Tone Oral health status and oral health behaviour of urban and rural schoolchildren in Southern Thailand Poul Erik Petersen Copenhagen, Denmark Niels Hoerup Aarhus, Denmark Nattaporn Poomviset, Janpim Prommajan and Achara Watanapa Hatyai, Thailand ‘Aim: To describe the level of oral disease in urban and rural schoo children in Southern Thailand; to analyse self-care practices and dental Visiting habits of 12-year-olds, and to assess the effect of socio-behav- ioural factors on dental caries experience. Design: A cross sectional study of 6- and 12-year-old children, urban and rural schools chosen at random from 19 districts of one province. Setting: Suratthani Province, Southem Thailand. Participants: A total of 1,156 children of grade 1 (6 yrs) and 1,116 children of grade 6 (12yrs). Methods: Clinical recordings. of dental caries and periodontal CPI scores 0, 1 or 2 according to WHO; structured interviews of 12-year-olds (n=1,084) concerning oral health behaviour and attitudes. Results: At age 6, 96.3% of children had caries and mean dmft was 8.1. In 12-year-olds, 70% had caries in permanent teeth and the level of DMFT was 2.4. Experience of pain during the previous 12 months was reported by 53% of 12-year-olds, 66% saw a dentist within the previous year and 24% reported that visits were due to troubles in teeth. Toothbrushing at least once a day was claimed by 88%. Significant numbers of the children reported having hidden sugar every day: soft drinks (24%), milk with sugar (34%), and tea with sugar (26%). Important predictors of high caries experience were dental visits, consumption of sweets, ethnic group (Muslim) and sex (giris) whereas lower risk was observed in children with positive oral health attitudes. Conclusions: Systematic health education may further improve the oral health of Thai children and the primary school provides a unique setting for such programmes. Key words: Oral epidemiology, self-care, dental visits, oral health proma- tion, schoolchildren in Thailand Correspondence to: Professor Poul Erik Petersen, University of Copenhagen, Facuity of Health Sciences, Department or Community Dentisty, 20Norr@ lle, OK 2200 Copenhagen, Denmark. E-malipep@odort ku.dk ‘2001 FDIWona Dental Press 7 Over the past two decades a marked decline in dental caries experience of children has been observed in many industrialised countries’, The widespread use of fluorides, especially in toothpaste: improvements in oral hygiene, changing patterns of sugar con- sumption, changes in diagnostic ria, and the preventive and restorative efforts by dental health services are often considered the main reasons for the decline in dental caries’. The possible role played by broad socio-economic factors has also been highlighted and studies of caries reductions have shown that dental services as such had little effect on caries prevalence, Against this, increasing levels of dental caries have been found in some developing countries, especially for countries where preventive programmes have not been established. In Asia, the prevalence of dental caries in chil dren is reported to be low to moderate‘, For example, in the People’s Republic of China the mean caries experience of 12-year~96 olds has been observed at 1.1-1.9 DMFT". Tt is worth noting, however, that the D-component constitutes most of the caries index. Moreover, gingival health status and oral hygiene habits of children seem poor. In Thailand, the Fourth National Oral Health Survey was conducted in 1994". ‘The dental caties level of 12-year old children was lower (1.6 DMET) than the figure recommended by the World Health Organization being the goal for oral health for the year 2000 that is at age 12 n0 more than 3 DMFT should be found as an average. However, the proportion of caries free ‘Thai chil dren of ages 5-6 was remarkably lower (14.9 per cent) than the global standard of at least 50 per cent of young children being free of caries. This recent national oral health survey included information on the oral health status of certain age groups whereas no data were collected on oral health habits and use of professional dental services. In Thailand, the health authorities are in process of implementing schoolbased otal health care programmes for children and to gain experience, oral health systems research projects have been estab- lished in a number of provinces of Southern Thailand. Systematic data on oral health behaviour will be needed for the planning and evalu- ation of oral health education "Therefore, the purposes of the present study were to describe the actual level of oral disease among urban and rural schoolchildren of ages 6 and 12 years in Southern pailand; to analyse the self-care practices and dental visiting habits of schoolchildren aged 12; and to assess the effect of socio-behav- ioural factors on dental caries experience in the 12-year-old, Study population and methods ‘The population in ‘Thailand is 61.7 million, of whom 7.9 million reside in Southern Thailand. Approxi- uauavsia Figure 1. Map of study area. mately 70 per cent of the popula- tion of Thailand live in rural areas. Children under the age of 15 years account for 24 per cent of the popu- lation and the life expectancy at birth is 69.9 years for males and 74.9 years for females. The infant mortality rate is 22.4 individuals per 1,000 live births, ‘This survey was carried out in the Suratthani province of Southern ‘Thailand (Figure 1) and children were identified for the study by two-stage random sampling. In each of the 19 districts of the province, two primary schools (one urban and one rural) were chosen at random and at the second stage school classes of grades 1 and 6 were selected ‘The total sample then comprised 1,156 children at grade 1 (mean age 6) and 1,116 children at grade 6 (mean age 12) (51 per cent boys, 49 per cent girls). All children in classrooms were examined and clinical data were collected on dental status and dental caries as described by the World Health Organization (WHO)"*. The Com munity Periodontal Index (CPI) ‘was used to record the periodontal conditions in children of grade 6, however, the registrations only in: cluded score 0 (healthy), score 1 (Gingival bleeding), and score 2 (cal: ulus). ‘The clinical examinations were performed under natural day light using standard explorers, mic rors and the CPI periodontal probes. Prior to the study, the Thai dlinical examiners (AW, NP, JP) were calibrated against an interna- tional oral epidemiologist (PEP) and the Kappa statistics at the level 0.87 0.91 were achieved”. In addition, 1,084 grade 6 children participated in personal interviews conducted on the basis of a standardised questionnaire developed by the WHO Collabo: rating Centre for Community Oral Health Programmes and Research, University of Copenhagen", The response rate was 97 per cent. The questionnaire was translated from English into Thai and pre-tested prior to the actual survey, and the interviews were carried out by trained dental nurses and assistants, ‘The questionnaire included 23 questions on perceived oral health status, oral health attitudes, oral hygiene practices, dental visiting interational Denial Journal 200%) Val SUNO®Dabits, dietary habits, sex, residency, ethnic group (Buddhist, Muslim), education of parents and family characteristics. ‘The survey was completed by 1997 and the data were subse- quently analysed in the University of Copenhagen (Denmark) by ‘means of the SPSS system. The data were described by frequency distri- butions; means of dmft and DMFT ‘were calculated and the CPI scores ‘were computed according to the recommendations of WHO". ‘The level of education of parents was categorised into low (primary and unfinished secondary school), moderate (secondary school and unfinished special school), and high (pecial secondary school and bach- clot/university level). In order to study the associations between caries experience and socio-behav- ioural variables, a number of additive indices were constructed: attirades towards teeth (scores 4 16); attitudes towards dental care (scores 4-16); consumption of sweets (scores 4-22), and consump- tion of sugary drinks (scores 3-18). ‘The scales were designed to fit ‘the Guttman-scale model” and in the final analyses the various scales were then categorised empirically into three levels: high, moderate and low. In the bivariate analyses, the statistical evaluations of means were performed by use of the Student's ttest or ANOVA whereas propor- tions were evaluated by the Chi-Square test. In addition, multi- ple linear regression analysis” and logistic regression analysis were applied for the assessment of the relative effect of socio-behavioural factors on caries experience in the ‘12-year-olds. Ia the dummy regres- sion analysis, the caries experience index (DMFT) was used as the dependent variable. In the logistic model the dependent variable was Presence or absence of caries and thereby the regression coefficients indicates the odds ratio (OR = P/ L-P) of dental caries. For the statis- tical evaluation of the regression coefficients, the t-test was used in Table 1 The prevalence proportion ate (PP in pc’) and the mean 2times a 8 BB Avoidsmiingorlaughingbecausoottesth 17 2 19178 Friends make fun of my teeth wo 2 4 wo B Miss schoo class due to dental pain 00 6 6 the dummy regression whereas the Chi-Square test was chosen in the logistic regression. Finally, representative samples of dsinking water were collected and the content of fluoride was analysed potentiometricaliy; the fluoride level ‘was lower than 0.1 ppm. Results At age 6, 1.7 per cent of the chil- dren were completely free of dental caties and the figure was 13.2 per cent for 12-year-olds. Table 1 summarises the occurrence of dental caties among the children examined, In all, 96.3 per cent of the 6-year-olds had caries in the primary dentition and neatly 70 per cent of the 12-year-olds had caries in their permanent teeth. The mean number of teeth affected was 8.1 dmfe at age 6 and 2.4 DMFT at age Peter a a: Oral aah in Souther Thalland sohoolhdren98 ‘Table4 The percentages o! 12-year-old Thal children who had seen the dentist within he last 12 months and the treatment recelved at ther last dental visit in relation to Urbanisation and gender ‘Urban Furl Boys Gils Total (n=629) (n=645)_(0=852)_ (n=532)_(n=1084) ‘Had seen the dentist within the lat 12 months 1-2times S48 aa > times 6 0 7 8 Novisits Sk wk Palntioublewasroasonoflastvist 29 © 18 «2621 Treatmentreceivedatlastdentalvst: Examination foal 77a aa roe are) Oralhygieneinstruction 577 8. Toothextaction 6 2 % @ Fillngs w» 2 8 2 # Romovalofcalculus v1 8 2 8 Gumtreaiment ieee a7 9 Fluoride application 7 9 8 9 8 Xnay eos 3 Onhodonticcare 3 2 2 38 3 Others Sle ee eat 3 ‘Tables Tho porcontages of 12-year-old Thal children who claimed certain teotheleaning practices inreisionto urbanisation andgender Rural Gris Total Boys. (0=599) (n=545) (n=852) (592) (n=1084) ‘Urban “Teathinushing twice a day 9 once a day 10 several times a weck 9 less often 2 Use of fuoride toothpaste 85 Use of wooden toothpicks 46 Uso of chowstck /Miswak 15 7% 67 OF n 1% 6 OH 11 8 OO 2 3 7 2 ole fonts | cole) oe ee ee 8 ‘Tables Tho 12-year-old Thal children cistributed (pct) according to frequency of consumgtion ‘of various foods and drinks (n= 1084) Several Daily 2-4 Once Several Never times times a timesa awoek week month Fresh rut os 2 @ 8 3 1 Biccutsicakesete. 4 3 twa damfroney ieee Se oa ‘Swoats 7 2 # 1 9 3 ‘Chewing gum with sugar 6 2 6 19 6 98 Lomonade,CocaCola,sotcrineks § = 1831 ‘Mik with sugar 8 2 7 2 9 8B Tos with sugar 5 2 6 45 12; the d/D components were dominant in both age groups. In the bivariate analyses only minor differences in dental caries experi- ence were found according to location and gender. Table 2 illus- trates that nearly half of the 12- year-olds had maximum CPI score 2 and on average 1.2 sextants had score 2; the total of 89.6 per cent of the children had gingival bleed- ing and calculus (score 1+2). ‘Table 3 presents the percentages of 12-year-old children who claimed various conditions of their teeth. Approximately 10 per cent of the children answered that their teeth were poor, nearly 20 per cent reported that they avoid smiling or Iaughing because of teeth, and 10 per cent of the children indicated that friends made fun of their teeth. More than half of the 12-year-olds declared that they had experienced pain or discomfort from their teeth during the previous 12 months ‘Two thirds of the children had seen the dentist within the previous 12 months and a quarter of the chil dren answered that they saw the dentist because of pain or acute problems (Table 4), Pain or trouble were reported mote often by urban children than children living in rural areas (P<0.01), and more urban children also answered having received tooth extraction at their last dental visit (P<0.05), (Table 4), Table 5 shows that most chil dren cleaned theie teeth twice a day and 9 out of 10 children claimed to use fluoride toothpaste. Signifi- cantly more Buddhist children (79 per cent) than Muslim children (55 per cent) reported toothcleaning at least twice a day (P<0.01). In all, 45 per cent reported the use of wooden toothpicks whereas tradi- tional chewsticks or Miswak were indicated as used by one fifth of the children. Chewsticks or Miswak were more frequently used in rural areas (P<0.01) and among boys (P<0.01). Table 6 describes the distribution of children aged 12 by frequency of consumption of sugary items. Hidden sugar in the form of soft drinks, milk with sugar and tea with sugar were often consumed and 30 per cent of the children had sweets on a daily basis. Table 7 highlights the dental attitudes of children; in general, the children had positive attitudes towards teeth and dental care, however, nearly 30 per cent of the children answered that they were afraid of going to the dentist because of possible pain. As shown in Table 8 most children had been informed about dental health by their parents, schoolteachers and the dentist. Table 9 presents the results of the multivariate analyses of dental caties experience in the 12-year-old ‘Thai children. Other factors being equal, significantly higher DMF scores were observed for gitls, Intemational Denial Journal (2001) Vol StINO®‘Table The dietbution (14) of 12 year-old Tha cldren by responses to statomonts on dental diseases: andprevention(n=1084) ‘Agree Disagree _Don'tknow 6 “Tooth decay can make me lookbad Keeping naturaltoethisnotthat important Falge leeth willbe lass of abother than naturalteoth T'matraidot going o the dentist because ofpossible pan Regularvststothe dentistkeep away dental problems Brushingmy teeth can preventtooth decay Brushing iy teeth wil keep me from having trouble with my gums. Eating andrnking sweet things doesnot cause oath decay Using varie isa good way of proventing tooth decay 2 2 ar ra 7 8 2 a Table 8 The percentages of 12-year-old Thaichlaren who reportedthatthey ad information about dental healt from various, sourcesinrelationto location oanad8Be8 urban Rural ‘Total (9589) (7545) _(n=1084) Parente 9 a 8 Teachers 7 7 a Dentist % B B TwiRado 55 8 55 Relatives 4 ow 3s Medical doctor 2 28 w Dentist's assistant 34 at a Newspapers! magazines 25, ey a Meaical nurse 2 28 26 Fronds 1 18 13 Ginema el 6 7 Video 4 7 6 omnes 3 4 3 ‘Table Multivariate analyses of dental cares experience (DMFT) and caries riskby socio- behavioural variables 12-year-old Thaichidren (n=1084), Regression coefficients (@) and ‘Odds Ratio (OR) are spectioa Tndopendent variable OF Gonder Location ‘Annual drtalvist Frequency toothbrushing Consumptionot sweets ‘Consumption sugary drinks Atitudestowardsteeth Attudestowards dentalcare Etmnicgroup Father's leveloteducation DMFT irs 028" Boys 5 ural oot Urban - Yes 053" No - Moreottenthanonceaday -0.004 Daly 03 Lesson than daly * High 08 Moderate ona tow < Hah 109 Moderate 022 tow S Vveryhigh sar High “O95 Moderate oer ae S High os Moderate “ore Low E Musi oar Busdhist - Don'tirow oss: Low oar" Moderate “oot Hin : 10" 0 135 ost ost 135 118: 13 089 ost oar 090 108 085. 18 20% 128 108 Pe0.05;"Pe0.01 ‘ater a as ral aah in Sather Thaland sehoolhigran100 ‘Muslim childeen, children with high consumption of sweets, and chil- dren with annual dental visits, whereas children living in rural areas had lower DMFT. Father's level of education also had some effect on dental caries among the children. Frequency of tooth- brushing had no significant impact on dental caries experience, how- ever, positive attitudes towards teeth and dental care implied lower DMFT scores. In addition, gis and children with annual dental visits had higher odds of caries (OR) while children with positive atti tudes towards teeth had lower caries risk, Discussion In Thailand, a number of oral epidemiological studies have been cattied out during recent years, however, systematic data on oral health behaviour of children are scarce. The present survey provides such information as regards to 12- year-old urban and rural children and emphasis was given to assess the relative effect of socio-behav- jioural tisk factors on dental caries experience. The survey was not conducted on a national scale and therefore the data are not repre~ sentative of the country in pure statistical tetms. Nevertheless, the population groups examined are assumed to be relevant for com- parison of urban and rural children in most communities of Thailand. In this study the external validity of results was ensured by random selection of both urban and rural schools identified from the list of all primary schools in the province. ‘The examinations of oral health status were carried out according to the WHO standard methods and ctiteria, therefore, comparisons of the data with similar studies would be possible. After completion of the calibration trials the inter- ‘examiner consistency of recording dental caries was high”, however, concerning validity of recordings the use of daylight during examina- tions could have resulted in an underestimation of dental caries. In 1994, the national oral health survey of Thailand reported the following figures! At age 6, 85.1 per cent of children were affected by caries in the primary dentition and the mean dmft was 5.7. For the 12-year-olds, the mean caries experience was 1.6 DMFT. ‘The national survey in 1994 indicated that the level of dental caries was substantially higher in Southern ‘Thailand than for other regions and that the mean caries experience was higher among urban children than rural children. Both observations ‘were confirmed by the findings of the present study, In a previous report” on 11-13-year-old school- children of Southern Thailand (Songkla) no difference in the total caries experience was found by urbanisation but urban children tended to have a prominent F- component as compared with the rural children. Such difference in the components of the caries index was not shown in the present survey. ‘The results from recording of the periodontal conditions of the ‘Thai children correspond fairly well to the CPI data on children in Indonesia”. Half of the ‘Thai chil- dren studied had gingival bleeding and calculus, reflecting poor oral hygiene. ‘The information on oral health attitudes and behaviour was collécted by means of interviews and due to the school-based approach a high response rate was obtained. However, the data collection method | may have certain limitations. With regard to attitudes towards tecth and dental care, oral hygiene habits and frequency of dental visits, over reporting has to be assumed whereas the consumption of sugiry foods and drinks has prob- ably been under reported. In addition, tecall bias should be considered with respect to consumption of food items and services received at the last dental visit, All in all, the present survey provides an overview of oral health behaviour and attitudes at the population level. ‘The data on self- assessment of oral health status showed that half of the 12-year- ‘olds complained of pain or diseom- fort and a significant number of the ‘children claimed several psycho-social implications of having poor teeth. Those responses are higher when compated to simi- lar surveys cattied out in China”, but they possibly reflect the higher prevalence of dental caries in 12- ‘year-olds in Southern Thailand, The higher level of dental caties in urban areas also explains the fact, that these children reported moze oral symptoms. In urban as well as jin rural areas, two thitds of the children had seen the dentist within the past year and visits were often prompted by experience of disease ‘or symptoms. Again telatively more urban children reported that their last visit was due to pain or acute problems, and half of the urban children reported to have experi- enced a tooth extraction compared with one third of the rural chil dren, In general, dental fillings were seldom offered but remarkably high percentages of the children answeted that they had received oral hygiene instruction. As to self-care practises, no significant differences in the frequency of toothbrushing were found by urbanisation, three quarters of the children brushed theie teeth at least twice a day and the majority of children claimed to use fluoride toothpaste. The girls were more likely to report that they cleaned their teeth at least twice a day and chewsticks were often used for cleaning among boys. The Miswak chewstick is recommended for cleaning of the teeth and mouth by Muslims and the present study showed that this traditional means of tooth cleaning was used by more tutal children, reflecting the fact that most Muslim children are found in rural areas. ‘The consumption of sweets was Intemational Dental Journal 200%) Va. StINO®401 relatively high when compared to similar surveys carried out in the region!*", particularly with respect to hidden sugar or sugary drinks. "This is in contrast to the observa- tion that most children seem to be aware of the negative effect of sugar. Various indices on attitudes and behaviour were constructed to provide for the smultivariate analy- ses of dental caries experience. Ia accordance with previous find- ings™, the multi causal nature of dental caries was confirmed by the results. After controlling for confounding variables, the most important predictors of high caries experience were dental visits and consumption of sweets, and signifi- cantly more caries was found among Muslim children and giels. Other factors being equal, signifi. cantly lower tisk of dental caries was observed for rural children and for those children who had posi- tive attitudes towards teeth and dental cate As to the further improvement of oral health in That children, health education therefore may play an instrumental role. Parents, schoolteachers and dentists were identified by the survey as being the most important key people in health communication and they should be targeted by the commu- nity ofiented health promotion programmes. In addition, a signifi- cant umber of respondents indicated that they were informed about oral health through TV ot radio and the relevance of using mass media is hereby shown. Finally, the primary schools also have great potential for influencing oral health behaviour, dental atti- tudes and self-esteem of young children®**, Such children spend considerable time in schools and can be reached at a life-stage when their health habits are being formed. ‘The schoolbased oral health programmes established in Southern ‘Thailand also include systematic oral health education and activities are integrated with general health education. The intention of the present project is to conduct follow-up studies of children in order to measure the oral health ‘outcomes. Acknowledgement The present study was supported financially by the Danida (Danish International Agency for Develop- ment) and the WHO Collaborating Centre for Community Oral Health Programmes and Research, Univer- sity of Copenhagen, Denmark. References 1. Marthaler TM, O’Mullane D, Vbsic V.'The prevalence of dental exis in Burape 1990-95, Caries Res 1996 30: 237-256. 2. Bure BA, Trends in caries preva lence in North American childeen. Int Dens J 1994 44: 403-413. 3. Brauhall D, Hinsel-Petersson G, Sundberg H. Reasons for the caries decline: what do the experts believe? Eur J Oral Sci 1996 104: 416-422. 4. Nadaoovsky P, Sheiham A. Relative consribution of dental services to the changes in casies levels of 12. year-old chiizea ia 18 industrial- ized countries in the 1970s and the ceatly 1980s. Commanity Dent Oral Epidemiol 1995 23: 331-339. 5, Sheikam A. Impact of dencal treat ment oa the incidence of dental cates in children and adults. Coa manity Dent Oral Epidemiol 1997 25: 10112, 6, Nithila A, Bourgeois D, Barmes DE al, WHO Global Oral Data Bank, 1986-96: an overview of oral heslth surveys ar 12 years of age. Balesin of the World Health Organization 1998 ‘6: 237-244, Petersen PE, Raranamiaja N. Oral Ihealth status of children and adults jin Madagasear. Inf Dent J 1996 41-47. 8. Petersen PE, Kaka M. Oral health status of children and adules ia che Republic of Niger, Afsica, Jn? Des J 1999 49: 159-164, 9. Shi ¥, Barmes D, Beatthall D, et 2k WHO pathfinder caries survey in Beijing extended with data fox preva. lence af Muans Streprococti. Int Dewt J 1992 42; 31-36, 10. Hu DY, Lin DW. Trends of earies 4 12. 13, 16 17 18 19, 20, 23 prevalence and experience in chil- dren in Chengdu City, West China, 1982-90. Community Dent Oral Epidemiol 1992 20: 308-309, Petersen PE, Guang LX. Dental caries experience in a group of schoolehildzen in Wohan City, PR China, 1993. Community Dent Oral Epidemiol 1994 22: 465-866, Peng B, Petersen PE, Ming-Wen F, ef al. Oral health status and oral health behaviour of 12-year-old turban schoolehilden in the People’s Republic of China. Community Dent Health 1997 14y 238-244, Petersen PE, Esheng Z. Dental caries and oral health behavioussita- ation of children, mothers and schoolteachers ia Wuhan, People’s Republic of China. Int Dont J 1998 48: 210-216, Ministry of Public Health. The Fours Natiowal Oral Health Survey, 1994. Bangkok: MOPH, Dental Health Division, 1996, sderation Dentaire Internationale/ World Health Oxganisatioa, Global {goals for oral health in the yeas 2000. Int Dent ] 1982 32: 74-77 World Health Organization. Oral Iealth tree, Basie Methods, Genevs: WHO, 1987 Wond Health Organization. Calfra- sion of examiners for oral beth epidana- Legical arse. Geneva: WHO, 1993. WHO Collaborating Centre for Communigy Oral Health Programmes and Research. Basie questionnaire for interviewing children. Copenages: University of Copenhagen, 1995. Petersen PE. Guttman seale analy sis of dental health knowledge and attitudes. Commanity Dent Oral femio! 1989 M7: 170-172 Salas-Wadge MH. Use of linear multiple regression analysis on dental survey data, Community Dent ‘Hialth 1994 Me 197-201 Hall GH, Round AP. Logistic regression — explanation and use. J Royo! Coll Physicians Landon 1994 28: 242-246. ‘Teanpaisan R, KintarakS, Chuncharoen C, 4 ah Mutans streptococci and denral caries ia schoolchildren in Southern Thailand. Coumanity Dent (Ona! Epidenrie) 1993 23: 317-318, Morgan MV, Wright FAC, Mateam 2N, st al, The oral health starus and health behaviour of 12 and 15 year old adolescents in Jakarta, Indone- sia, Conmanity Dent Heals 1992 9: elesan als Ora heath n Souther Thala sekooaniaren402 171-179, with children and adolescents. In tive oral health care and health pro- : 24, Petersen PE. Oral health behaviour Schou L, Bliakhora A. Orsi Health ‘motion provided for children and among 6-sear-old Danish childseo. Promotion. Oxford: Oxford Univer- adolescents by the Municipal Dental Acta Odontol Scand 1992.50: 57-64. sity Press, 1993 Health Service in Denmark. Int J 25,Honkala E. Oral health promotion 26, Petersen PE, Torres AM. Preven Paediaor Dent 1999 9 81-91 International Donal Jounal (2001) Vol 57ND?