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Int J Oral-Med Sci 11(1):30-37, 2012

Original Article
A Program to Improve the Oral Health of School Children in the Kingdom of Tonga:
the MaliMali Program
Reiri Takeuchi1, 2, Kohji Kawamura2, 3, Sayuri Kawamura2, 3, Mami Endoh2, 4, Sililo Tomiki2, 5,
Chieko Taguchi2, 6, and Seigo Kobayashi2, 6
1

Department of Pharmacology, Nihon University School of Dentistry at Matsudo, 2-870-1 Sakaecho-Nishi, Matsudo, Chiba
271-8587, Japan
2
South Pacific Medical Team, 3-8-14 Saiwaicho, Kawaguchi, Saitama 332-0016, Japan
3
Kawamura Dental Office, 3-8-14 Saiwaicho, Kawaguchi, Saitama 332-0016, Japan
4
Division of Oral Care and Rehabilitation, Kyushu Dental College, 2-6-1 Manazuru, Kokura-Kita, Kitakyushu, Fukuoka
803-8580, Japan
5
Vaiola Hospital, Ministry of Health, Nukuʼalofa, Kingdom of Tonga
6
Department of Preventive and Public Oral Health, Nihon University School of Dentistry at Matsudo, 2-870-1 SakaechoNishi, Matsudo, Chiba 271-8587, Japan
Article History

Abstract

Received 29 March 2012
Accepted 18 April 2012

The South Pacific Medical Team, a voluntary group organized by Japanese dentists, has
worked to improve oral health in the Kingdom of Tonga since 1998. Its main activity is theplanning and administration of a school-based program known as the MaliMali Program.
The MaliMali Program has been promoted by a Tongan team for preventive dentistry fromthe Dental Office of the Ministry of Health. In the present study, we describe the results of
the MaliMali Program and consider its effects from 1998 to 2009.
The MaliMali Program consists of the following three main programs, plus additional
activities: an education program for kindergarten and primary school children to prevent
caries (including leaflet distribution, lectures, and guidance about eating between meals); a
program teaching children about the proper use of toothbrushes and fluoride toothpaste;
and a program providing children with fluoride mouth rinse. In the latter program, 7-10 mLof a 0.2% NaF solution was given to children in primary school once a week; 5 mL of a
0.05% NaF solution (Miranol®) was given to children in kindergarten once a day. We

Keywords :fluoride mouth rinse, dental caries,
school children, the Kingdom of
Tonga
Correspondence to :Reiri Takeuchi
E-mail : takeuchi.reiri@nihon-u.ac.jp

investigated oral health habits (dietary habits in 2001, toothbrushing habits in 2008), oral
conditions (prevalence of dental caries in 2001 and 2007, effectiveness of fluoride mouthrinse for prevention of caries in 2008), and gingivitis and gingival bleeding (in 2003).
In 2008, 34 kindergartens, 101 primary schools (75.4% of all schools in Tonga), and 14,442
children in total participated in the MaliMali Program. In 2008, all children reported
brushing their teeth at least once a day. The mean decayed/missing/filled teeth (DMFT)
score DMFT and the decayed/missing/filled (DMF) person rate had decreased
significantly in 2007 compared to 2001. In 2008, we examined whether fluoride mouth rinseis effective for the prevention of caries and found that fluoride mouth rinse significantly
decreased the mean DMFT score. In 2003, 52.0% of children had gingivitis and 20.6% had
gingival bleeding.
The MaliMali Program is universally accepted in the Kingdom of Tonga. It has helped toestablish childrenʼs toothbrushing habits and the application of fluoride has decreased theincidence of caries.

Introduction
The Kingdom of Tonga (Tonga) is part of Polynesia in theSouth Pacific Ocean. It consists of 170 islands divided into

Int J Oral-Med Sci 11(1):30-37, 201231

five main island groups: the Tongatapu Islands, including the

Hospital, belonging to the Ministry of Health in Tonga,

capital city; the Haʼapai Islands; the Vavaʼu Islands; the Niua

established a section for preventive dentistry and a team to

Islands; and the ʻEua Islands. These islands are distributed

execute the MaliMali Program. The South Pacific Medical

across an area of 600 km north to south and 200 km east toTeam donates fluoride, toothbrush, dental materials, cars forwest. In 1998, the population of Tonga was about 100,000

transportation, and other necessities and plans the program.

and 35% of the population was 14 years old or younger. The

In 2006, SPMT entered into a contract with the Japandental clinical system in Tonga experienced problems, such

International Cooperation Agency (JICA). Part of the cost

as shortages of staff, tools, materials, and equipment. As aof executing the MaliMali Program is covered by funds fromresult, many Tongans had to undergo tooth extraction tothis contract. The role of the Ministry of Health in Tonga istreat dental problems that would be treated conservatively

to provide a professional workforce (dental officer, dental

in Japan. Despite the limited equipment available in Tonga,

therapist, dental nurse, and dental technician) and plan theprosthesis treatment with dentures after extraction andprogram. The role of the Ministry of Education in Tonga issimple preservation treatment were available. Manyto transfer materials to teachers in kindergartens andTongans have lifestyle diseases, such as diabetes andschools, establish time for toothbrushing after lunch, andcirculatory system diseases, which are thought to increase

execute the MaliMali Program in cooperation with thethe prevalence of dental diseases, such as dental caries andMaliMali team. The role of the MaliMali team is to provide

periodontal disease. Therefore, an oral health systemfissure sealant treatment in dental offices, apply fluoride (e.

including a preventive program was needed.

g., administer FMR), instruct children in toothbrushing,

The South Pacific Medical Team (SPMT), a volunteer

provide dental examinations, provide oral health education,group organized by Japanese dentists, has worked for thehold oral health festivals and workshops, and publicize theimprovement of oral health in Tonga in cooperation with the

MaliMali Program in TV, radio, and newspaper media.

Ministry of Health of the Kingdom of Tonga since 1998. The

The MaliMali Program proceeds as follows. The MaliMali

main activity of SPMT is the planning and administration ofteam visits kindergartens and primary schools once a week,

a school-based program to improve childrenʼs oral healthguides children in toothbrushing with help from teachers,(called the MaliMali Program; MaliMali means“smile”inand provides the FMR. The MaliMali team also gives

Tongan). The MaliMali Program consists of the following

presentations on oral health including leaflets and otherthree main programs in addition to other activities: an

media in schools twice a year. When the MaliMali team does

education program for kindergarten and primary school

not visit, the children brush their teeth after lunch under thechildren to prevent caries (including leaflet distribution,

guidance of their teachers. School-based FMR is adminis-

lectures, and guidance on eating between meals); a program

tered as follows. Primary school children receive 7-10 mL ofoffering toothbrushing guidance and encouragement in

0.2% NaF solution once a week and children in kindergarten

using fluoride toothpaste; and a program administering

receive 5 mL of 0.05% NaF solution (Miranol®) once a day.

fluoride mouth rinse (FMR). The MaliMali Program has

The fluoride solutions, tools, and materials are donated bybeen promoted by the Tongan team for preventive

SPMT. The fluoride solutions are prepared with distilled

dentistry, which consists of dentists and dental therapists

water every morning by the MaliMali team in the clinic. The

affiliated with the Dental Office of the Tongan Ministry ofamount of fluoride solutions used is recorded in a notebook.

Health.

In some primary schools, the prepared fluoride solution is

In the present study, we describe the results produced byalso delivered once a week by the MaliMali team and given

the MaliMali Program from 1998 to 2009 and evaluate theto students by teachers. This project became a cooperative

programʼs effectiveness.

effort with JICA in 2006 and has been executed incooperation with the Ministry of Health and Education,

Materials and Methods

Kingdom of Tonga. The projectʼs name is“The Project ofMaliMali Program

Oral Health in the Kingdom of Tonga”(a grass-roots

Figure 1 shows the structure of the MaliMali Program,support program involving technical cooperation that lasted

the content of its activities, and the cooperative organizationfrom April 2006 to March 2009) and“The Project ofof the MaliMali Program. In 1998, the dental section of Vaiola

Improving School-based Oral Health Activity in the

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Int J Oral-Med Sci 11(1):30-37, 2012

Fig. 1.

Structure of the MaliMali Program

Kingdom of Tonga”(a grass-roots follow-up program

Investigation of oral condition

involving technical cooperation that lasted from FebruaryA) Prevalence of dental caries

2010 to March 2012).

1) Comparison between 2001 and 2007
In 2001 and 2007, the prevalence of dental caries was

Investigation of oral health habitsdetermined. The study population was 12-year-old children:A) Investigation of dietary habits

45 boys and 21 girls in 2001 and 44 boys and 20 girls in 2007.

In 2001, the dietary habits of 882 children in all classes of

The caries were detected by inspection according to thesix primary schools on Tongatapu Island were studied via amanual published by the Japanese Society of School Healthsurvey. The staffs of the MaliMali team and classroom(1). A dental explorer was used to remove dental plaqueteachers read aloud the questionnaire for students and filled

and to assess the presence of dental caries.

out the answers on the form. The response rate was 100%.
2) Examination of whether fluoride mouth rinse is effectiveB) Investigation of toothbrushing habits

for the prevention of caries

In 2008, the toothbrushing habits of 829 children in all

In August 2008, 10-year-old children in six primaryclasses of six primary schools on Tongatapu Island wereschools on Tongatapu Island underwent dental exams. In

studied via a survey that was read aloud and filled out by the

total, 109 children were examined (control group: 63

staff of the MaliMali team and classroom teachers. The

children who had used FMR for less than 1 year; FMR

target population was children ages 5-14 years who hadgroup: 46 children who had used FMR for 5. 5 years or

participated in the MaliMali Program for 1-9 years. Themore). The examination was performed by one Japanese

response rate was 100%.

dentist with a dental mirror, standard dental explorer,
flashlight, and sunlight (1). The following items wereInt J Oral-Med Sci 11(1):30-37, 201233

Fig. 2. The number of schools and children enrolled in the MaliMali Program by year in theKingdom of Tonga

recorded for each tooth surface: sealant filling, C1-4, missing

under sunlight before evaluation. Gingivitis (+) includes

by caries, and filling. A stain solution (erythrosine) was

cases showing slight inflammatory symptoms (e. g.,

used to discriminate among healthy teeth, sealant-filled

redness and swelling).

teeth, and resin-filled teeth. X-ray diagnosis was not used.

The protocol was approved by the Committee on Studies

The“dental caries teeth”item in the results is the number

Involving Human Beings of the Nihon University School ofof teeth having an evident cavity. The item“Difference (%)

Dentistry at Matsudo (EC07-012).

of Mean DMFT”was calculated using the following
numerical formula: [(DMFT index of control group−

Results

DMFT index of fluoride group) / DMFT index of control

Diffusion of the MaliMali Program

group]×100.

Figure 2 shows the increasing number of kindergartens,
primary schools, and school children enrolling in theB) Evaluation of gingival bleeding and gingivitis

MaliMali Program every year. The MaliMali Program

In 2003, gingival bleeding and gingivitis were investigatedbegan with three kindergartens and 44 children in 1999. The

in 10- to 12-year-old children in eight primary schools onenrolled facilities totalled three kindergartens and six

Tongatapu Island who had participated in the MaliMali

primary schools in 2000 and 34 kindergartens, 101 primary

Program for 1-3 years. A total of 506 children participatedschools, and 14,442 children in 2008.

(271 boys and 235 girls). The detailed methods are as
follows.

Dietary habits

1) Gingival bleeding was evaluated after rubbing the surface

Table 1 shows the results of the dietary habit investiga-of the cervices of the front teeth with a toothbrush fivetion in 2001. On Tongatapu Island, the intake frequency oftimes according to the Bass method. Gingival bleeding

modern foods (e.g., sugar or sweetener, oils and fats, soft(+) includes slight bleeding. The original method was

drinks) of 15.97 was higher than that of traditional foods

used because the test must be performed rapidly and(3.91; e.g., green and yellow vegetables, root crops including

easily, and preferably outdoors(2).

taro, coconut cream). Among staple foods, the intake

2) Gingivitis was evaluated using photographs in the clinic.

frequency of grain (2.45) was higher than that of root crops

The gingivae of the six front teeth were photographed(0.90). Among modern foods, the intake frequencies of

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Int J Oral-Med Sci 11(1):30-37, 2012

Table 1. Comparison of intake frequencies between traditional foods and modern foods in 6 primary schools in
Tongatapu, 2001 (N=882)

Table 2. Distribution of daily tooth brushing frequency among
5- to 14-year-old children in Tongatapu, 2008 (N=829)

Table 3. Prevalence of caries in 12-year-old children in
Tongatapu, 2001 and 2007

were 1.84 and 2.10, respectively. Both the DMF person rate
and the mean DMFT score decreased significantly for bothboys and girls in 2007 from 2001.
Prevention of caries by school-based fluoride mouth rinse
Figure 3 shows that the effect of school-based FMR on
dental caries among 10-year-olds in 2008. The mean DMFT
score of the FMR group (0.87) was significantly lower thanthat of the control group (1.90) (P<0.01).
Foods are classified following Adachi et al. (3).

Prevalence of gingivitis and presence of gingival bleeding
Table 4 shows the proportion of 10- to 12-year-olds who

sugar or sweetener (5.02), oils and fats (3.15), and soft

had gingivitis and gingival bleeding in 2003. Of thesedrinks (2.92) were high.

children, 52.0% had gingivitis and 20.6% had gingival
bleeding.

Toothbrushing habits
Table 2 shows the results of the toothbrushing habit

Discussion

investigation among 5- to 14-year-olds in 2008. All children

As shown in Figure 2, the MaliMali Program, of which thebrushed their teeth at least once per day. Of these children,

main measureable outcome is school-based FMR, began in

17.5% habitually brushed their teeth once a day, 45.6%

three kindergartens with 44 children on Tongatapu Island

twice a day, and 36.9% thrice a day or more.

and the Haʼapai Islands in 1999. The program then spread tothe Vavaʼu Islands and the ʻEua Islands. The program was

Prevalence of dental caries

offered at four primary schools on Tongatapu Island andTable 3 shows the prevalence of dental caries among 12-

three kindergartens and two primary schools on the Haʼapai

year-olds in 2001 and in 2007. In 2001, the DMF person rates

Islands in 2000, and by 2008, it had expanded to 34

for boys and girls were 89 and 91, respectively, and the meankindergartens and 101 primary schools (75.4% of all schools

DMFT scores for boys and girls were 4.40 and 5.81,

in Tonga) with a total of 14,442 students. The numbers ofrespectively. In 2007, the DMF person rate was 70 for both

enrolled facilities and children increased notably in 2006 andboys and girls, and the mean DMFT score for boys and girls

2007. This increase might be related to the contract between

Int J Oral-Med Sci 11(1):30-37, 201235

Fig. 3. Comparison of the mean DMFT (S.D.) between the control group and the FMR group**: significant by t-test, P<0.01
Table 4. The proportions of 10- to 12-year-old children who had
gingivitis or gingival bleeding in Tongatapu, 2003 (N=506)

Tongans did so in 1999; however, all children brushed theirteeth once a day or more in 2008. Of the children studied,145 (17.5%) habitually brushed their teeth once a day, 378(45.6%) brushed twice a day, and 307 (36.9%) brushed
thrice a day or more. However, 50 children who did not
respond were excluded. Therefore, it is thought that the

SPMT and JICA and the international contract between the

MaliMali Program has contributed toward the strong

Ministry of Health, Ministry of Education, JICA, and SPMT.

establishment of the toothbrushing habit among Tongan

However, because some primary schools also have pre-children.

school programs, the total numbers of kindergarteners andprimary school children are unknown.

The prevalences of dental caries among 12-year-olds in2001 and 2007 were compared (Table 3). The mean DMFT

As shown in Table 1, in 2001, the intake frequency of grainscores and DMF person rates for both boys and girls in 2007

(in modern foods) was approximately 2.7 times higher thanwere significantly decreased compared to the 2001 values.

that of root crops (in traditional foods). The difference

The mean DMFT score decreased by 58.2% for boys andbetween the total intake frequencies of modern and63.9% for girls during this period. These changes might

traditional foods was around 4. 1. In 1979, the intake

have resulted from the activities of the MaliMali Program

frequency of grain was about 0.15 times that of root crops

aimed at decreasing the prevalence of caries: toothbrushingand the total intake frequency of modern foods was about

instruction, distribution of fluoride toothpaste, and school-

0.36 times that of traditional foods(3). In the past 22 years,

based FMR. These activities were executed principally by

Tongans have replaced many traditional foods with modern

the MaliMali team with the support of SPMT.

foods. The intake frequency of sugar or sweetener, meaning

Whether FMR is effective for the prevention of caries was

sweets that are sweetened with only sugar, was high (5.02).

tested using data from 2008 (Fig. 3). Fluoride mouth rinse

Adachi et al. reported that the intake frequency of sugar or

significantly decreased the mean DMFT score by 54.0%.

sweetener in 1979 was 0.26 and that Tongans ate grain

Fluoride mouth rinse makes the largest contribution to theboiled with saline rainwater and coconut cream without salt

prevention of caries of all activities in the MaliMali Program.

or sugar(3). Tongansʼ sugar intake has increased with the

The effect of school-based FMR has been investigated sincechange in their dietary habits. The MaliMali Programthe 1970s and researchers have demonstrated that it

advises children to decrease their intake of sugar, sweet

decreases the incidence of caries in children by 31-70% (4).

drinks, and sweets.

Twetman et al. and Fukai et al. have also reported that a

Toothbrushing habits were studied in 2008 (Table 2).

school-based FMR program has a strong effect on the

Tongans historically did not brush their teeth(3) and few

prevention of caries (5, 6). School-based FMR is very

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Int J Oral-Med Sci 11(1):30-37, 2012

effective and inexpensive (7, 8). Thus, it might be the bestbrush their teeth once a day or more and the mean DMFT

method of preventing caries in developing countries likescore of Tongan children has significantly decreased as the

Tonga. On the other hand, Kobayashi et al. reported that

program has become more established. Moreover, theFMR should be started at 4 to 5 years of age to protect theMaliMali team promotes the MaliMali Program in thefirst molars (9-11). The children in the fluoride group

following ways: oral health festivals (offering dental

started FMR at age 4 years 6 months to 5 years 5 months.

examinations, toothbrushing guidance, and FMR), work-

Thus, the method of school-based FMR might be appropri-

shops for Tongans interested in dentistry and education, andate. However, there are several problems with the MaliMali

publicity on TV, radio, and in newspapers. Moreover, fissure

Program that may diminish the effect of school-based FMR

sealant treatment is offered year-round in the dental section

on the prevalence of caries. Tonga has fewer days ofof Vaiola Hospital. The South Pacific Medical Team andprimary school (175 days; 35 weeks) than Japan does.

JICA in Japan handle the planning for the MaliMali

Because primary school in Tonga is closed when it is raining,

Program; procure toothbrushes, fluoride toothpaste, fluo-

the MaliMali Program may not be offered every day orride, dental materials, other materials, and cars; andweek. Classroom teachers manage childrenʼs toothbrushes

establish donation procedures for these materials. All ofat school, so when the teacher is not able to work, thethese activities decrease the incidence of caries amongchildren cannot use their toothbrushes and complete thechildren in the Kingdom of Tonga.

FMR. In addition, a childʼs toothbrush or FMR may be

The MaliMali Program is universally accepted in thewithheld as punishment. These weaknesses can be ad-society of the Kingdom of Tonga. The MaliMali Program has

dressed in the following ways. The MaliMali team should

contributed to establishing toothbrushing as a habit among

visit schools on a different day if it rains on the usual day.

children and to decreasing the prevalence of caries by

Fluoride mouth rinse should be administered independently

applying fluoride. However, the MaliMali Program cannotof brushing teeth. The MaliMali Program recommends thepresently prevent early caries in baby teeth before entrance

use of fluoride toothpaste. The effect of fluoride toothpaste

into kindergarten and primary school. Decreasing thehas been investigated since 1945 and it has been demonstra-prevalence of caries in baby teeth and immature permanent

ted to be effective for decreasing the prevalence of caries inteeth is very important. Therefore, babies and toddlers

clinical trials (12, 13). Thus, in addition to establishing ashould be included in the MaliMali Program and a new

toothbrushing habit, the fluoride toothpaste might contrib-

program of preventive dentistry should be formed for theseute to the effective prevention of caries.

children and their parents. Based on their experience up to

The prevalence of gingivitis and presence of gingival

2009, in addition to the MaliMali Program, SPMT and JICA

bleeding were investigated in 2003 (Table 4). Gingival

and the Ministry of Health of the Kingdom of Tonga

inflammation was for in 52% of the children and gingival

established“The Project of Improving School-based Oral

bleeding was found in 20.6%. These conditions wereHealth Activity in Kingdom of Tonga”in 2010. The aims ofinvestigated in 10- to 12-year-olds in a primary school inthis project include manpower training, creating a manual ofJapan in 2003 (2). This study included 165 children (93 boys

preventive dentistry, and decreasing caries in baby teeth

and 72 girls). In total, 74.8% of the children had gingivitis

and immature permanent teeth to improve the MaliMali

and 58.8% of the children had gingival bleeding. The

Program. In addition, water fluoridation is recommended as

gingivae of Tongan children might be healthier than those of

a way to administer fluoride in developing countries (14,Japanese children. This research was performed to prepare15). However, because Tongans use rainwater stored in

the reference materials for toothbrushing guidance. The

tanks at every household and facility, water fluoridation

original method of assessment was used for rapid and easy

might be difficult. Salt fluoridation has therefore been

investigation without causing the children discomfort.

proposed (16).

The MaliMali Program is executed primarily by the
MaliMali team. The main activities of this program are

Acknowledgments

enforcement of toothbrushing habits, use of fluoride

This investigation was supported by JICA Partnership

toothpaste, and administration of FMR in kindergartens andProgram from the Japan International Cooperation Agency,

primary schools. As a result of these activities, all children

Japan. The authors wish to thank all the members of

Int J Oral-Med Sci 11(1):30-37, 2012

MaliMali Team, the Ministry of Health, and the Ministry of
Education, the Kingdom of Tonga.
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