3 4

School type

Australian Dental Journal, February, I97 I

Socio- economic

level

The dental health and habits of South Australian

1 Percentage

23

children from different socio-economic environments

2 3 Percentage Percentage

50 28

D. M. Roder, B.D.S., M.P.H., F.A.C.D.S.*

Introduction

In 1969, children from nine primary and six secondary schools in Adelaide were examined under the auspices of the South Australian School Dental Service. The main purpose was to establish a baseline apprecia- tion of dental health to allow subsequent evaluation of the effects of fluoridation.

Parents completed questionnaires pertaining to their children’s dental habits. I t seems probable that bias might be contained in the answers, thereby prompting a n under-estima- tion of the extent of poor dental behaviour. Accordingly, results are not used to define the nature of dental habits: findings are con- sidered a guide to the comparative behaviour of different groups of children.

Results are used in this paper to study the dental health and habits of children from areas of contrasting socio-economic level.

Methods and materials A. Sample 1. Questionnaires relating to dental habits

were issued to the parents of 4,578 children,

Received for publication August, 1970. Senior Dental OfRcer-Research. South Aus-

tralian School Dental Service.

High . . Primary . . . .

Low . . High . .

Secondary . . . . Low . .

comprising all students aged 6 , 8, 10, 12, 14 and 16 years in the schools surveyed. The schools were located in widely scattered areas of varying socio-economic level in Adelaide. The occupations of the fathers of the examined children, as indicated by the records of the Education Department, are illustrated in Table 1. A sharper socio-economic contrast is evident at the primary rather than at the secondary school level.

2. Questionnaires were returned by 82.8 per cent of those approached.

3. Two thousand and twenty-six children were selected at random for examination, excluding subjects who:

(a) Had not resided in Adelaide since birth (9 per cent). Absences of less than three months were disregarded.

( b ) Had received fluoride tablets (15 per cent) or topical fluoride (10 per cent). The exclusion of these children might have led to an under-estimation of the level of good dental health, particularly in the younger age groups where more children were affected. Considering the relatively small number excluded over- all, the total effect would probably have been small.

TABLE 1 Sildren from

Number of

schools

4

5

3

3

* Occupational level :

:reas of varyinq socio-economic levels

Occupational level*

2 1 41 I 57

20 I 43 1 37

11 I 45 ! 44

1 signifies professional and high executive positions. 2 signifies skilled and middle management positions. 3 signifies unskilled positions.

Australian Dental Journal, February, I97 I 35

(c) Normally drank tank water ( 7 per cent). ( d ) Did not have parental consent for

As a similar number of boys and girls were examined in each socio-economic category, differences in the dental health and habits of children in these categories could not be explained by varying sex distributions. For economy of space, the comparative dental health and habits of males and females has been excluded from this report.

B. Examination techniques 1. Clinical and radiographic

All examinations were performed with mouth mirrors, sharp sickle explorers and standard lighting. Posterior bite-wing X-ray films were exposed with the aid of a paralleling device.")

Films were exposed and processed by stan- dard techniques. One investigator examined all the children; an assistant exposed the X-ray films. The clinical examiner interpreted all X-ray flndings. X-rays are scheduled for use in three of the eight remaining surveys as a check against examiner variability in the evaluation of fluoridation.

examination ( 4 per cent).

2. Indices ( a ) Caries.

The DMF(T) and df indices were used. The requirements for a positive classi- fication of caries and the interpretations of the indices have been outlined pre- vious1y.(2) Two elaborations were made, namely: ( i ) Missing teeth were divided into

those attributed (Mc) and those not attributed (Ms) to caries.

( i i ) Filled teeth were classified as those with (Fc, fc) and those without (Fs, fs) caries.

The DMF(S) was used as advocated in the Commission on Oral Statistics of the Federation Dentaire Internationale.(*) Clinical findings were recorded separately and after accumulation with X-ray

(1) Backer-Dirks, O., Van Amerongin, J., and Winkler, K. C.-A reproducible method for caries evaluation. J. Dent. Res.. 30 : 3. 346-359 (June) 1951.

e) World Health Organization. Expert Committee on Dectal Health. Geneva. Technical Report Series No. 242 1962 p. 23 (p. 9-12).

(8) Dirks, B. O., Dbvies, 'G. N., and Slack, G. L. Principal requirements for controlled clinical trials. Report of a Subcommittee on Caries Incidence. Studies of the F.D.I. Special Com- mission on Oral and Dental Statistics. Adopted 1 9 6 6 . Published 1967.

results. I n this paper, only accumulated clinical and X-ray findings a re reported. The clinical examiner interpreted all X-rays. A classification of caries was made when: (i) a definite V-shaped area of increased

radiolucency was apparent in the enamel,

or (ii) there were signs of caries in the

Prior to the survey, duplicate examina- tions were performed independently on 45 subjects to ensure that scoring tech- niques possessed an adequate degree of reliability.

dentine.

( b ) Dental habits Parents completed questionnaires on the dental habits of their children. Multi- choice close-ended questionnaires were used with four to six alternative answers per question. The circumstances of the survey pre- vented the provision of more than one questionnaire to parents to test the reliability of answers. Nevertheless, the validity of answers was tested by relating apparent habits to dental con- ditions. The results are displayed in Table 2. Although tests of statistical significance have not been performed, it is apparent that the dental habits reported a re SUP- ported by oral examinations. At all ages, children said to visit the dentist most regularly displayed more fillings. Children reported to consume sweets and cakes and related products most fre- quently had higher DMF(S) scores in 11 of the 12 group comparisons. I n all age groups, children said to brush most frequently had lower debris and gingival scores. The gingival and oral debris scores were measured by adaptations of the Periodontal Index(4) and the Oral Hygiene Index,'6) respectively. While the nature of dental habits might not have been accurately defined, a degree of validity is apparent.

(4 ) Russell A. L.-A system of classification and scorin'g for prevalence surveys of periodontal disease. J. Dent. Res.. 35: 3. 350-359 (June) 1956.

(5)Greene J. C., and Vermillion, J. R.-The Oral Hygikne Index: a method of classifying oral hygiene status. Am. Dent. J., 61: 2, 172-179 (August) 1960.

36

C. Frequency of Consumption of

1. More than once R week 2. Less often . . . . , .

cakes :

Australian Dental Journal, February, I 9 7 I

1.71 (267) 4.92 (284) 8.38 (272) 14.93 (256) 22.83 (261) 27.69 (236) 1.90 (70) 3.90 (64) 8.09 (66) 13.48 (80) 19.10 (72324.97 (102)

_____ _____

TABLE 2

Dental health and habits

I Mean number of fillings

I 6 yrs. 1 8 yrs. I 10 yrs. 1 12 yrs. I 14 yrs. 1 16 yrs.

A. Frequency of dental visits : 1. At least six-monthly 2. Less often . . . .

B. Frequency of consumption of ! l k a n ""(1) ~ I 1. More than once a week 1.82 (198) 5.05 (202) 8.83 (201) 15.66 (158) 24.31 (158) 29.26 (132) 2. Less often . . . . . . 1.64 (137) 4.30 (141) 7.56 (136) 13.66 (176) 19.95 (173)25.34 (206)

sweets :

, Mear gingival l o r e , (Number of subjects in brackets)

! E. Frequency of toothbrushing : 1. A t least twiccx R day . . 0.37 (82) 0.58 (77) 0.46 (88) 0.46 (118) 0.28 (144) 0.25 (159) 2. Less often . . . . . . 0.45 (252) 0.63 (267) 0.55 (247) 0.60 (217) 0.47 (189) 0.38 (179)

Results and comments

A. Treatment requirements 1. Permanent teeth

Findings demonstrate a poor state of dental health in children of all ages, particularly in the poorer areas. Results are displayed in Table 3.

The average DMF(T) values increased from 1.33 in 6-year-old children to 12.56 in the 16 year age group. At all ages, children from the poorer areas had higher DMF(T) scores and, with the exception of one age group, higher DMF (S) values.

Generally, children from the poorer areas had fewer fillings and more decayed teeth. The only exception was an adolescent age group, where the differences in socio-economic level were comparatively small.

The average numbers of decayed teeth rose from 1.24 in the 6-year-old child to 8.03 in subjects aged 1 4 years.

The average numbers of teeth apparently missing as a result of caries increased from zero in children aged 6 years to 0.60 in 16- year-old subjects, and was generally higher in children from the poorer areas.

Although the percentages of children with positive DMF scores rose from 56.8 in the 6-year-old to 99.7 in the 16-year-old child, the percentages with fillings were 4.5 and 89.9 respectively. At all ages, a smaller percentage of children in the poorer areas had fillings. In no instance did the F to DMF(T) ratio exceed one-third, and considerably lower values were evident in primary school children : 6-year-old subjects had an average ratio of 0.07. Generally, values were lower in children from the poorer areas.

At all ages except the 6-year-old, teeth were apparently missing a s a result of decay, and more children from the poorer areas were affected. Approximately a quarter (24.9 per cent) of the 16-year-old children appeared to have lost teeth because of caries.

2. Primary teeth

A poor level of dental health is evident, especially in the poorer areas. Results a re illustrated in Table 4.

At all ages, children from the poorer areas possessed fewer fillings and more decayed teeth. The average numbers of decayed teeth

Australian Dental Journal, February, 197 1 37

TABLE 3 S ta tus of permanent teeth by age and socio-economic level

__.

n Yumhei of

subject S!E level

Mc

6 yrs. : High .. Low ..

137

199

1.07

1.36

0

0

0.09

0.06

Total

8 ym. : High . . Low . .

Total --

336 1.24 - 2.55

2.72 __- 2.65

0 0 0 --

0.03 0

0.02 0

0 .03 0 ~-

0.07 0.05

0.23 0 .03 ~ _ _

0.16 0.04 --

0.22 0.21

0.37 0 .31

0.07

0.13

0.10

0 .11

143

203

346

0 . 7

1.5

1 .2

10 yrs. : High . . Low . .

3.32

3.79

146

191

2 .1

12.0 0.20

0.15 --

0.17

0.23

0.19

0.21

Total 337 3.58 7.7

12 yrs. : High . . Low . .

160

176

5.63

6.39

6.9

19.3

Total - ~ - 14 yrs. :

High . . Low . .

336 --

146

187

6 .03 - 8.26

7.85

13 .4 __ 11.6

28.3

14"0 f 0 . 5 2 99.1 69.0 _ _ ~ -

21.10 *o,97 100.0 82.2

:;::: 99.5 80.7

0.30 0.26 -- 0.28 0.51

0.66 0.39 __- 0.49 0.44 __-

0.46 0 .91

0.73 0 .71 -__ 0.60 0.80

0 . 2 2

0.24

To t4 ___ 16 yra. :

High . . Low . .

333 -

8.03 __

7.74

8.17 __ 7.96

21 .o --

21.1

28.2

0.23 2;:;; 99.7 81.4

26.17 *1,06 27.51

10.9R

99.4 93.2

100.0 87.0

161

177

0.33

0.31

Total 338 24.9 0.32

varied from 6.02 in the 6-year-old to 0.75 in the 12-year-old child.

In all age groups, the number of teeth missing for any reason was greater in children from the poorer areas. The higher numbers of missing teeth in these children i n the older ages appeared to cause lower df scores. At all ages, the total number of decayed, missing (for any reason) and filled teeth was higher in children from the poorer areas.

While the percentages of children with positive df values varied from 93.9 in the 8-year to 30.7 in the 12-year group, the per- centages with fillings were 42.2 and 11.3 respectively. At all ages, fewer children from the poorer areas had fillings.

The f to df ratios varied from 0.15 in the 8-year-old to 0.06 in the 12-year-old child, and were consistently lower in the poorer areas. The comparatively low values in the older age grouDs appeared to follow decisions not to fill teeth about to exfoliate.

3. Permanent and primary teeth In all age groups, the proportion of children

with untreated decayed teeth exceeded 90 per cent.

4. Comments While all teeth classified as decayed in

surveys may not be considered in need of treatment after broader examinations and

38 Australian Dental Journal, February. 1 9 7 I

TABLE 4 Status of primary teeth by age and socio-economic level -

Percentage of subjects with S/E

level Number

of subjects

df &S.E.M

dmf *S.E.M

9.50 *0.41 11-05

k0.32

10.42 k0.25

14.90 rlrO.25 15.65

60 .22

15.33 k0.17

d

5.13

6.63

fs

1.11

0.50

fc

0.55

0.38

f/df

0.18

0.07

m

3.27

3.92

df --

87.6

93.0

fs or fc

40.1

20.6

6 yrs. : High

Low

6.23 20 .32

7.13 f0 .24

137

199

Total -- 8 yrs. : High

Low

336

143

203

6.02 3.65 0.74 0.45 6.77 +0.19 90.8

92.3

95.1

93.9

28.6 0.11

5.66 &0*24

5.77 *0.19

5.72 *0*15

4.40

5.17

4.84

9.24

9.88

9.61

1.27

0.60

0.88

1.11

0.59

0.81

58.0

31.0

42.2

0.22

0.10

0.15 Total 346

10 yrs. : High

Low

3.66 k0.22

3.43 50.22

17.50 s 0 . 3 1 18.30

s 0 . 1 7

146

191

3.15

3.20

13.83

14.87

0.51

0.23

0.35

0.08

0.03

0.05

0.81

0.36 - -~

0.55

0.23

0.07

0.15

83.6

78.5

47.9

20.9

0.14

0.07

Total 337 3.18

0.74

0.76 ___

0.75

14.42

18.79

18.99

18.89

3.53 k0 .16 --

0.82 k0.12

0.79 &0.14

0.80 s 0 . 0 9

17.96 k0.17 ____

19.60 50.09 19.78

k0.13

19.69 kO.08

80.7 ~-

31.3

30.1

30.7

32.6 ____

15.6

7.4 --

11.3

0.10 -__-

0.10

0.04

0.06

12 yrs. :

High

Low

160

176

Total 336

case histories, the results of surveys are a valuable guide to the treatment needs of a population.

The results of this study demonstrate the wide diepariLy between needed and acquired dental care in South Australian children. Althougli the children in the poorer areas were generally aftected more seriously, a poor state of dental health is obvious in all areas. The similarity of the treatment requirements of children from all areas suggests that results closely resemble the overall Adelaide situation.

Fanning, Gotjamanos and Vowles have already described the disparity between needed and acquired dental care in adolescent South Australians and found i t to greatly exceed that in New Zealand.@) The results of this study confirm the findings of these investi-

gators; moreover, the F to DMF(T) ratios are lower in primary school children.

Table 5 illustrates the vast differences between f to df and F to DMF(T) ratios in South Australia and New Zealand.") These differences seem too large to be attributed to variations in examination or sampling tech- niques. Table 6 shows the greater number of teeth lost as a result of decay by South Australian children as compared with their New Zealand counterparts.")

The availability of free dental care to all New Zealand school children under the age of

( 8 ) Fanning, E. A,, Gotjamanos, T., and Vowles, N. J.-Dental health and treatment require- ments of South Australian secondary school- children. Aust. Med. J., 2 : 18, 899-901 (Nnvpmher 1 ) 1969 . ~. . . . . .. - . . - , -. . . .

(7) Beck, D. J.-Evaluation of dental care for children in New Zealand and the United States. N.Z. Dent. J., 63: 293, 201-211 (July) 1967.

Australian Dental Journal, February, I97 I

TABLE 5 Mean F to DMF(T) and f to df ratios in South Australian and New Zealand children

0.15 0.19 0.24 0.31

39

0.87 0.69 0.65 -

6 yrs. . . 8 yrs. . .

12 yrs. . . 14 yrs. . . 16 yrs. . .

10 yrs. . .

Age

6 yrs. . . -_

F t o DMF(T)

S.A. S.A. high low N.Z. S/E S/E _____ 0 0 0

S.A. high S/E

0.09 0.13 0.20 0 .23 0.22 0.33

8 JTS. . . 10 yrs. .. 12 yrs. . .

-- -_

S.A. low 1 N.Z. S/E

0.03 0.02 0

0.07 0.23 0.03

0.22 0.37 0.14

16 years seems the obvious reason for the better standard of dental health in that country.(*)

B. Dental habits

1. Children from the wealthier areas were found to have consistently better dental habits. Although children from all areas appear to consume cakes, sweet biscuits and related products to a similar extent, a greater number of children from the wealthier areas apparently:

( a ) Consume sweets infrequently. ( 6 ) Have received fluoride tablets daily or

( c ) Attend a dentist every six months. (d) Brush their teeth at least twice a day. ( e ) Use a toothpaste containing fluoride.

Results are outlined in Table 7. Chi square tests of statistical significance have been applied to each comparison.

“often”.

(8) Walsh, John-International patterns of oral health care: the example of New Zealand. N.Z. Dent. J., 6 6 : 304, 143-152 (April) 1970.

TABLE 6 Mean number of teeth nzi88ing as a result of decay in

South Australian and New Zealand children

14 yrs. . . I 0.28 I 0.66 I 0.13

I - 16 yrs. .. I 0.46 I 0.73

S.A. high S/E

0.18 0.22 0.14 0.10 - -

f to df

S.A. low S/E

0.07 0 .10 0.07 0.04 - -

N.Z.

0.90 0.93 0.93 0.83 - -

Comments

The inferior nature of dental habits in the poorer areas is consistent with their lower standard of dental health.

Despite the advances in clinical technology in recent decades, it is evident that unsatis- factory dental habits prevent the attainment of a high level of community dental health.

Fluoridation will greatly alleviate the situa- tion, but in the context of present knowledge, a high level of public dental health requires a considerable improvement in dental habits.

Summary and conclusion

Questionnaires on dental habits were issued to the parents of 4,578 children, comprising all students aged 6, 8, 10, 12, 14 and 16 years in the surveyed schools. The nine primary and six secondary schools included in the study were located in widely scattered areas of varying socio-economic level in Adelaide. Questionnaires were returned by 82.8 per cent of those approached.

Two thousand and twenty-six children were selected at random for examination, excluding subjects who: had not resided in Adelaide since birth; had histories of a significant exposure to fluoride; normally drank tank water; did not have parental permission for examination.

Results indicate a poor level of dental health in both primary and secondary dentitions at all ages and in all areas. Children from the poorer areas generally had:

( a ) More decay. ( b ) Fewer fillings. (c ) More missing teeth as a result of decay. ( d ) Inferior dental habits.

The standard of dental health in South Australia seems considerably lower than in New Zealand.

40 Australian Dental Journal, February, I97 I

TABLE 7 Dental habits of children by age and socio-economic level of area

S/E level

Percentage of subjects

Restrict sweets*

Taken fluoride tablets*

Frequent dental care*

Number Frequent brushing*

Use a fluoride paste*

51 .0 t 40 .9

49.53 36 .7

-

49.83 38.1

Restrict cakes*

25 .2 21 .1

19.6 18.5

17 .6 t 26 .2

____

22 .3 24.7

26 .6 24 .0

31 .5 32.8

6 yrs. : High . . . . Low . . . .

304 335

55.35 36 .1

43.65 16.5

60.45 28 .8

39.95 17 .9

8 yrs. : High . Low .

324 329

53.26 35 .0

37.55 10 .6

63.55 30 .9

65.35 30 .5

40.96 20 .4

10 yrs. : High . . . . Low . . . .

_ _ _ ~ ~ _ 12 yrs. :

High . . . . Low . . . .

262 358

278 392

48 .9t 39 .0

61.25 46 .0

24.46 7 . 1

19 .5s 7 . 4

43.95 2 2 . 1

61.25 39 .4

46.75 30 .2

44 .2 42.1

44.63 33 .4

14 yrs. : High . . . . Low . . . .

41.1 40.8

-

36 .9 33 .8

267 355

60.83 47 .3

8 .63 2 . 5

57.95 43 .4

16 yrs. : High . . . . Low . . . .

276 311

7 1 . 5 5 53 .8

6 . 9 t 2 . 6

49.8 46 .1

52 .4 46 .6

* 1. Restrict sweets : Restrict sweets to once a week or less. 2. Restrict cakes : Restrict cakes, sweet biscuits, etc., to once a week or less, 3. Taken fluoride tablets : Taken fluoride tablets daily or ‘‘ often ”. 4. Frequent dental care : Visit a dentist six-monthly. 6. Frequent brushing : Brush a t least twice a day. 6. Use a fluoride paste : Normally use a fluoride toothpaste.

t p<0.05 . 3 p<O.Ol. (i p<O*OOl.

Despite advances in clinical technology in recent decades, i t is evident that poor habits are preventing the attainment of a high level of community dental health.

Although fluoridation will alleviate the dental health problem, attention seems appropriate:

( a ) In dental health education, for example, research in the implementation of educa- tional programmes appears desirable.

(a) In exploring methods of reducing the financial barriers to dental care.

( c ) In expanding the effective dental man- power:

( i ) By reducing the dentist to popula- tion ratio.

(ii) By the effective: 1. Use of auxiliaries. 2. Use of equipment. 3. Management of practices.

(iii) By promoting a satisfactory dis- tribution of dentists throughout the State.

Acknowledgements The author wishes to thank the Honourable

A. J. Shard, M.L.C., Chief Secretary and Minister of Health, and Dr. P. S. Woodruff, Director-General of Public Health, for their co-operation, and their approval to publish this report. The author is also indebted to Mr. K. M. Cellier, Principal Research Scientist, Division of Mathematical Statistics, C.S.I.R.O., Adelaide, for his advice in the statistical aspects of this study.

South Australian School Dental

49 Hindmarsh Square, West, Service,

Adelaide, S.A. 5000.