Abstract
The prevalence of dental caries in peatlands and non-peatlands in West Kalimantan require preventive acts based on its natural conditions and the behavior of local communities. The objective was to analyse risk factors for dental caries in communities living in peatlands and non-peatlands in West Kalimantan. The research is a causal comparative study with cross-sectional approach. The samples were chosen by purposive sampling technique among adolescents aged 17–27 years, who were domiciled in Pontianak City (peatland) and Bengkayang (non-peatland) all their lives. The results showed that dental caries is significantly correlated with debris in peatlands (rs = 0.289). On non-peatlands, dental caries is correlated with drinking water phosphate (rs = 0.313) and calculus (rs = 0.034). In West Kalimantan, dental caries is significantly correlated with drinking water minerals (fluoride rs = −0.243; phosphate rs = 0.260), drinking water pH (rs = 0.235), behavior (rs = −0.327), and debris (rs = 0.240). The risk factors for dental caries in peatlands and non-peatlands in West Kalimantan are pH and drinking water minerals (fluoride and calcium), debris, calculus, and behavior.
HIGHLIGHTS
The formation of caries is influenced by the surrounding environmental conditions.
There are 49.55% of peatland residents in West Kalimantan who suffer from caries.
Caries in peatlands is caused by low pH and a lack of fluoride and calcium in drinking water.
The risk factor for dental caries in peatlands is debris, while in non-peatlands, the risk factors are calculus and water phosphate.
INTRODUCTION
The appearance of peatland ground water. Peatland has unique characteristics that make it unsuitable to be used as a daily source of drinking water. It has a very low pH, brown color, and a high level of iron.
The appearance of peatland ground water. Peatland has unique characteristics that make it unsuitable to be used as a daily source of drinking water. It has a very low pH, brown color, and a high level of iron.
Dental caries is influenced by the surrounding environment as a disposition factor which includes genetic and biological factors, social environment, physical environment, health behavior, and dental and medical care (WHO 2019). Previous research shows the important role of minerals in the dental caries process. Calcium, phosphate, and magnesium from food are correlated with children's dental caries (Lin et al. 2014). Water minerals that have a strong influence on dental caries are fluoride and calcium (Arvin et al. 2018; Sejdini et al. 2018; Hartami et al. 2019; Yani et al. 2019), followed by phosphate (Hartami et al. 2019) and magnesium (Sejdini et al. 2018). In addition, salivary minerals that influence the enamel mineralization process are fluoride and calcium (Velásquez et al. 2019).
Dental caries is a dynamic disease that can occur throughout life, both in primary and permanent teeth (Pitts et al. 2017). The results of the 2018 Riskesdas showed that 49.55% of the population of West Kalimantan province suffers from dental caries; on average, they have five carious teeth and 95.37% of people just let dental caries occur without taking treatment (Ministry of Health of the Republic of Indonesia 2018). Dental caries causes impacts such as pain, reduced chewing function, bad breath, poor facial appearance, and reduced chances of getting a job. Dental caries also contributes to decreasing the quality of health, damaging children's well-being (Chaffee et al. 2017), and reducing the quality of children's lives (Karamoy 2017).
The prevalence cases of dental caries in the peatlands and non-peatlands of West Kalimantan require preventive acts according to their natural conditions and the behavior of local communities. So, it is essential to find the risk factors of dental caries in communities living in the peatlands and non-peatlands of West Kalimantan.
METHOD
This research is a causal comparative study with a cross-sectional approach. It was conducted at the Pontianak Health Polytechnic from April to July 2022. The population in this study were first-year students of the Pontianak Health Polytechnic aged 17–27 years. The sampling method is purposive sampling. Inclusion criteria are indigenous people from peat areas (Pontianak, Mempawah, and Kubu Raya) and non-peat areas (Bengkayang district), as well as domiciles in the research area for their whole lives. The exclusion criteria were those not suffering from any systemic disease or infection during the study. The samples obtained were from 48 peatland respondents (Pontianak) and 48 non-peatland respondents (Pontianak).
Respondents brought 250 mL of drinking water in sterile plastic bottles. Water was obtained from drinking water sources they usually consume. Drinking water sample parameters are pH, which was analyzed by using the HANNA HI 98103 Checker pH Tester; fluoride by Fluoride Low Range Tool (HI729); calcium by Reff test kit Calcium Pro; and phosphate by Salifert phosphate test kit.
Behavioral data were collected through interviews and translated into the Oral Hygiene Behavior (OHB) index (Suryanti et al. 2019). Socio-economic variables are sought by calculating the number of family members who live together; parents' education level which was obtained by calculating the number of years of formal schooling they have had; and economics was obtained by calculating their monthly income.
The data obtained from the examination were dental caries by calculating the number of dental caries in the mouth; oral hygiene by calculating the debris index (DI); and calculus index (CI) (Fitri et al. 2023). The nutritional status was measured by body height (cm) and body weight (kg).
DATA ANALYSIS
Normality test was done using the Kolmogorov–Smirnov test, Mann–Whitney mean difference test, and Spearman correlation using SPSS v.27 software (IBM SPSS, Armonk, NY: IBM Corp) with p-value = 0.05; CI 95%; df 47).
ETHICAL POLICY
Participant consent was obtained as written informed consent and the research protocol was approved by the Human Participants Protection Committee, Health Research Ethics Committee (HREC) of Pontianak Health Polytechnic, Indonesia. The HREC states that this research protocol meets the ethical principles outlined in the 2008 Declaration of Helsinki. The ethical approval is stated in No. 65/KEPK-PK. PKP/IV/2022, April 11, 2022.
RESULT
The research showed that peat soil respondents had an average of five carious teeth, and non-peat soil respondents had an average of four carious teeth. Drinking water in peatland respondents has a low average mineral content (water fluoride 0.06 mg/L, phosphate 0.03 mg/L, calcium 15.21 mg/L) than non-peat water mineral content (fluoride 0.17 mg/L, phosphate and 0.155 mg/L, calcium 22.94 mg/L). The average height and weight of respondents are 158 cm and 56 kg, respectively, almost similar to the non-peatland respondents (average height 159 cm and body weight 55 kg). The behavior of the dental hygiene indicator was higher among the peat respondents than the non-peat respondents (Table 1).
Average values of research variables based on the location
. | . | . | Peatland . | Non-peatland . | Mann–Whitney . | |||
---|---|---|---|---|---|---|---|---|
. | Variable . | Sub-variable . | Mean (![]() | Std. dev . | Mean (![]() | Std. dev . | Mann–Whitney U . | p-Value . |
Dependent variable | Decay | 4.48 | 2.76 | 3.54 | 2.72 | 914.50 | 0.08 | |
Independent variable | Drinking water | pH | 6.97 | 0.69 | 6.82 | 0.48 | 945.00 | 0.129 |
Fluoride | 0.06 | 0.10 | 0.13 | 0.17 | 752.00 | 0.003 | ||
Phosphate | 0.03 | 0.04 | 0.28 | 0.18 | 164.50 | 0.000 | ||
Calcium | 15.21 | 8.99 | 22.94 | 30.48 | 1,059.00 | 0.483 | ||
Nutritional status | Height | 158.98 | 7.11 | 159.85 | 6.88 | 1,039.00 | 0.406 | |
Weight | 56.04 | 11.99 | 55.81 | 11.29 | 1,130.00 | 0.872 | ||
Social economy | Number of family members | 4.77 | 1.26 | 4.42 | 1.15 | 973.00 | 0.173 | |
Fathers' education level | 10.15 | 4.26 | 11.58 | 3.47 | 883.50 | 0.044 | ||
Mothers’ education level | 10.67 | 4.20 | 10.92 | 3.66 | 1,067.50 | 0.527 | ||
Economy | 43.38 | 19.33 | 41.25 | 17.77 | 1,092.00 | 0.616 | ||
Behavior | Behavior | 11.42 | 2.09 | 12.25 | 1.98 | 879.50 | 0.043 | |
Dental hygiene | Debris | 0.90 | 0.45 | 1.07 | 1.44 | 1,145.50 | 0.962 | |
Calculus | 0.63 | 0.56 | 0.99 | 1.36 | 960.00 | 0.156 |
. | . | . | Peatland . | Non-peatland . | Mann–Whitney . | |||
---|---|---|---|---|---|---|---|---|
. | Variable . | Sub-variable . | Mean (![]() | Std. dev . | Mean (![]() | Std. dev . | Mann–Whitney U . | p-Value . |
Dependent variable | Decay | 4.48 | 2.76 | 3.54 | 2.72 | 914.50 | 0.08 | |
Independent variable | Drinking water | pH | 6.97 | 0.69 | 6.82 | 0.48 | 945.00 | 0.129 |
Fluoride | 0.06 | 0.10 | 0.13 | 0.17 | 752.00 | 0.003 | ||
Phosphate | 0.03 | 0.04 | 0.28 | 0.18 | 164.50 | 0.000 | ||
Calcium | 15.21 | 8.99 | 22.94 | 30.48 | 1,059.00 | 0.483 | ||
Nutritional status | Height | 158.98 | 7.11 | 159.85 | 6.88 | 1,039.00 | 0.406 | |
Weight | 56.04 | 11.99 | 55.81 | 11.29 | 1,130.00 | 0.872 | ||
Social economy | Number of family members | 4.77 | 1.26 | 4.42 | 1.15 | 973.00 | 0.173 | |
Fathers' education level | 10.15 | 4.26 | 11.58 | 3.47 | 883.50 | 0.044 | ||
Mothers’ education level | 10.67 | 4.20 | 10.92 | 3.66 | 1,067.50 | 0.527 | ||
Economy | 43.38 | 19.33 | 41.25 | 17.77 | 1,092.00 | 0.616 | ||
Behavior | Behavior | 11.42 | 2.09 | 12.25 | 1.98 | 879.50 | 0.043 | |
Dental hygiene | Debris | 0.90 | 0.45 | 1.07 | 1.44 | 1,145.50 | 0.962 | |
Calculus | 0.63 | 0.56 | 0.99 | 1.36 | 960.00 | 0.156 |
Peatlands and non-peatlands have significant average differences in drinking water minerals (fluoride sig. 0.003; phosphate sig. 0.000; father's education sig. 0.044) and behavior of dental hygiene (sig. 0.043) (Table 1).
West Kalimantan respondents had an average of 4–5 carious teeth, normal drinking water pH (6.89), low drinking water minerals (water fluoride 0.09 mg/L; phosphate 0.14 mg/L; calcium 19.07 mg/L), and adequate nutrition (TB 159.93 and BB 55.93). The average number of family members in one house is five people, with almost the same education level of parents, ranging by 10–11 years of school (high school level). The average family income is 4.2 million rupiahs a month and the behavior of dental hygiene is moderate (range) (Table 2).
Normality test and average values of dental caries risk factors in West Kalimantan
. | . | . | Peatland . | Non-peatland . | 95% Confidence interval of the difference . | One-sample Kolmogorov–Smirnov test . | |
---|---|---|---|---|---|---|---|
. | Variable . | Sub-variable . | Mean (![]() | Std. dev . | Lower . | Upper . | p-Value . |
Dependent variable | Decay (Dental caries) | 4.01 | 2.77 | −0.17 | 2.05 | 0.04 | |
Independent variable | Drinking water | pH | 6.89 | 0.60 | −0.10 | 0.39 | 0.00 |
Fluoride | 0.09 | 0.14 | −0.12 | −0.01 | 0.00 | ||
Phosphate | 0.15 | 0.18 | −0.30 | −0.19 | 0.00 | ||
Calcium | 19.07 | 22.69 | −16.92 | 1.46 | 0.00 | ||
Nutritional status | Height | 159.42 | 6.97 | −3.71 | 1.96 | 0.00 | |
Weight | 55.93 | 11.59 | −4.49 | 4.95 | 0.00 | ||
Social economy | Number of family members | 4.59 | 1.21 | −0.13 | 0.84 | 0.00 | |
Fathers’ education level | 10.86 | 3.93 | −3.01 | 0.14 | 0.00 | ||
Mothers’ education level | 10.79 | 3.92 | −1.85 | 1.35 | 0.00 | ||
Economy | 42.31 | 18.50 | −5.40 | 9.65 | 0.00 | ||
Behavior | Behavior | 11.83 | 2.07 | −1.66 | −0.01 | 0.00 | |
Dental hygiene | Debris | 0.99 | 1.06 | −0.60 | 0.26 | 0.00 | |
Calculus | 0.81 | 1.05 | −0.78 | 0.06 | 0.00 |
. | . | . | Peatland . | Non-peatland . | 95% Confidence interval of the difference . | One-sample Kolmogorov–Smirnov test . | |
---|---|---|---|---|---|---|---|
. | Variable . | Sub-variable . | Mean (![]() | Std. dev . | Lower . | Upper . | p-Value . |
Dependent variable | Decay (Dental caries) | 4.01 | 2.77 | −0.17 | 2.05 | 0.04 | |
Independent variable | Drinking water | pH | 6.89 | 0.60 | −0.10 | 0.39 | 0.00 |
Fluoride | 0.09 | 0.14 | −0.12 | −0.01 | 0.00 | ||
Phosphate | 0.15 | 0.18 | −0.30 | −0.19 | 0.00 | ||
Calcium | 19.07 | 22.69 | −16.92 | 1.46 | 0.00 | ||
Nutritional status | Height | 159.42 | 6.97 | −3.71 | 1.96 | 0.00 | |
Weight | 55.93 | 11.59 | −4.49 | 4.95 | 0.00 | ||
Social economy | Number of family members | 4.59 | 1.21 | −0.13 | 0.84 | 0.00 | |
Fathers’ education level | 10.86 | 3.93 | −3.01 | 0.14 | 0.00 | ||
Mothers’ education level | 10.79 | 3.92 | −1.85 | 1.35 | 0.00 | ||
Economy | 42.31 | 18.50 | −5.40 | 9.65 | 0.00 | ||
Behavior | Behavior | 11.83 | 2.07 | −1.66 | −0.01 | 0.00 | |
Dental hygiene | Debris | 0.99 | 1.06 | −0.60 | 0.26 | 0.00 | |
Calculus | 0.81 | 1.05 | −0.78 | 0.06 | 0.00 |
This research variable has an abnormal data distribution for further statistical analysis using a non-parametric correlation test.
In peatlands, the risk factors for dental caries are significantly correlated (p-value 0.05) with debris only (rs = 0.289). Meanwhile, water minerals (phosphate rs = 0.313) and calculus (rs = 0.034) were significantly correlated with dental caries in the non-peatland community. In West Kalimantan, dental caries is significantly correlated (p-value 0.05) with drinking water minerals (fluoride rs = −0.243; phosphate rs 0.260), drinking water pH (rs = 0.235), behavior (rs = −0.327), and debris (rs = 0.240). Dental caries is not correlated with drinking water calcium, maternal education, height and weight, number of family members, and family economy (Table 3).
Relationship between dental caries risk factors and the rate of dental caries in peat and non-peatlands in West Kalimantan
. | . | Spearman's ρ . | ||||||
---|---|---|---|---|---|---|---|---|
. | . | . | Peatland . | p-value 0.05 . | Non-peatland . | p-value 0.05 . | Combination of West Kalimantan . | p-value 0.05 . |
. | Variable . | Sub-variable . | rs . | Sig . | rs . | Sig . | rs . | Sig . |
Dental caries | Mineral of drinking water | Fluoride | − 0.207 | 0.158 | − 0.087 | 0.556 | − 0.243* | 0.017 |
Phosphate | − 0.200 | 0.173 | .313* | 0.031 | 0.260* | 0.010 | ||
Calcium | − 0.019 | 0.899 | 0.167 | 0.256 | 0.080 | 0.439 | ||
pH | − 0.045 | 0.764 | − 0.139 | 0.347 | − 0.235* | 0.021 | ||
Social economy | Fathers’ education level | − 0.097 | 0.512 | − 0.001 | 0.993 | − 0.087 | 0.400 | |
Mothers’ education level | − 0.117 | 0.430 | 0.089 | 0.546 | − 0.062 | 0.551 | ||
Number of family members | − 0.032 | 0.832 | − 0.180 | 0.220 | − 0.079 | 0.443 | ||
Economy | 0.240 | 0.101 | 0.116 | 0.431 | 0.173 | 0.091 | ||
Behavior | Behavior | − 0.281 | 0.053 | − 0.234 | 0.109 | − 0.327** | 0.001 | |
Nutritional status | Height | 0.013 | 0.931 | − 0.248 | 0.089 | − 0.128 | 0.215 | |
Weight | 0.082 | 0.579 | − 0.081 | 0.582 | 0.004 | 0.972 | ||
Dental hygiene | Debris | 0.289* | 0.046 | 0.224 | 0.127 | 0.240* | 0.018 | |
Calculus | − 0.031 | 0.836 | 0.341* | 0.018 | 0.160 | 0.120 |
. | . | Spearman's ρ . | ||||||
---|---|---|---|---|---|---|---|---|
. | . | . | Peatland . | p-value 0.05 . | Non-peatland . | p-value 0.05 . | Combination of West Kalimantan . | p-value 0.05 . |
. | Variable . | Sub-variable . | rs . | Sig . | rs . | Sig . | rs . | Sig . |
Dental caries | Mineral of drinking water | Fluoride | − 0.207 | 0.158 | − 0.087 | 0.556 | − 0.243* | 0.017 |
Phosphate | − 0.200 | 0.173 | .313* | 0.031 | 0.260* | 0.010 | ||
Calcium | − 0.019 | 0.899 | 0.167 | 0.256 | 0.080 | 0.439 | ||
pH | − 0.045 | 0.764 | − 0.139 | 0.347 | − 0.235* | 0.021 | ||
Social economy | Fathers’ education level | − 0.097 | 0.512 | − 0.001 | 0.993 | − 0.087 | 0.400 | |
Mothers’ education level | − 0.117 | 0.430 | 0.089 | 0.546 | − 0.062 | 0.551 | ||
Number of family members | − 0.032 | 0.832 | − 0.180 | 0.220 | − 0.079 | 0.443 | ||
Economy | 0.240 | 0.101 | 0.116 | 0.431 | 0.173 | 0.091 | ||
Behavior | Behavior | − 0.281 | 0.053 | − 0.234 | 0.109 | − 0.327** | 0.001 | |
Nutritional status | Height | 0.013 | 0.931 | − 0.248 | 0.089 | − 0.128 | 0.215 | |
Weight | 0.082 | 0.579 | − 0.081 | 0.582 | 0.004 | 0.972 | ||
Dental hygiene | Debris | 0.289* | 0.046 | 0.224 | 0.127 | 0.240* | 0.018 | |
Calculus | − 0.031 | 0.836 | 0.341* | 0.018 | 0.160 | 0.120 |
*Correlation is significant at the 0.05 level (2-tailed).
**Correlation is significant at the 0.01 level (2-tailed).
DISCUSSION
Since the past, peatland communities have had groundwater that cannot be consumed, instead, they used rainwater as a drinking water source. In line with the growth of its economy, refillable water has become popular for public consumption (Komarulzaman 2017). Drinking water in peatland respondents has a low mineral content (water fluoride 0.06 mg/L, phosphate 0.03 mg/L, calcium 15.21 mg/L) compared to non-peat respondents. Peatland respondents had an average of five carious teeth, and non-peatland respondents had an average of four carious teeth. In general, in West Kalimantan, dental caries is significantly negatively correlated with fluoride, drinking water pH, and behavior. The higher the behavioral value, pH, and fluoride of drinking water, the lower the incidence of dental caries. Dental caries is positively correlated with phosphate, pH of drinking water, and debris. Peatlands have all sources of drinking water that contain very few minerals, especially fluoride, causing teeth to be easily attacked by dental caries, so the biggest risk factor for dental caries besides fluoride is debris. In non-peatlands, the mineral content of water is slightly higher, but still below the optimal limit, so the risk of dental caries is drinking water phosphate and calculus. Calculus is debris that has calcified and hardened. Calculus is a medium for plaque and debris to grow.
The environmental conditions in which people live could affect their health. The availability of clean water is one of the natural environmental factors that influences people's health (Northridge et al. 2003). Dental caries is influenced by the mineral content of water, which are fluoride and phosphate. Drinking water conditions that have fluoride levels below the optimal concentration (0.5 = 1.5 mg/L) are risk factors for dental caries (Selwitz et al. 2007). This risk determines whether or not a person or community is easily attacked by dental caries, and it can vary from time to time (Selwitz et al. 2007). Water with fluoride is good if the fluoride content is >1 mg/L and water with calcium is good if the calcium content is >150 mg/L (Quattrini et al. 2016). This mineral intake can be obtained from food and drinks consumed every day (Northridge et al. 2003) and correlates with the concentration of calcium and phosphate in saliva (Dawood & El-Samarrai 2018). Saliva plays a role in facilitating ion transport (Sejdini et al. 2018). There is a direct correlation between the calcium, magnesium, and fluoride content of water and dentin samples (Razvan 2020). Low fluoride levels affect the strength of teeth to withstand the demineralization process caused by the chemical process between bacteria and sucrose (Puspa Dewi et al. 2019). Fluoride has three mechanisms for dental caries control, namely increasing remineralization, inhibiting demineralization, inhibiting glycolysis in dental caries bacteria (Ahmad 2018), increasing remineralization with calcium and phosphate, and being antimicrobial (O'Mullane et al. 2016). During the demineralization process, calcium is released before phosphate ions, and calcium will have optimal potential if combined with phosphate (Lin et al. 2014).
The higher the debris, the higher the risk of dental caries. The demineralization process occurs as long as bacteria and food debris are on the surface of the teeth. Dental caries is caused by an ecological imbalance between dental minerals and oral biofilm. The demineralization process in teeth occurs at a low pH when the oral environment is not saturated with mineral ions compared to the mineral content of the teeth. Enamel crystals, consisting of carbonated apatite, are dissolved by organic acids (lactic and acetic) produced by the cellular action of plaque bacteria in the presence of dietary carbohydrates (Sejdini et al. 2018). Food waste (debris) is the main factor causing dental caries which must be kept to a minimum level by implementing good behavior in maintaining the cleanliness of the tooth surface (Wasfi 2018). Debris is related to food waste containing carbohydrates and sugar which are substrates for the growth of bacteria (Rathee & Sapra 2020). Diet (Fiorillo 2019), eating habits (Shaohong & Linmei 2020), increased intake of refined carbohydrates and refined sugar (DiNicolantonio & O'Keefe 2018), night feedings, and excessive sugar intake (Qin et al. 2008) are associated with dental caries.
In this study, behavior is closely related to dental caries. The entire surface of the tooth has the potential to become a place for plaque to grow along with bacteria that cause dental caries. The frequency of brushing teeth, daily gargling habits, and oral hygiene status are related to dental caries (Kyaw Myint et al. 2020). Good dental hygiene behavior can reduce the demineralization process by producing a clean tooth surface, so that food residue and Streptococcus mutans do not produce acids that could harm your teeth.
CONCLUSION
The risk factor for dental caries in peatlands is debris. The risk factors for dental caries in non-peatland are calculus and water phosphate. In general, the risk factors for dental caries in peatlands and non-peatlands in West Kalimantan are pH and drinking water minerals (fluoride and calcium), debris, calculus, and behavior.
DATA AVAILABILITY STATEMENT
Data cannot be made publicly available; readers should contact the corresponding author for details.
CONFLICT OF INTEREST
The authors declare there is no conflict.