|Year : 2020 | Volume
| Issue : 2 | Page : 76-81
Geographic disproportions in dental workforce distribution and its impact on oral disease burden: An Indian perspective
Krishnan Padminee1, R Anusha2, Krishnan Lakshmi2, Parangimalai Diwakar Madan Kumar2
1 Department of Pedodontics and Preventive Dentistry, SRM Dental College and Hospital, Chennai, Tamil Nadu, India
2 Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||30-Oct-2019|
|Date of Acceptance||19-Mar-2020|
|Date of Web Publication||08-Jul-2020|
Dr. Krishnan Padminee
Department of Pedodontics and Preventive Dentistry, SRM Dental College and Hospital, Ramapuram, Chennai, Tamil Nadu
Introduction: Dental workforce planning depends on the consumers need or demand and availability or supply of dental care. Dental workforce planning is commonly based on three methods that include dentist population ratios, demand-based models and need based models. Although the production of dentists has exponentially risen in the last decade, the oral disease burden does not seem to be reduced. Materials and Methods: Data regarding population census, number of registered dentists under Dental Council of India, number of government dentists, and disability-adjusted life years (DALY) measures for overall oral disease burden, Dental caries in deciduous and permanent teeth, edentulousness, periodontal disease, and other dental diseases for each state in India were collected from different sources and subjected to descriptive statistics. Association between dental workforce and DALY of oral disease burden was assessed using Pearson's correlation coefficient with P set at 5%. Results: The dentist population ratio ranged from 1:1000 to 1:20,000 in different states of India. The DALY 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). Conclusion: Dental workforce and the conspicuous geographical imbalance associated with it solely do not contribute to the oral disease burden in India. Need-based workforce planning along with optimal resource allocation in terms of material and funds might unlatch the barriers faced by the disadvantaged population with grave dental needs.
Keywords: Disability adjusted life years, dental manpower, oral disease burden
|How to cite this article:|
Padminee K, Anusha R, Lakshmi K, Madan Kumar PD. Geographic disproportions in dental workforce distribution and its impact on oral disease burden: An Indian perspective. SRM J Res Dent Sci 2020;11:76-81
|How to cite this URL:|
Padminee K, Anusha R, Lakshmi K, Madan Kumar PD. Geographic disproportions in dental workforce distribution and its impact on oral disease burden: An Indian perspective. SRM J Res Dent Sci [serial online] 2020 [cited 2021 Jun 22];11:76-81. Available from: https://www.srmjrds.in/text.asp?2020/11/2/76/289171
| Introduction|| |
Dental workforce planning depends upon the consumers need or demand and availability or supply of dental care. The last few decades have witnessed massive growth of dentists in India. This accelerated growth in the field of dentistry can be attributed to the fact that it is the second-most populous country in the world., On observing the changing trend in dental workforce from the early 20th century, it is very evident that there is a surplus production of dentists currently in India. With a dentist population ratio of 1:301,000 as in the 1960s, it has improved to a ratio of 1:9992 at present., However, geographic disproportions still exist and excessive workforce is being wasted due to the lack of proper workforce planning. Thus, the need of the hour is to steward the surfeit of human resources in dental fraternity and utilize their services to meet the growing demands of the diversified population.
Global disease burden (GDB) gives an estimate of about 3.9 billion people being affected by oral diseases. Dental caries, periodontitis and edentulousness pose to be the major cause for oral disease burden globally. Oral diseases are a serious impediment to the economic growth of a society and can catastrophically affect the quality of life of an individual and hence diminish his/her contribution toward the welfare of the nation. There is also abundantly available literature on the association between non-communicable systemic diseases and oral health.,,,,, A multi-centric study in India by Shah et al. reveals the prevalence of periodontitis as high as 100% in the regions of Rajasthan and Orissa. The prevalence of periodontal attachment loss >3 mm was found to be high in the state of Maharashtra (96%) in contrast to only 20% in Arunachal Pradesh. The prevalence of dental caries was only 27% in Kerala as opposed to 86% in the states of Delhi and Maharashtra., Studies conducted in West Bengal, Orissa and Sikkim by Mandal et al. observed that the prevalence of dental caries was higher (50%–60%) in children of ages 5–6 years and the occurrence of caries were more in urban areas than rural. It is very evident that the dental care demand or need is more in certain states for certain diseases and relatively less in certain regions. Therefore there is a demand for equitable distribution of oral health care. A state-wise assessment of the oral disease burden will help in redistributing dental man power in order to straighten the geographic imbalance.
Prevalence measures have been traditionally used to understand the disease burden. However they do not indicate the severity of the disease or the morbidity associated with it. Expressing Disease burden in measures that objectify the associated morbidity and mortality is more meaningful. Quantifying the disease burden aids in setting the priorities for health services and research. Disability-adjusted life years (DALY) are a composite indicator representing the functional component of health and mortality. The summation of years of life lost due to disability and due to premature death gives the DALY score. The dilemma that occurs while allocating resources to competing health programs can be circumvented by using DALY scores. The DALY thus can be used as a tool for making policies, for identifying disadvantaged populations or for carrying out cost analysis of health programs., DALY metrics are more commonly used for assessing noncommunicable diseases (NCDs) where both morbidity and mortality is to be considered. Oral diseases have now been included under NCDs in the National Health Policy. Therefore the present study aims to correlate the DALY measures for oral diseases with the dental workforce available in each state of India.
| Materials and Methods|| |
This study is a secondary data analysis of data gathered from National health profile (NHP) 2016 and GDB 2010 study. The NHP is the annual publication of the Central Bureau of Health Intelligence, the national nodal institute in the Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. Details regarding the population census, number of Dental Council of India (DCI) registered dentists and the ratio of average population served by the dentists in each state of India were taken from the NHP2016. The PDF version of the same is available at www.indianenvironmentportal.org.in. The GDB 2010 study is based out of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. DALY measures for overall oral disease burden, dental caries in deciduous and permanent teeth, edentulousness, periodontal disease and other dental diseases were obtained from the GBD 2010 accessed through www.healthdata.org. The GDB 2010 study India was brought out by IHME in association with the Indian Council of Medical Research, Public Health Foundation of India.
The cause list for GDB of oral conditions includes dental caries, periodontal disease, edentulousness, and other oral diseases that encompass a variety of oral malformations and lesions. [Table 1] contains the operational definitions for cases and disability. The DALY of oral diseases was calculated as the product of prevalence times the disability weight of the associated sequelae times the duration of symptoms. Two-trained reviewers (AR and PK) working independently extracted the data and assessed it. A third reviewer (MK) re-evaluated it and the inter-rater reliability was found to be adequate (κ = 0.9). All data were tabulated in Microsoft Excel worksheet 2007 for descriptive analysis. Correlations were analyzed using Pearson's correlation coefficient in SPSS software v20 (IBM Copr. Released 2011. IBM SPSS Statistics for Windows, Version 20. Armonk, Ny: IBM Corp). with statistical significance set at 5% (P = 0.05).
| Results|| |
[Table 2] shows the details on population census, number of registered dentists under DCI, number of government dentists, and DALY measures for overall oral disease burden, Dental caries in deciduous and permanent teeth, edentulousness, periodontal disease, and other dental diseases for each state in India.
|Table 2: Details on population census, number of registered dentists under Dental Council of India, number of government dentists, disability-adjusted life years measures for overall oral disease burden and various dental conditions|
Click here to view
Uttar Pradesh was found to be the most populous state with a population of 199,812,341 people followed by Maharashtra and Bihar and the least populated was Sikkim (610,577). Karnataka had the highest number of dentists (34,768) followed by Tamil Nadu, Andhra Pradesh, Maharashtra, Punjab, and Kerala. The least number of dentists were present in Jharkhand (99). Certain states, particularly in the North Eastern part of India had no record of the data on the number of registered dentists present. West Bengal (647) and Jammu and Kashmir (614) had the highest number of government dentists whereas Goa (29) and Mizoram (28) had the least number of dentists from government sector.
The total number of dentists registered under the DCI were found to be 155,140. The state wise dentist population ratio varied widely. Some states like Andhra Pradesh, Goa, Gujarat, Haryana, Himachal Pradesh, Jammu and Kashmir, Karnataka, Kerala, Maharashtra, Punjab, Tamil Nadu and Delhi had a dentist population ratio ranging from 1:1000 to 1:10,000. The ratio was higher than 1:20,000 in states such as Jharkhand, Assam, Bihar, and Uttar Pradesh. The DALY metrics for overall oral burden were between 250 and 350 in all the states with Goa and Kerala having the higher values. DALY measures for Dental caries (deciduous - 3 and permanent - 34.35) were high in Delhi. DALY for periodontal diseases was more in Goa (118.25) and Tamil Nadu (114.19). Kerala (125.9) and Goa (112.23) had elevated DALY scores for edentulousness.
[Figure 1] shows a dual axes graph representing the oral burden and DCI registered dentists in each state and [Figure 2] shows the same for government sector dentists. In the states of Jharkhand, Orissa, Goa, Arunachal Pradesh, etc., the DCI registered dentists were very less in number and the DALY for oral conditions was high. There were very few government sector dentists in Goa, Maharashtra, Jharkhand, Mizoram, Nagaland, etc., where the mean oral disease burden values were high. The dentists as registered under DCI were found to be very high in the state of Karnataka while the DALY for oral disease burden was still seen to be in considerable levels. Similarly, in the states Jammu and Kashmir, Haryana, and West Bengal, more number of government sector dentists were present. Yet, the DALY values for oral health burden were soaring in these states. However, there was no statistically significant correlation between the overall oral burden and DCI registered dentists (P = 0.084) and the government sector dentists (P = 0.587) in each state.
|Figure 1: Dual axes graph showing disability adjusted life years of overall oral disease burden and number of Dental Council of India registered dentists in each state|
Click here to view
|Figure 2: Dual axes graph showing disability adjusted life years of overall oral disease burden and number of government sector dentists in each state|
Click here to view
| Discussion|| |
Viewing oral health from an atomistic perspective is no longer welcomed. The new definition proposed by the FDI world Dental Federation portrays oral health as a multifaceted phenomenon with disease condition and status, Psycho-social functions and physiological functions as indispensible attributes. Oral health of an individual can markedly affect one's quality of life. Therefore providing effective oral health care is imperative beyond doubt. A health pattern as offered by morbidity indicators, which are easily available, would not reveal the disease burden in its entirety. Prevalence is a collective measure which indicates the disease presence in a region irrespective of the pathologic status or severity. Completely treated cases can also contribute to prevalence values, especially pertaining to oral diseases as they are cumulative and hence do not reflect the exact disease burden. Therefore, in the present study, DALY values for oral diseases were taken into consideration instead of prevalence. The GDB uses DALY to measure the noncommunicable and chronic disease burdens which include oral conditions based on fatal and non-fatal outcomes. This is a composite index which measure “life lost due to disability” (YLD) and “years of healthy life lost” (YLL). This measure added disability weights and discounting in the GDB 2010 study calculation.
Dental workforce planning is commonly based on various methods that include dentist population ratios, demand based models, need based models, World Health Organization (WHO)/FDI technique and network analysis. Among them the most commonly used method is determined by the type of data available. The dentist population ratio is a traditional measure that can be calculated with ease and is available in the public domain of our nation. This value is compared with accepted ideal ratio to identify the shortage or excess. Demand based models tend to be more reality biased and follow the health econometrics. The need based models utilize epidemiological data that assess disease burden and are not influenced by economic determinants, whereas the WHO/FDI method requires more assumption and is commonly used to project a future trend of dental force availability. Hence, based on the data gleaned for the present study, dentist population ratio and need based model were compared and discussed. Failure to meet dental needs in the most demanded region indicates that the inverse care law prevails in dentistry too. Hart proposed this law with anecdotal evidence in the field of medicine. The law operates in terms of access to services which is very much relatable to the current dental health scenario where it can be assumed that the distribution of dentists determines the availability of care.
The results of the present study show that the states of Karnataka, Delhi, Tamil Nadu, Kerala, Punjab, Goa, etc., have a dentist population ratio <1:5000, whereas a ratio as high as 1:60,000 can be seen in the state of Nagaland. North-Eastern states, Assam, Bihar, West Bengal, Tripura, Orissa, and Jharkhand have ratios >1:20,000. These ratios accord with those proposed by Jaiswal et al. in their secondary data analysis study done in 2014. The dentist population ratio in each state is, hence, a direct reflection of the state wise dentist distribution. The results of the current study show evidently the unequal distribution of dentists. The probable reason is the analogous unequal distribution pattern of dental colleges in India. According to Jaiswal et al. out of 301 dental colleges about 45 were present in Karnataka alone. In a review article by Tandon, a massive blemish in the geographical distribution of dental colleges was revealed. It is stated that about 50 dental colleges are situated in one state alone out of which 15 colleges were in one city only. Further no single dental institution was present in the North-eastern states of India. Moreover, dental students after graduating can continue to practice in their area of choice within India leading to the impending possibility of dental surgeons concentrating in a single region. According to the WHO, the ideal dentist population ratio should be 1:7500. This means 160,964 dentists are required for the current population of 1,207,234,160 people in India. The results of the present study shows that the number of dentists required as stipulated by the WHO ideal dentist population ratio is not far from the actual number of dentists present in the nation. This result is in harmony with the study done by Vundavalli where a similar estimate is given.
Although the production of dentists has exponentially risen in the last decade, the oral disease burden does not seem to be reduced. As per the results of the present study the DALY values for oral disease burden were high in the states where the dentists were very low. Also, the values were not as low as expected in the states which harbored high number of dental surgeons. New Delhi, Kerala, and Tamil Nadu had ideal dentist population ratios, yet the DALY values were more for dental caries, edentulousness, and periodontitis in the respective states. Effective delivery of dental care is, therefore, deficient in some states despite adequate or more than adequate dental workforce. India is one of the largest producers of dental workforce and ironically the DALY for oral conditions still seem to be of significant levels.
This discrepancies seen between high DALY scores and more dentist availability can be attributed to lacunae seen in health-care delivery system, though the through the Niti Ayog (National Institute for Training India) India is able to efficiently plan health care services very less importance is provided to oral care. Hence, appropriate oral care planning is warranted.
In similar lines Kothia et al. in their study on assessing the status of the National Oral Health policy in India, manpower, money and material are three important requisites for planning any program to flourish. Dental workforce is no longer a concern in India, as shown by the results of the present study. The excessive workforce has not helped much in reducing the oral disease burden which is also very evident from the results of the present study. The correlation coefficient showed no association between manpower and disease burden (P = 0.084 and 0.587). Therefore, financial constraints and material deficiency could be the reasons for inefficient oral health-care delivery. On the other hand the consumers also do not utilize the dental services. In developing countries like India, disadvantaged populations fail to effectively demand dental care since they are often confronted by economic, cultural, and social barriers. The access to dental health care is vectored to the individual's affordability for the service. Although correcting the geographical disproportions in workforce distribution might help in diminishing the oral disease burden to some extent, significant improvements can be achieved by altering the other determinants which enhance effective delivery of dental services.
The WHO recommends every country to spend 5% of Gross National Product (GNP) for healthcare. However, India is spending only 3% of its GNP. Health expenditure by the government of India is among the lowest in the world whereas that by private sectors is one of the highest. Need-based workforce planning along with optimal resource allocation in terms of material and funds might unlatch the barriers faced by the disadvantaged population with grave dental needs. Along with them there are hardly any governmental insurance schemes or alternate financial method other than out-of-pocket expenses for dental care.
In present times, numerous other barriers have been identified in utilizing dental care which could be well explained by using Anderson's utilisation model– predisposing factors, enabling factors and needs. Current study uses national data on dentist population ratio as enabling factors, nation's demographic and DALY of oral diseases as health need. Thus altering all the three factors would result in a better reduction of oral disease resulting in efficient utilization of present dental workforce.
The dental workforce ratio assessed would be a limitation as these ratios are meaningful only if dental diseases are ubiquitous. Further, there is no guarantee that all dentists who have registered under the DCI provide service. Therefore, future studies should aim to include only the number of dentists who actually practice and also take into consideration other determinants which affect dental care delivery. Workforce-based planning alone might not serve to combat the increasing oral disease burden since both the variables are multifactorial in nature.
| Conclusion|| |
Within the constraints of the present study, it can be concluded that dental workforce and the conspicuous geographical imbalance associated with it solely do not contribute to the oral disease burden in India. The North-Eastern states are still austerely deficient of dentists while states such as Karnataka, Tamil Nadu, Kerala, etc., have an oversupply of dentists. But the DALY for oral diseases is almost same in all the states of India. The DALY for oral diseases as seen in each state of India indicates that the need for dental service is high in all areas irrespective of the workforce status. Improvement in the oral health will be attained only when the demand/need and supply/availability ends meet. Therefore, reduction in oral health disparities can be achieved by strategic workforce planning combined with optimal resource allocation and by emphasizing the importance of utilizing dental services to the consumers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Goodman HS, Weyant RJ. Dental health personnel planning: A review of the literature. J Public Health Dent 1990;50:48-63.
Saliba NA, Moimaz SA, Garbin CA, Diniz DG. Dentistry in Brazil: Its history and current trends. J Dent Educ 2009;73:225-31.
Central Bureau of Health Intelligence. National Health Profile 2012. New Delhi: Central Bureau of Health Intelligence; 2013.
Parkash H, Duggal R, Mathur V. Guidelines for Meaningful and Effective Utilization of Aavailable Manpower at Dental Colleges for Primary Prevention of Oro-Dental Problems in the Country. GOI-WHO Collaboration Project; 2007.
Marcenes W, Kassebaum NJ, Bernabé E, Flaxman A, Naghavi M, Lopez A, et al
. Global burden of oral conditions in 1990-2010: A systematic analysis. J Dent Res 2013;92:592-7.
Desvarieux M, Demmer RT, Rundek T, Boden-Albala B, Jacobs DR Jr., Papapanou PN, et al
. Relationship between periodontal disease, tooth loss, and carotid artery plaque: The Oral Infections and Vascular Disease Epidemiology Study (INVEST). Stroke 2003;34:2120-5.
Holmlund A, Holm G, Lind L. Severity of periodontal disease and number of remaining teeth are related to the prevalence of myocardial infarction and hypertension in a study based on 4,254 subjects. J Periodontol 2006;77:1173-8.
Joshipura K. The relationship between oral conditions and ischemic stroke and peripheral vascular disease. J Am Dent Assoc 2002;133 Suppl 1:23S-30.
Okoro CA, Balluz LS, Eke PI, Ajani UA, Strine TW, Town M, et al
. Tooth loss and heart disease: Findings from the Behavioral Risk Factor Surveillance System. Am J Prev Med 2005;29:50-6.
Peres MA, Tsakos G, Barbato PR, Silva DA, Peres KG. Tooth loss is associated with increased blood pressure in adults—a multidisciplinary population-based study. J Clin Periodontol 2012;39:824-33.
Völzke H, Schwahn C, Dörr M, Aumann N, Felix SB, John U, et al
. Inverse association between number of teeth and left ventricular mass in women. J Hypertens 2007;25:2035-43.
Shah N, Pandey R, Duggal R, Mathur U, Kumar R. Oral Health Survey in India: A Report of Multicentric Study, WHO – Oral Health Survey 2004. Geneva, Switzerland: World Health Organization; 2005.
Shaju JP, Zade RM, Das M. Prevalence of periodontitis in the Indian population: A literature review. J Indian Soc Periodontol 2011;15:29-34.
] [Full text]
David J, Wang NJ, Astrøm AN, Kuriakose S. Dental caries and associated factors in 12-year-old schoolchildren in Thiruvananthapuram, Kerala, India. Int J Paediatr Dent 2005;15:420-8.
Mandal KP, Tewari AB, Chawla HS, Gauba KD. Prevalence and severity of dental caries and treatment needs among population in the Eastern states of India. J Indian Soc Pedod Prev Dent 2001;19:85-91.
Murray CJ. Quantifying the burden of disease: The technical basis for disability-adjusted life years. Bull World Health Organ 1994;72:429-45.
Murray CJ, Lopez AD, Jamison DT. The global burden of disease in 1990: Summary results, sensitivity analysis and future directions. Bull World Health Organ 1994;72:495-509.
Dua AS. Burden of Disease in India, National Commission on Macroeconomics and Health. New Delhi: Ministry of Health and Family Welfare, Government of India; 2005.
Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. Am J Orthod Dentofacial Orthop 2017;151:229-31.1.
da Mota JC, Valente JG, Schramm JM, Leite Ida C. A study of the overall burden of oral disease in the state of Minas Gerais, Brazil: 2004-2006. Cien Saude Colet 2014;19:2167-78.
Vundavalli S. Dental manpower planning in India: Current scenario and future projections for the year 2020. Int Dent J 2014;64:62-7.
Hart JT. The inverse care law. Lancet 1971;1:405-12.
Jones CM. Capitation registration and social deprivation in England. An inverse 'dental' care law? Br Dent J 2001;190:203-6.
Jaiswal AK, Srinivas P, Suresh S. Dental manpower in India: Changing trends since 1920. Int Dent J 2014;64:213-8.
Tandon S. Challenges to the oral health workforce in India. J Dent Educ 2004;68:28-33.
National Oral Health Policy: Prepared by Core Committee, appointed by the Ministry of Health and Family Welfare; 1995.
Kothia NR, Bommireddy VS, Devaki T, Vinnakota NR, Ravoori S, Sanikommu S, et al
. Assessment of the Status of National Oral Health Policy in India. Int J Health Policy Manag 2015;4:575-81.
Srinath R. High Level Expert Group Report on Universal Health Coverage for India. Planning Commission of India; 2011.
Herkrath FJ, Vettore MV, Werneck GL. Contextual and individual factors associated with dental services utilisation by Brazilian adults: A multilevel analysis. PLoS One 2018;13:e0192771.
[Figure 1], [Figure 2]
[Table 1], [Table 2]