Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2023 | Month : June | Volume : 17 | Issue : 6 | Page : ZE14 - ZE18 Full Version

Periodontal Health-The Gordian Knot in Public Health: The Indian Standpoint


Published: June 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/58562.18050
Krishnendu Debnath, Swet Nisha, Debanjan Das, Nilanjana Goswami, Sudipto Barai

1. Intern, Department of Periodontology, Haldia Institute of Dental Sciences and Research, Haldia, West Bengal, India. 2. Associate Professor, Department of Periodontology, Haldia Institute of Dental Sciences and Research, Haldia, West Bengal, India. 3. Associate Professor, Department of Conservative Dentistry and Endodontics, Haldia Institute of Dental Sciences and Research, Haldia, West Bengal, India. 4. Intern, Department of Periodontology, Guru Nanak Institute of Dental Sciences and Research, Kolkata, West Bengal, India. 5. Assistant Professor, Department of Conservative Dentistry and Endodontics, Haldia Institute of Dental Sciences and Research, Haldia, West Bengal, India.

Correspondence Address :
Dr. Swet Nisha,
Department of Periodontology, Haldia Institute of Dental Sciences and Research, Haldia, West Bengal, India.
E-mail: swetnisha1@gmail.com

Abstract

Oral health is an inherent part of public health and is intricately related to systemic health. The interdependency of oral health and systemic health merges at the knot called periodontal health. Systemic diseases like cardiovascular diseases, metabolic diseases, and autoimmune diseases affect periodontal tissues and there lies a bidirectional relationship between periodontitis and diabetes mellitus. Taking this into consideration, periodontal health maintainance is essential for better systemic health. With the advancing health complications in the present time and due to spatial disparities, periodontal health is taking the shape of a concerning public health problem. India is facing some definitive challenges in terms of the oral healthcare system. Periodontal health assessment needs introduction of oral health programmes focusing on periodontal assessment, oral health policies and promoting education regarding periodontal health. Continous surveilliance of the disease can help us in determing the prevalence of disease, disease progression, early diagnosis, and treatment. This review aims at finding the existing problems addressing periodontal health as a public health issue, key challenges, and possible ways out of this problem.

Keywords

Oral health education, Periodontitis, Public health practice

Health is defined as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity” (1). What we understand from it is that health is an idealistic goal rather than a realistic proposition. Oftentimes, the word “health” is used merely as a synonym for disease. The concept of health is variable from person to person, subject to subject, topic to topic (2).

From a public health perspective, no doubt the idealistic concept of sound health, the healthcare system, the different branches and dimensions of health, and community are intricately related to each other (2). As the human race progress, different chronic diseases are emerging and becoming a burden to this intricate system of various aspects of health and community (3). This interlink and interdependency of various oral diseases and general health is attributed to factors such as high prevalence and high incidence of oral disorders, distribution of diseases, and available resources (4). It is important to understand how chronic diseases can have implications and what are the possible ways to resolve the stumbling blocks (5).

While discussing diseases, it is extremely necessary to understand the criteria which act as a determinant to establish whether a disease is an actual threat to the community posing a concern to public health. The various factors include social, psychological, and economic impacts (2). Although it is imperative to note how the various types of oral diseases are prevalent, its impact on quality of life remains undetermined (6). Those who get affected, suffer severely from the disease. The key to conclusion is that undoubtedly chronic diseases are a public health concern, the challenge is to recognise the associated issues with it, advocacy for the benefit of patients, act on the issues, and find a solution for them. Tonetti MS et al., illustrated the global burden of periodontal disease with 442 billion USD/year cost for oral diseases and urged for common risk factor approach to disease management (7). Health is highly dependent on various factors, and it is extremely necessary to link the factors to give or create an optimum health delivery system (2).

Periodontal health and systemic disease association has been established over decades (8). In India, lack of oral health education, proper resources, oral health policies, and oral health programmes leads to delay in diagnosis and treatment of periodontal diseases (9). The progression of periodontal disease can lead to tooth loss eventually which will compromise the eating habits and affect overall nutrition status of an individual. Policies for regular oral health checkup are very limited and according to a recent meta-analysis the prevalence of periodontitis is about 50%, which will mount up over the years if steps are not taken in early diagnosis of the disease and government strategies for oral health promotion (10). This is a public health issue and should be seriously considered for suitable interventions by health promoters and administrators.

SPHERE OF THE PUBLIC HEALTH PROBLEM

Public health is an action-oriented discipline linked to social sciences in health and organised healthcare, and is defined as the process of mobilising and engaging local, national, and international resources to assure that people can be healthy (11). It is very important to understand how the concept of public health widened from the late 1800s to recent times. While the global sector was going through revolution, industrialisation, and modernisation, the approach of public health became inclusive of various communicable and non-communicable diseases (12). At the very same time, cooperation started amongst various nations, communities, and international bodies, that just jointly resulted in the formation of a central health organisation, namely, the World Health Organisation (WHO) in the year 1948, which developed successful ways to fight various public health problems through various measures (13).

As the magnification of modernisation is happening, new diseases are appearing and becoming public health concerns. For example, West African ebola virus epidemic, zika virus epidemic, Coronavirus Disease 2019 (COVID-19) pandemic, etc. Various determinants are there behind the public health problems and these determinants are interdependent (14). This interdependency leads to the association of other traditional health problems persisting with these emerging public health problems.

It is essential to recognise the concept that when the health of a population is under threat due to some diseases, it is not the sole responsibility of the government to prevent it by executing its powers, but by the combined action of citizens, various organisational bodies, government, and international cooperation (15). The standards used to determine and establish whether the threat is a public health problem is illustrated in (Table/Fig 1) (16).

The basic conclusion that we can reach is that the aim of public health is not limited to addressing, identifying, implementing, or finding a solution to the disease, but evidence-based intervention for the development of cooperation, which would ultimately help to develop various health programmes and delivery systems (17).

Periodontal Health Posing a Public Health Concern

Periodontitis is a chronic inflammatory disease, polymicrobial in nature which can lead to tooth loss, disability and poor nutritional status, compromising speech and quality of life (18). Sheiham A and Watt RG, gave benchmarks of public health problems and periodontitis fulfills all of them (19). According to community periodontal index data, it has been found that adults across the globe suffer from periodontium-associated diseases, more specifically periodontitis by a percentage of 10-15% (19). It is imperative to note that periodontitis is the sixth most common disease worldwide (20). Periodontitis is also associated with various other systemic diseases, such as diabetes mellitus, vascular disorders, obesity, metabolic diseases, rheumatoid arthritis, HIV/AIDS, and pregnancy outcomes (21). The global freight of periodontal disease makes it necessary to explore its new territories in the light of public health.

Our understanding of the disease process itself has transformed over the years. The change has occurred at both global and individual levels. Although periodontitis is an inflammatory disease of polymicrobial nature with altered host immune responses, it has also been indicated that periodontitis is not only a disease itself, but a disease that poses a serious public health concern with its essential component being socio-political repercussions (22). Considering the case of countries like Brazil, Afghanistan, Indonesia, Somalia, and Sri Lanka that are either developing or have slower economic growth, it has been observed that oral health is a relatively low priority in the health policy of these countries (23). It is crucial to note that the risk factors remain the same among the population of the developed countries, making them equally vulnerable to the disease (24). Periodontal disease management depends on various factors associated with patients’ awareness, clinician skills, treatment planning, its epidemiology, and health policies targeting the disease control (25).

Present Backdrop of Periodontal Health Problems in India

The population of India is 138 crores as of 2020 and the census of 2011 reported that in 29 states and 7 union territories the female to male ratio is 940 to 1000 respectively. The population living in villages is 65.53% and the population living in urban areas is 34.47% (26). The various differences that exist in India, plays a major role in influencing the health of the population. Similar differences exist in case of oral health also. It is extremely necessary to note that numerous studies were conducted from 2006 to 2015, based on various parameters of health, specific to oral health. Based on the data of the already conducted studies, it was observed that the dentist to population ratio is dissimilar in urban, rural and coastal areas (27). 95% of the Indian population is suffering from periodontal infections in terms of oral health (28).

The tribal population existing in India accounts for 50% of the world’s tribal population, who get very minimal access to healthcare. It has been seen that they practice their traditional methods for treatment of various ailments, such as diabetes mellitus, rheumatoid arthritis, as well as oral diseases (29). These are the possible backdrops that are associated with oral health in India, specifically periodontal disease. The prevalence of periodontal disease was found to be 45% even amongst the 15+ years age group (30). This widespread prevalence needs a call for a plan to act upon. (Table/Fig 2) summarises various studies that suggest the prevalence of periodontal disease is extensively alarming (7),(10),(26),(29),(30),(31),(32),(33).

Key Challenges to Oral Health in India

India is a developing country. India currently is undergoing a metamorphosis in the economic, demographic, social, health, and epidemiological sector. It is quite unfortunate to state that these developments come with the cons of disparities at various levels. These disparities are linked with various factors, such as socioeconomic standards, literacy rates, quality of life, mortality rates and gender ratios (34). It is very evident that while we look forward to providing equal opportunities to access oral health, there are various spatial disparities to be considered beforehand and a feasible solution should be devised (35).

The specific challenges faced by healthcare professionals can be described through a five-pointer (Table/Fig 3) called the Five A’s (36).

1.Lack of Awareness: A diverse country like India shows diversity in terms of oral health awareness as well. However, the gaps are existing due to inadequate knowledge and other disproportions like socioeconomic factors, various poor healthcare practices, and poor literacy rate. In a study by Gadde P et al., regarding awareness of periodontal disease in West Godavari district of Andhra Pradesh, they found that the highest periodontal knowledge score (9.42±3.12) was observed in the high income group, and the lowest score (7.85±3.08) was found in the low income group (37).

2.Lack of Access: The spatial disparity of access is the most basic determinant to achieve equality in oral healthcare. The access is highly dependent on the locality of the population i.e., whether it’s urban or rural, or semi-urban. Another important factor in access is infrastructure. Nayak PP et al., in their study suggested lack of access in coastal areas in terms of primary oral care services, six rural areas had only public health centres to cater to their oral health. This data suggests the need for oral health programmes targeting rural and neglected populations (27).

3.Absence of Human Power: Human resource is the most predominant determinant of oral healthcare access. The lack of personnel workforce, their deployment, and training are a few reasons behind health inequity. Mathur MR et al., highlighted the inadequacy of human power to primary care services for oral health and the need for oral health promotions in rural areas (34).

4.Lack of Affordability: It is the cost that comes with access to oral health services. The private healthcare sector plays a prepotent role and it is quite questionable how affordable it is for the population of various economic strata. Kothia NR et al., in their report mentioned the affordability as an important factor as a barrier towards seeking oral care by individuals (35). The national oral health programme needs to incorporate this issue and work to overcome such barriers by providing minimal cost and effective treatment at primary health centres.

5.Lack of Accountability: The lack of professional, political, and governmental accountability is amongst the key components in the existing oral health inequality of India. According to Kasthuri A, accountability is an important factor when we assess disparity in healthcare services and oral health policy is a recently emerging policy. The government and oral healthcare professionals together unitedly have to work for the betterment of patient care (36).

There are successful health models that exist in the developed countries, amongst which Canada, France, Germany and UK have shown how to tackle the disparities through various benchmarks in terms of overall health that they have achieved (38). The key learnings can be taken from the models of these countries and probable implementation can be done to face the Five A’s encountered by healthcare professionals. The key lessons and possibilities of implementation are described in (Table/Fig 4) (38).

In India, while there is a saturation of dentists across the country, there is a clear unequal distribution of dentists (18). A large number of dental surgeons are located in urban or semi-urban areas, while the concentration is low in rural or poor localities (38). Mostly, for better quality of life and income, the dental surgeons settle in urban/semi-urban areas and clinics are located far from rural areas. The government hospitals provide just basic oral care and advanced periodontal treatments are unaddressed due to unavailability of resources, clinician skills, and time and manpower related issues (39).This unequal distribution of dentist to population ratio is 1:9992, which often gives rise to the improper ratio of oral health workers and the population (40). This inequity also creates some barriers to the oral health status of the country that can be described as the following (41):

1. Lack of proper knowledge and awareness about oral health
2. Lack of access to treatment facilities
3. The cost of the dental treatment
4. Lack of quality dental care in rural and poor areas

It is essential to address these key challenges faced by the Indian population and to find a feasible solution to provide a healthy life.

Overcoming the Barriers-The Way Forward

A. T Tackling the Barriers of Oral Health Problems in India:

The national oral health system needs an integrated system focusing on oral healthcare, rendering better oral healthcare. To improve oral health access following suggested measures can be considered (42).

Mention steps to aid in the process of identification. Cite examples of specific reforms needed

(i) The most important concern should be identifying the various oral diseases and prevention of those diseases. Proper education and awareness regarding oral diseases can help in early diagnosis and management. National oral health programmes have promoted awareness by adversitements, dental camps and providing oral care at primary health centres (29).
(ii) The second priority should be an investment in the health sector by increasing the health budget, increasing access and allocation for financial resources.
(iii) The third concern should be improving the supply chain and increasing the workforce with equal distribution of healthcare workers. However, a study by Padminee K et al., in their study concluded that the Disability Adjusted Life Years (DALYs) of oral disease burden ranged from 250 to 350. Pearson’s correlation showed no association between dental workforce distribution and oral disease burden (p=0.084) (39).
(iv) The fourth priority should be in bringing various new technologies, promotion of health services, and bringing excellence into the healthcare-Ayushman Bharat Digital Mission is a great initiative for integrated digital health infrastructure of the country. Teledentistry can be a great initiative for oral health promotion.
(v) Last but not the least, the priority should be an acknowledgment and looking for policies to improve health equality. Mathur MR et al., suggested in their review the need for improving access and spreading the messages of health promotion across entire spectrum of socio-economic hierarch (34).

B Tacklingthe Barriers of Periodontal Health Problem in India:

As per the national health survey, the chronic diseases burden is concentrated on the diseases like infectious diseases, respiratory diseases, cardiovascular diseases, pulmonary diseases, and cerebrovascular diseases, all of which can be related to oral health (42). Nazir M et al., stated the global prevalence of periodontitis and distribution of periodontal disease increases with age (31). Janakiram C et al., found that in India the prevalence rate was 51.0% compiling the 24 studies they had taken into consideration (10). This data is very alarming and reforms in oral health programme and oral health policies are needed to prevent further progression of periodontal disease.

As we know, periodontal disease is irreversible with loss of periodontal tissue, rehabilitation should be instated early to prevent tooth loss.Periodontal disease symptoms and general term pyorrhoea can be used to educate the population. Oral health policies should target to address reforms to arrest disease progression. Together as a team we can bring changes and quality of life related to periodontal and oral care.

Therefore, it is evident changes and improvement in periodontal health is required which will reflect good oral health also and the following changes are suggested (43).

(i) Promotion and creating awareness about oral health through various collaborative programmes between government and public organisations or corporate and community or school and community. Dental education and school health programmes can be a great initiative targeting this issue. The oral health programmes have started educational programmes but its implementation at primary levels still needs proper planning and management (44).
(ii) Reducing the usage of tobacco or other carcinogenic materials to fight the oral cancers-awareness among individuals regarding effects of tobacco on oral and systemic health and providing counselling for quitting the habit. Training oral health workers for assessing and early management of tobacco related oral health problems through the national tobacco control programme is essential (45).
(iii) Optimally adjusted concentration of fluoride use in community.Dental fluorosis is a major public health problem in India in which 15 out of 32 states are affected by the burden of dental fluorosis (46). Providing safe and quality drinking water with maximum allowable limit of fluoride at 4 ppm. Community drinking water sources should be assessed regularly for fluoride levels. Also, school water systems should be checked for optimal fluoride levels (46).
(iv) By making dental care accessible and affordable to the population.
(v) By bringing the proper distribution of the human resources and improved budget allocation for oral health.
(vi) By introducing new oral health policies and the introduction of public-private-partnerships (PPP) models for oral health and finally, unification of oral and medical health utilities (47).

Conclusion

Public health includes the process of organising and drawing the focus of various resources from local, national and, international bodies. As India is a diverse country in terms of population, policies, and laws by the government, it is important to develop the concept of public health amongst the community both in terms of general health and oral health which should considerably focus on periodontal health.

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DOI and Others

DOI: 10.7860/JCDR/2023/58562.18050

Date of Submission: Jun 20, 2022
Date of Peer Review: Jul 25, 2022
Date of Acceptance: Nov 25, 2022
Date of Publishing: Jun 01, 2023

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 22, 2022
• Manual Googling: Oct 19, 2022
• iThenticate Software: Nov 24, 2022 (4%)

Etymology: Author Origin

Emendations: 7

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