|Year : 2021 | Volume
| Issue : 1 | Page : 15-22
Prevalence of dental caries among Indian tribal population – A systematic review
Anusha Raghavan, Krishnan Lakshmi, Parangimalai Diwakar Madan Kumar
Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||14-Oct-2020|
|Date of Decision||11-Apr-2021|
|Date of Acceptance||20-Apr-2021|
|Date of Web Publication||9-Aug-2021|
Dr. Anusha Raghavan
Department of Public Health Dentistry, Ragas Dental College and Hospital, 2/102, East Coast Road, Uthandi, Chennai - 600 119, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The aim of this systematic review was to assess the burden of dental caries among various tribal populations in India. Relevant studies were included from the period of January 2000 to March 2020. A detailed search strategy was developed for MEDLINE through the use of MeSH terms and was revised for Google Scholar, EBSCO, Cochrane, and TRIP databases. The search generated a total of 1444 articles of which only 14 articles were included in this review. Among the 76 Indian tribes present only, 11 were reported in the review. On the whole, our systematic review showed that there are a high level of heterogeneity and a moderate level of bias in all the studies included. Adequate representation of the tribal population through zone-wise assessment of a particular tribe is recommended in establishing the validity of the results.
Keywords: Dental caries, health care, India, oral health, tribes
|How to cite this article:|
Raghavan A, Lakshmi K, Kumar PD. Prevalence of dental caries among Indian tribal population – A systematic review. Int J Oral Health Sci 2021;11:15-22
| Introduction|| |
Despite the marked decline in oral diseases as reported by the World Health Organization (WHO), a high prevalence is still seen in certain specific populations predominantly referred as risk groups. Among these, the tribal communities form a special niche, which are more prone to diseases because of their hostile, isolated living conditions, poor sanitation, poor literacy, and employability. A total of 76 tribal communities are found in various ecological and geoclimatic conditions ranging from plains, forests to hilly and inaccessible areas of India.
Their concept of understanding health and disease is a result of the knowledge about that particular illness traditionally transferred through the generations. These tribes altogether demonstrate a different lifestyle, culture, and identity unique to their own groups in this era of globalization. Even though plenty of initiatives and developmental and welfare schemes are being brought about by the Government of India for their upliftment and mainstreaming, somehow these groups continue to remain economically back, socially weak and prone to risk. Various studies have reported the following health problems in this group which include hypertension (22%), followed by arthritis (17%), diabetes (10%), anemia, skin problems (12%), vision problems (18%), and also high prevalence of periodontal disease and oral mucosal lesions (56%) owing to their cultural and traditional beliefs in health-related issues and high prevalence of tobacco usage.,,,
In this context, health care can be viewed as a cultural construct arising from beliefs about the nature of disease and the human body, and thus plays a vital role in the delivery of effective preventive and curative services.
Even though the initiative for a separate oral health policy was started in the year 1986, it is only in 2017 oral health has been mentioned as a part of the National Health Policy (pt 4.6 page 13). During the in between years, a National Oral Health Program was also initiated with the following objectives:
- Determinants to improve of oral health
- Integration of oral health promotion and preventive services with general health-care system
- Promoting of public–private partnership model for achieving better oral health.
In addition, initiative like the Ayushman Bharat or “Healthy India” launched as a part of the National Health Policy 2017 aimed to achieve the vision of universal health coverage and was designed on the lines as to meet Sustainable Development Goal and its underlining commitment, which is “to leave no one behind.”
Despite such efforts, there are hardly any schemes or policies designed to include oral health for the tribal population. With the numerous tribal communities found in India, there hardly exists any consistent information on their oral health status based on which policies can be formulated. A first step to any problem will be an in depth understanding of the same, which when carried out by systematically analyzing the available literatures forms the highest scientific evidence.
Thus, the findings of this systematic review would provide evidence for making appropriate decisions to formulate required national policies for oral care which could further improve access to dental care services for these people across India making “inclusive dental care” a dream turned reality in near future.
Hence with this back ground, this systematic review was conducted to assess the burden of dental caries among various tribal populations in India.
| Materials and Methods|| |
The review did not have any human participation and hence was exempted from the institutional ethical review board.
A systematic review was undertaken using objective and transparent methods as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, to identify, evaluate, and summarize all relevant research findings. The protocol for this review is submitted to PROSPERO registry but is yet to be assigned a number.
On applying the PICO analysis to the articles searched, the criteria were set as shown below:
- POPULATION – Indian tribal population: children, adolescents, or adults (no restriction on age)
- INTERVENTION/INTEREST – Oral health status
- COMPARISON – Not applicable
- OUTCOME – Dental caries.
- Studies assessing the oral health status of Indian tribal populations as their primary or secondary aim
- Studies which had assessed oral health status in terms of dental caries
- Studies which had a population of healthy children, adolescents, or adults
- Studies published in the last 20 years were included
- Cross-sectional, cohort studies, qualitative studies, clinical trials, longitudinal studies, and comparative studies.
- Studies reporting oral health perception or oral health-related quality of life or other dental conditions
- Also studies that reported oral health status in subjective manner using questionnaires
- Reviews, editorials, books, expert opinion, and case series
- Publications with no abstract and those which were widely out of scope of the study were eliminated
- Studies that required translation to English language.
The remaining studies were sorted on the basis of their title and abstract. Finally, those studies in which the abstract fulfills all inclusion criteria were selected for full-text reading. In those cases in which a study met the eligibility criteria, but the information in the abstract was insufficient, full texts of the articles were also obtained. Further literature search was performed based on the bibliography of the selected articles. Hand searching of journals with scope on specific populations and oral health was performed but yielded no good results.
Relevant studies were included from the period of January 2000 to March 2020 via MEDLINE (PubMed), EBSCO, Cochrane, and Google Scholar. A detailed search strategy was developed for MEDLINE through the use of MeSH terms and was revised for Google Scholar, EBSCO, and Cochrane also [Table 1]. The first set of terms include “oral health status” and “dental caries” separated by Boolean operator OR. The second set included the term “Indian tribal population” and the third set included the term “children,” “adults,” and “adolescent” separated by Boolean operator “OR.” Data searches were done at December 2019 and again at March 2020. A bibliographic search of the excluded articles was done to ensure all primary research on oral health of tribal population was included. Only full papers written in English were included, where multiple publications reporting on the same study existed in different databases, and data from the study were extracted and reviewed only once. Duplication of article was identified using software (Zotero version 5.0 (Center for History and New Media at George Mason University)).
|Table 1: The search applied in terms of MeSH terms and search words for each database|
Click here to view
Study selection was conducted by two authors (LK and AR) independently who screened titles and abstracts against the inclusion/exclusion criteria and identified relevant papers. Then, the same two authors independently reviewed the full-text studies unable to be excluded by title and abstract alone. Comparison of papers was completed between the two authors with no disagreements regarding inclusion. The inter-rater agreement between the authors was recorded as 0.87 using SPSS software version 20 which is good in nature.
The data extraction from final 15 articles was done using a data extraction form. It includes the first author name, year of publication of the article, study population, method of obtaining relevant information (assessment tool), results/primary outcome.
Quality assessment of the included studies
The final analysis included 15 cross-sectional studies, and the methodological quality of the selected articles was assessed using the Modified Newcastle Ottawa Scale. For cross-sectional studies, quality score was based on seven items of the following categories: selection, comparability, and outcome. A maximum score of 5 points for group selection, 2 points for compatibility, and 3 points for outcome was recorded to determine the methodological quality of the included studies. The higher the score, better the quality of study.
Since there are no evident tool to assess the risk of bias for cross-sectional studies, based on our review objective, sample representativeness and assessment tool used were criteria chosen to determine risk of bias across studies which was computed using Revman software version 5.3.(Cochrane Collaboration, 2020).
| Results|| |
The search generated a total of 1444 articles from five different electronic bases: PubMed, EBSCO, Cochrane, TRIP, and Google Scholar. PubMed produced 692 articles, EBSCO database produced 0 article, Cochrane produced 669 articles, and Google Scholar produced 83 articles. PRISMA 2009 guidelines regarding the paper selection are shown as flowchart in [Figure 1].
|Figure 1: The search strategy according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines|
Click here to view
The full texts of 17 articles were obtained for further review. Based on inclusion and exclusion criteria, 14 articles were included initially in this systematic review.,,,,,,,,,,,,, Bibliographical search of the selected articles yielded no additional eligible studies for inclusion. Hence, the same numbers of 14 articles were considered for the final review. Among the excluded articles, two had reported only periodontal status and one assessed quality of life. All the studies included were of cross-sectional design.
The methodological quality and risk of bias were assessed using the Modified Newcastle Ottawa Scale which yielded moderate risk of bias for all the studies indicating unclear quality of methodology used. [Figure 2] shows the quality assessment along with risk of bias across the 14 articles included.
Author's name with year of publication, study population, assessment tool, outcome, and summary of these included studies are tabulated in [Table 2].
All the studies reported oral health status (dental caries) of tribal population in India. Among the 76 tribes present, only 11 were reported in the review. There was equal representation from northern and southern India. A wide age group from ≤5 years to 80 years have been studied amongst the included studies.
Majority of the included studies had described and validated their measurement tool to assess the dental caries status of tribal population, in India. Indices used include decayed, missing, and filled teeth (DMFT), SiC, and WHO 1997 pro forma to measure the dental caries status quantitatively. Five studies had measured dental caries status in terms of DMFT index; among them, two have also used SiC Index. Others had used WHO 1997 while one study conducted by Chhaya et al. has not mentioned regarding assessment tool used.
The entire assessment tools used were subjected to pilot testing to assess feasibility of the tool in this special population and also the inter-rater bias was eliminated by calibrating the examiner and reliability of the outcome was assessed using kappa statistics whose values ranged from (0.7 to 0.9) which were in good agreement in nature.
Included studies had sample size ranging between 120 and 2650 with age group ranging from ≤5 to 80 years. Almost half of the studies (7 out of 14) had only pediatric study group within 15 years of age.
Age of the study population was defined in all of the studies, and only eight studies had used a random sampling method owing to a moderate quality in sample representation.
Of the included studies, three studies conducted by Singh A et al., Kadanakuppe et al. had worked on tribes of Karnataka state, whereas seven studies done by Kumar TS et al., Viragi S et al., Kumar G et al., Das et al., Mandal et al., and Chayya et al. had investigated the northern state tribal population which includes two studies from Rajasthan and one each from Gujarat, Madhya Pradesh, West Bengal, Jharkhand, and Odisha. Two studies reported findings of tribal population from Tamil Nadu: one from Kerala and the other had not mentioned the place of the study.
Case definition about the study population was explicitly written in all of the included studies except in four studies conducted by Viragi et al., Kumar G et al., Bose AK et al., and Mandal S et al. where specifications of about the culture of the tribal population were ill defined.
Moreover, two studies were documented on Santal tribes by Kumar G et al. and Mandala S et al. with a gap of 4 years.
Dental caries status
Majority of the studies (8 out of 14 studies) had assessed the dental caries status of the population using WHO 1997 pro forma. Age-wise distribution of caries status was reported in five studies, among which Dhanappa et al. had used WHO index age groups. In these studies, higher DMFT scores were seen in pediatric and geriatric populations.
One study conducted by Singh A et al. had used a comparison to show increased mean DMFT score (4.2) seen among tribal children compared to their counterparts. The same author had also calculated dental caries status in terms of SiC index which could a useful parameter for comparison.
Two studies had compared dental caries in primary and permanent dentition and revealed that increase caries was seen among permanent dentition in Juang tribes whereas the contradictory was seen in Santal tribes.
The two studies which had reported on Santal tribes with a gap of 4 years showed an increase in caries prevalence over the years by 2%.
Gender-wise distribution was witnessed in two studies which presented higher decay prevalence among males than females. John BJ et al. in their study on Panamali tribes had divided the study group into urban and semi-urban; higher DMFT score (2.42) was seen among semi-urban compared to urban.
| Discussion|| |
Oral health plays a major impact on the quality of life of any individual. With respect to the tribal population, it is of even greater importance as these marginalized sections of the society predominantly live life in isolation and are away from the available health services. A similar view has been emphasized by Deepan Kumar et al., who stated that daily living was prioritized more compared to general/ oral health in these people. He therefore concluded past experience, behavior, and priorities are the major deciding factors in one's life. Among tribal communities, it can be rest assured that health is given the least priority compared to food, shelter, and occupation. Thus, in order to improve their general as well as oral health, our policymakers need to be precisely informed of the status of these communities.
The WHO has recommended periodic monitoring of health status and treatment needs and assessment of change in disease patterns over time for judicious allocation of resources. When the Indian tribal groups are considered, there is a lack of sufficient data on which the services can be built. However, few authors have suggested that the presence of dental caries has a significant negative correlation with the daily comfort in terms of eating restriction and appearance.,
Among all the oral diseases, dental caries is attributed mostly as the byproduct of affluence and civilization. Geographically isolated, these least vulnerable and primitive populations show exaggerated proneness to dental caries and put themselves in high risk due to their inadequate exposure to civilization. The reasons suggested by various authors in literature for the same include passive oral health services, poor utilization, lack of awareness, poverty, and illiteracy. This is further established by the high values of D and M component of the DMFT with very negligible F component indicating the high degree of unmet needs present in these primitive groups. Our systematic review also showed similar results wherein the authors reported high mean DMFT values.
On the whole, only 11 tribes out of the 76 in India have been studied. Hence, further insight into the remaining tribal population needs to be established for better understanding of their oral health needs. Furthermore, varied age groups have been reported by the authors, which make it difficult to compare the outcome and come to a consensus.
With respect to measurement of caries status, predominantly the WHO modification of 1997 has been used followed by DMFT/decayed, missing, and filled surface and the SiC index. Although WHO format is a universally accepted way of assessment, the categorization and reporting of the outcome has differed between the studies. For the future comparison, the reviewers suggest that reporting the caries status in terms of SiC index would be of better value as it would be easier to identify the subgroups within each tribal community with high treatment need.
The various tribal groups are as such scattered in various parts of India. Adequate representation of the tribal population being studied also needs to be taken care of through zone-wise assessment of a particular tribe which helps in establishing the validity of the results.
Another important finding in our review is that the Santal tribes, have been studied at two different points of time in a span of 4 years in two different regions which showed an increase in caries prevalence. These regional differences should also be accounted for in the future studies.
Apart from these, reasons for intertribal variations in terms of caries in primary and permanent dentitions should be studied in terms of the indigenous customs and practices, food habits, and way of living which attribute to the oral health of these communities. Historical landmark studies among specific tribal people have showed increased prevalence of dental caries with modification in their dietary pattern due to better development and intake of processed food. Similarly Singh et al. in both their studies, revealed that lack of knowledge and awareness among tribal children was a primary reason for more sugar intake and poor oral hygiene. Contradictory to the existing knowledge of gender-wise prevalence of dental caries, this review showed that males in the tribal communities are more susceptible than their female counterparts. This variation could be attributed to the unequal representation in the study group. Further studies should work to identify the plausible reasons for the same or is it artifactual outcome in this case.
Out of the 14 studies taken for review, only one reported outcome in terms of geographic location as urban or semi-urban, wherein the semi-urban population showed more dental caries. This further substantiates the existing literature that, lack of knowledge, availability of services play a major role in the oral health of a population.
| Conclusion|| |
On the whole, our systematic review showed that there is a high level of heterogeneity and a moderate level of bias in all the studies included. All the studies were of cross-sectional design, and validity of the findings is questionable. The authors recommend that future research should be in the form of pathfinder surveys to allow adequate representation the various tribal groups and ensure periodic follow-up of these populations to better understand whether there is effective utilization of resources when adequate care is provided to them.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]