FormalPara Key Points

  • Tribal populations in India are at risk of oral health issues related to tobacco use, and their treatment requirements are growing.

  • In this study, 45.4% of participants used tobacco in smoking or smokeless form daily.

  • Over the eight years of this study, tobacco use was reduced due to consistent messages about the importance of oral healthcare and the hazards of tobacco use.

  • Deep-rooted dental beliefs and treatment hesitancy were reasons for poor oral health among this population.

Adivasis (literally “original people of the forest”), or Scheduled Tribes, comprise a substantial Indigenous minority of the population of India. According to the 2011 census, Tribal people constitute 8.6% of India’s population (over 67.8 million people) [1]. After African countries, India has one of the world’s biggest Tribal populations with approximately half of the world’s Indigenous peoples, making it home to many Tribes with diverse origins, customs, and social practices. The Imperial Gazetteer of India describes a Tribe as a “collection of families bearing a common name, speaking a common dialect, occupying or professing to occupy a common territory and is not usually endogamous though it may have been so originally ” [2]. The Indian Government identifies 645 Tribal communities based on their preagricultural level of technology, low level of literacy, and small or diminishing population. They are generally considered the land’s Indigenous inhabitants [3]. Despite significant advancements in preventative and curative medicine, the healthcare delivery system among Indigenous populations remains deficient and needs strengthening to achieve the national objective of universal healthcare access.

Scheduled tribes make up the majority of the population in the hills of Tamil Nadu—including the Yelagiri and Kalrayan hills of Tirupathur district (formerly Vellore district); the Jawadhu hills in Thiruvannamalai; the Pachamalai, Kollimalai, and Yercaud in Salem district; the Anaimalai of Coimbatore district; and the Sitteri and Palani hills of Dharmapuri and Madurai districts. Yelagiri, located midway between Chennai and Bangalore (920 m above sea level), is a jumble of 14 small settlements spread across four hills (Fig. 37.1). The area is still relatively remote and secluded. The local inhabitants of the region are the Malayali Tribal people, who are involved in economic activities such as agriculture, horticulture, and forestry. The name Malayali is derived from the combination of the terms malai (hills) and alu (person).

Fig. 37.1
A political map of India traces the Yelagiri Hills and Jawadhu Hills near Tirupathur and the Kalvaraya Hills near Salem.

Yelagiri Hills, Tamil Nadu, India. (Map: Saravanan SP)

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Despite the rapid global development in diagnostic, therapeutic, and preventive medicine, many Tribal communities live remotely in natural surroundings and maintain their traditional values, traditions, beliefs, and myths (Fig. 37.2). However, they are also confronted with the imminent threat of environmental degradation. The health problems of each community are influenced by a variety of social, economic, and political factors. Beliefs, customs, and practices are also significant determinants of health outcomes [4]. Health attitudes, knowledge about healthcare, and learned social and cultural definitions of health and illness influence individual willingness to pursue healthcare [5]. Ethnic beliefs and values may promote or limit the utilization of health services, and research indicates that individuals from low socioeconomic backgrounds and ethnic minorities are less likely to utilize healthcare [6].

Fig. 37.2
A photograph of an elderly man, who covers his upper body with a shawl, is standing in front of a thatched house.

Traditional thatched house of the Malayali tribe. (Photo: DL Francis)

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Oral health is critical to overall health because it influences a person’s ability to eat, communicate, and socialize in the absence of disease, discomfort, or embarrassment [7]. It also adds to general wellbeing. However, the oral health of Tribal populations in India is characterized by a lack of access to community-based preventative oral health services such as water fluoridation, fluoridated toothpaste, and sugar-free beverages [8]. The health of the Malayali population has been the subject of several anthropological investigations [9]. However, there is no information in the existing literature about their oral health. In light of this, in 2010, the primary author conducted a doorstep survey to assess the oral health of 660 inhabitants of Yelagiri Hills.

The primary author has a high level of proficiency in the local language, Tamil, but does not have affiliations with the Malayali people and has not been involved in a Tribal advisory group. From 2010, she was engaged as a health educator and oral health program facilitator for this population. She observed that the prevalence of tobacco use among this Tribal population was much higher than the national average of 35%.

From 2010 to 2018, the primary author conducted an education program for the Malayali population in the Yelagiri Hills. The program involved regular oral health assessment and group health education sessions, designed to raise awareness within the community about the detrimental consequences of tobacco use and to disseminate information on effective strategies for tobacco cessation.

Methods

Ethical clearance and permissions were obtained from the village administrative officer, village panchayat leaders, and school authorities. A mass awareness program was then conducted through a cross-sectional household survey in the 14 villages. All age categories, including children, adolescents, adults, and the elderly were invited to participate; however, only residents consenting to do so were included. A school-based awareness program for children was implemented, with the permission of the school authorities. The program included health education, a tooth-brushing demonstration, and posters and videos illustrating the dangers of tobacco use. Adult study participants received an explanation of the study’s purpose and gave their written consent before participating (which could be a thumb impression given in the presence of a legally authorized representative). Prior to the clinical examination, a pretested questionnaire was used to obtain information about demographics, tobacco use, utilization of dental care services, and beliefs and practices about oral hygiene and dental treatment. Type III clinical examination (using mouth mirror, explorer, and adequate illumination) was performed by a single calibrated examiner with the assistance of a recording assistant, in accordance with World Health Organization (WHO) standards. After the clinical examination, all tobacco users were given tobacco cessation counseling and nonusers were given health education counseling on the hazards of tobacco. Statistical Package for the Social Sciences (SPSS) (V.21) was used to compare and analyze the collected data.

Results

The 2010 study had 660 participants. It revealed that approximately 60% of the community had not completed formal schooling and that 64.5% of females and 50.3% of males had no formal educational qualifications (a significant statistical disparity in relation to gender and education (p < 0.001)).

In response to questions about oral health, 62% stated they brushed their teeth with charcoal or brick powder, 9.5% used toothpaste and a toothbrush, 4.1% used toothpowder and a toothbrush, 15.8% used toothpowder and their fingers, and 1.8% used a neem stick. There is a statistically significant difference in brushing materials (Chi-square test = 18.567; p < 0.005). Participants gave varied explanations for not visiting a dentist: 24.2% had never had a dental problem, 4.7% were not interested in consulting a dentist, 50% said they used traditional medicines for dental ailments, 0.6% believed dental treatment was prohibitively costly, and 13% said that there was no dentist nearby. The population exhibited a prevalence of calculus (62.6%), periodontitis (26.5%) (mean attachment loss of 4–5 mm), gingival bleeding (18.6%), and dental caries (79.5%). Figure 37.3 illustrates the decayed, missing due to caries, and filled teeth (DMFT) among males and females.

Fig. 37.3
A grouped column chart plots the percentage of D M F T. The percentage values of decayed, missed, and filled teeth in males are 79.60%, 43.30%, and 0.60%, and in females, they are 79.50%, 51.20%, and 0.30%, respectively.

Decayed, missing, and filled teeth (DMFT) in the study population

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Nearly half of the participants (45.4%) reported regular tobacco use (either in smoking or smokeless form); however, only men and a small percentage of older women smoked tobacco. Only 10.9% used beedi, 16.0% used cigarettes, and 38.0% used cheroots (a locally produced form of smoking tobacco). Smokeless tobacco (SLT) use was more common than smoking: 9.85% chewed raw tobacco (5.42% of males, 13.87% of females), 2.73% chewed Hans (4.78% of males, 8.7% of females), 10.2% chewed Gukta, and 14% combined smoking and SLT. Among the elderly, 32% used snuff and betel leaves with areca nut powder. Statistical tests revealed a substantial relationship between tobacco use and gender, with much higher use by men than women (p < 0.004).

Out of the smokers, only 14.6% had been smoking for 10 years or more and 11% had been smoking for 6–9 years. In terms of tobacco consumption among smokers, 12.4% consumed tobacco more than ten times daily, 26% consumed tobacco four to nine times daily, and 14% consumed tobacco three times daily. There was a statistically significant difference between the duration and frequency of tobacco smoking, suggesting that a longer duration of tobacco use in years leads to a higher frequency of its use. The oral examination determined that the majority of the population (65.45%) did not have an abnormal condition of the oral mucosa. However, there was a prevalence of leukoplakia (19.09%), oral ulcers (3.94%), and leukoplakia with ulcers (15%). There were 5% malignancies affecting the oral cavity and 7.6% other abnormalities.

In 2018 at the 8-year follow-up, the awareness program (oral health and tobacco cessation education held at 3-monthly intervals), had 4456 participants, including 2271 school-aged children (aged 5–17) and 2185 adults (aged 18–85). Of the adults, 1195 (55.70%) were males and 990 (45.30%) were females; 75% used toothbrushes with toothpaste or toothpowder; and 52% had visited dental clinics in the nearby towns for tooth extraction, filling, and oral hygiene maintenance (calculus 45.3% and reduction in mean attachment loss). Reported tobacco use was 32.8%, and oral examination revealed leukoplakia and other oral abnormal conditions among 28.6%.

At follow-up, participants held firm beliefs about oral health and dental treatment, which were framed by religious and traditional belief systems: 69.1% believed spacing in the front teeth brings good luck, 67.3% believed cleaning with salt whitens teeth, 86.5% believed using clove kills germs, 94.5% believed burying milk teeth helps permanent teeth to grow correctly, 65% believed the extraction of an upper tooth leads to blindness, 81.1% stated they would not undergo dental treatment in the evening, and 71.2% believed the extraction of a single tooth loosens other teeth as well.

Discussion

The Malayali tribes of the Yelagiri Hills in Tamil Nadu present unique characteristics compared with other populations. Until recently, the group withstood acculturation. Living in isolation, the Malayalis had limited knowledge of oral health, and access to oral healthcare was primarily limited to the treatment of dental infections. No members of the Tribe had ever received preventive treatments such as oral prophylaxis or therapeutic services like root canal treatment. Acculturation and education have been pervasive in recent decades, resulting in a spectrum of diametrically opposed socioeconomic circumstances. The socioeconomic status of Tribal populations remains lower than that of other population groups, and due to their geographical, socioeconomic, and cultural characteristics, they endure a wide range of health problems. Differences between the oral health of Tribal communities and the general population are evident [10]. This study of the Malayali Tribe demonstrates characteristics consistent with this finding. The susceptibility to dental caries tends to increase with acculturation, particularly due to dietary modifications that increase the consumption of food containing sugar. As this study shows, dietary change may occur without substantial advancements in oral hygiene habits.

Oral hygiene is essential for preventing dental problems and achieving optimal dental health. In this study, the majority of participants reported using traditional methods to clean their teeth, while the use of dentifrice (toothpaste or powder) was low. The findings of this study are consistent with other studies of Indigenous populations, suggesting that Indigenous and Tribal people may not prioritize maintaining oral health [11,12,13]. The prevalence of dental caries in this study may be attributable to inadequate oral hygiene, alongside deep-rooted beliefs, the preservation of natural dentition, a lack of education, the preservation of traditional values, and a lack of awareness. In a similar study on the Bhil tribes of Rajasthan (India), Kumar et al. revealed that the Tribal population believed that the extraction of decayed teeth causes blindness [14].

A previous study by Janakiram et al. revealed that a significant proportion (73.8%) of the Tribal populations in Kerala (India) used tobacco in various forms [15]. The current study reveals a comparatively lower prevalence of tobacco usage (32.8%), similar to the prevalence found by Bhat et al. in a study of Kadukuruba tribes, where 38.50% used smokeless tobacco and 33.2% smoked tobacco [16]. According to the Global Adult Tobacco Survey (2016–2017) India report, on average, 33% of adults routinely used one or more types of SLT. Our data revealed a substantial connection between poor oral hygiene status and tobacco use, similar to the findings of Agarwal et al. in a study of Baiga tribes [17]. In India, the prevalence of SLT use is more than twice that of smoking. SLT use is associated with potentially malignant oral disorders (PMODs), such as leukoplakia, erythroplakia, erythroleukoplakia, and oral submucous fibrosis. In addition, SLT has been linked to physical health issues such as myocardial infarction, chronic obstructive pulmonary disease, infertility, and malignancies of numerous organs, including the pharynx, esophagus, and pancreas [18].

Our research found that Indigenous populations report an elevated sense of wellbeing through their consumption of tobacco, which they associate with resisting cold temperatures, alleviating pain, reducing stress and fatigue, and suppressing hunger. Adolescent females also used SLT to alleviate menstrual discomfort. Our follow-up study revealed that some participants opted to cease tobacco consumption following the continuous reinforcement of oral health education, with a reduction in tobacco use from 45.4% in 2010 to 32.8% in 2018. A prominent justification for consuming tobacco is social acceptance, which leads to addiction. The reduction in consumption that our study revealed may be due to consistent message reinforcement over eight years and heightened awareness about the hazards of tobacco use. This research demonstrates that reinforcement and motivation play a key role in tobacco cessation strategies.

Conclusion

The Malayali Tribes experience oral health challenges marked by a notable prevalence rate, substantial treatment needs, and limited availability of dental care resources. This study indicates that the community urgently needs healthcare assistance. Establishing healthcare programs for Indigenous populations can pose significant challenges due to low literacy rates, low socioeconomic status, and geographical remoteness. The lack of readily available medical and dental care services may contribute to the elevated prevalence of oral disorders within this community. WHO recommends using oral health surveys to gather data on a population’s oral disease, oral health status, and treatment requirements. These surveys serve as valuable tools in the strategic planning of dental services. There is an ongoing need to conduct data analysis pertaining to the incidence and severity of diseases, as well as the population’s treatment requirements. This is crucial to monitor fluctuations in the levels and patterns of these variables over time and to effectively allocate scarce resources to oral health.

The lead author sincerely thanks Dr. M. Dinesh Dhamodhar, reader, SRM Dental College and Hospital, Chennai; Dr. Kumara Raja MDS, reader, Ragas Dental College and Hospital, Chennai; Dr. Manojkumar M., tutor; Mr. Anantha Krishnan, camp organizing officer, Dental Interns (2013–2018), Tagore Dental College and Hospital, Chennai; and the management, staff, and students of Don Bosco College Yelagiri Hills, who actively supported the program. Special mention goes to all the participants, without whom the program would not be a success.