Marginalization and Its Association with Dental Caries among 5-12 Years Old Slum Children in Central India

Research Article

Austin J Public Health Epidemiol. 2017; 4(1): 1053.

# Marginalization and Its Association with Dental Caries among 5-12 Years Old Slum Children in Central India

Singh A¹*, Raushan SK² and Purohit BM³

¹Department of Dentistry, All India Institute of Medical Sciences (AIIMS), India

²Medical Student, All India Institute of Medical Sciences (AIIMS), India

³Department of Public Health Dentistry, People’s College of Dental Sciences, India

*Corresponding author: Singh A, Department of Dentistry, All India Institute of Medical Sciences (AIIMS), Bhopal, India

Received: November 03, 2016; Accepted: January 25, 2017; Published: January 31, 2017

## Abstract

Objective: The aim of the study was to assess dental caries and associated risk factors among 5-12 year old slum dwelling children in Bhopal City, Central India.

Methods: A total of 311 children were there in the 5-12 year old age group and all were examined. Information on demographic characteristics of participants along with parent’s literacy status, annual family income, oral health behaviors and visits to health personnel for dental needs were collected. Data was collected on dental caries of primary dentition (dmft) and permanent dentition (DMFT) using modified WHO criteria (1997). Linear and logistic regression analysis was performed to determine the factors associated with dmft/DMFT status. Odds ratio was calculated for all variables with 95% confidence intervals.

Results: Ninety three (26.7%) and sixty (19.3%) children were having one or more decayed teeth (dt/DT) in primary and permanent dentition respectively. Mean dmft/DMFT scores were 0.69 ± 1.42 and 0.35 ± 0.90 in the primary and permanent dentition respectively. Variables in the dmft/DMFT model explained only 18.3% and 8% of the variance in the primary and permanent dentition.

Conclusion: The study reveals exceptionally low dental care utilization and dental caries levels among slum dwelling children. Addressing marginalization will require a responsive and a caring workforce on the part of health authorities and government.

Keywords: Caries risk; Childhood caries; Disadvantaged children; Urban slum

## Introduction

Marginalization is the social process of becoming or being made marginal. Marginalized refers to being separated from the rest of the society, forced to occupy the edges and not to be at the centre of things [1]. Marginalized people experience a complex economic situations, social disadvantages, health problems as well as stigma [2]. Social exclusion narrates a process by which certain groups are thoroughly disadvantaged because they are discriminated against on the basis of their ethnicity, race, religion, caste or where they live.

Society and culture are linked to behavioral patterns or lifestyles [3]. Therefore, there is a need to explore the influence of social factors on health. One of the measures of social differentiation is socioeconomic status. Another important way of distinguishing people is by their area of residence. Slum inhabitants are one such marginalized and socially excluded community based on the type of residence.

United Nations Human Settlement Program (UN-HABITAT) defines slum as residential areas that are physically and socially deteriorated and in which satisfactory family life is impossible. They lack durable housing of permanent nature, sufficient living space, access to safe water, inadequate sanitation in form of toilets and insecure tenure. According to UN the rise in urban populations and the number of slum dwellers is rising. One billion people worldwide live in slums and the figure will likely grow to 2 billion by 2030 [4]. Populations report estimated urban slum population in India as approximately 70 million by mid 2011 [5]. Even more disturbing is a truth that urban poverty is underestimated as many of the urban poor live in undocumented squatter colonies and pavements.

In India children comprise 40% of a rapidly growing population. Approximately, 26.3% of the urban population resides in urban slums.5 Squalor, lack of clean drinking water, unhygienic sanitary environment, crowding and garbage disposal pose series of threats to the health of slum dwellers children in particular, as they spend most of their time around the unhygienic environment. Infant mortality rates are twice as high in slums as the national rural average. Nutritional problems like Protein Energy Malnutrition (PEM), anemia and vitamin A deficiency continue to plague a large proportion of Indian children. The nutritional status of slum children is worst amongst all urban groups and is even poorer than the rural average. On average, slum children are more nutritionally wasted than other children. Lack of education and information further aggravates the situation as residents depend on unreliable sources for prevention and cure [6].

These children are imperative to the nation’s present and its future. Yet populations vary considerably in their obligation to the collective health of children and in the resources that they make available to meet children’s needs. This is reflected in the ways in which society address their shared commitment to children’s health.

It is suggested that marginalized populations have grave and pessimistic views of health in general including oral health [7]. According to World Oral Health Report 2003, National Oral Health Survey 2003 and a number of point prevalence studies a fact appears that dental caries is increasing both in prevalence and severity over the last few decades in developing countries [8-10]. Dental caries is a major public health problem owing to their high prevalence and incidence globally, specifically among children. Unfortunately, no published study has investigated the prevalence of dental caries globally among slum children making it difficult to understand the pattern of oral health status in this marginalized community. Also, there is no data on the oral health status of children residing in slums in India. Therefore, this study explores the association between this marginalized group and oral health. Specifically, the aim of the study was to assess dental caries status and associated risk factors among 5-12 year old slum dwelling children in Bhopal City, Central India.

## Study design and subjects

The target population for the cross-sectional study was 5-12 year old children in an urban slum area in Bhopal City, Central India. All households were visited and the children aged 5-12 years were invited to participate in the study. If the house was locked or child not present at time of visit then a second visit was arranged to include the children in that particular house. A total of 311 children were there in 5-12 year old age group and all were examined.

Information on demographic characteristics of participants along with parents literacy status, annual family income, oral health behaviors such as frequency of brushing, material used for cleaning teeth, and visits to any health personnel for dental needs were collected by means of personal interviews administered by the examiner. Age was sub classified in 3 groups namely 5-6 years, 7 -10 years and 11- 12 years. Paternal and maternal literacy levels were categorized for study subjects. The four categories recorded were illiterate (no formal education), completed middle school (6th Grade), completed high school (12th Grade) and those with a graduation or higher degree. Similarly, family income levels were recorded as = 60,000, earning between Rs 60,000 – Rs 120,000 (~ 1000 to 2000 US $) and those earning = 120,000 (~ 2000 US$). The dental team comprised of the examiner assisted by a recording clerk.

## Clinical examination

All the subjects were examined under adequate illumination and clinical data were collected on dental caries of primary dentition (dmft) and permanent dentition (DMFT) using modified WHO criteria (1997) [11]. The examination was conducted with a plane mouth mirror. A systematic approach was adopted for assessment of dental caries. The examination proceeded in an orderly manner from one tooth or tooth space to the adjacent tooth or tooth space. A tooth was considered present in mouth when any part of it was visible.

Subjects were examined seated in a chair, with the examiner standing approximately in 10 o’ clock position, under natural daylight. The subject well positioned so as to receive maximum illumination, while avoiding discomfort from direct sunlight. The recorder was made to sit close enough so that instructions could be easily heard and the examiner could see that the findings were being recorded correctly. Oral examination was conducted by a single examiner and was done in uniform manner beginning from the maxillary right quadrant in a clockwise direction in maxillary and mandibular region

Ethical clearance was taken from Institutional Ethics Committee, All India Institute of Medical Sciences (AIIMS), Bhopal, Central India. Research had been conducted in full accordance with the World Medical Association Declaration of Helsinki. Informed written consent was taken from parents and children prior to conducting the survey. The survey was scheduled between the months of July 2014 and September 2014. Training and calibration of examiner was conducted in Department of Dentistry, AIIMS, Bhopal. A pilot study was conducted on 30 children each to see the feasibility of study. All examinations were performed by a single examiner and duplicate examinations were conducted on one of every ten subjects throughout the survey. Intra- examiner reliability for indices was assessed using kappa statistic which was in range of 0.92 – 0.94.

## Statistical analysis

Data was collected, entered and analyzed using SPSS version 16.0 (SPSS Inc., Chicago, Illinois, USA) for windows. Mean and standard deviations were used as basic descriptive statistics. Chi Square test was used to compare between categorical variables. Mann – Whitney U-test was used for comparison between two groups for quantitative variables. Analysis of Variance (ANOVA) was used to compare the mean dmft/DMFT scores among the three age groups. Linear and logistic regression analysis was performed to determine the factors associated with dmft/DMFT status. A set of independent variables including age, gender, parent’s education, annual family income, frequency of cleaning teeth, frequency of between meal sugar consumption (previous day) and utilization of dental care was considered in the regression model. Odds ratio was calculated for all variables with 95% confidence intervals. All the dependent variables to be included in the regression analysis were dichotomized.

Significance was fixed at p value of = 0.05.

## Results

A total of 311 children comprised the sample, of them 154 (49.5%) were males and 157 (50.5%) were females. No Significant gender differences were noted between the two groups. Also, no significant gender differences were noted among the three age groups of 5-6 years, 7-10 years and 11-12 years. Only, 16 (5.1%) of the paternal study population and 12 (3.9%) of the maternal population had a graduation or higher level of education. Higher levels of illiteracy, 70 (37.6%) were noted among the mothers, in contrast to their counterparts 117 (22.5%). Significant differences were noted between parental levels of education for the study subjects (p = 0.001). No gender differences were noted between annual family incomes for study population (Table 1).