|Year : 2018 | Volume
| Issue : 4 | Page : 308-312
Association between tobacco usage and dental caries among 35–44-year-old fishermen of North Coastal Region of South Indian State, Andhra Pradesh
Asha Lodagala, Srinivas Pachava, Devaki Talluri, Viswa Chaitanya Chandu
Department of Public Health Dentistry, SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh, India
|Date of Submission||04-Apr-2018|
|Date of Acceptance||01-Oct-2018|
|Date of Web Publication||29-Nov-2018|
Dr. Srinivas Pachava
Department of Public Health Dentistry, SIBAR Institute of Dental Sciences, Takkellapadu, Guntur - 522 509, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Tobacco usage is popular among rural and urban communities of India. Sporadic studies that were conducted to know the caries experience among tobacco users yielded conflicting conclusions. Fisherfolk communities form a special population in light of the variations in their dietary habits compared to general population. Aim: The aim of this study was to explore the dental caries (DC) experience among tobacco users and nonusers in fisherman communities residing in the north coastal region of a south Indian state. Materials and Methods: A comparative cross-sectional survey was done in fisherman community belonging to a north coastal region of a South Indian state. Stratified randomized sampling technique was employed to recruit 374 adult participants aged 35–44 years. The survey included interviewer-administered questionnaire and clinical examination for measuring DC experience. The questionnaire consisted of demographic data, brushing aids, 2 days sweet score, and a detailed record on tobacco use of subjects. Decayed missed and filled index (DMFT) and Simplified Oral Hygiene Index (OHI-S) were recorded. The study participants were dichotomized based on tobacco usage. The tests used were independent samples t-test, analysis of variance, and Chi-square test. Results: DC was present among 46.5% of tobacco users and 65.8% of nonusers. The mean DFT score for tobacco users (0.62 ± 0.23) was less when compared to that of nonusers (1.40 ± 0.52) after excluding missing component, which is statistically significant (P < 0.001). The mean OHI-S was higher among tobacco users than nonusers. There was no statistically significant difference in the mean sweet scores between these two groups (P = 0.172). Conclusion: Despite higher mean OHI-S scores among tobacco users and similar sweet scores among both the groups, DC experience among tobacco users was less when compared to nonusers. Longitudinal studies are recommended for further confirmative evidence.
Keywords: Dental caries, diet records, oral hygiene index, smoking, sweetening agents
|How to cite this article:|
Lodagala A, Pachava S, Talluri D, Chandu VC. Association between tobacco usage and dental caries among 35–44-year-old fishermen of North Coastal Region of South Indian State, Andhra Pradesh. J Indian Assoc Public Health Dent 2018;16:308-12
|How to cite this URL:|
Lodagala A, Pachava S, Talluri D, Chandu VC. Association between tobacco usage and dental caries among 35–44-year-old fishermen of North Coastal Region of South Indian State, Andhra Pradesh. J Indian Assoc Public Health Dent [serial online] 2018 [cited 2018 Dec 15];16:308-12. Available from: http://www.jiaphd.org/text.asp?2018/16/4/308/246365
| Introduction|| |
Tobacco usage is one of the greatest epidemic threats to public health globally. Approximately one-third of the adult population in the world use tobacco either in smoking, chewing, or any other forms and about half of them die prematurely. Due to severe addiction to nicotine, 4.9 million people died in the year 2000 worldwide as per the estimate by the World Health Organization (WHO). Approximately 7 million people are killed annually by tobacco use, which is assumed to increase to 10 million with 70% deaths occurring in low- and middle-income countries.
Tobacco use has a detrimental impact on both general and oral health. Major systemic adverse effects of tobacco consumption include various form of cancer (mainly lung cancer) and cardiovascular diseases. Likewise, there is strong evidence that tobacco use has numerous negative effects on oral health, ranging from staining of teeth and dental restorations to reduction in the ability to taste, development of oral diseases such as smokers' palate, oral cancer, potentially malignant disorders, oral candidiasis, and periodontal disease.,
Dental caries (DC) is the most prevalent pandemic chronic noncommunicable disease affecting any age group and is dependent on a number of factors such as lifestyle, socioeconomic and sociodemographic gradients, and the tobacco use. Although it is regarded currently as preventable disease with the regular oral hygiene habits, frequent fluoride usage, and less intake of sugars as major recommendations, it is still effecting the quality-of-life of many individuals of low- and high-income countries.,
Despite its multifactorial etiology, there exists an evocative relationship between tobacco use and incidence of DC. However, the veracious relation between these two is unclear till now since some studies suggest a positive association,,, whereas some negative.,,
Andhra Pradesh has 974 km of coastal line covering nine coastal districts from Srikakulam (North) to Nellore (South). Fishing is the main occupation of these fisherfolk communities living along the shores of these coastal lines and they also possess different cultures, traditions, and dietary habits which consist mostly of seafoods when compared to the general population. Thus, with this background, the current study was conducted to evaluate the association between tobacco usage and DC among 35–44-year-old fisherfolk population of north coastal region of South Indian state, Andhra Pradesh.
| Materials and Methods|| |
This study was carried out in 2015 among a fisherman community in North coastal region of a South Indian state, Andhra Pradesh. The study population comprised of 35–44-year-old individuals. A pilot study was conducted before the initiation of the main study among 50 individuals belonging to the same community who were not included in the main study through which a prevalence (p) of 37% was obtained. Accordingly, 187 tobacco users and 187 nonusers were recruited into the study with the total sample size being 374. Participants in the age group of 35–44 years without known systemic illnesses and drug usage that could influence DC experience were selected. For each tobacco user, a nonuser was selected randomly with gender and maximum permissible age variation of ±2 years as the matching criteria. Clearance for this study was obtained from the Institutional Ethical Board (protocol No. Pr. 08/IEC/SIBAR/2015), following the ethical guidelines Declaration of Helsinki. All examinations were carried out after proper authorization by participants through an informed written consent form which includes details of the current study along with participant's signature. Training and calibration of the examiner for clinical scoring were conducted before the initiation of the study, which yielded a κ = 0.85.
The study was conducted in the months of August to October 2015. Data collection was done through structured questionnaires and clinical oral examinations. The study was carried out outside the dwellings in the fisherman communities. Optimum lighting and ventilation were ensured for clinical examination. An interviewer-administered questionnaire which included information on demographic details, oral hygiene habits, and a comprehensive history on tobacco and alcohol consumption was used. A 48-h diet history including 1 weekday and 1 weekend was incorporated into the questionnaire. From this food sweetened with added sugars or natural sweets were extracted. Later, these sweetened foods were categorized and scored using Nizel and Papas method.
After completion of the questionnaire, a single examiner conducted clinical examination in natural illumination using WHO probe and mouth mirror following decay, missing, filled teeth (DMFT) index criteria. Oral hygiene status was also examined following Simplified Oral Hygiene Index (OHI-S).
Sweet and OHI-S scores were categorized for further analysis as follows: the median of sweet scores of total population was calculated and those scores above the median were categorized into high-sugar consumption (>5) and those scores below the median (<5) were categorized to low-sugar consumption. OHI-S sores were also categorized into good, fair, and poor based on the OHI-S index criteria.
All examinations were carried out after proper authorization by participants through an informed written consent form which includes details of the current study along with participant's signature.
Data were processed and analyzed using the Statistical Package for the Social Sciences software (IBM SPSS statistics for windows version 20, Armonk, NY, USA). Independent sample t-test and analysis of variance were used to compare the quantitative variables between the various groups. Chi-square test was used to test the association between tobacco usage and caries experience. P ≤ 0.05 was considered statistically significant.
| Results|| |
DC was present among 58.57% of tobacco nonusers, which was high when compared to tobacco users (41.43%) and the difference was statistically significant [Table 1]. The mean decayed filled teeth (DFT) of tobacco users and nonusers was 0.62 ± 0.23 and 1.40 ± 0.52, respectively, and the difference was statistically significant (P < 0.000). There was a statistically significant difference (P = 0.001) in the mean OHI-S scores among tobacco users and nonusers with the tobacco users having a higher mean of 3.45 ± 0.56 compared to nonusers having a mean of 1.69 ± 0.80. Tobacco users and nonusers were having a mean sweet scores 5.24±1.00 and 5.17 ± 0.86, respectively, and the difference was not statistically significant (P = 0.172) [Table 2]. The mean DFT was higher among individuals using both forms of tobacco (1.00 ± 0.52) followed by individuals using smokeless form (0.77 ± 0.23) and smoke forms (0.55 ± 0.24), and the difference was not statistically significant [Table 3].
|Table 2: Comparison of mean decayed filled teeth, Oral Hygiene Index, and sweet scores between tobacco users and nonusers|
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|Table 3: Comparison of mean DFT among the tobacco users according to the form of tobacco|
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The mean DFT was lower among the tobacco users with low- and high-sugar consumptions compared to their counterparts, and the difference was statistically significant (P < 0.001, P = 0.008) [Table 4]. The mean DFT of tobacco users with poor, fair, and good OHI-S scores was lower when compared to that of tobacco nonusers, and the differences were statistically significant (P = 0.005 P < 0.001 P < 0.001) [Table 5].
|Table 4: Comparison of the mean decayed filled teeth between low- and high-sugar consumption groups according to tobacco usage|
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|Table 5: Comparison of the mean decayed filled teeth between good, fair and poor Simplified Oral Hygiene Index groups according to tobacco usage|
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| Discussion|| |
Since its introduction by Portuguese in 600 AD, there has been a continuous raise in the usage of tobacco in various forms by the Indian population with a current data of 267 million adult tobacco users. Nicotine which is found in substantial amount in tobacco products makes addicts out of tobacco users. It is a stimulant with properties similar to those of cocaine and amphetamines and is 1000 times more potent than alcohol, 10–100 times more potent than barbiturates, and 5–10 times more potent than cocaine or morphine in its addictive potential. This addictive effect of nicotine is due to its capacity to trigger the release of dopamine which is a chemical in the brain that is associated with feelings of pleasure. This could be the induction of addiction to tobacco use among the people leading to an increased burden on their general and oral health.
The various ill effects tobacco has on the oral health have been supported in literature till decades.,,,, However, tobacco usage and its effects on DC is a subject of many opinions. Early literature supports a low DC among smokers., Schmidt, in 1951, supported this belief when he reported that increase in tobacco smoking was followed by a decrease in caries rate. Smoking increases thiocyanate level in saliva., Thiocyanate, which is a normal constituent of saliva, was found to have a possible caries-inhibiting effect. To date, quite a few investigators have discovered a correlation between elevated smoking level and DC. The higher number of lactobacilli and Streptococcus mutans group and the decreased buffering effect of smoker's saliva may indicate an increased susceptibility to caries., Studies have also shown that smoking is associated with lower salivary cystatin activity and lower output of cystatin C during gingival inflammation. These cystatins are thought to contribute to maintaining oral health by inhibiting certain proteolytic enzymes thereby increasing DC.,
This is the first study investigating the association of tobacco and DC among the individuals selected from a specific community. Since the full effect of DC can be appraised at 35–44 years, this age group has been included in the current study. DC being a multifactorial disease, several other predictor variables such as age, gender, oral hygiene habits, oral hygiene status, and sugar consumption had also been included in the current study along with tobacco usage. An assumption was made that these individuals own the same socioeconomic class since they were selected from the same community. Since diet, especially sugar consumption, and oral hygiene could act as effect modifiers in the association between smoking and DC experience, sugar scores and OHI-S scores were recorded. However, while defining DC experience, the missing component had been excluded due to the difficulty in distinguishing the reason for tooth loss which could be due to periodontitis which is more prevalent among tobacco users.
There was no statistically significant difference in the mean age of tobacco users and nonusers with an equal distribution of these two groups in both the genders. These findings confirmed the precision of matching. Indigenous methods of brushing were followed by 7.4% of tobacco users and 3% of tobacco nonusers, which exposits the oral health negligence among them. Majority of the tobacco users were using smoke form of tobacco (68.4%) and most of them have been having the habit from 11 to 15 years, depicting the chronicity of tobacco habit in this region.
The DC experience was high among tobacco nonusers compared to users with a significant difference between them. These results were in accordance with studies done by Schmidt and Hugoson et al. However, contradicting findings were observed in the studies done by Aguilar-Zinser et al. and Tada and Hanada. The reason for lower caries experience among tobacco users could be due to the elevated levels of salivary constituent thiocyanate in tobacco users, which have been proved to have an inhibitory effect on DC., The inference behind the studies showing high caries experience among tobacco users could be due to the inclusion of missing component of the DMFT which has an unpredictable cause., To negotiate, this overestimation of caries experience due to missing component, the M component has been excluded in the current study. Individuals using smokeless form of tobacco were having high caries compared to individuals using smoke form which was in par with studies done by Weintraub and Burt and Tomar and Winn. This could be due to the addition of various sugar constituents to the smokeless tobacco products.
Diet, especially with high-sugar content, can cause an increase in DC. The findings of the current study also showed a low mean DFT among individuals consuming low-sugar diet compared to individuals consuming high-sugar diet. However, there was no statistically significant difference between tobacco users and nonusers with respect to the mean sweet score. Among individuals with low and high sweet scores, tobacco users were having less mean DFT compared to their counter parts. Furthermore, among the individuals with poor, fair, and good OHI-S, tobacco users were having low mean DFT compared to nonusers. These two findings confirm the fact of less caries experience among tobacco users in spite of similar sweet scores and oral hygiene status. These verdicts of the current study confirm the role of tobacco solely in less caries experience. The factor of fish consumption was found to be equally distributed between tobacco users and nonusers, eliminating the effect modification possibility of fish consumption and DC, since DC is found to be less among individuals consuming high quantity of fish.
In spite of high caries experience in the current study population, the mean number of filled teeth was found to be less, which shows lack of awareness or inability to access proper dental care in this region since it is located in the rural coastal area. This alarming situation reflects the desideratum of health-care facilities to satiate the dental needs of this community.
It is the fact that people in minorities observe similar customs, traditions, practices, and holds similar beliefs. They are more homogenous compared to people who constitute a majority of population. Fisherman community being a minority section in India is expected not to be different from the above supposition. Keeping this in view, the authors opine that the results obtained in this study can be generalized to fisherman communities.
The limitations of this study include the shortcomings inherent to questionnaires like social desirability bias in responding to tobacco use. Employment of multilevel models would have yielded more confirmatory results. Elimination of missing component of DMFT, though beneficial in terms of not overestimating caries experience, however, carries the disadvantage of underestimating the same in case the reason for loss is caries.
The habit of tobacco use is high among the fisherman community compared to general population, regardless of gender. This study highlights the need for tobacco cessation counseling among these communities. Future studies attempting to find association between tobacco use and DC could consider the inclusion of both empirical and conceptually justified potential effect modifiers in this association and incorporate the interaction terms between these effect modifiers and exposure variables in the analysis of data.
| Conclusion|| |
The results obtained in this study highlighting less caries experience among tobacco users clearly do not promote the use of tobacco by any means. The study should be understood only in terms of the scientific quest of the authors to discern the association between tobacco and DC. The inherent shortcomings of cross-sectional studies apply here and it is recommended that well-designed longitudinal studies be conducted to find the exact nature of association between tobacco and DC.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]