ORIGINALFarsi ARTICLE et al
Caries Risk Assessment in Preschool Children in Saudi Arabia Najat Farsia/Leena Merdadb/Soleman Mirdadc Purpose: Caries is a prevalent condition in Saudi Arabia. At present, knowledge regarding caries risk factors in Saudi Arabia is limited. The present study aimed to identify characteristic features of Saudi preschoolers at high risk for caries, using the American Academy of Pediatric Dentistry caries risk assessment tool (CAT) and to report the most significant caries risk predictors. Materials and Methods: A sample of 407 children aged 4 and 5 years was selected randomly from private and public nursery schools. Their parents answered a questionnaire prepared using the CAT. Each child was examined for the presence of caries and his/her oral hygiene status. Results: According to the CAT, almost all children (89%) were considered to be at high risk. Caries was significantly more prevalent among children attending public than private schools. All CAT variables were significantly related to the presence of caries except general health condition and water fluoridation. Logistic regression analysis showed previous caries experience, enamel demineralisation, and socio-economic status to be the most significant caries risk factors. Conclusion: Most of the Saudi children are considered to be at high risk for caries. Previous caries experience, enamel demineralisation and socioeconomic status are the most significant caries risk predictors. These groups should be targeted for inclusion in caries prevention programmes. Key words: assessment, caries risk, children, Saudi Arabia Oral Health Prev Dent 2013;11:271-280 doi: 10.3290/j.ohpd.a30479
C
aries is the most common chronic disease in children and is virtually universal among adults (Li et al, 1996; Peres et al, 2005). However, it is both curable and preventable, and therefore it should be given top priority and the full resources of our profession. According to the caries balance concept, the development of dental caries is a dynamic process involving pathological factors that cause demineralisation, which are counterbalanced by protective factors that promote remineralisation (Featherstone, 2000). The theory that the formation of dental caries occurs on a reversible continuum of demineralisation until eventual irreversible cavitations a
Professor, Preventive Dental Science Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia.
b
Assistant Professor, Preventive Dental Science Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia.
c
Associate Professor, Community Medicine Department, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia.
Correspondence: Professor Najat Farsi, Preventive Dental Science Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia. Tel: +96-652-568-8054. Email:
[email protected]
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Submitted for publication: 23.11.11; accepted for publication: 31.07.12
are formed emphasises the importance of early detection and consequent intervention to potentially reverse the disease process (Featherstone, 2004). In turn, this concept reinforces the need for caries risk assessment to determine an appropriate course for the clinical management of individuals based on their caries risk. The American Academy of Pediatric Dentistry (AAPD) recognises that caries risk assessment is an essential element of contemporary clinical care for infants, children and adolescents (AAPD, 2008). Caries risk assessment involves the determination of the likelihood of the incidence of caries (i.e. the number of new cavitated or incipient lesions) during a certain time period (Reich et al, 1999). It also involves the evaluation of the likelihood that there will be a change in the size or activity of lesions that are already present. With the ability to detect caries in its earliest stages (i.e. white spot lesions), healthcare providers can help prevent cavitations (Ismail et al, 2003; Crall, 2006; Tsang et al, 2006). Assessment of a patient’s risk level for caries (low, moderate or high) may help to determine
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whether additional diagnostic procedures are required, identify subjects who require caries control measures, assess the impact of caries control measures, guide treatment planning decisions, help in proper material selection to reduce future failure in restored teeth and determine the timing of recall appointments (Beck et al, 1988; Disney et al, 1992; Filstrup et al, 2003). The AAPD developed a reliable caries risk assessment tool (CAT) that incorporates almost all caries predictors (AAPD, 2008). A review of the literature concerning caries risk indicators concluded that the previous development of caries was the best predictor for the formation of caries in primary teeth (Zero et al, 2001), followed by the level of parental education (Demers et al, 1992) and socioeconomic status (AAPD, 2008). Given the growing epidemic of paediatric caries in Saudi Arabia (Al Ghanim et al, 1998; Al-Malik et al, 2003), the CAT may play a prominent role in assessment and prevention of dental caries. Since CAT has never been used before in the Saudi population, it was appropriate to investigate this tool in the Saudi population. The purpose of the present study was to identify characteristic features of Saudi individuals at high risk for caries using the AAPD caries risk assessment tool and to report the most significant caries risk predictors.
MATERIALS AND METHODS Sampling procedure This study was carried out in the municipality of Jeddah, the main city on the west coast of Saudi Arabia. The study was approved by the ethics committee at the Department of Preventive Dental Sciences at King Abdulaziz University in Jeddah. A random sample of children was drawn from 4- and 5-year-olds attending nursery schools in Jeddah. Published tables were used to determine the required sample size based on given combinations of precision, confidence level and variability (Agricultural Education and Communication Department of Israel, 2007). The sample size needed for ± 5% precision with a confidence level of 95% was 385. The total number of children attending preschools in Jeddah is 12,159, with 1,954 children in public schools and 10,205 children in private schools. The preschools were stratified according to the funding source (private or public) and geographic location (east, center, north or south). From a total
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of 8 schools, one private and one public school were selected randomly from each of the geographical areas of the city. All children who were 4 or 5 years old and present at school with a signed consent form on the day of the examination were considered eligible to take part in the study. Children who refused the dental examination were excluded from the study. The AAPD caries risk assessment tool includes 2 parts: a history part using a questionnaire and a clinical examination part.
Questionnaire A questionnaire was formulated using the AAPD caries risk assessment tool, which is a practical tool that includes almost all reliable factors related to the disease. According to the CAT, some of the risk factors are categorised as either high or low, while other factors can be divided into high, moderate and low categories. The questionnaire assessed each child’s history of special health care needs, the frequency of routine dental visits, the child’s previous caries experience, the presence of a sibling who has tooth decay, exposure to sugar, oral hygiene habits, availability of fluoride in the drinking water and the family’s socioeconomic status (AAPD, 2008). A questionnaire with a cover letter explaining the purpose of the study and a consent form for participation in the study were sent to the parents of 600 children. Complete questionnaires were returned by 502 children. Of the children who returned the questionnaires, 95 were unable to take part in the study or were absent from school on the day of the examination. A total of 407 children were included in the study, which consisted of 164 children from public schools and 243 children from private schools. The study included 154 males and 253 females. There were 147 4-year-old children and 260 5-year-olds.
Clinical examination The clinical examinations were carried out in nursery schools using a pen light, mouth mirror and Community Periodontal Index (CPI) probe. According to CAT (AAPD, 2008), the children were examined clinically for the presence or absence of 1. visible plaque (white, sticky buildup), 2. gingivitis (red, puffy gums), 3. areas of enamel demineralisa-
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Table 1 Distribution of caries risk assessment variables in the study sample (N = 407) High N (%) Need health care
Moderate N (%)
yes 10 (2.5)
Low N (%) no 397 (97.5)
Dental visit
none 295 (72.5)
irregular 49 (12.1)
regular 63 (15.4)
Previous caries experience
2 years 240 (58.9)
Sibling has decay
yes 206 (50.6)
Exposure to sugar/day
≥3 times 362 (88.9)
1–2 14 (3.4)
Meal time 31 (7.6)
Brushing frequency/day
1 65 (15.9)
Enamel defects
1 19 (4.6)
present 222 (54.5)
tion (chalky white spots on the teeth) and 4. deep pits/fissures. The WHO criteria were used to record enamel defects (WHO, 1997). Caries was recorded as present when the screener could readily observe 2 things: a loss of at least 0.5 mm of tooth structure at the enamel surface (the ball at the tip of a CPI probe is 0.5 mm in diameter) and brown to dark-brown colouration of the walls of the cavity. Teeth that meet both of these criteria were considered decayed, even if a filling or a crown was also present. The criteria were applied to both pit and fissure cavities as well as those on smooth tooth surfaces (ASTTD, 2003). Children were examined by two calibrated examiners. Examinations in duplicate were carried out on 20 children who were not included in the study, using the kappa statistic to calibrate the diagnostic
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no 201 (49.3)
none 323 (79.3) absent 185 (45.4)
reliability of the examiners. Kappa values ranged from 0.80 to 0.95 for both inter- and intra-examiner reliability. To determine which of the investigated indicators were the most important for distinguishing high-risk groups for caries, a logistic regression analysis was performed.
RESULTS The findings of the CAT questionnaire are summarised in Table 1. A high percentage of the children (89%) could be considered to be in the group at high risk for caries when at least one risk factor was used. With respect to the health status, almost all children belonged to the group at low risk for car-
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Table 2 Distribution of CAT history variables according to school type, age and gender School type
History variables H Needs health care
L
M
L
H
Previous caries experience
M
H
L
M
H
M
(%)
(1.2)
(4.3)
4
6
(2.7)
(2.3)
H
L
Gender P-value
Male
Female
4
6
(2.6)
(2.4)
0.51
240
157
143
254
150
247
(%)
(98.8)
(95.7)
(97.3)
(97.7)
(97.4)
(97.6)
None
157
138
116
179
121
174
(%)
(64.6)
(84.7)
(78.9)
(69.1)
(79.1)
(68.8)
Irregular
36
13
16
33
12
37
(%)
(14.8)
(8.0)
(10.9)
(12.7)
(7.8)
(14.6)
Regular
50
12
15
47
20
42
(%)
(20.6)
(7.4)
(10.2)
(18.1)
(13.1)
(16.6)
2 years
162
78
89
151
81
159
(%)
(66.7)
(47.6)
(60.5)
(58.1)
(52.6)
(62.8)
Yes
105
101
76
130
82
124
(%)
(43.2)
(61.6)
(51.7)
(50.0)
(53.2)
(40.9)
0.41
0.40
No
138
63
71
130
72
129
(%)
(56.8)
(38.4)
(48.3)
(50.0)
(46.8)
(51.0)
>3 times
206
156
133
229
135
227
(%)
(84.8)
(95.1)
(90.5)
(88.1)
(87.7)
(9.7)
1–2 times
11
3
4
10
6
8
0.73
0.81
(%)
(4.5)
(1.8)
(2.7)
(3.8)
(3.9)
(3.2)
Meal time
26
5
10
21
13
18
(%)
(10.7)
(3.0)
(6.8)
(8.1)
(8.4)
(7.1)
2
166
59
76
149
75
150
(%)
(68.3)
(36.0)
(51.7)
(57.3)
(48.7)
(59.3)
No
22
34
18
38
24
32
(%)
(9.1)
(20.7)
(12.2)
(14.6)
(15.6)
(12.6)
Yes
221
130
129
222
130
221
(%)
(90.9)
(79.3)
(87.8)
(85.4)
(84.4)
(87.4)
0.50
0.05
0.12
(%)
0.00
P-value
0.88
No
0.00 L
Water fluoridation
7
5
0.00 L
Brushing frequency/ day
3
4
0.00
H
Exposure to sugar/day
Yes
P-value
0.00 L
Sibling has decay
Public
0.34
H
Dental visits
Private
Age (years)
0.40
H – high caries risk indicator; M – moderate caries risk indicator; L – low caries risk indicator
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ies, while frequent exposure to sugar placed most of the children (88.9%) in the high-risk group. Only 7.6% of the children reported that they consumed sugary foods only with meals. Other factors that placed children in the high-risk group were low water fluoridation and irregular dental visits. The majority of children reported drinking non-fluoridated tap water (86%) and 72.5% of the sample reported no history of previous dental visits. Table 2 presents the distribution of the CAT history variables according to age, gender and school type. All history-related caries risk indicators showed overwhelming evidence that children attending public schools have a significantly higher risk of developing caries than those attending private schools. In contrast, neither age nor gender was significantly related to the indicators of caries risk, except for tooth brushing frequency. Female participants reported significantly more frequent brushing, 2 or more times/day, than males.
The distribution of the variables included in the clinical evaluation with respect to age, gender and school type are shown in Table 3. None of the clinical indicators of caries risk showed differences between children attending public or private schools or between children who were 4 or 5 years old. However, females were more likely to have enamel defects and/or deep fissures than males, which classified them as being at a high risk for caries according to this variable. A bivariate analysis was used to determine the relationship between all caries risk indicators, including dental health history, socioeconomic and clinical variables as well as the presence of caries. Only 35% of the study sample was caries free. All CAT indicators were significantly correlated with the presence of caries, except special health care needs and water fluoridation (Table 4). To determine which of the investigated indicators were the most important for distinguishing high-risk
Table 3 Distribution of CAT clinical evaluation variables according to school type, age and gender School type Clinical variables H
Private
Public
Present
60
(%)
Age (years) P-value
4
5
47
42
(24.7)
(28.7)
Absent
183
117
(%)
(75.3)
Present
Gender P-value
M
F
65
47
60
(28.6)
(25.0)
(30.5)
(23.7)
105
195
107
193
(71.3)
(71.4)
(75.0)
(69.5)
(76.3)
33
24
16
41
24
33
(%)
(13.6)
(14.6)
(10.9)
(15.8)
(15.6)
(13.0)
Absent
210
140
131
219
130
220
(%)
(86.4)
(85.4)
(89.6)
(84.2)
(84.4)
(87.0)
>1
34
31
27
38
30
35
(%)
(14.0)
(18.9)
(18.4)
(14.6)
(19.5)
(13.8)
1
10
9
4
15
4
15
(%)
(4.1)
(5.5)
(2.7)
(5.8)
(2.6)
(5.9)
None
199
124
116
207
120
203
(%)
(81.9)
(75.6)
(78.9)
(79.6)
(77.9)
(80.2)
Present
135
87
77
108
30
77
(%)
(55.6)
(53.0)
(52.4)
(41.5)
(19.5)
(30.4)
Absent
108
77
70
152
124
176
(%)
(44.4)
(47.0)
(47.5)
(58.5)
(80.5)
(69.6)
P-value
Visible plaque L
H
0.21
0.25
0.08
Gingivitis L
H
Enamel demineralisation
M
L
H
0.43
0.30
0.34
0.11
0.25
0.05
0.28
0.11
0.01
Enamel defects L
H – high caries risk indicator; M – moderate caries risk indicator; L – low caries risk indicator
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Table 4 Bivariate analysis of the relationship between caries presence and caries risk assessment variables Variables
Caries
P-value
Absent
Present
n = 143 (%)
N = 264 (%)
5 (3.5)
5 (1.9)
0.24
regular
29 (20.3)
34 (12.9)
0.00
irregular
24 (16.9)
25 (9.5)
none
90 (63.4)
205 (77.7)
Never >2 years
134 (93.7) 3 (2.1)
87 (33) 16 (6.1)
1–2 years
3 (2.1)
42 (15.9)
