|Year : 2017 | Volume
| Issue : 1 | Page : 12-17
Prevalence of oral lesions among Jordanian children
Abeer A Hussein1, Azmi M. G. Darwazeh2, Suhad H Al-Jundi1
1 Department of Preventive Dentistry, Faculty of Dentistry, Jordan University of Science and Technology, Irbid, Jordan
2 Department of Oral Medicine and Surgery, Faculty of Dentistry, Jordan University of Science and Technology, Irbid, Jordan
|Date of Web Publication||14-Feb-2017|
Azmi M. G. Darwazeh
Department of Oral Medicine and Surgery, Faculty of Dentistry, Jordan University of Science and Technology, P. O. Box 3030, Irbid, 22110
Source of Support: None, Conflict of Interest: None
Introduction: Prevalence studies on oral lesions in children are scarce, and none of them was conducted in Jordan.
Objectives: To determine the prevalence of oral mucosal lesions among Jordanian children.
Materials and Methods: A stratified cluster random sampling technique was used to select a sample of first and sixth-grade school children. Systematic oral examination was performed using natural light, and lesions were diagnosed based on the clinical diagnostic criteria proposed by the WHO. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20 (SPSS Inc., Chicago, IL, USA), and P < 0.05 was considered statistically significant. Data were analyzed using Chi-squared test or Fisher's exact test where appropriate.
Results: The study included 1366 school children (639 [46.8%] males and 727 [53.2%] females) of whom 620 (45.4%) were 6-year-old and 746 (54.6%) were 12-year-old. The prevalence of oral lesions among children was 47.4%, without a significant difference in prevalence between males (46.6%) and females (47%). Prevalence was significantly higher in 12-year-old children (50%) compared to 6-year-old children (44.2%; P = 0.032). The most commonly diagnosed lesions were racial pigmentation (16.8%), fissured tongue (14.6%), and hematoma (5.3%).
Discussion: Oral mucosal lesions are common in children in general, with no overall preference to gender, but the prevalence increases significantly with age. General dental practitioners and pediatric dentists should be aware of the common oral mucosal lesions in their communities for optimum diagnosis, management, and possible prevention.
Conclusions: Oral lesions are common among Jordanian children and dentists should be aware of their diagnosis and management.
Keywords: Children, epidemiology, Jordan, oral lesions, prevalence
|How to cite this article:|
Hussein AA, Darwazeh AM, Al-Jundi SH. Prevalence of oral lesions among Jordanian children. Saudi J Oral Sci 2017;4:12-7
| Introduction|| |
The concept of child oral health has recently been broadened to include oral mucosal lesions and conditions in addition to dental caries, periodontal diseases, and malocclusion. Subsequently, the responsibility of the oral health-care providers in the total health care of oral and perioral region has been widely emphasized. The majority of epidemiological studies on oral mucosal lesions were conducted on adult populations. Only a few studies were designed to investigate the prevalence of oral mucosal lesions among children, despite that due to continuous emotional and biological changes in children, various types of alterations and lesions in the orofacial region can take place. In addition, some oral mucosal lesions have been shown to impair children's oral health-related quality of life. The awareness of the general dental practitioner and the pediatric dentist of the common oral mucosal lesions, and their etiology and treatment will facilitate proper diagnosis and then management or ultimately prevention of these lesions.
Reviewing the epidemiologic studies reveals wide variability in the prevalence of oral mucosal lesions in children in different parts of the world ranging from 4.1% to 52.6%. In Brazil, oral mucosal lesions were reported in 30.3% of children between 5 and 12 years, and geographic tongue was the most prevalent lesion. In a large US study based on a multistage probability sample included 39,206 children aged 5–17 years, Kleinman et al. reported a prevalence of about 4%, and recurrent aphthous ulcers (1.23%), and recurrent herpes labialis (0.78%) were the most prevalent lesions. In a later study on 10,030 individuals aged between 2 and 17 years age, oral mucosal lesions were detected in 10.26% of the individuals, where traumatic ulcers (1.89%) and recurrent aphthous ulcers (1.64%) were the most common lesions. As high as 38.9% prevalence was reported in Spanish children, and lesions were dominated by coated tongue (16.02%) followed by traumatic lesions (12.17%), whereas 28.9% of Italian children had oral lesions but oral candidiasis (29.2%) was the most frequent lesion recorded. Appropriate diagnosis and management of these lesions in children require the knowledge of pediatric dentist of the frequency of such lesions and to distinguish which of them is caused, or associated, with a systemic disease. In addition, baseline data on the oral mucosal lesions in children are important for health-care planning and education. Due to lack of national information on oral mucosal lesions and conditions among children, this study was designed to determine the prevalence of oral mucosal lesions among school children aged 6 and 12 years.
| Materials and Methods|| |
A random sample of 6- and 12-year-old children attending public schools in the province of Irbid north of Jordan was obtained. These ages are recommended by the WHO for population survey in children. The data were collected between February and July 2015. A stratified cluster random sampling technique was adopted to ensure proper presentation of the targeted school children in the province. Irbid Province is divided into seven main districts; hence, stratification was based on these seven districts through obtaining lists of all schools in each district to make sure all areas of Irbid province were represented. Randomization was done by obtaining lists of all schools in each of the seven districts of the province that teachfirst and sixth grade from the Jordanian Ministry of Education, and subsequently, the fifth school in the list was selected. Tables of the total number of students and their gender, in thefirst and sixth grade in each selected school of the district, were obtained. From those, 25% (every fourth student) of children in the table were selected to comprise the study sample.
During thefirst visit to a school, a letter including a formal consent form was sent to the parents of the selected children. A data form designed to collect demographic information and the child medical history was also given with the consent form. Only children who returned the consent form signed by their parents/legal guardian and were free of any systemic disease were included in the study. This study was approved by the Institutional Review Board for Human Use (IRB; Approval no. 1-82-2014), complying with the World Medical Association Declaration of Helsinki.
In the second visit to the schools, systematic oral mucosal examination was performed by one examiner (Abeer A. Hussein), under normal light and using a wooden tongue depressor and a dental mirror, and with the implementation of the standardized infection control measures in accordance with Occupational Safety and Health Act guidelines. The clinical criteria proposed by the WHO  were adopted to diagnose oral mucosal alterations. The diagnosis of traumatic lesions was made based on the clinical picture and the history of trauma.
Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 20.0 (SPSS Inc., Chicago, IL, USA). The association between study variables was calculated using Chi-squared test and Fisher's exact test, where appropriate, and P < 0.05 was considered statistically significant.
| Results|| |
A total of 1386 consent forms were signed and returned back to the author out of the original 1420 children recruited for the study, resulting in a response rate of 97.6%. Of the returned consent forms, twenty children were excluded due to having the following medical conditions: hepatitis A (n = 4), taking salbutamol (n = 4), anemia (n = 3), pulmonary artery stenosis (n = 3), pneumonia (n = 3), taking colchicine (n = 1), bronchitis (n = 1), and cystic fibrosis (n = 1). Thus, the study population was finally composed of 1366 school children of whom 639 (46.8%) were males and 727 (53.2%) were females. Based on the participants' age, 620 (45.4%) were 6-year-old, whereas 746 (54.6%) were 12-year-old.
Oral mucosal lesions were clinically diagnosed in 647/1366 (47.4%) school children without a significant difference between males and females (305/639 [47.6%] and 342/727 [47%] respectively; P = 0.7). It was found that 214 (15.7%) of the individuals had more than one lesion. These lesions were distributed over 24 diagnoses as shown in [Table 1] and [Table 2]. Racial pigmentations and fissured tongue were the most common lesions diagnosed in the study population [Table 1], whereas oral nonerosive reticular lichen planus and torus palatinus were clinically diagnosed in one child only [Table 2]. Oral mucosal lesions were diagnosed in 647 out of the 1366 school children which indicate that 47.4% of the study population had oral lesions. A total of 844 oral lesions and conditions were detected in the 647 school children included in the study. Data analysis revealed that the prevalence of fissured tongue, coated tongue, dry lips, and traumatic ulcer was significantly higher among males, whereas dental abscess fistula, geographic tongue, fibroepithelial polyp, nevus, and tied tongue were significantly higher among females [Table 1] and [Table 2].
|Table 1: Prevalence of more common oral lesions and conditions diagnosed in 1366 school children|
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|Table 2: Prevalence of less common oral lesions and conditions diagnosed in 1366 school children|
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Oral lesions were diagnosed in 274/620 (44.2%) 6-year-old children and 373/746 (50.0%) 12-year-old children (P = 0.032). Data analysis revealed that the prevalence of dental abscess and geographic tongue was significantly higher among 6-year-old children, whereas fissured tongue and racial pigmentations were significantly more common among 12-year-old children [Table 3].
Referring to [Table 1] and [Table 2], it was found that 148/844 (17.5%) lesions were traumatic lesions (hematoma, traumatic ulcers, frictional keratosis, fibroepithelial polyp, and scar). These lesions were not significantly different between males and females (63/639 [4.6%] and 84/727 [6.1%], respectively; P = 0.35) or between 6-year-old and 12-year-old children (70/620 [4.6%] and 78/746 [5.6%], respectively; P = 0.88).
[Figure 1] illustrates the site of the lesions. Dorsum of the tongue was the most common site for the lesions, followed by the gingiva and buccal mucosa. Hard palate was the least common site, whereas none of the lesions was diagnosed in the floor of the mouth.
| Discussion|| |
This study was thefirst to investigate the prevalence of oral lesions in Jordanian children. Since the socioeconomic status was shown to influence the prevalence of some oral mucosal lesions in children, this study was designed to include only children attending the public schools and to represent a fairly socioeconomically homogeneous group of children.
Oral lesions and conditions in children are not rare. The prevalence of oral lesions in children worldwide ranged between 4.1% and 52.6%, and the most common oral lesion differs from one country to another. The prevalence of oral lesions in this study (47.2%) is within the reported range. The tongue was the most common oral site affected, whereas it ranked second after the labial mucosa, in an American study. This emphasizes the importance of the careful examination of the tongue during intraoral examination. However, the overall prevalence of oral lesions in this group of Jordanian children was higher that reported in other countries in the Middle East region such as Turkey (26.2%) and Iran (28%). The wide variation in prevalence in different studies may be attributed to variations in the diagnostic criteria and method of lesions detection employed, examiners training, and calibration in addition to indigenous variations between ethnic groups examined. In accordance with our results, the lack of difference in the overall prevalence of oral lesions between male and female children has frequently been reported.,,
Epidemiologic information on racial (physiologic) melanotic pigmentation is rarely reported in the literature, possibly because many clinicians consider it as a variation of normal and bears no clinical significance apart from being esthetically objectionable when it is extensive. Racial pigmentations were the most prevalent lesion detected in our study, where they were diagnosed in 16.8% of the children. Interestingly, they were significantly more common in the older group of children, which agrees with the study of Ambika et al. in Indian children. However, there still no clear explanation for this observation. It is widely known that racial pigmentations are more common in dark-skinned people; therefore, ethnic and geographic variation in its prevalence is understandable.
Coated tongue is generally considered as an abnormal tongue alteration. Some studies described coated tongue as the most frequently encountered oral lesion with a prevalence of 16.02% in Spanish children  and 23.4% in preschool children in Brazil. Majorana et al. reported a prevalence of 7.23% in 0–12-year-old Italian children, whereas in our study, the prevalence of coated tongue is only 4%, and it was significantly more prevalent in males. Whether coated tongue is a mark of poor oral hygiene  or not, in otherwise, healthy children is a matter of debate.
Fissured tongue is a developmental anomaly of the tongue dorsum. The deep fissures may trap food debris leading to inflammation or secondary fungal infection and halitosis. Brushing of the tongue dorsum and using mouthwashes are commonly recommended to overcome these consequences. The literature reveals wide variability in the prevalence of fissured tongue among children worldwide. Even in the same ethnic group, the prevalence of 14.6% in this study is much higher than reported in Saudi Arabia (0.8%) and Iraq (2.6%), but much lower than reported in Yemeni children (26.7%). The higher prevalence of fissured tongue noticed among male and older age group Jordanian children has been previously reported in adult Jordanians., Hyposalivation associated with Sjögren's syndrome was claimed to markedly increase the prevalence of fissured tongue in adults. However, the higher prevalence of this congenital anomaly in males and with older age group needs explanation.
The 1.7% prevalence of geographic tongue in this study is lower than 4.4% previously reported among Jordanian adults. The prevalence of this tongue anomaly is widely variable globally ranging from 0.6% and 9.08%. This may be explained by the transient nature of geographic tongue which nictitates longitudinal, rather than cross-sectional, studies to determine its actual prevalence. In general, the reported association of geographic tongue to gender is inconsistent. While our results demonstrate higher prevalence among females, others reported higher prevalence among male children in Hungary.
The significant association of geographic tongue with lower age group in this study is consistent with other studies which reported a significantly higher prevalence among children up to the age of 4 years compared to older children. However, no gender predilection was observed in our study which is also consistent with other studies. Interestingly, an association was claimed between fissured tongue and geographic tongue with psoriasis in adults. Burning sensation is a common symptom in severe cases; therefore, hematinic, Vitamin B12, and folic acid screening is a safe clinical practice to exclude a possible systemic cause for the burning sensation. In this regard, the general dental practitioner must be aware that some of the common oral lesions in children, such as recurrent oral ulcerations, unexplained hematoma, and fungal infections, may be a manifestation of a systemic disease.
The presence of traumatic oral lesions such as hematoma, frictional keratosis, or traumatic ulcer is an indicative for the existence of an identifiable source of mechanical irritation such as cheek biting habit, a sharp cusp or restoration, or an edge of broken teeth, and these lesions usually resolve on the elimination of the irritant. This group of lesion constitutes a significant proportion of oral lesions in children.,
| Conclusions|| |
Lesions and conditions affecting oral mucosa in children are common; hence, the general dental practitioner and pediatric dentist should be aware of the clinical presentation and etiology of these lesions, and possible association with systemic disease, to be able to provide ultimate care for their patients. Moreover, educators in dentistry should put more emphasis in their curricula on more common lesions present in their community. However, for the current results to be generalized on Jordanian population, a larger scale study including children from all the provinces is needed.
Financial support and sponsorship
This research was sponsored by a grant from the Deanship of Research; Jordan University of Science and Technology (Research grant number 20150057).
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]