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Table of Contents   
ORIGINAL RESEARCH  
Year : 2011  |  Volume : 22  |  Issue : 3  |  Page : 410-418
Oral health status in relation to socioeconomic factors among the municipal employees of Mysore city


1 Department of Community Dentistry, Peoples Dental Academy, Bhanpur, Bhopal, Madhya Pradesh, India
2 Department of Community Dentistry, J S S Dental College and Hospital, Mysore, Karnataka, India

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Date of Submission22-Dec-2009
Date of Decision25-Mar-2010
Date of Acceptance25-Sep-2010
Date of Web Publication3-Nov-2011
 

   Abstract 

Aim: To assess the prevalence of dental caries, periodontal diseases, oral pre-malignant and malignant lesions in relation to socioeconomic factors among the municipal employees of Mysore city.
Settings and Design: The study was cross sectional in nature.
Materials and Methods: All the available employees (1187) during the study period were considered. World Health Organization (WHO) Oral Health Assessment form (1997) and a preformed questionnaire were used to collect the required data. Modified Kuppuswamy scale with readjustment of the per capita income to suit the present levels was used for classifying the individuals into different socioeconomic status (SES) categories. Data were collected by a single, trained and calibrated examiner (dentist) using mouth mirror and community periodontal index (CPI) probe under natural daylight. Data analysis was done using SPSS windows version 10. Quantitative data were analyzed using one-way analysis of variance (ANOVA) with Tukey's post hoc test and qualitative data were analyzed using chi-square or contingency coefficient.
Results: The age range of the study population was 19-57 years (mean 40.74 years, standard deviation 9.17). The prevalence of dental caries in the upper SES category was lesser (43.3%) compared to that in lower SES category (78.6%). 16.4% of the subjects in the upper category had a CPI score of 0 (healthy periodontium) and none of the subjects in the lower middle, upper lower and lower SES category had this score. The prevalence of oral pre-malignant and malignant lesions was higher in lower SES category (17.9%) than in upper class (0%).
Conclusion: There was an inverse relationship between oral health status and SES. The overall treatment need was more in the lower class people than in the upper class.

Keywords: Dental caries, malignant lesions, Modified Kuppuswamy scale, municipal employees, periodontal diseases, prevalence, socioeconomic status

How to cite this article:
Chandra Shekar B R, Reddy C. Oral health status in relation to socioeconomic factors among the municipal employees of Mysore city. Indian J Dent Res 2011;22:410-8

How to cite this URL:
Chandra Shekar B R, Reddy C. Oral health status in relation to socioeconomic factors among the municipal employees of Mysore city. Indian J Dent Res [serial online] 2011 [cited 2019 Jul 17];22:410-8. Available from: http://www.ijdr.in/text.asp?2011/22/3/410/87063
The enjoyment of highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, economic and social condition. [1] Health is multifactorial, influenced by factors like genetics, lifestyle, environment, socioeconomic status (SES) and many others. [2] Health cannot be isolated from its social context and the last few decades have witnessed that social and economic factors have as much influence on health as the medical interventions. [2] Socioeconomic factors are important determinants of health and this is dramatically reflected in the comment of Naina, wife of Boris Yelstin, former Prime minister of Russia, who says, "we have astronauts flying in space ships but we don't have enough wheel chairs". [1] Over the last century, health has improved significantly. This improvement, however, has not been experienced equally across the population, being considerably greater among the better off. [3] High economic status alone cannot contribute to better health. [2] Although it is a major factor for improving the health, [4],[5],[6],[7] it can be a contributing factor for illness as well, like in the occurrence of coronary heart disease, diabetes and obesity. [2] Studies indicate that education to some extent compensates the effect of poverty on health. Kerala with its high literacy status has better health (low infant mortality rate) compared to other parts of India, in spite of having lesser per capita income than the national average. [2]

Oral health is always an inseparable part of general health and several studies in the past have revealed an association between socioeconomic factors and oral health. [4],[5],[6],[7],[8],[9] The literature on the association between socioeconomic factors and prevalence of dental caries, periodontal diseases as well as oral pre-malignant and malignant lesions among adults in India is scanty. Municipal Corporation is a body consisting of employees of different socioeconomic categories, from a high (commissioner, deputy commissioner, health professionals, engineers, administrative officers, etc.) to a low socioeconomic class (sanitary workers, gardeners, gang men, etc.), under one organization. The literature on the oral health status of municipal employees in India is also sparse. The assessment of oral health status of these employees will provide an opportunity to assess the influence of socioeconomic factors on their oral health status and treatment needs. Hence, the present study was taken up as an attempt to assess the relationship between oral health status and socioeconomic factors among the municipal employees of Mysore city.


   Materials and Methods Top


The study was cross sectional in nature and ethical clearance was obtained from the institutional ethical committee. All the employees of Mysore City Corporation (that included the workers in the main office and nine branch offices) who were available during the period of study, which was conducted over a period of 3 months from March to May 2004, were considered for the study. Municipal City Corporation had 1198 employees on record. Among these, 11 subjects were on long leave and excluded from examination. After obtaining permission from the Commissioner of Mysore City Corporation, the concerned authorities were requested to issue a circular to all the employees notifying them about the intent of the study as well as date and place of their examination. The study involved completion of a pre-designed and structured questionnaire that was prepared to collect information regarding the demographic profile, the information on their educational status, income, occupation, place of residence in the first 10 years, the source of drinking water, etc. The questionnaire also included multiple option questions to collect information regarding their dental visits, the reasons for the visits, the reasons for not visiting a dentist on a routine basis, oral hygiene practices, dietary habits, exposure to fluorides, underlying systemic diseases, their awareness toward oral diseases, the frequency and duration of deleterious habits like smoking, pan chewing, alcohol consumption, as well as their awareness on the provision of reimbursement for dental care. The information on the concentration of fluoride in drinking water supplied to city at the time of study was obtained from the laboratory of Vani Vilas water works in Mysore, from where the water is supplied to the entire city after purification. The data regarding their oral health status were obtained through direct oral examination of the study subjects using World Health Organization (WHO) oral health assessment form (Basic Oral Health Surveys, 1997). [10] Dental caries was assessed using dentition status and treatment needs, periodontal status using community periodontal index (CPI), and the oral mucosal lesions using the criteria denoted in [Table 1]. The excision biopsy was done for all the participants who were given a score of 1 (malignant tumor), 2 (leukoplakia), 3 (lichen planus) and 8 (other conditions). The patients having positive histopathologic findings, suggesting pre-malignant and malignant lesions or conditions, were only included for the analysis.
Table 1: Criteria for assessing the oral mucosal lesions

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The examination was conducted by a single, trained and calibrated examiner (dentist). The calibration was done on a group of 20 patients examined by the same investigator, at two different times, with a time gap of 6 hours between the examinations. The intra-examiner agreement was found to be 92%. The examination was conducted at one particular location within the health section of the Municipal City Corporation on a foldable chair, under natural daylight, using a mouth mirror and a CPI probe. After the completion of oral examination, the questionnaire was filled by the examiner himself through personal interactions with the study participants, to ensure uniformity in data collection and to avoid misinterpretation of the questions by the subjects. Modified Kuppuswamy scale, [11] a comprehensive scale for classifying the individuals into different socioeconomic categories in India, was used, with readjustment of the per capita income to suit the present levels. [12] B G Prasad's scale, [1] that has correction factor for readjusting the per capita income based on All India Consumer Price Index was not employed, as it relates only to economic status, without considering the educational attainment as well as occupation, which are other important determinants of SES.

Rationale for readjustment of per capita income in Modified Kuppuswamy scale

The income categories in Modified Kuppuswamy scale were based on the 1988-1989 All India Consumer Price Index of 803, for industrial workers. There is no correction factor based on All India Consumer Price Index for readjusting the per capita income in Modified Kuppuswamy scale, as we see in B G Prasad scale. To make Modified Kuppuswamy scale suit the income levels at the time of study, the readjustment of the per capita income was made, after obtaining expert opinion from the Department of Economics and Co-operation, Manasa Gangothri, a reputed university in Mysore, Karnataka, and the concerned statistician.

Procedure for readjustment

The basic pay scales of all the 20 classes of state government employees from the first pay scale revision (1970) to the latest pay scale revision (1998) was collected. [11] Since the Kuppuswamy scale was modified based on the income categories of the 1988-1989 All India Consumer Price Index of 803 for industrial workers, the pay scale that was existent at the time of introduction of Modified Kuppuswamy scale (1985 pay scale) and the pay scale that existed at the time of study (1998 pay scale) were used for the readjustment procedure. Though the study was conducted in the year 2004, the 1998 pay scale only was used for upgradation purpose, as the salaries at the time of study were based on 1998 pay scale, with no further revisions thereafter. The basic pay of each class of employees in 1985 pay scale was compared with the basic pay of the respective class of employees in the 1998 pay scale. To determine by how many times the basic pay had increased from 1985 to 1998 in each class of employees, the basic pay of each class of employees in 1998 pay scale was divided by the basic pay of the respective class of employees in the 1985 pay scale. The average of this was taken. The calculation is illustrated in [Table 2]. The average was then multiplied with the original per capita income in the Modified Kuppuswamy scale. The fractions were rounded off to the nearest whole number while readjusting the ranges in the per capita income of the Modified Kuppuswamy scale. The readjusted values are denoted in [Table 3]. After this, a score was given for each item as per the weightages for education, occupation and per capita income in Modified Kuppuswamy scale and all the three scores were added together to get the total SES score. The subjects were then divided into different SES categories based on the total SES scores obtained, as denoted in [Table 4].
Table 2: Procedure of updating the per capita income in Modified Kuppuswamy scale

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Table 3: Readjusted values for per capita income in Modified Kuppuswamy scale

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Table 4: Division of study population in to different SES categories based on the total score for education, occupation and per capita income in Modified Kuppuswamy scale

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The data were entered onto a personal computer and the analysis was done using SPSS windows version 10. Quantitative data were summarized using means and standard deviations. Qualitative data were summarized using frequencies, percentages and ranges. Parametric tests were used for comparisons involving continuous data. One-way analysis of variance (ANOVA) was used to assess the difference in means between more than two groups. Wherever ANOVA yielded statistically significant results, Tukey's post hoc test was used for multiple pairwise comparisons. Qualitative data were analyzed using chi-square (χ2 ) test, the cross-tabs and contingency coefficient. The statistical significance was fixed at 0.05. Hot water sterilizer and chemical sterilization (Cidex, 2.45% for 10-15 minutes) methods were employed for sterilizing the equipments.


   Results Top


A total of 1187 subjects were examined in the study. The age range of the study population was 19-57 years, with a mean age of 40.74 years and a standard deviation of 9.17 [Table 5]. Among the 1187 subjects, 817 (68.8%) were males and 370 (31.2%) were females [Table 6].
Table 5: Age distribution of the study population in different SES categories

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Table 6: Sex distribution of the study population in different SES categories

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Dental caries experience

The prevalence of dental caries in the study population was 59.1%. The prevalence in the upper SES category was 43.3% and in the lower category it was 78.6%. The difference was statistically significant (P=0.0309) and the results were true even when the males and females in different SES categories were compared separately [Table 7]. Mean number of untreated dental caries for the entire study population was 0.90±1.55 (mean±standard deviation). These values for upper SES category and the lower SES category were 0.07±0.32 and 0.96±2.06, respectively. The difference was statistically significant (P=0.000) [Table 8]. Mean number of teeth missing because of dental caries for the study population was 1.06±1.91 (mean±standard deviation), whereas the corresponding values in the upper and lower SES categories were 0.51±1.27 and 1.46±1.50, respectively. The difference was statistically significant (P=0.002) [Table 8]. Mean number of teeth filled because of dental caries for the study population was 0.21±0.87 and the corresponding value in the upper SES category was 1.52±2.13. None of the subjects in the lower SES category had filled teeth. The difference was statistically significant (P=0.000) [Table 8]. Mean DMFT score for the study population as a whole was 2.18±2.73 (mean±standard deviation). The values in upper and lower SES categories were 2.10±3.01 and 2.43±2.46, respectively. Though the value was higher in lower SES category, there was no statistically significant difference in the distribution of overall DMFT scores between different SES categories (P=0.583) [Table 8].
Table 7: Prevalence of caries in different SES categories

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Table 8: Distribution of decayed, missing, filled and overall DMFT components in different SES categories

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Periodontal status

The periodontal status in the study was assessed using the community periodontal index and it was expressed in terms of CPI score and loss of attachment score. The highest CPI score and loss of attachment score among the sextants examined in a person were taken as the respective CPI and loss of attachment scores for the person.

16.4% of the subjects in the upper and 3.4% of the subjects in the upper middle SES category had a CPI score of 0, indicative of healthy periodontium, whereas none of the subjects in the lower middle, upper lower and lower SES category had this score. On the contrary, none of the subjects in the upper and upper middle SES category had a CPI score of 4, indicating a periodontal pocket of 6 mm or more, whereas 39.3% of the subjects in the lower SES category had this recording. This clearly suggests that the percentage of people having healthy periodontium was more in upper classes and the percentage of people having deep periodontal pockets (6 mm or more) was high in lower classes. The findings were statistically significant even when males and females in different SES groups were compared separately [Table 9]. 98.5% of the subjects in the upper and 35.7% in the lower SES category had loss of attachment score 0 (no loss of attachment or loss of attachment of less than 3 mm). None of the subjects in the upper SES category had loss of attachment score 4 (loss of attachment of 12 mm or more), whereas 0.4% of the subjects in the upper lower SES category had loss of attachment score 4. Here too, the percentage of population having loss of attachment score 0 (no loss of attachment) was more in upper classes and the percentage of population having loss of attachment score 4 (12 mm or more) was high in lower classes. The findings were statistically significant [Table 10].
Table 9: Distribution of CPI scores in different SES categories

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Table 10: Distribution of loss of attachment scores in different SES categories

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Oral pre-malignant and malignant lesions

The study subjects having the scores of either 1 (malignant tumor), or 2 (leukoplakia), or 3 (lichen planus), or 8 (any other pre-malignant lesion or condition) as per the criteria used for assessing the oral mucosal lesions, were only considered to be having evidence of oral pre-malignant or malignant lesions. These patients were referred to the college hospital on the same day and an excisional biopsy was done to confirm the diagnosis. The patients with positive results in histopathologic examination were only considered for the analysis. The patients with pre-cancerous lesions, conditions or malignancies were referred to a government hospital in the city for further follow-up care. The prevalence of oral cancerous and pre-cancerous lesions in the study was 5.2%. These lesions were not seen the upper SES category. They were seen in 0.7% of the subjects in the upper middle, 2.8% of the subjects in the lower middle, 6.5% in the upper lower and 17.9% in the lower SES categories. The prevalence of oral cancerous and pre-cancerous lesions increased with decreasing SES and the finding was statistically significant (P=0.000) [Table 11]. A statistically significant difference existed between upper and lower socioeconomic categories when the males were compared separately. But when females were compared separately, though there was higher prevalence in the lower SES categories, the difference was not statistically significant [Table 11].
Table 11: Prevalence of oral mucosal lesions among the study subjects in different SES categories

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There was no statistically significant difference in the dietary habits (P=0.997), sweet consumption (type, P=0.994; frequency, P=0.826; and time, P=0.998), the exposure to fluorides (P=0.213) and the distribution of subjects having systemic diseases like diabetes, hypertension, cardiovascular diseases, central nervous system diseases, etc., between different SES categories. Only 24 subjects had some systemic disease and these subjects were equally distributed, with no significant difference in their distribution among different SES categories (P=0.321). Oral hygiene practices [method of cleaning (P=0.000), frequency of cleaning (P=0.000)], the visits to the dentist (P=0.000), the awareness on oral diseases and the methods for preventing and controlling them (P=0.001), the awareness on the provision of reimbursement for dental care (P=0.000) was better among the subjects in the upper classes than their counterparts in the lower ones. The frequency of various deleterious habits like smoking (P=0.000), pan chewing (P=0.000) and alcohol consumption (P=0.000) was more among the subjects in the lower SES category than in the upper ones.


   Discussion Top


We found a higher prevalence of dental caries, higher mean number of untreated dental caries and teeth missing because of dental caries among the subjects in the lower SES category than the ones in upper classes in this study. The mean number of teeth filled because of dental caries was higher among the subjects in upper class, whereas none of the subjects in the lower class had fillings. The higher caries experience among the subjects in lower classes in comparison with upper ones may be attributed to their poor oral hygiene practices, [13] lack of awareness on the etiological factors for oral diseases [14] and poor utilization of dental services [15],[16],[17],[18],[19],[20],[21],[22] which in turn may be related to the cost, [16],[17],[20] lack of knowledge and motivation toward dental care [16],[17],[20] and lack of awareness on the provision of reimbursement for dental care, [23] the low priority given to dental health as well as lack of perception of the fact that the teeth are worth saving. [24] The study found no statistically significant difference in the diet, sweet consumption habits, the exposure to systemic or topical fluorides and the distribution of systemic diseases among the subjects in different SES categories. The drinking water source for majority of the population, right from their childhood, was mainly from Krishna Raja Sagar dam. The fluoride concentration in Krishna Raja Sagar water was 0.09 ppm at the time of study but the concentration in various seasons ranged from 0.02 to 0.16 ppm. [25] The supply sometimes gets ceased in summer seasons, during which time the entire city population gets ground water supplied from different bore wells in the city. The fluoride concentration in this ground water was 0.23 ppm. [25] The published literature also suggest the ground water sources in and around Mysore city to be having a fluoride concentration of less than 1 ppm. [26] Thus, all the subjects were equally exposed to systemic fluoride in drinking water irrespective of their SES. Majority of the study subjects from all the SES categories used

non-fluoridated tooth pastes, thus ruling out the difference in their exposure to self-applied topical fluorides as well. This rules out the possibility of fluoride as a confounder in determining the influence of SES on dental caries. The results of our study correspond with the findings of Third National Health and Nutrition Examination Survey conducted by the US department of Health and Human Services, National Center for Health statistics, [27] and a study by Antoft et al. [28] on Danish military recruits. The finding of higher mean number of untreated caries in lower SES category also corresponds with the findings of many studies in the recent past. [13],[14],[21],[22],[29] Thomson et al. [30] in their study found a higher percentage of subjects in the lower SES group (17.1%) to be having one or more teeth missing because of dental caries at the age of 18-26 years compared to those in the middle (9.6%) and upper SES group (6.5%). Similar results were obtained in a study by Cutress et al. [31] who, in their study on adult oral health and attitudes to dentistry in New Zealand, found the mean number of teeth missing because of dental caries to be higher in the lowest social group (3.5) compared to that in the highest social group (0.1). Jensen et al. [32] in their study found a direct correlation between SES and the mean number of teeth retained. They found the percentage of subjects who retained 26 or more permanent teeth to be significantly more among the high SES group (62%) compared to those in the middle (40%) and lower ones (15%). They thus concluded, "lower the socio-economic status, the earlier the teeth were lost". The results obtained in this study are similar to the findings in all these studies.

No statistically significant difference in the distribution of DMFT scores between different SES categories was found in this study. The lower SES categories had higher mean number of untreated carious lesions (D component) and higher mean number of teeth missing because of dental caries (M component). The mean number of filled teeth (F component) was significantly higher among the subjects in upper class and none of the subjects in the lower SES category had fillings. The higher mean D and M component scores in lower SES category was neutralized by the higher mean F component in upper SES category. Hence, the study found no significant difference in terms of mean DMFT scores between different SES categories. This highlights the need for assessing the individual components of DMFT separately between the SES categories rather than just comparing the DMFT scores all together. The assessment of individual components only can highlight the difference between SES categories in terms of treatment required and obtained. Klein and Palmer [33] in their landmark study on caries epidemiology found no difference in the distribution of overall DMFT score between different SES groups. Here too, the higher F component among the subjects in the upper SES groups lifted the overall DMFT score which compensated the higher mean D and M components among the subjects in lower SES group. The results of our study are consistent with the findings of this study.

Considering the CPI scores and the loss of attachment scores, it was clearly evident that the periodontal status was better among the subjects in the upper SES categories than those in the lower SES groups. Oral hygiene practices, [34],[35] the utilization of dental services, [13] presence or absence of deleterious oral habits like smoking, [13] pan chewing [34],[36] and the awareness on the dental diseases [37] are some of the proven factors having a role in determining the periodontal status in an individual. It was found in this study that the oral hygiene practices, awareness on the etiological factors for gingival and periodontal diseases, the utilization of dental services was better among the subjects in the upper SES groups. Conversely, the prevalence of deleterious oral habits like smoking and pan chewing which are proven risk factors for periodontal diseases was significantly higher among the subjects in lower SES categories. These may be the possible explanations for this difference in the periodontal status among the subjects in different SES groups. A study by Dye and Vargas [38] revealed a higher percentage of adult subjects (20-59 years) to be having the CPI scores 0, 1, 2 in the group that had some college education and high school completion, compared to those with some high school or no high school education. Conversely, the percentage of subjects having CPI scores 3 and 4 was significantly higher (P < 0.05) in the groups that had no high school education (26.3%, score 3; 8.08%, score 4) or some high school education (29.3%, score 3; 5.32%, score 4) in comparison to those who completed high school education (21.6%, score 3; 3.16%, score 4) and who had college education (14.5%, score 3; 1.10%, score 4). The studies by Russel, [39] Russel et al., [40] National Center for Health Statistics, USA (1965 and 1979), [41] Horton et al., [42] Ismail et al., [43] Oliver et al., [3] and Borrell [44] have all found the prevalence of periodontitis to be more among the subjects in the lower socioeconomic classes than those in the upper ones. The findings of this study correspond with all these studies.

The higher prevalence of oral pre-malignant and malignant lesions in lower SES group may be attributed to the deleterious habits like smoking, [45] pan chewing, [45],[46],[47] and alcohol consumption, [48] which are proven risk factors for the incidence of oral, pharyngeal, laryngeal and esophageal cancers. These deleterious habits were found to be significantly higher among the subjects in the lower SES category compared to those in the upper ones in the present study. The awareness on the causative factors for oral cancer was also significantly lesser in the lower SES categories than the upper ones. These factors possibly explain the higher prevalence of oral pre-malignant and malignant lesions among the subjects in the lower SES category. The results are in agreement with the results of studies by Hashibe et al. [49] who found the higher SES index, education and income to be associated with decreased risk of oral pre-malignant lesions and Elwood et al. [50] who conducted a case-control study on 374 patients with primary epithelial cancers of the oral cavity, oro- and hypo pharynx, and larynx. Their study found an increased risk with low SES. A systematic review of 41 case-control studies, with 15,344 cases and 33,852 controls, done by Conway et al., [51] found the pooled Odds Ratio for the risk of developing oral cancer to be 1.85 (95%CI 1.60, 2.15; n=37 studies) for those with low educational attainment, 1.84 (1.47, 2.31; n=14) for those of low occupational social class and 2.41 (1.59, 3.65; n=5) for those with low income. They concluded the low SES to be significantly associated with increased oral cancer risk in high and lower income countries. The conclusions of the present study correspond with this and many other studies. [52],[53]


   Conclusions Top


The study found an inverse relationship between prevalence of dental caries, periodontal diseases, oral pre-malignant and malignant lesions, mean number of untreated dental caries, mean number of teeth missing because of caries, and SES. There was a direct relationship between mean number of teeth filled because of dental caries and SES. The overall treatment need was higher among the subjects in the lower SES group.

Reducing inequality in oral health between different SES groups has been one among the major global goals for oral health. The development of equitable oral health system, which improves oral health outcomes and responds to people's legitimate demands with a fairness in finance, is one of the major strategic implications for WHO's oral health program. [54] When applied to a practical problem such as dental program planning, SES in effect adds a new dimension to the entire process. This is especially true in the field of chronic diseases, where people's living habits have so much to do with their susceptibility to disease. As an expression of attitudes, community groups, particularly the underprivileged, have clear feelings about the priorities in the health care field and the way health care is rendered. They realize their lack of expertise in the technical and scientific aspects of health care, but they want a real control in matters of priority, delivery of care, and perhaps even personnel selection. In any such programs, priority should be given to lower class people having higher prevalence of diseases and unmet treatment needs.

Since the study was conducted on state government employees, the per capita income in the modified Kuppuswamy scale was upgraded considering the basic pay scales of the state government employees and the upgraded scale was not previously tested by any expert sociologist before being applied in the study. Age also is an independent risk factor for most of the oral diseases, along with sex. But the sample size was small, especially in the age groups of 15-24 years as well as 55 years and above, to consider the analysis for various oral diseases, in individual age groups in different SES categories separately, as we did in the case of sex. Multiple logistic regression analysis could have authentically assessed the role of SES on oral diseases, which is predominantly multifactorial in nature. The sample size in different SES categories, particularly in the age group of 15-24 and 55 years and above, was too less to consider the application of multiple logistic regression analysis in the present study. Keeping these drawbacks in mind, further studies, preferably longitudinal studies, using stratified random sampling, to obtain equal distribution of the study population in all the subgroups are required to validate the results of this study.

 
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Correspondence Address:
B R Chandra Shekar
Department of Community Dentistry, Peoples Dental Academy, Bhanpur, Bhopal, Madhya Pradesh
India
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DOI: 10.4103/0970-9290.87063

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