JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 58-62

The prevalence of chronic periodontitis among the endangered toto tribe of India

1 Department of Periodontics, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India
2 Department of Periodontics, Burdwan Dental College and Hospital, Bardhaman, West Bengal, India

Date of Submission15-Oct-2020
Date of Decision07-Feb-2021
Date of Acceptance08-Apr-2021
Date of Web Publication26-Jun-2021

Correspondence Address:
Dr. Sohini Banerjee
83/2, B.P. Lane, Kolkata - 700 035, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_66_20

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Background: The endangered Toto tribe of North Bengal is unique in their traditional oral hygiene practices. Aims & objective: To evaluate the prevalence of chronic periodontitis in the unique genetically homogenous population and also to assess their oral hygiene status. Materials and Methods: The study was conducted on the population with help of two stage approach involving both preformed set of questionaries' and also the intra-oral examination in accordance with standard guidelines. Results and Observations: The data were subjected to statistical analysis and significant association was found between loss of attachment, oral habits, OHI-S scores. CPI scores could be positively associated with OHI-S scores. Discussion and Conclusion: It was observed that despite of having predominantly fair OHI-S scores, high prevalence of deleterious oral habits and other local factors, prevalence of periodontal disease was low among the population.

Keywords: Chronic periodontitis, homogenous, Toto tribe

How to cite this article:
Mukherjee S, Banerjee S, Biswas C, Bandopadhyay P K. The prevalence of chronic periodontitis among the endangered toto tribe of India. J Int Clin Dent Res Organ 2021;13:58-62

How to cite this URL:
Mukherjee S, Banerjee S, Biswas C, Bandopadhyay P K. The prevalence of chronic periodontitis among the endangered toto tribe of India. J Int Clin Dent Res Organ [serial online] 2021 [cited 2022 Aug 7];13:58-62. Available from: https://www.jicdro.org/text.asp?2021/13/1/58/319532

   Introduction Top

The uniqueness of periodontal diseases lies in its omnipotence. No society or culture has been able to escape from its clutches. Nevertheless, the prevalence of the various forms of periodontal diseases varies from one population to another. Recently, the genetic susceptibility of the host has also been put forward as a possible reason behind the differences in the occurrence of periodontal diseases among populations of diverse racial origin.[1],[2],[3],[4] To appreciate the influence of these parameters on periodontal diseases, quantification of the prevalence of such diseases is necessary, especially among closed groups of populations in whom the behavioral pattern has been conserved for generations. The aboriginal tribes of any country are potential populations for such studies. The Toto tribe was selected for the study as because they are genetically preserved population, the chances of heterogenicity are very low.

The Toto tribe is a primitive sub-Himalayan tribe of Indo-Bhutanese origin. The Toto tribe has lived in a small Himalayan hamlet named Totopara, in the Jalpaiguri district of West Bengal. The Toto people are endogamous in nature that is they always marry within their tribe, a tradition conserved since centuries and prevalent till date. As a result of such a practice, the entire Toto population is a genetically homogenous population. Moreover, the environmental factors have remained unchanged for generations due to their rigid social and cultural belief system.

Needless to say, these reasons have prompted several researchers to explore the various aspects of this unique tribe. Most of such studies have focused on their social behavior and anthropological point of view. Although few studies on their health and health-seeking behavior have been undertaken, till date, no study has been conducted to assess the status of their dental health, understand their oral hygiene practices, and know about their oral habits. Therefore, this population is a virgin population as far as oral health survey is concerned. This study was therefore conducted to quantify the prevalence of periodontal diseases among the Toto tribe and also to assess their oral hygiene status which is an indirect reflection of their oral hygiene practices as well. As they are genetically preserved population, the quantification of the prevalence of periodontal diseases would be helpful for the identification of genetic factors as well as their unique oral hygiene practices and oral habits on the disease occurrence and progression.

   Materials and Methods Top

The study was conducted in the Toto settlement of Totopara situated in the Madarihat block of Jalpaiguri district of West Bengal, India. The entire survey took 18 months to complete and was phased out into three phases. Every individual participant was surveyed again by a two-stage approach, the first comprising of an interview based on a preframed set of questionnaire and the second step being the intraoral examination which was conducted in accordance with the guidelines laid down by the World Health Organization (WHO) for oral health surveys. The help of an interpreter was sought for each phase to overcome the language barrier as a vast majority of the Toto people can communicate exclusively in their native Toto language.

The adult population, both males and females, belonging to the Toto tribe and residing in the Toto settlement of Totopara were included in the present study. Of the 642 adult Toto people, 515 were included in the present study. The remaining 127 people could not be surveyed as they relocated to distant places away from Totopara during the study period, mostly for job opportunities in the adjoining country of Bhutan.

Study tools

Each individual participant was examined using the following set of sterilized instruments:

  • Mouth mirror
  • Explorer
  • Tweezers
  • Community periodontal index (CPI)-E probe.

Torchlight was used as a source of illumination.

Study parameters

The study parameter for each individual participant consisted of two parts – the prefabricated question-based interview and the oral examination.

Questions for the interview

Information pertaining to the personal history, medical and past dental history etc., were collected by means of a questionnaire. The parameters included in it were as follows:

  1. Age
  2. Sex
  3. Educational status
  4. Marital status
  5. Whether multipara (applicable for females participants only)
  6. History of preterm labor (applicable for female participants only)
  7. Past medical history (included tuberculosis, malaria, diabetes mellitus, jaundice, asthma, cardiac diseases etc.,)
  8. Past dental history (included history of dental pain, extraction or other procedures, etc.,)
  9. History of any oral habits (included the habit of smoking, chewing tobacco, betel nut, etc.,)
  10. Brushing habits
  11. Tools used for brushing
  12. Whether the participant was under any medication.

Intraoral oral examination

The intraoral examination was conducted according to the guidelines laid down by the WHO for oral health surveys. During the preliminary intraoral examination, the patient's occlusion, presence or absence of carious lesions, wasting diseases (attrition, abrasion, or erosion), and other lesions such as ulcers, hyperkeratotic patches, and glossitis were noted. Further examination was carried out to assess the gingival index (GI), plaque index, oral hygiene index (OHI-S), and CPI.

The results obtained were then subjected to statistical analysis.

Ethical Clearance

Ethical Clearance of this study was provided by Ethical Committee of Dr. R. Ahmed Dental College and Hospital, on October,2018.

   Results and Observations Top

The total study population in this study was 515, aged 15 years and above, comprising 243 males and 272 females.

Periodontal diseases were estimated by the prevalence of gingivitis, the evaluation of the periodontal status by the CPI scores, and the extent of periodontitis as measured by the loss of attachment (LoA).

Gingivitis was found to affect 40.4% of the population. The distribution of mild, moderate, and severe gingivitis is summarized in [Table 1].
Table 1: Summary of the prevalence of gingivitis

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The most prevalent periodontal condition as per the CPI index was the prevalence of calculus. The distribution of the various CPI scores among this study population is summarized in [Table 2] and graphical representation of values is summarized in [Figure 1].
Table 2: Summary of corruption perceptions index scores

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Figure 1: graphical distribution of community periodontal index scores among populations

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Majority of the population, 66.8%, had a LoA of 0–3 mm. LoA of 4–5 mm was prevalent among 25.6% of the people and LoA ≥6 mm was demonstrated in 7.6% of the population. It is summarized in [Table 3]. Severe LoA of more than 9 mm was not found in this population. The distribution of LoA is summarized in [Figure 2].
Table 3: Summary of loss of attachment (loss of attachment)

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Figure 2: graphical distribution of loss of attachment among the different study groups of the population

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The PI scores for the population were on the lower side, and majority of the population had a fair OHI-S score (53.6%).

Chi-square test (χ2) was performed to determine the association between the various study parameters. A statistically significant (P < 0.01) association was found between LoA and oral habits, OHI-S scores, educational status, age, and gender. CPI scores could be positively associated with OHI-S scores, deleterious oral habits, and educational status and the association was statistically significant (P < 0.01).

Statistically significant association was found between the GI scores and OHI-S scores. The OHI-S scores, however, were independently associated with oral habits, educational status, brushing habits, and brushing tools. Since a direct association existed between OHI-S with CPI scores and LoA, therefore, it can be inferred that brushing habits and tools used for brushing were indirectly associated with the CPI scores and LoA.

   Discussion Top

India consists of one of the largest tribal population of the world. The present study population, the Toto tribe of North Bengal, was unique in more ways than one. The Toto community is one of the most primitive tribes of India as well as the world which has been able to resist acculturation for ages. This community has a distinction of being a genetically homogenous community, which perhaps makes it one of its unique as well as rare kinds in the world.[1],[2],[3],[4] Living in seclusion, the Totos have limited awareness and access to oral health care, which was mostly restricted to treatment of dental caries with probably none of the members of the tribe having undergone any kind of periodontal treatment ever. Moreover, due to the acculturation and access to education that has gradually seeped into the Toto society over the past few decades, leading the community to a dichotomous variety so far as their socioeconomic condition is concerned. Thus, while interpreting the data from this study, these facts should be borne in mind.

The prevalence of periodontal diseases was estimated by evaluating the percentage of population affected by gingivitis and periodontitis. Mild gingivitis was found in 31.65% of the population surveyed and 8.5% showed signs of moderate gingivitis as per the GI of Loe and Silness 1963.[5] Only one female, aged between 15 and 24 years, reported a positive history of spontaneous gingival bleeding, thus categorized as severe gingivitis, which probably was due to some underlying systemic disease, although it could not be specified by the individual concerned. A significant association was found (P < 0.01) between poorer oral hygiene scores and the severity of gingivitis which stems its support from the pioneering works of Loe et al.

The yardstick for the diagnosis of periodontal disease is the presence and extent of LoA. When the entire population is taken into consideration, the prevalence of moderate to advanced periodontitis, as estimated by a LoA of 4–5 mm and 6–8 mm or above, respectively, was present in 25.6% and 7.6% of the population. This is comparable to the findings among another Indian tribe, the Irugila tribe of Southern India.

In this study, a significant association was found between increase in age and higher LoA values. When seen from the perspective of age, it was found that the prevalence of moderate to advanced periodontitis was higher in the older age group, again a finding in accord with the Irugila tribe which is also a primitive Indian tribe like the Toto. However, the prevalence of advanced periodontal attachment loss was lower in the population when compared to the other Indian tribal populations, especially of the Nilgiris region.[6] A positive association of LoA was found with gender, with males showing higher LoA for a given age group. This might be due to the higher prevalence of deleterious oral habits such as tobacco habits among the males. This is further substantiated by the fact that a similar positive association was found among the tribes of the Nilgiris.[6]

The other parameter of periodontal disease, the presence of periodontal pocket, was low among this population with only 2.9% of the population showing the presence of periodontal pockets 4–5 mm deep. This is in stark contrast to the results which found among other Indian tribes where 4–5 mm deep periodontal pockets were found to be higher. The prevalence of periodontal pockets among the Totos was also lower when compared to the general population of the state of West Bengal of which the Totos are a part.

In the light of the above-mentioned facts, it can be inferred that the manifestation of periodontitis among the Toto population surveyed was in the form of gingival recession rather than the presence of deep periodontal pockets or severely inflamed periodontal tissues. A possible reason may be that the LoA resulted more due to deleterious oral habits and faulty brushing habits rather and less so due to some infective etiology. A similar observation was found among the primitive tribes of the Amazon River basin, and there too the cause of such an observation could not be conclusively ascertained.

The presence of calculus was the most common CPI score in this population. This is a universal trend among several Indian populations both tribal and nontribal. A positive correlation was found between higher CPI scores and higher OHI-S scores, thereby implying that with poorer oral hygiene, the periodontal status deteriorates.

As far as the Toto tribe is concerned, the low prevalence of periodontal diseases could, in part, be explained by the dietary habits of these tribal people which comprises mainly of whole grains, especially the locally grown “marua,” and an abundance of dairy products both of which are known to have a protective effect on periodontal health. Low genetic susceptibility for periodontal diseases as a possible explanation for such low prevalence cannot be excluded as any case of aggressive periodontitis, which has a definite genetic predisposition, was not found among the people surveyed. Moreover, the effect of any hereditary factor which has a protective role against periodontitis would be profound among these people as they are a genetically homogenous community and need to be further investigated.

The overall low prevalence of periodontal diseases in spite of unfavorable oral hygiene score is not unique to the Totos. Similar findings have been reported from other primitive tribes having similar sociological background settled in other parts of the world. Some researchers attempted to explain this phenomenon and observed that any primitive community living in seclusion from the outside world has an inborn immunity toward dental diseases.[1],[2] Although this fact has been well documented in case of dental caries, more extensive studies are required to establish the same for periodontal diseases. Some researchers had also speculated the role of some unique plaque flora that might be present among such primitive tribes and is essentially protective in nature.[3] This can be inferred from the fact that the flora associated with dental caries has an opposite relationship with the periodontopathogens as the nutritive and environmental requirements for the two floras are different and contradictory.[4] This fact becomes relevant in the present study population as well since it was observed that there existed a high prevalence of caries among the Totos with 68.3% of the population showing the presence of some form of carious lesion.

Attention needs to be drawn to another fact relevant while interpreting the results of this study. Periodontal diseases are usually a disease of the older adults, and severe LoA or periodontal destruction is seldom seen in younger age group except in cases of aggressive periodontitis and rarely as a periodontal manifestation of some systemic disease. In the light of this fact, it should be borne in mind that most of the people surveyed in this study were comparatively of a younger age group with an average age of 25–44 years. Moreover, the average life expectancy of the tribe is very low and was only 35 years even a few decades ago.

From the results of this study, it can be inferred that for this population, despite average oral hygiene, extensive oral habits and very poor almost nonexistent oral health-care access and facilities, the prevalence of periodontal diseases is low. The low prevalence of periodontitis needs to be explored further whether there is any genetic factor which makes them somewhat immune to periodontitis. Since this study is the first of its kind in this population, therefore, there is immense scope and need for further exploration of this topic in the future.

   Conclusion Top

It was observed in this study population that in spite of having a predominantly fair OHI-S score, high prevalence of deleterious oral habits and abundance of local factors, the prevalence of moderate to advanced periodontal destruction in the population was low. This issue needs to be addressed in the future by more elaborate studies, especially emphasizing on the genetic susceptibility, and other environmental factors present within the tribe that favors the development and progression of periodontal diseases.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Debnath M, Chaudhuri TK. HLA-A and HLA-B distribution in Toto-A vanishing sub-Himalayan tribe of India. Tissue Antigens 2006;67:64-5.  Back to cited text no. 1
Rodgers GS, Gupta S, Sharma AN, Sharma B. Demographic patterns and poverty among households in rural Bihar. In: Rodgers G, editor. Population Growth and Poverty in Rural South Asia. New Delhi: Sage Publication; 1989.  Back to cited text no. 2
Ronderos M, Pihlstrom BL, Hodges JS. Periodontal disease among indigenous people in the Amazon rain forest. J Clin Periodontol 2001;28:995-1003.  Back to cited text no. 3
Vivek S, Jain J, Sequeira PS, Battur H, Tikara S, Mahuli A. Understanding oral health beliefs and behavior among Paniyan tribals in Kerala, India. J Int Oral Health 2012;4: 23-8.  Back to cited text no. 4
Löe H. The gingival index, the plaque index and the retention index systems. J Periodontol 1967;38:610-6.  Back to cited text no. 5
Philip B, Chithresan K, Vijayaragavan VS, Maradi A. Prevalence of periodontal diseases among the adult tribal population in Nilgiris- An epidemiological study. Int J Public Health Dent 2013;4:8-12.  Back to cited text no. 6


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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