Hindi Essay

Hygiene, eating habits and oral health among children in three Nepalese Public High Schools. © Nordic School of Public Health
ISSN 1104-5701
ISBN 91-7997-151-2

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MPH 2006:18
Dnr U12/02:142

Master of Public Health
– Essay –
Title and subtitle of the essay

HYGIENE, EATING HABITS AND ORAL HEALTH AMONG CHILDREN IN THREE NEPALESE PUBLIC HIGH SCHOOLS
Author Kerstin Westbacke
Author’s position and address

District dentist, Public Dental Clinic, Långgatan 13, SE-460 10 Lödöse, Sweden Phone: +46 (0)520 660077, Fax: +46 (0)520 660838, E-mail: [email protected] Date of approval
2006-04-28

Supervisor NHV/External

Professor Arne Halling

No of pages

Language – essay

Language – abstract

39

English

English and Swedish 1104-5701

ISSN-no

ISBN-no

91-7997-151-2

Abstract – Currently, many developing countries are experiencing rising prevalences of caries associated with changes in lifestyle and living conditions. Objectives: To describe the hygiene, eating habits, and oral health status of Nepalese children. Materials and Methods: A stratified sample of 231 children 5–7, 11–13, and 15–16 years of age (53% boys, 47% girls) who attended public high schools in the rural area of the Lalitpur District, Nepal was selected. The study was a field study combining a clinical examination (plaque, gingivitis, calculus, and caries) and a questionnaire. The questions concerned sanitary conditions, health support, personal hygiene, tooth cleaning, and eating habits. Results: During the school day, half of the children ate nothing at all. General personal hygiene was associated with tooth-cleaning frequency. Four out of five children in the entire sample cleaned their teeth once/day or more, using their own toothbrush.

The use of fluoride toothpaste was rare. More frequent tooth cleaning and lower plaque indices were seen among girls and older children. More plaque was found on the occlusal surfaces of erupting permanent molars than on fully occluded permanent molars. Most children had a low prevalence of manifest caries in the primary and the permanent dentitions. However, every fifth 5–7-yr-old had manifest caries in three or more primary teeth. The occlusal surfaces of molars accounted for almost all registered caries in both dentitions. Conclusion: Although the prevalence of manifest caries was low, the low level of preventive activities may cause an increase in the prevalence of caries, as in other developing countries. The presumed risk scenario needs to be met by comprehensive and systematic health promotion and preventive measures.

Key words Nepal, eating habits, personal hygiene, tooth cleaning frequency, eruption stage, dental plaque, occlusal caries
Nordic School of Public Health
P.O. Box 12133, SE-402 42 Göteborg
Phone: +46 (0)31 693900, Fax: +46 (0)31 691777, E-mail: [email protected] www.nhv.se

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MPH 2006:18
Dnr U12/02:142

– Uppsats –
Uppsatsens titel och undertitel

HYGIEN, MATVANOR OCH TANDHÄLSA BLAND BARN I TRE STATLIGA
GRUNDSKOLOR I NEPAL
Författare

Kerstin Westbacke
Författarens befattning och adress

Distriktstandläkare, Folktandvården, Långgatan 13, SE-460 10 Lödöse, Sverige Tel: +46 (0)520-660077, Fax +46 (0)520-660838, E-post:
[email protected] Datum då uppsatsen godkändes

Handledare NHV/extern

2006-04-28

Professor Arne Halling

Antal sidor

Språk – uppsats

Språk – sammanfattning

ISSN-nummer

ISBN-nummer

39

Engelska

Engelska
Svenska

1104-5701

91-7997-151-2

Sammanfattning: I många utvecklingsländer sker förändringar av livsstil och levnadsförhållanden med samtidig ökad förekomst av karies. Mål: Att beskriva hygien, matvanor och munhälsa hos nepalesiska barn. Material och Metod: Ett stratifierat urval av 231 barn, som i åldrarna 5-7, 11-13 och 15-16 år (53% pojkar, 47% flickor), elever i statliga grundskolor på landsbygden, Lalitpur distriktet Nepal, användes. Studien utformades som en fältstudie med klinisk undersökning (plack, gingivit, tandsten och karies) kombinerad med en enkätstudie. Frågorna rörde sanitära förhållanden, hälsostöd från hemmet, personlig hygien, tandrengörings- och matvanor.

Resultat: Under skoldagen åt hälften av barnen ingenting alls. Allmän personlig hygien var associerad med tandrengörings frekvens. Av alla barn, som användande sin egen tandborste, borstade fyra av fem, en gång om dagen eller mer. Äldre barn och flickor rengjorde tänderna oftare och hade ett lägre plackindex. Mer plack fanns på erupterande molarers occlusalytor jämfört med molarer i full ocklusion. De flesta barnen hade en låg frekvens manifest karies i primära och permanenta bettet. Dock hade en femtedel av 5-7 åringarna tre eller fler manifesta kariesangrepp i primära bettet. Ocklusal karies på molarerna utgjorde nästan all registrerad karies i båda dentitionerna. Slutsats: Låg frekvens av manifest karies, men en låg grad av förebyggande aktiviteter, kan medföra en ökad kariesfrekvens liknande den i andra utvecklingsländer. Den förmodande risken måste bemötas med behovsinriktade och systematiska hälsobefrämjande och preventiva åtgärder.

Nyckelord

Nepal, matvanor, personlig hygien, tandrengörings frekvens, eruptionsstadier, dentalt plack, ocklusal karies
Nordiska högskolan för folkhälsovetenskap
Box 12133, SE-402 42 Göteborg
Tel: +46 (0)31 693900, Fax: +46 (0)31 691777, E-post: [email protected] www.nhv.se

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CONTENTS
Definition of terms…………………………………………………………………..4 Preamble……………………………………………………………..6 Introduction………………………………………………….…..…..7 Aims……………………..…………………………………….…..10 Materials and Methods……………………….……………………..10 Ethics………………………………………………………………15 Results……………………………………………………………..16 Hygiene
habits………………………………….……………..16 Eating habits……..……………..………………….…………..21 Plaque, gingivitis and calculus….…………………………….22 Caries………………………………..…………..………..26

Discussion…………………………………………..…..……………29 Conclusion……………………………………………….………….33 Acknowledgments…………………………………………………35 References………………………………………………………….35

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Abbreviations
CDHP
CMA
HA
High school
HMG
HP

Community Development Health Program
Community Medical Auxiliary
Health Assistant
A school consisting of classes from grades one to ten
His Majesty’s Government
Health Post – usually a government clinic in a village, which provides basic preventive and curative health services. Service is provided by a variety of auxiliary health staff, e.g. CMAs and HAs INGOs

International Non-Governmental Organizations
NGOs
Non-Governmental Organizations
PHC
Primary Health Care
Primary school A school consisting of classes from grade one to three or one to five UMN
United Mission to Nepal

Definition of terms
The different teeth and their numbers
The mouth is divided into four quadrants, with five teeth per quadrant in the primary and eight teeth in the permanent dentition.
Incisors – the four front teeth, known as the biting edge of the anterior teeth. Cuspids – the teeth next to the incisors; one tooth per quadrant primarily used in tearing/ripping food.
Premolars (only in the permanent dentition) – the teeth in between the cuspids and molars, two teeth per quadrant, used for chewing.
Molars – the posterior teeth, used for chewing; two molars per quadrant in primary and three in permanent dentition.
The 20 primary teeth are numbered in the following manner:
upper right; 55, 54, 53, 52, 51 – 61, 62, 63, 64, 65; upper left lower right; 85, 84, 83, 82, 81 – 71, 72, 73, 74, 75; lower left The 32 permanent teeth are numbered in the following manner: upper right; 18, 17, 16, 15, 14, 13, 12, 11 – 21, 22, 23, 24, 25, 26, 27, 28; upper left lower right; 48, 47, 46, 45, 44, 43, 42, 41 – 31, 32, 33, 34, 35, 36, 37, 38; lower left

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Stage of eruption
The stage, when the small tooth bud breaks through the gum until the whole crown of the tooth has completely erupted and is in occlusal contact with the molar in the opposite jaw. For a permanent first molar it takes about one year and for a second permanent molar about one and half years. The first permanent molars erupt behind the primary molars at about the age of 6 years. The second permanent molars erupt behind the first permanent molars at about the age of 12 years.

Surfaces of the tooth

Buccal – the surface of the tooth facing the cheek. Occlusal – The biting surface of a molar (and a premolar). The pits and fissures are retention places for plaque and at risk for developing caries, particularly on molars.

Lingual – the surface of the tooth facing the tongue.

Tooth diseases and the cause
Caries (decay): an oral infection disease of the teeth in which organic acid metabolites produced by the plaque and the diet lead to demineralization and destruction of tooth structure.
Calculus: mineralized plaque, which will be a retention place for plaque and new gingivitis.
Gingivitis: inflammation of the gingiva (gum) is reversible, which means that the gingiva heals after removal of plaque by toothbrushing.
Periodontitis: loss of the surrounding bone, which is irreversible, may develop as a result of chronic gingivitis, meaning no proper removal of plaque and calculus for years. Plaque is the bacterial-containing deposit that adheres to the surfaces of teeth.

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PREAMBLE
From my graduation in 1972 up to 1984, I worked as a general dental practitioner at the Public Dental Service, Älvsborg County, Sweden. My work involved performing different clinical procedures on patients in all age groups. Even so, the main emphasis was children and preventive dentistry. For a long time I have been interested in working in a developing country. After a few months of training in living and working in a foreign country, I went to Nepal. The first five months in Nepal involved learning the Nepalese language, learning about the Nepalese culture, and living for three weeks in a village in a mud house with no electricity but with a loving, chatty Nepalese family.

I worked as a dentist in Nepal for more than 12 years, between 1984-99. Half of the working-hours I spent in a modern dental clinic and the other half with teaching and the development of community oral health. My place of work was Patan Hospital, technically a governmental hospital, but financed and operated run by the UMN (United Mission to Nepal), an international Christian development organization. UMN operated hospitals, community health programs, schools, and industrial and village development programs all over Nepal. These programs often begin as small projects, develop into mature programs, and are often later taken over by HMG or another Nepalese NGO counterpart.

UMN had several hospitals with associated development and community health programs. Patan Hospital was one of them. It was situated in Patan, a twin city to the capital Kathmandu. Patan is in the neighboring Lalitpur District. While it was quite accessible for those living in the city of Patan, it was less accessible for those who lived in the rural, mountainous, southern part of the district. It took a journey of two days by vehicle and foot from the center to reach most remote villages.

In 1986, in the rural part of Lalitpur, there were five well working HPs (Health Posts) in Lalitpur. That year we dentists at Patan Hospital; one Nepalese and three expatriates (there were about 30 dentists in the whole country), discussed that instead of pulling teeth ourselves on patients, who often come from remote areas, health workers should be taught to do that. The outcome of this discussion was the establishment of the Lalitpur community oral health program in 1987.

In order to improve the program, I realized needed further training. On a furlough I went to courses in public health. An interesting course was Community Dentistry, and one of the tutors was associate professor Arne Halling. He became my supervisor. We talked about how to find simple methods to promote oral health among children in a country with limited resources.

Therefore for my master thesis I choose to study hygiene, eating habits and oral health. Colleges had done fluoride mapping all over Nepal and successfully lobbied to toothpaste manufacturers to make fluoride toothpaste. My study could contribute to direct an intensive toothbrushing program, at a time when the permanent molars are erupting as well as to support an integrated teaching approach regarding general hygiene and toothbrushing. Also to be stressed was a locally made nutritious snack/meal at lunchtime for schoolchildren.

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INTRODUCTION
Nepal, which was a closed country up to the early 1950s, has a geographical area of one third the size of Sweden. Nepal is divided into four regions: the Kathmandu Valley, east Nepal, central Nepal, and the west and far west Nepal (1). In 2004 the population was estimated to be approximately 24 millions (2). About half the population is under the age of 20 and a redoubling of the population is estimated to occur in the next 25 years (2). For the Nepalese, life expectancy at birth is 59 years with a high infant and maternity mortality (2).

The infrastructure, service and economics in the country have improved during the last decade, but still many Nepalese live under the poverty line and there is widespread illiteracy. Most of the population subsists on small farms with limited access to roads, health and educational systems (3). The inhabitants of Nepal can be classified culturally into three general groups: Hindu castes (Brahmin/Chetri 53.2%), ethnic groups of the hills (for example Newar 3.4% and Tamang 4.7%) and Northern border people of the population (1). Often a group/cast live concentrated in a particular part of the country having their own language, culture and traditions (1).

Lalitpur, one of Nepal’s 75 districts, consisting of both urban and rural areas, is situated south of the capital Kathmandu. Most of the inhabitants in the district are farmers and belong to three castes/ethnic groups:

1) the traditional Hindu castes (Brahmin/Chetri), who believe that body and oral cleanliness is a necessity before early morning worship (1,4).

2) Newars, who practice both Hinduism and Buddhism and who are characterized by having the most traditional and nutritious diet.

3) Tamangs, who practice Buddhism and who work as day laborers. In the rural area of the Lalitpur District there are 10 public high schools, one private high school and several dozen of public and private primary schools. Hygiene is a priority to Nepalese and traditionally it is a general custom to bathe regularly, as well as to clean hands prior to the rice meal. However, it is still rare to have water supplies close to the homes; forcing people to spend hours collecting water for their daily

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needs. In the rural part of the Lalitpur District, most people have enough water and even access to a tap in their own yard or nearby. The outdoor tap is a place for bathing, hair washing, washing of clothes and collecting water for the kitchen. A special brass jug with a pipe is used for cleaning the hands as well as for drinking clean water. Generally, the drinking water in Nepal (5) has a low fluoride content (p

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