EFFICIENCY ESTIMATION OF USING PHASED PROGRAM OF CARIES PREVENTION IN CHILDREN DOMICILED IN TRANSCARPATHIAN REGION

Uvod: Karijes je patološki proces koji se odvija u tvrdim tkivima zuba nakon erupcije zuba i smanjuje kvalitet života zbog značajnih komplikacija, posebno kod dece. Izuzetno visoka učestalost zubnog karijesa kod dece koja žive u transkarpatskom regionu zahteva obiman program prevenicje. Cilj ove studije bio je da se utvrdi efikasnost kompleksnog programa prevencije karijesa kod dece koja permanentno žive u područjima biogeohemijske deficijencije fluora. Materijal and Metode: Prilikom pregleda 346 dece uzrasta 3-8 godina, među kojima 163 (46.9%) dečaka i 183 (53,1%) devojčica ,utvrdilo se da je napravljen program u fazama kompleksne profilakse osnovnih bolesti zuba kod dece koja žive stalno u deficijentnim uslovima i koji uključuje: edukaciju dece predškolskog uzrasta i njihovih roditelja o higijeni, medikamentoznu spoljnu prevenciju, ranu identifikaciju i tretman karijesa korišćenjem konvencionalnih metoda prema protokolima lećenja, endogenu ne-medicinsku prevenciju, korekciju ishrane koji je dokazao svoju efikasnost. Rezultati: Indikator efikasnosti prevencije karijesa predloženim projektom iznosi za decu 5-7 (3-5) godina, 69,5%; za decu 8-10 (68) godina – 66,9%. Zaključak:Osnovni pravac pedijatrijskih stomatoloških usluga u Ukrajini treba da bude za dečju populaciju (starosti do 18 godina) formiranje nacionalnih i regionalnih programima za primarnu prevenciju glavnih bolesti zuba sa pružanjem adekvatnog finansiranja u dovoljnom obimu u cilju očuvanja zdravlja zuba nacije u dugom vremenskom periodu na 20 godina.


Introduction
Considering many years of experience with preventive dental programs, we can conclude that exactly the prevention of dental diseases is economically justified, effective and perspective direction of medicine development, including dentistry, especially in childhood 1,2,3,4,5 .This postulate is confirmed by many years of experience in functioning this direction of medicine in European developed countries and Canada 6,7 .
Interesting for analysis are prevention programs of countries, which in biogeochemical parameters, cope with the problematics in terms of prevalence and intensity of dental diseases among children 8,9,10,11,12 .
Switzerland has the most long-term prevention programs, which have been in use for over 40 years.Its efficiency is proved by practical absence of caries in permanent teeth of 12-year-old children (caries prevalence 2-5%), which is a perfect result.This program includes: hygienic education, endogenous non-medical use of fluorinated salts and fluorinated drinking water, topical fluoride varnishes and creams, tooth hermetic sealing of fissures.These measures are age-related and performed by the dentists. 13,14.
The task of the program "Healthy smile of Slovakia", which has been operating since 1997 in Slovakia has decreased the prevalence of basic dental diseases in children of all ages, by considering the children's psychological features.The coordinator of the program is Associate Professor Eva Kovalyova, who interned in Switzerland.Before starting the program in Eastern Slovakia, the level of caries spreading in permanent teeth of children in Slovakia was 85-90% in total.After 15 years of the program implementation, it was shown that the intensity of caries in permanent children's teeth decreased by 5 times 15,16 .
Aim of the study: To evaluate the efficiency level of using phased program of caries prevention among children of different age groups domiciled in Transcarpathian region.

Materials and methods
To increase the level of dental health in children in Transcarpathia, a scheme of early diagnosis, prevention and phased treatment of caries was established.
The scheme included the following stages: 1. Hygienic education of preschool children and their parents.2. The exogenous medicamentous prevention with the use of remineralization varnish Bifluorid-12, VOCO, Germany and Remin Pro, VOCO, Germany.3. Hermetic sealing of teeth's fissures -first molars in the age of 6-7 years.4. The treatment of hard tooth tissues lesions in the form of caries and its complications using conventional methods of treatment according to treatment protocols.5. Endogenous non-medicinal prevention, correction of nutrition.
To this dedicated section of the program in Transcarpathian Regional State Administration "Program of improving dental health of population in the region", approved by the Regional Council of Transcarpathian №395 dated 29 November 2007 (period of performance 2008-2012) and"Programs providing dental health of children population in 2009-2013 years" approved by the City Council of Uzhgorod №1148 of 16 July 2009 14 .
A total of 6.136 children, aged 3-6 years, who were in kindergarten and first class of the school in Uzhgorod were fully involved in the program.
Evaluation of the hygienic oral care quality was quality brushing, which was checked by interns-dentists at the second visit to the dental office.For visualization the method of staining dental deposit with a solution «Finder Plaque» (Curaprox, Switzerland) was applied.It is a very effective means of motivation for the quality oral hygiene.As shown by experience, children and adolescents were not aware that during cleaning their teeth, using an incorrect method of brushing, not all the plaque can be removed.
The control group consisted of children with similar age, in whom remineralization therapy and hermetization of fissures were not performed, the students of other schools not covered by the program (except hygiene training); the total number of children was 175.
To provide personal hygiene, the methods of group learning were used (talking, dialogue, repeating movements), individual learning (instructor for 5 children), theatrical performances including groups of favorite cartoon characters.
At the second visit, re-training and control of accuracy of brush movements were conducted.At the third and fourth visit of children, staining of the plaque that clearly shows the shortcomings of hygienic oral care and the ways of its elimination was individually carried out.Method was used for encouraging -a psychological motivational method including financial compensation for participation in specific educational and informative programs.
To evaluate the tendency to dental caries, the key indicators were usedprevalence, intensity, increase / reduction of the intensity of caries 17 .The caries prevalence -a ratio of the number of people (in percent) having caries, sealed and removed teeth out of the total number of patients.The intensity of caries index was determined by CS + CSE by calculating the amount affected by caries, sealed and removed the teeth, where C is constant tooth decay; S -seal permanent tooth; Epermanent tooth removed; c -temporary tooth decay; s -temporary tooth filling.
To evaluate the effectiveness of the implementation of health care methods, we determined the rate of reduction / increase of the caries, compared with the control group, in which prevention was carried out as follows 16,17 : Reduction / increase of caries = Mc / Ms × 100%, where Mc -the average growth rate in the control group, Ms -the average growth rate in the control group.
Caries prophylactic effectiveness was evaluated with the method proposed Kosenko KN et al. (2006)  16 and determined by the formula: CPE = CSEs2 × 100 / CSEs1 where CPE-caries prophylactic effect, the degree of reduction in the intensity of caries lesion, CSEs1 -the index of the intensity of caries in the number of cavities to treatment CSEs2 -index of intensity of caries the number of cavities 18 months after treatment.
For planning and analysis of the effectiveness of therapy increase, the intensity of impression caries was definedthe difference between the corresponding period of the last year (CSE) and the same indicator (CSE), which is set at the time of examination .P = A1-A2, where P is gain; A1 -an indicator of the year; A2 -last year.The gain was determined up to two years.
Statistical analysis of the data was performed using the methods of parametric and nonparametric statistics.Compliance empirical statistical distribution parameters of the theoretical Gaussian normal distribution was evaluated using the Kolmogorov-Smirnov criterion (K.-S.) and Shapiro-Wilks (W), was an indicator of reliability 29 .
Tvelve months after the first visit, the hygiene level was significantly improved, which is shown in Table 2.In all examined children a satisfactory level of hygiene prevailed, namely in 52,5% -85 boys and 49,7% -91 girls; good hygiene was found in 37,7% -61% boys and 45,4% -83 girls.
A small percentage of unsatisfactory hygiene was diagnosed in 9,8% of children -16 boys and 4,9% -9 girls.It can be explained by the lack of parent's participation in improving the hygienic education of children that plays a significant role.
In general, during the initial examination of children, good hygiene index was not diagnosed at all, satisfactory was observed in 22 children -6,0%, unsatisfactory HI -in 61 children -18,0%, bad HI -in 177 children -51,0% very bad HI -in 86 children -25,0%.After 12 months from the beginning of hygienic training, the indicators radically changed, particularly in 145 children -in 42,0% the hygiene index was good, in 176 children -51,0% was satisfactory and only 7,0% -25 children had unsatisfactory HI (Figure 1).
In preschool children these indicators were significantly higher than in children of primary school age, as seen in Figure 1, which can be explained by the features of psychological perception of preschoolers and stressful situation at beginning school.
Results of the prevalence and caries intensity in examined children of clinical group are represented in the Table 3.The control group consisted of preschool children and primary school children 85 persons 3-5 years old and 90 persons 6-8 years years nh b rold.Caries prevalence in the age group 3-5 years equaled: in the main group -98,3 ± 4,3, in the control group -97,9 ± 3,4; in the age group 6-8 years, the prevalence of caries was in the main group -95,3 ± 3,2, in the control group -94,1 ± 3,7.Remineralization therapy of hard tooth tissue carried out by dentist using Bifluorid-12,(VOCO, Germany) in children of primary school and cream Remin Pro (VOCO, Germany) in preschoolers at home applying toothbrush in the evening after brushing during three months with the subsequent control.Remineralization therapy of pupils of the first and second class consisted of varnishing with Bifluorid-12 for two times,(VOCO, Germany) of all teeth with an interval 6 months after the thorough cleaning with paste Clint (VOCO, Germany).Zalivanje fisura zuba sprovedeno je svetlosno polimerizujućim zalivačima, prema indikacijama.Kontrola zaptivanja se vršila u toku godine.
Restoration of hard tooth tissue conducted with glass ionomer and composite materials, according to indications of use, and preference was given to compomers for the temporary teeth (Twinky Star, VOCO, Germany) and nanocomposite light curing materials such as Polofil supra (VOCO, Germany) for masticatory groups of the teeth and Amarys (VOCO, Germany) for the frontal teeth.
To reduce the level of oral dysbiosis and microbial landscape, correction in the diet with the following products was introduced: cranberry, jostaberry, red currants for all children of the main group.After 24 months, they were examined and increase in the intensity of caries and caries reduction index was re-determined.Increase / reduction of caries intensity in preschool age group 3-5 years (5-8 years) was in the main clinical group F = 4,6-14,2 = -9.6; in the control group, F = 15,1-13,9 = 1,2.(Table 4

Discussion
Much attention is devoted to the research of prevention of caries among children of Ukraine, however, the high prevalence of this type of pathology determines the high need of new approaches and new ways of solving it.The highest rates are recorded in the regions where there is a lack of microelements in the water and soil, such as Transcarpathian region.This issue is complicated also due to the insufficient number of children's dentists and dental hygienists.The experience of the developed countries is that considerable attention in the prevention of caries is assigned to individual oral hygiene as the most efficient and economically viable method of prevention 4 .
Most favorable age to achieve a positive result is the pre-school and primary school age, and for this study such group was selected, in which hygiene education and oral sanitation were conducted 5 .
The main task is the popularization of rational individual oral hygiene and training of quality oral care.The training was conducted in kindergartens and schools in the city of Uzhgorod.Instructors were medical interns of dental faculty Higher Educational Establishment "Uzhhorod National University" as part of the curriculum in the section "Prevention of dental diseases" and doctors-dentists of pediatric department of Transcarpathian regionaldental clinics that hold meetings with children, demonstrate the general rules of hygiene and oral health in the form of games and motivate children to conduct hygiene measures 14 .
Sve jedinice programa su visoko efikasne zbog njihovoe kompleksne upotrebe; sprovedena analiza efikasnosti pokazuje perspektivu korišćenja regionalnih programa u Ukraini i vodi do značajnog smanjenja prevalencije i intenziteta glavnih oboljenja 3-6years, were almost completely involved in the program.This category at the correct motivation is able for easy and quick perception of new material aimed to deprive the feeling of fear before dental procedures and general fear of the dentist and dental surgeries.Every child is given the opportunity during his visit to the dental department to try himself as a doctor and medical vdyahnuvshy suit, gloves and a mask to inspect their friends who act as patients.After some time, the "doctor" and "patient" switch roles.
This game has a great interest in children and eliminates fear of dental office because all manipulations that will serve the dentist are not new, and therefore children are not afraid of it.This kind of study was performed on phantoms of dental units that fully correspond to the modern dental equipment that is extremely effective.
A visit of children's group at the faculty lasts 30-40 minutes, teachers of schools and kindergartens accompany them as parents agree and understand the necessity to maintain a healthy lifestyle.
Psychologically the correct is scheme of providing lesson.Especially interesting is the fact that learning under this program is carried out with children of preschool and primary school age and interesting them in the form of games involving favorite cartoon characters.It is important to illustrate the method and visualization of dental hygienist (children act as doctors who examine each other in the dental chair) that reduces the fear of visiting the dentist and shows safety being a doctor.The third block of classes was learning the methods of cleaning teeth individually with an instructor, practising diligently brushing movements for efficient removal of plaque.Average number of blocks was no more than 10-12 minutes, which is enough to focus the attention of children at this age.This method is most effective for teaching children and allows to develop communication skills in future doctors who study not only practical skills, but also communication with different patients' population.perspective for using of regional programs in Ukraine and lead to significant decrease of prevalence and intensity of main dental diseases, especially among zuba, posebno kod dece, koja su obezbeđena principima školskog stomatološkog sistema, organizacija od stomatoloških ordinacija u strukturi predškolskih ustanova, škola i drugih obrazovnih institucija (fakulteti i univerziteti), čija je delatnost regulisana državnim i regionalnim programima primarne prevencije glavnih stomatoloških oboljenja kod dece i adolescenata i koja će se rukovoditi principima kliničkog pregleda ove populacione grupe.

Zaključak
Osnovni pravac pedijatrijskih stomatoloških usluga u Ukrajini treba stvoriti je za dečju populaciju (starosti do 18 godina) nacionalnih i regionalnih programa za primarnu prevenciju glavnih oboljenja zuba sa pružanjem adekvatnog finansiranja u dovoljnom obimu kako bi se očuvalo zdravlje zuba nacije za dugogodišnji period od 20 godina.children, which is provided on the principles of the school dentistry system, organization of dental offices in the structure of pre-school, school and other educational institutions (colleges and universities), whose activity is regulated by state and regional programs of primary prevention of main dental diseases in children and adolescents and will be guided by the principles of clinical examination of this population groups.
The criteria for work quality of pediatric dentists in children's groups considered the number of healthy children.For geographically remote regions, it is advisable to gradually allow the provision of qualified dental care for children by general dentist and to increase accessibility of care for children.

Conclusion
The main strategy of pediatric dental services in Ukraine should be creating of national and regional programs for the population up to 18 years and for the primary prevention of main dental diseases with providing adequate financing in sufficient volume to preserve the nation's dental health for the next 20 years.

Slika 1 .
Indikatori indeksa higijene kod ispitivane dece na primarnom pregledu i posle 12 meseci.Picture 1.Indicators of hygiene index in examined children at the primary examination and after 12 months

Table 2 .
The state of oral hygiene in examined children aged 3-8 years after 12 months

Table 3 .
The prevalence and dental caries intensity in children according to the age at the primary examination