Oral health status of children in rural communities of Sri Lanka

INTRODUCTION

Inequalities in global oral health are viewed in the context of global public health and local challenges.^[1] Chronic medical conditions such as diabetes, cancer, and cardiovascular disease are often studied but oral disease, specifically dental caries, which is that one of the most prevalent of all health conditions are often overlooked.^[2-4] Interventions aimed at solving health inequalities continue to be studied by recognizing characteristics specific to countries worldwide. This knowledge will help to reduce the pain of oral disease experienced by children affecting their quality of life.^[3,5] In addition to treating oral disease, creating and establishing interventions which would be effective in preventing poor oral health in certain populations need to be identified. Health gradients and inequalities persist due to socioeconomic (SE) status^[6] which is measured by income, educational attainment, occupation, and race/ethnicity.^[7,8] It is also influenced by social conditions, the environment, and the context, in which individuals live and make decisions about their health.^[9]

This paper focuses on the prevalence of the oral disease in two different populations of children in Sri Lanka. One group included children residing in a tea estate in Nuwara Eliya, and the other groups were children from the Mullaithivu District. Although most oral diseases are preventable, untreated oral disease was observed in the majority of the children. This report addresses the poor status of children’s oral health in these rural communities of Sri Lanka, where access to oral health care is limited suggesting that an oral health program in these communities would be beneficial to improve the quality of life.

MATERIALS AND METHODS

A team of healthcare workers representing a non-profit NGO group from the USA collaborated with a non-profit group in Sri Lanka. The team was made up of two practicing pediatric dentists, one hygienist, and an administrative staff person from the USA and a Sri Lankan medical aide who was the interpreter. Between 2016 and 2019, the team visited a tea plantation in Nuwara Eliya and a beautiful coastal area on the Indian Ocean at the northeast corner of the island, Mullaithivu.

The two dentists from the USA worked together to develop a screening sheet that was used to collect data. Caries was noted as present or not present and affecting primary or permanent teeth. Information on oral hygiene practice and diet was also noted. With parental permission, oral health status was charted using the “open your mouth technique” and by observation using a tongue blade, gloved hands, and flashlight. The two examining dentists were calibrated using the same diagnostic tools. Gingivitis was noted by the condition of the gingival tissues as puffy, red, swollen gums with noticeable build-up of plaque, and calculus. Caries was noted as yellowish-brown and black areas and broken teeth.

The dental professionals examined 80 children from the tea plantation. These children were between the ages of 2–6 years old. Many of the children had ECC. ECC is defined as the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a preschool-aged child between birth and 71 months of age. Due to time restraints, only the presence of caries was noted.

From 2017 to 2019, approximately 800 children between the ages of 2–18 years old from Mullaithivu were examined. With parental consent, the same dental examiners using the same “open your mouth” and observation technique performed oral assessments. Equal numbers of male and female children were examined. Information gathered from parental interview indicated that the children did not clean their teeth regularly, and they consumed diets high in sugar and carbohydrates.

The oral assessment form used is shown in [Figure 1].

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Figure 1:

Child oral assessment.

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RESULTS

The data collected are descriptive and qualitative. No statistical analysis was drawn from the findings. In this report, a dichotomous classification of caries (caries versus no caries) was used and the data were strictly from observation.

1. Many of the children aged 2–6 years old residing in the tea estate experience ECC and tooth decay. Due to limitations from the tea plantation, no graphic data from this population are available. The estate children presented with a large amount of decay, ECC, and obvious lack of oral hygiene

2. Preschool-aged (2–5 years old) children in Mullaithivu and the majority of elementary and high school-aged children (from 6 to 18 years old) had tooth decay. The first graph represents the number of children with and without caries [Figure 2]. The second diagram [Figure 3] shows the number of children in hundreds and by age who presented with caries

3. Sri Lankan teenagers in the Mullaithivu District had extensive decay to the permanent molars

4. The number of carious molars was not tabulated but only noted on the assessment form utilized

5. Gingivitis and calculus buildup were evident in older children (9–18 years old) and were also noted on the form. [Figure 4] shows the number of children who exhibited the presence of calculus in July 2018

6. Preventive care was lacking. Many of the children did not own a toothbrush and daily teeth cleaning was not practiced. The frequency of brushing was not tabulated although the question was asked and noted on the assessment form. Toothpaste was rarely used due to lack of supplies

7. Diet: The majority of the children consumed tea with sugar and milk or honey at least 3 times a day.

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Figure 2:

Barplot for patient caries status.

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Figure 3:

Histogram of caries cases by age.

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Figure 4:

Barplot for the patient calculus status.

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When asked, the children did not know how to respond to experiencing dental pain although it was obvious that some had pain because they would refuse to open their mouths and would not smile. The majority of them have never seen a dentist.

DISCUSSION AND RECOMMENDATIONS

Observations from the Mullaithivu district indicated that age, area of residency, as determined by school district, were important factors related to the presence of caries and untreated carious lesions. Older children were more likely to have untreated caries. The vast majority of the children from 2 to 6 years old residing in the tea estate exhibited ECC* and gross dental decay. This information can be used to develop programs to address dental problems specific to these areas. Habits begin during childhood, and the earlier children start to learn good oral habits, the greater the chance of living a healthy life. Practicing good oral care habits at home during child development and providing dental education at school will positively influence children’s health. Older children will make their own decisions and develop daily routines. Persistent poverty and low income may directly or indirectly affect children’s dental health.

Many rural areas, including Mullaithivu, have a shortage of dentists as the number of practicing dentists is found mostly in the urban areas.^[18,21] Dental caries, as expected are less noticeable among children in communities with naturally occurring fluoride in the communal water. Residents of remote communities possess differing levels of knowledge and belief about oral health. Many did not have the means to clean or brush their teeth. They did not own a toothbrush nor did they care to clean their teeth.

SE status, such as family income and education, which may impact children’s dental health is considered as having an effect on oral health. The SE level in the estate life is at t poverty level and the average monthly income of the head of household is <50% of urban household income^[23] and demonstrated from the DCS-household income and expenditure survey 2008. The presence of caries and untreated dental caries serves as the indicator of poor dental health.

It is hoped that preventive care and treatment of dental disease can be made more assessable to rural areas of Sri Lanka by increasing the number of dentists and other oral health-care providers. Implementing preventive oral health programs, including modifying behaviors to keep teeth healthy through regular brushing and a proper diet, are suggested. Instruction in oral hygiene and emphasizing the importance of oral care, incorporating it into the school curriculum by educating teachers as well as parents on the importance of good oral hygiene will help to eliminate potential dental problems due to lack of access to dental care. An oral health program could be made available and repeated at certain intervals for the prevention of ECC and to maintain good oral health for all children. The increased awareness of oral health will improve the dental and overall health of children and families in rural communities, especially in the tea sector. The drastic decrease in population in Mullaithivu from 2010 to 2019 needs to be evaluated, along with the effect oral health may have on general health. Oral health could be a contributing factor to poor general health. Ultimately, the goal is to provide oral health services to eliminate pain and suffering from oral and dental disease which could lead to more devastating health issues.

Social determinants associated with housing and individual concerns affect health. Poverty and poor labor conditions in the tea estate compounded by the low social-economic status of women workers and the lack of education in this community preclude their ability for upward mobility and improvement.

Further, disparities in oral health will remain because children from low income and poor families experience higher rates of dental caries and other dental-related problems. Providing outreach and service to underserved and vulnerable populations with enhanced education to include oral health will help to provide the necessary means to eliminate oral pain and disease and it would help to build healthier lives. Continued study with oral evaluations is encouraged to assist in the development of oral health programs for these suppressed areas.