oral health in tuvalu

6
Oral Epidemiolog)! Oral health in Tuvalu JOHN D.win SPE.\KI;' .\.\n TIH.\L.\ M.\i..AKr ^South Pacific Commission, .\oumra. .\ew Caledonia and'Pntness .Mar/iarcl Hospiial. Fmmfuti. Tuvalu Speake. J. D. & Malaki. 'I'.: Oral health iti Tti\altt. Coniinunity Dent. Otal iipidetniol. 1982: 10: 173-177. Abstract - Citrreut WHO tnethods were employed to estimate the prevalence of oral pathology, dctitolacial anomalies, petiodontal di.sea.se, caries and prosthetic stattis as well as ttealmeut needs in Tuvalu, a newly emergent nation iu the South Pacific. Fluorosis \Aas endeime but other disotders of teeth, mtico.sa or bone wete exttemely rare and the presenee ol deiitofacial anomalies was very low. Periodontal disease was "moderate" at 15 years of age but .seemed to be a predisposing factor in caries from the laie teens onward. Comparison with a survey 8 years previously indieated that caries rates had risen from "very low" to "low" at 12 years ol age but treatment services had improved markedly. More t han hall ol pet sons in the 55-64 year age gtoup required lull maxillary and niandtbular denttties whilst 10"o already possessed them. Key wotds: dental caries; dental lluorosis; dentofaeial anotnalies; periodoutal disease; Tuvalu; WHO, survey. J. D. Speake. 42 Pctliebiidge Street. Pearce. .A. C. T. 2(iO7. Australia. .AccejMed for publicati(Jit 25 December 1981. With a population of some seven and a hall thousand and a total land area of 25.9 km' Tuvalu is truly one ofthe microstates ofthe South Paeific. It is made up of nine atolls extending in a winding line over 560 kilometres of sea. None of the atolls rise more than five metres above sea level. Formerly the Ellice of the Gilbert and Ellice Islands Colony, the country separated in 1975 and became independent of the United Kingdom m 1978. The people are of Polynesian stock. Records of refined sugar importation are avail- able only since 1976 and show considerable annual variation, but average out to 15.8 kg per capita per annum. Until recently, passenger communication with the outside was limited to a once a week air service with cargo boats bringing heavy freight to the capital, Funafuti, approximately six times a year. Inter nal communication has been confined to a 150 ton inter-island boat making about seven round voyages a year. The round trip takes around 3 weeks. With the exception of Funafuti and one other atoll, the lagoons arc inaccessible and pas- .sengers and cargo have to be transferred across the reef in small boats which calls for great skill in seamanship in all but the calmest weather. METHODS Two examinets working sinittltaneoitsly employed curretit basic V\ HO (5) critei ia. Both had pre\ ions stirvey experience . They were accompanied by two tecordets. .Xfter au initial discttssion to eustite agreement on the application ol the criteria, periodic cotisultation took place tlirotighotii. Sample selection of children was carried out by a random .selection ba.sed on sehool lists and proportionate to island school population. Schooling is virtually uuiveisal. Foradults, because there were no detailed lists available on each island, the sample was selected by notifying each island executive ollicer by tadio iu advance asking him to assemble as many people as possible just prior to ottr attival. Ftom those attending, a random selection was made In'age group wilh ihe number examined piopottionate to each island's population. Alternate age groups were examined. RESULTS The total sample consisted of 985 persons, half were male and half female with approximately equal numbers in each ofthe 10 specified age groups. Periodonlal status - Overall, soft deposits aliectcd 77% ofthe sample but no consistent trend with age was discernible (Table 1). The mean number of .segments affected (SDI) tended to follow a similar, apparently random, pattern with age. In conlrast, the percentage of subjects affected b\ calcuhis rose continuouslv\vith age to 97% at 35-44 years before 0.301-5661/82/04017:5-05 S 02.50/0 '• 1982 Mtniksgaard. Copetilu^vn

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Page 1: Oral health in Tuvalu

Oral Epidemiolog)!

Oral health in Tuvalu

JOHN D.win SPE.\KI;' .\.\n TIH.\L.\ M.\i..AKr^South Pacific Commission, .\oumra. .\ew Caledonia and'Pntness .Mar/iarcl Hospiial. Fmmfuti. Tuvalu

Speake. J. D. & Malaki. 'I'.: Oral health iti Tti\altt. Coniinunity Dent. Otal iipidetniol. 1982: 10:173-177.Abstract - Citrreut WHO tnethods were employed to estimate the prevalence of oral pathology,dctitolacial anomalies, petiodontal di.sea.se, caries and prosthetic stattis as well as ttealmeut needsin Tuvalu, a newly emergent nation iu the South Pacific. Fluorosis \Aas endeime but otherdisotders of teeth, mtico.sa or bone wete exttemely rare and the presenee ol deiitofacial anomalieswas very low. Periodontal disease was "moderate" at 15 years of age but .seemed to be apredisposing factor in caries from the laie teens onward. Comparison with a survey 8 yearspreviously indieated that caries rates had risen from "very low" to "low" at 12 years ol age buttreatment services had improved markedly. More t han hall ol pet sons in the 55-64 year age gtouprequired lull maxillary and niandtbular denttties whilst 10"o already possessed them.

Key wotds: dental caries; dental lluorosis; dentofaeial anotnalies; periodoutal disease; Tuvalu;

WHO, survey.

J. D. Speake. 42 Pctliebiidge Street. Pearce. .A. C. T. 2(iO7. Australia.

.AccejMed for publicati(Jit 25 December 1981.

With a population of some seven and a hallthousand and a total land area of 25.9 km' Tuvaluis truly one ofthe microstates ofthe South Paeific. Itis made up of nine atolls extending in a winding lineover 560 kilometres of sea. None of the atolls risemore than five metres above sea level.

Formerly the Ellice of the Gilbert and ElliceIslands Colony, the country separated in 1975 andbecame independent of the United Kingdom m1978. The people are of Polynesian stock.

Records of refined sugar importation are avail-able only since 1976 and show considerable annualvariation, but average out to 15.8 kg per capita perannum.

Until recently, passenger communication withthe outside was limited to a once a week air servicewith cargo boats bringing heavy freight to thecapital, Funafuti, approximately six times a year.Inter nal communication has been confined to a 150ton inter-island boat making about seven roundvoyages a year. The round trip takes around 3weeks. With the exception of Funafuti and oneother atoll, the lagoons arc inaccessible and pas-.sengers and cargo have to be transferred across thereef in small boats which calls for great skill inseamanship in all but the calmest weather.

METHODSTwo examinets working sinittltaneoitsly employed curretitbasic V\ HO (5) critei ia. Both had pre\ ions stirvey experience .They were accompanied by two tecordets. .Xfter au initialdiscttssion to eustite agreement on the application ol thecriteria, periodic cotisultation took place tlirotighotii.

Sample selection of children was carried out by a random.selection ba.sed on sehool lists and proportionate to islandschool population. Schooling is virtually uuiveisal. Foradults,because there were no detailed lists available on each island,the sample was selected by notifying each island executiveollicer by tadio iu advance asking him to assemble as manypeople as possible just prior to ottr attival. Ftom thoseattending, a random selection was made In'age group wilh ihenumber examined piopottionate to each island's population.Alternate age groups were examined.

RESULTSThe total sample consisted of 985 persons, half weremale and half female with approximately equalnumbers in each ofthe 10 specified age groups.

Periodonlal status - Overall, soft deposits aliectcd77% ofthe sample but no consistent trend with agewas discernible (Table 1). The mean number of.segments affected (SDI) tended to follow a similar,apparently random, pattern with age. In conlrast,the percentage of subjects affected b\ calcuhis rosecontinuouslv\vith age to 97% at 35-44 years before

0.301-5661/82/04017:5-05 S 02.50/0 '• 1982 Mtniksgaard. Copetilu^vn

Page 2: Oral health in Tuvalu

174 Spf:.\KE AND M A I . A K I

Table I .Periodontal .status

Age,years

ti8

1012141925-2935-4445-5455-64

n

9710395

1279094

100949689

.Solt deposits/(J

afiected

74.277.774.781.182.271.382.086.274.065.2

Vlean

2.43.33.03.23.22.73.53.93.02.6

Caleulu%

afleeted

7.231.232.652.860.088.391.096.881.373.0

s

Mean

0.10.50.71.51.73.03.94.73.93.3

Intensegingivitis

%alfected

18.629.145.340.235.654.371.080.979.273.0

Mean

0.40.71.2I.I0.81.62.63.63.43.3

Advanced periodontaldisease

%alfected

000001.16.0

29.845.833.7

Mean

0000000.20.91.51.1

declining and the calcuhis index (CI) followed asimilar pattern rising to 4.7 at 35-44 \ears.

The pattern of intetise gingivitis in terms of boththe percetitage ol persons and the mean numbei' ofsegments alfected (IGI) was one of increase withage in the children and decrease in the teenslollowed by a resttrge in early adttlthood beforedeclining in the two oldest age grottps.

Advanced periodontal disease was lirst manifestat 19 years and increased with age up 45-54 yearswhere the percentage affected and the APDIpeaked at 46% and 1.5 respectively.

Tooth mortality - The average number of primaryteeth missing due to caries was 0.7 at both 6 and 8years of age. In the permanent dentition tooth lossfrom caries was apparent from 10 years andcontinued to rise with age.

The extent of complete tooth loss in the samplewas not entirel)- consistent with age, bttt becamesigtiilicant at 45-54 years. In the oldest age groupabout one fifth of per.sons had less than 21 teeth, onethird had less than 15 teeth and one twentieth v\'ereedentulotts.

Dental caries - In the primary dentition 82.5 % of 6-year-old children had experience caries with amean dmf of 5.3. The majority of lesions were in thedecayed category and 0.2 teeth per child had beenfilled (Table 2).

In the permanent dentition, the percentage ofpersons affected rose progressively with age from20.6% to 100% at 45-54 years whilst the dentalcaries index (DMFT) rose in a similar fashion from0.3 to 16.9. Younger people had a higher pro-portion of filled teeth.

1 able 2. Caries status of [XMniancnt teeth (6 years and oldt'i)

Age

ti8

1012141925-2935-4445-5455-(i4

n

9710395

1279094

100949689

D-f-M + F%

all er ted

20.654.456.869.375.684.098.095.7

10097.8

D only%

alfected

15.533.031.637.045.674.579.078.766.773.0

MF'FMean

0.31.01.42.43.54.58.2

10.714.816.9

DMean

0.20.60.60.81.12.63.83.73.02.9

FMean

0.10.40.81.42 21.22.00.90.40.2

FDi*Mean

0000000.10.100

FD2*Mean

00000.1O.I0.2000

MMean

000.10.10.20.72.46.1

11.513.7

FDi. niled with primary decay.FD2. /illecl with seeondaiN' deca\\

Page 3: Oral health in Tuvalu

Oral health in Tuvalu I 75

Iable 3. Periodontal ireatmeiu lequiicnieiits: percentage ol

IJersons

Age

68

10121925-2935-4445-5455-64

tl

97U)395

12794

100949689

. \ o

treat.f j -

18.611.716.87.14.34.03.24.27.9

OHl

71.150.544.236.2

9.65.0——

1.1

Pro. -1-O H l

O

10.337.039.055.984.079.055.328.124.7

Perio.(are

/o

0000I.I8.0

22.316.7I4.()

Perio.ext.

0 '

000003.0

17.024.015.7

Fullext."„

00000I.O3.2

27.136.0

Oral pathology - Disorders oi the mucosa wereextremely rare and no conditions aflecting bonewere recorded.

Fluorosis was recot-ded under defects of teeth anda maximuin prevalence of 48% was recorded in the12-year-age gt-oup. Taking the whole sample, 27%showed evidence of iluorosis and of these approx-imately 49% were questionable, 11% very mild,31% mild, 9% moderate and 3% severe. Otherdefects of teeth were very rare amounting to lessthan 1 % of the total sample. Conditions recordedincluded supernumerary teeth; staining, believedto be caused by tetracycline; enamel hypoplasiaand localised enamel dysplasia.

Dentofacial anomalies - Employing WHO criteria,the number of cases were low and showed a veryfair constancy between the different age groups.Overall they averaged out to 3.5% of subjectsexamined.

Prosthetic status - At 19 years, 2.1% of subjectsexamined had dentures and the proportion ol

persons possessing and wearing full maxillary den-tures was highest in the oldest age group (9%). Fullmandibttlar dentures were less common as werepartial mandibular dentures. Dentures (full orpartial, maxillary or mandibular) were most com-monly found in the oldest age gt-oup, (10.1%).

Treatment needs - A need foi- full 'Tiaxillary and/ormatidibular dentut-es was first matiifest at 19 yearsand inci-eased with age reaching more than half ofthe oldest age group. Partial denture reqvtirementswere first appatent in the 25-29 year age group.The need increased steadily with age.

Periodontal treatment needs were confined tooral hygiene instruction alone or in combinationwith a scaling and cleaning up to 14 years.Pei-iodontal therapy needs were first apparentamong the 10-year-olds, extraction for periodontalreasons first manifest at 25-29 years and fullclearance for periodontal reasons also first recordedat 25-29 years (Table 3).

Throughout the age groups, caries expressed as apercentage of subjects constituted the most com-mon reason for extraction but periodontal diseasebecame discernible from 25-29 years on, whilstteeth needing extraction as a prerequisite fordentures were also apparent from 25-29 yearsupward. In terms of the mean ntimber of teeth persubject needing extraction, periodontal diseaseequalled caries as the cause by the 45-54 age groupand subsequently exceeded it (Table 4).

Quite a high proportion of persons requiringrelief of pain services were recorded, particularlyafter 19 years of age where they constituted over athird of subjects examined. Even higher percent-ages of subjects were adjudged to have lesions likelyto cause pain.

Table 4. Reasons for extractions: permanent dentition; percentage of ]5ersons and mean number of teeth

Age

68

1012141925-2935-4445-5455-64

/;

9710395

1279094

100949689

c::/o

005.33.13.3

17.048.042.649.049.4

ariesMean

000.1O.I00.31.4i.l1.71.7

Pel

%

0000001.09.6

28.132.6

'ioMean

00000000.62.72.6

Dentures"()

0000003.00

13.510.1

Mean

0000000.100.30.4

Other/O

01.93.10.801.10000

reasonsMean

0000000000

Page 4: Oral health in Tuvalu

176 SPEAKE ANt:) MALAKI

DISCUSSIONThe first dental survey in Tuvalu was conducted in1972 (1). Subsequently in 1979, caries data inpermanent teeth was collected from the children inthe capital (3) and when this was compared withthe 1972 results there was evidence ofa threefoldincrease in the 7 years. Although it was thoughtthat this was in part a result of the return ofsignificant numbers of public servants and theirfamilies from the Gilbert Islands where they hadbeen obliged to depend substantially on importedwestern style food, there was also evidence thatdevelopment in Tuvalu itself following indepen-dence was having an impact on the diet. It wastherefore decided to see whether the effects wereconfined to the capital or extended to the outerislands.

In the event, the boat's schedule was too tight toallow us to reach the original target number ofexaminations. Fortunately, this was recognisedearly on and the sample remained approximatelyproportional to the population on each island.Assuming a random selection, the standard error is+ 0.45 DMF teeth at 12 years of age with 95%confidence limits. The sample represents approx-imately one in seven of the total population.

The fact that it had been several years since anumber of islands had received a dental treatmentvisit may have had an influence on the results fromthe section on conditions needing immediate at-tention. The method of sample selection of adults,forced on us by field conditions, may also havetended to inct^ease the proportion of persons in-cluded already in pain as did our interpretation ofthe protocol to make allowance for the infrequencyof dental treatment visits. "Basic Adethods" suggeststhat the period within which services will beavailable should be from a few days to a month. Weextended this to a more realistic 1 year.

Although it was appreciated that subsample sizeswould in most instances be very small, caries ratesDMF (T) were calculated for all islands individu-ally. No island stood out as being consistentlyhigher or lower. However, when the DMF (T) ratesin Funafuti were plotted against all outer islandscombined, the former were found to be higher from8 to 14 years. And when the percentages of subjectsaffected were examined, it was found that those inFunafuti were consistently higher up to 19 years byan average of approximately 12%.

It had been postulated that wage earnets woulcibe in a better position to puixhase imported andpotentially cariogenic foods than villagers but com-parisons of caries rates wet-e vet-y inconclttsive.

It is worth noting the clinical impression re-ported in 1972 that periodontal disease took theform of recession rather than pocketing was sup-ported by similar impressions 8 years later. Analysisof the sites of identifiable carious lesions, i.e.excluding missing and grossly carious teeth in 1972,showed evidence of a marked increase in caries ofthe cementum after approximately 20 yeat-s of ageand was responsible for an increase in cariesincrement. And it was noticeable in 1980, amongstthe older age groups, that cat-ies of cementum wasfrequently to be Ibuncl in association with acK-ancedperiodontal disease and where extraction wasindicated, it was often difficult to decide which ofthe two was the major catise.

There was only slight evidence of a change inprimary caries rates. In the permanent dentition,however, caries prevalence showed a distinct in-crease since 1972 in all age groups. But it isimportant to consider this rise in the global per-spective. In terms of current terminology, Tuvaluhad moved from "very low" to the "low" categoryand is now very close to "moderate", using 12 yearsof age as a reference point. Using the 35-44 year oldage group as a reference point (2), the country fallswell within the "moderate" classification.

There is, however, evidence of an improvementin the provision of restorative services. In 1972, theDental Care Index amounted to only 0.008 forchildren aged 6-14 years, whereas in the 1980sample it had increased to 0.49.

Because different methods of periodontal assess-ment were employed in the two surveys,it is notpossible to make cjuantitative comparisons. Incurrent WHO terminology, assessing periodontaldisease at 15 years of age (5), Tuvalu falls into the"moderate" category.

Although there has been some improvement inthe percentage of persons with full dentures theoverall need appears to have grown. This inct-easewas particularly noticeable from 45 years onward.

The main aspect of the situation which haschanged significantly over the past few years is thatof caries which, though still "low" by world stan-dards, is increasing. There is also some evidence ofahigher percentage of persons becoming edentulous

Page 5: Oral health in Tuvalu

Oral health in Tuvalu 177

at an earlier age but this may refiect the increasedavailability of services as much as any increase incaries and or periodontal disease in the older agegroups. This same increased availability of serviceshas had a positive impact on the provision ofrestorative services for children.

••U-t;ni)ivledgenienls - This siir\e\- was Iliianced b\- a grant of.AusS 1000 from the South Pacific Commission. We v\ould like toexpress our thanks to the Oral Health L'liit of W H O . Geiie\afor the com])uter processing and to the (JON ei nment of Tiua lufor permission to publish this pajx-r.

REFERENCES1. HOI.1.IS. M. J. & M.AIAKI. T.: Final report of dental surveys

conducted in the Ellice Islands 1972. SPG, Noumea, mimeo1974.

2. S.VRDO-I.MiRRi. J. & B.\RMi:s. D. E.: Epidemiology of oraldisea.ses - differences in national problems. Inl. Denl. J.1979: 29: 183-190.

3. Si'E.vKE. J. D.: Report on a visit to Tuvalu. SPC, Noumea,mimeo 1979.

4. \^ orld Health Organization: Oratheatltisutreys: t>asicttiethods.2nd ed. Geneva 1977.

5. World Health Organization: Platmitii>-orat health servicrs.OITset Publ. No. 53. Geneva 1980.

Page 6: Oral health in Tuvalu