Introduction:

Oral diseases may be the greater influence to direct cause of tooth loss. Various social factors may
play a significant indirect role not only in the development and progression of such diseases but
also in the decision for extracting a tooth, even when there is better and advanced clinical option
available [1]. Caries was the principle cause of tooth loss and molar teeth. [2]Other than
periodontal attachment loss with severe tooth mobility and dental caries, no other factor was a
dominant predictor of tooth loss [3] .Older people exhibit higher number of missing teeth and a
lower number of natural teeth remaining, [4, 5]. Other reported factors associated with missing
teeth include education, income, oral hygiene practices, smoking, and gender [4, 6 7,]. Modification
of non-disease independent factors could reduce tooth loss and improve oral health. [6] Various
factors affect tooth loss in older age including cigarette smoking; however, evidence regarding the
association between smoking and tooth loss during young adulthood is limited. The loss of many
teeth often reduces the quality of life; embarrassment and self-consciousness which limit social
interaction and communication.

Because of chewing problems and decreased masticatory function, a limitation in food

selection may occur resulting in nutritionally poor diets. Poor nutrition might contribute to an
increased risk of several systemic diseases such as cardiovascular diseases and hypertension Tooth
loss may be a significant problem related to general health and the quality of life. [8] The effect is
graded, with a progressively higher incidence with lower SES as defined by occupational position,
income, and education in men and women [9] Lifestyle and tooth loss have a substantial
association. According to age group, these results Suggest tooth loss is an oral health problem in the
study population.

Till date in India it was not possible to do an insurance based research as there was no
insurance system for dental care in India. Dental insurance system has been recently started for the
employees of certain companies and banking system. This study was possible due to recently
introduced dental insurance system State bank of Saurashtra of Bhavnagar.

A similar type of recent survey two years was done in Brazil by Neto JM et al [11], and found
that during 2 years 264 teeth were extracted and the distribution of such extractions was rather
unequal. A strong suggestion of a social gradient was noted and the odds of tooth extraction
occurring per social strata, adjusted by age and gender, were five times higher in employees
pertaining to the lowest social stratum.The purpose of our study was to compare the odds of
individuals of distinct social strata being subjected to tooth extraction

Materials and Methods:

Design and the setting of the study

We conducted a retrospective unmatched case–control study of incident cases of tooth loss. The
population 1055 insured employees working in the head office of State Bank of Saurashtra, in
Bhavnagar City in Gujarat state. The bank provides insurance of total 1500 Rs (Approx U$37.5) per
month for any dental treatment.
In Bhavnagar region Population Dentist Ratio of 13,096 people per dentist and there are Number of
private clinics and one government dental hospital. Most of the Private System is financed by Direct
Payment to Dentist, which included dental care in all specialties including implant, Root Canal
Treatment etc. co-payment of dental procedure by the insured employees are 50-100% of dental fee.
Some companies also provide free dental treatment.
Ethical Approval:
Ethical approval was obtained from “Ethical committee for Research” of Darshan Dental College.
Definition of Case and Control
Cases were defined as all employees of the Bank, who had undergone at least one tooth
extraction from 1st March 2007 to 29th Feb 2008. We excluded employees who extracted only third
molars and those who were subject to orthodontic dental care in the period of the study. For each
case, three controls were randomly selected without matching from the list of employees without
records of tooth extraction in the same period. The final sample of the study consisted of 102 cases
and 306 controls.

Main exposure:

The main explanatory variable was „„social stratum‟‟, Obtained from the combination of two
indicators: the occupational position and the employee‟s monthly income. For the occupational
Position, employees were classified as professionals and technicians according to his/her
occupational level during the period of the study [17, 18].
Thirty Six percent of employees in the base population were professionals with Monthly salaries
varying from U$250 to U$1005 (INR 9750 to 39,195 approx.)
The other employees worked in technician levels (Maintenance, security guards, and peon) with
monthly salaries varying from U$200 to U$750. (INR 7,800 to 29,250)
The employee‟s monthly income was based on the basic monthly salary on 12/31/2001 and it was
divided by the national minimum salary in force on that date, i.e. approximately U$64. (INR 2550)
Thus, the Income is presented as the number of minimum salaries.
Employees were classified into four social strata according to their occupational level and monthly
income as follows:
(i) Social stratum 1: low-income technicians (between 3 and 7 national minimum salaries) (ii) Social
stratum 2: high-income technicians (between 8 and 11 national minimum salaries) (iii) Social stratum
3: low-income professionals (between 4 and 8 national minimum salaries) (iv) Social stratum 4:
high-income professionals (between 8 and 15 national minimum salaries).
Covariates
Other covariates included were age (in quartiles), gender, (female/male), Smoking and number of
years of employment.
Statistical analysis
We assessed the number of teeth extracted in each social stratum. Chi-square test and t-test for
categorical and continuous variables, respectively, were used to assess whether the differences
between cases and controls by social strata, age, gender, and years of employment were statistically
significant. Logistic regression models were used to assess the association of tooth loss incidence
with social stratum adjusting for age and gender. Analyses were performed using SPSS 11.0.
Results
Excluding the employees who underwent tooth extractions of third molars only and those
who were under orthodontic treatment during the period of the study 102 employees had 304
teeth extracted.

Care is needed when comparing results of independent studies which are carried out at different point
of time, as various sources of bias may invalidate the comparison. Important source of bias in the
context of the study may be different in the exclusion and non-response of dentists, the age of
patients. The classification and definition of reasons

for extraction, depends upon availability of dental services, treatment philosophy, attitudinal and
cultural factors of people too.

We have done study in the urban area of the Bhavnagar city. The insurance system was started since
1 year and all the participants were included from that time. The results of this study have shown that
the Social equality among insured employees. Our results were opposite to the Marmot and
Wilkinson [12, 13] and with others [14, 15]. In India insurance was equalizing tooth lose incidence
among various socio economic group of individual.

We found the equality in the odds of undergoing tooth extraction. The incidence of tooth extraction
was slightly higher in lower social stratum may be due to higher incidence of oral disease [19].
Higher social stratum (Social stratum 4) more prone to tooth loss may be because in that particular
social stratum subjects are of higher age.

The number of years worked in the time of year, a mean age of employee was much higher
in the cases (31.27 years) than in the controls (23.36). Previously the similar type of study was done
in Brazil in which smoking factor was not included [12).

In our study, the adjusted odds ratios were equal to the crude ones. In conclusion, lower
social strata were strongly associated with increased risk of having teeth extracted. Therefore,
dental insurance was not able to equalize the chances of tooth extraction among different social
strata, in a population of employed adults. Studies should be carried out to analyze how social
strata may influence the decision made by dentists and patients to extract or to keep a tooth. Such
information could help to reduce social inequality in tooth extractions. Among the various previous
research majorities where done for reason of tooth extraction in correlation with dental caries and
periodontal diseases but very few research describing the social inequality and dental insurance
system which can effect tooth extraction are reported till date. Although the lesser number of
participant were in 2 and 3 social stratum the result were statically significant. Our interpretation of
oral health inequalities is consistent with other observations. For instance established that
edentulism (having no natural teeth) was unrelated to underlying oral disease experience. Instead,
edentulism and part edentulism (or tooth loss) were related to patterns of treatment. The
observation that inequalities in oral health are marked for oral health outcomes, but less so for
underlying disease experience is also consistent with inequality in the percentage of the adult
population with self-reported edentulousness (no natural teeth), self-rated „average‟, „poor‟ or
„very poor‟ oral health, symptom experience, at so called oral health-related quality of life [10].

Among the various recent study done survery one in UK by Donaldson et al[16] who found
that social economic status aging dental attendance profile and various barrier to dental attendance
can affect no of sound teeth in adult which is similar to our study.
The possibility of having tooth extraction outside the dental insurance network may underestimate
the association, as low social strata employees may be more likely to have a tooth extraction in
government dental services the lack of information about the no of teeth baseline may also
underestimate the association as low social strata employees more likely have had fewer teeth
exposed during the study period.

In our study, the adjusted odds ratio were bigger than the crude higher status because higher
social status protects against tooth loss, age (confounding)increase the risk of tooth loss and
employees on the higher strata are older. Therefore, age reduce the force of the crude association
between social strata and tooth extraction.
In conclusion, lower social strata were slightly associated with increase risk of having teeth
extracted. Therefore, dental insurance was able to equalize the chances of tooth extraction among
different social strata, in a population of employed adult‟s future research.