82

ORIGINAL ARTICLE / ORIGINALNI RAD

Serbian Dental Journal, vol. 58, No 2, 2011

UDC: 616.314-07:613.9(497.1)

DOI: 10.2298/SGS1102082S

Dental Status of Adults in the Eastern Region of Republika Srpska

Nikola Stojanovi, Jelena Kruni, Smiljka Cicmil
Department of Restorative Dentistry and Endodontics, School of Medicine, University of East Sarajevo, Foa, Bosnia and Herzegovina

SUMMARY
Introduction A significant change in frequency and characteristics of oral diseases in developed countries has been detected recently. The aim of this study was to determine the dental status of teeth in adults in the eastern region of Republika Srpska and to determine possible difference in the prevalence of dental diseases according to the demographic characteristics. Materials and Methods The study included 182 respondents aged 35-44 years and 185 respondents aged 65-74 years, selected randomly from four municipalities in the eastern region of Republika Srpska. Dental examinations were conducted according to the standards and criteria developed by the World Health Organization. Dental status, determined by DMFT index, was analyzed according to the gender and place of residence (urban/rural). Results The mean DMFT index was 20.2 in the age group 35-44 years and 28.5 in subjects aged 65-74 years. The dominant component of the index in both studied groups was the number of extracted teeth. For subjects aged 65-74 years from rural areas a significantly higher DMFT index as compared to the residents in urban regions (p<0.05) was reported. Females had fewer caries lesions (p<0.05) and greater number of restored (p<0.01) teeth as compared to male respondents in the age group 35-44 years. On the other hand, in the older population study group, females had lower number of restored teeth (p<0.01), higher number of missing teeth (p<0.01) and higher DMFT index (p<0.2001) as compared to males. Conclusion The present results indicate that the prevalence of caries in adults in the eastern region of Republika Srpska is very high. Keywords: DMFT; adults; gender; dental status; urbanization

INTRODUCTION Oral health is much more than just healthy teeth; it is an inseparable part of general health and well being. Significant changes in the frequency and characteristics of oral diseases have been recorded in recent decades in European and worlds developed countries. Thus, the prevalence of caries in children has significantly decreased and number of people without carious lesions is increasing [1, 2]. Improved dental health in adults is achieved by reduction of extracted teeth and number of edentulous persons, as well as by increasing number of adults with functional dentition [3, 4, 5]. Possibilities for improvement are numerous and complex, but most often cited are: systematic implementation of preventive programs and health education, continuous use of toothpaste with fluoride, improved oral hygiene habits, and changes in lifestyle and living conditions. Epidemiological studies are recommended for reviewing the presence and activity of oral diseases in population. Very little information is available about the oral health of the population in Bosnia and Herzegovina (B&H). A study regarding the oral health of the population in SFRY was conducted before the civil war that led to the separation

of Bosnia and Herzegovina from the SFRY [6]. After the end of war in 1995, according to the Dayton Agreement, the country was divided into two entities: the Federation of B&H and Republika Srpska and administrative unit of Brcko District. Several studies on local or regional level were conducted in the Federation of B&H in order to determine the status of teeth in children (6-12 years) [7, 8, 9] and adults (35-44 years) [7]. On the other hand, there is almost no available data on dental status of adults in other entity of Bosnia and Herzegovina, Republika Srpska. Taking into account these facts, the aim of this study was to determine the dental status of people aged 35-44 and 65-74 years in the eastern region of Republika Srpska and to determine possible difference in the prevalence of dental diseases according to the demographic characteristics. MATERIAL AND METHODS The survey was conducted in 2010 in four municipalities in the eastern region of Republika Srpska: Bijeljina, East Sarajevo, Gacko and Nevesinje. In each of these sites at least 40 patients in two age groups 35-44 and 65-74

Address for correspondence: Nikola STOJANOVI, School of Medicine, Studentska 5, 73300 Foa, Bosnia and Herzegovina; nikolastojanovic@yahoo.com

Stomatoloki glasnik Srbije. 2011;58(2):82-89

83

years were examined. Respondents aged 35-44 years were randomly selected in work organizations, from the list of work organizations, while respondents aged 65-74 years were selected from pension clubs or day care facilities. The final sample included 182 persons aged 35-44 years (87 males and 95 females) and 185 persons aged 65-74 years (88 males and 97 females). Dental examination was carried out using artificial light, dental mirror and probe according to the standards and criteria of the World Health Organization [10]. The distribution of caries was determined using DMFT index and its components (D decay, M missing tooth, F filling). Dental caries was determined as a lesion that had visible cavity or any change in the base of pits and fissures, where the presence of caries was confirmed by careful examination with the probe. Status of teeth was analyzed according to demographic characteristics: gender and

place of residence. To categorize areas of living, urban areas were defined as municipalities with a population of over 20,000 inhabitants, and rural with population less than 20,000 inhabitants. Statistical analysis was done using SPSS 11.5 for Windows. Mean and standard deviation were calculated, and significance was determined using the Student t-test and ANOVA. Values of p<0.05 were considered as statistically significant. RESULTS In people aged 35-44 years the mean DMFT was 20.2, while the number of extracted teeth constituted the dominant component of index (50.3%) (Table 1). The difference in the mean values of DMFT index and its components in

Table 1. The average DMFT index and its components in subjects aged 35-44 years surveyed by the municipalities Tabela 1. Srednja vrednost indeksa KEP i njegovih komponenti kod ispitanika starih 35-44 godine prema pregledanim optinama
Municipality Optina East Sarajevo Istono Sarajevo Bijeljina Gacko Nevesinje Total Ukupno Number Broj 49 43 50 40 182 DSD KSD 2.493.36 2.913.44 2.622.96 2.331.55 2.592.94 MSD ESD 10.297.91 8.938.18 13.547.79*/** 7.256.67 10.197.97 FSD PSD 9.244.49 5.354.62 6.465.41 8.733.00 7.454.76 DMFTSD KEPSD 22.045.40 17.196.80 22.625.54 18.407.23 20.256.59

* p<0.05 as compared to the respondents from East Sarajevo; ** p<0.01 as compared to the respondents from Bijeljina i Nevesinje p<0.01 as compared to the respondents from Bijeljina i Gacko; p<0.01 as compared to the respondents from Bijeljina i Nevesinje * p<0,05 poreeno sa ispitanicima iz I. Sarajeva; ** p<0,01 poreeno sa ispitanicima iz Bijeljine i Nevesinja p<0,01 poreeno sa ispitanicima iz Bijeljine i Gacka; p<0,01 poreeno sa ispitanicima iz Bijeljine i Nevesinja

Table 2. The average DMFT index and its components in subjects aged 65-74 years surveyed by the municipalities Tabela 2. Srednja vrednost indeksa KEP i njegovih komponenti kod ispitanika starih 65-74 godine po pregledanim optinama
Municipality Optina East Sarajevo Istono Sarajevo Bijeljina Gacko Nevesinje Total / Ukupno Number Broj 46 45 50 44 185 DSD KSD 1.673.12 1.402.84 2.303.61 1.111.58 1.642.92 MSD ESD 25.857.54* 22.209.99 24.087.77 24.328.93 24.128.61 FSD PSD 0.521.18 3.825.66** 1.043.25 5.596.31** 2.674.93 DMFTSD KEPSD 28.045.62 27.365.84 27.425.98 31.481.19 28.525.32

* p<0.05 as compared to the respondents from Bijeljina; ** p<0.01 as compared to the respondents from E. Sarajevo and Gacko p<0.01 as compared to the respondents from Bijeljina, Gacko and Nevesinje * p<0,05 poreeno sa ispitanicima iz Bijeljine; ** p<0,01 poreeno sa ispitanicima iz I. Sarajeva i Gacka p<0,01 poreeno sa ispitanicima iz Bijeljine, Gacka i Nevesinja

Table 3. The average DMFT index and its components in subjects aged 35-44 years depending on the place of residence and gender Tabela 3. Srednja vrednost indeksa KEP i njegovih komponenti kod ispitanika starosti 35-44 godine u zavisnosti od mesta stanovanja i pola
Parameter Parametar Place of residence Mesto stanovanja Urban Urbano Rural Ruralno Male Muki Female enski Number Broj 92 90 87 95 DSD KSD 2.683.38 2.492.43 3.063.32 2.162.49* MSD ESD 9.658.03 10.747.92 10.317.73 10.088.23 FSD PSD 7.424.93 7.474.62 6.494.47 8.324.88** DMFTSD KEPSD 19.776.53 20.746.65 19.866.95 20.616.25

Gender Pol

* p<0.05; ** p<0.01 as compared to males * p<0,05; ** p<0,01 poreeno sa osobama mukog pola

84

Stojanovi N. et al. Dental Status of Adults in the Eastern Region of Republika Srpska

Table 4. The average DMFT index and its components in subjects aged 65-74 years depending on the place of residence and gender Tabela 4. Srednja vrednost indeksa KEP i njegovih komponenti kod ispitanika starosti 65-74 godine u zavisnosti od mesta stanovanja i pola
Parameter Parametar Place of residence Mesto stanovanja Urban Urbano Rural Ruralno Male Muki Female enski Number Broj 91 94 88 97 DSD KSD 1.542.97 1.742.89 2.003.31 1.322.49 MSD ESD 24.048.98 24.198.29 21.249.20 FSD PSD 2.154.37 3.175.40 3.695.58 1.744.07** DMFTSD KEPSD 27.705.71 29.324.81* 26.936.34 29.973.66**

Gender Pol

* p<0.05 as compared to respondents from urban area; ** p<0.01 as compared to males * p<0,05 poreeno sa osobama iz urbanog podruja; ** p<0,01 poreeno sa osobama mukog pola

Table 5. Percentage of edentulous patients in the two age groups depending on the place of residence and gender Tabela 5. Procenat ispitanika bez zuba u dve starosne grupe u zavisnosti od mesta stanovanja i pola
Parameter Parametar Urban Urbano Rural Ruralno Male Muki Female enski Age (years) Starost (godine) 3544 6574 4.3% 2.2% 3.4% 3.2% 3.3% 39.6% 36.2% 27.3% 47.4%* 37.8%

Place of residence Mesto stanovanja

Gender Pol Total Ukupno

group 35-44 years. On the other hand, in the older population group, females had a lower number of restored teeth (p<0.01), greater number of missing teeth (p<0.01) and higher DMFT index (p<0.2001) than males (Table 3 and 4). In the age group 35-44 years the percentage of edentulous subjects was 3.3% and in subjects aged 65-74 years, 37.8% (Table 5). Compared by the demographic characteristics, a significant difference in number of edentulous patients according to gender was observed in patients aged 65-74 years. In this age group, even 47.7% of females did not have any tooth (p<0.01). DISCUSSION A little is known about organization, development and availability of dental care in B&H. One of the main problems of the health system in B&H is its organization of the entities [11]. Free dental care in Republika Srpska is available to the children by the age of fifteen, women during pregnancy and the period of maternity leave up to one year, and persons over 65 years, while other insured persons participate in covering the costs of dental health care. Dental care is managed in health centers and private practice. The results of this study showed that the mean DMFT in the age group 35-44 years was about 20.2 while in subjects aged 65-74 years, about 28.5. Comparing these with the results from the Federation where DMFT in the age group 35-44 years is 15.1 [7] we can conclude that the condition of teeth in this age group in the studied region of Republika Srpska is worse. In Slovenia, DMFT in people aged 35-44 years have decreased from 20.5 to 14.7 between 1987 and 1999 [1]. Lower caries prevalence measured by DMFT index was recorded in people aged 35-44 years in other countries, mostly Western European [2]. In the eastern region of Europe DMFT index in this age group vary widely, ranging from 12 to 19.5 [12, 13]. Similar decrease in DMFT, especially the component of extracted teeth was recorded in patients older than 65 years [1, 14]. Based on the review article Bourgeois et al. [15] DMFT index in adults aged 65-74 years varies between 22.2 and 30.2. Possible changes in the status of the teeth in examined population are difficult to implement due to the limited amount of data on the state of dental health in B&H. By analyzing the components of DMFT index, it is obvious that the average number of carious teeth is about 2.6 in

*p<0.01 as compared to males * p<0,01 poreeno sa osobama mukog pola

relation to place of residence in subjects aged 35-44 years are shown in Table 1. Significant difference was observed between municipalities in the number of extracted and restored teeth, as well as the values of DMFT. Respondents from Gacko had more extracted teeth, respondents from East Sarajevo and Nevesinje had higher number of restored teeth as compared to people from other municipalities, while the highest values of DMFT were recorded for respondents in East Sarajevo and Gacko. In the age group 65-74 years, mean DMFT was 28.5 and number of extracted teeth represented the most dominant component of index (84.5%). Analysis of DMFT index and its components showed the significant difference in the number of extracted teeth, restored teeth, as well as the value of DMFT in patients depending on their place of residence (Table 2). The greatest number of extracted teeth was recorded among respondents in East Sarajevo, while respondents from Nevesinje had the greatest number of restored teeth and the highest DMFT index as compared to those from other municipalities. Respondents from urban and rural areas had similar values of DMFT components in both age groups. However, respondents aged 65-74 years from rural areas had significantly higher DMFT values than residents from urban regions (p<0.05) (Table 3 and 4). In relation to the gender, females had fewer caries lesions (p<0.05) and greater number of restored teeth (p<0.01) as compared to male respondents in the age

Stomatoloki glasnik Srbije. 2011;58(2):82-89

85

subjects aged 35-44 and about 1.6 in subjects aged 65-74 years. Lower number of caries lesions and restored teeth, especially in older group was probably caused by higher percentage of extracted teeth. These findings suggest that teeth extraction was common therapeutic procedure in the dental treatment of adults and point to the need for change in therapeutic approach and reorganization of oral health system. Differences in DMFT values in relation to the place of residence have been reported in both groups. The highest index values were observed in patients in East Sarajevo and Gacko, and lowest among respondents in Bijeljina in the age group 35-44 years. Respondents from Nevesinje had the highest DMFT in the age group 65-74 years. These findings can be attributed to the potential differences in organization and availability of health care, geographical differences of investigated municipalities, and socioeconomic factors. Variations in the incidence of diseases depending on the locality are important in epidemiological studies. Analysis of the dental status in relation to the place of residence showed that the respondents in age group 35-44 years from rural parts had greater number of extracted teeth, but the difference was not significant. On the other hand, in age group 65-74 years from rural parts DMFT index was significantly higher than that from urban areas, due to somewhat greater number of restored teeth and teeth with caries lesions. The impact of urbanization on the prevalence of dental caries is controversial issue in the literature [16, 17, 18]. It is believed that non restored carious lesions and tooth loss are more common in people from rural regions [16, 17]. Differences in dental and oral health can be attributed to the differences in living conditions, possible lower economic status and development of rural areas as well as to the differences in the access to dental care for people from different geographical areas. The problem is complicated by uneven distribution of professional staff with their increasing concentration in urban areas due to the economic factors, favorable employment and living conditions. Although it was noted that urbanization can have an impact on the prevalence of dental caries, this is not confirmed in all studies [18]. Accordingly, findings of this study indicated weak effect of urbanization on the prevalence of caries in adults. In the recent decades, great attention was paid to the association between gender and general health. However, there was weak link to the oral health [19]. According to the results of this study, women in the age group 35-44 years had significantly higher number of restored teeth and significantly fewer caries lesions as compared to males. On the other hand, in older group of patients, higher DMFT index was observed in women as a result of greater number of extracted and fewer restored teeth than men. Research shows that the number of restored teeth and DMFT are higher in women than in men. Teeth loss in women exist very often in younger age group [16 20, 21] which was also confirmed by this survey. Differences in dental status of different gender are not easy to explain. It is known that women have more positive habits and behaviors related to oral health than men [20]. However,

the level of caries is higher in females [21, 22] as well as the loss of teeth caused by caries process [21]. These variations of dental status were most often attributed to the biological factors, but recent findings suggest that mechanisms involved in the regulation of women oral health are more complex than those responsible for the oral health of males [19, 20]. The flow and composition of saliva, hormonal fluctuations during pregnancy, genetic variation and early eruption of teeth in females are biological factors that determine dental health of women. Of social determinants, eating habits are important as well as psychosocial and economic factors [19, 22]. Edentulism is an indicator of oral health of the population. Teeth loss is often a result of caries but also many other factors. Analysis of the results of this research shows that the percentage of edentulous persons increases with age. Namely, about 3.3% of respondents aged 35-44 years have lost all teeth, while this percentage is much higher for older age groups and it is about 37.8%. Results from France in 1997 [3] and Switzerland in 2002 [5] about the frequency of edentulous patients aged 35-44 years were overall lower than the results reported in this study. According to the findings of these studies, none of examined persons in France and 0.4% only of examined people in Switzerland were toothless [3, 5]. Also, the percentage of edentulous persons in older age-group study was higher than those observed in most European countries. According to the recent national review of the population in Hungary, the percentage of edentulous persons was around 19.8% [14] and in Switzerland about 13.8% in subjects aged 65-74 years [5]. Literature data showed that the prevalence of edentulous persons significantly varied between countries, different geographic regions of the country and different groups, in comparison to the level of education, urbanization, economic characteristics, habits, etc. [4]. Results of other studies indicate that number of older persons with natural teeth in European countries is increasing and number of people without teeth under the age of 60 years is very small. The prevalence of edentulous patients older than 65 years is still high and ranges from 15% to 72% [4]. In this study, there was no significant difference in the number of people without teeth related to the place of residence, but significantly higher number of females aged 65-74 years was edentulous compared to males of the same age group. Although findings of previous studies reported frequent loss of teeth in women, differences between genders are equalized over time in most countries [23, 24]. Even though the study provides important information about the dental status of teeth in the population of the eastern region of Republika Srpska, some shortcomings should be mentioned as well. The research covered only the part of adult population in some localities in Republika Srpska. Also, there was a small number of patients included in the study. Considering that there was almost no data about the dental status in population of elderly in this entity of Bosnia and Herzegovina, the results may have important practical implications. Systematic data about dental health in one population is needed not only to determine the need for treatment, but also for the

86

Stojanovi N. et al. Dental Status of Adults in the Eastern Region of Republika Srpska

successful reorganization of dental care. Namely, planning, organization, monitoring and evaluation of dental health services should be based on real data obtained in epidemiological studies. Also, this data can be used to monitor changes of the dental status in examined population after a certain period. CONCLUSION The present results indicate that the prevalence of caries in adults in the eastern region of Republika Srpska is still high. There is evident need to improve dental care in both examined groups, but in terms of public health, it seems difficult to control oral diseases using only traditional curative methods. Therefore, there is a need for systematic implementation of prevention and oral health promotion. ACKNOWLEDGEMENTS The study was supported by the project funded by the Ministry of Science and Technology of Republika Srpska (No. 06/0-020/961-83/09). REFERENCES
1. Vrbi V. Reasons for the caries decline in Slovenia. Community Dent Oral Epidemiol. 2000; 28:126-32. 2. Marthaler T. Changes in dental caries 19532003. Caries Res. 2004; 38:173-81. 3. Hescot P, Bourgeois D, Doury J. Oral health in 35-44 year old adults in France. Int Dent J. 1997; 47:94-9. 4. Muller F, Naharro M, Carlsson GE. What are the prevalence and incidence of tooth loss in the adult and elderly population in Europe? Clin Oral Implants Res. 2007; 18(Suppl 3):2-14. 5. Zitzmann NU, Staehelin K, Walls AWG, Menghini G, Weiger R, Zemp Stutz E. Changes in oral health over a 10-yr period in Switzerland. Eur J Oral Sci. 2008; 116:52-9. 6. Vrbi V, Vulovi M, Raji Z, Topi B, Tati E, Mali M, et al. Oral health in SFR Yugoslavia in 1986. Community Dent Oral Epidemiol. 1987; 16:286-8. 7. Ivankovi A, Luki IK, Ivankovi Z, Radi A, Vuki I, imi A. Dental caries in postwar Bosnia and Herzegovina. Community Dent Oral Epidemiol. 2003; 31:100-4.

8. Zukanovi A, Muratbegovi A, Kobalija S, Markovi N, Ganibegovi M, Beslagi E. Relationship between socioeconomic backgrounds. caries associated microflora and caries experience in 12-year-olds in Bosnia and Herzegovina. Eur J Paediatr Dent. 2008; 9:118-24. 9. Muratbegovi AA, Markovi N, Zukanovi A, Kobalija S, Draga MS, Juri H. Oral health related to demographic features in Bosnian children aged six. Coll Antropol. 2010; 34:1027-33. 10. World Health Organisation. Oral Health Surveys. Basic methods. Geneva: WHO; 1997. 11. Ivankovi A, Ravija J, kobi H, Vasilj I, Ivankovi Z, Pejanovi-kobi N, et al. Health status of population in federation of Bosnia and Herzegovina in 15 years of transitional period. Coll Antropol. 2010; 34(Suppl 1):325-33. 12. Marthaler TM, OMullane DM, Vrbi V. The prevalence of dental caries in Europe 1990-1995. Caries Res. 1996; 237-55. 13. Kunzel W. Trends in coronal caries in Eastern Europe: Poland, Hungary, Chech Republic, Romania, Bulgaria and the former states of USSR. Int Dent J. 1996; 46:204-10. 14. Madlena M, Hermann P, Jahn M, Fejerdy P. Caries prevalence and tooth loss in Hungarian adult population: results of a national survey. BMC Public Health 2008; 8:364. 15. Bourgeois D, Nihtila A, Mersel A. Prevalence of caries and edentulousness among 65-74-year-olds in Europe. Bull World Health Organ. 1998; 76:413-7. 16. Skudutyte R, Aleksejuniene J, Eriksen HM. Dental caries in adult Lithuanians. Acta Odontol Scand. 2000; 58:143-7. 17. Wang HY, Petersen PE, Bian JY, Zhang BX. The second national survey of oral health status of children and adults in China. Int Dent J. 2002; 52:283-90. 18. Vargas CM, Yellowitz JA, Hayes KL. Oral health status of older rural adults in the United States. J Am Dent Assoc. 2003; 134:479-86. 19. Doyal L, Naidoo S. Why dentist should take a greater interest in sex and gender. Br Dent J. 2010; 209:335-7. 20. Berta PC, Staehelin K, Dratva J, Kemp Stutz E. Female gender is associated with dental care and dental hygiene but not with complete dentition in the Swiss adult population. J Public Health. 2007; 15:361-7. 21. Lukacs JR. Sex difference in dental caries experience: clinical evidence. complex etiology. Clin Oral Investig. 2010 [in press]. 22. Ferraro M, Vieira A. Explaining gender differences in caries: a multifactorial approach to a multifactorial disease. Int J Dent. 2010; 2010:649643. 23. Osterberg T, Carlsson GE, Sundh V. Trends and prognoses of dental status in the Swedish population: analysis based on interviews in 1975 to 1997 by Statistics Sweden. Acta Odontol Scand. 2000; 58:177-82. 24. Mack F, Mundt T, Budtz-Jorgensen E, Mojon P, Schwahn C, Bernhardt O, et al. Prosthodontic status among old adults in Pomerania, related to income, education level, and general health (results of the Study of Health in Pomerania, SHIP). Int J Prosthodont. 2003; 16:313-8.

Received: 17/03/2011 Accepted: 20/05/2011

Stomatoloki glasnik Srbije. 2011;58(2):82-89

87

Stanje zuba odraslih stanovnika istonog dela Republike Srpske

Nikola Stojanovi, Jelena Kruni, Smiljka Cicmil
Katedra za bolesti zuba i endodonciju, Medicinski fakultet, Univerzitet u Istonom Sarajevu, Foa, Bosna i Hercegovina

KRATAK SADRAJ
Uvod Poslednjih decenija u razvijenim zemljama sveta uoene su znaajne promene u uestalosti i odlikama oralnih oboljenja. Cilj ovog rada bio je da se utvrde stanje zuba odraslih stanovnika istonog dela Republike Srpske i mogue razlike u rasprostranjenosti oboljenja u zavisnosti od demografskih obeleja. Materijal i metode rada U istraivanje su ukljuene 182 osobe starosti 35-44 godine (pr va grupa) i 185 osoba starosti 65-74 godine (druga grupa) izabrane metodom sluajnog uzorka iz etiri optine u istonom regionu Republike Srpske. Stomatoloki pregledi su vreni prema standardima i kriterijumima Svetske zdravstvene organizacije. Stanje zuba, odreeno indeksom KEP, analizirano je u zavisnosti od pola ispitanika i njegovog mesta stanovanja (urbano ili ruralno podruje). Rezultati Srednja vrednost indeksa KEP u pr voj grupi ispitanika bila je 20,2, a u drugoj grupi 28,5. Dominantnu komponentu indeksa u obe ispitivane grupe inio je broj ekstrahovanih zuba. Kod ispitanika druge grupe koji ive u ruralnom podruju zabeleena je znaajno vea vrednost indeksa KEP u poreenju sa stanovnicima iz urbanih regiona (p<0,05). U pr voj grupi ene su imale manji broj promenjenih zuba usled karijesa (p<0,05) i vei broj saniranih zuba (p<0,01). Meu ispitanicima starijim od 65 godina, ene su imale manji broj saniranih zuba (p<0,01), vei broj zuba koji nedostaju (p<0,01) i veu vrednost indeksa KEP (p<0,01) u odnosu na mukarce. Zakljuak Rezultati ovog istraivanja pokazuju da je prevalencija karijesa kod odraslih stanovnika istonog regiona Republike Srpske vrlo visoka. Kljune rei: indeks KEP; odrasli; pol; stanje zuba; urbanizacija

UVOD Oralno zdravlje je mnogo vie od zdravih zuba; ono je neodvojivi deo opteg zdravlja i blagostanja oveka. Znaajne promene u uestalosti i odlikama oralnih oboljenja zabeleene su poslednjih decenija u razvijenim zemljama Evrope i sveta. Uoeno je znaajno smanjenje prevalencije karijesa kod dece i poveanje broja osoba bez karijesnih lezija [1, 2]. Unapreenje zdravlja zuba odraslih osoba ogleda se u smanjenju broja ekstrahovanih zuba i broja osoba bez zuba, kao i poveanju broja odraslih s funkcionalnom denticijom [3, 4, 5]. Razlozi ovakvog unapreenja su brojni i kompleksni, ali se najee navode: primena sistematskih preventivnih programa i programa zdravstvenog prosveivanja, kontinuirano korienje pasti za zube sa fluoridima, poboljanje oralnohigijenskih navika, kao i promene naina i uslova ivota. Epidemioloka istraivanja se preporuuju radi sagledavanja rasprostranjenosti i aktivnosti oralnih oboljenja stanovnitva. Veoma malo podataka ima o oralnom zdravlju stanovnitva u Bosni i Hercegovini (BiH). Pre graanskog rata koji je doveo do izdvajanja BiH iz SFRJ izvedena je jedna nacionalna studija o oralnom zdravlju stanovnitva SFRJ [6]. Zavretkom rata 1995. godine, prema Dejtonskom sporazumu, BiH je podeljena na dva entiteta Federaciju BiH i Republiku Srpsku i administrativnu jedinicu Brko-distrikt. Nekoliko studija na lokalnom i regionalnom nivou izvedeno je u Federaciji BiH sa ciljem da se utvrdi kakvo je stanje zuba dece (uzrasta 6-12 godina) [7, 8, 9] i odraslih (35-44 godine) [7]. S druge strane, skoro da i nema dostupnih podataka o stanju zuba odraslog stanovnitva u Republici Srpskoj. Uzimajui u obzir ove injenice, cilj istraivanja je bio da se utvrde stanje zuba odraslih stanovnika istonog dela Republike Srpske i mogue razlike u rasprostranjenosti oboljenja u zavisnosti od demografskih odlika ispitanika.

MATERIJAL I METODE RADA Istraivanje je uraeno tokom 2010. godine u etiri optine u istonom regionu Republike Srpske: Bijeljina, Istono Sarajevo (I. Sarajevo), Gacko i Nevesinje. U svakoj od navedenih optina pregledano je najmanje po 40 ispitanika iz dve starosne grupe: 35-44 i 65-74 godine. Ispitanici prve grupe odabrani su metodom sluajnog izbora u radnim organizacijama, i to redom sa liste radnih organizacija, dok su ispitanici druge grupe izabrani u klubu penzionera ili dnevnom boravku za starija lica. Konaan uzorak inile su 182 osobe starosti 35-44 godine (87 mukaraca i 95 ena) i 185 osoba starosti 65-74 godine (88 mukaraca i 97 ena). Stomatoloki pregledi su obavljeni na terenu uz primenu vetakog osvetljenja, stomatolokog ogledalceta i stomatoloke sonde prema standardima i kriterijumima Svetske zdravstvene organizacije [10]. Klinikim pregledom je odreena rasprostranjenost karijesa pomou indeksa KEP i njegovih komponenti (K karijes, P plombiran zub, E ekstrahovan zub). Zubnim karijesom su se smatrale samo lezije sa formiranim kavitetom ili promene u podruju baza fisura i jamica koje su prilikom paljivog ispitivanja sondom potvrdile postojanje karijesa. Stanje zuba je analizirano u zavisnosti od pola ispitanika i mesta njihovog stanovanja. Za kategorizaciju podruja stanovanja, urbana podruja su definisana kao optine sa vie od 20.000 stanovnika, a ruralna podruja kao mesta u kojima ivi manje od 20.000 ljudi. Statistika obrada podataka uraena je u programu SPSS 11.5 za Windows. Odreene su srednje vrednosti i standardna devijacija, dok je znaajnost razlike odreena Studentovim t-testom i ANOVA. Vrednosti p manje od 0,05 smatrale su se statistiki znaajnim.

88

Stojanovi N. et al. Dental Status of Adults in the Eastern Region of Republika Srpska

REZULTATI Kod ispitanika starih 35-44 godine (prva grupa) srednja vrednost indeksa KEP bila je 20,2, pri emu je broj ekstrahovanih zuba inio dominantnu komponentu indeksa (50,3%) (Tabela 1). Razlike u srednjim vrednostima indeksa KEP i njegovih komponenti u odnosu na mesto prebivalita ispitanika prve grupe prikazane su u tabeli 1. Znaajne razlike izmeu ispitivanih optina zabeleene su u broju ekstrahovanih i plombiranih zuba, kao i vrednostima indeksa KEP. Utvreno je da stanovnici Gacka imaju vie ekstrahovanih zuba, ispitanici iz I. Sarajeva i Nevesinja vei broj saniranih zuba u odnosu na stanovnike drugih optina, dok su najvee vrednosti indeksa KEP zabeleene kod ispitanika iz I. Sarajeva i Gacka. U grupi ispitanika starih 65-74 godine srednja vrednost indeksa KEP bila je 28,5, a broj ekstrahovanih zuba bio je dominantna komponenta indeksa (84,5%). Analizom indeksa KEP i njegovih komponenti zabeleena je znaajna razlika u broju ekstrahovanih i plombiranih zuba, kao i u vrednostima indeksa KEP u zavisnosti od mesta prebivalita ispitanika (Tabela 2). Najvei broj ekstrahovanih zuba utvren je kod stanovnika I. Sarajeva, dok su ispitanici iz Nevesinja imali najvei broj saniranih zuba i najveu vrednost indeksa KEP u odnosu na ispitanike koji ive u drugim optinama. Ispitanici iz urbanih i ruralnih podruja imali su sline vrednosti komponenti indeksa KEP u obe starosne grupe. Ipak, kod ispitanika starih 65-74 godine iz ruralnih sredina ustanovljena je znaajno vea vrednost indeksa KEP u poreenju sa stanovnicima koji ive u urbanim mestima (p<0,05) (Tabele 3 i 4). Posmatrano u odnosu na pol, ene iz prve grupe imale su manji broj karijesno promenjenih zuba (p<0,05) i vei broj saniranih zuba (p<0,01). U starijoj ispitivanoj grupi ene su imale manji broj saniranih zuba (p<0,01), vei broj zuba koji nedostaju (p<0,01) i veu vrednost indeksa KEP (p<0,01) u odnosu na mukarce (Tabela 3 i 4). U prvoj grupi ispitanici bez zuba inili su 3,3% uzorka, a u drugoj grupi 37,8% (Tabela 5). Posmatrano u odnosu na ispitivane demografske odlike, znaajna razlika u broju bezubih pacijenata zabeleena je po polu kod ispitanika starih 65-74 godine. U ovoj starosnoj grupi ak 47,7% ena nije imalo nijedan zub (p<0,01).

DISKUSIJA Malo je podataka o organizaciji, razvoju i dostupnosti stomatoloke zatite u BiH. Jedan od glavnih problema zdravstvenog sistema u BiH je njegova organizacija u entitetima [11]. Besplatnu stomatoloku zatitu u Republici Srpskoj imaju deca do navrene petnaeste godine, trudnice, porodilje do navrene prve godine ivota deteta, kao i osobe starije od 65 godina, dok ostala osigurana lica uestvuju u snoenju trokova zdravstvene zatite. Stomatoloka zatita se ostvaruje u domovima zdravlja i privatnim ordinacijama. Rezultati ovog istraivanja pokazuju da su srednje vrednosti indeksa KEP kod ispitanika starih 35-44 godine 20,2, a kod ispitanika starih 65-74 godine 28,5. Poreenjem s rezultatima istraivanja iz Federacije BiH, gde je u starosnoj grupi 35-44 godine zabeleena vrednost indeksa KEP od 15,1 [7], uoava se da je stanje zuba kod ispitanika ovog ivotnog doba u ispitivanom

regionu Republike Srpske loije. U Sloveniji su vrednosti indeksa KEP kod osoba starosti 35-44 godine sniene sa 20,5 na 14,7 izmeu 1987. i 1999. godine [1]. Smanjenje prevalencije karijesa, mereno indeksom KEP, zabeleeno je kod osoba starih 35-44 godine i u drugim zemljama, uglavnom zapadnoevropskim [2]. U istonom regionu Evrope vrednosti indeksa KEP u ovoj starosnoj grupi znatno variraju: od 12 do 19,5 [12, 13]. Slino smanjenje vrednosti indeksa KEP, posebno E komponente, zabeleeno je i kod osoba starijih od 65 godina [1, 14]. U radu Buroa (Bourgeois) i saradnika [15] vrednosti indeksa KEP kod ispitanika starih 65-74 godine bile su izmeu 22,2 i 30,2. Mogue promene u stanju zuba ispitivanog stanovnitva teko je sprovesti zbog ogranienog broja podataka o stanju zdravlja zuba stanovnika BiH. Analizom komponenata indeksa KEP uoava se da je prosean broj zuba zahvaenih karijesom kod ispitanika starih 35-44 godine 2,6, a kod ispitanika starih 65-74 godine 1,6. Manji broj karijesno promenjenih, ali i saniranih zuba, posebno u starijoj ispitivanoj grupi, verovatno je posledica visokog procenta ekstrahovanih zuba. Ovi nalazi pokazuju da je ekstrakcija zuba est terapijski postupak u stomatolokom leenju odraslih, to ukazuje na potrebu promene terapijskog pristupa, kao i reorganizacije rada stomatoloko-zdravstvenog sistema. Razlike u vrednostima indeksa KEP u odnosu na mesto prebivalita zabeleene su u obe ispitivane grupe. U prvoj grupi najvee vrednosti indeksa utvrene su kod ispitanika iz I. Sarajeva i Gacka, a najnie kod ispitanika iz Bijeljine. Ispitanici s mestom prebivalita u Nevesinju imali su najvee vrednosti indeksa KEP u drugoj starosnoj grupi. Ovakvi nalazi se mogu pripisati moguim razlikama u organizaciji i dostupnosti stomatoloke zatite, geografskim razlikama izmeu ispitivanih optina i socioekonomskim faktorima. Varijacije u uestalosti oboljenja u zavisnosti od lokaliteta znaajne su u epidemiolokim istraivanjima. Analiza stanja zuba u odnosu na mesto stanovanja pokazala je da u prvoj grupi ispitanici iz ruralnih mesta imaju vie ekstrahovanih zuba, ali ta razlika nije dostigla statistiku znaajnost. S druge strane, u grupi pacijenata starih 65-74 godine iz ruralnih podruja vrednost indeksa KEP je bila znaajno vea od vrednosti ovog indeksa kod ispitanika iz urbanih mesta zbog neto veeg broja saniranih i karijesno promenjenih zuba. U literaturi se nalaze i opreni rezultati o uticaju urbanizacije na prevalenciju karijesa [16, 17, 18]. Smatra se da su nesanirani zubi zahvaeni karijesom i bezubost ei kod osoba iz ruralnih regiona [16, 17]. Razlike u dentalnom i oralnom zdravlju mogu se pripisati razlikama u uslovima ivota stanovnitva i moguem slabijem ekonomskom statusu i razvijenosti ruralnih podruja, kao i razlikama u dostupnosti stomatoloke zatite stanovnitva iz razliitih geografskih podruja. Problem uslonjava i injenica mogue neravnomerne raspodele strunog kadra, kojeg je mnogo vie u gradovima, kako zbog ekonomskih faktora, tako i zbog povoljnijih radnih i ivotnih uslova. Iako je uoeno da urbanizacija moe imati uticaja na prevalenciju karijesa, to nije potvreno u svim studijama [18]. U skladu s tim su i nalazi ovog istraivanja koji ukazuju na slab uticaj urbanizacije na prevalenciju karijesa kod odraslih osoba. Poslednjih decenija velika panja se posveuje vezi izmeu pola i opteg zdravlja stanovnitva, ali bez dovoljnog osvrta na oralno zdravlje [19]. Prema rezultatima naeg istraivanja, ene iz prve starosne grupe imaju znaajno vei broj saniranih i

Stomatoloki glasnik Srbije. 2011;58(2):82-89

89

znaajno manji broj karijesno promenjenih zuba od ispitanika mukog pola. U starijoj ispitivanoj grupi vea vrednost indeksa KEP zabeleena je kod ena kao posledica veeg broja ekstrahovanih i manjeg broja saniranih zuba u odnosu na mukarce. Istraivanja pokazuju da su broj saniranih zuba i vrednosti indeksa KEP vee kod ena nego kod mukaraca. Takoe, bezubost je esta kod ena ve u mlaem ivotnom dobu [16, 20, 21], to potvruju i nalazi ovog istraivanja. Razlike u stanju zuba u zavisnosti od pola nije lako objasniti. Poznato je da ene imaju pozitivnije navike i ponaanja u vezi sa oralnim zdravljem od mukaraca [20]. Ipak, nivo karijesa je vei kod osoba enskog pola [21, 22], kao i gubitak zuba uzrokovan karijesnim procesom [21]. Ove varijacije u stanju zuba su se najee pripisivale biolokim faktorima, ali noviji nalazi pokazuju da su mehanizmi ukljueni u regulaciju oralnog zdravlja ena mnogo sloeniji od onih koji su odgovorni za oralno zdravlje mukaraca [19, 20]. Protok i sastav pljuvake, hormonalne fluktuacije tokom trudnoe, genetske varijacije i ranije nicanje zuba jesu bioloki faktori koji odreuju zdravlje zuba ena. Od socijalnih determinanti pominju se razlike u navikama u ishrani, kao i psihosocijalni i ekonomski faktori [19, 22]. Bezubost je jedan od indikatora oralnog zdravlja populacije. Gubitak zuba je najee posledica karijesnog procesa, ali i brojnih drugih faktora. Analizirajui rezultate ovog istraivanja, moe se uoiti da se procenat osoba koje nemaju zube poveava sa starenjem. Naime, 3,3% ispitanika starih 35-44 godine bilo je bez zuba, dok je taj procenat bio znatno vei kod osoba druge starosne grupe 37,8%. Rezultati iz Francuske iz 1997. godine [3] i vajcarske iz 2002. godine [5] o uestalosti bezubosti kod ispitanika starosti 35-44 godine pokazuju znatno bolje rezultate. Prema nalazima navedenih studija, nijedna od pregledanih osoba u Francuskoj, odnosno samo 0,4% osoba u vajcarskoj nisu imale zube [3, 5]. Takoe, procenat bezubih osoba u starijoj ispitivanoj grupi bio je vei od onih zabeleenih u veini evropskih zemalja. Prema rezultatima skorijeg nacionalnog pregleda stanovnitva u Maarskoj, osoba koje su bez zuba bilo je 19,8% [14], a u vajcarskoj 13,8% meu ispitanicima starim 65-74 godine [5]. Podaci iz literature pokazuju da prevalencija bezubosti znaajno varira izmeu zemalja i izmeu razliitih geografskih regiona jedne drave, kao i izmeu razliitih grupa u odnosu na stepen edukacije, urbanizaciju, ekonomske odlike, ivotne navike itd. [4]. Rezultati pomenutih, ali i drugih istraivanja, pokazuju da se broj starijih osoba s prirodnim zubima u evropskim zemljama poveava, te da

je broj osoba bez zuba starosti do 60 godina veoma mali. Ipak, prevalencija bezubosti kod osoba starijih od 65 godina i dalje je visoka (15-72%) [4]. U naem istraivanju nije uoena znaajna razlika u broju osoba bez zuba u donosu na mesto stanovanja, ali znaajno vei broj ena starih 65-74 godine nije imao zube u poreenju sa mukarcima iste starosne grupe. Iako je prema nalazima ranijih istraivanja zabeleena ea bezubost kod ena, razlike meu polovima su se izjednaile tokom vremena u veini zemalja [23, 24]. Iako studija daje znaajne podatke o stanju zuba stanovnika istonog regiona Republike Srpske, treba pomenuti i njene mogue nedostatke. Istraivanjem je obuhvaen samo deo odrasle populacije na pojedinim lokalitetima u Republici Srpskoj. Takoe, mogui nedostatak je i mali broj ispitanika u starosnim grupama. Uzimajui u obzir da skoro i nema podataka o stanju zuba stanovnitva starijeg ivotnog doba u ovom entitetu BiH, dobijeni rezultati mogu da imaju znaajne praktine implikacije. Sistematski podaci o zdravlju zuba stanovnitva su potrebni ne samo za odreivanje vrste i naina leenja, ve i za uspenu reorganizaciju slube stomatoloke zdravstvene zatite. Naime, planiranje, organizacija, praenje i evaluacija rada stomatolokih zdravstvenih slubi treba da se zasnivaju na realnim podacima dobijenim u epidemiolokim istraivanjima. Ti podaci takoe mogu da poslue za praenje promena stanja zuba ispitivane populacije posle odreenog perioda.

ZAKLJUAK Rezultati ovog istraivanja su pokazali da je prevalencija karijesa kod odraslih osoba koje ive u istonom regionu Republike Srpske i dalje visoka. Postoji oigledna potreba za poboljanjem stomatoloke zatite u obe ispitivane grupe, ali s aspekta javnog zdravlja ini se da je teko kontrolisati oralna oboljenja primenom samo tradicionalnih metoda leenja. Stoga se namee potreba za implementacijom sistematskih programa prevencije i promocije oralnog zdravlja.

ZAHVALNOST Istraivanje je izvedeno u okviru projekta koji je finansiralo Ministarstvo nauke i tehnologije Republike Srpske (broj: 06/0-020/961-83/09).