Asia Journal of Public Health, July-December 2010 Vol.1 No. 2 Asia Journal of Public Health Journal homepage:http://www.ASIAPH.org Original Articles Oral Health Status among Elderly Hill Tribe Villagers in Mae Sot, Thailand Sroisiri Thaweboon* Boonyanit Thaweboon* Futoshi Nakazawa** Surachai Dechkunakorn* Theeralaksna Suddhasthira* Mari Fujita** *Faculty of Dentistry, Mahidol University, 6 Yothi Road, Rajthevee, Bangkok 10400 Thailand. ** School of dentistry, Health Science University of Hokkaido, 1757 Kanazawa, Tobetsu-cho, Ishikari-gun, Hokkaido 061-0293 Japan. 11 ARTICLE INFO Article history : Received July 2010 Received in revised form October 2010 Accepted November 2010 Available online January 2011 Keywords: Oral health elderly hill tribe Corresponding Author: Thaweboon S, Faculty of Dentistry, Mahidol University, 6 Yothi Road, Bangkok 10400,Thailand. Email : dtstw@mahidol.ac.th Asia J Public Health 2010;1(2):11-15 ABSTRACT Objective: This study aimed to determine the oral health conditions among elderly hill tribe villagers living in Mae Sot, Thailand. Materials and methods: The study was performed in 5 relatively isolated hill tribe villages. A total of 90 elderly villagers aged 54-80 years participated in this study. Dental caries were measured by the Decayed, Missing and Filled Tooth (DMFT) index according to criteria recommended by the WHO. Periodontal status was assessed using the Community Periodontal Index (CPI). Data were analyzed using ANOVA and Chi- square test. Results: The prevalence of dental caries was 78% with a mean DMFT-score of 6.53 + 6.32. All hill tribe villagers had periodontal disease with the mean CPI-score of 2.06 + 0.32. No statistically significant differences in DMFT- and CPI-scores were found among the villages or between males and females. Almost all of them (99%) had never accessed dental health care services. Very few (11%) had toothbrushes. The habit of chewing betel quid (Areca catechu L.) was found among all individuals. This may cause the deterioration of oral hygiene and the development of periodontal disease found in the study participants. Most of the participants had traditional knowledge of medicinal plants and they preferred using them as first aid remedies to treat illness. Conclusion: The oral health status of the elderly hill tribe villagers in Mae Sot, Thailand was quite poor. Periodontal disease was a major oral health problem though they did not request any dental care. The results from this study could be used as base-line information for health authorities and dental professionals for planning strategies for oral health promotion, prevention, and treatment among the elderly in hill tribe villages. INTRODUCTION Mae Sot is a district in Tak province, northwestern Thailand. It is located at the Thai- Myanmar border with the Moei River as a natural boundary. Therefore, Mae Sot is one of the most important gateways to Myanmar. Many indigenous people are native to Mae Sot, and many hill tribes have migrated from southern China and Tibet to this area. It is estimated that there may be thousands of hill tribe people including Karen, Akha, Lahu (Museur), Lisu, and Yao 1 . They have their own languages, cultures, ways of dressing and beliefs. Hill tribe people grow rice, corn and other agricultural products on mountainsides, living in rural remote areas, and have limited access to health services. The oral health status of elderly people has been gaining more importance in both developing and developed areas because this population segment is growing rapidly due to extended life expectancy. Dental caries and periodontal disease are the two major diseases found in the oral cavity. According to Reichart and Gehring 2 , the prevalence of dental caries in >50-year old hill tribe people of northern Thailand was quite low with a mean DMFT (Decayed, Missing and Filled Tooth) score of 0.2. No information regarding Asia Journal of Public Health, July-December 2010 Vol.1 No. 2 12 periodontal health was reported in this group at that time. At present, contact and trade between hill tribes and local natives has become frequent. Modernization has increased, causing many changes to the lifestyle of these people as well as affecting their health. Thus, the aim of this study was to determine oral health status in this group of hill tribe people residing in Mae Sot. MATERIALS AND METHODS The study was performed in February, 2008 in five relatively isolated hill tribe villages in Mae Sot after approval by the village committees and in accordance with Helsinki Declaration. They were Poo Tor, Rom Glao Sahamitr, Pa Dae, Koon Huay Mae Sot, and Huay Pla Lod villages. After giving their verbal consent, a total of 90 villagers aged 54-80 years agreed to participate in this study. We used 50 years of age and older as our definition of elderly, which is different from the general criterion of 60 years and older. The reason for this is based on the traditional social roles and functional abilities related to work and health status of this studied population. The dental examination took place in the village where they lived and was performed by one dentist from the Faculty of Dentistry, Mahidol University, Thailand. The study participants were comfortably placed on a chair in front of the examiner, both sitting. Examinations were performed with the aid of dental mirrors and ball point periodontal probes (Martin, Solinger, Germany) under natural light. The dental caries experience was measured by the DMFT index according to criteria recommended by the WHO, 1997 3 . Periodontal status was assessed using the Community Periodontal Index (CPI). The ten index teeth examined consisted of four upper molars, four lower molars, one upper incisor and one lower incisor (17, 16, 11, 26, 27, 37, 36, 31, 46 and 47). Each sextant containing at least two functional teeth was assigned a code number. The condition of the worst affected site in the sextant was recorded. Plaque and calculus was evaluated on all four surfaces of central incisors, canines and first molars. If one of these teeth was absent, the tooth distal to that was examined. Plaque and calculus were identified by means of a probe, sweeping the buccal, lingual (palatal), mesial and distal tooth surfaces. Bleeding on probing was recorded as present or absent after probing at each probing site on the same teeth that were scored for plaque and calculus. Pocket depth was measured from the free gingival margin to the base of the sulcus. The subjects were classified according to the highest code number (codes 0-4) assigned to any sextant of their mouth 4 . The data were analyzed using analysis of variance and Chi-square test to evaluate the statistical significance between variables. RESULTS The study population comprised elderly people from five villages, 28 from Rom Glao Sahamitr Village, 18 from Poo Tor Village, 23 from Pa Dae Village, 11 from Koon Huay Mae Sot Village, and 10 from Huay Pla Lod Village. Demographic data of subjects are shown in Table 1. Table1 Demographic characteristics of elderly hill tribe people. Villages Tribes Gender Age male female 51- 60 61- 70 > 70 1. Poo Tor (n=18) Karen 14 4 10 8 0 2. Rom Glao Sahamitr (n=28) Lahu, Lisu, Yao, Akha 17 11 13 13 2 3. Pa Dae (n=23) Karen 8 15 1 16 6 4. Koon Huay Mae Sot (n=11) Karen 6 5 8 2 1 5. Huay Pla Lod (n=10) Lahu 3 7 6 3 1 There were more males (53%) than females (47%). Almost all of these hill tribe people had never accessed dental health care services. Only one male reported that he had his tooth filled at a local hospital almost 20 kilometers down from the village. Very few (11%) had toothbrushes and among those who had a toothbrush, only 27% brushed their teeth twice a day. Interestingly, almost all of them (94%) disclosed that they chewed betel quid every day after meals. Seven (8%) were edentulous. The prevalence of dental caries in all the elderly hill tribe villagers was 78% with a mean DMFT-score of 6.53 + 6.32. Median and mean DMFT-scores in each village were shown in Table 2. No significant differences in DMFT-score were found between males and females. Even though those in Pa Dae Village showed the highest mean DMFT-score, no significant differences in DMFT-score were found among the villages. Asia Journal of Public Health, July-December 2010 Vol.1 No. 2 13 Table 2 Distribution of elderly hill tribe people by dental caries experience. Villages Decayed teeth Missing teeth Filled teeth DMFT* Edentulous median mean+ SD median mean+SD median mean+SD median mean+SD 1. Poo Tor 2.2 0.77+ 1.98 3 2.72+3.49 0 0 3 3.50+3.95 0 2. Rom Glao Sahamitr 5 2.32+ 2.65 5 3.96+5.61 0.5 0.04+0.20 2 6.65+6.32 2 3. Pa Dae 0 0 14 11.85+10.30 0 0 14 11.85+10.30 3 4. Koon Huay Mae Sot 0 0 5 4.70+ 6.07 0 0 5 4.70+6.07 1 5. Huay Pla Lod 3 1.33+2.23 2.5 2.33+3.57 0 0 2.5 3.66+5.59 1 * DMFT = Decayed, Missing and Filled Teeth Table 3 Distribution of elderly hill tribe people by periodontal health. Villages CPI Healthy Bleeding on probe No. (%) Calculus No. (%) Pocket 4-5 mm No. (%) Pocket >6 mm No. (%) median mean+SD 1. Poo Tor 2.15 2.14+0.23 0 18 (100) 18 (100) 9 (50) 3 (17) 2. Rom Glao Sahamitr 2.00 1.93+0.32 0 26 (100) 26 (100) 7 (27) 0 (0) 3. Pa Dae 2.20 2.11+ 0.07 0 20 (100) 20 (100) 4 (20) 1 (5) 4. Koon Huay Mae Sot 2.35 2.17+ 0.22 0 10 (100) 10 (100) 4 (40) 0 (0) 5. Huay Pla Lod 2.00 2.05+ 0.14 0 9 (100) 9 (100) 3 (33) 0 (0) The assessment of periodontal status (Table 3) according to CPI demonstrated that all hill tribe villagers had periodontal disease with the mean CPI-score of 2.06 + 0.32 and had calculus indicating poor oral hygiene. Almost all of them had moderate gingival inflammation according to the classification of Loe, 1967 5 . No statistically significant differences in CPI-score were found among the villages or between males and females. DISCUSSION No comprehensive data were available for caries and periodontal status among elderly hill tribe villagers in Mae Sot District, Thailand. The data collected showed poor oral health conditions among the hill tribes. All self-care oral health habits were excessively poor with high percentages of not having toothbrush (89%) and inadequate oral hygiene-related habits such as regular toothbrushing. Most of them performed oral hygiene procedures by sanding or polishing teeth with betel nut shell, charcoal powder, salt, and miswak or chewing stick. The mean number of caries expressed as the DMFT-score was found to be 6.53 of which the missing component was 5.5. Our results were different from those of the previous Turkish or Western Australian studies which reported higher DMFT-scores of 29.3 and 9.8 respectively. The major factors to explain these situations were the characteristics of the people and lifestyle. These hill tribe villagers lived on mountainsides isolated from urban areas with a high fluoride level in the water. In addition, their diet consisted of food grown on small plots of land and taken from the surrounding forest. Their diet included highly abrasive food while excluding those consisting mostly of refined carbohydrates, and included such foods as rice, chili paste with fermented soy bean, salt and vegetables. Consumption of meat was infrequent. The previous study of Reichart and Gehring in 1984 2 showed that the mean DMFT-score of northern elderly hill tribe villagers in Chiang Mai Province of Thailand was 0.2. We hypothesize that the increase in DMFT- score among these hill tribes from that reported in 1984 may be the effect of modern lifestyle invading their way of life such as advertising media that influenced them to access commercial cariogenic foods and beverages. In this study, two results were found to be similar to other studies 6-8 . First, the same percentages of males and females were edentulous. Second, all of these edentulous elderly and those with missing teeth reported tooth mobility due to loss of tooth support, the sign of periodontal disease. Other studies 9-10 have confirmed that periodontitis is the major cause of tooth loss commonly found in elderly population groups in many countries. Nevertheless, tooth loss was not found to be as widely prevalent as in other studies. The percentage of edentulism in this group of hill tribe villagers (8%) was much lower than the previous reported rates of 67.4% and 16-30% among the Turkish 7 and German subjects 11 , respectively. Asia Journal of Public Health, July-December 2010 Vol.1 No. 2 14 Conversely, it was quite closer to that reported for the elderly people in Southern Australia (3%). The reason may be the severity of periodontal disease in this group was quite low. Less than half of them (40%) had tooth pockets and very few (4.8%) had a pocket depth >6 mm. Even though periodontal disease was a significant health problem facing these hill tribe villagers, oral health was generally perceived to be of lower importance than physical health. According to a study among the elderly in Italy, though the level of self-reported problems such as pain and tooth mobility was high, only a small proportion of people requested dental care 12 . The habit of chewing betel quid (Areca catechu L.) was found in all individuals. Chewing betel quid is a traditional ritual which dates back thousand of years from South Asia to the Pacific. It constitutes an important and popular cultural activity in many Asian and Oceanic countries, including Thailand. Many studies have proven that regular chewing of betel quid is a risk factor for gum disease and oral cancer 13 . Betel quid generally consists of areca nut, piper betel leaf, and slaked lime. An experimental study showed that areca nut extracts impaired human gingival fibroblast functions by depleting intracellular thiols and inhibiting mitochondrial activity, supporting the concept that betel quid chewing may affect periodontal health status 14 . Additionally, areca nut extracts favor the colonization of periodontopathogens and interfere with the microbial mechanisms of neutrophils, suggesting that areca nut extracts might increase periodontal infection 15-16 . Hence, the chewing of betel quid may play an important role in the deterioration of oral hygiene and the increasing prevalence of periodontal diseases found among the participants in this study. Due to their minority status, hill tribes are not fully recognized in governmental resource allocation for public health services. Treatment of dental caries and periodontal disease is expensive and has been inaccessible to these hill tribe elderly villagers in Mae Sot. The long distance from health services forces them to stay in the village and seek traditional herbal remedies. Most hill tribe villagers have traditional knowledge of medicinal plants and they prefer using them as first aid remedies to treat illnesses such as cough, toothache or bleeding gums. Among those reported herbal medicines are Ya Kho (Nicotiana tabacum L.,) and Ba Ko (Illicium Hook .f.) used by cooking with chicken to treat a sore tooth or by chewing daily as preventive medicine 17 . In conclusion, the data show caries and periodontal diseases experienced in 90 elderly hill tribe villagers in Mae Sot, Thailand. Generally, the oral health was quite poor. Periodontal disease was a major oral health problem though they did not request any dental care. The data could be used as base-line information for health authorities and dental professionals for planning strategies for oral health promotion, prevention, and treatment in this group of villagers. ACKNOWLEDGEMENTS The Faculty of Dentistry, Mahidol University was thanked for funding this study. We gratefully acknowledge the help of the Royal Patrol Police Bureau at Mae Sot, the hill tribe leaders and all of the study participants in Poo Tor, Rom Glao Sahamitr, Pa Dae, Koon Huay Mae Sot, and Huay Pla Lod Villages. CONFLICT OF INTEREST We declare that we have no conflict of interest. REFERENCES 1. Ministry of Social Development and Human Security. Highland communities within 20 Provinces of Thailand. Bangkok: Ministry of Social Development and Human Security, 2002. 2. Reichart P, Gehring F. Streptococcus mutans and caries prevalence in Lisu and Karen of Northern Thailand. J Dent Res 1984; 63: 56-8. 3. World Health Organization. Oral Health Sur- veys: Basic Methods, 4 th ed. Geneva: World Health Organization, 1997. 4. Karikoski A, Ilanne-Parikka P, Murtomaa H. Oral health promotion among adults with dia- betes in Finland. Community Dent Oral Epi- demiol 2003; 31: 447-53. 5. Loe H. The gingival index, the plaque and the retention index. J Periodontol 1967; 38: 610-6. 6. Saub R, Evans RW. Dental needs of elderly hostel residents in inner Melbourne. Aust Dent J 2001; 46:198-202. 7. Unluer S, Gokalp S, Dogan BG. Oral health status of the elderly in a residential home in Turkey. Gerodontology 2007; 24: 2-9. 8. Kruger E, Smith K, Atkinson D, Tennant M. The oral health status and treatment needs of indigenous adults in the Kimberly region of Western Australia. Aust J Rehab Health 2008; 16: 283-9. 9. Quteish Taani DS. Periodontal reasons for both extraction in an adult population in Jor- dan. J Oral rehabil 2003; 30: 110-2. 10. Meyer MS, Joshipura K, Giovannucci E, Mi- chaud DS. A review of the relationship bet- ween tooth loss, periodontal diseases, and cancer. Cancer Causes Control 2008; 19: 895- 907. 11. Muck F, Mojon P, Budtz - Jorgensen E, Ko- Asia Journal of Public Health, July-December 2010 Vol.1 No. 2 15 cher T, Splieth C, Schwahn C, et al. Caries and periodontal diseases of the elderly in Po- merania, Germany; results of the study of health in Pomerania. Gerodontology 2004; 21: 27-36. 12. Pizzo G, Guiglia R, Gallo P, D’ Angelo M, Giuliana G. Request of dental care and perio- Dontal treatment needs in a population sam- ple of Palermo. Minerva Stomatol 2002; 51: 35-9. 13. International Agency for Reserch on Cancer. IARC Monographs on the evaluation of carci- nogenic risk to humans. Betel-quid and areca- nut chewing and some areca-nut derived ni- trosamines, 2004. 14. Chang YC, Hu CC, Lii GK, Tai KW, Yang SH, Chou MY. Cytotoxicity and arecoline mechanisms in human gingival fibroblasts in vitro. Clin Oral Invest 2001; 5: 51-6. 15. Hung SL, Chen YL, Wan HC, Liu TY, Chen YT, Ling LJ. Effects of areca nut extracts on the functions of human neutrophils in vitro. J Periodontal Res 2000; 35: 186-93. 16. Ling LJ, Hung SL, Tseng SC, Chen YT, Chi LY, Wu KM, et al. Association between betel Quid chewing, periodontal status and perio- Dontal pathogens. Oral Microbiol Immunol 2001; 16: 364-9. 17. Inta A, Shengji P, Balslev H, Wangpakapatta- nawong P, Trisonthi C. A comparative study on medicinal plants used in Akha’s traditional medicine in China and Thailand, cultural co- herence or ecological divergence? J Ethno- pharmacol 2008; 116: 508-17. . periodontal status among elderly hill tribe villagers in Mae Sot District, Thailand. The data collected showed poor oral health conditions among the hill tribes Conclusion: The oral health status of the elderly hill tribe villagers in Mae Sot, Thailand was quite poor. Periodontal disease was a major oral health problem