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Table of Contents   
ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 1  |  Page : 121
Access to public dental care facilities in Chandigarh


1 School of Public Health, PGIMER, Chandigarh, India
2 Unit of Oral Health Sciences, PGIMER, Chandigarh, India

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Date of Submission11-Sep-2010
Date of Decision04-May-2011
Date of Acceptance21-Jan-2012
Date of Web Publication26-Jul-2012
 

   Abstract 

Objectives: The objective of the study was to determine the level of dental health care access and associated factors, at various public health facilities in the Union Territory (UT) of Chandigarh.
Materials and Methods: A study was done using a multistage random sampling technique, to interview adult respondents at their homes and to interview the dentists in the public dental clinics and hospitals.
Results: The mean composite access score was 59.2 (SD 18.9) in urban areas and 60.5 (SD 20.9) in rural areas (P=0.64) on a scale of 100. The mean score for the self-perceived condition of their oral health was 6.47 (95% CI 6.17 - 6.76). Thirty-four percent of the respondents did not contact a dentist despite having a problem in the last year, primarily because dental problems were not important for them (45%), they lacked time (22%), and took self-medication (16%). Overall 58% of the respondents suggested government clinics and 44% liked private dentists for treatment of dental cavities. The government setup was preferred because the facilities were cheaper and affordable.
Conclusions: Dental health care access and only limited dental facilities were available in most of the dental clinics in Chandigarh. Self-reported dental problem was low, and people ignored their dental problems.

Keywords: Dental health care access, multistage random sampling

How to cite this article:
Verma H, Aggarwal AK, Rattan V, Mohanty U. Access to public dental care facilities in Chandigarh. Indian J Dent Res 2012;23:121

How to cite this URL:
Verma H, Aggarwal AK, Rattan V, Mohanty U. Access to public dental care facilities in Chandigarh. Indian J Dent Res [serial online] 2012 [cited 2019 Aug 20];23:121. Available from: http://www.ijdr.in/text.asp?2012/23/1/121/99057
Oral health is essential for overall health. As poor oral health affects morbidity more than mortality, the people as well as the government view oral diseases and conditions as less important than other life-threatening diseases. Thus, oral health programs get less priority in India. In India, the prevalence of dental caries is 50 - 60% and periodontal disease is about 90%. Absolute prevalence of these two dental conditions is expected to increase from 8000 lakhs in year 2000 to about 9800 lakhs in 2015, together. [1] The dentist population ratio in India is 1:30000 now, but the distribution of dental surgeons is skewed, that is, 1:8000 in urban and 1:80,000 in rural areas.

Knowledge and perceptions of the community about the treatment of various dental conditions, the cost of treatment, distance of the clinic, and self-reporting may influence access to treatment. Attention must be paid to create sufficient demand for dental care and adequate dental work force to respond to that demand. [2] Although, dental care is a part of primary health care in India, dental care services are available in very few states at the primary health care level. Patients are not covered under any type of insurance, and generally pay out of their pockets to get treatment from both public and private dentists.


   Materials and Methods Top


A cross-sectional study was done in Chandigarh in the year 2008, over a period of eight months, which had two components: Community survey and the Health Facility survey. The community survey included interviews of adult respondents at their homes and the health facility survey was done to interview the dentists at public health facilities to analyze the records in their clinics.

Demographics of Chandigarh

Area - 114 Km 2 Community Health center - 1

Rural area - 34.66 Km 2 Civil Dispensaries - 25

Population density - 7900 per Km 2 Rural dispensaries - 9

Literacy Rate - 75 - 86% (Rural females - 66%) Subcenter - 15

Infant Mortality Rate - 44.13 per 1000 live births Private nursing home - 25

Crude Birth Rate - 21.45 per 1000 (2005). [3]

The multi-stage sampling technique was used to collect information for the Community Survey. The municipal area of Chandigarh was divided into four zones and two localities were selected from each zone in the first stage. In the second stage, each unit was divided into four parts by using the already existing divisions. In the third stage, one street was randomly selected and in fourth stage, the first house was randomly selected. One adult respondent (either spouse) was interviewed in the selected house. Each consecutive house from the randomly selected houses was visited till the required number of 13 interviews was completed from the selected sub-unit.

The list of dental clinics in Chandigarh was prepared under three categories:

  • Large dental clinics in government and charitable hospitals
  • Small government dental clinics in urban areas
  • Government dental clinics in rural areas
There were eight dental clinics in category A, six in category B, and only one in category C.

Facility survey variables and measurements

A pre-tested, semi-structured checklist was filled for each dental clinic, to record the clinic timings, availability of dental doctors, types of services available, the cost of various treatments to the patients, availability of medicines, materials, instruments, average dental Out Patient Department per day, and the morbidity analysis report. Dental surgeons were interviewed with regard to the problems faced by them in delivering services, as also for suggestions for improvement in the working conditions at Government dental clinics.

The Community survey was conducted via a structured interview by using a set of questionnaires, which had four sections, as follows:

  • Identification and sociodemographic data - to record information on various socioeconomic parameters.
  • Knowledge assessment schedule - to ascertain the knowledge of the respondents about major dental conditions like dental cavities, bleeding gums, and lost teeth.
  • Treatment seeking practices - the respondents were asked to rate the condition of their oral health on a scale of 10. They were asked whether they had any dental problem at the time of the survey, and whether they felt the need to visit a dentist.
  • Access to dental care services - There were questions in this section to assess the access to dental care services of the population.
The method of a structured interview, where the forms were filled in by the researcher instead of the respondents was adapted, with an objective that more complicated questions could be asked and the data could be validated as it was collected, improving the data quality.

Sample size for community survey

Based on the assumption that 50% of the respondents would have knowledge about the dental problems, at 10% precision, a design effect of two, at 95% confidence interval, and an alpha risk of 5%, a sample size of 193 individuals was estimated for the community survey.

Statistical analysis

Summary measures like proportions and means were calculated to describe rural-urban differences in the socioeconomic characteristics, knowledge about dental problems, dental treatment costs, and dental healthcare utilization practices. The Chi-square test and the two-tailed t-test were used to test for the statistical significance. Mean scores for access of dental care in rural and urban areas and across different income groups were compared using the two-tailed t-test. The frequency distribution of the availability of dental care services in different categories of dental facilities was calculated. Cumulative frequency distribution for the time lag between decision for taking dental consultation and actual consultation was calculated and the Chi-square test was applied to test the statistical significance of rural-urban differences.


   Results Top


Community survey

A total of 203 persons were interviewed, 101 in urban areas and another 102 in the rural areas. Most of the urban respondents belonged to the salaried class, while most of the rural respondents were wage earners. Family size was smaller in the urban areas compared to the rural areas. Mean monthly family income was higher in the urban areas compared to the rural areas [Table 1].
Table 1: Sociodemographic profile of the study population

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Knowledge about dental problems, treatment, and cost of treatment

Almost every respondent knew about dental caries, but only 33.3% knew about gum problems and 10% about malaligned teeth [Table 2]. About 97% of the urban and 91% of the rural population had an idea about the replacement of a lost tooth, but awareness regarding restoration was 78% and the need of treatment for bleeding gums was 63%. Preference for a government setup was more among the rural respondents (68%) compared to their urban counterparts (48%) [Table 3]. The general perception regarding cost of a dental filling was Rs 466/- and for oral prophylaxis was Rs 670/- [Table 4]; 63.2% of the respondents said that there was no dental problems in the family last year, 16% had dental pain, and 6.3% had dental caries [Table 5].
Table 2: Respondents knowledge about common dental problems

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Table 3: Respondents knowledge about type of treatments needed for common dental problems

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Table 4: Respondents knowledge about cost and time required for treatment of common dental problems

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Table 5: Locality-wise dental problems in respondents families last year

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Dental health care utilization practices

Out of all the respondents who were having dental problems at the time of survey, 40% in the urban areas and 57.7% in the rural areas preferred to visit a dentist in the government setup for their problem. Among the respondents who had dental problems, but had not consulted the dentist, the reasons were, either the dental problems were not important for them (45%), lack of time (22%), or they took self-medication (16%), in decreasing order.

Nearly half of the respondents did not make any delay in consultation after deciding to go to a dentist. The rest of the respondents made a delay ranging from one day to more than three months. The time lag for consultation was higher in the rural areas as compared to the urban areas [Figure 1].
Figure 1: Time lag between decision for consultation and actual consultation. Pearson Chi square (6) 12.8788 Pr 0.045

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Only 20% of the population had taken an appointment at the time of visit to the dentist. Theirty-seven percent of the individuals, who had taken an appointment were from the urban population as compared to 7% from the rural population. Appointment was given on the same day to 60% of the people, and 95% by the sixth day of contacting the dental surgeon. Rural respondents took a greater time to reach the dentist as compared to their urban respondents. Average waiting time was 22 minutes before check up by the dentist; 20% of the people who had to wait, felt that it was longer than they would have

liked.

Access to dental health care

The mean composite access score was 59.2 (SD 18.9) in the urban areas and 60.5 (SD 20.9) in the rural areas (P=0.64) on a scale of 100. Affordability of treatment cost was higher in the urban areas (8.5) compared to the rural areas (7), whereas, for doctor and staff behavior, the score was higher in the rural areas (8) compared to the urban areas (6.5). No difference was found in the mean access scores among the different socioeconomic groups and people with different levels of knowledge, regarding dental problems. Scores for affordability of treatment in three different categories of income, that is, 1000 - 4000, 4001 - 24000, and 24001 - 200000 were 6.2, 7.7, and 8.7, respectively [Table 6].
Table 6: Locality-wise mean access scores for dental care services in public dispensaries and hospitals of Chandigarh

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Dental clinic facility survey

The Dental Outpatient Department (OPD) timings were generally from 8 a.m. to 2 p.m. The number of specialists working in the clinics ranged from 1 to 25 in the category A dental clinics, with three clinics without any specialists. No specialists were there in the category B dental clinics. Services for complete dentures were available at only one clinic and that was a charitable clinic and services for braces was available at only two dental clinics - a tertiary care hospital and a medical college [Table 7]. In one category B dental clinic, radiographic facility was not available. The cost was nearly equal in both the categories of dental clinics for most of the services, except for a few variations. Antibiotics and analgesics were available in all five category B clinics and five out of seven category A clinics. The average dental OPD in the category A dental clinics was 40 per day and in the category B dental clinics was 24 per day. Radiographs could not be taken in half of the clinics because the x-ray units were not in working order. Common problems faced by the dentists were lack of dental assistants or hygienists, slow process of repair and maintenance, and less space for the clinic.
Table 7: Availability of dental care services to the patients in category A and category B dental care public facilities

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   Discussion Top


The access to dental healthcare was of a similar level in both the urban and the rural populations. The access in terms of distance of the government dental clinic from home, timings of the government dental clinics, availability of the dentists and dental treatments at these clinics was high, but the access score was low in terms of long waiting times and long appointments given for the dental treatments at government dental clinics, unavailability of medicines, and lack of emergency dental services in these clinics.

Lack of incentives for the dentists to work in the rural areas is one of the major important determinants for availability of dentists in the rural areas. [4] Lack of routine medical check-up can be a risk factor for routine dental care also. [5] The long waiting lines and the long appointments given to the patients could be because of the high work load on the dentists, in terms of the number of patients or lack of dental assistance or both.

In the facility survey, the OPD load per day came slightly on a higher side (25 patients per dentist per day) in certain government dispensaries. Less dental OPD in others may also be because patients often do not visit a dental OPD for routine dental care. Dentists require substantial time to examine and perform procedures, and most of them are resource-intensive. [1] Dentists require the assistance of a support staff to work on the patient. These facilities were grossly deficient as per the recommended norms in most of the setups. [6] Complete denture facility was found nowhere in the government dental clinics of Chandigarh. The possible reasons could be lack of specialists, although a general dentist could also build a complete denture, but they require materials, instruments, and a dental laboratory, with support staff, which is not available anywhere. Self-reported dental problems are much less than the actual burden of oral diseases, both in the rural and urban areas. The possible reason for this discrepancy between the extent of the felt need and the existing problems may be that dental conditions usually show signs and symptoms at a very late stage and people are not aware of their problems.

Knowledge about the causes of dental problems and attitude of the respondents may influence dental treatment-seeking behavior. In a similar study, [7] it was observed that the patients did not know about the causes of these problems. People with favorable attitudes toward dental care reported the highest number of preventive and restorative visits and the lowest point-prevalence of toothache pain, temperature sensitivity, and painful gums, whereas, the frustrated believers might delay seeking dental care until the oral disease becomes more severe, based on their pattern of preventive, restorative, and dental extraction visits, which was similar to the findings of a similar study. [8]

The respondent's knowledge about the problem of dental cavity, and its treatment by filling, was high. Dental pain and dental caries was also a major reported problem in the family. Most of the workload in the dental clinics was for dental fillings and extractions. Thus it seemed that services for the treatment of dental caries were available in public dental clinics and these services were being used by the community. However, there was a gap in terms of affordability. Perceived cost of treatment as per community survey was four to ten times higher than the actual cost as recorded from the facility survey. This could be because patients had to pay for many other direct and indirect expenses that were usually associated with treatment, but were not counted as per the recommended government costs. High cost could be a major factor for delaying the dental treatment. In a similar study, [9] in Tanzania, the patients' lack of knowledge on restorative care and the high fee for restoration, were important barriers in seeking restorative care. Furthermore, the cost of treatment was an important driving factor to get treatment from government dispensaries. The majority of the rural population preferred government dental clinics because services were cheaper there. It was noteworthy that besides many problems being faced by the people in getting services in the public hospitals, as reported by them in our survey, like long waiting lines, long appointments, non-availability of the medicines, and lack of emergency services, the rural population still preferred the government setups. The urban population preferred the private setup, mainly because private dental clinics were time saving.

A little less than half of the respondents knew about the root canal treatment (RCT) for dental caries. As per the facility-based monthly report analysis, RCTs were done in the clinics. However, a radiographic facility was practically not available in the clinics, which was essential before RCT could be done. This meant that these patients might be spending more money to get the radiographs from private sectors. This caused inconvenience and could have forced the patients to opt for a private sector for the final treatment.

The knowledge about lost teeth and gum problems was moderate to low. These were not self-perceived problems. Denture service was practically non-existent in the clinics. The perceived cost of the dentures was more than double the actual cost, although the service was not available practically anywhere. As the geriatric age group was increasing, the problem of edentulousness was also increasing, thus denture service should not be ignored in any dental care program.


   Conclusion Top


All types of dental care treatments are still not accessible to the population of Chandigarh. This study has revealed the gaps in the knowledge of the respondents, about dental problems. Patients are not able to correlate early treatment with better health. Therefore, specific efforts targeted to increase awareness toward oral health are required. Dental health must be accorded the appropriate priority, and a wider range of dental care facilities must be made available at subsidized costs, to improve access to dental care.

 
   References Top

1.Shah N. Oral and dental diseases: Causes, Prevention and Treatment Strategies National Commission on Macroeconomics and Health, Govt. of India Background Papers. 2005. p. 275-98.  Back to cited text no. 1
    
2.Guay AH. Access to dental care: The triad of essential factors in access-to-care programs. J Am Dent Assoc 2004;135:779-85.  Back to cited text no. 2
[PUBMED]    
3.About Chandigarh. Available from: http://chandigarh.nic.in/knowchd_general. [cited in 2008].  Back to cited text no. 3
    
4.Allison RA, Manski RJ. The supply of dentists and access to care in rural Kansas. J Rural Health 2007;23:198-206.  Back to cited text no. 4
[PUBMED]    
5.Kane D, Mosca N, Zotti M, Schwalberg R. Factors associated with access to dental care for children with special health care needs. J Am Dent Assoc 2008;139:326-33.  Back to cited text no. 5
[PUBMED]    
6.Praksh H, Shah N. National Oral Health Care Programme implementation strategies. DGHS MOHFW Govt. of India; 2001.  Back to cited text no. 6
    
7.Goyal A, Gauba K, Chawla HS, Kaur M, Kapur A. Epidemiology of dental caries in Chandigarh school children and trends over the last 25 years. J Indian Soc Pedod Prev Dent 2007;25:115-8.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Riley JL, Gilbert GH, Heft MW. Dental attitudes: Proximal basis for oral health disparities in adults. Community Dent Oral Epidemiol 2006;34:289-98.  Back to cited text no. 8
    
9.Kikwilu EN, Frencken JE, Mulder J, Masalu JR. Barriers to restorative care as perceived by dental patients attending government hospitals in Tanzania. Community Dent Oral Epidemiol 2009;37:35-44.  Back to cited text no. 9
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Correspondence Address:
Arun K Aggarwal
School of Public Health, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.99057

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