oral health disparities among 12- 15 years children of

INTRODUCTION

ustaining good oral health is vital to improve thegeneral health and development predominantly in

children of school going age. In every community andcountry the children, particularly of school going age,are the most important natural asset. Their well-being,capabilities, knowledge and energy will determine thefuture of villages, cities and nations around the world.Even though oral health is considered as an integral partof overall health, the global evidence report that around90% of these school children worldwide experience poororal condition1.This suggests poor oral health as highlyprevalent, where South East Asian countries are noexception.

India and Pakistan are two neighbouring nations whoshare common border in South East Asia. The burdenof oral diseases among adolescents in both countries is

JPDA Vol. 23 No. 04 Oct-Dec 2014 170

ORAL HEALTH DISPARITIES AMONG 12- 15 YEARSCHILDREN OF INDIA AND PAKISTAN - A CROSS BORDERCOMPARISON

ABSTRACT: India and Pakistan are two neighbouring countries of South-East Asia, not only sharing commonborder but also socio-demographics, eating habits, cultural and climatic conditions. All these factors have an impacton general and oral health of individuals. This study was conducted with an aim to compare the oral health awarenessand dental caries status among school going children of India and Pakistan.METHODOLOGY: A cross-sectional study was conducted among children aged 12-15 years attending governmentschools of Moradabad and Karachi cities of India and Pakistan respectively. A two-stage sampling technique wasused to produce representative samples from each location based on probability proportional to enrolment size(PPE). Selected participants were interviewed using a close-ended, pre-tested questionnaire for assessing oral healthawareness followed by dental examination at respective locations using DMFT Index.RESULTS: : A total of 809 school children, 409 from India and 400 from Pakistan were examined. Mean DMFTof India was found to be 1.9 ± 1.46 and that of Pakistan was 1.00 ± 1.57.CONCLUSIONS: An increase in decayed component in comparison to the overall DMFT in both the countriesindicate the need of care, less utilization of available care, unavailability of care and ignorance. There is a need tochange the attitude and knowledge about dental health care in these developing countries to cope up with the lackof resources and still have a better dental health.KEY WORDS: Child Dental health, Dental Caries, Oral Health.HOW TO CITE: Qureshi A, Batra M, Pirvani M, Malik A, Shah AF, Gupta M. Oral Health disparities among 12-15 years children of India and Pakistan - A cross border comparison. J Pak Dent Assoc 2014; 23(4):170-174

1. Associate Professor & Head, Department of Community & Preventive Dentistry, Dr.Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences,Karachi, Pakistan2. Assistant Professor, Department of Public Health Dentistry, Surendra Dental Collegeand Research Institute, Sri Ganganagar, Rajasthan, India.3. Assistant Professor, Department of Dental Materials, Dr. Ishrat-ul- Ebad Khan Instituteof Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan4. Department of Community & Preventive Dentistry, Dr. Ishrat-ul-Ebad Khan Instituteof Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan.5. Department of Public Health Dentistry, Kothiwal Dental College and Research Centre,Moradabad Uttar Pradesh, India.6. Assistant Professor, Department of Oral Medicine & Radiology, Uttaranchal Dental& Medical Research Institute, Dehradun, Uttarakhand, India.Corresponding author: “Dr Ambrina Qureshi ” < [email protected] >

Ambrina Qureshi1 M. Phil, BDS, MDSManu Batra2 BDS, MDS

Madiha Pirvani3 BDS, MDSAeeza Malik4 BDSAasim Farooq Shah5 BDS, MDS

ORIGINAL ARTICLE

S

Mudit Gupta6 BDS, MDS

JPDA Vol. 23 No. 04 Oct-Dec 2014171

on higher side. The problems in both nations revolvearound the level of attentiveness towards oral healthamong children, specifically those belonging to ruralareas. It is pertinent to mention that almost 70% of thegeneral population in both these countries belong to ruralareas with low socio-economic status where the overalldevelopment is poor2.

Many oral health problems are preventable and theirearly onset reversible through imparting oral healtheducation since the very initial footstep of awareness. Ithas been reviewed that betterment in oral health may beanticipated through good understanding of an individual'sknowledge and perceptions about oral health3. Theevaluation of baseline awareness may therefore act asan important indicator for planning successful oral healtheducation programs in both the countries. Hence, theobjective of this study was to evaluate the discrepancyin the oral health awareness and dental caries status ofschool going children of India and Pakistan.

METHODOLOGY

The study sample consisted of school students aged12-15 years attending schools of rural areas of Moradabadand Karachi cities of India and Pakistan respectively. Atwo-stage sampling technique was used to producerepresentative samples from each location. In first stage,the schools were randomly selected. Four seniorsecondary government schools each from Moradabad(India) and Gulshan-e-Iqbal Town, Karachi city (Pakistan)were selected based on probability proportional toenrolment size (PPE). According to PPE, the schoolswith high number of regularly attending students weremore likely to be selected than schools with low numberof students regularly attending. In second stage, thestudents from these schools were randomly selected tobe included in the study through simple random samplingprocedure.

Before the start of study, permission was obtainedfrom the ethical review board of the respective institutesinvolved in data collection. Prior permission was alsoobtained from respective school authorities. The timeand date of the survey were intimated to the studentswell in advance and informed consents were obtained.Subjects with any systemic or oral disease, dentalprosthesis, absence of any index teeth and non-consentingcases were excluded from the study. Selected participantswere interviewed using a questionnaire prepared for

assessing health awareness in children. The close-endedquestionnaire was pre-tested among 25 school studentseach of Moradabad and Karachi, to confirm its validity(kappa >70%) and reliability (cronbach alpha >70%)and to avoid ambiguity. However, these students werenot included in the final analysis. Following the pre-test,some modifications in the order of questions andterminologies were made in the final questionnaire.

Considering the influence of teachers on the students'response, the school authorities were requested not tobe present in the class during the procedure of filling thequestionnaire. Students were assured that the informationthey provided would remain confidential and thuswere encouraged to be truthful in their response. Thestudents were instructed to give only single answer foreach question, which they felt was the most appropriate.

Dental examination was then performed to identifythe dental caries status of school children aged 12-15years. Examination was conducted by properly glovedand masked single examiner in each setting on thepermitted dates by the school administration on mobiledental units with the child supine, under the day timesunlight in school ground. Sterilized instruments (dentalmirror, probe and tweezers) were used to execute theexamination. Intra-examiner reliability of the singletrained examiner was assessed on 10% of the samplesubjects; however, inter-examiner reliability could notbe measured.

Preliminary descriptive statistics (Mean and frequencypercentages) was used to assess the distribution ofresponses of all study variables using SPSS package(version 20).

RESULTS

A total of 809 school children aged 12-15 years wereexamined in the present study, out of which there were409 from India and 400 from Pakistan. Preliminary datadescription with respect to age and gender is reported intable-1. The mean age of Indian study participants wascalculated as 13.21 ± 1.16 years and that of Pakistaniwas 13.06 ± 1.11 years.

Table 2 demonstrates the percentage distribution ofstudy participants' responses for each study variable.Majority of subjects from India (47.19%) cleaned theirteeth once a day, whereas many from Pakistan (62.75%)cleaned their teeth twice a day. The number of subjectwho responded with "sometimes" and "never" was more

Comparing Oral Health of Children of India and PakistanQureshi A / Batra M / Pirvani M /Malik A / Shah AF / Gupta M


from India and none from Pakistan; although this numbercovered approximately 10% of the total participants fromIndia.

Moreover, awareness regarding the use of fluoridatedtoothpaste was different in subjects from two nations.All subjects (100%) from Pakistan knew that their

toothpaste does contain fluoride whereas majority ofsubjects (70.6%) from India were not sure whether theirtoothpaste contains fluoride or not while cleaning theirteeth. According to this table, frequency of visit to adentist during last 12 months was much higher amongIndian children in comparison to Pakistani children. Itwas found that less than 1/2 of the Indian participantsnever visited a dentist in comparison to almost 3/4th

(83.25%) of the Pakistani participants during last 12months. Furthermore, consumption of sweets in excessand as regular was slightly higher among Pakistani thanIndian study participants.

Table 3 demonstrates the caries experience (meanDMFT) among the subjects. The decayed componentwas higher in Indian children in comparison to Pakistani

children which also led to a higher mean DMFT scoreamong Indian children in contrast to Pakistani children.

DISCUSSION

Dental caries is still a major health problem in mostindustrialized countries as it affects 60-90% of school-aged children and the vast majority of adults. At present,the distribution and severity of dental caries vary indifferent parts of the world and within the same regionor country1. In most developing countries, the levels ofdental caries were low until recent years but prevalencerates of dental caries and dental caries experience arenow tending to increase. This is largely due to the factorsknown to be associated with dental caries. It is suggestedthat social and biological factors in very early lifeinfluence dental caries levels later in life4. In addition,behavioural factors such as feeding pattern, toothbrushing, fluoride intake and other factors related toeducation level of the mother, country of birth, andgender of the child also generally influence the prevalenceof dental caries5.


Table1: Distribution of study participants according to age and gender

Table2: Percentage distribution of study participants with respect tostudy variables

Table 3: Dental Caries experience (Mean DMFT) among the studyparticipants

JPDA Vol. 23 No. 04 Oct-Dec 2014173

Worldwide, studies have highlighted differences in oralhealth knowledge, attitudes and practices between childrenand adults6 as well as children of different strata7. Thisstudy, however, was planned to evaluate these differencesamong school going children of India and Pakistan. Inan inter-country comparison, socio-economic status couldbe one of the most important confounding factors. Toimpound this confounding effect, public sector schoolswere selected from both the regions and socio-economicstatus was matched for both.Toothbrush and toothpaste are commonly used to retaingood oral hygiene8. However, the correct technique andfrequency of tooth brushing, and concentration of fluoridein toothpaste are the laid down factors associated withprevention of dental caries9. From the results of thepresent study, it was seen that more than 80% of thechildren from India and Pakistan cleaned their teeth atleast once a day, where majority from Pakistan (morethan 60%) practiced tooth cleaning twice a day. Otherconcordant studies from Chepang Nepal10 and China11

have also reported that 60% of children of similar agegroup brush their teeth at least once-a-day. On thecontrary, much lower tooth cleaning frequency (less than30%) has been reported from Indian schoolchildren byMathur et al12and Turkish school children by Bekirogluet al13. The practice of cleaning twice in children fromPakistan may be attributed to Muslim religion, wheretraditionally Muslim children are taught to use miswakat about age six that helps develop practice of brushingmore often than once14. Moreover, 100% of studyparticipants from Pakistan reported that they usedfluoridated toothpaste as compared to those of Indiancounterparts where only less than 10% of participantsreported that they use fluoridated toothpastes. Previousfindings from various states of India and China havealso reported that only 13-15 % of 12 year olds childrenuse fluoridated toothpaste15,16. On the other hand, Mirzaet al from Pakistan reported that nearly 60% studentsfrom Pakistani schools regarded fluoride as a toothstrengthening element and were properly aware aboutit17.

Regarding regular visits to dentist by children ofthis age group, we observed that participants from Indiavisited dentist more regularly than those belongingto Pakistan. This trend in Pakistan is commonly observedelsewhere whereeven less than 10%of theseparticular age group children regularly visit dentist18.One reason that may be suggested is unavailability of

the trained dental professionals specifically for childrenin Pakistan 17. In Pakistan, the government manageshealth care services since 1986-87, through the ministryof health, which provides the country with physicians,dentists and auxiliary health care workers. Dental surgeonshave been recruited under this scheme, but unavailabilityof the dental equipment renders the program useless.Lack of dental insurance, high cost of treatment, longwaiting period between appointments, phobia of thedentist and as well as the treatment are suggested ascontributing factors of low percentage of regular checkupsin Pakistan2. Moreover, the high treatment cost in Pakistanmay also be the main culprit in this difference. Addingto this, the present study also reported that sweetsconsumption was slightly higher in Pakistani childrenin comparison to Indian children, although thiscomparison may not be very significant in this study.Moreover, the sweet consumption, when compared tosimilar surveys from other regions in both the countrieswas relatively higher19,20.

Mean DMFT in subjects from India in this study wasobserved to be higher as compared to the subjects fromPakistan. However, when it is compared to a studyfrom another part of India (Chenai) the difference wasmore than double (DMFT= 3.94) than the currentobservation (DMFT= 1.9) in same age group children.On the other hand, the national data of India21 reportedmean DMFT in 12 years old as 1.7, which is concurrentto the result of this study. Similarly, a previous studyfrom Pakistan14 reported much higher DMFT (3.7) thanthat reported in the current study (DMFT= 1.0). Keepingin view the mean DMFT of Indian and Pakistani subjectsof the current study the differences may be attributed tothe fact that subjects from Pakistan reported to be brushingmore often and that too with fluoridated tooth paste, thanthe subjects from India. Moreover, this may be attributedto the lack of Inter-examiner calibration that could notbe conducted and measured due to the traveling distancebetween the two countries. However, the examiners wereconfident that the employed tool for examination wasthe DMFT index (decayed, missing, filled teeth) asrecommended by World Health Organization (WHO). Itis pertinent to mention that the DMFT Index is a generalindicator of dental health status of the population(particularly among children), and is considered reliable.Lower the index, the better the dental health of thepopulation. Although, it has been observed that despitemore than 50% of study subjects visiting dentist, their



decayed tooth component is still high with much reducedfilled tooth component. Overall high decayed components,especially in Indian subjects, indicate the need for dentalcare, inadequate availability of dental services and lessservice utilization by the study population. Furthermore,difference in the number of Filled teeth 'F' component inthe present population groups may be suggestive of thefact that these children may not have sufficient access tothe dental services. We need to further look into thereasons for this aspect of inequality in service utilizationin both the countries. However, it is still suggested thatit is high time that public education emphasizingprevention and conservation must come into action torectify this situationwith special focus towards thecountries with limited resources.

REFERENCES

1. Petersen PE, Bourgeois D, Ogawa H, Estupinan -DayS, Ndiaye C. The global burden of oral diseases and risksto oral health. Bull World Health Organ. 2005;83:661-9.2. Khan AA, Ijaz S, Syed A, Qureshi A, Padhiar I, SufiaS, Khan MK, Haleem A, Qiamuddin, Baloch M. OralHealth in Pakistan- A situation analysis. Dev Dent 2004;5:35-44.3. Dawani N, Qureshi A, Syed S. Integrated school-based child oral health education. J Dow Univ Health Sci2012; 6: 110-114.4. Peres MA, Latorre MRDO, Sheiham A, Peres KGA,Barros FC, Hernandez PG, et al. Social and biologicalearly life influences on severity of dental caries in childrenaged 6 years. Community Dent Oral Epidemiol.2005;33:53-63.5. Sufia S, Anwar S, Qureshi A, Farooq A, Khan A A.Maternal attitudes and practices towards 3 ½ & 4 ½children in Pakistan. Proceeding Shaikh Zayed PGMI.2006; 20, 87-94.6. Butani Y, Weintraub JA, Barker JC. Oral health-related cultural beliefs for four racial/ethnic groups:assessment of the literature. BMC Oral Health. 2008;8(1,article 26).7. Petersen PE. Inequality in oral health: the socialcontext for oral health. In: Community oral health (chapter3), Harris R & Pine C (Eds.). Community Oral Health.Copenhagen: Quintessence Publ. 2005.8. Mumtaz R. The Fluridation Controversy. Pak OralDent J 2007; 27: 137-144.

9. Malik A, Qureshi A, Malik S. Prevention of DentalDecay: Role of Fluoride in Dentifrices. J Dow UnivHealth Sci2013; 7: 59-62.10. Prasai Dixit L, Shakya A, Shrestha M, Shrestha A.Dental caries prevalence, oral health knowledge andpractice among indigenous Chepang school children ofNepal. BMC Oral Health. 2013;14:13:20.11. Tiano AV, Moimaz SA, Saliba O, Saliba NA. Dentalcaries prevalence in children up to 36 months of ageattending daycarecenters in municipalities with differentwater fluoride content. J Appl Oral Sci. 2009;17:39-44.12. Mathur A, Avinash J, Mathur A, Gupta T. Oral healthAttitude Knowledge Behavior and Consent towardsDental treatment among School children. J Orofacial Res2011; 1:6-10.13. Bekiroglu N, Tanboga I, Altinok B, Kargul B. OralHealth Care Behavior in a Group of Turkish Children.Iranian J Publ Health 2009;38:125-131.14. Khan MA. Prevalence Dental Caries among 3-12 oldchildren of Swat-Pakistan. Pak Oral Dent J 2009; 29:321-326.15. Bali RK, Mathur VB, Talwar PP, Chanana HB.National Oral Health Survey and Fluoride Mapping 2002-2003 India. Dental Council of India and Ministry ofHealth and Family Welfare (Government of India), 2004.16. Zhu L, Petersen PE, Wang HY, Bian JY, Zhang BX.Oral health knowledge, attitudes and behaviour of childrenand adolescents in China. Int Dent J 2003; 53:289-298.17. Mirza BAQ, Syed A, Izhar F, Khan AA Oral HealthAttitudes, Knowledge, And Behavior Amongst High AndLow Socioeconomic School Going Children In Lahore,Pakistan. Pak Oral Dent J 2011; 31(2).18. Mohiuddin S, Saadat S, Qureshi A. Oral HealthKnowledge, Attitude and Practices of Public SchoolChildren of Karachi, Pakistan. J Dow Univ HealthSci2011;5:126-128.19. Petersen PE, Hoerup N, Poomviset N, Prommajan J,Watanapa A. Oral health status and oral health behaviourof urban and rural schoolchildren in Southern Thailand.Int Dent J 2001; 51:95-102.20. Varenne B, Petersen PE, Ouattara S. Oral healthbehaviour of children and adults in urban and rural areasof Burkina Faso, Africa. Int Dent J 2006; 56: 61-70.21. Mahesh Kumar P, Joseph T, Varma R, Jayanthi M.Oral health status of 5 years and 12 years school goingchildren in Chennai city - An epidemiological study. JIndian Soc Pedod Prev Dent 2005; 23:17-22.


oral health disparities among 12- 15 years children of

Documents