Untreated Dental Caries Among Primary School Children and Dental Services Availability in Jawadhu Hills and Polur, Thiruvannamalai District, Tamil Nadu

UNTREATED DENTAL CARIES AMONG PRIMARY SCHOOL CHILDREN AND DENTAL SERVICES AVAILABILITY IN JAWADHU HILLS AND POLUR, THIRUVANNAMALAI DISTRICT, TAMIL NADU

Dr. SUSEENDAR KK

Dissertation submitted in partial fulfilment of the

Requirement for the award of

Master of Public Health

ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES

SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY, TRIVANDRUM

Thiruvananthapuram, Kerala. India – 695011

OCTOBER 2016

Special thanks to

Dr. K. Kolandaswamy, The Director of Public Health & Preventive Medicine, Chennai

Thiru. Annamalai, Directorate of Public Health & Preventive Medicine, Chennai

Ms R. Meena The Deputy Director of Health Services, Thiruvannamalai

Thiru. Rajendran, The District Elementary Education Officer, Thiruvannamalai

Ms Chandrika, The Assistant Elementary Education Officer, Polur

Thiru Govindaraj, The Assistant Elementary Education Officer, Jawadhu Hills

School Head Masters and Teachers, Polur and Jawadhu Hills

Block Medical Officers Polur and Jawadhu Hills

Medical Officers and staffs of Primary Health Centres, Polur and Jawadhu Hills

Primary School Children, Polur and Jawadhu Hills

Acknowledgements

I sincerely thank all my teachers, class mates, friends and family who made my journey of undertaking a master programme in public health possible.

It gives me immense pleasure to write this section. I take it as an opportunity to thank everyone who in one way or another, helped me in completing this piece of my course work.

I first, thank my Guide Dr. Biju Soman, Additional professor, AMCHSS, SCTIMST, for helping me find where my interest and strength lies. If it is not for his enduring patience in handling a student like me it would not have been possible to finish this task. He had always kept his doors open for us to interact even out of office hours. It was a great learning experience for the past one year under him.

I thank Dr. Srinivasan K, Additional professor for guiding and coordinating the batch of MPH 2015 for the past two years, especially during this whole process of dissertation.

I thank Dr. KR Thankappan and Dr Mala Ramanathan who provided us an impetus to begin this dissertation thesis by making us understand what research is and how a student researcher should view it.

I thank Dr. V Raman Kutty who inspired us in many ways. He always stood front in critiquing every step of student‟s dissertation work. It helped us review our own progress. His teachings of Epidemiology laid the foundation for us to build this work further.

I thank Dr. P Sankara Sarma, for reviewing the methodology drafted for this study; his teaching approach to new students of biostatistics helped us learn the basic and relevant skills necessary for doing this study.

I thank Dr. TK Sundari Ravindran, for having instilled in us „social thinking‟ in every opportunity she had. It made me believe strongly that health is social and both are inseparable. This in many ways influenced me to conduct a research among the disadvantaged population.

I thank Dr. Ravi Prasad Varma and Ms Jissa VT for reviewing the tools developed for this study. Those valuable inputs had helped in shaping the tool. Their suggestions had been incorporated.

I thank Dr. Manju Nair for her comprehensible way of teaching „Gender and health‟ for us. It made us understand why sex and gender matter in public health research.

I thank Dr Neethu Suresh, PhD scholar, AMCHSS for her support and continued interest she showed in this dissertation work

I thank my friends Dr Dasarathan and Dr Raja, Dental practitioners for their timely help during the course of this study.

I thank my friend and senior Dr Tijo George who had always remained a source of moral support all these two years both personally and professionally. It helped me in keeping myself composed in this journey.

I thank Dr Donald M Paul, Dr Sahane Vikram Kundlik and Dr Lalchhanhima Ralte for their contributions and support throughout the process of doing this thesis.

iii

DECLARATION

I hereby declare that this dissertation titled “Untreated dental caries among primary school children and dental services availability in Jawadhu hills and Polur, Thiruvannamalai district, Tamil Nadu” is the Bonafide record of my original research. It has not been submitted to any other university or institution for the award of any degree or diploma. Information derived from the published or unpublished work of others has been duly acknowledged in the text.

Dr. Suseendar KK

Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum

Thiruvananthapuram, Kerala. India -695011

October, 2016

CERTIFICATE

Certified that the dissertation titled “Untreated dental caries among primary school children and dental services availability in Jawadhu hills and Polur, Thiruvannamalai district, Tamil Nadu” is a record of the research work undertaken by Dr. Suseendar KK, in partial fulfilment of the requirements for the award of the degree of “Master of Public Health” under my guidance and supervision.

Guide:

Dr. Biju Soman Additional Professor Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum

Thiruvananthapuram, Kerala. India -695011

October, 2016

CONTENTS

Section No Title Page No

List of tables viii

List of abbreviations ix

Abstract x

Chapter 1- Introduction 1

1.1 Background 1 1.1.1 Prioritizing oral health 1 1.1.2 Public health approach for dental caries 1 1.1.3 Basic package of oral care (BPOC) 2 1.1.4 Integrating oral health care at primary health practice 2

1.2 Literature review 3 1.2.1 Current concepts of dental caries 3 1.2.2 Epidemiology of dental caries 4 1.2.3 Economic impact of dental caries 8 1.2.4 Oral health inequalities 9 1.2.5 Dental technology 9 1.2.6 Dental services 10 1.2.7 Recommendations and guidelines for dental services at PHC 10

1.3 Rationale for the study 12 1.4 Study objectives 14

Chapter 2- Methodology 15

2.1 Study design 15 2.2 Study setting 15 2.3 Study population 16 2.4 Sample size and sampling method 18 2.5 Sample selection procedure 19 2.6 Data collection 20 2.7 Variables used in the survey 22 2.8 Ethical considerations 24 2.9 Data management 25

Chapter 3- Results 27

3.1 Untreated caries among primary school children 27 3.1.1 Description of sample characteristics 27 3.1.2 Socioeconomic characteristics of the sample 28 3.1.3 Number and percentage of children by dentition 29 3.1.4 Prevalence of untreated caries in primary teeth 30 3.1.5 Prevalence of untreated caries in permanent teeth 31

CONTENTS

Section No Title Page No

Chapter 3- Results

3.1.6 Self report of dental health 32 3.1.7 Dental hygiene habits 33 3.1.8 Frequency of eating snacks 35 3.1.9 Results of bivariate analysis 36

3.2 Dental services availability at primary health centres 40 3.2.1 General features of primary health centres 40 3.2.2 Provision of dental services 42 3.2.3 Basic infrastructure of primary health centres 43 3.2.4 Specialist dental services at upgraded PHC of Jawadhu hills 44 3.2.5 Staff position at primary health centres 45

Chapter 4- Discussion 48

4.1 Untreated dental caries among primary school children 48 4.2 Dental services availability in primary health centres 51 4.2.1 Dental service provision 52 4.2.2 Access to referral dental services 53 4.2.3 Integration of dental services at primary health care practice 53 4.3 Strengths 54 4.4 Limitations 54 4.5 Conclusion 55

References 56 Annexure 1 Institutional Ethics Committee approval 2 Interview schedule 3 Clinical assessment form 4 Dental services availability checklist 5 Information sheet for parents 6 Parental consent form 7 Information sheet for chid 8 Child assent form 9 Information sheet for PHC staff 10 PHC staff consent form 11 Information sheet for parents (Tamil) 12 Parental consent form (Tamil) 13 Information sheet for chid (Tamil) 14 Child assent form (Tamil) 15 Permission from the Directorate of Public Health & Preventive Medicine, Chennai 16 Copy of Permission from office of District Elementary Education Officer , Thiruvannamali District, Tamil Nadu

vii

List of tables

Table No Title Page No

1.1 Global DMFT for 12 years old-trends 5 1.2 Age standardized prevalence rates of untreated caries in 6 deciduous teeth in 1990 and 2010 1.3 Age standardized prevalence rate of untreated caries in 6 permanent teeth in 1990 and 2010 1.4 Prevalence of dental caries among tribal, suburban and urban 7 regions of Thiruchengode and Erode, Tamil Nadu 1.5 List of recommendations for oral health care at PHC by working 11 group on disease burden, 2011 1.6 Jobs and responsibilities for Accredited Social Health Activist 11

1.7 Guidelines for oral health services at PHC 12

2.1 List of variables used in the interview schedule 22 2.2 Indices used for measuring caries and caries experience 22 2.3 Codes the dentition status -primary and permanent teeth 23 2.4 Indicators for dental services availability 23

3.1 Basic characteristics of sample 27 3.2 Socioeconomic characteristics of the sample 29 3.3 Number and percentage of children by dentition 29 3.4 Caries prevalence in primary and permanent teeth 30 3.5 Mean of decayed, missing, filled and dmft teeth-Primary 30 dentition 3.6 Mean of Decayed, Missing, Filled and DMFT score of 31 permanent teeth 3.7 Self report of dental health 31 3.7a Self report of dental health 32 3.8 Dental hygiene habits 34 3.9 Frequency of eating snacks 35 3.10 Caries of primary teeth by geographical location 36 3.11 Caries of primary teeth by sex and age groups 37 3.12 Caries of primary teeth by parent's occupation 38 3.13 Caries of primary teeth by class 38 3.14 Caries of primary teeth by brushing frequency and frequency of 38 snacks consumption 3.15 Caries of permanent teeth by sex and age 39 3.16 Caries of permanent teeth by parent‟s occupation 40 3.17 General features of Primary Health Centres of Jawadhu hills and 41 Polur block 3.18 Oral health promotion at PHCs 43 3.19 Basic infrastructure of PHCs 44 3.20 Dental services availability at upgraded PHC, Jawadhu Hills 45 3.21 Staff position at PHC of Jawadhu hills block 46 3.22 Staff position at PHCs of Polur block 47

4.1 Summary of studies from Rajasthan and Madhya Pradesh 49 4.2 Summary of dissertation study and previous studies from Tamil 50 Nadu

viii

List of abbreviations and symbols

AFT Affordable Fluoride Tooth Paste ART Atraumatic Restorative Treatment ASHA Accredited Social Health Activist BPOC Basic Package of Oral Care DALY Disability Adjusted Life Year def decayed extracted filled (primary teeth) dmft decayed missing teeth (primary teeth) DMFT Decayed Missing Filled Teeth (permanent) D3MFT Decay(frank cavitation) Missing Filled Teeth (permanent) DT Decayed Teeth FT Filled teeth GBD Global Burden of Disease IEC Information Education Communication IPHS Indian Public Health Standards LHV Lady Health Visitor MNREGA Mahatma Gandhi National Rural Employment Guarantee Act MT Missing teeth OUT Oral Urgent Treatment PHC Primary Health Centre RBSK Rashtriya Bal Swasthya Karyakram SARA Service Availability and Readiness Assessment SEARO South East Asian Region SPSS Statistical Package for the Social Sciences VHN Village Health Nurse WHO World Health Organization n Sample size µ Mean s Standard deviation χ Chi square

Abstract

Introduction Dental caries is a common oral condition affecting children. The objectives of the study were to estimate the prevalence of untreated caries among primary school children and dental services availability in primary health centres of Jawadhu hills and Polur blocks of Thiruvannamalai district, Tamil Nadu.

Methodology A total of 450 students, 225 from each block, were selected for the study using multi- stage stratified random sampling. Public schools in the areas were grouped into three strata based on their student strength and nine schools were selected from each block in a proportionate way. One or two classes were selected randomly from each school. Approximately 25 children were included from each school. Socio-demographic information was collected from all the selected children and a qualified dentist clinically examined them for caries teeth, using the WHO modified DMFT index. Dental services availability in PHCs was studied using a check list prepared in accordance with the WHO reference manual, the Service Availability and Readiness Assessment.

Results Untreated caries prevalence in primary teeth (n=430) was 70.9% (95% CI: 66.6%- 75.19%) and in permanent teeth (n=376) was 9.3% (95% CI: 6.36%-12.24%). The differences in caries prevalence among rural (78.6%) and tribal (63.8%) school children was statistically significant (p value <0.01). Survey on service availability revealed that the minimum assured dental services, as per the Indian Public Health Standards (IPHS), were available in all PHCs and specialist dental services were available in one block PHC.

Conclusion The prevalence of dental caries is very high, both in the hills and plain areas, and it is comparable to other published studies in the region. This is in spite of the availability of dental services in PHCs as per the IPHS norms. So this study supports the argument for revision of IPHS guidelines for dental care.

Chapter 1

Introduction

1.1 Background

1.1.1 Prioritizing oral health

The United Nations in 2011 recommended that oral diseases must be included along with prevention and control of noncommunicable diseases.(General assembly, 2012) World

Health Organization in its 2003 oral health report had emphasized the need for „common risk factor‟ approach to tackle oral diseases and other Noncommunicable diseases. Oral health was recognized as a basic human right during the Nairobi declaration in the year

2005.(Benzian et al., 2005) The declarations made in the last 15 years repositioned oral health as a priority. This had further strengthened 1989 world health assembly resolution.

The world health assembly resolution had stated that oral health should be integrated in to primary health care.

1.1.2 Public health approach for dental caries

Dental caries is a disease that affects teeth. It can cause tooth pain, inability to chew food, or interrupt one‟s routine activities. Dental caries is the most prevalent chronic disease.

The incidence of tooth ache due to dental caries was found to be high among other acute conditions. Dental caries is caused by multiple factors. The cost of treating dental caries or its consequences is high. The magnitude and burden of caries have created a need for public health approaches to control it.

1.1.3 Basic Package of oral Care (BPOC)

World Health Organisation had advocated provision of certain basic oral care services at first point of contact for people seeking oral and dental care. Basic Package of Oral Care

(BPOC) was introduced. It is a package of service that consists of three components Oral

Urgent Treatment (OUT); Affordable Fluoride Tooth paste (AFT) and Atraumatic

Restorative Treatment (ART). Basic Package of oral care had been developed and tried in different countries.(Frencken et al., 2002) This package mainly focuses on caries prevention, management and first aid treatment for tooth ache.

1.1.4 Integrating oral health care at primary health practice

Indian Public health Standards (IPHS) guidelines recommend dental care provision beginning at primary health centre level. School health programmes include screening for dental ailments. In 2011, working group on noncommunicable diseases, recommended provision of some additional dental services at primary health centres. Provision of services including oral health education, tobacco cessation counselling, oral prophylaxis, pain relief, simple restorations and early identification of oral cancer and referral were suggested. In 2009, training for female health volunteer, Accredited Social Health

Activist (ASHA) included topics about oral cancer and its prevention. The aim was to disseminate information through them to the rural population. The provision of basic minimum oral care in primary health centres will be a step towards improving oral health care access to all especially remote and resource poor setting.

1.2 Literature Review

1.2.1 Current concepts of dental caries

Dental caries is the localised destruction of susceptible dental hard tissues by acidic by- products from bacterial fermentation of dietary carbohydrates.(Fontana et al., 2010)

It is a subclinical, dynamic, ongoing de and remineralisation process which takes place within the microbial bio film (dental plaque) covering the tooth surface, due to disturbances in normal physiological balance resulting in loss of tooth mineral and a cavitated or a noncavitated carious lesion.(Fejerskov, 1997)

The term caries therefore denotes both the „process‟ and „outcome‟ of the process, the carious lesion.

The simple definition of caries as a cavity is inaccurate because it merely describes only the symptom or sign of an ongoing and past disease.

Defining caries as a continuous process has two implications,

1. Prevalence of dental caries may be higher as clinical and epidemiological

assessments had only measured or are able to measure only signs of cavitation.

2. Caries is not truly „preventable‟, can be controlled.

A great emphasis is placed in understanding this conceptual definition as it forms the basis for caries diagnosis, measurement and developing strategies for prevention and management.

Dental caries is a „complex‟ or „multifactorial‟ disease caused by an imbalance in physiologic equilibrium between tooth mineral and biofilm (dental plaque) fluid.(Fejerskov, 2004)

There is interplay of numerous factors in caries initiation and progression. Interaction of acid producing bacteria, fermentable carbohydrates and susceptible host tooth over time directly contributes to caries development. Oral environment, life style and behavioural factors also are implicated in caries development. The multifactorial etiology of dental caries makes prevention difficult creating a need for multiple interventions for its control.

Dental caries is also named under polymicrobial diseases, a group of diseases which are induced by presence of multiple microorganisms. The existence of an extraordinarily diverse ecosystem of different species of microorganisms in a caries lesion has been detected from DNA and RNA studies. This adds support to the concept that consortia formed by multiple microorganisms act collectively, probably synergistically to initiate and expand the cavity. It further reveals that Streptococcus mutans forms only a tiny portion of this ecosystem raising questions about the postulated role of S mutans in caries causation.(Simón-Soro and Mira, 2015)

1.2.2 Epidemiology of dental caries

Decayed, Missing and Filled Teeth

DMFT index is used to determine the prevalence of caries in permanent teeth. The „def index‟ is used to measure caries prevalence in deciduous teeth. WHO modified DMFT index (D3MFT, „D3‟ denotes „frank cavitation‟) is used in oral health surveys globally for it is easy application.

Global weighted mean DMFT is calculated using the formula,

Global weighted DMFT= (∑ {DMFTi x Populationi}) / Total

Global weighted mean DMFT value for 12 years old children in 2015 was 1.86 (Table

1.1). It was calculated using data from 209 countries. The Global DMFT for 12 years old

4 children had seen a declining trend till 2004 after which there is increase. Among the

WHO regions, weighted DMFT among 12 years old children of SEARO was the highest.

The weighted DMFT of SEARO region had increased from 1.12 in 2004 to 2.97 in 2015.

India had high caries level (3.9 D3MFT, 2003) among countries of WHO SEARO region.(Gavriilidou NN, 2015)

Table 1.1* Global DMFT for 12 years old- trends Year Global weighted mean DMFT

1980 2.43

2011 1.61

2015 1.86

*-extracted, Source-(Gavriilidou NN, 2015)

Highest level of caries was observed in Latin American countries (D3 MFT 2.4 ± 1.2) and

Europe (D3 MFT 2.1 ± 1.2). Countries which showed low prevalence include Middle East

(D3 MFT 1.9 ± 1.4), the Western Pacific (D3 MFT 1.5 ± 1.0), Southeast Asia (D3MFT 1.2

± 1.2), Africa (D3MFT 1.2 ± 1.6), and North America (D3MFT 1.1 ± 0.1). These observations were from data collected after 2000.(Lagerweij and Loveren, 2015)

Untreated caries

Global Burden of Disease (GBD) 2010 study defined and measured the prevalence of untreated caries so as to estimate the present level of disease unlike DMFT which measured life time caries experience. Global Burden of disease 2013 (GBD 2013) estimates show high incidence of acute pain due to caries in permanent teeth (200 million

5 cases). Also asymptomatic caries in permanent teeth was the most prevalent chronic condition which had affected 2.4 billion cases.(Vos et al., 2015)

Kassebaum et al reported the prevalence and incidence estimates of untreated caries by consolidating epidemiological data from 1990 to 2010 (Table 1.2, 1.3). He found the rates remain static for both deciduous teeth and permanent teeth for the 20 year period. He also concluded that the burden of disease varies among regions and has been shifting from children to adults. He reported 3 peaks in prevalence at age 6, 25 and 70 years.(Kassebaum et al., 2015)

Table 1.2* Age standardized prevalence rates of untreated caries in deciduous teeth in 1990 and 2010

Year Global South Asia 1990 8.9 (95% CI 8.6-9.2) 8.9 (95% CI 8.1-9.9)

2010 8.8 (95% CI 8.5-9.1) 9.4 (95% CI 8.6-10.3)

*-Abridged, Source: (Kassebaum et al., 2015)

Table 1.3* Age standardized prevalence rate of untreated caries in permanent teeth in 1990 and 2010

Year Global South Asia 1990 35.5 (95% CI 33.7-37.6) 41.6 (95% CI 36.0-47.5)

2010 35.4 (95% CI 33.7-37.3) 40.8 (95% CI 35.9-46.6)

*-Abridged, Source: (Kassebaum et al., 2015)

The weighted mean DMFT of WHO index age groups 5, 12 and 15 years from 1999 to

2014 in India showed that it was high among 15 years (2.56 ± 6.508) followed by 5

(2.49 ± 7.78) and 12 years (1.48 ± 3.292). The review by Kundu et al concluded that northern region of India showed high prevalence of caries than southern region. The pooled prevalence of dental caries was highest among 15 years (62.02%), followed by 5 years (48.11%) and 12 years (43.34%).(Kundu et al., 2015)

A study by veerasamy et al among 974 adolescents aged 12- 15 years in Tamil Nadu showed a dental caries prevalence of 61.4% with an average DMFT score of 2.03

(Veerasamy et al., 2016a). Another study conducted by John et al to study the associated factors influencing dental caries in tribal, suburban and urban regions of Thiruchengode and Erode of Tamil Nadu showed the following results, presented in table 1.4.(John et al.,

2015a)

Table 1.4* Prevalence of dental caries among tribal, suburban and urban regions of

Thiruchengode and Erode, Tamil Nadu

Location Number of affected Total

Tribal 138 (89.3%) 206

Sub urban 185 (77%) 411

Urban 369 (55%) 411

*-Created, Source: (John et al., 2015a)

The global burden of three common oral conditions namely severe tooth loss, untreated caries and severe periodontitis together was estimated to be 15 million DALYs in 2010 which is equivalent to an average health loss of 224 years per 100, 000 persons. Untreated caries ranked 80th position of top hundred causes of DALYs in 2010. The burden due to severe tooth loss had decreased whereas the burden due to untreated caries and severe periodontitis had increased since 1990. It is depending on the availability of preventive and conservative treatment the burden of severe tooth loss due to untreated caries and periodontitis can be averted in future.(Marcenes et al., 2013)

1.2.3 Economic Impact of dental caries

The global economic impact of dental diseases amounted to US$442 billion in 2010.

Direct treatment costs due to dental diseases worldwide were estimated at US$298 billion yearly, corresponding to an average of 4.6% of global health expenditure. Indirect costs due to dental diseases worldwide amounted to US$144 billion yearly, corresponding to economic losses within the range of the 10 most frequent global causes of death. (Listl et al., 2015) High income countries spend between 5% and 10 % of their health expenditure in treating tooth decay and gum diseases. Low and middle income countries do not have adequate resources to meet the need for dental treatment and those available are expensive. Estimation of traditional restorative dental treatment costs for permanent teeth of child population of low-income countries alone amounted to a value £1,024 ($US

1,618) and & £ 2,224 ($US 3,513) that exceeds the available sources for the provision of an essential public healthcare package for the children of 15-29 low-income countries.

(Kathmandu, 2002)

1.2.4 Oral health inequalities

Oral health inequalities exist both in developed and developing countries and are related to socioeconomic status, ethnicity, or region.(Robinson and Marshman, 2015) A study using UK adult dental health survey showed that inequalities in prevalence of caries exist across different income groups, with 10-18 percent increase in the probability of caries between the wealthiest and every other quintile.(Steele et al., 2014) Dental caries has changed from disease of affluence to a disease of deprivation in the global scale. In low and middle income countries oral health inequalities are compounded by lack of prevention programmes, unavailability of dental services or lack of access to it.(Peres and

Heilmann, 2015) Inequalities in caries prevalence by region were inferred from a study conducted by John et al in Erode, Tamil Nadu. Lack of access to dental services was mainly associated with high caries prevalence in the tribal region.(John et al., 2015a)

Gender and caste were predictors of caries in a study conducted in rural Thanjavur, Tamil

Nadu.(Veerasamy et al., 2016a)

1.2.5 Dental technology

Establishing dental services requires investment in dental equipments and materials, which is a burden for health systems of developing countries already restricted by poor resources. It is also necessary to have a supporting environment like continuous supply of electricity and water to operate these systems. (Hobdell and Sheiham, 1981) Adequate care and maintenance of dental devices is challenging due to unavailability of skilled manpower for the task. Developing countries depend on industrialized nations for their medical equipment needs. The technology developed for use in their environment often does not suit the needs of developing countries. High cost and difficulty in operating with no supportive environment limit the availability of dental services and contributes to

9 inequalities in their provision.(Robinson and Marshman, 2015) There is a need for developing cost-effective, sustainable technologies which can be used in rural settings.

1.2.6 Dental services

Dental services though had played a limited role in caries reduction are needed to treat the prevailing disease.(Robinson and Marshman, 2015) They reduce the impact of caries, prevent its consequences and improve the quality of life in those affected. Services must be available, accessible and affordable for use. It should be also acceptable and accommodating.(Penchansky and Thomas, 1981) It applies to dental services also. The factors that determine availability and access to oral health care are multiple and include dental workforce and infrastructure.

In India there is an output of 30000 dentists per year and it is projected that there will be more than one lakh dentists oversupply by the year 2020.(Vundavalli, 2014) The geographical imbalance in distribution of dentists has resulted in underutilization of trained dental manpower and under provision of services in rural areas.

1.2.7 Recommendations and guidelines for dental services at PHC

Recommendations of working group on disease burden in the year 2011 had come up with recommendations for providing dental services at primary health centres. Those are listed in the table 1.5

Table 1.5* List of recommendations for oral health care at PHC by working group on disease burden, 2011 Recommendations

Oral and dental care services Oral health education Tobacco cessation counselling Oral prophylaxis Pain relief Identification of oral precancer/cancer/common oral diseases & referral Atraumatic restorative treatment

Staff Dental hygienist Staff nurse ASHA

Training of staff Health education, tobacco cessation counselling, basic pharmacology, ART

Equipments As appropriate for providing above services *-created Source:(Working group on noncommunicable diseases, 2011)

The committee also had specified certain roles for Accredited Social Health Activist

(Table 1.6)

Table 1.6* Jobs and responsibilities for Accredited Social Health Activist

Responsibilities

Instructions on oral hygiene Simple methods of prevention of oral problems Dietary counselling Counselling on tobacco Early Identification & referral Infant dental care instructions Oral care for pregnant mothers Instructions on dental caries prevention during school programme Analgesics for tooth ache

*-Created Source: (Working group on noncommunicable diseases, 2011)

There are certain guidelines for oral health service provision at primary health centres put forth by Indian Public Health Standards (Table 1.7). Those are summarized as table below.

Table 1.7* Guidelines for oral health service at primary health centres

Oral health services

Minimum assured services (Essential) Oral health promotion Dental check up & referral

School health Dental check up & referral

Tobacco control Heath education & IEC harmful effects of tobacco use Promoting tobacco quitting Brief advice on tobacco cessation

Staff Responsibilities Medical officer Screening, dental care & referral Health assistant female (LHV*/Female supervisor) Health education for dental care Health worker female Assist Health assistant female

*-IEC-Information Education and Communication **-LHV-Lady health visitor *-Created Source:(Directorate General of Health Services, 2012)

1.3 Rationale for the study

The burden of caries remains static and has not declined.(Kassebaum et al., 2015) The very nature of caries disease, limitations of preventive strategies, high cost of existing treatment procedures, imbalanced distribution of dental services are some reasons identified in the literature. The continuing burden of caries had created a need for novel approaches to the problem. One such effort is to provide dental services at primary health centres (PHCs).

The need for providing primary oral health has been recognised.(Working group on noncommunicable diseases, 2011) The Indian public health standards had given guidelines for provision of dental services and oral health promotion at primary health centres.(Directorate General of Health Services, 2012) There have been prior recommendations by the working group on noncommunicable diseases for provision of some basic services at PHCs.(Working group on noncommunicable diseases, 2011) They have indicated the need to integrate oral care at PHCs. These are mainly directed to improve oral health care access to rural areas.

Primary health centres play a vital role in meeting health care needs of the rural population. Dental service provision at primary health centres will help reduce oral health inequities arising due to lack of services. What are the dental services provided at primary health centres? There is a lack of literature exploring availability of dental services at primary health centres in Tamil Nadu or in India as such. A survey of dental services available at primary health centres is therefore needed.

How many will be benefited by such services at primary health centres? In order to find how many will be benefitted an estimation of the prevalence of dental caries in a population was considered. It is more relevant to study the caries prevalence of school children as primary health centres play a direct role in school health. Also, there are cost effective treatments for treating dental caries of children like (Atraumatic restorative treatment) ART, which have already been recommended by experts. Have these recommendations been implemented? Are there any opportunities to integrate such services at primary health centres? These questions, explain the rationale for the study presented.

So there are two requirements which this study wanted to find. An estimation of prevalence of untreated dental caries among school children and survey of dental services availability at primary health centres. This will show how many are affected by caries and how many can be benefitted if services are available.

In short, this study will be an indicator of dental service provision at primary health centres and assessment of dental care needs of the population they serve.

1.4 Study Objectives

The objectives of the study are to

1. Estimate the prevalence of untreated dental caries among 5-12 years old children

in Government and Government aided primary schools in Jawadhu hills and Polur

blocks of Thiruvannamalai district, Tamil Nadu.

2. Assess dental services availability at primary health centres of Jawadhu hills and

Polur blocks of Thiruvannamalai district, Tamil Nadu.

Chapter 2

Methodology

2.1 Study design

The study design is Crossectional. The study was conducted as two parts.

Part 1: Survey among primary school children for assessing prevalence of untreated caries

Part 2: Survey of primary health centres for dental services availability

2.2 Study setting

The study was conducted at Jawadhu hills and Polur blocks of Thiruvannamalai district in

Tamil Nadu.

The rationale for choosing the above places is to study the caries prevalence and dental services availability in two geographically different places, a hill and a plain.

Jawadhu hills

Jawadhu hills form a part of the Eastern Ghats. The hills are about 80 km wide and 32 km long. They are located at a height ranging between 2350 feet to 3500 feet above sea level.(Department of economics and statistics, 2016) The Jawadhu hills block is specified as tribal block. There are 11 village panchayats. The population density is 358 per square kilometre and sex ratio is 963 females per 1000 males. The male and female literacy rates of the population are 62.14 per cent and 37.86 per cent respectively. The population of

Jawadhu block is 51,999 as per 2011 census. The percentage of Scheduled Cast among the total block population is 2.06 per cent and that of Scheduled tribes is 90.54 per cent.(Department of economics and statistics, 2016)

The tribes of Jawadhu hills are called as „Malayalies‟ meaning „a person from hill‟

(„malai‟-hill and „al‟-person). Their chief occupation is agriculture. They also migrate to work in plains, mostly as construction labourers.

Polur

Polur block represents both rural and urban administrative divisions. It is divided in to two town panchayats and 40 village panchayats. The population density is 637 per square kilometre and sex ratio is 1006 females per 1000 males. The male and female literacy rates of the population are 55.8 per cent and 44.2 per cent respectively. The block population according to 2011 census is 1, 77,772. The percentage of people living in rural areas (76.13 per cent) of Polur was more than urban part (23.9 per cent). The percentage of Scheduled caste among the total block population is 17.77 per cent and that of

Scheduled tribe is 0.3 per cent (Department of economics and statistics, 2016)

2.3 Study population

The study population for two main objectives are described in this section

Objective 1: Untreated dental caries

The study population were children studying in class I to V of Government and

Government aided schools. Primary school children fall in age group 5 to 12 years.

The rationale for selection was to assess the prevalence of untreated caries among children of 5-12 age groups. Literature evidences about how many are affected by primary teeth caries in the study setting was lacking.

A brief description of schools

There are about 100 elementary schools in Jawadhu hills and 107 schools in Polur block.

These include primary schools (class I – V) and middle schools (class I – VIII). The schools come under different administration namely, Panchayat, Forest department and

SC & ST welfare department.

In Jawadhu hills approximately 6060 students had enrolled in primary schools for the academic year 2016-2017. The number of primary school students in each school varied from 9 to 685. About 27.6% (1673 of 6060) of students study in schools that had strength less than 50 students, 32.2% (1954 of 6060) of students study in schools that had strength ranging from 50 to 100 students and 40.1% (2433 of 6060) of students study in schools that had students above 100.

In Polur, approximately 6847 students had been enrolled in primary schools for the academic year 2016-2017. The number of primary school students in each school varied from 6 to 270. About 17.9% (1226 of 6847) of students study in schools that had strength less than 50 students, 40.1% (2750 of 6847) of students study in schools that had strength ranging from 50 to 100 students and 41.9% (2871 of 6847) of students study in schools that had students above 100.

Objective 2: Dental services availability

The study subject for dental services availability was Primary Health Centres. All 7 primary health centres of Jawadhu hills and Polur were included.

The rationale for choosing primary health centres was to learn what services are available at first point of public health care system and what opportunities exist to integrate dental services at primary health care practice.

A brief description of primary health centres

In Jawadhu hills there are 2 Primary Health Centres and 13 Health Sub Centres. The

PHCs are at Jamunamarathur and Nammiyampattu. In Polur there are 5 Primary Health

Centres and 33 Health Sub Centres. The PHCs are at Kalambur, Kalasamudram, Kelur,

Thiruchurpettai and Vazhiyur. Each block has one upgraded primary health centre which serve as block PHC. The PHC at Jamunamarathur and Kalambur are upgraded Block

PHCs of Jawadhu hills and Kalambur respectively. The remaining PHCs are designated as additional PHCs.

2.4 Sample size and sampling method

The sample size for this study was calculated using Open Epi software. The total number of subjects for the study was estimated to be 450. The number of males or females in the study was subject to randomization.

A reported prevalence of 72 per cent dental caries (Saravanan et al., 2008) for this age group, by Saravanan et al and a design effect of 1.2 were used for sample size calculation.

Multi stage stratified random sampling method was used.

2.5 Sample selection procedure

The required number of students from each block was 225, for the estimated sample size

450. The sample selection procedure used for estimating prevalence of untreated dental caries is as follows.

Step 1: Stratification of schools

A list of schools in each block was prepared separately. They were stratified based on number of students.

Strata 1: Schools with number of students less than 50 Strata 2: Schools with number of students ranging from 50 to 99 Strata 3: Schools with number of students 100 and above

Step 2: Selection of schools

The number of schools selected from each stratum was based on the percentage of students studying in it. The number of schools selected was as follows,

Strata 1 (27.6%): 2 schools Strata 2 (32.2%): 3 schools Strata 3 (40.1%): 4 schools

A total of 9 schools were selected in Jawadhu block. Similarly in Polur block the schools were selected from each stratum as mentioned below,

Strata 1 (17.9%): 2 schools Strata 2 (40.1%): 3 schools Strata 3 (41.9%): 4 schools

Step 3: Selection of class and students

If the school strength was less than or equal to 25, all students were screened.

In schools with strength greater than 25, students were selected in the following manner.

First a list of classes and divisions in ascending order was prepared. Then 1 class or division was selected randomly by lottery method. If the selected division had less than

12 students another division was selected randomly.

Eligibility:

Inclusion criteria

1. Children enrolled as student of the selected school and were present

2. Children of both sexes were included

3. Children aged between 5-12 years were included

Exclusion criteria:

1. Children who were sick or absent

2. Children whose parent did not consent

3. Children who did not give assent

2.6 Data collection

The data collection at the study setting was taken up in the months of July and August,

2016. It was completed in the first week of September 2016. The outcome variable, data collection tools and procedure are explained below.

Untreated dental caries among primary school children

Outcome variable: Untreated caries in primary and permanent teeth

Operational definition:

The diagnostic criteria for dentition status defined by World Health Organisation were followed in this survey.

Caries is recorded as present when a lesion in a pit or fissure, or on a smooth tooth surface, has an unmistakable cavity. (World Health Organization, 2013)

Data collection tools:

The tools used were interview schedule and form for coding dentition status.

Data collection procedure:

The interview and clinical examination of the school children was done within the school premises. Children belonging to one school were interviewed and screened in one day;

20 however maximum number of children to be screened in a day was set to be 25. A separate classroom in the school was used for this purpose to ensure privacy of the participant.

The questionnaire was filled by the interviewer based on the responses from the child interviewed. The clinical examination of children was done using sterilized dental instruments, a mouth mirror and straight probe. Autoclave was used to sterilize instruments. In order to ensure availability 50 sets of sterilized dental mirror and probe were carried to the site. In addition disposable mouth mirrors were also kept ready for use in case of need. Permanent dentition status was recorded using numbered scores and the primary dentition status was recorded using letter scores.

Dental services availability at primary health centres

Outcome variable: Dental services availability

Operational definition

The WHO‟s SARA (Service Availability and Readiness Assessment) reference manual definition for service availability was used in this study.

Services availability: The physical presence of the delivery of services, encompassing health infrastructure, core health personnel, and service utilization.(World Health

Organization, 2015) Indicators used for dental service provision are described below for each domain in form of a table.

Data collection tool: Dental services availability check list

Dental services availability survey in PHCs was conducted using a check list. Check list had indicators for service provision. Response was obtained from medical officer of the health centre.

2.7 Variables used in the survey

Objective 1: Untreated dental caries among primary school children

Interview schedule

Table 2.1 List of variables used in the interview schedule

Variables/ Indicators Basic information Dental health Sex Self perception of health of teeth Age in completed years Presence of tooth cavity (self reported) Father‟s occupation History of tooth ache (self reported) Mother‟s occupation Health care seeking Religion Brushing frequency Caste Brushing aid Roof of the house Teeth cleaning agent Cell phone Mouth rinsing Motor cycle Frequency of eating snacks

Clinical assessment of dentition status

Table 2.2 Indices used for measuring caries and caries experience

Indicators for caries/caries experience Primary teeth Number of primary teeth decayed teeth (dt) missing teeth (mt) filled teeth (ft) dmft Index

Permanent teeth Number of permanent teeth Decayed teeth (DT) Missing teeth (MT) Filled teeth (FT) DMFT index

The codes used for the clinical assessment of the dentition status were followed with reference to World Health Organisation‟s manual for Oral health survey basic methods fifth edition. The table 2.3 that follows was extracted from the same manual.

Table 2.3 Codes for the dentition status -primary and permanent teeth

Code Condition/status Primary Permanent teeth teeth Crown Crown Root A 0 0 Sound B 1 1 Caries C 2 2 Filled, with caries D 3 3 Filled, no caries E 4 - Missing due to caries - 5 - Missing for any other reason F 6 - Fissure sealant G 7 7 Fixed dental prosthesis abutment, special crown or veneer/implant - 8 8 Unerupted tooth (crown)/unexposed root - 9 9 Not recorded Table extracted from Oral health survey-Basic methods Fifth edition (World Health Organization, 2013)

Objective 2: Dental services availability at primary health centres

Table 2.4 Indicators for dental services availability

Service availability Indicators Service provision Provision of essential dental service Provision of specialist dental services Number of days services provided in a week Service providing officer School dental health Community dental health Dental health education Specific services Dental emergency Tooth extraction Oral prophylaxis Restoration of tooth Removable dentures Infrastructure Presence of basic amenities Dental equipments Medicines Staff Medical officer Dental surgeon Staff Nurse Dental assistant Village health nurse Utilization Number of patients utilizing per day

2.8 Ethical considerations

The study was reviewed by Institutional Ethics Committee of Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum; approval was obtained before commencing the data collection. (Ref: SCT/IEC/907/MAY-2016)

Some measures taken in view of ethics are described as follows,

Risk:

The possible risk could have been discomfort or tooth pain during clinical examination.

In order to minimize the risk and to reduce anxiety, the procedure was explained prior to clinical examination. Care was taken not to do any harm. Probing of carious tooth was not done to avoid trigger of pain or discomfort.

Benefit:

The study participants were given a statement about their dental caries status and treatment required.

Privacy and Confidentiality

The data collected is kept safely with the investigator. Reports of the results or articles will remove any information that could allow anyone to identify the participant.

Information regarding the privacy was provided in the informed consent form.

Informed Consent:

The informed consent of parents was obtained through children. The information sheet in local language was provided to the parents through children prior to the study. Those who have difficulty in understanding the content were informed to contact the principal investigator. The contact number of the investigator was provided in the informed consent

24 form. The children‟s assent to participate in the study was obtained after parents had consented.

2.9 Data management

Data collected was followed by data entry and documentation. Data was entered using

EpiData version 3.1.

Data analysis was done using SPSS (Statistical Package for the Social Sciences) version

21.

Descriptive analysis:

Analysis of each variable was done first for description of data. Basic characteristics of the sample was described using analysis of variables namely sex, age groups, parent‟s occupation, religion, and caste. Children were grouped in to four categories based on age.

Five and six years old children were grouped as one category. Seven years, eight years old children were kept as two separate categories. Nine years old children and those aged above nine were grouped in to one. Indicators of socioeconomic status namely roof of the house, possession of cell phone and motor cycle were analysed to gain a sight of their economic status.

Self assessment of dental health was studied for which analysis of self report of dental health, tooth cavity, tooth ache, health care sought were done. Brushing frequency was analysed by categorizing in to three, those who brush once, twice and several times.

Similarly analysis for brushing aid, teeth cleaning agent and mouth washing habit were analysed for reporting. Frequency of eating snacks was analyzed as three categories as every day, several times a week and occasional consumption.

Analysis for number of decayed, missing, filled teeth, and dmft/DMFT for both the dentitions were done by taking frequencies. Also their mean were calculated.

Bivariate analysis

Chi-square test was used to analyze whether any of the variables like sex, age, geographical location, father‟s occupation, mother‟s occupation, brushing frequency and frequency of eating snacks were related to untreated caries.

Father‟s occupation was categorized as five in to own agriculture, coolie agriculture, coolie (other), small business and other. Similarly mother‟s occupation was categorized in to five namely own agriculture, coolie agriculture, MGNREGA, house work and other.

Frequency of eating snacks and fruits was categorized in to four categories as follows,

1. Frequent snacks (chocolate, biscuits and the like) with less frequency of eating

fruits

2. Frequent snacks with frequent fruit consumption

3. Less frequent snacks with less frequent consumption of fruits

4. Less frequent snacks with less frequent fruits

Chapter 3 Results

3.1 Untreated dental caries among primary school children

The number of children interviewed and examined for this survey was 452. It exceeds the estimated sample size by two. It was decided prior to screen all children present in the class for ethical reasons. The number of children from rural Polur was 228 and the remaining 224 were from Jawadhu hills.

3.1.1 Description of the sample characteristics

The sample includes 239 females, slightly more than males who were 213 in total. In both the blocks, female children were more in number. Table 3.1 contains the details of some basic characteristics.

Table 3.1 Basic characteristics of sample

Variables Categories Tribal % Rural % Total % (n=224) (n=228)

Sex Male 107 47.8 106 46.5 213 47.1 Female 117 52.2 122 53.5 239 52.9

Age groups Up to 6 years 49 21.9 59 25.9 108 23.9 (Completed 7 years 47 21.0 60 26.3 107 23.7 yrs) 8 years 52 23.2 66 28.9 118 26.1 9 years & above 76 33.9 43 18.9 119 26.3

Religion Muslim 0 0 7 3.1 7 1.5 Christian 8 3.6 9 3.9 17 3.8 Hindu 216 96.4 212 93.0 428 94.7

Class Backward 0 0 26 11.4 26 5.8 Most Backward 0 0 125 54.8 125 27.7 Scheduled Caste 1 0.4 76 33.3 77 17.0 Scheduled Tribes 223 99.6 1 0.4 224 49.6

The total sample was divided in to four age groups, each form about one fourth of the sample size. In tribal block, many children were nine years or above. In Polur block maximum number of children were aged 8 years.

Most of the children were Hindus (94.7 per cent), only less than four per cent of them were Christians and miniscule of them were Muslims. The children of tribal Jawadhu hill were all Scheduled Tribes, except one. Among the children of Polur block majority belonged to most backward class (54.8 per cent) and next to scheduled caste (33.3 per cent).

3.1.2 Socioeconomic characteristics of the sample

The occupation of fathers in tribal block was mainly agriculture. More than 50 per cent of them were cultivating in their own land. In Polur block, around 60 per cent fathers were employed as labourers (coolies), mostly in non-agriculture sector and also in agriculture.

In hill region mothers were involved in own agriculture (35.3 per cent). In the plain region about 34 per cent mothers sought employment under social security scheme

Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA). The next major proportion of mothers worked as labourers in agriculture or non agriculture jobs.

In the total sample 52 per cent children lived in concrete houses. About 95 per cent of the children‟s houses possessed at least one cell phone. More than half of them owned a motor cycle (57 per cent).

These features are listed in the following table 3.2

Table 3.2 Socioeconomic characteristics of the sample

Variables Categories Tribal % Rural % Total % (n=224) (n=228) (n=452)

Father‟s Own agriculture 119 53.1 10 4.4 129 28.5 occupation Coolie 62 27.7 35 59.2 197 43.6 Other 43 19.2 83 36.4 126 27.9

Mother‟s Own agriculture 79 35.3 5 2.2 84 18.6 occupation Coolie 34 15.2 60 26.3 94 20.8 MGNREGA 33 14.7 77 33.8 110 24.3 Housework 53 23.7 45 19.7 98 21.7 Other 25 11.2 41 18.0 66 14.6

Roof of the Concrete 110 49.1 125 54.8 235 52 house Not concrete 114 54.8 103 45.2 217 48

Cell phone Yes 209 93.3 221 96.9 430 95.1

Motor cycle Yes 206 47.3 152 66.7 258 57.1

3.1.3 Number and percentage of children by dentition

The study examined 452 school children of whom majority (78.3 per cent) had both primary and permanent teeth. They belong to mixed dentition stage of development.

Transition to permanent dentition had occurred in 22 children (4.9 per cent). The number of children with only primary teeth was 76 (16.8 per cent).

Table 3.3 Number and percentage of children by dentition

Type of Dentition frequency %

Primary dentition 76 16.8 Mixed dentition 354 78.3

Permanent dentition 22 4.9

3.1.4 Prevalence of untreated caries in primary teeth

The prevalence of untreated caries in primary dentition (n=430) was 70.9 per cent. In tribal block, Jawadhu hills the prevalence was 78.6 percent (n=206) and in Polur block the prevalence was 63.8 per cent (n=224).

In Jawadhu hills, female children (79.8 per cent) had decayed teeth left untreated more than male children (77.3 per cent). The mean measure of decayed primary teeth was

2.94±2.92. If we look at age wise percentage of children with primary teeth caries, 80 per cent or above were affected in five years, seven years and eight years age groups. Among six years old children 72.7 per cent (n=32) were affected. The mean dmft was same that of mean decayed teeth for males. There is a small increase in mean dmft than mean decayed teeth for females (Table 3.5).

Table 3.4 Caries prevalence in primary and permanent teeth

Type of Dentition frequency %

Primary dentition 430 70.9 Permanent dentition 376 9.3

Table 3.5 Mean of decayed, missing, filled and dmft teeth-Primary dentition

Indices Tribal ( n=224) Rural(n=228) Male Female Total Male Female Total

mean ±s mean ±s mean ±s mean ±s mean ±s mean ±s

decayed 2.94±2.82 2.92±3.03 2.93±2.92 2.53±2.74 1.98±2.62 2.24±2.68

missing 0 0.02±0.19 0.01±0.13 0.13±0.55 0.01±0.09 0.07±0.38

filled 0 0.01±0.09 0.01±0.15 0 0.03±0.21 0±0.07

dmft 2.94±2.82 2.97±3.06 2.96±2.94 2.66±2.73 2.00±2.62 2.31±2.69

3.1.5 Prevalence of untreated caries in permanent teeth

The number of school children who had one or more permanent teeth was 376. The prevalence of untreated caries in permanent dentition was 9.3 per cent (Table 3.4). The prevalence in tribal block school children was more (15.6 per cent) than in Polur (2.7 per cent).

In Jawadhu hill equal number of male and female children was affected. A little increase in prevalence was observed among males. Peak prevalence was observed among nine years age group.

In Polur 192 children had at least one permanent tooth. Among them five (2.7 per cent) had been affected with caries. The number of female children affected was four. Age wise prevalence shows that eight years old were affected most.

The mean of decayed, missing, filled and DMFT score of permanent teeth are presented in the table 3.6 below.

Table 3.6 Mean of Decayed, Missing, Filled and DMFT score of permanent teeth

Indices Tribal (n=224) Rural(n=228) Male Female Total Male Female Total

mean ± s mean ± s mean ± s mean ± s mean ± s mean ± s

Decayed 0.22±0.62 0.16±0.45 0.19±0.54 0.1±0.97 0.05±0.28 0.03±0.22

Missing 0 0 0 0 0 0

Filled 0 0.03±0.26 0.02±0.19 0.04±0.3 0 0.02±0.27

DMFT 0.22±0.62 0.2±0.51 0.21±0.57 0.05±0.4 0.05±0.28 0.05±0.34

3.1.6 Self report of dental health

Data from survey regarding self assessment of dental health are reported in table 3.7. The percentage of children who perceived having healthy teeth was 67.3 and 24.1 per cent stated that their dental health was poor. In Jawadhu hills 62.5 per cent reported having tooth cavity whereas in Polur 48.2 per cent reported presence of decayed tooth. Tooth ache was reported by 21.7 (n=98) per cent of the total study sample (n=452).

Among the children who reported having tooth ache in the past one month, most of them had tried simple home remedies for pain relief. Only 31.6 per cent had sought professional help. They had visited either a dentist (17.3 per cent) or a doctor (14.3 per cent). Some of self or home remedies reported include use of salt or salt rinse, lotion, milk of certain leaves, clove and tobacco. Self medication for pain relief was prevalent among both rural and tribal school children with later reporting more. Some had tried brushing teeth or removing lodged food from the tooth cavity. A fraction (15.3 per cent) of them who suffered tooth ache reported not taking any treatment.

Table 3.7 Self report of dental health

Variables Categories Tribal % Rural % Total % (n=224) (n=228)

Self Good 156 69.6 148 64.9 304 67.3 perception Poor 54 24.1 55 24.1 109 24.1 of health Don‟t know 03 1.3 14 6.1 17 3.8 of teeth No response 11 4.9 11 4.8 22 4.9

Tooth Yes 140 62.5 110 48.2 250 55.3 cavity No 77 34.4 116 50.9 193 42.7 (self No response 7 3.1 2 0.9 9 2.0 reported)

Table 3.7a Self report of dental health

Variables Categories Tribal % Rural % Total % (n=224) (n=228)

Tooth Yes 46 20.5 52 22.8 98 21.7 ache No 170 75.9 175 76.8 345 76.3 (self No response 8 3.6 1 0.4 9 2.0 reported)

Remedy Home 19 41.3 24 46.2 43 43.9 (n=98) Dentist 10 21.7 7 13.5 17 17.3 Doctor 5 10.9 9 17.3 14 14.3 No treatment 12 26.1 12 23.0 24 15.3

3.1.7 Dental hygiene habits

The study of brushing frequency of children in both rural and tribal blocks revealed that more than fifty percent brushed once daily. More children from Polur block (40.4 per cent) reported brushing twice a day than Jawadhu hills (31.7 per cent). When asked about the use of brushing aid, 96 per cent of children had reported using tooth brush mainly to clean their teeth. The number of children using toothbrush was same in both the blocks.

There were also reports of use of twigs or fingers to clean the teeth. Twigs were used both by rural (31.6 per cent) and tribal (26.3 per cent) children. In rural area 25 per cent of children reported using fingers alternative to tooth brush for cleaning their teeth.

The table below 3.8 shows the data related to brushing habits of children.

Table 3.8 Dental hygiene habits

Variables Categories Tribal % Rural % Total % (n=224) (n=228) (n=452)

Brushing Once 121 54.0 114 50.0 235 52.0 Frequency Twice 71 31.7 92 40.4 163 36.1 Several times 22 9.8 12 5.3 34 7.5 No response 10 4.5 10 4.4 20 4.4

Brushing Tooth brush 215 96.0 222 97.4 437 96.7 aid Twigs 59 26.3 72 31.6 131 29.0 Fingers 20 8.9 57 25.0 77 17.0

Tooth Tooth paste 193 86.2 217 95.2 410 90.7 cleaning Tooth powder 45 20.1 45 19.7 90 19.9 agent Brick powder 34 15.2 16 7.0 50 11.0 Ash powder 38 17.0 10 4.4 48 10.6 Stone powder 4 1.8 54 23.7 58 12.8

Washing Regular 200 89.3 141 61.8 341 75.4 mouth Irregular 3 1.3 33 14.5 36 8.0 (After Never 18 9.3 54 23.7 75 16.6 meal)

The agent used for cleaning teeth was primarily tooth paste and 90 per cent of the whole sample reported using it. Tooth powder use was also among 20 per cent of the children.

Brick powder and ash powder were also used for cleaning teeth. Though their use was reported in both Polur and Jawadhu hills more children of the hill had this practice. In

Polur, the use of stone powder for cleaning teeth existed among 23.7 per cent of the children in contrast to hill region where only less than two per cent reported its use. The practice of washing mouth after meals was regular more in children from tribal block

(89.3 per cent) than Polur block (61.8 per cent).

3.1.8 Frequency of eating snacks

A view of snack eating habits of children reveals that most of them take it occasionally.

Frequency of consuming chocolates and biscuits was more among Polur children when compared to children of tribal block. The percentage of children in Polur (chocolates: 11 per cent & biscuits: 16.2 percent) who eat them every day was more when compared to

Jawadhu hills (0.9 Per cent, 3.1 per cent). The pattern of consumption of fruits was almost similar in both the areas. The other snacks included mostly fried and packed foods. The percentage of children who consumed it several times a day (23.2 per cent) was more in tribal block when compared to children in Polur (13.2). The following table 3.9 gives the details of the frequency of consumption of snacks.

Table 3.9 Frequency of eating snacks

Variables Categories Tribal % Rural % Total % (n=224) (n=228)

Chocolates Every day 2 0.9 25 11.0 27 6.0 Several times a week 65 29.0 66 28.9 131 29.0 Occasionally 157 70.1 137 60.1 294 65.0

Biscuit Every day 7 3.1 37 16.2 44 9.7 Several times a week 86 38.4 83 36.4 169 37.4 Occasionally 131 58.5 108 47.4 239 52.9

Fruits Every day 3 1.3 5 2.2 8 1.8 Several times a week 49 21.9 46 20.2 95 21.0 Occasionally 172 76.8 177 77.6 349 77.2

Other Every day 1 0.4 11 4.8 12 2.7 Several times a week 52 23.2 30 13.2 82 18.1 Occasionally 171 76.3 187 82.0 79.2 79.2

3.1.9 Results of Bivariate analysis

The results of bivariate analysis for caries primary teeth by geographical location, sex, age groups, and parent‟s occupation are presented below.

Location

The prevalence of untreated caries in primary dentition varied between the children of

Jawadhu hills (78.6 per cent) and Polur (63.8 per cent). Chi square test results showed that observed differences in caries prevalence of primary dentition were statistically significant (p value is less than 0.01). Table 3.10 describes the percentage affected by location.

Table 3.10 Caries of primary teeth by geographical location

Location Primary teeth* (n=430) Permanent teeth** (n=376)

Caries % Total Caries % Total Tribal 162 78.6 206 30 15.6 184

Rural 143 63.8 224 5 2.7 192

 * χ (1) = 11.402 , p < 0.01, **χ (1) = 18.543, p < 0.01

Sex

Data from the study showed differences in prevalence of primary teeth caries between male and female children. The differences observed among male and female in plain region was found to be large than in case of Jawadhu hills (Table 3.10). In both locations they were statistically non significant. The p value of the chi square test results were greater than 0.05.

Age groups

Prevalence of caries increased from age 6 to 8 years among tribal children. The differences were not statistically significant (p value was greater than 0.05). Similarly the differences among different age groups in Polur were also statistically non significant.

Class

In Polur differences in caries prevalence was observed among children belonging to different classes. These were found to be non significant (p value was greater than 0.05).

The variations observed in caries prevalence by parent‟s occupation, brushing frequency, frequency of consuming snacks were found to be non significant.

Table 3.11Caries of primary teeth by sex and age groups

Variable Categories Tribal (n=206) Rural (n=224) Caries % Total Caries % Total

Sex Male 75 77.3 97 73 70.2* 104 Female 87 79.8 109 70 58.3* 120

Age groups 5 years 4 80.0 5 11 55.0 20 (completed 6 years 32 72.7 44 18 47.4 38 years) 7 years 38 80.9 47 42 70.0 60 8 years 43 84.3 51 46 69.7 66 9 years & 45 76.3 59 26 65.0 40 above

* χ (1) = 3.394, p value > 0.05

Table 3.12 Caries of primary teeth by parent's occupation

Variable Categories Tribal (n=206) Rural (224) Caries % Total Caries % Total

Father‟s occupation Own agriculture 83 80.6 103 5 50.0 10 Coolie agriculture 5 71.4 7 14 60.9 23 Coolie - other 42 77.8 54 70 64.2 109 Small business 6 66.7 9 25 75.8 33 Other 26 78.8 33 29 59.2 49

Mother‟s Own agriculture 50 78.1 64 1 20.0 5 occupation Coolie 27 79.4 34 40 69.0 58 MGNREGA 26 78.8 33 46 60.5 76 House work 43 82.7 52 33 73.3 45 Other 16 69.6 23 23 57.5 40

Table 3.13 Caries of primary teeth by class

Class Caries % Total (n= 224)

Backward 21 80.8 26 Most backward 78 63.9 122

Scheduled caste & T 44 57.9 76

Table 3.14 Caries of primary teeth by brushing frequency and frequency of snacks consumption

Variable Categories Tribal Rural Caries % Total Caries % Total

Brushing One time 95 77.9 122 72 59.5 121 frequency Two & more 67 79.8 84 71 68.9 103

Frequency of Frequent Snacks 84 76.4 110 80 65.6 122 eating snacks & less fruits Frequent Snacks 26 86.7 30 22 56.4 39 & more fruit Occasional snack 43 87.8 49 32 62.7 51 & less fruit Occasional snack 9 52.9 17 9 75.0 9 & more fruit

The results of Bivariate analysis for caries of permanent teeth among tribal children are as follows,

The sex differences observed in prevalence of permanent teeth caries among tribal children were not significant.

As age increases there was an increase in caries prevalence. The increase in prevalence was found to be statistically significant (p value was less than 0.001).

The differences observed among children based on the father‟s occupation were found to be statistically significant (p value less than 0.05). But the differences seen based on mother‟s occupation were not significant.

The tables 3.15 that follow present the number and percentage affected by sex, age and parent‟s occupation.

Table 3.15 Caries of permanent teeth by sex and age

Variable Categories Tribal (n=192) Caries % Total

Sex Male 15 16.1 93 Female 15 15.2 99

Age 6 years 0 0 20 7 years 1 2.2 46 8 years 5 9.8 51 9 years & above 24 32.0 75

Table 3.16 Caries of permanent teeth by parent’s occupation

Variable Categories Tribal (192) Caries % Total

Father‟s Own agriculture 24 22.6 106 occupation Coolie agriculture 0 0 4 Coolie other 2 4.3 47 Small business 0 0 7 Other 4 4 28

Mother‟s Own agriculture 18 24.0 75 occupation Coolie 3 10.3 29 MGNREGA 5 18.5 27 House work 2 4.9 41 Other 2 10.0 20

3.2. Dental Services availability at Primary Health Centres

The dental services availability survey was conducted at 7 primary health centres. There were 2 centres at Jawadhu hills and 5 were located in Polur block. Each block had 1 upgraded Primary Health Centre serving as central coordinating unit at block level (Block

PHC) for the remaining primary health centres (Additional PHCs).

3.2.1. General features of Primary Health Centres

All the centres existed in Government owned building and were functioning 24X7. All the health centres were accessible by road. Public transports were available within 500 metres to 1 Km from the facilities.

Four centres covered a population of 20,000 to 30,000; two centres served a population ranging between 30,000 and 40,000. One of the five centres at Polur served the needs of population of 48,939.

The average OP attendance a day varied between 90 and 250, with five centres registering

100-200 patients a day. The Highest average utilization was reported at block PHC of

Polur. Block PHC at Polur registered about 200 to 250 patients a day.

Essential services which include OPD, emergency, referral and inpatient services were available in all centres. Minimum assured services under maternal, child health, nutrition and adolescent health were available. School health and community outreach services were also reported to be available through all health facilities.

Table 3.17 describes the general features of primary health centres.

Table 3.17 General features of Primary Health Centres of Jawadhu hills and Polur block

Features Description / Number Categories of PHCs

Location Rural 5 Tribal 2

Upgraded PHCs Yes 2 * 24X7 Functioning Yes 7 Own building Yes 7

Public transport Availability Yes 7 Accessibility Less than 500 m 5 More than 1 Km 2

Population coverage 20,000-30,000 4 30,000-40,000 2 ˃ 40,000 1

Average OP attendance a day Less than 100 1 100-150 2 150-200 3 ˃ 200 1

Essential services OPD, Emergency services 7 Referral, In patient services

Other services ANC, Delivery, PNC, Child care 7 Nutrition, Adolescent health

School health, Community outreach 7

Dental services Essential dental check up 7 Specialist dental services 1

Distance of nearest unit 10-15 Km 3 With dental services 20-40 Km 2 More than 40 km 2

*One in each block

3.2.2 Provision of dental services

Essential dental service, the dental check up (minimum assured service) was available in all health centres. Patients with dental complaints were screened by medical officers on duty and referred to nearby Government health facility that provides specialist dental services. Prescription of medicines for pain relief was done for patients who came with complaints of dental pain.

The patients who sought relief for dental problems were referred to nearby Government facilities with dental services for treatment and management. The distance of nearest unit where dental services were available varied from 10 km to above 40 km.

Specialist dental services were available only at upgraded PHC of Jawadhu hills block.

Oral health promotion included provision of dental hygiene instructions through Village

Health Nurse during school visits. Table 3.18, gives a list of health promotion activities for oral health.

Community outreach services at Jawadhu hills had included dental check-up.

All primary health centres celebrated health days including world no tobacco day.

Rashtriya Bal Swasthya Karyakram (RBSK):

The national health programme Rashtriya Bal Swasthya Karyakram had been implemented in both the blocks. The RBSK team consists of two medical officers, one school health nurse, one staff nurse and two pharmacists. Dental caries is one of the conditions for which school children were screened. Instructions to maintain dental hygiene were provided to the school children by the visiting health team.

Table 3.18 Oral health promotion at PHCs Oral health promotion Availability/Description

School dental health Yes RBSK

Community dental health Yes

IEC activities RBSK* VHN **

Dental Dental hygiene Health topic

World NO Yes Tobacco day

* RBSK- Rashtriya Bal Swasthya Bala Karyakram, **VHN-Village Health Nurse

3.2.3. Basic infrastructure

Basic infrastructure such as bed, chair, table, light source, wash basin, water storage and autoclave for sterilization were available in all PHCs.

All the primary health centres had power back up in case of power failure. The two upgraded primary health centres and the additional primary health centre at Jawadhu hill were provided with power generator. All other centres were provided with inverter as standby during power break.

Bore well remained the source of water supply for all PHCs. All facilities had overhead tank and motor pump to facilitate water storage.

Medicines that are commonly prescribed for dental ailments namely Amoxicillin,

Metronidazole, Paracetomol and Aceclofenac were available in all PHCs.

Table 3.19, below presents the basic infrastructure available at the primary health centres.

Table 3.19 Basic infrastructure of PHCs

Features Description / Number Categories of PHCs

Basic infrastructure

Bed, Chair, Table, stool, Light source Yes 7 Wash basin, water storage Yes 6 Sterilizing equipment Yes 7

Power Continuous power supply 1 Occasional power failure 5 Regular power cuts 1

Standby in case of power failure Generator 3 Inverter 4

Water source Bore well 7

Over head tank Yes 7

Motor pump in Yes 6 working condition

3.2.4 Specialist dental services at upgraded PHC of Jawadhu hills:

The upgraded primary health centre of Jawadhu hill at Jamunamarathur was capacitated to provide specialist dental services. Specialist services were provided six days a week except Sunday. About 30-40 patients were utilizing the service per day. Diagnosis for dental problems and tooth extraction were the services provided at the PHC.

Dental infrastructure:

The Jamunamarathur PHC had been equipped with dental unit consisting of a dental chair and air compressor. Instruments for making diagnosis namely mouth mirror, straight probe and tweezers were available. Periosteal elevator and an extraction forceps were available. Local anaesthesia was available. A Plastic spatula and filling instrument were

44 available. Zinc oxide powder that is used as tooth filling material was available. The dental services available at Jawadhu hills block PHC are listed in the table 3.20.

Table 3.20 Dental services availability at upgraded PHC, Jawadhu Hills

Dental services Availability Dental setup & Instruments Availability

Dental pain relief Yes Dental chair Yes Tooth extraction Yes Air compressor Yes Oral prophylaxis No Mouth mirror Yes Tooth Restorations No Straight probe Yes Dentures No Tweezers Yes Scalar unit No Periosteal elevator Yes Tooth extraction forceps Yes Hand piece No Burs No Spoon excavator No Cement spatula No Plastic spatula Yes Glass slab No Filling Instrument Yes Incision & Drainage Yes Local anaesthesia Yes Suture material No Glass Ionomer No Zinc oxide Eugenol Yes

3.2.5. Staff position at primary health centres

The staff position and vacancy corresponds to time and date of data collection. The details are tabulated for Jawadhu hills and Polur in tables 3.21 and 3.22 respectively.

There were three medical officers at block PHC of Jawadhu hills and four at Polur block

PHC. The number includes block medical officer. Among additional primary health centres three had two medical officers each; each of two other centres was headed by one medical officer. Medical officers post were reported to be vacant at block PHCs, two at

Jawadhu hills and one at Polur.

The block PHCs had been sanctioned with 4 staff nurses each, one post remained vacant at block PHC of Polur. All additional PHCs except one had one or more staff nurses posted. Staff nurse vacancies were reported by five out of seven PHCs surveyed.

There were minimum six posts sanctioned for village health nurses (VHN) for each PHC.

All centres except block PHC at Jawadhu hills had reported vacancies for VHN. Two

PHCs had half of VHN posts not filled.

A dental surgeon had been posted at Jamunamarathur PHC, of Jawadhu hills. A dental assistant was in position.

Each block PHC had one Community Health Nurse (CHN) and one Block Health

Supervisor.

Each PHC had one sector health nurse (SHN) to coordinate and supervise the work of

Village Health nurses. Pharmacists, male health inspectors, multipurpose workers and hospital workers were other staff present at the PHC.

Table 3.21 Staff position at PHCs of Jawadhu hills block

PHC Jamunamarathur Nammiyampattu Staff Position vacant Position Vacant MO 3 2 1 2 DS* 1 0 CHN* 1 0 SN 4 1 3 DA* 1 0 SHN 1 0 1 VHN 7 0 3 3

Table 3.22 Staff position at PHCs of Polur block

PHC Kalambur Kalasamudram Kelur T.pettai Vazhiyur Staff Position Vacant Position Vacant Position Vacant P vacant IP vacant MO 4 1 2 0 1 2 0 2 0 DS* 0 1 CHN* 1 0 SN 3 1 3 0 2 3 2 1 0 3 DA* 0 1 SHN 1 0 1 0 1 0 1 0 1 0 VHN 5 1 4 2 5 2 4 4 4 2

MO-Medical officer, DS-Dental surgeon, CHN-Community Health Nurse, SN-Staff Nurse, DA-Dental Assistant, SHN-Sector Health Nurse, VHN-Village Health Nurse

*- Job position for only Block PHC

Chapter 4

Discussion

The main findings of the study are discussed in this section. Studies done in Tamil Nadu and in similar settings of India are used for comparison.

4.1 Untreated caries among primary school children

The prevalence of untreated caries in primary and permanent dentition was 70.9 per cent and 9.3 per cent respectively. A study among 6-12 years old at Kulasekharam, Tamil

Nadu had reported a caries prevalence of 77 per cent. Similarly, studies at Chidambaram

(5-10 years old) and Namakkal (4-6 years old) areas of Tamil Nadu have reported 71.7 per cent and 65.8 per cent respectively.

A recent survey of 12-15 years old at urban Chennai and rural Thanjavur reported a prevalence of 61.4 per cent (Veerasamy et al., 2016b)

The mean dmft for the study sample was 2.63±2.83 (mean age of the sample 7.6 years).

The mean dmft is used to describe severity of caries. Based on mean dmft the level of caries severity of the population studied is moderate. The age at which generally children are admitted for schools in the study setting is 6 years. It is important to note the level of caries severity at this age, as primary dentition exhibit changes in a short span of time. In the study population the level of caries severity of 6 years is moderate (dmft = 2.82±3.4).

There is a wide difference in prevalence of permanent teeth caries between rural and tribal population. The mean DMFT of school children from Jawadhu hills in this study was 0.21. Mean age of children with permanent teeth in the study population was 8 years.

A previous study conducted among 12 years old children at Jawadhu hills had reported a

mean DMFT of 0.65(Dhanappa et al., 2014)

The observed differences in caries prevalence among tribal and rural children were

statistically significant. This implies that location and prevalence of untreated caries

among the population in that location are related someway. A study which was conducted

among urban, sub urban and tribal school children in western district of Tamil Nadu

showed a similar result. The tribal children (89.3 per cent) were most affected, followed

by sub urban (77 per cent) and urban (55 per cent)(John et al., 2015b).

In contrast to above findings two studies conducted two decades ago at northern India

among children form tribal, rural and urban areas, had shown that tribal children were less

affected than the population compared (Table 4.1).

A summary of previous studies at different places in India and Tamil Nadu are presented

as tables 4.1 and 4.2

Table 4.1 Summary of studies from Rajasthan and Madhya Pradesh

Reference Study setting population Measures Prevalence DMFT/dmft/DMFS

(Kumar et al., Southern Bhil tribes/ 15- DMFT, - 15-24 yrs (n=434) 2009) Rajasthan 54 yrs/ male/ DMFS, µ D 2.18±1.95, n=1590 periodontal F=0, status, treatment needs

(Jalili et al., Mandu, Dhar, Tribal children Caries Caries µ dmft 0.8-1.25 µ 1993) Madhya 6-13 years prevalence, primary teeth DMF 0.5-1.4 pradesh n=1016 dmft 28%-37% permanent teeth 6%-17%

Table 4.2 Summary of dissertation study and previous studies from Tamil Nadu

Reference Study setting Study Measures Results population Prevalence DMFT/dmft/DMFS Dissertation Jawadhu hills, School Caries Primary Primary teeth- study Tamil Nadu children prevalence teeth-70.9% 2.63±2.83 Primary teeth Permanent Permanent teeth- & permanent teeth-9.3% 0.13±0.47 teeth

(Dhanappa et Jawadhu hills, Malayali DMFT, 12 12 yrs-(n=247) al., 2014) Tamil Nadu. tribes/ 12 yrs- Periodontal yrs(n=247) µ DMFT -0.65, µ 74 yrs/ both status Caries free- D-0.50, µ M-0.1, the sexes, 77% µ F-0.04 n=710 Caries – 23%

(Veerasamy et Thanjavur & School Caries Caries - µ DMFT-2.03 al., 2016a) Chennai, students 12-15 prevalence, 61.4% Tamil Nadu yrs / n=974 DMFT urban-58% Rural- 64.3%

(Rajesh et al., Kulasekharam, School Caries Caries-77% µ DMFT-1.25 2005) Tamil Nadu students 6-12 prevalence, (boys) 0.96 (girls), yrs/ n=150 DMFT, deft µ deft 2.09 (boys) 1.36 (girls)

(Karunakaran Nammakkal, School Caries Caries- µ dmft 2.86 et al., 2014) Tamil Nadu children 4-6 prevalence, 65.88% yrs/ n=850 dmft, Boys- 69.6% Girls- 61.5%

(John et al., Palamalai, School Caries Caries µ DMFT 2015a) Kolimalai, children prevalence Tribal- Tribal 2.88±1.9 Tiruchengode, 9-12 yrs DMFT, deft 89.3% Suburban Erode, Tamil n=1028 Suburban- 2.42±1.7 Nadu (Tribal- 206, 77% Urban 1.22±1.3 suburban- Urban-55% 411,Urban- µdeft 411) T-1.83±2.1 SU-0.86±1.5 U-1.22±1.39

(Saravanan et Chidambaram, School Caries Caries- µ dmft-3.00 al., 2008) Tamil Nadu children prevalence Primary µ DMFT-0.42 5-10 yrs teeth-71.7% n=510 Permanent teeth-26.5%

The sex differences in caries prevalence among both tribal and rural populations were not statistically significant. The wide difference between male (70.2 per cent) and female

(58.3 per cent) in Polur should be noted. A similar finding of high prevalence in males

(80 per cent) than females (73 per cent) was reported in a study conducted at

Kulasekharam, Tamil Nadu among 6-12 years old(Rajesh et al., 2005). Another study at

Namakkal showed the same finding of boys having more prevalence than the girls(Karunakaran et al., 2014).

The differences observed among different age groups in primary teeth caries prevalence were not statistically significant. There is increase in number of children affected by caries in ascending age groups, 6years (72 per cent), 7 years (80 per cent) and 8 years (84 per cent). The same pattern was seen in both the locations. This may be due to the fact that primary teeth show rapid changes.

In tribal school children increase in prevalence of permanent tooth caries was observed along 7, 8 and 9 years age groups and were statistically significant. Transition to school environment at six years introduces a child to multiple factors that could have played a role in increase.

The chi square test for caries in primary teeth by class yielded statistically non significant result. The relationship was explored only among rural population as Jawadhu hills were all belonging to one class. A recent study at Thanjavur had shown significant differences among different social classes.

4.2 Dental services availability in Primary Health Centres

The PHCs at Jawadhu hills and Polur cover 38 and 54 villages respectively. In terms of population coverage 2 primary health centres at Jawadhu hills serve a population slightly

51 more than the national norm of 20,000. In case of Polur, a plain region, one PHC has additional burden of 19,000 people.

National Rural Health Mission- State health society of Tamil Nadu had formulated plans in the year 2012-2013 for starting dental service provision at PHCs which did not have a dental unit. It also worked on strengthening dental services that were already available in

208 PHCs.(Health & family welfare, 2012)

4.2.1 Dental services provision

PHCs

IPHS guidelines for PHCs with regard to dental care provision had been implemented in all additional PHCs surveyed. Dental check up included under essential health service provision is available. The medical officers conduct the check up and refer the patient to nearest Government hospital for dental treatment. So the goal of providing a dental advice or appropriate referral for further management at first point of contact has been achieved.

Block PHC

Upgraded primary health centres (block PHCs) are preferred to have norms as that of a community health centre. IPHS Guidelines recommend setting up of dental infrastructure and provision of specialist dental services at community health centres.

In this study conducted at two blocks, specialist dental services are available at the block

PHC of Jawadhu hills. The centre had been sanctioned a dental unit under NRHM project during 2012-2013. Dental surgeon and dental assistant were employed on basis of payment per session. The services include dental check up and tooth extraction. Those patients who need other dental treatments such as filling, cleaning of teeth, complex extractions and the like are referred to facilities at plains.

The upgraded primary health centre at Polur is not equipped with a dental set up. Only minimum assured service, the dental check up is provided. The status of sanction of dental infrastructure and dental staff to the Polur block PHC was not known at the time of data collection.

4.2.2 Access to referral dental services

The distance of nearest public facility with dental service varies between 10 km to 20 km in Polur. There is a dental wing in the sub-district hospital at Polur block. The Patients are also referred to Government hospitals in neighbouring blocks and district where dental services are available. The private dental services are also clustered in town. Patients have to depend on transport and spend time to access those services. It will increase the burden of the patient in many ways.

In case of hills, the patients who need dental care other than dental consultation and simple extraction should travel more than 40 km to access dental service. There are no evidences of private dental service providers at Jawadhu hill. Jamunamarathur, the block headquarter is well connected to plains by roads with regular bus services, yet travelling more than 40 km for accessing dental treatment is a matter of concern. The case is worse for those who dwell in interior of woods which lacks connectivity.

4.2.3 Integration of dental service at primary health care practice

Availability of all essential and minimum assured services at PHCs in the study area provides opportunities to gain new entry points to integrate oral and dental care at primary health centre level.

Maternal oral health, Infant oral health, Adolescent oral health, Women‟s oral health can be provided as a component of their respective service domain. A study at Mangalore,

53 had demonstrated that pregnant women who visit for antenatal care can be provided simple restorations at primary health centre setting using Atraumatic Restorative

Treatment (ART). In the PHCs surveyed though advice and referral for pregnant women in case of dental emergency or complaint is available it would be appropriate if a routine dental check up is done at the first antenatal visit itself.

Similarly infant dental care instructions for mothers of newborn can be given along with advice on feeding practices. These simple efforts can educate them in the very beginning about importance of dental health of children and ways to protect it. It will help in the prevention of early childhood caries or motivate them for early intervention.

Comprehensive school children dental programme that was in existence in Tamil Nadu had now been integrated under Rashtriya Bal Swasthya Karyakram (RBSK). In both the blocks the RBSK programme had been implemented. The programme recommends screening of children aged 6 weeks to 18 years for dental caries and its management at

CHC.(NRHM, 2013) In addition, management of primary teeth caries can be initiated at

PHC setting through procedures like ART.

4.3 Strengths

The clinical examination was done by a single trained dentist. The possibility of inter observer bias has been removed. The accuracy of diagnosing caries will not be high as standard criteria of World Health Organisation‟s Oral health survey -basic methods were followed.

4.4 Limitations

Scrutiny or verification of the findings by an independent observer was not done.

Although this could be a potential bias, its chance is much less, as the investigator has

54 followed the standard protocols for the clinical examination and documented it meticulously using standard codes.

4.5 Conclusion

The prevalence of caries in the primary school children of the study setting was high above national average (50 per cent).(Working group on noncommunicable diseases,

2011) There are similar findings from other parts of the state which necessitates some novel approach to the problem.

Dental services availability at primary health centres are as per norms set by Indian Public

Health Standards. Inspite of dental service availability as per norms there is high burden of caries in the study setting.

The recommendations put forth by working group on noncommunicable diseases like introduction of treatment procedures like Atraumatic Restorative Treatment, equipping the primary health centres with basic equipment necessary for such procedures, inducting dental hygienists or training staff nurses in such procedures seems valid and relevant So this study supports the argument for revision of IPHS guidelines for dental care.

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Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum Achutha Menon Centre for Health Science Studies

Untreated dental caries among primary school children and dental services availability in Jawadhu hills and Polur, Thiruvannamalai district, Tamil Nadu

Questionnaire

Identification number

Section I General Information

S.No Information Response 1. Sex

a. Male b. Female

2. Age in completed years......

3. Father’s occupation

a. Own Agriculture b. Agricultural labourer (Coolie) c. Coolie (Non Agriculture) d. Cattle shepherd e. Business f. Salaried Monthly g. House Work h. Others (specify)

4. Mother’s occupation

a. Own agriculture b. Agricultural labourer (Coolie) c. Coolie (Non Agriculture) d. Cattle shepherd e. Business f. Salaried Monthly g. House Work h. Others (specify)

S.No Information Response 5. Religion

a. Muslim b. Christian c. Hindu d. Others ( specify)

6. Caste

a. GC b. OBC c. BC d. MBC e. SC f. ST

7. Economic status

Section II Dental health

S.No Question Response 8. How is the health of your teeth?

a. Good b. Poor c. Don’t know

9. Do you have any one of following?

a. Cavity in any tooth b. Food lodging in any tooth c. Discomfort while chewing food d. Sensitivity of teeth while taking water

10. Have you had toothache in the past one month?

a. Yes b. No skip to 12

S.No Question Response 11. What you did for its remedy?

a. Home remedy b. Visited a Dentist for treatment c. Visited a Doctor for treatment d. No treatment e. Others ( specify )

12. How many times you clean your teeth daily?

a. Once b. Twice c. More than two times d. Never

13. Which one of the following you use to clean your teeth daily?

a. Twigs b. Fingers c. Tooth brush d. Others ( specify )

14. Which one of the following you use to brush your teeth daily?

a. Brick powder b. Ash powder c. Tooth powder d. Tooth paste e. Others ( specify)

15. Which one of the following you do?

a. Wash mouth after every meal b. Wash mouth after meal, not always c. Never wash mouth after meal

16. How often you eat the following food/snack items? i ii iii iv

i. Sweets a ii. Biscuits iii. Fruits b iv. Others ( specify)

a. Every day c b. Several times a week c. Occasionally d d. Never

Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum Achutha Menon Centre for Health Science Studies

Untreated dental caries among primary school children and dental services availability in Jawadhu hills and Polur, Thiruvannamalai district, Tamil Nadu

Clinical assessment of dentition status

Identification number

Dentition status:

55 54 53 52 51 61 62 63 64 65

17 16 15 14 13 12 11 21 22 23 24 25 26 27

47 46 45 44 43 42 41 31 32 33 34 35 36 37 85 84 83 82 81 71 72 73 74 75

DMFT Index:

. Number of Decayed Teeth (DT) = . Number of Missing Teeth (MT) = . Number of Filled Teeth (FT) = . DMFT score (D+M+F) = dmft Index:

. Number of decayed teeth (dt) = . Number of missing teeth (mt) = . Number of filled teeth (ft) = . dmft score (d+m+f) =

Treatment needed:-

. Number of teeth that need extraction: . Number of teeth that need restoration: Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum Achutha Menon Centre for Health Science Studies

Untreated dental caries among primary school children and Dental services availability in Jawadhu hills and Polur, Thiruvannamalai district, Tamil Nadu

Dental services availability checklist

Primary Health Centre Identification Number: Section I Facility Identification

S.No Information Response 1. District

2. Block

3. Location 4. Urban/Rural/Tribal:

5. Is it an upgraded 24x7 PHC: Yes No

6. Date of data collection

7. Response obtained from Section II General Information

S.No Information Response

8. Building

a) Is a designated Government building available for the Yes No PHC? If Yes, Skip to 9

b) If there is no designated Government building, then where does the PHC located? 1. Rented premises 2. Other Government building 3. Any other ( specify )

9. Public transport a) Are public transports available to PHC? Yes No

b) Distance of nearest point where a public transport is available

1. Less than 500 m 2. 500 m to 1 Km 3. More than 1 Km

10. Distance of PHC from CHC (in km) 11. Distance of PHC from District hospital (in km)

Section III General Services Availability

S.No General services Response

12. Population covered in numbers

13. Average daily OP attendance

14. Are assured services (essential) available?

a) OPD services Yes No b) Emergency services Yes No c) Referral services Yes No d) In patient services Yes No

15. Are essential components of following services available?

a) Antenatal care Yes No b) Delivery Yes No c) Postnatal care Yes No d) Child care Yes No e) Nutrition services Yes No f) Adolescent care Yes No g) School health Yes No

16. Are outreach services in communities (community camp) done? Yes No

Section IV Dental Services Availability

S.No Dental services Response

17. Provision of dental services

a) Essential dental services (dental check-up) Yes No If Yes, Skip to 19 b) Specialist dental services Yes No If Yes, Skip to 19 18. Reasons for non provision of dental services ( Multiple responses can be Skip 20, 21, 22, 23 and 33 chosen) 1. Non availability of dental surgeon 2. Non availability of dental assistant 3. Non availability of dental equipments 4. Other reasons ( specify )

19. Where are the patients seeking dental care referred to ( Multiple responses can be chosen) 1. CHC 2. District hospital 3. Private providers 4. Any other ( specify)

20. Number of days dental services provided in a week

1. All days 2. All days expect Sundays 3. Special outpatient days 4. Any other pattern ( specify)

S.No Dental services Response

21. Prominent display of dental services availability in local Yes No language

22. Number of patients utilized the dental service in the past three months

23. Essential/Minimum assured dental services provided by

1. Medical officer 2. Dental surgeon 3. Both

24. Is dental check up done as a part of antenatal care? Yes No

25. Is screening for oral precancerous and cancerous lesions done? Yes No

26. School dental health

a) School dental health check up done Yes No

b) Number of schools covered in the last year

27. Community dental camp

a) Is dental check up done during outreach services in Yes No community?

b) Number of community camps done in the last year

S.No Dental services Response

28. Oral health promotion

a) Are IEC activities held for promotion of oral health? Yes No

If Yes specify

b) Number of IEC activities held in the last year

c) Is there any IEC material for oral health promotion Yes No available in this PHC

If Yes specify

d) Celebration of Health days Yes No If No Skip e)

e) Celebration of World No Tobacco day

29. Tobacco cessation services

a) Provision of tobacco cessation advice Yes No

b) Record of tobacco use by antenatal mothers Yes No

S.No Dental services Response

30. Availability of specific dental services If Specialist dental services are available answer ALL or answer question numbers 30 (a) and 31 (a) only a) Treatment for dental emergencies Yes No If Yes, answer 31

b) Tooth extraction Yes No

c) Oral prophylaxis Yes No

d) Restoration of tooth Yes No If Yes, answer 32

e) Fabrication of removable dentures Yes No

31. Are following dental emergency services provided? a) Relief of oral pain Yes No

b) Extraction of tooth Yes No

c) Treatment of post extraction complications Yes No

d) Drainage of oral abscesses Yes No

e) Other treatment procedures (specify) Yes No

32. Are following tooth restorations done? a) Amalgam restoration Yes No

b) Glass Ionomer Restoration Yes No

S.No Dental services Response

c) Zinc oxide Eugenol restoration Yes No

d) Other types ( Specify) Yes No

33. User fees

Should patients pay for any dental service provided? Yes No

If Yes, specify service and the fee collected

Section V Infrastructure

S.No Infrastructure Response 34. Basic infrastructure

a) Bed Available Not available

b) Chair with head support Available Not available

c) Table Available Not available

S.No Infrastructure Response

d) Stool Available Not available

e) Light source Available Not available

f) Washbasin Available Not available

g) Water storage Available Not available

h) Sterilizing equipments Available Not available

Specify

35. Electricity

a) Power supply

1. Continuous power supply 2. Occasional power failure 3. Power cuts in summer only 4. Regular power cuts

b) Standby facility (generator) available in Yes No working condition

S.No Infrastructure Response

36. Water supply

a) Source of water 1. Piped 2. Bore well 3. Well 4. Other

b) Whether overhead tank exist

c) Whether pump exists in working condition

37. Dental infrastructure Availability Use Function Answer ALL if dental services available or answer (c, d, e, p, q, r) only Available Not In use Not in Functional Faulty available use a) Dental chair

b) Air compressor

c) Mouth mirror

d) Straight probe

e) Tweezers

f) Scalar unit with tips

g) Periosteal elevator

h) Extraction forceps S.No Infrastructure Response

Dental infrastructure Available Not In use Not in Functional Faulty available use i) Airotor handpiece

j) Burs

k) Spoon excavator

l) Cement spatula

m) Plastic spatula

n) Glass slab

o) Filling instrument

p) Instruments for incision and drainage

q) Local anaesthesia

r) Suture materials

s) GIC powder and liquid

t) Zinc oxide powder and Eugenol liquid

Section IV Staff

S.No Staff Response 38. Availability of staff IPHS Sanctioned In position Vacancy Nature of Qualification Years of Recommended appointment service Additi Block (permanent/ onal contractual) a) Medical officer 1 2

b) Dental surgeon - 1 c) Staff nurse 3 10

d) Dental assistant - 1

e) Health educator*(Desirable) 1 1

f) Health assistant Female/LHV 1

g) Health assistant Male 1

h) Village health nurse 1

S.No Staff Response

39. Training of staff

a) Is training available for dental surgeon in Yes No If Yes, Specify developing skills related to public health practice

b) Is training available for health personnel for Yes No If Yes, Specify developing skills in providing dental care instructions

c) Is a training team for training PHC staff available at block level and district level?

1. Block training team Yes No If No Skip d)

2. District training team Yes No If No Skip d)

d) Does training team for health personnel include a dental surgeon?

1. Block training team Yes No

2. District training team Yes No

Section IV Medicines

S.No Medicines Response

40. Availability of medicines for common dental Available Not ailments available

a. Cap/Tab. Amoxicillin

b. Alternative to Amoxicillin (specify)

c. Tab. Metronidazole

d. Aceclofenac+ Paracetamol

e. Tab Paracetamol

f. Mucosal Pain relieving gels

g. Antimicrobial mouth wash

Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum Achutha Menon Centre for Health Science Studies

Information sheet for Parents

Study Title: Untreated dental caries among primary school children and dental services availability in Jawadhu hills and Polur, Thiruvannamalai district, Tamil Nadu

Investigator: Suseendar KK

Participation is voluntary It is your choice whether or not to permit your child to participate in this research. If you choose to allow him or her to participate, you may change your mind and have him or her leave the study at any time. Refusal to participate or stopping participation will involve no penalty or loss of benefits to which you or your child are otherwise entitled.

What is the purpose of this research? The purpose of this research is to check the amount of untreated caries in Government and Government aided primary school children and availability of services in your village for its treatment.

How long will my child take part in this research? Your child’s participation will take about 10-20 minutes.

What can I expect if my child takes part in this research? As a participant, your child will be examined for tooth decay and asked to answer few questions regarding his or her teeth and how they care for teeth.

What are the risks and possible discomforts? If you choose to allow your child to participate, we assure that there will be no risk or discomfort.

Are there any benefits from being in this research study? We do not expect any direct benefits to you or your child from your child taking part in this research. We cannot promise any benefits to you or your child from your child taking part in this research. However, possible benefits include you and your child knowing about his/her dental health status.

Will there be compensation for participating in this research? You or your child will not be compensated for participating in this research.

If my child takes part in this research, how will our privacy be protected? What happens to the information you collect? The data we collect will include sex, date of birth and age of your child. Details regarding occupation of parents, their income, BPL/APL status and caste will also be collected. A clinical examination will be done for presence of decayed teeth.

The information obtained from your child will be analyzed by the researcher and may be reviewed by people checking to see that the research is done properly The information about your child will be kept safely locked up. When I tell other people or write an article about research done, your child’s name will not used.

If I have any questions, concerns or complaints about this research study, who can I talk to?

The researcher for this study is I, Suseendar and I can be reached at Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram-695 011, Kerala, India. My contact number is 9941141991.

If you have questions, concerns, or complaints,  If you would like to talk to the research team,  If you think the research has harmed your child, or  If you wish to withdraw your child from the study.

This research has been reviewed by the Institutional Ethics Committee of Sree Chitra Tirunal Institute of Medical Sciences and Technology. They can be reached at Institutional Ethics Committee, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram-695 011, Kerala.

Contact persons 1. Dr. Mala Ramanathan Member secretary, Institutional Review Board SCTIMST Contact number: 0471-2524234

2. Suseendar KK Principal Investigator Mobile number-9941141991

Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum Achutha Menon Centre for Health Science Studies

Consent Form for parents

Study title: Untreated dental caries among primary school children and dental services availability in Jawadhu hills and Polur, Thiruvannamalai district, Tamil Nadu

Subject’s Identification Number:

Please initial box (i) I confirm that I have read and understood the information sheet dated ______for the above study and have had the opportunity to ask questions. [ ] (ii) I understand that my child’s participation in the study is voluntary and my child is free to withdraw at any time, without giving any reason, [ ] (iii) I understand that my child’s identity will not be revealed in any information released to third parties or published. [ ] (iv) I agree not to restrict the use of any data or results that arise from this study provided such a use is only for scientific purpose(s) [ ] (v) I agree to allow my child to take part in the above study. [ ]

Signature (or Thumb impression) of the parent(s) of the Subject: Date: _____/_____/______Signatory’s Name: ______

Signature of the Investigator: ______Date: _____/_____/______

Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum Achutha Menon Centre for Health Science Studies

Information sheet for child participant

Study Title:

Untreated dental caries among primary school children and dental services availability in Jawadhu hills and Polur, Thiruvannamalai district, Tamil Nadu

Investigator: Suseendar KK

My name is Suseendar. I am a student at the Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram. I am going to check how many of you have decayed teeth and availability of treatment services for it in your village. It will help to know the need for basic oral care services in your village. To do this, I am asking you and other children to take part in my research study. A research study is a way to learn more about something. This form explains the study.

If you decide you want to be in my study, I will ask you to answer some questions regarding yourself, your teeth and how you care for your teeth. I will also check your teeth for decay. It will take about 10-20 minutes. The information I write down about you and other children will be kept safely locked up. When I tell other people or write an article about my research, I will not use your name.

Your parent or guardian has to say it is OK for you to be in the study. After they decide, you get to choose if you want to do it or not. Before you decide, I will answer any questions you may have. You can also talk to your mother or father. It is okay if you decide you do not want to be in the study or if you change your mind and wish to stop at any time. You can say no even if your mother or father (or guardian) say yes.

My telephone number is 9941141991. You can call me if you have questions about the study or if you decide you do not want to be in the study any more. You can also contact Institutional Review Board, member secretary, Professor Dr. Mala Ramanathan, for any clarification.

Contact persons: Dr. Mala Ramanathan Suseendar KK Member secretary, Principal Investigator Institutional Review Board Mobile number-9941141991 SCTIMST Contact number: 0471-2524234 Date: Signature of the investigator

SUSEENDAR KK

Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum Achutha Menon Centre for Health Science Studies

Assent form for the Child Participant

Study title: Untreated dental caries among primary school children and dental services availability in Jawadhu hills and Polur, Thiruvannamalai district, Tamil Nadu

Subject’s Identification Number:

Please initial box (i) I confirm that I have read and understood the information sheet dated ______for the above study and have had the opportunity to ask questions. [ ] (ii) I understand that my participation in the study is voluntary and I am free to withdraw at any time, without giving any reason. [ ] (iii) I understand that my identity will not be revealed in any information released to third parties or published. [ ] (iv) I agree not to restrict the use of any data or results that arise from this study provided such a use is only for scientific purpose(s) [ ] (v) I agree to take part in the above study. [ ]

Signature (or Thumb impression) of the Subject: Date: _____/_____/______Signatory’s Name: ______

Signature of the Investigator: ______Date: _____/_____/______

Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum Achutha Menon Centre for Health Science Studies

Information sheet for respondent at Primary Health Centre

Sir/Madam,

I am Suseendar, doing Master of Public Health course at Achutha Menon Centre for Health Science Studies a wing of Sree Chitra Tirunal Institute for Medical Sciences & Technology. As a part of my course and dissertation I am doing a study. The information about the study and consent is given below.

Study title: Untreated dental caries among primary school children and dental services availability in Jawadhu hills and Polur, Thiruvannamalai district, Tamil Nadu

Investigator: Suseendar KK

Participation is voluntary It is your choice whether or not to participate in this research. If you choose to participate, you may change your mind and leave the study at any time. Refusal to participate or stopping your participation will involve no penalty.

What is the purpose of this research? The purpose of this research is to check the availability of dental services in primary health centres of Jawadhu hills and Polur blocks of Thiruvannamalai district. It also involves identifying opportunities for improving dental service provision at primary health centre level.

How long will I take part in this research? Your participation will last for about 30 minutes.

What can I expect if I take part in this research? As a participant, you will be asked to mark a check list which has details of different aspects of service availability. It includes the facility location, access, infrastructure, personnel and service utilization.

What are the risks and possible discomforts? There are no risks involved as necessary permission from health administrative authorities is sought.

Are there any benefits from being in this research study? We do not expect any direct benefits to you from your taking part in this research.

If I take part in this research, how will my privacy be protected? What happens to the information you collect? The data we collect will be kept in a protected space. Reports of the results will remove any information that could allow someone to identify you. The information will be analyzed by the researcher(s) and may be reviewed by people checking to see that the research is done properly.

If I have any questions, concerns or complaints about this research study, who can I talk to? The researcher for this study is I Suseendar This research has been reviewed by the Institutional Ethics Committee of Sree Chitra Tirunal Institute of Medical Science & Technology and you can contact the board for any of the following: If your questions, concerns, or complaints are not being answered by the research team If you cannot reach the research team If you want to talk to someone besides the research team, If you have questions about your rights as a research participant

Contact persons

1. Dr. Suseendar. KK Principal Investigator, AMCHSS, SCTIMST Thiruvananthapuram-695011 Mobile number-9941141991

2. Dr. Mala Ramanathan Member secretary, Institutional Review Board SCTIMST Thiruvananthapuram-695011 Contact number: 0471-2524234

Principal Investigator:

Suseendar K.K

Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum Achutha Menon Centre for Health Science Studies

Consent form for the respondent at PHC

Study title: Untreated dental caries among primary school children and dental services availability in Jawadhu hills and Polur, Thiruvannamalai district, Tamil Nadu

Investigator: Suseendar KK

1. I confirm that I have read and understood the information sheet for the above study and have had the opportunity to ask questions. 2. I understand that my participation in the study is voluntary and I am free to withdraw at any time, without giving any reason. 3. I understand that my identity will not be revealed in any information released to third parties or published. 4. I agree not to restrict the use of any data or results that arise from this study provided such a use is only for scientific purpose(s). 5. I agree to take part in the above study.

Signature of the respondent:

Date: _____/_____/______Signatory’s Name: ______

Signature of the Investigator: ______Date: _____/_____/______