Journal of Dental and Allied Sciences

: 2017  |  Volume : 6  |  Issue : 1  |  Page : 12--16

Oral health status and oral health behaviors of 12-year-old urban and rural school children in Udupi, Karnataka, India: A cross-sectional study

Arun Singh Thakur1, Shashidhar Acharya2, Deepak Singhal2, Nivedita Rewal3, Vinay Kumar Bhardwaj1,  
1 Department of Public Health Dentistry, Government Dental College, Shimla, Himachal Pradesh, India
2 Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Karnataka, India
3 Department of Pedodontics and Preventive Dentistry, Himachal Dental College, Sunder Nagar, Himachal Pradesh, India

Correspondence Address:
Arun Singh Thakur
Department of Public Health Dentistry, Government Dental College, Shimla - 171 001, Himachal Pradesh


Objectives: The objective of this study is to assess the oral health status and oral health behavior among 12-year-old urban and rural school children and to evaluate the relative effect of sociobehavioral risk factors on caries experience. Materials and Methods: A cross-sectional study was conducted which included urban and rural subgroups of 12-year-old school children. The final study population covered two groups: 12 years rural (n = 261) and urban school children (n = 264). Data were collected and compared using Chi-square test. Logistic regression analysis was done to assess the importance of variables associated with dental caries. Results: Highly significant differences (P < 0.001) were observed between rural and urban school children for the use of oral hygiene aids, frequency of tooth brushing, and dental services utilization. Dental caries level was significantly higher (P < 0.03) for rural children. Decayed teeth (DT) component constituted majority of decayed, missing, and filled teeth (FT) in both population. 55.6% of the rural school children required treatment compared to 42.4% of urban school children. Mean Oral Hygiene Index-Simplified values, mean DT, and FT were statistically significant for urban and rural school children. Logistic regression analysis showed that government or private school, dental care utilization, socioeconomic status, and malocclusion status were significantly associated with dental caries. Conclusion: Poor oral health and high treatment needs of children belonging to low socioeconomic background is an alarming situation. Strengthening of oral health care in the rural and underprivileged section should be priority of the policymakers.

How to cite this article:
Thakur AS, Acharya S, Singhal D, Rewal N, Bhardwaj VK. Oral health status and oral health behaviors of 12-year-old urban and rural school children in Udupi, Karnataka, India: A cross-sectional study.J Dent Allied Sci 2017;6:12-16

How to cite this URL:
Thakur AS, Acharya S, Singhal D, Rewal N, Bhardwaj VK. Oral health status and oral health behaviors of 12-year-old urban and rural school children in Udupi, Karnataka, India: A cross-sectional study. J Dent Allied Sci [serial online] 2017 [cited 2022 Oct 6 ];6:12-16
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Full Text


Dental caries is one of the most prevalent diseases among children. Major complications associated with dental caries are dentoalveolar infection and pain. These complications can adversely affect the quality of life in children and can place undue financial burden on their families. Studies have clearly established that dental caries is not a static process but instead dynamic process where demineralization and remineralization of tooth go side by side.[1]

Investigators are constantly reporting regional and international differences in the incidence and prevalence of dental caries. One consistent finding reported by all studies is that the prevalence of dental caries is decreasing in developed countries whereas there is an increase in the developing countries. Decreased prevalence of dental caries in developed countries can be attributed to changing lifestyle and behavior patterns, fewer intakes of refined sugars, and widespread use of fluoridated toothpaste and utilization of the dental care services. Contrary to this, increase dental caries in developing countries can be related to factors, such as economic development, changing living standards, rapid urbanization, and changing of dietary patterns to more refined carbohydrates.[2] In India, oral health status of children has been documented by various investigators. National oral health survey, 2003 reported a prevalence of 53.8% caries experience in 12-year-old, mean Decayed, missing, and filled teeth (DMFT) and SiC of 1.8 and 3, respectively. The majority of children aged 12 years had experienced caries in one or more of their total number of teeth.[3]

Study of this age group is important as India is a country of widespread diversity in the socioeconomic status and oral health status in rural and urban areas of same country.[4] India is a rapidly growing nation in terms of population and economic growth almost 31% of the total population belongs to the 0–14 years of age group.[5] This age group forms a significant proportion of Indian population today and is likely to further increase in the years ahead. Further, 12 years is a WHO recommended index age group for oral health surveys.

Hence, this study was conducted to assess the level of oral health status and oral health behaviors among 12-year-old urban and rural school children, and to evaluate the relative effect of social-behavioral risk factors on caries experience.

 Materials and Methods

This study was conducted among 12-year-old children of rural and urban schools in Udupi. The list of high schools in Udupi was obtained from the office of Deputy Project Coordinator, Sarvashiksha Abhiyan, Udupi. The schools were stratified into urban and rural schools. Rural and urban areas were classified according to the guidelines of census of India.[5] Ethical clearance was taken from the Institutional Ethics Committee. Permission to examine school children was obtained from the heads of the respective schools. Informed written consent was taken from parents and children before carrying out the survey.

All examination was carried out by single examiner. Training for the required clinical assessment was done on twenty children each with wide range of levels of oral diseases, in 12 years age group. Subsequently, a total of twenty children were examined twice, with a 30 min interval between the examinations. Intra-examiner reliability was assessed using kappa statistic which was in range of 0.78–0.82 for the parameters studied.

Inclusion criteria

Children who were 12 years of age according to their last birthday, present on the day of examination, willing to participate, positive parental consent, and no medical condition that contraindicates oral examination without appropriate modifications, for example, infective endocarditis were included in the study. Multistage random sampling was used. In the first stage, schools were selected into urban and rural schools from the complete list of high schools in Udupi taluka. In the second stage, one section was selected for 7th standard randomly. In third stage, individuals fulfilling the necessary inclusion criteria were randomly selected.

A total of 525, 12-year-old school children were included; 264 in urban and 261 in rural schools. The study consisted of close-ended questions comprising sociodemographic variables of age, sex, type of school, parent's education, occupation, and income. Four close-ended questions were asked regarding oral hygiene practices.

All the children were examined under adequate illumination in the school premises. WHO criterion was used for evaluation of dentition status and treatment needs. The criterion recommends examination for dental caries using mouth mirror and consumer price index (CPI) probe. The examination was conducted with a plain mouth mirror and CPI probe as given by the WHO 1997. The examination proceeded in an orderly manner from one tooth or tooth space to the adjacent tooth or tooth space. Clinical examination included the assessment of dentofacial anomalies according to the WHO Oral Health Assessment form (1997)[6] by recording: Enamel hypoplasia Development defects of Enamel Index,[6] Dental fluorosis Index-Modified criteria,[6] Dental Aesthetic Index (DAI).[6] Oral Hygiene Index-Simplified (OHI-S)[7] was used to assess oral hygiene status.

The school authorities were requested to pass on this information to all the parents/guardians so that children could be taken to dental college for availing free treatment through the referral cards given to them at the time of study.

Data analysis

Statistical analysis of the data was done using Statistical Package for Social Sciences version 11.5 (SPPS Inc., Chicago, IL, USA). Chi-square test was used to compare between urban and rural school children for categorical variables for oral hygiene pattern, dental visit pattern, and qualitative variables of dentition status, dental caries experience, treatment needs, enamel hypoplasia, fluorosis, and malocclusion status. Logistic regression analysis was performed to determine the importance of the factors associated with caries status. A set of independent variables including age group, gender, urban or rural school, government or private school, frequency of toothbrushing, visit to the dentist, socioeconomic status, and malocclusion. Odds ratio (OR) was calculated for all variables with 95% confidence intervals. P ≤ 0.05, P ≤ 0.01 was considered as statistically significant and highly significant, respectively.


A total of 525, 12-year-old school children were examined. Socioeconomic status was assessed using the Modified Kuppuswamy Scale [8] which was adjusted according to the CPI of June 2015. In both study groups, gender and type of school were equally distributed [Table 1].{Table 1}

Oral health behavioral characteristics of the study population are presented in [Table 2]. Brushing frequency in majority of children was once a day, with toothbrush and toothpaste. 62.2% of children in urban schools visited a dentist compared to 26.8% in rural schools, and this difference was statistically highly significant (P < 0.001). Oral health status of population is presented in [Table 3]. Overall, decay prevalence was 26.5% in the urban school children and 35.2% in rural school children which was statistically significant (P < 0.03). Statistical significant difference (P < 0.001) was observed for the prevalence of filled teeth (FT) which was 9.5% in urban and 1.5% in rural children.{Table 2}{Table 3}

“No treatment” was required in 57.6% of urban and 44.4% of rural school children, this difference was statistically highly significant (P < 0.009). Treatment needs for “one surface restoration,” “two surface restorations,” “pulp care and restoration,” “extraction and prosthodontic care” were not statistically significant between two groups. However, statistically significant (P < 0.04) differences were observed for preventive care [Table 3].

Mean differences in OIHI-S decayed teeth (DT) and FT were statistically significant for urban and rural school children. No significant difference was reported in categories of enamel hypoplasia, prevalence of fluorosis, and DAI [Table 4].{Table 4}

The results of logistic regression showed that government schools, dental visiting pattern, socioeconomic status, and handicapping status malocclusion were significantly related to dental caries. The association between government schools and dental caries was evident with an OR of 1.28; P< 0.05. Increase utilization of dental care was related to less dental caries (OR = 0.59; P< 0.002). Higher socioeconomic status was associated with less dental caries (OR = 0.42, P = 0.03). Association was found between malocclusion with dental caries; specifically with severe and handicapping malocclusion (OR = 1.32, P< 0.001) [Table 5].{Table 5}


The present study was undertaken to assess oral health behaviors and oral health status in 12-year-old in Udupi, Taluka. A target age of 12 years was selected as these age groups are WHO index age groups. Equal proportions of urban and rural school children were included in the study to allow their comparison.

In the present study, majority of the urban children used toothbrush and toothpaste. Similar findings were reported by the National Oral Health Survey and Fluoride Mapping 2002–2003[3] and other studies.[9],[10] This finding can be explained on the basis of increased awareness levels and easy access to toothbrush and toothpaste. Dental service utilization was reported significantly higher in urban school children compared to their rural counterparts. Similar findings were reported by Jürgensen and Petersen [11] Varenne et al.[2] It can be attributed to the lack of transport, financial resource, low awareness of oral health, cost of dental care, and location of dental clinics often located in urban areas.

Caries experience in the urban and rural children was 34% and 37.5%, respectively. Al-Shammery,[12] Shailee et al.,[13] Ferrazzano et al.[14] also reported same results. Our results revealed less caries prevalence than the results reported by Jürgensen et al.,[11] Goyal et al.,[15] Mahesh Kumar et al.,[16] John et al.[17] However, contrary to our findings, Lo EC et al.[18] have reported high prevalence of caries in urban children (30%), followed by peri-urban children (21%), and the lowest in rural children (13%). In our study, the DT component almost fully contributed to the DMFT, with virtually no missing teeth or FT component in 12-year-old urban and rural school children. The majority of investigators [2],[3],[11],[13],[18] have reported DT as dominant component in DMFT. DT component being dominant in DMFT can due to unmet treatment needs accumulated over a period.

The study observed high treatment needs for rural children. Most common treatment needs were one surface restoration followed by pulp care and restoration, two surface restoration, and extraction. Same results are reported from other studies;[13],[16],[17] these findings can be explained on the fact that dental care utilization in India, especially in rural areas, is limited due to barriers such as low dental manpower, financial cost and lack of awareness, other reasons can be fear, lack of dental knowledge among parents, low family income, lack of facilities and infrastructure, misconception regarding dental treatments due to illiteracy.[17] Oral hygiene status was poor in rural children. Poor oral hygiene in rural children reflects low awareness level and less use of oral hygiene aids in rural children. DAI recommended by the WHO was used to assess the prevalence and severity of malocclusion in the surveyed population. No significant difference was present in both subgroups for enamel hypoplasia, fluorosis, and DAI. Similar findings were reported by other investigators [3],[13] for rural and urban children.

The presence or absence of caries was significantly related to government schools, dental visiting pattern, socioeconomic status, and handicapping status malocclusion. Jürgensen and Petersen,[11] Kumar et al.[19] reported high risk for caries among males, children residing in semi-urban area, children with low and moderate socioeconomic standing, dental visits in the last 12 months. However, contrary to our study, Varenne et al.,[2] David et al.[20] reported high prevalence of dental caries with high utilization of dental services. Multivariate analysis in our showed study that those children who were studying in government schools were more at risk of developing dental caries as compared to subjects studying in private schools. Same findings were reported by other investigators.[13],[21],[22],[23] It can be attributed to socioeconomic status as these schools are accessed by the poor and the marginalized.


Urban-rural variations of oral health can be better described on the basis of socioeconomic status rather than urban and rural location. The poor oral health of children belonging to low socioeconomic background and high treatment needs of this group again confirms the complex relationship of socioeconomic status with oral health and targeting of poor and marginalized population for preventive and restorative care. Special emphasis must be given by the authorities to improve the oral health of these underprivileged children.


We acknowledge all the participants who agreed to take part in the study, administration of Manipal College of Dental Sciences for permitting to conduct the study and the statistician.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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