Dental caries (DC) is a major health problem affecting all age groups, gender, and races with manifestations persisting throughout life despite treatment. It is a complex and dynamic process where a multitude of factors initiate and influence the progression of the disease. It results from a complex interaction of diet, the normal bacterial flora, and the host. It is important to identify the exact etiology as well as modifiable risk factors for caries.
DC if left untreated can result in substantial morbidity due to pain, dysfunction, poor appearance, and possibly problems with speech development. Hence, it becomes important to identify the exact etiology and modifiable risk factors for caries. In spite of known effective methods for the prevention and management of DC, it continues to be a global burden.
Oral health neglect is a common feature of psychoactive substance (PS) abuse. While DC is all pervading in highly industrialized societies, the caries experience varies greatly among communities and with socioeconomically varied populations.
In many Asian countries including India, tobacco in smoking and chewing has been practiced for a long time irrespective of its ill effects in any form. According to the World Health Organization estimates, globally, there were 100 million premature deaths due to tobacco in the 20th century, and if the current trend of tobacco use continues, this number is expected to rise to 1 billion in the 21st century irrespective of a global commitment to reversing the tobacco epidemic made in 2003.
According to current trends, the mortality rate is expected to reach 10 million by the year 2030, with 70% of deaths occurring in low- and middle-income countries. Tobacco is mainly used in smoking cigarettes, cigars, beedis, and pipe tobacco and smokeless forms are gutka, Khaini, gul, pan masala, and plain tobacco.
The relationship of PS abuse to DC is a matter of debate till date. Given the paucity of this information, a hospital-based cross-sectional study was planned to evaluate the association of PS abuse to DC, stating the null hypothesis, as there is no difference in DC activity in substance abusers as compared to nonusers in participants visiting K. M. Shah Dental College and Hospital.
MATERIALS AND METHODS
The present cross-sectional study comprised 135 healthy participants nonusers of PS as healthy controls and 135 participants using tobacco, alcohol, and areca nut in any form, recruited from the Outpatient Department of K M Shah Dental College and Hospital. All the participants with their consent were screened by a single trained examiner, the intraclass calibration coefficient for intraexaminer reliability was 0.93, indicating that the examiner was trained sufficiently. Dentate participants in the age range of 20–50 years, using tobacco and/or related substances for a minimum of 5 years, residents of Piparia village, Vadodara city, and consuming only municipal water were included in the study. Occasional tobacco abusers and participants with special health-care needs (e.g., cleft lip and palate syndromes and medically and physically challenged) were excluded from the study.
A brief case history including tobacco and related substance habits for both smoking and smokeless tobacco abusers comprising duration, frequency, the quantity of tobacco, and related product intake was recorded in the prescribed proformas.
Each participant was examined on a dental chair with light using appropriate diagnostic aids, and oral hygiene status was scored using Oral Hygiene Index-Simplified (OHI-S). Decayed, missing, and filled teeth (DMFT) index was used to record DC and its pattern, and participants were categorized into three groups: Group I: No caries group: DMFT <1; Group II: Moderate caries group: DMFT >1 and <6; and Group III: Severe caries group: DMFT >6. The OHI-S value comprised debris index simplified and calculus index simplified and it ranged from 0 to 6 which were interpreted as: good – 0–1.2; fair – 1.3–3; and poor – 3.1–6. The time required for clinical examination and recording varied from 10 to 15 min.
All the data were entered into Microsoft Excel and analyzed using SPSS version 20.0 (SPSS Inc., Chicago, Illinois, USA). The data were statistically analyzed using descriptive statistics, Chi-square t-test, analysis of variance, and binary regression analysis. P < 0.05 was considered statistically significant.
Ethical approval for this study (Sumandeep Vidyapeeth Institutional Ethics Committee) was provided by the Ethical Committee of Sumandeep Vidyapeeth Deemed to be University, SVIEC on 31st August 2021.
In the present study, among the 270 participants, the mean age was 32.53 years and the majority were in the age range of 20–29. Tobacco abuse was the most common reported habit and was predominant in males [P = 0.001, Table 1]. The most commonly consumed smokeless tobacco was pan masala with tobacco (gutka). In the study group, among all participants, tobacco abuse was followed by gutka, smoking, betel nut, and lastly, mixed products. However, among the male participants, gutka abuse was most common followed by tobacco and smoking [Table 2].
In the present study, the mean DMFT in tobacco abusers was significantly higher than those of nonabusers [P = 0.0010, [Tables 3 and 4]. A statistically significant difference was found between total decayed teeth, total missing teeth, and total filled teeth among tobacco abusers to those of nonabusers. As the frequency of tobacco and related substance abuse increased, there was a statistically significant increase in caries (DMFT) [r = 0.15 and P = 0.013, Table 5]. Further, in moderate and severe DMFT, duration and frequency of tobacco abuse was significantly associated with a pattern of DC (P = 0.001). DMFT score increased with the duration of tobacco substance abuse (r = 0.24 and P = 0.0001) and it was statistically highly significant.
With gutka abuse (r = 0.17 and P = 0.005), a low degree of positive correlation was found and it was statistically highly significant. With tobacco substance abuse, there was an increase in DC (r = 0.05 and P = 0.384) but it was not statistically significant. Binary regression analysis [Table 6] showed an odds ratio of 0.123 (i.e., tobacco chewers were 0.123 times more prone to get DC than nontobacco chewers, gutka abusers were 0.217 times more prone to get DC than nongutka abusers, similarly, smokers were 0.085 times, betel nut abuser were 0.057 times, and mixed habit abusers were 0.050 times more prone to get DC than those of nonusers.
OHI was significantly higher in tobacco abusers than those of nonabusers (P = 0.0001). In Group I (no caries group), the OHI was good; as the grade of DMFT increased the OHI was found to be poor [Table 7]. The difference of DC and its association with OHI was statistically significant among tobacco abusers to those of nonusers. OHI was found to be poor with an increase in frequency and duration of tobacco abusers as compared to those of nonabusers and the difference was statistically significant (P = 0.001).
PS abuse is a disorder characterized by repetitive substance use that results in social or economic distress and that causes damage to physical or mental health. The common PS abuse that is of interest to a dentist in India includes alcohol, tobacco, and areca nut. The substances or drugs may be natural or synthetic, the use of which has a psychoactive effect and alters or modifies the functions of a living organism. Tobacco is detrimental to overall human health and any form of tobacco abuse leads to sinister effects in the oral cavity. Substance abuse both as smoking and smokeless tobacco forms can lead to poor oral hygiene and furthermore DC. DC being a multifactorial disease of lifestyle, socioeconomic, and sociodemographic gradients, tobacco abuse acts as a confounding factor.
The prevalence of DC in the present study was found to be 66.33%, and the majority of the participants (24.1%) were in the age range of 36–40 years with a mean age of 38.49 years. These findings are in accordance with that reported by Rooban et al., who also reported the mean age as 32.78 years. It is higher than the reported prevalence in India in various age groups, indicating that tobacco and related substance abuse play a role in DC and poor oral hygiene. These are also congruent with those of Kumar et al. who found tobacco and related substances habit to be most prevalent among 25–35 years of age. Axelsson et al. reported the smoking habit in the older age group, in their study of DC among smokers and nonsmokers.
The younger age group involved in tobacco abuse observed in the present study could be due to peer pressure, inability to cope to stresses, media exposure to tobacco and its related products, and ease of availability of tobacco and related substances. Another reason observed in the lower economic strata could be the family members exposing the younger ones to tobacco use at an early age.
Gutka abuse observed in the present study is similar to the findings of studies carried out on street children and adult pavement dwellers in Mumbai, reporting 49% and 20% of gutka consumption, respectively.
An increased DMFT score was observed across various types of tobacco abuse, suggesting that tobacco plays a definitive role in the caries process. Furthermore, the type of tobacco substance abuse influences the DC occurrence and oral hygiene status. Hence, the type of tobacco substance would probably be a major factor in determining the DMFT as well as OHI-S.
In the present study, the DMFT score was high in both smokeless and smoked forms of tobacco as compared to controls. This was in contrast to Rooban et al. and Möller et al. who reported that continuous chewing of tobacco leads to wear of occlusal surfaces accounting for less DC. The high caries experience observed in the present study could be due to the sweeteners and citric acid in smokeless tobacco as compared to smoked forms of tobacco.
The DMFT score in smokers was less compared to smokeless tobacco abusers, which could be due to thiocyanate concentration, a constituent of tobacco smoke in saliva with a possible caries-inhibiting effect. The findings are contradictory to those of Petersson and Twetman who reported habitual smoking to have a significant relation to caries increment over a 3-year period in young adults. Thus, smoking is a marker of lifestyle and socioeconomy, exerts biological influence on salivary buffer capacity, and levels of secretory immunoglobulin A.
Frequency and duration of habit was not congruent with the study of Rooban et al. who found a higher mean duration of tobacco abuse among the study groups, but did not contributory to the increase in mean DC. Tobacco and related substance abuse would probably be a major factor in determining the DC, DMFT as well as OHI-S. Tobacco and related substance abuse probably influence oral hygiene status and this poor oral hygiene is a cofactor with smokeless tobacco abuse in the development of DC and this finding was in congruence with the study reported by Rooban et al. and Offenbacher and Weathers. However, caries risk assessment by Mejàre et al. found insufficient evidence to determine the accuracy of oral bacteria and oral hygiene as risk factors for caries.
In the present study, as OHI degraded from good to poor, an increase in DMFT score was noted and this correlation between DMFT and OHI was positive. Poor oral hygiene and increased DMFT could be due to the fact that tobacco abuse induces alteration in the composition of oral microbiome including Candida, attributed to the components of tobacco such as nicotine, polycyclic aromatic hydrocarbons, polonium, nitrosodietheinal amine, and nitrosoproline. These act as nutrients for Candida species and thus augment their proliferation. Furthermore, nicotine leads to the alteration of local immune function through the impairment of neutrophil function, and subsequently converts the oral flora to opportunistic pathogens, leading to an imbalance between the host and the oral microbiota in favor of oral disease. This explains the increased caries activity observed in PS abuse participants in the present study.
This indicates that tobacco and related substances promote DC both through a direct effect of nicotine on caries-causing bacterial agents, as well as through other systemic physiological changes in the host. Furthermore, lower cystatin activities have been reported in tobacco smokers. Cystatins contribute to balanced oral health by inhibiting certain proteolytic enzymes. There have been contradictory reports of DC in tobacco smokers. Furthermore, the decreased buffering effect, possible lower pH of smoker's saliva, and the higher number of lactobacilli and Streptococcus mutans indicate an increased susceptibility to caries.
A positive correlation of tobacco abuse with DC observed in the present study is similar to many reported in the literature. Furthermore, the habits varied significantly and the DMFT score was influenced by the type of tobacco, frequency, and duration of abuse.
Tobacco habit is a risk factor for increased caries activity and it is higher in smokers as compared to smokeless tobacco chewers. PS abuse along with poor oral hygiene leads to an increase in caries incidence through various mechanisms. A decreased DC incidence and good oral hygiene can be ensured effectively through proper education and counseling of the patients for discontinuation of habits. Dental surgeons can play an important role in individual and population-based PS abuse interventions to limit the negative influence on oral health. A longitudinal study with regular follow-up needs to be planned for more accurate results.
Limitation of study
The oral hygiene measures as well as the method for cleaning of the oral cavity were not recorded in the present study. Reasons for missing teeth were also not recorded. Proximal caries was not confirmed with radiographs. DC being multifactorial an association between a single positive factor such as tobacco abuse and caries incidence is difficult to conclude.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
We would like to thank Mr. Ronak Shah for the statistical analysis.
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