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Year : 2016  |  Volume : 14  |  Issue : 4  |  Page : 389-396

Prevalence of dental caries, patterns of oral hygiene behaviors, and daily habits in rural central India: A cross-sectional study

1 Department of Health Sciences, Florida Gulf Coast University, Fort Myers, Florida, USA
2 Department of Health and Kinesiology, Texas A & M University, Texas, USA
3 Department of Health, Physical Education and Exercise Science, Lincoln Memorial University, Harrogate, Tennessee, USA

Date of Web Publication15-Dec-2016

Correspondence Address:
Payal Kahar
Department of Health Sciences, Florida Gulf Coast University, Fort Myers, Florida
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2319-5932.195828

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Introduction: Dental caries is seen across all age groups and in all populations. Several sociobehavioral factors existing in a broader cultural and environmental context can affect caries prevalence. Aims: To determine the prevalence and severity of caries across gender, age, and educational levels and to study the association between oral hygiene behaviors, daily habits, and caries. Materials and Methods: The cross-sectional study recruited participants ≥18 years from Ramgarh, Chhindwara district in Madhya Pradesh, India. Information was collected on demographics, oral hygiene behaviors, and daily habits. Overall caries experience was quantified using decayed, missing, filled tooth index through intraoral examinations. Results: Use of toothbrushes, (P < 0.001) toothpastes (P < 0.001), and fluoridated toothpastes (P = 0.01) was significantly higher in younger participants aged 18–34 years than in older adults. Brushing twice daily (P = 0.05), use of toothbrushes (P < 0.001), toothpaste (P < 0.001), and fluoridated toothpaste (P < 0.001) was significantly higher among participants with ≥8 years education than participants with no formal education or ≤8 years of education. Use of tobacco was significantly more common among people with no education, people with ≤8 years of education (P = 0.02), and males (P < 0.001). Participants ≥45 years had 3.2 times higher odds of having decayed, missing, filled teeth scores ≥1 than the younger age groups. Conclusions: Poor oral hygiene behaviors among older adults, males, and participants with ≤8 years of education were associated with higher caries experience and missing teeth as a result of caries.

Keywords: Daily habits, decayed, missing, filled teeth score, oral hygiene behaviors, rural adult

How to cite this article:
Kahar P, Harvey IS, Tisone CA, Khanna D. Prevalence of dental caries, patterns of oral hygiene behaviors, and daily habits in rural central India: A cross-sectional study. J Indian Assoc Public Health Dent 2016;14:389-96

How to cite this URL:
Kahar P, Harvey IS, Tisone CA, Khanna D. Prevalence of dental caries, patterns of oral hygiene behaviors, and daily habits in rural central India: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2022 May 19];14:389-96. Available from: https://www.jiaphd.org/text.asp?2016/14/4/389/195828

  Introduction Top

Dental caries is considered one of the most ubiquitous noncommunicable diseases with a worldwide prevalence of 35% for all ages combined contributing to the global burden of diseases.[1],[2],[3],[4] Oral conditions affect 3.9 billion people, and untreated caries is the most prevalent condition. Untreated caries resulted in average health loss of 4562 years per 100,000 population in 2010 (disability-adjusted life years).[3]

Based on published literature, little is known at this point about oral health in the rural adult population of central India. While an increasing number of studies exists, which assess the prevalence and severity of caries among children and urban populations, researchers see a paucity of socioepidemiological information on levels of caries found across the lifespan among rural residents.[5],[6],[7],[8] India is the second most populous country in the world with 70% (i.e., 851 million) of the population residing in rural regions.[8],[9] Essential health services are barely provided in rural areas, let alone oral health-care delivery. There is one dentist serving over a population of 2,50,000 in rural India.[10]

Behaviors such as tobacco use, dietary and brushing habits, and dental care visit influence oral health to a large extent. Controlling such modifiable risk factors is one of the important aims of oral health promotion programs. Furthermore, health education programs are cost-effective in India, which allocates <5% of the gross domestic product (GDP) toward total health care expenditures.[11] While allocation toward health-care expenditures is not known in Madhya Pradesh, the state's per capita GDP is the fourth lowest in the country.[12] Delivery of restorative dental care service is more expensive and also less feasible with limited resources.[13]

The clinical assessments and findings on oral behaviors in this study, greatly enhance the existing body of literature on oral health in developing nations, as well as determine the nature and urgency of health intervention required in rural communities. The objectives of this study were (1) to determine the prevalence and severity of dental caries by assessing the decayed, missing, filled teeth (DMFT) index by gender, age, and educational levels and (2) to study the relationship of oral hygiene behaviors, daily habits, and dental caries.

  Materials and Methods Top

A cross-sectional study recruited participants from Ramgarh, a village located in district Chhindwara, Madhya Pradesh, from July 2014 to December 2014. The research had been conducted in full accordance with the World Medical Association Declaration of Helsinki. The Institutional Review Board at a large Texas university reviewed and approved the survey questions and study procedures. Based on the population size of 800 adults in the village, confidence level of 90%, and margin of error of 5%, the estimated sample size was 202 adults.

Individuals who reported being over the age of 18 years and residents of the village were included in the study, and pregnant women were excluded from the study. The gatekeeper (village priest) and the author went to all the houses in the community, approached the occupants, and identified and listed adults over the age of 18 years. Adults were picked randomly and asked if they were willing to participate in the study. Only those who consented to participate were included in the study.

Participants underwent intraoral examinations performed by a trained dentist, and they had to answer a few questions pertaining to their oral hygiene behaviors and daily habits.

The questionnaire in Hindi prior to administration was checked by a public health professional based in India for content validity. Questions pertaining to oral hygiene behaviors and daily habits were adapted from the World Health Organization (WHO) oral health questionnaire for adults.[14] Some terms that seemed confusing or were unheard of were either eliminated or rephrased. Moreover, the questionnaire, pilot tested among eight residents, provided an opportunity to validate the wording of a few questions. To ensure intraexaminer reproducibility and reliability, a total of 25 participants were reexamined for dental caries at tooth level, and a perfect agreement was found with a value of kappa statistics to be 1.

The study collected information on age, gender, and educational levels, as well as oral hygiene behaviors, such as frequency of teeth cleaning per day, type of dentifrice used, whether or not toothbrush, and fluoridated toothpaste were used. Information was also collected on daily habits, such as the use of tobacco, alcohol, sweetened tea, and snacking habits. Age was noted as age at last birthday. While age or birth year was not recalled accurately by a majority of the participants, “age” in those cases was estimated based on major life events, such as their wedding year or the birth years of their children.

The clinical examination included the number of teeth that were decayed, missing, and filled as a result of caries. The WHO oral assessment form for adults was used to record the results of intraoral examinations.[2],[14]

Frequency distributions of demographics and caries prevalence (mean DMFT scores and percentage of adults with caries) were obtained using the SPSS Statistics version 22 (IBM SPSS version 22, Chicago, IL). Chi-square statistics were used to examine the associations of oral hygiene behaviors and daily habits by age, gender, and educational levels. Binary logistic regression was used to estimate the demographic variables, oral hygiene behaviors, and daily habits that influenced overall caries experience.

  Results Top

The sample consisted of 56% females and 44% males. The average age of the participants was 35.5 ± 15.1 years. About 11% of the study participants had no formal education. The majority of the participants (43.6%) had >8 years of education [Table 1]. Approximately 90% of the sample had very low to low levels of caries, and 6.9% of the sample population had high levels of caries (WHO caries severity criteria).[14]
Table 1: Demographics and levels of caries experience according to the WHO severity criteria (n=202)

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Females had a higher percentage of total lifetime decay (77.9%) and untreated decay (66.4%) as compared to males. While the percentage of total caries increased with the increase in age, individuals 35–44 years of age had the highest percent of untreated decay (70.5%). The overall prevalence of caries decreased with increasing educational levels; however, the same pattern was not observed with untreated decay. Participants with higher educational levels had more untreated decay than participants with no formal education or educational levels <8 years [Table 2].
Table 2: Percent of adults with caries and untreated decay in permanent teeth, prevalence of caries among adults by gender, age, and educational levels (n=202)

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The mean DMFT score for the study population was the mean number of filled teeth across all categories which was <1. With respect to gender, males had a higher DMFT score (4.6 ± 6.6), missing (2.6 ± 6.7), and filled teeth (0.03 ± 0.24) compared to females. The mean number of decayed teeth decreased with increasing age, while the overall number of caries increased with advancing age. Individuals older than 55 years had a mean DMFT score of 10.7 ± 9.8, compared to young adults (18–24 years) who had a DMFT score of 2.2 ± 2.1. Study participants with >8 years of education had lower mean DMFT than participants with no formal education or <8 years of education. However, these participants had a slightly higher mean decayed score (2.1 ± 2.1) when compared to other educational categories [Table 3].
Table 3: Mean number of decayed, filled, and missing teeth due to decay by gender, age, and educational levels, severity of decay measured by number of permanent teeth affected (n=202)

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Younger individuals (18–34 years) reported brushing their teeth with a toothbrush (72.7%) and toothpaste (55.6%) as compared to individuals older than 34 years (χ2 = 42.1; P < 0.001; χ2 = 28.4; P < 0.001, respectively). Individuals older than 34 years used toothpowder for cleaning purposes (71.2% for individuals >45 years). Similarly, younger adults (18–34 years) reported using fluoridated toothpaste, compared to mid- to late-life adults (>45 years) (χ2 = 16.8; P = 0.01) [Table 4].
Table 4: Distribution of oral hygiene behaviors and daily habits by age groups (n=202)

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Individuals with >8 years of education reported brushing twice daily (χ2 = 9.53; P = 0.05) using a toothbrush (χ2 = 35.4; P < 0.001) and toothpaste (χ2 = 28.0; P < 0.001) for cleaning, compared to individuals with either no formal education or education <8 years. Individuals with no formal education and <8 years of education reported smoking or chewing tobacco (χ2 = 1 1.7; P = 0.02). Similarly, the use of fluoridated toothpaste was more common among participants with higher educational levels (χ2 = 21.7; P < 0.001) [Table 5].
Table 5: Distribution of oral hygiene behaviors and daily habits by educational levels (n=202)

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The only daily habit that showed a statistically significant association in the bivariate analysis was the use of tobacco. Men were more likely to smoke or chew tobacco than females, and this difference in behavior was found to be statistically significant (χ2 = 23.6; P < 0.001) [Table 6].
Table 6: Distribution of oral hygiene behaviors and daily habits by gender (n=202)

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Binary logistic regression was carried out with the DMFT score (i.e., overall caries experience) as the dependent variable [Table 7]. Independent variables included age, gender, educational levels, and oral hygiene behaviors: Frequency of cleaning teeth, use of toothbrush, and type of dentifrice and daily habits: Drinking tea with sugar, use of tobacco, snacking in-between meals habit, use of fluoridated toothpaste, and use of alcohol. The result between the unadjusted and adjusted odds ratio was consistent for the variable age and significant. Participants aged 45 years and above had 3.2 times higher odds of having DMFT scores >1 than the younger age groups.
Table 7: Logistic regression with decayed, missing, f.ifilled teeth recorded (decayed, missing, filled teeth=0 vs. decayed, missing, filled teeth ≥1) as the dependent variable (n=202)

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  Discussion Top

Oral diseases, such as dental caries, show an increasing incidence and prevalence in middle-income countries such as India.[14] This study appears to be the first study that looks at the prevalence of dental caries and its associated factors in the rural community of central India. Prior literature also indicated the association between oral hygiene behaviors and dental caries. In a study conducted in a deprived district of Karachi, Pakistan, 32% participants who chewed pan and 27% used their fingers for tooth cleaning had increased risks for oral health problems.[15] In another study among the middle-aged and elderly population of Kaunas city, Lithuania, DMFT was lower among those who brushed their teeth twice daily than those who brushed their teeth once daily or less frequently (23.04% vs. 24.01%).[16]

While a greater percentage of females had untreated decay and caries experience, males had higher mean DMFT scores than females. While the findings showed females brushed more often, used toothbrush, and were mostly nonusers of tobacco as compared to males; further probing during interviews indicated their access to dental care was limited. Anecdotal information suggested that a majority of females avoided seeking dental treatment even if they had excruciating pain due to time constraints or financial reasons. While females were mostly dependent on their spouses for their financial needs, they also had additional responsibilities of caregiving. Previous studies documented a higher prevalence of untreated decay and caries among females and indicated economic dependency and social roles among the few factors that contributed to higher rates of untreated caries.[17],[18] Males, on the other hand, had higher mean DMFT scores and missing teeth mostly due to using tobacco and infrequent teeth cleaning. The national cross-sectional study in India showed tobacco chewing and smoking to be high in Madhya Pradesh (35.4%–40.4% of men smoked tobacco and 36.3%–45% of men chewed tobacco).[19] Results of our study showed a higher percentage (51.7%) of men either chewed or smoked tobacco.

The mean DMFT index for this sample was 3.99 ± 5.70 with missing teeth, comprising a higher percentage of the total DMFT score. People in this community considered tooth loss as a natural consequence of aging. The mean DMFT of 2.9 ± 2.9 among individuals between the ages of 35 and 44 years was lower than the mean DMFT score of 5–8.9 as reported by the WHO Global Review of Oral Health among the same age category in India.[1] The odds of having a DMFT score >1 increased with advancing age, with the age group 45 years and above having 3.2 times higher odds than younger age cohorts indicating dental caries to be age related.

While caries prevalence was highest among participants with lower educational levels, the decayed teeth index was highest among participants having >8 years of formal education. Both age groups (i.e., those 35–44 years followed by 18–24 years) had a higher percentage of untreated decay when compared to those older than 45 years of age. This difference implies that younger people attain higher levels of education when compared to the older generation but also a shift in dietary habits with increased consumption of refined sugars and lesser frequency of tooth brushing that resulted in higher incidences of dental caries among these subgroups. In a study in Uruguay, mean DMFT increased with age; 15.2 and 24.12 for the 35–44 and 65–74 years age groups, respectively. In addition, mean number of decayed teeth was 1.7 in adults and 0.66 in elders. High prevalence of dental caries among 35–44 years age group was related to low socioeconomic status, infrequent tooth brushing, and need for oral care.[20]

The filled teeth index was <1 in the study sample, indicating that access to dental care was almost nonexistent. Further exploratory questions during interviews indicated that people sought professional help only in cases of severe dental pain; otherwise frequently resorted to self-care methods such as using pain medications, using warm saline rinses, and avoiding foods such as red lentils, cauliflower, eggplant, and pumpkin they believed aggravated pain and swelling.

The level of caries experience in the study sample was very low to moderate in accordance with the WHO classification of caries severity index.[2] Several factors can contribute to such levels of caries prevalence.

Areca nut, consumed alone or with other ingredients, has been documented to cause dental attrition and staining of teeth; however, this could provide protection against dental caries.[21] While this study did not collect data on the prevalence of areca nut chewing, the nut was commonly chewed among both males and females along with paan (betel leaf) or paan masala.

Fluoride histories were unknown for participants, but the use of fluoridated toothpaste was seen more in younger age groups and among people with higher educational levels. It should be noted that the water quality assessments in surrounding areas of Chhindwara district have shown water fluoride levels to be higher (>10 mg/l) in that region than national and international water quality standards, mitigating the effects of poor oral hygiene, and the use of tobacco found in this community.[22]

Results also showed that frequency of drinking sweetened tea was only once daily for a majority of participants. Likewise, snacking in-between meals was only among 29%–36% of the participants with older age groups showing the lesser prevalence of this habit. On the other hand, a trend of increased snacking of packaged food among young-to-mid-life adults resulted in higher percentage of younger age group with untreated decay and prior evidence has shown the association between intake of refined food and caries occurrence in young adults.[23]

While daily habits such as the use of tobacco contributed to caries prevalence, the oral hygiene behaviors seemed insufficient in preventing oral diseases among the participants. Only 38% of the sample brushed twice daily and slightly >50% used toothbrushes for cleaning purposes. Further, probing during interviews and observations indicated chew sticks and fingers were more likely to be the chosen for teeth cleaning among individuals older than 34 years. Toothpowders, often herbal and locally manufactured containing high amounts of abrasives, were used by more than half of the participants. These toothpowders were believed to act as medication for tooth pain, swollen gums, and bleeding.[24] Other toothpowders contained tobacco that people claimed to have a sedating effect on their gums and teeth and provide temporary relief from orodental pain.[25],[26]

To the best of our knowledge, this is the first study that explored the caries prevalence and severity levels, and also identified the associations between oral hygiene and daily habits to caries in the village of Ramgarh in Chhindwara district. However, some inherent limitations of this study should be noted. Generalizing results to neighboring villages warrant some caution. This study sample consisted of more females, as well as younger participants. Self-report biases may have been incorporated when participants were asked about oral hygiene behaviors and other oral health-related habits. While participants were asked for the reason of tooth loss, low levels of literacy, and limited understanding of questions may have overestimated DMFT index when tooth loss could have been due to periodontal diseases or other reasons.

  Conclusions Top

Results from this study indicate participants had varying levels of caries and unmet treatment needs according to age categories. Poor oral hygiene behaviors found among older adults (45 years and older), especially males participants with <8 years of education, resulted in more caries and missing teeth as a result of caries. The community at large should be made aware of the importance of good oral hygiene behaviors and health hazards of tobacco consumption.


Oral health prevention programs designed in the form of educational campaigns should promote the use of toothbrush with fluoridated toothpaste. Likewise, health education with a greater emphasis on addressing myths of perceived benefits and health risks targeted for males and older individuals can help to reduce tobacco consumption rates. Future research should test the impact of such educational campaigns and interventions.


The authors are grateful to Dhananjay Dubey, Divya Sharma, and Shankar Lal Kahar for their contributions toward recruitment of participants.

Financial support and sponsorship

This project was partially funded by College of Education and Human Development, Texas A and M University. The other costs incurred in this project were covered through out-of-pocket expenses.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

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