Oral Health Status Related to Social Behaviors among 6 - 11 Year Old Schoolchildren in Kosovo.

AIM: The aim of the present study was to evaluate the current oral health status among schoolchildren in Kosovo aged 6-11 years.
MATERIAL AND METHODS: A study included 5679 schoolchildren aged 6 -11 years, from different towns of Kosovo. Dental health status was evaluated using the World Health Organization (WHO) caries diagnostic criteria for decayed, missing and filled teeth (dmft/DMFT index), for deciduous and permanent dentition. The observed children have answered a number of questions about their oral hygiene, eating habits, and dental visits. The analysis included frequencies and means. The differences between means were tested using the student t-test (p<0.05). The factors associated with dental caries were tested using the Spearman's rank.
RESULTS: The mean dmft/DMFT of schoolchildren aged 6-11 years was 4.36 ± 3.763 and 1.20 ± 1.488, respectively. Sealant placements were found among 90 schoolchildren, amounting to 1.58%. From 8 years of age, 50% of children brush their teeth twice a day. Confectionery consumption among the observed children has increased. Forty percent of them eat sweets at least once a day, and majority of them visit their dentists only when necessary. A significant correlation between consumption of confectionery, oral hygiene, dental visits and the prevalence of caries was confirmed.
CONCLUSION: The results of the present study show that there is a high prevalence of caries among 6-11 year old schoolchildren, thus pointing to a need for an extensive program of primary oral health care as well as utilizing preventive measures and regular dental visits.

Introduction

Dental caries, also known as tooth decay, is a multifarial disease which affects a huge proportion of the world's population regardless of age, gender or ethnicity, although it does tend to affect to a greater extent the individuals with a low socio-economic status (). It is also one of the most common chronic oral diseases in children (). Caries is a multi-causal, diet-dependent infectious disease. The increase of dental caries depends on the following factors: properties of saliva, dental plaque microorganisms, oral flora, dietary habits, the quality of enamel and histo-morphological characteristics of enamel surface (). It is a transmissible bacterial disease caused by acids from bacterial metabolism diffusing into enamel and dentine and dissolving the minerals (). The decline in the prevalence of dental caries has been attributed to preventive programs with the use of fluoride, a continuous participation in oral health programs, changes in oral hygiene and sugar intake habits. In contrast, the increase of dental caries has resulted from unhealthy dietary habits, limited use of fluoride and poor access to oral health services. In many of developed countries, most of the oral health services provide symptomatic treatment, with slight priority given to prevention and restoration ().

Good oral health improves general health and quality of life and contributes to self-image and social interaction (). Oral health in children and adolescents was accepted as the main concern action, while countries were encouraged to develop preventive approaches to health education in schools through partnerships between families, oral health professionals, communities by improving access to preventive and curative oral health services ().

The World Health Organization (WHO) goals for 2000 included a 50% reduction in dental caries for 6 year- old children and globally an average of the DMFT index not exceeding more than 3.0 for 12 year olds (). It has been already mentioned that dental caries is a worldwide spread disease due to increased consumption of refined foods, fizzy drinks and a wide variety of sweets. The additional reasons are a low utilization of fluoride supplements, fissure sealants, lack of widespread and regular use of toothbrushes with fluoride toothpaste, as well as lack of dental health education and promotion (, ).

In addition, healthy food lifestyle and good oral hygiene are the most useful measures to prevent caries and periodontal disease. Maintaining a good oral hygiene means regular tooth brushing with fluoride toothpaste at least twice a day. The majority of worldwide schoolchildren brush their teeth as daily routine once a day (-). Furthermore, the socio-economic factors have negative effects on oral hygiene practices among preschool and elementary schoolchildren. Facilitators for maintaining oral hygiene habits in primary schoolchildren were found to be a high level of self-esteem, peers influence and personal appearance (, ).

Dental sealants are applied as a preventive measure covering pits and fissures on occlusal tooth surfaces in order to prevent the development of caries among children. The effectiveness of fissure sealants in preventing caries has been well documented (, ). In particular, some studies have shown that the caries-free status of children 6-17 years of age has been associated with subsequent sealant placement ().

Kosovo is the youngest European country in Southeastern Europe with the total land area of 10, 908 km2 and about 1, 804 944 inhabitants (). Currently, Kosovo has an underdeveloped economy with relatively poor educational and health system. Basically, neither a training program for promotion of oral health, nor any concrete activities in preventive dentistry have been organized by Kosovo Ministry of Health (). The aim of this study was to assess the oral health status among schoolchildren aged 6 – 11, in Kosovo, based on age, gender, brushing habits, confectionery consumption, dental visits, and application of preventive measures such as fissure sealants.

Material and Methods

This cross-sectional study was performed using data from the epidemiological survey of oral health among 6-11 year old schoolchildren in Kosovo, performed between September 2016 and January 2017. The approval for the study was obtained from the Ministry of Education, Science, and Technology of the Republic of Kosovo, with Reference Number: 3752/2016. A two-stage cluster sampling was applied. The schoolchildren were chosen in town schools during the first stage which was followed by the second-stage. The schools were selected reasonably and randomly. An invitation was sent to each school for participating in this study and the first two of them who positively responded to the invitation were selected from each town. Therefore, children from every school in any town in Kosovo had equal opportunities of participating in the study. The sample included 5679 schoolchildren aged 6- 11 years of both genders who attended public schools in ten different towns in Kosovo.

The work team of six examiners received training and calibration in making clinical measurements independently from an experienced pedodontist-researcher and epidemiological pathfinder study to ward off the impenetrability of participants. The reliability of the inspection criteria was measured by a pre-test performed on a group randomly selected 30 schoolchildren, aged 6-11 years. Inter-rater agreement was measured by the Cohen kappa index, and the obtained results for the best and worst agreement were ranged between 0.88 and 0.80.

The assessment took place in the classrooms of the selected schools under standardized conditions recommended by the WHO, whereas dental examinations were carried out under artificial light using sterile dental mirrors and dental probes, without diagnostic adjuncts such as previous dental brushing and drying. Dental caries status was assessed using the dmft/DMFT index in the previously described manner, according to the criteria and procedures by the WHO (1997) for epidemiological studies (). Data collection was compromised by demographic data. The age, gender and schools of the participants were, also, recorded:

Decayed teeth – d/D, missing teeth m/M, filled teeth f/F and dmft /DMFT decayed-missing-filled index. DMFT/dmft index (for permanent and primary dentition) is a method to numerically express the caries experience and is obtained by calculating the number of decayed (D), missing (M) and filled (F) teeth (T).

DMFT/dmft free and application of preventive measures - fissure sealants.

Apart from oral examination and demographic data collection, the schoolchildren were also asked about their oral hygiene habits. They were asked how frequently they brushed their teeth during the day (the options were; rare, once or two times per day). Another question was related to eating habits – how often they consumed sweet food and confectionery items such as sweets and chocolate per day (rare, once, two or three and more times per day) and how often they went to see their dentists during the year (once in 6 months, once a year or only when necessary). The exclusion criteria for this study were; mentally, physically, sensory handicapped children and medically compromised patients, e.g. individuals suffering from leukemia, hemophilia and so forth. The abovementioned children were spared from participating in the study due to lack of cooperation and special requirements during the examination.

Statistical Analysis

The statistical analysis was carried out using MS Excel (Microsoft Office, Windows 2010, USA) and SPSS 19 for Windows (SPSS Inc., Chicago, Illinois, USA) software. The analysis included frequencies and means. The differences between means were tested using the student t-test. Statistical significance was set at p<0.05. The association between frequencies of consumption of confectionary, oral hygiene and dental visits with d/D components were tested using the Spearman’s rank correlation (Spearman's rho).

Results

Demographic characteristics of participants are shown in Table 1. The sample included participants (N = 5679) between 6-11 years of age, of both genders. Table 2 shows the structure of dmft index for the observed ages. The dominant component d (decayed teeth) or prevalence of caries were found at the age of 6 (d=27.6%). The highest prevalence for component m or missing teeth and component f or filled teeth were found at the age of 8 (m=24.8%; f = 29.6%), whereas the highest structure of dmft index was found for the age of 6 (dmft= 26.3%), which is shown in Table 2. The highest prevalence value of caries amongst permanent teeth was found for the age of 11 (DMFT=33.7%). The foremost component D – prevalence of decayed, components M and F (D= 30.4%; M = 57.7%; F= 41.6%) were also found for the same age (Table 3). Total dmft-free and DMFT-free for schoolchildren 6 to 11 years of age were found to be 23.5% and 49.3%, respectively (Table 4).

TABLE 1

Sample overview (age, gender, frequency)

Age	Total	Percent	Gender	Frequency	Percent
6 years	1011	17.8	Boys	492	8.7
			Girls	519	9.1
7 years	924	16.3	Boys	471	8.3
			Girls	453	8.0
8 years	951	16.7	Boys	510	9.0
			Girls	441	7.7
9 years	942	16.6	Boys	537	9.5
			Girls	405	7.1
10 years	867	15.3	Boys	423	7.4
			Girls	444	7.9
11 years	984	17.3	Boys	441	7.7
			Girls	543	9.6
Overall	5679	100.0	Boys	2874	50.6
			Girls	2805	49.4

Schoolchildren from Elementary Schools, from different towns, Republic of Kosovo

TABLE 2

Distribution of caries free and dmft values based on age groups

AgeGroup	d		m		f		dmft
	n	%	n	%	n	%	n	%
6 years	6162	27.6	246	12.3	96	22.5	6504	26.3
7 years	5712	25.6	468	23.5	66	15.5	6246	25.2
8 years	4860	21.7	495	24.8	126	29.6	5481	22.1
9 years	3390	15.2	477	24.0	75	17.6	3942	16.0
10 years	1719	7.7	270	13.6	42	9.9	2031	8.2
11 years	495	2.2	36	1.8	21	4.9	552	2.2
Total	22338	100	1992	100	426	100	24756	100

n= Number of teeth

TABLE 3

Distribution of DMFT values based on age groups

AgeGroup	D		M		F		DMFT
	n	%	n	%	n	%	n	%
6 years	201	3.8	3	0.8	6	0.5	210	3.1
7 years	567	10.7	3	0.8	21	1.8	591	8.7
8 years	987	18.6	36	10.2	90	7.7	1113	16.3
9 years	909	17.1	36	10.2	243	21.0	1188	17.4
10 years	1029	19.4	72	20.3	318	27.4	1419	20.8
11 years	1614	30.4	204	57.7	483	41.6	2301	33.7
Total	5307	100	354	100	1161	100	6822	100

n= Number of teeth

Table 4

dmft/DMFT - free on overall sample

AgeGroup	dmft- free onoverall sample		DMFT- free onoverall sample
	N	%	N	%
6 years	111	2.0	897	15.8
7 years	57	1.0	603	10.61
8 years	51	0.9	444	7.8
9 years	81	1.4	357	6.3
10 years	285	5.0	285	5.0
11 years	750	13.2	225	4.0
Total	1335	23.5	2811	49.3

N-number of schoolchildren

There was a statistically significant difference between the highest mean of dmft and DMFT index among 6 to 11-year-olds. The highest mean of the dmft index was found among 7 year- old boys (6.82 ± 3.608), while the highest mean for DMFT was found among 11 year- old girls (2.45 ± 1.901). Therefore, this study confirmed the fact that there is a decline in the caries prevalence in the primary dentition with increasing the age. On the contrary, there was an increase in the caries prevalence in the permanent dentition, which increases with age. The total value of dmft/DMFT index for children 6 to 11 years old based on age and gender was moderately high (dmft = 4.36 ± 3.763, DMFT=1.21 ± 1.489) (Table 5).

TABLE 5

Mean and standard deviation for dmft and DMFT in children based on their age and gender

AgeGroup	Gender
		dmft		DMFT
		X± SD	p	X± SD	p
6 years	Boys	6.56 ± 4.355	0.001	0.18 ± 0.675	0.001
	Girls	6.31 ± 4.388	0.001	0.23 ± 0.612	0.001
7 years	Boys	6.82 ± 3.608	0.001	0.59 ± 0.952	0.001
	Girls	6.70 ± 3.357	0.001	0.69 ± 1.051	0.001
8 years	Boys	5.72 ± 2.653	0.001	1.11 ± 1.282	0.001
	Girls	5.81 ± 2.704	0.001	1.24 ± 1.333	0.001
9 years	Boys	4.44 ± 2.730	0.001	1.28 ± 1.238	0.001
	Girls	3.85 ± 2.552	0.001	1.24 ± 1.195	0.001
10 years	Boys	2.56 ± 2.589	0.001	1.51 ± 1.444	0.001
	Girls	2.12 ± 2.509	0.001	1.76 ± 1.480	0.001
11 years	Boys	0.61 ± 1.282	0.001	2.20 ± 1.935	0.001
	Girls	0.52 ± 1.091	0.001	2.45 ± 1.901	0.001
Overall		4.36 ± 3.763	0.001	1.20 ± 1.488	0.001

T-Test; X=mean; SD=standard deviation; p<0.05

From all children observed, fissure sealants were found only in 90 schoolchildren, amounting to only 1.58% (Table 6). A number of sealed tooth surfaces, frequency and a total number of sealants are shown in Table 7.

TABLE 6

Sealant placements in overall sample

Sealant placement
Overallsample	N	Children withsealants	%
	5679	90	1.58

TABLE 7

Number of sealed tooth surfaces, frequency and total number of sealants

Number of sealedsurfaces	Children	Number ofsealants	%
1	24	24	26.7
2	36	72	40.0
3	12	36	13.3
4	18	72	20.0
5	-	-	-
6	-	-	-
7	-	-	-
8	-	-	-
Total	90	204	100.0

The oral health practices showed that from the age of eight, up to 50% of children brush their teeth twice a day (Table 8). Up to 40% of the observed children declared that they consumed sweet food and confectionary at least once on a regular daily basis. Also, the majority of children visited the dentist only when necessary (Table 8).

TABLE 8

Tooth brushing frequency, sweetened food and confectionery consumption and dental visits based on age

AgeGroup	6 years		7 years		8 years		9 years		10 years		11 years
N	1011		924		951		942		867		984
Brushing frequency(per day)RareOnceTwo times	n213426372	%21.142.136.8	n135372417	%14.640.345.1	n78366507	%8.238.553.3	n81198663	%8.621.070.4	n75204588	%8.723.567.8	n42285642	%4.229.066.8
Sweetened food and confectionery consumption (per day)RareOnceTwoThree or more times	324438135114	32.043.313.411.3	33637213581	36.440.214.68.8	258459123111	27.148.312.911.7	3574269069	37.945.29.67.3	24642011487	28.448.413.210.0	6242017584	63.520.47.68.5
Dental visitsOnce in 6 monthsOnce a yearOnly when necessary	2169921	2.16.891.1	2481819	2.68.888.6	18126807	1.913.284.9	231171540	24.518.257.3	195198474	22.522.854.7	318159507	32.316.251.5

With initial conditional univariate regression, using the Spearman’s rank correlation, it was confirmed that there was a significant association between frequencies of consumption of confectionary, oral hygiene, dental visits and d/D components (Table 9).

TABLE 9

Conditional univariate logistic regression analysis of oral hygiene, sweetened food and confectionery factors related to d/D component, and dental visits
Correlations

			Brushinghabits	Sweetened food andConfectionery	Dental Visits	D-Decay	d-decay
Spearman's rho	Brushing habits	Correlation Coefficient	1.000	0.040**	-0.081**	0.070**	-0.003
		Sig. (2-tailed)	.	0.002	0.001	0.001	0.797
		N	5679	5679	5679	5679	5679
	Sweetened andConfectionery	Correlation Coefficient	0.040**	1.000	0.076**	-0.060**	0.134**
		Sig. (2-tailed)	0.002	.	0.001	0.001	0.001
		N	5679	5679	5679	5679	5679
	Dental Visits	Correlation Coefficient	-0.081**	0.076**	1.000	-0.080**	0.268**
		Sig. (2-tailed)	0.001	0.001	.	0.001	0.001
		N	5679	5679	5679	5679	5679
	D-Decay	Correlation Coefficient	0.070**	-0.060**	-0.080**	1.000	-0.106**
		Sig. (2-tailed)	0.001	0.001	0.001	.	0.001
		N	5679	5679	5679	5679	5679
	d-decay	Correlation Coefficient	-0.003	0.134**	0.268**	-0.106**	1.000
		Sig. (2-tailed)	0.797	0.001	0.001	0.001	.
		N	5679	5679	5679	5679	5679

**. Correlation is significant at the 0.01 level (2-tailed).

Discussion

This study was designed to evaluate the prevalence of caries, brushing habits, fissure sealants, dental visits and frequency of confectionery consumption during the day. The sample included 6 -11 year old schoolchildren from Kosovo. According to the World Oral Health Report from 2003, dental caries is still a serious public health problem regardless of great improvements in the oral health of populations worldwide. In most of the developed countries, it affects 60–90% of schoolchildren and the majority of adults. Mainly, problems persist still among poor and disadvantaged groups in both developed and developing countries ().

The oral health was included also in the project "Strategy against chronic diseases in Europe" [23]. Work policies of the oral health promotion and disease prevention were designed for the training on oral hygiene, using daily basic methods - brushing teeth twice a day with fluoride toothpaste, cleaning interdental spaces using dental floss, balanced healthy diet, going to regular dental visits and using sugar-free chewing gums (, ).

Children in middle childhood (ages 6-11) create their own habits; they learn basic details and rules on maintaining oral health. Throughout this period, children need to be supported by their parents. They learn from their teachers, who are expected to inspire them. Oral health should be promoted by dentists or/and hygienists offering children basic knowledge on oral disease prevention (, ).

Generally, the total caries experience indicators are higher in the mixed dentition. Primary teeth are exposed to risk factors of caries such as regular consumption of sugar- sweetened snacks, sugar-sweetened beverages and confectionery items such as sweets and chocolate over a longer period of time than permanent teeth. This explains also why primary molars have a higher mean of a number of dentine caries lesions than permanent molars. Several studies have revealed common correlations in caries experience between primary and permanent teeth ().

As expected, the results of our study revealed that there was higher prevalence of dental caries in primary dentition than in permanent dentition. Boys had a slightly higher prevalence of caries in primary dentition than girls, whereas girls had higher prevalence of caries in their permanent dentitions. The highest dmft value was found among 7 year- old- boys, whereas the DMFT was higher in 11 year- old- girls. However, the total value of dmft or/and DMFT for schoolchildren aged 6-11 years, based on age and gender, was found to be relatively high.

The dmft and DMFT means for children aged 6 to 7 years in our study were higher than those in Germany (). Furthermore, the values in our findings are considered to be high compared to findings from Scandinavian countries, which have achieved a low degree of caries incidence across the time (-). Also, our results of dmft values were higher compared to those regarding 7-15 years old schoolchildren in Albania, whereas our DMFT values were lower. (). Therefore, our findings for DMFT values were found lowest compared with other studies in the region such as those obtained in Croatia and Bosnia and, also, for dmft values in Turkey and Filipino (-).

In our study, we have established that application of preventive measures throughout the country - dental sealants among children aged 6 - 11 was very low. Out of all the children observed, we have found sealed teeth only in ninety children. The low prevalence of dental sealants was found also in Greek adolescents aged 12 – 15 years (26% for the 12 and 19% for the 15-year-olds), but obviously, the values were higher than those in our study (). The mean DMFT scores for Germany declined from 2.44 in 1994-1995 and to 1.24 in 2000. In 2000, on average between 2.13 and 2.83 teeth with fissure sealants per child were found (). Also, a high prevalence of dental sealants was found in Denmark, where two-thirds of 15-year-old Danish children had at least one or more sealed surfaces. The mean number of sealants was 3.06 (SD=1.60) ().

The results of our study revealed that tooth brushing is relatively common or routinely practiced in a sample of 6–11-year-old children. Our data confirmed the results of previous studies on oral hygiene in the sense that the majority of children all over the world brush their teeth as daily routine at least once to two times per day (, ). Likewise, our study points to the fact that similar social norms are respected by children in Kosovo and, also, that the frequency and timing for oral hygiene are satisfactory. Another study published in 2012 reported a correlation between poor oral hygiene, dental caries experience and children’s age (). The lack of oral health education and proper technique of brushing teeth are other factors that have been formerly shown to be highly correlated with the prevalence of dental caries (, ).

In our study, we have found that the majority of children in Kosovo consume sugar sweetened beverages, sweets and chocolate at least once a day. Inadequate nutrition and fluid intake can result in serious problems; therefore, decreased intake of sugars and well-balanced nutrition can prevent tooth decay and premature tooth loss. The percentage of carious teeth in schoolchildren from Kosovo is lower compared to that of other studies (, ). Our results confirmed the fact that there is a significant correlation between frequencies of consumption of sweetened beverages and confectionery items such as sweets and chocolate per day, and prevalence of caries. Some studies reported that a large number of children aged 6-11 visit their dentists “only when necessary”. Such a high ratio is in line with our findings, the high dmft/DMFT index and low preventive measures with a small number of dental sealants. Furthermore, other studies reported that such a situation is calling for a national preventive program with sealants which could eliminate caries to a larger extent (, ). Consequently, our results suggest that for improving their oral health, children should spend more time on brushing their teeth. Besides, special programs for the promotion of oral health and prevention of oral diseases should be integrated into educational systems.

There is a large number of strengths and limitations of this study. The main strength of our study includes necessary steps and pilot testing for inter-rater agreement. In this way, the obtained results are reliable and consistent. Secondly, we have assessed oral status according to WHO criteria and procedures for epidemiological studies; hence the obtained results from Kosovo can be compared with the results obtained from other developed and developing countries with different cultures. Also, in our study, we have included schoolchildren aged 6-11 years from different towns of Kosovo, which gives an overview of the prevalence of caries in Kosovo. Few limitations of the study must be considered. Even though we have attempted to comprise schoolchildren from different towns, in general, we did not receive information regarding family monthly income and parents’ education level and we did not include children from rural areas. Therefore, we cannot exclude the important significance of broad socioeconomic factors, which could contribute to taking different approaches to specific population, thus improving preventive measurements efficacy, and enabling an easier and better access to preventive oral health services. It is a well-known fact that there are fewer dentists per population living in rural areas and this additional deficiency results in lower access and operation of dental care. Therefore, a potential variety bias in our sample cannot be completely excluded.

Conclusion

Dental caries among children aged 6-11 years in Kosovo remains a significant oral health challenge. Consequently, motivation and education of children are essential in our country for encouraging and inculcating early healthy lifestyle behavior. Parents and school teachers should increase dental awareness among schoolchildren by improving oral hygiene methods and habits together with pedodontists and/or hygienists, demonstrating the proper method, and duration of teeth brushing. In addition, early regular dental visits and preventive measures such as fissure sealants among children would decrease dmft/DMFT indexes. Since oral health is integral to general health, policy makers need to include oral health in public health policies, thus leading to improvement in the differences in health status of urban and rural population.