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Tooth Wear Among Tobacco Chewers in the Rural Population of Davangere, India

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Tooth Wear Among Tobacco Chewers in the Rural Population of Davangere, India 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 Davan- gere 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 patho- logically 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 Submitted for publication: 07.01.11; accepted for publication: 12.09.11 ata on global tobacco consumption indicate masala’ with tobacco are common modalities of to- Dthat an estimated 930 million of the world’s 1.1 bacco use. It has been reported that 77.3% and billion smokers live in developing countries (Jha et 83.1% in Uttar Pradesh and Karnataka states, re- al, 2002) with 182 million in India alone (Shimkha- spectively, use gutkha or pan masala-containing to- da and Peabody, 2003). By 2020, tobacco con- bacco (Chaudhry et al, 2001). Some reports sug- sumption has been projected to account for 13% of gest the prevalence of tobacco use among young all deaths in India (World Health Organization, people has remained steady in recent years (Sinha 1997; Kumar, 2000). People have consumed to- et al, 2008), while others imply it may be rising bacco since time immemorial and at present, the (Reddy et al, 2006; Daniel et al, 2008). world is in the grip of a tobacco epidemic. The various forms of tobacco chewing include In India, being no exception, the chewing of to- pan (piper betel leaf filled with sliced areca nut, bacco is very popular especially in rural areas, and lime, catechu and other spices chewed with or with- this habit has increased in recent times (World out tobacco), pan masala or gutkha (a preparation Health Organization, 1997). It has been estimated of crushed areca nut, catechu, paraffin, lime, fla- that 96 million (52%) of Indians consume tobacco vourings and small amounts – less than 10% – of in a smokeless form. The use of ‘gutkha’ and ‘pan tobacco), mishri (a powdered tobacco rubbed on the gums like toothpaste) and others. The nature of chewable areca nut and tobacco consumption in a Professor and Head, Department of Public Health Dentistry, Pacific India has undergone a rapid transformation with Dental College and Hospital, Udaipur, Rajasthan, India. the introduction of pan masala and gutkha. These b Reader, Department of Oral Pathology and Microbiology, Pacific products are conveniently packed, aggressively ad- Dental College and Hospital, Udaipur, Rajasthan, India. vertised and widely marketed in various forms such Correspondence: Prof R. Nagarajappa, Department of Public Health as khaini, mawa, zarda, mishri etc. These products Dentistry, Pacific Dental College and Hospital, Airport Road, Debari, Udaipur – 313024, Rajasthan, India. Tel: +91-900-134-1988, Fax: are commercially available under various brand +91-294-249-1508. Email: [email protected] names such as Vimal, Manikchand, Rajnigandha Vol 10, No 2, 2012 107 Nagarajappa and Ramesh Pan Masala, Pan Parag, etc (Sushma and Sharang, These villages were not more than 25 km from 2005). the urban area Davangere. Eligible participants The negative health effects associated with were located using a random selection and screen- smokeless tobacco consumption include oral, phar- ing procedure based on a multistage cluster sam- yngeal and oesophageal cancer (Winn et al, 1981), pling design. In the first stage, Davangere Taluk oral leukoplakia (Grady et al, 1990 and Tomar et al, was geographically divided into four regions – north- 1997), cardiovascular disease (Bolinder et al, east, northwest, southeast and southwest. In the 1994), periodontal disease (Robertson et al, 1990) second stage, from each of the geographical re- and nicotine addiction (US Department of Health gions, one village was randomly selected. Finally, and Human Services, 1986). Other dangers from 50 to 60 subjects from each village fulfilling the in- smokeless tobacco use include the following: gum clusion criteria were randomly selected and sur- recession that results in exposed roots and in- veyed to obtain a sample size of 208. Agriculture is creased sensitivity to heat and cold, drifting and the main occupation of the residents in these vil- tooth loss from damage to gingival tissue, abrasion lages. The socioeconomic and living conditions to tooth enamel because of high levels of sand and were comparable in all four villages. grit contained in smokeless tobaccos, tooth discol- A survey proforma was prepared to acquire per- ouration and bad breath (Tomar and Winn, 1999; sonal details such as age, sex, oral hygiene prac- Bowles et al, 1995). tices and patterns of smokeless tobacco use, spec- Studies have shown that the magnitude of the ifying the frequency, duration and type (tobacco effect of chewing tobacco on the occurrence of with pan, plain tobacco, pan masala with tobacco). tooth wear is high, with users having many times The survey instrument was pre-tested in a sample the risk of nonusers (Bowles et al, 1995). Tooth of adults of the same age group as the study par- wear is a composite term introduced to cover non- ticipants and, based on feedback provided by these carious tooth surface loss by attrition, abrasion and participants, the instrument was determined to be erosion (Addy and Bristol, 2005). Tooth wear may acceptable (Cronbach’s alpha = 0.88). be defined as the gradual loss of tooth substance The study protocol was reviewed and approved due to repetitive physical contacts or to chemical by the Institutional Review Board. Informed consent dissolution (Smith and Knight, 1984). When en- was obtained from all study participants. Subjects amel and dentine are gradually worn away by abra- in the age group of 35–44 years who satisfied the sion, the tooth normally forms secondary dentine, following criteria were selected. and when the tooth is exposed to increased amount of abrasives, the secondary dentine is also worn r Had a minimum of 12 functional teeth. down. In extreme cases, the clinical crown may be r Chewed only one form of chewing tobacco. worn away. r Used soft-bristled tooth brush and toothpaste for Because tobacco accounts for such a high pro- cleaning teeth. portion of these diseases, the current study was r Did not have habits such as bruxism, bruxoma- undertaken to assess and compare tooth wear nia, alcoholism. among chewers of various forms of tobacco in the r Had no eating disorders such as anorexia or bu- rural population of four selected villages of Davan- limia nervosa. gere Taluk, India. r Did not work in factories or have occupations that may promote tooth wear. MATERIALS AND METHODS The Tooth Wear Index (Smith and Knight, 1984) was used to assess the tooth wear among the sub- A cross-sectional survey was conducted among jects. Cervical (C), buccal (B), lingual (L) and oc- rural adults aged 35 to 44 years in four selected clusal/incisal (O/I) surfaces were recorded sep- villages of Davangere Taluk, namely, Shamanur, arately for all erupted permanent teeth; thus, a Alur, Bhathi and Kukkawada. Davangere district, an maximum of 128 surfaces was examined per sub- administrative district of Karnataka state in South- ject. Type III clinical examination of all individuals ern India covering a geographical area of was performed by a trained and calibrated examin- 5975.97 km2, comprises six Taluks: Davangere, er (kappa value = 0.89). The scores of the tooth Harihar, Honnali, Channagiri, Harapanahalli and wear index used in the study were as follows: Jagalur. 108 Oral Health & Preventive Dentistry Nagarajappa and Ramesh r Score 0 – no loss of enamel surface characteris- 39 ± 3.5 years) constituted the study population. tics on B/L/O/I and no change in contour on C. They were divided into four groups: tobacco with r Score 1 – loss of enamel characteristics on B/L/ pan (64.5% and 35.5% males and females, O/I and minimal loss of contour on C. respectively), plain tobacco (60.4% and 39.6%), r Score 2 – loss of enamel exposing dentine for pan masala with tobacco (68.5% and 31.5%) and less than 1/3 of the surface on B/L/O/I and de- control (47.7% and 52.3%). Pathologically worn sur- fect less than 1 mm deep on C. faces among the study subjects in the various r Score 3 – loss of enamel exposing dentine for groups were as follows: tobacco with pan (14.3% more than 1/3 of the surface on B/L/O/I and and 11% males and females, respectively), plain defect 1 to 2 mm deep on C. tobacco (12.4% and 10.3%), pan masala with to- r Score 4 – complete loss of enamel or pulp ex- bacco (15.9% and 11.6%) and control (6.2% and posure on B/L/O/I and defect more than 2 mm 4.3%). deep on C. It was observed that males had higher scores of pathologically worn sites than did their female The data were analysed using SPSS version 15 counterparts.
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