Dental Caries Experience and Oral Hygiene Status among Institutionalized Orphans of Bhubaneswar City, Odisha: A Comprehensive Dental Healthcare Program Outcome

INTRODUCTION

According to UNICEF, nearly 10,000 children become orphans every day.¹ It is internationally accepted that there are at least 140 million orphans worldwide and nearly 61 million in Asia alone.² The Indian National Family Health Survey (NFHS–4) reports that 5% of India’s population under the age of 18 years are orphans. The same survey reports that the north-eastern region of the country has the highest percentage of orphans.³ Odisha is a state in eastern India with a population roughly of 42 million where 40% belong to scheduled tribes and scheduled castes including 13 particularly vulnerable tribal groups.⁴ Children’s vulnerability in such populations deepens with high levels of poverty, displacement of families, frequent natural calamities, the presence of left-wing extremism, and the existence of rigid social norms and cultural practices.⁵

UNICEF and global partners define an orphan as a child %3C;18 years of age who has lost one or both parents to any cause of death.² Following the death of a parent, many children enter orphanages. The pattern of orphanage living is quite poor when compared to family living.⁶ Poor living conditions in orphanages may be related to many complex health problems like developmental disturbances and psychiatric disorders.⁷ This is due to numerous influences that affect these children like economic hardship, neglect, malnutrition, and abuse.⁸

UNICEF, UNAIDS, and USAID reported that orphanages can be unfavorable for the growth and development of children to their full potential because for children to survive and thrive, they need to grow up in a community and family environment that caters to their changing needs.⁹ Orphans, therefore, are considered a disadvantaged and socially marginalized population in whom disease burden is high.¹⁰ More disturbing is the evidence that the health care of orphans is often neglected. It has been well documented that the absence of family support adversely influences the knowledge on general and oral health behaviors.¹¹ Being an orphan is one of the most important predictors for poor oral health¹² as oral health care is one of the most common unmet health care needs of this group.¹³

Children from orphanages are expected to experience untreated dental caries and periodontal diseases as a consequence of their poor oral hygiene and dental neglect.⁸ Prevalence of dental caries among the children residing in orphanages of India has been reported to be as high as 88.5%.¹⁴ Similarly, studies conducted overseas have also reported comparable statistics; a study conducted in Yemen¹⁵ reports a prevalence of 84.7%, a study from Saudi Arabia¹⁶ reports 96% prevalence in 4- to 12-year-old orphans, and a study from China¹⁷ reports 50% prevalence in 4–17-year-old orphans. Such a high prevalence of untreated dental caries embraces the risk of dental sepsis¹⁸ along with a negative impact on child’s quality of life-impacting their appearance, ability to eat, communicate, and perform daily tasks at home or school.¹⁹

Good oral hygiene is recognized as the key to oral disease prevention. Regular toothbrushing with fluoride toothpaste and adequate mechanical dental plaque removal helps to control most oral diseases.²⁰ Children’s knowledge and skills of oral hygiene are mostly derived from their parents.^21,22 In orphanages, it is now the responsibility of caregivers to fill-in this gap. Often these caregivers fail in their duties to cater to the needs of their inmates. This lacuna has been attributed to low care-taker to child ratio, poor funding, and inadequacies in the public health care system.²³

Oral hygiene promotion is most effective among younger populations; as peer groups can be targeted as agents of behavioral change within their communities. It is the primary concern of public health dentists to impart positive oral health knowledge and behaviors in society. The first step in achieving this is to provide relevant information and raise their awareness of oral health.²⁴ Past research in similar populations confirms the limited knowledge and access to services.^12,25,26 Hence, implementation of comprehensive dental health care programs (CDHP) through outreach programs could serve dual purposes of creating oral health awareness and reducing the disease burden among this population.

No prior data exist regarding the oral health status and oral hygiene practices of orphans in Bhubaneswar, Odisha. Hence, this study was undertaken to assess the dental caries experience and oral hygiene status among the institutionalized Orphans of Bhubaneswar city, Odisha. The first objective of this study was to compare the dental caries experience with the study participants’ oral hygiene and dietary sugar consumption practices. The second objective was to compare oral hygiene status with study participants’ oral hygiene practices and finally, to provide CDHP services rendering both preventive and curative oral health care to this population.

MATERIALS AND METHODS

RESULTS

DISCUSSION

Epidemiological surveys assessing the oral health status of typical populations like school children, urban adult populations, and industrial workers are quite common. Whereas studies on such neglected segments of our society like the inmates of orphanages are scanty. This study provides us a unique opportunity to describe the dental caries experience and oral hygiene status in this marginalized population of society. Residents of these orphanages are considered to be marginalized as these homes can barely meet the needs of their inmates. Owing to this, orphans usually portray a poor oral hygiene status which is the root cause for the various oral hard and soft tissue diseases. There are very few specific studies on orphans living under institutionalized care in India and none conducted in Bhubaneswar city. Thus, the present cross-sectional study was undertaken to determine the dental caries experience and oral hygiene status of institutionalized orphans in Bhubaneswar city of Odisha, India.

The caries prevalence in the present study was 41.4%. Studies conducted on similar populations abroad reported a caries prevalence of; 96% in Saudi Arabia,¹⁶ 84.7% in Yemen,¹⁵ and 34.8% in Pakistan.³¹ Whereas, studies conducted in various states/cities of India reported a caries prevalence of; 66.2% in Jammu and Kashmir,³² 62.12% in Vadodara city,³³ 58.3% in Nellore,¹² and 50.2% in Mysore City.³⁴ Such high prevalence of dental caries in this population may be due to the low-cut nature of government funding which is insufficient to cater to the needs of its inmates. On the same grounds, the present study reported a caries prevalence of 57% in deciduous dentition. Identical studies have reported similar prevalence where; National Oral Health Survey and Fluoride Mapping³⁵ reported 50%. The caries prevalence was higher in younger ages owing to the lack of adult supervision leading to improper cleaning of teeth and frequent intake of sweet and sticky food. Yet, another reason behind this neglect is, primary dentition is not given the same importance as its permanent counterparts as they are considered temporary and ignored even when there is a definitive need for attention. Caries prevalence decreased with an increase in age as the deciduous teeth exfoliated naturally and permanent teeth which are more resistant to caries replaced them.

The dental caries experience was 1.07 ± 1.56 for permanent teeth and 0.96 ± 2.11 for primary dentition in the present study. Studies abroad have also reported comparable results; Pakistan (DMFT = 1.18 ± 0.39, dmft = 1.04 ± 0.23)³¹ and Yemen (DMFT = 2.06 ± 1.94, dmft = 2.28 ± 2.37).¹⁵ Various studies conducted in India have reported similar caries experiences; Jodhpur City, Rajasthan (DMFT =1.40 ± 1.78),³⁶ Jammu and Kashmir (DMFT = 1.74 ± 1.92, dmft = 1.35 ± 1.79),³² Udaipur City, Rajasthan (DMFT 1.16 ± 1.14),²⁶ and Nellore, Andhra Pradesh (DMFT = 1.01 ± 1.52, dmft = 2.21 ± 2.82).¹² Orphanages have their own faculty to cater to the educational needs of their children. However, no health education was imparted to these children which was a matter of concern.

Furthermore, it was observed that the caries experience was largely contributed by the decayed (d/D) component in both primary and permanent dentition. These findings are in line with the studies reported earlier.^32,37,38 This suggests a lack of access to dental care in these groups and also indicates that the reason for dental visiting/examination was problem-based. Many factors are contributing to such a high percentage of untreated carious lesions among the underprivileged orphan population; lack of knowledge about good oral hygiene practices among caretakers and concerned authorities, lack of motivation, low priority given to dental care in society, lack of the facility for early/regular oral health check-up and cost of treatment.

The mean DMFT was higher among males (1.86 ± 2.05) compared to females (1.70 ± 1.96) in the present study; though statistically insignificant. Correspondingly, Sudha et al.³⁹ and Laganà et al.⁴⁰ also found no statistically significant difference between genders. Whereas, Sharma et al.,⁴¹ Shailee et al.,⁴² and Saravanan et al.³⁸ found females had significantly higher caries experience than males. The authors of these studies attributed higher caries experience among females to an early eruption of teeth and their prolonged exposure to the deleterious oral environment. On the contrary, Thetakala et al.,³⁴ Khare et al.,²⁶ and Gaur et al.³³ reported significantly higher caries experience among males which, is in agreement with the observations of the present study. The higher caries experience among males could probably be because females were more particular about maintaining esthetics, appearance, cleanliness, and hygiene while males are negligent about their health particularly oral health.

In the present study, all participants (100%) used a toothbrush to brush their teeth and 80.8% of the participants brushed their teeth only once, while a very small percentage (8%) brushed twice daily. On the same lines, Gaur et al.³³ reported 99.4% of orphans brushed their teeth only once, and an insignificant 0.6% brushed twice whereas. While comparing this with children of the same age with parents disclosed that 72.7% brushed once and 27.3% brushed twice a day.³³ This lower percentage of children brushing their teeth twice may be due to limited availability of brushing aids (toothbrush and toothpaste), lack of motivation, and guidance from caregivers in the orphanages. It was also seen that the participants used a horizontal scrubbing method of brushing (66.8%). Though all the participants brushed their teeth, they seemed ignorant of its importance and the proper technique of brushing the teeth. Further, many were not even aware of the ill effects of frequent snacking in-between meals and adequate oral hygiene performance, which reflects poor oral health awareness.

Further, dietary sugar consumption history revealed tendencies toward having dental caries (DMFT > 1) increased as the; intake of sugars having a sticky consistency in-between meal increased. As far as the restriction of refined sugar intake was concerned in these orphanages, the people who visited them on a timely basis felt sympathetic toward the plight of these children and pampered them with sweets and snacks at the orphanages on social occasions leading to this practice of frequent in-between meal snacking.

Poor oral hygiene has been implicated in the etiology and progression of oral hard and soft tissue diseases. This is more so for those at risk due to their inability/failure to maintain adequate and proper oral health care resulting from lack of awareness and/or nonavailability of resources. Forty-nine percent of the study participants presented with fair oral hygiene. This is similar to the study by Shanbhog et al.¹⁴ where 47.5% of participants revealed fair oral hygiene status. However, higher percentages have been reported by Ojahanon et al.²⁵ (73.7%) in orphans of Benin city, Nigeria. Both the motivation of the individual and his/her manual dexterity in the use of oral hygiene aids influences the success of plaque removal.

The findings of our study showed that younger age groups had better oral hygiene when compared to participants above 13 years of age though, not statistically significant. On the contrary, a study by Mahesh Kumar et al.⁴³ reported older children having lower scores. It has been proven that brushing skills get better with age and that the duration and dexterity of brushing improved significantly as age advanced.⁴⁴ Our study indicated an insignificant difference in oral hygiene between genders (p = 0.422). Females (2.06 ± 1.14) had marginally less OHI(S) scores as compared to males (2.13 ± 1.27). On the contrary, Markeviciute and Narbutaite⁴⁵ reported a significant difference in oral hygiene between genders (p = 0.007) where females (0.86 ± 0.36) were significantly better than boys (1.28 ± 0.45). The better oral hygiene in females is suggestive of a possible growing awareness about esthetics and understanding the contribution of a healthy clean tooth for the same.

Toothbrush (100%) and toothpaste (93.2%) were the most common materials used for teeth. A mere 18% of the participants reported brushing their teeth at least twice a day whereas, in a study by Markeviciute and Narbutaite,⁴⁵ 32.8% of kids brush their teeth at least twice a day. Studies have reported that the frequency of toothbrushing does not always mean better oral hygiene rather the quality of toothbrushing is more imperative.⁴⁵ Nearly half of the study population (n = 487, 66.8%) brushed their teeth in a horizontal scrubbing motion. It is well known that the circular method is the best way to remove dental plaque from hardly reachable surfaces of children’s teeth. This irregularity in the method of toothbrushing may be due to the varying children’s ability to brush based on their experience, physical and neurological development.

Improvements in the oral health status of vulnerable groups can be achieved by initiating CDHPs catering to these populations’ dental needs and contributing to the improvement of their oral health condition. Such programs provide a platform to dispense oral health curative and preventive programs utilizing the oral health care infrastructure and manpower of an academic dental institution.

CONCLUSION

Children in orphanages are a neglected segment of our society. They face certain emotional, social, and psychological distress which affects their general as well as oral health. An effort has been made to throw some light on unattended oral health problems in orphanages. The oral health status revealed a huge occurrence of oral diseases and unmet oral health needs in the form of untreated dental caries and fair oral hygiene status. This was largely due to their poor oral health knowledge and limited availability of materials for the maintenance of proper oral hygiene. Even though the results of this study are fairly modest, it is enough to speculate that there is an apparent need for dental health programs to target the institutionalized orphans to improve their oral health status and prevent oral diseases.

It is obvious; however, that information about dental health and dental health behavior must be repeated and practiced over a longer period. Their caregivers need to update their knowledge of oral health care to ensure appropriate supervision. Creating opportunities for the orphans to visit dental health facilities for regular checks will assist them in achieving the same.

CONCLUSION

We wish to acknowledge all the participants including the staff of the orphanages for taking part in our study. We also wish to show our gratitude to Dr Shazia Ahmad, Internee, Department of Public Health Dentistry, Kalinga Institute of Dental Sciences, for her contribution.

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