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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 207-213

Oral health status and treatment needs of internally displaced persons


1 Department of Preventive Dentistry, Faculty of Dental Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
2 Department of Child Dental Health, Faculty of Dental Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
3 Department of Preventive Dentistry, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria

Date of Submission21-Apr-2018
Date of Acceptance02-Jul-2018
Date of Web Publication29-Nov-2019

Correspondence Address:
Dr. Kehinde Adesola Umeizudike
Department of Preventive Dentistry, College of Medicine, University of Lagos, PMB 12003, Idi-Araba, Lagos
Nigeria
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DOI: 10.4103/smj.smj_19_18

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  Abstract 


Background: Internally displaced persons (IDPs) from North Eastern Nigeria have limited access to dental health facilities. Information on their oral health problems is limited. There is a need to determine their oral health status and treatment needs. Objectives: The objective of this study is to assess the oral health status and treatment needs of persons in an IDP camp and provide needed oral health services. Materials and Methods: A descriptive cross-sectional study among adults and their children in an IDP camp in Lagos. Pro forma with sections on biodata, oral hygiene practice and status, and periodontal parameter was used. Descriptive statistics were used in data analysis, with P < 0.05 considered statistically significant. Results: One hundred and twenty-three individuals (67 adults and 56 children) were seen. Mean age was 16.7 ± 12.8 years, adults were 28 ± 4.9 years, and children were 3.8 ± 3.1 years. Females represented 61%. Most (68.7%) adults had secondary school education, while most children (73.2%) had not commenced formal education. Fewer (41.7%) brushed twice daily. Only 8.5% had visited the dentist. Overall caries prevalence was 20.3%, and mean Decayed, Missing, and Filled Teeth (DMFT) was 0.7 ± 1.7, while the mean dmft for children with primary teeth was 0.3 ± 1.0. Mean DMFT was significantly associated with the past dental visits (P = 0.003) and presence of at least one oral condition (P = 0.000). The restorative index was zero, while unmet treatment need was 76.7%. Low dental treatment index was 30.6%. Of the 30.1% with toothache, only 16.2% sought treatment in the hospital. Sixty-three respondents received dental treatment in the form of scaling and polishing, fluoride therapy, atraumatic restorative treatment and extractions. Conclusion: The IDPs had a caries prevalence of 20.3% and a DMFT of 0.7 which were relatively low. However, their unmet treatment needs were high, coupled with a zero-restorative index. The IDPs benefited from free oral health-care services.

Keywords: Dental caries, internally displaced persons, Nigeria, oral health status


How to cite this article:
Umeizudike KA, Dedeke AA, Nzomiwu CL, Ekowmenhenhen UI. Oral health status and treatment needs of internally displaced persons. Sahel Med J 2019;22:207-13

How to cite this URL:
Umeizudike KA, Dedeke AA, Nzomiwu CL, Ekowmenhenhen UI. Oral health status and treatment needs of internally displaced persons. Sahel Med J [serial online] 2019 [cited 2019 Dec 7];22:207-13. Available from: http://www.smjonline.org/text.asp?2019/22/4/207/272138




  Introduction Top


Internally displaced persons (IDPs) are people forced or obliged to flee their homes or places of habitual residence as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized State border.[1] By the end of the year 2016, Sub-Saharan Africa accounted for the highest number of new IDPs from conflict and violence approximating 2.6 million new displacements, out of which >500,000 were reported in Nigeria. These were largely attributed to the persistent violence from the Boko Haram terrorist group in three major North Eastern states; Borno, Adamawa, and Yobe.[2] The number of IDPs in Nigeria has more than doubled in the space of 3 years, from approximately 868,000 people in the North-Eastern regions at the end of 2014–1.7 million people by June 2017.[3]

IDPs are often impoverished of their ordinary living environment in terms of security, community support, and access to food, water, and shelter.[1] They are placed in camps in which they face hazardous health conditions and develop health problems, many of which are associated with their difficult living conditions.[3] The basic requirements of good health including peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice, and equity [4] are seriously threatened and in many instances denied IDPs.

Health must be viewed holistically and includes oral health which is indispensable to general health. Oral health has more recently been defined by the World Dental Federation (FDI) as being multifaceted, including the ability to speak, smile, smell, touch, chew, swallow, and convey a range of emotions through facial expressions in confidence and without pain, discomfort, and disease of the craniofacial complex.[5] Health services should, therefore, include oral health facilities. As a consequence of the precarious living conditions of IDPs, their general and oral health may be far from optimal. This is buttressed by a report from Afghanistan, a developing country that highlighted the major challenges faced by refugees living with oral pain and untreated oral problems for extended periods.[6] The oral health experiences of these refugees highlighted their poor access to good oral health services including emergency dental care in their transit settings.

In Nigeria, the oral health awareness and utilization of oral health facilities are low even among the general populace [7] attributed to limited access from limited resources in the developing countries.[8] Little information exists on how the conflict and violence in the Northeast part of Nigeria affect the oral health experiences of IDPs in Nigeria. This study aimed to determine the oral health status and practice and treatment needs of IDPs from Northeastern Nigeria residing in a camp in South West Nigeria and also to provide free and quality oral health-care services to this group.


  Materials and Methods Top


Ethical approval was obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital before commencing the study on December 6, 2016, with the Assigned No: ADM/DCST/HREC/APP/1365. This was a descriptive cross-sectional study carried out in Ibeju-Lekki area of Lagos State in South West Nigeria. The study participants were IDPs from the Chibok Community in Borno State (North East Nigeria) who were kept in a camp. The study was conducted as part of a free dental outreach program initiated and supported by a nongovernmental association in Lagos State. A purposive sampling method was utilized for the study. Study participants who gave their consent and assent for their children were included in the study.

Interviewer-administered questionnaires were used to collect the data followed by oral examination. The questionnaire had four sections: Section A: sociodemography including age, gender, state of origin, highest level of education, marital status, and occupation; participants were further stratified into pediatric group (birth to 16 years) and adults (17 years and above).[9] Section B recorded the oral hygiene practices and attitude to oral health problems such as frequency of tooth cleaning, tooth cleaning aid, dental attendance pattern, and history of toothache.

Section C recorded oral findings using sterile dental mirrors, sterile disposable latex gloves, face masks, hand sanitizer, and artificial light source. The examination was performed in an enclosed area with participants seated on mobile dental chairs to ensure some privacy. Teeth present, carious teeth, restored teeth, mobile teeth, and tender teeth were recorded. The simplified oral hygiene index (OHI) by Green and Vermillion, Decayed, Missing and Filled Teeth (DMFT), dmft and gingival index by Silness and Loe were utilized. Participants with dental problems (pain, asymptomatic tooth cavities) received both emergency and preventive dental treatment on mobile dental units and improvised dental chairs at the temporary treatment center provided by the research team and supported by the nongovernmental organizations (NGOs). Section D recorded the type of dental treatment provided. Disposable latex gloves, disposable facemasks, dental mouth mirrors, and dental explorers were all used for the oral examination. The dental mouth mirrors and explorers were sterilized using an autoclave and prepackaged in sterilization pouches from the dental clinics of the researchers. Participants who needed advanced treatments were referred to dental centers at the Epe General Hospital and Lagos University Teaching Hospital, Idi-Araba for further management. Data were analyzed with Statistical Package for Social Statistics (SPSS) Version 21.0 (SPSS Inc., Chicago, Illinois, USA). The results were expressed as frequencies and percentages. Pearson Chi-square test of association and Fisher's exact test were used where appropriate. The level of statistical significance of P < 0.05 was considered to be statistically significant.


  Results Top


A total of 123 participants were seen and included 67 adults and 56 children. Mean age of the participants was 16.7 ± 12.8 years (range 1–45 years). Adults had a mean age of 28 ± 4.9 years (range 17–45 years) while children had 3.8 ± 3.1 years (range 1–16 years). Females represented 61% (n = 75) of the population. Most (68.7%) adults had secondary school education, while most children (73.2%) had not commenced formal education [Table 1]. Majority (84.6%) cleaned their teeth with a toothbrush and fluoridated toothpaste once daily, while only 39% brushed their teeth two or more times daily. Majority (91.9%) had never visited a dentist [Table 2].
Table 1: Demographic profile of participants

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Table 2: Oral hygiene practices of participants

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Over half (51.2%) of the participants had at least one oral condition. [Table 3] shows the distribution of their oral conditions. The overall caries prevalence was 20.3% (25.4% in adults and 14.3% in children). One participant had gingival recession on 12 teeth. Six participants (4.9%) had a total of 12 teeth that were tender to percussion. Mean DMFT was 0.7 ± 1.7 (0.9 ± 1.9 in adults and 0.5 ± 1.4 in children). Mean dmft was 0.3 ± 1.0. Untreated carious teeth were 69 [Figure 1]. The restorative index was zero. The overall treatment need of the participants was 75.8%, and the index of treatment failure was 24.2%. Unmet dental treatment need was 30.6%. [Table 4] shows that the mean DMFT was significantly associated with previous dental visits (P = 0.003) and presence of at least one oral condition (P = 0.000).
Table 3: Distribution of oral conditions among participants

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Figure 1: Distribution of carious teeth among study participants

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Table 4: Distribution of mean Decayed, Missing and Filled Teeth by demography, oral hygiene, and oral conditions

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The oral hygiene status was objectively evaluated in 101 participants, while gingivitis was recorded in 19 participants (15 females and 4 males) with a mean gingival index of 0.98 ± 0.61.

Chronic periodontitis was observed in six participants. About half (50.5%) had good oral hygiene, while 4.9% had a poor oral hygiene [Figure 2]. The mean OHI-score was 1.4 ± 0.8 (1.6 ± 0.8 in adults and 1.1 ± 0.8 in children). The mean OHI-S was significantly associated with age (P = 0.022) and the oral conditions (P = 0.000) of the participants [Table 5].
Figure 2: Oral hygiene status of participants

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Table 5: Distribution of oral hygiene by demographics, oral hygiene practices, and oral conditions

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About a third (30.1%) gave a previous history of toothache, out of which 16.2% sought treatment from a hospital, 27% had self-medicated, while 32.4% did not seek treatment. Twenty-six (41.3%) with a history of toothache had dental problems (pain and asymptomatic tooth cavities) at the time of oral examination compared to 11 (18.3%) without dental problems which were significant (P = 0.009). Of those with the previous toothache, only 5.7% had attended a dental clinic. One participant (0.8%) was a denture wearer. A total number of 63 participants received dental treatment during the dental outreach program [Figure 3].
Figure 3: Dental treatments performed on participants

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  Discussion Top


There is a dearth of literature on the oral health status of internally displaced people in Nigeria, despite the numerous publications on oral health among the general population. The present study was carried out to assess the oral health status, practices, and treatment needs of IDPs residing in a camp in Lagos, Nigeria and to provide some dental treatment to meet their normative treatment needs, so as to improve their quality of life. This is important considering the emphasis placed on good oral in promoting systemic health and general wellbeing.

The slightly higher preponderance of females and children in this study is in tandem with the National population commission's report in which 80% of the 3.3 million IDPs in Nigeria are women.[10] This is of some concern considering the fact that women and children are already vulnerable population groups.[3] This places them at a disadvantage. Moreover, vulnerable people are reported to have less access to general health-care services. Furthermore, people in IDP camps face precarious health conditions related to their living conditions and have poor access to health services.[3]

The IDPs had a dental caries prevalence rate of 20.3%, a mean DMFT of 0.7 ± 1.7 and mean dmft of 0.3 ± 1.0. This is comparable to the 22.1% reported in a study among rural dwellers in a community in Delta and Edo, South-South Nigeria comprising of both children and adults,[11] a mean DMFT of 0.67 in Port Harcourt.[12] The caries prevalence from our study is, however, lower than the 35.5% among a rural community in Enugu state, Nigeria.[13] The disparity in prevalence could stem from the age differences between both study populations, considering the fact that their population were predominantly school children aged 11–16 years. Children tend to have a higher caries experience compared to adult populations globally. Tooth decay has been reported to affect up to 60%–90% of schoolchildren compared to adults particularly in industrialized countries.[14] The relatively low levels of tooth decay in Nigeria is consistent with the WHO report of a lower frequency and severity in Africa.[14] This low caries rate among the IDPs necessitates positive reinforcement through improved oral hygiene care and fluoride use. Much higher caries prevalence rates have however been reported in other IDP populations in other countries. For instance, Selivany et al. in Iraq reported a prevalence of 86.5% and a mean DMFT of 3.9 in 384 respondents aged 15–19 years.[15] Factors driving high caries rates include less than satisfactory oral hygiene practices, unhealthy dietary habits and poor access to dental care. According to the WHO, the incidence of dental caries is expected to increase in many developing countries in Africa, due to the epidemiologic transition and the growing consumption of sugars and inadequate exposure to fluorides.[14]

It was not surprising to find a significant association between the mean DMFT of the participants and their past dental visits and the presence of dental conditions. This could have motivated them to seek dental treatment in the first place, possibly from toothache. About one-third of the participants gave a history of toothache, while more than half had at least one dental problem including caries. Studies have shown that the most common reason for seeking dental care in Nigeria is pain/symptom-oriented rather than for a checkup.[16],[17] The association between the previous toothache with the presence of dental problems supports the reason for their dental visits. The association between toothache and dental caries in the present study has also been reported.[18]

Despite the low caries status of the participants, their unmet dental health needs were high (76.7%), with a low treatment index (30.6%). None of the participants had received any dental filling before the study; hence, the value for the F (Filled) component of the DMFT was zero, resulting in a zero-restorative index. The implication is that the IDPs had received minimal attention for their restorative problems, with the exception of one participant who had received a denture. The poor access to oral health-care facilities was reflected by their low dental visit (8.5%). The high unmet needs in Nigerians, especially among rural dwellers, have been previously reported.[11] This is corroborated by the reported limited access to oral health services in many developing countries, where teeth are either left untreated or extracted due to pain or discomfort. Unless, this gap in health care is promptly addressed through community intervention programs, there will be an increase in the prevalence of untreated dental disease and its sequelae among IDPs. It should be borne in mind that these IDPs were camped in Lagos. There might be some variation in the oral findings from IDPs residing in camps in close proximity to troubled zones in the Northeast.

An important aspect of oral health is good oral hygiene which helps prevent dental problems, such as dental caries and periodontal diseases. To maintain optimal oral health, regular dental visits, at intervals determined by a dentist have been recommended.[19] Other good practices include twice-daily tooth brushing with fluoridated toothpaste and regular dental flossing. This will ensure effective plaque control which is the primary factor implicated in periodontal diseases and dental caries.

The vast majority of participants reported brushing their teeth only once daily with toothbrush and fluoridated toothpaste. This is similar to some studies among inhabitants of rural communities in Nigeria in which over 60% of participants also cleaned their teeth once daily.[11],[20] Interestingly, this contrasts with the report from a national study in which only one-third of the participants brushed once daily.[21] The difference may perhaps be related to ethnic differences between participants in the present study and the National study which had a wider ethnic representation. Our study contrasts sharply with that of Idowu et al.[22] among young “Almajiris” in Nigeria, in which only 4% of the Almajiris cleaned their teeth with fluoridated toothpaste (majority cleaned their mouth with water only after taking meals). The Almajiris are not always in sheltered conditions. They also received little attention and education on their oral health care from their guardians, the Mallams[22] unlike the IDPs in more stable living conditions in the camps. Despite their once daily tooth brushing, most of them had good-fair oral hygiene. This finding mirrors a similar study carried out in Asia by Nazir et al.[23] The possibility of a more fibrous diet could explain this, as it has been suggested that hard and fibrous foods provide a cleansing action on tooth surfaces, resulting in less plaque formation.[24] Consequently, reduced dental calculus formation. It is noteworthy to point out that children had better oral hygiene compared to adults, which was better in those without oral problems. This may be related to plaque and calculus accumulation over a period on tooth surfaces of adults.

Gingivitis was objectively assessed and documented in 19 participants. This is a limitation in this study and was due to the time constraint considering the treatment scheduled for the IDPs. However, gingival index has been found to correlate with plaque index in children and adults.[25] In one of such studies, plaque and gingival indexes were compared in 30 sets of mother and their children with mixed dentition.[25] The mean plaque index of incisor teeth 1.38 positively correlated with the mean gingival index of 1.24 in children and 1.32 in their mothers, while the mean plaque index of molars in children (1.77) and mothers (1.56) also positively correlated with the mean gingival index of 1.58 and 1.51, respectively.[25] It would therefore not be totally out of place to infer that plaque index score ≥1 in our study may correlate and be used to extrapolate gingivitis presence to some extent in the present study, meaning that there could be a strong probability of gingivitis in the 43 participants with debris index score ≥1. Periodontal diseases particularly periodontitis is important as they may serve as risk factors for some systemic diseases and therefore adversely impact systemic health.[26]

The low prevalence of chronic periodontitis (5.7%) observed in this study is far less than the reported prevalence among Nigerians.[27],[28] This could be attributed to the method of diagnosis (mainly tooth mobility in the absence of trauma) and plaque and calculus deposits, rather than periodontal pocket or clinical attachment level assessment. This may have underestimated periodontitis in this study. Furthermore, the inclusion of younger children may have also brought about the lower prevalence of periodontitis.[29] It is important for future studies to assess periodontitis by measuring periodontal probing depths using a periodontal probe.

The health-seeking behavior of the respondents in this camp was poor as only 16.2% of the population sought treatment in a clinic for their oral health conditions. This result compares favorably with a study by Gilani et al.[30] who identified barriers to seeking health care in internally displaced camps in Pakistan.[30] This include lack of finance, nonavailability, and poor access to oral health-care facilities and emotional and psychological barriers.

A total number of 63 respondents benefited from on-site dental treatment within their settlements using mobile dental units and improvising for children. They had scaling and polishing with oral hygiene instructions, fluoride therapy, and atraumatic restorative treatment and tooth extraction for teeth of poor prognosis. The participants were further referred to nearby dental clinics and tertiary health institutions for more advanced oral diseases.


  Conclusion Top


In conclusion, the IDPs had a caries prevalence of 20.3% and a DMFT of 0.7 which were relatively low. However, their unmet treatment needs were high, coupled with a zero-restorative index. The IDPs benefited from free oral health-care services. There is a need to study the oral health status of IDPs in other remote camps. The free oral health-care services provided to the IDPs was well appreciated by the participants. The government and NGOs should provide regular and free oral health-care services to IDPs who represent a vulnerable group through community outreaches to mitigate their high unmet treatment needs and improve their oral health quality of life.

Financial support and sponsorship

The study was partly funded by the Doctors health initiative, a Nongovernmental Organization in Nigeria.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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