Prevalence of periodontitis and its correlates among tribal population of Attapady block, Palakkad District, Kerala.

BACKGROUND: Periodontal disease is an immunoinflammatory disease characterized by loss of clinical attachment with subsequent tooth loss. It includes periodontitis and gingivitis. The studies regarding the prevalence of periodontitis among the tribal populations are scarce. The periodontal health status of the tribal population of Attapady has not been reported so far.
OBJECTIVE: The present study was conducted to assess the prevalence of periodontitis and its association with oral hygiene habits, tobacco usage, and oral health beliefs among tribal population of Attapady.
MATERIALS AND METHODS: This population-based cross-sectional survey of periodontal disease consisting of 360 individuals was conducted among the tribal population of three different panchayats of Attapady. A multistage stratified random sampling was used in the selection of hamlets and cluster sampling for selection of study participants. The sociodemographic characteristics, oral hygiene habits, tobacco usage, and oral health beliefs were assessed using a questionnaire, and clinical examination was based on WHO oral health assessment form 2013.
RESULTS: The prevalence of periodontal disease among tribal population of Attapady was 87.5% (95% Confidence interval [CI] 78.48, 96.51).73.3% had gingival bleeding and 13.3% had no/mild periodontitis, The proportion of periodontitis was 84.2% (95% CI 75.5, 92.8). Among chronic perioodntitis subjects 22.8% had moderate periodontitis and 61.4% had severe periodontitis. A significant association was observed between tobacco use (Odds ratio [OR] 5.6, CI 2.99, 10.74), bad oral hygiene habits (OR 4.9, CI 2.64, 9.43), unfavorable oral health beliefs (OR 3.21, CI 1.63, 6.32), and periodontitis.
CONCLUSIONS: The prevalence of periodontal disease and periodontitis are high among tribal population of Attapady. Unfavorable oral health belief, bad oral hygiene habits, and detrimental habits like tobacco use were the modifiable risk factors identified in this group. Copyright:

INTRODUCTION

Periodontal diseases are one of the most prevalent oral disease affecting more than 50% of the Indian community.[1] There is wide variation in the periodontal status of people living in different geographic locations, which could be assigned to differences in lifestyles, oral hygiene habits, etc., In India, there are people still living in isolation in natural and unpolluted areas far away from civilization with their traditional values, customs, beliefs, and myths intact. They are commonly known as “tribals”. Kerala holds a unique position in the tribal map of India.[2] The district of Palakkad is the homeland for various tribal communities, Attapady is located in the North East of Palakkad, and the population of Attapady consists mainly of tribal communities.

It is mandatory to know the oral and periodontal health status, associated risk factors, treatment needs, oral health beliefs, and attitude toward dental treatment, to establish an effective dental and periodontal health program in this vulnerable group. Several studies have been conducted in Attapady region regarding systemic health of tribal population. So far, there is no authoritative data about periodontal health status among tribes of Attapady. Hence, the present study was conducted to assess the prevalence of periodontal diseases among the tribal population of Attapady. An attempt was made to find the association between periodontitis and various correlates such as tobacco use, personal tooth-cleaning practices, and oral health beliefs.

MATERIALS AND METHODS

This population-based cross-sectional survey was carried out in three different tribal groups of Attapady Block. Data collection was done by clinical examination and a structured questionnaire. The study population consisted of adult tribes (Irulas, Mudugas, and Kurumbas) and they were selected from three panchayats – Agali, Pudur, and Sholayur of Attapady region. The study was approved by the Institutional Ethics Committee. The study has been registered under clinical trial registry with registration number (CTRI/2017/10/010282). Permissions were obtained from the Subcollector Palakkad, District Medical Officer of Palakkad, and Assistant Project Officer, Integrated Tribal Development Project (ITDP), Attapady. Informed consent was obtained from all patients. A sample of 360 individuals was included in this study, thus making the total sample size as 360. A multistage stratified random sampling was done in selection of tribal hamlets. Cluster sampling was done in selection of the study participants [Figure 1]. Sample size of each tribal community was selected on the basis of probability proportional to the size of the total 360 individuals in this survey. Adult tribes of age above 20 years were included in the study. Those who were unwilling to give informed consent and systemically debilitated persons were excluded.

Figure 1

Study design flow chart

Periodontal status was assessed by community periodontal index (CPI) modified by WHO in 2013.[3] A modified and content-validated, questionnaire based on WHO oral health assessment form for adults, 2013 was used to assess the sociodemographic characteristics, habits, and clinical variables, and oral health belief was assessed by modified and validated questionnaire.[4]

The oral examinations were conducted by a single calibrated examiner (NGK) using a standard mouth mirror and CPI probe. Based on loss of attachment (LOA) score, severity of perioodontitis was further categorized as no/mild periodontitis (score 0 [LOA 0–3 mm]), moderate periodontitis (score 1 [LOA 4–5 mm]), and severe periodontitis (score 2, 3 and 4 [LOA 6 mm or more]) The oral hygiene habits were assessed using a questionnaire [Figure 2] comprising 5 questions and the median of the sum was obtained. Those individuals with values above median were considered as having good oral hygiene, and those with median value and below were having bad oral hygiene habits.

Figure 2

Oral hygiene habits assessment questionnaire

For assessment of oral health beliefs, a structured questionnaire [Figure 3] consisting of 11 questions each question is scored as either 0 or 1 (No - 0 and Yes - 1). Total score is the sum of all 11 questions, and median of the sum was obtained. All values above the median were taken as favorable response while the median and values below it were considered as unfavorable responses.

Figure 3

Oral health attitude questionnaire

Statistical analysis

Mean (± standard deviation) was calculated for quantitative variables and frequency was calculated for qualitative variables. Prevalence was expressed in percentage with a confidence interval (CI) of 95%. Chi-square test was performed to find the association of periodontitis and its correlates such as oral hygiene practices, tobacco use, and oral health beliefs. Decayed-missing-filled teeth (DMFT) was calculated. The α value was set at 5%.

RESULTS

In this study, 360 individuals were examined, and the mean age was 39.81. There were 123 (34.2%) males and 237 (65.8%) females. The study population comprises of 148 (41.1%) Irulas, 108 (30.0%) Mudugas, and 104 (28.9%) Kurumbas. Their education status revealed that 50.6% were illiterate [Table 1].

Table 1

Distribution of study participants by sociodemographic characteristics

Demographic data	Distribution
Age, mean (range) years	39.81 (20-98)
Gender, frequency (%)
Males	123 (34.2)
Females	237 (65.8)
Subcaste, frequency (%)
Irulas	148 (41.1)
Mudugas	108 (30.0)
Kurumbas	104 (28.9)
Education, frequency (%)
Illiterate	182 (50.6)
Primary school	83 (23.0)
High school	82 (22.8)
Graduate	13 (3.6)

Among 360 individuals, the percentage of teeth present with gingival bleeding was 49.51%. The proportion of persons with gingival bleeding among this population was 73.3% [Table 2].

Table 2

Distribution of gingival bleeding score

Distribution	Gingival bleeding score
	0 (absence of condition)	1 (presence of condition)	9 (tooth excluded)	x (tooth not present)	Total
Frequency of tooth (%)	3751 (32.56)	5704 (49.51)	956 (8.29)	1109 (9.62)	11,520 (100)
Frequency of individuals (%)	94 (26.1)	264 (73.3)	-	2 (0.6)	360 (100)

The percentage of teeth present with no periodontal pockets, shallow pockets, and deep pockets were 23.87%, 25.37%, and 32.7%, respectively. The percentage of individuals with no periodontal pockets, shallow periodontal pockets, and deep periodontal pockets were 11.9%, 29.2%, and 58.3% respectively [Table 3]. The proportion of periodontal disease (periodontitis and gingivitis) in this study population was 87.5% (95% CI 78.484, 96.516) [Figure 4].

Table 3

Distribution of pocket score (community periodontal index modified)

Distribution	Pocket score
	0 (absence of condition)	1 (pocket 4-5 mm)	2 (pocket 6 mm or more)	9 (tooth excluded)	x (tooth not present)	Total
Frequency of tooth (%)	2750 (23.87)	2923 (25.37)	3768 (32.7)	963 (8.35)	1116 (9.68)	11,520 (100)
Frequency of individuals (%)	43 (11.9)	105 (29.2)	210 (58.3)	-	2 (0.6)	360 (100)

Figure 4

Proportion of periodontal disease among the study participants

The percentage of individuals with LOA score 0, score 1, score 2, score 3, and score 4 were 13.3%, 22.8%, 39.7%, 17.5%, and 4.2%, respectively [Table 4]. The proportion of no/mild periodontitis, moderate, and severe periodontitis among this population was 13.3%, 22.8%, and 61.4%, respectively [Table 5]. The proportion of periodontitis (moderate–severe) among the tribal group was 84.2% (95% CI 75.55, 92.84) [Figure 5].

Table 4

Distribution of highest loss of attachment score

Distribution	LOA score*							Total
	0 (0-3 mm)	1 (4-5 mm)	2 (6-8 mm)	3 (9-11 mm)	4 (12 mm or more)	x (excluded segment)	9 (not recorded)
Frequency of mean number of sextants (%)	469 (21.71)	542 (25.09)	638 (29.53)	228 (10.55)	51 (2.36)	229 (10.60)	3 (0.13)	2160 (100)
Frequency of individuals (%)	48 (13.3)	82 (22.8)	143 (39.7)	63 (17.5)	15 (4.2)	9 (2.5)	-	360 (100)

*LOA – Loss of attachment

Table 5

Distribution of individuals based on severity of periodontitis

Periodontal disease severity	Frequency (%)
No/mild periodontitis	48 (13.3)
Moderate periodontitis	82 (22.8)
Severe periodontitis	221 (61.4)
Excluded	9 (2.5)

Figure 5

Proportion of periodontitis (moderate–severe) among the study population

Association between selected risk factors and periodontal health is shown in Table 6. Among 360 individuals, 75% had bad oral hygiene practices. Periodontitis was more (92%) among those having bad oral hygiene practices as compared to those who had good oral hygiene practices (69%) [Table 6]. The association between oral hygiene habits and periodontal health was found to be statistically significant. Moreover, individuals having bad oral hygiene practices are nearly five times more likely to have periodontitis (Odds ratio [OR] = 4.99) as shown in Table 7. Of total sample, 49.1% had favorable oral health belief and 50.83% had unfavorable oral health belief. The percentage of periodontitis among those having favorable and unfavorable oral health belief was 79.8% and 92.7%, respectively. A statistically significant difference (P< 0.05) had been found with an OR of 3.2.

Table 6

Association between selected risk factors and loss of attachment score

Oral hygiene habits/oral health beliefs/tobacco users	LOA score†						Total	χ2, P
	0	1	2	3	4	x
Oral hygiene habits
Good	27 (30)	25 (27.7)	28 (31.1)	7 (7.77)	2 (2.22)	1 (1.11)	90	38.19, 0.000*
Bad	21 (7.77)	57 (21.1)	115 (42.5)	56 (20.7)	13 (4.81)	8 (2.96)	270
Oral health beliefs
Favorable	35 (19.7)	47 (26.5)	65 (36.7)	18 (10.1)	8 (4.51)	4 (2.25)	177	24.67, 0.000*
Unfavorable	13 (7.10)	35 (19.1)	78 (42.6)	45 (24.5)	7 (3.82)	5 (2.73)	183
Tobacco users
Yes	1 (2.85)	1 (2.85)	14 (40)	14 (40)	4 (11.4)	1 (2.85)	35	26.08, 0.000*
No	47 (14.4)	81 (24.9)	129 (39.6)	49 (15.07)	11 (3.38)	8 (2.46)	325

*P<0.05; χ2 (df)=5; †LOA – Loss of attachment; χ2 – Chisquare value; P – P value

Table 7

Association between selected risk factors and periodontal health (n=351)

Risk factors	Periodontal health		OR	95% CI
	Periodontitis (+)	Periodontitis (−)
Tobacco users
Yes	243 (92.4)	20 (7.6)	5.6	2.99-10.74
No	60 (68.2)	28 (31.8)	7
Oral hygiene status
Bad	241 (92)	21 (8.0)	4.9	2.64-9.43
Good	62 (69.7)	27 (30.3)	9
Oral health belief
Unfavorable	165 (92.7)	13 (7.3)	3.21	1.63-6.32
Favorable	138 (79.8)	35 (20.2)

P (+) – Moderate–severe periodontitis; P (−) – No/mild periodontitis. OR – Odds ratio; CI – Confidence interval

In our study, tobacco users included smokers alone, chewers alone, and smokers and chewers. It was observed that among the tobacco users, 92.4% had moderate–severe periodontitis whereas in nontobacco users, 68.2% had moderate–severe periodontitis. A statistically significant association was found between tobacco users and periodontitis (P = 0.000), OR 5.670 (95% CI 2.991, 10.749). This study showed that individuals with periodontitis had 5.6 times increased exposure to tobacco [Table 7]. The mean DMFT of this population was 4.9 ± 5.4 [Table 8].

Table 8

Distribution of caries and mean decayed-missing-filled teeth score

DMFT score	Frequency (%)	Mean±SD
0	91 (25.3)	4.9028±5.439
1	36 (10.0)
2	33 (9.2)
3	25 (6.9)
4	25 (6.9)
5	20 (5.6)
6	20 (5.6)
7	15 (4.2)
8	23 (6.4)
9	14 (3.9)
10	12 (3.3)
11	7 (1.9)
12	6 (1.7)
13	4 (1.1)
14	5 (1.4)
15	5 (1.4)
16	3 (0.8)
17	2 (0.6)
18	3 (0.8)
19	4 (1.1)
21	1 (0.3)
22	2 (0.6)
24	1 (0.3)
27	2 (0.6)
32	1 (0.3)
Total	360 (100)

DMFT – Decayed-missing-filled teeth; SD – Standard deviation

DISCUSSION

Periodontal disease is a complex immunoinflammatory disease characterized by loss of clinical attachment, destruction of periodontal ligament with subsequent alveolar bone loss. It includes both periodontitis and gingivitis. The primary etiologic factor is specific microorganism.

In this study, the proportion of periodontal disease was 87.5% (95% CI 78.4, 96.5) This was in accordance with earlier studies conducted in different parts of Indian subcontinent.[56789] Philip et al. in 2013[10] reported an overall prevalence of periodontal disease in the tribal population of Nilgiris as 73.6%. Rao and Bharambe in 1993[11] reported the prevalence of periodontal disease as 99.6% in rural population of Wardha district. In all these studies, either CPI or CPITN indices was used, and there was a chance of overestimation of data by taking the highest CPI score in each sextant. However, in this study, CPI-modified index by WHO (2013) was used to overcome the above limitation. The periodontal status and gingival status of all the teeth were recorded by this index, and thus, the prevalence obtained in this study is the actual burden of periodontal disease experienced in this population.

Fifty percent of individuals participated in our study were illiterate. It is likely that the widely observed relation between educational levels and periodontal health is a function of better oral hygiene among the better educated, more positive response toward oral hygiene, and a greater frequency of dental visits among the more dentally aware.[1213]

In this study, 73.3% of population were having gingival bleeding. This result was not consistent with the report of earlier studies.[1415] Bhat and Kadanakuppe reported that 4.2% of individuals had gingival bleeding in Irula tribes.[15] The low proportion of gingival bleeding seen in the above-mentioned study may be due to the limitation of CPI index where tooth having highest CPI score is taken into consideration, and thereby, the actual gingival bleeding condition was underestimated. In the present study using CPI modified index (2013), a clear picture of gingival bleeding status was elucidated.

Bleeding on probing is an early indicator of periodontal disease.[16] An interesting observation in this study was that even though the prevalence of periodontal disease was high (87.5%), the proportion of gingival bleeding was low (73%). This low proportion of gingival bleeding as compared to the proportion periodontal disease could be due to the effect of tobacco use in this population. More than half of the study sample had the habit of tobacco use. Nicotine,[161718] the main constituent of tobacco, has a vasoconstrictive effect on gingival blood vessels that lead to decreased blood flow and decreased gingival bleeding. This observation was in accordance with previous studies.[1920]

The proportion of periodontitis in this population was 84.2% (95%CI 75.5, 92.8). Among them, 22.8% had moderate periodontitis, 61.4% had severe periodontitis, and 13.3% had no/mild periodontitis. Due to the inherent limitation of CPI (LOA score index), the exact percentage of persons with no periodontitis (periodontally healthy) could not be assessed. Hence, this group (13.3%) included persons with no periodontitis and persons with mild periodontitis. Hence, this group was classified as no/mild periodontitis. Most of the study population irrespective of their subcaste experienced severe periodontitis. Poor oral hygiene, presence of deleterious habits such as smoking, chewing tobacco, unfavorable oral health beliefs, and their reluctance to visit dentist and seek treatment may account for this.

The study assessed various oral hygiene practices followed by the study population. Charcoal, mango leaves, and neem sticks were the oral hygiene materials traditionally used by them. Majority of this study population (75%) were following bad oral hygiene practices. Oral hygiene of the individual appears to be closely associated with severity of periodontal disease. In this study, the association of oral hygiene practices and severity of periodontitis was statistically significant with an OR of 4.9. Even though half of the population used tooth brush and tooth paste for cleaning their teeth, the prevalence of periodontal destruction in this population still remains at a high level of 87.5%. This could be possibly attributed to the fact that majority of the respondents had never been professionally taught the correct brushing technique and to the lack of dental health promotion program in this rural areas. Only 7.8% had visited dentist, and this also might have contributed to unhealthy dental practices like faulty toothbrushing.

In addition to poor oral hygiene, the important risk factors for periodontal disease include tobacco use and malnutrition.[13] In this study, we observed that 77.2% individuals were under the effect of deleterious habits. Among them, 74.7% were using tobacco either in the form of smoking or chewing or both. The association between tobacco users and periodontitis was found to be significant with an odds of 5.6 which implied that individuals with periodontitis had 5.6 times increased exposure to tobacco than nonperiodontitis individuals. This result was in accordance with other studies.[2122] Tobacco in the form of smoking results in more aggressive periodontal breakdown by changes in the composition of the subgingival plaque, with increases in the numbers and/or virulence of pathogenic organisms; changes in the host response to the bacterial challenge; or a combination of both. Smokeless tobacco contains tobacco-specific nitrosamines which are likely to be a major source of chemical injury to gingival, chronically exposed to the quid. In addition, smokeless-tobacco induced epithelial proliferation that bridges the narrow lamina propria of sites with an alveolar dehiscence might also result in loss of marginal gingiva.[23] Thus, it was clear that tobacco use may contribute to increased proportion of periodontal disease in this population.

Majority of people belonging to this region irrespective of age and sex had the habit of chewing. They use betel leaves, areca nut, and tobacco for chewing. Local availability of betel leaves and arecanut led to the increased consumption of tobacco chewing. The predominant factors which influenced the initiation of tobacco consumption at an early age in both the sexes were social customs, followed by peer pressure and as a means to concentrate on work. Unhealthy practice of tobacco use was promoted by mothers and grandmothers in adolescent girls to ease their abdominal pain during menstruation. This was supported by Dongre et al. in 2008.[24]

In this study, we made an attempt to explore the oral health beliefs, and it was interesting to notice that high proportion of study participants had unhealthy dental treatment seeking practices and poor awareness about dental treatment. Among individuals with unfavorable oral health beliefs, 90.02% experienced moderate to severe periodontitis with an odds of 3.2, and this observation was in agreement with Kwan and Holmes in 1999.[25] The elderly and adult individuals of our study believed in traditional remedies and claimed that preventive oral health measures were ineffective. In contrast to this unfavorable oral health beliefs, Paniyan tribals of Kerala presumed that dental diseases would have severe consequences if neglected.[4] Overall caries prevalence among this tribal population was high, and the average DMFT was 4.9. This is consistent with reports of several studies.[1126]

This population had unhealthy dental treatment-seeking practices, poor awareness, and unfavorable oral health belief toward dental treatment. There is a dire need for periodontal and other dental treatment protocol with emphasis on motivation of individuals regarding favorable oral health belief, healthy dental treatment-seeking practices, and good awareness of dental treatment. It is high time to educate these population regarding the ill effects of deleterious habits such as smoking and pan chewing on systemic and oral health. There is an urgent need for well-organized oral healthcare delivery system. Strategies should be designed with an understanding of sociocultural realities of the community. Lack of authentic data posed a major challenge before oral health care in tribal population of Attapady region. The data collected in this study would possibly help to alleviate this lacunae and thereby help in assessment of community demands.

One of the limitation of this study is that it is not possible to determine causality due to the cross-sectional design of the study. The usage of interviewer-administered questionnaires despite its numerous advantages, also introduces elements of information bias, in forms of recall and social desirability biases.

CONCLUSION

The study population was characterized by high prevalence of periodontal disease, poor oral hygiene, high caries score, high dental treatment needs, and lack of proper dental care. Risk factors such as smoking and pan chewing are significantly associated with worsening of periodontal health. Education and motivation of this population is required to improve the oral hygiene and to refrain from deleterious habits. Under these circumstances, the implementation of a basic oral healthcare delivery system is mandatory for the tribal population of Attapady.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.