Current Status of Oral Hygiene: A Clinical Survey Report
Nitin Chandrakant Mohire*, Adhikrao Vyankatrao Yadav, Vaishali Kondibhau Gaikwad
Government College of Pharmacy, Vidyanagar, Karad. Taluka-Karad, District- Satara, Maharashtra, India- 415124.
*Corresponding Author E-mail: firstname.lastname@example.org
Objective To study the current clinical status of orodental problems in patient population and to find out its relationship with oral hygiene. The present work also aimed to create awareness about importance of oral hygiene and to provide tips for daily oral hygiene practices.
Methods An observational case study method was used for clinical survey of oral hygiene problems in south Maharashtra.
Findings Number of factors were studied to evaluate their relationship with oral hygiene and it has been found that; most of the factors are either responsible for development of poor oral hygiene or the response of poor oral hygiene. Caries and periodontal diseases are prominent in age group 20-40 years and poor oral hygiene was the main etiological agent.
Conclusion Mouth is a window into what's going on in the rest of the body, often serving as a helpful vantage point for detecting the early signs and symptoms. By studying various factors and their relationship with oral hygiene it can be concluded that maintain good oral hygiene to maintain overall hygiene. Very fewer efforts were undertaken by Indian Health Ministry regarding oral hygiene as compared to other countries. Thus it demands strong national health policy for good oral hygiene.
The importance of good oral hygiene was well discussed in our previous review entitled “Good Oral Hygiene for Good Overall Hygiene.” The present work was undertaken to study current situation of oral hygiene status in Indian population and its relationship with oral diseases and various factors affecting it.
Ethical conduct of study:
Observational case study of patients with oro-dental conditions was carried out in one hundred and twenty patients as per protocol approved by Institutional Ethics Committee, under the supervision of experienced and competent dentist. Patients were first informed about the study contents. ‘Oral Hygiene Status Form’ was filled only after patient’s permission and not a single patient was obliged for participation in study. For pediatric patients, written consent was signed by parents after getting full information regarding the study. Study involves only observation of orodental conditions and not related with use of drug, device, or improved therapy.
An observational case-control study of patients with orodental problems was carried out to find out influence of various factors like age, gender, habits, presence of plaque, dental visits per year, number of teeth present, oral hygiene status, associated diseases, health status, and deficiency of vital nutrients. Diagnosis, treatment and percent population suffered with specific oro-dental disease was also estimated.
We also studied the individual effect and magnitude of each risk factor and also tried to correlate their interdependency or aggregation of one or more factors that result in disturbance in oral hygiene.
Observations of the study:
Total 17 independent and 8 interdependent factors were studied and the observations of the same are mentioned below:
A] Independent factors:
These are the factors whose individual effect on oral health was recorded and mentioned in graphical way.
The importance of this factor is that paediatric as well as geriatric population is quite unable to perform good oral hygiene practices as compared to adults. Study results showed that magnitude of diseases in paediatric and geriatric population was nearly same and it has been also observed that age group of 20 to 40 years (younger ones) were more prone to oro-dental problems. Observed order of oral hygiene problems as per groups was 20-40 yrs. (42.49%) > 0-20 yrs (22.49%) = 40-60 yrs (22.49) > 60-80 (12.48%). (See Fig. 1.)
Fig. 1. Relation- Age and % oral problems
There was no significant difference observed in gender as an etiological agent. It has been also observed that though magnitude of oro-dental problems was same; responsible factors are different. In male smoking, chewing tobacco and gutkha (composition containing flavored tobacco), alcoholism were the primary etiological agents while in female tobacco misery (burned tobacco powder used as dentifrice), ignorance towards oral health and deficiencies of vital nutrients in diet were the most important etiological agents. Observed order of gender difference was female (51.67%) > male (48.33%). (See Fig. 2.)
Fig. 2. Relation- Gender and % Oral problems
3. Patient complaint:
This is the factor responsible for visit of patient into dental clinics. While interacting with patients it has been observed that many of the oro-dental problems are ignored, unrealized, undiagnosed and hence untreated resulting in irreversible loss of tooth and also makes many oral conditions complicated and difficult to treat. From study it has been observed that adult male and children were more prone to caries while females were more prone to gingivitis. Geriatric patients have more complaints of mobile teeth. Observed order of patient complaints was dental caries (76.67%) > gingivitis (35%) > and other (1.67%). (See Fig. 3.)
Fig. 3. Relation- Patient complaint of oral problems
4. Dental cleaning measures:
It is a most important factor of routine oral hygiene practice. Now a days most of people are using dentifrices like toothpaste and toothpowders to clean their teeth, tongue and freshening their breath; still more than 25 % population uses tobacco misery or like coarse powders to clean their teeth results in improper cleaning, development of plaque etc. Coarse nature of powder make scratches on tooth and long term use leads to staining of teeth and oral mucosa. Another observation was that use of tobacco misery and related coarse powder as a tooth powder was more common in rural areas than urban. Observed order of dental cleaning agent was tooth paste (71.66%) > tobacco misery (21.65%) > other (8.32%). (See Fig. 4.)
Fig. 4. Dental cleaning measures and its % use
5. Frequency of brushing:
According to good oral hygiene practices; tooth brushing to clean teeth, tongue, and internal oral mucosa must be done twice a day means after wake-up and before going to sleep to ensure complete oral cleaning. Findings of study shows that order of brushing frequency was once a day (59.99%) > twice a day (19.99%) > none a day (19.98%) It means that majority of population not following good oral hygiene practices. Most of the population use to clean their teeth at morning and not after dinner. So the food particles after dinner get deposited in tooth; which is the major cause of orodental disorders like cavities and halitosis. If food particles get accumulated in space between tooth and gum i.e. periodontal pockets; leads to bleeding and pus formation thus further increases the severity of periodontal diseases. (See Fig. 5.)
Fig. 5. Frequency of dental cleaning / day
6. Tobacco/ gutkha/ smoking:
These are the known primary etiological agents for most of the oral hygiene problems. Clinical survey reveals that patients having habit of Tobacco (TO), gutkha (GT), smoking (SM), and alcohol (ALC) were highly prone to many of the diseases of varying severity like from just dental staining to variety of oral cancers. Consumption of alcohol itself indicates person’s attitude towards oral and overall hygiene. As consumption of alcohol leads to dental erosion, halitosis, cancers, and number of the oral as well as systemic diseases and disorders; many of them are fatal. Study also reveals that age group 20-40 yrs is more prone to above habits than others; male are more addict than females. Observed order of habits was tobacco (19.99%) > alcohol (13.32) > smoking (11.66%) > gutkha (8.33%). (See Fig. 6.)
7. Tea, coffee and cold-drinks:
From study it has been observed that drinking of tea is part of daily activity. Some studies also mentions the beneficial effects of herbal tea in dental problems as it contains large amount of flavonoids and fluorides. But heavy drinking and high sugar containing tea may lead to development of caries. Coffee also causes same effects but popularity is less than tea. Cold drinks are always better to avoid, as they leads to decalcification of teeth and bones. Carbonated and high sugar content of cold-drinks cause dental erosion. Observed order of drinking habit was tea (79.15%)> cold-drinks (17.5%)> coffee (5%). (See Fig. 7.)
Fig. 6. Adductive habits and % Patient population
Fig. 7. Drinking habits and % Patient population
It is a thin, sticky, colorless film of bacteria that forms on teeth. It has been considered that plaque is the most important contributor of poor oral hygiene and the primary etiological agent for development of oro-dental problems like dental caries, gingivitis, trench mouth, infective endocarditis, oral abscess and many more. Presence of plaque itself indicates presence of many of oro-dental problems as it provides additional environment for bacteria. Study reveals that about 59.16 % of patients have such plaque on their teeth of varying thickness and spreading area. Observed order of plaque was as per age 20-40 yrs> 40-60 yrs> 60-80 yrs.> 0-20yrs; while males are more prone to develop plaque than females; patient with plaque is mostly suffered from caries and gingivitis than patient without plaque. (See Fig. 8.)
9. Regular dental check-up:
Regular check-up is highly important to keep good oral hygiene. According to many guidelines six monthly (twice a year) visits as a regular check-up and consulting dentist or oral hygienist is well accepted. It is always better to consult the dentist after initial start of orodental disease; instead of self medication. But it has been found that many of the times oral health problems are ignored or undiagnosed. From patients it has been also found that self medication for dental pain, caries, and gingivitis is preferred by most of the rural or poor patients. The problem behind this is that self medication is always for symptomatic relief and not for total cure. Next most unwanted effect is that due to symptomatic relief; disease progression continues without symptoms which generate false information about oral health which leads to development of serious conditions which are difficult to control or cure in end stage. Observed order of dental check-up was found that after progression of disease (POD) (89.16%)> twice a year (6.66%)> once a year (4.16%). So from figures it has been concluded that people with regular check-up are less susceptible to oral problems than people consulting dentist after progression of disease. (See Fig. 9.)
Fig. 8. Plaque and % Patient population
Fig. 9. Clinic visits and % population
10. Number of teeth:
According to one study, 46 % of participants who had lost up to nine teeth had carotid artery plaque; among those who'd lost 10 or more teeth, 60 % of them had such plaque. Finding reveals that cardiac problems were prevalent in patients having less number of teeth. The severity of heart problems increases with increase in number of teeth extracted. Diabetes also contributes to disturbance in oral hygiene. Observed order of number of teeth in % population was 27-32 teeth (57.5%) > 0-20teeeth (22.5%) > 21-26 teeth (20%). So it may be concluded that most of the patients have one to two teeth extracted and many of people extraction of teeth are more than two. (See Fig. 10.)
Fig. 10. No of teeth and % Patient population
11. Oral hygiene status:
Maintain oral hygiene to maintain overall hygiene. Most of the people with poor oral hygiene have complaints of oral problems like caries, gingivitis, periodontitis, infections and halitosis; and other systemic problems like infective endocarditis, uncontrolled diabetes, tissue abscess which are related with poor oral health. Observation of study reveals that most of the patients having habits of smoking, chewing tobacco, gutkha and not practicing oral hygiene practices were at increased risk of bad and worst oral hygiene status. Chances of developing bad and worst oral hygiene were also dependent on age, sex and presence of plaque. Observed order of oral health status was bad (54.16%)> worst (25.83%)> good (20%). (See Fig. 11.)
Patients are diagnosed as per their complaints and it was found that most of the complaints are related with dental caries, periodontitis and mobile teeth. Diagnosis was found to be dependant on age, sex and oral hygiene status. Observed order of diagnosis made by experienced dentist was dental caries with pain (DC) (72.487%) > Periodontal disease (PD) (47.5%) > mobile tooth (MT) (9.15%). (See Fig. 12.)
13. Allied diseases:
Patients with diabetes are already at greater risk of developing chronic gum diseases. Poor oral hygiene is causative agent for most of the systemic diseases. Observations of study shows that people with heart problems (8.33%) > diabetes (4.17) > others (3.33%). (See Fig. 13.)
Fig. 11. Oral hygiene status and % Patient population
Fig. 12. Diagnosis and % Patient population
Fig. 13. Allied diseases and % Patient population
14. Health status:
This factor is dependant on patients overall physical health status. It was found that most of the females were mal nutrited than males and most of the children were taking faulty diet. Patients with well- nutrited (70.82%) > mal-nutrited (29.16%). (See Fig. 14.)
15. Deficiencies of vital elements:
Minerals, vitamins and fibrous food are considered as vital elements for maintaining oro-dental hygiene. As minerals (calcium, phosphate, fluorides) and vitamin (vit-D) deficiencies lead to decalcification and erosion of tooth which are easily attacked by bacteria to develop serious health problems. Fibers are considered as natures toothbrushes as they clean and polish the plaque debris and food particles from teeth, gum and possible oral mucosal membrane; thus eliminating the environment for micro-organisms. Fibers also neutralize the acid either produced by bacteria or food itself and prevents chances of oro-dental problems result in maintaining good oral hygiene. Food lacking in fibers leads to development of plaque and debris, as well as production of acid. Observed deficiencies of vital elements were minerals (39.16%) > fibers (29.99%) > vitamins (24.98%). (See Fig. 15.)
Fig. 14. Health status and % Patient population
Fig. 15. Deficiency and % Patient population
16. Treatment given:
The treatment prescribed in oro-dental problems varies depending upon type and severity of problem. It has been observed that most of the patients come to clinic after getting pain, gingival ulceration, bleeding or pus formation. It indicates that most of the patients were diagnosed in severe disease stage. Recent advances in dentistry helps to save a badly caries tooth by root canal treatment but it is a costly alternative and hence not preferred by many of the patients. Treatment mostly includes pain killers (PK) (84.17%) > antibiotics (AB) (80.82%) > antacids (AC) (65%) > metronidazole (MET) (50%) > serratiopeptidase (SP) (27.5%) > ornidazole (ORN) (16.67%) > chlorhexidine (CH) (10%) > potassium nitrate (PN) (83.33%) > others (0.83%). (See Fig. 16.)
Fig. 16. Treatment and % Patient population
17. Geographical distribution and % Patient population:
The incidence of oral unawareness of poor people from rural area about oral hygiene coupled with non availability of oral healthcare products and services; the incidence of orodental problems was found significantly more in rural population as compared to urban population. The observed findings of incidence of rural (62.49%) > urban (37.49%). (See Fig. 17.)
Fig. 17. Geographical distribution and % Patient population
B] Interdependent factors:
The relationship of various factors on the particular disease was studied and observations were mentioned in graphs given below.
1. Major oral diseases and related factors:
While comparing between the two major oral hygiene problems i.e. caries and PD, it has been observed that primary etiological factors like 20-40 age group, rural population, tobacco misery, negligence towards dental cleaning, use of tobacco and related products, presence of plaque and irregular dental check-up, bad and worst oral hygiene status and malnutrition were prominent in PD than caries. (See Fig. 18.)
Fig. 18. Major oral diseases and related factors:
PD- Periodontal diseases, M-Male, F-Female, 0-20 and onwards,-indicates age group in years, PS-Paste, TM-Tobacco misery, OT-Other, Frequency of brushing- ON-once, TW-Twice, NO-None, TO-Tobacco, GT-Gutkha, SM-Smoking, AL-Alcohol, TE-Tea, CF-Coffee, CD-Cold drink, PP-Plaque present, PA-Plaque absent, VO-Visit once /year, VT-Visit twice / year, VD-Visit after disease progression, Oral hygiene status-GD-Good, BD-Bad, WR-Worst, WL-Well nutritioned, ML-Malnutritioned, DM-Deficiency of mineral, DV-Deficiency of vitamins, DF-Deficiency of fibers.
2. Plaque and related factors:
From survey it has been observed that plaque was more common in male, 20- 40 yrs age group and tobacco consumers. (See Fig. 19.)
Fig. 19. Plaque and related factors
3. Cold drink and related factors:
From survey it as been observed that colddrinks were mostly associated with male, 20-40 age group and responsible for caries, gingivitis and mineral deficiency. (See Fig. 20.)
Fig. 20. Cold drink and related factors
4. Amplitude of oral problems:
The amplitude of caries was more than gingivitis and mobile tooth. The patients with both i.e. caries and gingivitis were more in number than patients with only gingivitis. (See Fig. 21.)
5. Gender and malnutrition:
Malnutrition was predominant in female than males as an etiological factor for development of caries and PD. (See Fig. 22.)
Fig. 21. Amplitude of oral problems
6. Deficiency and gender difference:
All the vital elements that play important role in oral hygiene were found deficient in females than males. (See Fig. 23.)
Fig. 22. Gender and malnutrition
Fig. 23. Deficiency and gender difference
7. Dental cleaning measures and % gender difference:
Toothpaste was more common in males while tobacco misery was in females. (See Fig. 24.)
Fig. 24. Dental cleaning measures and % gender difference
8. Oral hygiene status and related factors:
Relationship between various factors, oral diseases and oral hygiene status was studied and presented in graphical way. (See Fig. 25.)
RESULT AND DISCUSSION:
From the study it was revealed that patient population with Good oral hygiene status (GOHS), Bad oral hygiene status (BOHS) and Worst oral hygiene status (WOHS) were about 25%, 63% and 32% respectively. Patients from the age group 20-40 were more common in all OHS groups; most of them have BOHS and also more prone to oral diseases.
Though their was no significant gender difference observed in percent oral hygiene problems, most of female have GOHS (16.66%) and BOHS (32.5%); while most of male have BOHS (28.33) and WOHS(15.33).
Geographical distributions of oral problems were found to be prominent in rural areas (62.49%) as compared to urban area (37.49%). The awareness regarding good oral hygiene practices in rural population was also less than urban population.
Toothpaste was preferred in all the cases about 71.66%; while use of misery was mainly in patients with BOHS (9.16%) and WOHS (10.83%). In most of the cases observed frequency of brushing was once/day (59.99%) than twice/day (19.99%) and none/day (19.98).
No bad habits viz. tobacco, gutkha, smoking and alcohol were associated in patients with GOHS; while all these habits were prevalent in male patients with BOHS (16.63%) and WOHS (23.32%).
Fig. 25. Oral hygiene status and related factors
M-Male, F-Female, 0-20 and onwards,-indicates age group in years, UR-Urban, RL-Rural, PS-Paste, TM-Tobacco misery, OT-Other, Frequency of brushing- ON-once, TW-Twice, NO-None, TO-Tobacco, GT-Gutkha, SM-Smoking, AL-Alcohol, TE-Tea, CF-Coffee, CD-Cold drink, PP-Plaque present, PA-Plaque absent, VO-Visit once /year, VT-Visit twice / year, VD-Visit after disease progression, WL-Well nutritioned, ML-Malnutritioned, DM-Deficiency of mineral, DV-Deficiency of vitamins, DF-Deficiency of fibers, , CR-Caries, PD-Periodontal disease, MT-Mobile teeth, OT-Other.
Presence of plaque was about 13 times more in patients with BOHS (33.33%) and 9 times more in patient with WOHS (23.33%) than patients with GOHS (2.5%).
Regular dental visits were totally absent in patients with WOHS and also very less in patient with BOHS.
Caries were prevalent in all the cases; while periodontal diseases were 5 times more in patients with BOHS (25%), and 2.5 times more in patient with WOHS (17.5%) than patients with GOHS (5%). Mobile tooth was highly associated with patients with BOHS and WOHS.
Most of patients with BOHS and WOHS were mal nourished and also have deficiency of mineral, vitamins and fibers, 4 times more than patients with GOHS.
An oral hygiene practice differs country to country and community to community and depends on various factors. Currently very less information regarding oral hygiene status in India is available and most of the survey data is from American and European countries. As etiological factors, magnitude and severity of oral problems in Indian population is not always same or even comparable to that of American and European situations. Thus present work will provide some sort of data regarding epidemiology of oral hygiene problems in Indian situation, preferably from south Maharashtra.
The intention behind conducting the present survey was to establish and confirm the data reported internationally as it is applied to Indian population. Most of the observations recorded in this survey confirm the international findings of earlier research workers. Moreover some of the factors specific to Indian situation and their effect on oral hygiene have also been identified here.
In some cases we found that magnitude of overall effect is nearly same but the responsible factors were different. Patient awareness regarding routine oral hygiene practices definitely helps to reduce incidences of oral problems and thereby increase quality of life. Thus it demands strong national health policy for good oral hygiene.
The survey indicates the need of development of oral hygiene products with better efficacy and performance that can specifically take care of the oral hygiene problems; as the currently available oral hygiene products partially fulfill the need identified here in our survey.
Authors are thankful to Dr. S.B. Bhise, Principal, Govt. College of Pharmacy, Karad, for providing all necessary facilities and Rameshwardasji Birla Smarak Kosh for providing financial support.
Refered the review article ‘Good Oral Hygiene for Good Overall Hygiene: A Review’ Research J. Pharm. and Tech, 2009; 2(2): 262-273.