Martin Hobdell

Untreated severe dental decay: a neglected determinant of low Body Mass Index in 12-year-old Filipino children

BackgroundDental decay is the most common childhood disease worldwide and most of the decay remains untreated. In the Philippines caries levels are among the highest in the South East Asian region. Elementary school children suffer from high prevalence of stunting and underweight.The present study aimed to investigate the association between untreated dental decay and Body Mass Index (BMI) among 12-year-old Filipino children.MethodsData collection was part of the National Oral Health Survey, a representative cross-sectional study of 1951 11-13-year-old school children using a modified, stratified cluster sampling design based on population classifications of the Philippine National Statistics Office. Caries was scored according to WHO criteria (1997) and odontogenic infections using the PUFA index. Anthropometric measures were performed by trained nurses. Some socio-economic determinants were included as potential confounding factors.ResultsThe overall prevalence of caries (DMFT + dmft > 0) was 82.3% (95%CI; 80.6%-84.0%). The overall prevalence of odontogenic infections due to caries (PUFA + pufa > 0) was 55.7% (95% CI; 53.5%-57.9%) The BMI of 27.1% (95%CI; 25.1%-29.1%) of children was below normal, 1% (95%CI; 0.5%-1.4%) had a BMI above normal. The regression coefficient between BMI and caries was highly significant (p < 0.001). Children with odontogenic infections (PUFA + pufa > 0) as compared to those without odontogenic infections had an increased risk of a below normal BMI (OR: 1.47; 95% CI: 1.19-1.80).ConclusionsThis is the first-ever representative survey showing a significant association between caries and BMI and particularly between odontogenic infections and below normal BMI. An expanded model of hypothesised associations is presented that includes progressed forms of dental decay as a significant, yet largely neglected determinant of poor child development.

Political priority of global oral health: an analysis of reasons for international neglect

Global Oral Health suffers from a lack of political attention, particularly in low- and middle-income countries. This paper analyses the reasons for this political neglect through the lens of four areas of political power: the power of the ideas, the power of the issue, the power of the actors, and the power of the political context (using a modified Political Power Framework by Shiffman and Smith. Lancet370 [2007] 1370). The analysis reveals that political priority for global oral health is low, resulting from a set of complex issues deeply rooted in the current global oral health sector, its stakeholders and their remit, the lack of coherence and coalescence; as well as the lack of agreement on the problem, its portrayal and possible solutions. The shortcomings and weaknesses demonstrated in the analysis range from rather basic matters, such as defining the issue in an agreed way, to complex and multi-levelled issues concerning appropriate data collection and agreement on adequate solutions. The political priority of Global Oral Health can only be improved by addressing the underlying reasons that resulted in the wide disconnection between the international health discourse and the small sector of Global Oral Health. We hope that this analysis may serve as a starting point for a long overdue, broad and candid international analysis of political, social, cultural, communication, financial and other factors related to better prioritisation of oral health. Without such an analysis and the resulting concerted action the inequities in Global Oral Health will grow and increasingly impact on health systems, development and, most importantly, human lives.

The effects of extraction of pulpally involved primary teeth on weight, height and BMI in underweight Filipino children. A cluster randomized clinical trial.

BackgroundSevere dental caries and the treatment thereof are reported to affect growth and well-being of young children. The objective of this study was to assess the effects of extraction of severely decayed pulpally involved primary teeth on weight and height in underweight preschool Filipino children.MethodsUnderweight preschool Filipino children with severe dental decay had their pulpally involved primary teeth extracted during a stepped wedge cluster randomized clinical trial. Day care centers were randomly divided into two groups; children from Group A day care centers received treatment as soon as practical, whereas children from Group B day care centers were treated four months after Group A. Clinical oral examinations using WHO criteria and the pufa-index were carried out. Anthropometric measurements were done on both groups immediately before treatment of Group A and at follow-up four months later. Height and weight z-scores were calculated using 2006 and 2007 WHO Growth Standards. Multilevel analysis was used to assess the effect of dental extractions on changes in anthropometric measurements after dental treatment.ResultsData on 164 children (85 in Group A and 79 in Group B), mean age 59.9 months, were analyzed. Both groups gained weight and height during the trial period. Children in Group A significantly increased their BMI (p < 0.001), and their weight-for-age (p < 0.01) and BMI-for-age z-scores (p < 0.001) after dental treatment, whereas untreated children in Group B did not. Children in Group A had significantly more weight gain (p < 0.01) compared to untreated children in Group B. However, children in Group A had an inverse change in height gain (p < 0.001). Adjustment for the time interval between the two visits had little effect on the results.ConclusionsThe extraction of severely decayed primary teeth resulted in significant weight gain in underweight Filipino children. Untreated dental decay should be considered an important co-factor affecting child growth and should be considered when planning for interventions to improve child growth.Trial registrationISRCTN90779069 http://www.controlled-trials.com/isrctn/isrctn_loa

Associations between oral health-related impacts and rate of weight gain after extraction of pulpally involved teeth in underweight preschool Filipino children

BackgroundSevere dental caries in young children is associated with underweight and failure to thrive. One possible mechanism for severe caries affecting growth is that the resulting pain and discomfort influences sleeping and eating, and that affects growth and weight. The objective of this study was to assess whether rate of weight gain after extraction of severely decayed teeth in underweight preschool Filipino children was related to reductions in oral health-related impacts and dental pain from severe dental caries affecting eating and sleeping.MethodsData are from the Weight Gain Study, a stepped wedge cluster randomized clinical trial where underweight Filipino children with severe dental decay had their pulpally involved teeth extracted. Day care centers were randomly divided into two groups; A and B. Group A children received treatment first and Group B children were treated four months after Group A. Clinical oral examinations used WHO criteria and the pufa-index. Self-reported oral health-related impacts and anthropometric measurements were collected for both groups at baseline, four months after treatment of Group A children and four months after treatment of Group B children. Weight-for-age z-scores were calculated using 2006 and 2007 WHO standards. Data were converted to a one-group pre-test post-test study design, where all children received treatment. Associations between changes in oral health-related impacts and weight-for-age z-scores after dental treatment were assessed.ResultsData on 145 children (mean age 61.4 months) were analyzed. There was a significant association between oral health-related impacts and rate of weight gain after extraction of pulpally involved teeth (p=0.02). Children free of impacts on sleeping related to having severely decayed teeth extracted gained significantly more weight compared to children who reported sleeping problems after dental treatment (p<0.01).ConclusionsAfter extraction of severely decayed teeth in underweight Filipino children, levels of oral health-related impacts were associated with rate of weight gain. Decreases in oral health impacts on sleeping appeared to be most strongly associated with weight gain.Trial registrationISRCTN: ISRCTN90779069

Poverty, social exclusion and dental caries of 12-year-old children: a cross-sectional study in Lima, Peru

BackgroundSocioeconomic differences in oral health have been reported in many countries. Poverty and social exclusion are two commonly used indicators of socioeconomic position in Latin America. The aim of this study was to explore the associations of poverty and social exclusion with dental caries experience in 12-year-old children.MethodsNinety families, with a child aged 12 years, were selected from 11 underserved communities in Lima (Peru), using a two-stage cluster sampling. Head of households were interviewed with regard to indicators of poverty and social exclusion and their children were clinically examined for dental caries. The associations of poverty and social exclusion with dental caries prevalence were tested in binary logistic regression models.ResultsAmong children in the sample, 84.5% lived in poor households and 30.0% in socially excluded families. Out of all the children, 83.3% had dental caries. Poverty and social exclusion were significantly associated with dental caries in the unadjusted models (p = 0.013 and 0.047 respectively). In the adjusted model, poverty remained significantly related to dental caries (p = 0.008), but the association between social exclusion and dental caries was no longer significant (p = 0.077). Children living in poor households were 2.25 times more likely to have dental caries (95% confidence interval: 1.24; 4.09), compared to those living in non-poor households.ConclusionThere was support for an association between poverty and dental caries, but not for an association between social exclusion and dental caries in these children. Some potential explanations for these findings are discussed.

Childhood stunting and caries increment in permanent teeth: a three and a half year longitudinal study in Peru

BACKGROUND Malnutrition has been consistently associated with caries in primary teeth, although an effect on permanent teeth has not been established because of the few longitudinal studies. AIM To explore the association between stunting and caries increment in permanent teeth over 3.5 years. DESIGN In 2003, 121 children aged 7-9 years were randomly selected from nine underserved communities in Lima (Peru). Parents provided demographic information and a food diary for their children. Clinical examinations included assessments of height, weight, oral hygiene, and dental caries. Stunting was defined using the 2000 CDC and 2007 WHO standards. In 2006, 83 children were re-examined, and the 3.5-year net DMFS increment was calculated. The association between stunting and net DMFS increment was assessed using negative binomial regression. RESULTS Stunting was related to net DMFS increment after adjustment for sex and age, oral hygiene, sugary snacks between meals, and caries experience in primary and permanent teeth. Consistent results were found when using either the 2000 CDC (incidence rate ratio: 1.61; 95%CI: 1.07, 2.44) or 2007 WHO standards (IRR: 1.79; 95%CI: 1.28, 2.51). CONCLUSION Stunting was a significant risk factor for caries increment in permanent teeth over a 3.5-year period, independent of other well-known risk factors for caries development.

The Human Development Index and Per Capita Gross National Product as Predictors of Dental Caries Prevalence in Industrialized and Industrializing Countries

High prevalence of dental caries in children in industrialized communities has been associated with high levels of available sugar. More recently, however the relationship between dental caries and sugar availability in industrialized countries has come into question, because of the effectiveness of different methods of dental caries prevention, despite continuing high levels of available sugar. As there has been a decline in overall dental caries prevalence in industrialized countries, so material deprivation has emerged as a contributing or associated factor of high dental caries prevalence. Factors indicative of material deprivation in preschool children that have been investigated are low birth weight, low uptake of polio vaccination, and being a part of a single parent family. This study was undertaken to explore two issues: first, whether the relationship between sugar availability and dental caries prevalence demonstrated by Screebny in 1982 1 still holds, given the reductions in dental caries levels that have occurred in industrialized countries since then. Second, whether the relationship between dental caries and deprivation could be demonstrated internationally, between countries, at different levels of socioeconomic development. Data were obtained from three separate sources: dental caries data from the World Health Organization Global Oral Epidemiology Data Bank, 2 sugar data from the United Nations Food and Agricultural Organization (UNFAO), 3 calculated as the mean sugar availability for the five years preceding the date of the dental epidemiological survey given in the 1994 WHO report; and socioeconomic data from the United Nations Development Programme (UNDP). 4 Additional dental caries and sugar availability data were obtained from the 1982 paper of Screebny, which contained comparable data for 47 countries. Complete 1982 and 1994 sets of data were available for 26 of Screebny’s original 47 countries. These were grouped according to their 1978 GNP classification. The composition of the HDI was not finalized in 1982, so it was not used in this comparison. The Human Development Index (HDI score) and annual per capita share of the Gross National Product (GNP in US

The UN High-level Meeting on Prevention and Control of Non-communicable Diseases and its significance for oral health worldwide

) were used as proxy measures of economic and material disadvantage. The 1994 WHO

Hit or miss: a window of opportunity for global oral health

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Childhood stunting and caries increment in permanent teeth: a three and a half year longitudinal study in Peru: Stunting and caries increment

are calling for a High-level Summit on Chronic Diseases in September 2011 because the international health community has finally realised that the burden of chronic diseases, such as diabetes, cardiovascular diseases and cancer, is growing at alarming rates. The Millennium Development Goals, which focused mainly on infectious diseases, will expire in 2015, giving an opportunity to agree on new international development commitments and health targets. The mantra of the oral health community over the last decade has been that oral health is part of general health, sharing the same risk factors of other chronic diseases. The upcoming summit would be a unique opportunity to mainstream oral health issues in a bigger global context. Wishful thinking? So far, unfortunately, it looks like a ‘miss’. Addressing the neglect of chronic diseases in international health and development assistance was long overdue; a paper in The Lancet recently concluded that ‘neglect of chronic diseases is a political, not a technical, failure since cost-effective interventions are available’. This is equally true for oral health. Caries affects more than 90% of the world’s population, between 40-90% of all 12-year-olds in lowand middle-income countries suffer from it and its consequences, such as pain, chronic infection, lack of concentration and absenteeism from school, low quality of life and significant impact on growth, development and educational performance. Even worse, in low-resource countries almost all caries remains untreated, exacerbating the consequences. For many populations, even in high-income countries, the levels of caries have reached epidemic proportions. Oral diseases are a serious public health problem, but there are realistic and evidence-based solutions available to address them, even in low-resource settings. However, the current public and informal discussions in preparation for the summit largely ignore the most prevalent chronic disease on our planet, caries. While it is perfectly reasonable to focus on conditions such as diabetes, obesity, cancer or cardio-vascular diseases, which are major causes of worldwide morbidity and premature death, the important and worldwide impact of oral diseases, particular caries, on health, health systems and budgets (OECD countries spend 6-12% of their health budgets on oral care) is largely forgotten or underestimated. Is there any visible action from international stakeholders in oral health? So far, once again, it looks like a ‘miss’. In the past, oral health stakeholders have not succeeded in framing the neglect of oral health in a way that resonates directly with broader public health agendas. It would be unfortunate if this was to result in oral health, once again, being neglected in favour of other disease entities simply because they have more visible advocacy campaigns during the high-level meeting on non-communicable diseases in September 2011. We believe that it is time that the global oral health community join forces and embark on a process of alignment and integration with the international health and development agendas. This would require a concerted collaboration, agreement on a common problem definition and the suggested solutions. First of all, it would require international organisations, such as the FDI World Dental Federation, the International Association for Dental Research, the WHO Oral Health Unit, as well as other national and international organisations, to sit and talk. Without joint action and bold leadership no significant changes can be made for the billions affected by oral diseases. The opportunity of the High-level Summit on Chronic Diseases could still be turned into a ‘hit’, but the clock is ticking. We join the WHO Director-General, Dr Margaret Chan, in her assessment during the 120th meeting of the WHO Executive Board in January 2007 when she said, that ‘oral diseases are a neglected area of international health. We have the tools and best practices to address them, but we need to ensure that they are applied and implemented.’ Dental diseases are not a niche area of health. It is only when oral health is incorporated within the current chronic disease discourse that lasting progress will be made. An important milestone in this process is ahead of us – let us not miss this unique window of opportunity!