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ORIGINAL ARTICLE
Year : 2018  |  Volume : 62  |  Issue : 4  |  Page : 282-286  

Influence of tobacco chewing on oral health: A hospital-based cross-sectional study in Odisha


1 Senior Resident, Department of Public Health Dentistry, S.C.B Dental College and Hospital, Cuttack, Odisha, India
2 Professor and Head, Department of Public Health Dentistry, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India
3 Senior Lecturer, Department of Orthodontics and Dentofacial Orthopedics, Hi-Tech Dental College and Hospital, Bhubaneswar, Odisha, India
4 Postgraduate Student, Department of Public Health Dentistry, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India

Date of Web Publication11-Dec-2018

Correspondence Address:
Dr. Shilpa Mahapatra
Department of Public Health Dentistry, S.C.B Dental College and Hospital, Mangalabag, Cuttack - 753 007, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_327_17

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   Abstract 


Background: Smokeless tobacco use in the Indian subcontinent is a part of many religious and cultural rituals and has gained a degree of social acceptance. The deleterious effects of smokeless tobacco are not as well-known as those produced by smoking. Objectives: The study was carried out to assess the influence of tobacco chewing on the oral health of adult patients attending the dental outpatients department of Khordha district headquarter, Odisha. Methods: A hospital-based cross-sectional study was conducted among 25–64-year-old patients attending the dental outpatient department of Gopabandhu Khordha district headquarter hospital. A total of 512 study participants, who were age and sex matched, were stratified into four age groups such as 25–34 years, 35–44 years, 45–54 years, and 55–64 years old. Oral health status of the participants was assessed using modified WHO Oral Health Assessment Form (2013). Pearson's Chi-square test, binary and multinomial logistic regression was performed to determine the relationship between oral health problems and tobacco chewing. Results: Among the tobacco chewers, 59.8% had gingival bleeding, 40.6% had periodontal pockets, 30.1% had loss of attachment, 48.4% had attrition, and 4.3% had potentially malignant disorders. Compared to the nonchewers, these oral problems were significantly higher among the chewers. Whereas dental caries experience was significantly lower among the chewers (40.6%) compared to the nonchewers (54.7%). Compared to the nonchewers, chewers had 1.71 times increased odds for gingival bleeding, 1.71 times increased odds for periodontal pockets, 2.39 times increased odds for loss of attachment, and 2.49 times increased odds for attrition, which were statistically significant. Conclusion: Hence, the study revealed that tobacco chewing definitely had an influence on oral health, with statistically significant increase in oral health problems in chewers compared to nonchewers. Moreover, loss of attachment and potentially malignant disorders increased significantly with the frequency of tobacco chewing. Periodontal pockets, attrition, and loss of attachment significantly increased with the duration of the chewing habit.

Keywords: India, oral health, smokeless, tobacco, tooth attrition


How to cite this article:
Mahapatra S, Chaly PE, Mohapatra SC, Madhumitha M. Influence of tobacco chewing on oral health: A hospital-based cross-sectional study in Odisha. Indian J Public Health 2018;62:282-6

How to cite this URL:
Mahapatra S, Chaly PE, Mohapatra SC, Madhumitha M. Influence of tobacco chewing on oral health: A hospital-based cross-sectional study in Odisha. Indian J Public Health [serial online] 2018 [cited 2019 Nov 15];62:282-6. Available from: http://www.ijph.in/text.asp?2018/62/4/282/247229




   Introduction Top


The epidemic of tobacco use is one of the paramount threats to global health today.[1] Tobacco is chewed, smoked, sucked, and sniffed and is the one product which is deleterious to the populaces, when it is used entirely as intended.[2] According to the report of a 1987 WHO study group, a smokeless tobacco user can have blood nicotine levels as high as, or even higher than, those found in tobacco smokers.[3] One of the many tobacco forms available in India, Gutkha, a dry preparation commercialized since 1975, contains areca nut, slaked lime, catechu, condiments, and powdered tobacco.[4]

Betel quid chewing is an ancient habit dating back to more than 2000 years.[5] In 2004, betel quid was ranked among Group 1 carcinogens by the International Agency for Research on Cancer.[6] In addition to tobacco, it consists of four main ingredients as follows: betel leaf (Piper betle), areca nut (Areca catechu), slaked lime, and catechu (Acacia catechu).[5] Areca nut is the fourth most commonly used psychoactive substance in the world after tobacco, alcohol, and caffeine.[7] Betel quid chewing is a widespread habit in South and Southeast Asia with about 600 million people still indulging in this habit.[8]

It is anticipated that among the 400 million individuals aged 15 years and over in India, 16% use tobacco in the smokeless form.[9] Age-adjusted rate of oral cancer in India is 20/100,000 population and accounts for over 30% of all cancers in the country.[10] The World Health Organization predicts that tobacco deaths in India may exceed 1.5 million annually by 2020.[11]

As stated by the Global Adult Tobacco Survey, India, 2016–2017, the prevalence of smokeless tobacco use in India is 21.4% in the above 15 age group.[12] Midst all the states and union territories of India, Tripura with a prevalence of 48.5%, Manipur with 47.7%, Odisha with 42.9%, and Assam with 41.7%, are the top four states with highest prevalence of smokeless tobacco use.[12] Khordha is a city in the Indian state of Odisha, where tobacco chewing, especially gutkha and betel quid, is pervasive as well as customary, irrespective of age, gender, or social class. As the final expression of oral diseases is foreseen on the complex interactions occurring within a byzantine mosaic of host, microbial, and environmental factors, it was felt that the contribution of tobacco as a risk factor in this particular setting might be worthy of investigation. Hence, this study was designed to visualize the oral health effects caused by tobacco chewing among the adult patients attending the dental outpatients department (OPD) of Khordha district headquarter hospital of Odisha.


   Materials and Methods Top


A hospital-based cross-sectional study was carried out from March 2015 to August 2015, among 512 adult patients, aged 25–64 years, of Khordha district headquarter hospital of Odisha, which encompassed of 256 tobacco chewers and 256 nonchewers. The nature and purpose of the study were elucidated to the Institutional Review Board and Ethical Clearance was acquired (MADC/IRB/2015/132). Prior permission was obtained from the Chief District Medical Officer of Khordha district to conduct the study in the dental outpatient department of Khordha district headquarter hospital. A tobacco chewer was defined as an individual who was currently consuming tobacco once a day or more often in the form of smokeless tobacco and had done so for at least during the last year.[13] Adult patients attending the dental OPD of Khordha district headquarter hospital, aged 25–64 years, were included in the study whereas participants using tobacco products other than smokeless tobacco, having alcohol habit, medically compromised patients, and those unwilling to give the full details of their habit were excluded from the study. Training exercises were carried out in the Department of Public Health Dentistry, on the outpatients, under the guidance of a trained person. Totally 20 participants were reexamined to assess the consistency of intraexaminer reproducibility, which was found to be 90%.

Out of 25 district headquarter hospitals in Odisha, Gopabandhu Khordha district hospital was chosen purposively based on feasibility. A pilot study was then carried out among 100 chewers and 100 nonchewers aged 25–64 years, randomly selected as exposed and unexposed groups, respectively. Subsequently, a sample size of 247 in each group was estimated based on the prevalence of loss of attachment obtained from the pilot study, considering 80% power and 5% error.

Sample size was calculated using the following formula:



Substituting the Z1-β value for 5% level of significance and Z1-β value for 80% power of the study:

Z1-α/2: 1.96

Z1-β: 0.84

P1 = Prevalence of loss of attachment among tobacco chewers obtained from pilot study: 32%

P2 = Prevalence of loss of attachment among nonchewers obtained from pilot study: 22%

P̄ = (P1 + P2)/2 = 27

Substituting the above values,



The OPD timing of the hospital being 9 am to 5 pm, a minimum of 18 patients were required to be examined per day, considering the average examination time per person as 20 min (according to WHO). At 11 am every day, the OP numbers of the patients were collected, and the study participants were then randomly selected using lottery method. Only those participants who fulfilled the inclusion and exclusion criteria were recruited for the study and then categorized into four groups based on age: 25–34 years, 35–44 years, 45–54 years, and 55–64 years. The tobacco chewers and nonchewers selected for the study were matched by age and sex in each age group. At least 31 males and 31 females were required in each age group to obtain a sample size of 247 in each group. Hence, only those tobacco chewers, whose corresponding age- and sex-matched pair existed in the nonchewer group, were included in the present study, until the required sample size was obtained. Eventually, each age group among the chewers and nonchewers comprised of 32 males and 32 females, amounting to 64 participants in each group. The study participants were examined clinically by a trained examiner adhering to the WHO Basic Oral Health Survey (2013),[14] which included an additional examination for tooth attrition also. ADA specification Type III examination was followed for the examination of the participants, who were seated comfortably on a dental chair in the dental outpatient department of the hospital.

The data obtained were subjected to statistical analysis using the Statistical Package for the Social Sciences (SPSS Inc, Chicago, IL, USA) version 18.0. Qualitative and quantitative data obtained were analyzed using Chi-square test and t-test, respectively. Association between the oral health problems and tobacco chewing habit was assessed using binary logistic regression and the association between oral health problems, and the type of chewing substance was assessed using multinomial logistic regression.


   Results Top


Among the tobacco chewers, 51.6% were betel quid chewers, 28.1% were gutkha chewers, and 20.3% were both betel quid and gutkha chewers. Compared to the nonchewers, a significantly higher number of tobacco chewers exhibited gingival bleeding (59.8%), periodontal pockets (40.6%), loss of attachment (30.1%), and attrition (48.4%). Potentially malignant disorders such as oral submucous fibrosis (2.3%) and leukoedema (2%) were observed only among the chewers. Whereas compared to the nonchewers (54.7%), the dental caries experience was significantly lower among the tobacco chewers (40.6%). The mean DMFT among the chewers was 1.36 ± 1.83, and among the nonchewers was 1.90 ± 1.97 [Table 1].
Table 1: Prevalence of oral health-related conditions among the study subjects

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Loss of attachment was observed among all the tobacco users who chewed tobacco 10–20 times per day compared to those who used <10 times per day (29.4%) (P = 0.02). Potentially malignant disorders were observed in 66.7% users who chewed tobacco 10–20 times per day compared to those who used <10 times per day (3.6%) (P = 0.000). Hence, loss of attachment and potentially malignant disorders appeared to increase significantly with an increase in frequency of tobacco chewing. In addition, periodontal pockets, attrition, and loss of attachment were observed to significantly increase with an increase in the duration of the chewing habit [Table 2].
Table 2: Distribution of oral health-related conditions among the tobacco chewers based on the duration of chewing habit

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Binary logistic regression results revealed that compared to the nonchewers, chewers had significantly higher odds for gingival bleeding (odds ratios [OR] = 1.710, 95% confidence intervals [CI]: 1.2–2.43) as well as periodontal pockets (OR = 1.715, 95% CI: 1.19–2.48). Moreover, tobacco chewing was also significantly associated with higher odds of loss of attachment (OR = 2.393, 95% CI: 1.55–3.69) and attrition (OR = 2.496, 95% CI: 1.73–3.61). Nevertheless, tobacco chewing was significantly associated with lower odds of dental caries (OR = 0.567, 95% CI: 0.4–0.8). Moreover, multinomial regression indicated that compared to participants chewing both gutkha and tobacco, betel quid chewers had significantly lower odds for periodontal pockets (OR = 0.495, 95% CI: 0.258–0.950). Hence, chewing both gutkha and betel quid was significantly associated with periodontal pockets [Table 3].
Table 3: Multinomial logistic regression for oral health-related conditions among the chewers based on the type of chewing substance

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   Discussion Top


The present comparative hospital-based cross-sectional study was intended to augment scientific knowledge about the effect of tobacco chewing on the oral health of adult patients attending the dental OPD of Khordha district headquarter hospital of Odisha. Compared to the present study, where a significantly higher number of tobacco chewers (40.6%) had periodontal pockets, a lower prevalence of 0.7% was reported by Agili and Park, 2013[15] in Saudi Arabia. Chewers had 1.7 times increased odds for periodontal pockets, which were similar to the OR of 1.6 reported by Parmar et al., 2008[16] in Gujarat. Higher values of 3.9 and 4.7 were reported by Akhter et al., 2008[17] in Dhaka and Sumanth et al., 2008[18] in Karnataka, respectively. Loss of attachment was significantly higher among the tobacco chewers, which were much lower than the prevalence of 61.7% reported by Anand et al., 2013[19] among smokeless tobacco users in Bhopal. Furthermore, chewers had 2.3 times increased odds for loss of attachment, which was similar to the OR of 1.7 and 2.9 reported by Parmar et al., 2008[16] in Gujarat and Anand et al., 2013[19] in Bhopal, respectively. Nevertheless, it was much lower than the OR of seven reported by Sumanth et al., 2008[18] in Karnataka. The hardness of the areca nut and interactions among the various ingredients with periodontal tissues might be responsible for the poor periodontal status of chewers. In addition to being cytotoxic to periodontal fibroblasts, arecoline also aggravates preexisting periodontal disease and impairs periodontal reattachment, by reducing the resistance to local irritants.[16] Nicotine also has an adverse effect on human periodontal ligament fibroblast growth, proliferation, and protein synthesis and thus may have a role in periodontal diseases.[18]

Dental caries was observed among 40.6% of the tobacco chewers, which were lower than the prevalence of 65% reported by Al Agili and Park, 2013[15] among the smokeless tobacco users in Saudi Arabia. The mean DMFT among the chewers in the present study was 1.36 and among the nonchewers was 1.90. DMFT values of 3.12 and 5.8 among the nonchewers and chewers, respectively, were reported in a similar study conducted by Amjad et al., 2012[2] in Pakistan. Moreover, Vellappally et al., 2008[20] reported higher values of 8.96 among nonchewers and 12.25 among chewers in Kochi. The plausible reasons that tobacco chewing diminishes dental caries are betel stain may act as a physical barrier to tooth demineralization; tannin content of betel may have antimicrobial properties; marked attrition of cusps, eliminating potential stagnation areas; the presence of added slaked lime and fluoride in levels ranging from 0.9 to 2.0 ppm; and increased production of sclerosed dentine in response to attrition.[15],[21],[22],[23]

The prevalence of potentially malignant disorders among the chewers in the present study was 4.3%. Higher prevalences of 22.7% by Vellappally et al., 2008[20] in Kochi, 38% by Amjad et al., 2012[2] in Pakistan, and 85.9% by Al Agili and Park, 2013[15] in Saudi Arabia have been reported. Compared to the present study, where the prevalence of oral submucous fibrosis among the chewers was 2.3%, higher prevalences of, 6.1% by Prasad et al., 2014[24] in Ghaziabad, 49% by Kawatra et al., 2012[25] in Maharashtra, 13% by Amjad et al., 2012[2] in Pakistan, and 7.08% by Patil et al., 2013[26] in Karnataka, have been reported. Areca nut contains psychoactive alkaloids, of which arecoline contributes the maximum quantity.[27] It is advocated that arecoline is the active metabolite in fibroblast stimulation crucial in oral submucous fibrosis.[5],[28] Potentially malignant disorders were predominantly observed in the younger age groups, which were in accordance with a study conducted in Jaipur, by Pratik and Desai, 2015.[29] The prevalence of leukoedema in the present study was 2%, which was almost similar to the prevalence of 3.7% reported by Mathew et al., 2008[30] in Manipal.

The present study had certain limitations which should be considered when interpreting the results. The cross-sectional design of the study made it difficult to establish a temporal sequence between smokeless tobacco use and oral health-related conditions. Hence, longitudinal studies need to be conducted to fathom this issue of temporal ambiguity. Detailed information has not been gathered on other confounders such as socioeconomic status, nutritional status, and BMI. Betel chewers are known to use various ingredients such as betel leaf, areca nut, and lime with the quid, in addition to tobacco. It is plausible that hitherto unknown complex interactions between such substances and tobacco might lead to distinct profile of oral health-related conditions in betel chewers. In India, the percentage of people who chew betel quid without tobacco is small.[31] Hence, this study included chewers who had betel quid with tobacco. Further studies are warranted to explore and compare the oral health effects of chewing betel quid with and without tobacco.


   Conclusion Top


This study revealed that tobacco chewing undeniably had an influence on oral health, with statistically significant increase in oral health-related conditions such as gingival bleeding, periodontal pockets, loss of attachment, attrition, and potentially malignant disorders, in chewers compared to nonchewers. Moreover, the frequency and duration of the habit were directly associated with the above-mentioned oral health-related conditions. The present research further emphasizes on the need to educate and promote awareness about smokeless tobacco products.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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