Dental health status and treatment needs of police personnel of a north Indian state: a cross-sectional study.

BACKGROUND: Oral health is an integral part of general health. Police personnel form the backbone for safety and security of a community hence their health is of utmost importance. AIM: The present study was conducted to assess the oral health status and treatment needs of police personnel employed in police stations of three districts within 35 km radius around Maharishi Markandeshwar University, Mullana. SUBJECTS AND METHODS: A cross-sectional study was conducted on all the available police personnel at various police stations. Final sample size comprised of 652 subjects. The data were recorded on modified World Health Organization format (1997).
RESULTS: The mean age of subjects was 41.02 years (standard deviation = 12.29), 98.9% (645/652) were males and 1.1% (7/652) were females. The prevalence of dental caries was 54.3% (352/652) and the mean decayed, missing and filled teeth was 3.05. Mean number of teeth requiring filling and extraction were 0.44 and 0.67 respectively. Only 2.92% (19/652) of subjects possessed prosthesis in mandibular arch and a same number of individuals possessed prosthesis in maxillary arch. Regarding highest community periodontal index (CPI) score, 23.6% (153/652) subjects had a healthy periodontium whereas maximum subjects (61.3%, 398/652) had a CPI score 2.
CONCLUSION: Prevalence of dental caries was quite high. Despite a high prosthetic need, only a small number of subjects possessed dental prosthesis. Overall periodontal status was satisfactory with a high number of subjects having completely healthy periodontium.

Introduction

Health continues to be a neglected entity despite continuous efforts for health promotion, world-wide. Health is often taken for granted and its value is not fully understood, until it is lost.[1] The state of Haryana State has nearly 2% of the India's population but just 1.4% of the total geographical area. There is a dearth of published information about the oral health status of the population of Haryana, especially adult population. The prevalence of dental caries in adult population of Haryana belonging to age group of 35-44 years is 77.2% and 88.9% of the adult population is affected by periodontal disease, which was calculated using community periodontal index of treatment needs (CPITN).[2] Ambala is one of the major districts of Haryana. According to a study report, the prosthetic needs of rural population of Ambala is 35.2% and 45.3% in maxillary and mandibular arch respectively while the prevalence of periodontal disease is 92.1%.[3]

The duty of police personnel of a state is to help the common man, to provide him security and to create a non-violent, peaceful and law abiding community with his co-operation.[4] Police occupies a same position in the state as that occupied by military in a nation. As state government employees, police personnel have access to free medical care at government hospitals and privileges for leave on medical grounds.[5] This demands for good general as well as oral health. However on the contrary, police personnel are a group of professionals who have all together a different working environment with 24 h duty and often being exposed to highest level of physical strain and mental stress. Due to frequent change in their day and night shifts leading to a change in their schedules of their life-styles, they often miss timely food, sleep, rest and recreation and family contacts. As a result of these, standard of living goes down which leads to various complications.[6] To maintain effective control over crime, the health of police officials is of utmost importance.

However, until date, no studies have been conducted to assess the dental health status of this vulnerable population group. In an era of evidence based medicine and oral health, scientifically testing such a fundamental concept of the prevalence of caries and periodontal disease among people engaged in specific occupations, should be given highest research priority The aim of this study was to assess the dental health status and treatment needs of police personnel employed in various police stations around our institute.

Subjects and Methods

Ethical clearance

This study was conducted after obtaining ethical clearance from the Institutional Review Board of Maharishi Markandeshwar (MM) University, Mullana with a prior permission from the Inspector General of Police, Ambala division (Haryana) and from Superintendent of Police (SP) of respective districts.

Study population

The state of Haryana is composed of four divisions and 19 districts.[7] MM University, Mullana comes under the Ambala district and occupies north-east region of the state. The area lying within 35 km radius of MM University, Mullana (which includes three districts, viz., Ambala, Yamunanagar and Kurukshetra) was taken up for this study. The study area comprised of all the police stations of three districts (Ambala, Yamuna Nagar and Kurukshetra) coming under 35 km radius of MM University. Informed consent was taken from each subject prior to recording oral health. The study was conducted from May 2008 to February 2009. The list of police stations was obtained from the respective SP offices. Marking of the various police stations was done on the Haryana map. The visit was scheduled at various police stations at Ambala, Yamuna Nagar, Kurukshetra, SP Office and Police line (sports and training area of police personnel). The study was conducted from 9 am to 4 pm; hence the subjects who were available during this time period comprised the study population and 652 subjects constituted the final sample size.

Recording and diagnosing criteria

On each visit, all the available police personnel were interviewed and a clinical examination was conducted and data regarding oral health status and treatment needs was recorded on modified World Health Organization (WHO) format [Table 1].[8] The diagnosis of oral lesions was carried out using WHO criteria[9] and Pindborg's color atlas.[10] The socio-economic status was evaluated using modified B.G. Prasad's classification.[11] Periodontal status was assessed using the CPITN procedure of the WHO.[8] It was used in this study because it has proved to be a simple and effective method for measuring and monitoring the severity of periodontal disease at the community level.[12] In addition, the International Classification of Diseases for Dentistry was also used for the same.[13]

Table 1

Variables used for collecting information from subjects

Examiner calibration

A single trained examiner, (First author-RKS) who was calibrated in the department conducted all the examinations. Intra examiner calibration was undertaken by examining 40 subjects followed by their re-examination a week later which resulted in 87% of diagnostic acceptability with a kappa value of 0.84. A well-trained assistant was also taken for recording the data. Dental examination was conducted using additional artificial light. For the diagnosis of dental caries, WHO type III examination was carried out using mouth mirrors and sharp probes.[14] Examination of the subjects was followed by provision of free dental treatment to the willing subjects at the police stations in the mobile dental van.

Statistical analysis

The data were analyzed using SPSS package version 13.0 (SPSS Inc., Chicago, IL, version 13.0 for Windows). One-way analysis of variance (ANOVA) and Z-test was used to determine differences at the 5% significance level (P < 0.05) whereas proportions were compared by the use of Chi-square test. P <0.05 was selected to denote statistical significance.

Results

The subjects’ mean age was 41 years (standard deviation [SD] = 12.3). A total of 98.9% (645/652) males and 1.1% (07/652) females were interviewed and examined. As the number of females covered was too low, no attempt was made to relate gender to any of the findings of the study. Majority of the subjects (61.5%, 398/652) belonged to lower middle class of socioeconomic status.

Maximum subjects, 58.7% (383/652), were educated until high school while only 2.1% (14/652) were post graduates. Among the self-reported systemic conditions, 9.97% (65/652) subjects reported to be suffering from hypertension and 4.45% (293/652) with diabetes mellitus. Most of the subjects, 55.7% (363/652), were vegetarian in diet. Nearly 35.7% (233/652) subjects were alcoholics and 34.2% (223/652) had a habit of using tobacco. All the subjects used to brush their teeth at least once a day.

On examination, 43.4% (283/652) subjects were found to be in normal range of body mass index (BMI) i.e. 18.5-24.99 and a same number of individuals, 43.4% (283/652) belonged to overweight category i.e. 25 to 29.99 BMI. Only 10.0% (65/652) of the subjects had normal systolic as well as diastolic blood pressure. Varicose veins were present in 1.53% (10/652) subjects. Only 0.5% (3/652) suffered from anemia.

Need for treatment

A subjective assessment of the need for dental treatment depicted that 54.14% (353/652) of the subjects were in need of one or the other dental treatment. Maximum subjects, 21.3% (139/652), had reported of decayed tooth/teeth whereas 12.4% (81/652) had reported of pain. Most of the subjects, 20.4% (133/652), had dental problem since more than 3 months. Out of the subjects having dental problem, 52.12% (184/652) reported that they could not seek treatment due to lack of time.

Distribution of oro-mucosal lesions

The prevalence of oral mucosal lesions was 6.4% (417/652) out of which leukoplakia and smoker's palate constituted 0.3% (2/652) and 4.3% (26/652) respectively. Palate and buccal mucosa were the most predominant sites for the occurrence of oral lesions. Majority of the oral mucosal lesions (33.33%, 221/652) were in the age-group of 45-54 years.

Dental caries

Mean number of teeth present per person was highest (30.16 (3.14) in the age group of 25-34 years and it showed a gradual decline with increase in age [Table 2]. Mean number of decayed and missing teeth were 1.07 (0.94) and 1.44 (1.01), respectively and their relation with age was found to be statistically significant (P < 0.01, ANOVA). Postgraduate subjects had lesser mean number of decayed (0.93, (0.56) and missing teeth (1.43,(1.17) when compared to high school subjects (1.13, (0.96) and 1.97, (1.42), respectively). Subjects in upper high socio-economic class had a higher mean number of decayed (3.00, (2.45) as well as missing teeth (due to caries 2.00, (1.86) and due to other reasons 1.33,(1.24) when compared to the subjects in poor socio-economic class (0.9 (0.87), 0.88 (0.75) and 0.12 (0.18), respectively). Mean number of teeth requiring filling and extraction were 0.44 (0.42) and 0.67 (0.68) respectively. Proportionally more elderly than younger adults needed extraction and caries was the major indication for extraction in all age groups.

Table 2

Distribution of dental caries prevalence and DMFT according to age

Prosthetic status and needs

Table 3 depicts prosthetic status and needs of subjects. The percentage of subjects having one or more missing teeth was 29.29% (191/652) but only 2.92% (19/652) of subjects possessed prosthesis in mandibular arch and a same number of individuals possessed prosthesis in maxillary arch. Prosthetic needs for mandibular arch were higher in all the age groups when compared to maxillary arch (P < 0.05, Chi-square). There was no edentulous subject found up to the age of 44 years. In the age groups 45-54 and 55-58 years the percentages of edentates were 0.15 and 0.31 respectively.

Table 3

Distribution of subjects according to prosthetic status and needs

Periodontal status

Of the 652 subjects, three subjects were excluded from the community periodontal index (CPI) computations either because of edentulousness or because extractions indicated for remaining teeth would have rendered the subjects edentulous. The percentage distribution of survey subjects according to the highest CPI score is shown in Table 4. Calculus was the most common finding which was present in 61.3 (398/652) of the study subjects.

Table 4

Distribution of subjects according to highest CPI score

Highest CPI score was non-significant in relation to socio-economic status. When education was compared with health of the supporting structures, it was found that 35.7% (5/14) of the post graduates had healthy periodontium when compared to 18% (69/383) among the high school ones (P < 0.01). Subjects with diabetes had higher maximum CPI score than subjects with any other self-reported systemic disease (P < 0.01).

Most of the subjects (95.38%, 619/652) had dental fluorosis with maximum subjects having questionable (73.60%, 475/652) and very mild (18.55%, 117/652) dental fluorosis.

Discussion

The intention of study was to provide systematic information on oral health of police personnel in a region that would aid in the planning and evaluation of oral health promotion programs. Moreover, a comparable prevalence data have not been recorded previously; hence the study was conducted to gather this data for comparing prevalence of lesions among other population of India and other countries. Rationale for this comparison was to assess the impact of differences in occupation, life-style and health care utilization on dental health. The results of the present study can be compared with military personnel and since they are exposed to the nearest equivalent working environment and the general population since data on the oral health status of police personnel is very limited.

More than half of the police personnel had “felt need” for dental treatment and lack of time due to job restrictions was cited as the major reason reported for not taking dental treatment. This is similar to study reports by Kawamura and Iwamoto.[15] Many time, the need persisted for more than 3 months. This discloses the hectic schedule of the police personnel, which acts as a barrier toward seeking healthcare.

The prevalence of oral mucosal lesions was higher than that of general population of Haryana.[2] However, some other studies reported a lesser prevalence.[161718] This may be related to the duration of tobacco use which was not recorded in the present study and hence no definite comments can be made in this regard. Findings of some other study conducted on Swiss army recruits reported a much higher prevalence of oral mucosal lesions when compared to the present study.[19]

Prevalence of dental caries was found to be quite high in the present study, which is in agreement to the results of some other studies.[20212223] A prevalence of nearing 100% with a mean decayed, missing and filled teeth (DMFT) of 19.13 was obtained by Andrew in his study among subjects enlisted in Royale Australian Air Force during second world war.[24] According to another study reports, caries prevalence of 96% was found among personnel in Malaysian Territorial Army.[25] The high prevalence of dental caries may be because police personnel have long working hours and hence more frequently involved in sugar exposures and cariogenic diets. Mean DMFT scores were significantly higher for all the age groups in a study conducted on Australian army recruits as compared to findings of the present study.[26]

Lo[27] and Ahuja[28] in their study have reported a low prosthetic need in their studies conducted among elderly in Hong Kong and army personnel in India respectively. This is contrary to the findings of the current study where subjects only a small number of subjects possessed some form of dental prosthesis despite a high prosthetic need. When more than half of the subjects in the present study had felt need for some form of dental treatment, but had not received the same, a low presence of prosthesis seems to be obvious. Number of subjects possessing prosthesis in the mandibular and maxillary arch was less in the present study when compared with the findings of some other study conducted on Japanese self-defense forces personnel.[29]

Percentage of subjects free from any signs of periodontal disease was higher as compared to some studies done elsewhere.[63031] Presence of calculus was the most common periodontal condition. Although presence of calculus was the most common finding, yet the proportion of these subjects was low compared with various studies.[2730] Lesser number of subjects had shallow pockets in the present study when compared to reports of another study conducted on Spanish military personnel.[32] Subjects with higher education had better periodontal health as compared to subjects with lower education which is similar to some other study reports.[33] This may be because all the subjects in the present study reported to be in a habit of regularly using oral hygiene maintenance aids. The state of Haryana being a high fluoride belt area, dental fluorosis was almost omnipresent.[2]

Conclusion

The sample of police personnel provides a unique opportunity to study a large population from diverse socio-economic and geographic backgrounds. It can be concluded from the present study that-

More than 50% of the subjects were in need of one or the other form of dental treatment

The prevalence of dental caries in the study population was 54.3% which is quite high

There was a high prosthetic need among the study subjects and only 2.92% of the subjects were having prosthesis

Overall periodontal health of the population was satisfactory and calculus was the most common finding which was present in 61.3% of the study population.

Recommendations

In view of the findings of the study some recommendations are put forth. The adverse outlook of this occupation makes it necessary for the government to either build health care, general and oral, clinics equipped with efficient manpower, especially for the police personnel or to regularly organize treatment camps at various police stations. Prevention oriented health education lectures should be delivered and possibly, should also from part of their training curriculum.