International Journal of Dental and Health Sciences Original Article Volume 04,Issue 04

PREVALENCE OF DENTAL CARIES AND DENTAL FLUOROSIS IN RELATION TO DIFFERENT FLUORIDE CONCENTRATION IN DRINKING WATER AMONG 14-15 YEARS OLD SCHOOL CHILDREN IN RURAL AREAS OF DISTRICT, Priyanka Kumari1, Veeranna Ramesh2 1.Post Graduate Student of Public Health Dentistry, Buddha Institute of Dental Sciences & Hospital, Patna 2.Professor, Department of Public Health Dentistry, Buddha Institute of Dental Sciences & Hospital, Patna

ABSTRACT: AIM: The aim of the study to determine the relationship between dental caries prevalence, degree of dental fluorosis with different concentration of fluoride in the drinking water among 14-15 years old school children in rural areas of Patna. METHODOLOGY: Cross-sectional descriptive study. SPSS version 16 is use for the analysis of data. Karl Pearson’s Coefficient of correlations is use to measure correlation between dental caries, dental fluorosis with varying concentration of fluoride in drinking water. P <0.05 was considered as statistically significant. RESULTS: The overall prevalence of dental caries was 181 (30.17%). Among males it was 54 (9%) and in females it was 127 (21.17%). Among 14 years old school children, the prevalence of dental caries was 119 (19.83%) and in 15 years old school children, it was 62 (10.33%). CONCLUSION: Present study was based on selected children and selected villages of , the results warrant a fully fledged epidemiological study to get a clear picture of the extent of problem Keywords: Dental caries, Fluoride, Rural areas, Drinking water

INTRODUCTION:

World Health Organization has defined structures, halitosis, dental fluorosis etc, Health as "a state of complete physical, will result in poor oral health. Among all mental and social well being and not the disease, dental caries is one of the merely an absence of disease or most common oral disease affecting infirmity". In recent years, this statement children in many underdeveloped and has been amplified to include the ability developing countries of Africa and Asia to lead a "socially and economically including due to lack of public productive life".[1] Oral health is an awareness and motivation, inadequate integral part of general health and any resources for sophisticated dental deviation would reflect the health of the treatments and changing dietary habits. individual in a significant way. Many National oral health survey and fluoride dental diseases or conditions like dental mapping in India, found the prevalence caries, periodontal diseases, of dental caries among 12 and 15-year- developmental variation in dento-facial old children to be 53.8% and 63.1%

*Corresponding Author Address: Dr. Priyanka Kumari. E-mail: [email protected] Kumari P.et al, Int J Dent Health Sci 2017; 4(4):827-841 respectively.[2-3] The consequence of enough fluorotic enamel is fractured and dental caries are of a major concern lost, causing pain, adversely affecting today as it leads to dental pain, loss of food choices, compromising chewing tooth structure, improper masticatory efficiency, and requiring complex dental efficiency, nutritional deficiencies treatment.[12] India lies within the leading to poor growth and development geographical fluoride belt that extends of the individual, esthetic concerns and from Turkey to China. Nearly 12 millions even difficulty in phonetics. It has also of the 85 million tones of fluoride resulted in loss of school days with deposits on earth's crust are found in diminished ability to learn.[5] A significant India.[15] Endemic fluorosis resulting from association has been shown to exist high fluoride concentration in between odontogenic infection due to groundwater is a public health problem untreated dental caries and low body in India.[10] In recent years, the mass index in children.[6] A great forward prevalence of dental and skeletal stride in the era of preventive dentistry fluorosis in India is increasing due to was ushered with the classical population overgrowth necessitating for epidemiological survey of 1930s among more and more water, indiscriminate children of 21 cities of U.S.A conducted digging of tube wells leading to more by T.H. Dean which established the usage of fluoridated water and total crucial link between dental caries unawareness of the importance of water experience & ingestion of fluoride in quality assessment and drinking water drinking water. His results reaffirmed the from any and every source.[16] The hypothesis of McKay that there is inverse available data suggest that more than 15 relationship between dental caries and States in India are endemic for dental fluoride concentrations.[9] Even the fluorosis (fluoride level in drinking water WHO in Oral Health Report (2003) has >1.5 mg/l), five of these have category III stated fluoride as most effective agent in (>50% of the districts affected) which is dental caries prevention.[10] Indeed, the quite alarming. The main fluoride use of fluorides is recognized as one of bearing areas are Gujarat, Rajasthan & the most successful measures for caries Andhra Pradesh where 50-100% districts prevention in the history of public are affected. 10-30% districts are health.[2] But, "fluoride is often termed as affected in the states of Jammu and double edged weapon"- the optimal and Kashmir, Kerala, and Chhattisgarh & judicious use of which offers maximum Eastern India. In Bihar, 30-50% districts caries protection, whereas injudicious are affected.[17] and excessive systemic consumption may lead to chronic fluoride toxicity, AIM: The aim of the present study is to which manifest as dental and skeletal determine the relationship between fluorosis.[2] Dental fluorosis may be more dental caries prevalence, degree of than a cosmetic defect as sometimes dental fluorosis with different concentration of fluoride in the drinking 828

Kumari P.et al, Int J Dent Health Sci 2017; 4(4):827-841 water among 14-15 years old school  Village should have at least one high children in rural areas of Patna district. school.  Village should have a common and OBJECTIVES: stable public drinking water supply 1. To assess the prevalence of dental from ground water source caries among 14 – 15 years old  Resident children of the village must school going children in rural areas have been using water for drinking of Patna district. from one source since birth. 2. To assess the prevalence of dental  12 villages was randomly selected fluorosis among 14 – 15 years old zone wise from 206 short listed school going children in rural areas villages by lottery method. of Patna district. EXCLUSION CRITERIA: 3. To determine the fluoride  Students belonging to other villages concentration in the drinking water but studying in the same school will in the study areas. not be included in the study. 4. To find out the association if any,  Medically compromised students between caries prevalence, degree will not be included. of dental fluorosis, with varying  Those who do not consent for the concentration of fluoride in drinking study will be excluded. water. STATISTICAL ANALYSIS: Data comparison MATERIAL AND METHODS: was done by applying specific statistical This is a cross-sectional study. A total of tests to find out the statistical 600 school children aged 14-15 years significance of the comparisons. The were included in the study. A total of 12 various parameters used for the purpose schools were selected for the study of analysis were arithmetic mean, purpose. A maximum of 50 available standard deviation and standard error. students from each school were included For the comparison of proportions, a chi- in the study, constituting a total of 600 square test, Correlation (r), unpaired t students. Ethical clearance is taken from test, Fisher’s Exact Test, was used with the Institutional Review Board of Buddha continuity correction whenever Institute of Dental Sciences and Hospital, appropriate. ‘p’ value of < 0.05 was Patna (Bihar). A survey was taken to be statistically significant for the systematically scheduled to spread over purpose of analysis. a period of 6 months from October 2014 RESULTS: to March 2015. Informed consent was taken. Out of 600 subjects, 390 (65%) subjects were in 14 years age group while 210 INCLUSION CRITERIA: (35%) subjects, were in 15 years age group.

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Kumari P.et al, Int J Dent Health Sci 2017; 4(4):827-841 The overall prevalence of dental caries Hence gender wise and age wise was 181 (30.17%). Among males it was comparison could not be made. (Table 4) 54 (9%) and in females, it was 127 Table 5 shows the correlation between (21.17%). The results were statistically different fluoride concentration in not significant with P-value (0.7713). drinking water and DMFT scores. This (Table 2) The overall DMFT score study shows a positive correlation. This distributions are as follows. A majority of shows definite association between 419 (69.83%) students had score 0, fluoride concentration in drinking water followed by 92 (15.3%) and 63 (10.5%) and dental caries with R- value 0.047. who are with score 1 and 2 respectively. Score 3 was seen among 16 (2.67%) and DISCUSSION: the least 10 (1.67%) had the maximum According to WHO (1994) the score of 4. The mean DMFT (SD) was recommended fluoride concentration of 0.3016 (0.8892). Among males, 130 drinking water is 0.5 – 1.0mg/L.[56] The (21.67%) had score 0, while 24 (4%) had Ministry of health, Government of India, score 1. Score 2 was observed in 19 has prescribed 1.0mg/L as the permissive (3.16%) of the school children. 8 (1.3%) limits and 2.0mg/L as the excessive limits and 3 (0.5%) had the score of 3 and 4 for fluoride in drinking water. The Indian respectively. Among females, 289 standard Specification for drinking water (48.16%) had the score of 0, while 68 gives a desirable limit of 0.6-1.2mg/L (11.3%) had score 1. Score 2, 3 and 4 (Indian Standards Institute, 1983; Nanoti were seen among 44 (7.3%), 8 (1.3%) and Nawlahke, 1988).[57] In the present and 7 (1.17%) of the school children study, the fluoride concentration in respectively. The results were not drinking water from the study areas of statistically significant in relation to Patna district (rural areas) ranged from gender with P-value 0.6848. (Table 3) 0.43 ppm to 0.59 ppm, which is less than Among 14 years old school children, 271 the recommended optimal fluoride (45.16%) had score 0, while 57 (9.5%) concentration. had score 1. Score 2 was observed in 41 (6.8%) of the school children. 14 (2.3%) ORAL HYGIENE PRACTICES: and 7 (1.16%) had the score of 3 and 4 respectively. Among 15 years old school The oral hygiene aids commonly used by children, 148 (24.66%) had the score of the school children for cleaning their 0, while 35 (5.8%) had the score 1. Score teeth are tooth brush (83.17%), followed 2, 3 and 4 were seen among 22 (3.66%), by sticks (14.66%) and finger (2%). A 2 (0.3%) and 3 (0.5%) respectively. The majority of them used commercial results were not statistically significant in available tooth paste (75.17%), followed relation to 14 and 15 years age group by tooth powder (12.17%). Though with P- value 0.3405. (Graph 2)The majority of the rural study population prevalence of dental fluorosis was zero. are using tooth brush and tooth paste or powder, some of them are also using 830

Kumari P.et al, Int J Dent Health Sci 2017; 4(4):827-841 traditional methods of oral hygiene social economically weak tend to put practices. The influence of use of their wards to government schools and traditional methods may be related to the affordability of health care needs are the customs or social or cultural strata very poor. And also lack of awareness practiced by the elders in that region. synergizes the effect. This observation is High percentage use of oral hygiene aids in agreement with reports of National by school children reflects good Oral Health Survey and Fluoride mapping awareness of the products availability (2004) in India.[68- 69] and also better purchasing power of the school children. This may not be the case DENTAL CARIES: with all school children elsewhere Dental caries is a common dental disease because due to economic reasons, the affecting children. Despite incredible use of tooth brush and tooth paste is still advances and the fact that caries is considered expensive in terms of preventable, the diseases continue to be purchasing power of the poor.[48] Similar a major public health problem. Dental findings were seen in other studies of caries continues to be major oral health Jurgensen et al.[62] Majority of the school problem for children in Southeast Asian children brushed their teeth once a day region because DMFT increased steadily (92%) and most of them followed the from 1.12 in 2004 to 1.87 in 2011 living horizontal method of brushing their in South East Asian countries. This teeth (94.67%). These findings of observation is expected to increase with brushing teeth once a day were higher time in this region. Dental caries affect when compared with findings of Shailee humans of all ages and in all regions of et al (64%),[51] Nurelhuda et al63 Petersen the world. These diseases may never be et al (88%)[64] and Bhayyya et al (90%).65 eradicated because of the complex Increased awareness can be one of the interplay of social, behavioral, cultural, main reason for this increase in dietary and biological risk factors that frequency of brushing among school are associated with their initiation and children. progression.[48] In the present study it The frequency of brushing the teeth was has been reported that an overall more among females (69.33%) when prevalence of dental caries was 30.67 %, compared to males (30.67%). It can be of which 9% were males and 21.17 % justified from various reports that were females. Among 14 years it was females are more concerned about their 19.83% and 10.3 % were among 15 year oral health when compared to males.[66, old school children. The mean overall 48, & 67] interestingly none of students DMFT was 0.3016. The results are used any other oral hygiene aids like statistically not significant with p >0.77. dental floss or inter dental brushes or Similar results were observed in studies mouth rinses. In a country like India, it is done by Shourie in 1947 with a caries generally observed that parents who are prevalence of 33.7% among Ajmer 831

Kumari P.et al, Int J Dent Health Sci 2017; 4(4):827-841 children.[17] The prevalence of dental to the fact that teeth erupt earlier in caries was lower than the Global and females than males which lead to SEARO (Mean DMFT 1.67 and 1.87 prolong exposure of the teeth to the oral respectively). In India, the data from the environment in females.[51] And it is also national oral health survey (2002-2003) possible that boys were better looked states that in children, the caries after than girls . It may also be due to the prevalence was 53.8 % and the mean food habits of taking snacks between DMFT was 1.8 which was comparatively meals for their longer indoor stay in higher when compared to our study. comparison to that of males, who mostly Other Indian studies where high spend their time outdoors.[48] Recently prevalence of dental caries observed are some evidence suggest that higher caries Bhat and Shetty (1946) 75.77%; susceptibility among females may also Chaudhury and Chawla (1957) DMFT be attributed to changes in salivary rates 1.9; Nagaraj Rao (1980) DMFT 4.54; Das and composition induced by hormonal JK et al (2002) DMFT 2.38; Dhar V et al fluctuations among females.[67] In (2007) 46.75 %;[17] Bagramian et al Contrast a study conducted by Moses J (2009) 63.1%. Other studies with higher et al, in Chidambaram among 5-15 years results include Al Haddad et al, Avinash J old children found an increased et al. In contrary studies which show less prevalence in caries among males prevalence of caries include Nodzak (51.42%) compared to females (1990) 25%; Jaili VP (1993) 27%; Rao SP (48.58%).[70] Among different age groups, (1993) 22.8%; David J (2005) 27%.[70] The 14 years old school children had the low prevalence of dental caries among caries prevalence of 19.83% while school children was mainly attributed to among 15 years school children had fluoride content in drinking water 10.33%. There was no literature available (though it was less than the to compare with the results of this study recommended optimal level) and among the age groups. increased use of commercially available toothpaste containing fluoride and also The prevalence of dental caries at better oral hygiene practice made varying fluoride levels had been children develop less dental caries. It is extensively studied during the last 50 also reasoned that lack of availability of years to know the safe and acceptable cariogenic diet, poor access to refined levels of fluoride in drinking water for sugar and sugar products can result in maximum caries protection and less caries.[48] aesthetically acceptable probable dental fluorosis. In India some studies to Females had significantly higher establish the relationship between prevalence of caries than males. This is in dental caries at varying fluoride levels in line with the findings of Al Shammery drinking water have been reported.[47] In and Gulie, Dummer et al., Sogi and this study with little variation in the Bhaskar, and Singh et al. This may be due concentration of fluoride in drinking 832

Kumari P.et al, Int J Dent Health Sci 2017; 4(4):827-841 water (Ranging between 0.43 - 0.59ppm) CONCLUSION: there was positive correlation between dental caries and fluoride concentration It is concluded from the present study in drinking water, i.e. with increase in that, fluoride concentration in drinking water,  Dental caries were commonly the prevalence of dental caries observed among school children in decreased. This observation has been in rural areas of Patna District. observed in many classical studies done  The concentration of fluoride in on fluoride and dental caries. drinking water showed less than DENTAL FLUOROSIS: (0.53ppm) the recommended optimal fluoride concentration (WHO), as a Endemic fluorosis continues to remain a result no dental fluorosis cases were challenging national dental health observed. problem. The effect of fluoride on  There was a positive correlation dentition is dose dependent and is not between dental caries and fluoride confined to increase caries resistance. concentration in drinking water. Although being a "late" measure of  Since the present study was based on fluoride exposure, dental fluorosis is the selected children and selected villages most sensitive sign of prolonged high of Patna District, the results warrant a fluoride exposure.[14] It is evident from fully fledged epidemiological study to many literatures that increased get a clear picture of the extent of consumption of fluoride, more than the problem. recommended optimal fluoride SUMMARY: The present study on school concentration in drinking water over children aged 14-15 years in rural school prolong period can result in dental of Patna district was aimed to assess the fluorosis. In this study the prevalence of prevalence of dental caries, dental dental fluorosis was zero. It is reasoned fluorosis and the possible relationship of that the concentration of the drinking fluoride concentration in drinking water water estimated in all study areas were with dental caries and dental fluorosis. less than the recommended optimal The study results are summarized as fluoride level of 0.7 ppm (Lower end of follows. the recommended concentration 0.7 - 1.2 ppm (WHO), thus no prevalence of  A total of 600 school children aged dental fluorosis was observed. The 14-15 years from 12 schools were correlation between the occurrence of included in the study. dental fluorosis and increased  30.67% were males and 69.33% were consumption of more than optimal level females. of fluoride in drinking water is a well  65% were among 14 years age group documented. The present finding of the and 35% were among 15 years age study justifies the above statement. group.

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Kumari P.et al, Int J Dent Health Sci 2017; 4(4):827-841  The overall prevalence of dental optimal fluoride concentration (0.7 caries was 30.17%. ppm WHO), hence no dental fluorosis  The overall prevalence of dental cases were observed. fluorosis was zero.  Association between dental caries  The fluoride concentration in and different fluoride concentrations drinking water varied between 0.43- in drinking water showed positive 0.59. The mean fluoride correlation. concentration in drinking water was 0.53 ppm.  Regarding the association. The fluoride concentration in drinking water was below the recommended REFERENCES:

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Kumari P.et al, Int J Dent Health Sci 2017; 4(4):827-841 TABLES:

Table 1 shows the distribution of study population from each study area Study Area No of children Gender examined Males Females 14 Years 15 Years 14 Years 15 Years 50 45 5 0 0 Parasa 50 11 2 26 11 Dumari 50 28 0 22 0 Punpun 50 22 1 23 4 Patna city 50 37 13 0 0 50 1 0 45 4 Maner 50 3 1 17 29 Sorampur 50 0 0 35 15 50 0 0 24 26 Athmalgola 50 0 0 17 33 Digha 50 0 0 12 38 Anouli 50 6 9 16 19 Total 600 153 31 237 179 Total 184 416

Table 2 shows the gender wise distribution of dental caries among the study population. Caries Present n(%) Caries Absent Total Gender n(%) n(%) Male 54(9) 130(21.67) 184(30.67) Female 127(21.17) 289(48.16) 416(69.33) Total 181(30.17) 419(69.83) 600(100.00)

Chi-Square Value df ‘p’ Value 0.08447 1 0.7713

Table 3 shows the gender wise distribution of the study subjects according to DMFT Score. Gender DMFT Score Male Female Total n(%) n(%) n(%) 0 130 (21.67) 289(48.16) 419 (69.83) 1 24(4) 68(11.33) 92 (15.33) 2 19(3.17) 44(7.33) 63 (10.50) 3 8(1.33) 8(1.33) 16 (2.67) 4 3 (0.5) 7 (1.17) 10 ( 1.67) Total 184(30.67) 416(69.33) 600 (100)

DMFT Score Gender Male Female Total Mean DMFT (SD) 0.5326 0.5000 0.3016 (0.9576) (0.8836) (0.8892) P value 0.6848 (NS) 839

Kumari P.et al, Int J Dent Health Sci 2017; 4(4):827-841 Table 4.Gender wise distribution of dental fluorosis in the study population

Dental Fluorosis Dental Fluorosis Total Gender Present n(%) Absent n(%) n(%) Male 0 184(30.67) 184(30.67) Female 0 416(69.33) 416(69.33) Total 0 600(100) 600(100)

Table 5 Shows the correlation between different fluoride concentration in drinking water and DMFT Score.

Correlation R value P value R2 Fluoride concentration v/s 0.047 0.25 0.002212 DMFT Score

GRAPHS:

Graph 1 shows the fluoride concentration of drinking water in different study areas.

Graph 2 shows the age wise distribution of the study subjects according to DMFT Score.

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Kumari P.et al, Int J Dent Health Sci 2017; 4(4):827-841 Graph 3 Shows the correlation between different fluoride concentration in drinking water and DMFT Score.

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