Dentistry Section DOI : 10.7860/JCDR/2018/32669.11956
Year : 2018 | Month : Aug | Volume : 12 | Issue : 08 Page : ZE08 - ZE13

Prevalence of Dental Caries in India among the WHO Index Age Groups: A Meta-Analysis

Chandrashekar Janakiram1, Bobby Antony2, Joe Joseph3, Venkitachalam Ramanarayanan4

1 Professor, Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.
2 Resident, Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.
3 Professor, Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.
4 Assistant Professor, Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.


NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Chandrashekar Janakiram, Professor, Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi-682041, Kerala, India.
E-mail: sekarcandra@gmail.com
Abstract

Introduction

Dental caries is widely prevalent globally but the distribution and severity of dental caries varies across countries and regions. In the absence of surveillance or real time monitoring of dental caries in India, there exist a need to assess the prevalence in the country for planning and implementation of oral health programs.

Aim

To assess the combined prevalence and mean DMFT of dental caries in India among the WHO index age groups (5, 12, 15, 35-44 and 65-74 years).

Materials and Methods

Epidemiological/point prevalence studies conducted (among index age groups) in various parts of India from January 2000 to April 2016 were retrieved from Pubmed central database using ‘Dental caries’ AND ‘India’ as MeSH terms and information from the only National Oral Health Survey and Fluoride Mapping (2002-2003) in India were used. The combined mean deft/DMFT and pooled prevalence of the dental caries was assessed region wise for each age group.

Results

The mean deft/DMFT was 2.36, 1.95, 3.31 and 7.01 among 5, 12, 15 and 65-74 years respectively. The SiC index shows steady increase from 3.36 to 8.11 across the groups. The mean prevalence of dental caries is almost similar at 5 years and 12 years at 49% while it shows steady increase from 15 years (60%) to 35-44 years (78%) and peaks at 65-74 year group (84%). In the Eastern and Western regions of India, the 15 year old had higher caries prevalence and mean DMFT compared to the 12-year-old. Across India, the 60-74-year-old had the highest DMFT of 7.01. In North and South India, 65-74-year-old had the highest caries prevalence of 84% and 85% respectively.

Conclusion

Irrespective of age groups, the prevalence of dental caries was found to be high and varied across India. This data could help health policy makers to tailor region specific oral health interventions.

Introduction

Dental caries is a widely prevalent disease world-wide. According to Global Oral Health Data Bank, prevalence varies from 49% to 83% across different countries [1]. Irrespective of age, it has shown to have a negative impact on the health related quality of life. Data suggests that there has been a decline in the prevalence of dental caries worldwide but has been at markedly different rates in high and middle/low income countries. While there has been a greater decline in the high income countries which could majorly be attributed to the use of fluorides and established preventive programs while in some low and middle income countries, there decline has been less or inverse because of the increasing consumption of sugars and refined foods [2].

Delivery of effective patient care, health services management, public health and health policy making are dependent on credible data [3]. The World Health Organization (WHO) has advocated epidemiological surveys to be undertaken every 5 years to monitor the changing patterns of oral diseases and to create a global oral health data bank [4]. The data currently available in the global oral health data bank has been sourced from countries having a robust disease surveillance/reporting system or on the basis of systematically conducted national oral health surveys. Though widely prevalent, the distribution and severity of dental caries varies across countries and among various regions within a country [5]. For global monitoring purposes, the WHO recommends the use of certain index age groups to summarize the burden of dental caries and other oral diseases. The age groups 5 years, 12 years, 15 years, 35-44 years and 65-74 years have been chosen to represent primary dentition, immediately after permanent teeth eruption (except third molars), exposure of teeth to the oral environment for a sufficient period of time, adulthood and geriatric population respectively.

India with its wide ethnic, geographic and cultural diversity is considered as a country of several nations. Quite expectedly disease patterns are also widely diverse within various states/regions of the country. However, with the absence of a robust disease reporting system, there is no real-time monitoring of oral diseases in the country. The lack of credible data fails to convince policy makers to accept oral diseases as public health problems and hence the low priority. India has had only a single National Oral Health Survey conducted in 2002 [6]. However, literature reveals innumerable prevalence studies done across the country on various age and population group. This data, if combined, can be used effectively for planning and implementation of oral health programs. This study thus intends to pool the available data on the region wise dental caries prevalence from January 2000 to April 2016 in the country thereby assessing its trend. For standardization purposes, only studies conducted among the WHO index age groups were included for the present review.

Materials and Methods

Study Design

It is a review (secondary data analysis) of prevalence studies on dental caries conducted among WHO index age groups.

Data Source and Search Strategy

Studies were retrieved from Pubmed Central database using ‘Dental caries’ and ‘India’ as MeSH terms. Data from the National Oral Health Survey and Fluoride Mapping (2002-03) were also included. The search was conducted in the month of May 2016 and articles till April 2016 were included. Search strategy and results are given in [Table/Fig-1].

Search strategy.

Inclusion Criteria

Point/period prevalence studies on dental caries prevalence or caries experience using deft/DMFT index done in India from January 2000-April 2016;

Studies with in the index ages (5, 12, 15, 35-44 and 60-74 years);

Only English language studies were included.

The search was restricted to articles published in Pubmed database and did not include other sources, government reports or grey literature.

Data Extraction

A proforma was prepared in Microsoft Excel to extract relevant data required for the review. Each article was read by the principal investigator and following variables were recorded; time period during which the study was performed, investigators and year of publication of study, study setting, age group, gender, category of study population, population size, mean deft/DMFT with standard deviation and the prevalence of dental caries. In order to assess the trend of dental caries in different index age groups in different regions, the studies were grouped - age and region wise.

Statistical Analysis

Data was entered in Microsoft Excel sheet and reliability check was done. Data was segregated region wise (north, south, east and west). Caries prevalence and mean deft/DMFT was separated from the master file. Some of the studies did not report either of them.

For mean deft/DMFT, the combined mean and standard deviation was estimated gender wise and region wise among the index age groups:

Combined mean DMFT, X = (x1 * n1) + (x2 * n2) + ……….. + (xn * nn) / N

Where, x1, x2 are mean deft/DMFT and n1, n2 are sample size of sample 1 and 2 and N is the total of all sample size.

d1 = x1 - X

Combined SD = SQ.RT n1*(SD12 + d12) + n2*(SD22 + d22) + ……. + nn*(SDn2 + dn2) / N

Standard Error was calculated and Confidence Interval were assessed for combined mean

Standard Error (SE) = Combined SD / SQ.RT of N

Confidence Interval, CI = lower limit to upper limit

Lower limit = X – 1.96 * SE, Upper limit = X + 1.96 * SE

For prevalence, the combined mean prevalence was estimated gender wise and region wise among the index age groups:

Combined mean Prevalence, P = (p1* n1) + (p2 * n2) + ……….. + (pn * nn) / N

Where, p1 and p2 are mean prevalence and n1, n2 are sample size of sample 1 and 2 and N is the total of all sample size. Standard Error was calculated and Confidence Interval was assessed for combined prevalence.

SE = SQ.RT P*(1- P) / N

Confidence Interval, CI = lower limit to upper limit

Lower limit = P – 1.96 * SE, Upper limit = P + 1.96 * SE

Significant Caries Index (SiC):

In order to account for the skewed distribution of caries prevalence, SiC was also calculated [7]. This index was proposed in 2000 to bring attention to those individuals with the highest caries scores in each population [7].

Results

A total of 29 articles including National Oral Health Survey and Fluoride Mapping (2002-03) were included for the final review [Appendix-1]. The studies were grouped under the region of India where it was conducted.

List of included studies for review.

Sl NoAuthorsTitle and publication detailsYearRegion
1Bali RK, Mathur VB, Talwar PP, Chanana HB [6].National Oral Health Survey and Fluoride Mapping 2002-03. Dental Council of India, New Delhi; 2004.2004All India
2Sujlana A, Pannu PK [8].Family related factors associated with caries prevalence in the primary dentition of five-year-old children. J Indian Soc Pedod Prev Dent. 2015;33(2):83–87.2015Northern India
3Gupta D, Momin RK, Mathur A, Srinivas KT, Jain A, Dommaraju N, et al [9].Dental caries and their treatment needs in 3-5 year old preschool children in a rural district of India. North Am J Med Sci. 2015;7(4):143–50.2015Northern India
4Das D, Misra J, Mitra M, Bhattacharya B, Bagchi A [10].Prevalence of dental caries and treatment needs in children in coastal areas of West Bengal. Contemp Clin Dent. 2013;4(4):482–87.2013Northern India
5Mittal M, Chaudhary P, Chopra R, Khattar V [11].Oral health status of 5 years and 12-year-old school going children in rural Gurgaon, India: an epidemiological study. J Indian Soc Pedod Prev Dent. 2014;32(1):3–8.2014Northern India
6Gambhir RS, Sogi GM, Veeresha KL, Sohi RK, Randhawa A, Kakar H [12].Dental health status and treatment needs of transport workers of a northern Indian city: A cross-sectional study. J Nat Sci Biol Med. 2013;4(2):451–56.2013Northern India
7Agrawal R, Gautam NR, Kumar PM, Kadhiresan R, Saxena V, Jain S [13].Assessment of dental caries and periodontal disease status among elderly residing in old age Homes of Madhya Pradesh. J Int Oral Health JIOH. 2015;7(8):57–64.2015Northern India
8Gaur A, Sujan SG, Katna V [14].The oral health status of institutionalized children that is, Juvenile home and orphanage home run by Gujarat state Government, in Vadodara city with that of normal school children. J Indian Soc Pedod Prev Dent. 2014;32(3):231–37.2014Northern India
9Joshi N, Sujan S, Joshi K, Parekh H, Dave B [15].Prevalence, severity and related factors of dental caries in school going children of vadodara city - an epidemiological study. J Int Oral Health JIOH. 2013;5(4):35–39.2013Western India
10Ingle NA, Dubey HV, Kaur N, Gupta R [16].Prevalence of dental caries among school children of Bharatpur city, India. J Int Soc Prev Community Dent. 2014;4(1):52–55.2014Western India
11Prabhu P, Rajajee KTSS, Sudheer KA, Jesudass G [17].Assessment of caries prevalence among children below 5-year-old. J Int Soc Prev Community Dent. 2014;4(1):40–43.2014Western India
12Gupta P, Gupta N, Singh HP [18].Prevalence of dental caries in relation to body mass index, daily sugar intake, and oral hygiene status in 12-year-old school children in Mathura City: A Pilot Study. Int J Pediatr. 2014;2014:921823.2014Western India
13Prakasha Shrutha S, Vinit GBG, Giri KY, Alam S [19].Feeding practices and early childhood caries: a cross-sectional study of preschool children in kanpur district, India. ISRN Dent. 2013;2013:275193.2013Western India
14Simratvir M, Moghe GA, Thomas AM, Singh N, Chopra S [20].Evaluation of caries experience in 3-6-year-old children, and dental attitudes amongst the caregivers in the Ludhiana city. J Indian Soc Pedod Prev Dent. 2009;27(3):164–69.2009Western India
15Shailee F, Girish MS, Kapil RS, Nidhi P [21].Oral health status and treatment needs among 12- and 15-year-old government and private school children in Shimla city, Himachal Pradesh, India. J Int Soc Prev Community Dent. 2013;3(1):44–50.2013Eastern India
16Kundu H, Patthi B, Singla A, Jankiram C, Jain S, Singh K [22].Dental Caries Scenario Among 5, 12 and 15-year-old Children in India- a retrospective analysis. J Clin Diagn Res JCDR. 2015;9(7):ZE01-05.2015All India
17Suprabha BS, Rao A, Shenoy R, Khanal S [23].Utility of knowledge, attitude, and practice survey, and prevalence of dental caries among 11- to 13-year-old children in an urban community in India. Glob Health Action. 2013;6:20750.2013Southern India
18Beena JP [24].Dental subscale of children’s fear survey schedule and dental caries prevalence. Eur J Dent. 2013;7(2):181–85.2013Southern India
19Das UM, Beena JP, Azher U [25].Oral health status of 6- and 12-year-old school going children in Bangalore city: an epidemiological study. J Indian Soc Pedod Prev Dent. 2009;27(1):6–8.2009Southern India
20Havaldar KS, Bhat SS, Hegde SK [26].Oral health status of Tibetan and local school children of Kushalnagar, Mysore district, India: a comparative study. J Indian Soc Pedod Prev Dent. 2014;32(2):125–29.2014Southern India
21John JB, Asokan S, Aswanth KP, Priya PRG, Shanmugaavel AK [27].Dental caries and the associated factors influencing it in tribal, suburban and urban school children of Tamil Nadu, India: a cross sectional study. J Public Health Res. 2015;4(1):361.2015Southern India
22Baskaradoss JK, Geevarghese A, Roger C, Thaliath A [28].Prevalence of malocclusion and its relationship with caries among school children aged 11-15 years in southern India. Korean J Orthod. 2013;43(1):35–41.2013Southern India
23Bharateesh JV, Kokila G [29].Association of root caries with oral habits in older individuals attending a rural health centre of a dental hospital in India. J Clin Diagn Res: JCDR. 2014;8(11):ZC80-82.2014Southern India
24Jain M, Singh A, Sharma A [30].Relationship of Perceived Stress and Dental Caries among Pre University Students in Bangalore City. J Clin Diagn Res: JCDR. 2014;8(11):ZC131-34.2014Southern India
25Karunakaran R, Somasundaram S, Gawthaman M, Vinodh S, Manikandan S, Gokulnathan S [31].Prevalence of dental caries among school-going children in Namakkal district: A cross-sectional study. J Pharm Bioallied Sci. 2014 Jul;6(Suppl 1):S160-161.2014Southern India
26Basha S, Swamy HS [32].Dental caries experience, tooth surface distribution and associated factors in 6- and 13-year-old school children from Davangere, India. J Clin Exp Dent. 2012;4(4):e210-16.2012Southern India
27Sarumathi T, Saravana Kumar B, Manjula Datta, Hemalatha VT, Aarthi Nisha V [33].Prevalence, severity and associated factors of dental caries in 3-6 year old children. J Clin Diagn Res JCDR. 2013;7(8):1789–92.2013Southern India
28Sukhabogi Jr null, Shekar C, Hameed I, Ramana I, Sandhu G [34].Oral health status among 12- and 15-year-old children from government and private schools in hyderabad, Andhra Pradesh, India. Ann Med Health Sci Res. 2014;4(Suppl 3):S272-77.2014Southern India
29Sukhabogi J, Parthasarathi P, Anjum S, Shekar B, Padma C, Rani A[35].Dental fluorosis and dental caries prevalence among 12 and 15-year-old school children in Nalgonda District, Andhra Pradesh, India. Ann Med Health Sci Res. 2014;4(Suppl 3):S245–52.2014Southern India

Northern India [6,813];

Western India [6,1420];

Eastern India [6,21,22];

Southern India [6,2335].

The mean deft/DMFT was 2.36, 1.95, 3.31 and 7.01 among 5, 12, 15 and 65-74 years respectively. Sufficient data was not available for 35-44 year age group. The SiC index shows steady increase from 3.36 to 8.11 across the groups. There is a considerable difference between the mean deft/DMFT of males and females across all age groups [Table/Fig-2].

Mean deft/DMFT among different age groups in India.

Index age groupsMalesFemalesOverall
Mean DMFT(CI)No. of StudiesMean DMFT(CI)No. of StudiesMean DMFT(CI)SiCNo. of Studies
5 years2.05 (1.99-2.11)41.95 (1.89-1.99)42.36 (2.3-2.42)3.3616
12 years1.16 (1.08-1.24)51.18 (1.1-1.26)51.95 (1.91-1.99)3.5231
15 years0.96 (0.79-1.13)31.14 (0.89-1.37)33.31 (3.21-3.41)5.1413
35-44 yearsNo data available-No data available-No data available--
65-74 yearsNo data available-No data available-7.01 (6.64-7.38)8.112

*SiC: Significant caries index


The mean prevalence of dental caries is almost similar at 5 years and 12 years at 49% while it shows steady increase from 15 years (60%) to 35-44 years (78%) and peaks at 60-74 year group (84%). Males had slightly higher prevalence at 5 and 12 years and females had a higher prevalence in the older age groups [Table/Fig-3].

Prevalence of dental caries among different age groups in India.

Index age groupsMalesFemalesOverall
Mean Prevalence (%) (CI)No. of StudiesMean Prevalence (%) (CI)No. of StudiesMean Prevalence (%) (CI)No. of Studies
5 years52 (51.03-52.97)1949 (47.98-50.02)1949 (48.46-49.54)32
12 years51 (48.95-51.05)1750 (48.93-51.07)1749 (48.43-49.57)46
15 years59 (57.97-60.03)1761 (59.94-62.06)1760 (59.35-60.65)26
35-44 years76 (75.11-76.89)1580 (79.13-80.87)1578 (77.38-78.62)15
65-74 years84 (83.2-84.8)1585 (84.19-85.81)1584 (83.43-84.57)16

Region wise data shows that South Indian five-year-old had a higher mean deft compared to their North Indian counterparts. However, among the 12-year-old, the highest mean DMFT was observed among West Indian children followed by North India and others. Studies done in Eastern region of India reported the least DMFT of 0.86 [Table/Fig-4]. The prevalence of the dental caries was consistently higher among all age groups in North India compared to the other regions [Table/Fig-5]. Forest plot of pooled prevalence of dental caries among various age groups in different regions of India is shown in [Table/Fig-6].

Mean deft/DMFT among different age groups in different regions of India.

Index age groupsNorth IndiaSouth IndiaEast IndiaWest India
MeanDMFT(CI)SiCNo. of StudiesMean DMFT(CI)SiCNo. of StudiesMean DMFT(CI)SiCNo.of StudiesMean DMFT (CI)SiCNo.of Studies
5 years2.07 (1.74-2.98)2.662.74 (2.61-2.87)3.610No dataNo data
12 years2.17 (2.09-2.25)361.28 (1.23-1.33)2.6180.86 (0.78-0.94)134.70 (4.44-4.96)84
15 years4.10 (3.95-4.25)4.221.17 (0.98-1.36)2.161.38 (1.22-.54)2.0636.18 (5.82-6.54)82
35-44 yearsNo data--No data--No dataNo data
65-74 years7.01 (6.64-7.38)8.112No data--No dataNo data

SiC: Significant caries index


Mean Prevalence of dental caries among different age groups in different regions of India.

Index age groupsNorth IndiaSouth IndiaEast IndiaWest India
Mean Prevalence in % (CI)No of studiesMean Prevalence in % (CI)No of studiesMean Prevalence (%) (CI)No of studiesMean Prevalence (%) (CI)No of studies
5 years52 (51.1-52.8)1447 (46.3-47.7)18No data-No data-
12 years61 (59.9-62.)1244 (43.5-44.8)2350 (48.4-51.6)441 (39.7-42.29)8
15 years76 (74.9-77.2)849 (47.9-50.1)957 (55.2-58.73)456 (54.5-57.4)5
35-44 years82 (81.2-82.7)974 (7.01-74.9)6No data-No data-
65-74 years84 (83.2-84.7)985 (84.2-85.8)7No data-No data-

Forest plot showing Mean Prevalence of dental caries among different age groups in different regions of India.

Discussion

This study was designed to meta-analyse the mean deft/DMFT and prevalence from all the point prevalence studies in India conducted from January 2000 to April 2016 among the WHO index age groups. The studies were heterogeneous in view of the population group studied but these provided vital information to get a relative estimate of the dental caries burden in different regions of India. Standardization was attempted by incorporating only those studies which used deft/DMFT index for assessment of caries and conducted only among specific age groups.

The study found that five-year-old children had mean deft of 2.36 (95% CI 2.3 - 2.42). Since deft is the past caries experience, its presence means the caries experience would have started at least two years prior. Early Childhood Caries (ECC) interferes with speech, self-esteem, daily routine activities, normal nutrition intake and results in underweight and abnormal cognitive development among children [21]. It also affects the overall oral health related quality of life [36]. Also, young children with dental caries have a higher probability of having dental caries in their permanent dentition [37]. The presence of dental caries in deciduous dentition is a predictor of future caries in the permanent dentition. Having deft 2.3 at 5-6 years is high considering the proportion of the children affected which is nearly 50%. Moreover the SiC is 3.36 for 5 years which is significantly higher for the age. This implies that nearly four teeth are affected by dental caries, out of which one or two may progress to involve the dental pulp.

In 2011, the total number of children in the age-group 0-6 years were reported as 158.79 million [38]. Nearly half of them, that is, around 79.4 million are affected by ECC in India. Five to six year old males had more dental caries experience than females. There was a slight difference in caries experience in southern and northern Indian studies. This difference may be attributed to socioeconomic indicators in southern states when compared to northern states as dental caries occurrence is largely related to degrees of industrialization.

The Global Oral Health Data Bank reports a mean DMFT of 2.97 among 12-year-old for the South East Asian countries. Though India comparatively reports better mean DMFT of 1.95, it is still higher compared to developed countries in the African, European and Eastern Mediterranean and Western Pacific regions of World Health Organization who report a mean DMFT of 1.06, 1.64, 1.81 and 1.05 respectively. This could probably be attributed to the absence of any organized programs for dental caries reduction/prevention in India. At this rate, there is a need to monitor and ensure the surveillance of oral diseases and its risk factors. Though DMFT, among 12-year-old was found to be 1.9 which falls under ‘low’ category according to the WHO, nearly half of the population was affected by caries. The mean DMFT of countries in the Americas is 2.08; higher than in India. This observation could possibly be attributed to the varied dietary patterns like candy culture and processed food intake being higher among the Americans. However, it has also been found that the dental caries rate is lower among the Mongoloid and the Afroamericans and the Caucasians and similar to that of countries like Thailand. It is relevant to note that SiC index for the same group (3.52) falls under the ‘moderate’ category.

In Northern India, 15 year olds had the highest mean DMFT of 4.10 compared to the 5 and 12 year age groups. Similar findings were observed in a systematic review which also reported that northern regions of India has more dental caries as compared to the southern regions [21].

The highest prevalence of dental caries was found among the 65-74-year-old and the proportion affected was almost 85%. This could possibly include a large number of Missing (M) components in DMFT; an indicator to assess the tooth lost due to caries in DMFT. However, there was a paucity of this data due to inadequate reporting in most of the studies. The tooth mortality and lack of prosthetic care contributed to unmet dental needs among the elderly population which is a growing global concern.

It is well documented that the best predictor of future caries is past caries, which means that children affected by severe caries are likely to have more caries in the future. Hence, this population could be identified for inclusion in caries prevention programs [39]. It is helpful to address the factors that influence children’s oral health in order to develop and implement complementary public health actions focused on children and parental behaviours, in an endeavour to provide them with good oral health and better quality of life [40].

Limitation

By limiting studies to index age groups and caries assessment methods, standardization was ensured. The use of statistical estimates like weight mean and combined prevalence resulted in meta-analysing the results of numerous studies.

One of the limitations of this review was the inability to calculate mean deft/DMFT and weighted prevalence for every age group in each region of India due to the lack of availability of data. Full texts of few articles could not be accessed leading to its exclusion.

Conclusion

The data from this study provide actionable health information to guide public health policy and programs, aimed at improving oral health services in India. Centers for Disease Control and Prevention (CDC) guidelines for evaluating public health surveillance systems around the globe recommends that the health related events (in this case oral diseases and conditions) be considered for surveillance if they affected many people, require large expenditures of resources, are largely preventable, and are of public health importance. Based on these criteria, oral health outcomes, associated health behaviours, and other factors linked to oral health should be included in public health surveillance systems [41]. Oral diseases and its risk factors need to be incorporated into the non-communicable disease surveillance in India.

*SiC: Significant caries indexSiC: Significant caries index

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