Dental pain and self-care: a cross-sectional study of people with low socio-economic status residing in rural India

Abstract

Context: Self-care is one of the ways in which people without access to professional care can actively engage in managing their oral health problems. Aim: To find out the prevalence of dental pain and the type of self-care remedies utilised for pain relief by people with low socio-economic status residing in Kollipara mandal, Guntur district, Andhra Pradesh. Settings and design: This was a cross-sectional population-based study. Methods and material: A multistage simple random-sampling technique was adopted to obtain an appropriate sample. A questionnaire, which consisted of sections on socio-economic and demographic variables, dental pain, pain characteristics and self-care remedies utilised to combat dental pain, was used to collect data. Statistical analysis used the chi-square test and descriptive statistics. Results: The survey covered a total population of 630 individuals. The mean age of the population was 32.8 ± 16.7 years. Among the total study subjects, 44.1% were male and 55.9% were female. The prevalence of dental pain reported during the preceding 6 months was 28.3%. Subjects who experienced dental pain reported the home remedies and self-care methods that they utilised to get relief from the pain. They more frequently reported using over-the-counter medication (49.6%) for pain relief. Conclusions: This study provides an insight into the type and usage of self-care in relief of dental pain. Pain sufferers used a variety of self-care methods to deal with their problems.

INTRODUCTION

Dental diseases are a major public health burden in India, with dental caries affecting 50–85% and periodontal diseases affecting 60–90% of the general population; research suggests that higher rates of oral diseases occur in rural areas¹. Huge differences exist in oral health between urban and rural populations in India². Despite having one of the largest dental workforces in the world, most people in rural India do not have access to basic oral health care³. The dentist to population ratio in rural India is as high as one dentist for every 100,000–250,000 residents, whereas this ratio is estimated as one dentist for every 4,000 residents in urban areas⁴. The low number of dentists in rural areas is a major barrier to oral health-care access for rural village residents⁵.

The most accessible, affordable and principal health-care facility for rural India, Primary Health Centers (PHC), did not provide dental services until recently. Currently, dental-care services at the primary health-care level are available in very few states⁶. Furthermore, only 20–25% of Community Health Centers, the point of secondary health care for rural villages within the Indian health-care system, provide dental care⁷. In the rural southern region of India, residents reported having to travel more than a half an hour to reach a dentist⁸. Although dental care is part of primary health care in India, patients are not covered by any type of insurance and generally pay out of their pockets to get treatment from both public and private dentists⁹. Facing numerous barriers to oral health care, low-income rural residents often are either forced, or choose, to use alternative strategies, forgo treatment and/or use self-care remedies for relief of dental pain. Self-care is one of the means by which people without access to professional care can actively engage in managing their oral health problems10., 11.. Self-care is the component of health self-management that includes behaviours, undertaken to enhance health, prevent disease, limit illness or restore health¹², which are derived from the individual’s knowledge and skills¹³.

Gilbert et al. explored dental self-care behaviours among patients who seek professional help only for certain problems and regular dental attenders. They reported that dental self-care behaviours included changes in diet and the use of over-the-counter (OTC) pain relief and home-made remedies to treat toothache and bleeding gums¹¹. Cohen et al. used a focus group design to elicit therapies used for toothache among low-income non-Hispanic White, non-Hispanic Black and Hispanic adults. They found that these adults use OTC medicines, OTC dental products and prescription medicines. The self-care behaviours included a wide variety of home and complementary therapies¹⁰.

The poor, who are most severely affected by dental disease and who rarely utilise dental services, are those who frequently encounter dental pain². In India, researchers have overlooked dental pain experienced by poor people and the use of self-care measures to combat dental pain. Given the large number of such people who may seek pain relief by means other than visiting a dentist, it is important to understand the ‘alternative’ treatment methods or self-care they utilise for pain relief. The purpose of the present study was to find out the prevalence of dental pain and the type of self-care remedies utilised by rural people of low socio-economic status (SES) residing in Kollipara mandal in the south Indian state of Andhra Pradesh.

This study investigated the prevalence of dental pain and self-care remedies utilised by people to alleviate pain. The study was carried out on a sample of 630 individuals, of low SES, residing in rural India.

SUBJECTS AND METHODS

A population-based cross-sectional survey was conducted among people of low SES residing in a rural locality of a state in south India. Kollipara, a rural mandal (administrative division), was selected for analysis in the present study. It is one of the 57 mandals of Guntur district in the south Indian state of Andhra Pradesh. The total geographical area of the mandal is 11,999 hectares, spread across 14 villages. It has a total population of 56,676 inhabitants residing in 17,694 houses. The demography of the selected mandal represents the typical rural population of southern India¹⁴. A sample size of 630 was calculated with the following parameters: prevalence from pilot study of 30%; precision (d) of 7; design effect (DeEF) of 1.5; and expected response rate (RR) of 0.8.

A multistage random-sampling technique was adopted to obtain the study sample. The investigator continued selecting households until the desired number of individuals was obtained. All individuals present at the time when the investigator visited the households and willing to participate in the study were interviewed. Edentulous individuals who had lost all their natural teeth 6 months before the start of the study were not included. Individuals with debilitating systemic disease and those who were mentally ill were excluded. Only those households of a lower socio-economic class, according to Pareek’s socio-economic scale¹⁵ were included. In India, Pareek’s classification, which consists of nine items, is widely used for rural areas. In this scale, the only items included are those for which quantitative information can be objectively collected. The items included were found to be significant in indicating the SES of rural families. The scale obtains information on important aspects of the SES of rural families – occupation, education and social participation of family head, caste of family, their land, house, farm power, material possessions and general nature of the family. Different weights are assigned to all the items. After all the information has been collected and scored, the total score for a given family is calculated. The overall score can be interpreted in terms of the class to which the family belongs.

Of the total 272 households visited, 61 families did not match the inclusion criteria and 14 did not wish to participate in the study. The total sample was collected from 197 households, in which the number of family members ranged from one to seven.

The pretested data-collection instrument was designed to collect information on socio-economic and demographic variables, dental pain, pain characteristics and self-care remedies utilised. The first section obtained information on demographic variables, such as age, sex, occupation, education and various other variables required, as per Pareek’s scale⁹. The second section inquired about dental pain experienced in the past 6 months according to the participant, its pattern and its duration. The severity of dental pain was assessed using the Numeric Pain Rating scale16., 17.. The participants were asked to choose a number, on a scale of 0–10 (where 0 = no pain and 10 = worst possible pain), that best described his/her level of dental pain.

The last section included questions on self-care remedies utilised to cope with dental pain. The questionnaire was prepared in English, which was translated into the regional language, Telugu, and later back-translated for data entry and statistical analysis.

Before the start of the study, ethical clearance was obtained from the Institutional Review Board of SIBAR Institute of Dental Sciences. The study protocol was later approved by the Nandamuri Taraka Rama (NTR) University of Health Sciences, Vijayawada (no. 31/114/12). The research was designed and conducted in full accordance with the World Medical Association Declaration of Helsinki. A schedule was prepared for data collection based on an average time of 4–5 minutes for interview and clinical examination of each individual. The interviews were scheduled to ensure maximum availability of all members in the household. The study was scheduled to run from August to September 2013. The interviewer explained the purpose of the visit to all the family members of the household. After the household members understood the aim and methods of the study, all were requested to participate in the study by responding to the questions posed by the interviewer. They were also informed that participation in the study was absolutely voluntary. Written, informed consent was obtained from the subjects willing to participate, or from their parents/guardians whenever participants were younger than 18 years of age. One trained and calibrated investigator conducted all the interviews, with a trained recorder recording the observations. For children younger than 10 years of age, parents were interviewed.

Data were analysed using SPSS Version 20.0.1 (IBM Corp., Armonk, NY, USA) and descriptive statistics were used to summarise the results. The dependent variable was cross-tabulated with the independent variables and then examined for significance using the chi-square test. The level of significance was set at P < 0.05 for all the tests.

RESULTS

The survey included a total population of 630 adults and children. The mean age of the population was 32.8 ± 16.7 years. The prevalence of dental pain observed in the study population during the 6 months before the study start was 28.3%. The mean pain score among the 178 subjects who had experienced pain was 5.8 ± 2.1 on a scale of 1–10. The dental pain characteristics of the study participants are shown in Table 1.

Table 1.

Dental pain prevalence and pain characteristics of the study population

Variable	n	%
Dental pain
Present	178	28.3
Absent	452	71.7
Pain severity
Mild	36	20.3
Moderate	96	53.9
Severe	46	25.8
Pain pattern
Intermittent	155	87.1
Continuous	23	12.9
Pain duration
Less than a day	102	57.3
Less than a week	60	33.7
1–4 weeks	12	6.7
1–6 months	4	2.3

The sociodemographic characteristics of the study population and its relationship with self-care utilisation are presented in Table 2. There were significant differences in utilisation of self-care among age groups and gender. More middle-aged (35–44 years), older (45–65 years) and elderly (>65 years) adults reported utilising self-care than younger adults (18–34 years) and children (<18 years). Fewer male subjects utilised self-care compared with female subjects. Self-care was also cross-tabulated with other sociodemographic variables, but no statistical differences were found between them.

Table 2.

Socio-demographic characteristics of the study population and their relationship with self-care utilisation

Variable	n	Self-care		P-value
		Utilised n (%)	Not utilised n (%)
Age group
<18 years	151	16 (10.6)	135 (89.4)	0.045*
18–34 years	177	22 (12.4)	155 (87.6)
35–44 years	125	28 (22.4)	97 (77.6)
45–65 years	153	24 (15.7)	129 (84.3)
>65 years	24	5 (20.8)	19 (79.2)
Gender
Male	278	52 (18.7)	226 (81.3)	0.024*
Female	352	43 (12.2)	309 (87.8)
Education
Illiterate	147	21 (14.3)	126 (85.7)	0.562
≤8 years	287	40 (13.9)	247 (86.1)
>8 years	196	34 (17.3)	162 (82.7)
Family size
Four or fewer	494	79 (16.0)	415 (84.0)	0.223
More than 4	136	16 (11.8)	120 (88.2)

^*Significant at P < 0.05.

Among those with dental pain, 95 (53.4%) subjects reported utilising at least one type of self-care. Pain sufferers described use of OTC medication, as well as various home remedies and self-care methods, to combat dental pain. Almost half (49.6%) of those experiencing dental pain reported using OTC medication for pain relief. The study participants mentioned using a wide range of home remedies to alleviate dental pain (Table 3). Sixteen individuals reported applying balm over the painful tooth region. Seven patients utilised herbal remedies, which included placing turmeric (Curcuma longa), cloves (dried flower bud of Syzygium aromaticum) or neem stick (Azadirachta indica) over the affected tooth. Fourteen subjects gargled with warm salt water to minimise their painful symptoms. Some patients also reported wrapping their face with cloth, applying warm compresses and praying to God. A few participants resorted to deleterious measures to obtain pain relief; they reported placing tobacco or applying lime to the affected area. Some patients even reported excessive alcohol intake to overcome their pain.

Table 3.

Self-care utilised by the study population

Type of self-care	n	%
OTC medication	67	49.6
Applied lime	10	7.4
Placed tobacco	9	6.7
Drank alcohol	6	4.4
Applied balm	16	11.9
Wrapped face	4	3
Herbal remedies	7	5.2
Salt water gargle	14	10.4
Warm compresses	1	0.7
Prayed to God	1	0.7

OTC, over the counter.

Less than one-quarter (22.4%) of those experiencing dental pain consulted health professionals. Of those who did, 31 visited dentists and nine consulted other health professionals. There was a significant difference in utilisation of self-care among participants who experienced different severity of pain. More participants who experienced moderate and severe pain had undertaken self-care compared with those who experienced mild pain (Table 4).

Table 4.

Pain severity and its relationship with self-care utilisation

	Pain severity
Self-care utilised	Mild (n = 36)	Moderate (n = 96)	Severe (n = 46)	Total (n = 178)	P-value
None	22 (61.1)	47 (48.9)	14 (30.4)	83 (46.6)	0.009*
≥1	14 (38.9)	49 (51.1)	32 (69.6)	95 (53.4)

Values are given as n (%).

^*Significant at P < 0.05.

DISCUSSION

This study was especially focused on people with low SES as such people have a higher prevalence of oral disease², often experience dental pain and frequently face financial as well as other barriers to private dental practice5., 7., 18., 19., 20.. In this study, the Pareek scale, a widely used classification for rural populations in India that is simple to implement and possesses good reliability¹⁵. The key finding of this study was that dental pain affects a significant proportion of this population and had forced the participants to use a number of self-care remedies.

Individuals experiencing dental pain do not always seek relief by visiting a dentist. Less than one-quarter (22.4%) of subjects experiencing dental pain had consulted health professionals. For individuals with low income and no access to dentists, self-care plays a palliative role²¹. Hastie et al.²² suggested that besides seeking professional care, an individual can choose other pain and impairment coping strategies, such as self-care. This was evident from the results of the present study. Subjects experiencing dental pain reported use of OTC medications, as well as the home remedies and self-care that they used to get relief from dental pain. Around 50% of the subjects who experienced pain utilised at least one type of self-care to overcome the painful experience, and almost half (49.6%) of subjects with dental pain reported using OTC medication for pain relief. This is consistent with the findings of other studies10., 21., 23., 24., 25.. The frequent use of non-prescription medicines suggests that there is a need for greater understanding of how people learn about the effectiveness and safety of non-prescription or OTC medications, to find a way to help them develop appropriate behaviours.

Gender and age differences were apparent in the use of self-care measures. Greater use of self-care remedies by women and by middle-aged (35–44 years), older (45–65 years of age) and elderly (>65 years of age) adults is consistent with other research26., 27.. However, more important than gender or age, use of self-care is driven largely by need. Subjects with moderate to severe pain are much more likely to engage in most of the self-care behaviours. Dandi et al.²⁸ showed that pain severity was a significant determinant for expressed needs (odds ratio = 1.44). Analogous results are found in the studies of Omitola et al.²⁹ and Ferreira et al.³⁰

A few participants resorted to deleterious measures to obtain pain relief, including excessive alcohol consumption or placing tobacco and lime on the affected tooth. Needless to say, these actions represent significant health risks and highlight the continuing need for health education among these populations. This study has shed some light into the type and usage of self-care in relief of dental pain. However, there is a need for additional research to elucidate the variety of self-care strategies utilised by people with low SES experiencing dental pain and their safety and effectiveness in alleviating dental pain.

The results of this analysis must be interpreted in light of specific limitations. The research used a cross-sectional survey design, which does not allow causal relationships to be determined between variables investigated and the outcome. Although a short time frame was used, the recall bias was inevitable. The research was conducted in a rural mandal and this may limit the generalisation of results owing to differences in SES, culture and access to and use of oral health services in India.

CONCLUSION

This research showed that individuals of low SES experiencing dental pain used a variety of self-care methods to deal with their problems. This study provides an insight into the type and usage of self-care in relief of dental pain; however, there is a need for additional research to explore the safety and effectiveness of these self-care behaviours.

Acknowledgement

None.

Conflict of interest

None.