Published Sep 02, 2026 | 7:20 AM ⚊ Updated Sep 02, 2026 | 7:20 AM
The researchers said the workers' income, occupation and location restricted their access to routine dental care.
Synopsis: A study of 540 tea plantation workers in Tamil Nadu’s Kothagiri Hills found that 62.6 percent had gum disease, with many cases classified as severe. Most workers did not use a toothbrush and toothpaste, and many had never visited a dentist, with low incomes, tobacco use and the plantations’ remote location limiting access to care.
In the tea plantations of the Kothagiri Hills in Tamil Nadu, workers rarely use a toothbrush or toothpaste. Many rely on tooth powder, charcoal, or simply their own fingers to clean their teeth. Some have never sat in a dentist’s chair, a study of 540 tea plantation workers across four estates has found.
It also found gum disease in 62.6 percent of those examined, with many cases reaching field-adapted Stage III/IV severity.
“Periodontitis is one of the most prevalent chronic inflammatory diseases worldwide and remains a major cause of tooth loss in adults,” the researchers write.
“Severe periodontitis affects nearly 11 percent of the global population and contributes substantially to impaired oral function, reduced quality of life, and healthcare burden.”
The workers were screened at community dental camps held between August and November 2023. Researchers examined them for bleeding gums, calculus, periodontal pocket depth, and clinical attachment loss.
“Tea plantation workers represent a socially and occupationally marginalized workforce in many low- and middle-income countries,” the authors write.
“Long working hours, physically demanding labor, tobacco use, and restricted access to healthcare may increase vulnerability to chronic oral diseases, including periodontitis.”
Among the 151 men screened, 31.1 percent had lost 6 mm or more of clinical attachment, compared with 19.3 percent of the 389 women. Calculus accumulation was recorded in 33 percent of men and 21 percent of women.
Clinical attachment level (CAL) measures the loss of the tissue and bone supporting a tooth and is used to assess the damage caused by periodontal disease.
“Male participants exhibited greater calculus accumulation and severe CAL, which may reflect long-term oral hygiene and tobacco-related behavioral factors,” the researchers write.
Women, however, recorded higher rates of bleeding on probing (BoP), deeper periodontal pockets and patterns of tooth loss.
Bleeding on probing was found in 35 percent of women, compared with 22 percent of men. Periodontal pocket depth (PPD), which measures the space between the gum and tooth, also showed differences between the two groups.
“The percentage of PPD at 4–5 mm was 26% in males and 22% in females, but for PPD ≥6mm was 12% in males and 17% in females… Loss of attachment of 0–3mm was also more prevalent in females,” the paper reads.
The study also found a substantial education gap among the workers. A total of 53 percent of the men and 79 percent of the women had no education. Secondary education had been attained by seven percent of men and three percent of women, while none of the participants had an undergraduate education.
Only 11.3 percent of the workers used a toothbrush with toothpaste. Charcoal was the most common cleaning material, used by 71.1 percent of participants – 79 percent of women and 69 percent of men.
The researchers attributed the pattern to both cultural practices and limited access to dental-care products in the hilly terrain.
“Dental hygiene materials varied with cultural practices and the restricted availability of dental health items in the hilly terrain of the Kothagiri hills in rural India. Commonly used agents were charcoal, tooth powder, and finger brushing, and these practices were most prevalent in females,” the authors write.
“High use of charcoal is due to its abrasive nature and limited plaque removal effect, which was associated with irregular oral hygiene practices.”
The researchers said finding is consistent with other research suggesting that SES and educational barriers affect oral hygiene effectiveness.
Nearly 44 percent of the workers—237 of the 540 participants—had never visited a dentist. The study also found that 94.4 percent earned less than ₹10,000 a month.
The researchers said the workers’ income, occupation and location restricted their access to routine dental care.
“Most participants were daily-wage laborers residing in geographically isolated plantation settings with limited access and irregular preventive and therapeutic dental care services,” the authors write.
The shortage of dental professionals outside urban centres and the plantations’ physical isolation adds to the problem, the researchers said.
“Oral health professionals are unevenly distributed in India, leading to access discrepancies, particularly among disadvantaged tribal tea plantation workers,” the paper reads.
“The geographically isolated occupational setting may contribute to difficulties in accessing regular preventive dental services,” the authors write.
Separately, tobacco use was widespread among the workers. Smokeless tobacco was used by 38.5 percent of participants, while 20.7 percent smoked beedis or cigarettes and 15.7 percent used raw tobacco. Only 25 percent reported avoiding tobacco altogether.
Researchers dropped tobacco from the final regression model, citing overlap with other factors.
The researchers did not retain tobacco variables in their final regression model because of multicollinearity – overlap between variables that can make it difficult to isolate their individual effects. They said this limited the analysis but did not negate tobacco’s role in periodontal disease.
“Tobacco exposure likely contributed substantially to periodontal disease severity and may have partially influenced the observed associations,” the authors write.
The researchers also connected the gender differences in calculus, periodontal pocket depth and clinical attachment loss to differences in tobacco consumption.
“Gender based disparities in calculus and PPD, with males showing deeper CAL, could be due to increased tobacco consumption, especially in smoked forms such as beedi and tobacco, which is a significant risk factor in promoting periodontal disease deterioration,” the authors write.
“Although tobacco-related variables were not retained in the final adjusted regression model because of multicollinearity concerns within this relatively homogeneous occupational cohort, tobacco exposure likely contributed substantially to periodontal disease severity,” the authors write.
The 540 workers were volunteers who attended community dental screening camps, rather than a randomly selected sample. They were recruited from four tea estates in a single district. The researchers said this could have affected the composition of the study group.
“Because participation was voluntary through community screening camps, individuals with greater oral health concerns or symptoms may have been more likely to attend, whereas healthier workers may have been underrepresented,” the authors write.
They also identified the sampling method as a source of possible selection bias.
“Participants were recruited through voluntary community dental screening camps using a non-probability convenience sampling approach from four tea estates within a single geographic region; therefore, selection bias cannot be excluded,” the authors write.
The clinical assessment had a separate limitation. The researchers used a simplified approach to classify disease severity rather than applying the full 2017 periodontal disease classification.
“The staging approach represented a simplified clinical approximation rather than a complete implementation of the 2017 classification system,” the authors write.
“This classification was used for epidemiological severity grouping and was not considered equivalent to complete diagnostic staging under the 2017 World Workshop framework.”
The analysis also did not account for the fact that workers were grouped within individual tea estates. The researchers said this could have affected the precision of the statistical estimates.
“Clustering of participants within tea estates was not accounted for in the regression analyses and may have resulted in underestimated standard errors, thereby overestimating the precision of the regression estimates,” the authors write.
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The researchers have called for better access to preventive periodontal assessments, oral health education, tobacco cessation support and appropriate referral services within plantation communities.
They attributed the persistence of untreated periodontal disease to several factors operating together.
“Limited accessibility to preventive oral healthcare services, high tobacco exposure, irregular dental attendance, and constrained oral health awareness may together contribute to persistent untreated periodontal morbidity in this setting,” the authors write.
The researchers said further studies should establish whether proposed interventions can work in plantation communities before they are implemented at scale.
“Future implementation and longitudinal research should assess their feasibility, acceptability, and effectiveness in plantation settings,” the authors write.
The researchers concluded that the study found a substantial burden of periodontal disease among tea plantation workers in Tamil Nadu, with severe disease more frequently associated with male sex, lower educational status and irregular dental attendance.
“This study suggests a substantial burden of periodontal disease among tea plantation workers in Tamil Nadu, with severe periodontal disease more frequently associated with male sex, lower educational status, and irregular dental attendance,” the researchers write.
“Future representative longitudinal studies using standardized diagnostic protocols are needed to confirm these findings and better inform targeted oral healthcare strategies for plantation worker populations.”
