1

CHAPTER 1

INTRODUCTION

1.1 Preamble

India is the largest democratic country in the world, covering 1/7th

of the total area

of the globe. However, there is growing evidence that general health conditions and the

oral health status in particular has enormous negative impact on healthy living and

economic development of households in India. There are significant differences between

the health care services available at village level and metropolitan cities. The health care

economists and planners have started thinking about reorganization of health care service

delivery and primary prevention through “National Rural Health Mission” and indeed

people are on the pathway of achieving the goals of “Health for all”.

Despite great efforts by the countries and WHO in the late 1960’s and early

1970’s to improve and extend health care services, large number of people, particularly in

the rural areas of the developing countries remain with minimum access to health care

facility.

1.2 Health – Definitions

Health is clearly a complex and multi dimensional concept. Personal or individual

health is largely subjective. Health is one of the prime concerns of any nation because of

the tremendous impact that the health of the people have on economic development of a

country (Panchamukhi, 1989).

Healthy people refer to those who are physically, mentally and intellectually

healthy. A healthy mind and proper intellectual development will help proper usage of

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manpower that is suitable for economic development. On the other hand, with greater

economic development better health facilities are needed and are also possible because of

the environmental implications of development as well as the opportunities created for

attaining health through better facilities.

In the preamble of the constitution of the World Health Organization (WHO)

health is described as “a state of complete physical, mental and social wellbeing and not

merely the absence of disease or infirmity” (Anand and Shikha Goel, 2008).

Health is both an instrument and product of development and is therefore, a major

factor in the economic development process. It is largely determined by the socio-

economic factors such as education, nutrition, population growth, income and

environment. Thus, health is multi-sectoral and inseparably linked to economic, social

and cultural development. It is not only a desirable goal in itself but a means and indeed

an indispensable component, if not a pre-requisite of social and economic development

(Population studies No.93).

An increasing level of interest in health promotion in the early 1980’s inspired a

WHO working group to compose a definition recognizing the role of individuals and

communities in determining their own health status. Health is a resource for everyday

life, not the objective of living; it is a positive concept emphasizing social and personal

resources as well as physical capabilities (Anand and Shikha Goel, 2008).

The health of humans cannot be dissociated from the health of the life-supporting

ecosystems with which humans interact and are interdependent. A definition of

“sustainable health” that recognizes this interconnectedness states that health is a

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sustainable state of equilibrium among humans and other living things that share the earth

(Anand and Shikha Goel, 2008).

Health should be considered as a fundamental human right and therefore the

attainment of the highest level of health should be the most important goal. The directive

principles of state policy of the Indian Constitution mention that “the state shall regard in

raising the level of nutrition and the standard of living of its people and improvement of

public health as among its primary duties” (Parthasarathy, 1998).

The constitution of the WHO says, “Enjoyment of the highest standard of health

is one of the fundamental rights of every human being without distinction of race,

religion, and political belief, economic and social condition” (WHO, 1968).

Health care

or medical care can be considered as an economic good, which can be produced and

consumed and that can yield utilities to its customers.

1.3 Health Economics - Meaning

Health Economics is a branch of Economics concerned with issues related to

scarcity in the allocation of health and health care. The major subject Welfare Economics

has branched off into many applied disciplines and important among them with

significant social relevance is Economics of Health. Awareness of the economic

manifestation of health and diseases and the limited resources allocated to health care

services has brought the new discipline, Health Economics into focus. In reality,

maximization of welfare is the keynote of health economics. In the prospective of human

resources development process, health care occupies a predominant position. Health care

is an important objective of normative economics. Apart from the development of the

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science of health care as such, improvement in the health status of the population is the

priority component and hence appropriate political, economic and social action are called

for. In fact, man is the primary factor of production. Basic standards of health and

improvements thereof provide an entry point to change agents (Shunmuga Sundaram and

Yasodha, 1979).

Health Economics has been defined by various authors in different terms. The

economics of health studies how healthcare and health-related services, their costs and

benefits and health care itself are distributed among individuals and groups in society. It

is concerned with the formal analysis of direct and indirect costs and benefits that are a

consequence of a health care intervention program or strategy.

Bauer defines health as, “a state of feeling well in body, mind and spirit together

with a sense of reserve power. It is based on normal functioning of tissues and organs of

the body and their harmonious adjustment to the physical and psychological environment

together with an attitude which regards health is not an end itself, but a mean to a richer

life as measured in constructive service of mankind” (Anand and Shikha Goel, 2008).

Thus good health is based upon the capacity of an individual’s physical, mental and

emotional coordination and takes into what the individual does during his/her life.

Planning Commission of India defines health as a positive state of wellbeing in

which harmonious development of mental and physical capacities of the individuals lead

to the enjoyment of a rich and full life. It implies adjustment of the individual to his total

environment, physical and social (Anand and Shikha Goel, 2008).

The commission also states that health is fundamental to the nation’s progress in

any sphere in terms of resources for economic development. Nothing can be considered

5

of higher importance than health of the people. For the efficiency of industry or of

agriculture, good health of the worker is an essential consideration.

Analysis of some of the definitions suggests that “health economics is the

discipline that determines the quantity and price of scarce resources devoted for the care

of the sick and promotion of health” (Klaraman, 1965). It encompasses the medical

industry as a whole and extends to such fields as the economic analysis of the cost of

diseases, benefits of health programmes, returns from investments in Medical Education,

Training and Research.

The definition, laid down by the WHO, in the inter-regional seminar seems to be

more comprehensive. It defines health economics as, “a branch of study that seeks

interalia to quantify over time, the resources used in health service delivery, their

organizational functioning and the efficiency with which the resources are allocated and

used for health purposes and the effect of preventive, curative and rehabilitative health

services on individual and national productivity (WHO, 1975).

Now-a-days health is becoming all the more economically valuable and disease

all the more economically expensive. This course of events has brought together two of

the applied areas of study viz. Medicine and Economics. As a result, the new discipline

“Health Economics” has emerged with the task of regulating the relationship between the

health objectives on the one hand and the valuable resources on the other (Satpath and

Bansal, 1982).

Evolution of health economics dates back to the late 17th

century, when Sir

William Petty, the so called father of political economy, first instigated the appraisal of

health services (Petty, 1974).

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The main focus of health economics on mankind is to provide the maximum

benefits for the money invested in health care. The term benefit refers to the reduction in

the disease burden of the community and improvement in people’s health and welfare.

Health care can be categorized into two components- preventive and curative

health care. Preventive health care includes supply of safe drinking water, sanitation,

awareness towards health education, food habits, income level, expenditure on health

care facilities etc. Curative health care includes medical care facilities in which hospitals

play a significant role. It includes all services for diagnosis, treatment and medical

rehabilitation. Measures to provide health care can be considered to be oriented to keep a

person fit, while the measure to provide medical care are meant to treat a person who is

not fit and to lift him from the state of illness (Panchamukhi, 1989).

1.4 Oral Health

Oral health means much more than healthy teeth. Hence oral health is integral to

general health (WHO).

Global Oral Health

The promotion of general health, with oral health as an integral component, has

been recognized as one of the key factors for a successful and productive society. Health

directly correlates with quality of life of both individuals and society, and also with

economic and social development of countries as a whole (FDI) (World Dental

Federation).

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Oral Health is Global Health

Health status is not determined solely by biological phenomena. The factors such

as social, economic, environmental and others may also be important. Oral health, an

integral part of general health, is subject to these determinants. Growing disparities

between the rich and poor countries and between different population groups within the

same nation are important characteristics of economic globalization in the late 20th

and

early 21st century. These differences are reflected in the growing disparity in oral health

between the rich and the poor throughout the world (The Commonwealth Oral Health

Statement, 2001).

Populations in the developing nations are afflicted by the same oral diseases such

as dental caries periodontal disease and oral cancers as those found in the developed

nations. In poorer nations, oral diseases are superimposed on poverty and lack of

education. A major obstacle is the lack of commitment by national leaders in developing

countries in providing cost-effective approaches to the prevention and treatment of dental

diseases (Greenspan, 2007).

Dental caries and periodontal diseases, as the most common oral diseases, have

burdened the majority of populations with heavy treatment needs (Petersen et al., 2005).

A holistic view of the components of a population’s oral health is necessary to achieve

comprehensive understanding of oral health needs. To provide dental services required

to match these needs, oral health needs assessment surveys are necessary both locally and

nationwide. Application of a comprehensive approach to oral health needs assessment

may also lead to more cost-effective oral health services provision (Asadi-Lari et al.,

2004) and has been recommended in the Liverpool Declaration (WHO 2008a). In the

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evaluation of oral health programmes, in addition to disease outcomes, intermediate

outcomes (which may be the risk factors) and measurement of health should be

considered (Petersen and Kwan, 2004).

Direct risk factors such as poor oral hygiene practices and dietary habits, tobacco

use and excessive consumption of alcohol are the factors that may lead to biological

disturbances causing oral diseases (Petersen 2005; Selwitz et al., 2007). The poor and

risky health behaviour mostly characterizes those of a low social level (Hobdell et al.,

2003). An individual’s risk for tooth decay may vary over time, since many factors

influencing physical and biological risks change during a life time. Risk factors for

dental caries include physical, biological, environmental, behavioural and life style

related factors such as numbers of cariogenic bacteria, inadequate salivary flow,

insufficient fluoride exposure, poor oral hygiene and poverty (Selwitz et al., 2007).

The generally held view is that Asians are predominantly susceptible to

periodontitis (gum diseases), and among them poor oral hygiene and calculus are

widespread (Corbet, 2006). But periodontal data for some Arab countries differ: they

speak for a low to moderate level of periodontal disease (Baljoon et al., 2005; WHO,

2008b). Whereas mild and moderate forms of gingival inflammation represent a

widespread periodontal condition among young adults, severe forms of periodontal

destruction are less common and may affect a minority of adult individuals in developed

countries (Albandar and Tinoco, 2002).

Studies on smoking uniformly address inferior periodontal conditions and a

higher risk for tooth loss among tobacco smokers (Dye and Selwiz, 2005; Bergstrom

2006; Okamoto et al., 2006). The level of accumulated exposure to smoking that causes

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oral disease outcomes, however, is still under study (Bergstrom 2003; Dietrich et al.,

2007).

A wide range of behavioural risk factors from smoking to brushing and flossing

the teeth, or regularly attending a dental check-up have an influence upon oral health

(Patrick et al., 2006). With increasing numbers of current tobacco users in the world, the

smoking epidemic will not stop during the life-span of readers of the current literature

(FDI/WHO 2005).

Oral diseases, particularly dental caries and periodontal disease at their end stage

result in tooth loss and edentulousness. Dental status is a trustworthy measure of the oral

health status among adult population (Aggeryd 1983; Ahacic et al., 1998; Bagewitz et al.,

2007). Rather than health system-related factors, socio-demographic and geographical

determinants, particularly social class, are associated with tooth loss and wearing a

denture (Mc Grath and Bedi, 2002).

Global data speak for a decreasing trend in edentulousness among adults. Tooth

loss is considered a rare condition in western countries (Douglas et al., 2002; Mojon et

al., 2004) as well as among middle-aged Chinese and Japanese (Lin et al., 2001; Hanioka

et al., 2007). However, the few available data on dental status in developing countries

demonstrate various patterns of tooth loss by populations (WHO, 2008b).

1.5 Risk Factors for Oral Health

Risk is defined as the possibility of an adverse outcome, or a factor that raises this

probability (Rothman, 2002). The World Health Report- 2002 (WHO, 2002a) presented

evidence of the risks to health and the burdens that diseases impose on populations.

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According to this report, no risk arises in isolation, and generally each disease stems from

a complex chain of causes. An adverse health outcome might have indirect (distal),

direct (proximal) or specific local (biological) causes or a combination (Fig. 1.1).

Indirect factors such as social gradients and socio-economic status (SES) factors,

environmental, cultural and demographic risk indicators, and health system factors are

risks that mostly occur at population level (Hobdell et al., 2003; Petersen, 2005). A

social gradient proposes that the less-healthy individuals move down the social hierarchy,

and the healthy ones move up (Kent and Croucher, 1998). SES indicators such as

education, occupation and income are some determinants of social status. These indirect

factors usually help to shape direct factors like psycho-social and behavioural factors that

are formulate as life style, and individuals have some control over the latter (Sheiham and

Watt, 2000). Biological causes are specific factors operating locally within the host’s

body or an environment like the oral cavity and we assess their effects independently for

each disease (Burt, 2005).

Theoretical Approaches to Oral Health and its Risk Factors

The study models evaluating oral health and its risk factors have produced

proposals of several theoretical approaches to describe determinants of oral health. Based

on the ICS II (International Collaborative Study-II) model (Petersen and Holst, 1995) a

person’s sex, education, occupation and health beliefs “predispose” him or her to engage

or not engage in specific oral health behaviour. As to enabling factors, income, having or

not having access to oral health care and of residence represent the position that might

facilitate or hinder the individual’s practice of oral health behaviour.

1

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The “Common Risk Factor Approach” (Sheiham and Watt, 2000) addresses the

question of which oral health promotion and prevention strategies should be adopted. A

health-related behaviour is not a simple matter of freedom of choice; lifestyle is

understood as an expression of the cultural and social environment in which people live

and work. People who smoke are more likely to have an unhealthy diet than are non-

smokers (Fehily et al., 1984). In the Common Risk Factor Approach, smoking, diet and

hygiene are indicated as the major factors causing dental and periodontal diseases.

Controlling a small number of risk factors may have a major impact on a large number of

diseases as well as on dental and periodontal diseases.

Assessment of oral health and its related aspects should include the understanding

of indirect and direct causes as well as biological factors.

Indirect Risk Factors

Cultural, environmental and socio-economic factors have a fundamental impact

on the oral health of societies, along with behavioural and biological risk factors (Mc

Michael and Beaglehole, 2000; Sheiham and Watt, 2000; Hobdell et al., 2003; Petersen,

2005). Social and environmental disadvantages, even of quite a subtle kind, can lead

directly to poor health behaviour and to subsequent biological disturbances: (Hobdell et

al., 2003), in a cross country study, showed a discernible association between three oral

diseases (dental caries, periodontal disease and oral cancer) and socio-economic

variables. The strongest association was for chronic destructive periodontitis and the

weakest one for oral cancer.

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Socio-demographic Risk Factors

Social context refers to the location of a person by time and place in a society.

Place refers to geographical location and to group membership such as family, friends or

age-group, and according to class, ethnicity residence and gender that arise out of the

social structure and economic arrangement of the society (Kuh et al., 2003).

Education is another constituting factor of an individual’s social class that usually

coincides with a higher level of income. Professionals with the highest level of education

are located at the top of the social-class pyramid, and unskilled workers at the bottom of

it (Kent and Croucher, 1998). Well educated people are more likely to rate their oral

health as very good, more likely to have visited a dentist recently, and less likely to visit a

dentist for a problem than are less-educated ones (Australian Research Centre for

Population Oral Health, 2006).

As a demographic determinant, age may have an influence on oral health for two

reasons. First is the idea of socialization which is defined as the process whereby one can

gradually learn the values and norms of a group or society. And the second one is that

older people often present with particular oral health problems (Kent and Croucher,

1998).

Oral health status varies by gender. Women usually have better oral health

behaviour (American Academy of Periodontology, 1996; Payne and Locker, 1996).

They are likely to visit a dental clinic more regularly than do men (Bayat et al., 2006;

Slack-Smith et al., 2007).

However, some reports speak for higher levels of

edentulousness among women (Herford and Spencer, 2007; Slade et al., 2007).

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Direct (Behavioural) Risk Factors

Behavioural risk factors for oral health can be defined as a wide range of activities

affecting oral health undertaken by an individual (Patrick et al., 2006). They vary from

positive behaviours like brushing and flossing the teeth, attending regularly a dental

check-up or negative behaviours such as smoking (Payne and Locker, 1996). Smoking,

diet and oral hygiene, in particular, are a core set of risk factors for oral health that are

causally linked to major chronic conditions affecting populations (Sheiham and Watt,

2000; Peterson, 2005). Alcohol consumption, stress, obesity and physical inactivity are

other risk factors in a common risk factor approach (Sanders et al., 2005).

Smoking

Worldwide, more than 1.2 billion people smoke, and due to tobacco use

approximately 4 million of them annually die (WHO, 2002b, Aquilino and Lowe, 2004).

Cigarette consumption, the dominant form of tobacco use peaked in the United States in

1960s, and the prevalence of tobacco use among adults at that time was 40% (Mackay

and Eriksen, 2002). With current tobacco users in the world it has been predicted to rise

to 1.6 billion by 2030. This is not an epidemic that is going to go away in the lifetime of

the present reader (FDI/WHO 2005).

Cigarette consumption is rising internationally, markedly in developing countries,

where more than 80% of the world’s smokers live (The World Bank, 1999). Over the past

three decades, smoking habit has seen a decrease trend in developed countries (WHO,

2002b; Kirkland et al., 2004, (CDCa, 2008)); while becoming more popular in

developing nations among the youth, especially among girls (Global Youth Tobacco

15

Survey Collaborative Group, 2002). Tobacco use varies by region, education, socio-

economic status, race and ethnicity (Craig et al., 2001). Poverty, for example, is

associated with higher prevalence of smoking (Datta et al., 2006). People with 16 or

more years of education are less likely to smoke than are people with 9 to 11 years of

education (Hopkins et al., 2001). Similarly, within the European Union, smoking is

consistently related to low level of education and income (Huisman et al., 2005).

Local Risk Factors

Oral Hygiene

The low level of oral hygiene, and consequently accumulation of dental plaque on

the cervical region of the teeth is an important risk factor for gingivitis and causes the

extension of periodontitis, regardless of age (Abdellatif and Burt, 1987; Albandar et al.,

1999). As the cause of dental caries, dental plaque is a site to retain fermentable sugars

and the bacteria around the tooth (Selwitz et al., 2007). A cavitated lesion protects the

bio-film, and if this area is not cleansed, caries continues progressing (Fejerskov, 2004).

1.6 Population Oral Health

Generally, studies on dental caries and periodontal diseases in developed

countries show a decreasing trend in oral diseases. However, it is hard to assess the

status of oral diseases in developing countries due to lack of continuous and reliable data.

Despite the WHO (1997) recommendations for oral health surveys, few studies are

comparable in sampling and data collection. Available data in the WHO (2008b), Global

Oral Health Data bank are based on sparse and disparate studies from different countries.

The following tables (Table1.1 and 1.2) depict the dental and periodontal data for young

adults and middle-aged individuals from selected countries.

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Source: WHO oral health country/area profile

(WHO, 2010)

Table 1.1 Country Profile Data on Oral Health among Adolescents and

Young Adults from Selected Countries According to WHO Region

Dental Caries Experience Country Year Age DMFT Mean % Affected

The Western Pacific

Australia 2002 18-24 7.8 n.a

Japan 2005 15-19 4.4 15.7%

China 1996 18 1.6 58.2%

South East Asia

Nepal 2004 12-13 0.5 25%

India 2004 15 2.4 63.1%

Sri Lanka 2003 15 1.5 52.3%

Thailand 1994 18 2.4 63.7%

Eastern Mediterranean

Pakistan 2003 15 1.9 n.a

Saudi Arabia 1992 15 1.7 to 5.9 64% to 96%

Syria 1998 15 3.6 n.a

Jordan 2004 15 3.1 76%

Lebanon 2000 15 5.4 81.5%

Kuwait 2001 14 3.9 78.3%

Bahrain 1995 19 3.3 n.a

Europe

Belarus 1995 18 6.8 94%

Turkey 2000 20 6.0 78.3%

Norway 2004 18 1.7 59.7%

Slovenia 1998 18 7.06 95.1%

U.K. 1998 16-24 8.6 n.a

Lithuania 2005 15 5.6 92.9%

Netherlands 1986 15-19 6.6 n.a

France 1991 15 4.9 80.9%

Denmark 2006 18 3.1 n.a

Germany 2005 15 2.2 n.a

Italy 2003-04 13-18 1.9 59.1%

Romania 1995 18 6.9 94%

Spain 2004 15-16 1.8 55.9%

Switzerland 2004 14 1.5 n.a

Africa

South Africa 2002 15 1.9 51%

Madagascar 1993 18 6.8 92%

Uganda 2001 13-19 2.9 80%

America

Brazil 2003 15-19 6.2 89%

Panama 1993 15 6.4 n.a

U.S.A 1991 16-19 3.3 78.2%

17

cont....

Table 1.2 Country Profile Data on Oral Health among the Middle-aged (35-44

yrs) from Selected Countries according to WHO Region

Dental Health Indicators

Country Year Teeth DMFT Mean % affected

The Western Pacific

Australia 2006 25.9 10.7 n.a

Japan 2005 25.5 14.2 49.1%

China 1996 27.4 2.2 64.6%

South East Asia

Nepal 1995 26.6 4.3 81.0%

India 2004 30 5.2 79.2%

Sri Lanka 2003 n.a 8.4 89.7%

Thailand 2002 n.a 3.4 85.6%

Eastern Mediterranean

Saudi Arabia 1992 23.8 8.7 76.0%

Syria 1998 23.4 11.2 n.a

Jordan 1991 26.4 4.8 85.0%

Lebanon 2000 21.6 14.7 97.8%

Kuwait 1985 25.3 6.0 n.a

Bahrain 1995 25.5 7.2 n.a

Europe

Belarus 1995 n.a 13.8 100.0%

Turkey 2002 n.a 12.6 58.2%

Norway 1990 25 20.5 n.a

France 1994 25 14.6 49.4%

Slovenia 1998 22.8 14.7 100.0%

UK 1998 22.7 16.6 n.a

Lithuania 1998 22 17.4 n.a

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cont... Table 1.2

The Netherlands 1986 23.4 17.4 n.a

Denmark 2001 n.a 16.7 n.a

Germany 2005 n.a 14.5 n.a

Italy 1995 n.a 9.44 94.2%

Portugal 1984 n.a 10.9 n.a

Spain 1993 n.a 10.9 99.0%

Switzerland 1988 n.a 18.8 n.a

Romania 1995 n.a 10.2 n.a

Africa

South Africa 1989 n.a 13.8 n.a

Madagascar 1993 n.a 13.1 98.0%

Uganda 2002 n.a 3.4 62.5%

America

Brazil 2003 n.a 20.1 99.4%

U.S.A 2004 n.a 10.01 94.3%

n.a – not available

Source: WHO oral health country/area profile (WHO, 2010)

1.7 Oral Health in some Selected Countries

The decline in dental caries in industrialized countries is attributed primarily to

the widespread use of fluoride toothpastes, a change in diet and infant feeding patterns,

and an improvement in oral hygiene as well as socio-economic factors (FDI). Some

countries, including the Scandinavian countries and the United Kingdom, have organized

public health services, providing oral health care, particularly to children and

disadvantaged population groups (Petersen et al., 2005).

A recent review (Hugoson et al., 2005 a) of dental care habits and knowledge of

oral health among individuals aged 3-80 years in Jonkoping, Sweden from 1973 to 2003

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showed great overall improvement in oral health during this 30 year period. In 2003,

approximately 90-95% of all individuals were regular attenders, with recall appointments

every two years. More than 90% brushed their teeth once or twice a day and all used

fluoride toothpaste (Hugoson et al., 2005).

Dental Caries Experience

Dental caries belongs to the group of non-communicable chronic diseases and is

considered as a ‘complex’ or ‘multi- factorial’ disease. There exists no simple causative

pathway to tooth decay (Fejerskov, 2004). Risk factors for dental caries are changeable

during life, and a person’s risk for caries may vary with time.

Dental caries is also related to an individual’s lifestyle and the socio-behavioural

factors which are clearly implicated. Some of these factors are poor dietary habits, poor

oral hygiene, and frequent consumption of refined carbohydrates and frequent use of oral

medications that contain sugar (Fejerskov and Kidd, 2003; Bratthall and Hansel Peterson,

2005). Other factors related to caries risk include poverty, social status, number of years

of education and dental insurance coverage (Brown et al., 2002; Petersen, 2005; Selwitz

et al., 2007).

In most countries, the prevalence of dental caries experience among adults is high,

as the disease has affected nearly the majority of citizens in all populations (Petersen,

2005; WHO, 2008b). A decline in dental caries has, however been observed in most

industrialized countries over the past 25 years or so (Chen et al., 1997; Kelly at al., 2000;

Petersen et al., 2005; Dye et al. 2007).

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Between 1964 and 1988, adult Australians saw a startling decrease in dental

caries experience with a more steady decline from 1988 to 1996 (Hopcraft and Morgan,

2003). In the United States, adults aged 18 to 45 years have enjoyed a 27% decline in the

total number of decayed surfaces from 1971-74 to 1988-1994 (Brown et al., 2002).

This pattern has been the result of a number of public health measures, including

effective use of fluorides, together with changing living conditions and lifestyles and

improved self-care practices (Petersen, 2005).

Most industrialized countries and some countries of Latin America show high

mean DMFT (Decayed Missed and Filled Teeth) values. Whereas levels of dental caries

experience are low in Africa and Asia (Petersen, 2005), the WHO reports speak for an

increasing trend in dental caries in these two continents. However, a study in Africa

shows a general decreasing trend in dental caries for children and adults (Cleaton – Jones

and Fatti, 1999).

In the EMR, the middle-aged in most countries have a low to moderate level of

dental caries experience (WHO, 2008b). Reports from Syria have pointed to a 14%

increase in mean DMFT values (from 9.8 to 11.2) among the middle aged between 1988

and 1998 (Beiruti and Helderman, 2004).

Robert and Sheiham (2002) estimated the burden of dental caries with the

traditional method of restorative dentistry is beyond the financial capabilities of the

majority of the low-income nations, as most of these countries cannot even afford an

essential package of health care services for children.

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Dental Status

Loss of permanent teeth among adult populations is a trustworthy measure of their

oral health status and an important explanatory factor for oral health-related quality of

life (OHRQOL) (Aggeryd, 1983; Ahacic et al., 1998; Bagewitz et al., 2007). Tooth loss

may be associated with an increased risk for systematic diseases and a higher mortality

rate. A 15 - year cohort study on 29,584 individuals among the Chinese population

(Abnet et al., 2005) point out that tooth loss as one risk marker for total death and death

from upper gastrointestinal cancer, heart disease and stroke.

In the developed countries, adults tend to maintain higher numbers of teeth

(Hescot et al., 1997; Kelly et al., 2000; Dye et al., 2007), and prevalence of partial or

complete edentulousness is on the decline (Mojon et al., 2004; Suominen – Taipale et al.,

2008). In the United States, a 10% decline in edentulousness has been reported with each

decade for the past 30 years (Douglass et al., 2002). According to a 10 year follow-up

study from Finland, the 10 year incidence of edentulousness was 8% for women and 7%

for men aged 40 years and over (Hiidenkari et al., 1997).

Some countries like China and Japan, also speak for a general trend toward a

decrease in loss of teeth, and tooth loss is considered a rare condition among middle aged

Chinese and Japanese (Lin et al., 2001; Hanioka et al., 2007). The mean number of

missing teeth for those aged 35 to 44 reported in the WHO data bank is from 2.9 for

Pakistan as the fewest to 8.3 in Jordan as the highest (WHO, 2008b).

The tooth loss phenomenon is a complicated subject related to all three sets of risk

indicators for oral health (indirect, direct and local risk factors) depending on level of

disease. Even in industrialized countries with well-developed oral health care systems,

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social gradient has been the risk indicator for edentulousness. Results of a U.S. study

indicate as determinants of tooth loss among adults: a lower self-rated level of general

health, being poor, older and white (Dolen et al., 2001).

A longitudinal study from Finland shows that the importance of some socio-

demographic determinants of edentulousness such as gender, urbanization and marital

status has disappeared during recent decades, while geographical area and education are

persistently related to edentulousness, suggesting that socio-economic determinants

become more important than demographic variables (Suominen – Taipale et al., 1999).

A study on Saudi Arabian children and adults, however, indicates tooth loss as

varying by age, gender and socio-economic status, but not by city or rural lifestyle (Al-

Shammery et al., 1998).

Oral Health and Smoking

Over the past two decades, the dentistry literature has accepted smoking as an

important risk factor for periodontal diseases (Albandar et al., 2000; Susin et al., 2005a;

Torrungruang et al., 2005). Smokers have greater odds for more severe bone loss than do

non-smokers, ranging from 3.3 for light and 7.3 for heavy smokers (Grossi et al., 1995).

Smoking even among young adults with rather few (6) years of smoking experience, was

in one study a major factor for periodontal destruction (Al–Wahadni and Linden, 2003).

Periodontal disease progression among smokers is approximately 3 to 9 years faster than

that of non-smokers (Torrungruang et al., 2005). Smoking is the most potent factor for

periodontal diseases; quitting smoking reduces the odds of having periodontitis (Nishida

et al., 2005; Yamamoto et al., 2005).

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A 10 year follow-up study has demonstrated that the relative risk (4.6) for loss of

teeth is greater (p<.001) for the 30 to 50 year old age-group smoking more than 15

cigarettes a day, than is the risk for those who do not smoke (Holm,1994). Recently, a 4-

year longitudinal study (Okamoto et al., 2006) also has indicated cigarette smoking as an

independent risk factor for periodontal disease and tooth loss with a linear trend. The

ongoing longitudinal “Health Professionals Follow-up Study” (HPFS) provides data on

51,529 male health professionals and evaluates the association between smoking and

tooth loss (Dietrich et al., 2007). This study’s results demonstrate a strong, dose-

dependent association between cigarette smoking and risk for tooth loss in men. The risk

declines soon after cessation of cigarette smoking, but remains elevated for more than 10

years compared with risk in non-smokers.

1.8 Oral Health in India

Oral diseases, particularly caries and periodontal disease, are an excessive and

unnecessary burden on the people of India. Although oral diseases are preventable,

inadequate application of preventive measures and inappropriate oral health care delivery

systems have resulted in ineffective control of these problems (WHO, 2004). Very little

information is available about the oral health and dental treatment needs of adult Indians.

Keeping this in view, the Dental Council of India undertook a national level

epidemiological study “National Oral Health Survey and Fluoride Mapping” in 2002-03

to assess the oral health problems of the people and practices they adopt in this regard.

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Table 1.3 Important Oral Health Conditions in India

Sl. No. Oral Disease Conditions Age in Years

15 35-44 65-74

1

Dental caries % prevalence 63.1% 80.2 85.0

Mean DMFT 2.4 5.4 14.9

Mean number of teeth present 27.9 30.0 18.9

2 Periodontal disease % prevalence 67.7 89.6 70.9

3 Loss of attachment % prevalence 6.9 58.1 22.3

4 Malocclusion (%) 23.9 43.1 n.a.

5 Dental Fluorosis (%) 9.9 7.2 3.7

6 Oral mucosal conditions (%) 2.3 7.1 10.3

7 Oral Cancer (%) 0.3 0.3 0.4

8 Edentulousness (%) n.a. 0.8 29.5

Source: National Oral Health Survey & Fluoride Mapping 2002-03, India.

As per the above table the prevalence percentage of subjects with caries

experience was 63.1% (15 years), 80.2% (35-44 years) and 85% (65-74 years). The

prevalence clearly increased with age. The mean DMFT value for the 15 year age group

was 2.4. It increased more than two fold to 5.4 in adults (35-44 years) and peaked at 14.9

(65-74 years).

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Table 1.4 Particulars of Oral Health Conditions in Tamil Nadu

Sl. No.

Oral Disease Conditions

Age in Years

15 35-44 65-74

1

Dental caries % prevalence 60.9 80.4 84.6

Mean DMFT 3.4 5.8 13.3

2 Periodontal disease Bleeding, Calculus or

pockets % prevalence 61.7 87.8 88.2

3 Loss of attachment % prevalence 94.6 61.9 29.2

4 Malocclusion (% prevalence) 32.4 39.1 n.a.

5 Dental Fluorosis (% prevalence) 17.8 8.0 4.5

6 Oral mucosal conditions (Nos.) 57 95 114

7 Oral Cancer (Nos.) 35 39 39

8 Edentulousness (%) 0.1 0.4 21.7

Source: National Oral Health Survey and Fluoride Mapping – Tamil Nadu 2002-03.

The prevalence of caries was 60.9 percent in 15 years; 80.4 percent in 35-44

years; and 84.6 percent in 65-74 years respectively. The mean DMFT incrementally to a

higher level as age advanced. It was 3.4 in 15 year olds; 5.8 in 35-44 year olds, and 13.3

in 65-74 year olds. There was no marked gender related or rural urban related

differentials. The pattern of distribution of caries by DMFT values was similar in rural

and urban areas and in between different regions in Tamil Nadu.

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Table 1.5 Particulars of Oral Health Conditions in Thoothukudi District

Sl. No.

Oral Disease Conditions

Age in Years

15 35-44 65-74

1

Dental caries % prevalence 70.3 82.7 86.8

Mean DMFT 4.3 7.9 17.1

2 Periodontal disease Bleeding, Calculus or

pockets % prevalence 63.1 87.6 77.9

3 Loss of attachment % prevalence 99.2 71.1 37.2

4 Malocclusion (% prevalence) 51.7 57.5 n.a

5 Dental Fluorosis (% prevalence) 11.0 2.8 1.6

6 Oral mucosal conditions (Nos.) 4 12 26

Source: National Oral Health Survey and Fluoride Mapping – Tamil Nadu 2002-03.

The prevalence of caries was 70.3 percent in 15 years; 82.7 percent in 35-44

years; and 86.8 percent in 65-74 years respectively. The mean DMFT incrementally to a

higher level as age advanced. It was 4.3 in 15 year olds; 7.9 in 35-44 year olds, and 17.1

in 65-74 year olds. There was no marked gender related or rural urban related

differentials.

1.9 Oral Health Manpower Resources

A dentist is a person licensed to practice dentistry under the law of the appropriate

state, province, territory or nation. These laws ensure that to become licensed, a

prospective dentist must satisfy certain qualifications such as,

1. Completion of an approved period of professional education in an approved

institution.

27

cont....

2. Demonstration of competence.

3. Evidence of satisfactory personal qualities.

Dentists are concerned with the prevention and control of the diseases of the oral

cavity and the treatment of unfavourable conditions resulting from these diseases. They

are legally entitled to treat patients independently, to prescribe certain drugs and to

employ and supervise auxiliary personnel. Dentists must be both licensed and registered.

The following table gives the oral health manpower available in some selected

countries.

Table 1.6 Oral Health Manpower (Dentists) Available in Some Countries

Country Year No./ Inhabitants

Australia 2007 1:2242

Bahrain 2004 46/1,00,000

Belarus 2003 44/1,00,000

Brazil 2004 1/1,500

China 2001 11/1,00,000

Denmark 2008 1:1141

Finland 2007 1:1178

France 2008 1:1556

Germany 2008 1:1247

India 2004 6/1,00,000

Italy 2007 1:1242

Japan 2004 1:1358

Jordan 2004 129/1,00,000

Kuwait 2001 29/1,00,000

Lebanon 2001 121/1,00,000

Lithuania 2008 1:1118

Madagascar 2004 2/1,00,000

Nepal 2008 1/47306

Netherlands 2008 1:1866

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cont.... Table 1.6

Country Year No./ Inhabitants

Norway 2006 1:1101

Pakistan 2004 5/1,00,000

Portugal 2008 1:1503

Romania 2008 1:1573

Saudi Arabia 2005 7/1,00,000

Slovenia 2008 1:1563

South Africa 2006 10647

Spain 2008 1:1886

Sri Lanka 2004 6/1,00,000

Sweden 2005 1:1238

Switzerland 2008 1:1680

Thailand 2004 7811

Turkey 2004 1:3656

Uganda 2004 1/1,00,000

U.K 2008 1:1976

USA 2003 1:1703

Source: WHO Oral Health Country/Area Profile (WHO, 2010)

From the above table we understand that the dentist ratio in the developed

countries: in Norway, it is 1:1101; in USA, it is 1:1703; in U.K., it is 1:1976, whereas, in

the developing countries like India, it is 1:16,667; in Nepal it is 1:47,306 and in Pakistan

it is 1:20,000. So the availability of dentists compared to the total population in

developing countries is low compared to the developed countries.

Oral Health Manpower in SEARO

Oral health manpower available in the South East Asian Region according to

WHO classifications are available in the following table.

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Table 1.7 Oral Health Manpower in SEARO

Country Year Number of Dentists No./ 1,00,000

Bangladesh 2004 2537 2

Bhutan 2004 58 2

India 2004 61424 6

Indonesia 2004 7379 1:32792

Korea 2003 8315 37

Maldives 2004 14 4

Myanmar (Burma) 2004 1396 3

Nepal 2008 624 1:47306

Sri Lanka 2004 1245 6

Thailand 2004 8076 1:7811

Timor-Leste (East Timor) 2004 45 5

Source: WHO Oral Health Country/Area profile (WHO 2010).

1.10 Importance of the Study

Oral health is a standard condition of the oral and related tissues which enables an

individual to eat, speak and socialize without active disease, discomfort or

embarrassment and which contributes to general well being. Dental caries and

periodontal diseases are the most common oral diseases affecting 50-60 and 95 -100% of

young and adult population respectively in India.

India is the second highest populated country with more than 1030 million

population. The dentist to population ratio is 1:10,000 in urban areas, whereas it is 1:1,

50,000 in rural areas. The country is presently producing 12,000 dentists per annum with

a dentist ratio of 1: 15713, in contrast to the WHO recommended dentist to population

ratio of 1: 7500 (IDA, 2008). There are several challenges being faced in delivery of oral

30

health care to the rural population, such as lack of man power and poor accessibility

which is compounded by poverty and illiteracy. Moreover there is a great paucity of data

pertaining to treatment seeking pattern of oral health which is essential for planning oral

health services for the population. The summary of its significance pertinent to this study

is as follows:

• This study will systematically give the oral health treatment seeking pattern of

people and associated socio demographic determinants among adult population in

Thoothukudi District.

• This study will investigate the cost effectiveness of filling of dental caries versus

replacement with dentures.

• This study will assist Governmental agencies and communities in policy decision

making to design and implement dental public health interventions by targeting

high risk populations.

• This study will help the decision makers determine how scarce resources would

be best allocated to prevent oral diseases and reduce disparities in oral health.

Despite significant improvements in recent decades, many people still suffer

unnecessarily from pain and discomfort from dental diseases, which remain an important

public health problem in India. In fact, most diseases of the mouth are preventable. Many

people now have good oral health but more vulnerable, disadvantaged and socially

excluded people experience higher levels of oral disease.

The oral diseases also have an adverse effect on the vital organs of the body. The

pus oozing pockets in advanced periodontal disease in adults act as a focus of infection

31

for other vital organs of body like kidney, heart, lungs and brain. The incidence of simple

morbidity becomes chronic and ultimately life-threatening. One needs not only to take

preventive measures, but early curative steps as well. It is unfortunate that oral health has

received much less attention perhaps because of its lower life threatening risk. Its role in

quality of life has been recognized now and thus all efforts taken should be to improve

oral health of the people.

Several adverse effects of poor oral health necessitate preventive, curative and

educational services/activities. They require an understanding of people’s knowledge,

awareness, attitudes towards oral health and their oral health practices, besides the

magnitude of the problem and corrective measures that people adopt. This information is

basic for the formulation of policy developing strategic measures and meeting

appropriate manpower needs and also for creating programmes for improvement of oral

health of people.

1.11 Objectives

The study has been carried out with the objectives to assess and examine the

following:

1. To study the profile of various oral health problems among patients treated in

various dental clinics.

2. To assess the oral health knowledge, attitude and practices of the patients.

3. To analyse the relationship between socio-demographic factors and oral health

practices.

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4. To determine patient’s willingness to pay (WTP) for root canal treatment (RCT)

and to investigate factors associated with it.

5. To evaluate the cost-effectiveness of filling versus extraction and replacement

with partial dentures.

6. To suggest policies for sound oral health practices.

1.12 Hypotheses

The above objectives require the following hypotheses to be empirically verified.

1. There is no significant difference between the prevalence of oral health problems

and area of residence.

2. Good oral health practices and education are directly related.

3. Willingness to pay is determined by the income of the family.

4. There is no significant difference between costs incurred and the types of

treatment (i.e. Filling and Denture).

5. There is no significant difference between the types of treatment in the

effectiveness of (OHRQOL) oral health related quality of life after treatment.

1.13 Scope of the Study

This is an empirical study conducted in a selected area namely, Thoothukudi

district, based purely on primary data. This study recognizes the fact that people living in

this district have diversity in eating habits and behavioral practices which could affect

their oral health. Therefore, this study would help to analyse the district-wise oral health

problems, the treatment seeking behaviour of the people, their knowledge, attitude and

33

practice towards implementation of policies and programmes on oral health activities and

services to improve the oral health of the people in the district as well as in the state level.

1.14 Limitations

The area of study is limited to one district, which may not necessarily be

representative of the state, Tamil Nadu. Regarding primary data, the respondents

maintain no records and have to rely on their memory; so data were subjected to recall

bias. In some cases, primary data had to be rejected due to unreasonable extreme values

reported by the patients, due to either ignorance or inability to recall. With all these

limitations the generalization of the inferences of this study has been done with care.

1.15 Organization of Thesis

The thesis is organized into seven chapters as follows:

CHAPTER 1: INTRODUCTION

This chapter presents the fundamental aspects and importance of the study for

treatment of various oral health problems, objectives, hypotheses, scope and limitations

of the study.

CHAPTER 2: REVIEW OF LITERATURE

A review of past studies related to oral health problems was done to understand

the prevalence of various oral health problems, and knowledge, attitude and practice

towards oral health management and treatment seeking behaviour of the people.

34

CHAPTER 3: METHODOLOGY

The methodology used for the collection, processing and analysis of data, and

empirical methods specified for the studies are described in this chapter.

CHAPTER 4: PROFILE OF THE STUDY AREA

An objective description of the study area, viz. Thoothukudi district, is given to

provide a backdrop to the analysis.

CHAPTER 5: RESULTS AND ANALYSIS

Prevalence of various oral health problems, their knowledge and practice and the

treatment seeking behaviour in Thoothukudi district and the results of analysis are

presented in this chapter.

CHAPTER 6: DISCUSSION

The results and analysis obtained in the study area are compared with similar

studies in other area/country are presented in this chapter.

CHAPTER 7: FINDINGS, SUGGESTIONS AND CONCLUSION

A summary of work done and salient findings of the study are presented.

Conclusions are drawn after verifying the hypotheses of the study and their implications

for policy are stated.

35