Oral health is understood as “a dentition that is comfortable, functional, and with such an appearance that allows the people to perform their social functions and daily activities without physical, psychological or social inconveniences.”1
India, a developing country faces many challenges in delivering oral health care needs. Dental caries being the most common chronic childhood disease worldwide.2 It is more prevalent as high as 60-80% in the younger age group which anticipates the oral health problems in future in India.3 It causes pain and discomfort also causes financial stress on parents.4 There are a number of factors that influence the incidence of Dental caries. They include socio demographic factors such as age, sex, race, ethnicity, socioeconomic status (SES) and presence of other oral habits.5 There are three measures in SES that predicts the poor health conditions ie, education, occupation and income or a combination of other factors.6 There is a huge difference that exist in oral health as well as the general health between urban and rural population in India.7 It shows a increase in prevalence of the oral diseases due to migration of the people from rural areas and urbanization causing changes in the lifestyle and diet patterns.8 There is always inequalities present in general as well as the oral heath. According to theories, these inequalities arise because of unfavorable situations; health influencing behaviors and other psychosocial factors.9 Dental disease often deprives people from their normal activities particularly those from low-income families 7 because majority of the people are unaware that good oral health is necessary for the overall health development and improvement in the quality of life as well.3 In India, about 70% of the total population reside in rural areas where there is lack of infrastructure, resources and dentists, ratio being 1:250,000 making dental caries an important public health problem. 10,11
ORAL HEALTHCARE SYSTEM IN INDIA
Mainly the following establishments deliver oral health care in India:
• Government organizations
o Government Dental Colleges
o Government Medical Colleges and Dental Wing
o District Hospitals with Dental Unit
o Community Health Centers
o Primary Health Centers.
• Non-governmental organizations
o Private Dental Colleges
o Private Medical Colleges with Dental Wing
o Corporate Hospitals with Dental Units.
• Private practitioners
o Private dental practitioners
o Private dental hospitals
o Private medical hospitals with dental units.
• Indigenous systems
o Ayurveda
o Sidda
o Unani
o Homeopathy.
The private dental practitioners, followed by non-governmental organizations, are providing majority of dental services in India.7
SOCIOECONOMIC STATUS OF INDIA
Total population of India-1,266,883,593 (July 2016)
Literacy rate-71.2%
Employment status-61.7%
Urban population-32.7% 12
The socioeconomic status being the most important determinant of health and other factors influences the accessibility, affordability, acceptability and the actual utilization of the available health facilities. People from low income are regarded as Below Poverty Line (BPL) families. Government has introduced subsidies scheme to benefit such families. So there is a need to identify such families and make them utilize the advantages. There are many scales available to measure the SES of a family, which in turn gives the SES of the nation.7
1) Kuppuswamy’s socio economic status scale (revision for 2015)
Measures the SES of an individual based on the following factors:
• Education
• Occupation of the head of the family
• Income of the family
2) Udai pareek’s socio economic status scale (revised)
Measures the SES of an individual based on the following 9 factors for rural
and mixed population only:
• Caste
• Occupation
• Education
• Social participation
• Land
• House
• Farm powers
• Material possession and
• Family.
3) B.G.Prasad’s socio economic status scale (revision for 2015)
Based on per capita monthly income and is classified into 5 groups. (I, II, III, IV, V)
Per capita monthly income = total monthly income of the family/total members of family.13
DOCUMENTATIONS FOR THE DIFFERENTIAL DENTAL CARIES EXPERIENCE
CASE-1
Prevalence of dental caries and its association with parents’ education level and their occupation
A multistage sampling procedure was conducted in school children of Udaipur district to obtain a sample size of 875 first standard children selected from 16 primary schools. Among them 461 and 412 belonged to urban and rural areas respectively. Kuppuswamy’s social status scale was used to classify the socio economic status of the parents to assess the relationship with dental caries. The mean caries experience was found to be 58.9% (515).
Statistical analysis reveals that there are significant changes in caries experience in relation socio economic status. 2
Table 1 demonstrates the caries experience of the children based on their location of residence
Dmft location gender
urban rural boys girls Total
Prevalence† % (n)
56.8 61.1 62.2 55.1 58.9
dt Mean (SD)
1.49 1.69 1.66 1.50 1.59
mt Mean (SD)
0.08 0.10 0.09 0.09 0.09
ft Mean (SD)
0.02 0.00 0.01 0.01 0.01
dmft Mean (SD)
1.60 1.79 1.77 1.60 1.69
Table 2 demonstrates the caries experience of the children according to their parents occupation
dmft professional Semi-professional Clerical, farmer, shop owner skilled Semi skilled unskilled unemployed
Fathers occupation n=4 n=10 n=350 n=154 n=118 n=224 n=0
d Mean (SD) 1.0 1.47 1.74 2.30 1.62 1.42 –
m Mean (SD) 0.00 0.09 0.07 0.20 0.15 0.09 –
f Mean (SD) 0.25 0.01 0.01 0.00 0.03 0.00 –
Dmft mean (SD) 1.25 1.56 1.83 2.50 1.80 1.51 –
Mothers occupation n=0 n=19 n=54 n=10 n=6 n=45 n=726
d mean (SD) – 0.80 1.74 2.00 2.00 1.60 1.56
m mean (SD) – 0.00 0.05 0.15 0.33 0.11 0.09
f mean – 0.20 0.00 0.00 0.00 0.00 0.01
Dmft mean (SD) – 1.00 1.79 2.15 2.23 1.71 1.66
Table 3 demonstrates the caries experience of the children according to parents’ level of education
dmft Professional or honors Graduate or PG Intermediate or post high school diploma High school certificate Middle school certificate Primary school certificate illiterate
Fathers education N=2 N=86 N=59 N=50 N=28 N=13 N=167
d mean (SD) 1.00 1.51 1.78 1.72 2.07 2.77 1.59
m mean (SD) 0.00 0.12 0.00 0.14 0.25 0.15 0.12
f mean (SD) 0.25 0.12 0.00 0.02 0.00 0.00 0.00
dmft mean (SD) 1.25 1.75 1.78 1.88 1.88 2.92 1.71
Mothers education N=0 N=75 N=28 N=62 N=22 N=11 N=185
d mean (SD) – 1.29 1.21 1.82 1.97 2.64 1.65
m mean (SD) – 0.14 0.11 0.14 0.00 0.18 0.12
f mean (SD) – 0.07 0.02 0.00 0.08 0.00 0.00
dmft mean (SD) – 1.50 1.34 1.95 2.05 2.82 1.77
From the above findings it can be concluded that prevalence of caries is at a higher rate in rural areas than in urban areas. Parents occupation and level of education also influenced significantly.
CASE-2
Prevalence of dental caries in children and its association with low education level
A cross-sectional study was carried out in 27 Anganwadis of Hingna, Nagpur. The total number of subjects was 324 out of which 213 were males and 111 were females. The subjects were under 5 years of age.
Caries prevalence was found to be 63.58%. However, a strong relationship was present between the prevalence of dental caries and the parents with low education level.5
The following table shows
Dental caries Present Absent
Parents education below SSC 92 26
Parents education above SSC 114 92
SSC=School site council
A significant association was found to be present caries prevalence and parents education level.
CASE-3
Prevalence of dental caries in adolescents and its relation with their area of residence
A cross sectional study was conducted in New Delhi with a study population of 1386 aged 12-16 years. Among them, 460 belonged to middle and upper middle class group, 464 from resettlement communities and 463 from urban slums.
The mean DMFT of the adolescents belonging to the urban slums was found to be 1.74, which is significantly higher than that of the other areas of residence. Likewise, the mean number of decayed teeth in adolescents was 1.58. This indicates that there is a clear social inequality present in the prevalence of caries.
The following table depicts the social inequalities in caries experience and decayed teeth:9
Variable DMFT (mean) Decayed teeth (mean)
Mean DMFT Mean number of decayed teeth
Middle/upper middle class 0.96 0.72
Resettlement communities 1.38 1.34
Urban slums 1.74 1.58
This study shows an association between caries rate and areas of residence.
CASE-4
Prevalence of early childhood caries in association with social status
A cross sectional study was conducted in Bangalore which is the third most populace city in India and the twenty eighth one in the world.
The study consisted random sample of 1500 children aged between 8-48 months, attending playschools and private hospitals. The socio economic status was based on the parents’ annual income. Based on this the children were divided into four groups.
The overall prevalence of caries was found to be 413. Children who belonged to Group I with an annual income below Rs.50, 000 (US $1000) had experienced quite higher rate of ECC. Education level of the mother influenced the outcome as well. On the other side, parents with an annual income more than
Rs.2,00,000 (US $4000) had less caries occurrence in their children. 14
The following table depicts the statistics of the same:
Income in Indian rupees (Rs) Caries affected
N (%) Total
N
Group 1 <50.0000Rs 214 (34.6%) 618
Group 2 50,000-1 lakh Rs 74 (24.2%) 306
Group 3 1 – 2 lakhs Rs 54 (35.1%) 154
Group 4 >2 lakhs Rs 71 (16.8%) 422
From the above results it can be concluded that the socioeconomic factors such as education level, occupation, income and the area of residence influence the caries prevalence.
INTERPRETATION
Dental caries is a disease with multifactorial etiology15 present in 60-80% of the children is a major public health problem in India.3 The causative factors include diet, microbial plaque, salivary activity, socioeconomic and other behavior related factors.16 However the role of sugar, bacteria and tooth susceptibility for the development of caries is known, the socioeconomic factors are considered as the major determinants of the disease. 17
Federation Dentaire Internationale has classified the obstacles to seek dental services as follows
a. Individuals themselves (lack of perceived need and access, anxiety or fear and financial considerations),
b. Dental profession (inappropriate manpower resources, uneven geographical distribution, training inappropriate to changing needs and demands and insufficient sensitivity to patient’s attitudes and needs), and
c. Society (insufficient public support of attitudes conducive to health, inadequate oral health care facilities, inadequate oral health manpower planning and insufficient support for research)18
Socioeconomic factors of the subjects include education status, occupation, income and the demography. There is an inverse relationship that exists between the caries prevalence and SES19 as it may have an impact on the knowledge and perspective of parents. People from low social status often suffer from financial instability.6 Parents with low educational level had a higher risk for caries development in their children as they themselves lack good oral hygiene practices and tend to neglect dental health leading to the development of caries at an younger age.5 Since mothers are the primary care givers to the children it usually becomes important to educate them regarding the oral health care.14 Perhaps economic status plays an important role in the child’s development as it undeviatingly influences the condition of life.
The next predictor of caries occurrence is the area of residence. Caries experience is relatively low in urban areas when compared to the rural places. Varenee, et al., suggested that urban centers facilitate access to toothbrushes and toothpaste and the use of these hygiene measures are considered a sign of modern life style.2 As rural areas lack basic infrastructures such as public water supply it is almost impossible to fluoridate drinking water and hence caries becomes a major public health problem.10
Approximately 25,000 graduates pass out every year from 289 dental colleges in India 7 and most of them are located in the urban centers.1 Though there is an adequate supply of manpower most of the people are not accessible yet because of the unequal distribution of the manpower between urban and rural communities. In urban areas, the ratio of the dentists to population is 1:10,000 whereas it vigorously falls to 1:150,000 in rural areas. And in the areas with resources there is limited utilization due to differences in the economic classes.7
A significant correlation present with SES and the caries can be measured in terms of income as well. A remarkable association was found to be present from the above observations. People who belong to the lower economic class often compromise with their dental health and do not visit a dentist until the caries has progressed into an abscess. They possess poor eating habits14 leading to malnutrition. The upper SES class individuals utilize the dental services more regularly, which improvises their understanding of the causes and the prevention of dental diseases and apply the same in their routine. The difference in the visits to the dentist explains the knowledge in regard to the dental diseases between upper and the lower class. Lower SES individuals are unable to afford oral hygiene aids (ex.toothpaste and toothbrush) and replace them with inexpensive ones.20
Ultimately all these above-mentioned factors results in a greater frequency and severity of dental caries.21