Comparison of Periodontal Status between Koraga Tribes and Malavettuvan Tribes in Kasargod District of Kerala: A Cross-sectional Study

1. Senior Lecturer, Department of Periodontics, Asan Memorial Dental College and Hospital, Chengalpattu, Tamil Nadu, India. 2. Professor and Head, Department of Periodontics, Sharavathi Dental College and Hospital, Shimoga, Karnataka, India. 3. Professor, Department of Periodontics, Sharavathi Dental College and Hospital, Shimoga, Karnataka, India. 4. Professor, Department of Periodontics, Sharavathi Dental College and Hospital, Shimoga, Karnataka, India. 5. Senior Professor, Department of Periodontics, Sharavathi Dental College and Hospital, Shimoga, Karnataka, India. 6. Reader, Department of Periodontics, Sharavathi Dental College and Hospital, Shimoga, Karnataka, India.

Abstract

Introduction: The lack of a healthcare system is one of the serious problems among the Koragas. The Koraga tribal community in the Kasargod district has a community health center in the area, but it lacks advanced medical and dental facilities, making it difficult for them to seek treatment in the few private hospitals in the area due to their economic backwardness. The Malavettuvan tribes are distributed only in the ghat areas of the Kasaragod District of Kerala. Their major occupation is agriculture, and they are educationally, economically, and socially backward.

Aim: To compare the periodontal status of the Koraga and Malavettuvan tribes of the Kasargod district.

Materials and Methods: This cross-sectional study was conducted among randomly selected 304 participants from both Koraga and Malavettuvan tribes aged 35-55 years. Clinical parameters such as the oral hygiene index, Community Periodontal Index (CPI), and loss of attachment were measured. A questionnaire was used to assess the oral hygiene habits, lifestyle, and other habits of the populations. Statistical analysis was carried out using the Mann-Whitney U-test.

Results: The results of the present study showed a significant difference in the oral hygiene index (Median OHI of Koraga-0.40, Malavettuvan-1.20 respectively, p-value <0.001) and CPI (Median CPI of Koraga-0.60, Malavettuvan-1.50, respectively, p-value <0.001) between both groups, while there was no difference in the loss of attachment (p-value-0.991). The majority of the Koragas and Malavettuvans used toothbrush and toothpaste as cleaning aids (70.06% and 78.28%, respectively). Smokeless tobacco was prevalent among Koragas compared to Malavettuvans (36.18% and 29.60%, respectively), while cigarette smoking was more common among Malavettuvans (50.98% and 42.10% for Koragas and Malavettuvans, respectively).

Conclusion: Even though the Koragas and Malavettuvans do not routinely seek dental care and have a primitive lifestyle with less formal education, a lower level of periodontal disease was observed among both groups. There is a need to promote more healthcare programs that emphasise oral health among these populations.

Community periodontal status, Dental care, Habits, Oral hygiene status, Periodontal diseases

India represents a vast land of diversity with its unique and intriguing culture, traditions, and beliefs. Despite rapid advancements in the fields of diagnostics and medicine, a more obscure picture of the ‘Tribes’, who represent the nation’s true indigenous colour, can be noticed. According to the census of scheduled tribes in 2011, the population of scheduled tribes constitutes 9.01% of the total population of India (1). Tribes are indigenous populations who live in isolated areas away from contemporary trends and economic developments of the land, holding onto their traditional values and customs (2).

Most of the scheduled tribal population is suffering from malnutrition and infectious diseases, often referred to as ‘diseases of the poor’ (3). Micronutrient malnutrition such as anaemia and iodine deficiency disorders are major health issues among the scheduled tribes (2). Studies have reported rising incidents of malaria and tuberculosis in the forest tribes; hence, they require special medical care due to their difficult terrain and isolation (4). Poverty, illiteracy, harsh living environments, high rates of beedi smoking, alcohol use, and poor access to oral and general healthcare are common risks of ill-health faced by them (5). Due to their inaccessible living areas, lack of education, and limited capacity to avail benefits, they have further reduced their chance of good health (2),(6).

The Koragas are indigenous to Dakshina Kannada, Udupi, Karnataka, and Kasaragod, Kerala, in South India. The places where they reside in Karnataka are usually called ‘Tulu naadu’ (7). According to the 2001 census of India, the total Koraga population of the nation is 16,071, which has increased to 16,376 in the 2011 census (8). Their language is Koraga, which has no script, and they speak Kannada, Tulu, and Malayalam according to the places they live (9).

The diet of the Koraga mainly consists of rice and meats such as beef and pork, along with pulses and vegetables (7). Their main occupation is basket making and food gathering (9). They medical and dental healthcare facilities. Diseases such as asthma, tuberculosis, skin conditions, malaria, and visual disabilities are common in this community (10). Women and children also suffer from malnutrition and chronic diseases such as anaemia (10).

Initially, the Koragas were inhabitants of Dakshin Karnataka. The Koragas migrated to Kerala when Kasargod district, which was part of Karnataka, was added to Kerala. As commercialisation increased, they became ‘outsiders’ and were alienated in the land they had inhabited for centuries (10).

The Malavettuvan tribes are scheduled tribes seen only in the Kasaragod District of Kerala, especially in the ghat areas. They are commonly called ‘Vettuvans’ and speak Malayalam and Tulu. They cultivate herbal plants used for treating ailments of the kidney, urinary bladder, skin-related diseases, etc., (11).

Physical distances and geographic barriers have imposed impediments to human interaction and have led to endogamous (i.e., within-group) mating patterns resulting in genetic substructure (12). An understanding of the unique patterns of genes across patient populations defined by race helps in identifying populations at risk of developing particular diseases. It enables better treatment planning and preventive measures to tackle those diseases [13,14]. Differences in socio-economic status also account for the health inequalities between indigenous and non-indigenous groups.

Several studies on tribal communities have reported a lack of education, economic progress, or healthy lifestyles, as well as limited access to medical or dental care, resulting in a high prevalence of oral diseases (15),(16),(17). Additionally, alcohol abuse, tobacco use, stress, and social hierarchy affect overall health. Except for a study by Dey MS et al., describing the periodontal status of the Koraga tribe, none have been published to date (15). Furthermore, literature describing the periodontal health or oral health status of Malavettuvan tribes is lacking. Hence, the present study was planned to determine the periodontal health status in these two different ethnic groups of Kasargod district, Kerala, which would provide details for a better understanding of the pathogenesis of periodontal diseases in these populations.

Material and Methods

This cross-sectional study was conducted in the tribal colonies of the Koraga and Malavettuvan tribes in Badiaduka and Panathadi panchayats of Kasargod district, Kerala, India systematically scheduled from November 2017 to May 2020. The list of tribal colonies in Kasargod district was obtained from the District Tribal Development Office, Kasargod, Kerala. The Institutional Review Board of a private dental college issued ethical clearance (SD/SMG/2017/648) and permitted the study to be conducted. Informed consent, verbally and in written form, was obtained from participants after a detailed discussion about the purpose of the study.

Inclusion criteria: Individuals belonging to the Koraga and Malavettuvan tribes, aged 35-55 years, residing in the rural areas of Kasargod district, Kerala were included in the study after giving informed consent.

Exclusion criteria: Bedridden patients, infants, and children, people residing in the same geographic area but not belonging to the Koraga and Malavettuvan tribes and those who had systemic diseases were excluded from the study.

Sample size estimation: A pilot study was conducted in the Badiadka panchayat of Kasaragod district on 30 subjects from both tribes to determine the sample size and the feasibility of the study. A sample size of 304 was required, with an expected prevalence of 60% in one group and 50% in the other, with a power of 80% and an alpha error of 10%.

Questionnaire: A modified and content-validated questionnaire based on the World Health Organisation (WHO) Oral Health Assessment Form for Adults, 2013, was used to assess the socio-demographic characteristics, habits, and oral health beliefs (18). The questionnaire included a total of 11 questions about the presence of pain, oral health practices, frequency of dental visits, dietary habits, tobacco use, alcohol consumption, and education. The validity and reliability score of the questionnaire was 0.85. Intraoral examinations were conducted using a mouth mirror and CPITN probe in a wooden chair under adequate natural light by a single examiner, with the findings recorded by a trained assistant.

Baseline data of all the patients were collected, including:

1. Socio-demographic data consisting of information on age, sex, geographic location, and occupation.

2. Oral hygiene practices, including brushing technique and material used.

3. Any associated deleterious habits.

4. Previous exposure to dental treatment.

5. Clinical parameters recorded were:
- Oral Hygiene Index (Simplified)- John C Greene and Jack R Vermillion 1964 (19).
- Community Periodontal Index (CPI)- Joint Working Committee of WHO 1982 (20).
- Loss of attachment using the cementoenamel junction as a reference point using the CPITN probe (18).

Statistical Analysis

The recorded data was evaluated and analysed using the Statistical Package for the Social Sciences (SPSS) software version 15.0. The Kolmogorov-Smirnov and Shapiro-Wilk tests were used to test for normality. As the majority of variables were not following a normal distribution, the Nonparametric Mann-Whitney U-test was applied to compare the clinical parameters. The Chi-square test was used for intragroup comparison.

Results

The total study population was 608, with 304 subjects in each tribal group. The participants in the Malavettuvan and Koraga groups had mean ages of 42.52±15.77 and 41.82±14.69 years, respectively. Among the Koragas, there were 140 men and 164 women, while in the Malavettuvan group there were 148 men and 156 women.

The median OHI scores for the Malavettuvan (1.20±0.833) and Koraga (0.40±0.559) groups differed significantly, which was statistically significant (p<0.001). The median CPI values for the Koraga Group were 0.60±1.954, while those of the Malavettuvan group were 1.50±1.885 (p<0.001) (Table/Fig 1).

According to the questionnaire, the Koraga group reported more pain and discomfort (n=125, 41.11%) than the Malavettuvan group (n=117, 38.48%) (p=0.56) (Table/Fig 2). Among the Koragas, 86.51% (n=263) brushed their teeth once daily, while in the Malavettuvan group, it was 80.92% (n=246) (Table/Fig 2). In the Koraga group, 70.06% (n=213) used toothbrush and toothpaste, and 29.93% (n=91) used charcoal as an oral hygiene aid. However, in the Malavettuvan group, 78.28% (n=238) used toothbrushes and toothpaste, and 21.71% (n=66) used charcoal (Table/Fig 2). Among the Koraga participants, 39.80% (n=121) visited the dental clinic within a 6-month interval, while 37.82% (n=115) of Malavettuvan tribes visited the dental clinic within the same interval (Table/Fig 2).

Betel nut use (n=76, 24.2%) and gutka use (n=110, 36.8%) were more prevalent among the Koragas than among the Malavettuvans (18.3%, n=55) and (29.60%, n=90), while cigarette use was more common among the Malavettuvans (n=155, 50.98%) (Table/Fig 2). Rice, vegetables, and cassava are more commonly consumed by Koragas, while rice, vegetables, and fruits are more commonly consumed by Malavettuvans (Table/Fig 3). Consumption of alcohol was higher among the Koragas (n=230, 75.65%) compared to the Malavettuvan group (n=168, 55.26%) (Table/Fig 2). Primary education was not received by 41.11% (n=124) of Koragas and 37.17% of Malavettuvans (n=113)
(Table/Fig 2).

Discussion

The present study conducted among the Koraga tribe and Malavettuvan tribe of Kasargod district showed a lower prevalence of periodontal diseases. A similar study conducted by Dey MS et al., among Koraga tribes in Mangalore Taluk concluded that Koraga tribes have a higher prevalence of gingival and periodontal diseases. It was evident from their study that Koragas are living a difficult life, have poor oral hygiene, and are deprived of awareness and access to treatment facilities (15).

The mean OHI-S index values for Koraga and Malavettuvans indicated fair oral hygiene status, but when compared between the two groups, the oral hygiene index of the Malavettuvan tribes showed a higher score. The present findings are in accordance with similar studies conducted on other communities such as the Koya and Lambada groups of Telangana, Australian aborigines, and residents of Kolar district (21),(22),(23). The high mean values of the oral hygiene index and its components suggest a widespread and uniform neglect of tooth cleaning/brushing habits among tribal groups. The relatively fair oral hygiene among the Koraga tribes may be due to their habit of gargling their mouth and a majority of them brushing their teeth with toothpaste and a toothbrush, indicating a change in attitude towards oral hygiene.

The CPI was used to determine the prevalence of periodontal disease among both tribes. The prevalence of periodontal disease was lower among both tribes. This is in accordance with a study conducted by Bharathesh JV and Reddy CVK, on the Todas, aboriginals of the Nilgiri Hills in South India (24). The Malavettuvan tribes showed a significantly higher prevalence of periodontal disease compared to the Koragas. The average number of sextants with bleeding on probing was significantly lower in the Koraga and Malavettuvan groups. Similar findings were observed by Jordan RA et al., in rural African Gambia (25).

The prevalence of loss of attachment was lower in both tribes, and there was no significant difference between the two tribes. This can be compared with a study conducted by Bagramian RA et al., among the Amish native people, where he observed low levels of periodontal diseases among the Amish, even though they did not seek regular dental care (26). This may be attributed to the fact that people belonging to these tribes consume large amounts of vegetables, tubers, and roots, which may have a self-cleansing effect on the teeth. Diet also plays a role in maintaining their oral hygiene, as the diet of Koraga tribes includes highly fibrous foods rather than refined carbohydrates, as observed during the study.

In the Koraga and Malavettuvan tribal populations, the majority of individuals cleaned their teeth using a combination of toothbrush and toothpaste. Khadir RA et al., who conducted a study on aborigines of Selangor, West Malaysia, reported that the majority of the population used a toothbrush with toothpaste and brushed their teeth once daily, which was also observed in the present study (27). Conversely, Bhat PK and Sushi K, reported that chew sticks (79.8%) were more commonly used than toothbrushes in Iruliga tribes in Karnataka (28). The authors suggested that participants typically provide socially acceptable answers to queries about dental health and dental health behaviour (28). Several epidemiological studies have been conducted across the country among tribal groups to assess periodontal health (Table/Fig 4) (15),(16),(17),(29),(30).

The Koragas mainly used tobacco in smokeless forms (gutka-36.18%, betel nut-24.2%) compared to the Malavettuvans (gutka-29.60%, betel nut-18.3%). This is consistent with the study conducted by Dey MS et al., in Koragas of Mangalore Taluk, where 34% of them had the habit of betel nut chewing (15). It was observed that they always carry a small pouch containing betel leaves and areca nut powder. Due to continuous betel nut chewing, the majority of them had generalised attrition, and many (38-42%) experienced pain and sensitivity. Cigarette smoking was found to be more prevalent among the Malavettuvans (50.98%) compared to the Koragas (42.10%). They believe that smoking and smokeless tobacco provide relief from the heavy labor they perform. This behaviour may also be associated with their illiteracy and lack of awareness regarding the harmful effects of these habits.

Education and motivation of the population are required to improve oral hygiene, implement oral hygiene measures, and discourage habits like smoking, smokeless tobacco use, and alcohol consumption.

Limitation(s)

Given the higher usage of tobacco among the tribes, additional parameters such as oral and mucosal lesions, dental stains, and dental caries could have been considered. There is a possibility that participants in the study may have provided socially acceptable answers to questions about dental health and behaviour. More interventional designs should be considered in tribal communities to enhance their oral health.

Conclusion

Within the limitations of the study, it can be concluded that although the oral hygiene measures of both tribes were inadequate, they still exhibit a lower prevalence of periodontal destruction. The Koraga tribe showed better oral hygiene and less periodontal destruction than the Malavettuvan tribes, partly due to accessibility to oral health care, education, and government-implemented programs. The role of diet, which includes rich fibers rather than refined sugars, their habit of frequent mouth gargling, genetic constitution, immunity, and other protective factors, may have influenced the prevalence of disease and deserve mention. Therefore, more community health care programs emphasising the importance of oral health among these tribal populations should be implemented.

DOI and Others

DOI: 10.7860/JCDR/2024/66246.19406

Date of Submission: Jul 18, 2023
Date of Peer Review: Sep 23, 2023
Date of Acceptance: Feb 22, 2024
Date of Publishing: May 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 18, 2023
• Manual Googling: Feb 17, 2024
• iThenticate Software: Feb 20, 2024 (16%)

ETYMOLOGY: Author Origin

EMENDATIONS: 9