Original Article
Geographic Distribution of Dental Problems and Utilization of Dental Services from the Perspective of a Private Dental College in Kasaragod District, Kerala
Authors:
Kuldeep Singh Shekhawat, Associate Professor, Department of Public Health Dentistry, Century International Institute of Dental Sciences, Poinachi, Kasaragod, Kerala, India,
Arunima Chauhan, Professor, Faculty of Dentistry, Melaka Manipal Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India,
Prathap MS Nair, Professor and Head. Department of Conservative Dentistry and Endodontics, Yenepoya Dental College, Yenepoya University, Mangalore, Karnataka,
Avinash V. Mehendale, Associate Professor, Department of Prosthodontics Crown and Bridge, A. J. Shetty Institute of Dental Sciences, Mangalore, Karnataka, India,
Shruthy Prathap, Associate Professor, Department of Periodontics, Yenepoya Dental College, Yenepoya University, Mangalore, Karnataka, India,
Anoop Shaji, Intern, Century International Institute of Dental Sciences, Poinachi, Kasaragod, Kerala, India.
Address for Correspondence
Dr. Kuldeep Singh Shekhawat,
Associate Professor,
Dept. of Public Health Dentistry,
Century International Institute of Dental Sciences,
Kasaragod – 671541, India.
E-mail: drkuldeepss@gmail.com.
Citation
Shekhawat KS, Chauhan A, Nair PMS, Mehendale AV, Prathap S, Shaji A. Geographic Distribution of Dental Problems and Utilization of Dental Services from the Perspective of a Private Dental College in Kasaragod District, Kerala. Online J Health Allied Scs.
2020;19(3):5. Available at URL:
https://www.ojhas.org/issue75/2020-3-5.html
Submitted: Sep 20,
2020; Accepted: Nov 18, 2020; Published: Dec 20, 2020 |
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Introduction:
A vast majority of Indians suffer from oral diseases that are chronic and preventable across all age groups. A high and varied prevalence of preventable oral diseases like dental caries and periodontitis is reported from different geographical regions of India [1- 5] The resulting burden from oral diseases has been found to be high in both developed and developing countries. [6] The skewed distribution of public health care services, [7] higher out of pocket expenditures for private health services [8] and constrained public resources [9] are some of the reasons that result in persistent and consequential health and oral health inequalities.
The prevalence and incidence of dental diseases in India is largely under-reported. Though the limited dental workforce in public sector provides a fair assessment of dental problems, however more than 75 percent of dental care is provided by private sector who are under no obligation to report and/or document the same to local health authorities. Therefore, India’s database on oral diseases is largely deficient, in addition to lack of a Centralized National Oral Health Database. The World Health Organization (WHO) is giving priority to the development of Global Oral Health Report that will provide information about the status of oral health. [6] WHO recommends reinforcing of oral health information systems for surveillance of dental problems to determine the scale, patterns and impact of oral diseases at regional level. This may encourage to draft policies that will assist in providing need-based community oral health programs with no extra expenditure.
Health care utilization is the actual attendance of general population at health care facilities to receive care [10] that depends on multiple factors like socio-demographic, socioeconomic, sociocultural and socio-psychological variable. [11] Equitable utilization of oral health services with equal access and health outcomes are the pillars of equity in health care. [12] It is known that utilization of oral health services are influenced by predisposing, enabling and need factors [13] Since utilization studies and distribution of dental problems serve as an important tool in drafting oral health policies, the present study was conducted to estimate the geographical distribution of dental problems in Kasaragod district of Kerala and determine factors associated with utilization of oral health services among patients who reported to the only self-financed private dental institute situated in Kasaragod district of Northern Kerala.
Methods
Area Profile: Kasaragod district is situated in the northern part of Kerala with an area of 1989 sq.km with a total population of 1,307,375. [14] It accounts for 5.13 percent of the total area of the state with a population density of 604 per sq. km. Administratively it has 2 taluks, 6 block panchayats that are divided into 38 gram panchayats and three municipalities. [15] There is one general hospital, one district hospital, one taluk hospital, 40 Primary Health Centers [(PHC’s) (including 10, 24x7 PHC’s)] and 9 Community Health Centers (CHC’s) in different areas of the district. In addition there are Family Welfare centers, Tuberculosis Center, Mobile ophthalmic unit and Tribal Mobile unit among others that cater to health care needs for the population of Kasaragod District. [14] The delivery of oral care in the district is through institutions administratively headed by Directorate of Health Services (public sector hospitals and CHC’s) and private sector (dental clinics/hospitals and one private dental college).
Data: The analysis is based on secondary data obtained from a survey that was conducted in 2017. (16) Data then, was extracted over a time frame of six months from Out Patient Files of patients visiting the private self-financed dental institute. File records of 2593 patients was extracted. Variables included age, gender, address, chief complaint, time gap before utilizing oral health services and the treatment availed. Since the primary data did not include patients below the age group of 15 years, the same is rectified in the present study.
We wanted the data to be a representative sample of Kasaragod District. Therefore, the data was initially screened to exclude patients not residing under Kasaragod district. In addition, distance between their areas of residence and the dental institute was calculated for every patient using google maps and used as a variable. Their areas of residences were further categorized as falling under taluks, block panchayats and their respective gram panchayats/municipalities.
Variables:
In the analysis, we included age (10 year age group) and gender under predisposing factors, the place of residence as enabling factor (distance between their residence and dental institute). Mean distance was calculated from each block panchayat to the dental institute. This was done by first determining the distance between each patients’ area of residence to dental college. It was followed by categorizing all patients belonging to a particular block panchayat. The average distance was then calculated between areas of residence from all areas of each block panchayat to dental college. Need factors in the present study was based on ‘self-reported morbidity’ (objective need like, decayed tooth, pain etc.) thereby assuming that patients are able to seek treatment when required. Therefore time taken to utilize dental care was considered as need factor that also represented their earliest perceived need for dental care. Due to limited number of variables from previous data we could not assess other factors.
The data was entered in Microsoft Excel sheet (Microsoft Office, 2013, Microsoft Corporation) and analyzed using Statistical Package for Social Sciences [SPSS ver 21 Armonk, NY]. Variables were analyzed for descriptive statistics and chi square test was used for proportion. Maps (Figure 4) under results was created in Microsoft Publisher [2013, Microsoft Corp, USA] without using any Geographic Information System Software. Figure 1 and Figure 5 were created using data visualization software Tableau Desktop [Trial version 2020.2]
Results
Data from 95 patients were excluded since they were not residing in Kasaragod District therefore data from 2498 patients was analyzed. The mean age was 35.5 ± 13.1 years with range of 15 to 81 years. Patients in the range of 21 – 40 years were more in proportion with more males than females. Majority of patients belonged to Kasaragod taluk and 30.2 percent were residing in gram panchayats under Kasaragod block panchayat. (Table 1)
| Table 1: Demographic variables of study participants |
| Variable |
% (N) |
Age |
Mean, SD |
35.5 ± 13.2 |
|
Range |
15 - 81 years |
Age Group |
15 - 20 years |
10.6 (265) |
|
21 - 30 years |
33.3 (833) |
|
31 - 40 years |
24.9 (621) |
|
41 - 50 years |
16.4 (409) |
|
51 - 60 years |
9.8 (244) |
|
61 - 70 years |
4.3 (107) |
|
above 70 years |
0.8 (19) |
Gender |
Male |
58.2 (1455) |
|
Female |
41.8 (1043) |
Taluk |
Kasaragod |
53 (1325) |
|
Hosadurga |
47 (1173) |
Block Panchayat |
Kasaragod block |
30.2 (755) |
|
Manjeshwer block |
1 (24) |
|
Kanhangad block |
24.1 (602) |
|
Nileshwer block |
4 (101) |
|
Karadukka block |
12.5 (313) |
|
Parappa block |
9.6(240) |
|
Kasaragod Municipality |
10 (251) |
|
Kanhangad Municipality |
5.8 (145) |
|
Nileshwer Municipality |
2.7 (67) |
| SD – Standard Deviation; yrs – Years; % - Proportion; N - Frequency |
The most common dental problem reported was dental caries followed by dental pain and deposits in most block panchayat and municipalities. (Figure 1 and Figure 1.1) Patients in the age group of 21 – 30 years had more dental problems. (Figure 2). Majority of patients who utilized oral health services were residing within a radius of 6 - 15 kilometers (km). (Figure 3) However, it was also observed that patients on an average travelled from distances as far as 40 km to utilize dental services and with increase in distance there was a reduction in proportion of patients. (Figure 4) Panchayat wise distribution of patient revealed that majority of patients were from Chengala, Chemanad gram panchayat and Kasaragod municipality respectively that was geographically within 15 km of dental institute. (Figure 5)
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Figure 1 A treemap showing distribution of dental problems in Kasaragod District |
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Figure 1.1 Distribution of dental problems across block panchayats of Kasaragod district |
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Figure 2: Distribution of dental problems according to age group in Kasaragod District |
 |
Figure: 3 Distance travelled by study participants to utilize oral health services |
 |
Figure 4: Mean distance between each block panchayat and dental institute |
 |
Figure 5: Distribution of patient according to their gram panchayat [The Color shows sum of distance in km. The marks (individual column) are labelled by number of patients from individual gram panchayats.] |
A significant proportion of males in the age group of 21 – 30 years and females in the age group of 31 – 40 years utilized dental services (P < 0.001) (Table 2).
| Table 2: Distribution of study participants according to age group and gender |
Age group |
Males |
Females |
Χ2 value |
Sig |
15 - 20 years |
11.2 (163) |
9.7 (102) |
|
|
21 - 30 years |
36.5 (532) |
28.8 (301) |
41.32 |
P < 0.001 |
31 - 40 years |
20.8 (304) |
30.9 (317) |
|
|
41 - 50 years |
15.3 (223) |
17.8 (186) |
|
|
51 - 60 years |
10.9 (159) |
8.14 (85) |
|
|
61 - 70 years |
4.2 (62) |
4.3 (45) |
|
|
= 70 years |
0.8 (12) |
0.6 (7) |
|
|
| Level of significance at P < 0.05 using Chi square test |
Only 13.7 percent utilized oral health services within a week from the onset of chief complaints with significantly higher proportion of males than females. (P < 0.04) (Table 3)
| Table 3: Distribution of study participants according to time of utilization by gender |
| Time |
Overall percentage |
Males |
Females |
Χ2 value |
Sig |
within 1 week |
13.65 (341) |
51.3 (175) |
48.6 (166) |
|
|
1 week to 1 month |
26.06 (651) |
60.5 (394) |
39.4 (257) |
11.19 |
P < 0.04 |
1 month to 6 months |
22.3 (559) |
56.3 (315) |
43.6 (244) |
|
|
7 months to 12 months |
21.9 (549) |
61.2 (336) |
38.7 (213) |
|
|
1 year to 5 years |
14.8 (371) |
58.7 (218) |
41.2 (153) |
|
|
more than 5 years |
1 (27) |
62.9 (17) |
37 (10) |
|
|
| Level of significance at P < 0.05 using chi square test |
Discussion
The provision of oral health services by public sector in India is minimal. [17] In addition factors like perceived low quality of services and infrastructural shortfalls are systemic barriers to utilization. [18] We observed that dental services was mainly utilized by patient in the age of 21 – 40 years that is supported by studies conducted in South India. [19 - 21] Though contrary to studies reported in literature, [22, 23] we attribute this finding among patients of this age group to a high oral health-care seeking behavior that motivated them to visit and utilize dental services. It was also found that utilization of dental services was higher among males in 21 – 30 years age group and higher among females in 31 – 40 years age group. There are enough studies to substantiate increased utilization of dental services by females [13, 24, 25] however, the present study found an increased utilization of dental services by males as observed from various studies conducted across India. [26-28]
The promptness in utilizing dental care determines intensity of perceived need by patients. The delay in utilizing dental services indicates poor attitudes towards their oral health, lack of personal motivation and perhaps their inability to decide whether dental services are truly essential. The present study found that only 13.7 percent of patients utilized dental services within a week from the start of their dental problems consisting of more males than females. The interplay of factors like less severity of dental problems, a tendency to neglect dental problems and perhaps assuming an interference in their daily work/routine by visiting a dentist could be possible reasons for delayed utilization of dental services. [29] However, surprisingly majority of patients utilized dental services after one week and within one month of their chief complaint.
In the present study, it was found that about 50 percent of patients who utilized dental services had their residence within a radius of 6 – 15 km. Similar results were reported in studies conducted in two dental institutions of South India. [19, 20] We also observed that as the distance from the dental institution increased the proportion of patients visiting dental institution also decreased. We made an attempt to determine the proportion of patients visiting the dental institute from each block panchayats. There was an inverse relationship between distance and patients visiting the dental institute. The latter was also supported by a study conducted in a South Indian state where dental services were not utilized since the dentist was located at a distance far from their residence. [30]
Oral health owing to its reduced mortality levels has failed to make a serious entry in health policies. The lack of oral health care provider at the Primary Health Center level has resulted in re-directing patients to private dental practitioners resulting in increased out of pocket expenditure. Since the predominant delivery of oral health services in Kerala is provided by private sector, we have used the data from a private dental institute to determine the distribution of dental diseases across Kasaragod district.
We observed that dental caries was the most common problem present in almost every block panchayat of the district followed by dental pain and deposits. These problems were observed in almost all age groups. Dental caries is the most prevalent dental problem affecting a large proportion of population both regionally and globally. [1, 31 - 33] Deposits as a dental problem was observed among 14.5 percent across different age groups in Kasaragod district. This was less than the national prevalence of 23 percent to 37 percent from Indian National Oral Health Survey conducted in 2002-03. [34] Missing teeth was most commonly observed between age group of 40 to 70 years. Fractured restoration as a dental problem was predominantly experienced in the age group of 31 – 40 years probably resulting in functional limitation.
Distribution of dental pain was also observed among all age groups. Pain generally prompts a patients to seek and utilize dental care. [35, 36] Interestingly, in the present study we observed that dental caries was preceded by pain, which meant, patients opted to utilize dental services long before experiencing discomfort associated with untreated dental caries e.g. pain. We attribute this finding to problems experienced by patients like difficulty in eating food or food lodgment that might have had an impact on their oral health related quality of life e.g. interference with their daily oral functional performances.
The study has some limitations. First, the data included was obtained from patients who reported to utilize dental services, therefore data for older age group and those staying far away from dental institute may not be sufficient to represent and compare the results. Second, other variables like socio-economic status, by-passing dental clinics, time taken to travel to dental institute and reasons for not utilizing dental services by public sector was not determined. Third, not all factors under predisposing, enabling and need factors was considered and finally, we did not use a geographical Information Software to map dental problems which otherwise would have provided a visual understanding regarding distribution of dental diseases.
The present study was an attempt to provide a gist on distribution of dental problems in a geographical area. Since most dental problems are under-reported/not reported, oral health diseases and associated burden seldom finds any comfort from national health policies. The authors in the present study recommend utilizing data from private sectors to create a wider database. This can be supported by the fact that observations in the present study are similar to findings from literature (institutional studies or otherwise) indicating similar distribution patterns. Inclusion of data from private sector may facilitate effective analysis so that appropriate policies can be drafted taking into consideration the magnitude of dental problems that is otherwise minimal owing to limited data from public sector.
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