Prevalence of Periodontal Disease and Oral Hygiene Practices in Kancheepuram District Population: An Epidemiological Study.

BACKGROUND AND OBJECTIVES: The purpose of the study was to evaluate the prevalence of periodontal disease status and oral hygiene practices in urban and rural population of Kancheepuram District, Tamil Nadu, India.
METHODS: This epidemiological survey was carried out on 1650 participants taken from both urban and rural areas of Kancheepuram District. The study groups will belong to rural and urban areas in the ratio of 1:2, respectively. Every individual was assessed with the oral hygiene index-simplified, community periodontal index of treatment needs and periodontal disease index. In addition, the oral hygiene practices were also studied and recorded in a specially designed pro forma. Data were subjected to statistical analysis using SPSS 19.0 software.
RESULTS: The study showed that 50% and 36% of the study participants have gingivitis and periodontitis, respectively, while only 14% of the study participants did not present with any form of periodontal disease. The study also showed that 16.63% of the study subjects among urban and 7.63% of them among rural do not have any type of periodontal disease. About 57.09% of the study participants among urban and 36.54% of the study participants among rural areas have gingivitis. The remaining 26.3% of the study participants in urban areas and 55.8% of the study participants in rural areas have periodontitis. It was observed that majority of participants brush once a day using Medium bristle tooth brush and toothpaste as dentifrice.
CONCLUSION: Periodontal disease is widely spread among population of Kancheepuram District, with greater prevalence in rural population than in urban population. This could be mainly due to the lack of awareness and limited availability of resources. These estimates are vital for the future planning of dental services in Kancheepuram District, Tamil Nadu, India. Copyright:

INTRODUCTION

Periodontal diseases are a heterogeneous group of infectious diseases that affect bone and supporting tissues around teeth leading to inflammation of gingiva, periodontal tissue destruction, alveolar bone loss, and possible exfoliation of teeth.[1] Knowledge on the prevalence of periodontal helps evaluate the importance of the disease, describe its progress, identify the potential etiological factors and also plan national and regional oral health promotion programs. These could lead to appropriate interventions among the affected people and improve their quality of life. Only two prominent studies in the general population have been carried out till date, the first, by the Dental Council of India and the second by the Directorate General of Health Services, Government of India; and the WHO as a combined project. Numerous other studies done in different areas were hospital based and all of them revealed a high incidence of periodontal disease with almost 70% of population being affected.[2]

In India, wide differences are found in the oral health status among urban and rural population with evidence showing that rural areas have higher measure of periodontal diseases. Oral hygiene practices in rural areas are different from those in urban areas. The rural population of India suffers from poor oral health due to the lack of health education, awareness, infrastructure, and oral health care. It is obvious that periodontal care and prevention in India are far from satisfying actual needs. There are many barriers and limitations which interfere with the practical applicability of gained knowledge in proper amount and quality to a therapeutic and preventive approach. The Kancheepuram District in Tamil Nadu, is an active agriculture dependent place with people from a wide spectrum of cultural, religious and socioeconomic status residing in it. With a projected population of approximately around 39.95389 lakhs for the year 2011 according to census of Kancheepuram District statistical office, it becomes evident that a proper oral health planning program is necessary. Since data on periodontal health status of the urban and rural population are scarce, the aim of the present study is to assess the periodontal disease status among the urban and rural population of Kancheepuram District, Tamil Nadu to evaluate the need for oral health care delivery to the affected population.[3]

MATERIALS AND METHODS

Source of data

The census projects a population of 39, 98,252 lakhs (20,12,958 lakhs males; 19,85,294 lakhs females) in which the rural population is 14,59,916 lakhs and urban population approximately 25,38,336 lakhs. According to 2011 census, Kancheepuram district has 10 taluks and 1019 villages. The participants for this descriptive cross-sectional study were selected from both urban and rural population from different areas of Kancheepuram District. The study groups will belong to both rural and urban areas in the ratio of 1:2, respectively.

Sample size

Sample size for this descriptive cross sectional study was calculated from the projected population for the year 2011.[4]

Multi stage random sampling with probability proportionate to size technique was implemented for this study. Kancheepuram District in total has 10 taluks. Each taluk head quarter was taken as an urban area, and 2 villages of each taluk were randomly picked by lottery method and assigned as rural areas. The total sample size will be proportionately distributed among urban and rural population.

Clinical examination

Participants were examined using community periodontal index of treatment needs (CPITN)-E probe, mouth mirror, explorer, and tweezer. The parameters checked were oral hygiene index-simplified (OHI-S) index, CPITN index and periodontal disease index (PDI). The entire study was conducted by a single examiner and an assistant who recorded the data. Natural light was used with the subjects positioned to ensure maximum illumination.

Organizing the study

Before starting the study, the Institutional ethical committee approval was obtained. Official permissions were taken from Chief Medical officers and Duty Medical officers from community health centers in urban areas as well as primary health centers in rural areas to conduct the proposed study. Prior information was provided regarding the dates to the concerned doctors and social workers of the respective areas about the dental checkup. Patients were informed about the study and consent form was obtained from each participant. Around 70–100 participants were examined in a day in both urban and rural areas.

Selection criteria

Inclusion criteria

Permanent residents of Kancheepuram district.

Patient with 60% of dentition intact.

Exclusion criteria

Temporary residents

Patient with <60% entire dentition.

Statistical analysis

Chi-square test was used for analyzing the data. The level of statistical significance was set at P < 0.05. Data were entered in Microsoft Excel spread sheet and analyzed using SPSS software (IBM Corp. Released 2010. IBM SPSS statistics for Windows version 19.0.IBM corp: Armonk, NY, USA). The results are presented as numbers, percentages, frequency, and distribution.

RESULTS

This cross-sectional study was conducted to evaluate the prevalence of periodontal disease status and oral hygiene practices in Kancheepuram District on a total of 1650 subjects among which 1100 (66.66%) subjects were from urban areas and 550 (33.33%) of participants were from rural areas. The study was done over a period of 10–11 months.

Status of population based on gender

Of the urban population, 491 (45%) were male and 609 (55%) female. 258 males (47%) and 292 (53%) females had participated from rural areas. No significant difference between male and female ratio was ascertained in our study. The total sample size was proportionately distributed among urban and rural population (P > 0.05) [Table 1].

Table 1

Status on population based on Gender

Gender	Location		Chi square	P Not Signification
	Urban	Rural
Male	491	258	0.764	0.206
Female	609	292

Status of study subjects based on community periodontal index of treatment needs

CPITN index revealed that, 183 (16.63%) participants among urban and 42 (7.63%) participants among rural areas did not have any type of periodontal disease. 628 (57.09%) participants among urban and 201 (36.54%) participants among rural areas had gingivitis. The remaining 289 (26.3%) participants in urban area and 307 (55.8%) participants in rural areas had periodontitis [Table 2]. An analysis with Chi-square test revealed that there is a highly significant difference between CPITN status of urban and rural areas (P < 0.05) [Table 2].

Table 2

Community periodontal index of treatment needs status of study participants

Location	CPITN			Chi square	P HS
	0	1-2	3-4
Urban	183	628	289	141.197	0.0001
Rural	42	201	307

Periodontal disease index status of study subjects

Plaque component of PDI revealed that 12 (1.09%) subjects among urban areas and 4 (0.80%) participants among rural areas did not have dental plaque accumulation, 695 (63.18%) participants in urban areas and 192 (34.90%) participants in rural areas had plaque present on some but not on all surfaces of the tooth and 374 (34%) participants among urban areas and 143 (26%) participants among rural areas had plaque present on all surfaces, but covering less than one half of them. 19 (1.72%) participants in urban areas and 211 (38.36%) participants in rural areas had plaque extending over all surfaces, and covering more than one half of these surfaces [Table 3].

Table 3

Periodontal disease index status of study participants (plaque component)

Location	Plaque				Chi square	P HS
	0	1	2	3
Urban	12	695	374	19	415.574	0.0001
Rural	4	192	143	211

Chi-square test revealed that there was a highly significant difference between the plaque component [PDI] of urban and rural areas (P < 0.05) [Table 3]. Calculus component of the PDI revealed that 627 (57%) subjects among urban areas and 73 (13.27%) participants among rural areas did not have dental calculus. 265 (24.09%) participants among urban areas and 23 (4.18%) participants among rural areas had supragingival calculus extending only slightly below the free gingival margin (not >1 mm). 186 (16.09%) participants among urban areas and 182 (33.09%) participants among rural areas had moderate amount of supra and subgingival calculus or sub gingival calculus alone. 22 (2%) participants among urban areas and 272 (49.45%) participants among rural areas have an abundance of supra and subgingival calculus [Table 4]. Chi-square test revealed that there was a highly significant difference between calculus component (PDI) of urban and rural areas (P < 0.05) [Table 4].

Table 4

Periodontal disease index status of study participants (calculus component)

Location	Calculus				Chi square	P HS
	0	1	2	3
Urban	627	265	186	22	754.981	0.0001
Rural	73	23	182	272

Gingival and periodontal component of the PDI revealed that 183 (16.63%) participants among urban areas and 42 (7.63%) participants among rural areas lack any type of periodontal disease. 628 (57.09%) participants among urban areas and 201 (36.54%) subjects among rural areas are suffering from gingivitis. 289 (26.27%) participants among urban samples and 307 (55.81%) participants among rural samples are suffering from periodontal disease [Table 5].

Table 5

Periodontal disease index status of study participants (gingival and periodontal component)

Location	OHIS			Chi square	P HS
	Good	Fair	Poor
Urban	183	628	289	141.197	0.0001
Rural	42	201	307

An analysis with Chi-square test revealed that there is a highly significant difference between gingival and periodontal component (PDI) of urban and rural areas (P < 0.05) [Table 5].

Oral hygiene index-simplified status of study subjects

OHIs status of the study participants revealed that 183 (16.63%) participants in urban and 42 (7.63%) subjects in rural had good oral hygiene. 6285 (7.09%) participants in urban and 201 (36.54%) participants in rural had fair oral-hygiene. 289 (26.27%) participants in urban and 307 (55.81%) participants in rural had poor oral-hygiene [Table 6].

Table 6

Oral hygiene index-simplified status of study participants

Location	OHIS			Chi square	P HS
	Good	Fair	Poor
Urban	183	628	289	141.197	0.0001
Rural	42	201	307

An analysis with Chi-square test revealed that there was a highly significant difference between OHI status of urban and rural areas (P < 0.05) [Table 6].

Types of cleaning methods

80 (7.27%) subjects in urban areas and 14 (2.54%) subjects in rural areas use a soft tooth brush. 914 (83.09%) participants in urban and 330 (60%) participants in rural use a medium tooth brush. 28 (2.54%) participants in urban and 62 (11.27%) participants in rural use a hard tooth brush. 56 (5.09%) subjects in urban and 105 (19.09%) participants in rural use their fingers. 22 (2%) subjects in urban and 39 (7.09%) participants in rural use a Neem stick [Table 7].

Table 7

Types of cleaning methods

DF	Location		Chi square	P HS
	Urban	Rural
Paste	1051	378
Powder	18	89	234.658	0.0001
Neem stick	22	39
Coal	9	44

An analysis with Chi-square test revealed that there was a highly significant difference between types of cleaning methods in urban and rural areas (P < 0.05) [Table 7].

Types of tooth cleaning material

1051 (95.54%) participants in urban areas and 378 (68.72%) participants in rural areas are using toothpaste. 18 (1.63%) participants in urban areas and 89 (16.18%) participants in rural areas use toothpowder. 22 (2%) participants in urban areas and 39 (7.09%) participants in rural areas use Neem stick, while 9 (0.81%) participants in urban areas and 44 (8%) participants in rural areas are using coal [Table 8].

Table 8

Types of tooth cleaning material

Frequency	Location		Chi square	P HS
	Urban	Rural
1	613	476
2	481	74	155.664	0.0001
3	6	0

An analysis with Chi-square test revealed that there was a highly significant difference between types of tooth cleaning material used in urban and rural results (P < 0.05) [Table 8].

Frequency of tooth brushing

613 (55.72%) participants in urban areas and 476 (86.54%) subjects in rural areas brush once daily. 481 (43.72%) participants in urban areas and 74 (13.45%) participants in rural areas brush twice daily. 6 (0.54%) participants in urban areas and 0 subjects in rural areas brush thrice daily [Table 9].

Table 9

Status of frequency of tooth brushing

Parameters	Location		Chi square	P HS
	Urban	Rural
Floss
Yes	249	32	73.399	0.0001
No	851	518
IB
Yes	117	14	32.840	0.0001
No	983	536
TP
Yes	91	108	44.643	0.0001
No	1009	442

An analysis with Chi-square test revealed that there was a highly significant difference between frequency of tooth brushing in urban and rural areas (P < 0.05) [Table 9].

Status of interdental aids used (location wise)

249 (22.63%) participants from urban areas and 32 (5.81%) subjects among rural areas used floss. 117 (10.63%) and 14 (2.54%) participants each from urban and rural areas, respectively, used interdental brushes. 91 (8.27%) urban participants and 108 (19.63%) participants among rural areas used tooth picks [Table 10].

Table 10

Status of interdental aids used on location wise

Parameters	Location		Chi square	P HS
	Urban	Rural
Floss
Yes	249	32	73.399	0.0001
No	851	518
IB
Yes	117	14	32.840	0.0001
No	983	536
TP
Yes	91	108	44.643	0.0001
No	1009	442

Chi-square test revealed that there was a highly significant difference between interdental aids used in urban and rural areas (P < 0.05) [Table 10].

Prevalence of periodontitis

289 (26.3%) participants had periodontitis in urban areas, whereas 307 (55.8%) participants had periodontitis in rural areas [Table 11].

Table 11

Status of prevalence of periodontitis

Location	Sample size	Periodontits
		Number	Prevalence
Urban	1100	289	26.3
Rural	550	307	55.8

Prevalence of gingivitis

628 (57.09%) participants had gingivitis in urban areas while 201 (36.54%) participants had gingivitis in rural areas. The prevalence of gingivitis was assessed by GPC which excludes the severe form of periodontitis [Table 12].

Table 12

Status of prevalence of gingivitis

Location	Sample size	Ginigivitis
		Number	Prevalence
Urban	1100	628	57.1
Rural	550	201	36.5

DISCUSSION

This descriptive cross-sectional study was done to determine the oral hygiene status, periodontal status and periodontal TNs among the patients visiting various urban and rural health centers in Kancheepuram District, Tamil Nadu, India. According to this study, females (55%) were more affected with periodontal disease compared to males (45%), which is in accordance to studies done by Silva and Zaveri,[5] Khamrco,[6] Kumar et al.[7] In contrary to the above findings, Doifode et al.[8] and Kundu et al.[9] reported that periodontal disease was more common in males. This could be due to adverse oral habits which are more prevalent in the male population. On assessing the oral hygiene practices of Kancheepuram District population, the usage of toothbrushes was found to be higher (urban-93% and rural-74%) in comparison to other methods. Results revealed a highly significant difference between types of cleaning methods in urban and rural areas. The work of Silva and Zaveri[5] further establishes tooth brush as an efficient cleaning method.

With regard to the frequency of brushing, 56% brushed once and 44% twice in urban population whereas 86% brushed once and 13% brushed twice in the rural population. A study reported by Osagie Akhionbre (2016)[10] showed that lower frequency of tooth brushing was associated with the increased presence of plaque, gingival inflammation. Considering the type of dentifrice used, toothpaste users were found to be more in number of subjects examined, indicating that toothpaste used with tooth brush was a very effective method of plaque control. The other aids such as charcoal, tooth powder, Neem stick were found to have deleterious effect on periodontium which were similar to findings by Silva and Zaveri,[5] Batra et al.[11] The present study reported the use of interdental aids like floss, interdental brushes and toothpicks to be more in urban population when compared to rural population.

CPITN status of the study participants revealed that, 183 (16.63%) participants among urban and 42 (7.63%) subjects among rural areas did not present with any type of periodontal disease. 628 (57.09%) subjects among urban and 201 (36.54%) participants among rural areas have gingivitis. The remaining 289 (26.3%) subjects in urban area and 307 (55.8%) participants in rural areas have periodontitis. The present study shows increased prevalence of periodontal diseases and TNs in the rural population. Similar findings were observed by GPI Singh (2005),[12] Singh and Kothiwale.[13]

Data analysis showed a high percentage of periodontal disease and TNs in the overall population (86%), which is relatable with other studies.

Similar outcomes were reported by Pol et al.,[14] Joshi and Marawar,[15] Bader et al.[16] PDI(Gingival and Periodontal Component) status of our study revealed that 14% of the study participants did not present with any form of periodontal disease, 50% of the population have gingivitis and remaining 36% of the population have periodontitis. The findings are in accordance with a study reported by Sheiham.[17]

Plaque component of PDI revealed that 1% of the study subjects don't have dental plaque accumulation while 53% of the study participants had plaque present on some but not all surfaces of the tooth and 31% of the study subjects had plaque present on all surfaces, but covering less than one half of these surfaces. 13% of the study participants had plaque extending over surfaces, and covering more than one half of these surfaces. This is in agreement with studies by and Pol et al.[14] Calculus component of the PDI revealed that 42% of the study participants did not have dental calculus while 17% of the study subjects had supragingival calculus extending only slightly below the free gingival margin (not >1 mm) and 22% of the participants had moderate amount of supra and subgingival calculus or sub gingival calculus alone. 18% of the study participants had an abundance of supra and subgingival calculus. The probable reason for this could be poor oral hygiene practices in the study population. This is in accordance with a study carried out by Torwane et al.[18] 14% of the study participants had good oral hygiene, 50%, fair oral hygiene and 36% were found to have poor oral hygiene. About 50% and 36% of the study population was found to have gingivitis and periodontitis, respectively, in the current study.

A limitation of the current study is that the samples were collected among the subjects who attended the urban and primary health centers. The burden of disease portrayed by the study might be slightly overstated due to the possibility of other systemic ailments (primary reason to visit health care center) which could influence periodontal disease.

CONCLUSION

The study was aimed to assess the overall prevalence of periodontal status with a comparison between urban and rural population and to also describe the various oral hygiene practices in Kancheepuram district population.

Higher prevalence of periodontal disease (86%) and TNs was observed, coinciding with lack of knowledge among the individuals about periodontal diseases. Habits such as smoking and methods of oral hygiene have a significant effect on the periodontal health and TNs. An increase in awareness could result in reduced prevalence, severity, and TNs. There was an increased frequency of chronic inflammatory periodontal disease in the rural population and most of this was untreated. In view of the difficulties in access to health care, it would be prudent to enhance preventive oral health care within the rural community by guiding the government to make policies toward better oral health maintenance with information from studies like the present one.

There also a need for further studies to be conducted with more detailed epidemiological data and surveys regarding the oral health status of the population of the area.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.