| Abstract|| |
Background: Provision of oral health care in India, especially for the underprivileged is limited due to inadequate finances and manpower. Resources of dental colleges in such a scenario can be utilized to provide prevention oriented oral health care.
Aim: To improve the oral health status of children at an institute in Nellore district of Andhra Pradesh, India, through prevention based comprehensive dental health care program (CDHP).
Design and Setting: A longitudinal institution based interventional study conducted among the primary grade children (n=162).
Materials and Methods: Baseline data collection included (i) basic demographic data (ii) body mass index (BMI) (iii) assessment of the dentition status and treatment needs according to WHO 1997 criteria. The CDHP included group based dental health education, professional oral prophylaxis, weekly (0.2%) sodium fluoride mouth rinse program, biannual application of topical fluoride (1.23% APF), pit and fissure sealants for all first permanent molars and provision of all necessary curative services.
Results: Mean treatment requirements per child decreased at 18 months. New caries lesions developed among four children. BMI of children with decay was seen to improve significantly after instituting the CDHP.
Conclusion: CDHP is effective in overall improvement of general and oral health. In resource limited countries like India, such programs organized by dental schools can improve oral health.
Keywords: Caries increment, comprehensive dental health care program, orphanage, primary grade children
|How to cite this article:|
Muralidharan D, Fareed N, Shanthi M. Comprehensive dental health care program at an orphanage in Nellore district of Andhra Pradesh. Indian J Dent Res 2012;23:171-5
The maximum burden of all diseases rests with the disadvantaged and socially marginalized.  Children from disadvantaged backgrounds have shown a high prevalence of dental caries and their utilization of dental care is low.  Provision of oral health care in developing countries like India, is limited due to lack of adequate dental manpower, financial resources, and lack of perceived need for dental care among the people.  Utilization of dental services is mainly for the relief of pain where the mother plays the primary motivating factor.  Preventive services are seldom received by these children.
|How to cite this URL:|
Muralidharan D, Fareed N, Shanthi M. Comprehensive dental health care program at an orphanage in Nellore district of Andhra Pradesh. Indian J Dent Res [serial online] 2012 [cited 2019 Feb 21];23:171-5. Available from: http://www.ijdr.in/text.asp?2012/23/2/171/100421
Children from orphanages have shown a high prevalence of dental caries,  gingivitis, and dental trauma.  This has been attributed to overcrowding, lack of adequate staff, poor oral hygiene, and improper dietary habits. Hence, implementation of prevention oriented comprehensive dental health care programs (CDHP) could help in reducing the burden of oral diseases. The success of such programs depends to a great extent on its periodic evaluation, so that timely interventions and modifications can be made.
CDHP among institutionalized children are few in number among the Indian population. This study was thus undertaken with an aim to improve the oral health status of children of an institute in Nellore district of Andhra Pradesh by implementation of prevention oriented comprehensive dental health care program (CDHP). The program was assessed in terms of changes in caries experience, BMI and caries increment.
| Materials and Methods|| |
A longitudinal interventional study was designed and undertaken at Bharath Vidya Vikas School to evaluate a CDHP targeting the primary grade children. As per the traditional Indian education system, primary grades include lower kindergarten (LKG) to fifth grades. The school comprises of children from an orphanage in Nellore district of Andhra Pradesh in South India. The present study is a part of an ongoing CDHP for the children of the orphanage by the Department of Public Health Dentistry, Narayana Dental College and Hospital, Nellore.
Ethical clearance was taken from the Institutional Ethics Committee and voluntary informed consent was obtained from the Director of the Orphanage. Permission to conduct the study was obtained from Department of Health and Family Welfare.
This is an ongoing program initiated from July 2008 and evaluation being performed after 18 months. Prior to implementation of the CDHP, baseline data on the oral health status was collected from primary grades to tenth grade. Baseline data collection includes (i) basic demographic data (ii) body mass index (BMI=weight in kilograms/height in meter 2 ) (iii) assessment of the dentition status and treatment needs according to WHO 1997 criteria.  Two investigators were trained and calibrated in recording baseline data in the Department of Public Health Dentistry. The related kappa value showed fair to good agreement between the investigators (kappa = 0.71). The data was analyzed and subsequently a CDHP was instituted for the children of the primary grades.
The CDHP included
All necessary treatments (preventive and curative) were performed in the school premises by Post Graduate students of the Department of Public Health Dentistry utilizing the services of the college mobile dental unit.
- An assessment of oral health knowledge and awareness using a specially designed pretested 15 item questionnaire.
- Group based health education to all children. The children were divided into two groups based on their level of comprehension - one group comprising of lower and upper kindergarten (UKG) and grade I and a second group comprising of grades II, III, IV, and V. A total of eight sessions for each group were conducted over a period of 18 months. These sessions also included reinforcement.
- Professional oral prophylaxis for all the children.
- Weekly mouth rinsing program using 0.2% sodium fluoride.
- Biannual application of topical fluoride solutions (1.23% APF).
- Pit and fissure sealants placement for all first permanent molar teeth.
- Provision of all necessary curative services which included restorations, pulp therapy and extractions.
Evaluation was performed at 18 months after initiating the CDHP. Dental caries experience was calculated as decayed, missing and filled teeth (DMFT) for the permanent teeth and as decayed and filled (dft) for the primary teeth. Missing component was not taken into consideration for the primary teeth in order to avoid inclusion of teeth lost due to exfoliation. BMI of children with decay and without decay at baseline was compared with that of 18 months post CDHP initiation. Caries increment was taken as the number of children developing new caries lesions at 18 months.
Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) 12 software. Comparison of means of DMFT/dft, individual components of the DMFT/dft indices and the BMI at baseline and at 18 months was done using paired sample t-test. Comparing the BMI of children with decay and without decay at baseline and at 18 months was done using independent sample t-test. A P-value of less than 0.05 was considered to be significant.
| Results|| |
There were a total of 221 children in the orphanage with a boy to girl ratio of 1.6:1. The initial questionnaire revealed poor oral health knowledge and awareness in majority of the children. Sixty seven percent of children were not aware of the causes of dental decay and periodontal disease. The number of children having dental caries at baseline was 129 (58.37%) with a mean DMFT of 0.89 ± 1.43 and mean dft of 2.86 ± 2.77. There was no significant difference in the distribution of dental caries among boys and girls. The mean BMI of the children at baseline was 14.97 ± 2.47 kg/m 2 .
There were 119 primary grade children (5-10 years) with a mean age of 7.93 ± 1.982 years. [Figure 1] shows the grade wise distribution of primary grade children. Of the total number of children with dental caries at baseline, 108 (66.6%) children belonged to the primary grades and had a mean DMFT of 1.02 ± 1.52 and dft of 2.21 ± 2.82. Thus, the CDHP was instituted for the children of the primary grades (n=162). Majority of the children required preventive care at baseline followed by the need for restorations and fissure sealants [Table 1].
|Table 1: Number and percentage of children requiring treatment at baseline|
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At 18 months, 34 children were lost to follow-up accounting to an attrition of 29%. A significant decrease in the mean number of decayed teeth (DT/dt) and an increase in the filled (FT/ft) components of the DMFT/dft index per child was noted (P=0.00) [Table 2] when compared to the baseline. An improvement in the mean BMI was also noted at eighteen months (P=0.00) [Table 3]. The mean treatment requirements per child decreased [Table 4] and sealant retention at 18 months was 100%. The mean baseline BMI of children with decay was seen to be less than the BMI of children without decay and this showed significant improvement (P=0.00) at evaluation after 18 months [Table 5]. Four children developed new caries lesions after 18 months.
|Table 2: Mean number of decayed, missing and filled teeth in the primary and permanent dentition at baseline and at second evaluation|
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|Table 3: Change in the various parameters recorded at baseline and second evaluation|
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|Table 4: Changes in the mean number of treatment requirements for each child from baseline to second evaluation|
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| Discussion|| |
The mean caries experience of the children at baseline was comparable to the caries experience (DMFT=1.8, dft=2.0) of 5-12 year old children reported in the Indian population.  The mean caries experience in the permanent dentition (DMFT=1.02) of the primary grade children was similar to reported findings of children of the state Andhra Pradesh (DMFT=1.7); however, the caries experience (dft) in the primary dentition (dft=2.21) was higher than the state average of 1.5.  Past caries experience has been shown to be the strongest predictor of future dental caries.  In our study, at base line, 91% of the children had dental caries indicating a population at risk for further developing dental caries.
The mean caries experience in this study was similar to that among the orphans in Pune, India.  However, the caries experience was less than a study conducted among children at a social welfare institute in Saudi Arabia.  In a study on orphans in Romania,  majority of the children (97%) under the age of six years and 86% of the children over six years were caries free with a mean DMFT/dmft of zero, though there was high prevalence of gingivitis and dental calculus. The treatment needs and the oral health knowledge and awareness tests conducted at baseline revealed very poor oral health awareness. In addition, only 2.26% of children had undergone treatments at baseline indicating poor utilization of the services of dentists. The poor oral health knowledge and awareness seen in our study was in contrast to a study on institutionalized children in Dare Es Salem, where 88% of the children knew the causes for tooth decay and bleeding gums though they had poor knowledge on prevention of these diseases. 
The diet of children in orphanages in India tends to be non-cariogenic where the food provided covers the three basic meals in a day. Studies from India have shown that in orphanages majority of the children are malnourished.  Early childhood malnutrition has shown to be associated with caries in primary dentition, , though its association with permanent dentition has not been substantiated. Enamel hypoplasia/hypomineralization and salivary hypofunction has been suggested as the possible biological mechanisms for the dental caries. Malnutrition has been associated with delayed exfoliation of the primary teeth, , which could be the reason for the presence of higher prevalence of caries in the primary teeth. The children in our study had mean BMI of 14.31 ± 1.93 which is well below the Food and Agricultural Organization (FAO) criteria for being "underweight" in the low income and affluent countries.  The overall mean BMI reflected the nutritional status of the children. Malnutrition along with poor oral health awareness and practices could be the reason for high dental caries in primary class children. The mean BMI of children with dental caries was seen to be less than those without caries at baseline and it significantly improved over a period of 18 months. Even though BMI increases with age, the difference at baseline between the two groups indicated a poorer nutritional status of children with dental caries. This supports the findings of studies by Alvarez J (1995) where mild to moderate malnutrition during the first year of life is associated with increased dental caries later.  No modifications were made to the meals provided to the children at the orphanage; hence, the improvement in BMI seen among children with dental caries suggests a catch up of growth following the institution of the CDHP.
At baseline, the need for preventive care exceeded all other treatment requirements. Therefore, for these children, combination of preventive and curative treatments was employed. At 18 months, only 2.46% of the primary grade children developed new caries lesion. Similar reduction in dental caries has been observed in other studies employing CDHP. , However, the New England Children's amalgam trial showed increase in the new caries lesion after five years despite semi-annual comprehensive dental care.  The reduction in the number of children with new caries lesions in the present study can be attributed to a combination of improved oral hygiene, weekly mouth rinsing, topical fluoride applications, placement of pit and fissure sealants, and the regular dental examinations. The weekly visits by the post graduate students could have acted as reminders and reinforced the children's oral hygiene habits. Periodic tests conducted showed improved oral health knowledge and awareness. Being an ongoing dental health care program for orphanage children, the weekly visits ensured regular follow-up of all the children. The CDHP resulted in improvement of oral and general health of the children. Assessment of long term effects of dental health care programs have shown that exposure to a regimen of regular dental treatment and health education resulted in positive dental habits that lasted even after completion of the program. , Regular follow-up is important to assess the long term effects of the comprehensive programs. Studies with long term follow-up have shown that preventive programs have to be comprehensive and continuous in order to have maximum benefit. ,
The lack of control group can be considered as a limitation of this study. However, since the study group comprised of disadvantaged children, it was not considered ethical to further create a group who would not receive oral health care. Our results cannot be generalized to the whole population of Indian children since the study group comprises of a high risk group of disadvantaged children of an institute who received a service oriented CDHP. Since a combination of preventive measures was used which of these measures produced the maximum reduction in dental caries could not be determined. Detailed studies assessing the outcome in terms of number of carious surfaces involved rather than the number of children developing new caries lesions will provide better insight to the outcome of such programs. Cost effectiveness and practical applicability of such programs on a large scale need to be studied further.
India has a population of 1.15 billion people  and 93,332 registered practicing dentists  serve this population. Dentist population ratio of India is 1:12,437.46.  In such a scenario, reach of dental care to common man is questionable, let alone children from such disadvantaged backgrounds. There are 252 dental colleges  in India. Resources of these dental colleges can be utilized for providing prevention oriented dental care for underprivileged children.
To conclude, the results of this study show that the CDHP is effective in reducing the number of children developing new caries lesions. The low BMI in children with caries at baseline showed improvement reflecting the effect of the program on general health. For maximum benefits, continuous and periodic evaluation of such programs is essential. In resource limited countries like India, innovative programs organized by dental schools can contribute in improving the oral health of underprivileged children.
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Department of Public Health Dentistry, Narayana Dental College and Hospital, Chinthareddypalem, Nellore, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]