|Year : 2014 | Volume
| Issue : 1 | Page : 28-32
Assessment of periodontal health among the rural population of Moradabad, India
Manu Batra1, Pradeep Tangade2, Devanand Gupta1
1 Department of Public Health Dentistry, Teerthankar Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India
2 Department of Public Health Dentistry, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh, India
|Date of Web Publication||18-Aug-2014|
Teerthankar Mahaveer Dental College and Research Centre, Delhi Road, Moradabad 244 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Oral health is an integral component of general health and is essential for well-being. India is one of the most populated countries in the world and majority of them resides in rural areas. Moradabad is one of the oldest cities of Uttar Pradesh with diverse culture and beliefs. Aim: The aim was to evaluate the periodontal health status of the rural Moradabad population. Materials and Methods: A representative transversal study on 550 adults aged 20-49 years of rural Moradabad was conducted from February 2011 to June 2011. The survey was carried out using a self-designed questionnaire. Periodontal health was assessed using WHO criteria (1997). Results: Overall the prevalence of periodontal diseases among study subjects was overall 91.6%. Males had a higher prevalence of periodontal disease (93.8%) as compared to females (89.5%). Out of total subjects 37.8% had Community Periodontal Index (CPI) score 4 and 32.5% had score 3. About 7.3% of subjects had loss of attachment (LOA) with 20.2% of them having LOA score 1. Statistically, there was a significant difference (P < 0.001) among the number of subjects having different CPI and LOA scores. In a multivariate binary logistic model with age > 35 years, smoking, tobacco chewing (independent risk factors) were significantly associated with CPI > 2 (dependent variable) (P < 0.05). Conclusion: The current periodontal health status of rural adult population of Moradabad city can be attributed to low literacy along with socio economic status and oral habits. To improve the periodontal health status of the rural population of Moradabad, it is suggested that a community-based approach can be designed.
Keywords: Adult, moradabad, periodontal health, rural
|How to cite this article:|
Batra M, Tangade P, Gupta D. Assessment of periodontal health among the rural population of Moradabad, India. J Indian Assoc Public Health Dent 2014;12:28-32
| Introduction|| |
Oral health means more than good teeth. Oral health is an integral component of general health and is essential for well-being.  This wider meaning of oral health does not diminish the relevance of the two globally leading oral afflictions - dental caries and periodontal diseases.  Poor oral health conditions such as these have a profound impact on health and the general quality of life. 
In industrialized countries, oral health has markedly improved while in developing countries there has been a general deterioration. These patterns and trends have been monitored and demonstrated by the WHO Global Oral Data Bank. The increase in the prevalence of periodontal diseases, and the resulting pain, infection, and impaired masticatory functions are causing an increasing burden on populations in these countries. 
Periodontal diseases are one of the major causes of tooth loss in India. Gingival and periodontal diseases affect 90% of the population.  Prevalence of periodontal disease depends on variables like age, sex, race, ethnicity, education, geographic and environmental status, oral hygiene habits, living patterns, social characteristics and dental awareness. 
Moradabad is situated in western Uttar Pradesh, India between 28°-21′ to 28°-16′ Latitude North and 78°-4′ to 79 Longitude Ganga river flows to the south-west of the city. It is famous for brass metal handicrafts not only in India, but also abroad since ancient times.
Urbanization has been viewed as a strong determinant for a variety of different health outcomes. Rural areas have often been associated with poverty and access issues, both of which can have a profound impact on wellness. There are urban-rural differences in the average level of education, the kind of work people do, incomes, and in associated aspects of well-being. Rural populations continue to experience marked disparities in health and health care access. Oral health disparities are also noticeable because of the above mentioned factors.
Epidemiological studies assessing the oral health status of school children have been conducted in Moradabad city. However, the data on periodontal health status of rural adult population is still not available. The aim of the current study is to assess the periodontal health status of the rural adult population of Moradabad. The data will serve as baseline data for formulating strategies for periodontal health prevention and treatment in the region.
| Materials and Methods|| |
A population representative transversal study of adults aged 20-49 years of rural Moradabad was conducted from February 2011 to June 2011. For estimating the sample size, the minimum expected prevalence of periodontal diseases was considered as 80%. This was based on results obtained during the pilot study conducted in study area. The sample size was estimated to obtain the true value at 5% level of significance. Estimated sample size of 550 subjects was calculated. Multistage Sampling Technique was used. Moradabad district constitutes of 6 tehsils. From each tehsil, 3 villages were randomly selected. Dental camps were organized to obtain a representative sample of that particular zone. Inclusion criteria included subjects residing in a rural area for 10 and more years were considered eligible for the study. Exclusion criteria included edentulous persons and those who were medically compromised.
Ethical clearance for the study was granted by Institutional Ethical Committee. A self-designed questionnaire was used, to record the demographic data and information regarding oral hygiene practices. Periodontal health was assessed using WHO criteria (1997) which included Community Periodontal Index (CPI) and loss of attachment (LOA) assessment.  Socio-economic status was evaluated by Modified Prasad's classification (1961)  based on Per Capita Monthly Incomes.
Clinical examination was performed by one single examiner. Intra-examiner calibration was performed before the study began. The intra-examiner degree of agreement (k = 0.91, 0.86, 0.84, and 0.81) for calculus detection, bleeding on probing, probing depth and clinical attachment loss, respectively.
Portable equipment was used to ensure ease of transportation to the examination sites. An adequate infection control was maintained throughout the survey. The cold sterilization procedure was carried out in the survey with glutaraldehyde (15%) solution by immersing the instruments for about 20-30 min. The examinations were conducted in selected areas which were having adequate illumination and had minimum of noise disturbances to have proper examination and recording. The digital manipulation of the oral tissues was avoided where it was found unnecessary to reduce the risk of cross-infection.
The data was analyzed using PSPP 0.7 software. Chi-square test was used to test the level of significance of differences among the groups. Multiple logistic regression is used to assess the relationship between poor periodontal health (CPI > 2) and other independent variables.
| Results|| |
Among 550 subjects, the number of subjects in the age group 20-29 years was 220 (40%). The number of subjects in the age group 30-39 years was 199 (36.2%). There were 131 subjects (23.8%) in the age group 41-49 years. Statistically, there was no significant difference in age of subjects (P = 0.750). There were 321 (58.4%) males and 229 (41.6%) females. Statistically, the difference was not found to be significant (P = 0.713).
Distribution of subjects according to socioeconomic status showed that out of total subjects, 317 (57.6%) were poor or very poor. 185 (33.6%) were of lower middle class. 48 (8.7%) were of upper middle class. Statistically, there was a significant difference in socioeconomic strata of subjects (P < 0.001).
Out of total subjects, 218 (39.6%) were illiterates. Subjects having primary education were 142 (25.8%) whereas 77 (14.0%) had high school education. Subjects having intermediate education were 72 (13.1%). The number of graduate subjects was 39 (7.1%). Statistically, there was a significant difference in educational strata (P < 0.001) [Table 1].
|Table 1: Distribution of subjects according to age, gender, socioeconomic status and education |
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Toothpaste was the most common material used for cleaning teeth, brushing teeth was the most common method of cleaning. Once a day cleaning of teeth was most frequent practice of dental care. There was statistically significant difference between the groups for material and method used for oral hygiene practice as well as frequency of oral hygiene practice (P < 0.001) [Table 2].
Overall prevalence of periodontal diseases among study subjects was 91.6%. Males had a higher prevalence of periodontal disease (93.8%) than females (89.5%). Out of 550 subjects 37.8% had CPI score 4 and 32.5% had score 3, followed by 21.6% of subjects having CPI score 2 [Table 3]. 37.3% of subjects had LOA with 20.2% of them having LOA score 1. Statistically, there was a significant difference (P < 0.001) among the number of subjects having different CPI and LOA scores.
As compared to females, males had higher CPI score. An increasing trend of mean CPI was observed with increasing age, which was also significant statistically (P < 0.001) subjects having adverse habits of smoking, tobacco chewing and alcohol consumption had higher mean CPI score in comparison to nonusers; difference was statistically significant difference was seen individually for the adverse habits [Table 4].
|Table 4: Distribution of subjects affected by periodontal status of CPI>2 according to age gender and habits |
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Multivariate binary logistic model was applied with age > 35 years, male gender, smoking, tobacco chewing and alcohol as the independent risk factors for the outcome CPI > 2 which was dependent variable, except for gender and alcohol use, all the other variables were found to be significantly associated with the outcome CPI > 2 (P < 0.05). It was observed that probability of having higher score (CPI > 2) among those aged > 35 years was maximum (odds ratio = 6.73) whereas among alcohol users, it was minimum (odds ratio = 0.827). For all other risk factors, odds ratios were above unity [Table 5].
|Table 5: Multiple logistic regression analysis model of factors affecting periodontal disease CPI>2 among participants |
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| Discussion|| |
Despite great achievements in the oral health of populations globally, problems still remain in rural communities around the world. Dental caries and periodontal diseases have historically been considered the most important global oral health burdens. The current epidemiological survey was conducted to assess the oral health status and treatment needs of adults (20-49 years) residents of rural areas of Moradabad. The intention of the study was to provide systematic information on periodontal health status of the rural population of Moradabad, which will further aid in the planning/evaluation for prevention and oral health promotion program.
The periodontal status was assessed using the CPI and measurement of LOA. About 92% of the population in the sample was suffering from one or the other form of periodontal disease. Such high prevalence may be due to lack of dental health care facilities,  exposure to certain risk factors such as smoking, chewing tobacco and use of indigenous oral hygiene methods for cleaning teeth prevalent in a rural population. Furthermore, lack of oral hygiene awareness among the rural population must have contributed to the increased risk of periodontal disease among them. 
The prevalence rate for periodontal disease nationwide for 35-44 year age group was 89.2% according to National Oral Health Survey and Fluoride Mapping.  A study done by Chinmaya et al.  at Chitradurga showed that 92% of the population in the sample was suffering from one the other form of periodontal disease.
Males had a higher prevalence of periodontal disease (93.8%) than females (89.5%). It is in accordance with a study done by Salman et al.  which showed that females tended to have higher percentage of healthy gingiva. This may be due to the fact that there were differences in practice of oral hygiene between sexes. Another study done by de Macκdo et al.  showed a similar result that in men, the frequency of periodontal disease was 35% higher. Kumar et al.  has also showed that females had healthier periodontium than males. This might be due to the fact that females are more aware of maintenance of their oral hygiene and regular professional dental care. Males are more exposed to deleterious oral habits like tobacco chewing and smoking, which are established as high-risk factors for periodontal diseases.  A study done by Khamrco  reported the inverse result, that is, males having more healthy gingiva than females.
In the present study, smokers were more affected by periodontal disease than nonsmokers. The results are in agreement with the study done by Sood  who also reported higher prevalence of periodontal disease among smokers. A study done by Humagain and Upadhyaya  also reported that number of healthy sextants was lower in smokers than nonsmokers. The reason for such finding can be due to nicotine which leads to increase in secretion of prostaglandin E2 via up-regulation of lipopolysaccharide mediated pathways. Moreover smokers also tend to have poorer oral hygiene status than nonsmokers. Smoking also reduces antibodies in saliva and leads to xerostomia, which can cause many oral health problems. The vasoconstrictive effect of nicotine causes a reduction in gingival blood flow, which translates into a weakening of defenses of gingiva. Smoking also depresses level of circulating antibodies, chemotactic and phagocytic activities of oral polymorphonucleocytes. 
The occurrence of periodontal disease was higher in tobacco users than the tobacco nonusers. Similar results were seen in the study done by Parmar et al.,  the occurrence of periodontal pockets, gingival lesions and gum recession, were significantly higher in quid-chewers than in nonchewers. A review did by Shaju et al.  have a citation of the study done by Doifode et al. that reported significant association between tobacco chewing and periodontal disease. Another review done by Agarwal et al.  had cited a study done by Sumanth et al. who reported that deep pockets were more in pan chewers with tobacco than in pan chewers without tobacco, approximately four times more.
It was seen that alcoholic subjects were more affected by periodontal disease than nonalcoholic subjects. A study done by Krustrup and Erik Petersen  shows similar results, it has been cited that there is a positive association between excessive alcohol intake and periodontitis. A study done by Reddy et al.  reported that maximum gingival bleeding scores were observed in an alcoholic group and the least in tobacco smoking group among the various groups of substance users. Alcohol has a toxic effect on the liver and, as a result, the prothrombin production, Vitamin K activity, and clotting mechanism may be disrupted. Hemorrhage may occur, and this may lead to exaggerated gingival response and bleeding with the slightest provocation in alcoholics.
In a multivariate binary logistic model showed that age, smoking and tobacco chewing were significantly associated with periodontal disease. A study done by Sakki et al.  showed that while performing stepwise logistic regression analysis with occurrence of periodontal pockets deeper than 3 mm as dependent variable, most significant variables were dietary habits, alcoholic consumption, tobacco smoking and tooth brushing frequency. A study done by Krustrup and Erik Petersen  showed that while performing multivariate linear regression analysis of dependent variable percentage of teeth with certain periodontal condition showed that age, education and dental visit habits were significantly related. A study done by Benigeri et al.  reported that while performing logistic regression model for predilection of people with at least one pocket ≥6 mm according to various characteristics, after controlling the confounding factors, only sex and family income were associated with periodontal problem.
A limitation of the current study seems that the sample was collected among the subjects who attended the dental camps. The population attending would have some ailment which made them attend the camps therefore, the burden of disease portrayed by the study can be slightly exaggerated than the general population.
| Summary and Conclusion|| |
Current study was carried out to evaluate the periodontal health status of the rural Moradabad population which might serve as a tool for formulating national and regional oral health intervention strategies for the rural population of India. The prevalence of periodontal diseases among study subjects was 92%. Males had a higher prevalence of periodontal disease compared to females. Out of total subjects 37.8% had CPI score 4 and 32.5% had score 3 followed by 21.6% of subjects having CPI score 2. 37.3% of subjects had LOA with 20.2% of them having LOA score 1. The low periodontal health status of rural adult population of Moradabad city can be attributed to low literacy along with socio economic status and oral habits.
Suggestions and recommendations
The current periodontal health status of rural adult population of Moradabad city can be attributed to low literacy along with socio economic status and oral habits. To improve the periodontal health status of the rural population of Moradabad, it is suggested that a community-based approach can be designed with an initial curative care followed by preventive care. Since the literacy rate is low in a rural area in comparison to the urban area, in a rural area more emphasis should be laid in the rural area on the behavioral sciences and community-based oral health education by addressing the importance of oral hygiene and making people aware of the deleterious effects of substance abuse on oral health. Training of health workers, Anganwadi workers and school teachers to educate the target groups such as mothers and school children about oral health can also be beneficial.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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