Oral Health Disparities Among 12- 15 Years Children of India And Pakistan – A Cross Border Comparison

Ambrina Qureshi1                                  M. Phil, BDS, MDS

Manu Batra2                                            BDS, MDS

Madiha Pirvani3                                    BDS, MDS

Aeeza Malik4                                           BDS

Aasim Farooq Shah5                           BDS, MDS

Mudit Gupta6                                          BDS, MDS

ABSTRACT: India and Pakistan are two neighbouring countries of South-East Asia, not only sharing common border but also socio-demographics, eating habits, cultural and climatic conditions. All these factors have an impact on general and oral health of individuals. This study was conducted with an aim to compare the oral health awareness and dental caries status among school going children of India and Pakistan.

METHODOLOGY: A cross-sectional study was conducted among children aged 12-15 years attending government schools of Moradabad and Karachi cities of India and Pakistan respectively. A two-stage sampling technique was used to produce representative samples from each location based on probability proportional to enrolment size (PPE). Selected participants were interviewed using a close-ended, pre-tested questionnaire for assessing oral health awareness followed by dental examination at respective locations using DMFT Index.

RESULTS: : A total of 809 school children, 409 from India and 400 from Pakistan were examined. Mean DMFT of India was found to be 1.9 ± 1.46 and that of Pakistan was 1.00 ± 1.57.

CONCLUSIONS: An increase in decayed component in comparison to the overall DMFT in both the countries indicate the need of care, less utilization of available care, unavailability of care and ignorance. There is a need to change the attitude and knowledge about dental health care in these developing countries to cope up with the lack of resources and still have a better dental health.

KEY WORDS: Child Dental health, Dental Caries, Oral Health.

HOW TO CITE: Qureshi A, Batra M, Pirvani M, Malik A, Shah AF, Gupta M. Oral Health disparities among 1215 years children of India and Pakistan – A cross border comparison. J Pak Dent Assoc 2014; 23(4):170-174


Sustaining good oral health is vital to improve the general health and development predominantly in children of school going age. In every community and country the children, particularly of school going age, are the most important natural asset. Their well-being, capabilities, knowledge and energy will determine the future of villages, cities and nations around the world. Even though oral health is considered as an integral part of overall health, the global evidence report that around 90% of these school children worldwide experience poor oral condition .This suggests poor oral health as highly prevalent, where South East Asian countries are no exception.

India and Pakistan are two neighbouring nations who share common border in South East Asia.  The burden of oral diseases among adolescents in both countries is on higher side. The problems in both nations revolve around the level of attentiveness towards oral health among children, specifically those belonging to rural areas. It is pertinent to mention that almost 70% of the general population in both these countries belong to rural areas with low socio-economic status where the overall development is poor2.

Many oral health problems are preventable and their early onset reversible through imparting oral health education since the very initial footstep of awareness. It has been reviewed that betterment in oral health may be anticipated through good understanding of an individual’s knowledge and perceptions about oral health3. The evaluation of baseline awareness may therefore act as an important indicator for planning successful oral health education programs in both the countries. Hence, the objective of this study was to evaluate the discrepancy in the oral health awareness and dental caries status of school going children of India and Pakistan.


The study sample consisted of school students aged 12-15 years attending schools of rural areas of Moradabad and Karachi cities of India and Pakistan respectively. A two-stage sampling technique was used to produce representative samples from each location. In first stage, the schools were randomly selected. Four senior secondary government schools each from Moradabad (India) and Gulshan-e-Iqbal Town, Karachi city (Pakistan) were selected based on probability proportional to enrolment size (PPE). According to PPE, the schools with high number of regularly attending students were more likely to be selected than schools with low number of students regularly attending. In second stage, the students from these schools were randomly selected to be included in the study through simple random sampling procedure.

Before the start of study, permission was obtained from the ethical review board of the respective institutes involved in data collection. Prior permission was also obtained from respective school authorities. The time and date of the survey were intimated to the students well in advance and informed consents were obtained. Subjects with any systemic or oral disease, dental prosthesis, absence of any index teeth and non-consenting cases were excluded from the study. Selected participants were interviewed using a questionnaire prepared for assessing health awareness in children. The close-ended questionnaire was pre-tested among 25 school students each of Moradabad and Karachi, to confirm its validity (kappa >70%) and reliability (cronbach alpha >70%) and to avoid ambiguity. However, these students were not included in the final analysis. Following the pre-test, some modifications in the order of questions and terminologies were made in the final questionnaire.

Considering the influence of teachers on the students’ response, the school authorities were requested not to be present in the class during the procedure of filling the questionnaire. Students were assured that the information they provided would remain confidential and thus were encouraged to be truthful in their response. The students were instructed to give only single answer for each question, which they felt was the most appropriate.

Dental examination was then performed to identify the dental caries status of school children aged 12-15 years. Examination was conducted by properly gloved and masked single examiner in each setting on the permitted dates by the school administration on mobile dental units with the child supine, under the day time sunlight in school ground. Sterilized instruments (dental mirror, probe and tweezers) were used to execute the examination. Intra-examiner reliability of the single trained examiner was assessed on 10% of the sample subjects; however, inter-examiner reliability could not be measured.

Preliminary descriptive statistics (Mean and frequency percentages) was used to assess the distribution of responses of all study variables using SPSS package (version 20).


A total of 809 school children aged 12-15 years were examined in the present study, out of which there were 409 from India and 400 from Pakistan. Preliminary data description with respect to age and gender is reported in table-1. The mean age of Indian study participants was calculated as 13.21 ± 1.16 years and that of Pakistani was 13.06 ± 1.11 years.

Table 2 demonstrates the percentage distribution of study participants’ responses for each study variable. Majority of subjects from India (47.19%) cleaned their teeth once a day, whereas many from Pakistan (62.75%) cleaned their teeth twice a day. The number of subject who responded with “sometimes” and “never” was more

Table1: Distribution of study participants according to age and gender
Table2: Percentage distribution of study participants with respect to study variables.

from India and none from Pakistan; although this number covered approximately 10% of the total participants from India.

Moreover, awareness regarding the use of fluoridated toothpaste was different in subjects from two nations. All subjects (100%) from Pakistan knew that their toothpaste does contain fluoride whereas majority of subjects (70.6%) from India were not sure whether their toothpaste contains fluoride or not while cleaning their teeth. According to this table, frequency of visit to a dentist during last 12 months was much higher among Indian children in comparison to Pakistani children. It was found that less than 1/2 of the Indian participants never visited a dentist in comparison to almost 3/4th (83.25%) of the Pakistani participants during last 12 months. Furthermore, consumption of sweets in excess and as regular was slightly higher among Pakistani than Indian study participants.

Table 3 demonstrates the caries experience (mean DMFT) among the subjects. The decayed component was higher in Indian children in comparison to Pakistani

Table 3: Dental Caries experience (Mean DMFT) among the study participants

children which also led to a higher mean DMFT score among Indian children in contrast to Pakistani children.


Dental caries is still a major health problem in most industrialized countries as it affects 60-90% of schoolaged children and the vast majority of adults. At present, the distribution and severity of dental caries vary in different parts of the world and within the same region or country1. In most developing countries, the levels of dental caries were low until recent years but prevalence rates of dental caries and dental caries experience are now tending to increase. This is largely due to the factors known to be associated with dental caries. It is suggested that social and biological factors in very early life influence dental caries levels later in life4. In addition, behavioural factors such as feeding patterns, tooth brushing, flouride intake and other factor related to education level of the mother, country of birth and gender of the child also generally influence the prevalence of dental caries5.

Worldwide, studies have highlighted differences in oral health knowledge, attitudes and practice between childern and adults6 as well as childern of different

strata7. This study, however, was planned to evaluate these differences among school going children of India and Pakistan. In an inter-country comparison, socio-economic status could be one of the most important confounding factors. To impound this confounding effect, public sector schools were selected from both the regions and socio-economic status was matched for both.

Toothbrush and toothpaste are commonly used to retain good oral hygiene8. However, the correct technique and frequency of tooth brushing, and concentration of fluoride in toothpaste are the laid down factors associated with prevention of dental caries9. From the results of the present study, it was seen that more than 80% of the children from India and Pakistan cleaned their teeth at least once a day, where majority from Pakistan (more than 60%) practiced tooth cleaning twice a day. Other concordant studies from Chepang Nepal10 and China11 have also reported that 60% of children of similar age group brush their teeth at least once-a-day.  On the contrary, much lower tooth cleaning frequency (less than 30%) has been reported from Indian schoolchildren by Mathur et al12and Turkish school children by Bekiroglu et al13. The practice of cleaning twice in children from Pakistan may be attributed to Muslim religion, where traditionally Muslim children are taught to use miswak at about age six that helps develop practice of brushing more often than once14. Moreover, 100% of study participants from Pakistan reported that they used fluoridated toothpaste as compared to those of Indian counterparts where only less than 10% of participants reported that they use fluoridated toothpastes. Previous findings from various states of India and China have also reported that only 13-15 % of 12 year olds children use fluoridated toothpaste15,16.  On the other hand, Mirza et al from Pakistan reported that nearly 60% students from Pakistani schools regarded fluoride as a tooth strengthening element and were properly aware about it17.

Regarding regular visits to dentist by children of this age group, we observed that participants from India visited dentist more regularly than those belonging to Pakistan. This trend in Pakistan is commonly observed elsewhere whereeven less than 10%of these particular age group children regularly visit dentist18. One reason that may be suggested is unavailability of the trained dental professionals specifically for children in Pakistan 17. In Pakistan, the government manages health care services since 1986-87, through the ministry of health, which provides the country with physicians, dentists and auxiliary health care workers. Dental surgeons have been recruited under this scheme, but unavailability of the dental equipment renders the program useless. Lack of dental insurance, high cost of treatment, long waiting period between appointments, phobia of the dentist and as well as the treatment are suggested as contributing factors of low percentage of regular checkups in Pakistan2. Moreover, the high treatment cost in Pakistan may also be the main culprit in this difference. Adding to this, the present study also reported that sweets consumption was slightly higher in Pakistani children in comparison to Indian children, although this comparison may not be very significant in this study. Moreover, the sweet consumption, when compared to similar surveys from other regions in both the countries was relatively higher19,20.

Mean DMFT in subjects from India in this study was observed to be higher as compared to the subjects from Pakistan. However, when it is compared to a study from another part of India (Chenai) the difference was more than double (DMFT= 3.94) than the current observation (DMFT= 1.9) in same age group children. On the other hand, the national data of India21 reported mean DMFT in 12 years old as 1.7, which is concurrent to the result of this study. Similarly, a previous study from Pakistan14 reported much higher DMFT (3.7) than that reported in the current study (DMFT= 1.0). Keeping in view the mean DMFT of Indian and Pakistani subjects of the current study the differences may be attributed to the fact that subjects from Pakistan reported to be brushing more often and that too with fluoridated tooth paste, than the subjects from India. Moreover, this may be attributed to the lack of Inter-examiner calibration that could not be conducted and measured due to the traveling distance between the two countries. However, the examiners were confident that the employed tool for examination was the DMFT index (decayed, missing, filled teeth) as recommended by World Health Organization (WHO). It is pertinent to mention that the DMFT Index is a general indicator of dental health status of the population (particularly among children), and is considered reliable. Lower the index, the better the dental health of the population. Although, it has been observed that despite more than 50% of study subjects visiting dentist, their decayed tooth component is still high with much reduced filled tooth component. Overall high decayed components, especially in Indian subjects, indicate the need for dental care, inadequate availability of dental services and less service utilization by the study population. Furthermore, difference in the number of Filled teeth ‘F’ component in the present population groups may be suggestive of the fact that these children may not have sufficient access to the dental services. We need to further look into the reasons for this aspect of inequality in service utilization in both the countries. However, it is still suggested that it is high time that public education emphasizing prevention and conservation  must come into action to rectify this situationwith special focus towards the countries with limited resources.


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  1. Assistant Professor, Department of Public Health Dentistry, Surendra Dental College and Research Institute, Sri Ganganagar, Rajasthan, India.
  2. Assistant Professor, Department of Dental Materials, Dr. Ishrat-ul- Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan 4. Department of Community & Preventive Dentistry, Dr. Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan.
  3. Department of Public Health Dentistry, Kothiwal Dental College and Research Centre, Moradabad Uttar Pradesh, India.
  4. Assistant Professor, Department of Oral Medicine & Radiology, Uttaranchal Dental & Medical Research Institute, Dehradun, Uttarakhand, India.
  5. Associate Professor & Head, Department of Community & Preventive Dentistry, Dr. Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan

Corresponding author: “Dr Ambrina Qureshi ” < ambrina.qureshi@duhs.edu.pk >