Title

Author(s)

Oral health status, knowledge, attitudes and behaviour of

adults in Guangdong, China

Lin, Huancai;

Citation

Issue Date

URL

Rights

1999

http://hdl.handle.net/10722/35900

Creative Commons: Attribution 3.0 Hong Kong License

O R A L H E A L T H STATUS, KNOWLEDGE, ATTITUDES AND

BEHAVIOUR O F A D U L T S IN GUANGDONG, CHINA

L I N Huancai
Ph.D. Thesis

T H E UNIVERSITY O F H O N G K O N G
1999

Abstract o f thesis entitled

Oral health statusknowledge, attitudes and behaviour of

adults in GuangdongChina
submitted by

Lin Huancai
for the degree of Doctor of Philosophy at The University of Hong Kong
in Decembei" 1998

Proper evaluation of oral health status, knowledge, attitudes and behaviour among
people Is a basis for planning preventive and curative oral health care programs, and
f o r devdaping training programs for dental personnel. However, such information is
lacking in China, especially among adults and among rural residents. The objectives
of this srudy were to describe the or^l health status and treaiment needs of 35-44 and
65-74 year-old Chinese in Guangdong Province, to explore the oral health
knowledge, aniludes and behaviour in these two age groups, and to determine
factors affeciing their oral health status and oral health behaviour,

An oral health survey was conducted in Guangdong Province in Southern China in

1996-97. A sample of 1,573 "35.44-year-oli and 1,515 65-74-year-old Chinese was
recruited from 8 urban sites and S rural sites through multi-^tagc cluster sampling. In
die siirv'ey, the subjects were first interviewed by trained interviewers using a
structured questionnaire. Then they underwent a clinical examination carried out by
one of three calibrated examiners. The examination procedures^ instalments and
diagnostic criteria used followed those recommended by the World Health
Organization (1997) for oral health surveys.

The subjects' oral health knowledge was found to be poor but their oral health
attitudes were generally positive. Alm(>s: all of the dcmale elderly surveyed daimed
that they brushed their teeth every day and used tooihp^le. Howevermost of them
did not know if their toothpaste contained fluorideTheir dental service utilization
Jow and problem-driven- Less than one-quarter of che subjects had visited a dentist
within a year. SociaJ and economic factors were fbund to relate To oral healih
knowledge, attitudes, and oral health behaviour in this population. The mean D M F T
score w a s 4.6 m the 35-44"year-olds and 15.6 in the 65-74"year-olds. M T was the
major component o f the D M F T score in both age groups. Rural residents, women
and those who w c r t Itss wealthy had higher D M F T scores. Pre&cnc^ of calculus and
shallow periodontal pockets was prevalent but not for deep periodontal pockets.
However, loss o f pcnodomal attachment was prevalent and severe in the surveyed
adults. Men exhibited worse periodomal status tban women but rural residents and
urban residents exhibited similar periodontal destruction. Only 4% of the elderly
surveyed were edentuloiis. Almost all o f the 35-44-year-olds and moat of the 65-74year-olds had at least 20 teeth present. Rural residents had a similar number o f
missing teetK but a greater number of teeth indicated for extraction than urban
residents. Only a small proportion o f the middle-aged and leS& than half o f the
elderly were found to have a dental prosthesis in either jaw. The prevalence o f
normative dental treatment need among the adult Southern Chinese was found to be
high but the rrcaunents were mainly simple ones. However^ the prevalence of
perceived treatment need in this population was low and the correlation between
these two types o f treatment needs was low.

iii

CONTENTS

PAGE
Abstract of thesis

ii

Declaration
Acknowledgment
Contents

vt

List of abbreviations

List o f Tables

xi

List o f Figures

xvi

1- INTRODUCTION
M . Background o f the present survey
1.2. Dental care policy and organisation in Mainland China
1.3. Guangdong Province

2
+ L I T E R A T U R E REVIEW
review of oral health surveys among adults m China
National oral health surveys
2.1.1. The First National Oml Health Survey

2
2 2 5
1 1 1 1

2A.

2 . 1 2 The Second National Oral Health Survey

2.2. Major regional and local surveys related to caries in
adults in Mainland China
Study population and sampling methods

22.2.

Methodology m d reliability

2.2.3

Maj or results

5
7
8
1 1 1 2

2.2.1.

2.3. Major regional and local surveys related to periodonla]

status in adults in Main J and China

2.3.2.

Methodology aad reliability

233r

Major results

3
4
22'

Study population and sampling methods

1
2

2J

PAGE

2.4. Major regional and local surveys rcJated to tooth loss and

26

prosthctic status i n adults i n Mainland China

2.5. Major regional and local surveys related to oral health

29

knowledge, attitudes and behaviour in adults in Mainland

China
2-6. Major or 1 health surveys amone Hong Kong adults
2.6.1. Methodology of the 19S4 Hong ECong Adult Oral

31
31

Health Survey
2.6.2. Methodology of the 1991 Hong Kong Adult Oral

32

Health Survey
2.6.3. Major results o f the two Hoag Kong adult oral

32

health svirveys
2.7. Summary o f literature review

35

3. AIM AND OBJECTIVES

37

4. M A T E R I A L S A N D M E T H O D S

3S

4.1, Study populaticrn and sampling methods

38

4.2. Recruitment of subjects

40

4.3r Fieldwork procedures

42

4.3.1. Interview

42

4.3.2. Clinical examination

45

4r4. Testing of water fluoride level m survey sites

51

4.5. Data processing and analyses

52

5. R E S U L T S

5S

5-1. Background o f study population

5.2. Inter-examiner

58
reliability

60

5 3 . Oral health knowledge, attitudes and oral hygiene habits

63

5,4, Utilization o f dental services

75

5-5- Coroaal arid root caries

S3

vii

PAGE
5.6. Periodontal diseases
5.7. Tooth ossand prosthetic status
5.S, Treatment needs

6. DISCUSSION
6.1, MethodoJogy

90
94
103

103
108

6-f -1, Sampling mettiods and recmitment of subjects

103

62Variables and measurements

110

6.2Resulns
6.2.1. Inter-examiner reliability and intra-examiner

114
114

reliability
6.2.2. Oral health knowledge attitudes and oral hygiene

116

habits
6.2.3. Utilization o f demal

120

6.2.4. Coronal and root caries

122

6.2.5. Periodontal diseases

126

6-2,6, Tooth loss and prostheUc status

130

6.2.7, Treatment needs

133

7. C O N C L U S I O N S

138

S, R E C O M M E N D A T I O N

HO

9. R E F E R E N C E S

141

10. APPENDICES
1.

Questionnaire used in the survey (Chinese version)

2.

Questiotmaire used in the survey (English version)

3.

Record f o r m used in the clinical examination for 35-44year-olds (Chinese version)

Record form used in the clinical examination for 3544year-oids (English version)
Record fonti used in the clinical examination for 65-74year-olds (Cliinese version)
Record form used m Lhe clinical examination for 35^4year-olds (English version)

LIST OF ABBREVIATIONS

A M T adjusted missing teeth

A K O V A analysis of variance
AXCOVA analysis of covariance
CI calculus index
C P I --- comminuty periodontal index
C P I T N community periodontal index for treatment need
C V coefficient of vajriation
DF-Root --- decayed and filled root
D F T decayed and filled teeth
DI debris index
D M F T --- decayed, missing and filled teeth (permanent dentition)
d m f t decayed, missing and filled teeth (primary dentition)
D T decayed teeth
FMPI

family material possession index

F T f i l l e d teeth
GI --- gingival index
I M T indicated missing teeth
L O A --- loss of attachment
M T missing teeth
N C O H National Committee for Oral Health
N T N --- normative treatnient need
O H I --- oral hygiene index
P D I periodontal disease index
PlI plaque index
PTN --- perceived treatment need
R C I rootcaries index
W H O w o r l d health organization

LIST OF TABLES
PAGE

2-1

Major regional and local surveys and results relatedo dental

caries of the middle-aged and elderly

2-2

Major regional and local surveys related io periodontal

conditions of the middle-aged and elderly

12

2-3

Percemages of individuals by maximura CPITN in the Chinese

middle-aged and elderfy age groups reported in previous
studies.

24

4-1

Calculation of family material possession index (FMPI),

45

4-2

Variables from questionnaire and their grouping or scaring

used in data analyses,

53

4-3

Variables from clinical examinaiion and their grouping or

scoring used in data analyses,

54

4-4

Analytic model for the ^tudy indicating the incorporated

variables.

55

4-5

Variables vsed in the analyses of cqvariance for knowledge

score, attitude score, DMFT, and A M T in the 35^l4-year-old5
aj^d 65-74-year-olds.

57

5-1

Sample size according to age group, gender and location.

58

5-2

Selected demographic characteristics of the subjects

(perceniage).

59

5-3

Kappa statistics f o r inter-examiner reproducibiJity

60

5-4

Mean nujnbers of DMFT, DF-Root, ajid M T by examiner.

61

5-5

Percentage of persona with periodontal pockets and LOA by

examiner.

61

5-6

Percentage of Chinese adults w h o indicaied various causes of

dental caries according lo age group and location of
residency (multiple response analysis).

63

5-7

Percentage of Chinese adults who indicated various preventive

methods against dental caries according to age group ai>d
location of residency (multiple response analysis).

16

63

PAGE

5-S

Percentage of C h i n e s adults who indicated various c-auaes of

gum disease according to age group aad location o f residency
(multiple response analysis),

64

5-9

Percentage of Chinese adults "who indicated various preventive

methods against gum disease according to age group and
location o f residency (multiple response analysis).

64

5-10

Relationship between dental knowledge score

selected
independent variables in 35-44-yeair-01ds (result o f A N C O Y A
analysis).

66

5-11

Relationship between dental knowledge score and sdccied

independent variables i n 65-74-year-olds (result of A N C O V A
analysis),

67

5-12

Channels through which the respondents received their oral

health information (multiple response analysis).

68

5-13

Proportion of subjects with a positive dental health belief or

artitude.

69

5-14

Relationship between dental attitude score and selected

independent variables i n 35-44-year-olda (result of A N C O Y A
analysis).

70

5-15

Relationship between dental attitude score and selected

independent variables i n 65-74-year-olds (result of A N C O V A
analysis).

71

5-16

Distribution o f Chinese adults according to reported oral

hygiene practice (%).

72

5-17

Result o f a logistic regression analysis on toothbmshing

frequency (once ar less vs twice or rnore daily) in 35-44-yearo\ds (rL=1573)-

73

5-18

Result of a logistic regression analysis oxv toothbrushing

frequency (once or less vs twice or more daily) in 65-74-yearolds (n=1515).

74

5-19

Recency of last dental visit in the two age groups according to

location o f residence (Percentages).

75

xii

PAGE

5-20

Distribution o f participants by reasoas given for not making a

dental visit within the past three years accordii^g to location of
residency (multiple response analysis).

76

5-21

Treatments received in the last dental visit among those who

had visited a dentist within [he past Three years (multipk
response analysis).

77

5-22

Selected factors in relation to use of denta! services in the 3544-year-olds-

79

5-33

Selected factors in relation to use of dental services in the 65

74-year"Old3r

80

5-24

Result of a logistic regression analysis on recent v\st of dentai

services (less ihan 2 years vs. more than 2 years) En the 35-44year-olds.

81

5-25

Result of a logistic regression analysis on rccent use of dental

services (less than 2 years vs. moie than 2 years) in the 65-74year-olds.

B2

5-26

Caries status according to age group, gender and location of

residency among adults in Guangdong.

84

5-27

Comparison of DMFT stores in different subject groups

among the 35-44-year-olds,

86

5-28

Comparison of DMFT scores in different subject groups

among the 65-74-yeai-olds.

87

5-29

Relationship between DMFT scores and dental knowledge,

attitude and FMJPI scores (Pearson's correlation coefficient),

88

5-30

Relationship between DMFT scores and selecied independent

variables among the 3 5-44-year-old Chinese (result of
ANCOVA analysis).

S9

5-31

Relationship between D M F T scores and selected independent

variables among the 65-74-year-old Chinese (result of
ANCOVA analysis).

89

5-32

Percentage distribution of the 35-44-year-olds according to

highest CPI score.

90

xiii

PAGH
5-33

Percentage di^tributioil ofhe 65-74-year-olds accordins to

highest C?I score.

5-34

Mean number of sextants by CPI score in the 35-44- year-olds.

91

5-35

Mean number of sextants by CPI score in che 65-74-year-olds.

91

5-36

Percentage distribution of the 35-44-year-olds according io

their maxirxuim LOA.

92

5-37

Pevcentage distribution of the 65-74-year-olds according to

their maximum LOA.

92

5-38

Mean number of sextsnts by LOA in lhe 35"44-yeir-old3.

93

5-39

M t a n number of sextants by LOA in the 65-74-ye;ir-olds-

93

5-40

Missing teeth (MT) indicated missing teeth (IMT) and adjusted

missing teeth ( A M I ) among adults in Guangdong.

95

5-4 J

Relationship between AMT and selected independent

variables in the 35-44-yeaj>olds (result of ANCOVA
analysis).

99

5-42

Relationship between A M T and selected independent

variables in the 65-74-year-olds (result of ANCOVA
analysis),

100

5-4 j

Percentage of 35-44-year-old subjects with dental prostheses

by arch.

101

5-44

Percentage of 65-74-year-old subjects with dental prostheses

by arch,

101

5-45

Percentage of subjects with dental prostheses according to

locaEion of residency.

102

5-46

Percentage di^tributioi) of subjects and mean number of teeth

(in parentheses) according to type of tooth-ba^ed treatment
needm d location of residency r

104

5-47

Percentage distribution of the 35-44-year-old subjects

according to their normative prosthetic treaunent need by arch.

104

5-48

Percentage distribution of the 65-74-y&ar-old. subjects according

to their normative prosthetic treatment need by arch.

105

JtlV

90

PAGE

5-49

Percentage distribution o f dentate subjects and mean number of

sextants (in parentheses) according to periodontal treatment need
category and location of residency.

105

5-50

Percentage distribution of subjects according to holistic

tr-eaimem need category and location o f residency.

106

5-51

Percentage distribution of 35-44-year-old subjects according

to thdr perceived treatment need (PTN) and normalive treatment
need (NTN).

107

5-52

Percentage distribution o f 65-74-year-old subjects according

to their perceived treatment need (PTM) and nomiative
treatment need (KTN),

107

xv

LIST OF FIGURES
4-1

Location of Guangdong Province ^nd survey regions.

4-2

Sampling method o f the Guangdong Ora Health Survey

1996-97.

4-j

Procedure in field work of Gutmgdong Oral Health Survey

1996-97.

5-1

Mean dental knowledge score (Maximum = 12) of men and

women in urban and niral areas i n Guangdong.

5-2

Mean dental attitude score (Maximum = 8) of men and

women in urban and rural areas in Guangdong,

5-3

Proportions o f F T and D T in D F T according tCf gender and

location of residency in 3 5-44-year-olds and 65-74-year-aids

5-4

Cuinulative percentage distribution of 35-44-year-old

subjects by location and gender according to adjusted
missing teeth ( A M T ) .

5-5

CumuUiive percentage distribution o f 65-74-year-old

subjects by location and gender according 10 adjusted
missing teeth ( A M T ) .

5-6

Proportions o f missing teeth (MT) and indicated missing

teeth (TMT) by tooth type i n the 35-44-year-old subjects.

5-7

Proportions o f missing teeth (MT) and indicated rmis^ing

teeth (IMT) by tooth type i n the 65-74-y&ar-old subjects.

xvi

1. INTRODUCTfON

1.1.

Background o f the present study

There is a general agreement in the dental professional community that the two most
prevalent oral diseases, dental caries and periodontal diseases are prevemable
through a combination of professional and &elf care activities and (hat people's
anitudes and behaviour play an important rqle in the development and prevention of
oral diseases (Gjermo, 1986; Schou and Blinkhom, 1993; Cohen and Gift. 1995),
Concern has been expressed that improvements i n oral health conditions were taking
place in many Western countries whereas deterioration i n oral health has been taking
place i n many developing countries (WHO1989; Barmes, 1989). Proper evaluation
o f such irends needs appropriate data which will be o f use f o r planning preventive
and curative otal care programs and developing training programs for dental
personnel. However, only a f e w studie? have been tanTied out in Mainland China
with collaborating investigators from abroad using internationally recognized
m ethod am ong which most were conducted in Northern China (Powell
Baeluin et aL, 1988a- Luan

1986j

1989a Luan ec aiy 1989b; Wright et al.^ 19S9:

Yang er ai, 1992; Douglass et aL, 1994; Petersen et al

descriptive ajid analytic epidemiological oral surveys have added considerably to the
knowledge concerning oral health o f the popiilation and provided a basis for ora
health policy there (Corbet and Lo, 1994 Corbet et aL, 1994; Holmgren et aL
Lim et cd 1994; L o and S c h w a s , 1994a L o and Schwarz, 1994b; L o et a1994;
Schwarz and Lo1994a; Schwarz and Lo] 994b; Schwarz et aLs 1994). Surveys
into Guangdong Province in Southern China will provide basic data related t o the
oral health status: knowledgeattitudes and behaviour of the people in Guangdong

Provmcc for formulating strategies for orai heaHh prevention and treatment. It w i l l
also help to fiEi the gaps i n the underst^mding of oral health developments in Hong
K o n g which is culturally closely related to Guangdong Province with most o f Hong
K.ong people being dc&cendanis o f lhe province. This research project surveyed
selected age groups (5-6 1235^44, 65-74 year-olds) and was conducted during
1996 to 1997, T h e project received support from the Faculty of DentisLryj The
University o f Hong FCong and also from the Department of Preventive Dentistry and
Department o f Epidemiology, Sun Yat-sen University of Medical Sciences in
Guangzhou (capital city o f Guangdong Province). This thesis reports major results
of the 35-44-year-olds and the 65-74-year-oid3 with regard t o their dental caries,
periodontal diseasetooth loss, and treatment needs a s well as salient factgrs for ora.!
health knowledge, anitudes and behaviour.

1.2. Dental care policy and organization in Mainland China

F o r a long period, oral health care had not been perceived as important in Mainland
China. T h e situation began t o change since 1980s with the grawdi in the economy,
increase in intemAtiGnal interflow, and more aiwi more demand for oral health care.
In 1981a WHO Collaborating Centre for Demtal Research and Tmining was se up
in t h e Beijing Medical University t o provide fuithei' training for dentists firom
different parts of China. I n 19S3, the first national oral health survey w a s conducted
among 131,340 primary and secondary school studems using methodology
recomnaended by WHO, In 1988the First National Conference for Preventive
Dentistry was. held in Tianjing and with the support of tbe Ministry of Public Health,
The National Committee for Oral Health was s^t u p in the same year. In 19S9? the
Ministry o f Public Health and related authorities designated the 20th of September

as the national Lave Teeth Day^ (Bian a i , 1995). Each year on this day,
numerous oral heakh education activities are conducted across the country to
di^seininate ora! health messages to the public and these provide a national focus on
the improvement o f oral health attitudes and behaviour. Fluoridated toothpaste has
become available i n China since early 1990s and is gradual J y spreading throughout
the country. School-based fissure sealant programmes have been introduced in sortie
schools in the major cities but the coverage is still very limited- In
nationaJ oral health survey was conducted among both children and adults in
selected provinces.

T h e National Committee for Oral Health (NCOH) which mainly comprises ocal
health experts f r o m different provinces of China is under t h e Departmem of Disease
Control, the Ministry of Public Health. The main task o f the committee is to assist
che Ministry o f Public Health to make policies for the prevention and treatment o f
denial diseases, to draw up a plan for manpower and personnel training, to
coordinate the dental prevention and treatment workto foster academic exchange
and to introduce new methods and new techniques (L\T 1993). Special ^ibcommittees f o r aral health edxication and promotion, primary health care, school
dental health care,

o f fluorides, and evaluation o f dental care products have been

set u p under the NCOH. A t present, all the provinces, autonomous regions, and
metropolitans directly under the central Chinese government have established their
own committee For oral health under their loca Department o f Public Health.

It has been long recognized that several different types o f dental persoruiel are
fundamental to the efficient provision o f dental care. Different countries may have

different types o f dental personncL In Mainland China, the tj'pes mainly include
deatist, middk-levd dentist, dental nurse, and dental technician.

The dentists (stomatoiogists) usualJy graduate from a universiiy after 5 yeari qf

study. There are at least 27 univergiti?? which provide such training of dentists (Bai
md Zhang, 1990J. Before students enter the universiiics, [hey have studied 6 years
in a primary school and 6 years in a secondary school. A s the competition is keen,
only those who obtain che high grades in the national university entrance
examination can enter the universitiesIn the universities, they usually spend three
years in the study of general medical courseone year in the study of theoretical
and experimental courses of dentistry, and one year in practice in. dental hospitals.
After graduation, they usually work in state-owned hospitals. Some of them wUl
continue to study for postgraduate qualifications in or outside China. There are some
dentists who are promoted from middle-level dentists (described in next paragraph)
after many years of work and after passing a special test. But such promotion
becomes m o t e and more difficult because more dentists graduate from universities
and the policy becomes stricter for such promotion.

The middle-level dentists graduate from health worker training schools after 3 years
of study. I n the late 1980s, there were 30 schools registered with various provincial
Departments of Public Health or with the National Educaticm Committee and they
provided training for middJe-leve! dentists (Bai and Zhang, 1990), Before students
enter the health schools, they usually have received 9 years of education (lower
secondary evd). After graduation, Ihcy may work in state-owned hospitals or in.
private dental clinics. Finding a j o b in state-owned hospitals becomes more and

more difficult for them. The number of health worker training schoois which provide
training for middie-leveE dentists has increased in recent years but the exact number
is unknown.

Few schools provide special iraming for dental surgery assistants in Mainland
ChinaDentists are assisted by 'dental nurses' in their clinical work. Nurses usually
receive three years training In a health worker training school after they finish lower
secondary school education. When they work in dental hospitals or clinics, they
receive a short period of training before they Sl^it working as dental nurses, They
have the same knowledge as other medical nurses so that they can work in an oral
surgical ward nursing in-patients as well ag work in dental clinics. Most private
dental clinics

no dental nurse.

Dental technicians also graduate from the health worker training schools, TTiey also
receive three years training after campleting lower secondary school educaiioiL The
namber of school$ which provide training for dental technicians is less than those
which provide the training for middle-level dentists. The student dental technicians
leam how to fabricate ciovviis, bridges and dentures in the schools- After graduailon,
they usually work i n big hospitals or clinics.

Private denial clinics are not yet as common in Mainland China as in xnmy other
countries but the tendency is to increase. Almost all the dental hospitals and dental
clinics in general hospitals belong to and get support Stem the government. T h ^ y are
supervised by public health buieaus in the cities or cQunries which import to the
Department of Public Health of the province. Medical insurance usually covers basic

den Ceil health care in Mainland China, such as filling and tooth extractiontoutnot for
orthodontics and denial proslhesis. Government Employee5 and people who work in
state-owned

institutions

and

companies

usually

can

get

partial

or

total

reimbursement o f the expenditure on basic dental health care in appointed hospitals.

The proportion o f the reimbursement varies from one work place to another. People
who are not working in state-owned work places, like farmers, usually h^ve no or
little medical insurance juid they can go to any dental hospitals or denial clinic^ to
get dental care services. Private dental clinics are more common in towns and small
cities than in big cities because th^ hospital coverage is better En big cities and
people working i n the cities usually have medical insurance which requires them to
go to visit a dentist i n a state-owned hospital for dental care,

1.3. Guangdong Province

There are 23 provinces? five autonomaiis regionsfour metropolitans directly under
t h e cemral goverrnnent in China. Guangdong Province located in the southern part
o f China is one o f t h e big provinces in population and a n important province in
economic terms in China. It has a land area of 178,100 square kilometers and a
3,368 kilometers long coastline. Animal average temperature is 2 L 7 0 C (Editing
Cormnittee o f Guangdong Encyclopedia, 1995), Administrativelyit is divided into
21 cities (ajdministrative region^} and can b e further subdivided into 42 urban
districts and 78 rural counties or county-level cities. T h e resident population in 1995
6 8 million and the male 10 female ratio w a s 1.05 : 1 (Guangdong Statistical
Bureau, 1996). Furthermore, there were more than 3 million immigrant workers
coming from other provinces. In 1995only about 2 % o f the population had an^oded
tertiajry or post-secondaiy education. Results o f the 1990 population census of

Guangdong Province (Population Census Office o f Guangdong Province, 1992)

showed chat 30% o f the population were 0-14 years old and 9% were 60 or more
years okL Around 60% of the working population were agricultural workers.
Another 22% of the work force were manual workers. The annual gross national
j
product in Guangdong Province wa^ R M B 1,403 billion (about USD 2,480 per
capita) in 1995 (Guangdong Statistical Bureau, 1996)

There are 16 dental hospitals in the major cities in Guangdong Province (Guangdorvg
Statistical Bureau, 1996) and there are dental clinics in most of the county-level and
city-leve! hospitaU- However, about half of the 1,500 iownship hospitals do not
provide dentai services (Zhang er at.t 1993b), There are approximately 1.5 university
trained dentists per 100,000 population (Zhang et aL, 1993b)In addinon, there are
about 1 7 000 middle-level dentists who have received 3 years of basic dental training
in a health worker training school. Thus, the overall dentist to population ratio is
about 1: 33,000. It should be pointed oat that the geographic distribution of dentists
is very uneven, there are many more dentists in the major chies and urban areaa than
in the towns, and hardly any in the rural areas.

In the rural areas of Guangdong Ptovince, like in other provinces, there are some
dental care providers who have been trained in traditional apprenticeship rather than
in dental schools. They mainly provide relief of dental paintooth extraction and
prosthetic treatment. However, no information is available regarding their number
and distribution-

Guangdong Province is the only province that has experienced coimnimity water

fluoridation in Mainland China. In July 1965. community water fluoridation was

introduced in a district o f Gu^gzhou City, Fangcun District snd this extended lo
other parts o f the city m November o f the same year (Luo et al.7 I9SS), A t the
beginning, the average cc-ncemration o f fluoride was 0.8 ppmh Le. 0.8-1.0 ppm
between November to AprU and 0.6-0,8 ppm between May to Ociober. Some
surveys were conducted several years after water fluoridation to evaluate the effect
and it was reported that denUl caries had been reduced by 40-60% in children
(Guangzhou Work Group for Water Fluoridation Programme, 1972; 1973).
However, dental fluorosis was foujid to have increased and the concentration of
fluoride was adjusted to 0.7 ppm i n March of 1975 (Department o f StomaJtologj" of
Second Affiliated Hospital of Zhongshan Medical College, 1979). Dining 19761978 (two and half years), water fluoridation was interrupted because of a Sack of
sodium silicofluoride from local factories. After thisthe progjtam was continued in
Fangcun District, but w a s basically stopped in other districts o f Guangzhou (Shen
and Gu, 1985). In 1978, the Epidemic Prevention Station and some dental academics
in GucLngzhou suggested to stop the water

fluoridation progjim. There were

different views held b y the medical and dental professionals in Guangzhou with
regard to this proposal. The reduction o f dental caries w a s generally acknowledged
but different extent o f the reduction of caries and different results o f dental fluorosis
were reported (Guangzhou Work Group f o r Water Fluoridation Prograinme, 1972^
Department of Stomatology o f Second Affiliated Hospital o f Zhongshan Medical
College1979; 5hen et aL7 1982). In September 1933, the Public Health Bureau o f
Guangzhou City told the water supply company to stop water fluoridation because it
claimed that according to the report from the Epidemic Prevention Station, the
average prevalence o f dental fluorosis among the children

high as 53%

although the average prevalence o f denml carics had dccreascd from 62% to 42%
(Shen, 19S9). In a town of Guangdong Province, Guangcheng, water fluoridation
was introduced in 1974 and stopped i n the late 1980s, Howeveii no &tudy vvas
conducted to evaluate the cffect of this programme.

2. L I T E R A T U R E REVIEW'
-review of oral health surveys among adults in China

Although there is compuier software and databases in China similar to Medline for
searching medical articles written i n Chinese, the number o f articles in dentistry is
limited and thus the retrieval of relevant Chinese dental literature is very difificulL
Several methods were used in this review to search for articles- A search on the
Medline Express C D - R O M system was performed using key words suth as China
"caries", and periodontal 10 iook for articles published in English and in Chinese.
In addition, a. Chinese periodical,
Chinese - Medical section" (Zhong^-en ECeji Ziliao MuluYixue Fence), was used
to search f o r articles in Chinese. Major dental joumats in Chinese (Sdw/^iz and Lin :
]997) in which articles on oral epidemiology and behavioural science were usually
published were also checked year by year to find the relevant articles. The
publications listed m the reference section of the retrieved aiticles w&re also
checked.

It was found that published infoTmation from oral epidemiological studies In

Mainland China was scarce although there were several artides which summarized
the caries status in some population groups in Mainland Chirua mainly based on
unpublished papers collected by authors (Yue5 1980; Editorial Board of Chinese
Journal of Stomatology, 19S3; Editorial Boaxd of West China Journal of
Stomatology, 1988),

Most of the study populations in the reported oral health surveys in Mainland China

10

were children and ajdolescentg and from urban areas o f big cities. Studies on middleage adults and elderly were muc-h less common. Moreover, many of these studies are
difficult lo interpret because o f unknown sampling method (Fan and Cat, 1988),
poorly defined criteria (Zhang and Li1995), frequent lack of stratification by
important variables such as age (Xu et ai

9S9), or unsuitable presentation of

results (Zhang ei al
surveys o n oral health status, knowledge, attitudes, and behavioxir ii\ adults in
Mainland China, No major review of this kind was found l o have been performed
earlier.

11

2.1National oral health surveys

Two natLOital oral health surveys have been conducted in Mainland China. The first
one was conducEed among childr-en and adolescents m 19S3 and the second one was
conducted among boih children and adults in 11 selected provinces in 1995,

2.1.1. T h e First National O r a l Health Survey

The First National Oral Health Survey vvras canicd out in 29 provinces of China
(Mitnistjy of Public Health, 1987), A total of I j 1,340 students aged 7912, 15 and
17 years old were selected through stratified sampling with respect to agegender,
location (urban o r rural), fluoride concentration of water a^d ethnicity. About half of
the students were selected from rural areas. Dental caries, periodontal diseases,
dental fluorosis and tetracycline stain were examined in the survey based on WHO
criteria. The mean dmft among V-year-old children was 4.8 in urban areas and 2,6 in
rural areas with prevalences of 84% and 62% respectively. The mesoi DMFT score
among 12-year-old children was 1.0 in urbaa areas and 0.7 in rural areas with
prevalences of 46 and 31% respectively. Mean number of sextants with gingivitis
(bleeding on probing) and calculus were 2.5 and 1.7 with prevalences of 77% and
62% respectively. Considerable variations between coastal and inland provinces
were also reported.

2A,2. The Second National Oral Health Survey

The Second Naiional Oral Health Survey was conducted among 140,712 subjects in
11 selecled provinces in 6 selected age groups, namely the 5, 121518, 35-446574 years. The ratio of subjects from rural areas to those from urban areas wh^ about

12

1:2. Guangdong Province was selected to represent the southern part of China. The
procedure and lhe major statistical tables of this survey have been reported recently
(Technical Instruction Group for The Second Nfacional Oral 1 teaitK Survey1998),
Multi-5tage cluster sampling was used in this sun/eyClinical exainination was
conducted in all 6 age groups whereas interview was con dueled only in the 12h 18,
35-44, and 65-74-year-olds. About 20% o f lhe subjects m these four age groups
were interviewed.

In the cIEtiical examination of adults, coronal and root caries, CPITN, prosthetic
status and treatment need were recorded. It was reported that the clinical diagnostic
criteria used were those recommended b y WHO (1937) except the criteria for the
diagnosis o f root caries. However, only 2S tfeeth (excluding the third mol^U^), instead
o f 32 teeih as recommended by WHO, were examined in this survey. At least in
Guangdong Provincethe examiners for this purvey came from local hospitals in the
survey regions 3 survey regions in each province) and were responsible for the
examination o f subjects in their own region. A s no duplicate examination
performed in this survey to monitor examiner variationlhe degree o f error is
unknown. Examination conditions, e.g. light, chair f o r exaniinees had. not been
mentioned

T h e mean D M F T of the 3 5"44-year-olds w a s reported to b e 2.11 (2.14 in urban areas

arsd 2,03 ijn rural areas) with a prevalence o f
F T scores were 1.10, 0.590.42, Mean number of teeth present in the 35-44-yearolds w a s 27.12. It is interesting to note that the sum o f this number and M T does not
equal lhe niimber o f teeth examined. It was described in Oral Health Surveys -

t
a

Basic Meihods" (WHO, 19S7) that M T comprised teeth missing due to carics as
well as other reasons for subjects aged 30 years and older. Therefore, the sum of the
numbtr of ceeth present and M T should equal the number o f teeth exanained. The
number o f teeth present in the 65-74"year-olds was re-ported to be 18.14The mean
DFT was reported to be 2.49 (2.36 in the rural areas and 2,74 in the ruraJ areas).

According to the highest CPITN score, 2rl% of the 3 5-44-y ear-olds and 4.3% of the
65-74-year-olds had deep periodontal pocket and 11.2% of lhe 35-44-yeai-olds and
17.9% of the 65-74-yeajM>kis had shallow pocket. 10.5 of the 65-74-year-olds
were edentulous and S.4% had complete dentures in both jaws. The proportion of
subjects who claimed to brash their teeth twice w d once daily were 32b/b and 53%
respectively in the 35-44-year-olds and 23% and 4S% respectively in the 65-74year-olds. Only 2 0 of both the 35-44-year-olds md the 65-74-year-olds had visited
a dentist within the preceding 12 months.

14

2,2, Major regional and local surveys related to caries in adults in

Mainland China

2.2A. Study population and Siimpling methods

Some o f the major regional and local surveys rehted to caries in adults i n Mainland
China are listed i n Table 2-1. Most studies only included urban residenis but a. few
also included rural residents. The ratio of urban subjects to rural subjects

about

1:1 in two surveys (Liu et al

Jiangjd Province (Yan ? 1995) and about 2:1 in the survey in Beijing (Luan et a i ,
l9S9a) r The urban subjects mainly came from big cities and only three surveys
included urban subjects from middle-sized or small cities (Petersen et ai 1997;
Chen er ai. 3 1993; Yan : 1995),

Different sampling methods were used in the surveys. Some surveys did not describe
the sampling methods used (Hu and Zhu1964; Liu et al., 1984; Yi et aL
Yan1995). Some survey? were performed o n convenience samples r Powell et
(19S6) examined staff aged 35-44 years avaiJable for examination in a dental faculty
in Shandong Province. Zhang e/ ai. 1988) examined the elderly who attended a
health care clinic. Several surveys used multi-stage cluster sampling (Chen

aL,

1993; Petersen et al1997; Feng et al. f 1998) whereas Luan er a l (1989a) applied a
systematic stratified sampling procedure to select the young adults and th-e middle
aged.

15

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usually 200 to 400 i n the surveys b i n more than one thousand 35-44-year-olds vere
surveyed b y C h e n et al. (1993), T h e report o f the survey conducted b y F e n g

ai.

(1998) d i d not gi ve saitiple size for each age group,

2.2.2. Methodology and reliability

M o s t o f the surveys reported that they performed the clirucal examinaiion bas^d o n
the methods recommended b y W H O . O n e survey recorded coronal a n d root caries
b y surface and recorded the depth o f coronal caries ( L u a n e i

i989a). One survey

used the diagnostic criteria recommended by the Chinese M i n i s t r y o f P u b l i c H e a l t h

( Y a n &t aL s 1983), T w o surveys d i d not report the diagnostic triieria o f dental caries
( C h e n et aL, 1935; Z h a n g et ai,, 1933).

M o u t h mirror a n d explorer were usuaily used i n the c l i n i c a l examination. O n l y two

surveys reported that they used artificial light during c l i n i c a l examination (Powell et
a i 1 9 8 6 ; Luajci er I I989a) r A n o t h e r three reported that they used natural light
( L i u et ai 19S4; P e t e r s e n et al^ 1 9 9 7 ; F e n g et ai 1 9 9 8 ) w h i l e the o t h e r s did n o t
m e n t i o n a b o u t this. M o s t s u r v e y s c o n d u c t e d a f t e r t h e 1 9 7 0 s h ^ d t h e i r d a i a a n a l y s e s
p e r f o r m e d on c o m p u t e r s e x c e p t t h r e e w h i c h d i d n o t m e n t i o n t h e m e t h o d o f d a t a
a n a l y s i s ( Y i ei ai 1 9 8 5 ; Z h a n g et gL, 1 9 8 8 ; Y a n , 1995),

T h e s u r v e y c o n d u c e d i n G u a n g d o n g P r o v i n c e ( C h e n s t al. y 1993} r e c r u i t e d n o n dental university students a n d trained t h e m t o b e examiners. H a l f of t h e surveys did

not report o n the tiuniber o f examiners employed i n the survey ( H u and Zhu. 1964;
Y i et ai., 19S5; Zhang el aL, 19SS; C h e n et a}.7 199^; Y a n , 1995). Only some listed
surveys mentioned the examiaer calibration methods and results. Coefficient o f
varia-tion ( C V ) was used by two surveys ( L i u er a!., 19S4; Y a n , 1995) to assess interexaminer reliability and a C V smaller than 0,2 was set aa the acceptable level b y
these surveys. K a p p a statistic wias more frequently used i n the recent surveys and the
results were rcponed to be 0,79-0.93 (Luan ei- aL, 19S9a}3 over 0 r S5 (Petersen el ai
1997), a n d over 0.4 (Feng

out duplicate examinaiions during the main survey to monitor examiner reUabiUty

2,2+ M a j o r results

Y u e (19S0) reviewed published and unpublished surveys conducted between the

1940s and the 1970s. T h ^ e data comprised a total o f 4.6 m i l l i o n people (unJcnown
age group) from, different parts o f C h i n a and the average dental caries prevalence
rale w a s 37.3% w i t h a n average o f 2,47 carious teeth for each subject affected. Mo&t
study subjects were f r o m urban areas and o n l y 1,6% were f r o m rural areas. O n l y a
very small percentage o f the subjects were adults. T h e majority o f the surveys were
conducted i n Shanghai, The author summarized: (1) Because such collected data had
not been appropriately designed w i t h age group, diagnostic criteria, sampling
m e t h o d s , d had not been reported appropriately i n papers, the difference among
provinces and the differenc-e between cities md rural areas could not be estabJished.

The mean DMFT/dmfl scores and percentage of people affected according to age
groups also h^d nor been imported(2) D i f f e r e n t e t h n i c g r o u p s d i d n o t exhibit

significantly different level o f dental caries whea they iived in the same areas, (J)

8
p

Higher fluoride concentration i n drinking water was associated with l o w t r

prevalence rales o f caries.

Table 2-1 shows the mean D M F T o r D F T m the middle-aged and the elderly which
were mainly f r o m surveys conducted after 19S0. The mean D M F T i n lhe 35-44
y e a r - o l d s w a^ frorn 1,5 t o 6,0, R e s u l t s f r o m studies c o n d u c t e d in B e i j i n g a n d
G u a n g d o n g g a v e relatively h i g h D M F T scores. T h e m e a n D M F T o f t h e 65-74-yearo l d a g e g r o u p i n H u b e i b a s e d o n 2 8 teeth w a s reported to b e 8-9 (Petersen et aL.
1997). A n o t h e r s u r v e y b a s e d o n 2 8 teeth reported t h e m e a n D M F T m 65-69-year-old
S h a n g h a i elderly to b e 12.1 ( F e n g el a/1998). B a s e d OR 3 2 teeth] L u a n et aL
( 1 9 8 9 a ) reported a m e a n D M F T s c o r e o f 16.6 in 60-69-ycar-old B e i j i n g elderly.
S o m e s u r v e y s j u s t g a v e t h e r e s u l t s o f D F T rather thim D M F T . D F T ranged, from 1.4
t o 37 i n t h e rtiiddle-aged a n d From 3 . 5 t o 15.2 in the etderly.

W o m e n w e r e u s u a l l y reported t o h a v e a h i g h e r m e a n DMFT o r D F T s c a r e t h a n m e n
( L i u er al.t 1934; P o w e l l et al.y 1986; C o o p e r a t i o n G r o u p f o r B e i j i n g Elderly Oral
FTeakh Survey
s u r v e y i n W e s t e r n C h i n a r e p o r t e d that u r b a n residents h a d a h i g h e r D M F T s t o r e
t h a n rural r e s i d e n t s i n t h e 3 5 - 4 4 - y e a r - d d s ( L i u et a
i n B e i j i n g , G u a n g d o n g P r o v i n c e a n d J i a n g x i P r o v i n c e f o u n d h i g h e r D M F T scores in
r u r a l r e s i d e n t s ( L u a n et ai 1989a; C h e n et ai,

1993; Y a n , 1995). B e s i d e s g e n d e r

a n d location, analysis o f t h e relationship b e t w e e n d e n t a l caries a n d other

d e m o g r a p h i c characteristics s u c h a s e d u c a t i o n leveloccupationajid i n c o m e o f
a d u h s w a s u n c o m m o n . A f e w s t u d i e s t r i e d t o find o u t factors w h i c h influenced
d e n t a l caries. C h e n et ai ( 1 3 ) found that people (combination o f children and

19

adults) who were older or had periodontal disease, maloctlusion. bad oral hvgiene,
and frequent rnLake of sweet food tended to have more caries. Petersen ef ai (1997)
found that women, those who hajd visited a. demist i n five yearsand those w h o
reported using fluoride toothpaste daily in the j5-44-yerar-olds had higher D M F T

score

S u r v e y s o n root cartes w e r e u n c o m m o n a n d only a f e w surveys reported the root

c a r i e s status b y prevalence a n d / o r m e a n n u m b e r of teeth affected, T h e prevalence o f
r o o t caries in the 60-69-yeajr-olds w a s reparted t o b e 3 2 % t o 5 0 % with 0,9 to 1.9
teeth a f f e c t e d per person e x a m m e d (Cooperation G r o u p f o r Beijing Elderly Oral
H e a l t h Survey, 19S3; L u a n ei al., 1989a; Z h a n g a n d LiT 1995}. Foe a caries lesion
a f f e c t i n g both t h e root a n d coronal s u r f a c e t h e lesion w a s recorded originating
i n the root b y Lua^i et al. (1989a). Other surveys did not dearly describe the criteria
for the diagnosis o f root caries. One survey among Shanghai elderly using Root
Caries Index (RCI) reported that the R C I was 5 A 2 i n 65-69-year-oid5 ( L i u et ai,

1992).

20

Major regional arid local surveys related to periodontal status in

adults in Mainland China

2.3,L Study populsitjun und sampling methods

Some major surveys related to periodontal conditions o f the middle-aged and the
eMerly i n M a i n l a n d C h i n a are listed i n Table 2-2. M o s t o f these sarveys "were
conducted amoxig urban residents i n b i g citiessuch a s Beijing, T i a n j i n g a n d
S h a n g h a i . O n l y a f e w s u r v e y s c o m p r i s e d s o m e rural residents.

S o m e o f t h e lisied s u r v e y s u s e d c o n v e n i e n c e s a m p l e s (Diao, 19S6; P o w e l l et ai,

19S6; Pilot ^ al.7 1989) a n d s o m e d i d n o t describe their s a m p l i n g m e t h o d s ( S h i er
ai,

19S3; L i u et al., 1984; W a n g

a 1987; "Wd1987). D i a o 1986) e x a m m e d

m i l i t a r y s t a f f a t t e n d i n g a clinic. P o w e l l et a l . (19S6) e x a m i n e d 3 5 - 4 4 - y e a r - c l d staff

i n a d e n t a l f a c u l t y i n S h a n d o n g Province. Pilot et ai

(19S9) examined factory

w o r k e r s in t h r e e f a c t o r i e s i n Shanghai- A multi-stage c l u s t e r s a m p l i n g w a s u s e d i n
t h e s u r v e y i n W u h a n (Petersen et ai. 1997). H u e / al. ( 1 9 9 0 ) r e p o r t e d t h a t t h e y u s e d
a stratified m u l t i - s t a g e r a n d o m s a m p l i n g m e t h o d b u t d i d n o t describe the sampling
p r o c e d u r e . M o s t o f t h e s e s u r v e y s recruited t h e i r s u b j e c t s f r o m f a c t o r i e s ( S h i e i aL,
1983; L i u ei

1984; W a n g eiaU

1987; W e L 1987; Pilot et ai 19S9)-

S a m p l e s i z e in e a c h a g e g r o u p (class interval w a s u s u a l l y 10 yeaxs qi 5 years) w a s

u s u a l l y 1 5 0 t o 4 0 0 i n t h e s e s u r v e y s , A bigger s a m p l e size o f a r o u n d 5 0 0 - 7 0 0 3 5 - 4 4 y e a r - o l d s w a s f o u n d in t h e s u r v e y s c o n d u c t e d b y D i a o (1986) a n d b y Pilot et ai.
( 1 9 8 9 ) . A s u r v e y report b y W a n g e i aL ( 1 9 8 7 ) did n o t g i v e individual s a m p l e size
f o r each a g e group.

21

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2,3,2+ M e t h o d o l o g y a n d r c U a b t y
Some internationally accepted indiccs for periodontal status and oral hygiene were
used i n the surveys listed in Table 2-2. C P I T N was the most common index used.
T w o composite indices, l h e Periodontal Disease Index (PDI) developed by Ramftord
(1959)

and the eriodomai Index (PI) developed by Russell (1956), were used i n

some surveys i n the 19803. T h e Plaque Index (PlI) developed by Silness and L o e
(1964) and the three indices developed b y Greene and V e r m i l l i o n (I960), i e. Debris
Index (DI)_ Calculus Index (CI) and O r a l Hygiene Index ( O H I ) were used i n some
surveys to measure plaque and calcuJus, L i u ef a L (1984) used the criteria defined by
W H O (1977).

L o s s o f periodontal altachmenl ( L O A ) i n adulis i n Mainland C h i n a

w a s seldom studied. A l t h o u g h the scoring o f P D i i^clude^the meajuTement o f L O A ,

P D I itself just gives a mean score for the periodonlal condition i n group o f people.
O n e survey i n B e i j i n g had measuredL O A i n adults by teeth (Baelum et al., 1996).

Concerning the instruments used, C P I T N probe was most often used to measure
C P I T N T w o o f t h e t h r e e studies u s i n g PDT u s e d G l k k m a n ' s periodontal p r o b e (Shi
ul

used (Diao, 1986). O n l y some o f the surveys used artificial light ( P o w d l et aL

19S6; W a n g et al,7 19S7; Baehrni et aL, 1996). O t h e r s c o n d u c t e d t h e clinical
e x ^ m i n a t i o t i u n d e r tiatuml l i g h t o r d i d n o t m e n t i o n t h i s S o m e s u r v e y s carried o a t
c a j i b r a t i o n s e s s i o n s b e f o r e t h e m a i n s u r v e y b u t Xhc results o f calibration for
p e r i o d o n t a l status w e r e s e l d o m reported r N o n e o f tKe r e v i e w e d suidi-es c o n d u c t e d
d u p l i c a t e e x a m i n a t i o n s d u r i n g t h e m a i n s u r v e y to m o n i r o r e x a m i n e r reliability.

23

2.3-3+ M a j o r results
Percentages o f the m i d d l c - a g t d and the eJdeily survey subjects ajccording to
m a x i m u m C P I T N score are s h o w n in Table 2-3. In the 3 5 - 4 4 - y e a r - o l d t h e
percentages o f subjects w i t h deep pockets ranged f r o m Q.7% to 11% a n d the
percentage o f subjects w i t h s h a l l ow pockets as their m a x i m u m C P I T N score ranged
f r o m 6.5% to 44%: Deep a n d s h a l l ow packets as m a x i m u m C P I T N score v/eie found
i n 2 2 % a n d 16% o f the 65-69-yeaj-olds i n Shanghai ( H u et al ] 9 9 0 ) a n d 38% a n d
1 6 . 2 % in t h e 65- 74- year - oJds i n W u h a n , H u b e i P r o v i n c e ( P e t e r s e n e / a L , 1 9 9 7 ) .
A l t h o u g h t h e C P I T N i n d e x w a s a l s o u s e d in a survey o f B e i j i n g adults (Wei^ 1987),
t h e r e s u l t s w e r e n o t reporced a c c o r d i n g t o t h e s t a n d a r d f o r m a t r e c o m m e n d e d b y
W H O (19S7). It s e e m s t h a i m t h i s s t u d y t h e p e r c e n t a g e s w e r e caJculated b a s e d o n
l h e o c c u r r e n c e o f the c o r r e s p o n d i n g s c o r e i n o n e o r m o r e o f t h e six s e x t a n t s in a
p e r s o n . T h e m e a n r i u m b e r s o f s e x t a n t s w i t h n o periodonEcd d i s e a s e , b l e e d i n g o r
h i g h e r s c o r e , c a l c u l u s o r h i g h e r s c o r e , ahalJow o r d e e p pocketSj d e e p p o c k e t s a n d
e x c l u d e d s e x t a n t s w e r e r e p o r t e d t o b e 0 , 7 , 5 , 3 , 4 . 8 , 1.3 7 0.2, 0 . 0 r e s p e c t i v e l y in t h e
3 5 - 4 4 - y e a r - o l d s ( P i l o t et al 19S9) a n d 0 4.2. 3.3, 0.7, 0.3L7 r e s p e c t i v e l y i n t h e
6 5 - 6 9 - y e a r - o l d s ( H u el ai 1 9 9 0 ) .

Table 2-3. P e r c e n t a g e s of individuals by maximum CPITN in t h e Chinese middle-aged

a n d elderty a g e groupsa s reported in previous studies.
Maximum CPITN score (%)
Survey

Age group

Location

35^4

Urban

Pilot ets!., 1939

35-44

Urban

H u e t a L 1990

05^9

Urban

Petersen et e/L 1997

35-44
65^74

PowelSe t ^

1986""

51

36

9"

43

44

11

SO

16

22

Urban

90

Urban

77

16

24

01

T h e percentages o f ""PD^O11 (with periodontal disease) and P D I > 3 (with loss o f

a t t a c h m e n t ) w e r e reported t o b e 92.9%

a n d 4 2 . 6 % w i t h a m e a n P D I soore o f 2,83 in

T i a n j m residents aged f r o m 7 lo m o r e than 7 0 years (Shi et al.y 1983). In another

s u r v e y in T i a n j i n , t h e corresponding percentages i n adults a g e d I S o O years were
9 8 . 8 % a n d 4 4 . 4 % respectively ( W a n g et ai7

1987). he P D I scores were not

reported individually by age groups in either paper. It was reported that the mean
P D I score increased from 0,70 i n men aged 20-24 to 0.96 in m e n aged 35-44 (Diao f
1936), H u and P a n (1984) found that the mean P D I score o f the elderly n i t h diabetes
was higher than that o f the elderly i n a control group. Based on the e>^mination o f
a l l teeth i n a group of

Baelum et al (1996) found that 63% were

affected by atlachment loss o f 4 m m or more and 11% by artachment loss o f 7 m m

or rnore. The corresponding percentages i n the 65-69-yeajr-oids were 100% and 30%
respectively,

S h i sf al. (I9S3) reported that the mean PIT score i n 35-39-year-olds was 1,64 and
the score increased w i l h age. The same study also found that farmers had the highest
P l I a n d C i scores among aJl occupation groups. D i a o (1986) reported that the
percentages of men aged 19-54 with debris and calculus were 99% and 94%
respectively. T h e mean D L C I and O H I scores increased w i t h ager and positive
relationships existed among DI^ C I and P D I i n the subjects surveyed. B a d u m ^ ^1.
(1996) found a mean o f 19,9 and 25.S teeth i n the 35-39-year-alds having calculus
and plaque respectively. It can be summarized that plaque and cabulus as measured
by these studies were common i n the adults i n Mainland China.

25

2.4. Major regional and local surveys related to tooth loss and prosthetic
status in adults in Mainland China

Surveys focusing on tooth loss and ptosthetic status were uncommon and mainly
conducted i n urban areas and in the elderly. A s recognized widely i n the worSd,
dental carles and periodontal disease are two important reasons causing the loss o f
teeth. A survey o f the elderly i n Chengdu reported that 77% o f tooth loss v/as due to
caries and 16% due to periodontal disease (Chen e i aL, 19S5). The proportions were
somewhat different from the results o f two studies based on clinical records which
g o i a lower proporlfon (45-53%) due to caries and a higher proportion {22-40%) due
to periodontal disease ( L e i el al 1987; Tian el al., 1995).

T h e survey i n C h e n g d u (Chen e/ id 1985) collected oral health data from a

c o n v e n i e n c e s a m p l e o f 926 elderly f r o m j o m e fajctaries, government organizations
and residential areas. O n e o r m o r e missing lct:th were found i n 9 5 % o f the subjects.
O n average^ e a c h person h a d lost 14-2 teeth, excluding third molars. In t h e 60-69
and 70-79 year-old groups^ the m e a n numbers o f missing teeth were 10.4 and 15.8
respectively. A survey o f 2,191 elderly, a g e d 60 years a n d over, f r o m 9 residential
area-s and a village o f Beijing reported that 9 1 % of them had l a s t o n e or m o r e teeth
a n d l h e m e a n n u m b e r of missing teeth w a s 11, excluding third molars (Cooperation
G r o u p f o r Beijing Elderly OraJ Health Survey, 1988), T h e m e a n n u m b e r o f missing
teeth i n t h e 60-69-yeaj:-oId3 w a s reported t o be S,4. Another survey i n Beijing
recruited 1,744 JO-SO-year-olds f r o m 3 urban districts a n d a rural village by
systematic sampling a n d found a m e a n o f 29.1 and 20-2 teeth present i n t h e 30-39year-olds a n d 60-69-year-olds respectively (Luan a l I 9 S 9 b ) . A follow-up study
i n t h e s e s t u d y subjects indicated that the incidence of tooth Iqs5 w a s m u c h higher in

26

the elderly than i n the young adults (Luan

at., 1994), Generally speaking, men

retained more teeth than women and urban residents retained more teeth than rural
Tehsidents (Chen ei al., 1985; Cai1987; L u a n ei al
u p p e r teeth t h a n l o w e r teeth a n d m o r e posterior teeth thati anterior Teeth w e r e
m i s s i n g ( C h e n et

L985; Cai, 19S7; X u et aL, 1989)_

T h e p r e v a l e n c e o f complete e d e n i u b u s n e s s w a s reported lo b e
6 9 - y e a r - o l d s i n Beijing (Cooperation G r o u p f o r B e i j i n g Elderly Oral health Survey,
19S8; Z h a n g et al,
u r b a n a r e a s o f C h e n g d u , Western C h i n a ( C b e n el al.. 1936).

A o c o r d i n g t o t h e criteria o f W H O ( 1 9 7 7 , 1987, 1997), the M - c o m p o n e n t o f D M F T

i n c l u d e all m i s s i n g teeth d u e 10 a n y r e a s o n s for subjects 3 0 y e a r s a n d older.
T h e r e f o r e , t h e M - c o m p o n e n t o f D M F T should b e t h e n u m b e r o f missing teeth f o r
t h o s e s u b j e c t s a g e d 3 0 y e a r s a n d a b o v e . H o w e v e r , s o m e surveys o n dental caries
listed i n T a b l e 2 - 1 o n l y g i v e t h e results o f D F T , A s m a l l score of M T , 1.1, w a s
r e c o r d e d by P o w e l l et al

(19S6) f b r t h e 35-44-y&ar-olds i n a university i n

Shangdoivg Proviivc^. T h e M T scores o f t h e 35-44yeai-olds a n d t h e 65-75-year-olds

i n urbaxi a r e a s in H u b e i P r o v i n c e w e r e r e c o r d e d a s 0 , 7 a n d 6,1 respectively b a s e d o n
2 8 Leeth e x a m i n e d (Petersen

a l 1997). A n o t h e r survey based o n 2 8 teeih

recorded t h e M - c o m p o n e n t i n t h e 35 - 3 9-year-olds a n d 6 5-6 9-year-olds i n u r b a n

a r e a s o f S h a n g h a i t o b e 0.5 a n d 8 . 9 respectively ( F e n g et a!,, 1998).

P e i c e n t a g e s o f l h e 60-69-year-olds i n B e i j i n g w i t h a full d e n t u r e i n o n e o r b o t h j a w s

27

were reported to be 8% and 6% respectively (Luan et al., 1989b), Percentages o f

subjects w t h one or more bridges and one or more partiaJ dentures were 6%
arid 14% in Ihis age group. The corresponding percentages i n the 30-39-year-olds
were 10% and
year-olds w i t h f u l l denture and with partial denture or bridges were reported to be

7%
Survey, 1988), A survey q>f a group o f 45^49-ye3J>olds and 65-69-year-old5 i n the
urbait area^ o f H e b e i Province showed thai 5% and 6% o f the middle-aged and 10%
and 39% o f the elderly had one or more bridges and one or more partial dentur-E5
respectively (Zhang, L9S5).

The proportion o f edentulous elderly who had received prosthetic treatment ranged
f o m 64% to S7% and the prevalence o f dental prosthesis among those who had lost
some o f their teeth ranged from 1S% to 30% (Chen
1939), Partial d e n t u r e s w e r e m o r e frequently s e e n i n u r b a n residents t h a n in rural
r e s i d e n t s j w h i l e b r i d g e s w e r e m o r e c o m m o n a m o n g r u r a l residents t h a n i n u r b i n
r e s i d e n t s ( L u a n et al^ i 9 8 9 b ) . T h e f a c t t h a t w o m e n a n d t h e o l d e r elderly usually
r e c e i v e d l e s s t r e a t m e n t w a s c o n s i d e r e d a reflection o f their attitudes t o tooth loss a n d
t h e i r e c o n o m i c status ( C h e n et al 1985), T h e gov-emment o f f i c i a l s , professionals
and p e o p l e w i t h h i g h educarional level u s u a l l y lost f e w e r l e e t h a n d received m o r e
treatment t h a n f a r m e r s , m a n u a l w o r k e r s a n d h o u s e w i v e s (Cai1987).

28

2.5Major regional and local surveys related to oral health knowledge]

attitudes and behaviour in adults in Mainland China

R e p o r t e d surveys o n oral health k n o w l e d g e , attimdes a n d behaviour i n adults i n

M a i n l a n d C h i n a were relatively u n c o m m o n and were usually without a g o o d design.
S t u d y subjects usually c a m e f r o m convenience samples i n urban

with a w i d e

age r a n g e , f r o m children t o middle-aged (Tm Et al.7 1992; Z h u , 1993). Surveys o n

t h e elderly w e r e scarce. R e s u l t s o f oral health k n o w l e d g e o r attitudes w e r e usually
reported by individual k n o w l e d g e i t e m (Tai e i al
o f oral heatth behaviour w e r e m a i n l y related t o t o o t h b m s h i n g habits. D u e to these
s h o r t c o m i n g s t h e validity a n d general izability o f t h e results m a y b e questionable.

It h a s b e e n reported that m o r e i h a n 9 0 % o f C h i n e s e children o r adults, aged f r o m 10

ye^rs, t h o u g h t that sugar w a s haimfiil to teeth (Zhu, 1993; P e n g et al., 1997). W h e n
a g r o u p o f m o t h e r s a f p r i m a r y school studernts w e r e a s k e d t o give the c a u s e s <yf
denta] caries, sugar w a s rrrentioned b y 4 2 % o f t h e m , bacieria b y 3 5 % , a n d w o r m s b y
1 0 % (Petersen a n d Z h o i ^ 1998). I n The s a m e study, 5 9 % of t h e mothers mentioned
incorrect looih

cleaning, 32%

m e n t i o n e d general illne&s a n d 23%

mentioned

nn.healthy diet (23/) a s a c a u s e o f bleeding gunL Toothbrushing a n d restriction of

s u g a r w e r e m o s t frequently r e c o m m e n d e d b y t h e m o t h e r s to prevent dental caries
b u t u s e o f fluorides w a s r e c o m m e n d e d o n l y b y 18%. P e n g el al. (1997) reported that
a r o u n d half o f the

residents i n W u h a n , H u b e i Province k n e w that fluoride m a y

prevent denta] caries a n d that t h e a n s w e r s given b y t h e adolescents, younger adults

and m i d d l e - a g e d w e r e similar. I t w a s reported that

urban residents thought that

dental diseases w e r e h a n n f i i l to t h e b o d y a s w h o l e (Tai et ai, 1992; Zhu, 1993).

29

Afmost ail younger adults in. urban areas brushed their teeth at leasi once daily (Luan
d aL, 1993; Peng ef cd1997). A survey oi" Shanghai elderly reported that S % of
t h e de nta te elderly did ciot brush their teeth daily a n d the proportion increased to
4 4 % a m o n g those a g e d SO y^sis and over (Hu el

19SS). A ma^s campaign o n

' X o v c Teeth D a y h a s b e e n carried out mationwide e a c h y e a r In China since 1939 to

raise ihe p e o p l e s awareness of dental health, a n d to promote community
involvement in oral health education programs and self-care (Bian et aL. 1995),
Better dental knowledge and toothbrushing behaviour were found i n W u h a n
residents after six yecirs of < : Love T e e t h Day' 1 c a m p a i g n s (Peng et al., 1997).

h h a s b e e n reported that 22% of the 35-44-year-olds a n d 35% of rtie 65-74-ye3r-oId5

i n u r b a n areas i n Hubei Province had b e e n t o the detiti^t within a year and t h e major
reasons f o r n p t visiting a dentist w e r e L na serious d e i n a l p r o b l e m ' and n o ' n e e d '
(Petersen et ai,

1997), Around half of the adults ifi urban ^uea^ in Hubei Province

and H u n a n P r o v i n c e stated t h a t their m a i n reason f o r visiting a demiat w a s toothache

(Zhu, 1993 P e n g erf a L , 1997). A collaborative questionnaire survey conducted in
s o m e provinces reported that only \5% of t h e urhan residents a n d 5 % of the rural
residents h a d visited a dentist w h e n they h a d dental p r o b l e m s (Sun. 1992), T h e main
reasons f o r n o t visiting a dentist given by t h e urban residents were ''inconvenience' 7
21%)"no n e e d (16%),
4i

L1

too busy" (15%),

"af r a id o f seeing dentist" (15%), a n d

t00 e x p e n s i v e " (6%), T h e m a i n reasons given b y t h e rural residents w^re

" i n c o n v e n i e n c e " (27

n e e d ( 1 0 % ) , a n d iL too expensive" (9%). H ow e ve r , t h e age o f the subjects surveyed
w a s not reported.

30

2.6. Major oral health surveys among Hong KLong adults

Although there u'ere a number o f oral health surveys conducted among H o n g K o n g

adults, only the t w o major surveys are reviewed here. They were lhe first and second
Hong Kong

adult

oral

health

surveys

conducted b y

the

Department o f

Periodontology and Public Health ? Faculty o f Dentistry, The Ifniversity o f H o n g

Kc?ng i n 1984 and i n 1991 respectively.

2.6.1. Methodology of the 1984 Hong Kong Adult Oral Heakh Survey
A multi-stage cluster sampling was used in this survey (Lirid et al 19S6, 19S7a. &
l 9 S 7 b ) . I n t h e first stage, a r e g i o n w i t h a population o f a b o u t 300,000 w a s selected
t a k i n g i n t o Consideration c o n v e n i e n c e o f the location a n d representativeness o f the
m a j o r s o c i o e c o n o m i c strata i n H o n g K o n g . A f t e r t h e r e g i o n w a s chosen, l i v i n g
q u a r t e r s w e r e detected b y s y s t e m a t i c sarnpting and w i t h i n e a c h l i v i n g quarter all
p e r s o n s a g e d 15-19 a n d 3 5 - 4 4 y e a r s c o m p r i s e d t h e s a m p l e . T h r o u g h conducting
h o m e visits a ^ d f o l l o w - u p t e l e p h o n e calls,, 5 6 3 15-19-year-olds a n d 6 7 6 35-44-yearo l d s w e r e finally r e c r u i t e d .

A q u e s t i o n n a i r e d e s i g n e d f b r self-coitipleticm w a s u s e d i n t h i s survey t o collect

sociocultural data

focusing o n oral health related p e r c e p t i o n s , k n o w l e d g e a n d

b e h a v i o u r o f t h e subjects, T h e s u b j e c t s w e r e a l s o clinically e x a m i n e d f o r p r e s e n c e o f
d e n t a l caries a n d t r e a t m e n t needdental prosthetic statusperiodontal conditions a n d
t e e t h p r e s e n t . T h e d i a g n o s i s o f d e n t a l c a r i e s a n d assessments f o r t r e a t m e n t n e e d
w e r e carried o u t a c c o r d i n g t o W o r l d H e a l t h Organization (1979) criteria. Periodontal
conditjcms w e r e a s s e s s e d b y a p p l y i n g t h e C P I T N u s i n g i n d e x teeth. E x a m i n e r

31

calibration was carried out prior to the survey and inter-examiner reliability was
monitored by duplicate examinations during the survey. The survey was carried o u i
i n the P r i a c e P h i l i p D e m d Hospital.

2+6.2, Methodology of the 1991 Hong Kong Adult Oral Health Survey
his study was planned to f o l l o w the guidelines for the Internationa GolJSaborative
S i a d y 11 ( C h e n et aL, 1997). F o r the 35-44-yeai-oId age groupthe survey

areas,

s a m p l i n g a n d subject r e c r u i t m e n t m e t h o d s w e r e essentially t h e s a m e a s t h o s e applied

in t h e 1984 su r v e y (Schwar^: ef a l 1994). A total o f 3 9 8 35-44-year-old5 w e r e
r e c r u i t e d f o r t h i s study. F o r i h e 6 5 - 7 4 ' y e a r ' O l d a g e g r o u p , s u b j e c t s \vere r e c m i t c d
f r o m elderly c e n t e r s i n difTerenc districts o f H o n g K o n g . F a c e - t o - f a c e interview,
i n s t e a d o f a self-c-ompletion q u e s t i o n n a i r e used i n t h e 19S4 s u r v e y , w a s u s e d i n this
s u r v e y . T h e in f o r m a t i o n c o l l e c t e d i n the interviews included t h e s u b j e c t ' s s o c i o e c o n o m i c b a c k g r o u n d , d e n t a l l a i o w l e d g e , attitudes a n d b e h a v i o u r , A dental
k n o w l e d g e 5 c o r e ( 0 - 1 2 ) w a s c o n s t r u c t e d a c c o r d i n g t o l h e s u b j e c t ^ r e s p o n s e s to f o u r
q u e s t i o n s a b o u t tooth d e c a y a n d g a m d i s e a s e ( S c h w a r z a n d L o , 1994a). A f t e r t h e
i n t e r v i e w , t h e subjects w e r e clinically e x a m m e d a c c o r d i n g to t h e procedures a n d
d i a g n o s t i c c r i t e r i a r e c o m m e n d e d b y W H O (1937).

2+6,3. Major results of the two Hong Kong aduh Aral health surv eys
I n t h e 1 9 8 4 survey25% o f t h e 3 5 - 4 4 - y e a r - o l d s d i d n o t k n o w t h e causes o f d e n t a l

caries and 56% did not know the causes of gum disease ( l i n d et al l9S7b)- These
p r o p o r t i o n s w e r e r e p o r t e d t o b e 8 % a n d 2 7 % i n the 1991 s u r v e y ( S c h w a r z a n d L o ,
1 9 9 4 a ) , F o r t h e 65^74-year-old3, a r o u n d h a l f o f t h e m w e r e r e p o r t e d to b e u n a w a r e o f
t h e c a u s e s o f d e ^ t J c a r i e s a n d g u m d i s e a s e ( S c h w a r z a n d L o a 1994a). I n both

32

surveys, almos; a l l the denote subjects claimed to brush iheir teeth once or more
daity (LSnd et ai,

1987b; L i m et aL, 1994). Some respondents were found to hold

Chinese health beEief towards periodontal disease i n both surveys (LSnd

af

19S7b; L i m ^ iil. ? I 9 9 4 ) r

C o m p a r e d l o t h e findings o f 19S4 survey, a slight change i n d e m a i visit p a r t e m w a s

f o u n d in t h e 1991 survey, w i t h 5 - 6 % increase in t h e proporxion o f j > 4 4 - y e a T - o l d
h a v i n g s e e n a dentist w i t h i n l h e preceding year. However, u s e o f dental services in
H o n g K o n g w a s generally l o w e r than in m a n y industrialized countries (Schwar?: a n d
Lo, 1994b). T h e m a i n reported xeason for n o t h a v i n g visited a dentist w a s no
perceived denml p r o b l e m (Lmd et a! l 9 S 7 b ; L o

BtkI

] 994a).

I n t h e 1984 survey, t e e t h j u d g e d i o b e u n e m p t e d t>r extracted as a result o f trauina Oi

f o r orthodontic r e a s o n s w e r e excluded from t h e calculation o f D M F T index in t h e
35-44-yeair-okls- A f t e r b e i n g a d j u s t e d accordingly^ it w a s f o u n d that t h e caries
situation a s m e a s u r e d b y t h e D M F T i n d e x w a s very similar t o that f o u n d in the 1991
survey ( L o a n d S c h w a r z , 1994b). T h e m e a n D M F T score w a s f o u n d to b e 8 . 7 i n the
35-44-year-ojds a n d 18,9 in (he 65-74-year-oId& in 1991. Tlie respective niean D T ,
M T a n d F T w e r e 1.0, 4.5, 3 . 2 f o r t h e middle-aged a n d 1,4, 17.0, and 0.5 f o r t h e
elderly. F o r t h e r o o t conditions, there w a s a reduction in t h e prevalence o f root
caries i n t h e j 5 - 4 4 y e a r - o l d s , f r o m 15% f b u n d i n 1984 t o 7 % i n 1991. it w a s
suggesred that t h e p o s s i b l e reasons f o r this i m p r o v e m e n t w e r e t h e b e n e f i t s o f 3 0
years o f w a t e r fluoridation a n d t h e mtroductioTi o f fluoridated toothpaste in t h e late
1970s ( L o a n d Schwarz, 1994b).

3
3

The periodontal condition o f the 35-44-year-old subjects as expressed by preva.!erce

and mean number o f sextants per person according to highest C P I score was very
similEir i n the two surveysIn i h e 1991 surveyit w a s f o u n d that 17% o f l h e 3 5 - 4 4 year-olds a n d 1 5 % o f t h e 6 5 - 7 4 - y t a r - o l d s h a d d e e p periodontal p a c k e t s ^ n d 5 7 % o f
t h e J 5-44-year-olds a n d 5 1 % o f the 65-74-year-olds h a d s h a l l o w p o c k e t s ( H o l m g r e n
et al 1994)-

h i t h e 19S4 survey, i t w a 5 f o u n d that 2 0 % o f rhe 35-44-year-olds w e r e denture

w e a r e r s ( L i n d e! a l ^ 1996). I n t h e 1991 survey, 1 2 % o f the 3544-yerar-old!5 h a d a
d e n t u r e o r d e n t u r e s , ] 7% h a d a b r i d g e o r b r i d g e a n d \ % h a d both (Corbet a n d Lo
1994). O f the 6 5 - 7 4 - y e a r - o l d 1 2 % w ^ r e edentulous. O n l y 2 9 % o f t h e elderly h a d
n o prosthesis, 5 2 % h a d a d e n t u r e o r dentures, 3 3 % h a d a b r i d g e o r b r i d g e a n d 13%
had both.

In lhe 1991 s u r v e y , s o m e holistic treatment n e e d categories w e r e used so as to

p r o v i d e s o m e i n f o r m a t i o n f o r d e n i a l m a n p o w e r p l a n n i n g . It w a s f o u n d t h a t t h e
t r e a t m e n t n e e d o f t h e v a s t m a j o r i t y o f t h e m i d d l e - a g e d a n d t h e elderly w a s simple
onesOnly a b o u t o n e - f i f t h o f t h e s u b j e c t s in both a g e g r o u p s required s o m e complex
t r e a t m e n t s ( L o er cfl.,

34

2J . Summary o f literature review

N o niajor review has previously

been carried out o n the reported socio-

epideiniologii studies i n M a i n l a n d China. M o s t ovdl h e a l t h s u r v e y s a m o n g adults i n

M a i n l a n d C h i a a w e r e c o n d u c t e d a f t e r the 19705- S t u d y s u b j e c t s o f regioni and Jocal
surveys were mainly urban r e s i d e n t l i v i n g i n b i g cities. Surveys cond^c-ted among
farmers were uncommon although the fanners comprised around three-quarters o f
C h i n a ' s population. M o s t surveys were i n or around Beijing, Shanghai, Chengdu ( m
Western China) and W u h a n (in Central China) which are a b o the location o f major
medical universities. Surveys in adults i n Southern C h i n a u r ere uncomnion- Dental
caries and periodonta disease v/ere t h e m a j o r dental d i s e a s e s studied. O n l y a f e w
s u r v e y s o n p e o p l e ' s oral health knowledgeattitudes, a n d b e h a v i o u r w e r e conducted
in r e c e n t ycens a n d m a i n l y i n H u b e i P r o v i n c e . P u b l i s h e d p a p e r s concerning dental
t r e a t m e n t n e e d s a n d utilization o f dental services anapng a d u l t s i n M a i n l a n d C h i n a
^ere scarce.

S a m p l e size v/as u s u a l l y n o t a m a j o r p r o b l e m m t h e s e s u r v e y s b u t m a n y surveys

\ised c o n v e n i e n c e s a m p l e s o r d i d n o t describe t h e s a m p l i n g methods,

In s o m e

surveys, t h e d i a g n o s t i c criteria u s e d w e r e p o o r l y d e f m e d a n d t h u s c a u s e d difficulty

i n t h e interpretation o f their results. R e c e n t s u r v e y s u s u a l l y c l a i m e d t o u s e
internationally a c c e p t e d c r i t e r i a s u c h a s t h o s e d e s c r i b e d b y W H O .

R e p o r t e d m e a n D M F T w a s l o w in a d u l t s i n M a i n l a n d C h i n a , M o s t srudies reported a
D M F T o f b e t w e e n 2 a n d 6 in the 35-44-year-olds a n d b e t w e e n
elderly y o u n g e r t h a n 7 5 y e a r s . C a l c u l u s arvd gingivilis w e r e r e p o r t e d t o b e c o m m o n

5
3

in adult Chinese but the reported proportion of subjects with sha]low and deep
periodontal pockets was not high. Complete edenluiGuiiness i n the 60-69-year-olds
was usually reported to be less than l 0 % r According to the data from the second
national survey i n China, about 14% o f the 35-44-year-olds and 19% o f the 65-74year-olda d i d not brush their teeth daily and only 20% o f both the 35-44-year-olds
and the 65-74-year-olds had visited a dentist within the preceding 12 months.

3. AIMS AND OBJECTIVES

T h e a i m o f this study was to describe the oral health k n o w l e d g e attitudes^ behaviour

and oral heahh status o f adults m Guangdong Province i n relation lo iheir personal
characteristics.

The objectives o f this study were:

(1)

10 describe the oral health knowledge, attitudes and behaviour o f 35^14 and
65-74-yeaj-oId Chinese i n Guangdong Province

(2)

t o describe t h e ora.[ health status a n d creaTm-ent n e e d o f t h e s e t w o a g e groups,

(3)

to i d e n t i f y t h e socio - d e m o graph i c characteriiitics w h i c h a f f c c t e d t h e oral

health behaviour a n d oral h e a l t h status o f these p o p u l a t i o n groups.

37

4. M A T E R I A L S AND M E T H O D S

4.1. Study population and sampling methods

T h e sites for carrying out this survey were in four regions i n the Guangdong
Province Illustrated below:

CHINA

Fig. 4-1- Location of Guangdong Province and survey regions,

TThe age groups surveyed i n the present study comprised the 35-44 and 65-74 yeaxolds. These are the standard target age groups for oral health surveys i n adults
recoimnended by the W o r l d Health Organization (1997) i n order to provide cross
national compart sons. Based on the situation

JS

the Guangdong Province^ a

combination o f muKi-stage cluster sampling and convenience sampling was used i n

this ^ludy (Fig. 4-2). A t the first stage, four o f the 21 major administrative regions o f
Ehe province, one each f r o m The central, eastern, wes t er n and northern parts o f the
province were selected as the sorvey areas. T h e y were Guangzhou (capital city o f
the province representing the soutb'central), Shantou

Zhanjiang (west) a n d

Q i n g y u a n ( n o r t h ) re&pectively. I n this st udy, iiTban residents w e r e s a m p l e d f r o m [he

b i g g e s t city in e a c h s u r v e y r e g i o n a n d rural r e s i d e n t s w e r e s a m p l e d f r o m t h e
c o u n t r y s i d e a n d v i i l a g e s in t h e r e g i o n . T w o u r b a n districts a n d o n e ruxal county' w e r e
s a m p l e d at r a n d o m f r o m t h e u r b a n a n d rural a r e a s o f c a c h selected region. O n e
s u b d i s t r i c t f r o m e a c h s a m p l e d u r b a n district a n d t w o t o w n s h i p s f r o m the s a m p l e d
c o u n t y w e r e s d e c t e d a t r a n d o m . T h e p o p u l a t i o n o f a t y p i c a l subdistrict or t o w n s h i p
w a s b e t w e e n 1 5 , 0 0 0 a n d 5 0 , 0 0 0 . I n e a c h subdistrict o r cownaiound 100 s u b j e c t s
(male to

female ratio w a s a r o u n d 1:1) w e r e r e c r u i t e d i n e a c h a g e g r o u p . T h u s ,

a r o u n d 4 0 0 s u b j e c t s w e r e r e o m i t e d i n e a c h s u r v e y l o c a t i o n a n d totally a r o u n d 1,600
e x a m i n e e s in e a c h a g e g r o u p .

Administrative region

Rural areas

Urban areas

Urban district 1

County

Urban district 2

Subdistrict 2

Township

Fig. 4 Sampling method af the Guangdong OraJ HeaJth Survey 1996-97.

39

Township 2

4,2. Recmitmmt o f subjects

W i t h assistance f r o m ihe Departmem o f Public Health o f Guangdong Province and

the S u n Yat-sen Umversitv o f M e d i c a l Sciences, relevant authorities i n the survey
siles were contacted before the tlcldwork started. Meetings were held to disseminate
the aims o f the study, and the detailed plans f o r the field work were introduced to the
persons i n charge. The Bureau o f P u b l i c Health, neighborhood committee i n urban
areas and the township government i n rural areas were usually very helpful i n the
recruitment o f study subjects and the arrangemenl o f logistics i n the study

T h e 3 5 - 4 4 - y e a r - o I d 3 in u r b a n a r e a s w e r e m a i n l y rccruited from fa c t o ri e s b e c a u s e
m a n u a l w o r k e r ^ constitute o v e r 2 0 % o f the w o r k i n g p o p u l a t i o n in t h e p r o v i n c e a n d
o t h e r o c c u p a t i o n g r o u p s like p r o f e s s i o n a l s , t e c h n i c i a n s , clerical w o r k e r s , a n d
a d m i n i s t r a t o r s c a n a l s o b e f o u n d i n t h e factories. I n e a c h u r b a n survey site, if i h e
n u m b e r o f t h e J 5 - 4 4 - y e a r - o l d s found i n A f a c t o r y WAS n o t sufficient^ other p l a c e s o f
worke.g. s c h o o l s , g o v e r n m e n t o f f i c e s a n d c o n u n e r c i a l c o m p a n i e s , w e r e contacted
t o r e c r u i t m o r e subjects. T h e 65-74-year-oid5 i n t h e u r b a n

w e r e recruited f r o m

t h e i r h o m e s w i t h t h e a i d o f n e i g h b o r h o o d c o m m i t t e e s in t h e s e l e c t e d subdistricts.
A d m i n i s t r a t o r s o f t h e conutnittee i n f o r m e d t h e resident elderly i n t h e subdistrict o f
t h e s u r v e y a n d invited t h e m l o g o t o t h e e x a m i n a t i o n v e n u e w h i c h w a s usually set u p
a t t h e n e i g h b o r h o o d c o m m i t t e e o f f i c e o r a n elderly c e n t e r

A l m o s t a l l o f t h e s t u d y subjec-ls i n t h e rural a r e a s w e r e f a r m e r s o r retired f a r m e r s .

T h e y w e r e r e c r u i t e d f r o m t h e v i l l a g e s w h e r e they lived w i t h t h e a i d o f the local
g o v e m m e n t . I f a n a u d i o a m p l i f i e r s y s t e m w a s available, i t w a s used to broadcast

40

information concerning the survey and ID invhe the farmers i n the sdected age
groups to aELend an examination, Despile this, the most effective way to recruit
subjects was when the ieaderi in the villages went to contact the villagers personally
and to encourage them to participate in the survey.- The examination ^ite was usually
set up i n a c o n v e n k n l place i n ihe vilJage.

41

4.3. Ficldwork procedures

The m a i n fie Idwork procedures included registration o f examinee, confirmation o f

correct age range, interview and clinical examination. One member i n the survey
team d i d the registration. Questionnaires were f i l l e d out by interviewers during the
face-to-fac-e incerviews. The completed questionn^irss were checked b y the
examiners before clinical examination. A f t e r the clinical exainination, a souvenir
g i v e n to each surveyed subject (Fig. 4-3).

4.3,1+ Intervievt
A structured questionnaire was developed especially for the interview i n this study.
The quesdonnciire included s i x sections: perceived orai heaJth conditionsoral health
knowledgeoral health attitudes^ o r a l h y g i e n e habils u s e o f dental s e r v i c e a n d
d e m o g r a p h i c b a c k g r o u n d (Appemdices 1 a n d 2). A pilot t e s t w a s c a r r i e d out o n
3 0 p a t i e n t s i n e a c h a g e g r o u p i n a dental hospital in Guangzhou, a n d a m e n d m e n t s
w e r e m a d e b e f o r e t h e m a i n survey

F o u r q u e s t i o n s ( Q 1 2 - Q 1 5 ) , w h i c h w e r e u s e d i n t h e 1991 H o n g K o n g A d u l t O r a l
H e a l t h S u r v e y ( S c h w a r z a n d L q 7 1994a), w e r e a s k e d s o a s to

MEASURE

the dental

k n o w l e d g e o f the subjects. T u o q u e s t i o n s w e r e o n the c a u s e s a n d p r e v e n t i o n

m e t h o d s of tooth d e c a y a n d t h e a n o t h e r t w o w e r e o n g u m disease. U p t o t h r e e
a n s w e r s w e r e a c c e p t e d f o r e a c h q u e s t i o n . A kjaowledge score, r a n g i n g From 0 t o 12
w a s c o m p u t e d f o r e a c h s u b j e c t a c c o r d i n g t o h o w m a n y a n s w e r s h e / s h e could g i v e t o
t h e s e f o u r q u e ^ t i a n s iti total- Thei:e w e r e n o d i r e c t l y w r o n g a n s w e r s , b u t 4<tio a n s w e r 1
and

Li

do n o t k n o w w e r e c o n s i d e r e d a s a n inability t o a n s w e r t h e question, ^ n d w e r s

s c o r e d 0. Thus, t h e h i g h e r t h e k n o w l e d g e s c o r e t h e m o r e o ra l h e a l t h k n o w l e d g e w a s
evident in the examinee.

42

u
i k
a> _

LJJ
jssejss-uj

spssu

cSELPe^
SUC^SSI
sp3vu"ue

^ajsbul

=uo!ujeexal-s^5

allEUUon

33:B!ajbCJ

43

Recorder 2

z6-966r

l-rrjmos

UJ
uollejjsct3y

Record

O
u
oj
tc

Examiner 3

cn

vl.

rt

Eight statements (Q24) about the importance o f oral health, importance o f retaining
natural teeth, dental service utilization, and dental health beliefs were set to explore
[he subjects' attitudes towards oral health. An attitude score, ranging from 0 to 8
w a s c o m p u t e d f o r e a c h s u b j e e l a c c o r d i n g t o t h e n u m b e r o f p o s i t i v e re s p o n s e s t o
t h e s e e i g h t s t a t e m e n t s . T h e h i g h e r t h e s t o r e , t h e m o r e positive t h e e x a m i n e e
a t t i t u d e w ^ s c o n si d e r e d .

P e r c e i v e d o r a l heaJlh c o n d i t i o n a n d p e r c e i v e d n e e d f o r t r e a t m e n t w e r e a s s e s s e d b y
Q 3 t o Q l l in t h e questionnaire, Q I 1 w a s set t o a s s e s s t h e p r o b l e m o f d e n m r e s w o r n
b y t h e s u b j e c t s . Reported oraJ h y g i e n e habits, including f r e q u e n c y o f toothbrushiiig T
u s e o f t o o t h p a s t e , o t h e r m e t h o d s u s e d to c l e a n teethand t o b a c c o s m o k i n g w e r e
r e c o r d e d d u r i n g t h e i n t e r v i e w ( Q 1 8 - Q 2 3 ) r Q 2 5 to Q 3 1 w e r e set t o e x p l o r e t h e u s e
o f dental s e r v i c e s b y t h e s u b j e c t s O n e s i n g l e question ( Q 3 2 ) w a s set to a s s e s s t h e
s u b j e c t s 1 dental f e a r ( N e v e r l i e n , 1990).

T h e m a i n d e m o g r a p h i c vinables i n c l u d e d gejider, a g e , l o c a t i o n o f residence,

e d u c a t i o n a n d e c o n o m i c status. A g e w a s t h e a g e o f t h e s u b j e c t s a t t h e i r last birthday
i n y e a r s . E d u c a t i o n w a s m e a s u r e d a s che educational level a t w h i c h t h e r e s p o n d e n t
l e f t t h e e d u c a t i o n s y s t e m , e.g. n o s c h o o l i n g , p r i m a r y s c h o o l , etc. B e c a u s e re l i a b l e
i n f o r m a t i o n a b o u t i n c o m e w a s d i f f i c u l t to obtain, t h e ^ F a m i l y M a t e r i a l P o s s e s s i o n
IndeK" ( F M P I ) w h i c h h a d b e e n p r e v i o u s l y u s e d i n H o t i g K o n g ( N g , 19S7; S c h w a r z
a i 1994) w a s u^ed t o m e a s u r e t h e e c o n o m i c status o f t h e s u b j e c t s s u r v e y e d . T h e
F M P I s c o r e c a n r a n g e from 0 t o 1 0 0 b a s e d o n t h e s u b j e c t ' s p o s s e s s i o n o f 17 items o f
f a n i i l y c o m m o d i t i e s , cgtelevision, air-conditioneT 1 , m o t o r c y c l e , w a s h i n g m a c h i n e ,
etc. E a c h i t e m i s a s s i g n e d a s c o r e a c c o r d i n g t o its a v e r a g e pricerarity a n d q u a n t i t y

44

i n the households (Table 4-1), I f a given commodity i s not recorded, a zero scorc is
returned. T h e total F M P I i s the summation o f the item scores, A higher score ts
taken as a n expression o f more material wealth o f the subject

Table 4-1. CalciiSation of family materia! possession index (FMPI).

Item
Ai-conditioner
Wa&hing machine
High-fide]ity souncT system
Video t a p e recorder
Microwave oven
Water heater
Camera
Television
Dish washer
Personal computer
Piano
Bathtub
Wooderi
floor
Telephone
Refrigerator
Motorbicycle
L ^ s e r d i s player

Score for prfe Score for radty

4
2
3
1
3
3
2
2
3
2
1
2
2
4
1
2
4
4
4
5
4
2
4
4
2
1
4
1
4
2
4
3

Scone for
extra quantity
1.2
i

1
1

Q u e s t i o n n a i r e s w e r e tilled o u t b y t h e i n t e r v i e w e r s d u r i n g t h e f a c e - t o - f a c e interview.
B e c a u s e s o m e o f t h e s u b j e c t s c o u l d o n l y ^ p e a k local diaJects, i n t e r v i e w e r s ^vere
rccmited

from

s t a f f of t h e locaJ h o s p i t a l s o r g o v e r n m e n t o f f i c e s w h o h a d a t least

s e c o n d a r y s c h o o l e d u c a t i o n level. T h r e e i n t e r v i e w e r s w e r e e m p l o y e d i n e a c h surv&y
sit& a n d t h e y a t t e n d e d a 3 - h o u j t r a i n i n g s e s s i o n b e f o r e t h e y started w o r k ,

4 3 . 2 . Clinical examinatiort
T h e c l i n i c a l e x a m i n a t i o n r e c o r d e d t o o t h status, t o o t h - b a ^ e d t r e a m e n t need,
p e r i o d o m a j h e a l t h statusprosthetic s t a t u s a n d t r e a t m e n t n e e d s , a n d o r a l m u c o s a l
l e s i o n s ( A p p e n d i c e s 5 a n d 6 ) . O r a l m u c o s a l lesions w i l l noi b e r e p o r t e d i n this t h e s i s
as they w e r e n o t prevalent i n t h e population studied.
5

The instrument, examination procedures, and diagnostic criteria recommended t>y

the W H O (1997) were adopted. A n over-head ighta m o u t h mirror a n d a
C o m m u n i t y P e r i o d o n t a l I n d e x ( C P ( ) p r o b e w e r e u s e d during clinical e x a m i n a t i o n .
A l l the i n s t r u m e n t s u s e d w e r e sterilized u s i n g a p o r t a b l e autoclave. E v e n t h o u g h
s o m e o f t h e e x a m i n a t i o n v e n u e s w e r e i n d o o r s w h i l e s o m e w e r e o u t d o o rs , a n
o v e r h e a d light wa^ a l w a y s u s e d d u r i n g d i n i o a l examinations. Portable chairs w e r e
c a r r i e d t o t h e s u r v e y sites s o that t h e s u b j e c t s c o u l d b e eKar^Lned in supine position
a n d t o i n c r e a s e s t a n d a r d i z e d e x a m i n a t i o n c o n d i t i o n s overall. T h e o r d e r o f t h e
ciinical e x a m i n a t i o n w a s : t o o i h Status a n d t r e a t m e n t needsprosthetic status a n d
t r e a t m e n t n e e d o r a l m u c o s a l lesions, C P i a n d loss o f attac-Kment ( L O A ) . T h e
diagnostic criteria u s e d are described i n the following paragraphs.

B o t h t h e s t a t u s o f t h e t o o t h c r o w n a n d the rGOt w e r e priiriarily assessed b y visual

i n s p e c t i o n a n d secondarily c o n f i r m e d b y tactile inspection u s i n g a W H O C P I p r o b e .
T h e t e e t h w e r e n e i t h e r c l e a n e d n o r dried b e f o r e t h e assessments but f o o d d e b r i s
o b s c u r i n g v i s u a l i n s p e c t i o n w a s r e m o v e d b y The p r o b e , N a ra d i o g ra p h s w e r e t a k e n .
C o r o n a l c a r i e s w a s r e c o r d e d a s p r e s e n t w h e n t h e r e w a ^ a cavity, a n d e r m i n e d
e n a m e l , o r a d e t e c t a b l e s o f t e n e d f l o o r o r w a l l . A r e si d u a l t o o t l e f t b e h i n d a s a. result
o f g r o s s c a r i e s w a s s c o r e d a s c o r o n a l c a r i e s only. W h e r e a n y d o u b t existed, caries
n o t r e c o r d e d a s present, R o o t c a n e s w a s r e c o r d e d a s p r e s e n t w h e n a lesion
l o c a t e d o n t h e r o o t s u r f a c e o r p r e s u m e d t o h a v e c o m m e n c e d o n t h e root s u r f a c e f e l t
s o f t w i t h t h e probeIf it w a s n o t p o s s i b l e t o j u d g e t h e original site o f a single c-aiiaus
l e s i o n a f f e c t i n g b o t h c r o w n a n d root, both w e r e r e c o r d e d a s p i e s e n L

46

W h e n calculating D M F I o r D F - R o o t scores, o n l y permanent restorations that were

j u d g e d to be placed for caries treatment and w i t h no decay were included i n the F component. Teeth not present for any reason were included i n the M-component.
T h e DF-K.oot scor^ was computed b y summing up the numbers o f decayed root ( D Root) and f i l l e d root (F-Root).

PeTiodonUil status was defined as being healthy, exhibiting bleeding o n probing,

h a v i n g calculus, having shallow or having deep pockets.L O A w a s categoried by the
amount o f attachment loss, A C P I probe w^s used for the assessment o f periodontal
status i n d L O A - The recommended use o f a sensing forcc w i t h the C P I probe was
practised b y placing the probe tip under the thumb nail and pressing with a force
until

blanching

occured.

( 1 7 j l 6,11 f26?27737?36.31

f 46,47)

For

the

35-44-year-old&.

index

teeth

for the s i x sextants were assessed for C P I and L O A ,

A s e c a n t w a s examined o n l y i f there were two o r more teeth present w h i c h were not

indicated f o r extraction. I f no index teeth o r tooth was present i n a. sextant qualifying
f o r examination, a l l the remaining teeth i n that sextant were examined and the
highest score w a s recorded as the ^core for the sextant. F o r the 65-74-yeajoidsthe
p e r i o d o n t a l s t a t u s of al] teeth n o t indicated f o r extraction w a s assessed. H o w e v e r ,
t h e c a l c u l a t i o n o f CPT a n d L O A for this a g e g r o u p w a s still b a s e d a n i n d e x teeth
a c c o r d i n g t o t h e m e t h o d d e s c r i b e d a b o v e . T h e p r e v a l e n c e o f t h e h i g h e s t CP I a n d
L O A s c o r e , a n d m e a n n u m b e r o f s e x t a n t s in e a c h C P I a n d L O A c a t e g o ry f o r t h e 354 4 - y e a r - o l d s a n d t h e 65-74-year-olds w e r e c o m p u t e d .

T e e t h n o t p r e s e n t for a n y reason, "were d e f i n e d a s m i s s i n g t e e t h ( M T ) , including

t h i r d m o l a r s . L o s s o f p e r m a n e n t t e e t h c a n resull f r o m o n e o f t w o w a y s . E i t h e r t h e

47

progres<iion o f dental and periodontal diseases is such thai teeth can be losi
spontaneousiy or else teeth may be extracted by oral health care providers, The latter
is c i o s d y l i n k e d to the provision o f and access to denial care services. People living
i n developing countries, especially those l i v i n g in ruxal areas, have le^s access to
dental health care services than urban dwellers o f ihose countries and less than those
l i v i n g i n industrialized countries. Therefore, it is assumed ihis lack o f ajccess w i l l
result i n more teeth w h i c h should be extracted slill remaining i n the mouth i n these
popiilation, Some authors have mentioned the state o f teeih indicated for
extract]on 1 s jji developing countries when they described the condition o f tooth loss
(Ekanayaka, 1934; M a n j i et ai.

1988; Lunn et al.7 l9S9b). A c c o r d i n g to W H O

(1997) criteria, a tooth was indicated for extraction when caries had so destroyed tlie
tooth that it c o u l d not be restored, when periodontal disease had progressed so far
that the tooth could not be restored to a functional state i n the clinical judgement o f
the examiner, w h e n a tooth needed to be extrajcted to make w a y for a. prosthesis,
when extraction w a s required f o r qrthodontic or cosmetic reasons or because o f
impaction.K o recording was made o f the reason f o r indicating a tooth as requiring
extraction. F o r convenience of description, the teeth indicated for extraction were
defined as ''indicated jnissing teeth ( I M T ) . T h e a d j u s t e d rnissing teeth ( A M T )
t h e r e f o r e i s t h e s u m o fM T p l u s I M T .

P r o s t h e t i c status w a s r e c o r d e d f o r e a c h s u b j e c t by a r c h according t o t h e criteria

r e c o m m e n d e d b y W H O (1997). T h i s w a s classified a s n o prostheses, o n e bridge,
t w o o r m o r e bridges, partial denturebridge a n d partial denture, o r c o m p l e t e denture.
O n l y s u b j e c t s w h o w e r e w e a r i n g o r w h o could s h o w t h e i r dentures a t the
e x a m i n a t i o n w e r e r e c o r d e d a s d e n t u r e wearer?.

48

A c c o r d i n g to the recommendations by W H O (1997), examiners are cncouraged to

use their o w n c l i n i c a l judgement when m a k in g decisions o n what type o f treatment
w o u l d be most appropriate i n the c o m m u m l y or countryTooih-based treatment
neede.g. f i l l i n g a n d extraction, w a s d e t e r m i n e d tooth by tooth i m m e d i a t e l y a f t e r t h e
a s s e s s m e n t o f T o o status. T h e t r e a t m e n t s considered included tho^e relating t o the
r e m o v a l o f c a r i e s a n d restoration a f lost tissueendodontics, repJacemcnt o f existing
f a u l t y r e s t o r a t i o n s a n d extraction o f t h e t o o t h o r retained root. Filling w a s indicaled
f o r c e r v i c a l abrasion lesions t h a t b a d e x t e n d e d to o r b e y o n d a depth o f t w o
millimeterSr H i e a s s e s s m e n t o f prostheiic treatment n e e d f o l l o w e d t h e assessment
r e c o m m e n d e d by W H O a n d u s e d t h e criteria t h a t h a d b e e n u s e d i n the 1991 H o n g
K o n g A d u l t Oral H e a l t h S u r v e y ( L o e/

1994). T h e n e e d f o r fixed or r e m o v a b l e

d e n t a l p r o s t h e s i s w a s n o t considered separately, instead w h e t h e r t h e n e e d w a s f o r a

o n e - u n i t o r a m u l t i p l e - u n i l prosthesis w a s recorded, A prosthodontic treatment n e e d
w a s i n d i c a t e d f o r s u b j e c t s w i t h o u t a n e x i s t i n g prosthesis if t h e r e w e r e , o r a s
i n d i c a t e d b y a s s e s s e d n e e d f o r extraction t h e r e w e r e g o i n g to befewer t h a n 2 0 teech
( p o n t i c o f b r i d g e s being c o u n t e d a s t e e t h ) ; i f there w a s tooth s p a t e anterior t o t h e
premolars o r i f the existing p r o s t h e s i s w a s assessed

i n n e e d o f replacement.

T h e n e e d f o r oral h y g i e n e a n d periodowtaj c a r e w a i derived i r o m the C P I w h i c h w a s

u s e d t o m e a s u r e t h e periodonlal status o f t h e subjects. A subject w o u l d b e assessed
a s n o t h a v i n g a n y periodontal treatment n e e d i f the highest C P I s c o r e w a s z e r o o r Lf
h e w a s , o r a s indicated b y a s s e s s e d n e e d for extraction going t o b e 7 ed&ntulous. If a
s u b j e c t h a d calciilu^ o n t h e index t e e i h o r h a d periodontal p o c k e t s ( C P I scares 2 a n d
a b o v e ) , t h e n h e w a s a s s e s s e d as h a v i n g a n e e d f o r scaling a n d instmction in oral

49

hygiene. N e e d for complex periodontal care was indicated for subjects who had
probing depth o f 6 m m or more i n any o f the index teeth or their substitutes.

In addition, far a n overview o f the differem ivpcs o f treatmemt that tht; subjects
needed, a holistic approach, similar to that used i a t h e H o n g K o n g survey (Lo e r a l . t
]994), was used to categorize the subjects into one o f the following five groups
according to the various combinations o f normative treatment needs: 1) no need for
any treatment; 2) dental prosthesis only 3 ) s c a l i n g a n d oral h y g i e n e instructions
o n l y ; 4 ) s i m p l e treatments inciuding scaling, M i n g e x t r a c t i o n a n d prosthesis b u t n o
c o m p l e x c a r e ; aitd 5) i n v o l v i n g endodontics o r c o m p t e x periodontal care.

A i l t h e clinical e x a m i n a t i o n a w e r e c o m p l e t e d by o n e o f three examiners. In additioa

t o the p r e s e m investigatorthe other t w o e x a m i n e r s w e r e recruited f r o m S u n Yat-sen
U n i v e r s i t y o f M e d t c a t Sciences in G u a n g z h o u , T h e y graduated f r o m the university
w i t h a B . D . S . d e g r e e a n d h a d several y e a r s o f experience in clinical work. T h e r e
w e r e t w o t r a i n i n g a n d calibration exercises f o r t h e e x a m i n e r s , o n e prior t o the
f i e l d w o r k in 1 9 9 6 a n d a n o t h e r p r i o r t o lh& f i e l d w o r k in 1997. wo epidemiologists
and one periodontist were responsible for the training course. One i n ten subjects
were reexamined b y another examiner throughout the survey. The results o i these
duplication examinations were used to monitor and assess the mter-e^ajniner
reliability.

50

4,4. Testing o f water fluoride l e v e l in survey sites

T w o to three samples o f c o m m u n i t y water were taken f r o m each survey site to

assess the fluoride concemration. Water samples were taken from, tap water i n urban
areas and i n the m r a l areas both tap water and "well water samples were t a k . T h e
tests were performed i n the University o f H o n g K o n g using B e n c h i o p PH/1SB Meter
( M o d e l 9 2 0 A ) ( O r i o n Research Incorporated, 1992) and Fluoride/combination
fluoride Electrode ( M o d e l 96-09) ( O r i o n Research Incorporated, 1991)r

M o s t o f the samples taken contained less than 0.4 p p m o f fluoride. Thre& samples o f
w e l l water f r o m villages o f two townships contained more than I p p m o f fluoride.
H o w e v e r , w e were informed b y th-e l o c a l P u b l i c Heatth B u r e a u that che people i n
these villages h a d stopped u^'mg the w e l l water a n d changed to tap water several
years ago due to the h i g h fluoride level. Because the fluoride level was generally
i n w i n the survey sites and people used different resources o f water i n m r a l ^isas,
fluoride level w a s not used as a n independent variable of dental caries i n data
analysis.

51

4.5, Data processing and analyses

D a i a collected were input into computer and were processed using the software
A c c e s s 2.0, A l l data input was done by one person i n Guangzhou slmutaneously as
data collection went on. Acceptable and unacceptable values were predefined i n the
A c c e s s databases to avoid or to identify possible errors arising f r o m data entry or
recording. A f t e r all data were inputproof-reading waa p e r f o r m e d b y t h e s a m e
p e r s o n . A logistic check w a s p e r f o i r n e d b e f o r e d a t a analyses. W h e n errors w e r e
f o u n d , o r i g i n a l f o r m s w e r e inspected to correct t h e errors. A f t e r d a t a d e a l i n g w a s
c o m p l e t e d . 1 % o f the questionnaires a n d clinical record f o r m s w e r e checked a n d
0 . 1 % o f t h e questionnaires a n d 0 , 0 4 o f t h e clinical record f o r m entries w e r e f o u n d
t o b e w r o n g - T h e s e error tevels w e r e c o n s i d e r e d to b e acceptable.

Data analyses w e r e mainly performed using SPSS

for

W i n d o w s . Multiple

c o m p a r i s o n f o l l o w i n g t h e analysis o f c o v a r i a n c e ( A N C O V A ) w a s p e r f o r m e d u s i n g
S A S for Windows.

V a r i a b l e s o b t a i n e d from interview and c l m i c a l examination a r e listed in T a b l e 4 - 2

a n d T a b l e 4 - 3 respectively.

categorical variables w e r e Tegrouped in

c o n s i d e r a t i o n o f t h e f r e q u e n c y disTribuTion a n d t h e n e e d o f d a t a analyses t o explore

t h e m e a n i n g s o f t h e data.

53

Table 4-2. Variables from questionnaire and their grouping or scoring used in data anaEyses
Variable

Grouping I scoring

Gender

male, female

Locscion

urban, rural

Education level (for 35-44-year-olcr&)

no schooling/primary, secondary, post-secondary

Education level {for 65-74-year-ol

no schooling, primary, secondary and above

Perceived ^ppea^anc-e of teeth

satisfied, no comment, not satisfied

Perceived condttion of teeth

Good

Teeth caused pain

yes: no

Perceived need for treatment

yes, no / do not know

Tobacco smoking

smoker/former sinoker. nansirsoker

AJcohol drinking

yes, no

Receipt of dental education

yes, no

Toothbrushing frequency

once or less daily, twice or moTe daily

Use of toothpaste

yes, no

Toothpaste contain fluoride

yes? no, do not know

Use of toothpicks

yes. rto

Time lapsed since last denUl visit

< 2years1 2-5 years. > 5 y^3r&

Treatinent received

examinatiori, scaling,fiJNng,extraction,
fixed prosUiesis, dentures, others

Reasons not visit dentist within 3 years no need, problem not serious, could not afford,
too busy, afraid of cfentist, others
Dental fear

yes, no

Dental knowledge score

0-12

Dental attitude score

O-B

FMPI

0-100

53

Table 4-3, Variables from clinical examination ajid their grouping or scoring used in data
anaEyses.
Vanabfe

Grouping /scoring

DMFT

0-32

DF-Rchot

0-32

Missing Leeth (MT)

0-32

Indicated missing teeth {[MT)

0-32

Adjusted missing

0-32

(AMT)

CPI

no bleeding, bleeding, calculus, shallow pocket, deep

pocket

Loss of attachment (LOA)

0-3 fnm, 4-5 mm, 6-8 mm, 9-11 mm, 12+- mm

Prosthetic status

no prostheses, bridge, partial denture, full denture

Prosthetic treatment need

no prosthe^ needed, 1-unit prosthesis:

2-units prosthesis, complete denture

Holistic ireatmerit need

No need: prosltiests only, OHI and scaling only,

Simple tneatment, compIeK care

C o h e n ' s k a p p a ( L a n d i s a n d K o c h . 1 9 7 7 ) w a s u s e d t o m e a s u r e t h e reliability b e t w e e n
e x a m i n e r s . Because t h e v a r i a b l e s e v a l u a t e d w e r e n o m i n a l data, e.gcrown c a r i e s a n d
C P I , u n w e i g h t e d k a p p a w a s c h o s e n ( B u l m a n a n d O s b o m f 19S9), A f t e r g e t t i n g t h e
frequency

c o u n t s o f t h e r e p r o d u c i b i l i t y d a t a usi n g S P S S f o r W i n d o w s , k a p p a

smtiatics w e r e c a l c u l a t e d u s i n g E x c e l f o r W i n d o w s . T h e calculation of k a p p a
statistics f o r c r o w n a n d r o o t c a r i e s v/as m a d e ort t h e original c a t e g o r i e s recorded.

T h e g u i d e f o r d a i a a n a l y s i s w a s s i m i l a r t o t h e m o d e l u s e d i n the S e c o n d
I n t e r n a t i o n a l C o l l a b o r a t i v e S t u d y ( C h e n et al., 1997). T h e m o d e l p o s t d a t e s that
s y s t e m - l e v e l v a r i a b l e s , s o c i o e m i r o n m e n t a l characteristics a n d oral health care
s y s t e m , t o g e t h e r w i t h p e r s o n a l p r e d i s p o s i n g a n d e n a b l i n g characteristics w i l l a f f e c t
a n i n d i v i d u a r s orai h e a l t h b e h a v i o u r a n d c o n s e q u e n t l y o r a l h e a l t h status.
P r e d i s p o s i n g v a r i a b l e s , s u c h a s g e n d e r , e d u c a t i o n level, o r a l h e a l t h k n o w l e d g e

54

predispose an i n d i v i d u a l 10 engage o r not engage i n certain oral health behaviour,

whi]e enabling variables, such
p^aclice o f ^uch behaviour. However, s y s i e m - l e v d variables were not used i n this
study because basically the same social, economic and oral health care systems were
i n operation i n a i l survey sites and age groups. In this aimpiified model, it was
postulated that a n i n d i v i d j ^ i ' s oral health behaviour was influenced b y his or her
predisposing a n d enabling d i a i a c t e r i s t i c T h i s w o u l d in turn, t o g e t h e r w i t h the
p r e d i s p o s i n g a n d e n a b l i n g f a c t o r s , a f f e c t l h e oral health s t a t u s o f t h e individual. T h e
v a r i a b l e s a n d t h e i r c l a s s i f i c a t i o n u s e d in this s t u d y are s h o w n in T a b l e4 4 .

Table 4-4. Analytic inodel for the study indicating the incorporated variables.
Predisposing factors

EnaWing factory Behaviour factors

Gender

FMPI

Oral health status

(Outcome factors}

Oral hygiene practices

DMFT

Edoc^atiort

Smoking habit

Missing teetii

Location of residency

Use

CPI

Dental knowledge score

Lass of attachment

Denta attitudes score

Pnosthetrc status

Dental fear

Treatment need

Teeth cause pain

Perceived conditiDn of teeth
Penceiued need for treatfrtent

T-test and analysis o f vaiiance (ANOVA)

were performed to highlight th-e possible

differences i n continuous variables between (or among) groups. Chi-square test u'as
performed to study whether the difference i n distribution o f categorical variables
between (yr among) groups were statistically significant Pearsons correlation
c o e f f i c i e n t w a s c a l c u l a t e d t o d e t e c t a p o s s i b l e relationship b e t w e e n t w o continuous
variables.

Spearman's

c o r r e l a t i o n c o e f f i c i e n t w a s calculated t o d e t e c t t h e

r e l a t i o n s h i p b e t w e e n t w o categorical v a r i a b l e s .

5
5

Logistic regression analysis was performed to determine factors which affected

toothbrushing frequency, and factors w h ic h affected recent use (within 2 years) o f
dental services in the 35-44-year-olds and the 65-74-year-old5. Si m i l a r to the linear
regression analysis, logistic regression analysis is used to study h o w the dependent
variable is affected by a &&t o f independ-eiit vaiiableg, Logistic regression analysis is
appropriate when the depcmdent variable is dichotompus (Lindsey,

Locatiojn,

gender, education level, dental knowledge score, dental attitude score, and F M P I
were selected as possible factors influencing toothbrushing frequency. Location,
gender e d u c a t i o n level, p e r c e i v e d dental conditions, t o o t h b r u s h i n g frequency,
d e m a i f e a r , t e e t h c a u s e d p a i n , p e r c e i v e d n e e d f o r treatment, d&ntal k n o w l e d g e score,
dentat attitude s c o r e , a n d F M P I w e r e selected a s possible f a c t o r s influencing recent
use o f d e n t a l services.

A n a l y s i s o f c o v a r i a n c e ( A N C O V A ) w a s p e r f o r m e d to d e t e r m i n e t h e factors
a f f e c i i n g d e n t a l k n o w l e d g e s c o r e , d e n t a l attitude score, D M F T , a n d A M T i n the 3 5 4 4 - y e a r - o l d 5 a n d 65"74-ycar-oids. T h e A N C O V A analysis is actually equivalent t o a
multiple l i n e a r r e g r e s s i o n a n a l y s i s w h e r e the categorical independent variables are
r e p r e s e n t e d b y indicator v a r i a b l e s ( d u m m y variable) (Lindgeyj 1995b). H o w e v e r , the
e o f A N C O V A prevented the creation q f indicator v a r i a b k s i n the present study
since most o f che independent variables involved i n the multivariate analysts were
categorical. The dependent variables and corresponding independent variables for
the A N C O V A analysis are listed in Table 4-5,

F o l l o w i n g each A N C O V A analysis: multiple comparison analysis was performed to

investigate the difference between groupst categoric^J variables. J u the p f e s e n t

56

^ u 6 y , B o n f e r r o n i ' s method, T u k e y m e t h o d a s w e l l a s SchefFe^s m e t h o d s f o r

m u l t i p l e c o m p a r i s o n w e r e all p e r f o r m e d a n d t h e o n e w i t h n a r r o w e s t c o n f i d e n c e
interval w a s c h o s e n . I h i s m e t h o d is p r o p e r s i n c e it d o e s n o t d e p e n d o n the observed
data (Neter

a L , 1990).

Table 4-5. Variables used in the analysis of covariance for knowledge score, attitude
score, DMFT, and AMT in the 35-44-year-olds and 55-74-year-o]ds.
Dependent variables
Dental knowledge

Independent variabJes
Location, gender, education level, receipt of dental educ^ton,
FMP]

Dental attitude score

Location, gender, education level, dental knowledge score, FI^Pl

DMFT

Location, gender, education Eevel, toothbrushing frequency,

dental fear, time lap&ed since a$L dental visit, FMPI.
dental knowledge score, dental attitude score

AMT

Location, education leveE, tocthbrushing frequency, tobbaco

smoking, dental fear, tinne lapsed since last dental visit, FMPIr
dental knowledge score, denta]

57

5. R E S U L T S
5 Background o f study population

A tola! o f 3,088 adults, 1,573 3 5 - 4 4 - y e ^ o l d s and 1,515 65-74-year-oIds s were

surveyed [n this study. Sample size according to age group, gender and residence 15
s h o w n i n T a b l e 5-1. Selected demographic characteristic? o i the subjects aie shown i n
T a b i c 5-2. T h e m a l e to female ratio was around 1:1 w h i c h was similar to the situation i n
the province. he urban to rural resident ratio was around 1:1 i n tlris snxdy but the ratio
i n the provi n c e i n 1995 w a s 1:2.3 (Guangdong Statistical Bureau, 1996), A l m o s t h a l fo f
the 65-74-year-old5 had not attended schools. T h e finding thiit the ;5-44-year-o]ds h a d
higher edacation l e v e l than the 65-74-year-oids was i n accordanc-e w i t h The aitnaticm i n
the province. Data f r o m the Population Census O f f i c e o f Guangdong Province (1992)
showed that 8 % o f the 3 5 - j 9-year-olds a n d 6 0 % o f the 65+- year-olds had no schooling.
T h e occupations recorded f o r ihe retired 65-74-year-oids were their reported former
occupation before they retired. T w o major occupation groups, agricultural workers and
n^anuaJ workers constituted 4 1 a n d 1 8 % o f t h e 3 5 - 4 4 - y e a r ^ l d a n d 50 a n d 23% o f
t h e 6 5 - 7 4 - y e a r - o l d s u b j e c t s r e s p e c t i v e l y , c o m p a r e d t o 6 0 % a n d 2 2 % i n the p r o v i n c e
( P o p u l a t i o n C e n s u s O f f i c e o f G u a n g d o n g Province

Table 5-1. Ssnnple si^e according to age group, gender and focation.
35^44-year-otds

S5-74-y ear-old 5

Men

Women

Total

Men

Women

TotaJ

Urban

393

40S

798

391

383

774

Rural

370

4D5

775

366

373

741

Total

763

610

1573

759

756

1515

Table 5-2, Selected demographec character sties of the subjects (percentage).

Gender

Guangdong

35-44-year-olds

65-74-year-olds

Province

1 5 7 3 )

^=1515)

Male

51

49

5 0

Female

49

51

5 0

Urban

30

51

51

Rural

7 0

49

49

Location3

Education Jevelb

No schooJlng

(6 years
and abov0)
15

Lower secondsry

27

30

22

Primary

31

Upper secondary
Post-second.-non-degree
Tertiary
Occupation"
Leglsfator & adininistrator

12

Professionals & technician

13

Comfnerc^ sector
Office worker
ManuaC worker

22

18

23

60

41

50

Service worker
Others
Agricultural worker
No job
Guangdong StatisiicaJ Bureau, 19&6
"Population Census Office of Guangdong Province, 1992

59

5.2. Interexaminer reliabilitv

Imer-examiner reliability as measured b y K a p p a statistics i s shown i n Table 5-3. T h e

K a p p a statistics among the thiee exajniners were over 0,5 for all items o f c l i n i c a l
esicLmination. T h e K a p p a statistics indicated that agreement between exaniiners was
g w d o r substantial except for C P I o f the 3>44"year-olds w h i c h was

moderate

according to W H O (1997) criteria.

Table 5-3. Kappa statistics for interrain in er reproducibilit/.

Examiner
1 vs 2

1 vs 3

2vs3

All

Crown caries

0.82

0.95

0.S7

0.89

Root caries

0.S7

0.64

0.55

0.60

CP[

0.59

0.4B

0.59

0.55

LOA

0.71

0.72

0.5S

0.62

Tooth-based tneatment need

0.79

a.eo

0.69

0.75

Prosthesis treatment need

0.53

0,S5

0.09

0^3

Crown caries

0.63

0.94

0.30

0.89

Root caries

0,33

0.05

0.87

0.35

CPI

0.79

a.ei

0.33

0.79

LOA

0.30

0.76

0.75

0.71

Tooth-based treatment need

0.75

0_72

0.75

0.75

Prosthesis treatfrient need

0.72

0.38

0.86

0.S2

35.44-y^r-olcfs

65-74-year-ofds

Because the allocation o f subjects to the examiners was random, the findings o f the
c l i n i c a l examinations conducted b y the three examiners should be similar. T h e mean
numbers o f D M F T , DF-Rool;, a n dM T o f the middle-aged and the elderly according to

60

i;he examiners a n d the results o f analysis o f variance are shown i n T a b i e 5-4. O n l y D F ROT[ o f the 65-74-year-olds had a statistically significant difference betu^en the
examiners but the difference was small i n absolute terms.

Table 5-4. Mean numbers of DMFT. DF-Root, and MT by examiner.

35^44-year-o Id s

65-74-ye^old s

Examiner

DMFT

DF-Root

MT

DMFT

DF-Root

MT

4.7

0.2

2.5

16

0.9

12.3

4.5

0.1

2.5

15.4

0.5

12.2

4.6

0.2

2.5

15.2

0.7

11.3

ANOVA

N.S.

N.S.

N.S.

N.S.

<0.01

N.S.

Prevaleirces o f s h a l l o w p o c k e t s , d e e p p o c k e t s , 4 - 5 m m o f LOA7

6 narti o f L O A i n the

middle-aged a n d rhe d d e r f y according to the examiners are presented i n T a b l e 5-5, T h e

difference i n L O A among the examiners w a s smalJ, However, f o r prevalence o f deep
periodontal pockets i n the elderly ? a b i g difference was found among the examiners.
T h i s indicated that the inter-examiner reliability f o r estimating the prevalence o f deep
pockets w a s l o w i n this study.

Table 5-5, Percentage of persons vvith periodontal pockets and LOA

""Shallow
Examiner

pocket

35-44-year-o[ds
Deep

LQA

GS^74-^ear-o!d

LOA

pocKet 4-5 min 6+ irinn

40

12

Sfiaflow
n
"341

33

630

29

52

11

504

41

520

23

42

13

441

35

<0.01

<0,01

<0.01

N.S.

61

LOA

LOA

pocK^t pocket 4-5 mm 6+ mm

Chi-sqtiare test

Deep

N.S-

43
1
6
<0.01

41

*52"
54

42

49

N-S.

M.5-

Oral health knowledge, attitudes and oral hygiene habits

Chinese medicine i s more than 4,000 years old- T h e Chinese traditional concept o f
heahh i s deep rooted m m a n y Chinese ( L e e e i aL, 1993)For e x a m p l e , intemai heai ? o f
t h e b o d y is c o n s i d e r e d a s a c a u s e o f s o m e dental d i s e a s e s . It is b e l i e v e d that
c o n s u m p t i o n o f s o m e f o o d called the ' h o t f o o d e . g . d e e p - f r i e d f o o d , c a n increase t h e
' m t e m a J h e a t 1 w h i l e d r i n k i n g herbal t e a c a n r e d u c e t h e 'internal h e a t \ W h e n s u b j e c t s
g ^ v e ' i n t e r n a l h e a t ' a n d e a t i n g h o t food a s t h e c a u s e s o f dental caries a n d g u m disease,
the responses w e r e classified as Chinese explanations.

T h e s u b j e c t s ' r e s p o n s e s t o t h e q u e s t i o n s c o n c e r n i n g t h e c a u s e s a n d p r e v e n t i v e m&asures
o f d e n t a l c a r i e s , a n d the c a u s e s a n d pr&ventive m e a s t i r e s o f s w o l l e n a n d bleeding g u m s
a r e s h o w n in T a b l e s 5 - 6 to 5 - 9 . T h e q u e s t i o n s a s k e d w e r e m u l t i p l e r e s p o n s e q u e s t i o n s
b e c a u s e t h e r e s p o n d e n t s c o u l d g i v e m o r e thajm o n e a n s w e r t o e a c h question. T h u s ,
m u l t i p l e r e s p o n s e analysEs w a s u s e d t o a n a l y s e t h e d a t a a n d suitunatioti o f the r e s p o n s e s
w a s m o r e t h a n 1 0 0 % . T h e p a t t e r n o f t h e a n s w e r s I n b o t h a g e g r o u p s w a s r a t h e r similar,
A h i g h p e r c e n t a g e o f t h e subjectsaboxit o n e - t h i r d in t h e m i d d l e - a g e d a n d o v e r half o f
t h e e l d e r l y g a v e E do n o t k n o w 1 a s t h e a n s w e r io ail q u e s t i o n s . F o r d e n t a l c a r i e s s u g a r or
s w e e t f o o d , p o o r o r a l h y g i e n e , a n d C h i n e s e expla n a t i o n w e r e m o s t f r e q u e n t l y
c o n s i d e r e d a s t h e c a u s e s ; a n d better t o o t h b r u s h i n g , rinsing a f t e r e a t i n g , a n d taking le
sugar were most fr^qoiently mentioned as the preventive methods b y the respondents.
Chinese explanation was most frequently considered a i the cause o f gum disease and
correspondingly a v o i d i n g hot f o o d o r d r i n k i n g herbal tea was mo&t frequemly stated as

the preventive method ag^mst gum disease. F o l l o w i n g the Chinese explanalion, oral
hygiene was o f next most concern w i t h regard to gum disease.

Table 5-6. Percentage of Chinese adufe who indicated various causes of dentaf canes
according to age gnoup 3nd locatJcn of residency (multiple re^onse analysis).
35-44-year-olds

65-74-ye3r-D^s

Urtian

Rural

TotaJ

Urban

ri=79&

n=774

n=1572

n=774

Rurai
n=7^1

ii=1515

24

11

18

20

-12
15

Total

Stated cause
Sug^r, sweet food

45

Poor ofal hygiene

48

15

32

Chinese explanation

22

14

21

Tooth worm

10

Bacteria, plaque

Sour food and drink

Others

Do not know

24

4S

36

50

63

55

TabTe 5-7, Percentage

against dental caries according to age group and iocation of residency
(multiple response analysis),
65-74-year-olds

3 5 ^ 4 - y ear-olds
Urban

Rural

Total

Urban

Rural

Total

n-79e

n=775

n=1573

n=774

n=741

n=1515

Better tchoth brushing

62

2G

44

32

12

Rinse after eating

31

19

15

Take Jess sugar

23

16

20

11

Use ffuofidat^d toothpaste

11

59

39

57

Prevention

Visit a dentist
Others
Do not know

20

63

76

64

T^ble 5-8. Percentage of Chinese adults who intficatsd vafious csusss of gufin disease
according to sge group and iocation of residency (multipfe response ^naJysig).
35-44-ye^r-oJds
Urban

Rural

P- = 79&

55-74-vear-c?[ds

TotaJ

Urban

n - 775 n 1573

Rural

n = 774

Total

n = 741

n 1515

St3Led cause
Chinese explanation

43

41

42

Poor oral hygiene

14

11

Trauma from brusiiing

10

30

49

39

34

35

34

54

@2

58

Bacteria, plaque
Inadequate diet
Inadequate s lee pi rig
Others
Do not Know

Table 5-9. Percentage of Chine&e adults who indicated various preventive methods
aga]nst gum disease according to age group and location of residency
(multiple response anaEysis ).
65-74-year-olds

35^44-year-oJds
Urban
n=799

Rural
n-775

Total
1=1573

Urban

Rurafc

%
23

Better toothbrushing

19

12

15

Rinse after eating

11

Use medicated toothpaste

11

Visit dentist
E^tfruit and nourishing food

Others

Do not know

38

67

53

25

18

o
1

18

23

11

Prevention
Avoid hot fcod / drink herbal tea

Total

n=774 n=741 1=1515

14

75

G7

Generally, the respondents h a d l o w dental knowledge scores (Fig- 5-1). It can be seen
that the overall dental knowledge level was low. T h e 35-44-year-olds had higher mean

64

knowledge scores than the 65-74-year-ol(ii and the urban residents had higher mean
knowledge scores thaa the rural residenis. T h e raeati dentai knowledge scores i n

the 35

44-year-old5 a n d the 65-74-year-old5 restdents were 3.5 and 2A respeclively

(t-test,

p<0-01)Dentai k n o w l e d g e
score

12
35-44-year-olds

10

65-74-year-olds |

BHrtir
Urban
men

Urban
women

Rural
men

Rural
women

F i g , S - i , Mean dentaE knowledge score [Maximum - 12) of men and women in

urban and rur^l areas in Guangdong.

R e s u l t s o f t h e A N C O V A a n a l y s i s o n d e n t a l k n o w l e d g e s c o r e axe s h q w n i n T a b l e s 5 - 1 0
a n d 5 - 1 L O n l y t h e s i g n i f i c a n t v a r i a b l e s ( p < 0 L 0 5 ) a r e s h o w e d i n t h e tables. I n the cables,
p o s i t i v e v a l u e s o f e ^ t i m a t s s i n d i c a t e t h a t t h e s e g r o u p s h a d h i g h e r dental k n o w l e d g e
s c o r e s t h a n t h e c o r r e s p o n d i n g r e f e r e n c e g r o u p s . F o r e x a m p l e in T a b l e 5-10an e s t i m a t e

o f 0.33 for w o m e n indicates tbac the w o m e n had a higher derrtd knowledge score than
the men. T h u t h e A N C O V A analysis results s h o w that t h o s e w h o w e r e w o m e n , h a d
h i g h e r e d u c a t i o n level, h a d r ecei ved o r a l h e a l t h education, a n d x h o ^ w h o w e r e
w e a l t h i e r h a d h i g h e r d e n t a l k n o w l e d g e scores i n th-e 3 5 ^ - y e a r - o l d s . A m o n g the
d d e r l y , t h o s e w h o h a d h i g h e r education leveL t h o s e w h o h a d r e c e i v e d oral health
e d u c a t i o n , arid tliose w h o w e r e w e a l t h i e r a l s o h a d h i g h e r d e n t a l k n o w l e d g e scores.

Table 5-10- Relationship between dental knowledge score and f l e e t e d independent

variables in 3S-^4-year-OidS (result Of ANCOVA analysis).
Bonferrcni's
E^imaie SE-Estimate

[ndependent variable

p-value multiple comparison

Se>
Mena
D.33

Women

0.12

Education leveC

<0.D1

(IJNo schooling /primary

(2)Secondarv

0.71

0.16

(3) Post-second a fy

2.05

0.27
<0.01

Receipt of dental education

Neve:

<0.01

11

2.18

0.15

FMPI

0.02

0.00

<0.01

(Intercept)

0.73

0.15

^0.01

Yes

F-value= 125.3;
a

1567; p<0.01

Reference category

66

Table 5-11, Relatsonship between dental knowledge score and sefetted independent
variables jn 65-74-year-oJds (result of AMCOVA analysis).
BonferronE's
Independent variable

Estiinate

SE-Estim^Ee

Education level

p-value

multiple compajlson

<0.01
3

(1) No schooling
(2) Pfimary

0.26

0.12

(3) Secondary and above

0.77

0.16

<O.Q1

Receipt of dental education

3

Nev^i'
Yes

1.71

0.11

FMPI

0.D2

0.00

:0.01

^ntercepi)

0.93

0.09

^0.01

F-value = 102.2; df = 41 1510 p<i.01

3

Refefence category

T e l e v i s i o n / r a d i o a n d n & w s p a p e r / m a g a z i n e w e r e t h e tu-'o m o s t c o m m o n c h a m e t s f r o m
w h i c h s u b j e c t s r e c e i v e d their o r a l h e a l t h informatioD ( T a b l e 5 - 1 2 ) . Percentages oi
s u b j e c t s w h o h ^ d r e c e i v e d i n f o n t i a t i o n f r o m t h e s e t w o types o f m e d i a w e r e 52% a n d
4 0 % a m o n g t h e raiddle-ag&d a n d 25% a n d 1% a m o n g t h e d d e r 3 y . H o w e v e r , f o r i h e
e l d e r l y l i v i n g i n m r a l areas, o n l y 4 o f t h e m d a i m e d h a v i n g r e c e i v e d ora] health
m e s s a g e s from n e w s p a p e r o r m a g a z i n e . O n l y 1 2 % oF t h e m i d d l e - a g e d a n d 5 % o f t h e
e l d e r l y h a d r e c e i v e d o r a l h e a l t h e d u c a t i o n from dentists or dental n u r s e s a n d

of

t h e m w e r e u r b a n residents, M o s t o f t h e 65-74"year-oJds60%) a n d o n e quarter o f t h e

35-44-year.olds

reported t h a t t h e y h a d n e v e r e x p e r i e n c e d a n y oral h e a l t h education.

67

FurLhonnore, m o r e rural residents than urban residents i n both age groups reported not
having received a n y era! hcaith education.

Tabfe 5-12, ChanneJs through w/hjeh the respondente received their oral health
Information (nultiple response analysis).
35-44-year-olds

S5-74-year-o[ds

Rurai

Toia^

Urban

Ruraf

n=798

n=775

n=1573

ri774

n=741 n=1515

Radio, teJevrsion

61

43

Newspaper, rr^aga^ine

60

19

Dentist dental nurse

13

Propaganda board

15

Types of media

13

Others

Had nev^r received

11

17

15

25
11

Family

32

Total

1 1

12

1 1

Friends

Jnfofmatio.n counter

2 0 2 0 2 0 0 1 5

Urban

46

46

73

T h t oral health beliefs and attitudes o f the subjects are shown i n Table 5-13. T h e
majonty o f the respondents i n both a^e groups h e l d positive attitudes to a l l statements
except to the statement "Just l i k e birth, ageing a n d death, loss o f teeth, i s a natural
process". M o s t of the respondents thought that lo^s o f teeth w a s a natural process. The
m e a n dentat attitude scores i n the 35-44-year-oIds and the 65-74-year-olds were 6.2 and
5-8 respectively ( F i g . 5-2). T h e 35-44-year-olds had a higher mean dental attitude score
the 65-74-yeaj-olds (latest, p<0.01). Results o f A N C O V A analysis o n the artimde
scores (Tables 5^14 and 5-15) showed that education level a n d dental knowledge score
had posi ti ve effects o n the

attitude score i n both age gjroups. Ttiose who had

higher education l e v e l and thos& w h o k n e w more about dental diseases i>e[d more

6S

positive oral heahh attitudes. A m o n g the h-44yerar-ddsthose w h o w e r e wealthier

held m o r e p o s i t i v e a t u t u d e s t o w a r d s orat health. F o r t h e 6 5 - 7 4 - \ e a r - o l d s , u r b a n
r e s i d e n t s a n d m e n s h o w e d m o r e p o s i t i v e attitudes th^n rural r e s i d e m s a n d w o m e n .

Tabfe 5-13. Proportbn of subjects with a positive dental health belief or attitude.
35-44

65-74-ye^r-cld s

Do you "agree" o : "disagree" w l h Positive

Urban "Rural

the fotlowirg statemanis?

n-ZBS n - 7 7 5 n=1573 n=774 n="Mi n=15l5

response

Total

Urban Rur^l"To^

20

20

23

T9

10

Agree

SO

30

85

ai

78

Agree

94

86

90

Disagree

92

85

89

68

73

33

Agree

91

33

89

88

85

87

Disagree

&5

33

&4

84

80

82

Agree

91

89

Just like birth, ageing and death,Disagree

14

loss of teeth [s a natural process.

The staie
with born and ha$ little relation.
with sell-protection.
Poor teeth are detrimental to

80

one's appearance.
The state of my teeth is of

&4

03

BS

great :nn porta nee to me.

Keeping natural teeth &
i not
importarit.
Dental problems can affect
the body as a whole.
False teetJi will be less of a
bother than natural teeth.
Regular visits to the dentist
keep away dencal pnoblein.

69

90

35

33

34

D e n t a l attitudes
score

3 5 - 4 4 ^ 3 ^ - 0 Id s
>j5-74-y6ar-oJds -

Urban
men

Urban
women

Rural
men

Rural
women

F i g . 5 - 2 , Mean dentai attitude s e e re [Maxifnuin - 3} of men and women in

urban and rursZ areas in Guangdong.

TabJe 5-14. Relationship between deritaf attitude score and selected independent
variables in 35"44-yeaiMjids (Result of ANCOVA analysfs).
onferrmi's
Estimate

Jrtdep^ndent varisbJe

SE-Estimste

p-value

muftipie comparison

<0.01

Education level
a

(1) No sclnooling/prijnary

(^(V

(2) Secondaiy

Q.48

0.Q3

(3) Post-secondary

0.73

0.13

Dentai knowledge score

0.04

0.01

<0,01

FMPI

0.01

0,00

<0.01

(Intercept)

5.55

0.D6

<0,01

F-v^lue = 43.84 d f = 4 f c 1 5 6 8 ; p<O.Ol

* Reference category

70

Table 5-15. Re'^Iionsnip m : c e n

attitude score and Effected independent
vsnjbl&s in 55-74^yc^.r-o!dE - R&SLilt of ANCOVA ^naiysls).
Bonferroni's
ridependeit e n a b l e

Estiinate

SE-Es^ima-e

Locatron

p-value

muUipfe comparison

<0.01

Rursl'
Urban

0 03

Gender
Men'

<0.05

Women

0 20

0 09

EdLtcaticn level

<0.01

{1) No scrioo?in^
(2) Prirrwy

0 53

D 10

(3) Seccntf^ry a n ^

G55

G 13

a x v

Dental knowledoe score

0.07

0.D2

<G.01

ftntercept}

5.25

0.10

<0.01

F-value = 3G 45; df ^ S. 1509. p-:0 Cn

.efsrence category

Tabic 5-lh

he

J i s t r t b u t u m o f tht s u b j e c t s according t t h e i r oral

h y g i e n e p r a c ^ i ^ s . W h i i c n m s t [idu]ts in u r b a n a r e a s claimerd t o brush t h e i r teeth t w i c e or

m o r e a d i i y , m o s t aduity in rural c i r c o s j a s t b r u s h e d their teeth o n c e daily. T e n p e r c e r u o f
th^6 5 - 7 4 - ^ ^ ^ 0 ] ^

that

did n o t b r u s h t h e i r teeth daily a n d t h e m a i n reasons

g i v e n b y t h e s e e l d e r l y w t r " n o o r t o o f e w t e e t h (44^/0) 1 " t o o old"' 27%). a n d tired o r

n o t i m e " ( 2 5 % ) . All of t h e m i d d l e - a ^ e d s u b j e c t s a n d a l m o s t all o f the u r b a n elderly
c l a i m e d io ust: t o o t h p a s t e d u r i n g t o o t h b r u s h i n g . H o w e v e r , m o s t of the adults d i d n o t

71

know whether their toothpaste contained fluoride or not, h was also found chat most of
the subjects used toothpicks, especially among the middle-aged.

Table 5-16. Distribution of Chinese adults according to reported oral hygiene practice ()
35-44'year-olds
Oral hygiene practice

Urban

Rural

65 - 7 4 ^ ear-olds

Total

Urban

Rural"

43

75

Total

TooShbrushirtg
U

Once a day

22

31

51

Twice or more a day

73

ia

40

56

100

10Q

100

96

35

Yes

49

28

19

12

No

12

10

14

Do not know

39

87

63

66

95

79

Yes

86

69

as

72

SO

S6

No

11

12

23

40

34

Less than once a day

58
32

Use of toottipasle
15

32
S

TooUipaste contain fluoride

Use of toothpicks

All Chi-square tests on each practice by urban and ruraleddents in each a g e group
are statistically significant except on "use tooth paste" in the 35-44-year-cilds

I n o r d e r t o a s s e s s d e t e r m i n a n t s for t o o t h b r u s h i n g f r e q u e n c y ( o n c e o r less d a l l y against

twice

or m o r e daily)a logistic- r e g r e s s i o n a n a l y s i s w a s p e r f o r m e d . T h e results s h o w e d

t h a t u r b a n r e s i d e n t s , w o m e n , t h o s e w h o h a d h i g h e r e d u c a t i o n level a n d those w h o h a d
h i g h e r deoital k n o w l e d g e BX\d dental attitude scores b r u s h e d t h e i r t e e t h m o r e f r e q u e n t l y
in b o t h a g e g r o u p s ( T a b l e s 5 - 1 7 a n d 5 - 1 8 ) A m o n g t h e 35-44'y&ai-oliis. those w t o w e r e
w e a l t h i e r a l s o b r u s h e d their t e e t h m o r e fiequently.

72

Table 5-17, Resultsf logistic regression analysis on toothbrushing frequency (once or

:e5S vs. twice more daiJy) in 3S^4^year-old& {n=1573}.
Independent variable

Beta (S.E.)

Odds rato (95% C.L)

1-58 (0.17)

4.05 (3.46^ 6.30}

p-value

Location
Ruraa

<0.01

UrbSLn
Gender
Men

[0.01

0-50(0.14}

Women

1_S4 [1,25-2.16)

Education level
No scJiooE^ng / priinsry

0.01
3

Secoridary

D_59{0.1S)

1.99{1.41 2 . 6 0 )

Post-secondary

0.36 {0.32)

2.36 (1.25 4.46)

FMPj

0.03(0.01)

1.04(1.02- 1.05)

<0.01

Dental knowledge score

0.13(0.03)

1.14 (l.OB- 1.20)

<0.01

Dental attitude score

D_15(0.06)

1 , 1 6 ( 1 . 0 3 - 1.30)

0.05

Constant

-2.22 [0.40)

C = 764; d f = 7P<D.01:
reference category

0.39

73

<0.01

T^ble 5-16- R e s u l t s
l e s s v s . "^vice or more daily) in 65-74-year-clds (n=1515).
h d e p e n d e n t variable

B e t a (S.E_)

O d d ratio (95 C.I.}

Lowtion

p-vaEug
<0.01

Rural1
Urban

2 . 4 4 ( 0 . 1 6 )

11.53 ( 3 . 3 9 - 1 5 . 3 6 )

Gender

^0.01

Men1
D.43 (G.16}

Women

1.61 (1.17 -2.2Z)

Education leve]
No sohooling

<0.C1

Primary

C.47{0.13)

1.60(1.^-2.26}

Secondary a n d above

1.18 (0.2T)

3.24 ( 2 . 1 5 - 4 . 6 9 )

Dental knowledge score

0.12(0.03)

1 . 1 2 11.06-1.19)

<Q.G1

Dental atritude s c o r e

0 . 1 6

1.17(1.07-1.29)

<0.01

Constant
X ^ = 527; d f = 6 ; p<0.01;
a
reference category

( 0 . 0 5 )

^2.17 (0_31)
0.29

74

<0.01

5,4. Utilization o f denial services

Table 5-19 shows the percentage distnbution of the study subjecii according to the time
lapsed since their last dental visit, by age group and lociiiion ofresidency,h can be seen
th^it in both lhe 35-44-year-olds and the 65-74^^-01^ le^ than one-quarter of the
subjects had visited a dentist within a yearThe dental service utilisation pattern of the rwo
age groups w a s similar but in both groups, proportionally more o f the urban residents had
made a recent dental visit than the mral residents (p<0.01).

Table 5-19. Recency of last dental visft iri the

gnoups according to location af

residency (Percentages).
65-74-^ear-olds J

35-44.year-old5
Urban

Rural

Tota!

Urban

Rural

Total

(n=79fl)

{n=775}

(r-1573}

(n=774)

(n=741)

fn=1515)

< 12 monlhs

28

17

23

30

18

24

1-2 years

13

11

13

10

T2

2-5 years

17

17

17

23

17

20

> 5 years

20

16

18

24

33

28

Never visit dentist

22

41

31

10

22

16

Time Japsed since

last den'al visSt

"StatisticaJJy signfficant between ufban and rur^l r&sidents (Ch3-squre test p^O.OI)

The most commonly ciled reason for not having seen a. dentist for ai ]ea5t three years was
no perceived need (Table 5-20). This w a s more frequently reported by the urban residents
than by the mral residents i n both age gxoiips {jp<0.01)_ The second most common reason
w a s that the dental problems were not serious. Close to one-third o f the rural elderly
indicated that fi^ianciai diffituity w a s ^ main burner to receiving dental c3i& but

75

percentages o f the urban elderly and the middle-aged who reported this were significantly
s m i i l e r (p^O.Ol).

Table 5-20. Distribution of participsnts by reasons given for not makEng a dental visit within the
past three year5 accordfng to lot^ion of residency (mUliple response analysis).
ye af-o Id s

Reasons
No n e e d B

"

Problenns not senoi^s

C o u l d not afford
Too busy

G5-74-ye a r-o fds

Urban

Rural

Total

Urban

Rural

Toial"

(r\^4n)

(n=509>

(n=922)

(n=3S9)

(n=472)

(n=331)

55

63

ea

43

51

25

31

23

29

29

29

10

10

2&

21

14

11

12

73"

Afraid of dentist

Others

statistically sigrJ^cant betv/een u r t s n and njrsl residenss in both age groups (Ghl-square
test; p<D.01)

A m o n g the subjects w h o had visited a dentist within three ye^r^ the three most common
treatments thaE they received during their last dental visit were fillings, extractions or
dental prosthesis (Table 5-21). It was fltrther foiind that, r d a t i v d y more o f the urban
residents had received fi Slings w h i l e more o f the mral residents h^d received extractions
and dental prosEhesis (p<0.05). Furthermore a rather l o w percentage o f t h e subjects
received scaling at theia^: dermal visit, 1 4 % in the middle-aged and onJy 2 % in t h e
elderly.

76

T a b l e 5-21
dentist within the p a s i three years (inultiple response analysis).
35-44-year-olds

Treatment received
Examination
Scaling

&

Filling 0
Extraction

F i x e d prosthesis
Dentures

65-74ye3r-olds

Urban

Rural

Totaf

" Urb^n

Rura[

Total

(n-3a5)

(n=265)

(n=650}

(n=415)

(n=263}

(n=&a3)

23

T4

17

11

14

53

25

41

16

13

17

21

33

26

30

36

33

19

13

23

34

27

14

to

12

1 9 " " " IB

13"

statistically significant beiween urban and rura! re^dertls in both age groups (Chi-square
test; p<0.C5 )
statistically s i g n i f F c a n square test; p<0.D5)

A m o n g the 35-44-year-o]d subjects, proportion i l l y more o f chose who lived i n urban

brasbed their teeth twice daily, had higher educationa! level, better oral hea!th knowledge
and attitudes, better economic status had made a recent denta.! visit and so did the women
(Table 5-22). F o r example, 42% o f those who brv^hed their teeth twice or more daily had
v i sited a dentist within rwo years but oaly 26% o f those Who brushed their teeth once or
less daily d i d so. Furthermore, having made ^ recent dental visit w&s more common among
thos^ w h o had poorer peroeived oral conditions, had experienced dental pain i n the
preceding year and had perceived trearment need. It was interestmg to find that having had
a more recent visit to ^ dentist was related to being ailraid o f the demist. A similar pattern
was found i n the 65-74-year-olds except that gender and dental fear did not h i v e a
Statistically significant rdation&hip with dental servke utilization (Table 5-23). The above
findings were confirmed b y the resu]U o f the logistic regression analysis shown in Tables
5-24 and 5-25. In fact, most o f the independent variables which were found to have a

77

si^Ssticajly significant rciation&hip with utilisaiion i n che bivariate analysis remained i n the
final Ec-gistic regression modtl. In Tables 5-24 and 5-75,
that

a positive Beta value indicates

subjeds in tiiis categoT\r had a higher chance to have visiied a dentist within iwo

years than the subjects in the reference category. A 95% confidence i n t e n d (95% C.I.) o f
odds ratio bigger dian orte indicates the subjects in this category had a higher chance to
have made a dental visit

two years, and the bigger the odds ratio the higher the

chance. F o r example i n Tabic 5-24, a Beta value o f 0.53 for the urban residents indicates
that they had a higher chance to have vissted a dentist within tv^'o years than the rural
residents.

78

Table 5-22. Selected factors- in relatron m u s e of dental servrces in the 35^4-yr-ods.

T i m e lapsed since la&t dental vp&it
2 years

2^5 years

Syeare

Factor
Location
Urban

793

41

43

Rural

775

27

55

763

30

54

310

37

45

No s c h o o l i r t g / p n m a f y

401

27

55

Secondary

953

36

46

Post-^econd^ry

154

42

1040

26

55

533

45

3&

O n c e or Less daily

316

26

56

T w i c e or m o r e daily

757

42

42

Yes

500

42

39

No

1073

30

1003

43

39

570

18

67

Yes

992

41

42

N o / Don't k n o w

531

21

62

1573

24.9

21.9

X
19.2

1573

5.4

6.2

6.1

1573

3.9

3.4

3 3

Gende"
Men
Women
Education levei

20

33

Perceived conditiori o f teeth

G o o d / no coinrrient
Bad
Tootfibrushing frequency

Dental

TeetJn caused pain ^

Yes
N o / Don't k n o w
Perceived n e e d f o r t r e a t m e n t

X
Mean F M P !

M e a n dental attitude s c o r e

M e a n dental k n o w l e d g e s c o r e b

significant b et w e e n g r o u p s with p^0.01 (AIVOVA)

79

Table 5-23. Selected factors in relatro.l Co use of Cental services in the E5[74-year^lds.
Time lapsed since last dental visit
2 years
Factor

2-5 years " > 5 years

Urban

774

43

23

34

Rural

741

23

17

55

Men

759

35

19

45

Women

756

36

20

44

No format schooling

722

30

21

49

Primary

540

35

20

4&

253

54

17

29

822

32

19

49

512

4D

21

39

O n c e or less daily

1030

30

10

52

T w i c e qt more daily

455

4B

24

28

Yes

377

30

20

No

1138

35

20

4&

Yes

929

43

19

33

Ho i DorTt know

586

25

21

55

Yes

763

43

19

38

No

752

29

21

51

X
.11.1

Location'1

Gender

E d u c t i o n leve] a

Secondary and a b o v e
Perceived condition of teeth

G o o d / no c o m m e n t
Bad
Toothbrushing frequer.cy

Dentai fear

Teeth c a u s e d pain *

Perceived n e e d for treatment *

Mean FMPI

M e a n dental attitude score

M e a n dental knowledge score D

b

1515

13.5

X
14.6

1515

5.9

6,0

S.S

1516

2.4

2.0

17

significant between gfoups with p-=0.01 (Chi-square test)

stgnificant between groups wiUn p^O.DI (AWOVA]

SO

T a b l e 5-24. Result of 3 logistic regression analysis on recent use of dental secvices

(fess than 2 years vs. more than 2 year^) in the 3S^44-year-Dlcl&.
Factor

Beta (S.E.J

Odds ratio [95% C.L)

Location

p-value
<0.01

Rural

Urban

0.53 (0.15}

1.7

(1.3-2.3}

Perceived condition of teech

<0.01

Good

B^id

0.46 (0.12)

1.S ( 1 . 2 - 2 . 0 }
=0.01

Toothbrushing
O n c e less da[[y

Twice Of more daily

0.54 0.14)

f . 7 1-2-2.3}
0.01

Dental fear
No

Yes

0.30 (0.12)

1 4 {1.1-1.3)
<0.01

Teeth caused pain

No

Yes

1.06 (0.14)

2.9(2.3-3.7)
<0.01

Perceived need for treatment

Yes
Constant
' = 241;d f - & ; p^O.Ol; f
reference category

2.2 ( 1 7 - 2 . 8 )

O J a {0.13)

<0.Q1

-0,92 (0.03)
= 0-15

SI

T a b l e 5-25- Result of a logistic r&gression analysis on recent u s e of dental services

( l e s s thsrs 2 y e a r s v s . mare than 2 years) in the 65.74-yea"OldsFactor

(S.E.)

Odds ratio { 9 5 % C.I.)

p-value

1.4(1.0-1.9)

<0,05

Gender
Men 3
Women

0.33 (0.15J

CQ.D1

Education level
Mo schoofing

Pfimary

0.34 {0.16)

Secondary and above

0.76 {0.20)

1 . 4 [ 1 . 0- 1 . 9 )
2 . 1

[ 1 . 4

3.2:

<0.01

Toothbrushing
O n c e o r less daily

T w i c e o r more daily

0.43 {0.13)

1.6(1.2-2.1}
<0.01

Teeth c a u s e d pain
No

Yes

0.82 {0.13)

2.3 ( 1 . S - Z . 9 ]
<0.01

Perceived n e e d f o r treatment
No

Yes

0.55 {0.12)

Family Material Possession

0.02 { , 0 . 0 1 )

Dental knowledge s c o r e

0.06 {0-03)

Constant

- 0 . S S [0.12}

= 1 9 3 d f = 5 ; pcO.01 =0.12
refernee category

S2

1 . 7 ( 1 . 4 - 2 . 2 ]

1 . 0 2 [ 1 . 0 1- 1 . 0 3 }

1.06 (1.00 - 1.11)

<0.01
<0.05
<0.01

5.5. Coronal and root caries

C o n d i n o n s o f coronal anJ root caries by age group, gender, and location o f

residency are s h w r i i n Table 5-26. Very high proportions o f the middle-aged and
almost a l l the elderly had D M F T > 0 . The unweighted mean D F M T score was 4,6 i n
the 35-44-year-old.5 and 15-6 i n the 65-74-year-olds and the weighted D M F T acores
were 4.7 and 16.0 respectively according to the total ratio o f urfcan to n u a l
population (1: 23)

i n the province. Women had higher mean D M F T scores than men

i n both age groups. Rural residents had higher mean D M F T scores than urban
residents i n a l l subgroups.M T was ihe major component o f the D M F T score i n both
age groups. T h e proportion o f subjeclS who had GNE OT more teeth w i t h root caries
was 11% i n the 35-44-year-olds and increased to 38% i n the 65-74-year-olds. Taking
into account o f the ratio o f urbsui to rural population i n the province. The weighted
prevalences o f root caries were 12 and 3 7 % respectively, DF-Root scores were
n e a r l y totally contributed b y D-Root.

T h e p r o p o r t i o n o f F T i n D F T w a s very Jow in the populations surveyed (Fig. 5-3).

That was 20

im the 35-44-year-^lds and 5 in the 65-74-yc^i-olds,

Men and

w o m e n hajd similar proportions b u t the proportions i n the urban residents w e r e

significantly h i g h e r thaja thai in the rural residents (p<0.01).

S3

9.0

{t-ov ro
(
{5V
(
(

uoi.
(1--0
f

fL.OV)

PS
(r?>

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u.?
{5=J
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ooytxooy-a

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CSJ

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rt.o
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35^M-y e ar-olds

6 5-74-y ear-o f d s

Fig* 5-3. Proportions Of F T and DT in DFT according to Render and location

35-44-yeaf-old$ and the 65-74-year-oJds.

Statistically signiftcan differences (p<0.05) i n D M F T scores wene f o u n d a m o n g

s u b - g r o u p s o f s u b j e c t s (Tables 5-27 a n d 5-28). Rural residents, women^ t h o s e w i t h
l o w e r e d u c a t i o n level h t h o s e n o t satisfied w i t h t h e appearante, o r with Lhue canditioti
o f t h e i r teeth h a d h i g h e r m e a n D M F T scores th^Ji other groups o f subjects i n b o t h
a g e g r o u p s . I n t h e 35r44>rear-oldssubjects w h o w e r e aftaid o f visiting a dentist also
h ^ d a h i g h e r m e a n D M F T score t h a n t h o s e w h o w e r e not. In relation to perceived
t r e a t m e n t n e e d , experience o f dental p a i n d u r i n g la^t year, a n d t i m e lapsed since last
d e n t a l v i s i t , t h e 35-44-year-olds a u d 65-74-year-olds s h o w e d d i f e r e m patterns.

85

TabSe S-27 CDTr.parison of DWiFT scores in different subject groups among the 35-44yesr-old&.

Location

Gender

Educatro^ :eveJ

Toothbrushing frequency

Dental fear

Perceived appearance
of teeth
Perceived condition
of teeth
Percei^ecf need for
treatment
Teeth caused pain

Time lapsed since last

dental visit

Group

Mea^S.E.)

Urban

793

4.3 {0 1)

Rural

775

4.9 (0.2)

Man

763

3.6(0.1)

Woman

&10

5.6 (0.2}

No schooling / primary

461

5.4 (0.2)

Secondary

955

4.3(0.1)

Post-secondary

154

4,0 (0.3)

Once or less daily

816

4.B (0.1)

Twice or more daily

7S7

4.5 {0.1)

No

107

4.3 (0.1)

Yes

500

5.3(0.2)

1038

4.1 (0.1}

485

5.9 0.2}

m o

3.7 (0.1)

Bad

533

6.5 (0.2)

Yes

992

5.2(0.1)

N o / D o not know

581

3.6(0.1)

1003

5.0^0,1)

Mo/Do not know

570

3.9(0.2]

< 2 years

532

5.6 (0.2)

2-5 years

265

5.4 (0.3)

> 5 years/nonuser

776

3,7(0.1)

Satisfied / no comment
Not satj&fied
Good / no comment

Yes

p-value
c0.01

<0.01

<0.01

0.1S

<0.01

0.01

<0.01

<0 01

<0_01

<0.01

T a b l e 5-23. Comparison o:- D M F T scores in different subject groups among Uie 65-74-

yep!"-olds.

Variable

Group

Mean(S.E.)

Location

Urban

774

14.7 (0-3)

Rural

741

1 6 5 {0.3)

Men

759

14.0 (0.3)

Woman

756

17.1 (0-3)

No schooling

722

17.3(0.3]

Primary

54 D

14.5 [0.4)

Seccndary and sbove

253

12.9 [0.5)

1030

15.5(0.5)

485

15.1 (0.4)

No

1133

15.7 {0.S}

Yes

377

15.2 (0.4}

Satisfi&d / no commeril

92S

13.6 0-3}

Not satisfied

5S7

18-7 (0.4}

Good / no comment

822

14.3 0-3)

Bad

693

-0 (0-3}

Yes

763

14.S (0.3)

No / D o not kno^v

752

1 6 J {0-3}

Yes

923

1S.2 (0-3)

No 1 D a not know

586

16.2 (0,4)

< 2 years

541

14.e (0.4)

2-5 yeans

301

16_4 (0.5)

5 years and above

673

16.0 (0.4)

Gender

Education levef

TooLhbru&hing frequency

Once or less daily

Twice o r more daiiy

Denial fear

Perceived ^ppearar^ce
of leeth
Perceived condition
of leeth
Perceived n e e d for
treatment
Teeth c a u s e d pain

T i m e lapsed s;nc^ Sa$t

dental visit

37

p-value
0.01

<0.01

<0.01

0.19

0.34

0-01

<0.01

<0.01

<0.05

^0.01

Denta] knowledge sccjre, denial attitude score and F M P I o f the <55-74-ycar-o]d& wcrt
found to have negative relationships w i i h the D M F T score, i.e. those with better
dental knowledge, those with more positive dental attitude, and those who were
wealthier had fower D M F T scores (Table 5-29). ,Ajnong the 35^-year-olds, only
The F M P I score had a statist]caliy significartt negaiive lelationship with the D M T T
score.

T a b l e 5-29. Relationship between D M F T scores and dentai knowledge, attitude and

F M P I scores {Pearson's correlation coefficient).

CorreJation coefficient

p-vaiue

Dental knowledge score

-0.01

0.76

Dental attitude score

-0.04

0.15

FMPI

-0.08

<0-01

Dental knowledge score

-0.09

<0.01

DentaJ attitude score

-0,12

<0-01

FMPI

-0.13

<0.01

35-44-year-olds

65-74-year-olds

The results o f A N C O V A analysis on mean D M F T scores for the 35-44-year-olds

and the 65-74-year-olds are shown in Tables 5-30 and Table 5-31 respectively. 11
was found that among the 35-44-year-olds, women, those who were less wealthy,
those who h a d visited a dentist within 5 years had higher D M F T scores. A m o n g the
elderly, women^ those who had lower education level, those who were less wealthy,
and those w h o held less positive attitudes towards dental heaJth had higher D M F T
scores.

8S

T a b l e 5-30. Relationship between D M F T scores and selected independent variables

a m o n g the 35-44-year-o!d Chinese (result of A N C O V A analysis].
Bonferronf1^
ncependent variable

Estimate

S E (Estrmate)

Gender

p-value

multiple comparison

^O.DI

Men'
Women

1.77

0.20

L a i i dental vis^t

^0.01

> 5 years n
2-5 y e a r s (2)

t.67

0.27

{2)>(1)

< 2 y e a r $ (3}

1.S2

0-22

(3^(1)

FMP

-0.02

0 1

<0.01

intercept)

3.34

0.19

<0.01

F-value = 46.05 df = 4, 1560 p<0.01

a

refsrsncG category

Table 5-31 Relationship between DMFT scores and selected independent variables
a m o n g the 65-74-year-old Chinese (result of ANCOVA analysis).
Bonfejrni's
n d e p e n c f e n t varisbSe

Estinate

S (Estimate)

p-value
<0.01

Gender
Men'
Women

1.89

0.55
<0.05

Education levei
{1] Mo schooling"
{2) Primary

-1.27

0.60

{3J Seoondajy and above

-2.07

0.79

FMPI

-0.05

0.02

<0.01

Dental attitude score

-0.35

0.16

<0.05

(Intercept)

IS.I-S

t.cn

F^vaSue = 1 6 . W ; df = 5 , 1 5 0 9 ; p<0-0l
a

reference category

89

multiple comparison

5-6. P e r i o d o n t a l diseases

Percentage
d

o f the 3 5-44-year-olds and the 6 5 - 7 4 - y e a r ^ l d s according to

the[r highest C P I score are shown in Tables 5-32 and 5.33. Prevalences of shallow
and d e e p p e r i o d o n t a l pockets were 3 ] % and 4 % in the 3 5 ^ 4 - y e a i - o l d s and 3 7 % and
6 in t h e 65-74-year-olds respectivejy. M e a n numbers o f sextants b y CPI score in
[he j5~44-year-o[ds a n d t h e 65-74'year-olds are shown in Table 5-34 and 5-35,

T a b l e 5-32. Percentage distribution of the 35-44-year-olds according to highest CPI

score.

Men"

n
763

Mo
bleeding
^~D

Bjgajing
0

Calculus
57

Shallow
pocket
as

Deep
pocket
B

Women

BOS

71

26

Urban

796

S1

34

Rural

774

63

29

Total

1572

64

31

" C h h S q u a r e t e s t p<0.0l

T a b l e S-33. Percentage distribution of the 65-74-yeaf-oFds according to highest CP!

Score.

Mo
bleeding

Bleeding

Caiculus

Shailow
pocket

Men'

S75

50

41

Women

611

61

32

Urban

603

54

37

Ruraf

603

57

37

T^tai

1235

"

C h i - s q u a r e test, p<0.01

90

5 5 "

37

Deep
pocfaet

T a b l e 3 4 . M e a n number of sextants by C P ! score in the 35^44-year-o:ds.

1+2+3+4

2+3+4

3+4

Ho

Bleeding or

Calculus or

Shaltow or

Deep

Exduded

bleeding higher score higher ^cone deep pocket

pocket

Men

763

0.1

s.e

5.5

0.9

0.1

0.1

Women

309

0.2

S.6

5.2

D.5

0,1

0.2

Urban

79a

0.2

5.7

5.3

o.a

0.1

0.1

Rural

774

0.2

5.7

5.4

0.6

<0.1

0.2

Total

1572

0.2

57

5.3

0.7

H i

0.1

Deep

Excluded

Tabe 3 5 . Mean number ot sextants by CPJ score in the 65-74-year-olds.

rr

1+2+3+4

2+3-r4

3+4

No

Bleeding or

Calcubs o r

Shallow or

bEeecfing higher score higher score deep pocket

pocket

Men

675

c0

4.4

4.2

0.9

0.1

1.5

Women

611

0.1

4.0

3.8

0.6

0.1

1.3

Urban

GS3

0.1

4.4

4.1

0.9

0.1

1.0

Rural

603

<0.1

4.0

3.B

0.7

0.1

2.0

Total

1286

0.1

4.2

4.0

o.s

0.1

1.3

91

Percentage distributions o f the 35^4-year-olds and the

65-74-ysay-oldi

by

m a x i m u m loss o f attachment ( L O A ) are shown i n Tables 5-36 and 5 o 7 . M o r e than

h a l fo f the 35-44-year-olds and more than 90% o f The 65-74-year-olds had 4 m m or
more o f l o s s o f periodontal attachment. M e a n numbers o f secants b y L O A i n the
35-44-year-olds and the 65-74-year'Olds are shown i n Tables 5-38 and 5-39.

T a b i e 5-36, Percentage distribution of the 35^l4-year-old$ according to their mimu

LOA.
n

0-3 m m

4-5 rnm

763-

37

49

"Ti

Women

309

45

45

<

Urbsn

793

44

45

Rural

774

39

49

Total

1572

41

47

Men

"

6-8 mm

9-11 mm

12+ m m

Chf-square t e s t p ' O - G

T a N e 5-37. Percentage distribution of the 65-74-year-olds according to thek maximum

LOA.
n

0-3 nnin

4-5 m m

Men"

675

. 39

"^0

10

Women

611

45

35

Urban
Rural

6S3
603

7
6

45
39

36
39

S
^

Totat

12S6

"42

6-8

j g

Clii-5q|uare test r p<0.01

92

9-11 m m

10

12+ m m
'

" 5
3

T a b l e 58. M e a n number of sextants by L O A in the 35-44.year-olds.

D-3 m m

4+ mm

6+ mm

9+ mm

12+- mm

Excluded

Men

763

4.2

1.7

0.3

0.1

<0.7

0.1

Women

809

4.6

1.2

0.2

<(\A

<0.1

0.2

Urban

790

4.6

14

0.2

<0.1

<11

0.1

RUJ^

774

4.3

1.5

0.2

<0_1

<0.1

0.2

1572

4.4

1-4

0.2

<0.1

<0.1

0.1

Total

T a b l e 3 9 . Wlean number of sextants by L O A in the 66-74-year-old5.

n
675
611

0-3 mm

4+ m m

6+- mm

9mm

'2-1- mm

Excluded

1.4
1.6

3_0
2.4

1.0
0.7

D.2
0.2

0.1
<0.1

1.6
1.9

1.6

2.e

a&

RuraJ

683
603

1,3

2.7

0.9

0.2
0.2

{LI
<0.1

1.6
2.0

Total

1236

I S

2.3

0.9

0.2

0.1

1.8

Men
Women
Urb^n

K o matter whether the periodontal status was measured by C P I or L O A ? men

demonstrated worse periodontal conditions than womer in both age groups but
urban a n d rural residents had similar periodontal conditions.

93

5.7i Tooth loss and prosthetic status

Complete edentubusncss was found i n 3,9% o f the 65^ye3rolds. T h a t w a s 4 . 4

in u r b a n residents

3-4% i n mral residents (Chi-square test, p>0.05}. If t h e teeth

indicated f o r exuraction w e r e removed, 6 , 1 % o f the eJderly would b e edentulous with

a prevalence o f 5 . 0 % m ^ r b a n residents and 7.3 in rural residents (Chi-square test,
p>0.05)-

O n l y o n e p e r s o n in t h e 35-44-year-olds w a s edentulous and she had

congenital demtal agenesis (complete anodontia)- The mean number o f iniasing teeth
( M T ) w e r e not significantly different between urbim and rural residents (Table 5-40)
b u t significantly h i g h e r I M T were f o u n d in rural residents than i n urban residents.
T h i s w a s f o u n d i n b o t h gender groups i n t h e middle-aged and t h e elderly. A s
m e n t i o n e d previously, t h e n u m b e r o f actual missing teeth ( M T ) and t h e n u m b e r o f
teeth indicated f o r extrac-iian (IMT) s u m u p t o a total o f adjusted missing teeth
( A M T ) . T h e highest A M T scores (4.] i n t h e 35-44-year-olds and 17.5 in t h e 65-74year-olds) w e r e f o u n d i n rural w o m e n i n both age groups. T h e m e a n M T and I M T
s c o r e s of w o m e n w e r e higher than those of m e n in both age groups (t-te5t; p<0.05).
A s iilustraied i n t h e cumulative frequency curves in Fig. 5-4 and Fig, 5-5, rural
w o m e n had t h e h i g h e s t adjusted missing teeth ( A M T ) a m o n g the f o u r subgroups in
both a g e groups. A b o u t 60% o f t h e middle-aged rural w o m e n h^d f o u r o r f e w e r
A M T w h e r e a s t h e corresponding figures w e r e about 8 0 % i n the middle-aged rural
m e n and u r b a n residents. M o r e obvious difference w a s f o u n d f o r the 65'74-ycarolds. A b o u t h a l f o f t h e rural w o m e n h a d 16 o r more AMT while only about one-third
o f t h e elderly m t h e other subgroups h a d s u c h high A M T scores. Nearly all of the
35_44_y e a r _ 0 ld5 and h a l f o f t h e 65-74-year-oldsexcept for t h e rural w o m e n ) h^d 20

94

or more o f their te^th remaining and not i n d i c t e d for extraciion, i.e. anA M T score

qT\2 or
I d

Table 5-40- Missing teeth (MT), indicated missing teeth (IMT} and adjusted missing teeth
AMT] among adults in Guangdong.
IM

Age group

AMT

Mean (SE)

Urban

393

2A (0.1)

Rural

370

2 . 1 0.1}

Tot^l

703

2.1 0.1)

0.6 (0.0)

2 7 (0.1J

Urban

405

2.7 0.1}

0.5 (0.1)

3 2 (0.2)

Rural

405

2.9(0.1)

Tot^l

010

2.0(0.1}

Urban

79 S

Rural

775

Location

Mean (SE)

>0.05

0.5(0.0)
07(0.

MesnSE)

35>44-year~DJds
Men

Women

LFL
CN

i i
T" T 1 "

TD
FN

Total 1573

o d -_K
d

Totar

>0.05

>0.05

1.2 (0.1J

2.6 (0.1)
^0.01

<0.01

2.9 (0.2)

4.1 (0.2J

0.9(0.1J

3.7(0.1)

0.5 [0.0)

2.9(0.1)

1.0 (0.1)

^:0.01

3.5 [0.1)

0.7(0.0)

3-2 [0.1)

1.7(0.1)

12.6 {0.4)

^0.05

<0.01

C0.01

05-74-year-old 5
Men

Women

Totsl

Urban

391

10.9(0.4)

Rural

363

10.5(0.4)

Total

759

10.7 (0.3)

2.3(0.1)

13.0(0.3)

Urban

S
I 3

12.4 (0.5)

1.3(0.1)

14,3 {0.5)

Rural

73

13.9(0.51

Total

56

1 3 ) (0.3)

27(0.1)

15.9(0.3)

Urban

774

(0.3)

1.8 (0.1)

13.4 (0.3

11.6

Rural 741

12.2 C0.3j

Totaf 1515

11.9(0.21

>0.05

<105

>0.05

2.9 (0.2)

3.6 (0.2]

3 3 (0.1}
2.5 0.1}

95

<0.01

<0.01

<0.01

T3.5 (0-5)

17.5(0.5)

15.5(0.3
14.4 (0.2

>0.05

<0.01

<0.01

Adjusted basing TeeOi

Fig. 5-4 r Cumulative percentage distribution of 35-44-yea^oJd subjects hy Jocatfon and

gender according to adjusted missfng teeth (AMT).

Urbafl rran
.q
_ _ Ruraf rftirt
Rural- women

G-

12

1?

iC

24

25

32

Adjusted Missing Tasth

F i g . 5 - 5 . C u m Native percentage distribution o f S 5-74-year-old subjects by location and
gender according to adjusted misstng teeth ("AMT).

Fig. 5 - 6 shows the di^tribation o f missing teelh by tooth type in the 35-44-yea^olds.
T h e teeth most frequently recorded as missing were the third molars (around 40%)
and the teeth ihac were indicated for extraction were mainly molars and premolars. In
the 65-74-\ear-olds, che sequence o f tooth type nterms o f proportion o f tooth loss
from highest to lowest was molar, premolar, incisor and canine (Fig, 5-7),
Proportions o f teeth indicated for extract ion were similar among aJ] tooth types in 6574 -year-olds.

50

40
30

20
10

S7

3 2

1 1

34

10
20
30

40
MT

IMT

50

F i g - S - 6 . Proportions of missing teeth (MT) artd indicated missing teeth <[MT) by^ tooth type
in tlie 35-44-year-old subjects.

91

BO 100

MT

MT

F i g . 57. Proportions of missing teeih (MT) a n d indicated missing t e e f h (IMT) by toolh type
in the 65-74*year-old subjects.

T h e results o f A N C O V A analysis f o r A M T Bmong the 35-44-year~oIds and the 6 5 74-year-olds are s h o w n in Tables 5 - 4 1 and 5 - 4 2 respectively. I t w a s found that
w o m e n , smokers, t h o s e w h o h a d lower education level, had dental anxiety, h a d
visited a dentist within 5 years, and those w h o w e r e less wealthy among t h e 35-44year-olds h a d higher A M T scores. B o n f e r r o n i ' s multiple comparison couid not detect
a significant difference between the three education g r o u p s but the difference

93

detect a significani difference between the three education groups but the difference
between the lowest and the highest group was very close to a statistically significant
level (p^O-O.^). A m o n g the 65-74-year-olds, women, those who had lower education
levelthose w h o did not b r u s h their teeth, a n d t h o s e w h o were economically less
welE o f f h a d h i g h e r A M I scores.

Table 5-41. Relationship between AMT and selected independent variabres in the 3544-year-old5 (result of ANCOVA analyst).
onfemoni's

Irtdependent variable

Estimate SEfEstimsite)

Gender

Men

p-v^lue

rr.ultiple comparison

<0.01

Women

1.07

0.2G

<0.05

Educatron level
No schooling / primary
Secondary

-0.43

0.20

Post-secondary

-0.&3

0 . 3 5

<0.05

DejnEa] fear

No"
Yes

0.39

0.1S

O.D5

Smoking Habits
Never been smoker"
Smoker / fofirer smoker

D.&4

0.26
<0.01

Last dental visit

[1) -5 years

p}>(

[2) 2-5 yeans

0.91

0.22

[3) <2 yeairs

0.64

a.i8

FMPI

-0.01

0.01

<0.01

(Intercept)

2.57

0.30

<0.0^

F-vaiue = 11.67; df = 8,
5

p<0.01

reference category

99

T a b l e 5 4 2 . Relationship between A M T and selected independent variables in ihe 65-74y e a r - d d s (result of A N C O V A analysis).
Sonferrni's
[ndependent variable

Estimate

S E (Estimate)

Gender

p-value

multiple comparison

(0-01

Men a
Women

i.se

0.55

Education level

<0.05

N o schooling 6
Primary

-1.09

0.60

Secondary & post

-2.29

0.78

Toothbrushing frequency

(3)

<0.01

O n c e or fno a (Jay

L e s s than Once a day

5.39

0.77

FMPI

-0.04

0.02

<0.05

(Intercept)

14.27

0.59

<0.01

F-value = 29-71; d f = 5, ^5Q^\p<Q,0 ^

refernee category

O n l y 14% o f the 55-44-year-olds were found to have a dental prosthesis i n either

j a w (Table 5-43). V e r y few complete dentures were encoumered. A m o n g the 65-74yearoid57 5 3 % p r e s e n t e d w i t h n o dental prostheses in either j a w (Table 5-44).
P r o p o r t i o n s o f t h e elderly with cojtnplete d e n t u r e in the msocilla onlyin the m audible
onIy s a n d i n b o t h j a w s w e r e 6.2%, 6 . 1 a n d 3 . 2 % respectively. B ri d g e s w e r e m o r e
c o m m o n t h a n p a r t i a l dentures in b o t h arches a m o n g t h e 35-44-year-olds a n d the
74-year-oIds,

100

Tab[e 5 ^ 3 . Percentage of 35^4-year-old subjects with dental prostheses by arch.

MAMLE

No

MAXILLA
No
One
2 o r more Partial
Bridge
Complete
-prostheses bridge bridges
denture ^denture denture
3S.6

53

0.5

1.3

0,1

O.I

2.3

1.6

0.1

0.1

2 o r mora
bridges

1.0

0.4

0.6

0.1

0.1

Partis]

0.2

0.3

prostheses
One

92.9

4.5

bridge

2.2

0.4

denture
Bridge
+ denture
Complete
denture
Total

39.5

7.3

1.3

0.2

0.1

1.7

10D.Q

T a b l e 5-44. Percentage of 65-74-year-oEd subjects with dental prostheses by arch.

MAXILLA
One 2 o r more PartiaJ
prostheses bridge bridges
denture
MANDIBLE
Mo
prostfieses

Bridge
Complete
^denture denture

Total

52,9

6.9

2.1

1.3

0.7

64.5

One
Bridge

4_2

7.7

2.

1.0

0.1

0.7

16.0

2 o r more
Bridges

O.S

2.6

3.0

0.6

0.5

7.5

Partia!
DenUJre

0.5

1.1

0.5

2.3

0.2

0.9

5.5

0.2

0.5

Complete
Denture
Total

0,1

0.2

Bridge
+ denture
0.2

53.5

13

0,4

0.6

19.7

8.4

6-6

101

0.2

0.5

S.2

6.2

6.1

100.0

In the j5-44-year-o[ds. more mral residents than urban residents had a dental
prosthesis but the reverse was found in the 65-74-yeaT-oids (Table 5-45").
groups, wearing a partEal denCurt; was more common in urban residents than in rural
residents. However, proporfionaliy more o f the middle-a^ed rural residents had
bridges than their urban countei-paru.

T a b l e -45. P&rcentage of subjects with dents! prostheses according to [Dcstion of

reaidency.
55^44-year-old5
Urban
{n = 793)
A n y prostheses

V^A

Rural
(n - 775)
17.5

p
"<001"

Urban
{n = 7 7 4 )
5^4

Rur^l
(n = 741}
4Z6

Bndge

3.0

17.4

<0.01

35,7

37.7

Partial denture

3,5

0.4

<0.01

16,5

4.2

Complete denture

0.1

>0.05

10-2

p
<=0.01"
0.05

>0.05

A m o n g the 3 5-44-year-olds who reported that they possessed one or more

removable dentures, 30% reported having eating problems, 26% compJained o f ihe
stability o f their denture, 15% reported having speaJcing problems, 22% reported that
their denture hurt, and 22% expressed that their denture was no pleasing in
appearance. T h e cotresponding percentages m t h e 65-74-yeaT-!jld3 were 34%, 22%,
13%, 2 2 % , a n d 2 0 % respectively.

102

5.3. T r e a t m e n t needs

In order to provide a more holistic measure of oial care needs in this study
population, which takes inio account all the various needs that were found with
regard to denial caries, periodontal diseases j m d prosthetic status, a fmai treatment
needs description is given in the following section.

able 5-46 shoves the percentage distribution of the study subjects according to
different types o f tooth-based treatnnent need. Only about a quarter of the 35-44year-olds and 12% of the 65-74-year-olds did noi have a normative need for filling
or extraction. Normative need indicaies the treaunent needs of examinees as judged
by examiners. The prevalence of normative need for simpk one-surface filling and
extrajction

high in both age groups. Proportionally more of the elderly were in

need o f fillings for treaiing cervical abrasion^ endodontic treatment and extractions
than lhe middle-aged. Furthermore, the middle-aged rural residents had a greater
need for extractions, pulp treatment and fillings, except those for cervical abrasiorij
than their urban counter-part (p<0.0l).

The majority of the middle-aged subjects, S5

dental prosthesis (Table 5 - 4 7 ) . L e s s than o n e per cent o f ihem were i n need o f
cornplete dentuures. O n the contrary"b about two-thifds o f th& elderly had. a. normative
prosthodontic treatment n e e d (Table 5 - 4 8 ) . Most o f the dental prostheses needed
w e r e multi-ujiit prostheses but the n e e d for complete dentures w a s relatively lovr. In

103

boih a g e g r o u p s , lhe nom^ative n e e d for a p r o s t h e s i s i n the u p p e r a n d l o w e r dental

arches was siniilar.

T a b l e S-46. Percentage distribution of subjects and mean number of teeth fin

parentheses) according to type of tooth-based ^eatment need a n d
location of residncy.
35-44 ea r-oJds
Urbar

Rural

65-74-ye3 r-old s

Total

Urban

(n=798) (n775) [n=1573}

N o n e e d for fining/extraction

29

24

Rural

Totai

(n=??4) (n=741) ( n = 5)

26

1S

11

12

TVe of-reatfrieni n e e d e d
Filling for cervical abrasion

a
s

25 0.7) 23 (0.9)

57 (2.5) 2 7 (1

4 2 [1.3)

Other ne^surface filling 6

31 (0.5} 4 1 (0.7)

36 (0.5)

31 (0.5) 31 0.5}

31 (0.5)

Other 2+-5Lirfaces fiSfing b

130.2) 20 (0.3)

16 t0-3)

16 (0.2) 16{0.2J

16 (D.2)

Crown

1{<0.^ <^<0.1)

PuJp treatnnent

14(0-2) 20 (0.3)

17(0.2]

32 0.5) 33 (0.5)

33 (0.5)

Extraction

29 (0.5) 4 3 ( 1 0 )

36 (0.7)

5 5 ( 1 . 8 ] 74 [3.3)

6 5 (2.5)

stati&ticaJly s i g n i t o n t between urban and rural residents in both ^ge-groups, p < 0 . a i

statistically significanl between urban and rural residents in 35-44 year-oids only, p < 0 . 0 l

T a b l e 5 ^ 7 . Percentage distribution of the 35-44-vear-oid subjects according to their

rtormative prosthetic tneatment need by arch.
Maxilla

Wo prostlieafs needed
Mandible

prosthesis
needed
35

1-unit proslhesis
2+-ursjts prosthesfs
C o m p l e te denture

104

1-unst
prosthesis

2+-urLits
prosthesis

Complete
denture

Table 5 ^ 8 . Percentage distribution of the 65-74-year-ofd subjects acconJipg to their

normative prosthetic treatment need by arch.
Maxilla
No pj-osth^si&
1-unrt
_needed
prosthesis
35

Nc prosthesis needed
Mandible

1-unit prosthe&is

2+-uriits prosthesis

Complete denture

2+-uriite
_prosthe&ia

Complete
denture

20

N e a r l y a l l o f t h e d e n t a t e subjects in b o t h a g e g r o u p s w e r e a s s e s s e d to b e i n n e e d o f
s c d i n g iind i n s t m c t i o a in oral h y g i e n e ( T a b l e 5-49)

H o w e v e r , o n l y a f e w per c e n t o f

l h e s u b j e c t s m b o t h a g e g r o u p s h a d a normative need for c-omplcx periodontal

treaiments, e . g . root-pfanirtg o r surgery.

Table 5-49. Percentage dfstribution of cfentate subjects and mean number of secants {in
according Eo periodontal treatment need category and locatjon
of residency.
3 5-44-ye3 r-o Ids

65-74-y

Urban

Rural

Total

(n=798)

{n=775)

0=1573)

N o Cn&sitment need

Oral hygiene instruction on]y

<1

<1

Or^l hygiene instruction +

scaling
Complex care

100(5.3100 (5.4) 100 (5.3)

5 (O.t)

3(0-1}

W h e n all t r e a t m e n t i t e m s w e r e c o n s i d e r e d

4 (0.1)

Urban

Rural

Total

(n=774) (n"741} tn=1515)

9 5 [3.5] 9 9 ( 3 . 1 } 9 9 [3.4J

7(0.1)

6(0-1)

6(0.1)

togethernone o f t h e m i d d l e - a g e d axid

o n l y a f e w p e r c e n t o f t h e elderly subjects did not h a v e any n o r m a t i v e treatrnent n e e d

( T a b l e 5 - 5 0 ) . T h e s e e l d e r l y w e r e m a i n l y e d e n t u l o u s subjects w e a r i n g satisfactory
c o m p l e t e d e n i u r e s . M o r e than h a l f o f t h e subjects in both, a g e g r o u p s w e r e a s s e s s e d

105

ta be in need of stmpk dental ireatmcnLi only, which may include scaling, filling:
extraction, oprosthesis. In addition, about a quarter o f the 3 5 4 4 year-olds only
needed simple periodontal care. About one^fifth o f t]]e middle-aged and more than
one-third o f the eiderly subjects had a normative need for complex dental c^re
including pulp treatment and complex periodontal treatment..

Table 5-50. Percentage distributfon af subjects according to holistic treatment need

categojy and location ot residency.
35-44-year-ol ds b

65-74-year-olds

Urtan

Rural

Totai

Urban

Rural

Total

(n=79S)

{rt-775}

(n=1573)

{n=774}

Ora] hygiene fnstruction

and scaling only
Sim pie treatments a

27

21

24

55

55

&3

54

54

Complex care

19

24

21

36

36

36

(n-741) (n=1515)

No treatinent need
Prosthesis only

a
4

Including scaling, filFing, extraction and/or prosthesis

statistically signrficant between urban and njra! residents {y^= 8.9

Despite having a high normative treatment need, less than two-thirds o f the middleaged subjects expressed a perceived need for denlaJ cane during the interview (Table
5-51), For all treatment types, pxiesence o f a normative treatment need as assessed by
the dentists

rarely matched by the presence o f a. perceived

as expressed by

the same individual. Although the correlation coefficients f o t filling, extraction and
dental prosthesis were statistically signifjeant, the values o f the coefficients were
l o w which indicated that there w a s iittJe correlation between the normative and
perceived treatment needs. Very similar results regarding the relationship between
the iiLorrtiative and perceived treatinenl needs were found smong the elderly subj ects
(Table 5-52). The prevalence o f perceived dental treatment need among the elderly

106

was very low when compared lo that of nomiative treatment need and again the
cortclation between the two types of treatment needs was very low

Table 5-51. Percentage distribution of 35^4-year-oEd subjects acconding to their perceived

treatment need (PTN) and normative treatment need [NTN).
:

NTM

yes

NTN - no

NTN = yes

NTN = no Corre]ation

PTN y e s

PTM = no

PTN = no

PTN - yes coefficient

Ne&d for any treatment

63

37

Need for perjedontaf

treatment
Need forfiling

12

87

0.00

14

46

0.10fl

Need for pulp treatment

81

16

0.01

Meed for extraction

61

31

0.l3fl

Meed fprosthesis

SO

13

0.13 fl

'p0-01

T a b l e S-52. Percentage distribution of 6S-74-year-old subjects according to their perceived

treatment need (PTN) and normative treatment r e e d (NTN).

WTN - y e s " N T N - no"M

=y e s

NTM = no Correlation

PTN y e s

P T N = no

P T N = no

49

40

N e e d for pe/FOdontal
Treatment
N e e d for fifffng

16

60

33

53

Need for pulp tneatment

S6

32

Need for extraction

34

60

0.0G n

(M5b

N e e d for any treaLment

Need for prosthesis

J

p < 0 . 0 5 : p<0.01

33
"

107

P T N = y e s coefftcient
2
0

0.07 a
0,04

6. D I S C U S S I O N

6 J . Methodology
H i - S a m p l i n g m e t h o d s a n d r e c r u i t t o c u t o f subjects

Sampling of the study populatioir took into consideration current population

sainplmg techniques d had to face the enorniity of the population and the situation
in Guangdong Province where the majority of the population art farmers scattered in
villages, A combination of niulti-stage sampling ajid convenience sampling was
used in the present study. The method used was similar io that us^d in the second
national oral health survey in China, Multi-siage sampling is used in large-scale
3urvys and i sample of first-stage sampimg units is chosen, each of the selected
units is divided into second-stage units, samples of seccindstage units are sdected,
and so on (Abramsojn, 1990). At the first-^tage of this study] foiu o f the 21 major
administrative regions were chosen mainly based on their geographical location. At
the second and third stages random sampling was used to select the urban
subdistricts and townships. The populations o f most selected subdi^tdcts and
townships were between 15,000 md 35,000. Further random sampling methods, like
those based on household registershad been thought about before the survey but
they were considered not practical because it is difficult io find a selected middleaged individual during day time and a computer register system is not available m
the rural areas. Therefore, convenience sampling

u ^ d while some principles

were set to guarajitee the representatives o f ttie sampler Iti urban areasan effort was
made to emit different occupation groups of the 35-44-year-olds, especially the
manual workers. In rural areas, the study subjects were recruited from their homts in
villages, not from lhe lovm itself, so as to recmit typical farmers who comprise the

108

maor population o f China, Acmally, it was difficult io recruit SO-lOO 3 5 - 4 4 ^ ^ otds and the same number o f 6>74.year-olds from each subdistrict ot township
using this sampling method. The difficulty arose from the exact age range
demanded, lack o f big factories in some subdistricta, small scattered villages in the
rural ^reass and tight fieldwork timetables, etc.

Recruitmernt o f survey subjects mainly relied on cooperaiion with local assistants. Jn

urban areas, they

the execuiive officers and medical professionals in the

factories and oihec work places, as well as admiriistrators of the neighborhood

committees- In rural areas, they were the administraiors in the villages. In surveys
conducted in developing couniries, concern about lhe validity o f the age of ihe
subjects might arise, Howeverconsiderable attention to this problem was paid
during the survey and an effort ^vas made :o reduce this bias. "We emphasized the
importance o f age to the local assistants and asked them to recruit subjects in the
exact age bands requested. In mban areas, registers are usually available in work
places (like factories, schools, etc.) and neighborhood comimittee?;. Thus, the local
assistants could recruit the appropriate people according to their registered age. In
mral areas in Mainland Chinaadministrators in the villages are fainiJiaj with
everything in their village. They are also familiar with lhe age of many people in
their village. That was of benefit to lhe recruimient of subjects. The survey team
member who was responsible for registering the subjects used a special method to
monitor the validity o f the subjects5 age. In traditional Chinese culture, a system
according to the year of

person's birth TS used widely to indicate and forecast a

person's character and future, similar to the zodiac consteliatioiis in Western culture.
This system includes a sequence of 12 kinds o f animah like rat, ox, tiger, etc. Each

o
ii

pwson is bom in the image of a specific animal, and even if a person is uncertain of
his/her agethe persoa will know in which animal's image he/she was bom. It is
known Chinese Astrology Year Chan", similar to the horoscope. Our survey
team ua&d this chart to check the age of a subject when it was considered necessary.
Asking people to show their identity caid should be a more rdiabk method but it
wa^ not practical. It is not common fbr people to cany thecr identity cards with them
in urban areas. People in rural areas seidom use their identity cards. In addition,
some people dislike showing their identirj-1 cards unless it is very necessary.

In summary? current survey ncchniques and the situations in Guangdong Province

were taken into consideration in the sampling aud recmitment of study subjects. The
sample surveyed was acceptably representative of the population studied although
some underr representation o f agricultural workers was found, as shovm in Tabic 5-2.
Thusif one w^nts io estimate the prevalence or severity of oraJ diseases in che
whole population in Guangdong Province, weighLings according to the urban to mral
population ratio have to be applied onto the raw findings

6.1,2. Variables and measurements

Variables and measurements used in the clinical examination were according to
those recommended by WHO (1997), This latest WHO recommendation uses lhe
Community Periodontal Index (CPI) instead of the Community Periodontal Index of
Treatment Need (CPITN^). The CPITN was developed at a time when the natural
history o f periodontal disease was believed to follow an inexorable progression
marginal gingival inflanutTionthrough periodontitis, to eventual tooth

(LSe et

al 1978a; LCe et al., 1978b), However, new knowledge indicates that gingivitis and

HO

penodontitis are likely to be separate entities; mo&E gingivitis Scsiorts do not progress
to p^nodonCLtis: periodontal dcsimctLon does not progress in a contmuou^ manner
but is episodic and in short bur^

of activity followed by periods of quiescence

(Lisigartcn ci a[.. 1985; Lindhe el alr> 19S9; Albander, 1990), Overviews o f survey
which used CPITN {WHO, J994) show calcuJus tQ be prevalent both in adolescents
and in adults. Thuscaling would comprise the greatest periodontal treatment need.
Satisiying this 3evel of need is both unrealistic and unnecessaryespecially in
developing
populations

countries, considering the reiativeiy small proportion o f these

that will

ultimately

experience

severe periodontal destmotion.

Therefore, some experts have suggested ihat 'treatment n-eed' be dropped and the
index be defined as CPI (Page and Morrison, 1994). As part of the same set of
reconimendation5s WHO recommended the measurement of Loss of Atmchmeiit
(LOA) in the 1997 oral health sorvey manual in addition to CPI As pointed f>ut by
Holmgren (1994) and Pilot and Miyazajci 199 CPI does not reflect the total
amount o f attachLment loss because the recession comp^n&nt is excluded. Thus, an
independent measure of oss of attachment may compensate for this shortcoming of
the CPI, Because most of the existing oral health data in th-e world have used WHO
recormnended criteria, the results of the present study can compare with results Irom
other countries or areas more easily. Howeverthe recently completed second
nation.9-1 oral health survey in Chin^ recorded oraJ health status based on 2B teeth.
This may lead to some difficulty in the comparison of the data.

In Chin^ the 65-74-yea^oIds usually are retired and most of tbem bave little or no
ineomeThey usually live together with their children and financially dependent on
thetn. This siluation is especially common in rural areas. Peraonal income therefore

111

is 101 a suiuhlo expression of economic stams of these subjects. Household bcome

is abo not suitable fbr the elderly because many of them do not know the household
income which they do not generate, FMPI was considered to be a more suitable
variable to measure economic status in the present study because all subjects,
including the elderly, should know whether certain items of household commodities
exist in their house. Also the possession of more commodines is a reflection of
material wealth.

Previous surveys on oral health knowledge and anitudes in people in Mainland Chim
usually reported the questionn^re results by individual items (Tai : aL,

Luan et

aL, 1993; Zhu, 199J). In the present study, a dental knowledge score and dental attitude
score were used to measure the subject's dental knowledge level and altitudes Towards
oral health. The dental knowledge score was computed by counting the number of
answers given by the subjects in response to the four questions about the causes of and
preventive methods o f tooth decay and gum disease. As dental caries and period&ntal
disease are still the two most prevdem dental disea^s snd they are preventable, the U5e
of these four questions to measure kno^edge level should be apprapriaw. The dental
attitude scone u a s calculated from the subjects response to eight statements about oral
health. Use o f the indices made interpretelion of results easier when oral health
knowledge and attitudes were us&d iri the multivariate analyses to explain or^l hygiene
habitsT use of dental serviceDMFT, etc.

Rea&ncy of last dental visit

used as the main variable to measure dental service

utilisation in this srudy because thts was one of the most commordy used variables
(Petersen and Hoist, J 995). The other common measures, such as number of dental

112

visits per vem and ri^uhrity of deiua] vi3it&? were considered noc sujtable in this study
because oc^td uLiliz^iLian wa_s expected to be low in this suidy popuh[ion.

113

6,2, Results

6.2.1. I n t c r - c \ a m i n e r r d i a b H i t y a n d i n t r a - e x a m i n e r r c l i a b i l i t j '

When there h more than one examiner in a survey, a test of inter-examiner

reHabiiity (reproducibility) is necessary (WHO, 1997). Some surveys used per cent
agreement to measure the reliability (Mivazaki et al., 1992; Cortes er ai, 1993) bur
[he kappa slaiistic is considered to be a more reliable way of assessing over&U
agreement between examiners (WHO, 1 9 9 7 ) - In the present study, the caJdilation of
kappa statistics for crown arid root caries was made on the original categories
recorded, not on a "yes/no" basis as used in the second national oral health survey in
China (Kational Committee for Oral Health, 1995). The use of a dichotomous
measurement in the latter study made it easier to achieve a higher kappa value-

Kappa statistics can range from any negative number to one. A value of one
indicates perfect agreement, a value of zero indicates agreement ao better than
chance3 and negative values indicate agreement worse than chance. A score of >0.S
indicates good agreement, 0,6-0.8 substantial agreement and 0.4-0.6 moderate
agreement (Landis and Koch, 1977; WHO, 1997), In the present study, tiie kappa
statistics (Table 5-3) indicated chat the agreement among the examiners was good or
substantial for all clinical parameters.

Intra-examiner reliability is also considered to be necessary in oral health surveys

fWHO, 1997), However, while some surveys measured intra-exafniner reliability
(Schier ei al., 1995; Alvarez-Arenal st al, 1 6; Brown et aL, 1996; Bourgeois et
al,

1997), many surveys did not report this (Brown et al., 1990; Miya^aJd et al.y

114

1992; Joshi ef a!., 1994; Holmgren e( al., 1994; Adegbembo and El-Nadeef, 1995,
Michk and Baucli. 1996; Petersen e[ aL
is difficult to imptement durijng fieldwork and the results of clinical examination by
the saine person may be considered easier to reach higher levels o f agreement than
by diflferent examiners, as shown in previous surveys (Selder et al., 1995 AlvarezArena) et al 1 ^ 6 ; Bouigeois et
kappa statistics for ttiter- and intra-examiner reliability were also reported by Brown

procedures

too

complicated,

only

inter-examiner reliability was

measured

throughout the present study.

Usually, higher reproducibilily is reported for coronal caries than for CPI in the
same studies (Lo and Schwars, 1994b; Holmgren et a/., 1994; Brown et aI-7 1996;
Winn et al 1996 Micheelis and Bauch, 1996)- A s ^hovm in Table 5-3, coronal
caries had good inter-examiner reliability (kappa statistic >0.8) in both age groups.
Higher kappa statistics scores on root carieSj CPI and LOA were found in the elderly
than in the middle-aged. This could be related to more missing teeth in the elderly ^
it is easier to get agreement between examiners on missing teeth. More missing teeth
among the elderly subject? also meant that more teeth or sextants were excluded
from periodontal examinationOne thing to be reminded o f is that Kappa statistic
reflects the reliability of a categorical variabie as a whole but it does not necessarily
reflect the reliability of any single category in a categorical variable. In the present
study^ kappa statistics indicated that CPI had substantial agceemeni] in the 65-74year-old subject? and inoderate agreement in the 3544-year~oid subjects between
the examiners. Howevei, the three examiners detected big differences m the

115

prcvakiice of deep pockeU in the elderly (Table 5-5), Airhou^h different examiners
examined different subjects, these differences indicated that the inter-examiner
reliability for the prevalence of deep pockct in the elderly was doubtful in this study.
However, this difTerent:& was not noted in the calibration exerciscs that were
performed und^r supervision. Inftiture studies, more attention shouJd be paid to the
r d l a b i l i t y o f d t t p periodoiita] p o c k e t s . T h b m a y i n c l u d e m o r e tr<tiruiLg ^nJ

calibration of examiners and thorough discussion when differentrecording fbr deep

periodoniaJ pockets between examiners are found at duplicate examinations during a
survey.

O r a l h e a l t h knowledge^ a t t i t u d e s a n d o r a l h y g i e n e h a b i t s

Chinese medicine is more than 4,000 years old. The Chinese traditional concopi of
health is deep rooted m many Chinese (Lee et al.. 1993). For example, 'internal
heat' ofhe body is considered as a cause of socnc dental disease, and consumption
oi some herbal tea \r thought to be abie to reduce the Mntemiil heat. Hong Kon^
Chinese have been shown lo hold strong Chinese health beliefs with regard to
periodontal diseases (Lim et ai 1994; Schwarz and Lo, 1994a). Re^uli^ of the
present study found the same beliefs expressed by Guangdong adultand they are
even stronger. The Chinese health belief, ^menial heatwas tht: most frequent J y
given answer to the question on etiology of periodontiil disease and "Avoid hot food
or drink herbal leawas the most frequently mentioned preventive melhod against
periodontal disease in both age groups. Chinese health

were particularly

prevalent among the rural residents (Table 5-6 to 5-9) who usually have less
exposure to weitetn mcdicinc and therefore know less about it. This might explain
why [he rural residents hold slronger Chinese health beliefs than the urbsm residents.

116

The method of calculating the dental knowledge score m the present study was the
same as that used in a recent oral health survey of Hong Kong adults (Schwarz and
Lo1994a). The oraJ health knowledge of the adults in Guangdong Province
generally poor and was poorer than lhai ofHortg Kong adults For example, only 5%
of the middle-aged and 3% of the elderly of the Guangdong iniervierwees stared that
bacieria/plaque was i cai^e o f dental caries; only 11% of the middle-aged and 6% of
rhe dderly stated rhat poor oral hygiene wa5 a cause of periodontal disease. The
corresponding percemages found m the Hong Kong survey weie 14%, 6%, 30% and
10% (Schwarz and Lo, 1994a). Turning to the attftudes towards dental health held
by these populations, howevei, an overa-U picture of positive attitudes was found
(Table 5 - ] 3Fig. 5-2)similar to those found in Hong Kong adults and in the
middle-aged in Hubei Province in CentraJ China (Schvvajz and Los 1994a; Petersen
et al 1997), The attitudes of ihe elderly appeared to be less positive than those o f
the younger adults, as found m other studies (Kiyak19S2; Kiya.!^ 1993). In the
present smdy, only 23% of the middle-aged and 14% of xhe elderly disagreed that
tooth loss was a natural process in aging. The proportions were reported to be 30%
and 17 in the second national oral heajth survey in China (Technical Instruction
Group fbr the Second National Oral Health Survey, 1998). These findings showed
that most Chinese adtiltii strongly believed aging causes loss of teeth and this
Tnisconcspticm was also coninionly held by Pajcific Asians and Caucasians (JCiyakf
1981), and by the elderly residents in the United States (Evans1984).

The mass media is a powerful and influential force in modem society. It was found
lo be the most common channel from which the study subjects received oral health

117

inform^tiorL (Fable 5-12)similar to that found in the second Jtiacional oral health
survey in China (Tectakal rnstruction Group fbr the Second National Orai Health
Survey, I99&)- Guangdong Province 15 a. relatively affluent province in China,
Television is found to be available in mere than 80% of the family of subjects
surveyed in the present study. City-level administrative region21 in Guangdomg
Province, usually have their own Television station in their local dialects. Thus, if
one wants to dissecninate oral heaLth messages to the popuianon via mass media in
Guangdong, tdevision programmes will be more appropriate than newspapers.
especialJy in the rural areas because newspapers are not commonly found in
farmer^ houses and mmy elderly have not attended schools. In urban areas3
newspaper and magazine can be used for conducting oral health education
programmes. The programmes should be provided in a way acceptable to the people
based on their culture and background. Besides mass media, another important
channel to increase people's oral health knowledge level is to enhance the provision
of such information through denusis,'"dental aur&es in clinics. However, the effect o f
this channel is probably limited because of a lack of dental professionals and a low
dental service utilization in the province as found in this study. In the provision o f
oral health education programmeSj more attention should be paid to people with
lower education level and those who are less wealthy as they are the ones who have
the poorest oral health knowledge (Table 5-11).

The present finding that almost all the middle-aged and dentate elderly bmshad their
teeth every day

similar to thoseo f th& Wuhan residents in Hubei Province

(Petfirsen et aL? 1997), The finding in other countries that peopJe with a higher
socioeconomic status have better tooth cleaning practices (Esa ^ g L , 1992; Ronis et

IIS

a1993) is supported by ihe prtsenl Uudy. Although the direct rcktionship

between oral health knowtedgerittitudeii and oral prevemtive behavior has been
questioned (Rayant, 1979Inger^oll, 1982; Christen and KaU, 1995), re&alts of the
present study (Table 5-17 ? 5-18) indicated that those who had more positive oral
health attitudes and b&tier dental knowledge had better toothbrushing habits. There
is much t o o t y x for improvement with regard to the knowledge of and use of
fluoridated toothpaste among the aduits in Guangdong Province, Th^ proportion of
the surveyed subjects who knew about and used fluorickied toothpaste was very low,
especially in rural area^ and among the elderly (Table 5-16). This is unsatisfactory
and more oral health education programmes NE^D io be earned OUT: in the province.
The use o f fluoridated toothpaste will probably increase drastically in the near
futureespecially in the urban areas, because there are two large toothpaste factories
which have starxed to manufacture international brand name fluoridated toothpaste
in Guangdong Province since 1994, If the price of these kinds of toothpaste could be
kept low, then the use o f fluoridated toothpaste would be enhanced.

Use o f toothpicks was very common among the subjects surveyed. Almost 90% o f
the middle-aged and Kvo-thirds o f the elderly had this habit. Th-e lower proportion in
the elderly rnay be due to the feet that they had fewer teeth and therefore less food
impaction. There is IittJe research to indicate a definite roie for the toothpick in oral
health a^d Tnany people use it because it is available and acceptable (Rounds and
Tilliss, 1995). In China, people use toothpicks mainly for removing food debris but
some plaque may be removed at the same time. For optimal plaque control, it has
been suggested that even in an apparently healthy oral environtxient, toothbrushing
should be supplem-ented with iddition^t nisans of interdental cleaning to prevent

119

disease (Graves e

1989). DentaE floss is the most commonly used interproximal

cleaning aid in western industrialized coumrics (Rounds and Tilliss,

1995).

However, people in Mainland China seldom use interdental cleaning devices other
than toothpicks. It can be found from the 1984 and 1991 Hong Kong surveys that
there had been little change for the use of dental floss in terms o f the proportion of
people who used it despite the many oral health education prograjtmncs (Lind ei ai,
1987b; Lim ei al., 1994). Therefore, impmving the use and effectiveness of
toothpicks for cleaming interdental areas may be a more practical way compared to
the promotion of the use of dental floss. The methods may include setting product
standards, teaching the correct way to u&e toorhpicks, etc,

6.2,3. L tiJizatiott o f d e n t a l services

findings from this study confirmed the assumption that dental service utilization
ainong adults in Mainland China was very low. Compared to the western industriafised
countries where about 60-50% of the adults would have visited a dentist within a year
(Miller era/., 1987; Todd and Lader, 1991; Petersen and Hoist, 1995), the comparable
proportions in the present study was onjy about one-third of these percentages. Even
when compared to the situation in Hong Kong where most of the people are Southern
Chinese (Lo and Schwab, 1994a), dental service utilization among the middle-aged
Guangdong subjects was low while that o f the elderly subjects was similar. The denial
services utilization rates o f the Guangdong adults were similar to those found in the
recent completed national oral health survey for adults in other provinces (Technical
Instruction Group for the Second National Health Survey1998). When compared to
the results o f a recent study in Central Chka, the proportion of the 35^4-year-olds was
similar while the proportion of the elderly was lowct than J5% in Wyhan residents

120

(Petersen e i cd

a [50 found ihnt use of dental service among the Guangdong adults was very

much symptom-driven and preventive denmi visits were rare (Tables 5-19 to 5-21).
Although Ehis partem was also found among Kong Kong Chinese, it was not as
extreme (Lo and Schwai^ 1994a). The ref^uonships between denral service utilization
and the main demographic variables, e.g. gender, location, education and wealth, found
in this study were similar to the findings of most dental utili^tion studies from Hong
Kong (Schwarz and Lo1994b) and other parts o f the world (Qift, 1984 Petersen and
Hoist, 1995). However, the relationship between dental fear and uiili^ation as found m
this study is worth some discussion, Beirig afraid of dentists is usually presented as a
barrier to dental service use (Feske
expect the regu[ar or more recent dental service users not to be aftaid of dentists. This
was not the case in this study and the odds ratio of 1.4 in lhe 35-44-Ye3r-o{d subjects
(Table 5-24) suggested that people who were afraid of a dentist would more likely to
have been a recent dental service user. This is probably because thje subject in this
study mainly visited a dentist when they had serious dental problems and one of the
most common treatirients received wa5 extractiorir The dental visits w^re usually very
unpleasant which would m3ke the nec^m users afraid o f dentists. This proposition was
supported by the finding th^t the recent users were also more likdy to have
experienced painto perceive their oral condition as poor and to have perceived need
for mane Dreatment. This kind of perception and behaviour hinders the development of
preventive dental visits and lots of efforts in Oral health education are needed to break
this vidous cycle among the Southern Chinese,

12L

6,2.4. Coronal And root caries

The

DMP 1 scores of the subjects found in the p-restiit study wcrt similar to

the results obtained from a survey conducted in Beijing

(Luan et aL, 19S9a). A

mean D F T score of 2.1 in 35-44^&1-0]|^& in the present study was somewhai. higher
than the mean DFT of 1.5 observed in j5^4-year-oIds in Chengdu, Western China
(Liu er a L 1984) and 1.0 detected in the recem pathfinder survey in Hubei Province
(Petersen et al^ 1997), The mean DFT scores of the 35-44^year-olds and the 65-74year-olds in the present study were 2.1 and 3.6 respectively which wa;e similar to
i-7 and 2.9 among the corresponding age groups b Guangdong Provinc-e reported in
the second national oral health survey (Technical Instruction Group for the Second
Nation al Oral Heaith SurveyI99S). The second nations! survey found that the
adults in Beijing, Guangdong Province, and Eastern China (Shanghai m d Zhejiang
Province) usual[y had higher DFT scores while people living in "Western and Central
China usually had lower scores. Such differences may be du-s to possible differences
in sugar consumption and dental visit behaviour, but more studies are required to
confirm or refute this proposition.

The Hong Kong Adult Oral Health Survey in 1991 reported rtia: the DMFT scores in
the 35-44-year^Ms and 65'74-ye^-olds were 8.7 and 18-9 respectively (Lo and
Schwarz 1994bwhich were higher than the present results from Guangdong
Province. The mean D T scores o f Hong Kong adults were lower than those o f
Guangdong adults in the same age group (1-0 vs. 1 -7 in 3the I

and 1-4

vs. 3.4 in the 65-74-year-olds). Tlie higher DMFT Scores in Hong Kong adults w&re
contributed by the larger MT and FT componcrts. Although the

unity dnnking

water in Hong Kong has been fLuondaced at various levels since 1961, DMFT scares

122

among Hong Kyng aduits were still higher than those among Guamgdong adu]tsPossibie reasons included the difference in ditt and in use of dental services between
Hong Kong residents and Guangdong residents. One can observe thit Eong Kong
adults have a more westernized lift-atyle. Furthermore, Hong Kong residents have
easier access to dental cart services than Guangdong residents, which can increase
the F T and M T scores. The caries diagnostic criteria adopted in epidemiological
studies probably is different from [hose used clinicaliy by demistIncipient caries
and some non-carious le^ians, which do not concribiice to DM?T scores odginaUy,
can contribute to FT after being filled- Teeth extracted due to t e n o n s other than
caries can also contribute to the MT component o f DMFT in subjects aged 30+ years
(WHO, 1997)_

The finding that women tended to have more caries than men is in agjreem^nt wilh
many other surveys (Luan et ai,
Cleaton-Jones, 1995; Winn er

1989a; Lo and Schwarz. 1994b; Schi&i and

1996), A proposed explanation for this tendency

m Chinese people was that women had easier access to carioge-nic foods during the
day than men (Luan ei aL, 1989a) but ftirther investigation would be necessary to
confirm this. For a long time, it was considered that urban populatiotis had more
caries than rural populations in Mainland China (Sichun Medical College1980),
However^ one study o f Beijing adults reported a reverse result (Luan e al1989a)
and this was also found in Guangdong Province in the present study. The second
national oral health survey in China (Technical Instruction Group for the Second
National Oral Health Survey, 1998) reported a mean DMFT ^coxe o f 2 . I in the urban
3 5 . 4 4 . y e a r . 0 l d s and 2.0 in the ruraJ residents, the respective mean DFT scones in the
65-74-ye^r-olds were 2.4 and 2,7, Thus, in that studythe average level of dental

123

canes in urban ad alts and rural aduks were similar in Mainland China. This change
in caries status in urban and rural residents might be related to the economic
development in coital provinces and metropolitans of China in lhe recent two
decades. In these areas, the mral residents now have similar access o sweet food as
the urban resident but they still bav^ l e u access to fluoridated toothpaste and
preventive dema! care. These may partly explain why the rural residents had moie
caries in Guangdong Province as well as in Beijing,

In the present study, subject's education level and FMPI were found to be associated
with DMFT stares in both age groups (Table 527 to 5-31). The results were
consistent with findings ftom other studies outside China which showed that people
in lower socia] clas^ had a higher risk o f deveioping dental caries (Peter&en1990;
Alvarez-Aren^l et al., 1996). In MainJand China, location of residency^ education
l e v d and material wealth are related to each other. People living in urban areas
usually have a higher education [evel and a bttter econamic status compaied to
people living in the rural areas (Guangdong Statistical Bureau1996). In multivariate
analyses, some independent variables which are statistical [y significant in bivariate
analyses may not show up when they have interaction with other independent
variables which have shown up. This may ^xplain why iocation of residency and
education level in the middle-aged and location of residency in the elderly were not
statistically significant m the ANCOVA analyses (Tables 5-30 tod 5-31) although
they were statistically significant in the bivariat-s analysesr

The low proportions o f FT in DFT showed that most of the carious cavities were not
restored in the populations surveyed (Fig. 5-3)The much lower proportions in the

124

rufal resident ^nd in lhe elderly may be due io their difficulty in accessing demal
service, lower afFordability, and less positive atliiudes towards dental heEilth.

Reported surveys or root caries were rare in Mainland China. The present finding
that 38% of the 65-74-veai;-olds had one or more DF-Roqt was similai to 32% in 6170-yeaT-oIds found by 2haj3g and Li (1995) in Jiangxi Province, Southeastern China.
However, mean DF-Root scores of 0.2 and 0,7 in the 35-44-year-olds and the 65-74year-oids detected respectively in

the

present

study were higher than ihe

corresponding scores of 0,07 and 0.39 reported in the second national oral health
survey in China (Technical Instmction Group for the Second Naiional Oral Heaith
Survey, 1998). Besides the DF-Root index, the Root Caries Index (RCI) developed
by Katz 1980) U al^o a popuEar index used to measure root caries status. The RCI
uses the concept o f teeth at risk. A tooth is considered to be at risk of root caries if
enough gingival recession has occurred l o expose pan o f the root surface to the oral
environment. The RCI is computed by dividing the number of teeth with root caries
lesions and restorations by the total number of teeth 'with gingival recession. In his
description of rhe RCI, Katz (19S0) acknowJedged the chances o f underestimation
brought on by gingival overgrowth subsequent to the loss of periodontal attachment
Since WHO (1997) recommends reporting root caries status of a population in terms
of percentage tjf subjects with root caries and the mean nwviber of teeth with root
caries per person, RCI was not ysd in this smdy. It has been reported thai RCI
increased with age in 50-70-year-olds in Shanghai (Liu et aL, 1992), but this result
was not directly compaxable with the present study since different measurements
were used. While DMFT scores of the subjects in the present study were lower than
those o f Hong Kong adults (Lo and Schwarz

125

6.2.5, Periodontal diseases

The advantages and limitations of CPI have been diseased (Pilot and Miya^aki
1994; Page and Morrison, 1994). Its advantages include simplicity^ need for minimal
equipmertL quick speed, inlern^tiona] uniformity, wide applitation m the world, etc.
Itii limitations are difficult reproducibility^ hierarchy of scoring, use of index teeth,
exclusion of attachment lo^j, no marker of disease activity, etc. The hierarchy of
scoring in the construction of CPI "was mainly criticized for rating calculus higher
than bleeding and some authors c[aimed that more than 50% o f sites that scored
positive for calculus did not exhibit bkedmg on probing (Holmgrei^ 1994; Gjermc^
1994), Use o f index teeth tends to underestimate the mean sextani scores fox shallow
and deep pockets (Di am anti-Kip iqti et aL

Both in the 35^4-year-DJds and the 65-74-year-olds in the present study, calculus
and shallovv" pockets were the two most prevalent conditions recorded by maximum
CPI score (Tables 5-32 and 5-33)- The percentages of persons and the mean
nwibers o f sextants per person affected by deep pockets were small (Tables 5-32 to
5-35)The trend was similar to that shown in most surveys which used CPI
worldwide (Pilot ec ai., 19S6; Pibt and Miyazaki? 1994; "WHO 1994).

Deep and shallow pockets, as highest CPI scores, were found in 4% and 31% of the
35,44.year-old subjects in this study, higher than the corresponding figures o f 2%
and 11% found in the second Chinese n&tional oral health survey (Techmcal
Instruction Group for the Second National Oral Health Survey, 199S)Other surveys
o f this age group in Mainland China fouind the prevalence o f detp pockets to be

126

between

1% and 11% and the proportion of people with ah^Jlovv packers the

highest CPI score ranged from 7% io 44% (Powell et ai 19S6; Pibt et ai, 1989:
Petersen et al 1997). The present finding t!iat 6% and 37% o f the 65-74-year-olds
had deep pockets and shallow p o c k m as their highest CPI score respectively were
higher than those found in the second C h i n e e national oral health survey. The
percentages o f 65-74-year-olds who had deep and shallow pockets sis their highest
CPI scores were reported to be 4% and 16% respectively by Petersen
but were 22% and 16% in the elderly aged 65-69 yearg surveyed by Hu

at, (1990).

A recent survey in Hong Kong found that 17% of the middle-aged and 15% t>f the
elderly had deep pockets and more than half of the subjects in both age groups ha.d
shallow pockets as their highest CPI score (Holmgren et ai, 1994). Different rcsuhs
from these purveys can be caused by real differences in the pOpiiiaTiOnS Studied^ Or
by different examiners working under dirfercnt clinical examination conditions. It
seems that such big differences in the prevalence of periodoiytai pocket in the same
eihnk subjects cannot be ocpiained mereJy by real differences because of th-e
similarity in the

popuJEations studied. These findings

tend

to highlight

th-e

disadvantage of CPI with regard to reliability. Therefore, the comparison of

periodontal status as recorded by highest CPI scores in different studies should be
made with caution.

In the WHO Global Oral Data Bank (WHO1994), the prevalence of deep pockets
in 35-44-year-olds wa^ reported to be from 0% to 75% in different studies but only a
f e w studies reported prevalence greater than 30. Sixty-six of the 146 studies
repoirted the prevalence to be from 0 to 10% and 46 of the studies found it to be
from 11% to 20%, Prevalence o f deep pockets m 6 5 - 7 4 - y ^ o S d ^ from 2 2 studies

127

reported to be from 3% to 91% and most of studies found it to be k than 2Q0/o.

W h e n c o m m e n t i n g o n w o r l d w i d e d a t a set^ P a g e a n d M o n i s Q n ( 1 9 9 4 ) p o i n t & j o u t
that t h e r e w a s a v a r i a b l e a m o u n t a f . n o i s e w h i c h h i n d e r e d c o m p a r i s o n o f o n e set
w i t h a n o t h e r . 1 he 'noi&e 5 includes v a r i a t i o n i n s a m p l e size, l a c k o f r i g o r o u s
srandardizatioa o f examiners, and variation i n p r o b i n g force. Probing force w a s
t h o u g h t t o b e a c c o u n t i n g f o r m u c h o f the observed v a j i a t i o n a m o n g studies.
A l t h o u g h t h e use o f a W H O r e c o m m e n d e d p r o b i n g f o r c eo f n o m o r e t h a n 2 0 g r a m s
w a s p r a c t i s e d by t h e e x a m i n e r s by p l a c i n g t h e p r o b e u p u n d e r the t h m n b n a i l a n d

pressing until blanching occorredj the consistency o f the force was unknown.
C o n s t a n t f o r c e p r o b e s c a n b e used f o r r e d u c i n g he v a r i a t i o n o f p r o b i n g force b u t
f a r t h e r imprOVennen'C a n d d e v e l o p m e n t a r e needed, e^pecialiy those d e s i g n e d f o r
e p i d e m i o l o g i c a l s u r v e y purposes ( A i n a m o a n d A i n a m o , 1994),

Although scoring LOA is generally considered the best availabfe measure of

periodontitis in epidemiology, it is far from ideal because LOA records past rather
t h a n p r e s e n t d i s e a s e ( B u r t a n d E k l i m d , 1992), C o m h i n a t i o n o f these meas u r es o f
p a s t d i s e a s e w i t h a m e a s u r e o f a c t i v e disease w o u l d b e m o r e useful, but n o

satisfactory measure of active periodontitis has yet emerged (Burt and Ektundf
1992),

Studies on LOA in populations usually report the results based on

e x a m i n a t i o n E at t o o t h o r site l e v e l ( B a e l u m /

1986; B a e l u m ei aL,

1988b;

B r o w n et ai

1995; B r o w n e aL, 1996). The results frcmi these studies are not directly comparable
to the results o f the prfes^nt study - One survey conducted in Japanese elderly used
th.^ m e t h o d o l o g y r e c e n t l y proposed b y W H O ( 1 9 9 7 ) t o m easure L O A ( M i y a z a k i c i
a ! . , 1 9 9 5 ) . W h e n c o m p a r e d t o Lhe results o f t h i s Japanese s u r v e y the present results

12a

showed a much more severe LOA i n Chinese elderty in Guangdong. In the present
study\ 52% of the 65-74-year-old subj^cLs exhibited 6-^ mm LOA in one or more
SCTtanl^ with a mean

of 0,9. but the corresponding figure in tiie 65-74-"vear-

old Japanese was 16% wilh a mean sextant of 0.2, Four dentists acted as ocamiiieri
in the Japanese study and while calibration of examiners was done on volufiteer
d&ntai students and periodontal patients^ no duplicate exaininatioTis of the sutvev^d
subjects were performed. The big diflference between the results of the present study
the Japanese study suggests th^t further comparisons of LOA in adults in
Mainland China with other countries

necessary. Moreover, rnore studies using

L O A recordings as advised by WHO (1997) and on the relationship between L O A

and CPI in various populations are also needed.

It was found in this study that women exhibited tetter periodontal status than men,
either measur-ed by CPI or LOA (Tables 5-32 to 5-39), That was consistent with the
results from other surveys (Badum ei aL. 19S6 Corbet et aL, 198S; Pil&t e al
19S9; Pecersen et al,

1997). The reasons for gender difference in p&riodontal

destruction have not yet been fully explained, One ctunmon explanation is that
women usually exhibit better oral hygiene (Burt and EkJund, 1992), Coincidentally^
the women surveyed in This study repented to brush their teeth more frequently than
men. Howeverthe urban and rwal residents in this study exhibited similar
periodontal status either by CPI or LOA (Tables 5-32 to 5-39) although most o f the
urban residents reported brushing their teeth twice or dore daily ind most of the
niTtil residents reported only once daily (Table 5-16). These results might indicate
that periodomal destruction has DO obvious relauorkship with toothbrushing habits in
this population.

6.2.6. T o o t h lo^s a n d p r o s t h e t i c s t a t u s

Although k w ot p^miancni teeth has dedmed in developed countries in che past two
to three decadesDowner, 1991 Spencer et aL% 1994; White et aL, 1995), recent
surveys have still shown more lost teeth among adults in industrialized countries
(Kaisbeek et al. 1991, O'Mulianc and Whelton, 1994; Alvarez-Arena! et aL, 1996:
Loh et al., 1996; Marcus et aL, 1996 Micheelis and Bauch, 1996) than in many
developing countries including China (Scheuti el aL, 19S3; Baelum and Fejerskov,
19S6; M a n j i et al 1988; L u a n ei &L, 1989b; M a t t h e s e n et aL, 1990),

The findings o f the present study showed that almost all of the 35"44-year-olds and
around half o f the 65-74-year-olds in Guangdong Province retained 20 or more of
their teeth not indicated for extractiom (Figures5 4 and 5-5). MT of the 35-44-yearolds in the present study is similar to the results o f a study in the same age group in
Western China (Liu e! ai., 1954) ajnd the MT o f the 65-74-year-olds h similar to the
findings among the elderly in Northern China (Luan et al., 1989b) a^d Western
China (Chen et ai,

1986) but higher than that foioJ recently in Central China

(Petersen et aLy 1997). MT of the two age groups surveyed in this study were lower
than that found in a study of Hong Kong adults (Lo aiid Schwarz, ]994b) who are
mainly descendants of Guangdong

Province

but have much higher income and

greater access to dental caje services. When compared to other developing countries,
MT or AMT o f the Guangdong adults was similar to the state among middle-aged
a d u l t s i n T a n z a n i a ( B a e l i u n a n d F e j e r s k o v , 1986) a n d K e a v a ( M a i v j i et al., 198S).

but iower than that in the middle-aged and thfi elderly in Sri Lanka (Ekjinayaka,
1984). When compared to the findings of recent surveys in industrialiEed coimtries

130

in Asia. Eump and North America (Kalsbeek e( aL,

1991 O'Mullane and

Whdwn, 1994; Atvarcz-Arenal a! ai, 1996; Loh et ai, 1996, Marais et al 199&
Michedis and Bauch, 1996), the number of missing teeth in the Guangdong
populations were smailer even after the teeth indicated for extraction have been
taken imo consideracion.

Although urban and rural adults had simiiair numbers of missing teeth, more teeth
indicated for extraction (IMT) were detected in the rural adults than in the urban
adults (Tabfe 5-40). This demonstrated that in Guangdong Province, poor access to
denial care providers in the rural areas leads to accLunuIaTion of tooth extmjctioa
needs in the population.

The present finding thai women

more missing teeth, than men was in accordance

with the findings among Northern Chinese adults (Luan et al.7 1989). Greater tooth
loss in women than men has he^n found in many countries bat the i^&sons are still
unclear (O'Mullane er al 1993). In the present sludy, women have b^en shown io
experience less p^nodontal disease but Hiore decayed tei&th (Table 5-26). As caries is
the principle cause o f tooth loss (Corbet and Davies, 1991; Burt and Ektund, 1992).
the greater number o f teeth losl among women could be related to th-e iTior& caries
t h e y experienced-

More than one third o f the third molars in the 35-44-year-old subjects in this study
were rtiissing. The reasons for this phenomenon were largely unknowrv Although
oral diseases might account for some of the missing teeth, some niighi have been

131

e x t r c d d u e tii i m p a c t i o n a n d a n t i m b e r o f t h e m m i g h t be u n e m p t e d ( & u s no[ seen

inthe c l i n i c ^ ] c>:a m i n a t i o n ) o r c o n g e n i t a Ely m i s s i n g T h u g , otie haa t o b e cautious
w h e n LissnyM T

m th]5 popuEatiori g r o u p t o i n d i c a t e t h e i r o r a l disease level.

Education evd and FMPI were found t o b e related t o adjusted missing teeth ( A M T )
in both a g e groups m this study (Tables 5-41 and 5 4 2 ) . Those w h o had higher
e d i i o a t i o n a n d t h o s e w h o w e r e w e a l t h i e r h a d l o w e r A M T scores. T h e s e results vvere

c o n s i s t c m w i t h findings from other studies outside China (K^isbeek et al.7 1991;

M i l l e r a n d L o c k e r , 1994 E t d u n d a n d Burt1994)- S m o k i n g has been f o u n d : b e

associated with a n increased risk o f tooth l o s s (Ragioarsson et ai, 1992; Holm, 1994;
KraJl el al 1997), In ihe A N C O V A model of the present study, it w a s also found
t h a t s m o k i n g w a s associated w i t h A V T T a m o n g t h e 3 5 - 4 4 - y e a r - o l d s , b u t n o t
s t a t i s t i c a l l y significamt f o r t h e 65-74^y^dX"Olds. T h i s re^uJt is s i m i l a r t o t h e f i m i i n g s

from s o m e other studies thit smoking a s a risk factor t o toothi loss was just foMnd in
y o u n g e r individuals (Eklund and Burt, 1994; Holm, 1994). The preseni: finding that
t h o s e w h o had a more recent dental visit aitiong the 35-44-year-oids had a higher
A M T than those w h o had not, could b e due to the therapeutic rather than preventive
approach adopted b y mast dentists in Gtiajigdong Province.

In t h e rural areas o f Mainland C h i n ^ there are still many dental care providers w h o
h a v e b e e n trained through a traditional apprenticeship rather than i n denial schoolsr
T h e s e dental care providers mainly provide relief o f dental

tooth extraction and

prosthetic treatments- They use ^ variety of materials and often rather special dent&l
prosthetic principles. They often provide a bridge rather than i partial dentureeven
though o n l y very f e w t^eth. m a y b e retained i n an arch- This i s the explanation o f the

pruem

whicli Aowcd cifierent prophetic treatment patterns between the

urban ^nd ru[[ r c s i ^ c n i s (Table 5-45).

6 , 2 . 7 . T r e a t m e n t needs

Without proper information on the dental treatment need o f the population^ it would
be v e r y d i t T t c i i l t t o m a k e decisions o n w h a t type o f and h o w m a n y dental personnel

should be Crain^d and what kind o f facilities is required fojr providing appropriate
o r a l care. I n a d d i t i o n t o epidemiological data o n n o i m a t i v e treatment need w h i c h i s

assessed by dentists, information o n people's perceived need for dental treatment i s

also v e r y importLnt as this wilJ a f f e c t the demand f o r ora! care services and
u l t i m a t e i y i n f l u e n c e the t y p e and quantity o f care that w i l l be utilised (Striffler
19S3). H o w e v e r , i i t t l e i n f o r o i a t i o n o n n o r m a t i v e a n d perceived dental treatrnent

n e e d o r demand fbr denta! cane from Chinese popuiEitions has been available.

O n e o f the [nain findings o f this smdy w a s that the need for simple dental treatments
$uch a s scalingfilling and extraction w^s very high among the adults i n GuangdorLg
Province (Table 5-46). This is probably a result o f life-long neglect o f dental care,
c o u p l e d w i t h difficult access to demal services. Utilization o f dental services among
this population w a s found to be l o w and problem-driven and proper dental care
services w e r e n o t readily avaJlLbleT especially t o people l i v i n g i n the rural arc&Sr

T h u s m o s t o f the dental diseases and their consequences were not treated in this
population. T h e prevalence and severity o f c o m m o n dental diseases in the study
subjects a s measured by the D M F T ^nd CPI indices were tiot worse than th^t o f
H o n g K o n g adults but the prevalence o f treatment need w a s much higher (Lo et al.,
1994). The demist t o population ratio in H o n g Kong i s about 1:4,000 (Schwarz and

133

Lo, 11^^}

that in Guangdong Province is about 1:33,000 (Zhang et alr.

1993b\ 1[ sire hti d k n e e

n aval lability of dental care providers between the two

places can aleast p[irt]_v explain the above finding.

Cervical abrasion [5 caused by o v e r s e a ! o u s hon^ontal toothbrushing with abrasive

toothpaste (Ford, 1992)Many o f the study subjecrs were found to have cervical
abrasion lesions that needed to

filled in ord^r to prevent pulp death or tooth

fracture (Table 5-46), Thi$ is most likely due t o the result o f improper toothbmshing
o v e r many years and thus this phenomenon was found to bti more prevalent among
the elderly and among the urban residents w h o brushed more frequently than the
rural residents. Daily toochbrushing is a common practice among the southern
Chinese adults but most toothbrushes in the market h^ve bristles that are too hard.
Another possible factot causing the high prevalence <?f cervical abrasion in this
popular tan is that many brandy o f toothpaste m the market in Guangdong Province
are probably t o o abrasive but no study on this ha5 been reportedr Therefore^ oral
health education is needed for both the general public and the dental product
tfianufacturers. H o w to choose a quality toothbrush and proper toothbrushing
technique should bekey messages in the oral health education programmes for this
community

in

order

to

prevent t h h

pioblem.

Moreover,

the

toothbrush

manufacturers should be asked to produce toothbrushes v^ith softer bristles and the
toothpaste manufacturers should b e told to produce less abrasive toothpaste.
Furthermore, standards should be set to monitor the qualiiy o f toothbrush and
toothpaste in order to safeguard the dental health o f the consumeTs.

T h e periodontal treatment needs i n this population as i n c l i n e d by the CPI results

134

thilt ^ massive commitmem of orai h^lth cart services should be directed

iarydy. t u w d the provision of om] hygiene instruction and scaling (Table 5-49).
However, .such inordinate demands on sources arc disproportionate lo the public
health importance of periodontal disease in this population in which most of the
aduks including the etderly retained at least 20 natural teeth, Thi^the prevention
and control o f periodontal disease in this population should be ba^ed primarily on
self-reliance and personal ora! hygiene.

For oral heaJth care planning and estimatioa o f manpower needs, noi only is it
impodant to know the amount o f various types o f treatment required, bat also
information on the proportion o f population with different combinations o f treatment
needs. T h e holistic approach in dividing the study subjects into diffbrent treatmen:
n e e d categories helps to identify what types o f dental personnel are required for the
provision o f care to the southern Chinese, Since mo^t o f the middle-aged and the
elderly subjects needed a combination o f various aimpje dental tr&aimems only
(Table 5-50)their required care can be provided b y the middle-level dentists i n
China w h o have received three years o f basic dental training in health worker
training schools. The output o f this category o f dental care providers should b e
increased s o a s t o cope with the large treatment need i n the population in a coste f f e c t i v e w a y . T h e training o f dental hygienists for the provision o f simple
periodontaJi treatment is warranted but the establishment o f another group of dental
auxiliary workers who only provide dental prosthesis, Crgr denturis: i n s o m e
c o u x i t r i ^ m a y not b e necessary as only a small percentage o f tfie elderly Chinese
have just prosthodontic treatnicnt need (Table 5-50)^ A proportion o f the dental
workforce should be composed o f uiuversiiy-trairied dentists and dental specialists

135

to

the ocbtzr less well-trained dental workers and [o provide the complex caro to

the people who are in need,

The large discrepancy and lack of correiauoii between the subject's normative and
perceived treatment needs is o f m^jor concern (Tables 5-51 and 5.52). Although
similar findings were also obtained in studies conducted in Hong Kong (Lo et aL2
1994) and in other counrries (Tervonen and Knuurtila, 19SS; Mojon and Macentee,
1992), this is more senous in populations that have tow ytilizaiion of dental services
such as this one. Most subjects in this study population would not visit a dentist
when tbey had no perceived treatment jneed or when the dental problems were not
too serious. A s the prevaJence o f perceived need was low in this population^ so was
the utifizatioa

rate.

Since most dental diseases including dental caries and

periodontal disease are chronic and not until at a very advanced Stage will acute
symptoms arise, the probability thai the diseases be det-ected. at an early stage h low
when people do not visit demist regularly. When dental diseases are presented at an
advanced stage to a dentist, the provtsion of simple or conservative treatment may
not be possible. Tooth extractions or complicated tretment would be tommort
outcomes o f such & dental visit which naate the encounter with the demist an
unpleasant oae. Thi& will further deter dental visits and a vicious cycle wiJl be built
up. The estabfbhment o f dental s&rvioes thar are passive and only respond to
people's ctemand for treatment will not help to break this vicious cycle and improve
the situation. Therefore, active oral health edvication programm-es are needed to raise
the dental awareness o f th southern Chinese and outreaching denta] services art
n&edcd to detect the presence o f dental diseases in the population. Prevention and
s i m p l e Treatments should then be provided to the people once dental diseases are

detected or when high-risk groups are identified. Further studies are required io find
out why tlie prevalence of perceived trcaimeni need is so km

among ihe soudiern

Chinese and how thh can be improved. The dental profession and health authority
should also see whether lhe normative treatments are appropriate for this population
group and find out what is the realistic treatment need.

137

7. C O N C L U S I O N S

The present study in Guangdong Province was conducied using raethodoloey and
dinical diagnostic criteria most recently recommended by WHO and face-to-face
interview with a highly sxructured questionnaire specialJy designed for this study.
The results from this study provide a wealth of information for formukting
strategies for o[al health promotion, oral disease prevention and oral health care in
Guangdong Province. Much of the infomiation provided by this study concerning
adults in MainEand China has seldcun been presented previously, eLg. loss of
periodontai attachment, utilization of dental servicesimd treatment needs. H i e
major findings o f this study were a s follows:

1.

Oral health knowledge w a s poor but oral health attitudes were generally
positive among adults in Guangdong Province. Aimost ajl o f the middleaged and more than 9 0 % o f t l i e dentate elderly surveyed claimed that diey
brushed their teeth every day and used toothpaste during toothbriishing.
However, most o f them did not know i f the toothpaste they used contained
fluoride. Their denial service utilization was l o w and problcm-diiven. Oral
heahh knowledge, attitudes, and oral health behaviour were found to be
related to soda and economic factors m
i this population.

2.

The mean D M F T score was 4.6 in the 35-44-year-olds and 15.6 in the 6574-year-olds. M T was the major componem of the DMFT score in boih
age groups. The proportion of F T in D F T was very small in this
population. Rural residents, women and ihoae wlw were less wealthy

138

higher DMF'i' scores.

Calculuii ^uid shallow periodontal pockets were the two most prevalent
mrniiimns oimaximum CPI score in both age groups. L O A w a s prevalent
and s e v e r e In adults in Guangdong Province, M e n had worse periodontal
stauss than w o m e n but rural residents m d urban residents exhibited
similar periodontal destruction.

Edentulousne^s w a s uncommon. A l m o s t all o f the 35-44-year-oids and

m o s t o f the 65-74-year-olds had at [east 2 0 teeth present. Rural residents
had similar M T but greater IMT than urban r&&idea!sr Only a small
prgportioTi o f the middle-aged and less t i w i half o f the eldeily were found
to h a v e o n e o r more denial prostheses in either j a w .

T h e prevalence o f normative dental treatment need, arnong the aduJt

southern Chinese w a s found to b e high l>ut the treatments were mainly
s i m p l e ones. Howeverthe prevalence o f perceived treatment ne^d in this
population w a s l o w and the coitielation between these two types o f
treatment needs w a s low.

8. RECOMMENDATION
More oral hulth education programs on correct use o f looihbmsli and
toothpick, use ot fluoridated toothpaste, and the importance of making
regular denta] visits should be carried out.

The health authority and the consumer organizations should aet up product
standards for toothbrushtoothpaste, and toothpick.

The output o f middle-level dentist in Guangdong Province should be

increased to provide the required simple dental treatments to the popuIatiOQ
in a cost-efficient w a y and the establishmenl o f dental hygienists shouJd be
seriously considered by the health authority.

Outrcaching dental services should

s&t up to provide simple dental

treatment to people living in rural areas and in institutions.

KO

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159

Treatment

Appendix 1

1996-1997
(354465-74)

21

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38.

tl

QUESTIONNAIRE F O R I N T E R V I E W I N G
A D U L T S EN G U A N G D O N G R E S E A R C H
(35-44, 65-74 years old)

Sex

2,

City
2

D
0
M
F
GZ QYZJ ST

H O W OLD ARE YOU TODAY?

5,

A-

A R E Y O U SATISFIED WTIH I H E APPEARANCE OF YOUR TEETH?

j

Satisfied

No comment

4r

YEARS OLD?

I am going to ask you some questions (xbout yo^r

3.

Locaiton
Urban 1 Urb^nS Rural I RuraT?.

H o t satisfied

HOW WOULD YOU D E S C E THE STATE OF YOUR T E E t H AND GUMS?

i

Good

D 2

Average

Poor

Don't know

C A N Y O U TELL ME HOW MANY NATURAL TEETH YOU HAVE?

(Show card I )
i

20 or more tectfi

10-19 teeth

3
flj

1-9 teeth
No teeth left

DURING THE PAST 12 MONTHS DID YOUR TEETH OR MOUTH CAUSE ANY
PAIN OR DISCOMFORT?
Yes

Don't know

DO Y O U THINK YOU MEED ANY DENTAL TTtEAmENT AT PSESEKT?

G o to Q7a
^ D
- Q

Yes

No

G o to QS MH 3

Don't know

7a.
WHAT TYPE OF TELEATMHNT DO YOU THESK YOU NEED?
(Show card 2, U p to 4 answers are accepted)
i

Dentil examination

S caling/ cleaning

Fillings

[14

CrowiVbridge work

Q 3

Pulp therapy

Dentures

Orthodontic therapy

Extraction

Oral hygiene instruction

n !Fluoride/p reventive treatment

D u

Other treatmentj specify

HOW OFTHH DO YOU AVOID SIvULING OR LAUGHING ON ACCOUNT OF

YOUR TEETH?
D i

Often

D j

Occasionally

Q 3

Never

HOW OFTEN DO YOU AVOJ CONVERSATION ON ACCOUNT OF T O i m

UNATTRACTIVE TEETH, GUMS, OR BAD BFATH?

Often

Occasionally

Never

C A N Y O U CHEW HARD THINGS, SUCH AS PEANUTS OR APPLES?

D O Y O U H A V E A N T REMOVABLE DENTUR5?
A partis denture
Partial denture

t oQ l l i

Full denture only

to Q12 <

Gj

No denture

Ha. DO Y O U H A V E A N Y PROBLEMS WITH YOUR DENTURE3? (Read

each iteica)
No
Can you prQnoancfr clearly?
0

D o you have difficulty eating?

Are your dentures well fixed?

3
2

D o your dentures hurt?

Are your dentures nice to look at?

No-^ I
to ask you some kno^l^dg^ your itmTr^^e; and practice related to dental
fieahh.
12.
WHAT DO Y O U THINK CAUSES TOOTH DECAY?
( U p i o t h r e e a i u w e r s axe accepted)

13.

Poor oral hygiene

u^ i

Sugar and sweet food

Lj3

B^cteri^ plaque

G *

Ajrid

Chinese explana-tions (e.g. hot^ fire)

Others

Don't know

WHAT D O Y O U THINK CAUSES SWOLLEN ORBLEEDING GUMS?

three answers are ajccepted)
Poor oral hygiea^ (no or poor toothbrushing)
Inadequate diet, lack of vitamin C
Bacteria, plaque
Calculus
Chinese explanations (e.g. hot, fire)
Inadequate steeping
Trauma &Qin brus^g
Others

Don't know
14.

WHAT D O Y O U THUSfK Y O U CAN DO TO PREVENT TOOTH DECAY?

(Up to three answers are accepted)
Q Rinse the mouth after eating

Toothbrushing (morefrequent or better)

D 3

Use fluqridated toothpaste

Take less sugar

Visit a dentist

 j
[

15,

6
3

[J 2

17.

D o n ' tk r o w

W H A T D O YOU TONK YOU CAN D O TO PBVENT SWOLLEN OR

BLEEDING GUMS?
(Up to three answers are accepted)
LJ [

I6r

Others

Kinse the mouth after eating

Toothbriishljag (more frequent or better)

0 3

U s e medicated ttK>thpa5te

Driak cooling

[I j

Visit a dentist

LJ 7

Others

LJ^

Don't know

or herbal medicine

SOME PEOPLE SAY THAT GUM DISEASE IS CAUSED B Y HOT AIR", DO

Y O U AGREE?
Lj i

Agree

Disagree

Don't know

F ^ O M WHAT CHANNEL, DID YOU HHCEIVE INFORMATION OF ORAL

HEALTH? (Show card 3, more answers axie accepted)
[_| i

Rajdio/televisio a

O x

Ncwspapers/magaziiie

[J 3

D entist/dental nurse

Propaganda board in hospital

O j

Infonnation counter oti street

Friend

D a

Others

Cj 9

Did not receive information

IS.

HOW O F T E N DO YOU BRUSH YOUR TEETH? (Show card 4)

Never
Go to Q. ISa

to Q. 19

19.

CI j

Seldom

"Dj

1-6timesa "week

*01

Once a day

0 j

Twice or more a day

18a,

W H Y DO YOU NOT BRUSHY O m TCETH? (Up to three answer are

accepted)

Too much trouble

D 2

Tired/basy

D 3

It is usdess

Q 4

Teeth are not dirty

A&aid of being made fun of

Bleeding

D 7

No money to buy toothbrush and toothpaste

D i

No habit

Others

D O Y O U U S E TOOTHPASTE WHEN Y O U BRUSH YOUR TEETH?

to Q19a
No
to Q20

-Q3

I never brash my testh

DOES YOUR TOOTHPASTE CONTAIN FLUORIDE?

Yes
No
Don't know

20.

D O Y O U USE ANY OF THE FOLLOWING TO CLEAN YOUR TEETH?

fRead each item)
Yes

n i

Toothpicks

CJ i

n j

Rinsing with tea

Cj i

D j

Rinsing with salt water

i
2L

23.

D i

Other

D O Y O U SMOKE?
i

22.

No

Yes,

pieces/grams perday, for

Used to, for

years

Never

HOW OFTEN DO YOU TAKE ALCOHOL, SUCH AS BRANDY, WHISKY OR

RICE-WEKE?
Q i

Every day

Several times a week

Seldom

[ L

Never

IF Y O U H A V E THE FOLLOWING PROBLEMS, WOULD YOU

"COOUDSTG" TEAS OR CONSUME HERBAL MEDICINE TO CURE T
(Read each item)

^Som" feeling in your teth

No

a)

Toothache

Don't know
w

Swollen or bleeding gums

Oral ulceration

Yes

DEJNK

24.
Don?t
( R e a d e a c h statement)

Agrte
(i)

Disagree
)

" J u s t like birch, ageing and death,

loss o f t e e t h is a natural process"

" T h e s t a t e o f teeth is decided by

t h e n a t u r e o f teeth, and has little
relation w i t h t h e seif-protecdon"
' T o o r t e e t h a r c detrimental
t o o n e ' s a-ppearance"
<

*Thft s t a t e o f m y t e e t h is
of g r e a t i m p o r t a n c e t o me1"

' ' K e e p i n g natural t e e t h is

n o t important"
"TJentai problems can afifsct
t h e organism as a whole"
' T a i s e t e e t h will b e Ie55 of a
b o t h e r t h a n natural teeth"
" R e g u l a r visits t o t h e dentist
k e e p a w a y dental problems**

//inv

25.

I am going

to askyou

questions

the

of dental.

H O W L O N G I Sr r S I N C E Y O U L A S T S A W Y O U R D E N T I S T ?
- Q
G ot o Q . 26

Less than 6 months

6 - 1 2 months

G 2

M o r e t h a n a y e a r , b u t less than 2 years

M o r e th^n 2 years, but less than 3 years

know
(

G o to Q 31

uJ j

M o r e than 3 ye^rs, but

M o r e than 5 years

"O7
26.

ess than 5 years

N e v e r r&cdved dental care

WHAT
DENTIST?

II G o for check-^Ltp

27.

G o f o r cleaning

G o f o r treatment

Pain/troubles w i t h teeth o r gums

D o n ' t know/donrenntmber

WHHEUE D I D Y O U G O F O R
( S h o w card 5 )

TOATMENTLAST

TIME?

D e n t i s t i n hospital in city
a

Dentist i n hospital In county

D e n t i s t i n h o s p i t a l in t o w n
JENT d o c t o r in County

G ,

Private dentist in t o w n

Private doctori n town

s
2S,

P r i v a t e d e n t i s t I n city

D e n t i s t i n a rnaritet/jtr^ct s i d e

W H A T T Y P E O F T R E A T M E N T D I D Y O U RECETVE A T Y O U R M O S T D E C E N T
V I S I T ? ( S h o w card 2, up t o 4 answers are accepted)

1 Ii

D e n t a l examination

Scalmg/cleaniag

Crown/bridge work

Pulp -therapy

Dentures

O r t h o d o n t i c therapy

Extraction
OraJ hygiene instrucrtion
FIuo ud^/preventive treatment
Other treatment^

29-

30.

specify

WHO P A Y FOR YOUR DENTAL T R E A I W H T ? (Show card 6)

i

100% by work unit or medical insurance

'i

1-49% by yourself

D ^

50% by yourself

51 -99%

100% by yourself

by yourself

WERE YOU SATTSHED WXXH YOUKLAST V l S n TO THE DENTIST?

Satisfied
N o comment

Dissatisfied
fGo to 0 3
3I r

WHAT IS THE MAIN REASON YOU DID NOT VTSTI A DENTIST

LA5T 3 YEARS? (Up to three answers are accepted)
n i

Couldn't afford it

Don't want to waste money on dentai care

Afraid of seeing dentist

Bad memoiies of last visit

Too busy

D i

K o need/nothing wrong

D 7

Dental problems ruot serious

Dentist's office (djnlc) too j&r away

Other

32

'

y o u a j f r a i d o f g o i n g TOt h e DE^nnST?

No

n 2

A little

Yes, quite

Yes, very

Ntnv 1 atn going to oskyou. some questions shout yourself andyouT family.

J 3.

WHAT WOULD YOU SAY YOUR EDUCATIONAL LEVEL IS?

E~11

No scho oting/Kindergarcen

Primary

Lower secondary

Upper secondary

6
34-

P o ^t-^econdajcy - non-^degxee course

Tertiary education degree course

WHAT IS YOUR OCCUPATION?

L e g a t o r s smd Adoiini^trators
Professional and Technical

Commerce

Clerk

Service

F amier/fisheraien
Worker
Others
Jobless

3 1

FOR HOW
PROVINCE?

HAVE YOU BEEN

II

GUANGDONG

36-

ARE "mE FOLLOWING OBJECTS OR FACILITI5S PRESENT IN

HOME? (Read out the list)
i

[J 2

Waching machine

Ds

High-fidelity sound system

D 4

Video Upe recorder

Q ^

Oven, microwave oven

Water heater

Camera (if ye^ how many?)

Cabinet/shelf system

D 9

Television (if yes, how many?)

io

Dish washer

Q u

Persona] computer

si

Piano

Bathtub

i*

W o o d e n floor

15

Telephone

Refrigerator

Motorbicycle

1 7

37.

Air-conditioner ( i fyes,h o w mary?)

L a s e r displayer

HOW MUCH WAS YOUR HOUSEHOLD INCOME LAST YEAR? (Show card S)

RMB2T000-4,999
RMB^OOO-S^

KMB 10,000^9,999

11^1650,000-99,999

RMB100S000-199?999

^RMBSOO.OOO

12

33.

HOW M A N Y PEOPLE ARE THERE IN YOUR FAMDLV?

PEOPLE

THAT COMPLETES OUR INTERVIEW

THANK Y O U VERY MUCH FOR YOUR COOPERATION!
Interviewer

13

Appendix

1 9 9 6 - 9 7
3

0'

II

#:

3 5 - 4 4

' 2 1 32

33

26

27

23

ii

36

37

33

35

51

3:32

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f i l L e ^ . a,id decayBd
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minen^ , Cb(L a i tCOw
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4- = uLfl Ci7^ + r e 5 t o E l = i f l i l

5 ] ExtriCt. icn

a a F i l l i c i i j i^Li-e. t o a b r a s i o n
7 CambLnl^ i o n o t
6 O t h e r trea'Mient.

TtOSTH^5IS

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0
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= Birid-ge +
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0 ^
need
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2 ] 2+ u n i t s prthftsj
3 *
= ComhLrvitl oh
F u l l p r o st:KedL j

y i ? . 5 M , LE5T0N5
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vemlli.OR bardic
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LESION
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g - l J , Tflrtl
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Appendix 5
n

19-97
6574)
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i = 2 = 3

L7

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:6 f 15

47

35
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43

44

21

22

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25

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3:

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37

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311

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37

3E

Appendix 6
Qi t : e

C^se No

G U A N G D O N G O R A L H E A L T H P U R V E Y 1996-97
A3ULXS ^ 5 - 7 4 y e a x - o l d )
Lin^
19 17 16
CMWt?

+ - -

zx

22

21

14

ROOT

XSSATi^SNT

49 4 7 46 4 5 4 4 42 42

3 1 3 2<^ 3 34

37 j S

caoww
KDO^

TFLSATHZNT

CTOwn a n d Roat:

Tgeabmerit:

0
3.
^
2
4
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0
1
2
3
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26 17

^ai^nd
F i l l E d And d e c a y e d
F i _ I I e d r n i rfeca^&d
Hissing1
t o ca.E-i.es
H i s s i n g F my O t k e i r r - e a s o n i
B r i d g e i S t r t m e i i t , s-p&cjLal CJ

* NO
1 surfAC6
"fillLng"
= 2 - 4 stii^fae f i l l i n y
Crown
H ^ n L p ca^-a + s1est;ora-^ic.
- E K t r i c t jian

6 - Falling d-e ta atr^siari

7 =* Copihx n a t i a n o f tJr&a.tmfintE
Q w Othfl:

9 = Hot; i s C O E - d e d
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Traatment

2+

THEATZtGNT

MaCOSAL.

pajc^ial dAnturt
+ pajrciil
COrapi^te d e n t u r e

0 12 3 4

No p ^ o a t h e s 2_s
One b r i d g e

ST^TtTS

- H o need
i Mnit
^ 2 m i L t s p u D s - t h e s i s
CambLp.a.lli-311.
-FuLJL p r a s t h M l a

LZSTO^S
LdC&tion

iHncacion
a - Not
1 - V e ^ m i l i - o n tocrdar
Ccauai
Lips
5ti
t i
4

BU-CCAX onlCP^A.
> E'Xcn?QKiu-EJl
Tongue
SAT^/so^ p^atft
ar

-:^:0005TATrJ5
16 1 ?
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11

C?:

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4 47 4

C?I
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i
1

(
l , 5 | l 4 J.2 12 L l -{ 2 1 22 2 5
r
1

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\
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44 4 3 2

31

22

32 > 4 3535 37

1
i
i

F e r i Q ^ Q ^ t a j. _.5^^^4.3

L g j s o attaglTLrnart^.

0
1
2
3
45
E
$

0 a 03 am
1 4 - 5 dm

= tto b l e e d L r g
= ELeedi_ngr
= CAIcuLUS
*
mm Q O C k e i
= 63 1 p a c k e t
9 l i cnm
- 12+ ffto p f l c k e t
Excluded

fj.e^ixks

l
1

- 5 - X L nm
=12+" CMl
9 * EKClueied