|Year : 2021 | Volume
| Issue : 1 | Page : 48-54
Oral health-related quality of life among adult smokeless tobacco users and nontobacco users of Ghaziabad district, Uttar Pradesh: A cross-sectional study
Iram Ahsan, Ipseeta Menon, Ritu Gupta, Vikram Arora, Asifa Ashraf, Dipshikha Das
Department of Public Health Dentistry, I.T.S Centre for Dental Studies and Research, Ghaziabad, Uttar Pradesh, India
|Date of Submission||04-Apr-2020|
|Date of Decision||28-Apr-2020|
|Date of Acceptance||14-Feb-2021|
|Date of Web Publication||31-Mar-2021|
Department of Public Health Dentistry, I.T.S Centre for Dental Studies and Research, Delhi-Meerut Road, Murad Nagar, Ghaziabad - 201 206, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Smokeless tobacco (ST) being a crucial determinant of oral health and oral health-related quality of life is a part of many religious and cultural rituals which has gained a degree of social acceptance in the Indian subcontinent. Aim: The aim of this study was to assess the oral health-related quality of life (OHRQoL) among adult ST users and nontobacco users of Ghaziabad. Materials and Methods: A hospital-based cross-sectional study was designed to determine the oral health status and OHRQoL of ST users and nontobacco users. A sample of 620 adult individuals was taken. A pretested questionnaire was used to collect the demographic variables. Oral health status was assessed using the World Health Organization 2013 Oral Health Assessment Form, and OHRQoL was measured with the Oral Health Impact Profile-14. Statistical analysis was done by the Statistical Package for the Social Sciences version 20.0. Chi-square test, Spearman's correlation coefficient, Mann–Whitney U-test, and Kruskal–Wallis test were applied. Statistical significance was considered at P < 0.05. Results: In ST users, 90.3% had gingival bleeding, whereas 58.4% of the nontobacco users had gingival bleeding; 53.2% of the ST users had periodontal pocket compared to 47.7% of the nontobacco users. ST users had higher mean scores on the handicap (1.96 ± 1.29), psychological disability (1.89 ± 2.66), psychological discomfort (1.44 ± 1.31), functional limitation (0.92 ± 1.35), physical pain (0.79 ± 0.91), and social disability (0.52 ± 0.70) when compared to the nontobacco users. A ST user has a higher (8.03 ± 4.14) mean score when compared to nontobacco users (4.56 ± 4.01) (P < 0.001) in all subscales of OHRQoL. A statistically significant difference in the oral OHRQoL between ST users and nontobacco users was observed. Conclusion: Hence, the study revealed that ST users definitely had an influence on OHRQoL, with a statistically significant increase in oral health problems in ST users compared to nonusers.
Keywords: Adult population, Oral Health Impact Profile, quality of life, smokeless tobacco
|How to cite this article:|
Ahsan I, Menon I, Gupta R, Arora V, Ashraf A, Das D. Oral health-related quality of life among adult smokeless tobacco users and nontobacco users of Ghaziabad district, Uttar Pradesh: A cross-sectional study. J Indian Assoc Public Health Dent 2021;19:48-54
|How to cite this URL:|
Ahsan I, Menon I, Gupta R, Arora V, Ashraf A, Das D. Oral health-related quality of life among adult smokeless tobacco users and nontobacco users of Ghaziabad district, Uttar Pradesh: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2021 Oct 22];19:48-54. Available from: https://www.jiaphd.org/text.asp?2021/19/1/48/312647
| Introduction|| |
The tobacco epidemic is one of the major public health threats the world has ever faced, killing more than 8 million people each year. More than 7 million of those deaths are the result of direct tobacco use while around 1.2 million are the result of nonsmokers being exposed to secondhand smoke. It is the foremost preventable cause of mortality all over the world, even above high blood pressure and obesity. Tobacco accounts for about one in five deaths annually. It kills one person every 6 s. Tobacco users die approximately 15 years prematurely, and 1 billion that is 100 crore cigarettes are smoked everyday in India.
In India, smokeless tobacco (ST) is the most popular form of tobacco. ST includes the two forms of tobacco that are snuff and chewing tobacco. Snuff is a fine-grain tobacco that often comes in teabag-like pouches that user “pinch” or “dip” between their lower lip and gum while chewing tobacco is in the form of gutka, khaini, and pan masala and all are easily available in the market.
As per Global Adult Tobacco Survey 2, more than one-thirds (35%) of adults in India use tobacco in some form. The use of ST is much more prevalent than smoking tobacco. The prevalence of ST use (26%) is almost twice or the prevalence of smoking (14%). In Uttar Pradesh, 42.6% of men, 15.2% of women, and 29.4% of all adults currently use a smokeless form of tobacco. In any form, tobacco consumption is still high in contrast with neighboring states.
Apart from systemic adverse effects of tobacco consumption, other things can occur like cancer (mainly lung cancer) and cardiovascular diseases. Tobacco use can also cause staining of teeth and dental restorations to reduction in the ability to taste, development of oral cancer, potentially malignant disorders, and periodontal disease.
Oral diseases such as dental caries or periodontal disease are highly prevalent, and their consequences are not only physical, but also they are also economic, social, and psychological. Oral diseases are not usually fatal but can affect the ability to eat, speak, and socialize without active disease or can cause embarrassment and contribute to ones' general well-being. In essence, oral disorders can affect various aspects of life, including oral function, appearance, interpersonal relationships, and other daily activities and therefore the “goodness” or “quality of life.” The Oral Health Impact Profile-14 (OHIP-14) is a scale commonly used to determine an individual's perceptions of the social impacts of oral disorders on their well-being. It also provides an indication of the level of discomfort, disability, and/or dysfunction they feel as a result of their oral conditions.
Various studies have reported tobacco as a risk factor for periodontal disease. The prevalence of periodontal disease ranges 60.5%–78.5%. The negative health effects of tobacco on oral soft tissue including premalignancy and malignancy are well documented. Two previous studies show the overall prevalence of oral mucosal lesions in the ST users to be 54.18% and 73.8%, respectively.
Tobacco use is a major public health problem among adult not only in developed countries but also in developing countries, and in recent years, few studies indicated a positive correlation between oral health-related quality of life (OHRQoL) and ST usage, but the conclusions are not wholly consistent and more studies are required to highlight this relation. The aim of the present study was to assess the OHRQoL among adult ST users and nontobacco users of Ghaziabad district of Uttar Pradesh.
| Materials and Methods|| |
A hospital-based cross-sectional study was conducted to assess OHRQoL among adult ST users and nontobacco users of Ghaziabad district of Uttar Pradesh.
The present study was conducted in tobacco cessation clinic and dental outpatient department (OPD) in Ghaziabad Institute.
Source of data
A total sample of 620 adult patients aged above 18 years were selected randomly from tobacco cessation clinic and dental OPD in Ghaziabad Institute.
Sample size determination and sampling procedure
The sample size was estimated based on the prevalence of loss of attachment (LOA) obtained from the pilot study, considering 80% power and 5% error.
The sample size was calculated using the following formula:
Substituting the Zα/2 value for 5% level of significance and Zβ value for 80% power of the study:
P1 = Prevalence of LOA among ST users obtained from pilot study: 38%
P2 = Prevalence of LOA among nontobacco users obtained from pilot study: 27.5%
Substituting the above values,
= = 309 rounded off to 310
Accordingly, 310 ST users and 310 nontobacco users were recruited into the study with the total sample size being 620.
- The adult patients attending the dental OPD and tobacco cessation clinic in Ghaziabad Institute, aged above 18 years, who were willing to participate, were included in the study
- ST users were considered who are currently consuming tobacco at least once a day or more often in the form of ST and had done so for over a year
- Age- and gender-matched study participants not taking tobacco in any form were included as the nonusers.
- Participants using tobacco products other than ST, individuals having alcohol habit, and medically compromised patients were excluded from the study.
The nature and purpose of the study were elucidated to the institutional review board, and ethical clearance was acquired (ITSCDSR/IIEC/RP/2018/020). Prior permission was obtained from the institutional ethical committee and review board, Ghaziabad. Written informed consent was obtained from all the study participants.
The data were collected over a period of 6 months from August 2019 to January 2020.
A predesigned questionnaire was used with ST and nontobacco users to know the demographic variables, and socioeconomic status was assessed using the modified Kuppuswamy socioeconomic scale.
ST and nontobacco users were examined for oral health status and OHRQoL. Oral health status was assessed using the World Health Organization Oral Health Assessment Form (2013), and OHRQoL was assessed using the pretested questionnaire that is OHIP-14.
Training and calibration
Two-day training sessions for standardization and calibration of the data collection methods were organized in the department of public health dentistry. The investigator was trained and calibrated by carrying out the examinations on the preselected participants twice at the interval of 30 min. The diagnostic variability in two assessments was found to be small, and an agreement was found to be in the range of 88%.
The data were entered into the computer (MS Office, Excel) and were subjected to statistical analysis using the statistical package IBM SPSS Statistics for Windows, Version 20 (IBM Corp., Armonk, N.Y., USA). Descriptive statistics such as mean, standard deviation, median, and frequency percentage were calculated. The normality of data was tested by Shapiro–Wilk test. Spearman's correlation coefficient was calculated for the correlation between OHIP-14 with decayed, missing, filled, and total (DMFT) score and Fagerstrom Test for Nicotine Dependence (FTND)-ST. The significant difference of parameters the OHRQoL (OHIP-14) between ST users and nontobacco users was tested by Mann–Whitney U-test and significant difference of parameters the OHRQoL (OHIP-14) between intraoral lesions by Kruskal–Wallis test. The levels of significance 5% (P < 0.05) and 1% (P < 0.01) were significant and highly significant, respectively.
| Results|| |
The present study was conducted on adult ST users and nontobacco users, with a mean age of 41.38 ± 13.77 and 43 ± 13.3 years, respectively.
Majority 88.4% of the study participants were male using a smokeless form of tobacco. 32.9% of the smokeless form of tobacco users belonged to upper lower class followed by 24.8% belonging to lower middle class, whereas among nontobacco users, 33.5% belonged to upper middle class followed by 31.3% belonging to lower middle class [Table 1].
Oral health indicators
On intraoral examination, 63.9% of the ST users had healthy mucosa, 17.4% had leukoplakia, 14.5% had tobacco pouch keratosis, and 4.2% had oral submucous fibrosis, whereas among nontobacco users, only 1.6% had oral mucosal condition (lichen planus). In ST users, 90.3% had gingival bleeding, whereas among nontobacco users, 58.4% had gingival bleeding. Among ST users, 53.2% had periodontal pocket, whereas among nontobacco users, 47.7% had periodontal pocket. The present study showed LOA in 38.1% of the ST users, whereas among nontobacco users, 29.7% had LOA. Among ST users, the mean DMFT score was 2.96 ± 1.9, whereas among nontobacco users, the mean DMFT score was 2.4 ± 2.16 [Table 2].
|Table 2: Comparison of various oral health indicators among smokeless form of tobacco users and nontobacco users|
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Level of nicotine dependence according to the Fagerstrom Test for Nicotine Dependence among Smokeless Form of tobacco users
Out of the 310 ST users, 63.9% were highly dependent, 29.4% were moderately dependent, and only 6.85% were low dependent on the smokeless form of tobacco [Table 3].
|Table 3: Level of nicotine dependence according to the Fagerstrom Test for Nicotine Dependence among Smokeless Form of tobacco users|
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Oral health-related quality of life
ST users had higher mean scores on the handicap (1.96 ± 1.29), psychological disability (1.89 ± 2.66), psychological discomfort (1.44 ± 1.31), functional limitation (0.92 ± 1.35), physical pain (0.79 ± 0.91), and social disability (0.52 ± 0.70) when compared to the nontobacco users [Table 4].
|Table 4: Comparison of oral health-related quality of life among smokeless form of tobacco users and nontobacco users|
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The highest mean score of functional limitation (1.24 ± 1.41) and physical disability (0.64 ± 0.75) was observed among patients with leukoplakia. In patients with tobacco pouch keratosis, the highest mean score was observed for psychological discomfort (1.57 ± 1.52), psychological disability (1.81 ± 3.28), and handicap (2.17 ± 1.43). Among patients with oral submucous fibrosis, the highest mean score for social disability (0.61 ± 0.65) subdomain of OHIP-14 was observed [P < 0.05, [Table 5]].
|Table 5: Comparison of oral health-related quality of life based on presence and absence of oral lesions among smokeless form of tobacco users|
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A statistically significant negative correlation was found between DMFT score and handicap (−0.123*) subdomain OHRQoL. Furthermore, a highly significant negative correlation between Fagerstrom nicotine dependence and OHIP-14 subdomains – functional limitation (−0.239**), physical disability (−0.266**), and psychological disability (−0.209**) – was observed in the ST users [Table 6].
|Table 6: Correlation between the oral health-related quality of life with decayed, missing, filled, and total and Fagerstrom Test for Nicotine Dependence-Smokeless Tobacco scores|
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| Discussion|| |
The present comparative hospital-based cross-sectional study was intended to augment scientific knowledge about the effect of ST on the OHRQoL of adult patients.
In the present study, the prevalence rate of ST users was higher among younger (22.9%) and middle age groups (21%). This is in agreement with the studies done by Goyal G et al. whose prevalence rate of chewing tobacco was found to be significantly high 21% in young individuals. The high prevalence of ST use among young individuals might be an indication of the strong cultural acceptance and lack of legal and social restrictions imposed on its use by young people.
The prevalence rate of ST has found to be significantly high among males (88.4%) as compared to females (11.6%) in the present study which is comparable to the study done by Petkar P et al. where 92.8% of the tobacco users were males while 7.2% were females. This could be due to South Asian countries including India, considering tobacco consumption a predominantly male behavior socioculturally unacceptable for females. This is a contrast to the study done by Vellappally S et al. smokeless form of tobacco use higher among women (75.2%) as compared to men (24.8%).
Socioeconomic status is one of the risk factors for poor health and OHRQoL. Persons of lower socioeconomic status suffer disproportionately more from nearly all diseases than people of higher socioeconomic status. In the present study, 32.9% of the ST users were of lower socioeconomic status, followed by lower middle class (24.8%), and very low fraction of the ST users studied were from high socioeconomic status. This is comparable to the study done in Barabanki where study participants were from the upper lower (25.8%) and lower class (39.6%), and a similar study done by Vellappally S et al. tobacco consumption is often found to be disproportionately higher among lower socioeconomic groups (10.6%). This may be probably because lower socioeconomic class people are more likely tobacco consumption because of lack of knowledge and awareness.
ST use is very common in India, especially in western Uttar Pradesh. Tobacco or tobacco-containing products are chewed or sucked as a quid, applied to gums, or inhaled. The prevalence of leukoplakia (17.4%) was highest in our study population followed by tobacco pouch keratosis (14.5%). This is in contrast to the study done by Kamala et al. where the prevalence of tobacco pouch keratosis (30.95%) was higher than followed by leukoplakia (8.27%). This may be due to stronger effects of ST because of the direct contact of carcinogenic substances present with oral mucosa in the former. In nontobacco users, lichen planus was observed in 1.6%. This might be due to local irritation or chronic stimulation of the lenfoid tissue in oral mucous membrane.
The prevalence of bleeding on probing (90.3%), periodontal pocket formation (53.2%), and LOA (38.1%) was higher among ST users in the present study which is comparable to the studies done on tobacco users by Goyal J et al. where ST users had higher bleeding on probing (57.9%) than nontobacco users. These results are in contrast to the study done by Shimazaki et al. LOA was found to be significantly greater in ST users which is similar to the study done by Biradar et al. The increased prevalence of periodontitis could be due to the poorer oral health status of the tobacco users. This could also be due to most of the tobacco users being illiterate and belonging to poor or lower socioeconomic classes. Furthermore, it could be due to lack of knowledge and awareness regarding the harmful effects of smokeless form of tobacco.
In our study, the mean DMFT value of ST users (2.96) is higher when compared to nontobacco users (2.4). A biologically reasonable explanation for an association between ST users and dental caries may be the presence of high levels of fermentable sugar in smokeless form of tobacco products, which can stimulate the growth of cariogenic bacteria and local loss of keratinized gingiva at the site where ST is held. There is a similar study done by Amjad et al., 2012, in Pakistan where DMFT values of 3.12 and 5.8 among the nonusers and ST users, respectively, were reported. Moreover, Vellappally et al., 2008, reported higher values of DMFT (8.96) among nonusers and a value of 12.25 among ST users in Kochi. This is in contrast to the study done by Mahapatra et al., 2018, in Odisha where the mean DMFT among the ST users was 1.36 and among the nonusers was 1.90.
In our study, ST users had poor OHRQoL (8.03 ± 4.14) when compared to nontobacco users (4.56 ± 4.01). This is comparable to a study done by Bakri NN which found a statistically significant association between tobacco and (OHRQoL). This might be due to lack of knowledge and neglect toward one's oral health which is turn may impact the oral health related quality of life. It is equally essential to lay stress upon improving their attitude toward preventive mechanisms that could reduce the negative impact on their quality of life.
In the present study, we observed that patients with leukoplakia had main effects on functional limitation and physical disability whereas patients with tobacco pouch keratosis were affected by psychological discomfort, psychological disability, and handicap. The psychological discomfort was because of the sensation of feeling worried and tense when the patients were seeking treatment during their first visit without knowing their diagnosis and prognosis. Patients with oral submucous fibrosis had main effects on social disability subdomain of OHIP-14; these findings are in contrast with the studies by Jena AK et al. that the maximum effect of oral submucous fibrosis on quality of life was because of physical pain and psychological discomfort. Thus, oral submucous fibrosis might cause embarrassment particularly if the lesion has involved lips and tongue. However, the deterioration of OHRQoL in oral lesions patients was more compared to patients with other oral diseases.
There was a negative correlation between handicap (−0.123*) and DMFT components in the present study. This is comparable to the study done by Drachev et al. which found that a higher DMFT index was associated with low OHRQoL. In contrast, a Swedish study did not find any difference in OHRQoL between young adults at high risk (DMFT >8) and low risk (DMFT = 0) of caries. Dental caries was significantly correlated to the impact on the life of these people, since it leads to pain, food lodgment, interference with mastication, and the daily routine activity, which is perceived by the patient as handicap and psychological disability.
In our study, also a highly significant negative correlation between Fagerstrom nicotine dependence and OHIP-14 subdomains – functional limitation (−0.239**), physical disability (−0.266**), and psychological disability (−0.209**) – was observed among ST users, thus indicating that as the dependence on ST increased, OHRQoL decreased.
| Conclusion|| |
This study demonstrated the high prevalence of oral mucosal lesions and dental caries among ST users as compared to nonusers, which in turn had an impact on their quality of life. The OHIP has a multitude of substantive applications for the field of dentistry, health care, and dental research providing a comprehensive measure of self-reported dysfunction, discomfort, and disability attributed to oral conditions. The lack of the right attitude and negligence toward one's own oral health has a negative impact on the quality of life, tending to more functional and physical disability. The dental health-care provider can play an important role in identifying and motivating the individuals while providing the preventive care and can collaborate with an interdisciplinary team to assist the individual to quit this habit.
- A reinforcement of oral health education programs regarding tobacco effects, especially in western Uttar Pradesh where smokeless form of tobacco is mainly used, is needed
- Regulations should extend to encompass ST products as well while measures should be taken to overcome barriers posed by the strong cultural acceptance of ST use, particularly in the form of betel quid.
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], [Table 6]