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Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 11-17

Tooth loss and associated risk factors among rural population of Wardha District: A cross-sectional study

Department of Public Health Dentistry, Sharad Pawar Dental College, DMIMS (Deemed to be University), Wardha, Maharashtra, India

Date of Submission22-Jul-2017
Date of Acceptance25-Jan-2018
Date of Web Publication23-Mar-2018

Correspondence Address:
Dr. Sourav Sen
Department of Public Health Dentistry, Sharad Pawar Dental College, DMIMS DU, Wardha, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_106_17

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Introduction: Regular dental care and daily cleansing habits are one of the key aspects of keeping healthy teeth for a lifetime. Common Indian concept is, with age people become more prone to oral health problems. If they follow their oral hygiene practices meticulously, then age may not act as a risk factor for tooth loss. Aim: The aim of this study is to evaluate the risk factors associated with tooth loss among adults and the elderly among the rural population of Wardha District. Materials and Methods: In this cross-sectional study, among the rural population, two World Health Organization index age groups (35–44 and 65–74 years) were selected. A self-administered questionnaire was distributed, and complete clinical oral examination was done. The data were statistically analyzed using descriptive statistics and Chi-square test. The value of P < 0.05 was considered statistically significant. Results: Nearly 75.3% of laborers were partially edentulous. Habits, including smoking, tobacco chewing, and alcohol consumption, had an impact on tooth loss. Patients suffering from diabetes and hypertension had 97.5% and 100% had tooth loss, respectively. Regarding the first visit to the dentist, 65.6% population underwent dental treatment from the dental college in the vicinity. “No dental problems” were reported by 68.4% of patients of the total population and among them 81.3% were edentulous. Regarding “Self-perceived treatment” the result revealed that 72% of them had felt the need for dental treatment. Conclusion: The study showed that risk factors such as habits, systemic diseases, and self-perceived oral health played a significant role in tooth loss. Brushing type, method, and material used for cleaning were some other factors that influenced tooth loss.

Keywords: Habits, oral health, risk factors, self-perception, tooth

How to cite this article:
Sen S, Balwani T, Sahu A, Parate N, Gehani A, Deolia S. Tooth loss and associated risk factors among rural population of Wardha District: A cross-sectional study. J Indian Assoc Public Health Dent 2018;16:11-7

How to cite this URL:
Sen S, Balwani T, Sahu A, Parate N, Gehani A, Deolia S. Tooth loss and associated risk factors among rural population of Wardha District: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2018 [cited 2024 Mar 4];16:11-7. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2018/16/1/11/228292

  Introduction Top

The oral health is center to a person's overall health and well-being. The ability to retain more number of teeth throughout life is one of the most important oral health indicators. Oral health goals recommended by the World Health Organization (WHO) for the year 2020 has stated that there should be an increase in the number of individuals with functional dentitions (21 or more natural teeth) at the ages of 35–44 and 65–74 years.[1]

Tooth loss is a result of complex interactions such as poor oral hygiene and dietary habits, other demographic factors influencing tooth loss are – age, gender, geographic region, education, occupation, and income. There is a lack of oral health awareness regarding causes and consequences of tooth loss. It includes the need perceived by a patient to get the dental treatment done. Other risk factors, such as tobacco chewing, may restrict the blood flow to the tissues, which would limit the nutrients necessary to the bone and periodontal support of the teeth causing tooth loss. Availability and utilization of the dental services are an important reason as well. Systemic diseases, such as heart disease, respiratory disease, diabetes, HIV, malnutrition, and immunosuppression, are all associated with different forms of periodontitis and often results in tooth loss.[2]

Edentulism or tooth loss can hamper not only the ability to chew and properly digest the food but also has serious social, psychological, and emotional consequences impacting the quality of life of the patient, self-image, and self-esteem.[3]

In a broader sense, aging reflects all the changes that occur over the course of life causing some physical decline, making the individuals more vulnerable to chronic diseases. The oral cavity is no exception. Therefore, it is believed that elderly people are more prone to tooth loss. Even if they were dentate, they often had only a few functional teeth than the adult population. If preventive measures were taken into care, then tooth loss can also be prevented among the elderly population.[3]

Past evidence have concluded that tooth loss was an effect of multi-variable interactions.[3] Hence, this study was conducted with the aim to assess risk factors associated with tooth loss among the rural population of Wardha district.

  Materials and Methods Top

A cross-sectional study was conducted in the private dental institution, located in Wardha district, Vidarbha region, in the year 2017. This study was conducted among the rural population who attended the private dental institution for treatment or as accompanying persons. Two WHO index age (35–44 and 65–74 years) groups were included in the study.

A pilot study was conducted on 40 patients for the determination of sample size. These patients did not participate in the main study. The formula used for determining the sample size of sample:

n = z 2 [P (1–P)]/e 2

Where, n = size of the sample; z = critical value at a specified level of confidence = 1.96

P = sample (0.50); e = difference between sample proportion and population proportion = 0.05

The sample size was calculated according to the formula, and it was found to be 384. For the convenience of calculation, it was rounded off to 500.

Further, these 500 patients were divided into two WHO index age groups, i.e. 35–44 years and 65–74 years.

The self-administered questionnaire was prepared in the English language first and later translated to Marathi (local language). The Marathi version was later translated back to English to check for language reliability. These translations were done by language experts who had expertise in translation work. An analyst was assigned to assessing the validity and reliability of the data. The reliability of the questionnaire was found to be acceptable (Cohen's kappa statistics = 0.82), along with the face, and content validity (Aiken's V index = 0.83).

Before commencing with the study permission from the Institutional ethical committee was obtained. The procedure of the study was explained in detail to each participant and written informed consent was obtained.

Patients were provided with a self-administered questionnaire consisting of information about their demographic details, behavioral factors, and information about the history of systemic diseases; followed by the assessment of the oral health including the number of teeth missing from the oral cavity. The examination was carried out by the single examiner in the Department of Public Health Dentistry under adequate illumination using artificial light.

Teeth were considered to be missing if the teeth are missing on examination or teeth indicated for extraction (grossly carious, root stumps, the presence of mobility), presence of removable, and fixed partial denture. Supernumerary teeth and bilateral maxillary and mandibular 3rd molars were excluded. Socioeconomic status was measured according to B. G. Prasad's classification.[4] Oral examination was carried out under adequate illumination using artificial light.

The data were entered into an MS Excel sheet. Descriptive statistics and Chi-square test were used for the analysis. The level of significance was set at P < 0.05. SPSS 11.5 (IBM, Chicago, IL, USA) software was used to perform the statistical analysis.

  Results Top

This study was conducted in Wardha district among 500 patients using two WHO index age groups. As the “tooth loss” was basic inclusion criteria, all risk factors were assessed according to it.

Regarding gender-wise distribution 86.1% of males and 36.6% of females had “tooth loss.” Age-wise distribution regarding “tooth loss,” 79.1% and 76.3% among 35–44 years and 65–74 years age groups, respectively. Considering marital status, widow/widower had highest “tooth loss” with 88.9%. Patients with the qualification of “up to 12th Standard” had maximum “tooth loss,” which was 94.9%. Majority of the patients who had their “per capita” income between the ranges of “Rs. 1547–2577” had experienced “tooth loss.” According to the occupation, there was no statistically significant difference found among the groups (P = 0.616) [Table 1].
Table 1: Distribution of study subjects on the basis of various risk factors for tooth loss

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Regarding oral hygiene practices, 95% of the study participants who were using the stick for cleaning teeth had “tooth loss.” Toothpowder and brick powder users had 100% “tooth loss.” “Tooth loss” was observed among 86.5% of participants who practised horizontal method for cleaning teeth [Table 1].

According to dietary habits, 86% of vegetarians had “tooth loss.” On inquiring about subject's sugar consumption, 85.9% who consumed sugar twice daily had maximum “tooth loss.” Among the study participants who consumed sugar “in-between meals,” 78% had “tooth loss” [Table 1].

Furthermore, the majority of the partially edentulous participants had the habit of smoking, chewing tobacco “>3” times per day and had the habit of alcohol consumption. Majority of the study participants with systemic diseases experienced “tooth loss” [Table 1].

About 65.6% partially edentulous population availed the dental treatment from “Dental college,” whereas, 49.6% of them availed the benefit of outreach dental services. Majority of those who visited the dental hospital had “tooth loss” [Table 1].

Subjects were inquired about the “self-perceived oral health,” among them, 68.4% had “no dental issues,” and among them, 81.3% had “tooth loss.” Among the total population, 72% agreed that they needed the dental treatment, of them, 78.6% had “tooth loss” [Table 1].

  Discussion Top

With the recent advancement of dental knowledge and technology “tooth loss” among adults has decreased, but still, significant differences remain in some population, especially in rural areas. Hence, it was necessary to explore all possible risk factors for “tooth loss,” so that preventive measures could be undertaken for remaining teeth for those people from rural areas. All possible risk factors were given equal importance. Most of the population in rural areas had wrong impression that with age, they would inevitably lose their teeth, but tooth loss was far from inevitable. While time and age can cause a decline in oral health, it was not age itself that caused tooth loss. There was no statistically significant difference in “tooth loss” found between two age groups, i.e. 35–44 years (79.1%) and 65–74 years (76.3%). This goes in accordance with few other studies presented by Jaleel et al. and Natto et al.[1],[2] The results of this study were contradictory to Gupta et al.,[3] that concluded that edentulism was positively associated with aging.

According to this study, 86.1% of males had “tooth loss.” The probable reason for this might be that females were more proactive than men in the maintenance of their oral hygiene as they had a better understanding about what good oral health entails and they also had a more positive attitude toward visits to the dentist. Social embarrassment was one of the major issues for females, as bleeding gums, halitosis, and lost teeth would have a negative impact on their personality and they felt less confident about themselves. Self-consciousness to look beautiful encouraged them to maintain oral hygiene. Males, on the other hand, were hardly concerned about preserving their teeth. Other studies showed that men were less regular attenders for check-ups due to their working schedule and they found it more difficult to visit the dentist. Moreover, men had habits such as tobacco chewing and smoking which might be a reason for tooth loss. This justification is in accordance with Jaleel et al., Gupta et al., Dudala and Arlappa et al., and Davies and Ware [1],[3],[4],[5] On the other hand, marital status might be an independent factor for better oral health and better care as a result delving for less tooth loss. Marital relation acts as an enticement for seeking oral healthcare out of partner's support. It was observed that 88.9% widows/widowers were partially edentulous, which was in accordance with Jaleel et al. and De Marchi et al.[1],[6] Loss of partner affected the psychology of the people in such a way that they isolated themselves from others, felt lonely and unwanted by the family.

Results showed that 90.1% of participants, whose per capita income was between Rs. 1547–2577, were partially edentulous. There were only 7 participants who were highly educated and completely edentulous. Looking at these parameters, this can be concluded that lower income and lower education were both associated with increased risk of tooth loss although education had a stronger association because these people lack the knowledge of oral health and were more likely to have habits like tobacco chewing and were hardly aware of the needs of comprehensive on-going dental care and therefore failed to use the oral health services. People who earned less and were less educated and were seen suffering from more dental problems than the people who were highly educated as they were more aware, had good jobs and therefore had a higher income.[1],[2],[4],[7],[8],[9],[10]

According to oral hygiene practices, the result came under two different heading, i.e. stick and toothpaste. The study showed that 95% of stick users were partially edentulous, that may be because using a stick can cause damage to gingiva and result is recession which is due to the excessive scrubbing of the stick which is rough and hard. This result was contrary to some studies given by Dahiya et al. and Cury and Tenuta.[11],[12] According to this study majority of toothpaste, users were completely edentulous. The natural repair of the early lesion through remineralization played a major contribution in the dramatic downfall of numbers of decaying, missing, and filled teeth.[13] Topical fluoride applied regularly in low concentrations in the form of toothpaste increases the strength of the teeth. Shah et al. presented that fluoride concentration in the fluid phase of remnants of a dental biofilm could be sustained at superior values for a longer period, given the reduced clearance in such locations.[14]

In this study, it was seen that 86% of vegetarians had “tooth loss” (P< 0.001). Very few studies had estimated the effect of diet on tooth loss. Jaleel et al., Adegboye et al. and Telivuo et al. established that there was higher protein content in the mixed diet which supplies essential amino acids for the health of the teeth and periodontium.[1],[15],[16] It also plays a major role in repair of wear and tear of the supporting tissues. Majority of the individuals who consumed sugary snacks/drinks twice and between meals each day had “tooth loss.” This finding is in line with the study presented by Jaleel et al.[1] which talked about the population who consumed sugary snacks/drinks ≥5 times in between meals per day had higher tooth loss compared to individuals who had ≥4 times experience. A study carried out in Finland by Featherstone [13] also showed that a number of missing teeth was correlated with the greater frequency of daily sugar intake. The release of acids from bacterial interaction with food causes increases in tooth damage when food particle remains in the mouth for a longer period resulting in dental decay and ultimately tooth loss. In accordance with Jiang et al.[17] the stickiness of starch enhances the retention time of sugars, ensuing in a delayed pH fall. This is why sticky foods such as candies and caramel, as well as those that break into smaller pieces to lodge between the teeth (such as chips and cookies), causes more harm. In this study, all participants who had sticky food showed partial edentulism.

Among the 400 patients who suffered from diabetes, 97.5% were partially edentulous. In accordance with other studies, one of the many complications of diabetes was a periodontal disease. People suffered from diabetes were at high risk due to a higher concentration of glucose in saliva, poor healing of oral tissues and therefore, infections and prescribed medications that cause xerostomia, which had a negative influence on the quality of life of population suffered from it. All hypertensive patients, 299 (100%), were partially edentulous. In hypertension, there were changes that took place in microcirculation which leads to ischemia in the periodontium, which favored periodontal disease and therefore, resulted in tooth loss.[18] All of them who suffered from asthma also had “tooth loss.”[1],[2],[3],[5],[6],[7],[8],[9],[10]

Any form of tobacco is harmful to oral health. According to this study, 450 out of 500 patients had a tobacco chewing habit, among whom 86% were partially edentulous. Nearly 82% of patients had a habit of smoking of which 94.4% were partially edentulous. Smoking and tobacco chewing cause blood vessels to constrict, and also turns the mouth into a breeding ground for bacteria. Apart from this, smoking also weakens the immune system and therefore reduces or impairs the body's ability to heal. This may result in a decline in oral health and therefore causes tooth loss. Whereas tobacco chewing resulted in the recession of the gingiva which results in damage to the gums as well as bone and if bone surrounding the tooth erodes too much, it results in permanent tooth loss.[1],[2],[3],[8],[9],[10],[19] Among the patients who consumed alcohol 86% had “tooth loss” and this finding was in accordance with Veiga et al.[19]

A major number of the patients being partially or completely edentulous believed that they had no dental problems and they did not need treatment for it, but among them, 81.3% had “tooth loss.” The elderly stated that the general health problems and the medical care that is needed for it, crowd out the dental problems they had; that was because the medical problems they had were treated at the higher priority and dealing with those problems were hardly left with the financial resources or energy to seek dental care. The adult population thought that it would be better if they invested their money for better future of their children rather than on dental treatments which were supported by Jaleel et al.[1] People suffering from dental problems, i.e. 328 (65.6%) visited the dental hospital for the treatment; this confirmed that people were aware of the dental facilities available to them these days.

As we looked at the socioeconomic status of the population, most of the people came into the category of low socioeconomic status and therefore low-cost treatment that was provided at the dental hospitals was satisfactory to such people when compared to the comprehensive dental clinics. Two patients (100%) who visited private clinics were completely edentulous, which concludes that the people who visit private clinics regularly were more concerned about their oral health and received proper dental care and therefore were less prone to loss teeth.[1],[6],[3],[10],[20]

This study has several limitations. The cross-sectional study design is applicable to analyzing the database, but it does limit the generalizability of results by not identifying causal effects. Another limitation is that all data, except partial and complete edentulism, were self-reported. This interjects' participants own perception of their oral health status into the data. Future research is needed to further examine risk factors for “tooth loss” with a larger population to generalize the result and to prevent risk factors to “tooth loss.”

  Conclusion Top

This study suggests that total tooth loss is not only a disease-related extension but also rather a different phenomenon with several risk factors playing a prominent part. Achievement of the goal of reduction of total tooth loss even further will demand a better understanding of the social-attitudinal factors among rural population involved. Oral diseases appear to be the major risk factors for partial tooth loss, though, in this study, results suggest that social and behavioral factors also play a role.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Jaleel BF, Nagarajappa R, Mohapatra AK, Ramesh G. Risk indicators associated with tooth loss among Indian adults. Oral Health Dent Manag 2014;13:170-8.  Back to cited text no. 1
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Dudala SR, Arlappa N. An updated prasad's socio economic status classification for 2013. Int J Res Dev Health 2013;1:1-28.  Back to cited text no. 4
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