Source 29

Oral health is fundamental to general health and well being. From a theoretical point of view, three major dimensions of oral health has been identified; clinically assessed disease and impairment, disease and treatment specific symptoms and functional and psychological disabilities. It is now widely accepted that in addition to clinical indicators, functional, social and psychological aspects of oral health status should be considered when assessing dental needs. Several subjective oral health indicators have been developed to assess functional, social and psychological oral health outcomes ranging from single item global indicators, such as satisfaction with oral health and satisfaction with appearance of teeth, to complex inventories and scoring systems. In dentistry, many multi-item scales have been applied, but single item indicators have shown to be advantageous and is widely used in oral health research. Cunny and Perri suggest that when operational costs tend to increase, single-item indicators might be appropriate for use as they are strongly correlated with multi-item scales.
The majority of subjective oral health indicators have been used to evaluate oral health outcomes in adult populations. Oral health outcomes in children have also been explored. According to recent reports, age-specific questionnaires are valid and reliable instruments for assessing oral health outcomes in children. In this study information on subjective oral health was achieved by introducing a questionnaire to 12-year-old schoolchildren. By this age, children are thought to have matured enough to report on oral health and influencing factors.
Reisine and Bailit suggested that age, gender, social class and clinical status may be important variables in understanding how an individual perceives his/her oral health status. It is evident, for instance, that girls perceive their oral health more positively than boys, but tend to be less satisfied with the appearance of teeth. Subjects of higher socio-economic status (SES) tend to be more satisfied with oral health than lower SES counterparts, whereas dental pain has been reported to be most prevalent in families of lower income and education. On the other hand, schoolchildren resident in urban areas have been found to be more dissatisfied with oral health than those from rural areas. Gherunpong et al. and Marshman et al.provided evidence that bleeding gums and number of missing teeth impacted the oral health related quality of life of schoolchildren. Oral problems such as bad breath and bleeding gums have been identified to impact on students' perceived health and well-being.
Few attempts have been made to assess the prevalence and socio-behavioural determinants of children's perceived oral health status in developing countries such as India. This is notable, since children experience more oral impacts than adults. Children who have poor oral health have been found to be 12 times more likely to have restricted activity days than those who do not. As developing countries have limited resources allocated for oral health services, as for instance in India where less than seven percent of the gross national product is spent on health care, it is anticipated that self-reports can be utilized together with clinical indicators to assess the need for dental care. In this study, self-reported state of teeth refers to the child's present opinion regarding his or her state of teeth as good or bad. The aims of the present study were to assess the prevalence and correlates of self-reported state of teeth in 12-year-old schoolchildren in Kerala, India.

Nearly one-fourth (23%) of the 12-year-old schoolchildren reported having bad teeth. Self-reported state of teeth was significantly associated with poor school performance, self-reported oral problems in terms of bad breath and food impaction, dental visits, dissatisfaction with appearance of teeth and having caries experience. Similar findings have been reported elsewhere in terms of social and behavioural factors impacting on adult's as well as on schoolchildren's self-reported oral health. The prevalence of impaired oral health assessed here falls below what has been obtained with multi-item indicators in previous studies from developing and developed countries. The low prevalence of self-reported bad state of teeth accords with the caries prevalence observed in this study population. Compared to the European average DMFT score of 2.6 in 12-year-olds, the present DMFT score of 0.45 is low. It compares, however with findings from other developing countries in that a high proportion (91%) of the DMFT score was attributable to untreated caries. A majority of the children (81%) investigated showed good oral hygiene, although 83% of the pupils confirmed experience with bleeding gums.
The structured questionnaires applied in this study might have certain limitations. Reporting bias due to giving socially desirable answers and lack of recall are frequently encountered by children. Thus, the percentage of children reporting bad state of teeth may have been underestimated, because of socially desirable answers or the fact that children were reluctant to express negative opinions and attitudes. Alternatively, a global single item measure of oral health as used in this study might not have been sensitive enough to determine differences in state of teeth scores. Nevertheless, the positive associations between self-reported state of teeth, clinical dental status and self-reported oral problems accords with results from other studies and with theory, thus supporting the validity of the single item self-reported oral health indicator used in this study. According to theoretical models, impairments refer to the immediate biophysical outcomes of disease, commonly assessed by clinical indicators. Functional limitations, pain and discomfort constitute the earliest negative impacts, which in turn are followed by oral disadvantage and individual's overall assessment of oral health status. Reproducibility scores of the dental caries examination and of the questionnaire items were acceptable. The reliability was strengthened by translating the questionnaire into the local language and consequently ensuring cross-cultural adaptation and validation.
Evidence suggests that children and adults belonging to wealthy families, in terms of education and economic status, tend to have less impaired oral health than their poorer counterparts. Nicolau et al., have suggested that lower socio-economic status and family living conditions affect school performance and oral health behaviour. School performance was included in multiple logistic regression analysis along with the sociodemographic variables as it has been acknowledged that school progress shows a positive gradient with material possessions. In this study, children who performed poorly in school were more likely to report their teeth status to be bad when compared to subjects who considered that they performed well in school. Although the question regarding school performance was judged according to schoolchildren's own view rather than to their actual grades, it seems surprising to find one-fifth claiming to have performed poorly. It was anticipated that on being questioned about themselves the children would provide positive remarks , which does not seem to be the case in this study. The reported bad school performance might be a reflection of children's general state of life as well as of their bad state of teeth.
Consistent with findings in previous studies, the present results revealed positive associations between self-reported state of teeth and dental caries and self-reported oral problems. Studies should be done to see whether perceived oral health status could be improved through strengthening of preventive and therapeutic dental services for primary school children. Gherunpong et al., found that gingival inflammation and bleeding impacted negatively on children's oral quality of life and subsequently prevented them from brushing their teeth. Whereas numerous studies have identified a gap between professionally – and self-defined oral health others have found statistically significant associations of various strength. Thus, the present finding also supports previous studies suggesting that caries experience is a consistent clinical correlate of adolescent's oral quality of life. The positive association between DMFT scores and self-reported state of teeth might be attributed partly to a high level of untreated dental caries and a high level of unmet need for dental care and partly to a high level of awareness and self-perception of dental disease on the part of the children investigated. Contrary to the results reported by Ostberg et al, the DMFT index was possibly sensitive enough to be associated with self-reported state of teeth even in the presence of low mean DMFT scores.
It is noteworthy that schoolchildren who had experience with dental visits, reported to have bad state of teeth more often than their counterparts with no dental visits. Similar results have been reported previously in developing countries and might reflect symptomatic dental visiting habits and need for emergency care rather than an unexpected response to dental treatment.
Children who were dissatisfied with their appearance of teeth tended to perceive their teeth status as bad. Earlier studies have reasoned children to be dissatisfied with dental appearance in the presence of fractured anterior teeth, malpositioned teeth and untreated malocclusion. Although children in the present study had fractured anterior teeth, no significant difference was found between those with and without anterior trauma when reporting the state of their teeth as bad. This type of difference in self-perception might be predisposed by socio-cultural variations. Further investigation might be required to assess the impact of malpositened teeth and malocclusion on self-reported state of teeth.

It is interesting how the perception of bad oral health is connected with bad school performance. In a developing country with a part of the population not being able to get formal education, there might be a higher perception of bad oral health. Those unfamiliar with how to maintain proper oral health may not understand the importance of it. It will be interesting to see how this plays out in India.