Community Dent Oral Epidemiol 2003; 31: 100±4 Printed in Denmark. All rights reserved
Dental caries in postwar Bosnia and Herzegovina Ivankovic A, Lukic IK, Ivankovic Z, Radic A, Vukic I, SÏimic A. Dental caries in postwar Bosnia and Herzegovina. Community Dent Oral Epidemiol 2003; 31: 100±4. ß Blackwell Munksgaard, 2003 Abstract ± Objectives: To present the prevalence of dental caries in postwar Bosnia and Herzegovina (BH). Methods: A survey focused on dmft and DMFT indices was carried out in four cantons of the Federation of BH in 1997. The dental health of 6- and 12-year-olds was assessed in random samples (n 238 and 318, respectively). DMFT index in adult population was assessed in clients coming to dental of®ces in the same area (35±44-year-olds; n 401). All the subjects were clinically investigated. Results: During the 1991±95 war, all four cantons were affected by the migration of population. The population per dentist ratio considerably increased in three cantons. In 6-year-olds, the average dmft (SD) was 4.9 4.0, and 86% of the children were affected with dental caries. The average DMFT of 12-year-olds was 6.2 3.9. On the average, 94% of the 12-year-olds were affected with dental caries. Mean DMFT of adult clients was 15.1 7.0. Almost every adult (98%) was affected with dental caries. Conclusions: The dental status in postwar BH is rather poor and the mean DMFT in all investigated age groups may be considered high. The detrimental effect of 1991±95 war on social conditions and the health care system should be considered in explaining such poor dental health. Despite the limitations, the presented data may be used to assess the treatment needs, assure the visibility for dental issues in BH, and help the west European countries to plan dental services for refugees from BH.
Dental health has rarely been associated and/or analyzed in the context of war. However, it might re¯ect public health situation better than some more important but more speci®c aspects of health. The relative expensiveness and sophistication of dental health services (1) constitute a system sensitive to adverse effects, such as war and war-related events. The war in Bosnia and Herzegovina (BH) started in April 1992 and ended in the fall of 1995 with the Dayton (OH, USA) Peace Agreement (2). The agreement divided BH into two entities: Federation of BH, under Croat±Bosniak Muslim control, and Republic Srpska, under Serb control. The Federation of BH is administratively divided into 10 cantons, three with Croat and ®ve with Bosniak Muslim majority, and two almost equally mixed (Fig. 1) (3). To asses the oral health of the BH population after the war, we performed a survey of dental health in order to provide a minimum amount of data needed to plan preventive and restorative oral health
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Ante IvankovicÂ1, Ivan KresÏimir LukicÂ2, Zorana IvankovicÂ3, Ankica RadicÂ4, Iljo VukicÂ5 and Ankica SÏimicÂ6 1 Mostar University Hospital, Kardinala Stepinca bb, 36000 Mostar, Bosnia and Herzegovina; 2Department of Anatomy and Croatian Institute for Brain Research, Zagreb University School of Medicine, SÏalata 12, Zagreb, HR-10000, Croatia; 3Podstrana, Split, HR-21000, Croatia; 4Livno Health Center, Ulica Svetog Ive bb, 34000 Livno, Bosnia and Herzegovina; 5Fra M. NedicÂa 4, Tolisa, 31000 OrasÏje, Bosnia and Herzegovina; 6I. G. KovacÏicÂa bb, 39000 Grude, Bosnia and Herzegovina
Key words: Bosnia and Herzegovina; dental caries; DMFT and dmft index; epidemiology Ivankovic A, DDS, PhD, Mostar University Hospital, Kardinala Stepinca bb, 36000 Mostar, Bosnia and Herzegovina Tel: 387 36 313 158 Fax: 387 36 313 154 e-mail:
[email protected] Submitted 9 January 2001; accepted 7 August 2001
programs. The survey was conducted on the territory of Federation of BH in 1997 and focused on the prevalence of dental caries in children (6- and 12-year-olds) and adults (35±44-year-olds).
Subjects and methods Study groups
Each of the four studied cantons (Fig. 1) was represented by a sample of patients from two to three towns: West Mostar, EÁitluk and EÁapljina in Herzegovina±Neretva canton; SÏiroki Brijeg, PosusÏje and Grude in West Herzegovina canton; Livno and Tomislavgrad in Herzeg±Bosnia canton; and OrasÏje and OdzÏak in Posavska canton (Fig. 1). The basic data on the geographical area, population, number of dentists, and number of dentists' of®ces before (1991) and after (1996) the war were obtained from of®cial statistical registers (4±8).
Dental caries in postwar BH
Fig. 1. The Republic of Bosnia and Herzegovina consists of two entities: Federation of Bosnia and Herzegovina, populated by Croats and Muslims (gray) and the Republic Srpska, the Serb-controlled part. Following cantons of the Federation of Bosnia and Herzegovina were investigated: 1 ± Herzegovina±Neretva canton; 2 ± West Herzegovina canton; 3 ± Herzeg±Bosnia canton; and 4 ± Posavska canton. The towns included in the study and the capital of the Republic of Bosnia and Herzegovina, Sarajevo, are shown.
Subjects
The caries prevalence in 6- and 12-year-olds was assessed in random samples (n 238 and 318, respectively). A dental team visited randomly selected kindergartens or primary schools in each town and examined all present children. Due to economical limitations and political situation in the Federation of BH in 1997, we were not able to select a random sample of adults. Therefore, all adults (aged 35±44) coming to dental of®ces in Health Centers of the towns in the investigated areas during a week period were enrolled in the study (n 401).
Assessment of dental health
Caries was diagnosed using a plane mouth mirror, blunt dental probe, and arti®cial light. The WHO method and criteria were used for the recording of data collection (9).
Results As shown in Table 1, all cantons were affected by the migration of population. In 1996, the proportion of refugees in the population varied from 2% in
Posavska to 22% in Herzegovina±Neretva canton. During the war, the population per dentist ratio increased in three out of four cantons. The number of dentists' of®ces in Herzegovina±Neretva, and Posavska cantons decreased to approximately 50% of the prewar number. In contrast, the number of dentists of®ces slightly increased in West Herzegovina and Herzeg±Bosnia cantons. The mean dmft in the group of 6-year-olds was 4.9 4.0 (Table 2). Decayed teeth were the principal component of the dmft index, except for the Herzeg± Bosnia canton. The proportion of children affected with dental caries varied from 77% in Herzeg±Bosnia, to 100% in Posavska canton, with the average of 86%. Table 3 represents the prevalence of the dental caries in the group of 12-year-olds. The mean DMFT was 6.2 3.9 with almost equal contribution of decayed and ®lled teeth. On the average, 94% of the 12-year-olds were affected with dental caries (range: 86% in West Herzegovina to 98% in Posavska canton). The mean DMFT of the adults (35±44-year-olds) was 15.1 7.0 (Table 4). The dominant components of the DMFT index were missing and ®lled teeth. The proportion of adults affected by the dental caries
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Ivankovic et al. Table 1. Demography of dental care in four cantons of Federation of Bosnia and Herzegovina before (1991) and after the war (1996) Canton Features
Herzegovina±Neretva
West Herzegovina
Herzeg±Bosnia
Posavska
1662 75, 927 71 1096 47 2 38 7
839 60, 672 25 2427 16 0 14 2
1961 70, 609 22 3210 14 1 12 1
371 58, 432 10 5843 14 0 10 4
1257 98, 153 None 22 28 3505 28 2 17 9
1070 69, 825 None 13 17 4107 18 0 13 5
1961 66, 284 16 10 19 3489 18 0 10 8
371 28, 082 53 2 5 5616 6 0 3 3
60
113
129
43
Before the war (1991) Surface (km2) Population No. of dentists Population/dentist ratio No. of dentist's offices In hospitals In health centers Private After the war (1996) Surface (km2) Population % domicile population lost in war % refugees from other cantons No. of dentists Population/dentist ratio No. of dentist's offices In hospitals In health centers Private % of prewar number of offices
Table 2. Dental caries in 6-year-olds Canton Features
Herzegovina±Neretva
West Herzegovina
Herzeg±Bosnia
Posavska
Total
n dt mt ft Mean `dmft' % `dmft'
68 4.4 4.2 0.9 1.5 0.4 0.9 5.7 4.4 88
50 3.3 3.5 0.6 1.0 0.5 1.0 4.4 3.7 78
61 0.7 1.2 0.0 0.0 1.5 1.5 2.2 1.5 77
59 4.3 3.7 1.4 1.4 1.3 2.2 6.9 3.9 100
238 3.2 3.7 0.7 1.3 0.9 1.6 4.9 4.0 86
The mean dmft and the mean number of decayed (dt), missing (mt), and filled (ft) teeth are represented as mean value SD.
Table 3. Dental caries in 12-year-olds Canton Features
Herzegovina±Neretva
West Herzegovina
Herzeg±Bosnia
Posavska
Total
n DT MT FT Mean DMFT % DMFT
117 2.2 2.5 0.3 0.7 2.2 1.9 4.7 2.7 97
80 3.3 2.9 0.5 0.8 2.5 2.6 6.3 4.4 86
61 2.9 2.6 1.3 1.4 3.7 2.9 7.7 3.8 93
60 3.2 3.3 1.3 1.4 2.8 2.2 7.2 4.4 98
318 2.8 2.9 0.7 1.1 2.7 2.4 6.2 3.9 94
The mean DMFT and the mean number of decayed (DT), missing (MT), and filled (FT) teeth are represented as mean value SD.
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Dental caries in postwar BH Table 4. Dental caries in adults (35±44-year-olds) Canton Features
Herzegovina±Neretva
West Herzegovina
Herzeg±Bosnia
n
88
140
85
DT MT FT Mean DMFT % DMFT %D
3.3 2.5 3.5 2.9 6.4 4.5 13.2 4.9 98 89
3.6 3.2 5.6 5.2 6.8 4.3 16.2 6.6 96 79
3.4 3.5 6.8 6.6 5.2 3.4 15.6 6.6 98 87
Posavska 88 3.8 3.2 6.3 6.1 4.4 5.8 14.8 9.3 100 86
Total 401 3.5 3.1 5.7 5.7 5.9 4.6 15.1 7.0 98 84
The mean DMFT and the mean number of decayed (DT), missing (MT), and filled (FT) teeth are represented as mean value SD.
varied slightly between the cantons, from 96% in West Herzegovina to 100% in Posavska canton (average 98%). In addition, 84% of the adults had untreated decayed teeth.
Discussion Our survey showed that the dental health of the population in postwar BH was rather poor. According to the WHO criteria (10), the mean dmft in the group 6-year-olds and the mean DMFT in the group of 12-year-olds (4.9 and 6.2, respectively) may be considered high, whereas the mean DMFT of 15.1 in the adults is very high. Furthermore, the status of dental health services is rather unfavorable. Between 1991 and 1996, population per dentist ratio increased in three cantons. Although the ratio in Posavska canton has actually slightly decreased, it was still very high. In two investigated cantons, the number of dentists' of®ces was reduced to approximately a half of the prewar number. The remaining of®ces dealt with the failure of basic supplies and inadequate ®nancing (11). In addition, all cantons received signi®cant number of displaced persons, whose dental health was generally reduced. The reasons behind such poor dental health in postwar BH are probably numerous and complex. However, comparison with the prewar situation is dif®cult because there are little data on dental health in BH before the war (12). Moreover, our crosssectional survey did not address causal relationships. However, due to similar political and historical background, including common health care system (13), the oral health in BH may be compared to that in Croatia and Slovenia, which also emerged from the former Yugoslavia. In Croatia, the mean dmft of 6-year-olds increased from 3.4 in 1990 to 4.1 in 1999 (14), whereas the mean DMFT of 12-year-
olds increased from 2.6 in 1991 to 3.5 in 1999 (15). In contrast, between 1987 and 1998, the mean DMFT values in Slovenia decreased from 5.1 to 1.8 for 12-year-olds and from 20.5 to 14.7 for 35± 44-year-olds (16). The notable improvement of dental health in Slovenia may be explained by various preventive programs (16), as well as the absence of material destruction or population migration (the armed con¯ict in Slovenia lasted for three days in 1991). On the other hand, the 1991±95 war in Croatia and BH led to massive migration of population, devastation of health care system infrastructure, and very serious ®nancial shortages (3, 17, 18), which left no resources available for oral health preventive programs (11). However, the situation in BH was far more serious. For example, the health care system in BH in 1993 could not meet even the basic health needs of population (19). Moreover, it is estimated that the shortage of health care professionals will not be made up before the 2025, and the reconstruction of the damaged buildings and rebuilding of the area before the 2010 (17). The war in Croatia was especially disruptive for the pediatric dental health care system (14). Our data indicate that the same may be true for health care system in BH. The mean DMFT of 12-year-olds in BH is higher than in other former socialist countries in the region, such as Romania and Hungary (mean DMFT of 3.4 and 3.8, respectively) (20, 21). Since the survey was conducted in 1997, the 12-year-olds actually got their permanent teeth during the war. It might be reasonable to conclude that the detrimental effect of war on social conditions and the health care system was re¯ected on the dental health of those children. The presented study has several limitations. Firstly, it was conducted only on a part of the population and territory of BH. However, we
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Ivankovic et al.
believe that these ®ndings can be extrapolated to the entire BH, because the situation in the other parts of the country can only be worse, due to the total collapse of the health care system during the war (3, 17). Secondly, the total sample of 957 subjects was further divided into three age groups and four cantons so that the subsamples could be considered relatively small. Finally, the dmft/DMFT is not sensitive enough to measure an impact of major social disturbances on dental health of population. Despite the limitations, this study has very important practical implications. The ®rst is that the average status of dental health care in Bosnia and Herzegovina is seriously lagging behind west European countries and even its neighbors (16, 20±24). Second, our data could not only be used to assess the treatment needs, but to assure the visibility for dental issues in BH as well (25). Finally, the majority of west European countries have seen large number of refugees from BH applying for refugee and asylum status. Since our data indicate that their oral health is rather poor, this report might help the host countries in planning and provision of most appropriate and effective dental services.
Acknowledgments The authors are indebted to Ana MarusÏicÂ, MD, PhD, and Matko MarusÏicÂ, MD, PhD, for their help and advice during the preparation of the manuscript.
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