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Dental caries and oral health practice among 12year old school children from low socio-

economic status background in ZimbabweBrighton Tasara Mafuvadze1, Lovemore Mahachi1, Benford Mafuvadze2, &

1Department of Dentistry, College of Health Sciences, University of Zimbabwe, Zimbabwe,2Departmentof Biomedical Sciences, University of Missouri, USA

&Corresponding author Benford Mafuvadze, Dalton Cardiovascular Research Center, University of Missouri, Columbia, 65201,USA

Abstract

Introduction: Dental caries is one of the most prevalent chronic diseases affecting children inSub-Saharan Africa. Previous studies show a higher prevalence of dental caries in children fromlow socio-economic status backgrounds. The purpose of this study was to determine the prevalence of dental caries among 12 year old children in urban and rural areas of Zimbabwe andestablish preliminary baseline data.Methods: A descriptive cross-sectional study wasconducted among 12 year old children at primary schools in Harare and Bikita district. A Pre-tested questionnaire was administered to elicit information from the participants on toothcleaning, dietary habits and dental experience. Dental caries status was assessed using the DMFTindex following World Health Organization (WHO) guidelines.Results: Our results showed ahigh prevalence of dental caries in both urban (59. 5%) and rural (40. 8%) children. The meanDMFT in urban and rural areas was 1. 29 and 0. 66, respectively. Furthermore, our data showeda general lack of knowledge on oral health issues by the participants.Conclusion: There is high prevalence of dental caries among 12 years old school children in both urban and rural areas ofZimbabwe. This calls for early preventive strategies and treatment services. We recommendincorporation of oral health education in the elementary school curricula.

Introduction

Dental caries remains a major oral healthdisease affecting children world-wide[1].While the prevalence and severity of dentalcaries in most industrialized countries havedeclined substantially in recent years, indeveloping countries like Sub-SaharanAfrica the prevalence is predicted toincrease[2]. This disparity betweenindustrialized and developing countries has

been attributed to preventive oral health care programs adopted by the former andchanges in dietary habits coupled withinadequate exposure to fluorides indeveloping countries[2]. According to theWorld Health Organization (WHO) the prevalence of dental caries among schoolaged children is estimated to be as high as90% in some countries[3]. For children in particular, poor oral health can havenegative impacts on quality of life and
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academic performance at school[4]. Apartfrom causing chronic pain and discomfort,untreated dental caries can impact dailyactivities in terms of play, sleep, eating andschool activity[5, 6].

Establishing baseline data on children dentalcaries and other oral health issues throughregular national surveys is crucial for planning and development of intervention programs[1]. Unfortunately, most countriesin Sub-Saharan Africa focus on highmortality diseases like HIV and AIDS,cancer, tuberculosis, diabetes and malaria

and pay little attention to oral health issues. No study has investigated the prevalence ofdental caries among school children inZimbabwe in the last decade rendering itdifficult to understand the status and patternof oral health. To our knowledge, the lastoral health survey targeting children lessthan 12 years old was done in Zimbabwe in1985 by Chironga et al[7]. The othernational survey done in 1995 coveredadolescents and adults[8]. Both surveys,however, showed that the prevalence ofdental caries in Zimbabwe was high acrossall age groups. The occurrence of dentalcaries has, however, been observed towidely vary from place to place and fromtime to time depending on socio-demographic characteristics such as familyincome[9]. When faced with hard economicchallenges, it is likely that most people willgive less priority to oral health issues. Sincethe last oral health survey, Zimbabweexperienced major economic challengesculminating in widespread poverty and highunemployment rates[10]. We hypothesizedthat the socio-economic situation that prevailed in Zimbabwe between 2000 and2010 resulted in an increase in dental cariesamong school-going children. Previousstudies show a higher prevalence of dental

caries in children from low socio-economicstatus backgrounds[11]. Apart from thehighlighted economic challenges, theintroduction of multi-currency use inZimbabwe in 2009 indirectly led to an

increase in consumption of high sugar-containing products which are known to promote development of dental caries inchildren[12]. Due to unavailability of lowdenominations and coins for the majorcurrencies currently in use such as the SouthAfrican rand and the USA dollar, most people find it convenient to use easilyavailable sugary products like sweets andchocolate during purchasing transactions aschange. The frequent and high consumption

of sugars is the major cause of dental cariesin children[12].

The main focus of this study was todetermine the prevalence of dental cariesamong twelve year old school children fromlow socio-economic status backgrounds in both urban and rural areas of Zimbabwe.Our results show a high prevalence of dentalcaries in both urban and rural children.

MethodsStudy design: This is a descriptive cross-sectional study designed to assess dentalcaries experience among 12 year old schoolchildren from low socio-economic status background attending public primaryschools in Zimbabwe.

Setting and study population: Forconvenience purposes, participants in thisstudy were drawn from two primary schoolsin urban (Harare, the capital city) and rural(Bikita district, located 400km, south ofHarare) areas respectively. The study population consisted of 12 year old childrenattending public primary schools. We particularly focused on this age group as it isthe WHO recommended index age[13].
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Sampling method: For convenience purposes two public primary schools wereselected in Harare (urban) and Bikita (ruralarea). The schools were selected to representhigh and middle density urban and rural

communities since our goal was to assessdental caries in children from a low socio-economic status background. At participating schools, all students withwritten consents were included in the studyand examined. The sample size wasestimated using Dobson's formula byapplying an estimated dental caries prevalence of 15%, a design effect of 2, anda precision of 0. 05 and was determined as170 children.

Data collection technique and tools: A pre-tested questionnaire comprisinginformation about the children'sdemographic background, oral healthknowledge, attitudes and practices, dietaryhabits and dental services utilization historywas administered and completed by participating children under supervision.Dental caries experience among the participants was assessed using the Decayed,Missing and Filled Teeth (DMFT) index,which is a measure of life time dental cariesexperience in permanent dentition. Clinicaloral examination of the children was performed by one of the authors (BTM, aqualified practising dentist) following WorldHealth Organization (WHO) diagnosticcriteria[13]. All examinations were done inthe classrooms with the children seated in anupright chair.

Ethical consideration: The study wasreviewed and approved by the University ofZimbabwe Joint Ethics and ResearchCommittee. In addition, permission wassought and granted by the Ministry ofEducation Sport, Arts and Culture. At participating schools, permission was soughtfrom headmasters, teachers, and only

children whose parents/guardians gavewritten consent were included in the study.

Data analysis: Collected data were entered,cleaned and stored using Epi-info statistical

package-7. Statistical analysis was doneusing the T-test, Chi-square and Wilcoxontest. Association between variables such asgender, socio-economic status and locationon dental caries occurrence was determined .Significance level was set at p


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study to have dental cavities were lower jawteeth and overall, the occlusal surface tendedto be the most affected. On the other hand,first lower molars accounted for 44. 8 % ofthe affected teeth.

Dietary habits and oral health practicesof participating children

Table 2 below shows the frequency atwhich children reported consumption ofdietary products commonly associated withdevelopment of dental caries in this agegroup. Our results showed a higherconsumption of high sugar-containing products like sweets, chocolate and soda

drinks by urban children. Not surprising, asignificant association between regularconsumption of sugary products and a highDMFT was observed among urban children.As shown in Table 2 , urban children whoreported regular consumption of sweets andchocolates had significantly (p


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Saharan countries[14], which show higher prevalence of dental caries among urbanchildren compared to their ruralcounterparts. This disparity in dentaloccurrence between urban and rural children

has been partially attributed to increasedaccess and consumption of high sugar-containing foods and beverages in urbanareas [14]. While most people in rural areasin Zimbabwe cannot afford and perceivethese sugary-products as non-beneficial,affording them is often considered a symbolof higher socio-economic status. In contrastto our prediction, the consumption of sugary products in rural areas is still moderatelylow. Given the low consumption of sugary

products reported by rural children in thisstudy, the higher prevalence of dental cariesis potentially due to other factors. Economicchallenges tend to have severe impact onrural people since they have limitedfinancial resources. This is quite evidentfrom this study as shown by limitedavailability of basic oral hygiene productssuch as fluoride-containing tooth pastes andthe widespread use of wooden sticks forcleaning teeth reported by rural children.

Despite reporting high use of commercialfluoridated toothpaste and frequent teethcleaning, the prevalence of dental caries (59.9%) observed among urban children in thisstudy is significantly higher than what wasreported recently in similar studies in Sudan[15], Uganda[16], Tanzania[17], andKenya[6]. We hypothesize that this might be a direct reflection of socio-economicsituation in Zimbabwe and partially aconsequence of the increased consumptionof high sugar-containing products. Thisstudy revealed high levels of untreatedcaries with DMFT values of 1. 225 and 0. 65for urban and rural children respectively(Table 1 ). This trend of high level ofuntreated caries parallels what was observedin several Sub-Saharan African countries[6,

14, 16-18]. This is an indicator of a generallack of professional oral health service inZimbabwe. In addition, the high numbers ofuntreated teeth may also be a result of thelow priority placed on oral health care

compared with other needs. As previouslydescribed by Dye and Thornton-Evans[9] when people are faced with economicchallenges they are unlikely to prioritize oralhealth unless they are well informed on thesignificance of maintaining good oralstandards.

While previous studies in industrializedcountries show a lower caries prevalenceamong children who reported prior

consultation with a dentist[19], in thisstudy; we observed a higher prevalence ofdental caries among urban children whoreported ever consulting a dentist(Table 2 ).We did not enquire on the reasons forconsulting dentist by children in this study but it appears consultation was not forroutine preventive clinical examination butlikely for treatment of already existing problems. Routine annual dental check-upsthat are common in industrialized countriesare not affordable to most people inZimbabwe; as a result children are onlytaken to a dentist as a last resort in mostcases to have the teeth extracted. Previousstudies[6, 16-18] have shown similarfindings of untreated dental caries pointingto a common prevailing situation throughoutSub-Saharan Africa.

Despite limitations of this study whichinclude use of a small convenient samplesize drawn from only two schools coupledwith our inability to verify the informationreported on the questionnaire, our findingsconcur with previous studies done inZimbabwe[7, 8] and several other Sub-Saharan Africa countries[6, 16-18]. Ourdata from the self-reported survey clearlyshows deficits in healthy oral hygiene
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behavior while dental examinations revealeda high degree of inadequate dental care.Based on our findings, we advocate for ashift from the current restorative orienteddental services to preventative oriented

services if an improvement in oral healthdelivery is to be achieved in Zimbabwe.Concerted effort from oral health professionals, schools, governments and theworld health organization is required inorder to increase general oral healthawareness in both urban and rural areas .Evidence from developed countries showsthat reduction of dental caries prevalencecan only be achieved through targeted preventative and oral hygiene promotion

programmes[19]. Since most urban childrenin this study reported not getting anyinformation on oral health issues at school,one strategy that can used to increase oralhealth awareness among children is toincorporate oral health issues in the schoolcurricula. We propose that schools could promote preventive oral health practicesthrough various activities like educativedramas, poetry, music and art. In this study,no oral health education campaigns havereportedly been done in the two areasstudied in a long time. Thus, the Ministry ofHealth in collaboration with the WorldHealth Organization could also increasegeneral oral health awareness by regularlyholding national oral health awareness promotion campaigns. As a long termmeasure, it is important that Zimbabwe andother Sub-Saharan African countries supportthe training and education of oral health professionals who can develop and maintainoral health strategies and policies. Wefurther recommend establishment of nationalsystems for periodic collection, analysis andinterpretation of oral health data for allindicator age groups.

Conclusion

Our data shows a high prevalence of dentalcaries among 12 year old school childrenfrom low socio-economic status background

in both urban and rural areas of Zimbabwe.This data may be of importance in theevaluation of the past and planning of futureoral health prevention and treatment programs targeting young children in primary schools. A comprehensivecommunity-focused oral health careintervention that includes oral healtheducation in elementary schools and homesis recommended to increase general oralhealth awareness.

Competing interests

The authors declare that there are noconflicts of interest. Authors contributions Brighton Tasara Mafuvadze designed thedata tool, collected the data and wasinvolved in initial data analysis and draftingof the manuscript. Lovemore Mahachi hadoversight of all the stages of the researchand reviewed the final draft for academic

content. Benford Mafuvadze analyzed thedata and critically reviewed the finalmanuscript. All authors approved the finalmanuscript. Acknowledgments

The authors would like to thank all theteachers and the children who participated inthis study.

Tables

Table 1 : Dental caries experience in participating children from rural and urbanschoolsTable 2 : Dietary habits and oral practicesamong participating children and associatedcaries prevalenceTable 3 : Knowledge of potential causes ofdental caries and preventive measures
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dental caries and oral health practice among 12 year old school children from low socio

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