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 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 like ) 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 (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), (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- from damage to gingival tissue, lages. The socioeconomic and living conditions to 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 , 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 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 , 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 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. We also observed a statistically sig- (SPSS; Chicago, IL, USA). The total number of sites nificant P( < 0.001) difference between tobacco scored and the number rated as showing pathologic- chewers and control group in relation to the patho- al wear were calculated. The chi-square test was logically worn sites. In particular, the pan masala used to test whether there were significant differ- with tobacco chewers showed the most tooth wear. ences in outcome measures. P ≤ 0.05 was consid- The distribution by surface of pathologically worn ered statistically significant. 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 RESULTS chewers than in the control group (Table 1). A higher risk of tooth wear was associated with a A total of 208 subjects, 127 (61.1%) males and 81 greater frequency of tobacco chewing. In all the (38.9%) females, aged 35 to 44 years (mean age 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 Sex Study Total Cervical Buccal Occlusal/ Lingual Total n = 208 subjects surfaces Incisal n (%) scored n (%) n (%) n (%) n (%) n (%)

Tobacco M 40 (64.5) 4019 116 (20.1) 24 (4.2) 428 (74.3) 08 (1.4) 576 (14.3) with pan n = 62 F 22 (35.5) 2309 49 (19.4) 10 (3.9) 185 (72.8) 10 (3.9) 254 (11)

Plain tobacco M 29 (60.4) 2969 84 (22.8) 14 (3.8) 258 (69.9) 13 (3.5) 369 (12.4) n = 48 F 19 (39.6) 1979 47 (23.2) 09 (4.4) 139 (68.5) 08 (3.9) 203 (10.3)

Pan masala M 37 (68.5) 3269 73 (14) 19 (3.6) 421 (80.5) 10 (1.9) 523 (15.9) with tobacco n = 54 F 17 (31.5) 1588 29 (15.8) 07 (3.8) 145 (78.8) 03 (1.6) 184 (11.6)

Control M 21 (47.7) 2365 39 (26.5) 09 (6.1) 95 (64.7) 04 (2.7) 147 (6.2) n = 44 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 patho- The pathologically worn surfaces in both sexes logically worn sites also increased. This relation- chewing any form of tobacco for more than 5 years ship was statistically significant except in the plain was significantly higher than in subjects who chewed tobacco group. A highly significant difference was less than 5 years. Similarly, regardless of duration, seen between the tobacco chewers regardless of the tobacco chewers and non-chewers also differed frequency and non-chewers (Table 2). 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

I. Tobacco with pan 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)

II. Plain tobacco 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)

III. Pan masala with tobacco 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)

Controls 21 23 2365 2503 147 (6.2) 107 (4.3)

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

I. Tobacco with pan 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)

II. Plain tobacco 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)

III. Pan masala with tobacco 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 353 381 (72.8) 126 (68.5)

Controls 21 23 2365 2503 147 (6.2) 107 (4.3)

Significance set at P ≤ 0.05. I , II, III a vs b, 1 vs 2: P <0.001; tobacco chewers vs controls: P < 0.001.

110 Oral Health & Preventive Dentistry Nagarajappa and Ramesh

DISCUSSION contribute to significant dental attrition, leading to the need for dental restorations in advanced cases Smokeless tobacco use is often mistakenly regard- (Bowles et al, 1995; Milosevic and Lo, 1996). ed as a safe alternative to cigarette smoking. Most Hence, in the treatment planning for patients who smokeless tobaccos contain substantial quantities use the various forms of smokeless tobacco or of nicotine, leading to a pattern of addiction similar smoke cigars, the clinician needs to be aware of to that of cigarette smoking (Severson, 1993). the potential loss of tooth substance as well as the People’s identification with Western culture may in- effects these abrasives may have on restorative crease their risk for tobacco use, while mainten- materials. ance of more traditional, Indian ways of living may Tooth wear is common in adults. The relationship confer some protection (Melissa et al, 2010). with primary physical causes including inadequate The present findings of increased tooth wear dental hygiene measures, bad oral habits or occu- among subjects who chew tobacco vs the control pational harm as well as other factors such as diet- group were similar to those of other studies (Bowles ary acid, salivary buffering and symptoms of gastro- et al, 1995; Dahl et al, 1989). This might be attri- oesophageal reflux is complex and requires further buted to the fact that tobacco contains abrasive investigation. silica particles a result of fallout from airborne dust. Moreover, the root system of tobacco plants absorbs monomeric silicic acid Si(OH)4, a soluble CONCLUSIONS compound of silicon found in the soil. This com- pound can be transported in plant fluids to leaves The individuals who chewed tobacco had more and stems and is deposited in insoluble forms. tooth wear than did non-chewers. The number of These deposited particles are known as opaline pathologically worn surfaces increased with the si- phytoliths. These abrasive particles are present multaneous increase in the frequency and duration within the plant structure and washing has little ef- of chewing tobacco. As abrasive materials in to- fect on reducing the abrasive content (Dahl et al, bacco products may contribute to dental attrition in 1989). chronic tobacco chewers, their effects should be When tobacco products containing abrasive sili- taken into consideration during dental treatment ca are mixed with saliva and chewed, an abrasive planning. Furthermore, such analyses are critical paste is formed that over time can wear down the for designing comprehensive tobacco control pol- teeth. The minute sizes of most particles prevent icies, which are necessary to reduce the burden of chewers from perceiving the product as an objec- tobacco-related oral diseases. tionably gritty, but the particles are abrasive in spite of the small size. Among the tobacco chewers, it was observed REFERENCES that individuals who chewed pan masala with to- bacco had maximum tooth wear, followed by indi- 1. Addy M, Bristol. , tooth wear and dentine hypersensitivity – are they associated? Int Dent J viduals who chewed pan with tobacco. Individuals 2005;55:261–267. who used plain tobacco exhibited the lowest tooth 2. Bolinder G, Alfredsson L, Englund A, de Faire U. Smokeless wear of tobacco chewers. This observation might tobacco use and increased cardiovascular mortality among be due to the addition of certain inorganic sub- Swedish construction workers. Am J Public Health 1994;84:399–404. stances containing sodium, iron, calcium etc and 3. Bowles WH, Wilkinson MR, Wagner MJ, Woody RD. Abrasive heavy soluble salts such as chloride, fluoride, etc in particles in tobacco products: a possible factor in dental those attractive packets (Dahl et al, 1989). Simi- attrition. J Am Dent Assoc 1995;126:327–331. larly, the subjects who chewed tobacco with pan 4. Chaudhry K, Prabhakar AK, Prabhakaran PS. Prevalence of had more tooth wear than did the individuals who tobacco use in Karnataka and Uttar Pradesh in India 2001 – Survey conducted by the Indian Council of Medical Re- chewed plain tobacco, which may be explained by search with financial support by World Health Organization, the fact that it is customary to sprinkle lime (CaOH) South East Asia Regional Office. Available at http://www. on the leaves before use. searo.who.int/LinkFiles/Regional_Tobacco_Surveillance_ It was also observed that as the frequency and System_SentinelIndia2001.pdf 5. Dahl BL, Stolen SO, Oilo G. Abrasives in snuff? Acta Odon- duration of chewing tobacco increased, the number tol Scand 1989;47:239–243. of pathologically worn surfaces increased simultan- eously. Abrasive particles in chewing tobacco may

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