University of Zambia Medical Library


ZAMBIA HEALTH INFORMATION DIGEST

Volume 6 Number 1 Jaunuary -- March 1999

PUBLISHED BY:
THE UNIVERSITY OF ZAMBIA MEDICAL LIBRARY

IN ASSOCIATION WITH:
THE MINISTRY OF HEALTH, ZAMBIA
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[ZHID Table of Contents]

EDITORIAL BOARD:
Dr. J.C. L. Mwansa, Microbiologist: University Teaching Hospital
Dr. Andrew L.Mbewe, Consultant Paediatrician: Kitwe Central Hospital
Dr. Oliver Bowa, Surgical Anatomist: University of Zambia Surgery Department
Ms. Regina Shakakata, Health Information & Promotions Officer: World Health Organisation-Zambia
Dr. Katele Kalumba: Minister of Home Affairs, Zambia
Dr. Mannasseh Phiri, Chief Medical Officer: Company Clinic, Kitwe
Mr. Sikwanda Makono, Specialist, Health Education, Ministry of Health
Ms. Christine Kanyengo, Medical Librarian (Acting): University of Zambia Medical Library

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The Zambia Health Information Digest is produced to provide current information to health workers who have little access to current health related publications and information.

SOURCE:
The abstracts of journal articles published in this quarterly Digest are obtained from the MEDLINE databases provided by the Dreyfus Health Foundation of New York. Abstracts are also selected from a database of Zambian health articles, which is continually being compiled at the UNZA Medical Library. Readers are encouraged to send in their work for inclusion in this Zambian health information database.
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Production costs are supported by The Dreyfus Health Foundation of New York. Full articles on unsafe abortion are provided by courtesy of Commonwealth Regional Health Community Secretariat for East, Central and Southern Africa (CRHCS), who have also contributed generously to the expansion of the Digest. We encourage readers to submit requests for articles highlighted in the Digest.

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Zambia Health Information Digest: January - March 1999

TABLE OF CONTENTS:

EDITORIAL: DENTAL HEALTH

 This issue of the Digest covers a wide variety of topics that should be of interest to all health care providers. We have covered for instance; Allergies; Tuberculosis; Iron Deficiency; Genital Herpes; and Hirschsprungs. Allergies occur frequently within Zambian society. However their manifestations and treatment are still being a subject of study. Included in this issue of the Digest are abstracts on studies done on allergic conditions in Zambia. We have particularly selected mostly abstract on Zambia, not only to highlight the studies that have been done but also to give to some extent an indication of the type of treatment and management that were followed. A full article on Asthma in children has been included. Tuberculosis is a disease, which is very prevalent in the country. An article dealing with this condition discusses the management and control of the disease. The article further elaborates on how the TB patient and relatives should manage the patient once he/she has been discharged from the hospital. It also looks into the measures to be taken so that it does not spread to the others in society who come into contact with the patient. The relevance of the Aetiology of Iron Defiency (IDA) study in the Zambian context cannot be over emphasised. Here in is a study that gives a true picture of the situation of IDA in the country and the results indicates that 65% of children; 42% of pregnant women and 25% of men were anaemic. A study on the management of Hirschsprung’s disease in a rural hospital in the Eastern Province of Zambia provides vital data that would help other health care providers operating in similar conditions. We hope you enjoy reading through this issue..

DENTAL HYGIENE (CURRENT ABSTRACTS OF JOURNAL ARTICLES -- MEDLINE)

Motivation for dental hygiene in adolescents

Tuber Lung Dis 1994 Apr;75(2):110-5 [Human immunodeficiency virus type-1 infection in Zambian children with tuberculosis: changing seroprevalence and evaluation of a thioacetazone-free regimen] Luo C, Chintu C, Bhat G, Raviglione M, Diwan V, DuPont HL, Zumla A Department of Paediatrics, University Teaching Hospital, Lusaka, Zambia. SETTING: This study was conducted at the Department of Paediatrics and Child Health, University Teaching Hospital (UTH), in Lusaka, Zambia. OBJECTIVES: To monitor the seroprevalence of HIV type-1 in children with tuberculosis and to evaluate the response to anti-tuberculosis therapy using a thioacetazone-free treatment regimen. DESIGN: A prospective cross-sectional study of all consecutive newly diagnosed cases of TB in children from 1 month-15 years of age seen at the University Teaching Hospital (UTH) in Lusaka, Zambia between 1 October 1991 and 31 May 1992. RESULTS: 120 children with a clinical diagnosis of Tuberculosis and 167 controls were enrolled in the study. The overall HIV type-1 seroprevalence rate in children with tuberculosis was 55.8% (67/120) compared to 9.6% (16/167) amongst the control group (P < 0.0001: odds ratio = 11.50; 95% CI = 5.99-22.7). Common clinical presentations among children with TB were bronchopneumonia (45/162), miliary TB (30/162) and tuberculous lymphadenopathy (21/33). There were no significant differences in clinical presentation of TB between the HIV-negative and HIV-positive groups. The follow-up of those patients with tuberculosis was poor, with only 65 patients (55%) returning to the clinic for scheduled appointments after discharge. All the 16 patients who died did so within 60 days of discharge from hospital; all of them were seropositive for HIV. There were no deaths among the HIV-negative group. Despite the exclusion of thioacetazone from the treatment regimen, cutaneous reactions occurring within 8 weeks of commencing treatment were observed in 7 of the 65 (11%) patients, 2 of whom developed fatal Stevens-Johnson syndrome. All 7 patients were seropositive for HIV-1. CONCLUSIONS: The seroprevalence rate of HIV type-1 among children with tuberculosis in Lusaka continues to rise; careful monitoring of anti-TB therapy (even in regimens excluding thioacetazone) for potentially lethal side effects should be carried out.
Macgregor ID. Balding JW. Regis D.
Motivation for dental hygiene in adolescents.
International Journal of Paediatric Dentistry. 7(4):235-41, 1997 Dec.

Liaison psychiatry and psychology in dentistry

Trans R Soc Trop Med Hyg 1994 Jan-Feb; 88(1):113-5 [Cutaneous reactions to thiacetazone in Zambia--implications for tuberculosis treatment strategies] Kelly P, Buve A, Foster SD, McKenna M, Donnelly M, Sipatunyana G, Monze District Hospital, Zambia. Tuberculosis in patients infected with human immunodeficiency virus (HIV) is a growing threat to public health in Africa. Thiacetazone, one of the continent's most widely used antituberculous agents, may lead to severe cutaneous reactions in the HIV infected individual. We describe the impact of this reaction on the tuberculosis (TB) control programme of a district hospital in Zambia in 1990, and examine the cost implications of changing the standard treatment regime. We carried out a retrospective survey of records of all patients beginning TB treatment in 1990, together with HIV test results and the cost of all treatments given. From this we derived estimates of costs of different regimes which are and could be used in TB control in Zambia. Severe reactions occurred in 18.7% of all HIV seropositive patients receiving thiacetazone, fatally so in 1.2% (odds ratio 16.6). The greatest part of the cost of the current regime is that attributable to the inpatient stay; we estimated that 29.4% of patients would be unable to receive drugs as out-patients but, even allowing for this, rifampicin-based regimes given to outpatients where possible would not cost more than the current strategy. We conclude that ethical and economic considerations support a change to rifampicin-based regimes in areas of Africa where HIV seroprevalence is high. Comments: Comment in: Trans R Soc Trop Med Hyg 1995 Mar-Apr;89(2):238 Feinmann-C; Harrison-S
Liaison psychiatry and psychology in dentistry
J-Psychosom-Res. 1997 Nov; 43(5): 467-76

A practical guide for the diagnosis and treatment of acute sinusitis

Arch Dis Child 1993 May;68(5):665-8 [Cutaneous hypersensitivity reactions due to thiacetazone in the treatment of tuberculosis in Zambian children infected with HIV-I] Chintu C, Luo C, Bhat G, Raviglione M, DuPont H, Zumla A Department of Paediatrics, University Teaching Hospital, Lusaka, Zambia. Tuberculosis is one of the most common infections in Zambian adults and children infected with HIV. In Africa, cutaneous hypersensitivity reactions attributed to thiacetazone during treatment of tuberculosis in adults infected with HIV-I have been well documented. This study monitored adverse drug reactions during treatment for tuberculosis over an 18 month period (1 April 1990 to 31 October 1991) in 237 children with a clinical diagnosis of tuberculosis (125 boys and 112 girls; 88/237 (37%) infected with HIV-I) and 242 control children (149 boys and 93 girls; 26/242 (11%) infected with HIV-I). Twenty two (9%) of the 237 children with tuberculosis developed hypersensitivity skin reactions during the course of treatment. Adverse skin reactions were seen more often in children infected with HIV than in those who were not (odds ratio 11.65, 95% confidence interval 3.07 to 34.88). These represented 19 (21%) of 88 children infected with HIV and three (2%) of 149 children not infected with HIV. These skin reactions occurred after a period of treatment ranging between two and four weeks among 14 children receiving the HST (isoniazid, streptomycin, thiacetazone) regimen and eight children receiving the HSTR (isoniazid, streptomycin, thiacetazone, rifampicin) regimen. Twelve (55%) of the 22 children who reacted adversely to treatment developed the Stevens-Johnson syndrome. All 12 of these children with the Stevens-Johnson syndrome were infected with HIV. The mortality among these children who developed the Stevens-Johnson syndrome was 91% (11 of 12 died within three days of the onset of the reaction). AU: Glaser-C; Lang-S; Pruckmayer-M; Millesi-W; Rasse-M; Marosi-C; Leitha-T
Clinical manifestations and diagnostic approach to metastatic cancer of the mandible.
SO: Int-J-Oral-Maxillofac-Surg. 1997 Oct; 26(5): 365-8

Children's dental health in Europe: an epidemiological investigation of 5- and 12-year-old children from eight EU countries

This thesis is based on a cross-sectional comparative study of dental health, treatment needs and attitudes to dental care in groups of 5- and 12-year-old children from the following eight cities in respective EU countries: Athens-Greece, Berlin-Germany, Cork-Ireland, Dundee-Scotland, Gent-Belgium, Sassari-Italy, Stockholm-Sweden and Valencia-Spain. A total of 3,200 children, 200 in each age group, were clinically examined by well-calibrated dentists, the parents completing a questionnaire on dental habits, parental and children's attitudes to dental care, smoking habits and parental occupations. The results disclosed pronounced differences in dental health and treatment need among the children from the different countries. The Scottish, Italian and German 5-year-olds exhibited the highest values for decayed, missing and filled teeth (dmft). The m component dominated for the Scottish sample, the d component in the Italian and d and f in the German sample. The highest values for DMFT in the 12-year-olds were found in the German, Greek and Italian samples followed by the Swedish sample. The F component dominated in the German and Swedish samples, while D dominated in the Greek and Italian samples. Analyses of the influence of socio-demographic and behavioural factors on the dental health, expressed as dmft/DMFT, showed that the most important factors explaining differences in caries experience were toothache, social class of the family and dental fear in the children. The frequency of similar attitudes (dental fear) in subjects and parents was 50% or higher in all the samples, and the frequency of similar dental attendance patterns in child and parent was 42% or higher in all the samples. For both age groups the proportion of subjects with regular dental attendance habits was highest in the Swedish, Belgian, German and Scottish samples. These findings, together with the high frequency of regular attenders without treatment need in the Swedish 5-year-olds indicate that organization of dental care must be closely adapted to the population it is set to serve. Separate strategies are necessary to manage the dental needs of healthy respectively diseased children. Reliable epidemiological data are necessary for planning, so that resources can be directed to the individuals with the greatest needs. However, to reach the children before onset of disease, parents, teachers, general health workers, sports coaches etc. must work jointly together with the dental profession. Among the eight countries, there is greater similarity in the organization of dental care for schoolchildren than for pre-school children. Only the Swedish system offers both preventive and restorative treatment irrespective of initiatives from the parents. In the other countries parents are mainly responsible for arranging for restorative treatment, above all for pre-school children. Different policies to promote dental health in the child population can be seen. Fluoridation of domestic water supplies has been implemented in Ireland, and the frequent use of fissure sealants in the Scottish, Irish and also the Belgian 12-year-olds is another example of a cost-effective measure influencing the dental health..
Bolin-AK
Children's dental health in Europe. An epidemiological investigation of 5- and 12-year-old children from eight EU countries..
Swed-Dent-J-Suppl. 1997; 122: 1-88.

A case of pulmonary tuberculosis complicated with gingival lesions

Vet Rec 1989 Jun 3;124(22):583-4 [Delayed-type hypersensitivity test for assessing tick-immune status of cattle in Zambia] Smith RE, Mwase ET, Heller-Haupt A, Trinder PK, Pegram RG, Wilsmore AJ, Varma,MG Royal Veterinary College, London. Delayed-type hypersensitivity skin reactions were used to assess the tick resistance status of Tonga calves in Zambia. The antigen used in the tests was a homogenate of unfed nymphal Rhipicephalus appendiculatus which had been shown to give protective immunity in guinea pigs to adult female R appendiculatus. There was a significant negative correlation between the intensity of the reactions and the total number of ticks (Amblyomma variegatum, Rappendiculatus, Hyalomma truncatum, Boophilus decoloratus and Rhipicephalus species) on the animals.

Dental health and dental treatment needs among recruits of the Finnish Defence Forces, 1919-91

The first two surveys of the dental health of young Finnish men were conducted in 1919 and 1965. The objective of four subsequent surveys (1976, 1981, 1986, and 1991) was to collect both interview and clinical examination data for the monitoring of changes in the oral health status of the recruits. A significant reduction in self-reported toothache, gingival bleeding, and number of decayed teeth was observed from 1976 to 1991. At examination, the numbers of decayed teeth, teeth indicated for extraction, teeth in need of fillings, and missing teeth decreased substantially, as did the teeth with visible plaque, subgingival calculus, and teeth with 4-mm or deeper periodontal pockets. This comprehensive series of successive cross-sectional oral health surveys clearly shows that since 1976 a significant decrease in oral disease and treatment needs has taken place among the Finnish population of young men.
Ankkuriniemi-O; Ainamo-J
Dental health and dental treatment needs among recruits of the Finnish Defence Forces, 1919-91
Acta-Odontol-Scand. 1997 Jun; 55(3): 192-7

Oral disease, impairment, and illness: congruence between clinical and questionnaire findings

In 1992 a questionnaire was sent to 50-year-olds in two Swedish counties. These self-report data were compared with clinical observations with regard to number of teeth, removable dentures, caries, and periodontitis. Complete information from both data sources was obtained for 1041 persons. The relevant questionnaire item explained 71% of the missing tooth variance. An agreement of 0.91 (Cohen's kappa) was obtained for removable dentures. A question about problems in opening the mouth differentiated clearly with regard to measured mouth opening ability. Toothache and tooth sensitivity were reported with 95% probability when having 22 decayed teeth and with 46% when there were no decayed teeth (58% correctly predicted). Two teeth with pockets > or = 6 mm gave 5% probability and 22 such teeth gave 39% probability of reporting migration of front teeth. The main conclusion from this study is that there is good correspondence between subjective self-reports and clinical findings, especially for those conditions that are relatively easy for the patient to observe, such as the number of teeth and the presence of dentures. Thus questionnaire data can be used for information and screening about some well-defined oral conditions.
Unell-L; Soderfeldt-B; Halling-A; Paulander-J; Birkhed-D
Oral disease, impairment, and illness: congruence between clinical and questionnaire findings.
Acta-Odontol-Scand. 1997 Apr; 55(2): 127-32

Nonodontogenic toothache

Toothache is a common complaint in the dental office. Most toothaches have their origin in the pulpal tissues or periodontal structures. These odontogenic pains are managed well and predictably by dental therapies. Nonodontogenic toothaches are often difficult to identify and can challenge the diagnostic ability of the clinician. The most important step toward proper management of toothache is to consider that the pain may not be of dental origin. Signs and symptoms suggestive of nonodontogenic toothache are as follows: 1. Inadequate local dental cause for the pain. 2. Stimulating, burning, nonpulsatile toothaches. 3. Constant, unremitting, nonvariable toothaches. 4. Persistent, recurrent toothaches over months or years. 5. Spontaneous multiple toothaches. 6. Local anesthetic blocking of the suspected tooth does not eliminate the pain. 7. Failure to respond to reasonable dental therapy of the tooth.
Okeson-JP; Falace-DA
Nonodontogenic toothache.
Dent-Clin-North-Am. 1997 Apr; 41(2): 367-83.

Headache and teeth

Headache, facial pain and toothache are poorly localized and irradiate in distant areas. Thus, toothache often causes facial pain and headache, but, in turn, it can also be mimicked by several forms of these disorders, in particular by a myoarthropathy of the masticatory system, a migraine, a tension-type headache, a neuropatic pain and a trigeminal neuralgia. The atypical odontalgia is a nonodontogenic form of toothache that is difficult to diagnose; therefore, it leads to a number of invasive dental procedures which normally worsen the pain condition. The atypical odontalgia can often be solely diagnosed by means of a diagnostic block. Headache and facial pain can also be caused by a myoarthropathy of the masticatory system. This disorder is often misdiagnosed, because the signs and symptoms are not pathognomonic, and they are frequently present also in healthy individuals. The disorder has a good prognosis, the therapy is generally simple and follows the treatment principles for chronic musculoskeletal disorders. The burning-mouth syndrome is an other poorly understood form of intraoral pain that occurs primarily in postmenopausal females. Several etiologic factors have been described, but treatment based on one or more of these factors is often ineffective. Spontaneous remission occurs in about half of the patients after several years. Palla-S
Headache and teeth
Ther-Umsch. 1997 Feb; 54(2): 87-93

Importance of dental problems according to 12- to 16-year-old children

The willingness to take preventive action is partly determined by the perceived importance of the disease. The purpose of this study was to investigate the relationship of age, sex, education, and ethnicity to the importance of dental and other health problems by 12- to 16-year-old children. The children (361 boys, 272 girls) attending Dutch schools were asked a series of questions requiring a choice by students as to the more important problems in a given pair of conditions. Conditions included systemic, dental, and psychological problems. Nervousness was the least important problem and hearing disability the most of the nine ranked. Having full dentures was ranked third, bad teeth fifth, and toothache sixth of the nine from least (first) to most important (ninth). Age, sex, education, and ethnicity showed no relationship to importance of problems alone or in aggregate..
Assink-MH; Verhey-JG; Hoogstraten-J; Goedhart-H
Importance of dental problems according to 12- to 16-year-old children
Pediatr-Dent. 1996 Sep-Oct; 18(5): 391-4

Biological rhythm, inflammation and non-steroidal anti-inflammatory agent

The inflammation is characterized by a multifrequency time structure described both in the edematous reaction and in the migration of neutrophilic polymorphonuclear (PMN) in the inflammatory site. The circadian rhythm of PMN migration appears to be similar when the migration was induced by BCG, LPS or carrageenan. The corticosteroids play an important role in the mechanisms in the circadian rhythm of PMN, but recent data in intact and castrated mice indicated that testosterone is also involved in these mechanisms. In arthritic patients, the signs and symptoms of the diseases varied as a function of time of day and of the type of arthritic diseases. Human data with indomethacin, ketoprofen and piroxicam indicated that it is possible to find an optimal time of day for the administration of these non-steroidal anti-inflammatory agents (NSAID). Clinicians can use these chronopharmacological data to maximize the analgesic effect and to minimize the side effects of the NSAID. The research on biological rhythms in inflammation and in the effects of NSAID lead to a better understanding of the mechanisms of inflammation and to the rational use of the drugs in arthritic patients.
Bureau-JP; Labrecque-G
Biological rhythm, inflammation and non-steroidal anti-inflammatory agent
Pathol-Biol-Paris. 1996 Sep; 44(7): 610-7

Barodontalgia among flyers: a review of seven cases

Once referred to as "flyer's toothache," barodontalgia is defined as tooth pain occurring with changes in ambient pressure. It usually occurs in people who fly or dive. It can develop in conjunction with sinusitis, and in teeth experiencing pulpitis after restorative treatment, new and recurrent caries, intra-treatment endodontic symptoms, dental and periodontal cysts, or abscesses. Although the causal process of barodontalgia is not well understood, it may be related to pulpal hyperemia, or to gases that are trapped in the teeth following incomplete root canal treatment. Patients who are frequently exposed to changes in ambient pressure should be encouraged to follow good oral health practices, attend regularly-scheduled dental recall examinations and accept the timely completion of restorative treatment to minimize the possibility of developing barodontalgia. By employing a classification system to document cases of barodontalgia, dentists will be better prepared to provide appropriate and successful treatment. Seven case reports of barodontalgia are presented and compared to previously documented cases. The author also reviews the reasons why military flyers are more likely to develop barodontalgia than others, although the passengers and crews of commercial airliners may also suffer from this condition..
Holowatyj-RE
Barodontalgia among flyers: a review of seven cases.
SO: J-Can-Dent-Assoc. 1996 Jul; 62(7): 578-84

Thermographic assessment of neuropathic facial pain

Ongoing pain, intermittent sharp pain, or intermittent dull aching pain around the teeth can evoke the suspicion of tooth pathology. However, when no dental cause can be found clinically or radiographically, the differential diagnosis involving neuropathic pain and pulpal pathology is still a challenge. Neuropathic facial pains are still too often misdiagnosed as tooth pain of dental origin, resulting in unnecessary dental extraction or endodontic therapy. The purpose of this study was to determine if electronic thermography was able to differentiate neuropathic facial pains presenting as toothache from pulpal pathology. Electronic thermography was used to compare asymptomatic subjects and subjects with neuropathic facial pains. Asymptomatic subjects and subjects with trigeminal neuralgia, pre-trigeminal neuralgia, and pulpal pain without periapical pathology showed no thermographic difference in the territory of the pain complaint when compared to the opposite nonpainful side. Patients with sympathetically maintained traumatic trigeminal neuralgia (atypical odontalgia) and half of the group with sympathetically independent traumatic trigeminal neuralgia presented with "hot" thermograms. The other half of the patients with sympathetically independent traumatic trigeminal neuralgia displayed "cold" thermograms in the area of their pain complaints. Electronic thermography was the least selective test for the group showing "cold" thermogram patterns (80% agreement with the thermographic characterization criteria). These data suggest that electronic thermography may be helpful in differentiating neuropathic pains from pulpal pathology.
Graff-Radford-SB; Ketelaer-MC; Gratt-BM; Solberg-WK
Thermographic assessment of neuropathic facial pain
SO: J-Orofac-Pain. 1995 Spring; 9(2): 138-46

Oral disease, impairment, and illness: congruence between clinical and questionnaire findings

In 1992 a questionnaire was sent to 50-year-olds in two Swedish counties. These self-report data were compared with clinical observations with regard to number of teeth, removable dentures, caries, and periodontitis. Complete information from both data sources was obtained for 1041 persons. The relevant questionnaire item explained 71% of the missing tooth variance. An agreement of 0.91 (Cohen's kappa) was obtained for removable dentures. A question about problems in opening the mouth differentiated clearly with regard to measured mouth opening ability. Toothache and tooth sensitivity were reported with 95% probability when having 22 decayed teeth and with 46% when there were no decayed teeth (58% correctly predicted). Two teeth with pockets > or = 6 mm gave 5% probability and 22 such teeth gave 39% probability of reporting migration of front teeth. The main conclusion from this study is that there is good correspondence between subjective self-reports and clinical findings, especially for those conditions that are relatively easy for the patient to observe, such as the number of teeth and the presence of dentures. Thus questionnaire data can be used for information and screening about some well-defined oral conditions.
Unell-L; Soderfeldt-B; Halling-A; Paulander-J; Birkhed-D
Oral disease, impairment, and illness: congruence between clinical and questionnaire findings Acta-Odontol-Scand. 1997 Apr; 55(2): 127-32

A STUDY OF DENTAL CARIES AT THE UNIVERISTY TEACHING HOSPITAL, LUSAKA.

By Namwinga Chintu

 INTRODUCTION:
Dental caries and tooth decay has been described as the most common disease in the world as there are very few people who have not suffered from it at one time or another. The word carries is derived from a Latin word meaning rotting. It is a form of progressive destruction of enamel dentine and cementum initiated by microbial activity at the tooth surface.

Poor oral and dental hygiene have bee closely associated with the aetiology of dental caries. Oral hygiene is dependent on culture diet and what the individual has been taught on the above during childhood. It is aimed mainly at the removal of plaque from the tooth surface. The most common method is tooth brushing. If plaque is allowed to accumulate it may eventually calcify and is known as calculus. Other factors, which have a bearing on formation of caries, include diet, saliva flow, from, position and structure of the tooth and fluorination of water. Very few studies have been done on dental caries in Zambia hence the necessity of this study.

ORAL HYGIENE
Oral hygiene is mainly aimed at the removal of plaque from the tooth surface. The most common method used is tooth brushing. Plaque consists of aggregation of bacteria and their products on the tooth surface. Absence of adequate oral hygiene, dental plaque can accumulate beyond the level compatible with oral health. This leads to shift in the balance of predominant bacteria away from those associated with health; such shift can predispose a site of caries and periodental disease (Author Marsh P.D.). Title:- Significance of maintaining the stability of the natural flora of the mouth, Source: Unique identifier from MEDLINE 1992).

Various strains of plaque bacteria have been implicated in the formation of caries. These include Streptococcus mutans, Streptococcus sanuis and Streptococcus salivarius. However Streptococcus mutans is the most significant bacteria in terms of etiology of caries. The Acidogenic theory implicates the importance of plaque in the formation of caries. The basic theory suggests that sugars in the diet be converted into acids by the action of plaque bacteria. The acids subsequently destroy the calafied material of the tooth. Oral hygiene is therefore important in controlling plaque and subsequently controlling caries.

DIET
The type of diet is important in the etiology of caries. Diet can influence he health of dental tissue in the following ways:
The role of Sugar in the etiology of caries. Sucrose has been shown to be the substrate, on which bacteria act to produce lactic acid, which subsequently destroys the tooth. The production of acid occurs immediately sugar is eaten and the pH of the plaque begins to drop. The normal plaque PH is about 6.8 and ten minutes after exposure it drops to 5 and returns to normal after 30-6- minutes. Therefore the quantity and frequency of sucrose in ones diet is an important factor of the formation of caries.

Mode of action of Fluoride
It is suggested that fluorides reduce caries in several ways

ZAMBIAN LITERATURE
Very little has been done in the study of dental caries in Zambia. However, a study of dental caries in rural and urban primary school in Zambia carried out by Baboo et al, revealed that dental caries are a major health problem. It also concluded that health education directed at high lighting the disadvantages of refined carbohydrates, proper dental hygiene especially among the most vulnerable group would go along way. The study recommended that dental caries must receive its proper place on the National Health Programme if meaningful goods are to be achieved (Medical Journal of Zambia 1981 page 59 volume 15).

AIM OF THE PROJECT

DISCUSSION
Of the 50 patients recruited 62% (31) were female and 42% (19) were male. The male and female ration was found to be 1:1.63. The age of patient's recruited ranged from 1 year 6 months to 64 years. Th peak incidence of caries was found between the ages 23 and 18 years of age (36%) (18) caries the child of 1 years 6 month would de attributed to bottle feeding and are known as Nursing caries or baby bottle syndrome. These are rampant type of caries and occur in some youngsters who are permitted to use nursing bottles filled with carbohydrate containing liquids when lying down to sleep. The four-maiximillary incisors are most mechanism assumed is that of acid demineralization. As a child falls asleep while sucking, the saliva flow and frequency of sucking decreases. This causes a stagnant pool of carbohydrates to acids over the entire period of sleep. (Ref: Oral Biology, author Gerald I, Roth and Robert Calims) In this case the child was often bottle fed at night while in bed. The parent denied having performed any dental hygiene measures to prevent caries e.g tooth brushing. The maximillar incisors were involved in this case.

64% (320 patients had dental plaque. Of the 32 patients, 14% (7) had abundant plaque visible to the naked eye. Of the 14% (2) did not brush their teeth regularly. I brushed once a month with ashes and a finger and the other used salt and water and brush on alternate days. 46% (23) brushed once a day and 38% (19) brushed twice a day. Only one did not brush because he was 1 year 6 months and according to the parents was too young.

The main complaints among the patients were toothache (64%) (32) and the average duration of complaint was 3 weeks. It should be noted that even though 3 weeks was the average duration, there must have been other dental problems preceding the toothache. Most people tend to ignore the "prodormal" symptoms because the onset is inciduous and does no seriously affect the health or well being of the affected individual. The prodormal symptoms preceding the toothache. The prodormal symptoms include bleeding gums small painless hole in the tooth, sensitivity to hot and cold liquid and sometime even air.

The relatively long duration of complaint can be attributed to the fact that dental facilities are generally not readily available though out the country. Only 40% (20) of the recruited patients had access to dental facilities in their area. A general fear of dentist may have also contributed to the long duration of complaint before presentation to the hospital. To add to the problem, most government clinics are understaffed and do not have the required drugs and machinery to perform various procedures. Facilities commonly out of stock include local anaesthetic, amalgam filling and dental drilling equipment (information obtained from UTH dental clinic). It therefore follows that even if patients reported to the clinics in time, they may have been turned away because of lack of facilities.

28% (14) complained of caries (hole in the tooth) with little or no pain. 6% (3 complained mainly of a swollen jaw). I this case teeth were badly decayed with sepsis of surrounding tissue and halithosis. There could have been underlying osteomyelitis but this was not proved at the time of the study. 1(2%) 18 year old male complained of discoloured teeth. There was no evidence of other members of his family and community with similar staining. However there was a history of respiratory track infection and treatment with tetracycline in his mother when she was expecting him. They were no cases of teeth staining. NO cases of mottling or staining due to excessive fluoride were noted.

Only 36% (18) had no dental plaque. This shows that even though 94% (47) admitted to brushing teeth regularly, they are most likely using the wrong method of brushing leading to plaque formation of caries. Associated problems includes not being able to eat on affected side due to pain 50% (25), pain 20% (10), bleeding gums 26% (13) which is evidence of gingivitis, and swollen face 4% (2). 94% (47) of the patient admitted to eating food such as sweets, biscuit, tea (more than 2 spoons of sugar) and fanta between meals. 30% (15) complained of stained teeth due to the above. Eating confectioneries especially sweet ones is important in the formation of caries.

CONCLUSION

RECOMMENDATION
In order to reduce the incidence and prevalence of dental caries in Zambia, the government through the Ministry of Health must stress the importance of oral health and oral hygiene. More money must be given to clinics and hospitals to improve dental services and to obtain machinery and drugs. As the clinics are understaffed efforts to train more manpower must be made.

It is necessary to carry out more research on dental caries to find out exactly what impact they have in Zambia and to find out in depth the factors affecting and causing them.

(Note: This is an edited version of a student project, UNZA).

GOLDEN RULES FOR HEALTH WORKERS

Just imagine you are the patient. What sort of things would you dislike about coming for treatment. Here are some more thoughts from Papua New Guinea. LOOK

GUM AND TOOTH PROBLEMS

Dental caries, gingivitis, periodontitis, edentulism - they're a mouthful. These maladies can make you ache, bleed, swell, sometimes even make your breath smell. Fortunately, none of them is inevitable as long as you take well care of your teeth and gums.

Not that many years ago, a kid wasn't a kid without a few cavities. Today, thanks to improved dental hygiene, half of America's schoolchildren have no tooth decay at all. Those who do have cavities have fewer than their parents or grandparents did when they were young. Measures such as using fluoride toothpaste and switching to sugarless gum are preventing tooth decay among children.

Dental health is better among grown ups, too. Adults today are less likely to end up with dentures and without their natural teeth (a condition called edentulism). According to a survey of oral health nationwide, more than a third of Americans still have all their natural teeth, and approximately half have lost just one tooth. Only 4 percent of employed Americans have had all their teeth replaced. That's the good news. What does remain a serious problem, however, is periodontal disease. About 43 percent of adults in the national survey had problems with bleeding gums, and 84 percent had deposits of tartar. Both are signs of gum disease.

Plaque: The Bacterial Barrage
The culprit behind most tooth and gum problems is plaque, a substance that is naturally present in everyone's mouth, day in and day out. Plaque is made of dried saliva, food debris, and bacteria, about 300 different kinds of which call your mouth home, regardless of how clean you may keep it. Most of these bacteria actually serve a protective function, fending off other germs to keep you free of infection. But they can turn on you when their numbers and types get out of balance. And the damage they do pretty much depends on how old you are.

Tooth decay can start as early as infancy. A baby's very first tooth is susceptible. Most cavities occur during childhood and adolescence. When you grow up, decay of your teeth slows down. As an adult, however, you're more vulnerable to decay down in the roots of your teeth and are more likely to develop gum problems. How can you prevent the bacteria in your mouth from multiplying and doing damage?

Avoid eating a sugary, high-carbohydrate diet, which throws things out of kilter very quickly. The bacteria gorge on sugar and carbohydrates, multiply into sticky masses, and adhere to the surfaces of your teeth. In a healthy mouth, plaque is colorless and virtually invisible. But you can see the damage it causes all too well. Plaque produces acids that eat away your teeth's protective enamel. The result is tooth decay. If plaque isn't removed from your teeth, it combines with calcium and phosphorus to form more visible white or yellowish deposits called tartar, or calculus. Layer upon layer builds up, wreaking greater havoc on your teeth and hardening to the point that only your dentist can chip it away. Plaque can also do its dirty work along the roots of your teeth and beneath your gums, causing periodontal disease. This condition gradually destroys your gums and other structures supporting your teeth.

Most Americans over 40 have some form of periodontal disease. The problem can begin in childhood, though the disease doesn't usually reveal itself until adulthood. One study showed that gingivitis, the earliest form of the disease, affects more than one-third of children aged 6 to 11 and more than two-thirds of adolescents.

If you have gingivitis, your gums will become red and you'll notice swelling around one or more of the teeth, symptoms that will worsen with time. Eventually, your gums may begin to bleed easily, especially while you're brushing or flossing your teeth. Gingivitis, it left untreated, can escalate to periodontitis. Infected pockets form between the teeth and gums. Your breath smells bad, but worse yet, the bone that supports the teeth is destroyed, so that the teeth become loose and eventually start falling out.

Give Plaque the Brush-Off
The most important point to remember about both tooth decay and periodontal disease is that you can prevent them. At some stage, periodontal disease can even be reversed. Dentists find that, when properly treated, inflammation can subside, swollen gums can shrink and grow firm, and loose teeth may even become more stable.

The key to proper treatment is plaque control, a job that is never done. Within 24 hours after removing one layer of plaque, a new layer begins to glom onto your teeth. To unglom it, you need to brush your teeth for 3 minutes at least once or twice a day. Brushing is especially important at bedtime. While you sleep, saliva secretion is reduced. Preventing plaque's formation in the first place is also important, especially when it comes to your diet. If there's anything plaque loves, it's a nice sugary treat like a candy bar or a can of soda pop between meals. Plaque uses the sugar to establish a stickier stronghold in your mouth. What's more, every time you eat anything, sweet or not, plaque launches a 20-minute acid attack with your teeth in the direct line of fire. So try to limit eating or mealtimes. If you do snack, eat nondecay-promoting foods like nuts, popcorn, or raw vegetables. Cheese, by the way, seems to actually neutralize the formation of acid. Chewing sugarless gum a few minutes after a snack appears to help neutralize acids, too.

See your dentist regularly, at least twice a year, for a checkup and to have tarter removed professionally. If you show signs of periodontal disease, your dentist may recommend more frequent cleaning.
-- Natural Healing, Judith Lin

ORAL AND DENTAL HYGIENE

Effective and dental hygiene
Plaque is the build up of bacteria on the teeth and around the gums. When plaque reacts with food and drinks containing sugar, it forms an acid that attacks the tooth enamel and leads to cavities. Brush and floss at least twice a day, after breakfast and before you go to bed, to fight plaque. Brush properly (not hard) where the teeth and the gums come together. Ask you dentist's advice about which toothbrush is the best for your teeth (soft, medium or hard). Brush every area for about ten seconds. It's also good to get a new toothbrush every two or three months. Floss isn't only good to get rid of food, but also to fight plaque. Be careful when you floss that you don't cut the gums. Visit your dentist at least once a year to ensure your mouth and teeth are kept in good condition.

Mouth ulcers
What causes it?

What can I do about it?

When should I go to the dentist?

Stained Teeth
What causes it?

What can I do about it?

True Vitality Magazine, March 1999.

BREASTFEEDING AND HIV TRANSMISSION

SAFAIDS FACT SHEET No. 1.98

Individual cases of mother-to-child HIV transmission through breast-feeding were first documented in 1985. By 1992 the level of risk was more clearly understood, but much is still unknown about the risks and mechanisms of transmission. It is clear, however, that mothers with HIV can transmit infection and need advice on what is best for their babies. The World Health Organization (WHO) and the United Na-tions Children's Fund (UNICEF) have been slow to support moves to-wards non-breastfeeding for mothers with HIV in developing countries. This is because of the real risk that more babies will die of malnu-trition and diarrhoeal infections than would be saved through avoid-ing HIV infection. Two considerations are changing this view: the high levels of maternal HIV in some areas (over 20% of pregnant women in most of southern Africa, for example) and recognition of the right of women and families to information on which to make their own decisions.

How Risky is Breastfeeding?
WHO suggests that the risk of HIV transmission from-mother-to-child is roughly as follows:

Breastfeeding is more risky when:

These factors mean either that the mother has a high viral load in the milk (or that blood might be present in the milk); or that the baby's mucosa are more susceptible to infection because of sores and inflammation (e.g. caused by mixed feeding or formula feeding). The factor conferring greatest risk is the mother becoming infected herself during pregnancy or lactation.

Policy dilemmas
Where maternal HIV infection is high, huge numbers of babies are potentially at risk of infection. The most important strategy must be trying to reduce maternal infection, trying to protect young women in particular from becoming infected in the first place. In addition to this, the number of infected babies can be reduced by:

Only changed obstetric practice and micronutrient supplementation, however, can be effected for all pregnant mothers regardless of HIV status. These low-cost interventions should be undertaken as a priority. The other interventions are more costly and require that mothers know their HIV status. This means they must have access to voluntary counselling and testing (VCT) which, in turn, requires a substantial infrastructure linked with existing primary and maternal and child health facilities. It also means that many social and cultural problems may arise, for instance if the HIV positive woman is rejected by her partner or family.

The strategy of avoiding breastfeeding, although an important option is problematic because, if replacement feeding is undertaken only by HIV positive mothers, their confidentiality over their HIV status is automatically lost. If HIV negative mothers also stop breastfeeding, many babies in poor families will die from malnutrition and diarrhoea who were at no risk of HIV.

Infant feeding recommendations
The new WHO, UNAIDS and UNICEF policy guideline on breastfeeding is that all women should:

INTERNATIONAL CONFERENCE ON AIDS AND STDs IN AFRICA - 11th (ICASA-99):
12 to 16 September, 1999.

SECOND ANNOUNCEMENT AND CALL FOR ABSTRACTS

 LOCATION:
Mulungushi International conference Centre, Great East Road, Lusaka

THEME
LOOKING INTO THE FUTURE SETTING PRIORITIES FOR HIV/AIDS IN AFRICA

The Scientific Programme

IMPORTANT DEADLINES

NO ON-SITE REGISTRATION
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Contact thef the XI-ICASA Organising Secretariat
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Last updated September 26, 1999