Oral hygiene status, oral hygiene practices and periodontal health of brick kiln workers of Odisha.

AIM AND
OBJECTIVE: The aim of this study was to assess the oral hygiene status, oral hygiene practices, and periodontal health among brick kiln workers of Odisha.
MATERIALS AND METHODS: Four hundred and eight subjects (300 males and 108 females) between the ages of 22 and 65 years with mean age of 33.44 ± 2.34 years working in various brick kilns in the district of Khordha, Odisha, participated in the survey. Data were collected through personal interview and clinical examinations.
RESULTS: Overall prevalence of periodontal diseases among brick kiln workers was 86.27%. There was a statistically significant difference in the distribution of Community periodontal index (CPI) (P < 0.001) and loss of attachment score scores (P < 0.001). Periodontal disease was significantly associated with age, oral hygiene status, practices, and tissues abuse habits. Most of the workers were males (59%), in the age group of 30-40 years (40.69%), having only a primary level of education (75.98%) and were married (80.88%). Majority of the workers brushed their teeth once daily (78.9%) with toothbrush (51.5%) and used toothpaste (41.2%). Most of them were found to be consuming paan or gutkha as compared to cigarette or beedi smoking. Among the subjects with a CPI >2, higher prevalence of periodontal disease was seen in subjects older than 50 years of age (86.7%), those brushing once daily only (75.2%), brushing with finger (82.8%), with higher frequency and duration of consumption of tobacco and alcohol, and having a poor oral hygiene (85.5%).
CONCLUSION: The survey among brick kiln workers revealed that the oral hygiene status was poor, they had ill-informed oral hygiene practices and most of them were suffering from periodontal disease.

INTRODUCTION

Our general health is dependent upon the influences of our work environment and the way we respond to it. Infrastructural and housing demands have led to a substantial increase in the need for building materials such as bricks. Bricks being largely made in brick kilns are often seen around cities, towns, and villages. This industry has been a regular generator of employment and is associated with community-dwellers who work in these kilns for a season or so. Brick kiln industry is functional throughout the week where the workers are engaged in the laborious work round-the-clock in alternate shifts.[1] The physically tiring and tedious work often drives them into tissue abuse habits, neglect oral hygiene which may eventually lead to deterioration of their general as well as oral health.

Dental caries and periodontal disease are the most common oral ailments worldwide and its neglect can lead to loss of teeth.[2] However, data about its prevalence among specific occupational groups and such community-dwellers is relatively scarce. Although previously, oral hygiene status has been assessed in similar study populations in India such as coal-mine workers[3] and stone-mine workers,[4] until date, no literature is available worldwide and in India concerning the oral health status of brick kiln workers. Therefore, the purpose of this survey was to assess the oral hygiene status, oral hygiene practices and periodontal status of brick kiln workers of Odisha.

MATERIALS AND METHODS

A cross-sectional survey was conducted among the of brick kiln workers of Odisha from January 2016 to June 2016. Sample size estimation was done using free, web-based, open-source, operating system-independent software program (OpenEpi, version 3.01; www. OpenEpi.com) at 95% confidence interval and 5% allowable error with an expected prevalence of periodontal disease of 60 which yielded 369 subjects. The survey sample was drawn from the District of Khordha, Odisha, using a stratified random sampling design. The district was divided into East, West, North, and South zones and all the currently operating brick kilns were identified. Four brick kilns were then randomly selected from each zone. Oral health check-up programs were organized to assess the oral and periodontal health of brick kiln workers in each of the selected brick kilns. For inclusion, adult subjects working in brick kilns not <1 year and with at least 20 erupted teeth were considered eligible for the survey. Unwilling, edentulous, pregnant, lactating, and medically compromised participants were not included in the survey. The survey protocol was assessed and cleared by the Institutional Review Board and the study was conducted in accordance with the declaration of Helsinki. All subjects gave their written informed consent before participation. The data were collected through personal interview and clinical examinations at the respective locations where the subjects worked. Personal interview was done in the local language. Examination of the oral cavity was done in a comfortable well-ventilated room during the day, and whenever necessary an additional artificial light source (hand-held battery operated torch) was used. Examination was done using mouth mirrors, explorers, and Community periodontal index (CPI) probes as recommended by the World Health Organization.[5]

The demographic data collection included age, gender, level of education, and marital status. The work details included designation, income, nature of work, and working experience. The oral hygiene practices included the type of oral hygiene aid used, method of oral hygiene, and frequency of brushing per day. Tissue abuse habits included the duration and frequency of smoking, use of smokeless tobacco and alcohol consumption. Oral hygiene status was assessed using the simplified oral hygiene index (OHIS).[6] OHIS has two components, the debris index-simplified and the calculus index-simplified, both of which are calculated separately and are added to get the OHI-S score for an individual. OHI-S scores may be interpreted as; good (0–1.2), fair (1.3–3.0) and poor (3.1–6.0). Periodontal status was assessed by using the community periodontal index (CPI)[5] and was expressed in terms of CPI code and loss of attachment score (LOA). Pocket depths were measured at six sites around each specified index tooth (mesial, middle and distal on facial and lingual/palatal surfaces). The highest CPI and LOA scores for the sextants examined in a subject were taken as the respective CPI and LOA for the person. After the recording of data, all subjects were also given oral health education and those needing intervention were referred for dental treatment.

All clinical examination was performed by a single team consisting of an examiner and two recording assistants who were sufficiently trained in theory and practice before the commencement of the survey. Intra-examiner reliability for various indices was assessed using kappa statistic which was 91.4%. The collected data were analyzed using Statistical Package for Social Statistics version 20.0 (IBM SPSS Statistics 20, Chicago, Illinois, USA). Summary statistics (frequency, percentages, and cross-tabulations) were prepared. Test of significance was done with Chi-squared test. A value of P of ≤ 0.05 was considered to be statistically significant.

RESULTS

A total of 408 subjects (300 males and 108 females) between the ages of 22 and 65 years with mean age of 38.33 ± 8.37 years were assessed for their oral hygiene, oral hygiene practices, and periodontal health. Table 1 presents the distribution of the study population according to gender, age-groups, level of education, and marital status. Most of the workers were males (59%), in the age group of 30–40 years (40.69%), having only a primary level of education (75.98%) and were married (80.88%). Table 2 presents the distribution of subjects according to the designation, income, nature of work, and work experience. Most of the workers were semi-skilled (33.3%), engaged in manual work (51%), earning at least Rs. 2000 or more per week (81.4%) and had a work experience of 10–15 years (50%).

Table 1

Distribution of subjects according to age, gender, educational level, and marital status

	n (%)
Gender
Male	300 (59.31)
Female	108 (40.69)
Age group (years)
Upto 30	70 (17.16)
30-40	166 (40.69)
40-50	142 (34.80)
50 and above	30 (7.35)
Educational level
Uneducated	10 (2.45)
Primary	310 (75.98)
Secondary	88 (21.57)
Graduate	0 (0.00)
Postgraduate	0 (0.00)
Marital status
Married	330 (80.88)
Unmarried	78 (19.12)

n – Number of subjects

Table 2

Distribution of subjects according to designation, income, nature of work, and work experience

	n (%)
Designation
Supervisor	30 (7.4)
Skilled worker	118 (28.9)
Semi-skilled worker	136 (33.3)
Unskilled worker	124 (30.4)
Income (INR per week)
<2000	142 (34.8)
2000	208 (51.0)
>2000	58 (14.2)
Nature of work
Manual	332 (81.4)
Machine	76 (18.6)
Work experience (years)
1-5	26 (6.4)
5-10	76 (18.6)
10-15	204 (50.0)
>15	102 (25.0)

n – Number of subjects

Assessment of their oral hygiene practices revealed a statistically significant difference in the distribution of brushing frequency (P < 0.001), toothbrush type (P < 0.001), and dentifrice used (P < 0.001) by them [Table 3]. Majority of the workers brushed their teeth once daily (78.9%) with a toothbrush (51.5%) and used toothpaste (41.2%). Assessment of their tissue abuse habits revealed a statistically significant difference in the distribution of frequency (P < 0.001) and duration (P < 0.001) of consumption of smokeless tobacco, smoking, and alcohol use [Table 4]. Majority of the brick kiln workers were found to be using smokeless tobacco as compared to cigarette or beedi smoking. Most of them consumed pan/gutkha 6–10 packets per day (52%) for 6–10 years (44.6%). Among the smokers, most of them smoked 1–5 cigarettes/beedis per day (32.8%) for 6–10 years (28.4%). However, there were more number of brick kiln workers who did not consume alcohol (61.3%).

Table 3

Distribution of subjects according to oral hygiene practices

	n (%)	χ2	P
Brushing frequency
Once	322 (78.9)	136.52	<0.001
Twice	86 (21.1)
Thrice	0 (0.0)
Brush type
Toothbrush	210 (51.5)	64.64	<0.001
Twig/Datun	82 (20.1)
Finger	116 (28.4)
Dentifrice
Toothpowder	114 (27.9)	78.36	<0.001
Toothpaste	168 (41.2)
Coal ash	48 (11.8)
Tobacco	78 (19.1)

Chi-squared test; P<0.001 – Highly significant; P<0.01 – Very significant; P<0.05 – Significant; P>0.05 – Not significant. P – Probability value; n – Number of subjects; χ2 – Chi-square value

Table 4

Distribution of subjects according to tissue abuse habits

	n (%)	χ2	P
Smokeless tobacco frequency (per day)
None	44 (10.8)	82.47	<0.001
1-5	78 (19.1)
6-10	212 (52.0)
>10	74 (18.1)
Smokeless tobacco duration (years)
None	44 (10.8)	120.8	<0.001
1-5	58 (14.2)
6-10	182 (44.6)
>10	124 (30.4)
Smoking frequency (per day)
None	132 (32.4)	84.78	<0.001
1-5	134 (32.8)
6-10	120 (29.4)
>10	22 (5.4)
Smoking duration (years)
None	132 (32.4)	36.62	<0.001
1-5	54 (13.2)
6-10	116 (28.4)
>10	106 (26.0)
Alcohol frequency (drinks per week)
None	250 (61.3)	170.54	<0.001
1-5	122 (29.9)
6-10	36 (8.8)
Alcohol duration (years)
None	252 (61.3)	311.6	<0.001
1-5	32 (7.8)
6-10	86 (21.1)
>10	40 (9.8)

Chi-squared test; P<0.001 – Highly significant; P<0.01 – Very significant; P<0.05 – Significant; P>0.05 – Not significant. P – Probability value; n – Number of subjects; χ2 – Chi-square value

Table 5 presents the distribution of subjects according to oral hygiene status and periodontal status. There was a significant difference in the distribution of oral hygiene scores (P < 0.001) with most of the subjects having a poor oral hygiene status (81.4%) and meager 2.5% having a good oral hygiene status. The overall prevalence of periodontal diseases among brick kiln workers was 86.27%. There was a statistically significant difference in the distribution of CPI (P < 0.001) and LOA scores (P < 0.001). Most of the subjects had a CPI score of 4 (61.27%) and LOA score of 3 (45.59%). Table 6 presents the distribution of subjects affected by the periodontal status of CPI >2 according to age, gender, oral hygiene practices, tissue abuse habits, and oral hygiene status. There was no statistically significant difference in the prevalence of periodontal disease between the males and females. However, there was a statistically significant difference in the prevalence of periodontal disease among the workers according to age group (P < 0.001), brushing frequency (P < 0.006), toothbrush type (P < 0.015), and dentifrice and oral hygiene (P < 0.001). Among the subjects with a CPI > 2, higher prevalence of periodontal disease was seen in subjects older than 50 years of age (86.7%), those brushing once daily only (75.2%), brushing with a finger (82.8%), using coal ash as a dentifrice (100%). The prevalence of periodontal disease was also higher in subjects who had a higher frequency and duration of consumption of tobacco and alcohol and had poor oral hygiene (85.5%).

Table 5

Distribution of subjects according to oral hygiene status and periodontal status

	n (%)
Oral hygiene status
Good	10 (2.5)
Fair	66 (16.2)
Poor	332 (81.4)
χ2; P	435.24; <0.001
Periodontal status
CPI score
Healthy	18 (4.41)
Bleeding observed by probing	38 (9.31)
Calculus detected by probing and black band visible	64 (15.69)
Pocket 4-5 mm with black band visible	38 (9.31)
Pocket 6 mm or more and black band is not Visible	250 (61.27)
χ2; P	447.5; <0.001
LOA score
0-3 mm	32 (7.84)
4-5 mm	94 (23.04)
6-8 mm	84 (20.59)
9-11 mm	186 (45.59)
12 mm or more	12 (2.94)
χ2; P	225.04; <0.001

n – Number of subjects; χ2 – chi-square value; P – Probability value, P<0.001 – highly significant; P<0.01 – very significant; P<0.05 – significant; P>0.05 – not significant; CPI – Community periodontal index; LOA – Loss of attachment

Table 6

Distribution of subjects affected by the periodontal status of community periodontal index>2 according to age, gender, oral hygiene practices, tissue abuse habits, and oral hygiene status

	Total	Number of affected (%)	χ2	P
Age group (years)
Upto 30	70	40 (57.1)	21.88	0.01
30-40	166	106 (63.9)
40-50	142	116 (81.7)
50 and above	30	26 (86.7)
Gender
Male	242	168 (69.4)	0.4	0.66
Female	166	120 (72.3)
Brushing frequency
Once	322	242 (75.2)	15.34	0.006
Twice	86	46 (53.5)
Brush type
Toothbrush	210	130 (61.9)	16.9	0.015
Twig/Datun	82	62 (75.6)
Finger	116	96 (82.8)
Dentifrice
Toothpowder	114	80 (70.2)	26.16	0.004
Toothpaste	168	104 (61.9)
Coal ash	48	48 (100.0)
Tobacco	78	56 (71.8)
Smokeless tobacco frequency (per day)
None	44	0 (0.0)	199.84	<0.001
1-5	78	30 (38.5)
6-10	212	186 (87.7)
>10	74	72 (97.3)
Smokeless tobacco duration (years)
None	44	0 (0.0)	141.56	<0.001
1-5	58	30 (51.7)
6-10	182	150 (82.4)
>10	124	108 (87.1)
Smoking frequency (per day)
None	132	64 (48.5)	82.2	<0.001
1-5	134	86 (64.2)
6-10	120	116 (96.7)
>10	22	22 (100.0)
Smoking duration (per day)
None	132	64 (48.5)	118.9	<0.001
1-5	54	18 (33.3)
6-10	116	106 (91.4)
>10	106	100 (94.3)
Alcohol frequency (drinks per week)
None	250	146 (58.4)	48.5	<0.001
1-5	122	106 (86.9)
6-10	36	36 (100.0)
>10	0	0 (0.0)
Alcohol duration (years)
None	250	146 (58.4)	50.6	0.001
1-5	32	24 (75.0)
6-10	86	78 (90.7)
>10	40	40 (100.0)
OHIS
Good	10	0 (0.0)	192.12	0.001
Fair	66	4 (6.1)
Poor	332	142 (85.5)

χ2 – Chi-square value; P – Probability value, P<0.001 – Highly significant; P<0.01 – Very significant; P<0.05 – Significant; P>0.05 – Not significant; OHIS - Simplified oral hygiene index

DISCUSSION

The current epidemiological survey was conducted to assess the oral hygiene status, oral hygiene practices, and periodontal health of brick kiln workers of Odisha. The intention of the survey was to gather information about the community-dwelling workers of brick kiln workers who share common habitats, living conditions, and working environment. The collected data will aid in the planning and implementation of prevention and oral health promotion programs among community-dwelling workers such as that of the brick kiln industry. To the best of our knowledge, this is the first time such a survey has been conducted.

The periodontal status of the brick kiln workers was assessed using the CPI codes and measurement of LOA scores which have been widely used in periodontal health surveys.[78910] Overall, about 92.16% of the workers in the surveyed sample were suffering from one or the other form of periodontal disease. Such high prevalence may be due to first, lack of dental health awareness and access to facilities,[7] poor education level among majority of workers, exposure to smoking, paan, gutkha, etc., and use of native oral hygiene practices prevalent in community-dwellers.[11]

The percentage of subjects suffering from periodontal disease increased with advancing age. While the subjects in the 30–40 years age group showed a prevalence of 63.9%, the highest prevalence rate of 86.7% was seen in subjects older than 50 years of age. This was in accordance with the fact that chronic periodontitis is cumulative in nature and tends to be seen more in older individuals.[12] However, this is in contrast to the highest reported prevalence rate of 89.2% for 35–44 years age group in a national survey.[13] Similarly, a multi-centric national survey in Odisha revealed that the highest reported prevalence was seen in 65–74 years age group and was found to be 90%.[14]

Female brick kiln workers had a higher prevalence of periodontal disease (72.3%) than male workers (69.4%). However, the difference was not statistically significant. Other studies[1516] on gender differences reported significantly higher prevalence of periodontal disease in males as compared to females.

The fact that those brushing once daily only and brushing with the finger also were found to be affected in larger number was an expected observation. However, a significantly greater number of subjects were found to use toothbrush in comparison to the prevalent practice of datun and finger. This can be attributed to the wider and easy availability of toothbrushes and dentifrices. However, the use of datun and finger for brushing and coal ash as dentifrice still existed as reported in previous studies.[4] Further, use of coal ash was also significantly associated with periodontal disease. It is a prevalent practice among the rural dwellers in India to use ash powder as a dentifrice. Most of the brick kiln workers were migrant laborers from nearby rural areas.

There was a greater prevalence of use of smokeless tobacco such as paan and gutkha among the brick kiln workers as compared to smoking. This is in accordance with the fact that smokeless tobacco is the major form of tobacco which is used in this region of the country.[17] Furthermore, use of paan and gutkha has been reported to be associated with the periodontal disease as seen in the brick kiln workers.[1819] Tobacco smoking is one of the risk factors for periodontal disease and has a substantial bearing on the initiation, progress and treatment results of periodontal disease.[20] Widespread tobacco smoking has been reported in previous surveys in India.[112122] Our survey revealed that 67.6% of the brick kiln workers were smokers and out of them 96.7% of those who smoked 6–10 cigarettes/beedis per day had periodontal disease.

The current survey examines the oral hygiene status and periodontal health of the brick kiln workers of Odisha. The burden of oral illness of this community has never been reported until now. It being a cross-sectional research, has its limitations because it gathers information about the exposure and the outcome simultaneously. Therefore, there is difficulty in establishing a temporal relation between them. This can be applied to the results of our study and thus longitudinal studies may be planned in future. However, brick kilns across the world are undergoing modernization from burnt mud-bricks to fly-ash based bricks and do not require community-dwellers as seen in our survey population.

CONCLUSION

Within the limitations of this survey, we may conclude that brick kiln workers of Odisha have poor oral hygiene status, they are engaged in ill-informed oral hygiene practices and majority of them were suffering from periodontal disease. Oral health awareness programs must be extended to these community-based worker groups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.