Assessment of Periodontal Disease Among the Dental Prosthetic and Nonprosthetic Wearers in an Adult Rural Population in Mangalore Taluk, South India.

BACKGROUND: Oral health as an integral part of general health. Rural population neglect oral health as they lack awareness on oral diseases and also due to inadequate availability of dental services. There is a very high prevalence of chronic inflammatory periodontal disease in the rural Indian population, which is left untreated. Hence, this cross-sectional survey was taken up in the rural area of Mangalore taluk, Karnataka, India.
MATERIALS AND METHODS: A cross-sectional survey was carried out on 1312 participants aged 18 years and older. The prevalence of periodontal disease among the dental prosthetic and nonprosthetic wearers was assessed. The World Health Organization format was used to record the periodontal status and loss of attachment. Data collected were analyzed using chi-square test. P < 0.05 was considered as significant. RESULT: Of the 1312 included subjects, 520 were males (39.6%) and 792 were females (60.3%). Periodontal status showed that calculus was found to be high among all age groups. When the prevalence of periodontal disease was assessed among the prosthetic wearers, it was found that subjects wearing removable partial denture showed increased prevalence of periodontal pocket depth and attachment loss irrespective of age group, gender, and educational qualification.
CONCLUSION: Lack of awareness among the individuals regarding periodontal diseases has been associated with consistently higher prevalence of periodontal diseases and treatment needs. Demographical studies need to be carried out at regular intervals, thus helping in planning the treatment needs nationwide for better oral health care in rural population.

INTRODUCTION

Dental diseases are a significant public health problem in India as well as across the globe. World health Organization (WHO) recognizes the oral health as an integral part of general health.[1] An individual’s overall health and well-being is hampered by the consequences of widespread poor oral health such as caries and periodontal disease.[2] Generally, people in rural areas neglect oral health as they lack awareness on oral diseases and also due to inadequate availability of dental services and percentage of illiteracy prevalent in the Indian population.[3]

Periodontitis is a destructive inflammatory disease of the supporting tissues of the teeth and is caused either by group of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone resulting in periodontal pocket formation and/or gingival recession.[4] There is a very high prevalence of chronic inflammatory periodontal disease in the rural Indian population, which is left untreated and it is due to the lack of a structured oral health care system.[35]

Thus poor oral health in rural Indian population can be attributed to various factors and the most important are inadequate facilities of oral health care, oral health education, and awareness of oral hygiene practices that are not being up to the mark. Consumption of alcohol and tobacco is also responsible for poor oral health.[6]

Hence, this cross-sectional survey was taken up in the rural areas of Mangalore taluk, Karnataka, India, among 1312 individuals. Periodontal status among denture and nondenture wearers was assessed along with their demographic profile.

MATERIALS AND METHODS

A cross-sectional survey was carried out on 1312 participants aged 18 years and older. Sixteen gram panchayats were selected by simple random sampling and a house-to-house survey was conducted to determine the prevalence of periodontal disease among dental prosthetic and nonprosthetic wearers in the rural population of Mangalore taluk, Karnataka State, India. The survey pro forma was designed to collect information regarding the demographic profile, educational status, and occupation. The WHO format was used to record the periodontal status and loss of attachment. Data collected were analyzed using chi-square test. P < 0.05 was considered as significant.

RESULTS

Of the 1312 included subjects, 520 were males (39.6%) and 792 were females (60.3%). The subjects were divided into four age groups: 10.82% of 18–30 years (142), 37.42% of 31–45 years (491), 24% of 46–60 years (315), and 27.74% of >61 years (364). On the basis of the education, 9.60% of the subjects were illiterate, with maximum (27.89%) subjects had primary education.

Periodontal status showed that calculus was found to be high among all age groups. Whereas pocket depth was found higher in the age group of 46–60 years (P = <0.001) [Table 1]. According to gender, bleeding and calculus scores were more among females and pocket depth was higher in males [Table 2]. Results showed that calculus score was more among all age groups except for postgraduates, whereas bleeding score was found to be higher in postgraduates. Pocket depth was higher among illiterate subjects [Table 3].

Table 1

Distribution of study subjects according to age group and periodontal index

Highest score CPI	Age group				Total
	18–30	31–45	46–60	>61
Healthy	87 (61.3%)	202 (41.1%)	139 (44.1%)	250 (68.7%)	678 (51.7%)
Bleeding	13 (9.2%)	83 (16.9%)	35 (11.1%)	32 (8.8%)	163 (12.4%)
Calculus	34 (23.9%)	156 (31.8%)	97 (30.8%)	51 (14.0%)	338 (25.8%)
Pocket 4–5 mm	6 (4.2%)	26 (5.3%)	22 (7.0%)	20 (5.5%)	74 (5.6%)
Pocket 6 mm	2 (1.4%)	24 (4.9%)	22 (7.0%)	11 (3.0%)	59 (4.5%)
Total	142 (100.0%)	491 (100.0%)	315 (100.0%)	364 (100.0%)	1312 (100.0%)

Calculus was found to be high among all the age groups. Pocket was high among subjects aged 46–60 years CPI = community periodontal index

χ2 = 90.951

P = <0.001

Table 2

Distribution of study subjects according to gender and periodontal index

Highest score CPI	Gender		Total
	Male	Female
Healthy	284 (54.6%)	394 (49.7%)	678 (51.7%)
Bleeding	62 (11.9%)	101 (12.7%)	163 (12.4%)
Calculus	118 (22.7%)	220 (27.7%)	338 (25.8%)
Pocket 4–5 mm	30 (5.8%)	44 (5.5%)	74 (5.6%)
Pocket 6 mm	26 (5%)	33 (4.4%)	59 (4.5%)
Total	520 (100.0%)	792 (100.0%)	1312 (100.0%)

Bleeding and Calculus was more among females. Pocket was high among males.

CPI = community periodontal index

χ2 = 5.27

P = 0.260

Table 3

Distribution of study subjects according to education and periodontal index

Highest score CPI	Education						Total
	Illiterate	Primary	Secondary	PUC	Graduate	Postgraduate
Healthy	43 (34.1%)	152 (41.5%)	193 (62.5%)	147 (55.3%)	100 (56.2%)	43 (64.2%)	678 (51.7%)
Bleeding	12 (9.5%)	40 (10.9%)	29 (9.4%)	42 (15.8%)	28 (15.7%)	12 (17.9%)	163 (12.4%)
Calculus	42 (33.3%)	121 (33.1%)	71 (23.0%)	59 (22.2%)	36 (20.2%)	9 (13.4%)	338 (25.8%)
Pocket 4–5 mm	15 (11.9%)	26 (7.1%)	8 (2.6%)	10 (3.8%)	12 (6.7%)	3 (4.5%)	74 (5.6%)
Pocket 6 mm	14 (11.1%)	27 (7.4%)	8 (2.6%)	8 (3.0%)	2 (1.1%)	0 (0.0%)	59 (4.5%)
Total	126 (100%)	366 (100%)	309 (100%)	266 (100%)	178 (100%)	67 (100%)	1312 (100.0%)

Except for postgraduates, calculus was high among all age groups. Bleeding is more among postgraduates. Pocket was more among illiterates

CPI = community periodontal index

χ2 = 101.069

P < 0.001

Highest score of loss of attachment was found in the age group of 46–60 years (>12 mm)[Table 4]. Prevalence of loss of attachment was higher among females than males [Table 5]. It was also evident that the loss of attachment was higher among illiterate subjects. As the education level increased, the severity of loss of attachment was reduced [Table 6].

Table 4

Distribution of study subjects according to age group and loss of attachment

Highest score LOA	Age group				Total
	18–30	31–45	46–60	>61
0–3 mm	135 (95.1%)	442 (90.0%)	270 (85.7%)	322 (88.5%)	1169 (89.1%)
4–5 mm	7 (4.9%)	32 (6.5%)	29 (9.2%)	18 (4.9%)	86 (6.6%)
6–8 mm	0 (0.0%)	15 (3.1%)	13 (4.1%)	20 (5.5%)	48 (3.7%)
9–11 mm	0 (0.0%)	2 (0.4%)	1 (0.3%)	4 (1.1%)	7 (0.5%)
>12 mm	0 (0.0%)	0 (0.0%)	2 (0.6%)	0 (0.0%)	2 (0.2%)
Total	142 (100.0%)	491 (100.0%)	315 (100.0%)	364 (100.0%)	1312 (100.0%)

Loss of attachment was found to be highest among subjects in the age group 46–60 years

χ2 = 25.345

P = <0.013

Table 5

Distribution of study subjects according to gender and loss of attachment

Highest score LOA	Gender		Total
	Male	Female
0–3 mm	461 (88.8%)	708 (89.3%)	1169 (89.1%)
4–5 mm	39 (7.4%)	47 (5.9%)	86 (6.6%)
6–8 mm	19 (3.5%)	29 (3.7%)	48 (3.7%)
9–11 mm	1 (0.2%)	6 (0.8%)	7 (0.5%)
>12 mm	0 (0.0%)	2 (0.3%)	2 (0.2%)
Total	520 (100.0%)	792 (100.0%)	1312 (100.0%)

Prevalence of loss of attachment was higher among females

χ2 = 4.39

P = 0.356

Table 6

Distribution of study subjects according to education and loss of attachment

Highest score LOA	Education						Total
	Illiterate	Primary	Secondary	PUC	Graduate	Postgraduate
0–3 mm	87 (69.0%)	310 (84.7%)	287 (92.9%)	251 (94.4%)	169 (94.9%)	65 (97.0%)	1169 (89.1%)
4–5 mm	23 (18.3%)	36 (9.8%)	12 (3.9%)	7 (2.6%)	6 (3.4%)	2 (3.0%)	86 (6.6%)
6–8 mm	13 (10.3%)	16 (4.4%)	9 (2.9%)	7 (2.6%)	3 (1.7%)	0 (0.0%)	48 (3.7%)
9–11 mm	2 (1.6%)	4 (1.1%)	0 (0.0%)	1 (0.4%)	0 (0.0%)	0 (0.0%)	7 (0.5%)
>12 mm	1 (0.8%)	0 (0.0%)	1 (0.3%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	2 (0.2%)
Total	126 (100%)	366 (100%)	309 (100%)	266 (100%)	178 (100%)	67 (100%)	1312 (100.0%)

Loss of attachment was high among illiterates. Level of education was significantly associated with the LOA scores. As the educational levels increases, the severity of LOA reduced

χ2 = 89.483

P < 0.001

When the prevalence of periodontal disease was assessed among the prosthetic wearers, it was found that subjects wearing removable partial denture (RPD) showed increased prevalence of periodontal pocket depth and attachment loss irrespective of age group, gender, and educational qualification [Tables 7-9].

Table 7

Distribution of study subjects according to highest periodontal score (greater than 6 mm pockets) among prosthetic wearers in relation to age group

	Age group
	18–30		31–45		46–60		>61
	Yes	No	Yes	No	Yes	No	Yes	No
Prosthetic wearers
RPD	2 (100%)	14 (10%)	6 (25%)	148 (33.5%)	4 (18%)	69 (28.5%)	1 (10%)	53 (33.1%)
Fixed	0 (0.0%)	20 (14.1%)	1 (4.1%)	36 (8.1%)	0 (0.0%)	13 (5.3%)	0 (0.0%)	9 (5.6%)
Combination	0 (0.0%)	3 (2.1%)	1 (4.1%)	13 (3.2%)	0 (0.0%)	6 (2.4%)	0 (0.0%)	7 (4.3%)

Periodontal disease (pockets) was high among RPD wearers in all the age groups

χ2 = 36.1

P < 0.001

Table 9

Distribution of study subjects according to prevalence of periodontal disease among denture wearers and education level (greater than 6 mm pockets)

Periodontal disease	Education
	Illiterate		Primary		Secondary		PUC		Graduate		Postgraduate
	Yes	No	Yes	No	Yes	No	Yes	No	Yes	No	Yes	No
Prosthetic wearers
RPD	2 (14%)	8 (9%)	3 (11%)	47 (15%)	1 (12%)	40 (18.7%)	5 (63%)	89 (46.7%)	2 (100%)	71 (49%)	0 (0.0%)	29 (50%)
Fixed	0 (0.0%)	3 (3%)	1 (4%)	14 (4%)	0 (0.0%)	21 (10%)	0 (0.0%)	16 (8.3%	0 (0.0%	22 (15%)	0 (0.0%)	3 (5%)
Combination	0 (0.0%)	0 (0.0%)	0 (0.0%)	9 (10%)	0 (0.0%)	5 (2.3%)	1 (12%)	6 (3%)	0 (0.0%)	6 (4%)	0 (0.0%)	3 (5%)

Periodontal disease was high among RPD wearers at all levels of education qualification

χ2 = 4.42

P = 0.817

DISCUSSION

In this study, pocket was high among subjects aged 46–60 years (P < 0.001). Bleeding and calculus were more among females. Pocket was high among males (P = 0.260). When incidence of periodontal disease and education was evaluated, except for postgraduates calculus was high among others. Bleeding was more among postgraduates. Pocket was more among illiterates (P < 0.001). The results denote that awareness toward oral hygiene would have resulted in lower level of calculus in postgraduates. Tobacco use and brushing habits would have resulted in pockets in men. Loss of attachment was found to be highest among subjects in the age group 46–60 years (P < 0.013). As age progresses, the general health condition of the patient deteriorates thus reducing patient’s personal adaptability toward oral self-care. It was higher among females (P = 0.356). Level of education was significantly associated with the loss of attachment scores. Loss of attachment was high among illiterates (P < 0.001). As the educational levels increase, the severity of loss of attachment reduced.

When evaluating the periodontal disease among the different dental prosthesis worn, it was found that periodontal disease (pockets) was high among RPD wearers in all the age groups, genders, and education qualification compared to fixed partial denture (FPD) wearers. The clasps and the gingival coverage of the RPD can favor attachment of deposits on the teeth around the prosthesis, thus resulting in higher incidence of periodontal disease in RPD wearers than FPD wearers.

The removable prosthesis usually retains food debris and makes oral hygiene maintenance difficult, leading to formation of plaque and calculus or even pockets in worse conditions. Other factors such as their frequent visits to the dentist, getting proper oral hygiene instructions from the dentist, frequent oral prophylaxis, and frequent follow-ups also play an important role. Drake and Beck,[7] Yusof and Isa,[8] Kern and Wagner,[9] Qudah and Najwa,[10] Moimaz et al.,[11] Mishra et al.,[12] Al-Sheikh et al.,[13] and Linda et al.[14] assessed the periodontal condition among RPD wearers and found that partial dentures with problems, when oral hygiene was less than adequate, patients suffering from diabetes, lack of professional maintenance, and the low rate of follow-up showed worse periodontal conditions. In the studies by Bergman et al.,[15] Chandler and Brudvik,[16] and Isidor and Budtz-Jorgensen,[17] before the prosthetic treatment all patients were given oral hygiene motivation and instruction as well as periodontal therapy where indicated. Study participants were given carefully planned and designed RPD; mild changes were found, but without periodontal damage. It was difficult to compare the findings with the authors who concluded that only minor changes in periodontal status were recorded in the patients treated with FPD or RPDs, because these authors have checked the periodontal condition before placing the dentures and they have also given oral hygiene instructions during recall visits. In this study, the periodontal condition before inserting the denture was not assessed.

In this study, the periodontal disease was assessed according to the age, gender, and education. No studies evaluated these profiles.

CONCLUSION

Lack of awareness among the individuals regarding periodontal diseases has been associated with consistently higher prevalence of periodontal diseases and treatment needs. Improved oral hygiene habits and creating awareness for the cessation of habits such as smoking and alcohol consumption have a significant improvement in the periodontal health and reduction in severity of periodontal health. At the same time, demographical studies are to be carried out at regular intervals, which will help to provide a clear data about the existing periodontal status among the population, thus helping in planning the treatment needs nationwide for better oral health care in rural population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 8

Distribution of study subjects according to prevalence of periodontal disease among prosthetic wearers and gender (greater than 6 mm pockets)

	Gender
	Male		Female
	Yes	No	Yes	No
Prosthetic wearers
RPD	6 (23%)	122 (32%)	7 (21.2%)	162 (27.1%)
Fixed	0 (0.0%)	40 (10.3%)	1 (3%)	39 (6.5%)
Combination	1 (4%)	8 (2.1%)	0 (0.0%)	21 (3.5%)

Men and women wearing RPD showed greater incidence of periodontal disease

χ2 = 16.6

P = 0.05