J Dent Educ. 69(3): 382-386 2005
© 2005 American Dental Education Association
International Perspectives on Dental Education |
Does School-Based Dental Screening for Children Increase Follow-Up Treatment at Dental School Clinics?
Mamata Hebbal, B.D.S.;
Ramesh Nagarajappa, M.D.S.
Dr. Hebbal is a Postgraduate Student and Dr. Nagarajappa is a Reader—both in the Department of Community Dentistry, Bapuji Dental College and Hospital, Davangere, India. Direct correspondence and requests for reprints to Dr. Mamata Hebbal, Department of Community Dentistry, Bapuji Dental College and Hospital, Davangere 577 004, Karnataka, India; 91-8192-220575, ext. 333 phone; 91-8192-220578 fax; drmamatahebbal{at}yahoo.co.in.
Key words: dental screening program, response rate, school children
Submitted for publication 07/13/04;
accepted 12/10/04
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Abstract
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The purpose of this study was to evaluate the effectiveness of a screening program and referral system in stimulating dental attendance of children in need of treatment at Bapuji Dental College and Hospital of Davangere, India. A total of fourteen schools in the Davangere area were selected randomly and divided into two groups: seven schools that had a dental screening program (study group, n=2100 children), and seven schools that did not have one (control group, n=2400 children). The attendance rate by members of the study group was determined during the three-month period from the date of initiating the school screening program. During this same period the students who visited the college from the control group underwent a dental examination. Chi-square tests were used to test the difference between different variables. The response rate for seeking treatment was 31 percent for the study group (34.2 percent for males; 26.2 percent for females) and 10 percent for the control group (9.6 percent for males; 10.5 percent for females). In both the groups, the treatment need was highest for dental caries (study group=36.3 percent, control group=11.1 percent) and least for fluorosis (study group=21.2 percent, control group=1.2 percent). The study demonstrated that screening and motivation significantly improved the percentage of school children who sought dental care.
The effectiveness of school-based dental screening in many countries has come under scrutiny in recent years. It has been proposed that dental screening of children in their schools achieves the aim of "encouraging dental attendance and demand for care" and serves as "a means of dental health education." Questions have been raised about the effectiveness and appropriateness of screening. Efforts have been made to improve its efficiency, and in many Community Dental Services (CDS), clear objectives have been set and standard protocols for the process have been produced and adopted.1
In India, children form about 38–40 percent of the total population, and 80 percent of them have high levels of dental disease.2 School dental screening has a clear role in identifying children with untreated disease and encouraging them to seek dental care by informing them about their dental needs.
The Department of Community Dentistry, Bapuji Dental College and Hospital at Davangere city, Karnataka, India is conducting a regular school dental screening program biannually for most of the schools of Davangere. All the children are screened thoroughly for dental diseases, and necessary oral health care instructions are provided for each individual. Children who require treatment are referred to the dental college by giving them referral cards; dental care is provided to them there free of cost.
The aims of the study were to 1) evaluate the effectiveness of the screening program and referral system in stimulating children with dental problems to seek treatment at Bapuji Dental College and Hospital, and 2) compare the rates of dental treatment among different age groups and among males and females following screening.
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Materials and Methods
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The present study was conducted among school-going children of Davangere city who were between six and fifteen years old. Before the start of the study, a complete list of all the registered schools in Davangere city was obtained from the office of the deputy director of public instructions (DDPI). There were a total of 223 schools, consisting of 131 government (public) schools and ninety-two private schools. Out of these, twenty government (public) schools had similar demographic characteristics and were almost equidistant from the dental college. They reflected similar socioeconomic status and opportunities regarding the accessibility to dental care.
These twenty schools were then subjected to a two-stage simple random sampling technique for selection of the schools. In the first stage, fourteen schools were selected out of twenty by lottery method, and in the second stage these schools were assigned randomly either to the study or control group (seven schools in each group). All the authorities of the selected schools responded positively when approached for permission to conduct the study. Informed consent was also obtained from the parents of all participants.
The respective schools were informed well in advance about the date and time of examination. All the students from six to fifteen years of age who were present on that day were examined for common dental problems such as dental caries, gingivitis, malocclusion, and fluorosis, according to WHO Oral Health Surveys Basic Methods, 19973 by a single examiner.
The study population was thus made up of 2100 children (M=1117 and F=938) in the study group (SG) and 2400 children (M=1259 and F=1141) in the control group (CG). The children were divided into three groups according to their ages: six to eight (SG, n=600 children; CG, n=696 children); nine to eleven (SG, n=734 children; CG, n=842 children); and twelve to fifteen years (SG, n=766 children; CG, n=862 children).
After screening, referral cards were given to all the children requiring treatment. Information on the cards included dental college name and address, its working hours, clinical findings on examination, and the treatment required. After screening, oral health education was given to the children in the study group regarding importance of teeth, maintenance of oral hygiene, and prevention of oral diseases. Oral health education and the offer of free treatment served as the motivational factors for these children to seek treatment at the dental college. Concerned school authorities also helped provide motivation by informing the parents of the children in need of dental care to seek the treatment as soon as possible.
The response rate was calculated during the three-month period from the date of initiation of the school screening program. During this period, the students who visited the dental college from the control group were examined, and dental findings were recorded. In order to obtain data regarding the number of children requiring treatment in the control group, a separate screening program was conducted after the waiting period of three months.
A level of p=0.05 was adopted to determine the statistical significance between different groups. Chi-square test was used to test the difference between different variables.
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Results
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Table 1
shows total number of children examined in the six to fifteen years old age group among both genders. Table 2 represents the number of children in need of treatment and the response rate in the study and control groups. In the study group, 56.7 percent of the children (1190 out of 2100 examined) had dental problems. In the control group, on examining the 2400 children after the waiting period, it was noted that 1296 (54 percent) children were in need of treatment. Out of 1190 children in the study group in need of treatment, a total of 368 children reported to the dental college to undergo treatment. The response rate was 31 percent. In the control group, out of 1296 children, only 130 reported for treatment, which accounts for 10 percent. The difference in the attendance rate was statistically significant (p<0.05).
Table 3 shows the attendance rate among males and females in both the populations. The response rate in the study group was 34.2 percent in males and 26.2 percent in females as compared to 9.6 percent in males and 10.5 percent in females in the control group. The result was statistically significant in the study group (p<0.05), but not in the control group (p>0.05).
Table 4 shows the response rate according to age. In the study group, the response rates were 13.6 percent in those six to eight years old, 33.3 percent in those nine to eleven years old, and 40.5 percent in those twelve to fifteen years old. Response rates in the control group were 12.5 percent, 12.2 percent, and 6.7 percent, respectively for the three age groups. In the study group, as the age increased, the response rate also increased, which was statistically significant (p<0.05). In the control group, the differences in response rate by age were not significantly different.
Table 5 reflects the response rate according to the specific oral disease. The maximum response rate in both groups was for dental caries (36.3 percent and 11.1 percent, respectively) and the least was for fluorosis (21.2 percent and 1.2 percent, respectively). When comparison was made according to the specific diseases, it was observed that the response rate was higher among the study group children than the control group and that difference was statistically significant (p<0.05).
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Discussion
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In this study, the response rate to seek dental treatment in the study group was 31 percent but was only 10 percent in the control group. The results were similar to the studies done by Donaldson et al., Zarod et al., and Harding et al.4–6
Although the children in the study group were informed about their oral health and were urged to undergo the treatment, provided free of cost, the response rate was only 31 percent. Explanations for low utilization of dental services are complex and involve the interplay of many other factors including costs, the value placed on dental health, mother’s educational level, ethnic grouping, and dental anxiety. Many of these factors have proven difficult to modify, and some authors advocate a sociopolitical approach. Parents will have to bear other expenditures such as the cost of transportation to receive the treatment, and they may prefer to not see their child absent from school to get the dental treatment, as appointments are scheduled during school hours only. Some parents are also concerned about quality of treatment given.7
In the study group, the utilization and treatment were comparatively higher among males than females. Historically, in a country like India where more preference is almost always given to the male child over the female child in all walks of life, it was not surprising to see that attendance for treatment was greater among males than among females.8 In the control group, no significant difference was found among males and females, though females had higher attendance rates, which may be due to their self-perceived need for treatment.
The response rate in the study group was higher among the nine to eleven and the twelve to fifteen groups than among those six to eight years of age. Most people in India have an attitude that the primary dentition is not of much importance as it will be replaced by the permanent dentition. In addition, the caries in permanent teeth in young children will usually be in the initial stages and may not cause discomfort to the child so that parents may be unaware of treatment needs at this age. These reasons might have contributed to low attendance rate among the six to eight years old children even though they were aware of need for dental treatment.
As found in this study, the response rate in this community in India tends to be higher in the older age groups because parents are more concerned about the permanent teeth and the child becomes self-conscious about his esthetics and is influenced by his or her peer groups. It has also been reported that the older child may feel more independent and may come for treatment without waiting for a parent to accompany him or her.1,9 No relationship was found between age and attendance rate among control group because the children might have been unaware of their oral health status and treatment needs or they were not aware that free treatment was available in the dental college.
In this study, most of the children who reported to the dental college either from the study or control group presented with dental caries in contrast to the other pathological conditions. This may be because people in India tend to associate dentistry with treatment of carious teeth only, rather than with gingivitis or fluorosis, which cause hardly any discomfort to the patient. Few parents and children who were really concerned about esthetics reported to the college for treatment of malocclusion and fluorosis. A person’s initial motivation and willingness to take preventive action and his actual health care behavior may depend at least partly on his or her perception of the severity of dental problems.11 Further studies should be undertaken that take into consideration the parent’s knowledge, behavior, education level, and income.
In conclusion, this study demonstrated that school-based screening and motivation significantly improve the percentage of children who seek free dental treatment at a dental school, but also suggests that reinforcement is essential to further improve the response rate for the treatment of dental problems.
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Acknowledgments
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The authors wish to thank the school children, teachers, and parents for their cooperation during the study.
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REFERENCES
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- Preston ST, Davies GM, Craven R. An investigation of parents’ attitudes to dental health and school dental screening. Community Dent Health 2001;18:105–9.[Medline]
- Damle SG. Pediatric dentistry: scope and rationale. In: Damle SG, ed. Pediatric dentistry. New Delhi: Arya (Medi) Publishing House, 2000:4.
- Oral health surveys: basic methods. 4th ed. Geneva: World Health Organization, 1997.
- Donaldson M, Kininons M. The effectiveness of the school dental screening programme in stimulating dental attendance for children in need of treatment in Northern Ireland. Community Dent Oral Epidemiol 2001;29:143–9.[Medline]
- Zarod BK, Lennen MA. The effect of school dental screening on dental attendance: the results of a randomized controlled trial. Community Dent Health 1992;9:361–8.[Medline]
- Harding M, Taylor G. The outcome of school dental screening in two suburban districts of greater Manchester, U.K. Community Dent Health 1993;10:269–75.[Medline]
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- Ghosh S. Discrimination begins at birth. Indian Pediatr 1986;23:9–15.[Medline]
- Michael D, McCunniff, Damiano PC. The impact of WIC dental screenings and referrals on utilization of dental services among low income children. Pediatr Dent 1998; 20:181–7.[Medline]
- Hoogstraten J, Verhey JCG. Judging the severity of dental problems in relation to other individuals’ problems. Community Dent Oral Epidemiol 1986;14:65–8.[Medline]
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Abstract
Materials and Methods
