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Year : 2021  |  Volume : 19  |  Issue : 3  |  Page : 201-205

Utilization pattern of dental care and dental caries prevalence among children aged 12- and 15-year in Himachal Pradesh, India

Department of Public Health Dentistry, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh, India

Date of Submission07-Dec-2020
Date of Decision29-Apr-2021
Date of Acceptance14-Sep-2021
Date of Web Publication15-Oct-2021

Correspondence Address:
Sumeet Bhatt
Department of Public Health Dentistry, Himachal Institute of Dental Sciences, Paonta Sahib, Sirmour - 173 025, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_218_20

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Background: Regular dental visits are associated with better oral health outcomes in children. In India, data on the utilization of dental services among children are insufficient. Aim: The aim of this study was to find the prevalence of dental services use among 12- and 15-year-old school children and to assess if there is an association between utilization pattern and dental caries prevalence. Materials and Methods: A cross-sectional survey was conducted among ten randomly selected government senior secondary schools in Paonta Sahib Education Block. A total of 1120 children aged 12- and 15-year were included in the study. The children were examined for the presence of untreated dental caries as per the guidelines of the World Health Organization. The information on dental visiting pattern was obtained from the parents using a structured questionnaire. Descriptive statistics and Chi-square test were used to analyze the data. Results: The prevalence of dental service use in this sample was 13%. Most of the visits were because of pain/tooth removal. “No dental problem” was cited as the main reason for never having visited the dentist. Overall dental caries prevalence was 52.5%. The prevalence of dental caries was higher in those who had visited the dentist before (P < 0.001). Conclusions: A very low dental service use was observed among 12- and 15-year old children in this study. The visits were mainly for pain alleviation rather than prevention of oral health. Lack of perceived need was the major barrier for accessing dental care.

Keywords: Dental care for children, dental caries, school children

How to cite this article:
Bhatt S. Utilization pattern of dental care and dental caries prevalence among children aged 12- and 15-year in Himachal Pradesh, India. J Indian Assoc Public Health Dent 2021;19:201-5

How to cite this URL:
Bhatt S. Utilization pattern of dental care and dental caries prevalence among children aged 12- and 15-year in Himachal Pradesh, India. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2023 Nov 29];19:201-5. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2021/19/3/201/328276

  Introduction Top

Along with prevention and good oral hygiene, an important determinant of oral health is regular dental care.[1] Research has shown that those with irregular dental visiting pattern have poor oral health outcomes. Moreover, a social gradient has been observed to exist in children's oral health status and dental care utilization. Disparities in oral health status and dental care access among children have particular health services and epidemiological significance. Children who are in racial/ethnic minority and or living in poverty are less likely to visit the dentist than their more advantaged counterparts.[2],[3] Infrequent use of dental services and poverty status appear to independently affect children's oral health.[2] Irregular dental visits and lower socioeconomic status were independently associated with higher rates of decayed and missing teeth.[4]

Oral health problems are not self-limiting; rather they progress if left untreated. In a developing country like India, dental care is sought only in cases of emergencies.[5],[6] Unlike developed countries, there is no dental insurance, and the cost of the treatment has to be borne by the individual. It creates a vicious spiral in which delayed care or lack of care creates more severe health care needs, which, in turn, results in increased barriers because dental problems become more complicated and more expensive to treat.[2]

Children and adolescents are less prone to receiving dental care and therefore have unmet oral health care needs.[7] Children represent a dependent population. Especially, those in rural areas with low socioeconomic status are pushed toward high unmet dental needs. In such regions, due to lack of knowledge, perceived dental needs, and many barriers, dental care in not utilized.[8]

Children in rural areas tend to receive episodic or emergency dental care. Determinants of access to dental care among low-income children are multi-factorial: poverty, low education levels of parents, lack of transportation, limited number of dental providers within these communities, and inadequate infrastructure at primary health care level.[9]

Children are particularly vulnerable to dental caries as well as poor utilization of dental care. Visits to the dentist are mainly because of pain.[6] Regular visits are rare and early signs of caries are usually not diagnosed resulting in an iceberg phenomenon with an increased burden of undiagnosed and untreated dental decay in the community.

In most developing countries, data about the utilization of oral health services by schoolchildren are scarce.[10] There have been very few studies on utilization of dental services among school children in India.[11],[12] Evaluating the prevalence of utilization of dental health services among school children could be useful for policy-making and resource allocation. Our objective in this study, therefore, was to assess dental utilization pattern and dental caries experience among 12- and 15-year old children from Government Schools of Tehsil Paonta Sahib, Himachal Pradesh (HP).

  Materials and Methods Top

This study was conducted to assess the utilization pattern and dental caries experience of a representative sample of 1120 12- and 15-year-old school children living in Paonta Sahib, a Tehsil in the state of HP. In India, the public school system is the major education provider. According to a report by the Ministry of Human Resource and Development, nearly 72% of all school children were enrolled in government schools in 2015–2016.[13] The government school children, therefore, constitute a major portion of school-going children in India.

The study began after approval of the Institutional Ethics Committee (Reference No. HIDS.PS/294-A). The study was conducted in accordance with the guidelines of Helsinki Declaration for study on human subjects. Before data collection, a list of all the government senior secondary schools in Paonta Sahib Education Block was obtained, which yielded a total of 21 such schools. A multistage sampling considered all government senior secondary schools as the primary survey units; and, 10 out of 21 schools were randomly selected. A sample of children aged 12 and 15 years was selected from these schools. 12- and 15-year age groups were selected because these are two of the World Health Organization (WHO) recommended age groups for population-based surveys.

The sample size calculation was done based on the following parameters: 5% standard error, 95% confidence interval level, and expected prevalence of 50%.[14] In addition, we applied a design effect of 1.4% and 10% addition to nonresponse. A minimum sample size of 560 children in each age group was estimated to satisfy these requirements.

The data collection started in September 2019. For the acquisition of data, permission was obtained from the Principals of the selected schools and a written informed consent was obtained from parents of school children. Dental examination was conducted as per the international criteria standardized for oral health survey by the WHO. The children were examined in a room with natural light, using community periodontal index probes and plane dental mirrors. The occurrence of untreated caries was noted in the clinical examination, corresponding to a nonzero D component in the Decayed, Missing, Filled Teeth index. Caries was recorded as present when a lesion in a pit or fissure or on a smooth tooth surface had an unmistakable cavity, undermined enamel, or a detectably softened floor or wall. Tooth with a temporary filling, or one which is sealed/filled but also decayed, was also included in this category.[15] Intra-examiner reliability of caries measurement was measured using the Kappa statistics, which showed a kappa value of 0.92.

Data on the socioeconomic characteristics and utilization pattern of dental health services were collected from parents of the children examined. Dental care utilization was represented by: (1) A reported visit to a dentist during the previous year. (2) The pattern of dental visit, classified as regular use (every year), episodic use (as needed) and no use (never visited a dentist).[2]

Information on dental visit was obtained by asking “Have you visited a dentist before?” If the subjects responded in positive, next questions were “How long ago was your last visit to the dentist?” and “What was the main reason for your dental visit?” If the participants had never visited a dentist before, question asked was “What is the main reason that you have never visited a dentist before?” The data collection was completed in December 2019.

Statistical analysis

The statistical analysis was done using SPSS for Windows. Descriptive statistics were used to summarize the data using number and percentages. The outcome variable was the presence or absence of dental caries, and the predictor variable was use of dental services. The comparison of dental caries prevalence in visitors and nonvisitors was done using Chi-square test.

  Results Top

The present study was conducted among 1120 children from government schools of Paonta Sahib, HP. There were 560 children in 12- and 15-year age groups each. There were 541 (48.3%) boys and 579 (51.7%) girls [Table 1].
Table 1: Demographic information of study participants

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Data on dental visiting patterns showed that 972 (86.8%) children had never visited a dentist before. Among those who had made a dental visit (n = 148), only 13 went for regular check-up. Majority of the visits (n = 135) were episodic or need-based. Among the visitors, “painful tooth/tooth removal” was the main reason for dental visit (64.7%), followed by “tooth filling” and “tooth alignment” [Table 2].
Table 2: Dental care utilzation pattern of study participants

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The main reason for never visiting a dentist was cited as “no dental problem” (93%). Other reasons included dental fear of the child, high cost of dental treatment, and “no dentist in the area” [Table 3].
Table 3: Reason for never visiting the dentist

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[Table 4] shows the dental caries status of the study population based on their dental visiting pattern and age group. The overall prevalence of dental caries in this study was found to be 52.5%. The prevalence of dental caries among visitors was 66.2%, whereas that among nonvisitors was 50.4% (P < 0.001, χ2 = 12.866). Among 12-year-old children, dental caries prevalence was found to be 50.7%, and it was 54.3% in 15-year old children (P = 0.231).
Table 4: Dental caries experience in relation to dental visitng pattern

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  Discussion Top

In this study, we found a very low utilization (about 13%) of dental services among 12- and 15-year old school children from government schools. This is lower than utilization observed in previous studies. In a study on 12-year-old Brazilian school children, Piovesan et al. found that 47.8% of children had visited the dentist.[10] Similarly, another Brazilian study found that 46.8% of school children used dental services regularly.[16] A dental utilization prevalence of 27.7% was reported among 6–12 years old school children in Mexico.[17] A study in suburban African schools found 1.7% prevalence of dental services use among 12-year-old school children,[18] which is lower compared to the findings of our study. Among developed countries, a 40% prevalence of dental service use was reported in Spain.[19] In the US, different studies have reported prevalence of dental services use ranging from 50% to 78%.[1],[2]

Among the visitors, regular visit was quite low. Most of the participants visited the dentist episodically, i.e. when in need. Episodic visits and no visits to the dentist are considered signs of inadequate utilization and indicate that barriers to accessing dental care exist.[2] The main reason reported for visiting the dentist was pain/removal of tooth. These results give an indication toward the awareness and attitude of parents for their child's oral health needs. This situation has been reported in several previous studies where dental care and early signs of disease are neglected till there is pain and emergency.[12],[20],[21],[22] However, a study from Saudi Arabia reported regular dental check-up as the main reason for dental visit in young children.[23]

The major reason for never visiting a dentist was cited as “not having a dental problem.” Similar findings were observed in studies on children from Canada, US, and Brazil where most common reason for never visiting a dentist was no perceived need for dental care.[24],[25],[26] In a community with low oral health awareness and minimal priority for oral health, pain-free teeth are considered to be problem-free and do not warrant a visit to the dentist. Treatment is sought only in cases of pain or emergency. Other reasons mentioned for never visiting a dental facility were high cost of dental treatment and dental fear of the child, both of which are recognized barriers for accessing dental care.[5],[24],[27] Finally, some parents mentioned that there was no dental care facility in their area, and they have to travel far for treatment, which costs both time and money. Studies have shown that not having a dental facility in the vicinity can affect the dental visiting behaviors of the public.[5],[28] In India, dental care has not been fully integrated into primary health care.[29] Consequently, the primary health centres situated in rural communities have neither the workforce nor the infrastructure for providing quality dental treatment.

In this study, the prevalence of dental caries was found to be 52.5%. The 12-year-old children showed caries prevalence of 50.7%, whereas the same for 15-year-old was 54.3%. This pattern is similar to that observed in other parts of the country for these age groups.[14] Our analysis found that the participants who had visited the dentist had a higher prevalence of dental caries than those who had never made a dental visit. This finding is inconsistent with previous research done in this area.[2],[4],[12] Such an observation which contradicts the conventional wisdom could be due to the fact that the dental visiting patterns seen in this study are mainly episodic, focused on alleviating the pain, rather than preventing the tooth. As discussed previously, such dental visits are signs of inadequate utilization and cannot be expected to improve the oral health of visitors. Further research is recommended in this particular area. More than merely increasing dental services use, there is a pressing need to change the attitude of public toward oral health.

This study did not attempt to assess the variables which could be possibly associated with dental utilization such as socioeconomic status of the parents. Despite this, the study explores an important area of oral health research. The findings of this study have important epidemiological significance. This study could serve as a baseline for exploring the prevalence of dental service utilization among children in other parts of country. Future research should be directed toward finding association between dental utilization and peculiar conditions existing in the country, especially in rural areas. The study also has important policy implications. In view of the low utilization as observed in this sample, measures should be taken to improve the dental utilization patterns and associated behaviors. The focus should be on increasing the use of preventive care rather than episodic visits for alleviating pain. Health education of parents should be an important first step because dental care of children is dependent on their caregivers. Health education should include child's dietary and oral hygiene habits, importance of deciduous teeth, and regular visit to the dentist. At school level, a nationwide oral health program is recommended as part of the overall health promotion of school children. Lack of access is an impediment to regular use of health care. Efforts should also be directed towards increasing the availability of dental services in rural areas. We recommend the appointment of dental surgeons along with infrastructure development at the primary health center level throughout the country.

  Conclusions Top

A very low and deficient utilization pattern was observed among children in this study. Dental visits were mainly for pain relief rather than for the improvement of oral health. The main barrier for seeking oral health care was lack of perceived need for dental treatment. Policy-formulation should be directed towards improving both level and quality of dental utilization among children in India.


The author would like to thank the interns in the Department of Public Health Dentistry, Himachal Institute of Dental Sciences for their support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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