Oral health status of 5-year-old Aborigine children compared with similar aged marginalised group in south western India

Abstract

Objective: To compare and assess oral health status of 5-year-old Aborigine children with similar aged, marginalised children in coastal region of south western India. Materials and methods: A total of 418 Aborigine children were invited to participate in the study and a total of 428, 5-year-olds were selected randomly for comparison from other government schools to form the other marginalised group. The WHO (1997) proforma was used for clinical examinations. Chi Square test was used to compare between categorical variables. Mann–Whitney U-test was used for comparison between the two groups for quantitative variables. Logistic and linear regression analysis was performed to determine the importance of the factors associated with caries status. Odds ratio was calculated for all variables with 95% confidence intervals. P ≤ 0.05 was considered as statistically significant. Results: Dental fluorosis was present in 50 (11.9%) Aborigine children, whereas in the other marginalised group 7 (1.6%) children had dental fluorosis (P ≤ 0.001). Untreated dental caries was 76.3% for the Aborigine children and 70.3% in the comparison group. Mean dmft values in the two groups were 4.13 ± 3.90 and 3.58 ± 3.60, respectively (P > 0.01). High frequency of between-meal sugar consumption was related to dental caries (OR = 1.20; P = 0.001). Utilisation of dental care and dental fluorosis were inversely related to dental caries (OR = 1.16; P = 0.001 and OR = 1.91; P = 0.001). Conclusion: The study revealed poor oral health status among both the marginalised groups. Significant differences were noted between the two groups with respect to oral hygiene practices, dietary habits, and dental utilisation pattern. Schools for tribal children, male gender, low frequency of cleaning teeth and higher in between-meal sugar consumption were significantly related to dental caries.

INTRODUCTION

Marginalisation is the social process of becoming or being made marginal; the marginalisation of the underclass. Being marginalised refers to being separated from the rest of the society, forced to occupy the fringes and edges and not to be at the centre of things. Marginalisation at the individual level results in an individual’s exclusion from meaningful participation in society. Globalisation (global-capitalism), immigration, social welfare and policy are broader social structures that have the potential to contribute negatively to one’s access to resources and services, resulting in marginalisation of individuals and groups. Globalisation impacts the lives of individuals and groups in many capacities with the influx of capitalism, information technology, company outsourcing/job insecurity, and the widening gap between the rich and the poor. Globalisation and structural forces aggravate poverty and continue to push individuals to the margins of society, while governments and large corporations do not address the issues¹.

Many communities experience marginalisation. In Aboriginal communities it is a product of colonisation as a result of which Aboriginal communities lost their land, were forced into destitute areas, lost their sources of income, and were excluded from the labour market ². Adivasi is an umbrella term for a heterogeneous set of ethnic and tribal groups believed to be the Aboriginal population of India. They comprise a substantial indigenous minority of the population of India. Terms such as atavika (Sanskrit for forest dwellers), vanvasi or girijan (hill people) are also used for the tribes of India. Adivasi carries the specific meaning of being the original and autochthonous inhabitants of a given region, and was specifically coined for that purpose in the 1930s³.

About half of the world’s autochthonous people, comprising 635 tribal communities (including 75 primitive tribal communities) live in India. The Indian Constitution assigns special status to the Scheduled Tribes (STs), which constitute about 8% of the Indian population. There are 573 STs living in different parts of the country, having their own languages, which are different from the one mostly spoken in the state in which they live. The ST groups who were identified as more backward communities among the tribal population groups have been categorised as ‘Primitive Tribal Groups’ (PTGs) by the Government at the Centre in 1975. So far 75 tribal communities have been identified as PTGs in different states of India. These hunting, food-gathering, and some agricultural communities, who have been identified as more backward communities need special programmes for their sustainable development⁴.

In India, children comprise 40% of a rapidly growing population. Compared to rapid expansions of schools, the provision of health care to these children is poor. Inadequate peripheral health services pose additional problems. Dental health services are poor and school dental health services are almost non-existent in India. According to the 2001 census, the tribal population in India is 74.6 million. There were 16 million ST children (10.87 million of 5–10 years and 5.12 million of 11–14 years) as of March 2001, out of the total child population in India of about 193 million in the age group of 5–14 years (Selected Educational Statistics – 2000–2001, Government of India). Education of ST children is considered important, not only because of the Constitutional obligation but also as a crucial input for total development of tribal communities.

Social exclusion describes a process by which certain groups are thoroughly disadvantaged because they are discriminated against on the basis of their ethnicity, race, religion, caste or where they live. Social exclusion is the denial of the capability of individual or group to participate in, and be respected by, society more meaningfully. Social exclusion of children in education is an issue of violating their rights to education. Social exclusion in education hampers the holistic development of children⁵.

The constitution of India guarantees the right of equality in education. The constitution guarantees every child a fundamental right to free and compulsory education up to the age of 14 years. Tribal schools are government schools for the children of backward classes, i.e. ST. These residential schools charge no fees; instead parents are given a financial incentive to educate their children. These schools attract children from lower socioeconomic strata.

It is often presumed that the tribal communities are nomadic and move from one place to the other within the state as well as other neighbouring states, live mainly in the quest for livelihood, so they face serious problems in educating their children. But the major problem faced by tribal students who want to study lies with the poor access to education and lack of infrastructure, much needed to promote quality education especially in tribal belts.

Amongst school children, different socioeconomic groups have been identified based on different school types attended by the children. This study explores the association between marginalised groups and oral health. Specifically, the aim of the study was to compare and assess oral health status of 5-year-old Aborigine children with similar aged marginalised children in the coastal region of south western India.

MATERIAL AND METHODS

Study design and subjects

The target population for the cross-sectional study was tribal children of Udupi district located in coastal regions south western India. There are six schools for Tribal children in Udupi district and details, including pupil numbers were obtained from the Indian Tribal Development Office, Udupi.

A total of 418 children attended in the 5-year age group in tribal schools; all the children were selected and invited to participate in the study. A total of 428, 5-year-olds were randomly selected for comparison from other government schools as the other marginalised group of lower socioeconomic status.

Information on demographic characteristics of participants along with oral health behaviours such as frequency of brushing, material used for cleaning teeth and visits to any health personnel for dental needs was collected by means of personal interviews administered by the examiner. The dental team comprised of the examiner assisted by a recording clerk, an interpreter and a local health worker.

Clinical examination

All the subjects were examined under adequate illumination (Type III) and clinical data were collected on dental fluorosis, periodontal status, dental caries and treatment needs. A pilot study was conducted on 50 children each in both the marginalised groups to assess the feasibility of the study and to deduce sample size for the comparison group.

Dean’s index criterion was used to assess dental fluorosis. The recording was made on the basis of the two teeth most affected. If two teeth were not equally affected, the score for the less affected of the two teeth was recorded. WHO’s criterion was used for detection of dentition status and treatment needs⁶. The examination was conducted with a plane mouth mirror. A systematic approach was adopted for assessment of dentition status and treatment needs. The examination proceeded in an orderly manner from one tooth or tooth space to the adjacent tooth or tooth space. A tooth was considered present when any part of it was visible. Data on treatment needs are of great value at local and national levels because they provide a basis for estimating personnel requirement and costs of an oral health programme under prevailing or anticipated local conditions. Treatment requirements were assessed for the whole tooth, including both coronal and root caries. Significant Caries Index (SiC) scores were calculated in order to bring to attention those children with the highest caries scores in the study population. The SiC Index is the Mean dmft/DMFT of the one-third of the study group with the highest caries score. The index is used as a complement to the mean DMFT value.

Ethical clearance was given from the Kasturba Hospital Ethics Committee, Kasturba Hospital, Manipal. Informed written consent was obtained from parents and children before carrying out the survey. The survey was scheduled between the months of August 2007 and February 2008. All examinations were performed by a single examiner and duplicate examinations were conducted on one in every 10 subjects throughout the survey. Intra-examiner reliability for various indices was assessed using Kappa statistic which was in the range of 0.88–0.90.

Statistical analysis

All the data collected were entered into spreadsheets. SPSS software version 13 was used for statistical analysis (SPSS Inc., Chicago, IL, USA). Mean and standard deviations were calculated for dmft and their components. Chi Square test was used to compare between categorical variables. Mann–Whitney U-test was used for comparison between two groups for quantitative variables. Logistic and linear regression analysis was performed to determine the importance of the factors associated with caries status. A set of independent variables including type of school attended, gender, frequency of cleaning teeth, frequency of between-meal sugar consumption, utilisation of dental care and dental fluorosis was considered. Odds ratio was calculated for all variables with 95% confidence intervals. All the dependent variables to be included in the regression analysis were dichotomised. P ≤ 0.05 was considered as statistically significant.

RESULTS

A total of 846 children comprised the sample. Of the 418 children from tribal schools, 226 (54%) were males and 192 (46%) were females. In the other marginalised group, out of the 428 children examined, 219 (51%) were males and 209 (49%) were females. Significant differences were found between the two groups with respect to frequency of cleaning teeth, material used for cleaning teeth and type of diet (Table 1).

Table 1.

Demographic and oral health behavioural characteristics of study population

Oral health related behaviour variables	Tribal school, N (%)	Government school, N (%)	P-value
Gender
Male	226 (54)	219(51)
Female	192 (46)	209(49)
Mode of cleaning teeth
Finger	0	47 (10.9)	<0.001
Toothbrush	418 (100)	381(89.1)
Frequency of cleaning teeth
Once daily	60 (14.4)	324(75.8)	<0.001
Two or more times a day	358(85.6)	104(24.2)
Material used for cleaning teeth
Toothpaste	418 (100)	361(84.4)	<0.001
Toothpowder	0	67 (15.6)
Type of diet
Vegetarian	0	83 (19.4)	<0.001
Mixed	418 (100)	345(80.6)
Frequency of sugar consumption
Once a day	–	110(25.8)	<0.001
Two times a day	135(32.2)	211(49.2)
Three times a day	283(67.8)	70(16.4))
≥3 times a day	–	37 (8.6)
Dental visit
Never visited	418 (100)	307(71.8)	<0.001
1–3 months back	–	47 (10.9)
4–6 months back	–	54 (12.5)
>6 months back	–	20 (4.7)
Reason for dental visit
Pain with teeth or gums	–	109(83.3)	<0.001
Routine check-up	–	22 (16.7)

In schools for tribal children 283 (67.8) children consumed between-meal sugar three times a day. In the other marginalised group 70 (16.4) and 38 (8.6) children reported of having between-meal sugar consumption three times a day and more than three times a day, respectively (P ≤ 0.001; Table 1).

None of the children from tribal schools had visited the dentist. From the comparison group of the 131 children reported of having made a dental visit, 109 (83.3%) made a visit due to pain with teeth or gums; only 22 (16.7%) went for a routine check-up (P ≤ 0.001; Table 1).

Dental fluorosis was present in 50 (11.9%) children from tribal schools, whereas in the other marginalised group only 7 (1.6%) children had dental fluorosis (P ≤ 0.001) (Table 2). Out of 14 children with dental fluorosis in the tribal school, 11 (21.6%), 29 (57.2%), and 10 (21.4%) children had very mild, mild, and moderate fluorosis, respectively. In the other group, 7 (100%) children had mild dental fluorosis.

Table 2.

Oral health status of study population

Oral health related behaviour variables	Tribal school, N (%)	Government school, N (%)	P-value
Dental fluorosis
Absent	368 (88.1)	421(98.4)	<0.001
Present	50 (11.9)	7 (1.6)
Decayed teeth (dt)
Absent	99 (23.7)	127 (29.7)	0.107
Present	319 (76.3)	301 (70.3)
Missing teeth (mt)
Absent	411 (98.3)	411 (96.1)	0.246
Present	7 (1.7)	17 (3.9)
Filled teeth (ft)
Absent	418 (100)	417 (95.2)	0.113
Present	–	11 (4.8)
Mean dmft	4.13 ± 3.90	3.58 ± 3.60	0.191
Range dmft
0	162 (49.6)	260 (76.4)	0.657
1–3	129 (40.1)	63 (18.6)
≥3	36 (10.3)	17 (5)

Mean value of decayed teeth and dmft value in the Tribal children was 3.97 ± 3.92 and 4.13 ± 3.90, respectively. In the second marginalised group mean value of decayed teeth, and dmft values were 3.52 ± 3.60 and 3.58 ± 3.60, respectively (P > 0.01) (Table 2). Significant caries index (SIC) scores in tribal children was 8.02 where as in the second group a score of 6.22 was seen. Table 3 depicts the stepwise multiple linear regression analysis of the caries status (dmft) in relation to several independent variables, which included school attended, gender, frequency of cleaning teeth and frequency of between-meal sugar consumption. All the variables in the model explained only 59% of the variance in caries status for the combined 5-year-old group. Schools for Tribal children, male gender, low frequency of cleaning teeth and higher between-meal sugar consumption were significantly related to dental caries.

Table 3.

Multiple linear regression model for dental caries

Model I	R	R2	Adjusted R2	SE	R2 change	P-value
1	0.24*	0.05	0.05	3.94	0.05	0.05
2	0.31†	0.09	0.09	3.97	0.04	0.05
3	0.61‡	0.37	0.37	3.94	0.28	0.001
4	0.77§	0.59	0.59	3.91	0.22	0.001

^*Predictors: school.

^†Predictors: school, gender.

^‡Predictors: school, gender, frequency of cleaning teeth.

^§Predictors: school, gender, frequency of cleaning teeth, frequency of between-meal sugar consumption.

Logistic regression analysis was employed to determine the contribution of type of school attended, gender, oral hygiene practices, frequency of between-meal sugar consumption, dental visits and dental fluorosis to dental caries. The results showed that all independent variables were significantly related to dental caries. The association between tribal schools and dental caries was evident with an odds ratio of 0.80 times. Males were more likely to have dental caries, as compared to females with an odds ratio of 0.70. Subjects who cleaned their teeth two or more times a day were less likely to have dental caries than those who cleaned their teeth sometimes or never (OR = 1.68; P = 0.001). High frequency of between-meal sugar consumption was also related to dental caries (OR = 1.20; P = 0.001). Utilisation of dental care and dental fluorosis were inversely related to dental caries (OR = 1.16; P = 0.001 and OR = 1.91; P = 0.001) (Table 4).

Table 4.

Logistic regression analysis for study population with dental caries as dependent variable (absence of dental caries, dt score 0 vs. presence of dental caries, dt scores ≥1) and school, gender, frequency of cleaning teeth, frequency of between-meal sugar consumption as independent variables

Variables	B	SE B	P-value	OR (95%CI)
School	0.60	0.0032	0.05	0.80 (0.70, 0.88)
Gender	0.37	0.0023	0.05	0.70 (0.63, 0.77)
Frequency of cleaning teeth	0.71	0.0027	0.00	1.68 (1.60, 1.76)
Frequency of between-meal sugar consumption	0.65	0.0014	0.00	1.20 (1.14, 1.26)
Dental visit	0.73	0.0012	0.00	1.16 (1.10, 1.23)
Dental fluorosis	0.76	0.0026	0.00	1.91 (1.85, 1.98)

Variables – school: tribal and other government schools; gender: male and female; frequency of cleaning teeth: sometimes or once a day and more than once; frequency of between-meal sugar consumption: one time and more than one; dental visit: never and more than once; dental fluorosis: absent and present.

In Tribal children, one surface filling (1.40 ± 2.84) was the most required treatment followed by extraction (1.25 ± 0.3) and (1.32 ± 1.82) and (1.16 ± 0.41) for the other marginalised group, respectively. A need for topical fluoride and fissure sealants was observed for both groups (Table 5).

Table 5.

Mean number of teeth requiring treatment by age group

School	One surface filling	Two surface filling	Crown	Pulp care	Extraction
Tribal	1.40 ± 2.84	0.44 ± 0.31	0.3 ± 0.2	0.4 ± 0.2	1.25 ± 0.3
Government	1.32 ± 1.82	0.48 ± 0.12	0.2 ± 0.13	0.26 ± 0.24	1.16 ± 0.41

DISCUSSION

Equity is an ethical concept grounded in the principle of distributive justice⁷. Equity in health reflects a concern to reduce unequal opportunities to be healthy associated with membership of less privileged social groups, such as poor people; disenfranchised racial, ethnic or religious groups; women; and rural residents. In operational terms, pursuing equity in health means eliminating health disparities that are systematically associated with underlying social disadvantage or marginalisation⁸. An equity framework systematically focuses attention on socially disadvantaged, marginalised, or disenfranchised groups within and between countries, including but not limited to the poor ⁹.

Achieving equal opportunity for health entails not only buffering the health-damaging effects of poverty and marginalisation: it requires reducing disparities between populations in the underlying conditions, such as education, living standards, and environmental exposures necessary to be healthy. Thus, both human rights and equity perspectives require that health institutions deal with poverty and health not only by providing care to improve the health of the poor but also by helping to alter the conditions that create, exacerbate, and perpetuate poverty and marginalisation. Governments are accountable, as parties to human rights treaties, for setting benchmarks and targets towards progressive achievement of full realisation of human rights: ‘progressive realisation requires that they should show movement in good faith towards full realisation of all rights¹⁰’.

Vaish et al.¹¹, in a study in Phulbani Orissa noted that Tribal school children used only datun for cleansing their teeth. Tewari et al.¹², in a study in Haryana, reported only 3% of children cleaned their teeth once a day with a toothbrush and toothpaste. In the National Oral Health Survey and Fluoride Mapping 2002–2003 in Karnataka State regarding oral hygiene practices for 5-year-olds, 94% of respondents said they cleaned their teeth once a day, while 57% said they used toothpastes¹³. In the present study all the Aborigine children and the majority (89.1%) of children in the comparison group used a toothbrush for cleaning teeth.

Bali et al.¹³ reported 24–30% taking sugar the previous day, and 14–15% had taken sugar two or more times a day as recorded in the National Oral Health Survey and Fluoride Mapping 2002–2003 in Karnataka State for the 5-year age group. In the present study, 100% Aborigine children reported having consumed between-meal sugar, two or more times the previous day compared to 74.2% in the other group. The differences were highly significant (P ≤ 0.001).

Villalobos-Rodelo et al.¹⁴, in a multivariate model, found that younger age, and low tooth brushing frequency were associated with poor oral hygiene in schoolchildren aged 6–12 years in Navolato, Sinaloa, Mexico. Petersen et al.¹⁵ in a study in 6-year-old school children in southern Thailand found that as high as 66% had seen a dentist within the previous year and 24% reported that visits were due to troubles in teeth. None of the children in tribal schools reported having visited the dentist. From the comparison group, 71.8% children reported having never visited the dentist. The difference was highly significant (P ≤ 0.001). Out of 131 (100%) children reported as having made a dental visit, 83.3% made a visit due to pain with teeth or gums; only 16.7% went for a routine check-up.

Dental fluorosis was present in 11.9% children from tribal schools and only 1.6% in the comparison group (P ≤ 0.001). The higher prevalence could be attributed to the fact that these children lived in the higher fluoride belts in Karnataka State. Among the Tribal children, 76.3% children had one or more decayed teeth, 1.7% children had missing teeth, and no fillings were present. In the other marginalised group, 70.3% children had one or more decayed teeth present, 3.9% had missing teeth and 4.7% had fillings. The differences were not significant. Similar mean dmft scores of 3.53 ± 3.07 in boys and 3.49 ± 2.83 in girls were reported by Mahesh et al.¹⁶ Adewakun et al.¹⁷ reported mean dft scores of 3.74 ± 3.63, in 6-year-olds in a study in Trinidad. Higher mean dmft values were reported by Petersen et al.¹⁵ in a study in southern Thailand. At age 6, 96.3% of children had caries and a mean dmft of 8.1. Similarly Viqild et al.¹⁸ reported a high mean deft of 6.2 in 6-year-olds in Kuwait. There was no difference in decayed, missing and filled teeth, and dmft values between the two groups, although both the groups had high percentages of children with decayed teeth. This could be attributed to improper brushing techniques, high between-meal sugar intake, and low dental utilisation pattern.

Jamieson et al.¹⁹ described oral health inequalities among indigenous and non-indigenous children in the Northern Territory of Australia using an area-based measure of socioeconomic status (SES). Data were obtained from indigenous and non-indigenous 4- to 13-year-old children enrolled in the Northern Territory School Dental Service in 2002–2003. Indigenous children aged 5 years had almost four times the dmft of their nonindigenous counterparts in the same disadvantage category. Parker et al.²⁰ revealed higher levels of dental caries experience, untreated disease and social disadvantage of children attending Pika Wiya, providing evidence for the need to address the health inequalities for Aboriginal children living in South Australia’s mid-north region. While most public health efforts are intended to benefit the poor and vulnerable, experience has shown that a strategic approach is necessary to overcome the tendency for the poor or marginalised to benefit too little from even the best-intentioned efforts. Meaningful participation of those who represent the poor or disadvantaged and other civil society groups, of political leaders, and of policy-makers from all relevant sectors is essential.

There exist only few incentives for new practitioners to set up practice in socially vulnerable communities. We need enlightened policies that promote practice among vulnerable communities (which also address issues of access, such as those encountered by non-status persons). The use of social epidemiology in the study of the health needs of the population, of the urban-marginalised population, appears to be important.

CONCLUSION

This study revealed poor oral health status among both marginalised groups. Significant differences were noted between the two groups with respect to oral hygiene practices, dietary habits and dental utilisation pattern. Addressing marginalisation will require a responsive and caring workforce and a progressive manpower policy on the part of government, regional health authorities and universities.