………………………………………………………......24

4. RESULTS AND DISCUSSION

4.1 To find out the characteristic of diet pattern among the gender, schools, social

economic

status……………………………………………………………………………………..25

4.2 The prevalence of dental caries among gender, schools, social economic

status…………………………………………………………………………………… .32

4.3 The association of diet and dental caries……………………………………… …....35

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5.CONCLUSION……………………………………………………………………………40

6.PARTICLRECOMMENDATION………………………………………………………41

7. REFERENCES………………………………………………………………………… 42

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INTRODUCTION

Dental caries is an ancient disease, dating back to the time that agriculture replaced

hunting and gathering as the principle source of food. Diet plays a central role in the

development of dental caries. Dental caries is considered a major public health problem

globally due to its high prevalence and significant social impact. World Health Organization

reports 60-90% of schoolchildren worldwide have experienced caries, with the disease being

most prevalent in Asian and Latin American countries [WHO, 2008].

Dental caries is a multifactor disease which occurs due to demineralization of enamel

and dentine (the hard tissues of the teeth) by organic acids formed by bacteria in dental

plaque through the anaerobic metabolism of sugars derived from the diet. When sugars or

other fermentable carbohydrates are ingested, the resulting fall in dental plaque pH caused by

organic acids increases the solubility of calcium hydroxyl apatite in the dental hard tissues

and demineralization occurs as calcium is lost from the tooth surface. During the past two

decades, increasing levels of dental caries in children and adolescents have been observed in

developing countries, in contrast to developed countries. Among children, adolescents are

particularly at higher risk for dental caries.

Dental diseases are connected to lifestyles, and multiple risk factors may affect dental

health habits and dental health. There are several factors which govern the well being of our

oral health, out of which, Socio-economic status and lifestyle, awareness and education,

familial and physiological well being, dietary and daily habits and area they live, are a few of

them, especially in adolescent children. Those hailing from a higher socio-economic strata,

and urban areas, in spite of having adequate knowledge of the disease, are exposed to the

availability of junk foods and more susceptible to its frequent consumption.

Whereas those from a lower economic group and rural area are not as much exposed

to such food habits and do not indulge in it because of the cost. Although adolescents have a

basic knowledge of dental health, such as importance of proper brushing and diet in

preventing dental caries, many fail to brush their teeth effectively and tend to consume

cariogenic foods. They may underestimate health risks and tend to oppose their parents and

teachers, making it the most difficult period for health education. Children with caries eat

snacks between meals more frequently than those without caries.

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The primary public health measures for reducing caries risk, from a nutrition

perspective, are the consumption of a balanced diet and adherence to dietary guidelines and

the dietary reference intakes; from a dental perspective, the primary public health measures

are the use of topical fluorides and consumption of fluoridated water.

The main purpose of this study is to find out the co-relation between diet and dental

caries among adolescent school going children, form the private and public schools and

associate the problem to factors such as socio economic status, habits, knowledge and

awareness.

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1. AIMS AND OBJECTIVES

Aim.

The aim of the present study is to determine the relationship between diet and dental

caries, among adolescent children, between the age group of 13 to 14 years in the city

of Chennai, India.

Objectives.

The main objectives of this study are:

1) To find out the characteristics of diet pattern among school going children.

2) To analyze the prevalence of dental caries among school going children.

3) To determine the association between of diet with dental caries

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2. REVIEW OF LITERATURE

2.1. The Dental Caries process

Dental caries occurs due to demineralization of enamel and dentine (the hard tissues of the

teeth) by organic acids formed by bacteria in dental plaque through the anaerobic metabolism

of sugars derived from the diet (Arens U; 1998). When sugars or other fermentable

carbohydrates are ingested, the resulting fall in dental plaque pH caused by organic acids

increases the solubility of calcium hydroxyl apatite in the dental hard tissues and

demineralization occurs as calcium is lost from the tooth surface. The deciduous teeth erupt

from 6 months and are lost by the early teens. The permanent dentition replaces the

deciduous dentition from the age of 6 years and is complete by age 21. Teeth are most

susceptible to dental caries soon after they erupt; therefore, the peak ages for dental caries are

2 to 5 years for the deciduous dentition and early adolescence for the permanent dentition

(Paula et al; 2004). Studies have reported missed school hours, toothache and several

impairments of daily life activities associated with a high decayed component in both primary

and permanent dentition (Jurgensen N et al, 2009). The stage when permanent teeth begins to

show up and assumes full position in the dental arch is the age of adolescence. This age is

very crucial in development as a lot of problems like dental caries, periodontal diseases and

orthodontic problems such as overcrowding of teeth; malocclusion etc. begin to manifest,

bringing changes and altering the facial profile, aesthetic appearance; thereby affecting

certain psychological factors, self confidence and social outlook of the individual and will

have a permanent effect on the psychology of the child throught life if not treated. This

constitutes a growing problem of public health concern as most of the children are affected in

this age group and developing countries face a problem in tackling this situation due to lack

of awareness, neglect when compared to general health problems, lack of expertise and

insufficient budget provided by the government. In low-income countries, the cost of

traditional restorative treatment of dental disease is disproportionately expensive in light of

the low public health priority and it would exceed the available resources for health care. The

large financial benefits of preventing dental diseases should be emphasized to countries

where current disease levels are low (Paula Moynihan and Poul Erik Petersen, 2004).

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2.2. Effects of dental caries

The assertion that diet plays a central role in the development of dental caries is

unquestionable. The development of caries requires sugars and bacteria. Observations in

humans and animals, have shown clearly that frequent and prolonged oral exposure to certain

carbohydrates and sugars are fundamental to caries activity. Streptococcus mutans and

Streptococcus sorbrinus are important bacteria in the development of dental caries, both these

bacteria readily produce organic acids from dietary sugars and aid in bacterial colonization on

the tooth surface. The bacteria attached to teeth in dental plaque which is found as a thin film

on the surface of the enamel, utilize mono and disaccharides (e.g., glucose, fructose, sucrose)

to produce energy, and acid is a by product of this metabolism. Consequently, the acidity of

dental plaque may fall to a point where the demineralization of the tooth commences. (The

"critical pH" value for demineralization is in the range of 5.2 to 5.5). The initial stages of

tooth loss occur just below the enamel surface and produce a visual whitening of the tooth,

referred to as the "white spot lesion." At this stage of mineral loss, the lesion may not

progress any further, or could even regain minerals (i.e., remineralize) if the cariogenic

environment diminishes. Treating the tooth with fluoride, decreasing the carbohydrate source

to the bacteria, reducing the levels of cariogenic bacteria, or lessening the ability of bacteria

to produce acid are the preventive approaches that can remineralize the initial carious lesion.

However, if disease suppression procedures are not initiated and the acidic challenge is

unabated, the initial lesion will continue to lose mineral. The progressive dissolution of

enamel and loss of enamel surface structure eventually give rise to a frank carious lesion

(Norman Tinanof et al, 2000 ). The process of dental caries is very important to understand

the way most of the constituents of food products such as sugars affect the tooth and also the

effect that habitual consumption of these dietary products exert on our teeth. In today’s

world, children are more exposed to junk foods, colas, sweets and other dietary products

which are easy to access and readily available, making it prone to habitual consumption

which will easily give rise to dental caries. Hence this disease almost becomes like an

epidemic, although it is not transmissible and fatal. In a public health point of view, models,

charts etc. of the dental caries process and the way the teeth get affected by such food

products can be constructed and made use of in conducting public dental health camps,

awareness campaigns, advertisements and models for awareness and education of dental

diseases.

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2.3. Dietary Factors in the Initiation and Progression of Dental Caries

Sucrose is the major dietary factor affecting dental caries prevalence and

progression (Rugg Gunn AJ; 19963). One example of low consumption is from a study of the

Hopewood House in Australia, conducted between 1947-52. Children residing in this closely

supervised environment consumed diets that were virtually free of sugar and white flour

products. Data collected from these children revealed an extremely low dental caries

prevalence, compared to children attending other Australian schools ( Harris R; 1963)

The effects of high sugar consumption are best revealed from the report of the

classic Vipeholm study (Gustafsson BE et al;1956.). This study examined the effects of the

frequency of sugar consumption, the timing of sugar ingestion and the consistency of the

sugar on dental caries rates. The results showed that the addition of sugar to the diet caused

increased caries activity, but the degree was very dependent on the consistency of the sugar.

Sugar increased caries, most if consumed between meals, and in a form that was retained for

a long time in the mouth, such as toffee. Products that are sticky, retained for long periods in

the mouth, or consumed with high frequency have a higher cariogenicity than foods that are

eliminated quickly from the oral cavity. Therefore, frequent ingestion of foods such as hard

candies and throat lozenges that contain fermentable carbohydrates can be extremely harmful

to the teeth. The conclusions from this study, conducted a half century ago, are still well

regarded today:

1) Only a small increase in caries is noted if sugar is taken with meals.

2) Sugar consumed as snacks between meals is associated with a marked increase in

caries increment.

3) Caries activity is greatest if consumed in the form of sticky sugar-containing candies.

4) Caries activity may vary greatly among individuals.

5) Caries activity will decline with the withdrawal of sugar-rich foods.

The classic Vipeholm study in Sweden and Hopewood House study in Australia are

two major studies which are of public health significance because it brings into light

the detrimental effects of sugars in causing tooth decay. Children generally consume

diets which are rich in sugars like sweets, candies, cakes, colas etc. and a lot of

awareness has been raised since many years about the ill effects of such food products

on teeth. These days especially in developing countries, foods normally consumed in

households also contain certain amounts of sugars which are ingested frequently.

Hence these two studies are of great public health significance when conducting

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preventive dental health programs especially in schools where the drawbacks of

consuming such diet containing sugars can be addressed.

2.4. Types of Food Products which play a main role in the development of Dental Caries

A lot of evidence shows that sugars are undoubtedly the most important dietary

constituent and the factor studied most often in the development of dental caries. The term

‘sugars’ refers to all mono and disaccharides while the term ‘sugar’ only refers to sucrose, the

term ‘free sugars’ refers to all mono and disaccharides added to foods by manufacturer, cook

or consumer, plus sugars naturally present in honey, fruit juices and syrups and the term

‘fermentable carbohydrate’ refers to free sugars, glucose polymers, fermentable

oligosaccharides and highly refined starches (Paula et al; 2004).

Sucrose appears to be the most cariogenic sugar, not only because its metabolism

producesacid, but mutans streptococci which is the main microorganism which produces

dental caries, can utilize this sugar to produce glucan, a water-insoluble polysaccharide. This

extracellular "glue" enables mutans streptococci to adhere firmly to teeth (Schachetele CF;

1980)

Fresh fruits contain various sugars and may be capable of causing caries under some

conditions. However, fruit juice and flavored drinks, especially aerated beverages like cola

have a much greater cariogenic potential because of their high sugar content and the way they

are often consumed. They are offered frequently to children because of their high acceptance,

low cost, and the belief by parents that they are nutritious (Dennison BA; 1996). However,

this concept is in recent times changing because of an increased awareness about its ill effects

by public health initiatives through programs, campaigns, various forms of advertising by the

media, school dental health check up camps etc.

Milk. Another most frequently consumed food among school children is milk. The sugar

found in milk (lactose) is not fermented to the same degree as other sugars. It may be less

cariogenic because the phosphor-proteins in milk inhibit enamel dissolution and the

antibacterial factors in milk may interfere with the oral microbial flora.

Starch often is regarded as a relatively low cariogenic carbohydrate. It may be highly refined

or consumed in its natural state, it is sometimes consumed raw (e.g. in fruits and vegetables)

but is largely consumed in a cooked form. Human and animal experiments have found that

starchy foods such as rice, potatoes, pasta, and bread have very low cariogenicity. However,

if starch is finely ground, heat treated, and eaten frequently, it can cause caries, but lesser

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than sucrose. Additionally, starch that is retained on the teeth long enough to be hydrolyzed

by salivary amylase also can be broken down to mono and disaccharides and consequently

metabolized by bacteria. Starchy foods containing substantial amounts of sucrose appear to

be as cariogenic as a similar amount of sucrose. Some argue that cooked and processed

starches enter into the caries process because starches are broken down by salivary amylase

releasing glucose and maltose and that these are metabolized by oral bacteria to produce

acids. All these factors should be considered when assessing the potential and relative

carcinogenicity of starches. Rugg-Gunn (1993) extensively reviewed the evidence on the

relationship between starches and dental caries and concluded that:

1. Cooked staple starchy foods such as rice, potatoes and bread are of low cariogenicity

in humans.

2. The cariogenicity of uncooked starch is very low.

3. Finely ground and heat-treated starch can induce dental caries but the amount of

caries is less than that caused by sugars.

4. The addition of sugar increases the cariogenicity of cooked starchy foods. Foods

containing cooked starch and substantial amounts of sucrose appear to be as

cariogenic as similar quantities of sucrose.

Fruit and dental caries. Fruits may participate in the caries process; however, as consumed as

part of the mixed human diet there is little evidence to show fruit to be an important factor in

the development of dental caries. Animal studies revealed that all fruits cause less caries than

sucrose. Epidemiological studies have shown that, as habitually consumed, fruit is of low

cariogenicity. Dried fruit may potentially be more cariogenic since the drying process breaks

down the cellular structure of the fruit, releasing free sugars and dried fruits tend to have a

longer oral clearance. Studies have shown that, Fresh fruit appears to be of low cariogenicity

and citrus fruits have not been associated with dental caries. Increasing consumption of fresh

fruit in order to replace ‘non-milk extrinsic sugars’ (free sugars) in the diet is likely to

decrease the level of dental caries in a population (Rugg-Gunn AJ; 1993). Although excessive

exposure to fructose may produce dental caries, fresh fruits are likely to be much less

cariogenic than most sucrose rich snack foods consumed by children.

One hundred percent fruit juice has also been associated with caries, but the

relationship is less clear. Data from children aged 2 to 10 years who participated in National

Health and Nutrition.

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Examination Survey (NHANES) suggest that children who consume more than 17

oz 100% juice are more likely to have caries than those who are high water or milk

consumers (Sohn W et al, 2006). Conversely, in a cohort of low-income African- American

children, 100% fruit juice was found to be protective of caries (Kolker J et al 2007). Given

that 100% fruit juice contains about the same amount of sugar as the average sugar sweetened

beverages (Marshall T et al, 2007) it is important to understand its role in caries.

Carbohydrates. Glucose polymers (glucose syrups and maltodextrins) are increasingly being

added to foods in industrialized countries. Evidence on the cariogenicity of these

carbohydrates is sparse. Studies suggest that maltodextrins and glucose syrups are cariogenic

(Grenby TH et al; 2000) isomaltooligosaccharides and glucooligosaccharides may be less

acidogenic compared with sucrose (Ooshima Tet al,1998). However, there is evidence that

fructooligosaccharides, which are more widely available in foods, are as acidogenic as

sucrose. Nutritional transition with easy access to refined carbohydrates, low use of

fluoridated toothpaste and irregular tooth brushing habits lead to increasing trend in dental

caries in developing countries (Prasai Dixit et al, 2013).

Cheese. Evidence exists that certain foodsbesides milk may be protective against caries. Aged

cheese has been shown to be protective because it stimulates salivary flow and raises the

calcium, phosphorus, and protein content of plaque.

The sugar alcohols (e.g., sorbitol,mannitof, and xylitol) are sweeteners that are metabolized

by bacteria ata much slower rate than glucose orsucroseor not at all. Clinical studieshave

shown that xyIitoI chewing gumeven can reverse initial white spot lesions on teeth.

Dental decay also results in tooth loss, which reduces the ability to eat a varied diet. It

is in particular associated with a diet low in fruits, vegetables and non-starch polysaccharides

(NSP), and with a low plasma vitamin C level (Moynihan PJ et al, 1994). NSP intakes of less

than 10 g/d and fruits and vegetable intakes of less than 160 g/d have been reported in

edentulous subjects. Tooth loss may, therefore, impede the achievement of dietary goals

related to the consumption of fruits, vegetables and NSP. Tooth loss has also been associated

with loss of enjoyment of food and confidence to socialise (Steele JG et al, 1998). It is,

therefore, clear that dental diseases have a detrimental effect on quality of life both in

childhood and older age.

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2.5 Eating Between Meals

Because refined carbohydrates exert their effect in promoting dental caries by

serving as a substrate for caries-producing streptococci, it is apparent that for older children

as well as for infants that not only the total quantity but the form of the carbohydrate and the

frequency of consumption are important. A single piece of sticky candy may adhere to the

teeth for almost an hour. In the case of sugars that are not in sticky form, a specified amount

consumed at one time is likely to be less conducive to formation of dental caries than the

same amount consumed in small portions throughout the day. Considerable evidence exists

that between-meal snacks favor development of dental caries (Zita et al., 1959; Weiss et al,

1960). Foods to be avoided between meals are the following: sugar, honey, corn syrup,

candies, jellies, jams, sugared breakfast cereals, cookies, cakes, chewing gum and sweetened

beverages, including flavored milks, carbonated drinks, sweetened fruit juices and fruit or

fruit-flavored drinks.(Weiss RL et al;1960) Finally, eating frequency, particularly constant

grazing or sipping of foods and beverages, is also caries promoting. (Gustafsson B et

al;1954,Burt B et al;1988) In a recent study in a diverse sample of children aged 2 to 6 years,

eating frequency was associated with severe Early Childhood Caries.(Palmer C et al, 2010)

2.6. Dietary fluoride and water fluoridation

Increased exposure to fluoride is largely responsible for the reduction in dental

caries. Dietary fluoride principally comes from drinking water, but seafood and tea leaves are

also rich sources. Ingested fluoride becomes incorporated into enamel during tooth formation,

increasing the resistance of the tooth to decay. This pre-eruptive mode of action affects the

primary dentition in utero and the permanent dentition up to the age of 6 years. However, the

main protection from dietary fluoride is the lifelong localized intra-oral effect. Fluoride

promotes the remineralisation of damaged enamel with resistant fluoroappatite and also

inhibits bacterial metabolism of sugars (Murray, 2003). The benefits to the teeth of exposure

to fluoride are therefore lifelong. Where natural water supplies are low in fluoride, it may be

added to an optimum concentration of 1 mg/l as a cariespreventive measure. Murray et al.

(1991) have reviewed the published data on the effect of water fluoridation on caries and

have concluded that on average water fluoridation reduces dental caries by 50%. Water

fluoridation is a cost-effective public health measure because it reaches the entire population.

In a study of 5-year-old children residing innorth east England Carmichael et al. (1989) have

demonstrated that water fluoridation is effective in reducing dentalcaries across social classes

and, in terms of the number of teeth saved per child, the benefits are greatest in the lower

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social classes. This finding is important because UK national surveys have indicated that

those from lower social classes have higher levels of dental diseases, poorer oral hygiene

practice and are less likely to visit the dentist (O’Brien, 1994).Despite the indisputable

benefit of fluoride in reducing caries, it has not eliminated it. Fluoride repairs the damage

caused by acids produced by plaque bacteria but does not remove the cause of caries, i.e.

dietary sugars. Prevention requires both optimum exposure to fluoride and a reduction in

sugars intake, which are the twomain factors that have been shown to have an additive effect

on caries prevention (Weaver, 1950).India has shown dental caries in

53.8% in 12 year-old children and 63.1% in 15 year-old teenagers A very extensive

and comprehensive National Health Survey [National Oral Health Survey and Fluoride

Mapping. An Epidemiological Study of Oral Health Problems and Estimation of Fluoride

Levels in Drinking Water. Dental Council of India, New Delhi] conducted in 2004, conclude

that a preventive dentistry program, such as water fluoridation, should be initiated to address

this national crisis in dental caries. Schools provide the ideal setting to reach millions of

children and ensure strong foundations for a healthy life at an early stage.

2.7. DMF Index

The Decayed, Missing, Filled (DMF) index has been used for more than 70 years and

is well established as the key measure of caries experience in dental epidemiology. The DMF

Index is applied to the permanent dentition and is expressed as the total number of teeth or

surfaces that are decayed (D), missing (M), or filled (F) in an individual. When the index is

applied to teeth specifically, it is called the DMFT index, and scores per individual can range

from 0 to 28 or 32, depending on whether the third molars are included in the scoring. When

the index is applied only to tooth surfaces, it is called the DMFS index, and scores per

individual can range from 0 to 128 or 148, depending on whether the third molars are

included in the scoring (Cappelli DP et al; 2007).

When written in lowercase letters, the dmf index is a variation that is applied to

the primary dentition. The caries experience for a child is expressed as the total number of

teeth or surfaces that are decayed (d), missing (m), or filled (f). The dmft index expresses the

number of affected teeth in primary dentition, with scores ranging from 0 to 20 for children.

The dmfs index expresses the number of affected surfaces in primary dentition (five per

posterior tooth and four per anterior tooth), with a score range of 0 to 88 surfaces. Because of

the difficulty in distinguishing between teeth extracted due to caries and those that have

17

naturally exfoliated, missing teeth may be ignored according to some protocols. In this case,

it is called the df index. (Cappelli DP et al; 2007)

I. Calculating DMFT: The teeth not counted are unerupted teeth, congenitally missing

teeth or supernumerary teeth, teeth removed for reasons other than dental caries, and

primary teeth retained in the permanent dentition. Counting the third molars is

optional. When a carious lesion(s) or both carious lesion(s) and a restoration are

present, the tooth is listed as a D. When a tooth has been extracted due to caries, it is

listed as an M. When a permanent or temporary filling is present, or when a filling is

defective but not decayed, this is counted as an F. Teeth restored for reasons other

than caries are not counted as an F.(Cappelli DP et al; 2007)

II. Calculating DMFS: There are five surfaces on the posterior teeth: facial, lingual,

mesial, distal, and occlusal. There are four surfaces on anterior teeth: facial, lingual,

mesial, and distal. The list of teeth not counted is the same as for DMFT calculations,

and listing D, M, and F is also done in a similar way: When a carious lesion or both a

carious lesion and a restoration are present, the surface is listed as a D. When a tooth

has been extracted due to caries, it is listed as an M. When a permanent or temporary

filling is present, or when a filling is defective but not decayed, this surface is counted

as an F. Surfaces restored for reasons other than caries are not counted as an F. The

total count is 128 or 148 surfaces.(Cappelli DP et al; 2007)

III. Calculating dmft and dmfs: For dmft, the teeth not counted are unerupted and

congenitally missing teeth, and supernumerary teeth. The rules for recording d, m,

and f are the same as for DMFT. The total count is 20 teeth. For dmfs, the teeth not

counted are the same as for dmft. As with DMFS, there are five surfaces on the

posterior teeth and four surfaces on the anterior teeth. The total count is 88 surfaces.

(Cappelli DP et al; 2007,Edward LO et al; 2007.)

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2.8. Prevalence of Dental Caries among School Children in India

Dental caries is one of the leading problems of Public health concern, in school

going children as well as in adults. Dental caries is the single most prevalent chronic

childhood disease worldwide( Donahue GJ et al; 2005). The World Health Organization

(WHO) has recognized dental caries as a pandemic and reported its prevalence among school

children to range from 60%-90%. In the developing countries like India the prevalence of

dental caries is very high particularly among the children and adolescents. The prevalence is

even higher in rural people and among school children. Majority of Indian population resides

in rural areas, of which more than 40% constitute children, These children cannot avail dental

facilities due to inaccessibility, financial constraints and stagnation of public dental

healthcare services (Thomas S et al; 2000). Dental caries is not only a medical problem, but

many socio-demographic factors are said to be associated with this. The prevalence and

incidence of dental caries in a population is influenced by a number of risk factors such as

age, sex, ethnic group and dietary patterns. Other factors are, per capita income of the

parents, socio economic status, number of siblings, and oral hygiene habits such as

frequency of tooth brushing, rinsing the mouth and factors such as tooth ache, bad breath etc.

Many studies conducted in different rural and urban populations in India suggest that the

prevalence of dental caries increased with increase with age. Students belonging to the lesser

income group tend to develop dental caries higher than in comparison to students in higher

income group. Usually people belonging to lower income group are devoid of hygienic

practice and they live in unhygienic environment. These factors often lead to dental caries.

Prevalence of dental caries was assessed according to presence of siblings. It is observed that

students having no sibling or one sibling were significantly less commonly suffering from

dental caries as compared to students having more than one siblings. Usually when the

number of children increases, less care is given to each child by the mother and the elder ones

suffer most (Pratiti Datta et al; 2013).

2.9. Socioeconomic factors responsible for the prevalence of dental caries among school

children.

Socio-economic factors have been identified as predisposing factors in the

development of both dental caries and periodontal diseases. Low income, negligence in oral

care and poor education have been reported to influence dental caries and periodontal status.

19

Research in industrialized countries has revealed that children of high social class families

experience less caries than those of lower social classes. However, this relationship appears

to be reversed in the developing countries. (Cyril.OE; et al 1981). This variation in caries

experience and the oral hygiene status in various socio-economic groups are usually

explained by differences in oral habits, sugar consumption, use of fluoride in its various

forms and oral hygiene practices. In addition to this utilization of oral health services has

been related to social class differences in caries experiences. In Brazil, it has been seen that

access to dental care varies among social groups. Children from lower socioeconomic status

groups receive irregular care through the school dental services, which are based mostly on a

pain relief. On the other hand most of the children from higher socio-economic groups

receive regular dental check ups and treatment through the private systems (Maria Cristina et

al; 1992). Individuals from the lower socioeconomic status experience financial, social and

material disadvantages that compromise their ability to care for themselves, afford

professional health care services and live in healthy environment. In addition,low socio

economic status individuals have more fatalistic beliefs about their health and have a lower

perceived need for care, leading to less selfcare and lower utilization of preventive health

services. The possible influences of socio-economic status on dental health may also be

aconsequence of differences in dietary habits and the role of sugar in the diet (Ridhi N et

al;2013).

Oral health has made remarkable progress in most developed countries, as a result of

the rapid advances in the field of preventive dentistry. However, the situation is beginning to

deteriorate in many developing countries, wherethe oral diseases are on the increase and the

treatment access and awareness is still under developed (Sogi GM et al; 2002).

2.10. The impact of dental caries on quality of life.

Despite a low mortality rate associated with dental diseases,they have a

considerable impact on self-esteem, eatingability, nutrition and health both in childhood and

olderage. Teeth are important in enabling consumption of avaried diet and in preparing the

food for digestion. Inmodern society, the most important role of teeth is toenhance

appearance; facial appearance is very important indetermining an individual’s integration into

society. Teeth also play an important role in speech and communication. The second

International Collaborative Study of Oral Health Systems (ICSII), revealed that in all

countries covered by the survey substantial numbers of children and adults reported impaired

20

social functioning due to oral disease, such as avoiding laughing or smiling due to poor

perceived appearance of teeth (Chen M et al; 1997). Throughout the world, children

frequently reported apprehension about meeting others because of the appearance of their

teeth or that others made jokes about their teeth. In addition, dental diseases cause

considerable pain and anxiety (Kelly M et al 2000). Dental decay also results in tooth loss,

which reducesthe ability to eat a varied diet. It is, in particular, associatedwith a diet low in

fruits, vegetables and non-starch polysaccharides (NSP), and with a low plasma vitamin C

level. Tooth loss may, therefore, impede the achievement of dietary goals related to the

consumption of fruits, vegetables and NSP. Tooth loss has also been associated with loss of

enjoyment of food and confidence to socialize (Steele JG et al; 1998). It is, therefore, clear

that dental diseases have a detrimental effect on quality of life both in childhood and older

age.

21

3. MATERIAL AND METHODS.

3.1. Research design and sampling:

3.1.1. Study population.

The survey was conducted in the city of Chennai, India. A total of 200 children participated

in the survey between the age groups of 13 to 14 years. In each of these age groups an

attempt was made to include equal number of male and female subjects. Out of these 200

children, 100 were from the private school which is situated in the city and 100 were from the

public school which is located in the suburbs. The schools were selected based on the socio-

economic status. Children belonging to the low socio-economic groups were those studying

in the public school and the high socio-economic group comprised of children studying in

private school. The consent for examining of the children was obtained from the principal of

the two schools. The criteria for selection of the study subjects were that the children should

be permanent residents of Chennai and should be full time students enrolled in the school.

Depending on the conditions of the school, the exact arrangement for conducting the

examination was determined. The subjects were examined on an upright chair in adequate

natural light. A torch light was used to examine the oral cavity (mouth). Examination of the

child was done by only one examiner to avoid inter-examiner variability. Recording of data

was done by a two trained dental assistants who assisted throughout the study. Prior to the

examination for dental caries, a questionnaire was filled by the subject to find out the

personal data and oral hygiene habits. Tooth surface was dried and examination of the oral

cavity was made using a dental mouth mirror, and dental probe. Calibration procedures were

performed prior to and during the study to ensure that a consistent standard of the diagnosis

was maintained. Re-examinations were carried out on approximately one in ten children

selected at random to have a constant check on the inter examiner variability. The data was

recorded on a Performa and were entered into a computer.

22

3.2. Organizing the survey:

3.2.1. Obtaining ethical clearance and permission from the concerned authorities.

The ethical clearance for the present study was obtained from the Lithuanian

university of health science, Kaunas Lithuania, The Dental council of India and the Principals

of the public and private schools. The required official permission for the study was obtained

from Health & Family Welfare Office of Chennai Tamilnadu and local medical officers of

Primary Health Centers and Sub-centers. For examination of children in the rural areas, co-

operation and oral consent was taken from school principle heads.

3.2.2. Scheduling.

The present study was conducted from June 2013 to August 2013. A detailed

monthly schedule of the survey was prepared well in advance and the concerned authorities

were informed regarding examination place, date and timings. On an average 20 subjects

were interviewed and examined on each day. Examination of each individual took

approximately 8-10minutes.

3.3 Implementing the survey:

3.3.1. Informed consent

Consent from each study subject was taken after explaining the nature of the study.

3.3.2. Data collection

The data was collected with the usage of proforma, which included

questions related to socio-demographic characteristics22, oral hygiene practices,

adverse oral habits, some other habits like brushing teeth, coca cola and sweet consumption,

frequency of dental visits and professional cleaning.

3.3.3. Armamentarium: The following instruments and supplies were used for the study.

1. Plane mouth mirrors

2. Explorers

3. Tweezers

4. Containers

5. Surgiscrub

6. disposable tumblers

23

7. Chemical disinfectants

8. Towels

9. Gauze

10. Gloves and Mouth Masks

11. Survey Proforma

Adequate number of sterilized instruments was made available during the survey and

current recommendations and standards were followed for infection control.

24

3.4. Implementing the survey:

Table 1: General distribution of the study population

Table 1. shows that 100 (50.0%) children from the public school and 100 (50.0%) from the

private school participated in the study, out of which, 112 (56.0%) boys and 88 (44.0%) were

girls. Out of the 200 children who took part in the study, 86 (43.0%) were from the poor

socio-economic group, 72 (36.0%) were from the average and 37 (18.5%) were fro the rich

socio-economic group.

The children’s nutrition, frequency of consumption of different products were recorded

in the diet pattern.

The cariosity and socio-economic determinants were recorded in self administered

questionnaires.

Diet pattern such as fruits, green vegetables, milk and cooked vegetables were

categorized into healthy foods. It was further subcategorized into healthy and non healthy,

under this healthy were children taking this food, every day, several times in a day and five to

six times a day; not healthy were those who were taking these foods once a week, less than

once a week and never.

Diet pattern such as sweets, cakes, pastries, cookies, coca cola, other soft drinks

containing sugars and energy drinks were categorized into not healthy foods. It was further

subcategorized into healthy and not healthy.

N %

Gender

Boys 112 56.0

Girls 88 44.0

School

Private 100 50.0

Public 100 50.0

25

For cariosity, DMFT (decayed, missing filled teeth) criteria was used. The DMFT

Index is applied to the permanent dentition and is expressed as the total number of teeth or

surfaces that are decayed (D), missing (M), or filled (F) teeth, in an individual. When the

index is applied to teeth specifically, it is called the DMFT index. Cariosty was categorized

into caviation and not cavitation groups..

Factors such as car, bedroom, holiday, family, father’s and mother’s job was included

in socio-economic determinants and were recorded. This criteria was categorized into three

groups, low income as poor, average and rich.

3.5 Statistical analysis:

The data collected was analyzed using Statistical Package for Social Sciences for Windows,

version 17 (SPSS Inc., Chicago, IL). Descriptive statistics (mean, proportion, standard

deviation) were used to describe the characteristics of the sample. The Chi-square test was

used to explore the association between dental caries and diet pattern and socio-economic

status .The statistical significance was considered as P ≤ 0.05. Simple and Multiple logistic

regression analysis was used to find the degree of association between diet, dental caries and

socio-economic status. 95% confidence interval and odds ratio was calculated.

26

4. RESULTS AND DISCUSSION

4.1. Characteristics of diet pattern among school children

4.1.1. Diet pattern among the gender

The diet pattern among boys and girls was categorized as healthy and not healthy.

Fruits, green vegetables, cooked vegetables, and milk and yogurt were recorded as variables

under healthy foods and sweets and candies, cakes and pastries, coca-cola and energy drinks

were recorded as variables under unhealthy foods.

Table 2: The distribution of diet pattern among boys and girls

Variable

Boys

N=112

Girls

N=88

P

value

> 4 days <= 4 days Total > 4 days <= 4 days Total

Healthy

foods

N (%) N (%) N (%) N(%) N(%) N(%)

Fruits 52(61.9) 60(52.6) 112(56.6) 32(38.1) 54(47.4) 86(43.4) 0.24

Green

vegetables

48(49.5) 64

(63.4)

112(56.6) 49(50.5) 37(36.6) 86(43.4) 0.06

Cooked

vegetables

71(53.4) 41 (63.1) 112(56.6) 62 (46.6) 24 (36.9) 86(43.6) 0.224

Milk and

yogurt

65 (61.9) 47 (50.5) 112(56.6) 40 (38.1) 46 (49.5) 86(43.6) 0.116

27

Not

healthy

foods

Sweets,

candies

71(53.0) 42(63.6) 113(56.5) 63(47.0) 24(36.4) 87(43.5) 0.17

Cakes,

pastries

107(56.9) 6 (50.0) 113(56.5) 81(43.1) 6(50.0) 87(43.5) 0.76

Coca-cola 98 (54.4) 15 (75.0) 113(56.5) 82 (45.6) 5 (25.0) 87(43.5) 0.98

Energy

drink

104 (55.9) 9 (64.3) 113(56.5) 82 (44.1) 5 (35.7) 87(43.5) 0.59

According to Table 2, it was found that boys ate more healthy food such as fruits,

green vegetables, cooked vegetables, milk and yogurt (61.9%, 49.5%, 53.4%, 61.9%

respectively) when compared with girls (38.1%, 50.5%, 46.6%, 38.1% respectively), however

the difference was not statistically significant.

Consumption of unhealthy foods such as sweets and candies , cakes, coca cola, Energy drink

was more among the boys (53. 0,56.9, 54.4, 55.9) than girls (47.0,43.1,45.6,44.1), however

the difference was not statistically significant.

28

Figure 1: Consumption of healthy and unhealthy diet among gender

According to Figure 1, it was found that boys consume both healthy and unhealthy

foods more than girls.

Some studies have categorized fruits and vegetables under ‘Healthy’ dietary pattern

and pudding and snacks consisting mainly of high fat and/or high sugars under ‘Unhealthy’

dietary pattern (Leone CA Craig et al, 2008). A similar dietary pattern was also followed in

our study, except for that we included milk and yogurt, additional to fruits and vegetables

under healthy dietary pattern and sweets, cakes, colas and energy drinks under unhealthy

dietary pattern. Few studies have examined the effects of fast-food consumption on nutrition

or health-related outcome. Consumption of unhealthy foods like fast foods was more frequent

among males (Shanthy A Bowman et al, 2004) and its consumption seemed to have an

adverse effect on the dietary quality that may increase the risk for certain diseases.

Reason for higher consumption of unhealthy food among boys when compared to

girls seems to be unknown, but it may be due to the sample size as in this study the

participants among boys were more than that of girls.

Nutrition habits of the majority children did not meet the recommendations for the

healthy nutrition. It was established that children aged 13-14 years do not eat fresh fruits and

vegetables, cooked vegetables, milk and yogurt frequently enough. On another hand, excess

consumption of unhealthy food, sweets, cakes pastries, coca cola, Energy drinks and sweet

soft drinks was established by our study.

61,9

49,5 53,4

61,9

53 54,4 55,9 56,9

38,1

50,5 46,6

38,1

47 45,6 44,1 43,1

Eat fruits Green vegetables

Cooked vegetables

Milk and yogurt

sweets coca cola Energy drinks

Cakes

Boys >4 days Girls >4days

29

4.1.2. Diet pattern among socioeconomic status

The consumption of healthy and unhealthy diet pattern was recorded among the poor,

average and rich socio-economic status category and tabulated.

Table 3: Distribution of diet pattern among socio-economic status

Socio-economic

status

DIET PATTERN

Fruits, vegetables, milk –

healthy foods

Sweets, candies, colas – not healthy

foods

<= 4 day

N (%)

>4 days

N (%)

P value

<= 4 day

N (%)

>4 days

N (%)

P value

Poor 47(54.7) 39(45.3)

0.601

84(97.7) 2(2.3)

<0.001

Average 45(62.5) 27(37.5) 64(88.9) 8(11.1)

Rich 21(56.8)

16(43.2) 27(73.0) 10(27.0)

According to Table 3, out of the 200 children examined in the both public and private

school, it was found that children under the poor socio-economic group consumed more of

healthy food (45.3%) followed by children under the rich socio-economic group (43.2%)

and children under the average socio-economic group (37.5%). But the difference is not

statistically significant. However, the difference was not statistically significant. On the other

hand, children under the rich socio-economic status group consumed more of not healthy

foods (27.0%) followed by an average (11.1%) and poor (2.3%) socio-economic group. The

difference was statistically significant.

30

Fig 2.The characteristics of diet pattern among socio-economic status

According to Fig.2, children from the poor socio-economic status consumed more healthy

food followed by the rich and average socio-economic group.

Some studies have found a significant relationship between dietary patterns and socio-

economic indicators where consumption of ‘healthier’ dietary pattern were associated with

children from the lower income group and consumption of ‘unhealthy’ dietary patterns was

more among the higher income and higher education group (Leone C. A. Craig, 2010). In

another study it was found that children of lower socioeconomic status had less diverse diets

but ate less snack foods than children of higher socioeconomic status (Wendy S and Cathy C,

1993). Our study showed similar results.

The reason for more frequent consumption of unhealthy diet such sweets, cakes, colas and

others among children from the rich socio-economic status group may be due to its easy

availability they being able to afford it when compared to children from the poor socio-

economic group.

45,3

2,3

54,7

97,7

37,5

11,1

62,5

88,9

43,5

27

56,8

73

Healthy>4 days unhealthy >4 days Healthy<=4 days unhealthy <=4 days

poor Average Rich

31

4.1.3: Diet pattern among schools:

The distribution of the frequency of consumption of healthy and unhealthy foods

among children in the public and private school was recorded and tabulated.

Table 4: Distribution of diet pattern among school type

Private Public Total P value

N (%) N (%)

Healthy

food

<=4days 58(50.0) 58(50.0) 116(100) 0.88

>4 days 40(48.8) 42(51.2) 82(100)

Unhealthy

food

<=4

days

79(44.1) 100(55.9) 179(100) 0.00

>4 days 21(100.0) 0(0) 21(100)

According to the Table 4, the frequency of consumption of healthy food such as fruits,

green vegetables, cooked vegetables, milk and yogurt was consumed more among children

from the public school (51.2%) when compared with private schools (48.8%), however the p

value was not statically significant.

Unhealthy food such as sweets, cakes, coca cola, energy drinks was consumed more

among the private schools (100%) when compared with public school (0%). The results were

statistically significant.

The frequency of healthy food consumption less than 4 days was equal among the

public and private school (50.0% vs 50.0%). Whereas the unhealthy food frequency was

more among the public school when compared to private school (55.9% vs 44.1%.). However

the difference was not statistically significant.

32

Fig3 .The association of diet pattern with schools

Some studies have shown that children from private schools, who are generally of

higher socioeconomic status than those from public schools, tended to consume more

unhealthy foods than public school children (Florentino RF et al, 2002).

On the contrary, some studies have shown better eating patterns, such as higher fruit and

vegetable consumption and limited consumption of unhealthy foods, among private

schoolchildren (Filipe Ferreira da Costa and Maria Alice Altenburg de Assis, 2012).

Reason for unhealthy food consumption was more among the private school

children because easy of availability and a unhealthy food such as coca cola, energy drink,

cakes and pastries and sweets and they can afford to eat this. The children belonging to the

lower socio economic status group, receive a healthy vegetarian diet from the public school,

they cannot afford to eat unhealthy or junk foods and also there is less awareness and

availability of junk foods in the sub urban and rural areas. This is more prevalence in urban

area than rural area.

48,8

100

50 44,1

51,2

0

50 55,9

Healthy food >4 days

Unhealthy food >4 days

Healthy food <=4 days

Unhealthy food <=4 days

private public

33

4.2.Prevalence of Dental Caries among children

The prevalence of dental caries was recorded as cavitation and non-cavitation and was

analyzed among the socio-economic status, gender and school.

Table 5: Prevalence of Dental Caries among school type children and gender, social

economic status

Non cavitation Cavitation Total P value

No. % No. %

Socio-

economic

status

Poor 36 41.9 50 58.1 86

0.147 Average 40 55.6 32 44.4 72

Rich 21 56.8 16 43.2 37

Gender Boys 52 46.0 61 54.0 113 0.164

Girls 47 54.0 46 46.0 88

School Private 52 52.0 48 48.0 100 0.286

Public 47 47.0 53 53.0 100

According to Table 5, it was found that the prevalence of dental caries is more among

children in the public school (53.0%) when compared to the private school (48.0%). However

the difference was not statistically significant. Between boys and girls in public and

Private school, the prevalence of dental caries among boys (54.0%) is more when compared

to girls (48.0%). But the difference was not statistically significant. Children from the poor

socio-economic status group were more prone to dental caries (58.1%) followed by children

from the average (44.4) and rich socio-economic group (43.2). However, the difference was

not was statically significant.

Hence it clearly shows that the prevalence of dental caries was more among boys than

girls, more in the public school than the private school and more among the poor socio-

economic status.

34

Fig 4. The prevalence of dental caries among the gender, schools,

Fig 5. The prevalence of dental caries with social economic status.

46

54

52

47

54

48 48

53

Boys Girls Private Public

Non Cavitation Cavitation

41,9

55,6 56,8 58,1

44,4 43,2

Poor Average Rich

Non caviation Cavitaion

35

In a study done by Sudha P et al (2005), they found that the prevalence of caries

was greater in the low socio-economic group when compared to the high socio-economic

group . These findings are in accordance with the observations of Singh et al. (2006).

Chandra and Chawl, on the contrary observed higher caries prevalence in children belonging

to the high socio-economic status. Having filled teeth was highly associated to urban

location, having a literate mother, and having an advantaged socio-economic position while

untreated decay was associated mainly to semi-urban location. These findings may indicate

differences in access to health services and different levels of education on oral health.

Significant variation in total caries was however only observed across socio-economic

groups. Such differences may be related to the financial capacity of buying large amounts of

sweets and snacks among the socio-economic advantaged groups (Nanna J et al, 2009).

The grouping of subjects according to the socio-economic status encompasses

the influence of income, education, and social environment. Determination of social class is

complicated, especially in developing countries like India, where there are no specifically

accepted criteria for the same. In spite of the clear correlation between social status and

caries, in the assessment of caries risk, the reported sensitivities and specificities have been

low (Sudha P et al,2005).

Reason for the high dental caries among the poor lower social economic class

and among the public schools when compared to the high socio-economic group and private

schools because awareness, easy accessibility for dentist and affordability towards the dental

treatment and also having a literate mother, and having an advantaged socio-economic

position while untreated decay was associated mainly to semi-urban location. These findings

may indicate differences in access to health services and different levels of education on oral

health.

36

4.3. Diet pattern and dental caries

Dental caries was recorded as cavitation and non-cavitation and its association

with healthy and unhealthy foods was recorded and tabulated.

Table 6: The association of Dental Caries with Diet pattern

Diet pattern

Cariosity

P value Non cavitation cavitation

Healthy foods

Fruits,

vegetables and

milk

<=4 days 55 (56.1) 61 (61.0) 0.486

>4 days 43 (43.9) 39 (39.0)

Not healthy

foods -

Sweets,

candies and

cola ,energy

drink

<=4 days 90(50.3) 89(49.7) 0.340

>4 days 9(42.9) 12(57.1)

Table 6, shows that children who consumed healthy foods less frequently are more

prone to dental caries (61.0%), when compared to children who consumed healthy foods

more frequently (43.9%). However the difference is not statistically significant.

Children, who consumed unhealthy foods more frequently, show more prevalence of

dental caries (49.7%), when compared to children who consumed healthy foods less

frequently (42.9%). However the difference is not statistically significant.

37

Fig 6. The association of diet pattern with dental caries

In this cross-sectional study we have analyzed the relationship between dental caries and

the consumption of healthy and not healthy dietary pattern. Whereas most of the studies have

investigated the relationship between total sugars intake which is considered as not healthy in

our study and caries development. Gustafsson et al (1954) found a significant relationship

between caries development and intake of sugars for both the primary and permanent

dentition. In a comprehensive study of dental caries increment and diet of over 400 English

adolescents (aged 11–12 years) a small but significant relationship was found between intake

of total sugars and caries increment over 2 years. The results of this study were almost similar

to the present study but the difference was not statistically significant.

Reason for high consumption of unhealthy food was due to easy availability, affordility

in the city than the suburbs easy availability of healthy diet in the rural areas when compared

to the city where there is less awareness and access to unhealthy food and junk foods.

43,9 42,9

56,1

50,3

39

57,1 61

49,7

Healthy >4 days unhealthy>4 days Healthy<=4 days unhealthy food<=4days

Non cavitation cavitation

38

Table 7: Binary Logistic regression

`` crude model 1 Adjusted Model 2

Socio economic status Odd ratio(95%CI) Odds ratio(95%CI)

poor Ref Ref

Average 0.57(0.30-1.08) 4.11(1.20-14.08)

Rich 0.54(0.25-1.19) 1.58(0.63-3.92)

Diet pattern

1Coca cola >4 days Ref Ref

Coca cola<=4 days 0.65(0.25-1.67)

Cakes>4 days Ref

1.34(0.34-5.35) Cakes<=4days 1.54(0.43-5.50)

Sweets>days Ref

0.51(0.26-0.88) Sweets<=4days 0.63(0.34-1.18)

Energy>4 days

2.09(0.93-4.68) Energy<=4days 1.57(0.16-2.86)

Gender

Boys Ref Ref

Girls 0.60(0.41-1.27) 0.40(0.76-2.59)

Schools

Private Ref Ref

Public 1.22(0.70-2.12) 0.62(0.24-1.57)

39

The relative risks (odds ratios) for cariosity adjusted for confounding is estimated for

categories such as socio-economic status, gender, type of school and diet pattern.

The evaluation of socio-economic status revealed insignificant differences among the

subgroups in low, average and rich categories, of school children respectively reported for

dental caries (df=1, P=0.147). However, the poor socio-economic group reported for a higher

prevalence of dental caries when compared to the average and rich group. The odd risk of

dental caries is calculated for the average and rich socio-economic group, keeping the poor

socio-economic group as the reference category. The elevation in risk is two times less

among both average and rich group with values 1:0.65 and later is 1:0.54

The evaluation of unhealthy diet pattern with dental caries of school children respectively

However the coca cola, Sweet, Energy drinks, cakes >4 days as reference reported for dental

caries. The odd risk of dental caries is calculated .The elevation for risk is more .

The evaluation of odd risk for private school has reference group the odd risk ratio for the

public school is 1.22(0.70-2.12).The elevation is 2 times more.

The evaluation of odd risk for gender boys has the reference groups the odd risk ratio for the

girls 0.60(0.41-1.27).odd risk ratio is 2 times lesser.

In general, results of our study shows that school health survey is an excellent means to

screen large number of children with minimum resources. The present study provides

information on diet pattern, social economic status, and dental caries among adolescents. The

study was not conducted on large scale for the entire state and therefore the results are not

generalized to the whole state and country. The information on oral health was collected by

means of interview and being a school based study, a response rate was obtained. Among the

total children (200) completely filled the and returned the

questionnaire. The present study provides the charters tic of diet pattern among gender,

social economic status and schools the association between dental caries among the gender,

schools and social economic status and finally between the association between diet pattern

and dental caries 75% of them respondents.

The present study shows that dental caries was more among poor social economic status

compared to rich social economic status. But not statically significant because sample size is

40

quite small but this study shows the tendency of unhealthy food such cakes, sweets, coca cola

and energy drinks towards the dental caries.

Reason for more dental caries among poor social economic status inspite of having more

healthier diet when compared to rich social economic status may be due to having filled teeth

was highly associated to urban location, having a literate mother, and having an advantaged

socio-economic position while untreated decay was associated mainly to semi-urban location.

These findings may indicate differences in access to health services and different levels of

education on oral health. This study is important in public health point view because to create

awareness, affordability of dental treatment and also to provide the regular periodic dental

checkups among poor social economic status in public schools. This study is a pointer to the

fact that there still exist a large segment of the population who continue to remain ignorant

about the detrimental effects of poor oral health and the multiple benefits enjoyed from good

oral health.

Systematic approach to the control of this disease is needed. Due to scarcity of public

resources for oral health care and keeping in mind the current incidence of dental caries, a

national oral health policy that emphasizes prevention rather than curative care is more

advantageous. The implementation of community-based oral health promotion progra me’s is

a matter of urgency. In relation to children, such programme’s could be initiated through

health promoting school projects. The identification of significant caries risk factors specific

to children living in Chennai city may be quite useful in developing these preventive

programmes.

Limitations of the study. My research had limitation this study was primarily limited by its

small sample size. The sample size could have been more .Ideally the number of participant

would have been more evenly distributed across gender and year in school etc. A larger and

more detailed study with equal sample size in each group could help in getting an insight into

the relationship between diet and dental caries .It is possible that real differences in caries

experience may exist between diet pattern, but even if they do, they are masked by and are of

secondary importance to the social and cultural factors in the environment.

Determination of social class is complicated, especially in developing countries like India,

where there are no specifically accepted criteria for the same. In spite of the clear correlation

between social status and caries, in the assessment of caries risk, the reported sensitivities and

specificities have been low.

41

CONCLUSIONS

1) The diet pattern of Indian school going children aged between 13 to 14 years was not

healthy among the boys and girls. Children under the poor socio-economic category

consumed more healthy diet followed by the rich and average socio-economic group

and consumption of unhealthy diet was more among the rich socio-economic group

followed by average and poor socio-economic group. Children in the public school

consumed healthy food more than children from the private school.

2) The prevalence of dental caries and its relation with various risk factors was estimated

among 13- 14year-old school children of Chennai city. Prevalence dental caries was

more among the boys when compared to girl’s .The children belonging to the low

socio-economic status had higher caries prevalence than those belonging to the high

socio-economic status. Caries prevalence was more among the public school children

when compared to private school.

3) Caries prevalence was lower among healthy diet patterns. A correlation was seen

between unhealthy diet consumption and caries, with the prevalence of dental caries

increasing with increasing exposure to unhealthy food. The unhealthy food

consumption was found to have a highly significant relation with the socio-economic

status.

42

PRACTICAL RECOMMENDATIONS

1 Monitoring. The unhealthy diet pattern such has coca cola , sweets, cakes, pastries,

Energy drinks major problem of dental caries in the developing countries like India among

school going children. Despite of larger emphasis on tooth brushing and awareness in the

schools .The schools should also pay increasing attention towards diet pattern among both

private and public .The monitoring is in routine bade every month is very important.

2 Health education. The lessons of health education should be implemented into teaching

curriculum starting from kindergarten and primary schools and higher secondary schools. It is

important to provide for children the appropriate nutrition knowledge and skills.

3 School. The role of school health service should be increased. They should

concentrate more on oral health promotion programs on nutrition .The school can incorporate

oral health promotion as an integral part of schools curricula.

4 Oral health. Oral health professional can plan, propose and implement school oral health

promotion activities as part of building up oral health promoting school.

5 Family and family health services. Parents need more health education on the matters

related with nutrition, dental problem. Family dentist also should take integrated efforts with

school health services to educate and instruct parent’s on health promotion matters of their

children.

43

LIST OF REFERENCES

1. Arens U. Oral Health, Diet and Other Factors: Report of the British Nutrition

foundation Task Force. 1998

2. Brighton Tasara Mafuvadze, Lovemore Mahachi, Benford Mafuvadze. Dental caries

and oral health practice among 12 year old school children from low socio-economic

status background in Zimbabwe; Pan African Medical Journal 2013; 14: 164.

3. Burt B, Eklund S, Morgan K. The effects of sugars intake and frequency of ingestion

on dental caries increment in a three-year longitudinal study; Journal of Dental

Research; 1988; 67(11):1422-1429.

4. Cappelli DP, Mobley CC. Prevention in Clinical Oral Health Care. Philadelphia, Pa:

Mosby Elsevier; 2007

5. Chen M, Andersen RM, Barmes DE, Leclercq MH, Lyttle SC. Comparing Oral

Health Systems. A Second International Collaborative Study. Geneva: World Health

Organization, 1997

6. Cyril.O.Enwonwo. Review of oral disease in Africa and the influence- of socio-

economic factors. International Dental Journal;1981(31):29-38

7. Donahue GJ, Waddell N, Plough AL, Del Aguila MA, Garland TE. The ABCD’s of

treating the most prevalent childhood disease. American Journal of Public

Health. 2005 August; 95(8): 1322–1324.

8. Dennison BA: Fruit juice consumption by infants and children: a review, Journal of

American College of Nutrition 1996, 15(5):26-29

9. Edward Lo; The DMF index; taken from a published lecture on; Caries Process and

Prevention Strategies: Epidemiology.

10. Gustafsson B, Quensel C, Lanke L. The Vipeholm dental caries study: The effect of

different levels of carbohydrate intake on caries activity in 436 individuals observed

for five years. Acta Odontologica Scandanivaca. 1954;11(3-4):232-264.

44

11. Harris R. Biology of the children of Hopewood House, Bowral, Australia. 4.

Observations on dental caries experience extending over five years (1957-61) ;

Journal of Dental Research; 1963 Nov-Dec;42:1387-1399

12. Joyson Moses, Rangeeth BN, Deepa Gurunathan. Prevalence of dental caries,

socio-economic status and treatment needs among 5to15 year old school

children of Chidambaram; Journal of Clinical and Diagnostic Research 2011,

5(1):146-151

13. Jurgensen N and Petersen PE. Oral health and the impact of sociobehavioural factors

in a cross sectional survey of 12-year old school children in Laos. BMC Oral Health

2009, 9:29.

14. Kelly M, Steele J, Nuttall N, Bradlock G, Morris J, Nunn J. Adult Dental Health

Survey. Oral Health in the United Kingdom 1998. London: The Stationery Office,

2000.

15. Kolker J, Yuan Y, Burt B, et al. Dental caries and dietary patterns in low-income

African American children. Pediatric Dental Journal. 2007;29(6): 457-464.

16. Lonim Prasai Dixit, Ajay Shakya, Manash Shrestha and Ayush Shrestha. Dental

caries prevalence, oral health knowledge and practice among indigenous Chepang

school children of Nepal; BMC Oral Health 2013; 13:20

17. Marshall T, Levy S, Broffitt B, et al. Dental caries and beverage consumption in

young children. Pediatric Dental Journal; 2003;112(3):184- 191.

18. Maria Cristina Rigatto Witt; Pattern of Caries experience in a 12- year-old Brazillian

population related to socio-economic background. Acta Odontologica Scandanivaca.

1992; February; 50 (1): 25-30

19. Manzar AK, Dilabaz K, Zia Ur Rahman K. Dental ailments between low and high

socio-economic status school children; Pakistan Oral and Dental Journal 2011, 31(2):

388-391.

20. Marthaler TM. Epidemiological and clinical dental findings in relation to intake of

carbohydrates; Caries Research; 1967; 1(3): 222-238.

21. M.L. Mattila, P. Rautava, M. Sillanpaa and P. Paunio. Caries in Five-year-old

Children

and associations with Family-related Factors; Journal of Dental Research; 2000;

79 (3): 875-881

45

22. Moynihan PJ, Snow S, Jepson NJA, Butler TJ. Intake of non-starch polysaccharide

(dietary fibre) in edentulous and dentate persons: an observational study. British

Dental Journal 1994; 177: 243–7.

23. Munjal V, Gupta A, Kaur P, Garewal R. Dental caries prevalence and treatment needs

in 12 and 15-year-old school children of Ludhiana city. Indian Journal of Oral

Sciences 2013; 4:27-30.

24. Nanna Jurgensen and Poul Erik Petersen. Oral health and the impact of socio-

behavioural factors in a cross sectional survey of 12-year old school children in Laos;

BMC Oral Health 2009; 9:29.

25. Norman Tinanoff, Carol A Palmer. Dietary determinants of Dental Caries and Dietary

Recommendations for Pre School Children; Journal of Public Health Dentistry; 2000;

60 (3): 197-206

26. Palmer C, Kent R, Loo C, et al. Diet and caries-associated bacteria in severe early

childhood caries. Journal of Dental Research. 2010;89(11):1224- 1229.

27. Paula Moynihan. The interrelation between diet and oral health; Proceedings of the

Nutrition Society 2005; 64; 571–580.

28. Prabu S, Joseph Jonh. Dental caries prevalence among 12 year old school children

from urban and rural areas in Tamil Nadu, India – A comparative study; e-Journal of

Dentistry 2013; 3(1).

29. Pratiti Datta and Pratyay Pratim Datta. Prevalence of dental caries among school

children in Sub-urban India; Epidemiology, an open access journal 2013; 3(4).

30. Rai B, Jain R, Duhan J, Anand S. Relationship Between Dental Caries And Oral

Hygiene Status Of 8 To 12 Year Old School Children. The Internet Journal of

Epidemiology 2006;4(1).

31. Ridhi Narang, Litik Mittal, Kunal Jha, Anamika, Roseka. Caries Experience and Its

Relationship with Parent’s Education, Occupation and Socio Economic Status of the

family among 3-6 Years Old Preschool Children of Sri Ganganagar City, India; Open

Journal of Dentistry and Oral Medicine 2013; 1(1): 1-4.

32. Rugg-Gunn AJ. Diet and dental caries. In: Murray JJ. Prevention of Oral Disease.

Oxford: Oxford University Press, 1996: 3-31

46

33. Schachetele CF. Dental caries: prevention and control. A textbook of preventive

dentistry. 2nd edition. Philadelphia: W. B. Saunders, 1980

34. Steele JG, Sheiham A, Marcenes W, Walls AWG. National Diet and Nutrition

Survey: People Aged 65 Years and Over. Volume 2: Report of the Oral Health

Survey. London: The Stationery Office, 1998.

35. Singh S, Kaur G, Kapila VK. Dental disorders in primary school children of Faridkot

City. Journal of Indian Dental Association 1985;57:305-8

36. Sogi GM, Bhaskar DJ. Dental caries and oral hygiene status of school children in

Davangere related to their socio-economic levels: An epidemiological study; Journal

of Indian Society of Pedodontic and Preventive Dentistry 2002; 20 (4):152-157.

37. Sohn W, Burt B, Sowers M. Carbonated soft drinks and dental caries in the primary

dentition. Journal of Dental Research. 2006; 85(3):262-266.

38. Sudha.P, Bhasin.S, Anegundi R.T. Prevalence of dental caries among 5 to 13 year old

children of Mangalore city; Journal of Indian Society of Pedodontic and Preventive

Dentistry 2005; 22: 2.

39. Thomas S, Tandon S, Nair S. Effect of dental health education on the oral health

status of a rural child population by involving target groups. Journal of Indian Society

of Pedodontic and Preventive Dentistry 2000; September;18(3):115-125.

40. Weiss RL and Trithart AH. Between-meal eating habits and dental caries experience

in preschool children. American Journal of Public Health; 1960;50:1097

41. Whitney Evans, Catherine Hayes, Carole A. Palmer, Odilia I. Bermudez, Steven A.

Cohen, Aviva Must. Dietary Intake and Severe Early Childhood Caries in Low-

Income, Young Children; Journal of the Academy of Nutrition and Dietetics; 2013;

113: 1057-1061.

42. World Health Organization, 1997. Oral Health Surveys, Basic Methods. 4th edition.

47

QUESTIONNARIES

CHILDREN'S ORAL HEALTH AND RELATED QUALITY OF LIFE

INVESTIGATION

FORM TO BE FILLED BY STUDENTS

Dear students,

Thank you for participating in this study. In response to this questionnaire, it will help us learn more about

children's oral health. This will allow dentists and researchers to explore, deeper children's teeth and other oral

diseases organ to disclose their reasons for selecting the best treatment. This will be useful as healthy teeth are

very important for good health and your happiness.

How to fill in the questionnaire?

Carefully read each question. In response to it, the box, which is near or below the most likes you the answer.

For each question tick only one box, otherwise we will not be able to count your answers. If it is difficult to

choose a single answer, so think, at that moment which answer is accurate. In other cases, write a response to

the points marked.

Please reply to the questions yourselves. After filling the form, insert it in an envelope, stick and give it yourself

to the school visiting doctors. We promise that no one at school and parents (guardians) will know your

answers.

Thank you in advance for honesty and sincerity.

The study by the Lithuanian University of Health Sciences

The study coordinator

Shilpa.G.Mirajkar

48

1) Today's date: Day..... Month..................... Year 201…..

Questions about yourself

2) When were you born?

I was born on: Day..... Month..................... Year ….................

3) Who are you: a boy or a girl?

4) Which class do you study in?

In brackets, write the letter and class, for example, 7 (A) class, if any.

I am studying in ........................... (..........) classroom

5) Where do you live?

Questions about General health and happiness

6) How would you describe your health?

49

7) In general, how you feel thinking about your current life?

happy

8) The picture drawn ladder: At the top of the ladder is score 10 – if you are most satisfied with your life,

at the bottom is 0 – if you are least satisfied with your life.

Where on the ladder do you feel you standing now?

Mark the box that best reflects your position.

10 Most satisfied

with life

9

8

7

6

5

4

3

2

1

0 least

satisfied with life

Oral health status and complaints

9) How would you describe your oral health?

Mark one box for each row

50

very good well average poor very bad

a) Dental

b) Lip

c) Gum

d) Stomatitis

e) Jaws and joints

10) During the past three months as part of a mouth organ Thee plagued health disorders?

Mark one box for each row

Just not a

trouble

A little

distressed

somewhat

distressed weary

It is very

tiring

a) Dental

b) Lip

c) Gum

d) Stomatitis

e) Jaw and joints

51

11) In the last three months of the dry felt an organ pain?

Mark one box for each row

never

once or

twice sometimes often

almost

every day

a) Dental

b) Lip

c) Gum

d) Stomatitis

e) Jaw and joints

12) During the past three months has your mouth had such problems?

Mark one box for each row

Never

once or

twice Sometimes often

almost

every day

a) When cleaning your

teeth, do your gums

bleed

b) Sores or wounds on

the lips

c) Mouth sores or

wounds

d) Bad breath from

mouth

e) Does food get caught

between your teeth

f) Are your teeth

sensitive to hot, cold

or sweets

52

13) During the past 3 months due to dental or oral condition, do you ...?

Mark one box for each row

Never

Once or

twice Sometimes Often

Almost

every day

a) Tear and chew solid

food like apple and

meat

b) Take longer time

than others to chew

the food

c) Could not drink or

eat anything hot or

cold

d) Could not drink

through a straw

e) Could not be opened

wide

14) During the past 3 months due to dental or oral condition you ...? Mark one box for each row

If this was not associated with dental or oral condition, note the answer "Never"

Never

Once or

twice Sometimes Often

Alm ost

every day

a) Breathing through

the mouth

b) Could not form

words

c) Blogs slept

d) headaches

e) In general, you feel

ill (nausea, felt

fatigue, etc.).

53

Questions about your feelings and emotions

15) During the past 3 months due to dental or oral condition

You are ...? Mark one box for each row

If this was not associated with dental or oral condition, note the answer "Never"

Never

Once or

twice sometimes often

Almost

everydy

a) Cries, suddenly

excited

b) Lack of courage,

self-confidence

c) You were

embarrassed, felt

ashamed

d) Were you nervous,

irritable, angry

e) you feel lonely

f) Do you feel,others

are thinking badly

about your teeth or

mouth

g) Do you feel,your

teeth or mouth does

not look as nice as

the other

h) Do you feel, your

teeth or mouth are

not as healthy as

other

i) Did you feel

dejected because of

their teeth or mouth

j) Do you feel,you

stand out from the

rest thanks to their

teeth or mouth

appearance

54

Questions about school, friends and leisure time

16) During the past 3 months due to dental or oral condition

You are ...? Mark one box for each row

If this is not related to the teeth or mouth, note the answer "Never

Never

Once or

twice Sometimes Often

Almost

every day

a) Avoiding school

b) Could not

concentrate at school

c) Could not concentrate

with homework

d) Avoid loud talking in

class or read

e) Avoid attending

sports, choir or other

circles, get-togethers

or school trips

f) Avoid talking with

your friends

g) Avoid eating when

other people were

around

h) Avoid smile or laugh

when you are around

other children were

i) In general, avoid

being with other

children

j) It was hard to play

wind musical

instruments (if you

play)

55

17) During the past 3 months due to dental or oral condition ...?

Mark one box for each row

If this is not related to the teeth or mouth, note the answer "Never"

Never

Once or

twice sometimes often

Once or

twice

a) Other kids made fun of

You

b) Other children avoid

you

c) Other children asked

what happened to your

teeth or mouth

How do you take care of their teeth and mouth

Remember the last 3 months

18) How often do you brushing your teeth with a toothbrush and toothpaste?

19) Have you noticed that brushing your teeth with a toothbrush and toothpaste, it is difficult to clean your

teeth? (eg dental remains of food)

20) What kind of toothbrush you use?

1

56

special

21) What kind of toothpaste you use?

22) Do you rinse your mouth with mouthwashes?

1 Never

2 Sometimes

23) Do you use sanitary thread (floss) between the teeth to clean?

1 Never

2 Sometimes

ften

24) Do you use toothpicks to clean between the teeth?

1 Never

2 Sometimes

ften

Treatment / Healing

25) Do you have a filled tooth?

1 Yes

No

57

26) Do you have rotten teeth that need to be treated?

ng was noticed by the doctor

27) Over the last 12 months, you visited the dentist?

28) If "Yes", visited the why? Mark all that apply. If "No", skip this question.

sore tooth

29) How much do you fear dental treatment?

30) Have you ever noticed that your teeth are irregularly placed, or did you notice a bad bite?

e doctor said

58

31) Do you wear / wore dentures?

How long have wearing ............................................. ....

32) Do you wear / wore braces?

t worn

33) If you wear / wore dentures or braces, how much do you think this treatment has helped you (improved

health, appearance or other)?

plate or braces

do not know because recently wearing

Diet and smoking

Remember the last 3 months

34) How often do good or eat these foods?

Mark one box for each line.

Never

Less than

once a week Weekly

2-4 days a week

5-6 days a week

Every day,

once a day

Every day, several

times a day

a) fruit

59

b) green vegetables

c) cooked vegetables

d) Candies, chocolate

e) Cakes, brownies, cookies

f) Coca-Cola and other carbonated soft drinks

g) various energy drinks

h) Milk, yogurt, cottage cheese, cheese and other dairy product

35) Have you ever smoked (at least one cigarette)?

1 Yes

36) How often do you smoke?

60

Questions about your parents and family

37) How often do you talk to parents about your dental and oral health?

Mark one box for each row

Veryeasy Easy It is

difficult

It is very

difficult

Do not

have or

see this

person

a) The father

b) The stepfather (sponsor)

c) with mom

d) The stepmother (Patron)

38) Overall, how easy is it to talk to your parents, about the different things that are important to you and made

you worried about?

Mark one box for each row

Very easy Easy It is

difficult

Very

difficult

Do not

have or

see this

person

a) The father

b) The stepfather

(sponsor)

c) with mom

d) The stepmother

(Patron)

39) Does your family have a computer?

61

40) Does your family have a car?

1 .No

41)How many times in the past 12 months you together with your family, went on trips (vacation)?

1. Never

42) Do you have your own room?

1. yes

2. no

43) How well off do you think your family is?

1

2

3

4

5 not at all well off

44) Does your father have a job?

44). Does your mother have a job?

2 No

62

Questions about your abilities

45) The table shows the wide variety of claims about your abilities. After reading each statement, note how

many agree with him or disagree

Mark one box for each line.

Strongly

agree Agree Disagree

Strongly

disagree

a) I feel that I am inferior to other

b) It seems to me that I have more

good qualities

c) Overall, I think that I am a loser

d) I am able to everything as well

as many other

e) I feel that I have little to be

proud of

f) About myself I feel good

g) Overall, I am a self-satisfied

h) I prefer a more self-respect

i) Sometimes, I feel to be useless

to anyone

j) Sometimes I think that I am

nothing?

63

CHILDREN’S ORAL HEALTH RELATED QUALITY OF LIFE

RECORD FORM FOR

ORAL HEALTH EXAMINATION

SCHOOL ...................................... CLASS.............

ID ..................................................................

1. Today‘s date: ________ / _________ / 201____

DAY MONTH YEAR

2. Date of birth: ________ / _________ / _______

DAY MONTH YEAR

3. Gender

1 Boy

2 Girl

1.1.1.1.1.1 4

.

1.1.1.1.1.2 Ask the child if the following questionnaires

were completed:

1.1.1.1.1.3 1.1.1.1.1.4 A. For child himself 1.1.1.1.1.5 1.1.1.1.1.6 B. For parents (guardians)

1 Yes 1 Yes

2 No 2 No

64

To

p /

Lef

t

Bo

tto

m /

Lef

t

7 –

sea

l

8 –

sea

l +

act

ive

dec

ay

9 –

sea

l +

sta

bil

ized

dec

ay

10

– e

xtr

act

ed t

oo

th d

ecay

on

11

– e

xtr

act

ed t

oo

th fo

r o

rth

od

on

tic

pu

rpo

ses

12

– r

eta

ined

to

oth

13

– s

eala

nts

2

8

38

27

37

26

36

25

35

24

34

23

33

22

32

21

31

11

41

0 –

wh

ole

su

rfa

ce i

s h

ealt

h

1 –

in

tact

su

rfa

ce a

ctiv

e d

ecay

(sm

ear)

2 –

act

ive

dec

ay

, th

e su

rfa

ce e

na

mel

def

ect

3 –

act

ive

dec

ay

, d

eep

en

am

el d

enti

ne

def

ect

4 –

in

tact

su

rfa

ce s

tab

iliz

ed d

eca

y (

smea

r)

5 –

sta

bil

ized

dec

ay

, th

e su

rfa

ce e

na

mel

def

ect

6 –

sta

bil

ized

dec

ay

, d

eep

en

am

el d

enti

ne

def

ect

12

42

13

43

14

44

15

45

16

46

17

47

18

48

M

O

D

B

L

۞

M

O

D

B

L

۞

To

p /

Rig

ht

Bo

tto

m /

Rig

ht

65

A1. Oral Hygienic Index (by Silness & Loe) 4 points assessment

0

No plaque

1 The small amount of plaque at cervical region

2 Plaque is clearly visible at cervical region and interdental space

3 Thick deposits of plaque on the surface of the tooth to the gum and interdental spaces which are clearly visible and run through probe

A2. Assessment of periodontal status (CPITN index)

0 – Healthy

1 – Bleeding on probing

2 – Stones

3 – A pocket of 4-5 mm

4 – 6 mm pockets and deeper

5 – Missing sextant

A3. Dental fluorosis classification (by Thylstrup & Fejerskov)

The upper jaw The lower

jaw

Central incisors

Lateral incisors

Canines

First premolars

Second premolars

First molars

Second molars

A4. Discoloration or damaged tooth

Discoloration

Hipoplasia

Tetracycline

Erosion

Attrition

66

B. Tooth position and occlusal evaluation

1.1.1.1.1.7 B

1

.

1.1.1.1.1.8 Lateral teeth ratio (Angle class):

Ratio of the first molars:

1.1.1.1.1.9 1.1.1.1.1.10 Right 1.1.1.1.1.11 1.1.1.1.1.12 Left

1 Angle I 1 Angle I

2 Angle II 2 Angle II

3 Angle III 3 Angle III

1.1.1.1.1.13 B

2

.

Ratio of the canines

1 Angle I 1 Angle I

2 Angle II 2 Angle II

3 Angle III 3 Angle III

B3. No teeth (solving of adentae, ectopic and retained teeth)

Mark observed disturbances

Classification Criteria

0 No changes

1 Retained tooth

(excluding third

molars)

5.i Did not spring up teeth due to crowding,

dislocation, overcomplement tooth, ankylosing

deciduous teeth, and other pathological reasons

2 Mild hipodontia 4.h Missing one tooth in any quadrant and required

orthodontic treatment prior to restorations or

gaps closing to avoid the prosthesis

3 Severe hipodontia 5.h Missing more than one tooth in any quadrant

and required orthodontic treatment prior to

restorations

4 Partially appearance

of teeth 4.t Partially appearance of teeth, leaning and

blocked the adjacent tooth

5 Overcomplement

tooth

4.x Extra teeth

67

B3. No teeth (solving of adentae, ectopic and retained teeth)

Mark observed disturbances

6 Milk tooth

ankylosis

5.s

B4. Horizontal mouth overlay (HMO): ........................... mm

Classification Criteria

1 A small positive,

competent lips

2.a 3.5 mm <HMO ≤ 6 mm, lip competent

2 A small positive

incompetent lips 3.a 3.5 mm <HMO ≤ 6 mm, lip incompetence

3 Medium positive 4.a 6 mm <HMO ≤ 9 mm

4 Bright positive 5.a HMO > 9 mm

5 Slightly negative 2.b -1 mm ≤ HMO < 0 mm

6 Average negative free

speech and chewing

problems

3.b -3.5 mm ≤ HMO < -1 mm, no speech and

chewing problems

7 Bright negative free

speech and chewing

problems

4.b HMO < -3.5 mm, no speech and chewing

problems

8 On average, the

negative, with a speech

and chewing problems

4.m -3.5 mm ≤ HMO < -1 mm, is a speech and

chewing problems

9 Bright negative, with

speech and chewing

problems

5.m HMO < -3.5 mm, is a speech and chewing

problems

B5. Lips

0 Competent

1 Incompetent

B6. Chewing disorders

0 No

68

B6. Chewing disorders

1 Yes

B7. Speech disorders

0 No

1 Yes

B8. Cross-bite (CB)

0 No

1 Yes

B9. CB: .......................................... mm

Measured distance (CB) between the retruded contact urface and the

intermound surface.

B10. CB location B11. CB functional disorders

1 Front

0 No

2 Right side

1 Yes

3 Left side

4 Single tooth

69

B12. Classification Criteria

0 No changes

1 A small front or side 2.c CB ≤ 1 mm

2 Average front or side 3.c 1 mm < CB ≤ 2 mm

3 Bright front or side 4.c CB > 2 mm

4 Lateral lingual 4.l One-sided or double-sided lateral lingual CB

without functional occlusal contacts

B13. Displacement of the contact points (DCP): ........................... mm

(crowding). Measured distance between the two most crowded permanent teeth

Classification Criteria

0 No changes

1 Small 1.- DCP ≤ 1 mm

2 Noticeable 2.d 1 mm < DCP ≤ 2 mm

3 Quite a bit 3.d 2 mm < DCP ≤ 4 mm

4 Bright 4.d DCP > 4 mm (pronounced shift in the

point of contact)

70

B14. Vertical moth overlay (VMO): ............................. mm

Classification Criteria

0 No changes

1 Increased OB, deep

bite

2.f VMO ≥ 3.5 mm no contact with the gums

2 Increased OB, deep

bite 3.f Deep bite, reaching the gums or palate, no

injuries

3 Increased OB, deep

bite 4.f Deep bite, reaching the gums or palate with

trauma

4 Front or side open

bite

2.e 1 mm < VMO ≤ 2 mm

5 Front or side open

bite

3.e 2 mm < VMO ≤ 4 mm

6 Front or side open

bite

4.e VKP > 4 mm

B15. Lip or cleft palate and other anomalies

1 No

2 Yes (5.p)

B16. Pre-normal or post-normal occlusion without other abnormalities

1 No

2 Yes (2.g)

B17. Photo

1 Was made

2 Was not made

B18. Aesthetic component (1.....10)

71

B18. Aesthetic component (1.....10)

.....................................................................

Dental component of the ICON index

3 A. Open incisors bite B. Incisors overlay

0 Edge to edge

0 <1/3

1 < 1 mm 1 From 1/3 to 2/3

2 From 1.1 to 2 mm

2 From 2/3 to the full

3 From 2.1 to 4 mm

3 Full

4 > 4 mm

4 The upper and lower posterior teeth ratio from front to back (in arrow direction):

Right Left

0

The upper lateral teeth in contact with the protuberance of

lower teeth:

Angle I, II, III

0

1 Any tuberosity ratio but not in thalamus to the thalamus 1

2 Thalamus to the thalamus 2

1 A. Crowding B. Spaces between the teeth

0 < 2 mm 0 < 2 mm

1 From 2.1 to 5 mm

1 From 2.1 to 5 mm

2 From 5.1 to 9 mm

2 From 5.1 to 9 mm

3 From 9.1 to 13 mm 3 > 9 mm

4 From 13.1 to 17 mm

5 > 17 mm

5 Retained teeth

72

PHOTOGRAPH.

Material used for data collection.

Dental examination carried out in public school

73

Dental examination carried out in private school