| Abstract|| |
Objective: The aim and objective of the present study was to determine the prevalence and severity of gingivitis and evaluate the factors associated with gingivitis in children residing in rural and urban areas of Panchkula.
Materials and Methods: The present study was carried out on a sample of 1269 school children, aged 5, 12 and 15 years, randomly selected from the rural and the urban schools of Panchkula and gingival index was recorded as devised by Loe and Silness (1963) to assess the severity of gingivitis. A standardized questionnaire was self prepared, which was filled by the examiner prior to the clinical examination. The data were subjected to SPSS, version 13, and statistically analyzed using Chi test, F test, ANOVA test.
Results: In the age group of 5 years, the children affected with gingivitis in the rural and the urban areas were 67 and 33%, respectively, which was statistically highly significant (P = 0.0001). In the age group of 12 years, the children affected with gingivitis in the rural and the urban areas were 94 and 92%, respectively (P = 0.537), whereas in 15-year olds, the children affected with gingivitis in the rural and the urban areas were 98 and 64%, respectively (P = 0.0001). The children who brushed once a day had higher prevalence of gingivitis as compared to children who brushed more than once per day in all the age groups.
Conclusion: The results showed that the percentage of children affected with gingivitis was significantly higher in the rural areas in 5- and 15-year-old children, but this trend was not seen in 12-year age group, reflecting the lack of awareness in rural areas.
Keywords: Brushing, gingival index, gingivitis
|How to cite this article:|
Kaur A, Gupta N, Baweja DK, Simratvir M. An epidemiological study to determine the prevalence and risk assessment of gingivitis in 5-, 12- and 15-year-old children of rural and urban area of Panchkula (Haryana). Indian J Dent Res 2014;25:294-9
Gingivitis, a common oral disease starts in early childhood and its severity increases with age. Accumulation of microbial biofilm is the main cause of gingivitis and predisposing factors include advanced carious lesions, smoking, decreased manual dexterity, use of orthodontic bands etc., Gingivitis, if left untreated, can eventually progress to a severe form of periodontal disease. Periodontal disease shows an increase during adolescence because of the increased level of sex hormones (progesterone and estrogen), which in turn affects the inflammatory response of the body.  If not removed regularly, plaque mineralizes to form calculus, which further initiates the degenerative process of periodontal disease. Initially, the inflammation is confined to the gingiva leading to bleeding gums. At this stage the periodontal disease can be treated successfully. If not treated, inflammation spreads to surrounding tissues and involves the alveolar bone leading to tooth mobility and eventual tooth loss.
|How to cite this URL:|
Kaur A, Gupta N, Baweja DK, Simratvir M. An epidemiological study to determine the prevalence and risk assessment of gingivitis in 5-, 12- and 15-year-old children of rural and urban area of Panchkula (Haryana). Indian J Dent Res [serial online] 2014 [cited 2020 Sep 26];25:294-9. Available from: http://www.ijdr.in/text.asp?2014/25/3/294/138310
Despite credible scientific advances and the fact that gingivitis is preventable, the disease continues to be a major undiagnosed untreated public health problem in a developing country like India. Studies show that developing countries continue to show increased trend of oral periodontal diseases, , whereas reverse trends are seen in developed countries. 
Hence, the present study was carried out with the aim to determine the prevalence and severity of gingival disease and evaluate the risk factors associated with gingivitis in 5-, 12- and 15-year-old children residing in rural and urban areas of Panchkula.
| Materials and methods|| |
The present study was carried out on a sample of 1269 school children, aged 5, 12 and 15 years, randomly selected from the rural and urban schools of Panchkula, Haryana, and gingival index was recorded as devised by Loe and Silness  to assess the severity of gingivitis.
School selection criteria
Written permission to examine the schoolchildren was obtained from the district education officer of Panchkula. Every third school from the list of the various schools in Barwala (rural) and Pinjore (urban) block of Panchkula were approached.  The Principals of the schools were informed about the nature of the study. The final selection of schools was done after obtaining permission from the respective school Principals, who in turn took the consent from the parents of children to be included in the study.
The two selected blocks were at a distance of 15 km from each other. The selected schools were situated within 2, 5 and 15 km from centre point of two blocks (primary health centre in Barwala and General hospital in Pinjore block).
Sample selection criteria
Five-year-old children were selected for this study if they had been born and brought up in that area. Twelve- and fifteen-year-old students who were enrolled in school for continuously 3-4 years were selected.
The slips numbered 1-5 were made and a child was asked to select any one slip. If the slip selected by the child was numbered 4, starting from roll number 4, every third child from the roll call register was examined and the age was ascertained from date of birth. In both the urban and the rural schools, an attempt was made to have an equal representation of children from both the sexes. If a child was absent, the next roll number was considered. Approximately 200 children from each age group i.e. 5 years (+6 months), 12 years (+6 months) and 15 years (+6 months), residing in urban and rural areas were included in the study making a total sample size of 1200. The final sample size was 1269, because of slight variation in the strength of classes in different schools [Table 1].
The inclusion criteria were:
- Children aged 5 years (+6 months), 12 years (+6 months) and 15 years (+6 months) for respective groups.
- Children with no chronic systemic disease.
The exclusion criteria were:
- Children with any special healthcare needs
- Children with crowded dentition
- Children undergoing orthodontic treatment.
A standardized questionnaire was prepared, which was filled by the examiner prior to the clinical examination. It contained information regarding personal history, medical history, oral hygiene practiced and frequency of visits to a dentist.
The questionnaire was filled before recording of gingivitis to eliminate any bias as examiner was not aware of the gingival health status of the child. In the 12- and 15-year-old children, the information was obtained by questioning them directly. For 5-year-olds, the questionnaire was sent by school authorities to the parents, who sent back proformas, which were later collected by the examiner. The questionnaire was prepared in Hindi, for the parents of 5-year-old school children of the rural areas, which were necessary to eliminate any linguistic barriers.
The study was approved by the institutional ethics committee. Total 641 rural children and 628 urban children were examined. The children were examined in their respective schools. The participants were examined in bright daylight sitting on an ordinary chair facing away from direct sunlight and a trained assistant recorded the observations on the specially designed proformas for intraoral examination.
Armamentarium used for examination was sterile mouth mirror and a CPITN probe. For each examination session, 20 sets of sterilized probes and mirrors in sterile packs were taken. Intraoral examination proceeded in an orderly manner from one tooth to the adjacent tooth starting from upper right quadrant to lower right quadrant in a clockwise direction.
The Gingival Index devised by Loe and Silness was used to assess the severity of gingivitis.  The index teeth were examined in the order 16, 12, 24, 36, 32 and 44 for permanent dentition and 55, 52, 64, 75, 72 and 84 for deciduous dentition. The order of the surfaces examined was mesiobuccal, buccal, distobuccal and lingual.
Oral health education
Dental health education material was provided in the form of Microsoft PowerPoint presentations in schools. Pamphlets were distributed to teachers and children regarding care of teeth. Parents of children, who required treatment were recalled in the schools and given instructions about oral health care.
All completed questionnaires and recording proformas were analyzed and the data were transferred on the Microsoft Office Excel sheet. The data were subjected to SPSS, version 13, and statistically analyzed using Chi test, F test and ANOVA test. P < 0.05 was considered to be statistically significant.
| Results|| |
In 5-year-olds, 43 and 24% children in the rural area, whereas 32 and 0.45% children in the urban area were affected with mild and moderate gingivitis, respectively, which was statistically highly significant (P < 0.0001).
Fifty six percent of children cleaned their teeth in rural area compared to 64% of the urban children. The P value of 0.10 depicted that it was statistically non-significant. Amongst those who cleaned, 55% of rural children and 63% urban children cleaned their teeth with tooth brush. The P value of 0.10 showed that it was not significant. There was no statistical difference between the number of children cleaning their teeth with chewing stick, finger, or mouth rinsing.
More number of the urban children cleaned their teeth in the morning before breakfast as compared to the rural area. The P value of 0.0095 depicted that it was statistically significant. More number of children cleaned their teeth at night before bed in the urban area as compared to the rural area. The P value of 0.0004 depicted that it was statistically significant. There was no statistically significant difference between the number of children cleaning their teeth in morning after breakfast and at night after dinner.
In 12-year-olds, 56% children were affected with mild gingivitis in the rural area compared to 54% children in the urban area, which was statistically insignificant (P = 1). Thirty eight percent children were affected with moderate gingivitis in the rural area and 38% children in the urban area. None of the children were affected with severe gingivitis in 5- and 12-year age group. All the children of the rural and urban area cleaned their teeth. Ninety two percent children used tooth brush in rural area, whereas 95% of the urban children used toothbrush as a cleansing aid. The P value of 0.179 depicted that it was not significant. The P value of 0.01 depicted that there was a statistically significant difference between children cleaning their teeth with chewing stick in the urban and rural areas. There was no statistical difference between children cleaning their teeth with finger, or mouth rinsing. There was no significant difference found between children of the rural and the urban area cleaning their teeth once a while (P = 0.44). There was a significant difference between the children of both areas cleaning their teeth 1-2 times per week. There was a highly significant difference found between children cleaning their teeth 1-2 times per week, once a day and greater than once per day (P < 0.0001). P value of 0.42 depicted that there was no significant difference between the number of rural and the urban children cleaning their teeth in morning before breakfast. Also the difference was not statistically significant between the number of children who cleaned their teeth in the morning after breakfast, at night after dinner and at night before going to bed.
In 15-year-olds, 61% children were affected with mild gingivitis in the rural area, whereas 49% children in the urban area, which was statistically significant (P = 0.008). Thirty four percent children were affected with moderate gingivitis in the rural area and 15% children in the urban area, which was statistically significant (P = 0.043). Three percent children were affected with severe gingivitis in the rural area and none of them in the urban area, which was statistically insignificant (P = 0.07). Ninety six percent of the rural children cleaned their teeth while 100% of urban children practiced oral hygiene. The P value of 0.01 showed that it was statistically significant. Of those who cleaned their teeth, 92% of the rural children and 100% children of urban area used a tooth brush. The P value of 0.0002 showed that it was statistically significant. No difference was found between the number of children cleaning their teeth once a while in the urban and the rural areas (P = 1). There was significantly higher number of children in the rural area who brushed their teeth 1-2 times per week. There was a difference between the number of children in the urban and the rural areas who cleaned their teeth once a day and more than once per day (P < 0.0001). More number of children cleaned their teeth in the morning before breakfast in the rural area as compared to the urban area. The P < 0.0001 depicted that this was statistically highly significant. More number of children cleaned their teeth at night before going to bed in the urban area as compared to the rural area. The P < 0.0001 depicted that this was also statistically highly significant. There was no significant difference between the number of rural and urban children who cleaned their teeth in the morning after breakfast and at night after dinner.
| Discussion|| |
The main objective of the study was to determine and compare the prevalence of gingivitis in the rural and the urban school children of Panchkula and to evaluate the risk factors associated with gingivitis. The occurrence of the disease correlates with awareness regarding oral hygiene practices and oral health in general. Rural areas generally have low dentist to population ratio and more poverty, which together limits dental care access for rural children.  The level of awareness in rural children is low as compared to urban children.
For diagnosis of gingivitis, Silness and Loe index  was used as it gives the severity of gingivitis. This recording criterion requires minimum equipment and is easy to use in the field conditions. Our study showed significantly greater numbers of rural children affected with gingivitis [Table 2] as compared to the urban children in the 5-year-old age group. Since an oral hygiene practice at this age is not a significant factor due to limited dexterity of the child, the other probable factors have to be accounted for. Decreased awareness among parents of the rural children regarding oral hygiene regime could be one of the factors that might have influenced the disease process since our study showed greater number of carious teeth [Table 3] in the rural children as compared to the urban children. The broken teeth, the loss of embrasure form and broken contact areas interfere with self-cleansing mechanism and make gingival tissues more vulnerable to inflammation. According to Matsson,  the degree of gingivitis in children is not directly associated with the amount of plaque, but rather with other factors, such as microbial composition of plaque, differences in immune system and anatomy of primary teeth. Silness and Roynstrand  found that surfaces without interdental contact had a more favorable periodontal condition than surfaces with contact. Children with better oral heath behaviors have a higher chance of good periodontal health in adulthood.  Moreover, hygiene habits of preschool children are modeled by family behaviors particularly maternal behavior. 
There was no statistically significant difference in gingivitis among 12-year-old children of rural and urban areas. This might be because of the pre-pubertal form of the disease that is mainly influenced by hormonal surge and some newly erupted teeth in the oral cavity. Even minimal accumulation of plaque at this age may also lead to heightened immune response. However, the 15-year-old children had significantly higher gingivitis in the rural as compared to the urban children. The reason in rural areas seemed to be lack of dental health awareness, unavailability of quality toothbrushes either due to traditional beliefs or economic restrains.
In our study, a maximum of 21% children in 5-year-age group of the rural area and 7% of the urban brushed once a while [Table 4] and 64% in rural and 79% in urban brushed once a day. These results are in agreement with the Hofstedt et al.,  study, 6% children brushed twice a day, and none of them in the rural area. The reasons given by Hofstedt were that basic oral health knowledge was relatively poor, and approximately 70% of the total group did not know the cause of tooth decay. The reasons in our study could be lack of awareness about the importance of cleaning teeth.
According to the severity of gingivitis, the most common form in which it manifested was mild gingivitis in both rural and urban school children in all the age groups. It was seen that significantly higher number of rural children of 5 and 15-year-old age group had mild and moderate form of gingivitis as compared to urban children. Statistically no significant difference was found in other forms of gingivitis in 12-year-old age group between the rural and the urban children. However, there was a significant difference in moderate and mild gingivitis. According to Emilson,  if the oral hygiene procedures are suspended for 3-7 days, gingivitis appears. Hence, the main factor that influences both caries and gingivitis is the oral hygiene practices being followed, which were lacking in rural children.
Results of our study showed that children who brushed once a day had higher prevalence of gingivitis as compared to children who brushed more than once per day in all the age groups. However, it is well documented that not only the frequency of brushing is important but also the technique and the timing of tooth brushing. It was seen in our study that most of the children brushed their teeth in morning before breakfast. However, brushing after breakfast and after dinner are two most important timings to maintain oral health. The trends in our study clearly pointed to the lack of dental awareness and attitudes amongst masses. Special efforts must be made, especially at community level by Pediatric and Community dentists to generate awareness among children about correct timing and technique of brushing. In the urban area due to oral health education in their school curriculum, more number of children followed the habit of brushing before bed as compared to the rural children.
With best available resources, efforts were made to decipher the prevalence of gingivitis and various risk determinants in the rural and the urban school children in the age groups of 5, 12 and 15 years. Also selection bias might have occurred because of students' absence during the day of examination.
Since India is a developing country, the preponderance of infectious diseases limits the available health services to fund the treatment needs in dental field. Many of our attitudes and habits concerning food and health are acquired in early childhood. These behavioral changes are easier to implement at an earlier age and the chances of their benefiting public at large are greater than when attempted at a later stage. 
To initiate the change towards oral health attitudes and general health amongst masses, an essential screening during entry to the schools should be made mandatory. Oral health programs can be integrated with vaccination schedules for children whereby pediatricians can promote desirable attitudes. Early referrals can also be made through primary health centers so that disease can be curbed at its initial stage. Last but not the least, unanimous effort on the part of teachers, caretakers and health professionals are required to inculcate lasting oral health attitudes amongst children.
| Summary and conclusion|| |
The results showed that the percentage of children affected with gingivitis was significantly higher in the rural areas in 5- and 15-year-old children, but this trend was not seen in 12-year age group. This might be attributed to increased use and frequency of tooth brushing in urban area.
That shows the development has reached in the rural areas, but oral health awareness is still lacking. Although there has been a drastic change in lifestyle that the technological revolution has brought, it has not been able to alter the deep-rooted traditional beliefs.
| References|| |
|1.||Fiorellini JP, Kim DM, Ishikawa SO. Clinical features of gingivitis. 10 th ed. Carranza's Clinical Periodontology. p.362-73. |
|2.||Goel P, Sequeira P, Peter S. Prevalence of dental caries amongst 5-6 and 12-13 year old children on Puttur municipality, Karnataka state, India. J Indian Soc Pedo Prev Dent 2000;18:11-7. |
|3.||Dhar V, Jain A, Van Dyke TE, Kolhi A. Prevalence of gingival diseases, malocclusion and fluorosis in school going children of rural areas in Udaipur district. J Indian Soc Pedo Prev Dent 2007;25:103-5. |
|4.||Hugoson A, Sjodin B, Norderyd O. Trends over 30 years, 1973-2003, in prevalence and severity of periodontal disease. J Clin Periodontol 2008;35:405-14. |
|5.||Loe H, Silness J. Periodontal disease in pregnancy: I, Prevalence and severity. Acta Odontol Scand 1963;21:533-51. |
|6.||Board of school education. Available from: http://www.haryana.htm. [cited in 2011]. |
|7.||Vargas CM, Ronzio CR, Hayes KL. Oral health status of children and adolescents by rural residence, United States. J Rural Health 2003;19:260-8. |
|8.||Matsson L. Development of gingivitis in preschool children and young adults: A comparative experimental study. J Clin Periodontol 1978;5:24-34. |
|9.||Silness J, Roynstrand T. Effects on dental health of spacing of teeth in anterior segments. J Clin Periodontol 1984;11:387-98. |
|10.||Lissau I, Holst D, Friis-Hasche' E. Dental health behaviors and periodontal disease indicators in Danish youths: A 10-year epidemiological follow-up. J Clin Periodontol 1990;17:42-7. |
|11.||Blinkhorn AS. Factors influencing the transmission of the tooth brushing routine by mothers to their preschool children. J Dent 1980;8:307-11. |
|12.||Hofstedt H, Stillerman E. Oral Health status, knowledge and dietary habits among urban and rural 6-7 year old children in the Windhoek area, Namibia. p. 229-38. |
|13.||Emilson CG, Wintergreen G. Effect of chlorhexidine on the relative proportions of Streptococcus mutans and Streptococcus sanguis in Hamster plaque. Scand J Dent Res 1977;87:288-95. |
|14.||Blinkhorn AS. Dental preventive advice for pregnant and nursing mothers-sociological implications. Int Dent J 1981;31:14-21. |
Department of Paediatric and Preventive Dentistry, BRS Dental College and Hospital, Sultanpur (Panchkula) Haryana
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]