Dental Public Health, Barriers in oral health care delivery systems, socio-cultural issues

1. SOCIO CULTURAL
BARRIERS IN ORAL
HEALTH
Dr.Priyanka Sharma
III Year MDS
Dept. of Public Health Dentistry
JSS Dental College & Hospital

2. CONTENTS
 Introduction
Social environment
Social Science
Society
Culture
 Terminologies
 Classification of barriers in oral health
FDI Classification of barriers
US Academy of general dentistry
Jain et al

3.  Reasons for changing pattern of oral diseases globally
 Indian scenario of oral health and medical health
 Social context of Oral health
 Role of culture & religion on oral health
 Strategies for breaking the barriers
 Conclusion
 References

4. INTRODUCTION
SOCIAL ENVIRONMENT
 Social environment is an important as the physical and
biological environment in relation to health and disease in
man.
 The effect of social environment on health is clearly
reflected in the differences in disease patterns of rural
versus urban and developing versus developed countries.

5.  The term social environment denotes the complex of
psychosocial factors influencing the health of the
individual and the community.
 This environment is unique to man.
SOCIAL SCIENCE
FIVE SOCIAL
SCIENCES
BEHAVORIAL
SCIENCES
SOCIOLOGY
CULTURAL
ANTHROPOLOGY
SOCIAL
PSYCHOLOGY
ECONOMICS
POLITICAL
SCIENCE

6. Customs
Cultural
Values
Habits Beliefs
MoralsAttitudes
Religion Education
Occupation
Income
Standard
Of Living
Community
Life
Political
Organization
Social
Organization

7.  Sociology : Science concerned with the organization or
structure of social group.
 SOCIETY - A system of uses and procedures of authority
and mutual aid of many groups coupled with division of
control of human behavior and liberty.
 Community : A group, small or large living together in
such a way that the members share not one or more
specific interests rather the basic conditions of a
common life. Eg) People living within a residential
layout.

8.  Social norms: The rules that a group uses for appropriate and
inappropriate values, beliefs, attitudes and behaviours.
 Values are broad cultural principles defining what is good or desirable.
Reflected to knowledge, attitude and self-care practices of oral health.
 Social norms: Folkways : William Graham Sumner
A study of sociological importance of manners,customs, mores and morals.
 Mores : Mores derived from the established practices of society rather
than the written laws.
Eg. Sanctions : are rewards or punishments used to encourage socially
acceptable behavior.

9.  Custom : Practice that has been repeated by number of
generations, practices that tend to be followed simply
because they have been followed in the past. Have a
traditional, automatic, mass character.
 Habit : Habituated routines of behaviours that are
repeated regularly. It is an acquired tendency to
respond in an identical way to a situation or stimulus.
 Belief : An acceptance that something exists or is true,
especially one without proof.

10. CULTURE
 It is the accumulation of learned behaviors, beliefs and skills of
mankind as a whole.
 It comprises everything which one generation can hand down to
the next.
 Oxford dictionary definition: The training and refinement of mind,
tastes and manners, the condition of being thus trained and
refined.
 An understanding of cultural background is important when
attempting to change health beliefs and attitudes &
 Also to understand why people accept or do not accept dental or
health care.

11. SOCIO-CULTURAL
 A set of beliefs, customs, practices and behavior that
exists within a population.*
*http://www.businessdictionary.com/definition/socio-
cultural-environment.html#ixzz3l10w0vh8
BARRIERS
 Can be defined as something that prevents or controls
advances, access or progress.

12. FEDERATION DENTAIRE INTERNATIONALE
(FDI)
B
A
R
R
I
E
R
S
Related to individual :lack of perceived
need, anxiety and fear, financial
consideration and lack of access.
Related to Dental Professional:
Inappropriate manpower resources,uneven
geographical distribution, in appropriate
training to changing needs, insufficient
sensitivity to patients’attitudes and needs.
Related to Society: Insufficient public
support of attitudes conducive to health,
inadequate oral health care facilities,
inadequate oral health manpower planning
and insufficient support for research.

13. The U.S. Academy of General
Dentistry(2012)
Oral health
literacy
Psychological
factors
Financial
factors
Patients with
special
needs
Psychological factors
a Turning literacy into healthy
behaviors (Patient activation)
b. Treatment mentality vs.
prevention mentality
c. Social and cultural misperceptions
Financial factors
a. Economics of sustainable care
delivery
b. Provider distribution

14. BARRIERS TO ORAL HEALTH CARE DELIVERY SYSTEM IN
INDIA (Jain et al.2013; Health Talk,Vol-5,Issue3)
Barriers in
Affordability
• Inadequate
financial
coverage or
high cost
• Poverty the
biggest barrier
Barriers in
Accessibility
• Geographic
barriers
• Age, gender
and occupation
• Social and
cultural barrier
• Lack of clear
information for
beneficiaries
about dental
services
Barriers in
sustainability
• Workforce
barriers
• Barriers within
the dental
profession

15. Principle factors involved in
changing oral disease patterns
worldwide
Oral
disease
& Health
Oral health system
Delivery models
Finance of care
Dental manpower
Population-directedhigh
risk strategies
Environment
Climate
Fluoride and water
Sanitation
Population
Demographic factors
Migration
Society
Living conditions
Culture and lifestyle
Self-care
Book Community Oral Health
Cynthia Pine CBE & Rebecca Harris
2007

16. INDIAN SCENARIO
 Changes in the lifestyle of the people are resulting in a
dual disease burden.
 This emanates from the complexity of oral diseases in
the rural and urban regions of the country.
 The occurrence of these disease patterns has impacted
the healthcare infrastructure requirements and has
resulted in infrastructural challenges for the
government and the private players.
 India rates poorly on even the basic healthcare
indicators.

17. • The dentists: population ratio of India, on date is 1:
10,000. However, the reality is that; in rural India 1 dentist
is serving over a population of 2,50,000. *
Indicators year India USA UK Brazil China
No. of
Dentists
2009 55,344 4,63,663 25,914 2,17,217 1,36,520
No. of
doctors
per
1000
population
2009 0.6 2.7 2.1 1.7 1.4
Source: www.oecd.org, www.whoindia.org
*Ahuja et al 2011,IJDS

19.  75% of health infrastructure, dental man power and other health
resources are concentrated - urban areas where 27% of the populations
live (Inverse care law).
 India has traditionally been a rural, agrarian economy.
 Nearly three quarters of the population, currently 1.2 billion, still live
in rural areas.
 India is drawing the world’s attention, not only because of its
population explosion but also because of its prevailing as well as
emerging health profile and profound political, economic and social
transformations.
 Despite several growth orientated policies adopted by the government,
the widening economic, regional and socio-cultural disparities
are posing challenges for the health sector.
Kulkarni A.P, Baride J.P, Doke P.P, Mulay P.Y. Text book of Community Medicine. Ch-15 Health Care in India- Part A. 4th ed. Mumbai: Vora Medical Publications; 2013.

20. http://first5oralhealth.org/rural_smiles/downloads/chapter1/Potential%20Barriers.pdf

21. SOCIAL FACTORS AFFECTING
ORAL HEALTH
 According to Petersen, socio-cultural and environmental
factors play an important role in oral disease and health, and
this has been demonstrated in several reports.
 The social, economic, political and cultural determinants of
health are considered to be significant, and better health can
be achieved by reducing poverty.
Hashizume LN.
Journal of Oral Science.2011;53(3):307-312.

22. Socioeconomic status &
Oral health
(Dental caries
,periodontal diseases)
Race /
Ethnic
Education,
Income and
Occupation
Age/ Gender
knowledge
variations
Multicultural
Issues
Social
barriers

23. SOCIO-ECONOMIC STATUS
 Socioeconomic status (SES) is the social standing of an
individual or group in terms of their income, education, and
occupation.
 Research suggests that both physical and mental health is
associated with SES.
 Socioeconomic factors have been identified as predisposing
factors in the development of oral disease.
 The association between SES and the number of sound teeth
suggested that reducing the barriers to regular dental
attendance and promoting regular dental attendance for low-
socio-economic groups may reduce oral health inequalities to
some extent.
Biradar & Hiremath et al , 2013 Journal of Medical Education and Research

24. SES & DENTAL CARIES & PERIODONTAL
DISEASES
 Brennan DS et al in 2011, explained the relationships between
disease experience, treatment, attendance and socioeconomic
status.
 Irregular attenders had significantly higher dmft, dt and mt,
and fewer filled teeth. Both socioeconomic status and visiting
behaviour exerted significant independent effects on dmft, but
dental attendance alone had a significant effect on ft.

25.  Borrell LN et al in 2006 concluded that children who live in areas
with lower average income present greater risk of having higher
caries severity and poorer oral hygiene in comparison to those
living in more affluent areas, and children with an immigrant
background also have higher likelihood to present higher dmft and
DMFT values.
 Another study by Gundala R et al in 2006 reported that dental
behavior in terms of brushing and visiting was associated with
social gradients in oral health for decayed teeth
across income groups, with less favourable dental behaviour
having a stronger negative association with oral health among
lower income group

26.  A study conducted by Chandra Shekar BR et al 2009
stated that significant decrease in periodontitis is seen
when income and educational levels increased.
And also the prevalence of periodontitis associated
with healthy lifestyle is significantly lower compared
to unhealthy lifestyle.
Signifying a strong association of lifestyle, education
level, and socioeconomic status with periodontal
health.

27. RACE & ETHNICITY:
 Significant racial and income differences were evident in
dentists' reports of payment mix, characteristics of typical
patients, types of procedures typically done, typical fees,
practice busyness, waiting room times, and delays to get an
appointment.
 Systematic differences in the dental practices attended were
evident, as a function of the person's race and income,
differences that are associated with social disparities in oral
health.
Gilbert GH et al 2007 J Health Care Poor Underserved

28.  Racial and ethnic disparities in health have long been
documented in public health literature. The underlying
mechanisms include differing health behaviours, medical
decision-making, quality and access to care, and cumulative
effects of discrimination. These mechanisms are
intertwined with socioeconomic status, which has been
linked to health generally through, for example, relative
and absolute disadvantage, neighborhood effects and
residential segregation, and access to care.
Nicklett EJ. Socioeconomic status and race/ethnicity
independently predict health decline among
older diabetics. MC Public Health. 2011;11:684.

29. AGE/GENDER
 Gender as well as age remains an important consideration when
planning dental health education or other interventions at the
workplace.
 Women perceived oral health as having a greater impact than men on
their quality of life in general, having a greater positive impact.
 Specifically women perceived oral health as causing them more pain,
embarrassment and being detrimental to their finances compared to
men.
 Women also more frequently perceived oral health as enhancing their
life quality, their moods, their appearance and their general
wellbeing than men.
 There are gender variations in the social and psychological impacts of
oral health.
Biradar & Hiremath et al , 2013 Journal of Medical Education and Research

30.  Females had more positive dental health attitudes and
behaviours (making regular visits the dentist, being more
educated about professional tooth brushing and taking
more care with brushing their teeth).
 As the age increases the oral health problems widen and
the affordability and accessibility to dental care reduces.
 The knowledge among rural area females were found less
than the urban level in India.
 Reason behind this is poverty and lack of accessibility.
Biradar & Hiremath et al , 2013 Journal of Medical Education and Research

31. CULTURAL BARRIERS & ORAL
HEALTH
 The role of culture and religion on oral health can be
discussed under following headings :
 Family
 Mother and child care
 Food habits
 Oral hygiene practices
 Other habits
 Caste
 Sex and marriage
 Social class
 Tooth mutilation and soft tissue mutilation

32. Family
 The family is a primary unit in all societies. It is a group
of biologically related individuals living together and
eating from a common kitchen. As a biological unit, the
family members share a pool of genes; as a social unit,
they share a common physical and social environment;
and as a cultural unit, the family reflects the culture of
wider society of which it forms a part and determines
the behaviour and attitude of its members.

33.  Joint family is a kind of grouping which is common in
India, Africa, and in Middle East countries. It is more
common in rural areas than urban areas, the presence
of parents, grand parents, uncles, aunts, and relatives
play a vital role in building up of one's behaviour and
attitude. The mother takes absolute care in bringing up
of the infants and children upto a certain age, the
father provides for education and teachers the child the
social traditions, customs and culture.

34.  In case of nuclear or elementary family, the absence of
grand parents, uncles, aunts, and near relatives places
a greater burden on the husband and wife in terms of
responsibilities for child rearing and brining up. The
parents cannot provide adequate attention on the
children where both the parents becomes the earning
members of the family.
 Hence we can say that joint family play an important
role in shaping an individual in adapting healthy life
styles.

35.  In America and European culture, the children above 12
years start living on their own. Due to the lack of
parental attention or due to peer influence, they may
acquire habits like smoking, chronic alcoholism,
nacrotic drug addiction etc.
 In America and European culture, the children above 12
years start living on their own. Due to the lack of
parental attention or due to peer influence, they may
acquire habits like smoking, chronic alcoholism,
nacrotic drug addiction etc.

36.  In India, there are common beliefs especially in the
rural areas of Bihar, U.P. and Madhya Pradesh that
children are gifts of god, the number of children in the
family is determined by God, they think that children
are poor mans wealth, all lead to close birth intervals
causing maternal malnutrition, anemia and low birth
weight. This has an impact on mothers as well as
child’s oral health.

37.  Mother and Child Care :
In many parts of India eating Papaya (more common in T.N.
and Pondicherry) and certain other food items eg. Eggs,
meat, leafy vegetables are forbidden to pregnant women
due to the misbelief that they may induce abortion or
generate heat in the body and that may affect the
developing foetus. So in this way rich sources of Vitamin A,
iron, calcium, are not available to mother and developing
foetus. These practices have a negative bearing on oral
health of mother as well as developing foetus.

38.  In rural areas of India, the child is not put to breast
feeding during the first 3 days due to misbelief that
colostrum is harmful, this prevents the passive transfer of
immunity from mother to child making the child more
susceptible to oral infection.
 Adverse cultural practices relating to premature
termination of breast feeding and feeding child with over
diluted cows milk leads to protein energy malnutrition and
thereby oral health of the child is affected (Shah et al
1974).

39.  There are beliefs that diarrhoea in children during
teething is a normal phenomenon and some believe that
diarrheoa takes out the heat from the body, hence
mothers are reluctant to get their children treated,
these beliefs would cause malnutrition and affects oral
health

40.  Food Habits :
Food habits are among the oldest and most deeply entrenched
aspects of any culture. They have deep psychological roots,
religious influence, customs, beliefs and influence of local
conditions. The family plays an important role in shaping the
food habits and these habits are passed from one generation to
other.
Rice is the staple food in Eastern and Southern states of India.
Deficiency of riboflavin is wide spread particularly in these
populations where rice is the staple food.

41.  On the other hand pellegra due to Niacin deficiency is
historically a disease of the maize eating population.
Pellagra has been reported in India in Telangana area of
A.P.
 Studies of Gopalan et al (1971) have shown that amino acid
imbalance caused by excess of leusine is the cause of
pellagra in both maize and jowar eaters. Also studies of
Krishnamachari et al 1978, shows that severity of dental
fluorosis is high among the jowar eating population in the
endemic areas of dental fluorosis in Karnataka.

42.  Vegetarianism is given a place of honour in Hindu
society, hence there are chances in them for
development of nutritional anaemia especially Vitamin
B12 which would affect their oral health.
 In certain communities of India, the men eat first and
women eat last and poorly, this is more common among
orthodox Hindus. This poor nourishment could affect
the oral health of women.

43.  In many parts of A.P. and N.Karnataka the habit of taking spicy
food and high consumption of green chilies is prevalent. This habit
increase the occurrence of oral cancer and peptic ulcer in them
which affects oral health.
 Many religious has rules that concern food. Some religious do not
permit their members to eat certain food. Some group of Hindus
are forbidden to eat any meat. This religious custom is one way
helpful as it prevents the occurrence of the disease Taeniasis
caused by adult form of Taejia Saginata which manifests orally as
oedematous mucosa ulcers, gingival bleeding etc.

44.  Among Muslims pork is forbidden to eat as they are
considered scavenging animal which feeds on human
exereta and garbages. This religious rule prevents the
occurrence of taenialis and cysticercalis which
manifests orally as oedematous mucosal ulcers, gingival
bleeding and lesions mimicking mucoceles.

45.  The tribal populations and Aborigines populations like
Eskimos, Newzealand Maoris, Australian aboriginel, etc
have diet pattern free from refined carbohydrata (the
staple food consist of maize, millet, topica, potatoes)
most of them are good sources of fluorides. In these
populations caries prevalence is low due to cultural
food habits.

46.  The Scandinavians enjoy herring and other fishes they are also
noted for heir excellent cheese, these food habits may provide
them the anticaries effect.
 In many of the cast and central African countries especially in the
tribal areas of Tanzania, Trona a mixture of slate is used as a
tenderizer, flavouring agent and preservative. This trona is a rich
source of fluorides. This practice of using Trona in their cooking
process increases the occurrence of dental fluorosis in those
population (Mabolya 1992).

47.  ORAL HYGIENE PRACTICES :
Keeping oral cavity clean is a culturally ingrained practice in India.
Mouth cleaning is to be done in the morning after getting up as a daily
ritual. Copious gargling with water and cleaning teeth and tongue with
various oral hygiene aids and materials is a custom.
 Hindus :
Bhramins, Preists, Clean their teeth with cherry wood for about an hour
facing rising sun reciting prayers and involving heavenly blessings on
them and their family members. This is quite common in Varnasi (UP).
This culturally inbuilt practice would help in promotion of oral health.

48.  Muslims :
 Muslims as a part of "Namaas" clean their teeth five times a day,
this has a bearing on oral health and improves the oral health.
They use Miswak stick, tooth picks and gum massaging as apart of
oral cleaning aids during "Namaas".
 Chewing Twig :
 Many people in country side of India use twigs of cashew, mango,
neem, coconut fibres and datun to clean their teeth. The practice
of using mango twigs and cashew twigs as oral cleaning aid is quite
common in rural areas of Karnataka and A.P. the use of neem and
Banyan twigs is common in T.N. and coconut fibres in Kerala, Datun
is used in North Indian states.

49. As these twigs have antimicrobial properties, these cultural practices
and mechanical cleaning action can improve the oral hygiene and could
be considered a substitute for those groups who can not effort tooth
brushes.
 Chewing Pan :
In India offering pan is a way of welcoming the guest. This
practice is common in North in Indian states like West Bengal, U.P.,
Rajasthan, Maharastra etc. Refusing pan may be considered insulting,
this lead to keep going the practice. This practice made people chew
pan several time as day and it become a habit. This causes oral cancer
and staining of teeth.

50.  Cola Chewing :
 The chewing of cola nut is common in West and Central Africa. The
chewing of cola nut play an important role in religious functions. It
contains alkaloids like coffiene, throbromine and tannin. The high
tannin level in the nut is reported to exert a beneficial effect on healing
of oral mucosal lesions and to exert a possible cariostatic effect.
 Alum Rinsing :
 There is a wide belief that rinsing the mouth with alum solution would
make the gums stronger. The astringent effect of alum gives a feeling of
that but it is not so. They may have an adverse effect on oral health.

51.  Fomeutation :
 There is a widely held belief that fomentation reduces
pain in decayed teeth. Sometimes this fomentation
may not worsen pain but on most occasions it increases
the spread of inflammation along the facial planes
causing cellulitis.

52.  Caste :
 Indian society is based on caste system. Caste system is less rigid in
urban areas. In rural India caste is an important basis of social
differentiation. Upper caste people consider the lower caste
people as untouchables. Lower caste peoples children are
forbidden to attend the schools they will be ill treated in all
aspects including discriminations in providing health facilities.
 These lower caste people work in agricultural fields of land lords
and they in turn get their daily wages mostly in kind, which will be
insufficient to pass a day. These practices have direct and indirect
effect on oral health of the lower caste people.

53. Sex and Marriage :
 Sexual customs vary among different social, religious
and ethnic groups. Among the Muslims there are
restrictions against orogenital sex and to have
intercourse during menstruation. Orthodox jews are
forbidden to have sex for 7 days after the men cycle.
These customs have an important bearing in family
planning and there by have effect on oral health.
 In India polyandry (marriage of several men with one
women) is found among the Todas of Nilgris hills (T.N.)
and in U.P. these cultural practices would attribute to
high rate of veneral diseases and they affect oral
health.

54. TOOTH MUTILATIONS AND SOFT TISSUE MUTILATIONS :
 The practice of deliberate mutilation of the human
dentition is known to have existed since prehistoric times
in an ethnically and geographically diverse range of peoples
these practices include ;
 Tooth evulsion (non therapeutic extraction of tooth)
 Alterations in the shape of the tooth crown by filling and
chipping
 Lacquering and staining of teeth
 Decorative inlays and crowns

55.  Tattooing
 Uvulectomy
 Facial scarring.
These practices are performed for reasons like
 To ensure a life after death
 As a sign of marriageable age in females
 To facilitate orogential sexual activity
 To facilitate the use of blow pipe
 To mark the transition from childhood to manhood or womenhood.
 Tribal identification
 As a sign of bravery
 As a sign of punishment

56. Tooth Evulsion :
 It is practiced in African countries which includes
Tanzania, South Africa, Nigerai, Uganda, Zambia and Sudan.
 In majority of cultures where tooth evulsion is performed
the tooth are knocked out by placing a piece of wood or
metal against the labial aspect of the tooth crown and then
striking the end of it with a stone or piece of rock etc.
Prior to knocking out a teeth, the gingiva around the tooth
is freed by means of a small sharpened stick or a piece of
bone or with the help of finger nails (Van Rippen et al
1918).

57. Complications of Tooth Evulsions are ;
 Alveolar bone fracture
 Laceration of oral mucosal tissues
 Fracture of root and leaving it in situ causing wound
sepsis, abscess or cyst.
Complications due to evulsion of deciduous teeth are :
 Removal of the succedaneous permanent tooth germ.
 Hypoplasia and malformation in shape of succedaneous
permanent teeth.
 Non erupting of permanent teeth.

58. Fate of Evulsed Tooth :
 Ritual tooth evulsion is frequently associated with
ceremonial events or occasions which are of great
significance to the societies concerned. Great care is
sometimes taken to dispose the evulsed teeth in an
appropriate manner. Ritual disposal of shed teeth,
especially deciduous teeth is a world wide
phenomenon.
 Townend 1963 suggested a relationship between ritual
deciduous tooth disposal and permanent tooth evulsion

59. MUTILATIONS OF THE TOOTH CROWN
 Mutilation of the tooth crown comprise a range of
practices which alter the shape of the teeth. They
include;
 Alteration of the shape of the tooth crown by chipping
and filling.
 Dyeing and lacquering of teeth
 Decoration of the tooth crown by inlays, overlays and
other forms of adornment.

60. 1) Alteration of the shape of tooth crown :
 In common with tooth evulsion the custom of altering
tooth crown shape is confined to anterior teeth by the
upper and lower jaws. The resultant deformity is thus
highly visible.
 Geographical Distribution : These practices were once
widespread geographically in central and South America
is evident from the early, classic work of Van Rippen
who described tooth crown mutilation practices among
prehistoric peoples in Mexico, Peru, Bolivia, Costarica,
Brazil.

61. Reasons for Altering the Shape of the Teeth :
 In general terms the reasons include aesthetics, tribal
identity, initiation rituals, religious motives, and
identification with animals. However while these broad
groups of reasons encompass the motivations for tooth
crown mutilations through the world, particular people
tend to have specific reasons for these practices. The
nature of these specific reasons is often difficult to
establish.

62. Patterns of Tooth Chipping or Filling :
 In general the various forms of chipping and filling of
tooth crown primarily involve mutilation of
 The incisal edge
 The mesial / distal incisal angle
 The labial surface
 The whole tooth crown

63. Methods of Chipping and Filling :
 The operations producing the deformities generally involve a
procedure of chipping away the enamel and dentin with some form
of chisel and mallet until the desired shape is obtained. In some
cultures secondary refinement of deformation may then be
undertaken by smoothing the defects with an abrasion tool such as
metal file or abrasive stone.
Complications of Crown Chipping and Filling :
 Dental caries
 Pulp necrosis
 Periapical cyst or granuloma
 Cellulitis
 Tooth loss

64. Dyeing and Lacquering of Teeth :
 Extensive staining of the erupted tooth crown can be a
consequence of a variety of causes. These include poor
oral hygiene habits such as tobacco smoking and
chewing, beetle nut usage and the deliberate
application of stains and dyes to the tooth crown.

65.  In ancient Japan the deliberate blackening of teeth
using an iron containing mixture applied to the tooth
surfaces was a widespread and important custom
practiced by all until the mid-ninetieth century. The
antiquity of this tradition can be appreciated by
reference to the fact that the ancient Chinese in ADIS
referred to Japan as the country of the black teethed
people (Lewis and Elvin 1977). The custom of tooth
blackening was primarily used to signify marriage and
aesthetics.

66.  The motivation for tooth crown staining is variable. Among
some people the principal purpose appears to be related to
the concept of beauty and sexual appeal or maturity and
some people reportedly blacken their teeth to help prevent
tooth decay.
 The specific techniques used to lacquer and stain teeth
vary staining of teeth is usually accomplished by chewing
the leaves of specific plant species, occasionally a plant
extract is employed.
 The custom of lacquering teeth is distinct from tooth
staining involves a variety of techniques and agents. The
process is complex and variable with respect to the specific
nature of agents used. In general, usually involves a

67. process of etching of the enamel surface followed by the
application of appropriate staining agents.
 Techniques employed by others may include the use of
iron-containing mixtures, shellac etc.
 The adverse effects associated with the customs of
deliberate staining of teeth are not adequately
documented. The view has been expressed by (Elvin
and Lewis (1938) that, because of the apparent
anticaries effect of these customs, these practices
should be further researched with the view of
establishing their caries preventive effect.

68. MUTILATIONS OF SOFT TISSUES :
 Tattooing of soft tissues is a practice which remains
relatively popular in many non-tropical and tropical
areas of the world. While tattooing of the skin is the
most commonly encountered expression of this
practice, tattooing of the lip and gingiva (Mani 1985) is
occasionally seen. Tattoos in the oral region must be
distinguished from other forms of diffuse, intrinsic or
acquired pigmentation of the oral mucosa.

69.  The custom of tattooing the gingiva is one which
appears to be largely confined to countries in the region
of N.Africa and the middle East. In these countries
tattooing of maxillary alveolar gingiva is mainly
practiced by females especially those belonging to the
Muslim faith.
 According to Gozi 1986, the gingiva may be tattooed
when female reach puberty, or when they get married.
Interestingly, Gazi records that this custom may be
practiced by men to relieve the pain associated with
diseased gums.

70.  This particular use of the custom implies a belief that
gingival tattooing has therapeutic benefit. Expression
of this belief is found in Dakar where gingival tattooing
is incorporate in the training program of dental
auxiliaries.
 The technique of gingival tattooing involves painting
the gingiva with a layer of pigmented material (usually
carbon) which is then impregnated into the gingival
mucosa with the help of sharp thorns which pierce the
mucosa. A blue black colouration is the usual hoe
achieved with gingival tattoos. However (Gazi, 1986)
indicated that other colours like white may be use in
gingival tattooing.

71.  The carbonized material used to tattoo the gingiva may
be obtained from calcified peanuts, burned wood, or
from lamb black. Histologically, tattooed gingiva shows
subepithelial deposits of finely particulate black
material both dispersed and aggregated within mucosal
connective tissue.
 Tattooing of the lower lip occasionally may be
encountered chiefly in the region of N.Africa. A
tattooed lower lip in a Sudanese women signifies that
the women is married (Prabhu 1987).

72. Other Forms of Soft tissue Mutilation :
 A variety of other mutilation practices having their basis
in ritual or custom and involving orofacial soft tissues
occasionally may be encountered among people in the
tropical regions of the world.
These include :
 Piercing of lips, and perioral soft tissues and the insertion
of material such as wood, ivory, or metal.
 Uvulectomy
 Facial scarring
 The temporary piercing of orofacial soft tissues for
ceremonial purposes

73.  Practices involving the piercing of orofacial tissues and
the placement of foreign bodies into the defects fall
into two main categories.
 The through - through piercing of tissue from the skin
surface to the oral cavity and the subsequent placement
of pieces of wood, bamboo, bone through the defect
without significant explosion in the size of original
defect.

74.  King (1985) provides a beautiful illustration of this form of
piercing habit as practiced by females of the South
American Yonamani tried in Venezuela.
 Through - through or partial thickness creation of a defect
in soft tissues and the gradual expansion of the size of the
defect by placing, over a period of time, of plugs of greater
size until the described size is achieved. This form of
defect may be single or multiple and involve the upper lip,
the lower lip, both lips and the perioral facial tissues.
 Uvulectomy is carried out by Muslims but there does not
appear to be a direct link with particular religious beliefs.

75. ATTITUDES TOWARDS ORAL HEALTH :
 Evans cites four dental "myths" or beliefs embraced by
older people that are detrimental to their oral health.
These include the belief that aging is naturally
associated with tooth loss, dental are is expensive,
dental treatment require lengthy visits and dentists and
dental delivery systems do not vary from each other.
Such attitudes can create barriers to seeking
appropriate dental care.

76. STRATEGIES FOR REDUCTION
OF THIS BARRIER
 It has been established that rural India is experiencing
wide-spread challenges of socio-cultural barriers in oral
health.
 Identifying cases of poor oral health without providing
any follow-up care, or providing a referral for a
treatment that is both far away and expensive, simply
raises the prevalence of disease, as more cases will be
identified through screening.
 Additionally, it is unethical to identify a disease in a
person when treatment is not accessible (Shickle &
Chadwick, 1994). For these reasons, screening alone
simply cannot begin to address oral health in India.

77.  Oral health has been an area of focus for government officials in
India for almost fifteen years. However, in that time, much of
the work that has been accomplished has been formative
research, with pilot programs as the bulk of programming that
has been implemented (Pandve, 2009).
 While pilot programs are a necessary part of program
development, the pilots have been concentrated in the North-
Eastern states of India; residents of those states may have
benefited from the programs, but as no nation-wide programs
have been implemented, no nation-wide effects have been
documented (Kishor, 2010).
 Additionally, the focus of the government has been on
preventative care, which, while a crucial portion of oral health
care, is simply not enough to impact the general oral health of a
population when access to curative treatment is so challenging.
In order to have a significant impact on oral health, a
comprehensive plan is necessary, in which primary, secondary
and tertiary prevention and care are integrated into a multi-
faceted intervention.

78.  Accordingly, this intervention is designed to
comprehensively address these challenges, through the
implementation of an intervention that delivers
primary, secondary, and tertiary level prevention.
 The primary prevention strategy is a school-based oral
health promotion program, including behavioral oral
hygiene education and the provision of fluoride-
supplemented oral health products.
 The implementation of a comprehensive screening
program is the secondary prevention strategy, and
improving access to professional curative dental care is
the health intervention proposed as tertiary prevention
strategy.

79.  Cultural competence : in health care may be defined as
an understanding of the importance of social and
cultural influences on patients’ health beliefs and
behaviours; considering how these factors interact at
multiple levels of the health care delivery system; and
finally devising interventions that take these issues into
account to assure quality health care delivery to diverse
patient populations.
 Barriers can be reduced by community-based
interventions through a peer health advocate, or a lay
person health promoter, who best understands the
socio-cultural perspective of the population.

81. By
understanding
the Social and
cultural aspects
of the rural
population
Increase in
emphasis of oral
health
education by
various health
education
model

82. Conclusion
 Oral health care providers’ignorance of cultures can
also impair their communication with patients, resulting
in culturally irrelevant services or mis-interpretationof
side effects of folk-medicines.
 Successful communication requires recognition and
consideration of socio-economic diversity and differing
communication style.
 Dismissal of beliefs held by people from other cultures –
termed ethnocentrism – can create a barrier of
misunderstanding.
 Hence, it is important to address socio-culture
multifaceted issues for improving the oral health of the
population.

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