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Caries Prevention in Children - The Indian Challenge

In the modern society, the human life expectancy is showing an upward trend ,thanks to the improved health care, nutrition , sanitation, and relief from communicable diseases. In 1982, Keki Mistry1 reported that the relative improvement in general health was in glaring contrast to the deteriorating situation in oral and dental health in developing countries.

The cause of deterioration in dental health seems readily apparent. Increasing industrialisation is invariably linked to rising levels of sugar consumption and inevitable breakdown of the dentition. This process merely mirrors similar changes in developed countries during the industrial revolution two hundred years ago.

The scenario in India, a subcontinent in the continent of Asia, is changing. India accounts for only 2.4% of the world area i.e., 3.28 million sq. km and has 15% of the world population. There is an effective control in child mortality and life expectancy has increased from 32 years in the fifties to 54 years in the nineties. The literary level has increased. At the economic level, the per capita income is on the rise. To-day, our country is progressing in all fields, leading to changes in the individual’s life- style.

Improved marketing strategies and increased transport facilities have brought food materials like bread and chocolates to even the remotest villages. Children who consume these sticky food stuffs are not trained to clean the teeth properly afterwards. Moreover, such items are freely consumed as in between snacks.

In 1979, the World Health Assembly adopted a resolution calling for attainment of "Health for all" by the year 2000. In line with this, the FDI recommended the establishment of specific oral health schedule on the time scale. Of the WHO goals for global oral health, the first goal is that 50% of 5-6 years old children should be caries free and the second goal is that the global average should not be more than 3 decayed, missing, or filled teeth at 12 years of age.

By early 1980 s many industrialised countries had achieved the second goal. By contrast, the developing countries showed increasing DMF values at this time.

Epidemiological studies conducted in the community of Jonkoping, Sweden, by Anders Hugoson and others2 in 1973 and 1983 revealed an increase in the number of teeth in different age groups. In the 20 year olds, the mean number of DS was 6.5 in 1973 and 4.5 in 1983. An analysis of the carious lesions showed that 86% of the lesions were restricted to the enamel. According to recent data for 5-6 year old group, the percentage of caries free children in Sweden is 72. 3

[The recent data for 5-6 year old children indicate a mean dmft value of 2.0 in the USA, and the percentage of caries free children is 50 3..]

On the other hand, dental caries is highly prevalent in India, which is influenced by the lack of dental awareness among the public at large. Epidemiological survey conducted by Ramachandran and others4 during 1966-68 in Tamil Nadu, a south Indian state, revealed a caries prevalence of 66.2% in urban population and 47.8% in rural population.

We conducted a survey on a section of Belgaum population 5 to evaluate the trends in caries in different age groups and the influencing factors for its causation and prevention. This study revealed a DMF/ dft score of 4.61 in the 6-11 years of age group, with a DMFS score of 9.21. In this age group, 88% of the children suffered from dental caries.

So when I say caries prevention in children, the image that conjures up in your minds is entirely different from the picture in my mind.

The 20th century has given tremendous knowledge in the understanding of oral diseases and possibilities for preventing and treating these diseases. This knowledge cannot be put into action in a developing country like India due to financial constraints and lack of man power.

In a country where 70% of population inhabit the villages the dentist population ratio is 1: 35,000, and only one out of five dentists return back to the rural area to serve, prevention of caries will be a much more viable option than rendering restorative treatment Let me just outline the problems we have to face while streamlining a caries prevention programme in India.

1. First of all, in villages where 70% of the population live, there is no communal water supply. So fluoridation of water supply, the most cost effective and a very efficient method of caries prevention will remain an elusive dream for majority of people.

2. Even in urban areas there is no attempt at fluoridating the water supply. There are areas where local water contains high level of fluoride. So unless a fluoride mapping of the entire country is completed, national fluoridation programme cannot be implemented. This involves two hurdles. One is the cost factor. Then there is a strong anti-fluoride lobby in India which widely publicizes that fluoride is a dangerous element which can cause fluorosis of teeth, bones etc., They oppose even topical fluoride applications and usage of fluoride tooth pastes with the contention that even from the tooth paste, the soft tissues absorb fluoride, which will have cumulative effect over a period of time, leading to fluorosis of bones.

3. Indians by nature are highly tolerant. Even when teeth are affected by caries, a good number of them wait till the last stage when the excruciating pain forces them to the dentist. In such a scenario, to make them visit a dentist for measures at prevention demands high motivation. Widespread and intense measures at public awareness are needed to bring dental health to a priority level . Routinely, dental health occupies a very low priority as compared to the general health. Many of them do not hesitate to come and demand extraction of an offending tooth.

4. The cost involved in assessing the high caries risk group by S-mutans test and other methods in Indian situations is so high that it cannot become a routine procedure in the near future.

So you can see, in the existing situation in India, it calls for real dedicated and strenuous effort to implement caries prevention programmes.

Western Methods for caries prevention as such will not be successful here and they need to be modified to suit the local needs and habits.

New methods of identifying caries risk groups should be formulated

One fourth of the country’s population is below the age of 14 years. To persuade the children to modify or start any new habit, it is very important to gain their parent’s co-operation. So any nationwide policy should have a two pronged approach.

1. Community based programmes.

2. School based programmes.

One basic myth that has to be eradicated from the minds of majority of Indians is that the milk teeth are not important because they will be replaced by another set of teeth later. Since the first molars erupt when deciduous teeth are still present, very often they suffer the consequences of neglect.

A recent survey of North London boroughs by Rambohul and Karmi has revealed an increased prevalence of dental caries on pre-school South Asian children . They reported that the disparity in dental health between Asians and others seems to disappear after the second dentition is established.

Controlled studies have to be planned to monitor the blood level rise of fluoride after topical application. It has to be conclusively proven that topical fluoride application will not lead to cumulative fluoride accumulation in blood, resulting in fluorosis of bones, as claimed by the antifluoride lobby.

Coming to the school based activities, regular oral health programmes should be conducted in schools, to reach large number of children. At the beginning teachers need to be trained intensely for proper implementation. These programs should be based on fluoride rinsing, topical fluoride applications, supervised tooth brushing, professional tooth cleaning, occlusal sealants, health education and dietary advice. There is acute need for simple, robust, easy to service and inexpensive equipment for use in rural surroundings.

The development of glass ionomer sealants will make sealant application more practical due to the cost factor and their low technique sensitivity as compared to the resin sealants.

Application of antimicrobial varnish should be a viable option if it can be made cost effective. Fluoridated varnishes (Durafluor/ Duraphat or Fluor Protector) have been proven to be effective in preventing carious lesions on smooth surfaces7,8. The application sequence suggested by Dr. Lars Petersson 9 where the varnish is applied to clean, isolated and dried quadrants three times weekly, once a year will be very suitable for the Indian situation.

Oral hygiene methods

The knowledge of the importance of oral hygiene is not recent for Indians. The dental fiber pencil was used by the Indians long before as described by the great physician and surgeon Susruta, who lived in the 6th century B.C10. The Hindu vedas contain descriptions of oral hygiene procedures, which are advised to be performed twice a day. Hindus used various Ayurvedic preparations made specifically for dental application10,11. They cleaned their teeth with the twigs of various aromatic shrubs frayed at the end. These twigs are called Datuns.

In 1984, we conducted a study on oral health status of young adults using indigenous oral hygiene methods(CLICK HERE TO SEE STUDY). Indigenous materials used for maintenance of oral hygiene can be classified into three main groups.

1. Plants and parts.
A. Leaves
Mango (Mangifera indica)
Cashew (Anacardium occidentale)
Coconut (Cocos nucifera)

B. Twigs and Stems
Babul (Acasia arabica), See clinical trial at the end of page
Neem (Azadiarchita indica)
Banyan (Ficus bengalens)

C. Fruits and its parts
Coconut

D. Barks Walnut (Juglans regia)

2. Charcoal from burnt...
A. Rice husk
B. Walnut shell
C. Almond shell
D. Coconut shell and its sheath
E. Wood
F. Coal (ash)
G. Dried cowdung cake

3. Powders etc.,
A. Sand
B. Common salt (powder and crystalline)
C. Brick and tile powder
D. Tobacco
E. Arecanut
F. Different types of indigenous tooth powders

In the southern Karnataka state of India, the mango leaf is widely used13. A fresh mango leaf is washed and the midrib is removed. The leaf is then folded lengthwise with glossy surfaces facing each other. It is rolled into a cylindrical pack. One end of this pack is bitten off 2-3mm to create a raw surface which is rubbed on the teeth. The pack is held between the thumb and the index finger. At the end, the midrib, which was first removed, is used as a tongue cleaner.

We evaluated the efficacy of mango leaf as an oral hygiene aid and got some interesting findings. Despite having higher soft deposit scores in the group that used mango leaf, the caries experience in this group was similar to the group that used tooth brush. Mangiferin, a compound present in mango leaves has been reported to have significant antibacterial property against certain strains of Pneumococci, Streptococci, Staphylococci, and Lactobacillus acidophilus.

Recently, Saimbi and co-workers14, tested the antiplaque efficacy of Neem extract , Ayurvedic tooth powders and commercial tooth pastes. The Neem extract came out on top and commercial tooth pastes were the last.

 
 
Substances tried Antiplaque efficacy %
1% Neem extract 71.4 
0.5% Neem extract 69.61
5% Neem extract 54.9
Ayurvedic tooth powder A 43.0
Ayurvedic tooth powder B 37.5
Commercial tooth paste 29.8

Tooth brush is not commonly used by the rural folk. As compared to food, they find the cost of tooth brush and paste to be expensive. A tooth brush costs Rs. 11/-, 200 gm tooth paste costs Rs.30/- and a loaf of bread costs Rs.5/-.

The oral health of the community can be improved by understanding the cultural attitudes, changing the beliefs of the people and modifying their habits.

Intensive research need to be done on how to modify their traditional oral hygiene methods as to make them more effective. Research on mango leaf and neem extract will definitely yield positive results. Notwithstanding the advice given in the ancient books for cleaning the teeth twice a day, it is difficult to understand why Indians have restricted their oral hygiene practices once a day in the morning. The habit of night brushing has to be reinstated.

Manufacturers should be encouraged to develop clinically proven and affordable tooth paste formulations for use15. Role of diet.

Traditional Indian food is very much balanced with lots of fibrous components. Industrialisation has brought in increased sugar consumption and availability of refined carbohydrate foodstuffs. The consumption of western type food including "junk food" is rapidly increasing. In the vicinity of schools, vendors await school children who consume sugar candies and chocolates bought with their pocket money.

We, Indians are habituated to drinking lot of water. Consumption of sweetened, aerated beverages is replacing the water intake in the younger generations. What implications this would have in future has to be observed.

Education of school children with audiovisual aids on the extreme harmful effects of these in between snacks is highly necessary. Components in traditional diets that may favor oral health have to be identified and propagated.

Conclusion

India is a vast country with limited resources and man power .

Western Methods for caries prevention as such will not be successful here and they need to be modified to suit the local needs and habits.

New methods of identifying caries risk groups should be formulated.

Caries preventive programmes should have a two pronged approach- Community based and school based.

Short-term clinical effects of commercially available gel containing Acacia arabica: a randomized controlled clinical trial
Australian Dental Journal, Volume 55 Issue 1, Pages 65 - 69

Background: Certain plants used in folk medicine serve as a source of therapeutic agent by having antimicrobial and other multi-potential effects. This prospective, randomized, placebo and positively controlled clinical trial was designed to evaluate the short-term clinical effects of a commercially available gel containing Acacia arabica in the reduction of plaque and gingival inflammation in subjects with gingivitis.
Methods: Ninety subjects diagnosed with chronic generalized gingivitis were selected and randomly divided into three groups: Group I placebo gel, Group II gumtone gel and Group III 1% chlorhexidine gel. Clinical evaluation was undertaken using the gingival index of Loe and Silness and the plaque index at baseline, 2 weeks, 4 weeks and 6 weeks. A subjective evaluation was undertaken by questionnaire.
Results: Gumtone gel showed significant clinical improvement in gingival and plaque index scores as compared to a placebo gel. This improvement was comparable to 1% chlorhexidine gel. Unlike chlorhexidine gel, gumtone gel was not associated with any discolouration of teeth or unpleasant taste.
Conclusions: Gumtone gel may be a useful herbal formulation for chemical plaque control agent and improvement in plaque and gingival status.

References

1. Keki Mistry: Establishment of community dental health units in developing countries. JIDA 1982 54(10):361-366.

2. Anders Hugoson et al: Caries prevalence and distribution in individuals aged 20-80 years in Jon Koping, Sweden 1973 & 1983. Swed Dent J 1988 12:133-140

3. Murray J J: Comments on results reported at the Second International Conference "Changes in Caries Prevalence". Int Dent J 1994 44: 457-458.

4. Ramachandran et al: Epidemiological studies of dental disorders in Tamil Nadu population. Prevalence of dental caries and periodontal disease. JIDA 1973 45(4):65-70.

5. Asha John: Trends in caries in different age groups in Belgaum population - Master thesis for MDS, 1994.

6. Bratthal Douglas: Caries, Views and Perspectives. Scand J Dent Res 1992 100:47-51.

7. Clark D, Stamm J, Robert G, Tessier C: Results of a 32 month fluoride varnish study in Sherbrook & Lac-Megantic, Canada. JADA 1985 111:949-953.

8. Von Lieser O, Scmidt H: Caries preventive affect of fluoride lacquer after several years’ use in children. Deutch Zahnarztl Z 1978 33:176-178.

9. Petersson L et al: Caries inhibiting effect of different modes of Duraphat varnish reapplication- a three year radiographic study. Caries Res 1991 25:70-73.

10. Emslie R D: The value of oral hygiene. BDJ 1964 117:373.

11. Meenakshy Shetty, Bhat J V: Indigenous dentifrices and oral hygiene. JADA 1949 21:1.

12. Sumant Goel, Beena R Goel, Bhongade M L: Oral Health status of young adults using indigenous oral hygiene methods. Stomatologica India 1992 5(1):17-23.

13. Nagaraja Rao et al: Oral health status of 500 school children of Udupi. JIDA 1980 52: 367-370

14. Saimbi C S et al: The efficacy of neem extract -reported in Jeevaniya Health Care magazine.

15. Blinkhorn A S and Davies R M: Caries Prevention A continued need worldwide. Int Dent J 1996 46: 119-125.

16. Rambohul V, Karmi G: Dental health and ethnic minority children. London: NE/NW Thames Regional Health Authorities, 1992. Sited from:-

17. Karmi G: Migration and health. Int Dent J 1996 46(Supplement 1), 181-187.

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