Framework for development ofOral Health Policy and Strategies in Myanmar

June, 2019

Prepared by
WHO Collaborating Centre for Translation of Oral Health Science
Niigata University, Japan

Contents
I.

BackgroundII.

Findings from National Oral Health Survey
1. Dental caries status
2. Periodontal status

III.

Developments for Myanmar Oral Health Strategy
Overall mission
Goal 1: Establishment of an appropriate monitoring system on oral health
Goal 2: Improvement of the quality of routine oral health care services by developing
appropriate oral health guidelines and policies for provision of oral healthpromotion programs
Goal 3: Develop oral health human resources development plan
Summary
Summary Flowchart
Missions to be considered with different time frames

Ⅳ.

References

Ⅴ.

Appendix

Report of National Oral Health Survey in Myanmar (2016)

1

I. Background
The Republic of the Union of Myanmar, one of the developing countries, is located inSoutheast Asia. Myanmar is 676,578 square kilometers in area and the population is53.58 million in 2017. The average life expectancy of Myanmar people is 66.6 years inmale while 69.9 years in female population.
The national representative oral health survey was unknown in Myanmar until 2016.
The lack of nation-wide survey might be due to the limited health expenditure in
Myanmar (3.38% of general government expenditure). Beside the national survey, only
regional surveys could be performed and there have been a few reports in Myanmar. 1-4
The regional survey as pathfinder oral health survey was collected in four large cities in
2006-2007. Therefore, the WHOHQ, WHOCO in Myanmar, WHOCC Niigata University,
WHO Experts in Myanmar, the Borrow Foundation and Ministry of Health in Myanmar
were collaborated to perform a National Oral Health Survey in Myanmar.
The first National Oral Health Survey in Myanmar was conducted from December
2016 to January 2017. The 43 local dentists examined a total of 6,273 subjects aged 6, 12,
15-19, 35-44, and 60-74 years olds from 23 townships and districts. The final number ofstatus that were included in data analysis was 5,928 and 4,667 for dental caries andperiodontal respectively.

II. Findings from National Oral Health Survey
1. Dental caries status
1.1. Dental caries on primary teeth
Only 15.8% of 6 years old group subjects were free of dental caries on their primary
teeth. Most of the 6 years old group subjects (98.6%) and all of the mixed dentition
age range have their carious primary teeth left untreated. Most of the primary teeth
left within the mixed dentition age range were carious. The 12 years old subjects havecaries on all of their primary central incisors. Only one child had a ft score of 3 in 6
years old, while no ft score was found in 12 years or 15-18 years old subjects.
1.2. Dental caries on mixed dentition
The 6 years old group subjects have the highest prevalence of caries (primary andpermanent teeth). As early as the age of 6 years, the subjects have already got caries
on their newly erupted permanent teeth, hence in the older age groups, they havedouble burden of caries on their primary as well as permanent teeth.

21.3. Dental caries on permanent teeth
More than 90% of all age groups have left their active carious permanent teeth caries
untreated. The percentage of carious maxillary and mandibular anterior teeth was low,
and conversely for posterior teeth. A higher percentage of caries experience was
detected in left mandibular second premolar. First and second molar were found tohave the highest percentage of caries experience.
The DMFT score of 6 years old group have a score of 0.14 and 0.11 for male andfemale respectively. The highest percentile for the age group of 6 years old was 8.
There are also subjects from the age group of 6 years old who has an MT score of 2.
Within the age group of 35-44 and 60-74 years old, there are some subjects who havemaximum DMFT score and also maximum MT score (32 for the highest percentile).
The proportion of missing (M) score was considerably higher than decayed (D) andfilling (F) for adult age groups. The 60-74 years old group subjects have the highest
prevalence of caries (93.6%) to be compared to the other age groups.
2. Periodontal status
Less than 50% of all of the subjects involved in this survey had a healthy gingival
condition. The pattern between genders was almost similar within all of the agegroups. The female subjects have a smaller proportion of periodontal disease thanmales.
The age group of 12 years old has the least severe periodontal condition while 6074 years old was most severe. The proportion of teeth with shallow pocket wasslightly lessened in younger age groups. It was found that 2.5% of the subjects were
suffering from shallow pocket and gingival bleeding with the age group of 15-18
years old. The proportion pattern of subjects with shallow pocket and gingival
bleeding between the age groups of 35-44 and 60-74 years old was similar. The
highest percentage (77.2%) of gingival bleeding was found in the male subjects
within the age group of 60-74 years old. The 60-74 years old group was the only age
group which has some proportions of the subjects with deep pocket and gingival
bleeding (4.1%). Within the age group of 60-74 years old, it was found that thehighest proportion of teeth with shallow pocket (5.5%).

3

III. Developments for Oral Health Policies and Strategies in Myanmar

Overall Mission
Provision of adequate and effective oral health promotion programs would be essential to
improve oral health situation in Myanmar. It should be accomplished by means of
performance goals with different time frames, in a way that may lead to better oral healthoutcomes for Myanmar people.

Goal 1: Establishment of an appropriate monitoring system on oral health
System of regular oral health examination programs such as annual/routine datacollection, analysis and reporting of common oral diseases should be developed in various
settings.
Specific Objective 1: To establish a system of routine oral examination for pregnant
women and children 0-5 years
As there are no routine oral examination programs for pregnant women and children
0-5 years, it is not easy for them to access and receive required oral health care. Therefore, asystem of routinely dental examination should be established as a conjunct with general
health check-up. In Thailand as a neighbored country, oral health promotion and prevention
service for children 0-2 years is integrated with general health promotion program. Children
receiving immunization program are transferred for further oral health check-up for hygiene
and early stage tooth decay, with a plan for continuous necessary oral health services and care.
In children for 3-5 years, oral health check-up is incorporated into other health care in the day
care center for 2 times a year.7 This system is necessary to establish by proposing government
authority for approval and financial support in oral health examination to pregnant womenand children 0-5 years. The note book/sheet for dental examination should be established formaternal and child care. Public health dentists should have to collaborate with Maternal andChild Care Society to perform routine infant and mother dental examination, and collaborate
with Ministry of Social Welfare, Relief and Resettlement for dental examination in preschool
children.
Step by step key facts(Pregnant women and children 0-2 years)
1. Authorized persons from Ministry of Health and Sports-

Discuss with Maternal and Child Care Society for monitoring oral health inpregnant women and children 0-2 years
4-

Create a format oral health examination chart including dental caries, periodontal
status and oral hygiene for pregnant women, oral hygiene and early stage of tooth
decay for children 0-2 years (If possible, establish a maternal and child caregeneral health note book/sheet including oral health examination chart)-

Consider for model townships (for example, select a township in each region orstate)

2. Local dentists from Department of Public Health-Perform oral examination using a format chart at Maternal and Child Care Centersof selected townships-

Collect the first year’s data by 2020

3. Local public health experts-

Analyze the collected data (for example, public health experts from universities
will analyze the data)-

Report the first year’s data to authorized persons from Ministry of Health andSports by 2021

4. International supports-

With the results of first year’s data, international experts will support theauthorized persons from Ministry of Health and Sports to establish oral healthmonitoring system(Children 3-5 years)
1. Authorized persons from Ministry of Health and Sports-

Discuss with Ministry of Social Welfare, Relief and Resettlement for monitoring
oral health in preschool children-

Create a format dental examination record including dental caries status and oral
hygiene-Consider for model preschools (for example, select a preschool in each township)

2. Local dentists from Department of Public Health-Perform oral examination using a format chart at selected preschools-

Collect the first year’s data by 2020

3. Local public health experts-

Analyze the collected data (for example, public health experts from universities
will analyze the data)

5-

Report the first year’s data to authorized persons from Ministry of Health andSports by 2021

4. International supports-

With the results of first year’s data, international experts will support theauthorized persons from Ministry of Health and Sports to establish oral healthmonitoring system

Specific Objective 2: To establish an appropriate annual dental examination and datacollection system in the school settings“School health program” has been started with the main responsibility by School
Health Division of Department of Public Health.5 School health team of a township is visiting
schools at least once a year. In each school health team, there is usually a public healthdentist who is responsible for the performance of school oral health activities. Their main role
are conducting dental examination, emergency dental treatments and giving oral healtheducation to school children.
There is still lacking an appropriate system of collection and recording the data ofschool children in Myanmar. It should be established a system of annual collection andrecording data of dental disease prevalence and severity in the school dental service using
format dental examination record form. According to the standard procedures and guidelines,
the dentist can check the oral health status of all the students for conditions such as dental
caries, malocclusion, gingival status, dental plaque and TMJ disorders. Every school children
must have their own dental examination chart and so the dentist can easily recognize theirpattern and severity of dental diseases. By collecting the data annually, the dentist cancompare and adjust the oral health status and oral health care needs of each child. The
dentists should have to collect the data of each child, combine the data of each school,
analyze and report these annual data.
Step by step key facts
1. Authorized persons from Ministry of Health and Sports-

Discuss with Ministry of Education for appropriate monitoring oral health inschoolchildren-

Create a format dental examination record form including dental caries,
malocclusion, gingival status, dental plaque and TMJ disorders-

Consider for model schools (for example, select a school in each township)6

2. Local dentists from Department of Public Health-Perform oral examination using a format chart at selected schools (with their own
chart)-

Collect the first year’s data by 2020

3. Local public health experts-

Analyze the collected data (for example, public health experts from universities
will analyze the data)-

Report the first year’s data to authorized persons from Ministry of Health andSports by 2021 (What was the progression or the main problem in each school,
how do we solve, and what is the future plan, etc.)

4. International supports-

With the results of first year’s data, international experts will support theauthorized persons from Ministry of Health and Sports to establish oral healthmonitoring system

Specific Objective 3: To establish a system of oral health data collection in the hospitalsettings (adults and elderly)
Oral health division of Department of Medical services is taking responsibility fordelivering hospital-based dental services in the country.6 Hospital-based dentists are mainly
providing oral health care services to community people, who seek for emergency treatments
at hospitals. Routine dental examination at public hospitals should be mandatory. Therefore,
it should be established a system of routine collection and recording data in hospitals using
comprehensive patient record form. If oral health problems are detected, necessary oral healthservices including emergency treatments should be introduced at any public or private dental
office. Public health dentists have to take the collaboration with appointed dentists intownship level hospitals for monitoring routine oral health care services till grass root level.
Step by step key facts
1. Authorized persons from Ministry of Health and Sports-

Create a comprehensive patient record using WHO oral health assessment form-

Consider for model hospitals (for example, select a township hospital in eachregion or state)

2. Local dentists from Department of Medical Services-

Perform oral examination using a format chart at selected public hospitals-

Collect the first year’s data by 2020
7

3. Local public health experts-

Analyze the collected data (for example, public health experts from universities
will analyze the data)-

Report the first year’s data to authorized persons from Ministry of Health andSports by 2021 (What was the progression or the main problem in each school,
how do we solve, and what is the future plan, etc.)

4. International supports-

With the results of first year’s data, international experts will support theauthorized persons from Ministry of Health and Sports to establish oral healthmonitoring system

Specific Objective 4: To conduct a routine National Oral Health Survey
National as well as regional oral health survey should be conducted periodically tomonitor oral health trends and needs. Second National Oral Health Survey for key ages
should be conducted by 2022 based on WHO Oral Health Survey Basic Method 5th Edition inorder to allow monitoring of changes in oral health among Myanmar. The survey should be
performed periodically every 5 years.
Step by step key facts
1. Authorized persons will discuss with international experts for planning
2. Local and/or international public health experts will train local dentists for oral healthsurvey3. Local public health dentists will conduct 2nd National Oral Health Survey by 2022
4. Local public health experts and/or international experts will analyze the collected data
and reports to authorities and plan for future oral health promotion programs
5. Repeat the survey every 5 years

Goal 2: Improvement of the quality of routine oral health care services by developing
appropriate oral health guidelines and policies for provision of oral health promotion
programs
Public oral health services are taking main responsible by the Oral Health Unit of the
Department of Medical Services are run based on the national oral health strategies with anemphasis on: (i) strengthening primary oral health care services for rural and remotecommunities (focusing on the health promotion and education, disease prevention, andprovision of basic and emergency oral health care), (ii) the fluoride project (including8

prevention of dental fluorosis in endemic areas and promotion of affordable fluoride
toothpaste), and (iii) delivery of quality routine oral health care services by hospitals, urban
health centers and school health teams.8 However, there is still a need to address inequalities
in oral health care in urban and rural areas of Myanmar. Basic oral health care services
should be implemented properly through states and regions of the country till grass root level.
Strengthening strategic coordination and collaboration among multi-sectorial
stakeholders is an important way to promote community’s oral health.9 Therefore, it isstrongly need to develop a formal set of oral health guidelines and policies based on oral
health data that previously collected in various sectors. By using the data that obtained fromdata collection and data analysis, it is important to notify what kind of preventive strategies
would be provided to the community. This should be considered for prevention of all types oforal diseases as well as common risk factors. System of oral health care services including
oral health education, prevention and promotion programs should be provided for community
such as children 0-5 years, school children, adults and elderly people separately.

Specific Objective 1: To establish/improve oral health promotion program for pregnant
women and children 0-5 years
Early childhood caries is currently a serious oral health problem in Myanmar.
Previous study has shown that caries prevalence of preschool children in Yangon city was
about 83% with mean dmft of 6.4.10 Recently, the Oral Health Unit of the Department of
Health introduced oral health promotion activities for preschool children entitled with “Early
Childhood Caries Prevention Program”. It is mainly focused on correct tooth brushingactivities in below 5-year-old children and giving oral health education to caregivers throughcollaboration with the Ministry of Social Welfare, Relief and Resettlement. This program
should be developed as routine and constant nation-wide program in the future.
The Oral Health Unit should be major concerned with addressing the tooth decay
problem among children as it may pose adverse effect on children’s oral health, general
health and their quality of life. It is also necessary to develop a policy to prevent and control
tooth decay among the childhood by setting a national indicator in Myanmar. In line with thisnational indicator, oral health care services should be provided including oral health checkup,
skill trainings on tooth brushing for caregivers, receiving fluoride varnish application or othersuitable forms for children with high risk caries. There is also a need for development of oral
health care services for pregnant women and children 0-2 years through the collaboration

9

with Maternal and Child Care Society. Children receiving immunization program should be
conjunct with oral health care services.
Step by step key facts
1. With established oral health monitoring system, local public health dentists will
perform routine oral examination in various settings through the country
2.

International experts will discuss with local authorities to develop relevant oral healthguidelines and policies for oral health promotion programs

3.

Local authorities will discuss with Maternal and Child Care Society (pregnant
women, 0-2 years) and with Ministry of Social Welfare, Relief and Resettlement (3-5years) for oral health care services in respective settings

4.

Local dentists (public health dentists and hospital-based dentists) provide oral healthcare services in respective settings

4.1. Oral health care services for pregnant women, children 0-2 years
The services should be integrated by local dentists at maternal and child care centers.
(Oral examination)-

With established maternal and child care general health note book/sheet including oral
health examination chart, oral check-up for hygiene and early stage tooth decay will
be performed in children who will come to maternal and child care centers for
immunization programs.

-

Plan and advice parents for continuous oral health service and care.

-

For pregnant women, it should be emphasized on periodontal examination and oral
hygiene instruction, as well as necessary treatments (plan it during pregnant or afterlabor).

-

Necessary oral health services and care will be received at public hospitals (byhospital dentists)(Oral health education)-

Maternal Oral Health Education Program together with oral health services for
pregnant women should be implemented to improve overall maternal and child health.

-

Advice the pregnant women for key oral hygiene care (for example, key oral healthmessages to pregnant women should be included as followed.)

10

① Brush teeth twice daily with a fluoride toothpaste and mouth rinsing after meals② Limit foods containing sugar to mealtimes only
③ Choose water or low-fat milk as a beverage. Avoid carbonated beverages during
pregnancy④ Choose fruit rather than fruit juice to meet the recommended daily fruit intake- Train the pregnant women for self-periodontal check-up (for example gingival color,
contour and any signs of gingival bleeding, etc. If positive signs of gingivitis occurred,consult with hospital dentists for necessary oral health care services.)-

Advice and train the parents how to clean and brush their child’s oral cavity. (forexample, advice the parents the following key messages.)① Prepare a piece of gauze, cotton or cloth and a glass of drinking water② Wash your hands thoroughly with soap
③ Wrap the gauze, cotton or cloth around your finger and damp it with water④ Gently put your finger inside your baby's mouth. Wipe the upper and then thelower gum pad once

(Fluoride program)-Children with any white sport found should receive any fluoride application such as
fluoride varnish or other suitable forms, with follow-up appointments until 3 years old.

4.2. Oral health care services for children 3-5 years-

Early Childhood Caries Prevention Program should be developed as nation-wideroutine and constant program in Myanmar.

-

The services should be integrated by local dentists at preschools.

(Oral examination)-

With established a format dental examination record form for preschool children, oral
health checkup by public health dentists for at least once a year.

-

Inform parents for their children’s oral health status and advice for necessary
treatments-

Necessary treatments except school-based programs will be received at public
hospitals (by hospital dentists)11(Oral health education)-

As lunch is providing by government in preschools, supervision of dietary control iskeenly important.

-

Mainly focus on regular tooth brushing with active motivation to preschool children
by means of poems, stories, etc.

-

Oral health education aiming at positive behavioral changes including dietary habits
should be provided to parents, guardians and preschool teachers.

-

Adequate oral hygiene practice should also be provided. If possible (second priority),collaborate with Ministry of Social Welfare, Relief and Resettlement to establish“Campaign for Tooth Brushing after Lunch” in preschools.
① Each child will need to support for the presence of toothbrush and toothpaste② Toothbrush and toothpaste should be additionally distributed every three months③ There must be a clean environment to store their own toothbrush at preschools or
they will be asked to bring back home and take it everyday④ Specific time should be decided after meal and supervised by trained nursing
teachers(Fluoride program)-

Preventive measures such as topical application of fluoride varnish should be used on
sound teeth and early white spot lesions.

-

Active caries treatment such as use of silver diamine fluoride is necessary. Silver
diamine fluoride should only be applied to active enamel caries and early dentine
carious lesions. GI sealants can also be applied to early dentine carious lesions.

-

SMART/ART should be applied to open cavitation lesions.

Specific Objective 2: To establish/improve oral health promotion programs for schoolchildren
In many countries, dental specialists (dentists and dental hygienists) and school
teachers spend lots of time in promoting children’s oral health. In Thailand, oral healthprevention and promotion in school-age children has long been implemented continuously
under the structured framework using key strategies.11 In Vietnam, the School based Dental
Program (SDP) was implemented in collaborative work with Ministry of Health and Ministryof Education and Training. The SDP is mainly operating oral health education, fluoride
12

mouth rinsing and tooth brushing, clinical prevention and fissure sealants to primary schools
all over the country.12 It should also be implemented well organized school-based oral healthpromotion programs in Myanmar.
2.1. Oral Health Education Program
The result of this survey suggested that oral health promotion programs should
include effective oral health education for improving dental awareness. Oral health education
is a fundamental and very common approach, whereas effective oral health education could
establish good oral health behaviors and habits by enhancing a person’s oral healthknowledge.13 Although knowledge was just improved unless attitude or practice improvement,
oral health education could not be effective enough for oral health promotion in Myanmar.
In every school, at least a teacher should be trained in school health activities, and heor she will be responsible to make joint activities with school health team of the respective
township. Public health dentists, nursing teachers and classroom teachers should be involvedin conducting oral health education. Moreover, oral health education for children should be
involved in a routine curriculum by classroom teachers and school nursing-teachers. The typeand extent of oral health education program is dependent on the individual school’s needs,
problems, curriculum and timetable. Generally, school nursing teachers will teachschoolchildren how to brush their teeth properly, highlight the importance of oral health forstudents and how to protect themselves. As dental caries in children is very high in Myanmar,
nutritional guidance of limiting snacking sweet foods, drinks and regular dietary patterns
should be mainly focused in the educational interventions. Government is expected as a keyrole to take the initiative and to act in developing and implementing oral health promotional
strategies, with support from health care professionals and relevant organizations.
Step by step key facts
1. Authorized persons from Ministry of Health and Sports (with international supports)-

Develop an appropriate oral health education framework based on previous data-

Develop the education materials (for example, education poster will be developed
and pasted in the classrooms)-

Public health experts will share knowledge to local public health dentists about
effective oral health education with the following information included:① Use correct tooth brushing technique② Brush twice a day with fluoride tooth paste (before immediately bed time andafter breakfast)13

③ Choice of tooth brush and amount of fluoride tooth paste④ Brushing time (minimum of two minutes)⑤ Spit out well after brushing, but minimize rinsing behaviors with water-

Cooperate with Ministry of Education to form school oral health education team-Oral health education schedule involve in a school curriculum (government)
Appropriate tooth brushing with adequate fluoride toothpaste should be actively
educated in schools.

2. Local dentists from Department of Public Health-Branch training from dentists to dental nurses, assistants and health care workers-

Ask at least a teacher from each school for school oral health education team-Oral health education trainings to selected nursing teachers-

Local dentists will give oral health education to schoolchildren at least once a year
(if possible twice a year) in a township level-

Dental nurses or community health care workers will give oral health education toschoolchildren at least once a years in a rural/village level-

School nursing teachers will train oral hygiene care and oral health education toschoolchildren with scheduled timetable (for example, once a week)-

Set up school oral health education teams

School Oral Health Education Team
Ministry of Health

Ministry of Education

Local public healthdentists

School nursing teachers

Dental nurses, health care
workers

Oral health education at schools through the country

14

School-based Fluoride ProgramsBase on the national oral health survey, the subjects have already got caries on their
newly erupted permanent teeth as early as the age of 6 years. Therefore, various school-based
fluoride programs should be developed with the support of government and nongovernmental organizations.
Fluoride mouth rinsing program
It is recommended for caries prevention and reduction dental caries inequalities
among schoolchildren, and FMR under supervision also frequently has been used in schoolbased programs to prevent dental caries in children. FMR usually oriented for preschool
children, primary school children and junior high school children with different frequency
and concentrations, which has contributed to caries prevention of permanent teeth.
Supervised regular use of FMR by children and adolescents is associated with a large
reduction in dental caries development. WHO documented that FMR should only be used for
6-years-old children and above due to concerns about dental fluorosis. On the other hand,first permanent molars already erupted at the age of 6, and it might be delayed to prevent
dental caries occurrence for first permanent molars in 6-years-old. So, measurements for
FMR uses among preschool children were performed in Japan, and reported FMR could be
performed by preschool children safely and efficiently.
Step by step key facts
1. Authorized persons from Ministry of Health and Sports (with international supports)-

First step is to attempt for easily available in local markets-

Training programs to local dentists for effective FMR methods

2. Local dentists from Department of Public Health-Branch trainings to school nursing teachers, dental nurses, assistants and healthcare workers-

Practice the initial mouth rinsing with water in schoolchildren to avoid
swallowing or left over in cups-

Implement 10ml 0.2% sodium fluoride mouth rinse weekly under supervision ofschool nursing teachers at schools-

Start fluoride mouth rinsing from grade 1 primary schoolchildren and continue
until end of middle school

15

Clinical application of sealants or fluoride varnish-

Perform annual dental examination with established format dental examination form-

Clinical application of sealant or fluoride varnish should be used in children who needpreventive measures in the school settings(Resin-based sealants or GIC protective coatings)
It should be applied to the first permanent molars (once they have fully erupted) of 5and 6- year-old children who have-one or more primary teeth missing due to caries,-

three or more filled primary teeth, or-

deep, sticky and retentive fissures on their first permanent molars.

(Fluoride varnish applications)
Topical fluoride varnish applications should be used in schoolchildren on earlysmooth-surface lesions on-

permanent teeth or-

deciduous teeth which have at least two years remaining prior to exfoliation.

(Silver diamine fluoride applications)
Active caries treatment such as use of silver diamine fluoride is necessary. Silver
diamine fluoride should only be applied to-active enamel caries of deciduous teeth or-

early dentine carious lesions of deciduous teeth.

(SMART/ART)
It is also considered to be an alternative method of restorative treatment of primary
tooth in school-based environment. Simply remove dental caries, minimal cavity preparation
using only hand instruments and fill it with glass ionomer cement. It is suitable to apply in-open cavitation lesions (involving dentine),-

accessible to hand instruments, or-

one surface more than multiple surface cavities.
16

After lunch tooth brushing program
In 2013, Live-Learn-Laugh Project (LLL project) was successfully established withthe joint cooperation of Myanmar Dental Association, FDI and Unilever. According to theseresults, after lunch tooth brushing would be beneficial to reduce prevalence and incidence oforal diseases among the school children. Therefore, “Campaign for Tooth Brushing after
Lunch” should be re-performed at model schools and then developed nation-wide in the
future.
2.2. Clinical Prevention (Early Treatments)
Clinical preventive activities consist of periodic oral examinations and early treatment
for emergency dental care in schoolchildren.
Step by step key facts
1. Public health dentists will go to schools for oral examination (with established oral
examination form) at least once a year
2. Refer to public health centers or hospitals for necessary treatments except schoolbased fluoride programs
3. If possible (second priority), collaborative work with public health dentists andhospital dentists. Provide early treatments such as deciduous teeth extraction, ART,
scaling, etc. in the school settingsSpecific Objective 3: To establish/improve oral health promotion programs for adults(including elderly)
Based on this survey, dental caries status and periodontal status were severe in both35-44 years and 65-74 years age groups. The 60-74 years old group subjects have the highest
caries prevalence as well severe periodontal disease to be compared to the other age groups.
People awareness on oral diseases seems to be still poor and their oral health literacy is low.
Accordingly, their oral health behaviors as well as status are inadequate. These factors may
be attributed to increase prevalence of dental caries and periodontal disease in Myanmar.
Therefore, prompt and adequate preventive strategies and measures should be implemented
for Myanmar people.
Nowadays, it is moving toward an aging society worldwide and also expected to beaged society in future in Myanmar. A higher proportion of elders cause higher prevalence of17oral diseases with common risk factors and need more complexity care than the younger.
Tooth loss is the main oral health problem in aging population and related with eating,chewing and swallowing inabilities, affected to poor nutrition, unhealthy and low quality oflife. Therefore, oral health programs for aging population related with improved quality oflife should be considered.
3.1. Oral Health Education
Oral health education pamphlet and video programs were telecast on the national TV
program.1 It is also performing by dental public health section of Myanmar Dental
Association and joint dental public health activities with international organizations such as
JICA, IADR, ICD, etc. In education, motivation is more important than informing the people.
Simply education is not enough and so, the most important thing is to use effective andmotivational education approach instead of traditional education approach in the futurenationwide. It is necessary to involve local leaders as people learn the best from whom they
respect and regard. Further, education strategies (based on previous data) should beconsidered with different purposes in community.
For example,-

Focus on the dietary control, fluoride use, oral hygiene care, etc. for caries-risk
community-

Focus on regular tooth brushing, nutrition guidance, oral hygiene care, etc. forperiodontal disease-risk community-

Focus on restriction of fluoride uses for high fluoridated areas-

Focus on betel quid chewing, oral cancer awareness, making tobacco free zone inpublic areas, etc.

Step by step key facts
1. Local dentists from Department of Public Health-Branch training to dental nurses, assistants and health care workers-

In addition to institutionalized services, local public health dentists together withdental nurses and community health care workers will go to community until grassroot level-

Give oral health education to community people at rural health centers

18-Involvement of local authorized persons (i.e. head of a village, religious leaders
such as monk)-

Set up community-based oral health education teams-

Local dentists, dental nurses, community health care workers-

Local leaders-

Village health volunteers

2. Authorized persons from Ministry of Health and Sports-

Continue national TV programs through the country (oral health messages forcommon oral diseases as well as oral cancer awareness)

3.2. Oral health care services-

Oral health care of Myanmar people is mainly providing by private practitioners.
So, private sector is also important, the general practitioners should provide not
only dental treatments but also oral health check-up. It is necessary to persuade
the patient for recall visits and regular oral health check-up.

-

It is also necessary to improve oral health care services in hospitals by actively
providing efforts in urban areas, rural areas, remote areas-

Continue outreach activities of Myanmar Dental Council, Myanmar Dental
Association and other international organizations (with emphasis on preventive
procedures)

Oral health care services for elderly
If a person who lose their teeth, it would be difficult to enjoy food and make them feel
unhappy, mental health is ill and lost their quality of life. So, it should be covered dentureservices and preventive services for root caries in community outreach activities all over thecountry. Oral health programs for institutionalized elderly (elderly care centers, nursinghome) should also be designed to improve their oral health status. Oral health care services
such as oral examination, emergency treatments and oral prophylaxis should be provided.
Oral hygiene care such as tooth brushing to elderly should be supervised or performed bynurse-aids and caregivers. In Thailand, the Bureau of Dental Health offered a development
program for elderly club to arrange the activities for oral health promotion of members. It isnecessary to initiate new approach to oral health care system for elderly (such as elderly club)on selected townships, and then gradually expand to nationwide.

19

1. Charity dentist groups-

Provide denture services in community field trips-

Provide root caries preventive services (silver diamine fluoride, fluoride mouthrinse, sealants) for elderly in community field trips

2. Local dentists from Department of Public Health-Routine oral health care delivery for institutionalized elderly (nursing home,elderly care centers)

3. Local dentists from Department of Medical Services-

Support and contribute the current oral health care efforts in hospitals (including
dentures, fixed prosthesis, etc. for elderly)

4. Authorized persons from Ministry of Health and Sports-

Initiate elderly club and activities groups in selected townships and expand
gradually nationwide-

Arrange various activities including oral health care

3.3. Community fluoridation programs-

There is still lacking information about community fluoridation in Myanmar. So,
it is necessary to update the information on the fluoride content of water supplies.

-

Provide the most appropriate fluoridation method in community
For example, water fluoridation to public water system in selected townships.
Then, evaluate their oral health status after 5 years.

-

There is still no special fluoride mouth rinse program in Myanmar. Therefore, (ifpossible) it should be initiated some fluoride mouth rinse program such as homecare use for adults and elderly.

-

Authorized persons should evaluate the fluoride contents of locally available
fluoride toothpastes and strictly perform to add accurate fluoride content in
toothpastes.

3.4. Oral Cancer Awareness Program
Among the subjects involved in the survey, some subjects were indicated to have oral
cancer by the examiners. Areca/betel nut chewing habit was commonly found within sometraditional ethnics, in Myanmar. Since 2013, the special interest group of oral medicine andoral pathology initiated the “Oral Cancer Awareness Program” by screening among tobaccoand betel quid consumers at suburban and rural areas.14 Myanmar is one of the highest
prevalence in tobacco consumption countries with an increasing trend. As betel quid chewing
habits are widely spread in Myanmar, it should be necessary to widely motivate people for20

oral cancer awareness nationwide. Further, government should be initiate the public restrict
areas for tobacco smoking and chewing.
Step by step key facts
1. Authorized persons from Ministry of Health and Sports-

Government should initiate public restrict areas for tobacco smoking and betel
quid spitting with some punishments-

Training to local dentists for oral cancer screening methods-

Active programs in oral cancer awareness month

2. Local dentists-

Oral cancer screening should be widely performed at public hospitals (by hospitaldentists)-

Oral cancer awareness messages should be developed nationwide (by publichealth dentists)

Specific Objective 4: To establish public health insurance system
As there is no universal health coverage in Myanmar, it is also a big threat for people
to cure effectively even though they know treatment is actually needed. Installment of healthinsurance scheme (national/private) can be considered to reduce future incidence andprevalence of common oral diseases in Myanmar.
Step by step key facts
1. Authorized persons should have to report to government for developing public healthinsurance system
2. With international supports, plan and develop the mandatory health insurance system(e.g. deduction of some amount of salary for performing health insurance)

Goal 3: Develop oral health human resources development plan
Specific Objective 1: To increase the numerous qualified oral health personnel who aid
various oral health promotion programs with future perspectives
Dental human resources are very limited in Myanmar compared with WHO standard.
There are only 3695 dentists (2014) and the number of dentist per population ratio is 6.8 per
100,000 populations in Myanmar. Regarding the dental education, there are only two dental
schools (both are nationals) in Myanmar, while 10 dental schools (8 public and 2 private) in
Thailand, 7 public dental schools in Vietnam. As the role of oral health professionals is to21

support the community people for a leading outcome and better process of health promotion,
increment of dental human resources is keenly important for better oral health situation in
Myanmar. Therefore, it is necessary to develop new dental schools (public or private) in
Myanmar. Further, there is still limited number of teaching staffs in dental universities.
In townships without school health teams, township medical or dental officer is taking
the duties for school health affairs. It is necessary to appoint public health dentists in every
township in Myanmar. Public health dentists take main responsibility for monitoring routine
oral health care services through the country. There is no dental hygienist in Myanmar.
Currently, limited number of the dental nurses is producing by Universities of Dental
Medicine in Myanmar. Those dental nurses are appointing at public hospitals for assisting theduties and responsibilities of public dentists. It is still necessary to develop capacity of thedental nurses to be able to practicing such as emergency dental care and preventive fillings
etc, especially in rural areas, to offer available dental services.
Key facts (teaching)
1. Develop the number of qualified teaching staffs in dental universities
2. Authorized persons have to propose the government for development of new publicdental schools, private dental schools
3. Train the dental students with intensive courses
Key facts (public health and medical services)
1. Increase the number of public health dentists
2. Available of the dentists and/or oral health personnel to grass root level of community(special offers to those dental workers)
3. Promote the number of dental nurses and appoint to every public hospital
4. Format dental workforce system should be developed in every township. (e.g. at leasta public health dentist, a hospital dentist, a dental nurse in each township)

Specific Objective 2: To train oral health personnel
For contributions of oral health education and preventive procedures to thecommunity, the dentists, dental nurses and dental assistants should be trained and guided
routinely as part of their continuing education. This is an urgent need to ensure adequate andappropriate continuing dental education in preventive dentistry.

22Key facts
1. Ensure adequate and appropriate continuous education in dental public health
2. Advanced studies, trainings and/or hand-on courses to the dentists, dental nurses anddental assistants by means of free and/or low cost (*not only to government staffs but
also to private dentists)
3. Training of basic dental treatments (such as scaling, ZOE dressing, etc.) tocommunity health workers
4. Attendance of continuous dental education by means of point system
5. Point system will be aid for consideration of dental license extension, foreign
trainings and promotions
Specific Objective 3: To involve public health experts in national level-

The government need to empower the dental workforce by their direct involvement
and participation in the national level oral health policy formulation, implementationand planning to overcome oral health challenges.

-

Public health experts will format dental workforce framework with assigned role andaction of dentists in various sectors (public health dentists, hospital dentists,
university dentists, MDA, MDC, private dentists)-

This is critical for appointing and active participation of dental public healthspecialists in the national level in order to ensure that the steps being taken currently
and to develop further oral health betterment in Myanmar.

23

Summary

1. Multi-sector collaborative works with other ministries and organizations should be
performed.
2. Format dental examination record forms should be urgently implemented in various
settings.
3. A national oral health database should be established which can be accessible in various
ways.
4. Routine national oral health survey should be conducted every 5 years.
5. An appropriate oral health guidelines and policies for provision of oral health careservices should be developed in various settings.
6. A formal dental workforce framework should be conducted.
7. Dental human resources should be developed for various oral health care programs in
Myanmar.
8. Routine basic oral health care services should be implemented properly through states andregions of the country.
9. Adequate and appropriate continuing dental education in dental public health should be
developed.
10. The government needs to empower the dental workforce by their direct involvement andparticipation in oral health policy formulation, implementation and planning to overcome
oral health challenges.
11. Well-trained dental public health specialist is necessary to ensure the steps being taken
currently and develop further oral health care programs in Myanmar.

24

Summary Flowchart① Maternal and Child Care Society② Ministry of Social Welfare③ Ministry of Education

Ministry of HealthFormat oral healthexamination record form

Public health dentists collectdata (selected townships)
International supports

Local public health experts
analyze first year data

Report first year data

Oral Health Monitoring System

Oral health guidelines and policies

Develop Oral Health Human Resources
Format dental workforce framework

Oral Examination
programs

Oral Health Promotion Programs
through the country

Oral health education
programs

Fluoride programs

Oral cancer
awareness programs

25

Missions to be considered with different time frames (emphasis within 3 years)
Short term

Term
1 (2019)

2 (2020)

3 (2021)

Goal 1: Oral health monitoring system
1.1. Pregnant women andchildren 0-2 years-Discuss with Maternal and Child Care

-Collect the data at selected townships-Combine, analyze and report the firstyear’s data

Society-Establish maternal and child care bookincluded oral examination chart-Select model townships

1.2. Children 3-5 years-Discuss with Ministry of Social Welfare-Collect the data at selected preschools-Combine, analyze and report the firstyear’s data

-Establish format record form
-Select model preschools
1.3. Schoolchildren-Discuss with Ministry of Education-Collect the data at selected schools-Combine, analyze and report the firstyear’s data

-Establish format record form
-Select model schools
1.4. Adults and Elderly-Establish comprehensive patient record in-Collect the data at selected hospitals and-Combine, analyze and report the first

hospitals (if possible, record form for(if possible, at elderly institutions)

year’s data

institutionalized elderly)-Select model hospitals-Plan for public health insurance system

Goal 2: Routine oral health care services-Discussion with international experts to
set up guidelines and policies and assignfor oral health programs
Goal 3: Human resources Development-Increase the number of dentists-Ensure trainings for ongoing oral health-Involve well-trained dental public healthcare programs

specialists in national level-Special trainings-Plan for dental workforce framework-CDE with point system

26

Missions to be considered with different time frames (emphasis within 6 years)
Middle term

Term
4 (2022)
Goal 1: Oral health monitoring system

5 (2023)

6 (2024)-National Oral Health Survey-Analyze and report the data of NOHS-Continue routine data collection through-Collect routine data through the country- Analyze and report the annual data

the country-Continue oral health care services-Continue oral health care services-Continue oral health care services-Continue oral health care services-Continue oral health care services-Continue oral health care services-Continue oral health care services-Continue oral health care services

hospitals, field trips and elderly home

-Initiate the elderly club in selected-Spread the elderly club through the-Prosthesis for elderly

townships (if possible)

country (if possible)-Consider for new dental schools-Consider for new dental schools-Consider for new dental schools-Special trainings, CDE with point system-Special trainings, CDE with point system-Special trainings, CDE with point system-Establish a national oral database
Goal 2: Routine oral health care services-Start public health insurance system

2.1. Pregnant women-Oral health education to mothers andand children 0-2 years

pregnant women-Fluoride program

2.2. Children 3-5 years-Training to preschool teachers-Oral health education-Fluoride program

2.3. Schoolchildren-Develop education materials and train toschool teachers and educate to children-Fluoride programs and early treatments

2.4. Adults and Elderly-Public education (e.g. TV program)-Education through local leaders-Oral cancer awareness program-Oral

healthcare

services

through-Community fluoridation programs
Goal 3: Human resources Development

27

Missions to be considered with different time frames (emphasis within 10 years)
Long term
Term
7 (2025)
Goal 1: Oral health monitoring system

Goal 2: Routine oral health care services

Goal 3: Human resources Development

8 (2026)- Continue routine data

- Continue routine datacollection through the country

collection through the country-Continue oral health care

9 (2027)

10 (2028)-National Oral Health Survey-Evaluation-Continue oral health care-Continue oral health care

-Evaluation

services

services

services-Special trainings, CDE with-Special trainings, CDE with-Special trainings, CDE withpoint system

point system

point system-Evaluation

28

Ⅳ. References
1. San MM. Country Report on Dental Caries Epidemiology and Relevant Interventions (2):
Caries prevention in Myanmar. International Dental Conference on "Caries Control
throughout Life in Asia"; November 20-22, 2013; Krabi, Thailand. p. 210-23.
2. Chu CH, Chau AM, Wong ZS, Hui BS, Lo EC. Oral health status and behaviours ofchildren in Myanmar - a pilot study in four villages in rural areas. Oral Health &Preventive Dentistry 2012;104:365-71.
3. Ogawa H, Soe P, Myint B, Sein K, Kyaing MM, Maw KK et al. A pilot study of dental
caries status in relation to knowledge, attitudes and practices in oral health in Myanmar.
Asia Pac J Public Health 2003; 15: 111-117.
4. Thwin KM, Lin WT, Than A. A pilot study of oral health situation of Chin population inwest hilly regions of Myanmar. Myanmar Dent J 2018; 25 (1): 31-39.
5. Maw KK. Profile of oral health in school health programs of Myanmar. Myanmar Dent J
2004; 5(2): 15-19.
6. Department of Medical Services, Ministry of Health and Sports, The Republic of theUnion of Myanmar. [Last access on 5th April, 2019]http://www.doms.gov.mm/Default.aspx
7. Jienmaneechotechai S, Ungchusak C, Dalodom S, Prasertsom P, Matangkasombut O.
Country Report: Thailand. International Dental Conference on Caries control throughout
life in Asia 2013; Krabi, Thailand: 295-314.
8. World Health Organization, Regional Office for South-East Asia. Formulating oral healthstrategy for South-East Asia: Report of a regional consultation, Chiang Mai, Thailand
2008.
9. Aung EE, Maung K, Zaitsu T, Kawaguchi Y. An overview of oral health situation andchallenges in Myanmar. Asian J Res Med Sci 2018; 1(1): 1-10.
10. Thwin KM, Zaitsu T, Ueno M, Kawaguchi Y. Early childhood caries and related risk
factors among Myanmar preschool children. Int J Clin Prev Dent 2016; 12 (4): 229-236.
11. Prasertsom P, Jirapongsa W, Changban P, Luengvara P, Rattanarungsima K, Rityue A. 37
years of experience of oral health promotion in schoolchildren. Thailand J Health Promo
Environ Health 2009; 32: 24-33.
12. Hai TD, Khanh ND. Country Report: Vietnam. International Dental Conference on Caries
control throughout life in Asia 2013; Krabi, Thailand: 315-339.

29

13. Thwin KM, Zaitsu T, Ueno M, Kawaguchi Y. Effects of oral health education in
Myanmar preschool children and guardians. J Invest Clin Dent 2018; e12346.

30

Ⅴ. Appendix

Report of National Oral Health Survey in Myanmar(2016)

Prepared by
WHO Collaborating Centre for Translation of Oral Health Science
Niigata University, Japan31

1. INTRODUCTION AND BACKGROUND
1.1. Myanmar demographic profile
The Republic of the Union of Myanmar is located in South East Asia bounded by India,
Bangladesh, China, Laos and Thailand on the land side and 1760 miles of coast line isbounded on west by Bay of Bengal and Andaman Sea. Myanmar covers wide geography of
676,578 square kilometers in total land and water. The country is divided into Nay Pyi Taw
Council Territory and 14 States and Regions. It consists of 74 districts, 330 townships. 1 The
provisional result of 2014 population census shows the total population of Myanmar as
51,419,420 where Female 51.8% and Male 48.2% which does not include people who wereout of the country at the time of census. The population density shows 76 persons per square
kilometer and 30% of population resides in urban areas.2 There are 8 major national ethnic
races which comprises 135 distinct ethnic groups. The 89% are Buddhists while the rest are
Christian, Islam, Hinduism and others. Total population life expectancy is 65.24 years where
89.9% of population can read and write. Development of social sector has kept pace witheconomic development. Expenditures for health and education have risen considerably.3
1.2. Political situation and health care system in Myanmar
Myanmar health care system evolves with changing political and administrative system since2010 first election. Myanmar has life expectancy at birth 67 years old. Based on 2014 census,
the maternal mortality ratio is 282 deaths per 100,000 live births, and under five childmortality rate is 72 deaths per 1,000 live births, malnutrition is highly prevalent, the burdenof disease from Non-communicable diseases is alarming. Health care system reform brings inintroducing health related policies in 2013 and 2014 and public spending on health has
increased 9 folds. But the health care delivery services and interventions does not reach entire
population due to limited readiness of health facilities and human resources which may
shows great variations of quality of care.4 Since 2016 April, new presidential government has
started with new administration structure in Ministry. There are lots of new opportunities andnumerous challenges in this transition stage. NLD health committee is leading initiatives toachieve Universal Health Care Coverage in 2030. Ministry of Health is now combined with
Ministry of Sports and stand as Ministry of Health and Sports with new administrative
structure with challenges in human resource management under new organization structureand system. In each ministry, 100 days project activities have been started from 1st May 2016
to 30th July, 2016 as initial steps of change.
321.3. Human resources for oral health and oral health care system in Myanmar
There are two dental universities (Yangon and Mandalay) offering B.D.S, Dip.D.Sc, M.D.Sc,
Dr.D.Sc, Ph.D, Diploma in Dental Technology, Diploma in Dental Nursing and B.D.S,
Dip.D.Sc, M.D.Sc, Dr.D.Sc respectively. In year 2013 – 14, there are 3219 registered dental
surgeons in country where 782 dentists in public sector and 2437 in co-operative and private
sector. There are only 357 dental nurses in the whole country.
With the new administrative structure of Ministry of Health and Sports, Oral Health Unit isunder Department of Medical Services. Under which every township hospital has dental careunit which provides dental services to community with shared cost. There will be variationsof health facilities, human resources and quality of care in each township. There has no
defined and specific basic oral health care services available free of charge at public hospitals
yet which need to discuss in moving forward universal coverage for 2030. Since 1992,
Primary oral health care services have been integrated into primary health care services incollaboration with WHO SEARO. There were nationwide school heath programs runningwhich comprise of dental health education, tooth brushing and oral health examination andtreatment. Dental fluorosis is prevalent in some part of country and fluoride mapping wasonce conducted in collaboration with occupational health division in Wet Let Township,
Sagaing Region.
Under new organization structure of Ministry of Health, dental public health activities havebeen diminished or blurred with no specifically defined and assigned unit or department ofdental public health unit. Oral Health Unit under new ministerial structure is also
implementing 100 days project activities. But the clear vision, planning and management ischallenging part to effectively manage and sustain those dental public health programs.
1.4. Oral health status of Myanmar people
The Oral Health statistics previously available for Myanmar was from the research articles
carried out on specific populations and could not represent the whole population in the
country. The 2003 WHO figures says Myanmar as low dental caries region (1.2 to 2.6) for 12
years old children which need to update with representative data.

33

2. AIM AND OBJECTIVES
2.1. Aim
There were limited information and evidences challenge in strategic planning, policy making
and delivering effective oral health care services and prevention programs for the whole
population under clear vision and objectives. Therefore, the aim of this survey was toinvestigate the oral health status and oral health behaviors of the people of Myanmar,
compare internationally and perform strategic planning and effective management of oral
health programs integrating with other public health programs.
2.2. Specific objectives
1. To access the dental caries status of the indicator aged groups as mentioned in WHO
pathfinder methodology
2. To access the periodontal status
3. To access the status of oral mucosal lesion, dental fluorosis and relevant oral
conditions in indicator aged groups according to WHO pathfinder
4. To access the Oral health behaviors of the people in selected indicator aged groups
5. To access the fluoride concentration from different sources of drinking water fromselected sample site34

3. METHODOLOGY
3.1. Study design
The survey was a cross-sectional descriptive study using WHO oral health survey basic
methods (fifth edition) at the national level. It was conducted in twenty one selected locations
from fourteen states and regions including Nay Pyi Taw.
The study was performed in 6 years old, 12 years old, 15 to 18 years old, 35 to 44 years old
and 60 to 74 years old. The survey was conducted between December 2016 to January 2017at selected townships from all states and regions.
The following data collection instruments was used
1. WHO oral health clinical assessment form (2013) for oral health diseases andconditions, occurrence, severity and treatment needs
2. WHO questionnaire (2013) to collect data about Oral Health seeking behaviors,
knowledge, attitude, oral hygiene practices and habits
3.2. Personnel involved (role and responsibility)
Protocol was developed with contribution from National and International dental publichealth professionals.
-

Management team (chief of oral health unit, Dr. Khin Maung was the PI of thesurvey) with a committee members from some technical and survey team and seniorpublic health dentists and a potential secretary.

-

Technical team (dental university, statistics, preventive and community dental
department, senior dental public health dentists, WR, internal and external experts)-

Survey team had at least 3 team member:o team leader (local senior dentists) who was the liaison officer or coordinator to
conduct the survey smoothly with local administration staff under ministry ofhome affair and health volunteers to do logistical arrangement. Local seniordentist was the most responsible person for the survey to recruit the dentists as
examiner and recorder of the team.
o young dental officers (dentists) who has the good eight sight and can copewith the travelling and can also participate fully with the team in each35

location) as one dentist to do examination as examiner and one dentist to dorecording as recorder.
-

Questionnaire assessment was performed by non-dentist in local language and pretest.

36

3.3. Sample selection
The sampling is based on administrative divisions of a country which has 14 different statesand divisions. Each state and regions reside by majority of each different ethnic group.
Specific sample site selection is based on administration figure of 2014 population census.
The 21 locations were selected using stratified 2-stage sampling technique (based on
geographic location, township simple random sampling, urban/rural, schools SRS >> student
systematic sampling, and for other age groups: in township base on schools).

State/Region

Township

KACHIN
KAYAH
KAYIN
CHIN
MON
RAKHINE
SHAN SouthSHAN East
SHAN NorthSAGAINGTANINTHARYINAY PYI TAWBAGOYANGONYANGON
MANDALAY
MANDALAY
MAGWAYMAGWAYAYEYARWADDY
AYEYARWADDY

ShweguDemosoHpa-AnFalam
Mudon
Pauktaw
PindayaKengtung
NamhkanMonywaYebyu
TatkonZigon
Dagon Myothit (South)
Hlaingtharya
Amarapura
Pyigyitagon
Chauk
MagwayBogalePantanaw

The number of subjects to be examined in each index age groups was planned to have 30 foreach sampling sites with equal number of males and females. There are 5 index age groups ateach site.

37

Total sample = number of subjects to be examined in each index age group x number ofindex age group x selected sites x urban and rural
30 sample for each age group (30 x 5 x 21 x 2 = 6,300)
On the initial design for this pathfinder survey, it was planned to have an equal number ofsubjects (1,260 subjects) for each age group.
However, due to some unforeseeable conditions in the field (the age of 27 subjects were outof the age-range which has been determined for this pathfinder survey, based on the WHO
categorization), there were in total of 6,273 subjects examined for this survey. Furthermore,
due to some technical examination errors, the final number of subjects who were eligible tobe analyzed was 5,928 and 4,667 for caries and periodontal status respectively (Table 1).

Table 1. Description of number of subjects involved in the survey
Initialdesignof

thenumber of subjects

Numberofsubjects

examined*

Sex
Total
Femalesubjects

analyzedforcariesFemaleofsubjects

analyzed for periodontal

Sex
Total

Male

Numberstatus***

Sex
Total

Male

of

status**

Age
group

Number

Sex
Total

Male

FemaleMale

Female

Total

6,300

3,150

3,150

6,273

3,132

3,141

5,928

2,943

2,985

4,667

2,312

2,355

6

1,260

630

630

1,260

635

625

1,260

635

625

-

-

-

12

1,260

630

630

1,260

624

636

1,155

557

598

1,155

559

596

15-18

1,260

630

630

1,260

630

630

1,022

508

514

1,021

510

511

35-44

1,260

630

630

1,248

621

627

1,246

621

625

1,246

621

625

60-74

1,260

630

630

1,245

622

623

1,245

622

623

1,245

622

623

Notes:* Out of age group range for 27 subjects** Incomplete data for 345 subjects*** Incomplete data for 373 subjects

38

3.4. Training and calibration of examiners
In order to obtain an acceptable level of reliability, all examiners were trained and calibrated
prior to the survey. To limit the confounding factors arising from inter-examiner and intraexaminer variations, dentists received training and calibration course from WHO-CC at
Niigata University, Japan with the gold standard (Dr. Hiroshi Ogawa and team).
The non-dental personnel were also calibrated to take care of action for questionnaire under
the supervision of survey team leader.
The operation manual, survey manual (code and criteria of every index and questionnaire)and guideline for water collection was developed before calibration.
3.5. Pilot survey
After the calibration workshop to test the validation and practice the survey team, a real pilot
survey was exercised in the examination site in September 2016.
3.6. Consent form
Adults were participated by signing in consent form themselves, while for the age of 6 and 12
years, parents or caregivers signed a written consent form to allow their children toparticipate in the study.
3.7. Data collection procedure
There were 10 survey teams, where as a team consists of a local senior dentist (team leader),two young dentists (examiner and recorder). During data collection, the teams were actively
involved with the local authorities as well as school principals and administrators. Person in
authority of institution or organization where people will be examined was contacted one
month ahead. In school, the principal or head teacher was consulted about school term dates
and when the children would be available for examination and for suitable area or room toarrange for assessments. The total data of the whole country was collected over a period of
two months.
The team began by explaining to the participant the reasons for the survey and the benefits
thereof, checking and re-confirming the consent obtained that the participant was willing toparticipate in the survey. Oral examinations were carried out with a plain mirror andperiodontal probes under daylight or, where necessary with a portable light source. No
radiographs were taken.

39

Clinical Assessment was include assessment of-

Dentition Status for all age groups-

Periodontal Status with revised basic method in older age groups: 15 – 19, 35 – 44
and 60 – 74 years old-

Dental Fluorosis with Dean’s index for 12 and 15-19 years old-

Dental Erosion for 15-19 and 35-44 years old-

Traumatic Dental Injuries for all age groups-

Oral Mucosal Lesion for 15-19, 35-44, 60-74 years old-

Tooth Loss and Denture Status and Need for 15-19, 35-44, 60-74 years old

Self –assessment, interview of oral health status, practices and risk factors throughquestionnaire (which need to be in Local language) were performed for12 years old, 15 –19
years old, 35 – 44 years old and 60 –74 years old age groups.
3.8. Statistical analysis
The daily data verification, entry and cleaning was performed every evening in Myanmar toverify and check the missing data and consistency of data. After the data entry, two dentists
from Myanmar were sent to Niigata University, Japan for trainings in data analysis and they
performed data analysis in Niigata University, Japan.
Statistical analysis was carried out using statistical software SPSS 23.0 (SPSS, Chicago, IL,
USA). Descriptive statistics such as Chi-square test and ANOVA test were computed toreport the mean or proportions of their oral health status and habits. The level of statisticalsignificance for all tests was set at p<0.05.

40

4. RESULTS AND DISCUSSION
4.1. Dental caries status
4.1.1. Dental caries on primary teeth
Based on the dentition data for primary teeth, it can be observed that only 15.8% of 6 years
old group subjects who were free of dental caries on their primary teeth. As shown in Figure
1, even within the mixed dentition age range, the prevalence of primary dentition was still
considerably high. This result indicates that even in the mixed dentition age range, some ofthe subjects still have carious primary teeth. Moreover, the data showed that most of the 6
years old group subjects (98.6%) and all of the mixed dentition age range have their carious
primary teeth left untreated.

(%)
100
90
80
70
60
50
40
30
20
10
0
Male

FemaleMale

6 y.o.
subjects with dental caries

Female12 y.o.

Male

Female15-18 y.o.

Subject with untreated caries

Figure 1. Primary teeth caries prevalence

Figure 2 shows that the age group of 6 years old has the highest total dft score (5.2) whichwere similar between males and females (5.21 and 5.13, respectively). The age group of 6
years old was also the one who have the highest percentage of teeth with df. However, eventhe dft scores for mixed dentition age range (12 and 15-18 years old) was lower, thepercentage of primary teeth left with df was similar to the 6 years old group. This result
indicates that most of the primary teeth left within the mixed dentition age range were carious.

41

(dft)

(%)

6

100
90

5

80
70

4

60
3

50
40

2

30
20

1

10
0

0
Male

FemaleMale

6 y.o.

Female12 y.o.

mean dft

Male

Female15-18 y.o.

teeth with df

Figure 2. Mean dft and percentage of teeth with df

As shown in Figure 3, within the age group of 6 years old, there are some subject who havecaries (dft score) on all of their primary teeth (20 for the maximum percentile). The medianfor this age group was 4. On the other hand, the maximum percentile for the age group 15-18
years old was 1. Figure 4 which shows the distribution of dt score, was showing the similar
pattern with Figure 3. This can be explained by the pattern shown in Figure 5, whichindicated that only 1 subjects who have an ft score of 3 as the maximum percentile for the agegroup of 6 years old, while no ft score found in the other age groups.

(dft)
25

20
minimum (0%)
25%

15

median (50%)
75%

10

90%
maximum (100%)50
6 y.o.

12 y.o.

15-18 y.o.

Figure 3. Percentile distribution of dft score
42

(dt)
25
20
minimum (0%)
25%

15

median (50%)
75%

10

90%
5

maximum (100%)0
6 y.o.

12 y.o.

15-18 y.o.

Figure 4. Percentile distribution of dt score

(ft)
3.5
3
minimum (0%)

2.5

25%
2

median (50%)

1.5

75%

1

90%
maximum (100%)

0.5
0
6

12

15-18

Figure 5. Percentile distribution of ft score

Figure 6 shows pattern difference of the percentage of dft scores by tooth type between theage group of 6 and 12 years old. It can be observed that the similar pattern was found for themandibular teeth. The percentage of carious mandibular anterior teeth was low, andconversely for posterior teeth. On the other hand, a significant different pattern was found forthe maxillary teeth. The group of 12 years old subjects has caries on all of their primarycentral incisors, while for the age group of 6 years old, approximately 43% of these teeth
were carious. These findings might be explained by the nature of mandibular incisor which
has been replaced by permanent teeth within the age of 6-12 years old. Whilst, the existence43

of maxillary central incisors in the age of 12 years old was prolonged, since they should havebeen replaced by permanent teeth within the age of 9-11 years old. However, the highpercentage of carious posterior teeth either maxillary or mandibular will certainly need an
appropriate attention.

(%)

Figure 6. Percentage of dft scores by tooth type

4.1.2. Dental caries on mixed dentition
Based on the data for mixed dentition, it can be observed that the 6 years old group subjects
have the highest prevalence of caries (primary and permanent teeth) to be compared the 12
and 15-18 years old group (Figure 7). Furthermore, as shown in Figure 8, it can be observedthat the score of dft was higher than DMFT for 6 and 12 years old group of subjects. On theother hand, the 15-18 years old group have almost equal proportion of scores between dft and44

DMFT, 0.3 and 0.6 respectively (appendix Table III-2). This finding indicate that as early as
the age of 6 years, the subjects have already got caries on their newly erupted permanent
teeth, hence in the older age groups, they have double burden of caries on their primary as
well as permanent teeth.

(%)
100
90
80
70
60
50
40
30
20
10
0
Male

FemaleMale

Female6 y.o.

Male

12 y.o.

Female15-18 y.o.

Figure 7. Mixed dentition caries prevalence

6
5
4
3
2
1
0
Male

FemaleMale

6 y.o.

Female12 y.o.

dft

MaleFemale15-18 y.o.

DMFT

Figure 8. Proportion of dft and DMFT in mixed dentition45

4.1.3. Dental caries for permanent teeth
Figure 9 shows that the 60-74 years old group subjects have the highest prevalence of caries
to be compared to the other age groups. The total caries prevalence for this age group was
93.6% with a similar condition between males and females (93.7% and 93.4% respectively).
Furthermore, as shown in Figure 10, it can be observed that female subjects of the 60-74
years old group have the highest DMFT score of 12.04, and the subjects of the 6 years oldgroup was having the lowest DMFT with a score of 0.14 and 0.11 for male and female
respectively. Likewise, the highest percentage of teeth with DMF was found in the female
subjects of the 60-74 years old group (56.9%), while the lowest was for female subjects of the
6 years old group with a percentage of 1.9%. Furthermore, the proportion of Missing (M)score was considerably higher than Decayed (D) and Filling (F) for adult age groups.
Moreover, Figure 11 showed that more than 90% of all age groups have left their active
carious permanent teeth caries untreated.

(%)
100
90
80
70
60
50
40
30
20
10
0
Male

Female6 y.o.

Male

Female12 y.o.

Male

Female15-18 y.o.

MaleFemale35-44 y.o.

MaleFemale60-74 y.o.

Figure 9. Caries prevalence of permanent teeth46

(DMFT)

(%)

14

60

12

50

10

40

8
30
6
20

4

10

2
0

0
Male

FemaleMale

6 y.o.

Female12 y.o.

Male

FemaleMale

15-18 y.o.
DMFT

Female35-44 y.o.

MaleFemale60-74 y.o.

Teeth with DMFT

Figure 10. DMFT and percentage of teeth with DMF

(%)
100
90
80
70
60
50
40
30
20
10
0
Male

Female6 y.o.

Male

Female12 y.o.
Subjects with caries

Male

Female15-18 y.o.

MaleFemale35-44 y.o.

MaleFemale60-74 y.o.

Subjects with untreated caries

Figure 11. Percentage of untreated active caries

47

As shown in Figure 12, within the age group of 35-44 and 60-74 years old, there are somesubjects who have maximum DMFT score (32 for the highest percentile). The median forthese age groups were 1 and 9, respectively. On the other hand, the highest percentile for theage group 6 years old was 8. Figure 13 and 14 which shows the distribution of DFT and DT
score was showing the similar pattern. This can be explained by the pattern shown in Figure
15, which indicated that only few subjects who have an FT score for each of the age groups
which shown as their highest percentile. Furthermore, Figure 16 shows that within the agegroup of 35-44 and 60-74 years old, there are some subjects who have maximum MT score(32 for the highest percentile). Moreover, surprisingly there are also subjects from the agegroup of 6 years old who has an MT score of 2. These findings indicate that tooth extraction
was still being one of the solutions in favor for the subjects involved in this survey on
overcoming tooth caries, even for the young generation.

(DMFT)
35
30
minimum (0%)

25

10%
20

25%
median (50%)

15

75%
90%

10

maximum (100%)50
6 y.o.

12 y.o.

15-18 y.o.

35-44 y.o.

60-74 y.o.

Figure 12. Percentile distribution of DMFT score

48

(DFT)
30

25
minimum (0%)
20

10%
25%

15

median (50%)
75%

10

90%
maximum (100%)50
6 y.o.

12 y.o.

15-18 y.o.

35-44 y.o.

60-74 y.o.

Figure 13. Percentile distribution of DFT score

(DT)
30

25
minimum (0%)

20

10%
25%
15

median (50%)
75%

10

90%
maximum (100%)50
6 y.o.

12 y.o.

15-18 y.o.

35-44 y.o.

60-74 y.o.

Figure 14. Percentile distribution of DT score

49

(FT)
10
9
8
7

minimum (0%)
10%

6

25%
5

median (50%)

4

75%
90%

3

maximum (100%)2
1
0
6 y.o.

12 y.o.

15-18 y.o.

35-44 y.o.

60-74 y.o.

Figure 15. Percentile distribution of FT score

(MT)
35

30

25

minimum (0%)
10%

20

25%
median (50%)

15

75%
90%

10

maximum (100%)50
6 y.o.

12 y.o.

15-18 y.o.

35-44 y.o.

60-74 y.o.

Figure 16. Percentile distribution of MT score

50

Figure 17 shows pattern difference of the percentage of DMFT scores by tooth type among
all of the age groups. It can be observed that the similar pattern was found for the maxillary
and mandibular teeth. The percentage of carious maxillary and mandibular anterior teeth waslow, and conversely for posterior teeth. First and second molar were found to have thehighest percentage of teeth experiencing caries. However, surprising finding was observed
for the age group of 6 years old who have a high caries experience percentage for left
mandibular second premolar. This finding indicates that caries were still found even in the
period of early teeth eruption. This unfortunate event will certainly need an appropriate
attention to prevent the incidence of decayed teeth.

Figure 17. Percentage of DMFT scores by tooth type51

4.2. Present permanent teeth and Denture wearing
The mean of present permanent teeth (PT) of all the age groups were shown in Figure 18. The
highest mean PT was found on the male subjects of 35-44 years old age group (30 teeth).
However, within the age group of 60-74 years old, it was found that the mean PT was similar
between males and females subjects at 21.9 and 21.1 teeth respectively. This finding indicatesthat within this age group, there were in average of 10 – 11 tooth loss. Furthermore, as shownin Figure 19, it can be observed that the mean PT among urban, peri-urban, and rural
originated subjects was similar within each age group.

35
30
25
20
15
10
5
0
Male

Female6 y.o.

Male

Female12 y.o.

Male

Female15-18 y.o.

MaleFemale35-44 y.o.

MaleFemale60-74 y.o.

Figure 18. Mean of present teeth by age group and sex

52

35
30
25
20
15
10
5
0
6 y.o.

12 y.o.

15-18 y.o.
Urban

Peri Urban

35-44 y.o.

60-74 y.o.

Rural

Figure 19. Mean of present teeth by age group and urbanity

In regard with permanent teeth present (Figure 20), the age group of 15-18 and 35-44 years
old have a similar pattern. Most of the subjects within these groups were still having ≥ 28
teeth (87.4% and 83.7%, respectively). However, within the age group of 60-74 years old, thepattern was considerably different. The number of present teeth of 20-27 teeth was being thehighest percentage for this age group (36.5%), with a considerable proportion of 1-9 and 1019 teeth present. Furthermore, as shown in Figure 21, there were subjects within the agegroup of 35-44 years old who have no permanent teeth present. This finding is important in
the need of raising the awareness to prevent total tooth loss at an early age which is not afavorable issue.

53

(%)
100
90
80
70
60
50
40
30
20
10
0
6 y.o.

12 y.o.
0 tooth

1 - 9 teeth

15-18 y.o.
10 - 19 teeth

35-44 y.o.
20 - 27 teeth

60-74 y.o.

≥ 28 teeth

Figure 20. Mean percentage of present teeth category by age group

35

30

25

minimum (0%)
10%

20

25%
median (50%)

15

75%
90%

10

maximum (100%)50
6 y.o.

12 y.o.

15-18 y.o.

35-44 y.o.

60-74 y.o.

Figure 21. Percentile distribution of permanent teeth present

54Figure 22 shows the percentage of denture need and wearing. The age group of 60-74 years
old was the highest age group in need for dentures (96.14%). There were similar proportions
for males and females among the age groups, except for the age group of 35-44 years old(42.77% and 59.58, respectively). However, the percentage of subjects wearing dentures wasvery low. In the total average, only 0.5% of the subjects in need of dentures were wearing it,with the male subjects aged 60-74 years old being the highest proportion (0.8%). This finding
indicate that the awareness of the subjects involved in this survey was still very low in termsof rehabilitating their oral health and teeth function by wearing dentures according to theirnecessities.

(%)
100
90
80
70
60
50
40
30
20
10
0
Male

FemaleMale

15-18 y.o.
Subject in need of prostheses

Female35-44 y.o.

MaleFemale60-74 y.o.

Subject wearing prostheses of total

Figure 22. Percentage of denture needs and wearing55

4.3. Periodontal status
Based on the data shown in Figure 23, it can be observed that less than 50% of all of thesubjects involved in this survey were having a healthy gingival condition. The highest
percentage (77.17%) of gingival bleeding was found in the male subjects within the agegroup of 60-74 years old. The pattern between genders was almost similar within all of theage groups. Furthermore, based on the highest score of periodontal condition, the age groupof 60-74 years old has the most severe periodontal condition. This age group was the only
age group which has some proportion of the subjects with deep pocket and gingival bleeding(4.1%). Moreover, within the age group of 15-18 years old, it was found that 2.5% of thesubjects were suffering from shallow pocket and gingival bleeding. On the other hand, noneof the groups have a proportion of subjects with deep pocket and no gingival bleeding (Figure24). The proportional pattern of subjects with shallow pocket and gingival bleeding between
the age groups of 35-44 and 60-74 years old was similar, with female subjects have a smaller
proportion than males (Figure 25).

100%
90%
80%
70%
60%
50%

Gingival bleeding

40%

Healthy gingiva

30%
20%
10%
0%
Male

Female12 y.o.

Male

Female15-18 y.o.

MaleFemale35-44 y.o.

MaleFemale60-74 y.o.

Figure 23. Proportions of subjects with gingival bleeding

56

100%
90%
80%

Deep pocket (highest score) andgingival bleeding70%

Shallow pocket (highest score) andgingival bleeding

60%

Deep pocket (highest score), no
gingival bleeding

50%
40%

Shallow pocket (highest score), no
gingival bleeding

30%

Only ginval bleeding

20%
Healthy periodontal condition
10%0%
12 y.o.

15-18 y.o.

35-44 y.o.

60-74 y.o.

Figure 24. Proportions of subjects’ periodontal conditions

100%
90%
80%

Deep pocket (highest score) andgingival bleeding70%

Shallow pocket (highest score) andgingival bleeding

60%

Deep pocket (highest score), no
gingival bleeding

50%
40%

Shallow pocket (highest score), no
gingival bleeding

30%

Only gingival bleeding

20%
Healthy periodontal condition

10%
0%
Male Female Male Female Male Female Male Female
12 y.o.

15-18 y.o.

35-44 y.o.

60-74 y.o.

Figure 25. Proportions of subjects’ periodontal conditions by sex

57

Figure 26 shows the proportion of teeth with gingival bleeding (bleeding on probing). The
age group of 60-74 year old has the highest proportion of teeth with bleeding on probing(29.3%). This finding indicates that within the average number of 22 teeth present, there will
be approximately 6 teeth with bleeding on probing found in the age group of 60-74 years old.
Furth more, the proportions of teeth with bleeding on probing were slightly lessened inyounger age groups. Furthermore, the pattern of gender differences within each groups weresimilar between males and females (Figure 27).

100%
90%
80%
70%
60%
Excluded
50%

Bleeding on probing
No bleeding

40%
30%
20%
10%
0%
12 y.o.

15-18 y.o.

35-44 y.o.

60-74 y.o.

Figure 26. Proportions of teeth with bleeding on probing

58

100%
90%
80%
70%
60%
50%

Excluded

40%

Bleeding on probing

30%

No bleeding

20%
10%
0%
Male

Female12 y.o.

Male

Female15-18 y.o.

MaleFemaleMale

35-44 y.o.

Female60-74 y.o.

Figure 27. Proportions of teeth with bleeding on probing by sex
Figure 28 shows the proportion of teeth with periodontal pockets. The age group of 60-74
years old has the highest proportion of teeth with shallow pocket (5.5%). Moreover, this age
group was also the age group who has the highest percentage of teeth with deep periodontal
pockets (0.34%). Furth more, the proportions of teeth with shallow pocket were slightly
lessened in younger age groups. The proportional pattern of teeth with shallow and deep
periodontal pockets between the age groups of 35-44 and 60-74 years old was similar, withfemale subjects having smaller proportions than males (Figure 29).

100%
98%
96%
Tooth excluded
PD 6< mm (Deep pocket)

94%

PD=4-5 mm (Shallow pocket)
92%

PD 0-3 mm (Healthy)

90%88%15-18 y.o.

35-44 y.o.

60-74 y.o.

59

Figure 28. Proportions of teeth with periodontal pockets

100%
98%
96%
94%

Tooth excluded
PD 6< mm (Deep pocket)

92%

PD=4-5 mm (Shallow pocket)
PD 0-3 mm (Healthy)

90%
88%
86%
Male

Female15-18 y.o.

MaleFemale35-44 y.o.

MaleFemale60-74 y.o.

Figure 29. Proportions of teeth with periodontal pockets by sex

60

4.4. Oral mucosa abnormalities
Among the subjects involved in the survey, there were some subjects indicated to have oral
cancer by the examiners. This condition was found in the age group of 6, 12 and 60-74 years
old (Figure 30). Furthermore, the most prevalent oral mucosa abnormalities found wasulceration, with age group of 15-18 years old having the highest number among all the agegroups. Other oral mucosa abnormalities found were leukoplakia, abscess and other condition(unspecified). The oral cancer finding should raise the awareness for the importance of oral
health, particularly cancer early detection measures to prevent any life-threatening conditions.

25

20
Malignant tumor (oral cancer)
Leukoplakia
15

Lichen planus
Ulceration
Acute Necrotizing Gingivitis

10

Candidiasis
AbcessOther condition

50
6 y.o.

12 y.o.

15-18 y.o.

35-44 y.o.

60-74 y.o.

Figure 30. Oral mucosa abnormalities614.5. Tooth-brushing frequency
Figure 31 shows the frequency of tooth-brushing by the subjects involved in the survey. Mostof the subjects stated that they have brushed their teeth at least once daily and two or moretimes a day. However, there were some subjects who stated that they have only brushed theirteeth 2-3 times a month, or once a week, or 2-6 times a week. Moreover, there were also stillsome subjects from the age group of 6, 12, 35-44, and 60-74 years old stated that they neverbrushed their teeth. These findings indicate that oral health education will still be needed inorder to habituate a proper tooth-brushing behavior with a right method, frequency, andappropriate timings.

1000
900
800
700
600
500
400
300
200
100
0
6 y.o.

12 y.o.

15 - 18 y.o.

35 - 44 y.o.

NeverOnce a month

2-3 times a month

2-6 times a week

Once a day

Twice or more a day

60 - 74 y.o.

Once a week

Figure 31. Tooth-brushing frequency

62

4.6. Cigarette smoking behavior
Tobacco use, particularly cigarette smoking, was scientifically proven to be a risk factor for
general and oral diseases. As can be observed on Figure 32, most of the subjects involved inthis survey stated that they are ‘never smokers’. However, there were also some subjects who
were daily smokers in the age group of 35-44 and 60-74 years old. Moreover, surprisingly
there were some subjects from the age group of 15-18 years old, who stated that they weresmoking seldom, or several times a month, or once a week, or even several times a week.
These findings urge the need of smoking cessation action and strengthening the control for
tobacco use in order to save the younger generation from this bad habit, which eventually will
prevent them from general as well as oral diseases.

100%
90%
80%
70%
Never
60%

Seldom50%

Several times a month
Once a week

40%

Several times a week

30%

Every day

20%
10%
0%
15 - 18 y.o.

35 - 44 y.o.

60 - 74 y.o.

Figure 32. Cigarette smoking frequency

63

4.7. Areca/betel nut chewing
Another risk factor which has also been scientifically proven to be related with oral cancer
was areca/betel nut chewing. Areca/betel nut chewing habit was commonly found withinsome traditional ethnics, particularly in South-east Asian countries. Figure 33 shows thefrequency of this activity. It can be observed that within the adult age group (35-44 and 60-74
years old), some part of the population were having a daily habitual of this activity.
Surprisingly, there were also some subjects form the younger generation (15-18 years old)
who has been practicing this habit. These findings indicate that oral health education
particularly related with healthy oral health behavior, need to be started at an early age, inorder to prevent the incidence of lifestyle-induced oral cancer. Since this habit was also partly
institutionalized with some cultural beliefs, a considerable grounded approach might beneeded in ensuring the effectiveness of the education action.

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Male

Female15 - 18 y.o.

Every daySeveral times a week

Male

FemaleMale

35 - 44 y.o.
Once a week

Several times a month

Female60 - 74 y.o.
SeldomNever

Figure 33. Areca/betel nut chewing frequency

64

4.8. Food/sugar consumption
Figure 34 to 42 shows the sugar consumption based on the type of foods and beverages
consumed by the subjects involved in this survey. Within the types of daily beverages such astea, coffee, as well as milk (particularly for children and adolescence), as shown in Figure 40
to 42, it can be observed that approximately 50% of the subjects among all of the age groups
were consuming these beverages with sugar added. Furthermore, consumption of biscuit,lemonade and sweet pie were considerably high, with a frequency of at least several times amonth (Figure 35, 39, and 43) for all of the age groups. Moreover, consumption of sugary
chewing gum and sweet candy (Figure 37 and 38) were also considerably high, particularly
within the age group of 6, 12 and 15-18 years old. However, as shown in Figure 34, theconsumption of fresh fruit was high among all of the age groups; with none of the subjects
aged 12 years old and only few of the subjects within the other age groups were stating thatthey were seldom/never consume fresh fruits. On the other hand, approximately 70% of thesubjects within all of the age groups were seldom/never consuming jam/honey (Figure 36).
Since excessive sugar consumption was one the main risk factor for dental caries as well as
systemic disease such as diabetes, sugar consumption control needs to be included in the oral
and general health promotive policy.

100%
90%
80%
70%
Seldom / never
60%

Several times a month50%

Once a week
Several times a week

40%

Every day30%

Several times a day

20%
10%
0%
6 y.o.

12 y.o.

15 - 18 y.o.

35 - 44 y.o.

60 - 74 y.o.

Figure 34. Fresh fruit consumption frequency
65

100%
90%
80%
70%

Seldom / never

60%

Several times a month50%

Once a week
Several times a week

40%

Every day30%

Several times a day

20%
10%
0%
6 y.o.

12 y.o.

15 - 18 y.o.

35 - 44 y.o.

60 - 74 y.o.

Figure 35. Biscuit consumption frequency

100%
90%
80%
70%

Seldom / never

60%

Several times a month50%

Once a week
Several times a week

40%

Every day30%

Several times a day

20%
10%
0%
6 y.o.

12 y.o.

15 - 18 y.o.

35 - 44 y.o.

60 - 74 y.o.

Figure 36. Jam/honey consumption frequency

66

100%
90%
80%
70%

Seldom / never

60%

Several times a month50%

Once a week
Several times a week

40%

Every day30%

Several times a day

20%
10%
0%
6 y.o.

12 y.o.

15 - 18 y.o.

35 - 44 y.o.

60 - 74 y.o.

Figure 37. Sugary chewing gum consumption frequency

100%
90%
80%
70%

Seldom / never

60%

Several times a month50%

Once a week
Several times a week

40%

Every day30%

Several times a day

20%
10%
0%
6 y.o.

12 y.o.

15 - 18 y.o.

35 - 44 y.o.

60 - 74 y.o.

Figure 38. Sweet candy consumption frequency

67

100%
90%
80%
70%

Seldom / never

60%

Several times a month50%

Once a week
Several times a week

40%

Every day30%

Several times a day

20%
10%
0%
6 y.o

12 y.o.

15 - 18 y.o.

35 - 44 y.o.

60 - 74 y.o.

Figure 39. Lemonade/Coca-Cola consumption frequency

100%
90%
80%
70%
Seldom / never
60%

Several times a month50%

Once a week
Several times a week

40%

Every daySeveral times a day

30%
20%
10%
0%
6 y.o.

12 y.o.

15 - 18 y.o.

35 - 44 y.o.

60 - 74 y.o.

Figure 40. Tea with sugar consumption frequency

68

100%
90%
80%
70%

Seldom / never

60%

Several times a month50%

Once a week
Several times a week

40%

Every day30%

Several times a day

20%
10%
0%
6 y.o.

12 y.o.

15 - 18 y.o.

35 - 44 y.o.

60 - 74 y.o.

Figure 41. Coffee with sugar consumption frequency

100%
90%
80%
70%
Seldom / never
60%

Several times a month50%

Once a week
Several times a week

40%

Every day30%

Several times a day

20%
10%
0%
6 y.o.

12 y.o.

Figure 42. Milk with sugar consumption frequency

69

100%
90%
80%
70%

Seldom / never

60%

Several times a month50%

Once a week
Several times a week

40%

Every day30%

Several times a day

20%
10%
0%
15 - 18 y.o.

35 - 44 y.o.

60 - 74 y.o.

Figure 43. Sweet pie consumption frequency

70

5. SUMMARY
5.1. Dental caries
Dental caries on primary teeth
Only 15.8% of 6 years old group subjects were free of dental caries on their primary teeth.
Most of the 6 years old group subjects (98.6%) and all of the mixed dentition age range havetheir carious primary teeth left untreated. Most of the primary teeth left within the mixed
dentition age range were carious. The 12 years old subjects have caries on all of their primarycentral incisors. Only one child had a ft score of 3 in 6 years old, while no ft score was foundin 12 years or 15-18 years old subjects.
Dental caries on mixed dentition
The 6 years old group subjects have the highest prevalence of caries (primary and permanent
teeth). As early as the age of 6 years, the subjects have already got caries on their newly
erupted permanent teeth, hence in the older age groups, they have double burden of caries on
their primary as well as permanent teeth.
Dental caries on permanent teeth
More than 90% of all age groups have left their active carious permanent teeth caries
untreated. The percentage of carious maxillary and mandibular anterior teeth was low, andconversely for posterior teeth. A higher percentage of caries experience was detected in left
mandibular second premolar. First and second molar were found to have the highest
percentage of caries experience.
The DMFT score of 6 years old group have a score of 0.14 and 0.11 for male and female
respectively. The highest percentile for the age group of 6 years old was 8. There are also
subjects from the age group of 6 years old who has an MT score of 2. Within the age group of
35-44 and 60-74 years old, there are some subjects who have maximum DMFT score andalso maximum MT score (32 for the highest percentile). The proportion of missing (M) score
was considerably higher than decayed (D) and filling (F) for adult age groups. The 60-74
years old group subjects have the highest prevalence of caries (93.6%) to be compared to theother age groups.

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5.2. Periodontal status
Less than 50% of all of the subjects involved in this survey had a healthy gingival condition.
The pattern between genders was almost similar within all of the age groups. The female
subjects have a smaller proportion of periodontal disease than males.
The age group of 12 years old has the least severe periodontal condition while 60-74 years
old was most severe. The proportion of teeth with shallow pocket was slightly lessened inyounger age groups. It was found that 2.5% of the subjects were suffering from shallow
pocket and gingival bleeding with the age group of 15-18 years old. The proportion pattern of
subjects with shallow pocket and gingival bleeding between the age groups of 35-44 and 6074 years old was similar. The highest percentage (77.2%) of gingival bleeding was found in
the male subjects within the age group of 60-74 years old. The 60-74 years old group was the
only age group which has some proportions of the subjects with deep pocket and gingival
bleeding (4.1%). Within the age group of 60-74 years old, it was found that the highest
proportion of teeth with shallow pocket (5.5%).

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6. CONCLUSION AND RECOMMENDATIONSThis first National Oral Health Survey for Myanmar which was in urgent need while country
is reforming and trying to get universal coverage in 2030 could provide oral health status of
Myanmar population.
The study represented oral health status of the whole country drawing sample from all state
and regions including urban and rural segments. The survey findings provided not only the
update information on oral health statistics of Myanmar but also attention of otherstakeholders including policy makers, health managers etc.
Further, it could also be a benchmark for future research in oral health. The data from thissurvey should be used for formulation of policy, strategic planning, and implementation of
the both preventive and curative interventions. Then the ministry of health and otherstakeholders should be involved to allocate limited resources of human, finance andinfrastructure in an efficient and effective way.
Recommendations
Regular monitoring or collecting data in various sectors with format dental
examination record form

National oral health database which can easily accessible in various ways

Development of an appropriate oral health guidelines and policies for provision oforal health care services



Oral diseases prevention and oral health promotion interventions into acomprehensive primary health care services



Optimal level of resources including financial supports and formal dental workforce
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7. REFERENCES
1. Ministry of Health and Sports, the Republic of the Union of Myanmar. Health in Myanmar(2014) http://mohs.gov.mm/Main/content/publication/health-in-myanmar-2014
2. The Population and Housing Census of Myanmar. Summary of the Provisional Result(2014)

https://reliefweb.int/report/myanmar/population-and-housing-census-myanmar-

2014-summary-provisional-results
3. https://en.wikipedia.org/wiki/Myanmar
4. National Health Network. Programme of Health Reforms, A Roadmap Towards Universal
Health Coverage in Myanmar (2016 – 2030) Version
http://themimu.info/sites/themimu.info/files/assessment_file_attachments/programme_of_
health_reforms_-_version_1_0_-_2016_03_29.pdf
5. World Health Organization. Oral Health Survey: basic methods, fifth edition (2013).
Geneva, World Health Organization.
https://www.who.int/oral_health/publications/9789241548649/en/

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8. ACKNOWLDEGEMENTS

This report was prepared by Dr Hiroshi Ogawa, Dr Hideo Miyazaki and Dr Lisdrianto
Hanindriyo, WHO Collaborating Centre for Translation of Oral Health Science, Niigata
University, Japan.
Special thanks for technical advice are due to Dr Prathip Phantumvanit, Thammasat
University, Thailand; Dr Yupin Songpaisan, Suranaree University of Technology, Thailand;
Dr Yuka Makino, WHO Geneva; and Dr Myo Paing, WHO Country Office for Myanmar.
The publication of this report received kind financial support from the Borrow Foundation,
United Kingdom.

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