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
9
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
18
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
19
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.
24
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.
29
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.
32
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