Australian Dental Journal, June, I96 I 151 Periodontal disease in a group of school children in Thailand Robert Harris* Introduction Reference has been made in several publica- tions(1)(n)(8) to the prevalence of periodontal diseases in various Asiatic countries and more recently, under the auspices of the World Health Organization and the Government of India, Greene'') conducted a study in Bombay and in a nearby rural area. His study was designed to use Russell's(5) methods for estab- lishing an index of periodontal disease and also to measure oral hygiene. One difflculty in endeavouring to compare the prevalence of periodontal diseases existing in different communities has been the absence of a method for measuring the prevalence of the disease which could be readily applied to sufflcient numbers of individuals by various observers and from which appropriate data could be used to establish an index of the disease. Apart from the work of Massler and Schour(*) no important contribution had been made until the work of Russell and Greene. * W.H.O. Consultant Thailand November, 1957- January, 1958 ; Janua;y-May, 1980. Lecturer, Part- time, University of Sydney. Clinical Assistant Superintendent (Preventive), United Dental Hos- pital, Sydney. (1) Marshall-Day, C. D., Stephens, R. G., and Quigley, L. F.-Periodontal disease : Prevalence and incidence. J. Periodont., 26: 185 (July) 1955. (2) Mehta, F. S., Sanjana, M. K., and Shroff, B.C.- Prevalence of periodontal disease. 5. Epidemi- ology in Indian child population in relation to their socio-economic status. Internat. D.J., 6 : 31 (March) 1956. (8) Sanjana, M. F., Mehta. F. S., Doctor, R. H., and Baretto. M. A-Mouth hygiene habits and their relation to periodontal disease. J.D. Res., 35: 645 (Aug.) 1956. (4) Greene, J. C.-Periodontal disease in India. Report of an epidemiological study. J.D. Res., 39 : 302 (March-April) 1960. Russell, A. L.-A system of classification and scoring for prevalence surveys of periodontal disease. J.D. Res., 35: 350 (June) 1956. C8) Massler, M., and Schour, 1.-The P.M.A. index of gingivitis. J.D. Res., 28: 634 (Dec.) 1949 (Abst.) c This deficiency has been appreciated by many investigators and it formed the subject of considerable discussion at the W.H.O. Seminar on Dental Health, Adelaide, 1959. The present study is part of a broader study of school children in the age groups 9-19 years, predominantly of Thai and Chinese nationality, in which observations were made and recorded on the prevalence of dental caries, torus palatinus, oral hygiene and periodontal disease. The children lived in Naradhivas, Songkla and Yala, provincial towns of southern Thai- land. The economy of the area is based on agriculture, with rice, rubber, and coconuts being the important products. Three racial groups live in this part of the country but the arrangements of travel prevented our arrival in this area at a time when the majority of Islamic children were available for examination. The few that were seen at the schools provided only a small amount of information and it has not been included in this study. Of the children examined, 666 Thai and Chinese children provide the material for this report. Material and Methods The study group comprised 328 Thai children (boys 142, girls 186) and 238 Chinese children boys 133, girls 105). The age groups cover the range 9-19 years and of this range the older children came from a secondary school which provided a group of 56 Thai girls aged 16-19 years. Data recorded were: (1) location and name, (2) race and sex, (3) dental caries prevalence score, (4) presence of torus palatinus, (5) scores for oral debris and oral calculus, and (6) periodontal disease score.
Transcript
Australian Dental Journal, June, I96 I 151
Periodontal disease in a group of school children in Thailand
Robert Harris*
Introduction Reference has been made in several publica-
tions(1)(n)(8) to the prevalence of periodontal diseases in various Asiatic countries and more recently, under the auspices of the World Health Organization and the Government of India, Greene'') conducted a study in Bombay and in a nearby rural area. His study was designed to use Russell's(5) methods for estab- lishing an index of periodontal disease and also to measure oral hygiene.
One difflculty in endeavouring to compare the prevalence of periodontal diseases existing in different communities has been the absence of a method for measuring the prevalence of the disease which could be readily applied to sufflcient numbers of individuals by various observers and from which appropriate data could be used to establish an index of the disease. Apart from the work of Massler and Schour(*) no important contribution had been made until the work of Russell and Greene.
* W.H.O. Consultant Thailand November, 1957- January, 1958 ; Janua;y-May, 1980. Lecturer, Part- time, University of Sydney. Clinical Assistant Superintendent (Preventive), United Dental Hos- pital, Sydney. (1) Marshall-Day, C. D., Stephens, R. G., and Quigley,
L. F.-Periodontal disease : Prevalence and incidence. J. Periodont., 26: 185 (July) 1955.
(2) Mehta, F. S., Sanjana, M. K., and Shroff, B.C.- Prevalence of periodontal disease. 5. Epidemi- ology in Indian child population in relation to their socio-economic status. Internat. D.J., 6 : 31 (March) 1956.
(8) Sanjana, M. F., Mehta. F. S., Doctor, R. H., and Baretto. M. A-Mouth hygiene habits and their relation to periodontal disease. J.D. Res., 3 5 : 645 (Aug.) 1956.
(4) Greene, J. C.-Periodontal disease in India. Report of an epidemiological study. J.D. Res., 39 : 302 (March-April) 1960.
Russell, A. L.-A system of classification and scoring for prevalence surveys of periodontal disease. J.D. Res., 35: 350 (June) 1956.
C 8 ) Massler, M., and Schour, 1.-The P.M.A. index of gingivitis. J.D. Res., 28: 634 (Dec.) 1949 (Abst.)
c
This deficiency has been appreciated by many investigators and it formed the subject of considerable discussion a t the W.H.O. Seminar on Dental Health, Adelaide, 1959.
The present study is part of a broader study of school children in the age groups 9-19 years, predominantly of Thai and Chinese nationality, in which observations were made and recorded on the prevalence of dental caries, torus palatinus, oral hygiene and periodontal disease.
The children lived in Naradhivas, Songkla and Yala, provincial towns of southern Thai- land. The economy of the area is based on agriculture, with rice, rubber, and coconuts being the important products. Three racial groups live in this part of the country but the arrangements of travel prevented our arrival in this area a t a time when the majority of Islamic children were available for examination. The few that were seen at the schools provided only a small amount of information and it has not been included in this study.
Of the children examined, 666 Thai and Chinese children provide the material for this report.
Material and Methods The study group comprised 328 Thai children
(boys 142, girls 186) and 238 Chinese children boys 133, girls 105). The age groups cover the range 9-19 years and of this range the older children came from a secondary school which provided a group of 56 Thai girls aged 16-19 years.
Data recorded were: (1) location and name, (2) race and sex, (3) dental caries prevalence score, (4) presence of torus palatinus, (5) scores for oral debris and oral calculus, and (6) periodontal disease score.
I52 Australian Dental Journal, June, I 96 1
TABLE 1. Periodontal disease, oral debris, calculus and oral hygiene scores by age for 328 Thai children in southern
The scoring for oral debris and calculus on which the index of oral hygiene was calculated followed the method of Greene and Vermillion: (’)
Debris : Score Criteria
0 No debris or stain present. 1 Soft debris covering not more than the
gingival third of the tooth. or the presence of extrinsic stains without other debris regardless of area.
2 Soft debris covering more than one-third and not more than two-thirds of the exposed tooth surface.
3 Soft debris covering more than two- thirds of the exposed tooth surface.
Calculus : Score Criteria
0 No calculus present. 1 Supra-gingival calculus covering not more
than one-third of the tooth surface. 2 Supra-gingival calculus covering more
than one-third but not more than two- thirds of the tooth surface or the presence of individual flecks of sub-gingival cal- culus around the cervical portion of the tooth.
3 Supra-gingival calculus covering more than two-thirds of the tooth surface or a continuous heavy band of sub-gingival calculus round the cervical portion of the tooth
Rule : When in doubt assign lower score.
(7) Greene, J. C., and Vermillion, J. R.-The oral hygiene index-a method of classifying oral hygiene status. J.A.D.A., 61 : 172 (Aug.) 1960.
The condition of the periodontal structures was recorded using Russell’s method which refers to the clinical evidence of obvious mild gingivitis as well as signs of more advanced gingivitis and destruction of the alveolar bone.
Russell’s periodontal index : Boore Criteria
0 Negative. 1 Mild gingivitis - a n overt area of
inflammation in the free gingive, but this area does not circumscribe the tooth.
2 Gingivitis - inflammation completely circumscribes the tooth. but there is no apparent break in the epithelial attachment.
6 Gingivitis with the fomration of pockets-- the epithelial attachment has been broken and there is a pocket. No interference with normal function; the tooth is firm and has not drifted.
8 Advanced destruction with loss of masti- catory function-the tooth may be loose, drifted and depressible in its socket.
Rule: When in doubt assign lower score.
The examinations were made in good natural lighting with mirror and periodontal probe, the observer assessed the condition and called the appropriate score to a recorder who entered the data for each tooth on the patient’s chart.
Thirteen children (2.25 per cent) had evidence of pocket formation which involved 78 teeth; and only four children were free of periodontal disease and had zero oral hygiene scores (Table 6 ) .
The dietary pattern was not made the subject of a n intensive survey, but the general pattern of the daily intake of food was similar in character to that reported by Neilson,(*) Chandra~anond,‘~’ and the author.(1o) Because two of the towns were situated on the eastern coast and were therefore small ports where fairly brisk commercial activity was evident, it was not surprising to see an increased amount of sea feed eaten in restaurants and homes. The impact of European taste is shown in the sample meal available in one of the private schools (Fig. 5). In this will be seen two biscuits made from white flour and sugar filler, bananas and typical Thai food-noodles, meat, rice, and fish sauce.
Results Oral hygiene and periodontal indices by age
groups for the Thai and Chinese children are shown in Tables 1 and 2. Mean oral hygiene indices for the Thai boys and girls are 2.45 and 2.27, and for the Chinese boys and girls 247 and 2.32 respectively.
0 01 0I .W 06 09 12-13 I6.I I PERIODONTAL O l K l Y SCORE
Fig. 1.-Mean oral hygiene scores compared with periodontal disease scores for Thai and
Chinese children aged 9-19 years.
Tables 3 and 4 show the relation between the periodontal disease score and oral hygiene, the oral hygiene index lying between 04‘8-5.2 for the Thai and 1.5-5.0 for the Chinese boys, and between 1.20-6.05 for the Thai and 1.32- 5.22 for the Chinese girls. This relation is shown in Fig. 1.
The mean periodontal scores related to age for all children and a comparison with Greene’s flgures for Indian children in four age groups is shown in Fig. 2.
The mean scores for oral debris, calculus, and hygiene, related to age for all children, a re shown in Fig. 3.
As the dental caries prevalence had been recorded it was possible to compare the caries index and periodontal disease index for each child and the diagram, Fig. 4, shows the distribution of the two conditions.
The absence of periodontal disease was noted in 24 children (4.16 per cent) and despite 114 (20.14 per cent) zero scores for calculus only five children had zero oral hygiene scores.
Discussion Periodontal disease was found to be prevalent
amongst a group of 566 Thai and Chinese school children examined in three towns in southern Thailand. Of this number 542 had
Fig. 2.--Periodontal disease score related to age for children of urban southern Thailand and comparison with those from urban India
(Greene).
some evidence of the disease as determined by Russell’s methods. However, only a small percentage of the children had the condition advanced to the stage where pocket formation had occurred. In those children affected, pocket
(8) Neilson. H. R.-The nutritional problems of Thailand. Canad. Nutrition Notes, 14 : 7, 1958.
(9) Chandrapanond, A.-Dietary surveys in Thailand. Bangkok, Nutrition Laboratory, School of Public Health, 1952.
(10) Amatayakul, K.. Ladavalya, N., and Harris, R.- A dental survey of a small group of Thai children. Amer. J. Clin. Nutrition, 8 : 2, 240 (March-April) 1960.
Australian Dental Journal, June, I96 1
formation was limited to 78 teeth and pockets were not found in any child under thirteen years of age and none was found in the Chinese boys.
There was no significant difference in pre- valence of periodontal disease between boys and girls and between Thai and Chinese. I t will be noticed, despite change in the pattern
I55
Fig.
The somewhat higher index at nine years may be brought about by the possibly greater amount of gingivitis present in the mouth a t the time of transition from deciduous to the permanent dentition. On the other hand, the noticeable increase in the score for the sixteen- year-old children is brought about by the presence of a group of 56 girls from a domestic
DEBRIS. 0 CALCULUS. I ORAL HYGIENE.
3.-Mean scores for oral debris, age for Thai and
calculus, Chinese
and oral children.
hygiene, related t o
for Chinese girls, that the periodontal score increases as the mean oral hygiene score rises (Fig. 1). This is the pattern noted by Greene") in his study of urban and rural Indian children and American children. The mean periodontal disease score related to age and compared with some of Greene's flndings shows at eleven and seventeen years of age the children of urban India have somewhat less periodontal disease than the children of southern Thailand. Since the difference is small this may well be due to differences in technique of examination and assessment.
science school. A few of the older of these girls had particularly clean mouths, but it will be seen from Table 1 that calculus and oral hygiene mean score for the sixteen-year-olds are the highest in the series. The reason for this is not known but it is possible that in the older girls the impact of the secondary education developed an interest in good oral hygiene, for the staff of the provincial health officer included a dental hygienist who attended this school. At this school, in some of the children's mouths the presence of small amounts of sub-gingival calculus was noted.
I56
Race and Sex.
Australian Dental Journal, June, 196 I
1 Periodontal Debris. 1 Calculus. Oral Number Disease. Hygiene.
Examined., -, I-,
3
P E R *' 0 D 0 n T : 2
P t A s 1.5
S C 0
L 1.0
05
-
Thai Boys .. Girls .. Boys .. Girls ..
Chinese
I
Per cent. j No. ~ Per cent. No. Per cent.
3 2.10 3 2-10 1.06 :i I ?:::: 2 1.06 2
I- 142 4.23 186 i 1: I 6.40
566 4.16 17 0 . 9 1x1 20.14 5 0 .9
I 133 0 - 24 18.04 0
~ ; , 3.01 105 1.90 0 - 21 20.00 0
- -
. .
I
I
I
- - . . . , i - r : * : - L : - ! , ' t - 1
4 8 z 1 6 L O ' c i '
CARIOUS TEETH P E R CHILD
Fig. 4.-Distribution of dental caries and periodontal disease in 566 children from urban southern Thailand.
The deposit of calculus was thin, smooth and The change in the value of the components dark, lying beneath the free margin of the of the oral hygiene index shows the importance gingiv;E in which there was no overt areas of the development of deposits of calculus; of inflammation: a n example of this type of there is a marked advance between 10 and 11 mouth is shown in Fig. 6, and can be compared years which steadily progresses, except for a with the example of gingivitis shown in Fig. 7. slightly lower level at fifteen years, and remains
TABLE 5. Numbers of children with zero scores in debris, calculus, oral hygiene and periodontal disease indices.
Australian Dental Journal, June, 196 I 157
at the high level of 1.4 in the older children (Fig. 3). As the calculus deposits increase the oral debris scores decline. This would seem to indicate some possible relationship between calculus deposition and physiological develop-
No significant differences could be demon- strated between racial groups and between boys and girls. Also there appeared to be no relationship between the prevalence of dental caries and periodontal disease. Fig. 4 shows the distribution of the two diseases for the whole group and it will be seen that 369 children had periodontal disease scores of 1.0 or less and a caries index in the range 0-16. One hundred and seventy-nine of these have less than four carious teeth (mean for the group 4.99). The severity of the two conditions bears no relation to one another.
In general, it may be concluded that the group as a whole suffers periodontal disease to the extent of gingivitis, although some individuals have frankly established destruc-
Fig. 5.-Example of school lunch provided in a private school.
ment, and also the need for careful examination to discover the existence of small amounts of calculus beneath the free gingival margin.
The survey shows clearly that while perio- dontal disease is highly prevalent, it has not advanced beyond the stage of soft tissue involvement in many of the children of the
Fig. 7.-Child with overt areas of gingivitis.
tive disease. It has been recognized that the periodontal index does tend to under-estimate somewhat the total number of lesions, but the effect of a constant under-estimation on sample size or accuracy of conclusion is slight,(lS) and i t does not affect the comparability of results as between communities.
Fig. 6.-Mouth 0f.a child with no overt areas of gingivitis, but wlth small masses of calculus
lying beneath the free gingival margin.
age groups examined. Goldman and Cohen'") and Parfitt(l*) amongst others, have stressed the importance of gingivitis in children and the possibility that therein lies the basis for more severe periodontal disease in later life.
(11) Goldman, H. M.. and Cohen. D. W.-Periodontia. St. Louis, The C. V. Mosby Co., 4th ed., 1957 (D. 430).
Qa) P&fitt, .G. J.-Clinical pedodontics (Edited S. B. Finn). Philadelphia, W. B. Saunders Co., 1957 p. 4 4 4 ) .
Summary and conclusions An epidemiological study using the indices methods of Russell and Greene was made of 566 children of Thai and Chinese nationality living in urban areas in southern Thailand in 1960.
Periodontal disease was prevalent in this group, slightly more severe in the eleven- and seventeen-year-old children than recorded by Greene for similar groups in urban India.
(18) World Health Organization. Expert committee on Dental Health-Report on Periodontal Disease. W.H.O. Report, Ser. No. 207, Geneva, 1961 (p. 2 3 ) .
I58 Australian Dental Journal, June, 196 I
the school children in appropriate methods of oral hygiene and the use of the dental staff for the removal of supra-gingival and sub-gingival calculus.
9. The methods of Russell and Greene appear to be satisfactory for determining the extent of periodontal disease and oral hygiene in a community.
3. No significant difference in the prevalence of periodontal disease was demonstrated between the Thai and Chinese children, nor between boys and girls.
4. Alveolar bone destruction was observed in varying degree in 13 children.
5. The relation between the severity of periodontal disease and oral hygiene was close.
6. There was no relation between the presence of periodontal disease and dental caries.
7. More extensive studies including dietary patterns, methods of oral hygiene, and larger numbers of children, including those from rural areas, would be profit- able.
8. Dental health in this community could be effectively improved by the instruction of
Acknowledgement Thanks are due to Dr. Nibhasara Ladavalya
who acted as recorder for these observations and made all arrangements for the survey. Without his assistance this project could never have been attempted.
United Dental Hospital, 2 Chalmers Street,
Sydney, N.S.W., Australia.
Appraisal 0 I t has most certainly not been my intention to deny the tremendous importance and the major contributions which biochemistry and biophysics and the biological sciences generaliy have achieved within our lifetime. I have merely wanted to point out that we do not always get closer to the truth as we slice and homogenise and isolate-that what we gain in precision and in the rigorous control of variables we sometimes lose in relevance to the normal function, and that in the case of certain diseases or problems the fundamental process may often be lost in the cutting.-geymour Eetz, ScCence, December 25, 1960.
