INTRODUCTION
Dental diseases have a large impact on the general health of the patients beyond the immediate oral concerns. This is true more so in cases where multiple teeth are affected for long periods of time. Although the patterns of dental disease are gradually changing, periodontal disease and dental caries and are still the most important reasons for extraction of permanent teeth among most of the population.[1 extraction and further rehabilitation can be performed, chronic diseases of pulp and periodontium can in themselves cause significant disturbance in the ability to consume food efficiently. People with impaired mastication either adapt their food choices to softer diet that is often limited in nutrients, which may induce imbalance in dietary intake, or swallow coarse particles resulting in decreased bioavailability of nutrients and gastrointestinal disturbances. In both situations, the impaired dietary or nutrient intake may increase nutrition-induced disease risks.[2
Anemia is a frequent finding in most diseases that cause malabsorption with the most frequent etiology being the combination of iron and vitamin B12 deficiency. While this has mostly been studied in the malabsorbtive disorders of the stomach and intestines, the masticatory process is also crucial for optimal absorption of nutrients from some essential harder food components such as meat and vegetables. In addition to mechanical breakdown, proper mixing with oral digestive enzymes is also a critical function of mastication .[3 , 4
While anemia and other nutritional deficiencies have been associated with the edentulous state, masticatory disturbances start much before this stage, where either pain, loss of tooth structure, or loss of tooth support prevents the patients from utilizing them, forcing the patients to adapt their masticatory patterns. Our study aimed to evaluate the correlation between chronic dental diseases requiring extraction of multiple teeth and the anemic status of the patients undergoing these procedures among the rural population around Nalgonda. Our objective is to understand the correlation between chronic dental conditions requiring multiple extractions and the anemic status of the patients
MATERIALS AND METHODS
The study sample included patients who reported as outpatients to the OPD of the department of oral and maxillofacial surgery with chronic dental complaints requiring multiple teeth extraction . Chronic, for the purpose of the study, was defined as when onset of the complaint was 6 months or more. Multiple extractions were defined as 3 or more teeth. In addition, patients who required extraction of one or two teeth who had reported undergoing extractions in the previous 1 month were also included. Patients with acute dental complaints and systemic disorders including women with a history of menorrhagia were excluded from the sample. Patients with a history of smoking and alcohol consumption were also excluded. A sample size of 200 patients was included over the period of 1 year. Ethical clearance was obtained for the study from Institutional Ethical Committee with IEC Number KIDS/IEC/2018/09.
Informed consent was obtained from the patients for the study. Information of the patients along with the diagnosis, number, and position of teeth to be extracted was noted. A venous blood sample was drawn from all the patients who were tested for hemoglobin levels by Sahli's method. Patients were then categorized as anemic where the values were less than 11 g% in female patients and 12 g% in male patients.
RESULTS
Of the 200 patients included 62% were female and 38% were male. The average age of the patients was 52.3 years. The maximum number of patients at 45%, belonged 51–75 years age group. A total of 74 patients (36.8%) reported with pulp-related diseases including grossly decayed teeth with chronic pulpitis and root stumps. A total of 126 patients (62.6%) reported with periodontal complaints with tooth mobility of different grades. The mean number of teeth extracted was 3.8 ± 2.39.
Hemoglobin values in the male patients showed Hb range of 9.0 g% to 14.0 g% with an average 11.8± (1.38) g%. In female patients the hemoglobin ranged from 8.0 g% to 13.5 g% with the average Hb being 10.8± (1.14) g%. Based on whether the Hb values fell within the normal range for the specific sex of the patients, the patients were further divided into Group 1 (Anemic group) and Group II (Normal Hb group). 86 of the 200 patients (43%) fell into Group I and 114 patents 57% of patients fell into Group II
In the anemic group (Group 1), of 86 patients, 26 patients were male (30.2%) and 60 patients were female (69.7%). 42 of the 86 patients (48.8%) were of the age group 50 to 75 years with the mean age of the group being 52.53± (16.38) years.
The average hemoglobin in this group was 9.9 ± 0.86 g% for females and 10.5 ± 0.91 g% for males. The number of teeth extracted in Group I ranged from 1 to 13 with an average of 4.18± (2.64) [Figure 1 ]. 32 of these patients (37.2%) were diagnosed with deep caries/chronic pulpitis and 54 patients (62.7%) were diagnosed with chronic periodontitis. Among these 76 of the 86 patients underwent extraction of posterior teeth with or without anterior teeth accounting for 88.3% and 10 patients (11.6%) underwent extraction of only anterior teeth [Figure 2 ].
Figure 1: Comparison between mean number of teeth requiring extraction in Group I and Group II
Figure 2: Comparison between Percentage of posterior teeth in Group I and Group II
In the normal Hb group (Group II) of 114 patients, 50 patients were male (43.8%) and 64 patients were female (56.2%). 48 patients were present in the age groups of 25 to 50 and 50 to 75 each with the average age of the group of 51.61± (15.64) years.
The number of teeth extracted in Group II ranged from 1 to 12 with an average of 3.5± (2.14) [Figure 1 ]. 42 of these patients (36.8%) were diagnosed with deep caries/chronic pulpitis and 72 patients (63.1%) were diagnosed with chronic periodontitis. 88 patients of this group underwent extraction of posterior teeth, with or without anterior teeth accounting for 77.1% and 26 patients (22.8%) underwent extraction of only anterior teeth [Figure 2 ].
The statistical significance was calculated for the number of teeth extracted between Group I and Group II using t test where the difference was found to be statistically significant (P = 0.024). The statistical significance of the percentage of patients who had their posterior teeth extracted was calculated between the two groups using the Chi-square test, where the difference was found to be statistically significant (P = 0.0436).
Among patients with number of teeth requiring extraction of 5 or more, which were 48 in number, 28 cases showed anemia (58.3%). However, the difference with the full data set was not statistically significant.
DISCUSSION
Awareness about oral health and dental care in India is very low and this becomes even more marked in rural populations. In the absence of acute pain that may disrupt their daily life, patients tend to ignore chronic dental issues, either due to lack of time, awareness, accessibility of health care resources, or cost factors. This leads to not only the worsening of their oral health but also causes numerous of systemic issues. The most direct impact of this is seen on the masticatory ability and thus the patient's capacity of eat and digest various kinds of food leading to various malnutrition disorders of which anemia is the most common.
WHO defines anemia as less than 120 g/L (12 g%) in females, and less than 130 g/L (13 g%) in males. While similar values have been used by some authors in studies of Indian population, other studies have noted that these values may vary from among different ethnic populations. This difference has been seen to be more pronounced in female population compared to the male population. A recent study on hemoglobin cut-off values in Asians based on national nutritional surveys stated that 11.22 g% as the cut of value to define anemia in women.[5 6
Iron deficiency is the most common cause of anemia globally, but other nutritional deficiencies (Folate, Vitamin B12, and Vitamin A), acute and chronic inflammation, parasitic infections, inherited and acquired disorders of hemoglobin synthesis, RBC's production or RBC's survival, can all cause anemia Although clinical evaluation of anemia requires multiple laboratory tests to identify the severity, type and cause of anemia , hemoglobin concentration is the most reliable indicator of anemia at the population level.[7 8 9 anemia was noted to be 34.2% in male and 48. 3% in female patients which was higher than the general population in line with the expected results for our study.
The correlation of periodontal diseases with anemia has been recorded in literature However contradicting literature attributes this variously to both iron deficiency and anemia of chronic diseases caused due to inflammatory cytokines.[10 , 11 , 12 anemia has not been documented. In our study, both the anemic and the non-anemic groups had near-identical distribution of teeth involving both pulpal issues with severe loss of tooth structure and those having periodontal disease. Thus it was concluded that in our study anemic status did not depend on the specific diagnosis.
A statistically significant difference was noted between the anemic group and the normal group in the average number of teeth which required extraction , with the anemic group showing higher mean number of affected teeth. The ratio of posterior teeth to anterior teeth in the anemic group was also higher compared to the normal group which was also found to be statistically significant. It was also noted that when the subset of patients who required extraction of 5 or more teeth was considered the percentage of anemic patients in this subset was 58.8% was higher than the percentage in the full sample group. Although this difference was not statistically significant, along with other findings it suggests the import of two main factors, i.e. number of teeth and position of teeth, correlating with the anemic status in patients requiring multiple extraction . These finding strongly point towards a correlation with dental dysfunction affecting the masticatory efficiency. Mastication plays a critical role in both mechanical breakdown of food and mixing of food with enzyme present in the oral cavity which affect the intake and absorption of food. But beyond that it is also noted that change in masticatory patterns and efficiency affected the oral residence time, eating rate, muscle fatigue and other oral processing attributes. Alteration and compromise in diet due to masticatory disturbance may also affect the appetite and food intake.[13
Further studies examining the co-relation between masticatory disability due to chronic dental pathologies and lack of adequate nutrition leading to anemia are required in the future, incorporating more detailed assessment of related factors including RBC indices like MCV, MCH, MCHC, ferritin, free erythrocyte protoporphyrin, serum and plasma iron, total iron-binding capacity, transferrin saturation and serum transferrin receptor.
Longstanding dental diseases requiring multiple extractions compromise mastication and thus may have a twofold effect on the nutrition of the patient. Patients are limited to a diet of softer food that may impact the amount of food they consume. In addition, the food they consume is not properly digested. We noted a significant correlation between the number of posterior teeth which are nonfunctional and the presence of anemia in the patients even before they undergo extraction . This has to be taken into consideration in order to plan better treatment and more expedient rehabilitation of patients in future.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Kumar BP, Venkatesh V, Praveen P, Devi VV. Reasons relating to the
extraction of permanent teeth in the regional population Indian J Dent Adv. 2018;10:105–8
2. N'Gom PI, Woda A. Influence of impaired
mastication on nutrition J Prosthet Dent. 2002;87:667–73
3. Keller J, Layer P. The pathophysiology of malabsorption Viszeralmedizin. 2014;30:150–4
4. Fernández-Bañares F, Monzón H, Forné M. A short review of malabsorption and
anemia World J Gastroenterol. 2009;15:4644–52
5. Varghese JS, Thomas T, Kurpad AV. Evaluation of haemoglobin cut-off for mild anaemia in Asians-analysis of multiple rounds of two national nutrition surveys Indian J Med Res. 2019;150:385–9
6. Pasupula DK, Reddy PS. When is a South Indian really anemic? Indian J Clin Biochem. 2014;29:479–84
7. de Benoist B, Erin Mclean, Egli I, Cogswell M. Worldwide prevalence of anaemia 1993-2005 WHO Global Database on Anaemia. 2008 World Health Organization
8. IIPS O National Family Health Survey (NFHS-3), 2005-06: India. 2007;I Mumbai International Institute for Population Sciences
9. Malhotra V, Krishna H, Divya Bharati V. An epidemiological study on prevalence of anaemia among elderly population residing in rural Nalgonda, Telangana, India Sch J Appl Med Sci. 2015;3:1641–4
10. Enhos S, Duran I, Erdem S, Buyukbas S. Relationship between iron-deficiency
anemia and periodontal status in female patients J Periodontol. 2009;80:1750–5
11. Naik V, Acharya A, Deshmukh VL, Shetty S, Shirhatti R. Generalized, severe, chronic periodontitis is associated with
anemia of chronic disease: A pilot study in urban, Indian males J Investig Clin Dent. 2010;1:139–43
12. Gokhale SR, Sumanth S, Padhye AM. Evaluation of blood parameters in patients with chronic periodontitis for signs of
anemia J Periodontol. 2010;81:1202–6
13. Krop EM, Hetherington MM, Nekitsing C, Miquel S, Postelnicu L, Sarkar A. Influence of oral processing on appetite and food intake – A systematic review and meta-analysis Appetite. 2018;125:253–69
