Oral Hygiene Practices and Knowledge on Periodontal Diseases and Therapy: A Cross-Sectional Questionnaire Study on Gypsy Narikuravars in Puducherry.

Background: Gypsy "Narikuravars" constituted separate sociocultural groups having distinct cultures, customs, traditions, and lifestyles. Oral health-seeking behavior of this group remains to be an ignored part. This study aims to assess the oral hygiene practices and knowledge on periodontal diseases and therapy among Gypsy Narikuravars in Puducherry. Materials and
Methods: The total study population consisted of 100 subjects, and a performed validated pro forma about oral hygiene practices and knowledge on periodontal diseases was used.
Results: There is no significant association between sociodemographic factors and knowledge on periodontal disease and therapy. Majority (90%) of the participants have poor knowledge of periodontal disease and therapy. 56% of the participants used their fingers to clean the teeth, and very few subjects (13%) used toothbrush to clean their teeth, and most of the participants (92%) brushes once daily using manual method.
Conclusion: The practice of poor oral hygiene and lack of knowledge on periodontal disease and therapy was observed. Hence, the implementation of oral health programs and provision of comprehensive health services for these Gypsy population should be a high priority. Copyright:

INTRODUCTION

Widening inequities in oral health status and treatment needs exist among different social groupings and even within various countries.[1] In this modern era, there are people still living in isolation in natural and unpolluted surroundings with their traditional values, customs, and beliefs. They are known as “tribes,” for which India is a homeland providing shelter.[2] The tribal group constitutes about 8% of the total Indian population.[3] Among them, the Narikuravar community is playing a significant role. The Narikuravars are a “GYPSY,” seminomadic society that falls across borders but mostly lives in Tamil Nadu of India.[4] Their traditional occupation was hunting jackals and other animals in the forest of the sub-Indian continent, but hunting was outlawed. Hence, they switched occupations to bead making and cleaning the streets.[5] They are acknowledged to face inequity that transforms into low-socioeconomic status, low education level, and lack of suitable access to health care.[4]

Available research studies point out that the tribal population has distinctive health problems, which are mainly governed by their habitat, difficult terrains, and ecologically variable niches.[6] As periodontal diseases are the most widely prevalent disease in India, it is considered as a major health concern. It serves as a risk factor for many systemic diseases such as cardiovascular disease, preterm low birth weight infants, respiratory disease, diabetes mellitus, and cerebral infarction.[7] To date, there is no study available which describes their awareness of periodontal disease among Narikuravars in Puducherry. Hence, in the present study, an attempt has been made to assess the oral hygiene practices and knowledge of periodontal disease and therapy among Narikuravars in Puducherry.

MATERIALS AND METHODS

A cross-sectional questionnaire study was undertaken, and whole sample of 100 participants above the age of 18 years was included. The subjects who were willing to participate and those who gave consent were included in the study. A self-designed structured pro forma comprised patient information form, demographic details, informed consent form, and prevalidated questionnaire was prepared. The questionnaire addressed the knowledge about periodontal disease and therapy, oral-systemic disease link, and oral hygiene practices. The questions were translated into the local language. The content validity ratio was 0.63 indicating satisfactory results, and face validity of questionnaire was done by expert opinions. After obtaining the informed consent, questionnaire was administered by direct personal approach. The participants took 15 min to complete the questionnaire and there were no missing data.

Ethical approval

Ethical clearance was obtained from the Institutional Review Board of Indira Gandhi Institute of Dental Sciences (IGIDSIEC2016NRP54FASKPAI).

Statistical analysis

The collected data were organized, tabulated, and subjected to statistical analysis by the Statistical Package of Social Sciences Software (IBM SPSS statistics version 17, License Authorization Wizard.Ink, Chicago, USA). Descriptive statistics were generated in terms of percentages. Chi-square test was used to associate the demographic variables and knowledge status. Significance level was set at P ≤ 0.05.

RESULTS

The study included 100 tribes aged above 18 years belonging to the Narikuravar community in Puducherry. There was no missing data with respect to study participants (100% response rate).

Oral hygiene practices

Majority of the subjects (56%) used their finger to clean the teeth. Few of the subjects (13%) used toothbrush to clean their teeth, and 8% of the subjects did not use any material to clean their teeth. Almost 92% of the participants brushes once daily using manual method and however they were not sure of the type of the toothpaste. Nearly 86% of the subjects cleaned their teeth in the horizontal direction, and 6% used the vertical method of brushing. Very few subjects (13%) changed the brush more than 3 months, and they were not aware of the particular type of bristles used. None of them reported to use other forms of oral hygiene aids [Table 1].

Table 1

Distribution of the study subjects based on oral hygiene practices

Oral hygiene practices	Type	Frequency (%)
Brushing mode	Finger	56
	Toothbrush	13
	Others	24
	None	8
Frequency of brushing	Once	92
	Twice	0
	None	8
Method of brushing	Vertical	6
	Horizontal	86
	Circular	0
	None	8
Type of brushing	Manual	92
	Powered	0
	None	8
Type of bristles	Hard	0
	Medium	0
	Soft	0
	Not aware	13
	None	87
Duration of changing toothbrush (months)	1-2	0
	3	0
	>3	13
	None	87
Type of toothpaste	Medicated	0
	Nonmedicated	0
	Not aware	92
	None	8
Other oral hygiene aids	Mouthwash/dental floss	0
	None	100

Association between demographic variables and periodontal knowledge

Table 2 describes the association between demographic variables and knowledge of periodontal diseases. The knowledge scores were categorized into good knowledge and poor knowledge for analysis purposes. There were totally of 71 subjects with poor knowledge and 29 subjects with good knowledge about periodontal disease. Among 100 subjects, 48 were males and 52 were females. The subjects with poor knowledge among males were 33% and females were 38%. The association between gender and knowledge was not statistically significant (P = 0.634). Out of 71 subjects with poor knowledge, those who completed postgraduate was none, posthigh school was one, high school was two, middle school was 11, primary school was 18, and illiterate was 39. The association between education and knowledge was not statistically significant (P = 0.07). Similarly, among subjects with poor knowledge, one was farmer, two were skilled workers, two were semiskilled workers, 36 were unskilled, and 30 were unemployed. The association between occupation and knowledge was not statistically significant (P = 0.483). Similarly, there were three subjects in the income range of INR (1866-5546) and 68 subjects earned below INR 1865 among subjects with poor knowledge. The association between income and knowledge was not statistically significant (P = 0.554).

Table 2

The association between demographic variables and knowledge status among study subjects

Variables	Poor knowledge (%)	Good knowledge (%)	χ 2	P
Gender
Male	33	15	0.227	0.634
Female	38	14
Education
Postgraduate	0	1	9.859	0.07
Posthigh school	1	0
High school	2	0
Middle school	11	5
Primary school	18	2
Illiterate	39	21
Occupation
Farmer	1	1	3.468	0.483
Skilled worker	2	0
Semiskilled	2	2
Unskilled	36	17
Unemployed	30	9
Income (INR)
1866-5546	3	0	0.261	0.554
<1865	68	29

P>0.05 nonsignificant

Periodontal disease knowledge

Table 3 describes the knowledge of the study participants toward periodontal disease and treatment. The study results showed that 93% of the participants were not aware that oozing of blood from gums is a serious threat of gum infection as well as loosening of tooth is due to lack of gum support. Majority (91%) of the participants did not visit the dentist for soreness of gums, and they were not aware that treatment of gums prevents bad smell. Almost 89% of the population were not aware of the existing relationship between food lodgment and periodontal infection. 95% of the participants did not know that gum infection induces dull pain and is associated with diabetes. 89% of the population did not know about any specific gum treatment, and 98% did not know about the regeneration of supporting bone tissue through the treatment of gum infection. None of them were aware that mobile teeth could be stopped by treatment of gums.

Table 3

Distribution of the study subjects based on knowledge of periodontal disease and therapy

Questions	Yes (%)	No (%)
Do you know oozing of blood from gums is a serious threat of gum infection?	7	93
Have you promptly visited your dentist for frequent soreness of gums?	9	91
Do you know a relationship exists between food lodgment in the teeth and gum infection?	11	89
Have you heard of tooth loosening due to lack of tooth support?	7	93
Do you know that gum infection is associated with the dull type of pain and tendency to poke the gums with sharp objects?	5	95
Do you know most of the diabetic (excess blood sugar) patients will have gum disease?	5	95
Do you know about any gum treatment specifically?	11	89
Have you heard that gum treatment involves regrowth of affected tissues and bone supporting the tooth?	2	98
Do you know shaking teeth can be stopped by gum treatment?	0	100
Do you know gum treatment can prevent foul or bad smells?	9	91

DISCUSSION

The tribal societies throughout India have remained socially and culturally alienated from mainstream Indian society until developmental and conservation activities in tribal areas forced interactions between them.[8] A key public health challenge is to determine the health needs of indigenous populations using approaches that appropriately reflect their conditions and concerns while respecting their culture and identity.[9] The present study was the first of its kind, which was carried out to explore the oral hygiene practices and knowledge on periodontal disease and therapy in the population of Gypsy Narikuravars in Puducherry. These subjects have a residence at Narikuravas colony, Karuvadikuppam, approved by the Government of Puducherry.

Global epidemiological studies have found that periodontitis is extremely common.[10] Recent studies have also found a high prevalence of periodontitis in developing countries and among poor and minority populations. The alarming rise in the rate of prevalence of periodontal disease in India has drawn interest to conduct this survey.[1112]

The study design is cross-sectional, allowed the collection of information from the Gypsy population, and direct personal approach was used which gives an extremely good response rate. The study includes almost equal proportion of males and females to reduce variability. The occupation of majority of the participants in the study conducted among tribes in Telangana was business (65%); however, in the present study, most of the participants engaged in different unskilled occupations (53%) followed by unemployment (39%).[13] Similarly, majority of the respondents (60%) were illiterate, and most of the study population's income status was low. The study results suggest that very difficult economic situation experienced by Narikuravars in Puducherry. The education and poverty status would seriously affect the utilization of health care. Hence, there is an urgent need for various government initiatives such as local income-generating projects and allocation of education funds to empower this community.

In this study, we made an attempt to explore the periodontal disease and treatment awareness among the population, and it was observed that majority of the respondents had poor knowledge about periodontal disease and treatment. The association between sociodemographic factors and knowledge on periodontal disease and treatment was not statistically significant.

The study assessed the various oral hygiene practices. There are no traditional or improved methods of oral hygiene for the maintenance of oral health. Majority of the participants cleaned their teeth using their fingers, and few of them used neem sticks and brick powder. This is in contrast to the study conducted by Sindhu et al., wherein the majority of the nomadic subjects (64.3%) used toothbrush with toothpaste.[14] The present study showed only a few subjects (13%) change the toothbrush once in 3 months, whereas 33% of subjects of the Paniya tribes change the toothbrush once in 3 months.[15] Toothbrushing drills and oral health education programs highlighting the benefits of oral hygiene should be conducted among these populations.

There is a dire need for periodontal disease screening and treatment protocol with emphasis on motivation of individuals to seek good oral hygiene practices. Mobile dental services are a viable option to render oral health service to the doorsteps of trial population. Strategies should be designed with an understanding of sociocultural beliefs of the community. As there is dearth of information about oral health status on Narikuravars, the data collected in this study would possibly help to bridge the gap between Gypsy and health-care workers. Further, studies to know the prevailing oral health myths, oral health behavior, and periodontal status of the Gypsy population are required.

The present study has few limitations. The usage of interviewer-'administered questionnaires introduces elements of recall bias and social desirability bias. The periodontal examination could not be performed, as most of these tribes were resistant to undergoing dental screening. This implies that the perceived benefits of oral health needs among Narikuravars tribes are low.

CONCLUSION

The present study concludes that almost 90% of the population had poor knowledge about periodontal disease and the various causes leading to the same. The Narikuravar population was not aware of basic oral hygiene practices like proper toothbrushing methods, materials used for toothbrushing like toothpaste, and other oral hygiene aids. This present study data is useful in bringing about periodontal diseases awareness in these populations. There is an urgent need for comprehensive oral health-care services, and community-based oral health literacy interventions should be made available to these populations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.