Introduction {#sec1-1}
============

The oral cavity is described as an integral part of the overall health of human being.\[[@ref1]\] It is rightly said by Seymour that "Good general health cannot be achieved without good oral health. "\[[@ref2][@ref3]\]

Oral disease is a complex phenomenon and association with various elements leads to its increased occurrence.\[[@ref4]\] The etiology of oral diseases is multifactorial.  Various risk factors are also associated with increased risk of oral diseases; adverse habits such as smoking, tobacco, areca nut chewing, etc.,  prevail as the most important risk factor for the occurrence of oral diseases including cancer.  In the world, India is one of the largest producers and consumer of tobacco.\[[@ref5]\] Hence, the risk of dental problems and oral cancers is high in these residents.  Primary prevention reduces the prevalence of dental problems and oral cancer and act as a preventable cause. 

Patient associated factors such as age, gender, and family background appear to be particularly significant components in the advancement of oral diseases while in rural population risk seems to increase due to their geographical location, food habits, and oral hygiene practices.  The most important determinant of oral disease is Socio Economic Status (SES).\[[@ref6]\] Oral hygiene behaviors differ greatly among regions, countries, and even within countries.  Different oral hygiene behaviors result in different oral health outcomes across the nation.  For example, use of tobacco and areca nut for recreational and therapeutic purposes is widely prevalent in rural regions of central India resulting in high incidence of abrasions, dental caries, periodontal diseases, and oral lesions.\[[@ref7]\]

Health Seeking Behavior (HSB) is described as the action to be taken by an individual to preserve or regain good health.\[[@ref8]\] HSB is an outcome of the complex interaction between patient illness and household characteristics.\[[@ref9]\] HSB is greatly affected by the availability and accessibility of health care services.\[[@ref10]\] In both developing and developed communities, poor attentiveness regarding oral health has been particularly seen among unprivileged group.\[[@ref11]\] Poor-feeding conditions, food habits, and lower levels of literacy and health awareness among the population are inadequate which lead to poor utilization of healthcare facilities could be some of the reasons for it.\[[@ref12]\] The most affected population having oral diseases (dental caries) are children; hence, educating the parents is of utmost importance.\[[@ref13]\]

The reasons for people avoid visiting the clinicians and neglect the symptoms of oral diseases are economic instability, fear of cancer, or lack of faith in medical services.  This is known as "patient delay" or "diagnostic delay. "\[[@ref11]\] The early detection and prevention is an important key in stopping the progression of oral diseases and improving the quality of life of patient.  To amend health behavior and improve their quality of life while reducing social inequalities regarding health, it seems crucial to consider both patients' portrayals regarding health as well as the social and emotional elements of their decision and behavior.\[[@ref9]\]

Health service deficits (HSDs) are evolving concepts that assess healthcare access and utilization.  Conceptually, healthcare access and utilization are distinct yet inter-related since access is necessary for utilization.  Access to health services entails the timely use of personal health services to achieve the best health outcomes.  Access involves being able to make use of necessary healthcare, at a physical location, from a healthcare provider that the patient is able to communicate and trust (personal relationship).  Healthcare utilization, in contrast, entails the actual use of healthcare services.\[[@ref14]\]

Inaccessibility to dental care is one of the major challenges; poor utilization of services is another dreadful challenge attenuating the scope for improvement of the oral health status of rural India.\[[@ref15]\] Especially, when it comes to the rural population, many challenges exist pertaining to the betterment of oral health care.  In a country where thousands of dentists are graduating per year, it is astounding to know that only a handful of them serve the rural population, while the majority of dentists prefer to serve in an urban area.  Shortage of dental professionals can lead to reduced availability to oral health services and poorer oral health status for rural dwellers in comparison to urban populations.\[[@ref16]\]

Approach to health-seeking behavior is usually determined by knowledge and attitude of the people.\[[@ref17]\] To provide need-based health care services to the people, a thorough understanding of the health-seeking behavior is crucial.  By understanding patients health-seeking behavior, their attitude toward oral health can be judged which would help to reduce the amount of damage caused by neglecting dental problems.  Hence, the aim is to study the perception of people belonging to rural areas about common oral diseases and their health-seeking behavior related to those diseases.  Proper understanding of health-seeking behavior could reduce the delay in diagnosis and improve the treatment compliance and the strategies for health promotions. 

Subjects and Methods {#sec1-2}
====================

A cross-sectional study was carried from December 2018 to April 2019 after receiving approval from the Institutional Ethical Committee \[DMIMS (DU)/IEC/2018-19/7575\], 28^th^ September 2018.  The study was conducted in the rural areas of Maharashtra on age group 18 years and above.  The study Performa comprised of informed consent, demographic information, and questionnaire. 

The questionnaire was self-administered and closed-ended.  Expert committee was established and items were generated by referring to the questionnaire used in the study by Bommireddy *et al*.\[[@ref15]\] The questionnaire was translated and back translated and the final questionnaire was prepared in the regional language, Marathi.  To check the understanding, feasibility, reliability, and validity of the structured questionnaire, a pilot study was conducted on 30 participants.  The Cronbach\'s alpha and split-half reliability values were found to be 0.83 and 0.78, respectively.  The results and participants of the pilot study were not included in the main study. 

The questionnaire consisted of three parts.  The first part consisted of demographic details.  The second part was based on oral health literacy; it included questions like knowledge, attitude, and habits of oral health, deleterious habits, and frequency of dental care visits.  Third part had nine questions which were based on health-seeking behavior of participants like any visit to a dentist, frequency, and reason for visits.  The responses of seven questions were scored as one and two, while scores for the remaining two questions were given one, two, and three, respectively.  One is the minimal score.  The maximum total score was 20 and the minimum was 9.  Further, patients were divided into two groups based on total score.\[[@ref18]\] Negative health-seeking behavior was scored from 9--14 and positive from 15--20. 

The main study data was done on 700 participants.  Data was recorded with an allotted time of 5 min for each patient by a single investigator.  After the data collection, data was entered into the MS Excel (MS Office version 2007 developed by Microsoft, Redmond, WA).  The analysis was done using Chi-square test by SPSS version 21(SPSS statistics IBM CORPORATION).  The difference was statistically significant (*P* \< 0.05). 

Results {#sec1-3}
=======

[Table 1](#T1){ref-type="table"} shows that use of smokeless tobacco was reported by 46% of males and 43.3% of females, while the habit of betel nut chewing was seen more in females (23.1%) as compared to males (20.2%).  Toothbrush (48.7%) was the most commonly reported cleaning aid and toothpaste (40.4%) was the commonly used cleaning material. 

###### 

Descriptive statistics on habits and oral hygiene of study participants based on gender

  Variable                                            *n*                 \%     Male *n* (%)   Female *n* (%)   Chi-square   *P*     
  --------------------------------------------------- ------------------- ------ -------------- ---------------- ------------ ------- -------
  Adverse habits                                      Smokeless tobacco   386    55.2           162 (46)         150 (43.3)   0.866   0.352
  Smoke tobacco                                       35                  5.0    54 (15.3)      55 (15.9)                             
  Betel nut                                           151                 21.6   71 (20.2)      80 (23.1)                             
  Others                                              73                  10.4   29 (8.2)       44 (12.7)                             
  How do you clean your teeth?                         Brush               341    48.7           182 (51.7)       159 (45.8)   4.465   0.215
  Fingers                                             318                 45.4   148 (42)       170 (49.0)                            
  Neem stick                                          38                  5.4    22 (6.2)       16 (4.6)                              
  Others                                              3                   0.4    1 (0.3)        2 (0.6)                               
  What material do you use to clean your teeth?        Toothpaste          283    40.4           145 (41.2)       138 (39.8)   2.419   0.490
  Snuff                                               135                 19.3   60 (17.0)      75 (21.6)                             
  Powder                                              276                 39.4   145 (41.1)     131 (37.8)                            
  Others                                              6                   0.9    3 (0.9)        3 (0.9)                               
  What method do you follow for cleaning the teeth?    1\. Horizontal      221    31.6           109 (31.0)       112 (32.3)   0.576   0.902
  2.vertical                                          181                 25.9   96 (27.2)      85 (24.5)                             
  3\. Both                                            298                 42.5   148 (42)       150 (43.2)                            
  How often do you change your tooth brush?            1\. 3 months        82     11.7           45 (12.8)        37 (10.7)    1.694   0.638
  2\. 6 months                                        94                  13.4   50 (14.2)      44 (12.7)                             
  3\. 1 year                                          143                 20.4   67 (19.0)      76 (21.9)                             

Total 68% of people reported with a dental problem, out of these, 73.1% were males and 65.4 were females.  Toothache was the most common dental problem reported by 33.2% of males as compared to 34.3% females followed by the mobility of teeth, which was a second most common dental problem.  Over 53.1% of study participants visited dentists for their dental problem; 41.5% of males and 43.8% of females visited a dental clinic for pain \[[Table 2A](#T2){ref-type="table"}\]. 

###### 

Table 2A: Differences in responses of oral health problems based on gender among study participants

  Variable                                               *n*                   \%     Male *n* (%)   Female *n* (%)   Chi-square   *P*      
  ------------------------------------------------------ --------------------- ------ -------------- ---------------- ------------ -------- ---------
  Dental problem                                         Yes                   476    68.0           257 (73.1)       227 (65.4)   4.372    0.037\*
  What kind of dental problem?                            Toothache             236    33.7           117 (33.2)       119 (34.3)   10.598   0.102
  Bleeding gums                                          58                    8.3    38 (10.8)      20 (5.8)                               
  Mobile teeth                                           136                   19.4   65 (18.5)      71 (20.5)                              
  Caries                                                 36                    5.1    22 (6.2)       14 (4)                                 
  Ulcers                                                 15                    2.1    9 (2.6)        6 (1.7)                                
  Others                                                 14                    2.0    9 (2.6)        5 (1.4)                                
  Span of dental problem                                 Less than one month   135    19.3           69 (19.6)        66 (19.0)    2.721    0.257
  More than one month                                    359                   51.3   189 (53.7)     169 (48.7)                             
  Have you ever visited dentist?                          Yes                   372    53.1           184 (52.3)       188 (54.2)   0.255    0.614
  For what dental/problem did you visit dental clinic?    Pain                  298    42.6           146 (41.5)       152 (43.8)   0.938    0.816
  Bleeding gums                                          19                    2.7    11 (3.1)       8 (2.3)                                
  Sensitivity                                            54                    7.7    26 (7.4)       28 (8.1)                               
  Esthetics                                              0                     0      0              0                                      
  How often do you visit a dental clinic in a year?       Once                  276    39.4           141 (40.1)       135 (38.9)   1.971    0.578
  Twice                                                  18                    2.6    9 (2.6)        9 (2.6)                                
  Not at all                                             77                    11.0   33 (9.4)       44 (12.7)                              

\*The value of significance *P*\<0.05

In [Table 2B](#T3){ref-type="table"}, we can see that out of the total study population, 47.4% of people had dental clinics nearby.  Out of 353 males 65 (18.5%) and 68 (19.6%) females out of 347 visited government hospital for receiving dental care due to less expenditure of treatment.  This shows that less expenditure plays a key role in choosing oral health-care facilities.  It was found that fear is the major reason among 26.1% of males and 22.5% of females for not receiving dental treatment. 

###### 

Table 2B: Differences in responses about receiving oral health care based on gender among study participants

  Variable                                         *n*                   \%     Male *n* (%)   Female *n* (%)   Chi-square   *P*       
  ------------------------------------------------ --------------------- ------ -------------- ---------------- ------------ --------- -------
  Who has advised you to visit dental clinic?       Neighbors             172    24.6           87 (24.7)        85 (24.5)    1.184     0.881
  Relatives                                        141                   20.1   68 (19.3)      73 (21.0)                               
  Colleagues                                       45                    6.4    23 (6.5)       22 (6.3)                                
  No one                                           13                    1.9    5 (1.4)        8 (2.3)                                 
  Do you have any dentist nearby your place?        Yes                   332    47.4           166 (47.2)       166 (47.8)   0.032\*   0.857
  Have you ever received any dental treatment?      Yes                   291    41.6           141 (40.1)       150 (43.2)   1.599     0.450
  Where did you go for dental treatment            Government hospital   133    19.0           65 (18.5)        68 (19.6)    0.766     0.858
  Private dental clinic                            51                    7.3    25 (7.1)       26 (7.5)                                
  Medical store                                    107                   15.3   51 (14.5)      56 (16.1)                               
  Not undergone any treatment.                      409                   58.4   211 (59.9)     197 (56.8)                              
  Reasons for preferring particular center         Others advice         69     9.9            31 (8.8)         38 (11.0)    3.901     0.564
  Accessibility                                    72                    10.3   37 (10.5)      35 (10.1)                               
  Less expenditure                                 121                   17.3   55 (15.6)      66 (19.0)                               
  Quality treatment                                21                    3.0    13 (3.7)       8 (2.3%)                                
  Reasons for not receiving any dental treatment   Fear                  170    24.3           92 (26.1)        78 (22.5)    3.669     0.598
  No time                                          76                    10.9   35 (9.9)       41 (11.8)                               
  Expensive                                        87                    12.4   38 (10.8)      49 (14.1)                               
  Lack of knowledge                                46                    6.6    24 (6.8)       22 (6.3)                                
  Do not think important                           61                    8.7    34 (10)        27 (7.8)                                

\*The value of significance *P*\<0.05

365 (52.1%) of respondents used home remedies for curing their dental problem.  77.8% of males felt that there is a need to improve their oral health.  40.6% of the total study population felt that dental facilities should be improved around them.  Majority of them (19.6%) suggested that the cost of treatment should be reduced while free treatment (9.7%) was also one of the common suggestions \[[Table 2C](#T4){ref-type="table"}\]. 

###### 

Table 2C: Differences in responses about health care seeking behavior on gender among study participants

  Variable                                                    *n*             \%     Male *n* (%)   Female *n* (%)   Chi-square   *P*     
  ----------------------------------------------------------- --------------- ------ -------------- ---------------- ------------ ------- -------
  Have you tried home remedies for dental problem?             Yes             365    52.1           178 (50.9)       187 (53.9)   0.911   0.340
  What kind of home remedies?                                  Clove oil       137    19.6           69 (19.6)        68 (19.6)    1.802   0.615
  Balm                                                        214             30.6   101 (28.6)     113 (32.6)                            
  Opinion on your state of teeth                              Above average   97     13.9           51 (14.5)        46 (13.3)    1.615   0.656
  Average                                                     415             59.3   203 (57.6)     212 (61.1)                            
  Below average                                               176             25.1   94 (26.7)      82 (23.6)                             
  Opinion on your state of gums                               Above average   97     13.9           52 (14.8)        45 (13.0)    5.607   0.132
  Average                                                     352             50.3   163 (46.3)     189 (54.5)                            
  Below average                                               241             34.4   134 (38)       107 (30.8)                            
  Do you think there is a need to improve your oral health?    Yes             526    75.1           274 (77.8)       252 (72.6)   2.276   0.131
  Suggestions to improve dental facilities around you         Less cost       137    19.6           71 (20.2)        66 (19.0)    2.371   0.668
  Free treatment                                              68              9.7    31 (8.8)       37 (10.7)                             
  Dentist nearby                                              49              7.0    29 (8.2)       20 (5.8)                              
  Dental camp nearby                                          31              4.4    15 (4.3)       16 (4.6)                              

Association of Health seeking behavior toward common oral diseases and demographic variables is presented in [Table 3](#T5){ref-type="table"} which depicts that maximum negative and positive behavior was shown in the age group 21--40 years.  In addition, the majority of males and females have negative health-seeking behavior toward oral diseases. 

###### 

Association of health-seeking behavior toward common oral diseases and demographic variables

  Sample characteristics   Variables      Health seeking behavior   Chi-square   Df       P    
  ------------------------ -------------- ------------------------- ------------ -------- ---- -------
  Age in years             20 and below   15 (0.78)                 4 (0.21)     22.440   27   0.715
  21-40                    295 (0.73)     105 (0.26)                                           
  41-60                    185 (0.73)     68 (0.26)                                            
  61 and above             21 (0.75)      7 (0.25)                                             
  Gender                   Male           264 (0.75)                88 (0.25)    6.059    9    0.734
  Female                   252 (0.72)     96 (0.27)                                            

Discussion {#sec1-4}
==========

Oral health importance in the maintenance of general health has been long acknowledged by the WHO.  There have been a lot of efforts toward raising awareness on oral health among the public by various local, national, and international bodies/organizations.\[[@ref15]\] Despite these efforts, oral health continues to be neglected by the people, especially in rural areas as observed in our study.  The present study reported that significantly males had more dental complaints than females. 

In this study, toothache was the most common reason (33%) for seeking oral care which was also reported by Bommireddy *et al*.\[[@ref15]\] It could be comprehended from these observations that oral healthcare services were elective unless there was pain in the view of a majority of the rural population.  However, in another study, missing tooth was the major complaint for seeking dental care.\[[@ref2]\] The fact that they conducted a study on geriatric population might be the reason for this variation. 

Furthermore, it was reported by the participants that low expenditure (12.4%) was one of the main reasons why they had chosen the facility at which they had sought care.  Contrary results were seen two other studies who reported accessibility as the reason for choosing the particular center for seeking dental treatment.\[[@ref15][@ref19]\] It could be concluded that people choose government hospitals over private dental setups because of less treatment cost. 

In the present study, 12.4% of the people stated that expenses of treatment were the reason for not utilizing oral health services and the results of Gupta *et al*.\[[@ref20]\] coincide with the results of the present study.  The possible cause for this could be difficulty in accessing oral health facilities due to poor transport system, residing in a rural area, or poor health. 

National health authorities should actively take part to develop policies for oral health sectors.  It is recommended that dental camps in the rural sector, mobile dental clinics, and oral health education and promotion should be conducted to spread awareness among the people.  The cost of dental treatments should be revised and made affordable for the rural population.  The health centers should have a complete oral health setup so that people do not have to travel long distances to get oral health care.\[[@ref20]\]

Conclusion {#sec1-5}
==========

Healthcare seeking behavior among rural population toward oral diseases was poor.  As the primary intervention is the key to effective prevention, appropriate steps should be taken to prevent it.  Poor attitudes of people on the importance and awareness of oral health are quite evident, and efforts must be made to bring a change in this scenario.  Hence, there still is need for awareness among the population.  People should be told about the importance of primary prevention.  The services should be provided on the basis of felt needs of the rural population so that utilization of dental services can be increased, thereby improving the oral health status of the underprivileged population.  Despite national goals for achieving health equity, persistent disparities in dental utilization remain for underprivileged population of central India.  Hence, dental camps, oral health education, and awareness camp should be conducted and dental services should be made readily accessible to rural population. 

List of Abbreviations {#sec2-1}
---------------------

HSB = Health seeking behavior, SES = Socioeconomical status, HSD = Health service deficit

Financial support and sponsorship {#sec2-2}
---------------------------------

Nil. 

Conflict of interest {#sec2-3}
--------------------

There is no conflict of interest.