The assessment of primary teeth condition in 6 year-old children in Podgorica municipality

Summary Introduction The most frequent oral disease in children is tooth decay. The aim of this study was to determine the health status of primary teeth in 6 year-old children. Material and method The study included 203 children of both genders living in the territory of Podgorica municipality. Only children whose parents gave consent were included. The parameters used for assessing oral health condition were: number of decayed, missing, and filled teeth due to caries (dmft) and Significant Caries Index (SiC). One dentist clinically examined all respondents in accordance with methodology and criteria of the World Health Organization (WHO). Results The average value of dmft in 6-year-olds in Podgorica was 4.9. On average, 80.3% of examined children had dental decay. The SiC Index was 8.3. Among examined children, 12.3% had at least one tooth with fissure sealant. In dmft structure dominated untreated decay (92.6%). Conclusion Results showed high prevalence of primary teeth decay in 6 years old children, indicating the absence of preventive measures and programs in Montenegro.


INTRODUCTION
Oral health is an important part of general health and as such is of primary importance for the functioning and quality of life. Preventive programs can improve oral health significantly with low financial implications [1].
Dental decay is the most common oral disease. It is a chronic, infectious, progressive, multifactorial disease, where nutrition plays a key role in its development. Children are particularly predisposed to the development of dental decay. Its complications have significant effect on overall child health, nutrition, growth and weight [2,3,4]. Also, dental decay causes discomfort, pain, sleeping problems, learning and absence from school [5,6,7]. Odontogenic infections as a result of untreated dental decay are the most common cause of hospitalization of young children [7]. Primary teeth are extremely important for nutrition and speech, they preserve space for permanent teeth and serve as guides, and there is also aesthetic role. In addition, primary teeth condition influences permanent teeth health as well. Oral hygiene habits and children's diet are encouraged by the family [8]. Early start of dental decay is an indicator of missed opportunities for preventive care and endangers children's general health. Therefore, it is necessary to include preventive-prophylactic methods early in life. Epidemiological data provide insight into disease developing and can be used to create preventative programs with the aim of improving oral health [9].
Montenegro health system is currently focused on a curative approach rather than preventative measures. Mon-tenegro is an area with low fluoride content in drinking water (from 0.05 to 0.2mg / L).
The aim of this study was to determine the health status of primary teeth in 6 year-old children.

METHODOLOGY
The survey included 203 children of both genders living in the territory of Podgorica Municipality, who came to dental examinations at the Faculty of Medicine, during 2017. Only children who were not older than 6 years were included in the study, medically healthy and without a mental, physical and sensory handicap. One dentist according to the principles of good clinical practice performed all clinical exams. Kappa statistics were used to test the researcher reliability. Kappa's value was 0.94.
The parameters used to assess oral health condition were: number of decayed, missing, and filled teeth due to caries (dmft) and Significant Caries Index (SiC), according to the World Health Organization recommendations [10]. All children that participated in the study were screened with standard dental diagnostic tools on dry teeth, in dental chair using overhead light. Clearly visible lesions with formed cavity on the tooth surface were registered as tooth decay, while changes in the transparency or initial demineralization of enamel with intact surface, without cavitation, was registered as healthy tooth. The state of deciduous dentition was estimated using the dmft index as described by the WHO criteria and procedures for ep-idemiological research [10]. In addition, demographical data, age, gender, school and address of residence (urban or suburban) were entered: • Decayed teeth -d, missing teeth -m, filled teeth -f (dmft) (for primary dentition) is a method to numerically express the caries experience and it is obtained by calculating the number of decayed (d), missing (m) and filled (f) teeth (t). • dmft free and application of preventive measuresfissure sealants. The SiC index (significant caries index) represents the upper third of the frequency distribution of dmft. It is introduced with the aim of pointing to respondents with the highest caries values in each population. This index is used as an addendum to mean values of dmft, and gives true picture of patients with highest caries risk. It is obtained in the following way: all examined children are distributed by dmft values; then one third of children with the highest values of dmft are selected and obtained number represents the subset of SiC; the resulting dmft score for this subset represents the value of SiC [11,12].
Statistical data processing was done in SPSS v.11.5 for Windows (SPSS Inc., Chicago, IL, USA). Descriptive and analytical statistics were used to describe the results. To test statistical significance in the mean values between the two independent samples, Student's t-test I X 2 test were used. Values of p < 0.05 were considered statistically significant.

RESULTS
A total of 203 children, 99 girls and 104 boys from urban and suburban areas of Podgorica municipality were examined. No statistically significant difference was found in regards to gender and place of residence ( χ² test, p > 0.05). The distribution of six-year-olds according to gender and place of resedence is shown in Table 1.
On average, 80.3% of examined children had dental decay. The average value of dmft index in 6-year-olds in Podgorica was 4.9 (4.5 to 5.6). Lower dmft index was recorded in girls compared to boys. Also, children from urban residence had lower values of this index than the children from the suburban residences. However, there were no statistically significant differences in the values of this index in relation to sex and place of residence (t-test, p > 0.05; Table 2).
In the dmft structure dominated decayed teeth (92.6%) followed by filled teeth (5.7%) and small percentage of extracted teeth (1.2%). Statistically significant differences were not found in the dmft structure in relation to the gender and place of residence (Table 3).
SiC's subgroup included 67 children. The index (upper third of the frequency allocation dmft) was 8.36. Among the examined children, 12.3% had at least one tooth with fissure sealant.

DISCUSSION
Primary teeth are very important. They stimulate normal growth and development of jaws, allow chewing, partici-pate in speech development, preserve the space for their succesors, and participate in aesthetic appearance. Healthy primary teeth allow permanent teeth to grow in healthy environment. The condition of deciduous dentition is largely reflected on the state of permanent dentition.
The results of our study showed that primary teeth did not receive adequate attention. The percentage of children with all healthy teeth in our study was low (19.9%). High values of dmft index indicated high distribution of decay in primary teeth both in boys and girls, with somewhat worse picture in Podgorica's suburban area. When compared with similar epidemiological studies from neighboring countries, it is not encouraging picture. Average values of number of decayed primary teeth per respondent ranged from 4.17 in Republika Srpska, while the percentage of children with all healthy teeth was 3.94% [8]. In Serbia, 20.6% of children aged 6 years had all healthy teeth [13]. In Croatia, the value of the dmft index for sixyear-olds was 4.7 [14], while in Kosovo the value of the dmft index ranged from 6.31 for boys to 6.56 for girls [15]. The average dmft index for children from Poland was 5.56 [16]. However, in developed countries dmft index ranged from 2.1 in Austria [17], 2.0 in Australia [18], 1.9 in Switzerland [19], 0.9 in Germany [20].
Special attention was paid to high-risk individuals, and an analysis of the average dmft index of one third of the most affected respondents was performed giving SiC index. The average dmft index for 6-year-olds in Austria was 2.1 and the SiC was 5.3 [17]. The SiC value in Italy amounted to 3.8 a dmft index 1.4 [21]. In Ireland, the SiC index for children 6 years was 4.0, and dmft 1.3 [22]. The value of this index for children in Montenegro was 8.36, which is much higher than the above-mentioned values. The percentage of our respondents with at least one tooth with fissure sealant was very low (12.3%). Small percentages of fissure sealants also had children from Kosovo (1.3%) [15], while no children were found with fissure sealant of this age in Republika Srpska [8]. Fissure sealants have proved to be good prophylactic measures in the prevention or control of decay, and therefore should be applied.
Efficiency of the organization of dental health care can be best achieved by observing the dmft structure. After analyzing individual components of dmft, it was observed that decayed teeth in our subjects were dominant. Dental caries was the most represented in the structure of dmft both in boys and girls. There was very small percentage of filled teeth. Similar results were found in Republika Srpska [8]. Although the Health Insurance Fund offers free dental services in Montenegro to this population group, the prevalence of decay is high. This situation is likely the result of non-educated parents who believe that primary dentition will be replaced by permanent and children would be brought to dentist mainly when they have toothache. Health habits and nutrition control are very important in preventing oral diseases [23]. It is therefore necessary to propose a plan of preventive activities towards the education of parents and children.

CONCLUSION
The main reasons for poor oral health in 6 years old children is the absence of population prevention programs and dental services oriented mostly toward treating disease. It is important to stress preventive and prophylactic measures, and raise the level of oral health consciousness, both at individual and social levels.