Journal of Indian Association of Public Health Dentistry

: 2019  |  Volume : 17  |  Issue : 3  |  Page : 181--185

Differences in oral health status leading to tooth mortality based on socioeconomic stratification: A cross-sectional study

Nijampatnam P.M Pavani, Pachava Srinivas, Nandita Rani Kothia, Viswa Chaitanya Chandu, Vikram Simha Bommireddy, Srinivas Ravoori 
 Department of Public Health Dentistry, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India

Correspondence Address:
Dr. Nijampatnam P.M Pavani
Assist. Professor, Department of Public Health Dentistry, SIBAR Institute of Dental Sciences, Takellapadu, Guntur, Andhra Pradesh


Background: Oral health is always an inseparable part of general health. The inequalities in socioeconomic status (SES) are the causes of many health disparities including oral health in the world. Aim: To document the differences in oral health status leading to tooth mortality based on socioeconomic stratification. Materials and Methods: A cross-sectional study was done using stratified random sampling. Centers/facilities providing dental care were stratified into government general hospital (GGH), teaching dental hospital (TDH), and private dental clinics (PDCs). Sample size was taken as 750. Demographic data were taken from each patient; clinical examination of existing teeth was done, while decayed-missing-filled teeth (DMFT) and community periodontal indices were recorded. Data were analyzed by Statistical Package for the Social Sciences software version 20, and Chi-square, ANOVA, and Spearman correlation tests were used for statistical analysis. Significance level was set at P ≤ 0.05. Results: Of the total study subjects, 40% (n = 300) were taken from TDH, 33.3% (n = 250) were taken GGH, and 26.7% (n = 200) were taken from PDCs. A majority (50.5%) of them belongs to the upper-lower class. Majority (n = 412) were with community periodontal index (CPI) score of 2, and most of the people (n = 175) had loss of attachment (LOA) score below 2 6–8 mm), of which a majority of them belonged to upper-lower and lower SES. Both CPI and LOA were statistically significantly related with SES ( P < 0.001). As SES decreased, the mean DMFT increased and this relation was highly significant ( P < 0.001). The mean number of teeth to be extracted was increased with increased SES. Conclusion: Inverse correlation was observed between SES and mean DMFT. Majority of the low socioeconomic people were with sub- and supra-gingival calculus. It implies that socio-economically disadvantaged people are in great need of dental treatment. Hence, dental health education programs should be targeted to uneducated and low-income groups to reduce the rate of extractions.

How to cite this article:
Pavani NP, Srinivas P, Kothia NR, Chandu VC, Bommireddy VS, Ravoori S. Differences in oral health status leading to tooth mortality based on socioeconomic stratification: A cross-sectional study.J Indian Assoc Public Health Dent 2019;17:181-185

How to cite this URL:
Pavani NP, Srinivas P, Kothia NR, Chandu VC, Bommireddy VS, Ravoori S. Differences in oral health status leading to tooth mortality based on socioeconomic stratification: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2020 Jul 8 ];17:181-185
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Full Text


One of the fundamental rights of every human being, irrespective of race, religion, economic, and social conditions, is enjoying the highest attainable standard of health.[1] Health is influenced by many factors such as genetics, lifestyle, environment, and socioeconomic status (SES) and it is multifactorial. In the last few decades, we have witnessed that social and economic factors have as much influence on the health as much as medical interventions. Hence, health cannot be isolated from its social context.[2] Oral health is always an inseparable part of general health. The inequalities in SES are the causes of many health disparities, including oral health in the world.[3] Oral diseases place a huge social burden and also an economic burden on the population in terms of many sufferings, expenditure on treatment, and prevention.[4] There is a severe influence of oro-dental disease upon the whole community, and it plays an adverse role in general health.[5] Because of recent shifts into unhealthy diets such as rich in sugar and increase consumption of tobacco, the burden of oral diseases is likely to grow in many developing countries.[6] Extraction is the terminal event in the life of a tooth and is a frequent episode in the people with uncared and neglected oral cavity.[7]

Tooth loss and edentulism, one of the major public oral health problems in India, has been reported to be on decline in developing countries.[8] Industrialized countries spend 5%–10% of their national public resources (gross national product) on oral health care of people every year, while no budget allocation for the same in developing countries.[9] Even though there is an increase in specialization and fields of medical practice in the country, no changes have been seen in the service provision for oral health care and oral hygiene status. We need some modifications which will involve oral healthcare services at the primary, secondary, and tertiary levels of healthcare delivery systems. These bring a noticeable improvement in the knowledge, attitude, and practices in the general people in terms of nutrition, oral hygiene, and health-seeking behavior.[5] Low priority is given to the dental health in India, and it is not astonishing to find that the oral health problems have received adequate attention.[10] Differences in the prevalence of oral health problems between individuals of higher and lower SES can be described as the concept of socioeconomic inequalities in oral health. Therefore, the intention was to find the differences in oral health status, leading to tooth mortality based on socioeconomic stratification.[11]


This study was cross-sectional in design. Ethical clearance was obtained from the institutional review board (No. 138509010). The study was carried out in Guntur city which is one of the medical hubs in India. Guntur offers a wide access to top medical care at reasonable prices and has a variety of charity hospitals that serve as a safety net for the destitute. It possesses major medical facilities (super-specialty hospitals) and related research institutions.

Centers providing dental services in Guntur were stratified into government general hospital (GGH), teaching dental hospital (TDH), and private dental clinics (PDCs). Reason behind this stratification was to include people from different socioeconomic level as they choose different types of healthcare centers based on their priorities and opinions. Necessary permissions were taken from the superintendent of GGH, principal of TDH, and practitioners in selected PDCs in advance.

A pilot survey was conducted and the number of extractions per day at different centers was recorded. The results of the pilot study showed that 35.8% of patients attending GGH, 42.83% of patients attending TDH, and 28.6% of patients attending PDCs underwent extraction over 3 weeks. Therefore, the prevalence of dental extractions on an average was taken as 39%. Absolute level of precision (d) which specifies the width of the confidence interval was kept as 5. The sample size was calculated using below formula.


The estimated sample size was 746. It was rounded to 750 for the convenient division of the sample into three categories. Stratified random sampling technique was adopted to draw the appropriate and representative sample. Sample drawn from each type of center was in proportionate to the average number of patients undergoing extractions per day as per the records (pilot survey) at different types of centers.

Since there were only one GGH and only one TDH in Guntur that provide services for low cost and conduct free camps throughout the district, they were included in the study without sampling. Fifteen PDCs were randomly selected from a total of 107 dental clinics in Guntur.[12] All adult patients who were willing to participate and gave consent were included. Patients with restricted mouth opening were excluded.

The pro forma was prepared in English, and the investigator had interviewed the patients in the regional language Telugu. The investigator had prior training on the interview procedure and was supervised by a group of experts in the initial phase of data collection. Demographic details were taken from each patient. SES division was done in accordance with the modified Kuppuswamy scale (2014).[13] Clinical examination for remaining existing teeth status was done using community periodontal index (CPI), loss of attachment (LOA) index, and dentition status and treatment needs as per the World Health Organization Basic Oral Health Survey 1997. Type III American Dental Association examination[14] was done using mouth mirror, CPI probe, and adequate illumination. Data were analyzed by IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM Corp.), and statistical tests used were Chi-square test, ANOVA, and spearmen correlation test. P ≤ 0.05 was considered statistically significant.


In the study sample, 40% (300) were taken from TDH, 33.3% (250) were from taken GGH, and 26.7% (200) were taken from PDCs. Half of the study subjects belonged to upper lower socioeconomic class, i.e., 50.5%. Most of the upper (52.5%) and upper-middle (59.7%) class people were visiting PDCs and most of the lower-middle (48.7%), upper-lower (47.5%), and lower class (39.6%) people were visiting TDH and GGH [Table 1].{Table 1}

Oral hygiene behavior of the participants was documented, and it was found that there was no significant difference in the oral hygiene behaviors between patients from three different types of oral health facilities consider in the study.

Periodontal status was assessed using CPI by taking CPI scores and LOA scores [Table 2]. The highest CPI and LOA scores among the sextants examined in a person were taken as CPI and LOA scores, respectively, for that person. Half of the subjects (n = 412) were with supra- and/or sub-gingival calculus, of which 261 (63.3%) subjects belong either upper-lower or lower class. 57.5% (n = 431) of the study subjects were with no LOA and most of the people who had LOA were underscore two (LOA of 6–8 mm), a majority of them belong to upper-lower and lower SES. Both CPI and LOA had statistically significant association with SES ( P < 0.001).{Table 2}

Mean decayed-missing-filled teeth (DMFT) was found to be highest in the lower class. The difference was statistically significant ( P < 0.001). As SES decreased, the mean DMFT increased [Table 3]. Spearman correlation test showed significant weak positive correlation between SES and DMFT (r = 0.2, P < 0.001).{Table 3}

As SES decreased, the number of teeth to be extracted increased, but reverse was observed for number of teeth retained after a scheduled extraction [Table 4].{Table 4}

SES showed highly significant positive correlation with the number of teeth to be extracted (r = 0.234, P < 0.001) and highly significant negative correlation with the number of retained teeth after a scheduled extraction (r = −0.289, P < 0.001).


Tooth loss can be considered as dental equivalent of mortality. It is the end product of many dental diseases and it reflects the SES and attitude of patients toward availability and accessibility of dental care. One of the major handicaps in the elderly population is the loss of tooth affecting mastication, dietary intake, and nutritional status. Many studies have consistently shown the role of specific diseases such as dental caries and periodontal disease as major causes of tooth loss.[15] Studies have long established a close relationship between SES and health.[16],[17],[18]

The study results showed that the majority of the people were visiting TDH for oral care. This may be attributed to less treatment cost and/or availability of all specialty treatments in one place. Most of the study participants belonged to lower SES, indicating that people from low SES are getting massive dental problems because of poor oral hygiene practices,[17] lack of awareness on the etiological factors for oral diseases,[18] and poor utilization of dental services.[19],[20],[21] Poor utilization may in turn be related to cost, lack of knowledge and motivation toward dental care,[20],[21],[22],[23],[24] lack of awareness on the provision of reimbursement for dental care,[25] low priority given to dental health, and lack of perception of the fact that the teeth are worth saving.[26]

The maximum number of upper-class people was visiting PDCs. This may be because they are staying within the city limits, good at affording conservative treatment, lack of time in the morning sections, high quality and quick treatment, the feasibility of dental clinics, convenient appointments, etc.[27],[28],[29]

Most of the subjects were with sub- and/or supra-gingival calculus and LOA 6–8 mm. Higher number of subjects in upper-lower and lower-middle class categories were with CPI scores 1–4. Similar results were seen in a study by Chandra Shekar and Reddy[26] because of poor oral hygiene practices,[30],[31] nonutilization of dental services, presence of deleterious oral habits such as smoking,[17] pan chewing,[30],[32] and the lack of awareness on the dental diseases,[3] which are proven to have a role in determining the periodontal status of an individual. This poor periodontal status for long period ultimately leads to tooth mortality.

In this study, SES and mean DMFT were showing inverse relationship. Mean DMFT was more in the lower SES group, indicating the neglecting oral health behavior. Similar results were seen in the study done by Chandra Shekar BR and Reddy C. Where mean number of teeth to be extracted was increased as the SES decreased.[26] In lower SES classes, the number of teeth to be extracted was more, and at the same time, the number of teeth retained in the oral cavity was less. This might be attributed to poverty, ignorance, and lack of knowledge about dental care.[5] They give little or no importance for the preservation of their teeth for the entire lifetime and prefer extraction over restoration[33] because of less affordability and more time consumption. In contrast, high income permits access to good oral health services and good environment for health and offer opportunities to adopt to appropriate oral health behavior.[34] In general, losing teeth in turn shows a great impact on their quality of life.

In our study, the number of teeth to be extracted was positively correlated SES and reverse was true in case of number of teeth retained after a scheduled extraction. It was highly statistically significant.


Low SES people are in great need of dental treatments. Dental health education should be targeted to uneducated and low-income groups to reduce the rate of tooth mortality. Every dental professional should take care of their patients and has to encourage toward fulfillment of their dental normative needs and should take care of preventive dental care and create awareness regarding proper utilization of government dental health schemes.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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