Program for Dental Health Advancement in Children "Dental Passport".

OBJECTIVE: The need for improving oral health in the Republic of Croatia was based on health indicators and poor oral health status and resulted in the implementation of measures to improve the use of dental health care for schoolchildren through the national program called "Dental Passport", which began in the 2017/2018 school year.
PURPOSE: The aim of this study was to present the content and results of its implementation and to analyse them with emphasis on the sustainability and inclusion of the program and its implementation in preventive activities and procedures.
MATERIAL AND METHODS: The data were collected from the completed "Dental Passport" forms from September 2017 to August 2018. The dental examinations and diagnostic-therapeutic procedures were recorded in The Central Health Information System of Croatia.
RESULTS: In the school year 2017/2018, 24,729 6th grade elementary school students visited a dentist. The response rate in the Republic of Croatia was 68%. According to the CEZIH data, in the period from September 1 to December 31 2017, an increase in the number of first examinations and diagnostic-therapeutic procedures was observed in children aged 12 years, compared to the same period in 2015. The least reported preventive procedures in preschool children and 6th grade students were fissure sealing and sealing restorations, while motivating and instructing children on oral hygiene were the most common reported procedures.
CONCLUSION: Good organization of work in school medicine provides the basis for the implementation of dental programs involving schoolchildren. However, greater motivation of the dental health care provider in the implementation of preventive procedures and motivation of parents and patients for a more active involvement in the "Dental Passport" program are important determinants in further implementation and improvement of oral health in children.

Introduction

Oral health is an integral part of overall health and an important indicator of a population’s health status. As an indicator of oral health, public health policy places special emphasis on health status during pre-school and school age and the implementation of preventive measures in the field of dental medicine (). Dental caries is the most common oral cavity disease that affects 60-90% of schoolchildren and is a major public health problem (). Knowledge on the occurrence and development of caries has led to a change in its treatment and made preventive, non-invasive procedures particularly important in reducing its prevalence. The best results are achieved with preventive activities to ensure good oral health. However, their purposefulness essentially depends on a structure that includes appropriate facilities.

Therefore, the deficiency of systems in preventive approach is the most common reason for unsuccessful programs, or programs with insufficiently measurable effects. In 1991, the reform of the health care system in Croatia resulted in the loss of systematic preventive and curative dental health care for children provided by pedodontics, which resulted in a decline in the quality of dental medical care in the pediatric population and high DMF index values (4.18 in 12-year-olds, 4.14 in 6-year-olds) (). Excessive workload in regular daily routine and provision of dental health care at the elementary level, considering specific needs of the pediatric population, did not contribute to building a sustainable prevention system through organized preventive examination (). Good practice in European countries such as Denmark has shown that a targeted proactive approach for providing and organizing preventive care within public health dental care has had significant results in improving the oral health of the Danish population. The average DMFT index in 12-year-olds decreased by 78%, from 4.5 to 0.98, in the period from 1974 to 2000. Establishing local clinical facilities to provide free and affordable dental health care to children and adolescents, with health education and preventive activities from infants to 18-year-olds, through organized written invitations to parents and response monitoring/follow up are a good example of a successful dental program (, ). The systematic dental health care in other Scandinavian countries has given low DMF figures for 12-years-olds in Sweden (0.8) and Norway (1.7). The need to plan and implement a preventive dental program in Croatia with the purpose to improve the use of dental health care for children started with the pilot project called the "Dental Passport" in the school year 2016/2017 and the project became the national program from the school year 2017/ 2018. All children aged six and 12 are referred by a school doctor to a dentist for preventive examination. The program is designed and implemented, based on the Plan and Program of Health Care Measures from Compulsory Health Insurance (Official Gazette No. 126/2009) defining specific health promotion and disease prevention measures characteristic of certain groups; pregnant women, infants and children under three years of age, preschool children (from the age three to school), school children, young people under 18 years, and adults and people over the age of 65. They include the following preventive activities: regular check-ups, health education, tooth brushing with fluoride preparations, records of mandatory epidemiological data as defined by the World Health Organization, with the emphasis on systematic preventive dental care for children and young people (). The aim of the Dental Passport program is to organize comprehensive preventive dental examination (dental status, preventive procedures, treatment and follow-up) for all children aged six and 12, with a response rate of 100% at age six and about 60-70% at age 12. Its purpose is reducing the DMFT index, increasing the use of fluoridation and remineralization preparations and improving oral hygiene habits in children. The aim of this study is to present the content and results of the implementation of the “Dental Passport” program and to analyse them with the focus on the sustainability and coverage of the program and its implementation in preventive activities and procedures.

Material and Methods

The data were collected from the completed “Dental Passports” forms between September 2017 and August 2018 (Figure 1). The 6th grade students (12 years old) and pre-schoolers enrolling in the 1st grade of elementary school (6 years old) had received the forms directly from the school medicine doctor or at school. During systematic examination when enrolling in the first grade of elementary school, the "Dental Passport" form is a part of the compulsory medical documentation collected by the school doctor. From 6th grade students, the form was collected during the following regular activities: Hepatitis B vaccination, spinal examination and control of height and weight (growth and development monitoring). After dental examination, the child / parent / guardian returned the completed form to the school medicine doctor. The collected forms were sent to the Croatian Institute of Public Health, where data were entered through a system for centralized information collection based on an open source project - Lime Survey ().

Figure 1

”Dental Passport” Form

In the school year 2016/2017, data were entered for all examined 6th grade students in Splitsko-Dalmatinska and Primorsko-Goranska County from those who had returned the completed forms. In the school year 2017/2018, samples were entered for 6th grade students and pre-schoolers enrolling in the 1st grade of elementary school from each county of Croatia. The data included the following: demographic data (age and sex), dental status (healthy tooth, caries, tooth extracted due to caries, filled tooth), preventive procedures, treatment and follow-up visits. The dental examinations and diagnostic-therapeutic procedures were recorded in the Central Health Information System of Croatia during clinical examinations carried out by dental practitioners who were contractors of the Croatian Health Insurance Fund.

Results

In the school year 2016/2017, out of the 6,994 planned 6th grade students, 51.6% were examined in the Splitsko-Dalmatinska and Primorsko-Goranska county. According to the CEZIH data, between September 1 and December 31, 2015, there was a total of 5,761 dental inspections of 12-year-old children. For the same period in 2016, the number of dental consultations was 9,648 and 11,911, respectively, in 2017. The number of preventive procedures (topical fluoridation, motivation and demonstration of tooth brushing, fissure sealing per tooth, sealing restorations) in twelve-year-olds in 2016 increased by 118% compared to the same period in 2015, and by 19% in 2017 compared to 2016 (Figure 2). In the school year 2017/2018 (20 counties and City of Zagreb), out of the total number of 6th grade students, 98.8% of them received the form directly from the school medicine doctor or at school in September 2017. In the period from September 2017 to June 2018, out of 3,184 students, 24,729 have visited dentists, with the response rate of 68% for the Republic of Croatia. The analysis showed that the numbers of 6th-grade students in that period ranged from almost complete examinations by dentists (Krapinsko-Zagorska 98.7%) to marginal implementation (The City of Zagreb 25.1%)(Figure 3). In the sample of 6,802 6th grade students, the most commonly observed preventive procedures were motivation of children for oral hygiene demonstration of mouth cleaning topical fluoridation - liquid or gel, while fissure sealing per teeth and sealing restorations were the least reported procedures (Figure 4). During the examination, treatment was not required in 51.92% of children, while the start of a treatment was planned for the next visit in 26.48% of children, and in 12.19% treatment was started at the same visit, with 9.41% of children whose treatment was started and completed on the same visit. Motivation of children for oral hygiene, demonstrations of mouth cleaning and topical fluoridation were the most performed preventive procedures found in Viroviticko-Podravska and Sibensko-Kninska counties, while the number of fissure sealing per tooth was highest in Dubrovnicko-Neretvanska county, Pozesko-Slavonska county and in the City of Zagreb (Figure 5). According to the CEZIH data, in the period from September 1 to December 31, 2017, an increase in the number of first examinations (by 174%) and diagnostic and therapeutic procedures was observed in children aged 12 compared to the same period in 2015 (Figure 6). During examinations (spring of 2018) which included the generation of preschool children (42,432) enrolling in the first grade of elementary school for the 2018/2019 school year, a sample of 4,410 children revealed that 31.15% of children did not need treatment, while 39.64% needed treatment that was planned for the next visit or started and completed during the same visit. The least performed preventive procedures for preschool children were fissure sealing and sealing restorations, followed by fluoride prophylaxis, while demonstrating mouth cleaning and motivating children for oral hygiene were the most commonly reported procedures (Figure 7). No gender differences were found in therapy and treatment plan.

Figure 2

Trends in numbers of diagnostic-therapeutic procedures (CEZIH)

Figure 3

Examined 6th grade students according to counties

Figure 4

Preventive procedures for 6th grade students according to sex (Dental Passport Form)

Figure 5

Preventive procedures for 6th grade students in counties (Dental Passport Form)

Figure 6

Preventive procedures for 6th grade students in 2015 vs in 2017 (CEZIH)

Figure 7

Preventive procedures in preschool children according to sex at enrolment into1st grade of elementary school (Dental Passport Form)

Discussion

In 1995, the World Health Organization adopted the Global School Health Initiative to promote health care through schools, which included oral health care (). Globally, about 80% of children attend school. Hence, schools represent a suitable environment for access to almost all population groups of children and the opportunity to play a role in national development and efforts to improve health and education among children and adolescents (). Within the public health system of the Republic of Croatia, school medicine implements preventive, specific and health education measures, as defined in the Program for Preventive and Educational Measures for health protection of schoolchildren, which is a part of the plan and the program of health care measures covered by compulsory health insurance. (). Considering poor oral health status in children and insufficient organized dental examinations in the Republic of Croatia, school medicine became an important specialty and link in the implementation of oral health care measures through schools, fostering parental/ guardian responsibilities for regular screening and preventive procedures. The increase in the number of visits and preventive procedures for twelve-year-olds in 2016 and 2017 compared to the same period in 2015 indicates the importance of implementation of the screening program through the education system that shows that regular oral health assessment is more effective than the standard dental care model (). The aim of programs involving schoolchildren is not only to identify children with oral health problems, but also to encourage children to contact the dental health services for regular check-ups (). Praveen et al. reported an increase in the number of examinations and procedures in children enrolled in school dental programs compared to non-school children (). Donaldson and Kinirons reported similar results in the study conducted among children in Northern Ireland, with emphasis on school dental programs and their role in reducing health inequalities, especially in lower socioeconomic status (). Sometimes, schools can also be the only place where children at highest risk of hard and soft tissue diseases of the oral cavity have access to oral health services, especially in developing countries due to inaccessibility and lack of dental care (). The inclusion analysis of examination of twelve-year-olds shows a low rate, especially in the City of Zagreb, where the use of dental health care should be satisfactory given the number of contracted teams and the availability of health compared to Zadarska county and the potential poorer accessibility given the county's divergence. In the Republic of Croatia, free dental care is provided for all children until the age of 18, which should be motivating, taking into account socio-economic factors and the need for expensive treatment. Almost 50% of children (0-7 years old) do not excercise the right to dental health care and enrolment for school is often the reason for the first visit to the dentist (). The high percentage of pre-school children who require dental treatment in relation to the number of healthy children indicates the need for enhanced implementation of diagnostic and therapeutic procedures, especially for a therapeutic treatment of a new permanent tooth with existing caries. It is a critical period of risk for caries, especially since permanent molars in eruption do not have functional occlusal contact, which affects the accumulation and retention of dental plaque in fissures of the occlusal surfaces of the teeth and the action of acids on immature enamel. Adolescence is the second period of risk for caries due to poor oral hygiene and carbohydrate-rich foods with a high cariogenic potential. The most commonly reported preventive procedures for 6th grade pupils in the Dental Passport Program such as motivation for oral hygiene, demonstration of tooth cleaning and fluoride prophylaxis were justifiably applied in clinical practice, although at that age there is also a need for fissure sealing or sealing restoration based on individual assessments during control examination. A low number of topical fluoridations was noted in preschool children with respect to the recommended two to four times a year, as well as the number of fissure sealing, which should be the rule, not an exception with respect to the number of preschool children requiring treatment given the relatively high incidence of caries (, ). Increase in number of dentist examinations through an organized and targeted program enables monitoring of oral health indicators and application of various preventive procedures such as motivation and patient education on oral hygiene, professional mechanical tooth cleaning, the use of preparations for chemical prophylaxis and plaque control, topical fluoridation and fissure sealing and other non-invasive procedures. These procedures are recommended in childhood because they defer the development and progression of dental concern and anxiety, and show effectiveness in reducing caries.

There are studies assessing the most effective and unbiased public health intervention for caries prevention. They place emphasis on the basic principle of prevention, which states that the most efficient intervention occurs when the risk of a disease is the highest. Hausen et al. reported reduced incidence of caries in children with active caries in their study conducted among Finnish children, when a number of preventive measures had been implemented (). Considering the need to implement preventive measures in order to improve oral health in children through the Dental Passport program, Croatia begins not only with the revitalization of dental health care in schoolchildren but also in oral health education. Oral health education in an educational setting combined with professional dental preventive care has been shown to produce effective results in reducing dental caries in children. Teaching children how to practice good oral hygiene, with demonstration of brushing techniques and exercises can, except in clinical practice, be performed in schools and it may include daily supervised toothbrushing with fluoride toothpaste. According to the Curriculum for Health Education for Elementary and Secondary Schools within the module “Living Healthy in the Republic of Croatia”, nurses from school medicine teams educate children in the first grades of elementary school about proper tooth brushing (). In the school year 2018/2019, Republic of Croatia launched a pilot project and developed the National Standards for Supervised Toothbrushing in Kindergardens and Primary Schools (). The results of the Dental Passport program reveal sustainable implementation of dental examinations and preventive procedures in schoolchildren, as school is a right place to carry out population-based prevention programs and public health interventions in health education. The monitoring and creation of databases of oral health indicators through the Dental Passport program and the CEZIH is oriented towards development of consistent national oral health and caries databases. Upon the realization, further activities will be planned. Other important factors in further implementation are greater motivation of dental care providers and the motivation of parents and patients to become more actively involved in the Dental Passport program.

Conclusion

Good organization of work in school medicine provides the basis for the implementation of dental programs involving school children. The results of the Dental Passport program acknowledge sustainable implementation of dental examinations and preventive procedures in schoolchildren, but there is a need to include preschool children in regular dental check-ups through the Dental Passport program when enrolling in nursery and to implement other prevention measures that include regular oral hygiene, fluoride prophylaxis, proper nutrition and health education in order to decrease the prevalence of caries in children.