ORIGINAL ARTICLE
Tooth Wear Among Tobacco Chewers in the Rural Population of Davangere, India Ramesh Nagarajappaa/Gayathri Rameshb Purpose: In India, people chew tobacco either alone or in combination with pan or pan masala, which may cause tooth wear. The purpose of this study was to assess and compare tooth wear among chewers of various forms/combinations of tobacco products in the rural population of Davangere Taluk. Materials and Methods: A cross-sectional study was conducted on 208 subjects selected from four villages of Davangere Taluk. Tooth wear was recorded using the Tooth Wear Index by a calibrated examiner with a kappa score of 0.89. The chi-square test was used for statistical analysis. Results: The subjects chewing tobacco had significantly greater tooth wear as compared to the controls (P < 0.001). It was also observed that the frequency and duration of chewing tobacco was directly proportional to the number of pathologically worn sites. Conclusion: The abrasives present in the tobacco might be responsible for the increased tooth wear among tobacco chewers. Key words: rural population, tobacco, tooth wear Oral Health Prev Dent 2012; 10: 107-112
D
ata on global tobacco consumption indicate that an estimated 930 million of the world’s 1.1 billion smokers live in developing countries (Jha et al, 2002) with 182 million in India alone (Shimkhada and Peabody, 2003). By 2020, tobacco consumption has been projected to account for 13% of all deaths in India (World Health Organization, 1997; Kumar, 2000). People have consumed tobacco since time immemorial and at present, the world is in the grip of a tobacco epidemic. In India, being no exception, the chewing of tobacco is very popular especially in rural areas, and this habit has increased in recent times (World Health Organization, 1997). It has been estimated that 96 million (52%) of Indians consume tobacco in a smokeless form. The use of ‘gutkha’ and ‘pan
a
Professor and Head, Department of Public Health Dentistry, Pacific Dental College and Hospital, Udaipur, Rajasthan, India.
b
Reader, Department of Oral Pathology and Microbiology, Pacific Dental College and Hospital, Udaipur, Rajasthan, India.
Correspondence: Prof R. Nagarajappa, Department of Public Health Dentistry, Pacific Dental College and Hospital, Airport Road, Debari, Udaipur – 313024, Rajasthan, India. Tel: +91-900-134-1988, Fax: +91-294-249-1508. Email:
[email protected]
Vol 10, No 2, 2012
Submitted for publication: 07.01.11; accepted for publication: 12.09.11
masala’ with tobacco are common modalities of tobacco use. It has been reported that 77.3% and 83.1% in Uttar Pradesh and Karnataka states, respectively, use gutkha or pan masala-containing tobacco (Chaudhry et al, 2001). Some reports suggest the prevalence of tobacco use among young people has remained steady in recent years (Sinha et al, 2008), while others imply it may be rising (Reddy et al, 2006; Daniel et al, 2008). The various forms of tobacco chewing include pan (piper betel leaf filled with sliced areca nut, lime, catechu and other spices chewed with or without tobacco), pan masala or gutkha (a preparation of crushed areca nut, catechu, paraffin, lime, flavourings and small amounts – less than 10% – of tobacco), mishri (a powdered tobacco rubbed on the gums like toothpaste) and others. The nature of chewable areca nut and tobacco consumption in India has undergone a rapid transformation with the introduction of pan masala and gutkha. These products are conveniently packed, aggressively advertised and widely marketed in various forms such as khaini, mawa, zarda, mishri etc. These products are commercially available under various brand names such as Vimal, Manikchand, Rajnigandha
107
Nagarajappa and Ramesh
Pan Masala, Pan Parag, etc (Sushma and Sharang, 2005). The negative health effects associated with smokeless tobacco consumption include oral, pharyngeal and oesophageal cancer (Winn et al, 1981), oral leukoplakia (Grady et al, 1990 and Tomar et al, 1997), cardiovascular disease (Bolinder et al, 1994), periodontal disease (Robertson et al, 1990) and nicotine addiction (US Department of Health and Human Services, 1986). Other dangers from smokeless tobacco use include the following: gum recession that results in exposed roots and increased sensitivity to heat and cold, drifting and tooth loss from damage to gingival tissue, abrasion to tooth enamel because of high levels of sand and grit contained in smokeless tobaccos, tooth discolouration and bad breath (Tomar and Winn, 1999; Bowles et al, 1995). Studies have shown that the magnitude of the effect of chewing tobacco on the occurrence of tooth wear is high, with users having many times the risk of nonusers (Bowles et al, 1995). Tooth wear is a composite term introduced to cover noncarious tooth surface loss by attrition, abrasion and erosion (Addy and Bristol, 2005). Tooth wear may be defined as the gradual loss of tooth substance due to repetitive physical contacts or to chemical dissolution (Smith and Knight, 1984). When enamel and dentine are gradually worn away by abrasion, the tooth normally forms secondary dentine, and when the tooth is exposed to increased amount of abrasives, the secondary dentine is also worn down. In extreme cases, the clinical crown may be worn away. Because tobacco accounts for such a high proportion of these diseases, the current study was undertaken to assess and compare tooth wear among chewers of various forms of tobacco in the rural population of four selected villages of Davangere Taluk, India.
MATERIALS AND METHODS A cross-sectional survey was conducted among rural adults aged 35 to 44 years in four selected villages of Davangere Taluk, namely, Shamanur, Alur, Bhathi and Kukkawada. Davangere district, an administrative district of Karnataka state in Southern India covering a geographical area of 5975.97 km2, comprises six Taluks: Davangere, Harihar, Honnali, Channagiri, Harapanahalli and Jagalur.
108
These villages were not more than 25 km from the urban area Davangere. Eligible participants were located using a random selection and screening procedure based on a multistage cluster sampling design. In the first stage, Davangere Taluk was geographically divided into four regions – northeast, northwest, southeast and southwest. In the second stage, from each of the geographical regions, one village was randomly selected. Finally, 50 to 60 subjects from each village fulfilling the inclusion criteria were randomly selected and surveyed to obtain a sample size of 208. Agriculture is the main occupation of the residents in these villages. The socioeconomic and living conditions were comparable in all four villages. A survey proforma was prepared to acquire personal details such as age, sex, oral hygiene practices and patterns of smokeless tobacco use, specifying the frequency, duration and type (tobacco with pan, plain tobacco, pan masala with tobacco). The survey instrument was pre-tested in a sample of adults of the same age group as the study participants and, based on feedback provided by these participants, the instrument was determined to be acceptable (Cronbach’s alpha = 0.88). The study protocol was reviewed and approved by the Institutional Review Board. Informed consent was obtained from all study participants. Subjects in the age group of 35–44 years who satisfied the following criteria were selected. r Had a minimum of 12 functional teeth. r Chewed only one form of chewing tobacco. r Used soft-bristled tooth brush and toothpaste for cleaning teeth. r Did not have habits such as bruxism, bruxomania, alcoholism. r Had no eating disorders such as anorexia or bulimia nervosa. r Did not work in factories or have occupations that may promote tooth wear. The Tooth Wear Index (Smith and Knight, 1984) was used to assess the tooth wear among the subjects. Cervical (C), buccal (B), lingual (L) and occlusal/incisal (O/I) surfaces were recorded separately for all erupted permanent teeth; thus, a maximum of 128 surfaces was examined per subject. Type III clinical examination of all individuals was performed by a trained and calibrated examiner (kappa value = 0.89). The scores of the tooth wear index used in the study were as follows:
Oral Health & Preventive Dentistry
Nagarajappa and Ramesh
r Score 0 – no loss of enamel surface characteristics on B/L/O/I and no change in contour on C. r Score 1 – loss of enamel characteristics on B/L/ O/I and minimal loss of contour on C. r Score 2 – loss of enamel exposing dentine for less than 1/3 of the surface on B/L/O/I and defect less than 1 mm deep on C. r Score 3 – loss of enamel exposing dentine for more than 1/3 of the surface on B/L/O/I and defect 1 to 2 mm deep on C. r Score 4 – complete loss of enamel or pulp exposure on B/L/O/I and defect more than 2 mm deep on C. The data were analysed using SPSS version 15 (SPSS; Chicago, IL, USA). The total number of sites scored and the number rated as showing pathological wear were calculated. The chi-square test was used to test whether there were significant differences in outcome measures. P ≤ 0.05 was considered statistically significant.
RESULTS A total of 208 subjects, 127 (61.1%) males and 81 (38.9%) females, aged 35 to 44 years (mean age
39 ± 3.5 years) constituted the study population. They were divided into four groups: tobacco with pan (64.5% and 35.5% males and females, respectively), plain tobacco (60.4% and 39.6%), pan masala with tobacco (68.5% and 31.5%) and control (47.7% and 52.3%). Pathologically worn surfaces among the study subjects in the various groups were as follows: tobacco with pan (14.3% and 11% males and females, respectively), plain tobacco (12.4% and 10.3%), pan masala with tobacco (15.9% and 11.6%) and control (6.2% and 4.3%). It was observed that males had higher scores of pathologically worn sites than did their female counterparts. We also observed a statistically significant (P < 0.001) difference between tobacco chewers and control group in relation to the pathologically worn sites. In particular, the pan masala with tobacco chewers showed the most tooth wear. The distribution by surface of pathologically worn sites showed the occlusal/incisal surface as the main surface accounting for most of of the tooth wear. Occlusal tooth wear was higher in tobacco chewers than in the control group (Table 1). A higher risk of tooth wear was associated with a greater frequency of tobacco chewing. In all the subgroups, it was observed that as the frequency
Table 1 Distribution of study population according to sex and individual pathologically worn surfaces Pathologically worn surfaces Groups n = 208
Sex
Study subjects n (%)
Total surfaces scored
Cervical
Buccal
n (%)
Lingual
Total
n (%)
Occlusal/ Incisal n (%)
n (%)
n (%)
Tobacco with pan n = 62
M
40 (64.5)
4019
116 (20.1)
24 (4.2)
428 (74.3)
08 (1.4)
576 (14.3)
F
22 (35.5)
2309
49 (19.4)
10 (3.9)
185 (72.8)
10 (3.9)
254 (11)
Plain tobacco n = 48
M
29 (60.4)
2969
84 (22.8)
14 (3.8)
258 (69.9)
13 (3.5)
369 (12.4)
F
19 (39.6)
1979
47 (23.2)
09 (4.4)
139 (68.5)
08 (3.9)
203 (10.3)
Pan masala with tobacco n = 54
M
37 (68.5)
3269
73 (14)
19 (3.6)
421 (80.5)
10 (1.9)
523 (15.9)
F
17 (31.5)
1588
29 (15.8)
07 (3.8)
145 (78.8)
03 (1.6)
184 (11.6)
Control n = 44
M
21 (47.7)
2365
39 (26.5)
09 (6.1)
95 (64.7)
04 (2.7)
147 (6.2)
F
23 (52.3)
2503
29 (27.1)
07 (6.5)
69 (64.5)
02 (1.9)
107 (4.3)
Significance set at P ≤ 0.05. Tobacco chewers vs controls: P < 0.001.
Vol 10, No 2, 2012
109
Nagarajappa and Ramesh
of chewing tobacco increased, the number of pathologically worn sites also increased. This relationship was statistically significant except in the plain tobacco group. A highly significant difference was seen between the tobacco chewers regardless of frequency and non-chewers (Table 2).
The pathologically worn surfaces in both sexes chewing any form of tobacco for more than 5 years was significantly higher than in subjects who chewed less than 5 years. Similarly, regardless of duration, the tobacco chewers and non-chewers also differed statistically significantly (P < 0.001, Table 3).
Table 2 Distribution of pathologically worn surfaces according to sex and frequency of chewing tobacco No. of subjects
Total surfaces scored
Pathologically worn surfaces n (%)
Groups and frequency Male (1)
Female (2)
Male
Female
Male
Female
40
22
4019
2309
576 (100)
254 (100)
Less than 5/day (a)
17
13
1912
1365
205 (35.6)
105 (41.3)
More than 5/day (b)
23
09
2107
944
371 (64.4)
149 (58.7)
29
19
2969
1979
369 (100)
203 (100)
Less than 5/day
11
12
1238
1260
159 (43.1)
98 (48.3)
More than 5/day
18
07
1731
719
210 (56.9)
105 1.7)
37
17
3269
1588
523 (100)
184 (100)
Less than 5/day
15
09
1326
951
173 (33.1)
74 (40.2)
More than 5/day
22
08
1943
637
350 (66.9)
110 (59.8)
21
23
2365
2503
147 (6.2)
107 (4.3)
I. Tobacco with pan
II. Plain tobacco
III. Pan masala with tobacco
Controls
Significance set at P ≤ 0.05. I) a vs b, 1 vs 2: P < 0.001; II) a vs b: not significant; II) 1 vs 2: P < 0.001; III) a vs b, 1 vs 2: P < 0.001; tobacco chewers vs controls P < 0.001.
Table 3 Distribution of pathologically worn surfaces according to sex and duration of chewing tobacco No. of subjects
Total surfaces scored
Pathologically worn surfaces n (%)
Groups and duration Male (1)
Female (2)
Male
Female
Male
Female
40
22
4019
2309
576 (100)
254 (100)
Less than 5 years (a)
16
15
1718
1675
173 (30.1)
92 (36.2)
More than 5 years (b)
24
07
2301
634
403 (69.9)
162 (63.8)
29
19
2969
1979
369 (100)
203 (100)
Less than 5 years
16
15
1691
1578
132 (35.8)
84 (41.4)
More than 5 years
13
04
1278
401
237 (64.2)
119 (58.6)
37
17
3269
1588
523 (100)
184 (100)
Less than 5 years
12
12
1260
1235
142 (27.2)
58 (31.5)
More than 5 years
25
05
2009
353
21
23
2365
2503
I. Tobacco with pan
II. Plain tobacco
III. Pan masala with tobacco
Controls
381 (72.8)
126 (68.5)
147 (6.2)
107 (4.3)
Significance set at P ≤ 0.05. I , II, III a vs b, 1 vs 2: P
