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Table of Contents   
ORIGINAL RESEARCH  
Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 611
Dental pain as a determinant of expressed need for dental care among 12-year-old school children in India


1 Department of Public Health Dentistry, Narayana Dental College and Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
2 Vice Principal, Narayana Dental College and Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India

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Date of Submission08-Jan-2011
Date of Decision22-Feb-2011
Date of Acceptance01-Mar-2011
Date of Web Publication26-Nov-2011
 

   Abstract 

Objective: We have undertaken a cross-sectional study to assess factors associated with dental pain that determine the expressed needs for dental care among 12-year-old school children in India.
Materials and Methods:
A total of 2 250 school children were surveyed after being drawn through stratified cluster random sampling. The simultaneous effects of sociodemographic characteristics, pain characteristics, and the impact of pain on the quality of life were studied in association with the expressed needs for dental treatment.
Results: Among the studied school children, 71.4% suffered from dental pain, only 27.7% expressed need for dental healthcare. Socioeconomic status (SES) was a statistically significant determinant. Pain characteristics like the severity of pain and pain on eating hot and cold foods were significantly associated with expressed needs. Impact characteristics associated with expressed needs were embarrassment in showing teeth, brushing teeth, and difficulty in eating and drinking. Logistic regression analysis yielded a Nagelkerke R 2 value of 0.106.
Conclusion: Important determinants of expressed needs for dental care among the studied population were SES, pain intensity, pain on thermal stimuli, impact characteristics like eating/drinking and embarrassment in showing teeth.

Keywords: Dental care, dental pain, expressed needs, pain impact

How to cite this article:
Dandi KK, Rao EV, Margabandhu S. Dental pain as a determinant of expressed need for dental care among 12-year-old school children in India. Indian J Dent Res 2011;22:611

How to cite this URL:
Dandi KK, Rao EV, Margabandhu S. Dental pain as a determinant of expressed need for dental care among 12-year-old school children in India. Indian J Dent Res [serial online] 2011 [cited 2019 Sep 22];22:611. Available from: http://www.ijdr.in/text.asp?2011/22/4/611/90320
Health is a prerequisite for having an enjoyable and productive life. Oral health is an essential and integral component of health throughout life. No one can be truly healthy unless he or she is free from the burden of oral and craniofacial diseases and conditions. The 2005 Liverpool Declaration has reaffirmed oral health as an integral part of general health and well-being and as a basic human right. [1] Millions across the globe experience oral diseases, resulting in needless pain and suffering. Contemporary concepts of health suggest that oral health be defined in terms of physical, psychological, and social well-being in relation to oral status. Disruptions in physical, psychological, and social functioning are therefore important in assessing oral health. Need assessment has thus become complementary to the traditional measures which measure oral health through clinical indices.

Ever since Bradshaw described the taxonomy of needs, [2] considerable research has been focused on assessing various types of needs and their importance in oral healthcare. Normative need assessment in oral health has been documented extensively in published dental literature and country profiles of normative needs for oral health are also available from the World Health Organization.

The inadequacy of normative approach in measuring oral health has been recognized and this has led to the development measures related to oral health-related quality of life. [3] These measures determine the extent to which oral conditions disrupt normal functioning and impact the quality of life as perceived by the subjects and have been referred to as perceived needs. [3],[4] Perceived need has gained considerable attention among health researchers in dental service planning. [5] It has been suggested that perceptions of need for dental care play a key role as to whether people in general will seek dental care and that lack of need perceptions constitute an important barrier for the utilization of healthcare services otherwise called as Expressed Dental Needs. [6] Reportedly, the main benefits of dental treatment relate to improvement in psychological and social well-being. [7] Thus, oral symptoms and functional and psychological impacts from oral conditions seem to be of great significance in the assessment of individuals' perceived need for dental care. [7],[8] Need perceptions correlate weakly with normative need assessment, suggesting that people give more importance to oral symptoms and functional impacts of oral diseases in evaluating their need for oral healthcare services. The extent to which oral symptoms and impairments play a role for need perceptions and whether or not dental care is sought are modified by social and cultural factors, such as the ability to afford and attend dental care in the context of needs and other burdensome life circumstances.

Pain in children is a common experience; it results in substantial restrictions on daily living, thus making it an important public health problem. Dental pain is a common outcome of untreated dental disease. [9] The prevalence of dental pain and its impact on daily living has been the subject of recent research as it gives an indication of the subjective oral health status. [10] Pain has also been cited as a common reason for children to seek dental care.

Pioneering work on the association between pattern of dental attendance and reported dental pain started in the UK and has been subsequently reported in literature. [11] As not all people who experience dental pain express a need for dental treatment, , the assessment of pain beyond its mere presence to include its characteristics and associated impact can give a more accurate indication of care seeking which will help in appropriate planning of need-based dental healthcare services. [12]

This study was thus undertaken with an aim of determining the simultaneous effects of sociodemographic characteristics, pain characteristics, and impact of pain on daily living upon the expressed need for dental care among 12-year-old children.


   Materials and Methods Top


Study design

A community-based cross-sectional descriptive study was designed to study the simultaneous effects of sociodemographic, dental pain characteristics, and the impact of dental pain on the quality of life that determine the expressed needs for dental healthcare among 12-year-old children in Nellore District of Andhra Pradesh, India.

This age group was chosen for the study as it is one of the index age for studying oral conditions as specified by the WHO. [13] This index age has also been incorporated by most federal governments across the world for attaining the objective of improving oral health by 2020, [14] more specifically as an important age to improve dental attendance.

The ethics committee of Narayana Dental College and Hospital, Nellore District of Andhra Pradesh, approved the study. Permission was also obtained by the Regional Educational authorities to conduct the study in the schools of their jurisdiction. Voluntary informed consent was obtained from the parents/guardians of the subjects by the respective class teachers.

Study procedure

The sample size was calculated in a finite population of approximately 30 000 with an estimated prevalence of dental pain of 60%. [15] The calculated sample size was 2 141 with 95% confidence level at 2% precision. An additional 5% of the calculated sample was added to compensate for sampling loss if any. The final sample thus accounted was 2 250 number of 12-year-old school children. The required sample was drawn from across the district through stratified cluster random sampling procedure, the district comprises of three administrative divisions, a list of schools from each administrative division was obtained from the office of the regional education authority, and proportional number of schools from each division was included in the sampling frame. A total of 23 schools from rural areas and eight from urban areas were included in the study. Individual class of 7 th standard students became the sampling unit.

The data collection instrument was a self-administered questionnaire consisting of three parts. Part one recorded the sociodemographic variables like gender, geographic location, and parental occupation, mode of transport, and socioeconomic status (SES) of the family. The SES of the family was recorded using Kuppuswamy's socioeconomic scale [16] which is widely used in health research in India. This scale records the SES of the family, based on the total income, highest occupation, and highest educational level in the family. Each family is then classified into poor, upper poor, lower middle, upper middle, and high class. Part two was a translated version of Dental Pain Assessment Questionnaire (DePaQ); [17] it consisted of a set of 10 simple questions measuring various parameters of dental pain, viz. pain intensity, pain duration, pain in a single tooth or multiple teeth, etc. Part three of the questionnaire was a translated version of eight questions adapted from Child Oral Impact on Daily Performance (COIDP). [18] The questions were simplified by converting the responses into a dichotomous scale measuring whether an impact was experienced or not. Both DePaQ and COIDP were assessed for the past one month, keeping in mind the possible errors of memory/recall bias if any.

The expressed needs of the population were assessed by asking the participants whether they sought professional advice or consultation for their pain or suffering in the past one month.

Inclusion criteria

All willing participants aged 12 years present in the respective schools on the day of the survey.

Exclusion criteria

Children with an obvious pain or discomfort due to reasons other than dental and those with compromising medical conditions or any handicap.

The study was conducted in the month of July 2008, two months after the summer vacation. One of the investigators himself visited the schools and administered the questionnaire.

Statistical analysis

Data were analyzed using Statistical Package for Social Sciences (SPSS version 12.0 Inc., Chicago II, USA). At the first step, data were analyzed to find the association between the various independent variables and the expressed needs for dental care. Chi square test, risk ratio analysis, and univariate logistic regression were performed to calculate the odds ratio (OR) with 95% confidence interval (CI). Those significant variables associated with expressed needs were further included in binary logistic regression analysis by enter method. Beta value and SE of beta are presented in the table. The level of significance was set at P < 0.05 for all tests. The Nagelkerke R 2 values are presented to indicate the explained variance contributed by the independent variable.


   Results Top


A total of 2 250 school children participated and returned the completed survey forms. Forty-seven forms (2.08%) were rejected as they were either incomplete or illegible. Final number of survey forms amenable for data analysis was 2 203.

Analysis of sociodemographic variables and their association with dental pain experienced in the past one month is presented in [Table 1]. There was an almost equal representation of boys (50.4%) and girls (49.6%). Majority of the sample (70.4%) had a rural background, 95.9% of the school children had their fathers working and maternal employment was 56.8%. Public transport was the most common mode of transport being used by the respondents accounting to 58.6%. SES assessed using Kuppuswamy's scale revealed that majority (45.5%) of the school children belonged to the upper middle class; there was no representation from the high class.
Table 1: Sociodemographic characteristics and their association with expressed needs for dental treatment in the past one month

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A total of 1 573 school children reported having experienced dental pain in the past one month accounting to a pain prevalence of 77.40%. Only 436 school children sought professional advice, denoting an expressed need for dental pain of 27.7%, as presented in [Table 1].

Univariate logistic regression analysis was preferred for risk estimation. Risk estimates of sociodemographic characteristics and their association with expressed needs for dental care of the studied school children are presented in [Table 1]. There was no statistically significant difference between gender, even though the expressed need for dental pain was higher among females (OR = 1.16). A respondent from an urban area, whose mother was not working and had reported using either a motor cycle or car as a mode of transport at home, had significantly higher expressed need for dental attendance compared with their counter parts. In contrast, as the SES decreased, the expressed need for dental care was higher; the difference was statistically significant for lower middle class and the poor.

Analysis of pain characteristics revealed that 78% of the respondents had experienced pain of less than one-week duration. About 22% of the respondents reported experiencing severe pain, whereas mild and moderate pain was reported by 42.4% and 36% of the respondents, respectively. About 55% of the respondents reported continuous pain throughout the day, and 74% of the respondents reported having felt pain in one tooth. Pain on thermal stimuli was reported by about 67% of the respondents, while difficulty in swallowing was reported by about 57% of the respondents, as depicted in [Table 2].
Table 2: Dental pain characteristics and their association with expressed needs for dental treatment in the past one month

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Evaluation of the pain characteristics that resulted in expressed need for dental care is presented in [Table 2]. More severe the pain, more continuous the pain and pain that aggravated on thermal stimuli had a significantly higher expressed need for dental care in comparison with the counterpart. Other determinants like the duration of the pain, pain experienced in one or multiple teeth, and difficulty in swallowing were found to have statistically insignificant association with expressed needs.

Impact of pain on daily living characteristics revealed that difficulty in brushing teeth was the highest, with 83% reporting difficulty in performing this routine task. It was followed by difficulty in eating and drinking and embarrassment in showing teeth, both being reported by about 64% of the studied population. Speaking and pronouncing was the third in order of magnitude to be affected with 55.4% reporting difficulty in carrying out this activity. Sleeping and regular school activities were reported to have been affected by 40.7% of the respondents. The least reported impact was observed for playing and laughing with 31.1% and 29.8%, respectively, reporting that these qualities were also affected, as shown in [Table 3].
Table 3: Impact of dental pain on daily living characteristics and their association with expressed needs for dental treatment in the past one month

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The impact of pain on daily living was estimated for expressed need for dental treatment and the results are presented in the [Table 3]. It was found that embarrassment in showing teeth was very important determinant of expressed need for dental treatment. Other daily living characteristics that were significantly associated with expressed needs for dental care were pain while brushing and cleaning of teeth, pain while eating or drinking, inability in attending or performing school work, difficulty in getting sleep, and inability to go for playing.

Multivariate logistic regression analysis was carried out to assess the relative contribution of the independent variables in determining the expressed needs for dental care among the studied school children. Independent variables that were significantly associated with expressed need for dental treatment in the past one month were chosen for the final model and the results are presented in [Table 4]. It revealed that SES with an OR of 2.11 (95% CI: 1.35-3.28), severity of pain with an OR of 1.44 (95% CI: 1.44-1.99), continuity of pain with an OR of 1.29 (95% CI: 1.01-1.66), pain on sleeping with an OR of 1.43 (95% CI: 1.09-1.17), and embarrassment in showing teeth with an OR of 1.65 (95% CI: 1.28-2.74) were the significant determinants for the expressed needs among the studied school children. The model analysis yielded a Nagelkerke R 2 value of 0.106.
Table 4: Sociodemographic characteristics, pain characteristics and impact of pain on daily living regressed* over the expressed needs for dental treatment in the past one month

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   Discussion Top


The terminology to describe needs of persons in the community can vary; four types of needs have been described by Bradshaw-normative, perceived, expressed, and comparative needs. Normative needs relate to the gap between a person's status and an accepted norm. Perceived needs are those felt by individuals, which, once articulated, become expressed needs. Comparative needs are those identified by comparing different groups or individuals with each other.

Need assessment in oral healthcare has been documented extensively but has traditionally focused either on normative or perceived needs. Expressed needs for oral healthcare have gained scant representation among the researchers. We have therefore attempted to know the determinants of expressed needs for oral healthcare among the school children. Characteristics of pain and its impact on the quality of life are recognized to be one of the most important parameters associated with expressed needs for dental care; hence, these factors are studied in this study.

The important finding of this study was that a significant proportion of the school children suffered from pain but only about one-third of the studied population expressed their need; the factors that determined are discussed as under.

Prevalence of pain in the past one month reported in this study was 71.4% in accordance to a study conducted in South Africa [5] that reported 70% prevalence. However, it is much higher compared with the reported prevalence of Greek, [19] Chinese, [20] Brazilian, [9] and Pakistani [12] children where it was found to be about 35%. This difference could be due to the fact that these studies estimated pain prevalence for a time frame of one month to one year. It should also be realized that the collection of self-reported health data necessarily depends on the recall ability of the respondents which is a function, among others of the time interval between the occurrence and the recall of the event. [21] One month time interval used in the present study was short, ensuring more accurate prevalence estimation.

Furthermore, this study reported that 27.7% of the subjects experiencing pain in the past one month reported to have expressed their need for dental healthcare, one study reported 64% among Pakistani children, [12] while another reported 44% treatment seeking value among Canadian population. [22] Research also points to the fact that not all who experience pain seek professional care, [23],[24] suggesting that this expressed need may just be the tip of a symptom iceberg. [22]

Sociodemographic characteristics were found to have a significant impact on the expressed needs, urban subjects were found to have better expressed needs compared with their rural counterparts; these findings are in accordance with the reported studies. [25] Maternal employment status was found to have a negative effect on children's expressed needs, as evidenced in this study, compared with their counterparts, which is in accordance to the reported findings of Pau et al., [12] this could be due the nonavailability of the mother for the needs of the children; however, further studies need to be conducted before drawing any logical conclusions.

The mode of transport employed at home had significant effect on the expressed needs, with families using motor cycles and cars having better expressed needs. This study also found the expressed needs and their associations to SES. It was found that school children belonging to the lower middle class and the poor had better expressed needs. This study found that 20.65% of the school children belonging to the upper middle class had expressed needs compared with their immediate counterparts (the upper middle class) at 26.7% contrary to the traditionally accepted view that individuals belonging to the upper echelons of the society seek dental care more often.

The results of this study indicate that those expressing their dental needs were more likely to have certain pain characteristics and impacts. Pain characteristics such as severity of the pain at 55%, pain continuity at 31%, and pain following thermal stimuli at 11% were found to have a statistically significant effect upon the expressed needs of the children, in accordance to the reported findings. [12] However, the duration of pain did not have any effect on the expressed needs contrary to the reported findings. [12] It is worth mentioning here that pain characteristics and its association with expressed needs have not been reported much in literature. Hence, these findings cannot be discussed in relation to the available published literature.

Pain in general has been reported to impact children's daily activities [10] and dental pain and its impact on the quality of life of children has been widely reported in literature. Assessment of impact characteristics has been recommended as an adjunct to clinical or normative need assessment. [26] This study also found variations of the impact of pain on the daily activities of the children; the overall prevalence of the sample experiencing an impact in the past one month due to dental pain was 85%, in accordance to Sudaduang et al. [3] who reported a 89.8% among Thai children of the same age and lower to the one reported by Pau et al. [12] among the Pakistani children at 95%. Other studies have also reported the impact of pain on the quality of life of those affected; it was 73% among New Zealand children, [27] 32% among Brazilian adolescents, [9] and among Ugandan Children. [28] The impact characteristics found to be significantly associated with expressed need in this study were eating and drinking, 30.3%; sleeping, 30.6%; attending school, 31.7%; brushing teeth, 29%; and embarrassment in showing teeth, 31.5%.

Logistic regression analysis after eliminating all the confounding variables revealed that SES was the only significant determinant among the sociodemographic factors to have an association with expressed needs. Pain characteristics like the severity of pain, continuity of pain and impact characteristics like impact on sleeping and embarrassment in showing teeth were strong determinants for expressed needs among the studied population. The Nagelkerke R 2 value explained 0.106 of the variance in this study.

Studies on expressed needs have focused on predictive and enabling characteristics rather than on symptoms and have reported variations in expressed needs pertaining to gender, race, ethnicity, rural/urban gradient. This study has taken into consideration these factors and has further included the most common symptom of dental disease, that is, pain, and also the impact of this symptom on the quality of life. The study was conducted on a wide range of population involving most of the social strata in India; thus, the external validity of the study can be considered to be good.

The possible limitation of this study could be the ability of the participants in answering the questionnaire; an attempt was made to overcome this limitation by having questions both in English and regional language, allowing the participants to answer the questions in the language of their choice. A further limitation could be that this study has tried to assess expressed needs following pain which has been argued as a delayed expressed need, a stage where preventive intervention is of questionable value. It should also be considered that normal pain during teeth eruption could also have been considered as a symptom of dental disease by the respondents.

Oral health problems are neither self-limiting nor self-healing; they are progressive if left untreated. Lack or delay in oral healthcare creates more severe needs. The relationship between needs and utilization in oral health is thus complicated by this progression. We have studied perceived needs in terms of pain in association with expressed needs in terms of utilization. Although healthcare services cannot remove the effects of an adverse environment and are not the only solution for health inequalities, they are also important in protecting, promoting, and restoring health. Thus, understanding the determinants for healthcare utilization is of prime importance.

The results of this study indicate the widespread prevalence of dental pain, its impact on the quality of life of the children, and more importantly the meager amount of expressed needs among the studied population. The study has further pointed as to what characteristics of pain are important determinants for expressed needs.


   Acknowledgments Top


We express our gratitude to all the teachers and regional educational officers of Nellore District, Andhra Pradesh, India, for providing us with the necessary assistance in carrying out this study. Our sincere thanks are to Dr. Sharath Babu P.R and Dr. Sudhakar K post graduate students, Department of Community Dentistry, Narayana Dental College, for providing us with the necessary support in carrying out this study.

 
   References Top

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Correspondence Address:
Kiran Kumar Dandi
Department of Public Health Dentistry, Narayana Dental College and Hospital, Chinthareddypalem, Nellore, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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