Dental Diseases and Factors Defining Utilization of Dental Care Services among Rural Children Aged 12 Years in Nellore District, Andhra Pradesh: A Community-Based Study.

BACKGROUND: Rural children are predisposed to variety of dental problems, which may influence their overall health and well-being. Despite relentless efforts and achievements in oral health promotion by authorities, its impact seems limited in rural areas of developing countries. AIM: To generate data on the prevalence of dental caries and gingivitis, among 12-year-old rural children of Nellore district, Andhra Pradesh and factors facilitating or impeding uptake of dental care services.
METHODS: A cross-sectional, house-to-house survey was conducted in Kavali revenue division of Nellore district by random selection. A cluster sampling methodology was followed, and a total of 169 adolescents were involved in the study. Dental caries detection was performed according to the World Health Organization dentition status criteria and gingivitis according to modified Community Periodontal Index as gingivitis present or absent. Descriptive statistics were calculated.
RESULTS: Overall prevalence of dental caries and gingivitis was 39% and 35%, respectively, with <15% utilization of oral health care services. The main hurdle for this notably low utilization of oral health care services was that dental issues were not fatal or life-threatening.
CONCLUSION: The prevalence of dental caries and gingivitis was high and poor utilization of oral health services was an importunate finding in this study. Understanding the trends of common oral diseases and hurdles in uptake of oral health care services could provide a basis for further research and improvement in accessibility to oral health care services in rural areas of developing nations. Copyright:

INTRODUCTION

Educating young children regarding their dental health is an important responsibility of all oral health care givers. A healthy dentition is a fundamental requisite for overall welfare of a child. Globally, dental caries is the most ubiquitous disease of childhood, affecting 60%–90% of most children.[1] The National Oral Health Survey Report 2004, stated caries prevalence to be 53.8% at 12 years of age in different Indian regions.[2] Gingivitis, characterized by inflammation of the gums, occurs, especially around pubertal age and if left untreated, may progress to periodontitis and eventually lead to tooth loss. Dental problems impede the children's school attendance and annually, >52 million hours of schooling are lost owing to dental-associated ailments.[3]

Alongside oral disease trends, it is also essential to understand the utility of dental care services among these children. Dental care utilization is the fraction of the people who access dental services over a specified period.[4] A complex set of factors influence the utilization of dental care among children. Reviewed literature suggests the most common factors affecting utility could be; perceived need, parents' knowledge of oral health, beliefs and attitudes toward oral illness, socioeconomic status, level of income, geographic accessibility, feeling of vulnerability, and care giving behavior of caregivers.[5] The most frequently observed obstacles of utilization were lack of perceived need,[67] fear of dental treatment, financial constraints, and lack of access, followed by inapt human resources, disproportionate geographic distribution, and inadequate sensitivity to patient's needs by the dental professionals.[8]

India is primarily a rural country, with 68.84% of her population residing in villages.[9] The occurrence of oral problems among these children from rural areas are as diverse as are the reasons for nonutility of dental care services.

So far, no systematic estimation has been carried out on the prevalence of these common oral maladies, their unmet dental needs and receipt of dental treatment among rural 12-year old children in this population of Nellore District.

With this backdrop, we decided to determine prevalence of dental caries and gingivitis and pattern of utilization or nonutilization of dental care services among 12-year-old rural children with dental problems. This data provide an overview of the existing dental status as regards this age group, and would be of immense value for developing further tools and techniques for comprehensive studies.

STUDY PARTICIPANTS AND METHODS

Study design and study setting

A cross-sectional design was proposed for this study as we intended to generate data on the prevalence of dental diseases of the child population residing in this rural area. Furthermore, this being an unexplored area, there were no data available regarding dental problems of any kind, among the residents. This house-to-house community survey was carried out in rural areas of SPSR Nellore district, Andhra Pradesh,[9] in two villages, Ananthapuram and Anemadugu, of Kavali revenue division.

Study population and sampling procedure

Multistage random sampling was followed while selecting the villages. Among the five revenue divisions of Nellore district, Kavali revenue division was selected randomly in the first stage. Then two mandals, Kavali Mandal and Kaligiri Mandal from nine mandals of Kavali revenue division, were chosen randomly in the second stage. From these, Anemadugu village from Kavali Mandal and Ananthapuram village from Kaligiri Mandal were selected randomly by the lottery method in the third stage [Figure 1].

Figure 1

Flow chart showing sampling strategy for selecting villages

Information regarding details of all households with 12-year-old children in the selected villages was obtained from Anganwadi centers and cluster resource persons for those villages. We planned to enroll one hundred children, both boys and girls, from each village (total of 200 children) completing 12 years at the time of examination. If the required number of children could not be obtained from a single village, the adjacent village children were included. Once the specified number was attained, they were line-listed and based on the eligibility criteria, 92 children from Ananthapuram and 77 children from Anemadugu were enrolled for the study. Thus, the study was carried out with a total of 169 children.

Inclusion and exclusion criteria

Children completing their 12th birthday or those in the 13th year of life after age verification of their Aadhar cards, both males and females without medical complications, were included in the study. Children who were unwilling to participate in the survey or, who did not get their parent's consent or any health condition which prevented their participation, were excluded from the study.

Before the interview and oral examination, informed consent from their parents and assent from each participants and were obtained. Ethical clearance and approval for conducting the study was obtained from the Institutional Ethical Committee (NDCH/IEC/2018/09-3).

Data collection

For a direct interview, a semi-structured questionnaire with both open-ended and closed-ended questions was designed. Information regarding the demographic data, dental problems, utility of dental care services, and reasons for nonutilization of dental health care services was collected. Participants were interviewed in the native language, Telugu. Dental interns and postgraduate students from specialty of Public Health Dentistry were trained for conducting interviews and oral examination ahead of data collection. Training was provided in the direct interview technique and standardization was carried out in dental teaching institution before data collection. Kappa value of 0.88 was attained during standardization for intraexaminer agreement.

Clinical examination

Following the interview, Type III clinical examination of each participant was carried out in their homes, in a normal chair with head rested on to the wall, wherever possible, and a torch light. The WHO dentition status for dental caries and modified Community Periodontal Index for gingivitis, were employed for recording clinical findings.[9]

Data quality assurance

The principal investigator (VCR) accompanied each team of an internee and postgraduate student to ensure that no deviation from correct methodology of data collection occurred. Cross checking the interview schedule and verification of filled questionnaires was done by the principal investigator, who also checked for the completeness of every questionnaire before leaving the village, for the respective day. Incomplete questionnaires and improperly filled clinical examination forms were verified and corrected. The entire data were collected between September 2018 and December 2018.

Statistical analysis

The prevalence of dental caries and gingivitis and proportion of utilization of dental care services were calculated at 95% confidence intervals (CIs). Descriptive statistics were presented using frequency tables.

RESULTS

A total of 169 children participated in this study of which 52% were boys and 48% were girls. Ninety-eight percent (166) of them were school going, and three percent were school drop outs. Ninety-two percent of them belonged to Hindu religion and 42% belonged to Scheduled tribe community [Table 1]. Overall prevalence of dental caries and gingivitis was 39% (95% CI: 31–46) and 35% (95% CI: 28–42), respectively, among these participants [Table 2]. The utilization of dental care services was 12% (95% CI: 06–22) where only eight participants among 66 children with dental caries and six participants among 59 children with gingivitis visited dentist for their management [Table 3].

Table 1

Descriptive characteristics of the rural children aged 12 years, Nellore District, Andhra Pradesh, India, 2018

Characteristics	n (%)
Gender
Boys	88 (52)
Girls	81 (48)
Religion
Hindu	156 (92)
Christian	4 (2)
Muslim	9 (5)
Community
Scheduled caste	40 (24)
Scheduled tribe	72 (43)
Other backward class	53 (31)
Open category	4 (2)
Children going to school daily
Yes	166 (98)
No	3 (2)

Table 2

Prevalence (percentage and 95% confidence interval) of dental caries and gingivitis among rural children aged 12 years (n=169), Nellore District, Andhra Pradesh, India, 2018

Prevalence by gender	Boys (n=88)	Girls (n=81)	Overall (n=169)
Dental caries	41 (30-51)	37 (27-48)	39 (31-46)
Gingivitis	42 (32-52)	27 (18-38)	35 (28-42)

Table 3

Prevalence (percentage and 95% confidence interval) of utilization of dental care services among rural children aged 12 years (n=169) with dental caries and gingivitis, Nellore District, Andhra Pradesh, India, 2018

	Number of children utilized dental care services
	Dental caries (n=66)	Gingivitis (n=59)
Utilized dental care services	12 (6-22)	10 (4-21)

Out of 169 participants, 71 participants did not have caries or gingivitis. Among the 98 participants who suffered from either dental caries or gingivitis or both, 10 participants had utilized dental care services in the past 1 year. The reasons for nonutility of dental care among the remaining 88 participants, 69 children (79%) were unaware of their dental caries or gingivitis status. Twelve (14%) of them had not visited their dentist as they felt dental problems were not life-threatening. Other reasons include their parents unwillingness to take them to dental clinic (3%), whereas, two participants (2%) attributed nonutility to absence of dental clinic in their village. Two of them (2%) said they had not visited the dentist due to fear [Table 4].

Table 4

Reasons for nonutilization of dental care services among rural children aged 12 years (n=88) with dental caries and gingivitis, Nellore District, Andhra Pradesh, India, 2018

Reasons for not utilizing dental care services	n (%)
Not aware of dental caries/gingivitis*	69 (79)
Dental diseases are not life threatening	12 (14)
My parents have not taken	3 (3)
No dental clinic in our village	2 (2)
Afraid of dentist	2 (2)

*These participants did not give any reason for not visiting the dentist as they were not aware of their dental caries and gingivitis condition and were identified by the investigator in oral examination

DISCUSSION

The burden of oral conditions seems to have increased in the past couple of decades, though unevenly and a greater part of the literature implies dental caries and gum diseases as the chief contributors to this burden. A great disparity lies in the prevalence of dental caries in different studies and may be ascribed to diverse study populations, study settings, differences in eating patterns, varied cultural practices, oral hygiene habits, fluoride content of water, etc.

Our study highlights prevalence of routine dental problems associated with rural 12-year-old children and measured their dental attendance. It is this age group that has highest prevalence of caries and lowest rate of dental attendance. However, regular dental attendance by children in this age group depended on the willingness of parents and care givers. The oral health care services provided in rural areas of Nellore district are relatively inadequate as the rural dental health services are sparse as per the data provided by district medical health officer. After a thorough search, we identified that, there were no data available on the child population of Nellore district specific to rural areas. We therefore proposed to understand the oral disease trends in this population.

National oral health survey carried out in India during 2003–2004 has shown prevalence of 53.8% dental caries among 12-year-old children in India. In Indian southern states, a meta-analysis on the prevalence of dental caries in India among the WHO Index age groups, the overall prevalence at 12 years was 49%.[10] In the state of Telangana, the capital city of Hyderabad, had a prevalence of 41.4% while it was 60.5% in Nalgonda district of same state.[11] Similarly, a study reported a prevalence of 31% in neighboring Tamil Nadu state.[12] A similar trend was observed in our study where, we recorded a caries prevalence of 39% among 12-year-old, in this rural population.

The Indian scenario on prevalence of gingivitis is no exception, with 57% prevalence of periodontal disease at 12 year age.[2] It varied from 12.23% in Ahmedabad[13] to 93% in Panchkula.[14] The present study has observed a prevalence of 35% gingivitis in a population of this age.

Utilization is the actual attendance to receive care by the people at health care facilities. Factors dictating dental care utilization are manifold and incorporate an apparent need for care, cultural variations, language, and so forth as the internal factors. External factors comprise of the adequacy of dental workforce and ability to pay for care. In addition, sociodemographic factors such as age, sex, educational attainment, and household income; perceptions and oral health behaviors, access to health facility, dwindling health funding, dental insurance, and cost of treatment are also cited.

India's National Oral Health Survey (2004)[2] reported 32% of utilization of dental care services among 12-year-old children. From a study involving Udupi children in Southern India, the utilization was recorded as 62.2% in urban and 26.8% in rural areas.[15] However, our study reported a proportion of utilization of dental care services as 12%, which, on comparison, was very low. The reasons for this low utility could be varied.

Oral health care services in rural areas are inadequate due to lack of perceived need for dental care and even if a need arises, there seems to be a shortage of work force. Another important reason could be financial constraints. In our study, barriers of utilization of dental care were that dental problems are considered unimportant, as they are not life-threatening; parents ignored dental problems of children and did not take them to dental facility, fear of dentist due to which the child did not inform parent about problem, unavailability of dental clinic in either villages, and other dental clinics were distant[67] and therefore inaccessible.

Our study emphasizes on understanding the oral disease trends and obstacles that prevent these 12-year-old children from seeking appropriate and timely oral health care interventions. Adequate knowledge of facilitators and promoters of healthcare services uptake in the community, is essential to maintain and improve health care outcomes. This knowledge may provide inputs for tailoring extensive studies, which could subsequently aid in designing oral health programs and develop oral health care policies, especially for rural populations.

Limitations of the study

Even though efforts were made to involve all the children, few of them could not get their parent's consent to participate in the study and some of them were staying away from their homes for their schooling purpose. Hence, there are possibilities of underreporting of dental caries and gingivitis in these children who may have high caries and gingivitis prevalence. Moreover, data were collected by using the WHO criteria, which considers only obvious cavitation as caries. This method underestimates caries prevalence, but makes the results comparable to other studies using same criteria.

CONCLUSION

The overall prevalence of dental caries was 39% and gingivitis was 35%, while the proportion of utilization of dental care services was 12%, which was very low. The mainstream basis for nonusage of oral care services among this 12-year-old population were that dental problems are not fatal, parents did not take children to dentist or dental clinic was far from their village and fright from visiting the dentist.

The data collection tool designed for the study was successfully tested and yielded valuable information. An explicit discrepancy was observed between children and parents as regards the dental issues and that, children's understanding of their dental predicaments was more coherent with the clinical findings. Therefore, the involvement of children alone, for gathering data regarding their dental problems, was found more reliable and adequate. Parents' contribution toward the study was limited to providing information related to socioeconomic status.

Contrary to government data, an interesting and significant finding in this study was that the school enrolment rate was found to be >97% (Ananthapuram village it was found to be 100%, and in Anemadugu it was found to be 96%), and therefore, a school-based study involving this age group could be contemplated in this rural population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.