Assessment of Oral Mucosal Lesions (OML), Periodontal Health Conditions, and Unmet Dental Treatment Needs in the Rural Adult Population of Jharkhand, North India

Background Dental diseases like caries, periodontal diseases, and oral mucosal lesions (OML) are common findings in rural adult populations that greatly impact their quality of life. Aim To assess OML, periodontal health conditions, and unmet dental treatment needs in the rural adult population in Jharkhand. Methodology A total of 700 permanent residents of Bero Block, Jharkhand, North India, in the age group of 35-44 years, participated in this cross-sectional study. Both men and women were equally represented. Their socio-demographic characteristics and previous dental visits were collected using standardized proforma. An assessment of periodontal health conditions, OML, and unmet dental treatment needs was done using the World Health Organization (WHO) Oral Health Assessment Proforma of 1997. Results It was found that over half (54.3%) of the study population had the adverse habit of smoking and chewing paan. Males were more likely to experience leukoplakia (18.87%), whereas females were more likely to experience abscesses (9.43%). The majority of males and females had a community periodontal index (CPI) score and loss of attachment (LOA) score greater than two, which indicated poor periodontal health as assessed by the periodontal index. Both males and females needed extraction of the diseased teeth as their primary treatment. Conclusion The rural adult population residing in the Bero block of Jharkhand showed poor periodontal health and high unmet dental treatment needs. These people need effective oral health promotion policies and dental health education to improve their oral health.


Introduction
Dental health is an important and integral part of contributing to the overall health of an individual, which goes beyond just having healthy teeth.The factors that are essential for having good oral health include healthy gums, proper oral hygiene practices, periodic dental checkups, a balanced diet, prevention of tobacco and alcohol consumption, stress management, etc. [1].To have optimal oral health, these factors have to be taken care of as needed.Oral diseases are extremely prevalent and have a significant social impact, making them a health concern [2].There are several systemic diseases associated with dental caries like infective endocarditis, cardiovascular diseases, diabetes mellitus, bacterial pneumonia, chronic obstructive pulmonary disease, and gum disease that impact 60% to 80% of the Indian population and almost half of the world's population, that is, 45% or 3.5 billion people globally [3].
Oral mucosal lesions (OML), periodontal diseases, and unmet dental treatment are often subjects of concern.OML are generally the abnormal tissue lining of the oral cavity due to a wide variety of reasons like trauma, chronic oral inflammatory diseases, oncogenic processes, etc.Additionally, tobacco use is a major contributor to the development of oral mucosal lesions.There is a wide spectrum of oral mucosal alterations and lesions that can result from tobacco use, whether it is smoked or smokeless.A tobacco user's type, manner, and frequency of usage will determine the type and location of the lesion.These lesions may appear in different sizes and structures and occur at different places.These lesions may be leukoplakia, malignant tumors, lichen planus, candidiasis, ulceration, abscess, etc. OML are usually associated with various local and/or systemic conditions and have been reported in 41.2% of the Indian population [4].The patient's eating, drinking, and speaking habits are affected by OML; as a result, the person's regular activities are hampered because of the pain and discomfort caused by these lesions [5].
Periodontal diseases are very common in the rural adult population.Several factors may contribute to this, including a low level of awareness about oral health, financial constraints, and a lack of oral health care facilities [6].Periodontal disease manifests itself in the form of bleeding from gums, gingival recession, food lodgement, interdental spacings, halitosis, and others [7].
Unmet dental treatment needs are in those cases that need dental treatment but do not get a dental care assessment in the required timeframe [8].
There have been minimal studies carried out in Jharkhand, especially in the rural population, wherein their oral health and unmet dental needs have been assessed.Hence, this study was carried out to assess OML, periodontal health conditions, and unmet dental treatment needs in the rural adult population in Jharkhand.

Materials And Methods
This cross-sectional study was conducted in Bero block, Jharkhand, and included adults in the age group of 35-44 years.The study took place between January 2022 and May 2023 (14 months).Based upon the findings of the pilot study and using the formula recommended by the World Health Organization (WHO) for sample size calculation [9], it was found that a minimum number of 374 would be sufficient.As per the recommendations of the WHO, the formula of N=z2p(1-p)/d2 was used for calculating the sample size where z is the statistic corresponding to the level of confidence, p is the expected prevalence and d is the precision value.Keeping the z value to be 1.96, prevalence to be 42%, and precision value to be 0.05 in the above formula, a minimum sample size of 374 was obtained.We decided to include 350 males and 350 females after doing the necessary design effect corrections for cross-sectional studies.
These studies included all adults (over 35 years of age) who were willing to participate and were residents of Bero block for at least 10 years.The study excluded participants who were unwilling or medically compromised.To select the study population, a simple random sampling method was used.
The study was conducted after obtaining approval from the Institutional Ethics Committee at Rajendra Institute Of Medical Sciences (RIMS), Ranchi, with institutional ethical clearance number IEC RIMS Memo No. 282.The socio-demographic data, periodontal health conditions, OML, and unmet dental treatment needs were assessed according to the WHO Oral Health Survey assessment forms.To assess periodontal health, the community periodontal index (CPI) and loss of attachment (LOA) index were used as per the WHO recommendation [9].As per the WHO CPI, the status of the periodontium of 10 teeth was examined and evaluated with a 0.5 mm ball tip, with the WHO CPI probe present in the oral cavity.The scoring was done depending on the clinical finding associated with the individual teeth, as per the literature available [9].The teeth were assessed clinically and the CPI score was assigned in the form of a numeric score ranging from 0 to 4. CPI scores 0, 1, 2,3, and 4 represent healthy periodontium, bleeding of the gingiva, calculus, and bleeding of the gingiva, a periodontal pocket of 4-5 mm, and a periodontal pocket of ≥ 6 mm, respectively.The teeth present in the oral cavity were also examined and assessed for LOA.The teeth were assessed clinically and the LOA score was assigned in the form of a numeric score varying from 0 to 4. The LOA scores of 0, 1, 2, 3, and 4 show a loss of attachment of about 0-3 mm, 4-5 mm, 6-8 mm, 9-11 mm, and ≥12 mm respectively [9].
The data were collected through various dental camps organized in Bero block, Jharkhand.As part of the data collection process, the dentist was trained on how to perform various oral exams based on standardized criteria.A mouth mirror, a CPI probe, and a light source were used in the oral examination.
The study instruments were sterilized after use.In the event of an emergency oral health condition requiring immediate intervention, the patient was referred to a trained specialist right away.
An analysis of the data was conducted using SPSS (IBM Corp. Released 2011.IBM SPSS Statistics for Windows, Version 20.0.Armonk, NY: IBM Corp).The data were distributed based on their frequency.Chisquare tests were performed on categorical variables.When a p-value of 0.05 was used, a statistically significant difference was considered.

Results
More than two-thirds of the study population were literate, working, and did not suffer from any systemic diseases.More than half (54.3%) of the study population had the adverse habit of tobacco and paan consumption.The majority (92.6%) of them had never visited a dentist before.In males, leukoplakia (18.87%) was the most common lesion found followed by lichen planus (12.87%).In females, abscesses (9.43%) followed by ulceration (4.86%) were more commonly observed.
The periodontal health condition was assessed by the CPI and LOA scores and the findings are tabulated in Table 3.The results of Table 3 show that males and females had significantly different periodontal health.More than half of the males showed a CPI score of 4 (52.82%) and an LOA score of 4 (54.28%).The majority of the females showed CPI and LOA scores of 2 or 3.

Factor
Depending on the research study, it was found that different kinds of dental treatment were needed for males and females, which is illustrated in Table 4.

Male Female
Preventive care 0 (0.00%) 0 (0.00%) Fissure sealant 0 (0.00%) 0 (0.00%)  Extraction, followed by pulp care, was the major treatment needed in both males and females.In addition, one and two surface fillings were also required in most of the males and females.Those study population who were diagnosed with different oral mucosal lesions (OML) and periodontal diseases were referred to the Department of Oral Medicine and Radiology and the Department of Periodontology, respectively, at RIMS, Ranchi, Jharkhand, for the needful treatment.
was missing in the study population.Early intervention in the development of dental diseases could have prevented the teeth from being extracted at earlier stages.Hence, effective policies for the upliftment of oral health should be drafted for this study population.

Table 1
shows the sociodemographic characteristics of the study population based on several factors like age, education, occupation, habits, etc.

TABLE 1 : Sociodemographic characteristics
N(%): number of participants in the study.Males and females had significantly different OML as shown in Table2.

TABLE 2 : Oral mucosa condition of males and females
p-value: level of significance.

TABLE 3 : Periodontal health condition assessed by the CPI and LOA scores
p-value: level of significance, CPI: community periodontal index, LOA: loss of attachment