Oral Health in the State of Kuwait: An Appraisal

BACKGROUND

Oral health issues have received significant attention from most global health agencies, which have integrated these issues into their noncommunicable disease, sustainable development, and universal health coverage objectives.

METHODS

This paper provides an update on the progress made in the last 2 decades and aims to highlight some of the challenges faced by the oral health care system in Kuwait.

RESULTS

Despite the nation's rising expenditure on oral health care, the prevalence of oral diseases remains high in Kuwait. The lack of reliable data on periodontitis and edentulism limits the ability of researchers to comment on the trends of these conditions. This emphasises the critical need for a nationwide household-level oral health survey in both pediatric and adult populations that would provide valuable information on the oral health status of these populations.

CONCLUSION

In the future, Kuwait must invest more in oral disease prevention programs, especially among children and the high-risk communities of the population.

Relationship Between Oral Health Knowledge, Attitude and Practices of Primary School Teachers and Their Oral Health-related Quality of Life: A Cross-sectional Study

PURPOSE

To measure oral health (OH) knowledge, attitude and practices (KAP) of primary school teachers and to evaluate the relationship between these measures and oral health-related quality of life (OHRQoL).

MATERIALS AND METHODS

A total of 1013 school teachers from all regions of Kuwait were randomly selected in this cross-sectional study. A questionnaire on demographics, knowledge, attitude, practices and OHRQoL was used. Frequencies and means (SD) were used for data description. Correlations between KAP and OHRQoL were evaluated using Pearson's correlation coefficient. Associations between practice-specific knowledge and its corresponding practice as well as knowledge and practices and OHRQoL were determined using the chi-squared test.

RESULTS

About 71% of the participants were females, 57% were 30-50 years old, and 75% had a college education. The mean (95%CI) knowledge score was 60.2% (57.2-62.0), ranging from 15.4% to 93%. The well-known OH facts were the importance of brushing twice a day with fluoridated toothpaste, the cariogenic effect of sticky, sugary foods and snacks, as well as the damage that soft drinks can cause to teeth. The least known facts were replacement frequency of toothbrush, parent's supervision of children's brushing and the benefit of regular flossing. Weak but significant correlations were found between KAP components and OHRQoL (p < 0.05). All practice-specific OH knowledge was significantly associated with its practice, except brushing and flossing (p > 0.05). Self-esteem was the mostly frequently affected OHRQoL construct by improper OH practices.

CONCLUSION

Oral health knowledge by itself is not enough to change improper OH practices. Developing behaviourchanging interventions based on OHRQoL outcomes may be beneficial.

The salivary microbiome is altered in the presence of a high salivary glucose concentration

Background

Type II diabetes (T2D) has been associated with changes in oral bacterial diversity and frequency. It is not known whether these changes are part of the etiology of T2D, or one of its effects.

Methods

We measured the glucose concentration, bacterial counts, and relative frequencies of 42 bacterial species in whole saliva samples from 8,173 Kuwaiti adolescents (mean age 10.00 ± 0.67 years) using DNA probe analysis. In addition, clinical data related to obesity, dental caries, and gingivitis were collected. Data were compared between adolescents with high salivary glucose (HSG; glucose concentration ≥ 1.0 mg/d, n = 175) and those with low salivary glucose (LSG, glucose concentration < 0.1 mg/dL n = 2,537).

Results

HSG was associated with dental caries and gingivitis in the study population. The overall salivary bacterial load in saliva decreased with increasing salivary glucose concentration. Under HSG conditions, the bacterial count for 35 (83%) of 42 species was significantly reduced, and relative bacterial frequencies in 27 species (64%) were altered, as compared with LSG conditions. These alterations were stronger predictors of high salivary glucose than measures of oral disease, obesity, sleep or fitness.

Conclusions

HSG was associated with a reduction in overall bacterial load and alterations to many relative bacterial frequencies in saliva when compared with LSG in samples from adolescents. We propose that hyperglycemia due to obesity and/or T2D results in HSG and subsequent acidification of the oral environment, leading to a generalized perturbation in the oral microbiome. This suggests a basis for the observation that hyperglycemia is associated with an increased risk of dental erosion, dental caries, and gingivitis. We conclude that HSG in adolescents may be predicted from salivary microbial diversity or frequency, and that the changes in the oral microbial composition seen in adolescents with developing metabolic disease may the consequence of hyperglycemia.

Salivary Biomarkers in Pediatric Metabolic Disease Research

The increasing prevalence of childhood obesity and obesity-related metabolic disorders is now considered a global pandemic. The main goal of the pediatric obesity research community is to identify children who are at risk of becoming obese before their body mass index rises above age norms. To do so, we must identify biomarkers of metabolic health and immunometabolism that can be used for large-scale screening and diagnosis initiatives among at-risk children. Because blood sampling is often unacceptable to both parents and children when there is no direct benefit to the child, as in a community-based research study, there is a clear need for a low-risk, non-invasive sampling strategy. Salivary analysis is now well recognized as a likely candidate for this purpose. In this review, we discuss the physiologic role of saliva and its strengths and limitations as a fluid for biomarker discovery, obesity screening, metabolic disease diagnosis, and response monitoring after interventions. We also describe the current state of the salivary biomarker field as it pertains to metabolic research, with a special emphasis on studies conducted in children and adolescents. Finally, we look forward to technological developments, such as salivary "omics" and point of service diagnostic devices, which have the potential to accelerate the pace of research and discovery in this vitally important field.

Unhealthy Phenotype as Indicated by Salivary Biomarkers: Glucose, Insulin, VEGF-A, and IL-12p70 in Obese Kuwaiti Adolescents

OBJECTIVE

Here, we investigated the relationships between obesity and the salivary concentrations of insulin, glucose, and 20 metabolic biomarkers in Kuwaiti adolescents. Previously, we have shown that certain salivary metabolic markers can act as surrogates for blood concentrations.

METHODS

Salivary samples of whole saliva were collected from 8,317 adolescents. Salivary glucose concentration was measured by a high-sensitivity glucose oxidase method implemented on a robotic chemical analyzer. The concentration of salivary insulin and 20 other metabolic biomarkers was assayed in 744 randomly selected saliva samples by multiplexed bead-based immunoassay.

RESULTS

Obesity was seen in 26.5% of the adolescents. Salivary insulin predicting hyperinsulinemia occurred in 4.3% of normal-weight adolescents, 8.3% of overweight adolescents, and 25.7% of obese adolescents (p < 0.0001). Salivary glucose predicting hyperglycemia was found in only 3% of obese children and was not predictive (p = 0.89). Elevated salivary glucose and insulin occurring together was associated with elevated vascular endothelial growth factor and reduced salivary interleukin-12.

CONCLUSION

Considering the surrogate nature of salivary insulin and glucose, this study suggests that elevated insulin may be a dominant sign of metabolic disease in adolescent populations. It also appears that a proangiogenic environment may accompany elevated glucose in obese adolescents.

Continuous Metabolic Syndrome Scores for Children Using Salivary Biomarkers

Background

Binary definitions of the metabolic syndrome based on the presence of a particular number of individual risk factors are limited, particularly in the pediatric population. To address this limitation, we aimed at constructing composite and continuous metabolic syndrome scores (cmetS) to represent an overall measure of metabolic syndrome (MetS) in a large cohort of metabolically at-risk children, focusing on the use of the usual clinical parameters (waist circumference (WC) and systolic blood pressure (SBP), supplemented with two salivary surrogate variables (glucose and high density lipoprotein cholesterol (HDLC). Two different approaches used to create the scores were evaluated in comparison.

Methods

Data from 8,112 Kuwaiti children (10.00 ± 0.67 years) were used to construct two cmetS for each subject. The first cmetS (cmetS-Z) was created by summing standardized residuals of each variable regressed on age and gender; and the second cmetS (cmetS-PCA) was defined as the first principal component from gender-specific principal component analysis based on the four variables.

Results

There was a graded relationship between both scores and the number of adverse risk factors. The areas under the curve using cmetS-Z and cmetS-PCA as predictors for severe metabolic syndrome (defined as the presence of ≥3 metabolic risk factors) were 0.935 and 0.912, respectively. cmetS-Z was positively associated with WC, SBP, and glucose, but inversely associated with HDLC. Except for the lack of association with glucose, cmetS-PCA was similar to cmetS-Z in boys, but had minimum loading on HDLC in girls. Analysis using quantile regression showed an inverse association of fitness level with cmetS-PCA (p = 0.001 for boys; p = 0.002 for girls), and comparison of cmetS-Z and cmetS-PCA suggested that WC and SBP were main contributory components. Significant alterations in the relationship between cmetS and salivary adipocytokines were demonstrated in overweight and obese children as compared to underweight and normal-weight children.

Conclusion

We have derived continuous summary scores for MetS from a large-scale pediatric study using two different approaches, incorporating salivary measures as surrogate for plasma measures. The derived scores were viable expressions of metabolic risk, and can be utilized to study the relationships of MetS with various aspects of the metabolic disease process.

Children's perception of caries and gingivitis as determinants of oral health behaviours: a cross-sectional study

AIM

To evaluate the relationship between children's perception of caries and gingivitis and their oral health behaviours.

DESIGN

Participants in this cross-sectional study were children aged 11-14 years. A questionnaire for measuring children's perceptions and behaviours was developed, validated and applied. Perceptions were analysed as predictors for behaviours using multiple logistic regression analysis.

RESULTS

A total of 434 children (57% males) participated in the study. Half of them perceived caries as a disease and believed in visiting the dentist regularly regardless of dental need. More than 60% were unaware that gum bleeding is a sign of disease and only 60.7% believed that it requires a management. Being aware that gum bleeding is a sign of disease and that it requires treatment increased the odds of brushing 2.83 (OR = 2.83, 95% CI:1.33-6.12) and 2.1 (OR = 2.1, 95% CI:1.05-5.55) times, respectively. Children aware of importance of dental visits even without dental decay were 2.9 times more likely to visit the dentist regularly (OR = 2.86, 95% CI:1.25-5.75) and were 77% more likely to never miss a dental appointment (OR = 1.77, 95% CI:1.03-3.37).

CONCLUSION

Being aware that bleeding gum requires treatment was a determinant of toothbrushing habit. Improved perceived need for dental check-up regardless of dental problem may promote children's preventive dental attendance.

Impact of dental health on children's oral health-related quality of life: a cross-sectional study

Background

To assess the impact of children’s dental health status (DHS) on their oral health-related quality of life (OHRQoL).

Methods

Participants were 11- and 12-year-old children attending public schools in the Kuwait Capital Region. Children’s DHS was evaluated by clinical examinations and presented using decayed, missed, filled teeth/surface (DMFT/dmft, DMFS/dmfs); restorative (RI), plaque (PI); and pulp, ulcers, fistula, abscess (PUFA) indices. Children’s OHRQoL was assessed using Child’s Perception Questionnaire 11–14 (CPQ_11–14)_. Means (SD) and frequencies were used for data description. Different factors were analyzed as predictors of OHRQoL by logistic regression analysis.

Results

A total of 440 children aged 11–12 years (50.7 % females) participated in this cross-sectional study. Mean (SD) DMFT/dmft, RI, PI, and PUFA scores were 2.91(2.75), 0.21 (0.34), 3.59 (1.63), 0.31 (0.85), respectively. The mean total CPQ_11–14 was 20.72 (16.81). Mean scores of oral-symptoms, functional-limitations, emotional and social well-being were 4.26 (3.32), 5.40 (4.92), 5.48 (6.15), and 5.33 (6.05), respectively. Children with more than four fillings were 95 % less likely to have had oral symptoms than those with no fillings. Children with a DMFT/dmft of 2–3 were 2.8 times more likely to have functional limitation than those with a DMFT/dmft of 0, while children with a DMFT/dmft of more than 4 were 4.4 times more likely to experience limitations. Having two or three non-cavitated lesions reduced the odds of having functional-limitation by 58 %. Children with more than four missing teeth were 45 % more likely to experience emotional stress. Having more than four fissure sealants reduced the odds of having emotional stress by 46 %.

Conclusions

The increase in the number of carious teeth was associated with a limitation in oral functions. Preventive treatment had a positive impact on children’s emotional well-being and restorative treatments improved their oral function.

Salivary glucose concentration exhibits threshold kinetics in normal-weight, overweight, and obese children

BACKGROUND

Metabolic syndrome in childhood predicts the development of cardiovascular disease and type 2 diabetes (T2D) in adulthood. Testing for features of metabolic syndrome, such as fasting plasma glucose concentration, requires blood sampling which can be difficult in children. Here we evaluated salivary glucose concentration as a surrogate measurement for plasma glucose concentration in 11-year-old US children.

METHODS

Children from Portland, Maine, and Cambridge, Massachusetts, with a mean age of 10.6±0.2 years provided 6-hour fasting samples of both blood and whole saliva. Salivary glucose levels were measured with a high-sensitivity assay (sensitivity =0.002 mg/dL). Plasma glucose levels were determined by a commercial clinical laboratory. Blood pressure, salivary flow rate, height, and weight were also measured.

RESULTS

Of the 65 children enrolled, there were two underweight children (3.1%), 30 normal-weight children (46.2%), 12 overweight children (18.4%), and 21 obese children (32.3%). The mean overall glucose concentrations were 0.11±0.02 mg/dL in saliva and 86.3±0.8 mg/dL in plasma, and these did not differ significantly by body-weight groups. By regression analysis, the plasma concentration equaled 13.5 times the saliva concentration, with a threshold level of 84.8 mg/dL. Salivary glucose values less than threshold plasma concentration were essentially zero. Diagnostic analysis indicated a positive predictive value of 50%, a negative predictive value of 90%, and a sensitivity and specificity both of approximately 75%. The salivary glucose concentration did not vary with saliva flow rate.

CONCLUSION

Taking into account the threshold response characteristics of the salivary glucose concentration response, these results suggest that testing salivary glucose levels may be useful as a screening assay for high fasting plasma glucose levels. The low false positive value is important to assure a low fraction of missed diagnoses.

Metabolic disease risk in children by salivary biomarker analysis

Objective

The study of obesity-related metabolic syndrome or Type 2 diabetes (T2D) in children is particularly difficult because of fear of needles. We tested a non-invasive approach to study inflammatory parameters in an at-risk population of children to provide proof-of-principle for future investigations of vulnerable subjects.

Design and Methods

We evaluated metabolic differences in 744, 11-year old children selected from underweight, normal healthy weight, overweight and obese categories by analyzing fasting saliva samples for 20 biomarkers. Saliva supernatants were obtained following centrifugation and used for analyses.

Results

Salivary C-reactive protein (CRP) was 6 times higher, salivary insulin and leptin were 3 times higher, and adiponectin was 30% lower in obese children compared to healthy normal weight children (all P<0.0001). Categorical analysis suggested that there might be three types of obesity in children. Distinctly inflammatory characteristics appeared in 76% of obese children while in 13%, salivary insulin was high but not associated with inflammatory mediators. The remaining 11% of obese children had high insulin and reduced adiponectin. Forty percent of the non-obese children were found in groups which, based on biomarker characteristics, may be at risk for becoming obese.

Conclusions

Significantly altered levels of salivary biomarkers in obese children from a high-risk population, suggest the potential for developing non-invasive screening procedures to identify T2D-vulnerable individuals and a means to test preventative strategies.

Caries prevalence, oral hygiene, and oral health habits of Kuwaiti infants and toddlers

OBJECTIVE

The purpose of this study was to describe the oral health, oral hygiene, and oral health habits of Kuwaiti infants and toddlers.

SUBJECTS AND METHODS

This cross-sectional study of a convenience sample included 336 infants and toddlers (156 females and 180 males). The teeth of the infants and toddlers were examined using a mirror and a light source. Oral hygiene was recorded, and then all teeth were cleaned with gauze and examined for caries. Parents were interviewed regarding their children's feeding habits, brushing or tooth cleaning, and night feeding. The evaluation criteria for caries were sound teeth, noncavitated lesions, cavitated lesions, filled teeth, and missing teeth.

RESULTS

The mean age was 11.1 ± 2.4 months (range 2-23). Of the 336 subjects, 247 (73%) had good oral hygiene, 64 (19%) had parents who brushed or cleaned their infants' and toddlers' teeth; 288 (86%) were bottle-fed, and 290 (86%) were also night fed. The mean number of teeth upon examination was 4.6 ± 2.7 (range 2-8). Three percent of the infants and toddlers had caries. Cavitated lesions were present in 6 patients (1.8%), while 4 (1.2%) had noncavitated lesions. The mean d1d2t (caries teeth: noncavitated lesions and cavitated lesions) was 0.03 ± 0.3, and the mean d1d2s (carious surfaces) was 0.07 ± 0.5.

CONCLUSION

The caries prevalence and severity was low in infants and toddlers. However, poor oral health practices and habits as well as unhealthy feeding practices that could affect the future caries prevalence were noted.

School Oral Health Program in Kuwait

The School Oral Health Program (SOHP), Kuwait, is a joint venture between the Ministry of Health, Kuwait, and Forsyth Institute, Cambridge, Mass., USA. This program provides oral health education, prevention and treatment to almost 280,000 public school children in Kuwait. Services are delivered through a system of center- and school-based clinics and preventive mobile teams. One of the recent developments is the effective use of portable dental units for the delivery of preventive care to children in schools without the need for children to go to dental clinics. Preventive procedures performed under this program are the biannual application of fluoride varnish and the placement of pit and fissure sealants on newly erupted permanent molars and premolars. During recent years, the SOHP has improved its coverage of children, with prevention up to 80%. This has resulted in a considerable reduction in treatment needs, which is evident from the reduced number of composite restorations performed under this program during the last 6 years. This indicates that the disease level is on a decline, which can be confirmed from the results of the ongoing National Oral Health Survey on Kuwaiti school children.

Obesity and dental decay: inference on the role of dietary sugar

OBJECTIVE

To evaluate the relationship of children's obesity and dental decay.

METHODS

We measured parameters related to obesity and dental decay in 8,275 4(th) and 5(th) grade Kuwaiti children (average age = 11.36 years) in a cross-sectional study. First to determine body weight, height, age for computation of BMI . Second, to determine numbers of teeth, numbers of fillings and numbers of untreated decayed teeth to determine extent and severity of dental disease. From these measurements, we computed measures of dental decay in children from four body weight categories; obese, overweight, normal healthy weight and underweight children.

RESULTS

The percentage of children with decayed or filled teeth varied inversely with the body weight category. The percentage of decayed or filled teeth decreased from 15.61% (n=193) in underweight children, to 13.03% (n=4,094) in normal healthy weight children, to 9.73% (n=1,786) in overweight children to 7.87% (n=2,202) in obese children. Differences between all groups were statistically significant. Male children in this population had more dental decay than female children but the reduction of tooth decay as a function of BMI was greater in male children.

CONCLUSIONS

The finding of an inverse obesity-dental decay relationship contradicts the obesity-sugar and the obesity-dental decay relationship hypotheses. Sugar is well recognized as necessary and sufficient for dental decay. Sugar is also hypothesized to be a leading co-factor in obesity. If the later hypothesis is true, one would expect dental decay to increase with obesity. This was not found. The reasons for this inverse relationship are not currently clear.

Pattern of antibiotic prescription in the management of oral diseases among dentists in Kuwait

OBJECTIVES

The use and abuse of antibiotics have been of concern to the medical and the dental profession for sometime now, due mainly to the emergence of antibiotic-resistant bacteria. The objective of this project was to determine the rationale and the pattern of antibiotic prescription for dental management in Kuwait.

METHODS

A questionnaire was distributed to 200 dental practitioners working in the Ministry of Health dental centers in Kuwait. The questionnaires sought answers to the clinical and non-clinical factors; signs, clinical conditions and dental treatment modalities for which the practitioners would prescribe antibiotics.

RESULTS

Of the 200 questionnaires sent out, 168 (84%) respondents returned fully completed forms. A total of 107 (63.7%) of the respondents were males. Of respondents, 90% would prescribe antibiotics for patients with elevated body temperatures and evidence of systemic involvement, gross or diffuse facial swelling and closure of the eye due to inflammatory swelling. However, over 50% would prescribe antibiotics for cases with localized fluctuant swelling without any systemic involvement, while 59.6% would prescribe for patients with difficulty in swallowing as a result of an oral infection. Many respondents would consider antibiotic prescription for routine dental extraction, and for non-clinical reasons such as uncertainty of diagnosis, convenience, expectation of the patient and lack of time to treat immediately. Amoxicillin was the most frequently prescribed antibiotic. Higher knowledge regarding adequate indications for antibiotic use was associated with longer professional experience.

CONCLUSIONS

The results of this analysis suggest that there is lack of uniformity in the rationale for antibiotic use among dental practitioners in Kuwait. There is an urgent need for the formulation of evidence-based guidelines, which should take into account the peculiar behavioral characteristics of the community.