Oral health has long been recognized as an integral part of general health, particularly given the Indian population's growing life expectancy, oral health plays a critical role in improving an individual's quality of life. Unfortunately, the trend indicates a rise in oral health problems in developing countries such as India. A multitude of problems exist when it comes to rural population in terms of developing oral healthcare. For a country where 30,570 dentists graduate annually, it is astonishing to note that only 10% of dentists represent rural citizens, who make up about 68.8% of the country's population. Though inaccessibility to dental care is one of the major challenges, inadequate use of facilities is yet another formidable challenge that mitigates rural India's potential for improving oral health status. With a pronounced diversity inherent in Indian culture, variations in oral health among people from different socioeconomic and religious backgrounds may be anticipated, considering the variations in cultural values, social norms, and oral hygiene practices.
Oral healthcare data creates an actionable roadmap to provide oral preventive health services in the primary care setting and strengthen the referral process from primary care doctors to dentistry. Oral healthcare-seeking behavior/utilization is the actual involvement of members of the public at healthcare facilities that reflects the number of visits every year or the number of individuals with at least one visit in the previous year as a significant method for oral health policy decision-making.
This study is mainly focused to determine the oral healthcare-seeking behavior in Tenali Mandal, Guntur (Dist.), Andhra Pradesh among WHO recommended index age groups.
Aim and Objectives
To find out the oral healthcare-seeking behavior, profile, and pattern in Tenali Mandal among WHO recommended index age groups. To document self-reported oral health diseases that the population suffered in recent times along with the type of service received, place, avenue, and personnel involved in delivery of health services and also to determine the factors influencing pattern of oral healthcare-seeking behavior.
Material and Methods
A cross-sectional, single-visit, multilocality, pretested (Cronbach's α value of 0.7) and interviewer-administered questionnaire-based study was done to generate evidence on oral healthcare-seeking behavior.
Both males and females of WHO recommended index age groups- 5 years, 12 years, 15 years, 35–44 years, and 65–74 years.
Sample size calculation
All the five WHO index age groups were selected from each site of 4 urban, 2 peri-urban, and 9 rural sites where 20 individuals from each group i.e. a total of 100 individuals from each site were selected resulting in sample size of 1500 and for the age groups of 5 years, 12 years, and 15 years the questionnaire was administered to their parents/guardians.
Each site 5 age groups = 5 × 20 questionnaires = 100
15 sites = 100 × 15 = 1500 sample size.
National Pathfinder Survey (Stratified cluster random sampling)
Inclusive criteria and exclusive criteria
Subjects with the following criteria were included in the study
- Both male and female subjects of WHO recommended age groups.
- Subjects who are available on the day of the study
Subjects with the following criteria were excluded from the study
- Uncooperative and mentally challenged
- Nonresidents of the study area.
Ethical clearance was obtained from the Institutional Ethics Committee of SIBAR Institute of Dental Sciences with IEC protocol no: Pr. 35/IEC-SIBAR/CIR/15/B and an informed consent were obtained from all the study participants prior to the start of the study while the study was done from July 2017–September 2017.
Formulation of questionnaire
A pretested, interviewer-administered questionnaire was used which consisted of 2 parts. The 1st part of the questionnaire includes sociodemographic details, 2nd part consists of 8 questions regarding the utilization of oral health services, and a single common question regarding the importance of both general and oral health.
Through pilot test internal consistency of the questionnaire was tested and yielded a result of Cronbach's α value (0.81) which was satisfactory.
Statistical package for social sciences (IBM SPSS, Chicago) version 20.0 was used for the analysis and P value of ≤ 0.05 was regarded as statistically significant. Statistical tests such as descriptives, Chi-square test, Spearman's correlation, and binomial logistic regression were used.
The study sample comprised of 1500 subjects who were equally divided among WHO index age groups. Out of 1500 subjects, 52.8% were females and 47.2% were males [Table 1] with 60% of the study participants belonging to rural areas followed by urban (26.7%) and peri-urban (13.3%). Majority of them belonged to open category (O.C) caste (53.1%)
Only 35.4% of the study participants utilized dental services while most of them sought care in the last 1–6 months (23.4%) and the main reason for the last dental visit was tooth pain (20%), followed by gingival problems (7.2%) [Table 2].
When asked about nearest available facility, its distance, place of care sought, and their experience regarding treatment received most of them reported utilizing private dental services (85.4%) with distance from their residence less than 5 km (52.6%) and majority sought care from private dental clinics (33.3%) followed by dental college and hospital (1.5%) while the main reason for the selection of particular center/place was accessibility (18.7%) followed by doctors reputation (11.7%) and lastly they reported that they were very much relieved from suffering after they sought care. Majority of the participants has spent around 251–500 INR (21.3%) for their last dental visit and the main mode of payment was out of pocket (34.7%) [Table 3].
Decayed tooth without pain (8%) was the prominent reason among those who had not utilized the services and predominant barriers found for not seeking care was lack of time (4%), followed by high cost (2.1%), does not affect my work (1.9%), and milk teeth shed-off (1.9%). Moreover, a majority (38.1%) of the respondents had reported that oral diseases are as important [Table 4].
Oral healthcare-seeking behavior among 12 years age group was 1.611 times more when compared to 65–74 years age group which was statistically significant (P ≤ 0.010). For dental care service utilization among gender, the males utilized 0.982 times less when compared to females which was not statistically significant (P ≤ 0.881), while for the place of residence, urban place was 2.707 times more utilizing the services when compared to rural place which was statistically significant (P ≤ 0.001). Dental care service utilization among socioeconomic status, the upper middle class was 13.135 times more when compared to lower class which was statistically significant (P ≤ 0.001) while for utilization among pink card ration card holders it was 1.577 times more when compared to no card holders which was statistically significant (P ≤ 0.036) [Table 5].
Dental health professionals should recognize that oral health is a health norm that allows a person to eat, talk, and socialize without active disease, pain, or embarrassment, and contributes to general well-being. To lead a healthy and longer life, people should be made aware of all these information.
The present study was conducted on a sample of 1500 subjects who were permanent residents of Tenali Mandal. The sample comprised of 47.2% males (708) and 52.8% females (792), showing a slight female preponderance.
Dental services utilization
Oral healthcare-seeking behavior in the present study was 35.4% and it was on par with the studies done by others, namely, 21.4% in Pradeep et al. (2016), 31.9% in Vikram et al. (2016), and 36% in Priyadarshini et al. (2016). While the access to care was higher in the studies done by 80.01% in Neha et al. (2019) and 68% Deolia (2020). It may be due to the type of region covered/attitudes and research on trends of oral healthcare-seeking behavior and barriers towards seeking treatment provide a foundation for oral health promotion strategies being formulated and executed.
Center/place where care has been sought
In the total study population, 94.16% sought care from private dental clinic, though a bit higher but similar to studies which have reported 90%, 68.25%, and 68.25% by Thomas et al. (2011), Vikram et al. (2017), and Vikram et al. (2014), respectively which was explained by the fact that the majority of the study participants reported private clinic (85.4%) as the nearest center and which was less than 5 km (52.6%) from their place of residence and this was evident from the study by Devaraj and Eswar (2011) where place of residence and income/month were significantly associated with dental service utilization.
Reasons for selection of particular dental center/place
Around 18.7% of the respondents reported that the main reason for selection of particular service was accessibility near, which was on par with the study done by Vikram et al. (2017). This could be due to the fact that the private dental clinics and most of the dental college hospitals are situated within the city limits or even in the peri-urban regions and very less or virtually no dental care services are available in the rural areas. Usually the dental treatments are complex, hence, multiple visits are needed for its completion and also appointments may take longer as dental colleges will be working only during week day with day shifts mostly, which acts as a barrier for working class because missing 1 day at work, they may lose wages for 1 day's pay. Government clinics do not provide wide variety of services and the aim of the service was to relieve dental pain of the patients and they provide service for free while the treatment includes extraction and medication.
Since oral healthcare-seeking behavior was a phenomenon, which gets affected by multitude of factors, it was almost inevitable that differences exist between the studies, similarly in the present study there was complimentary and contrasting results which were observed.
Reasons for last dental visit
Decayed tooth with pain and discomfort was the main reason for last dental visit and it was on par with the studies, 58.5% in Salunke et al. (2019),, 46.32% in Vikram et al. (2017), 71% in Priyadarshini et al. (2016), and 68.5% in Shailee et al. (2013). Besides, in the study done by the Shekhawat et al. (2019) the main reason for last dental visit was decayed teeth followed by the tooth pain. Pain was an important factor in the utilization of dental services, and may be caused by pulpal, periodontal, and oral lesions where etiology and treatment management require an interdisciplinary approach.
Reasons for refraining from seeking dental care
The main reason for not seeking care was lack of time off from the work where as other studies like Sarika et al. (2014), Ravneet et al. (2014), Bindu et al. (2016), and Pradep et al. (2016) mainly reported the high costs of dental treatments as the main reason for not seeking care viz. 90.03%, 57.5%, 68.6%, and 48%, respectively, where as poor attitudes towards seeking oral care was reported by Vikram et al. (2017) with 43.75% and finally accessibility and affordability was also mentioned as a reason Anehosur et al. (2016). This might be due to the fact that most of the participants were under 15 years and majority being females along with poor attitude towards dental problems due to lack of knowledge. Females who are engaged in agriculture; besides, executing the household responsibilities, may restrict to spend more time in the quest of seeking oral healthcare. According to Uma Shankaret al. (2012), they are largely dependent on other family members, and decisions regarding matters such as visits to the dentists are made by others while two-thirds being 15 years and below, the responsibility towards their children depends on parents attitude and anxiety. For preadolescents and adolescent's, dental attendance and compliance with preventive advice will be influenced by their stage of psychological development as mentioned by Nandhini et al. (2013). Health behaviors are closely connected with ways of living while theories from sociology, education, and psychology describe learning and behavioral change in any individual as well as in mothers of young children. This was also proved in the study done by Sujlana et al. 2016.
Last time of visit for seeking dental care
In the present study, 23.4% have visited a dentist within last 6 months, which was in accordance with the study done by Devaraj and Eswar (2012) where 31.4% of the study participants utilized services in less than 6 months. Time since last dental visit represents dental care that was initiated by the people and therefore, could reflect personal motivation and independent decision making.
Mode of payment during their last dental visit
In the present study, 98.11% of the participants have paid in the form of out-of-pocket for their dental care expenses and mostly they spent around 251–500 INR. This was more when compared to study done Naidu et al. 2014 (54.5%). Since our country does not provide dental insurance for most of the common people in India, the magnitude of out-of-pocket expenses on dental care was almost always 100% (Garcha et al. 2010) which was not the case in countries like the United States (Manski et al. 2002) and Australia (Marshall and Spencer. 2006) which have governmental or insurance support.
Various dental problems of the participants who have not utilized the services
Decayed tooth without pain was the main reason for not seeking care showing the negligent behavior and this could be due to the fact that people do not go to a dentist unless severe symptoms appear as dentistry was perceived to be a useful service only when necessary but it was not a crucial part of overall health. This reflects their compliance towards one's oral health and the low priority given to oral problems as people think dental problems were not life-threatening.
Perception on importance of oral health in comparison with general health
Around 34.06% of the study population had reported that oral health was as important as general health followed by 24.5% moderately important while 7.3% said that it was little important and 20.73% had reported that oral health was not important as general health.
Most oral diseases share common risk factors with NCDs (noncommunicable diseases) such as cardiovascular diseases, cancers, diabetes, and respiratory diseases. These risk factors include unhealthy diets (particularly those high in added sugars), tobacco, and alcohol use. They result in a very similar pattern of inequalities in oral and general disease burden between different population groups.
With the global improvement in life expectancy, a life-course approach to oral health will become more important. Different ages in life have different oral health needs, and the specific problems of older people, who are often also suffering from other diseases, are becoming more prevalent. Knowledge and awareness of the close associations between oral and general health are thus important for holistic care, as was the collaboration between oral and general health professionals.
With inadequacy to tackle social and material determinants and incorporate oral health into general health promotion, millions suffer intransigent tooth problems and poor quality of life and end up with a great suffering. Only a broader integrative strategy that takes account of the common risk factors and the root determinants of health will result in fair and equitable approaches in promoting better oral health and general health.
By validating the data on oral health provides the picture of prevalence, trends of oral disease occurrence, care sought by the populace, and also the economic impact of oral health and on overall health, by providing primary health are physicians to establish reasonable care.
The sampling process assured representativeness of the population and contributes to the validity of the study. On the other, the process of training and standardization that the research went through, and also by the high concordance obtained through kappa test ensured the reproducibility of the data.
The study revealed inadequate utilization of oral health services due to the fact that dental problems are not considered as life-threatening situations when compared to general health problems. This unveiled the need of health education and awareness programs to remove the disparities in oral healthcare-seeking behaviors. The study revealed that lack of time, accessibility, and usage of self-care remedies are the most common reasons for not utilizing professional dental and general health services, respectively. There is a need to minimize these barriers by motivating people and making them aware about the oral and general health problems so that they develop positive attitude towards healthcare utilization.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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