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ORIGINAL

Cueto
ARTICLE
et al

Evaluation of an Oral Health Promotion and Preventive


Programme: A Case-Control Study

Alfredo U. Cuetoa/Alan S. Barrazab/Daniela A. Muozc/Silvana Changd

Purpose: To evaluate the oral health of children who were beneficiaries of a promotion and preventive programme for
more than 6 years and to estimate the factors relating to their oral condition.

Materials and Methods: In this case-control study, the total population comprised all 7- to 13-year-old children who
attended the Paediatric Dentistry Centre of Reference Simn Bolvar (CROSB), a programme for students of the com-
munity of Via del Mar, Chile. The case group was treated from the age of 7 to 13 years and controls were only seen
at the age of 13 (had not been previously enrolled in the programme). The compilation of data was carried out through
examination of clinical records. Statistical analysis included Fishers Exact Test, the chi-square and Mantel-Haenszel
tests to determine odds ratios, log-linear models to study some types of relationships between the different qualitative
variables and Moods Median Test for quantitative variables. Finally, a logit-type generalised linear model (GLM) was
adjusted to estimate the probability of a caries-free child according to the different variables under study.

Results: The main finding is that this programme does not successfully control the local risk factors of caries. The
factors that jointly explain the presence of caries-free children were: non-participation in the programme, attending
public school and the presence of sealed teeth.

Conclusion: Even though the evaluated programme creates equity in the indicators of oral health among its beneficiar-
ies, it does not reach the levels of oral health of the non-vulnerable population. It is recommended that this programme
seek more effective tools.

Key words: children, oral health, preventive dentistry, programme evaluation

Oral Health Prev Dent 2016;14:49-54 Submitted for publication: 18.03.13; accepted for publication: 28.03.14
doi: 10.3290/j.ohpd.a34994

P romotional and prophylactic actions carried out


systematically contribute to the maintenance of
oral health in children.9 On this basis, a series of
should be periodically evaluated to measure their
impact on the target population in order to optimise
and refocus the actions and resources.
prevention and promotion programmes in oral In Chile, this type of programme has tradition.
health have been implemented. These programmes Since 1984, the Paediatric Dentistry Centre of Ref-
erence Simn Bolvar (CROSB Centro de Referen-
a
Titular Professor, Faculty of Dentistry, University of Valparaso,
cia Odontopeditrico Simn Bolvar) has been de-
Valparaso, Chile. Experimental design, wrote and proofread the veloping promotional, prophylactic and curative
manuscript, consulted on and performed statistical evaluation, dental activities through a programme that covers
contributed substantially to discussion.
b vulnerable schools both public and private, the lat-
Assistant Professor and Statistician, Faculty of Dentistry, Univer-
sity of Valparaso, Valparaso, Chile. Experimental design, proof- ter only when they are partially state subsidised.
read the manuscript, performed statistical evaluation. The promotional-preventive programme starts with
c
Assistant Professor and Dental Surgeon, Faculty of Dentistry, Uni- the visit of an educator from the module to the
versity of Valparaso, Valparaso, Chile. Wrote and proofread the
manuscript, contributed substantially to results, discussion and school to encourage participation and attendance
conclusion. in the programme and meet with parents, guardi-
d
Dental Surgeon, Faculty of Dentistry, University of Valparaso, Val- ans and children. Then, the entire grade level is
paraso, Chile. Study idea and hypothesis, experimental design,
performed the experiments in partial fulllment of requirements taken from the school to the premises where the
for a degree, wrote part of the manuscript, contributed substan- programme takes place for a week. During that
tially to discussion. time, they receive education in oral health consist-
Correspondence: Professor Alfredo Cueto, Subida Carvallo 211,
Playa Ancha, 502250-9 Valparaso, Chile. Tel: +56-32-508-568, Fax: ing of six units (mouth, cavities, healthy eating,
+56-32-508-534. Email: alfredocuetourbina@yahoo.es habits, dental trauma and my dentist) through

Vol 14, No 1, 2016 49


Cueto et al

classes, videos, hands-on activities, games and Cases were chosen according to inclusion criteria:
songs, in a specially equipped classroom. Within the 4 permanent molars had erupted by the time of
these units, oral hygiene techniques are taught and entry into the programme, children entered the pro-
practiced in a toothbrushing room (a space with gramme in 2003 and were controlled in 2009 at
mirrors and sinks at the height of the children) the age of 13 years. In this group, some of the clin-
where hygiene indices are also calculated. Synchro- ical records of children were excluded, i.e. those
nously, they receive clinical care using the four- and who had been released from treatment due to re-
six-hands technique to treat as many teeth as pos- peated absences. For both groups, incomplete or
sible in one session and keep full treatment time to missing clinical records led to exclusion.
a minimum. Treatment mainly consists of primary This Centre provides a promotional-preventive
activities, i.e. sealant application, various fillings, dental programme for students of educational insti-
tooth polishing, supragingival scaling, topical fluor- tutions (public and partially state-subsidised
ide application, extractions, pulpotomies and ortho- schools) from the city of Via del Mar which have a
dontics. This makes it possible to release the chil- School Vulnerability Index greater than 30%. This
dren from treatment and then perform periodic index is calculated by estimating the percentage of
checkups. children in the institution whose parents had less
The same professionals who work on the pro- than 8 years of education and a very low socioeco-
gramme also offer health fairs at public squares, nomic level (less than US $5000 per year) or were
schools, etc, to reach the entire community, not indigent, receiving a family allowance from the
just children. state.
According to our literature search, this study is Data were collected by reviewing files and trans-
the first to evaluate the results of a promotional- ferring data to a form made especially for this pur-
preventive programme in oral health. Thus, the pur- pose. The following qualitative variables were re-
pose of this study was to evaluate the oral health corded: first molars caries-free (y); case-control
of children who attended a promotional-preventive (x1); gender (x2); educational establishment (x3) with
programme for more than 6 years and analyse their a measurement scale of public and partially state-
oral health status-related factors. subsidised as a proxy variable for socioeconomic
status; occupation of the mother (x4) and father
(x5); low (x6) and middle (x7) socioeconomic status
MATERIALS AND METHODS and systemic factors (x8). The quantitative variables
comprised the Greene-Vermillion Simplified Oral Hy-
In this case-control study, the total study popula- giene Index (x9);7 number of first molars sealed
tion comprised all children admitted to the Paediat- (x10), and DFE-molars (Decayed, Filled, Extracted)
ric Dentistry Centre of Reference Simon Bolivar be- by tooth (numbers 16, 26, 36 and 46). A database
tween 2003 and 2009 with complete clinical was subsequently built, protecting the identity of
records, amounting to 16,379 children. The sample the study subjects.
size was calculated with a statistical power of Statistical analysis consisted of describing the
81.35%; to determine it for the control group, the results obtained through descriptive measures, ta-
national prevalence of caries-free status reported bles and overview graphics. To compare propor-
by Ministerio de Salud Chile in 2009 was take as tions in qualitative variables, Fishers Exact Test
the reference,9 and was estimated to be 37.5% at was used, and the chi-square and the Mantel-Haen-
age 12. For the case group, the reference used was szel tests were used to determine odds ratios
52%, in accordance with the study by Cueto et al,5 (OR).14,15 Log-linear models were also applied to
which reported the outcome of this programme. study some types of relationships between differ-
Cases included 362 clinical records of children who ent qualitative variables incorporated in the soft-
had attended the programme and were checked ware Minitab 15 and R-Cran 2.13.1 (Minitab, Penn-
periodically from the age of 7 to 13 years; controls sylvania State University; State College, PA, USA.
included 140 clinical records of children who en- The Mood median test was used to compare quan-
tered this Centre at the age of 13 years and had titative variables between groups. Finally, a logit-
not previously been beneficiaries of the programme type GLM model was adjusted to estimate the prob-
at the time of the evaluation. Both cases and con- ability of a child to be caries-free according to the
trols were selected by simple unpaired random different variables under study.
sampling and with the respective authorisation.

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Cueto et al

Table 1 Distribution of systemic diseases and schools between cases and controls
Cases Controls

Variable Caries free Not caries free Caries free Not caries free p

Yes 34 15 9 12

% 17.89% 8.72% 13.85% 16.00%


Systemic
No 156 157 56 63 0.2474
diseases
% 82.11% 91.28% 86.15% 84.00%

Total n 190 172 65 75

Municipal 161 154 48 36

% 84.74% 89.53% 73.85% 48.00%

Compound group: state


26 18 12 27
subsidized + private
Type of
0.3297
school % 13.68% 10.47% 18.46% 36.00%

No information available 3 0 5 12

% 1.58% 0.00% 7.69% 16.00%

Total n 190 172 65 75

Total % 52.50% 47.50% 46.40%% 56.60%

RESULTS Public Partially State Subsidized School


dmft/DFMT

The total number of cases was 362 and the total


number of controls 140. The proportion of caries- Decayed

free children in the case group was 52.5%


Filled
(n = 190), which was slightly greater than controls,
where it was 46.4% (n = 65); this difference is not
Missing
significant (p = 0.234). This implies that no signifi-
cant change was observed in the frequency of car-
No. of Sealed
ies-free children between the two groups
(OR = 1.275; 95% CI = 0.86211.8844). Bivariate Groups
Cases
Control 0 1 2 3 4 0 1 2 3 4
analysis showed that although the differences are No. of teeth
not statistically significant (Table 1), they will be rel-
evant in the regression models that we propose. Fig 1 Distribution of dental indices according to study
groups and type of school.
The mean dmft score was 0.914 (SD 1.200) in
cases and 1.286 (SD 1.446) in controls, with no
statistically significant difference (p = 0.174). How- trols 1.143 (SD 1.477), this difference was statisti-
ever, the comparisons of case vs control within cally significant (p = 0.000).
each component showed significant differences The dmft/DMFT scores differed statistically sig-
(p = 0.00): 0.003 (SD 0.053) vs 0.421 (SD 0.814) nificantly between the study groups and types of
for the decayed component, 0.912 (SD 1.201) vs school (p = 0.039), being higher in the control
0.814 (SD 1.227) for filled and 0.000 (SD 0.000) group from partially state-subsidised establish-
vs 0.050 (SD 0.249) for the extracted component. ments (Fig 1). In addition, both the number of cari-
The Oral Hygiene Index for cases showed a mean ous teeth and sealed teeth differed significantly
of 34.09% (SD 12.29) and a median of 33.30%, between the study groups and types of school
and controls exhibited a mean of 35.06% (p = 1.1e-06 and p = 2.2e-08, respectively), with
(SD = 12.46) and a median of 33.30%. In terms of higher numbers found in the case group. In con-
sealed teeth, cases had 3.075 (SD 1.206) and con- trast, the number of filled and extracted teeth did

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Cueto et al

Table 2 Saturated log-linear model to explain caries-free children


Model Chi-square test: p
Residual devia-
Notation Description tion AIC Comparison with [123]

[1][2][3] Mutual independence 31.021 83.27252 3.031e-06

[1][23] 8.9602 63.21149 0.02982

[2][13] Joint independence 29.824 84.07513 1.503e-06

[3][12] 30.62 84.8712 1.022e-06

[13][23] 7.7629 64.01411 0.02062

[12][23] Conditional independence 8.5589 64.81017 0.01385

[12][13] 29.423 85.67382 4.083e-07

[12][13][23] Uniform association 7.6041 60.25125 0.005824

[123] Saturated model 4.5741e-14 65.85533 -------

Table 3 Estimated probabilities of caries-free children according to protective variables


Estimated probability
Cases group (x1) Attending municipal school (x3) Number of sealed teeth (x10) of a caries-free child (%)

Yes Yes Yes 0.376

Yes Yes No 0.031

Yes No Yes 0.154

Yes No No 0.012

No Yes Yes 72.187

No Yes No 17.623

No No Yes 51.504

No No No 8.049

not differ significantly between the study groups or of sealed teeth significantly explain the data (Devi-
types of school (p = 0.130) and (p = 0.6452). ance Dif. [Null, Residual] = 304.78; GL = 3; p = 9.h-
Thus, a log-linear model was adjusted for the 66; AIC = 343.61). Hence, the equation estimated
variables caries-free [1], study group [2] and type of for the model is:
school [3]. The results are given in Table 2. How-
ever, significant differences were obtained between
all the adjusted models and the saturated model
(chi-square test deviances: p < 0.05), i.e. statisti- where is the estimated probability of observing a
cally significant evidence was found that the state caries-free child according to established values of
of being caries-free, the socioeconomic level and x1, x3 and x10. The estimated probabilities for differ-
the study groups interact. ent combinations of values of x1, x3 and x10 are
A logit-type GLM was used to estimate the prob- shown in Table 3.
ability of a child to be caries-free considering the It was observed that the intercept and the varia-
following explanatory variables: study group, gen- bles x1, x3 and x10 are significant for model. Accord-
der, type of school, unemployment of mother or fa- ing to the obtained deviance, it can be concluded
ther, socioeconomic level of childs family, pres- that the model significantly explains the observed
ence of systemic disease, Oral Hygiene Index and data (Deviance Dif. [Null, Residual] = 352.127;
number of sealed teeth. This showed that only the gl = 10; p = 1.049747e-60; AIC = 352.13). The re-
variables study group, type of school and number sults when non-significant variables are removed

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Cueto et al

Table 4 Coefcients of the reduced model for caries-free children


Coefcients of the reduced model Estimation Standard error Z-value p

Intercept -2.4357 0.4393 -5.544 2.95e-08

x1 -6.5318 0.8461 -7.720 1.16e-14

x3 0.8936 0.3728 2.397 0.0165

x10 2.4959 0.2391 10.437 2e-16

are presented in Table 4. This shows that the re- ber sealants applied (mean 3.1 on first molars) in
duced model significantly explains the observed the case as opposed to the control group. It has
data (Deviance Dif. [Null, Residual] = 304.7772; been shown that sealants can prevent demineral-
gl = 3; p = 9. 200573e-66; AIC = 343.61). Compar- isation of enamel pits and fissures and arrest non-
ing the two models, it is apparent that both the re- cavitated carious lesions.3,4,8
duced and the full model statistically explain the Comparing cases and controls in relation to type
observed data (Deviance Dif = 5.4859; gl = 7; of school, the children attending partially state-sub-
p = 0.6009). Evaluation of the reduced model dem- sidised schools exhibited less deterioration of oral
onstrates that it contains no significant atypical health, since they are protected by the programme,
points (Bonferroni test: p = 0.19423) and although unlike the control group, which had worse oral
it would be expected that remainder varies around health. One reason for this may be that, through
zero, this is statistically not true (test of symmetry the programme, cases regardless of school type
MGG: p < 2.2e-16). Finally, no effects of the re- had access to a higher level of knowledge of risk
sponse (dependent) variable on the model were behaviours and their parents at home supported
observed. prophylactic measures, such as access to tooth-
brushes and checking proper hygiene techniques.
On the other hand, when the type of school is pub-
DISCUSSION lic, children not covered by the programme (control)
have less tooth decay than cases. Possible expla-
Although the promotional-preventive dental pro- nations are that 1) children in the case group at-
gramme offered by the Paediatric Dentistry Centre tending public school are particularly vulnerable
of Reference Simon Bolivar reduces the gaps be- (because a very important but undetermined pro-
tween long-standing beneficiaries so that children portion of the cases were extremely vulnerable chil-
of different socioeconomic origin achieve the same dren and always included in the programme) and 2)
dental indices/level of dental health, the main find- controls from public schools also had access to a
ing is that this programme fails to reach the stand- series of measures implemented for vulnerable
ards of the non-vulnerable population. This is children in Chile, e.g. the National School Assis-
shown by the lack of significant differences in the tance Council (JUNAEB) oral health programme,
DMFT-molar and the oral hygiene indices between which treats children through 272 modules through-
groups, which is remarkable considering that the out the country and reaches 191,987 children per
case group participated in a systematic programme year,13 and Chile Solidario, which is independent of
of more than 6 years; the programme failed to con- other programmes and is the model programme of
trol the local risk factors for tooth decay. dental care provided in municipal primary health-
It was found that the overall DMFT-molar score of care centres.
0.91 was almost exclusively attributable to the Another possible explanation for the contradic-
filled component (0.91), followed by decayed tory result described above is that groups were not
(0.002) and extracted (0). The explanation for this comparable in terms of school type, since in the
is that the promotional-preventive programme incor- control group, the proportion of public school chil-
porates many rehabilitation activities that will limit dren was 40%, but in the case group only 12%. This
the damage as well as a large number of specific occurs because the programme covers high vulner-
prophylactic activities, resulting in a significant re- ability schools and therefore there are no accurate
duction of caries in the participants of the CROSB. controls to compare them, for while it is true they
This is can definitely be attributed to the large num- entered the programme late (13 years old), it was

Vol 14, No 1, 2016 53


Cueto et al

because they did not come from vulnerable schools REFERENCES


or came from other cities.
The authors suggest that CROSB search for 1. Albashaireh Z, al-HadiHamasha A. Prevalence of dental
caries in 12-13-year-old Jordanian students. SADJ
more effective tools, such as reorienting their re- 2002;57:8991.
sources towards specific protection delivered 2. Badenier O, Cueto A, Mario R, Acevedo R. Estudio de
through sealants, expanding its coverage and mon- prevalencia de enfermedades bucodentales y necesi-
itoring the correct indication and incorporating ef- dades de tratamiento de la V regin, cdigo SAOI20044.
Fondo Nacional de Investigacin y Desarrollo en Salud,
fective measures to control risk behaviours. In ad- FONIS, CONICYT, MINSAL, 2007.
dition, fieldwork should take a different approach, 3. Bakhshandeh A, Qvist V, Ekstrand KR. Sealing occlusal
perhaps such as the massive application of fluoride caries lesions in adults referred for restorative treatment:
varnishes in schools. 23 years of follow-up. Clin Oral Investig 2012;16:521
529.
In terms of the oral health of 13-year-old chil-
4. Borges BC,de Souza Borges J,Braz R,Montes MA,de As-
dren, the literature is vast1,6,12 and evaluates only suno Pinheiro IV. Arrest of non-cavitated dentinal oc-
permanent first molar, since this molar most sig- clusal caries by sealing pits and fissures: a 36-month,
nificantly contributes to the DMFT index and in nor- randomised controlled clinical trial. Int Dent J 2012;
62:251255.
mal 13-year-olds completely erupted years ago,
5. Cueto A, Barraza A, Chang S, Muoz D, Morales C. Eval-
making it possible to study the progression of de- uacin despus de 6 aos de la aplicacin de un progra-
cay with confidence. In fact, our experience shows ma preventivo en escolares. Rev Fac Odont UV
that first molars account for over 70% of the DMFT 2011;4:11691175.
index value in 12-year-olds.2 6. Ghandehari-Motlagh M, Kohestani A. An investigation on
DMFT and first permanent molars in 12-year-old blind chil-
Our study was based on a review of clinical re- dren in residential institutes for blinds in Tehran (2000
cords, some of which had to be discarded at the 2001). J Dent (Tehran) 2004;1:5661.
time of data collection for being incomplete. A weak 7. Greene JC, Vermillion JR. The Simplified Oral Hygiene In-
point of the study was that the records did not in- dex.J Am Dent Assoc 1964;68:713.
clude bitewing x-rays for early diagnosis of inter- 8. Hiiri A, Ahovuo-Saloranta A, Nordblad A, Mkel M. Pit and
fissure sealants versus fluoride varnishes for preventing
proximal caries. dental decay in children and adolescents. Cochrane Data-
The national statistics on the DMFT index for base Syst Rev 2010;17:CD003067.
12-year-olds in Chile is 1.9; based on this, the DM- 9. Ministerio de Salud, Chile. Gua Clnica: Salud oral integral
FT-molar would be 1.33. In our study, the DMFT- para nios y nias de 6 aos. Santiago: Ministerio de
Salud, 2009:10.
molar in controls was 1.29, highly comparable with
10. Oulis CJ, Berdouses ED, Mamai-Homata E, Polychronopou-
national index, but in cases it was 0.91. The inter- lou A. Prevalence of sealants in relation to dental caries
national literature reports similar DMFT-molar indi- on the permanent molars of 12- and 15-year-old Greek
ces for 12-year-olds, such as 1.25 1.78 in Mexi- adolescents. A national pathfinder survey. BMC Public
Health 2011;11:100.
co,11 1.9 1.6 in Iran12 and 1.62 in Greece.10
11. Prez S, Gutirrez M, Soto L, Vallejos A, Casanova J.
Caries dental en primeros molares permanentes y fac-
tores socioeconmicos en escolares de Campeche, M-
CONCLUSION xico. Rev Cubana Estomatol [online] 2002;39:265281.
Available at http://scielo.sld.cu/scielo.php?script= sci
_arttext&pid=S0034-75072002000300001&lng=es&nr
The evaluated programme creates equity in oral m=iso> , Accessed Feb 10, 2013.
health indicators among its beneficiaries; however, 12. Sadeghi M. Prevalence and bilateral occurrence of first
it does not achieve the oral-health levels of the permanent molar caries in 12-year-old students. J Dent
non-vulnerable population. Factors that would joint- Res Dent Clin Dent Prospects 2007;1:8692.
ly explain the presence of caries-free children were: 13. Senado de Chile. Informe Programa Salud Oral. Glosa N
03 Ley de presupuesto ao 2012. JUNAEB. Ministerio de
not participating in the programme, attending a Educacin. 2012. Available at http://www.senado.cl/site/
public school and the presence of sealed teeth. presupuest o/cumplimiento/Glosas%202012/cuarta_sub-
comision/09%20Educaci%C3%B3n%202012/ORD.%20
1144/Informes/Inf%20Comisi%C3%B3n%20Mixta_S%20
Oral.pdf, Accessed Feb 10, 2013.
14. Van Belle G, Fisher LD, Heagerty P, Lumley T. Biostatistics:
a methodology for the health sciences, ed 2. New York,
NY: John Wiley and Sons, 2004.
15. Wasserman L. All of nonparametric statistics, ed 1. Berlin:
Springer, 2006.

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