oral mucosal and periodontal ststus among 35-44year old

Oral Mucosal and periodontal ststus among 35-44year old tobacco and non

tobacco users in Karnataka State

By Shamaz Mohamed

Under the guidance of

Dr. Ganesh Shenoy Panchmal Dept of Preventive and Community

Dentistry Yenepoya Dental College

2009

XIV

TABLES PAGE NO.

1. DISTRIBUTION OF STUDY SUBJECTS ACCORDING 41

TO RURAL/URBAN REGIONS


TO SEX

3. PERCENTAGE OF STUDY SUBJECTS AMONG DIFFERENT 42

TABACCO USERS AND NON-TOBACCO USERS IN

RURAL AND URBAN AREAS

4. PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT 42

TYPES OF TOBACCO USE IN KARNATAKA STATE

5. PERCENTAGE OF STUDY SUBJECTS WITH ORAL 43

MUCOSAL CONDITIONS ACCORDING TO THEIR LOCATION

6. PERCENTAGE OF STUDY SUBJECTS WITH COMMUNITY 44

PERIODONTAL INDEX SCORES IN THE AGE GROUP OF

35 – 44 YEARS IN KARNATAKA STATE

XV

7. PERCENTAGE OF STUDY SUBJECTS WITH LOSS OF 45

ATTACHMENT SCORES IN THE AGE GROUP OF 35 – 44

YEARS IN KARNATAKA STATE

8. MEAN NUMBER OF HEALTHY SEXTANTS AND SEXTANTS 46

WITH BLEEDING or HIGHER SCORE, CALCULUS or HIGHER

SCORE, SHALLOW POCKETS or HIGHER SCORE,

DEEP POCKETS IN KARNATAKA STATE

9. MEAN NUMBER OF SEXANTS WITH LOSS OF ATTACHMENT 47

SCORES IN SUBJECTS OF AGE GROUP 35 – 44 YEARS IN

KARNATAKA STATE

10. PERCENTAGE OF DIFFERENT STUDY SUBJECTS 48

WITH COMMUNITY PERIODONTAL INDEX

SCORES IN TOBACCO USERS AND NON-TOBACCO USERS

11. MEAN NUMBER OF HEALTHY SEXTANTS AND SEXTANTS 49

WITH BLEEDING or HIGHER SCORE, CALCULUS or HIGHER

SCORE, SHALLOW POCKETS or HIGHER SCORE, DEEP POCKETS

AMONG TOBACCO AND NON-TOBACCO USERS

XVI

12. PERCENTAGE OF STUDY SUBJECTS WITH VARIOUS 50

FORMS OF TOBACCO USE AND COMMUNITY

PERIODONTAL INDEX SCORES IN KARNATAKA STATE

13. MEAN NUMBER OF SEXTANTS WITH HEALTHY PERIODONTAL 51

TISSUE, BLEEDING or HIGHER SCORE, CALCULUS or HIGHER

SCORE, SHALLOW POKETS or HIGHER SCORE, DEEP POCKETS

AMONG VARIOUS FORMS OF TOBACCO USERS


FORMS OF SMOKING HABITS AND COMMUNITY

PERIODONTAL INDEX SCORE IN KARNATAKA STATE


FORMS OF CHEWING HABITS AND COMMUNITY


16. PERCENTAGE OF STUDY SUBJECTS ALONG WITH 54

DURATION OF SMOKING HABITS AND COMMUNITY

PERIODONTAL INDEX SCORES


DURATION OF CHEWING HABITS AND COMMUNITY

PERIODONTAL INDEX SCORES

XVII


ATTACHMENT SCORES AMONG TOBACCO USERS AND

NON- TOBACCO USERS

19. MEAN NUMBER OF SEXTANTS AFFECTED PER PERSON 57

WITH LOSS OF ATTACHMENT (LOA) SCORES AMONG

TOBACCO AND NON-TOBACCO USERS


FORMS OF TOBACCO USE AND LOSS OF ATTACHMENT

SCORES IN KARNATAKA STATE

21. MEAN NUMBER OF SEXTANTS WITH LOSS OF ATTACHMENT 58

BY SCORES AMONG VARIOUS FORMS OF TOBACCO USERS


FORMS OF SMOKING HABITS AND LOSS OF ATTACHMENT

SCORES IN KARNATAKA STATE


FORM OF CHEWING HABITS AND LOSS OF

ATTACHMENT SCORES IN KARNATAKA STATE

XVIII


DURATION OF SMOKING HABITS AND LOSS OF



DURATION OF CHEWING HABITS AND LOSS OF


26. PERCENTAGE OF STUDY SUBJECTS WITH ORAL 63

MUCOSAL CONDITIONS AMONG TOBACCO USERS

AND NON-TOBACCO USERS


FORMS OF TOBACCO USE AND ORAL MUCOSAL

CONDITIONS IN KARNATAKA STATE


FORMS OF SMOKING HABITS AND ORAL MUCOSAL



FORMS OF CHEWING HABITS AND ORAL MUCOSAL


XIX


DURATION OF SMOKING HABITS AND ORAL MUCOSAL



DURATION OF CHEWING HABITS AND ORAL MUCOSAL


XX

CHARTS PAGE NO.


TO RURAL/URBAN REGIONS

2. PERCENTAGE OF STUDY SUBJECTS 69

AMONG DIFFERENT TOBACCO USERS AND

NON-TOBACCO USERS IN RURAL AND URBAN AREAS


TYPES OF TOBACCO USE IN KARNATAKA STATE

4. PERCENTAGE OF STUDY SUBJECTS WITH COMMUNITY 70

PERIODONTAL INDEX SCORES IN TOBACCO USERS

AND NON-TOBACCO USERS

5. PERCENTAGE OF STUDY SUBJECTS WITH 71

VARIOUS FORMS OF TOBACCO USE AND COMMUNITY

PERIODONTAL INDEX SCORES IN KARNATAKA STATE


FORMS OF SMOKING HABITS AND COMMUNITY


XXI


DIFFERENT FORMS OF CHEWING HABITS AND

COMMUNITY PERIODONTAL INDEX SCORE IN

KARNATAKA STATE


ATTACHMENT SCORES AMONG TOBACCO USERS

AND NON- TOBACCO USERS


VARIOUS FORMS OF TOBACCO USE AND LOSS OF

ATTACHMENT SCORES IN KARNATKA STATE


FORMS OF CHEWING HABITS AND LOSS OF

ATTACHMENT SCORES IN KARNATKA STATE

Introduction

1

INTRODUCTION

Tobacco – “weapon of mass destruction”.

Habits are as old as mankind. Human behaviour relates to health directly as well

as indirectly. Human habits and lifestyle behaviour through social norms, culture as well

as environment for which we do not have much control, affect health indirectly. Diet,

physical fitness actions, preventive and self-care behaviour have its effects on health

directly.

The major kinds of behaviour or health related habits that are harmful are tobacco

use, excessive alcohol use, drug use, improper nutritional practices etc. All these involve

a dependency component in behaviour and result in widespread mortality and morbidity

and social pathology in the community.

Tobacco use is a pernicious habit of world today. It is one of the greatest single

health hazard and a self imposed risk. Being the world’s biggest preventable killer, our

universe is in a state of tobacco epidemic, with larger population of tobacco users

emerging day by day.1

Introduction

2

According to World Health Organization, nearly 1/3rd of the global adult

populations (1.3 billion people, with female population being 200 million) are tobacco

users. India accounts for one fifth of the world’s tobacco consuming population.2

India is the world’s second largest tobacco growing country, which produces an

average of 68,000 tonnes every year. Nearly 0.2% of all available land is used for tobacco

growing and 5 million people are estimated to be engaged in full time in tobacco

manufacturing. 4 million people work in growing and curing tobacco.3, 4

Dating back to history, according to the Huron Indian myth, when the land was

barren and the people were starving, the Great Spirit sent forth a woman to save

humanity. As she traveled over the world, wherever her right hand touched the soil, there

grew potatoes and wherever her left hand touched the soil, there grew corn and when the

world was rich and fertile, she sat down and rested. When she arose, there grew tobacco.5

Christopher Columbus was reported to have gifted some strange dry leaves from a

native of San Salvador. It was seen that these leaves were being traded and used for

ceremonial and medicinal purposes. These leaves subsequently came to be known as

tobacco. The Indians inhaled the powdered tobacco leaves through a hollow, Y shaped

piece of cone or pipe by applying the fork ends into each nostril. These pipes were

Introduction

3

artistically carved. The Indians called this instrument as “Tobago”; the Spaniards later

slightly altered the name and applied it to the plant and its curved leaves as tobacco.6

In India tobacco was introduced by Portuguese traders in the kingdom of Adil

Shahi, the capital city of Bijapur, presently in Karnataka in South India. Asad Beg,

ambassador of the Mughal Emperor Akbar, visited Bijapur during 1604-1605 and took

back large quantities of tobacco from Bijapur to the Mughal Kingdom in the north and

presented some to Akbar along with jewel-encrusted European-style pipes. Several

nobles in Akbar’s court were also given tobacco and pipes, and tobacco was appreciated

by everyone, and thus the practice was introduced. After that the merchants began to sell

it, so the custom of smoking spread rapidly.7

In the early use of the plant the leaves were ground up or grated and either snorted

through the nose or placed between the lip and gums and sucked. Men and women

performed the use of tobacco as a way to relax after a meal or as a medicinal agent for

headaches. Tobacco habits are practiced in various different forms and many of them are

specific to certain areas of India. The reasons for the initiation of tobacco use are many.

Generally, the most important reason is a tooth-related complaint, followed by peer-

group influence.8

Introduction

4

The use of tobacco can be detrimental to the user. Its use has been linked to

various forms of cancer and the loss of teeth. Therefore, why has man been using and

profiting from the plant for so long? It is very hard to stop using tobacco after the user

has been using tobacco in whatever form, a long-time smoker or chewer will justify it. It

is without a doubt that nicotine in the plant, which makes it addictive and a hard habit to

break no matter how harmful the use of tobacco may be to the user.

The effects of tobacco use on the population’s general health have been well

illustrated. However, the effects of tobacco on oral health are also important to take into

consideration. Tobacco use and its association with oral diseases is a major contributor to

the global oral disease burden, responsible for up to half of all periodontitis cases among

adults. Some of the most common diseases and problems are Oral cancer, Leukoplakia,

Erythroplakia, Oral mucosal conditions like Smoker’s palate, Smoker’s melanosis,

tobacco associated effects on the teeth and supporting tissues like Periodontal diseases,

Premature tooth loss, Acute Necrotising Ulcerative Gingivitis, Staining, Halitosis etc.9

In a country like India, it is important to take in to account the various indigenous

forms of tobacco use and the associated lesions. The common forms of tobacco habits in

India are bidi, cigarette, chillum, hookah etc. and betel quid, pan-masala, gutka etc in

smoked and chewed form respectively.10

Introduction

5

Evidence suggests that tobacco related lesions are also associated with duration

and amount of tobacco used.11 The age group of 35 to 44 years is the standard monitoring

age group for health conditions of adults. In this age group the full effect of periodontal

and other oral lesions can be seen.12 Also there is a scarcity of information regarding the

dose related and time related relationship between tobacco use and oral mucosal and

periodontal lesions in Karnataka state. Hence this study was conducted on 35-44-year-old

to find the oral mucosal and periodontal status among tobacco and non-tobacco users in

Karnataka state. This data will enable dental professionals, decision-makers, government

and non-governmental organizations and general public to control tobacco use and to

create awareness regarding the harmful effects of different types of tobacco on oral

tissues.

Aim and Objectives

6

AIM AND OBJECTIVES

AIM:

To find out oral mucosal and periodontal status among 35-44-year-old tobacco

and non-tobacco users in Karnataka state.

OBJECTIVES:

1. To find out the prevalence of oral mucosal and periodontal diseases among

tobacco and non-tobacco users.

2. To find out the oral mucosal and periodontal health status with respect to use of

different forms of tobacco.

3. To find out oral mucosal and periodontal health variation with duration of use of

tobacco.

Review of Literature

7

REVIEW OF LITERATURE

• Pindborg JJ et al 13 (1984) in a pilot survey of oral mucosa in betel nut chewers

on Hianan islands of the People’s Republic of china studied 100 people for their

smoking and chewing habits and their condition of their oral mucosa, 95% of the

study population chewed betel nut. In two men a small commissural leukoplakia

was found. Three women had clinical and histologic changes pointed toward oral

submucous fibrosis.

• In a study by Reichart et al 14 (1987) on Precancerous and other oral mucosal

lesions related to chewing, smoking and drinking habits in Thailand, 1866

individuals were examined. Leukoedema, preleukoplakia, leukoplakia and

chewer's mucosa were recorded. Chewing of betel and miang was more prevalent

among older people. Leukoedema was observed in 12.4%, preleukoplakia in

1.8%, leukoplakia in 1.1% and chewers mucosa in 13.1%. A positive correlation

was demonstrated between mucosal lesions and smoking and chewing habits.

• A study by Axell T 15 et al in 1990 conducted a study on Prevalence of oral soft

tissue lesions in out-patients at Malaysian and Thai dental school in Chiang Mai,

Thailand, and Kuala Lumpur, Malaysia respectively. 234 and 233 consecutive

out-patients of mean ages 33.8 and 31.0 year respectively, were examined for the

presence of oral mucosal lesions. Tobacco in some form was regularly used by


8

31.7% and 27.5% of the study populations respectively. In Chiang Mai three

persons chewed betel quids and nine smoked banana leaf cigars daily. In addition,

there were 24 habitual chewers of tea leaves (miang). In Kuala Lampur six

persons chewed betel quids daily. One and three cases of betel related lesions

were found in Chiang Mai and Kuala Lampur respectively. One case of a

squamous cell carcinoma was found in a 45-yr-old Indian woman in Kuala

Lampur who had been chewing betel with tobacco daily for many years. High

prevalence of leukoplakia (1.3%) and lichen planus (3.8%) was seen in the study.

• A study was conducted by Ying-Chin Ko et al 16 and published in the year 1992

on Prevalence of betel quid chewing habit in Taiwan and related

sociodemographic factors. 6% of them were current betel chewers and 4% were

ex-chewers, whereas 42% of the aborigines aged over 15 years were current

chewers and 1% ex-chewers. Betel chewing enjoys island wide popularity among

the 20 million inhabitants of Taiwan; the number of current and ex-users was

estimated at 2.0 million (95% CI 1.6–2.4 million). A high proportion of chewers

were also smoker and drinkers, but tobacco was not found to be chewed together

with betel quid.

• A study was conducted by Sally JL et al 17 (1992) on Smokeless Tobacco Habits

and Oral Mucosal Lesions in Dental Patients. Data was collected on tobacco use


9

habits and oral health from 245 male aged 15 to 77 years. Results showed that

78.6 percent of tobacco users had observable oral lesions, 23.6 percent of which

were clinically advanced lesions. Of the lesions noted, 85 percent were in the

same location the patient identified as his primary area of tobacco placement. In a

comparison sample of 223 non-users with the same age distribution, only 6.3

percent had observable lesions. A multiple logistic regression model for tobacco

users showed presence of lesion and severity were most significantly related to

current frequency of tobacco use.

• A study was conducted by Ikeda N et al 18 (1995) on prevalence of oral mucosal

lesions in a selected Cambodian population. Information on smoking habits, betel

nut chewing habits, and alcohol use was collected by 4 Khymer dental personnel.

In total, 71 lesions were recorded in 64 (4.9%) individuals. Leukoplakia was

found in 1.1% of subjects, Candidiasis in 1.4%, submucous fibrosis in 0.2%,

cancer in 0.1% and other diagnoses in 0.8%. The prevalence of leukoplakia was

2.2% and 0.6% among men and women respectively. The overall prevalence of

oral mucosal lesions in the population was 1.8%.

• A study was conducted by Yang MS et al 19 (1996) to evaluate the prevalence

and related risk factors of betel quid chewing by adolescent students in southern

Taiwan. In the junior high school 1.9 % of students including all grades (13-15

years old) and both sexes were found to be current betel quid chewers and 14%


10

were ex-chewers. Whereas 10.2% of vocational school students (16-18 years old)

were current chewers and 31% were ex-chewers. The prevalence of betel chewing

was significantly higher among boys than girls and a high proportion of chewers

were also smokers and alcohol consumers.

• In a study by Reichart PA et al 20 (1996) on Betel chewer's mucosa in elderly

Cambodian Women, a total of 102 rural Cambodian women with a mean age of

60±8.5 years (range 39 to 80 years) who chewed betel quid were examined for

oral mucosal lesions. The average duration of betel quid chewing was 15.5±12.8

years. The average number of daily betel quids was 5.4±2.9. Thirty-eight (37.3%)

did not show any oral mucosal lesion. Sixty-two (60.8%) showed betel chewer's

mucosa. Homogeneous leukoplakia was found in three women (2.9%). Out of

130 sites affected by chewer's mucosa, the buccal mucosa was the most frequently

involved (n = 68). The presence of a lesion was significantly associated with the

duration of the habit and the number of betel quids consumed per day.

• A study was conducted by Zain RB et al 21 (1997) on oral mucosal lesions of a

representative sample of the entire population of Malaysia. The age in the sample

ranged from 25 to 115 years with a mean of 44.5±14.0. The sample comprised

40.2% males and 59.85% females. 55.8% were Malays, 29.4% Chinese, 10.0%

Indians and 1.2% other ethnic groups. Oral mucosal lesions were detected in

(9.7%) subjects, 0.04% had oral cancer, 1.4% had lesions or conditions that may


11

be precancerous (leukoplakia, erythroplakia, submucous fibrosis and lichen

planus) and 1.6% had betel chewer's mucosa. The prevalence of oral precancer

was highest amongst Indians (4.0%) and other Bumiputras (2.5%) (The

indigenous people of Sabah and Sarawak), while the lowest prevalence was

amongst the Chinese (0.5%).

• Tomar et al 22 (1997) in a study on oral mucosal smokeless tobacco lesions

among adolescents in the United States noticed that 1.5% of the students,

including 2.9% of males and 0.1% of females had smokeless tobacco lesions. The

lesions were more prevalent among whites (2.0%) than among African-Americans

(0.2%). Among white males, current snuff use was the strongest correlate of

lesions, followed by current chewing tobacco use. Lesions were strongly

associated with duration, monthly frequency, and daily minutes of use of snuff

and chewing tobacco. This study showed very little evidence that the use of

alcohol or cigarettes may increase the risk of smokeless tobacco lesions.

• In an investigation by Shah N & Sharma PP 23 (1998) on the role of chewing

and smoking habits in the etiology of oral submucous fibrosis (OSMF). It was

found that chewing of areca nut/quid or pan masala was directly related to OSMF.

Also, pan masala was chewed by a comparatively younger age group and was

associated with OSMF changes earlier than areca nut/quid chewing. However,

chewing or smoking tobacco with various other chewing habits did not increase


12

the risk of developing OSMF. It was also found that frequency of chewing rather

than the total duration of the habit was directly correlated to OSMF.

• Priscilla M. Walsh 24 (2000) stated that tobacco use has many oral effects

including leukoplakia, oral cancer, loss of periodontal support, and staining of

teeth and composite restorations and systemic effects such as nicotine

dependence, transient hypertension and cardiovascular disease may also result

from smokeless tobacco use.

• Newell Johnson 25 (2001), in a review states that for both genders, cancer of the

mouth and pharynx ranks sixth overall in the world. It is also the third most

common site among males in developing countries. In industrialized countries,

men are affected two to three times as often as women, largely due to higher use

of alcohol and tobacco. Ethnicity strongly influences prevalence due to social and

cultural practices, as well as socioeconomic differences. In population terms,

survival rates around the world show little improvement. In terms of etiology, the

effects of tobacco use, heavy alcohol consumption, and poor diet together explain

over 90 percent of cases of head and neck cancer.

• Itsuo Chiba 26 in a review in 2001 states that Betel quid chewing is the major risk

factor for buccal mucosal and gingival cancer. He further states that Oral


13

premalignancies are also very common in betel quid chewers and about 10% of

these undergo malignant transformation.

• Georgia K. Johnson 27 (2001) in a review on Impact of Tobacco Use on

Periodontal Status, says that approximately half of periodontitis cases have been

attributed to either current or former smoking. Both cigar and cigarette smokers

have significantly greater loss of bone height than nonsmokers, and there is a

trend for pipe smokers to have more bone loss than nonsmokers. Unlike smokers,

who experience widespread periodontal destruction, the most prevalent effects of

smokeless tobacco are localized to the site of placement, in the form of gingival

recession and white mucosal lesions.

• A study was conducted by Ling et al 28 (2001) to know the association between

betel quid chewing, periodontal status and periodontal pathogens. The periodontal

status of 34 betel quid chewers and 32 non-betel quid chewers were compared. A

significantly higher prevalence of bleeding on probing was found in betel quid

chewers than non-chewers. Betel quid chewers had higher plaque level, greater

gingival inflammation, deeper probing depth or greater attachment loss.

• Yasin Cicek 29 (2003) in a review states that smoker’s melanosis tends to increase

significantly with tobacco consumption and tobacco smokers have significantly

more oral surfaces pigmented than non-tobacco users.


14

• Gupta PC & Ray CS 30 (2003) in a paper on smokeless tobacco and health in

India and south Asia, stated that South Asia is a major producer and net exporter

of tobacco. Over one-third of tobacco consumed regionally is smokeless.

Traditional forms like betel quid, tobacco with lime and tobacco tooth powder are

commonly used and the use of new products is increasing, not only among men

but also among children, teenagers, women of reproductive age, medical and

dental students and in the South Asian diaspora. Smokeless tobacco users studied

prospectively in India had age-adjusted relative risks for premature mortality of

1.2-1.96 (men) and 1.3 (women). Current male chewers of betel quid with tobacco

in case-control studies in India had relative risks of oral cancer varying between

1.8-5.8 and relative risks for oesophageal cancer of 2.1-3.2. Oral submucous

fibrosis is increasing due to the use of processed areca nut products, many

containing tobacco.

• Brian L. Schmidt 31 (2004) conducted a study to examine the relationship

between smoking versus never-smoking history and the stage and site of

presentation of oral squamous cell carcinoma. The findings of this study

demonstrate that approximately one third of patients with oral squamous cell

carcinoma will report that they have never smoked. There was a strong

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Gupta+PC%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Ray+CS%22%5BAuthor%5D


15

association between a history of smoking and carcinoma involving the postero-

lateral tongue and floor of mouth.

• A study was conducted by Lars Salonen et al 32 (2004) to find out the

relationship between tobacco habits and mucosal lesions and to analyze the time

needed for treatment of the lesions was estimated. A positive correlation could be

demonstrated between tobacco use and leukoplakia, frictional white lesion, coated

tongue, hairy tongue and excessive melanin pigmentation, while a negative

correlation was observed for geographic tongue and apthous ulcers.

• Minati Mishra 33 in 2005 conducted a study to explore the etiological factors for

leukoplakia and their detection through exfoliative cytology. The results showed

that tobacco use in some form or other was associated with the development of

leukoplakia.

• A study conducted by Ching-HC et al 34 (2005) on Oral precancerous disorders

associated with areca quid chewing, smoking, and alcohol drinking in southern

Taiwan. 136 precancerous lesions and conditions were detected among 1075

subjects (12.7%). The analysis of the spectrum of oral precancerous disorders

detected, leukoplakia (n = 80), OSMF (n = 17) and verrucous lesions (n =9)

demonstrated an association with gender (P < 0.001). There were statistically

significant associations among leukoplakia (P < 0.01), OSF (P < 0.001), and


16

verrucous lesions (P < 0.001) and the life style of current areca quid chewing,

smoking, and alcohol drinking.

• M.A. Fisher 35 (2005) conducted a US population based study to evaluate the

association between smokeless tobacco use and severe active periodontal disease.

It was found out that all adults and never-smokers who currently used smokeless

tobacco were twice as likely to have severe active periodontal disease at any site.

• Ariyawardana et al 36 (2006) conducted a case-control study on effect of betel

chewing, tobacco smoking and alcohol consumption on oral submucous fibrosis

in Sri Lanka. It was found that betel chewing was the only significantly

associated factor in the aetiology of OSMF. There were no interaction effects of

chewing, smoking and alcohol consumption in the causation of OSMF.

• A study was conducted by Kumar et al 37 (2006) on tobacco habits in northern

India. In the survey, chewing was prevalent in 74.5%, smoking in 59.3%, and

snuffing in 0.9%. In the study population, women significantly preferred

smokeless tobacco. Gutka consumption was significantly higher in youngsters

(<25 yrs) and most subjects used tobacco in frequency of 7-24/day. Majority users

started consuming tobacco before 21 years and about 22% of them before 15

years.


17

• Milisha Chotai 38 in a literature study on the effects of chewing tobacco on

periodontal health in the younger population of India, states that Chewing tobacco

affects oral health in several ways; it can result in bad breath, yellowish stains on

teeth and mouth sores. The consequences are bleeding and receding gums and

bleeding lips. He further states that chewing tobacco affects human

immunological factors, which in turn increases the susceptibility to aggressive

periodontitis.

Methodology

18

METHODOLOGY

A study was conducted among tobacco and non-tobacco users in Karnataka

state to find out their oral mucosal and periodontal status and also the effects of

different forms of tobacco and the duration of consumption.

Background of study area:

Karnataka acquired the status of a state in the Indian union, with Bangalore as

its capital in 1956. With a total area of 191791sq km, Karnataka has 6 percent of the

country’s total land mass. The state is divided into four administrative divisions and

29 districts. The total population living in urban areas in the state was 34 percent in

2001. Karnataka is predominantly an agricultural state with majority of its population

living in the rural areas. However the tag of an agricultural state is lost over time,

with the manufacturing and other sectors increasing their share of domestic product.

The industrial sector playing an important role in Karnataka, Bangalore is also called

Silicon Valley of India. According to 2001 censuses Karnataka has a population of

over 50 million. Kannada being the official language of the state, many local dialects

of Kannada are prevalent with respect to distinct social, economic and cultural

characteristics of the state.39

Sample size: Sample size was determined based on prevalence rate of periodontal

disease (95%), as the prevalence of oral mucosal lesions in Karnataka was estimated

to be low (0.5%).39 The permitable error was fixed at 1% for convenience in

selection of sample. The sample size was selected based on the formula40

N= 4pq/L2

Methodology

19

p- Prevalence rate

q- Probability level

L- Permissible error in the estimate of p

N= 4x95x5/(0.950)2

=2100

The sample size was estimated to be 2100.

Sample selection:

Karnataka state was divided into four regions namely Northern dry, Central,

Southern and Hills and Coastal region.39 A multi-stage sampling design was

followed. In the first stage random selection of district was done from each of the

four regions. The second stage was the random selection of 5 urban regions (Talukas)

and 7 rural areas (villages) with probability proportional to size (pps). The

information was obtained from the office of Karnataka Census Board, Bangalore.

Sampling strategy thus ensured randomness and representativeness by concentrating

the subjects into 48 areas.

Sample size was 525 examinees from each region. It was expected that 525

households in each district in the state, would give the sample of 525 examinees and

lead to a total of 2100 in Karnataka state.

When the desired samples were not obtained more households were covered to

get the number of examinees.

Representation was given both to rural and urban areas as two-third and one-

Methodology

20

third of the sample size respectively as 66-70% of population in the Karnataka state

reside in rural areas. Hence, 350 households in rural areas and 175 households in

urban areas were selected per district.

In rural areas as decided, seven villages were selected based on probability

proportional to size (pps). Therefore a total of 350 households (7 rural areas x 50

households per village) were selected in each district.

Accordingly, five urban areas were selected per district and a total of 175 households

( 5 urban areas x 35 households/urban area) were selected per district for the study.

The districts selected in the study were; Bagalkot from northern dry region,

Chitradurga from central region, Hassan from southern region, Coorg from hills and

coastal region.

Data collection:

Urban areas: In the urban areas the details of number of wards was obtained

and randomly one ward was selected. One street was randomly selected from the

ward. A coin was tossed to choose the side of the street to be surveyed. It was decided

earlier that head side of the coin will represent right side and tails the left side of the

street. The first house in the street was surveyed and followed to the next household

on the same side of the street. On reaching the cross road, the survey was conducted

in the cross road on the same side of the street as decided earlier. The procedure was

continued till the required sample size was obtained.

Methodology

21

Rural areas: In the rural areas data collection was done by visiting houses

till the sample size was met.

The study was conducted for duration of three and half months, with average

of 26 patients per day.

The sample size in the four districts was as follows:

Bagalkot- 535 respondents (183 in urban and 352 in rural areas)

Chitradurga- 538 respondents (185 in urban and 353 in rural areas)

Hassan – 538 (185 in urban and 353 in rural areas)

Coorg- 545 (183 in urban and 362 in rural areas)

District Urban Rural District Urban Rural

Bagalkot Jamkhandi Bilgi Mudhol Badami Villages Sitamani Manahalli Husoora Nagasampangi Rampura Nayanegali Nagarala

40 38 39 35 36

50 51 51 50 50 50 50

Chitradurga Holalkere Hosdurga Chalkere Hiriyur Villages Madakari halli Mallapura Halekallahalli GuddadanayakanahalliMadanaykanahalli Chikkagondanahalli Havalenahalli

41 36 37 36 35

52 50 51 50 51 51 50

Methodology

22

District Urban Rural District Urban Rural

Mercara Virajpet Siddapura Kushalnagar Gonikoppa Villages Kunjalageri Maithadi Arji Bittangala Halugunda Kottoli Arameri

40 35 37 36 35

52 51 51 51 51 53 53

Hassan Sakleshpura Belur Chanrayapatna Arasikere Villages Harle Gandhole Hebsale Ajjigudde Kyamanahalli Madanapura Heggade

39 36 38 36 37

50 52 50 51 50 50 50

Overall, in the study 1420 people in rural areas and 736 in urban areas of 4

districts of age group 35 to 44 years were covered amounting for 2156 people.

Study tools:

The study consisted of a questionnaire for recording the information on

tobacco use and a part of WHO oral health assessment form 1997 to collect the data

regarding oral mucosal and periodontal conditions.12 A trained recorder was a part of

the survey for recording. The questionnaire was pre-tested on 30 patients and

standardized. Intra examiner calibration was also done and the kappa value was 0.926.

Tobacco users were classified as follows:

Tobacco user- An individual who is currently using tobacco once a day or

more often in the form of smoke or smokeless tobacco.

Methodology

23

Non- tobacco user- An individual who had never used tobacco in the form of

smoke or smokeless tobacco.

Occasional user- An individual who is using tobacco occasionally in form of

smoke or smokeless tobacco.

Ex-user – An individual who had been using tobacco more often in form of

smoke or smokeless tobacco and has quit the habit for past one year.

Armamentarium used:

The instruments used in the study were:

• Mouth mirrors

• Tweezers

• CPITN-C probes

• Kidney trays

• Gloves

• Mouth masks

• Cotton rolls

• Tumblers

• Cotton and gauze

• Gluteraldehyde solution

• Autoclave (Pressure cooker)

Methodology

24

Sterilization:

Autoclaved instruments were carried to the examination site. During the

survey, the used instruments were washed with water, stored in Glutaraldehyde

solution then autoclaved using pressure cooker.

Examination procedure:

The examinations were carried out under natural light in open areas of the

houses with the patient seated. The examiner stood in front of the subject during the

examination procedure. The recorder stood close to the examiner for recording the

codes for oral mucosal and periodontal conditions which were read out loudly by the

examiner. The examiner was also able to see the data being entered. Patients were

asked to rinse their mouth with water before examination. Approximately 7-8 minutes

per subject was taken to examine and record the data.

Data analysis: The obtained data was coded and entered in to the Microsoft

Excel sheets. The data was then fed into the SPSS (Statistical Package for Social

Studies) software-15 for analysis. In the software the data was renamed into different

variables, based on the questionnaire used in the study and analyzed. Karl Pearson

Chi-square test was used in analysis of the data. Chi-square test was used in analysis

as the data were in frequencies of more than one categories and also it was able to

find the significance (P value) if any in the same data. Students t-test and ANOVA

test was used to compare the means and find the significance if any.

Methodology

25

FIGURE 1: ARMAMENTARIUM USED

FIGURE 2: STERILIZATION OF INSTRUMENTS

Methodology

26

FIGURE 3: CASE RECORDING AND EXAMINATION


Methodology

27


FIGURE 6: LEUKOPLAKIA

Methodology

28

FIGURE 7: LEUKOPLAKIA

FIGURE 8: CHEWERS MUCOSA

Methodology

29

FIGURE 9: ORAL SUBMUCOUS FIBROSIS

FIGURE 10: ACTINIC KERATITIS

Methodology

30

FIGURE 11: CANDIDIASIS

FIGURE 12: CAVERNOUS HEMANGIOMA

Methodology

31

FIGURE 13: MALIGNANT TUMOUR

Results

32

RESULTS

The present study was conducted among tobacco users and non-tobacco users

in Karnataka state to assess the oral mucosal and periodontal status among 35-44-

year-old. Data collected was analyzed and showed the following observation.

From the total of 2156 subjects examined, 1420 subjects were from rural and

736 subjects were from urban areas (TABLE-1, CHART-1). The study subjects

comprised of 1118 males and 1038 females (TABLE-2).

Among the study subjects 65.5% were current tobacco users, while 32.4% of

subjects were non-tobacco users. Ex-users and occasional users accounted for 1.4%

and 0.7% of the study population respectively (TABLE-3, CHART-2).

A total of 26.5% of tobacco users were smokers, 44.6% of them were chewers

and 28.9% of them used both forms of tobacco i.e. Smoked and Chewed forms.

(TABLE-4, CHART-3).

Beedi smoking (60.5%) was the most popular form of smoking followed by

cigarettes (39.5%).

Paan with tobacco consumption (53.3%) was the most popular form of

chewing habit among tobacco chewers followed by gutkha use (25.15%) and plain

tobacco with lime consumption (13.25%).

Results

33

In the study both oral mucosal and periodontal status were assessed among

tobacco users and non-tobacco users.

The overall prevalence of oral mucosal conditions in Karnataka state was

found to be 5.6%, with leukoplakia being the most prevalent condition (3.1%).

Chewers mucosa was found in 1.3% of subjects and oral submucous fibrosis in 0.8%

of study subjects.

In the current study only a single case of malignant tumour was found

(TABLE-5).

Periodontal status was assessed using community periodontal index. Bleeding

was observed in 13% of subjects and 41.4% of subjects had calculus, while pocket of

4 to 5 mm were detected in 35.4% of subjects. Deep pockets were observed in only

19% of study subjects (TABLE-6).

Further, loss of attachment of 4 to 5 mm was observed in 28.8% of subjects,

while 18.8% of subjects had loss of attachment of 6 to 8 mm (TABLE-7). The

difference in community periodontal index scores and loss of attachment scores

among the study subjects in the state was found to be statistically significant

(p<0.001).

When the comparison was done with community periodontal index scores and

the mean number of sextants involved in the study subjects, it was found that

0.75±1.07 sextants were having healthy periodontal tissue, while bleeding or higher

Results

34

score was seen in 4.85±1.29 sextants. Calculus or higher score was present in

3.90±1.65 sextants, while shallow pockets or higher score was observed in 2.05±1.39

sextants (TABLE-8).

Loss of attachment of 0 to 3 mm was observed in 3.7±1.64 sextants, while

attachment loss of 4 to 5 mm was observed in 1.11±1.23 sextants in the study

population (TABLE-9).

In current tobacco users and non-tobacco users bleeding was observed in 6.2%

and 6.6% subjects respectively. Calculus was found to be higher among current

tobacco users (25.1%) than in non-users (14.7%). Periodontal pockets of 4 to 5 mm

were also significantly higher among current tobacco users (28.6%). There was a

statistically significant difference (p<0.001) among various forms of tobacco users

and non-tobacco users along with community periodontal index scores (TABLE-10,

CHART-4).

The mean number of sextants with calculus or higher score was 3.28±1.05

among current tobacco users and 4.55±1.27 among non-tobacco users. The difference

was statistically significant (p<0.05). Deep pockets were observed in 0.87±1.03 and

0.30±0.93 sextants among current and non-tobacco users was statistically highly

significant (p<0.01) (TABLE-11).

In subjects who used tobacco, chewers had higher prevalence of calculus

(21.15%) compared to tobacco smokers (9.9%). Shallow pockets were more among

Results

35

chewers (17.2%) compared to other forms of tobacco users. Deep pockets were

considerably higher among users of both forms of tobacco (4.65%) followed by

chewers (2.75%) and tobacco smokers (1.8%). The difference in community

periodontal index scores and various forms of tobacco users was statistically

significant (p<0.001) (TABLE-12, CHART-5).

Among tobacco users 0.72±1.05 sextants were healthy among tobacco

smokers, 0.58±1.29 sextants among chewers and 0.42±1.20 sextants were healthy

among users of both forms of tobacco. While bleeding was observed in 5.23±1.19

sextants among smokers, 5.50±1.6 sextants among chewers and 5.64±1.3 sextants

among users of both forms of tobacco (TABLE-13).

When community periodontal index scores were compared with various forms

of tobacco smokers, it was found that beedi smokers had more bleeding on

probing(5.8%), more calculus(19.8%) and pockets of 4 to 5 mm (25.6%) compared to

cigarette smokers. There was a statistically significant difference (P<0.01) among

beedi and cigarette smokers. (TABLE-14, CHART-6).

Among the subjects who used pan with tobacco had more of bleeding on

probing (3.8%), more calculus (26.1%), more shallow pockets(16.85%) and also more

deep pockets(6.6%) when compared to gutkha chewers and plain tobacco chewers

with lime. The difference was statistically highly significant (p<0.001) among various

Results

36

forms of tobacco chewers and community periodontal index scores (TABLE-15,

CHART-7).

The prevalence of community periodontal index scores along with duration of

use of smoked forms of tobacco was highest among subjects who smoked for a

duration of 2 to 5 years. 5.8% of subjects having the habit of smoking had bleeding on

probing, 12.5% had calculus, 22.6% had shallow pockets and 3.9% of subjects had

deep pockets (TABLE-16). There was a statistically significant difference (p<0.001)

in community periodontal index scores along with duration of smoking habits.

Similarly the difference in community periodontal index scores and duration

of chewing habit was statistically significant (p<0.001). The highest prevalence was

seen in subjects who used tobacco for 4 to 5 years duration, with bleeding present in

3.25% of subjects, calculus in 13.5% subjects and pockets of 4 to 5 mm in 13.65%

subjects (TABLE-17).

When attachment loss was assessed in the study, current tobacco users had

considerably more loss of attachment than non-tobacco users. Loss of attachment of 0

to 3 mm was found in 31.05% of current tobacco users and 19.15% of non-tobacco

users. Loss of attachment of 4 to 5 mm was found in 20.95% of current and 6.35% of

non-tobacco users (TABLE-18, CHART-8). The difference among tobacco users and

non-tobacco users along with loss of attachment scores was found to be statistically

significant (p<0.001).

Results

37

The difference in mean number of sextants affected along with loss of

attachment of 4 to 5 mm among tobacco users and non-tobacco users was statistically

significant (p<0.05). The mean number of sextants affected with loss of attachment of

4 to 5 mm among current tobacco users was 1.29±1.59 and 0.87±0.85 sextants among

non-tobacco users (TABLE-19).

Among various forms of tobacco users, chewers had high prevalence of

attachment loss of 0 to 3 mm (23.2%) and attachment loss of 4 to 5 mm (15%)

compared to smokers and users of both forms of tobacco (TABLE-20, CHART-9).

The difference was statistically highly significant (p<0.001) among various forms of

tobacco users and loss of attachment scores.

In various forms of tobacco users the mean number of sextants affected with

loss of attachment scores of 0 to 3 mm was 2.95±1.61 among smokers, 1.96 ±1.40

among chewers and 2.22± 1.05 sextants among users of both forms of tobacco. Mean

number of sextants affected with loss of attachment of 4 to 5 mm were 2.05±1.27

among smokers, 1.90±1.25 sextants among chewers and 2.08±0.76 sextants among

users of both forms of tobacco (TABLE-21). The difference however was not

statistically significant (p>0.05).

Beedi smokers had more attachment loss than the subjects who smoked

cigarettes. 29.5% of beedi smokers had attachment loss of 0 to 3 mm compared to

14.8% of subjects who smoked cigarettes (TABLE-22). The difference in loss of

Results

38

attachment scores and various forms of smoking habits was statistically significant

(p<0.002).

Among tobacco chewers loss of attachment of 0 to 3 mm was found more

among chewers of pan with tobacco (23.4%) followed by gutkha users (10.35%).

Attachment loss of 4 to 5 mm was found in 14.85% of pan with tobacco users and

12.6% of gutkha users (TABLE-23, CHART-10). The difference in loss of attachment

scores among various forms of chewing habits was found to be highly significant

(p<0.001).

The prevalence of loss of attachment scores increased along with increase in

duration of use of smoked tobacco. The highest prevalence of attachment loss of 0 to

3 mm was found in subjects who had the habit for 2 to 5 years (19.8%) followed by

subjects who had the habit for 5 to 10 years (TABLE- 24). The difference in

attachment loss along with duration of use of smoked form of tobacco was

statistically highly significant (p<0.001).

Similar findings were observed among chewers along with duration of use of

chewed forms of tobacco. The highest prevalence of loss of attachment of 0 to 3 mm

was observed among chewers having the habit for 2 to 5 years duration (16.5%)

(TABLE-25). The difference in loss of attachment scores along with duration of use

of chewed form of tobacco was highly statistically significant (p<0.00).

Results

39

Highest prevalence of oral mucosal conditions was found in current tobacco

users in the present study (4.7%) than in non-tobacco users (0.9%). Leukoplakia was

found in 2.55% of subjects who were current users of tobacco while it was present in

only 0.55% of non-tobacco users (TABLE-26). There was statistically significant

difference in presentation of oral mucosal condition among different groups of

tobacco users and non-tobacco users in the study (p<0.05).

High prevalence of leukoplakia was found among users of both forms of

tobacco (1.95%) followed by chewers (1.8%) and smokers (0.5%). Chewers mucosa

was present in 1.05% of users of both forms of tobacco followed by chewers (0.6%)

and smokers (0.1%) (TABLE-27). The difference in various forms of tobacco users

and oral mucosal conditions was statistically significant (P<0.01).

Beedi smokers (4.85%) compared to cigarette smokers (3.45%) had slightly

more percentage of mucosal conditions found in the study. 2.65% of beedi smokers

and 1.8% of cigarette smokers had leukoplakia, 1.35% of beedi smokers and 0.7% of

cigarette smokers had chewers mucosa. The difference in various forms of tobacco

smoking and oral mucosal conditions was found to be statistically significant

(P<0.001) (TABLE-28).

Similarly among tobacco chewers pan with tobacco users had significantly

more mucosal conditions like leukoplakia (2.3%), chewer’s mucosa (1.1%) and oral

submucous fibrosis (0.45%) compared to other forms of tobacco chewing habits in the

Results

40

study. One case of cavernous hemangioma was also found in the study (0.05%). The

difference in occurrence of oral mucosal conditions among various forms of tobacco

chewing habits was found to be statistically significant (P<0.01) (TABLE-29).

The prevalence of oral mucosal conditions increased along with increase in

duration of use of smoked tobacco. Smoking habits for 5 to 10 years had the highest

prevalence of oral mucosal conditions with 1.5% of subjects having leukoplakia, 0.6%

chewer’s mucosa and 0.7% of them having oral submucous fibrosis. The difference in

duration of smoking habits and occurrence of oral mucosal conditions was found to be

statistically significant (P<0.05) (TABLE-30).

The percentage of subjects affected by oral mucosal conditions increased

along with duration of use of chewed form of tobacco. Subjects in the study having

the habit for 2 to 5 years were found to have more mucosal conditions. Leukoplakia

was found in 2.4% of subjects and chewers mucosa in 1% of subjects. (TABLE-31).

However there was no statistically significant difference (p > 0.05) in oral mucosal

conditions along with duration of use of chewed form of tobacco in the study.

Results

41

TABLE 1: DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO RURAL/URBAN REGIONS

RURAL URBAN TOTAL DISTRICT - 1 352 183 535 DISTRICT – 2 353 185 538 DISTRICT – 3 353 185 538 DISTRICT – 4 362 183 545

TOTAL 1420 736 2156

TABLE 2: DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO SEX

MALE FEMALE TOTAL DISTRICT - 1 281 254 535 DISTRICT – 2 277 261 538 DISTRICT – 3 278 260 538 DISTRICT – 4 282 263 545

TOTAL 1118 1038 2156

Results

42

TABLE 3: PERCENTAGE OF STUDY SUBJECTS AMONG DIFFERENT TOBACCO USERS AND NON-TOBACCO USERS IN RURAL AND URBAN

AREAS

TOBACCO USERS AND NON-USERS RURAL URBAN TOTAL

CURRENT TOBACCO USERS 72 59 65.5

NON TOBACCO USERS 26.5 38.3 32.4

EX-USERS 1.3 1.5 1.4 OCCASIONAL

USERS 0.2 1.2 0.7

TABLE 4: PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT TYPES OF TOBACCO USE IN KARNATAKA STATE

TYPE OF TOBACCO

RURAL URBAN TOTAL

SMOKE 18.95 7.57 26.5

CHEW 30.75 13.82 44.6

BOTH 20.6 8.27 28.9

TOTAL 70.27 29.7 100

Results

43

TABLE 5: PERCENTAGE OF STUDY SUBJECTS WITH ORAL MUCOSAL CONDITIONS ACCORDING TO THEIR LOCATION

LOCATION

V

ER

MIL

ION

B

OR

DE

RS

CO

MM

ISU

RE

LIP

S

SUL

CI

BU

CC

AL

M

UC

OSA

TO

NG

UE

TO

TA

L

LEUKOPLAKIA 00 0.2 0.05 0.65 2.15 0.05 3.1

LICHEN PLANUS 00 00 00 00 0.05 00 0.05

CANDIDIASIS 00 00 00 00 00 0.05 0.05

OSMF 00 00 00 00 0.8 00 0.8

ABSCESS 00 00 00 0.05 00 00 0.05

MALIGNANT

TUMOURS 00 00 00 0.05 00 00 0.05

CHEWERS MUCOSA 00 00 00 00 1.3 00 1.3

ULCERATIONS 00 0.05 00 0.05 00 00 0.1

CAVERNOUS

HEMANGIOMA 00 00 00 00 0.05 00 0.05

CO

ND

ITIO

N

ACTINIC KERATITIS 00 00 0.05 00 00 00 0.05

Results

44

TABLE 6: PERCENTAGE OF STUDY SUBJECTS WITH COMMUNITY PERIODONTAL INDEX SCORES IN THE AGE GROUP OF 35 – 44 YEARS IN

KARNATAKA STATE

DISTRICTS CPI

SCORES DISTRICT 1

DISTRICT 2

DISTRICT 3

DISTRICT 4

TOTAL

HEALTHY 00 00 0.1 00 0.1

BLEEDING 3.7 2.2 3.6 3.5 13

CALCULUS 10.7 8.3 11.6 10.9 41.4

POCKET 4 – 5 mm

8.5 9.6 8.5 8.7 35.3

POCKET 6mm or MORE

1.8 4.8 1.2 2.2 10

NOT RECORDED

0.1 00 00 0.05 0.1

Results

45

TABLE 7: PERCENTAGE OF STUDY SUBJECTS WITH LOSS OF ATTACHMENT SCORES IN THE AGE GROUP OF 35 – 44 YEARS IN

KARNATAKA STATE

DISTRICTS LOSS OF

ATTACHMENT DISTRICT 1

DISTRICT 2

DISTRICT 3

DISTRICT 4

TOTAL

LOA 0 to 3 mm 13.8 7.7 16.2 12.8 50.5

LOA 4 to 5 mm 6.5 8.7 5.9 7.7 28.8

LOA 6 to 8 mm 4 7.2 2.6 4.4 18.8

LOA 9 to 11 mm 0.4 0.7 0.2 0.4 1.7

LOA 12 mm or MORE 00 0.1 00 00 0.1

NOT RECORDED 0.1 00 00 00 0.1

Results

46

TABLE 8: MEAN NUMBER OF HEALTHY SEXTANTS AND SEXTANTS WITH BLEEDING or HIGHER SCORE, CALCULUS or HIGHER SCORE, SHALLOW

POCKETS or HIGHER SCORE, DEEP POCKETS IN KARNATAKA STATE

CPI SCORES MEAN NO. of SEXTANTS

STANDARD DEVIATION

HEALTHY PERIODONTAL

TISSUES 0.75 ± 1.07

BLEEDING or HIGHER SCORES

4.85 ± 1.29

CALCULUS or HIGHER SCORE

3.90 ± 1.65

SHALLOW POCKETS or HIGHER SCORE

2.05 ± 1.39

DEEP POCKETS 0.4 ± 0.51

Results

47

TABLE 9: MEAN NUMBER OF SEXTANTS WITH LOSS OF ATTACHMENT SCORES IN SUBJECTS OF AGE GROUP 35 – 44 YEARS IN KARNATAKA

STATE

LOSS OF ATTACHMENT MEAN NO. OF

SEXANTS STANDARD DEVIATION

0 to 3 mm 3.7 ± 1.64

4 to 5 mm 1.11 ± 1.23

6 to 8 mm 0.65 ± 1.07

9 to 11 mm 0.35 ± 0.63

MORE THAN 12 mm 0.18 ± 0.16

Results

48

TABLE 10: PERCENTAGE OF DIFFERENT STUDY SUBJECTS WITH COMMUNITY PERIODONTAL INDEX SCORES IN TOBACCO USERS AND

NON-TOBACCO USERS

CPI SCORES

TOBACCO USERS AND NON-USERS

HE

AL

TH

Y

BL

EE

DIN

G

CA

LC

UL

US

POC

KE

T 4

–

5 m

m

POC

KE

T

6mm

or

MO

RE

NO

T

RE

CO

RD

ED

CURRENT TOBACCO

USERS 0.1 6.2 25.1 28.6 6.8 0.2

NON TOBACCO USERS 0.1 6.6 14.7 6.5 3.2 0.0

EX-USERS

0.0 0.0 1.2 0.1 0.0 0.0

OCCASIONAL USERS 0.0 0.3 0.2 0.1 0.0 0.0

TOTAL 0.2 13.1 41.2 35.3 10 0.2

Results

49

TABLE 11: MEAN NUMBER OF HEALTHY SEXTANTS AND SEXTANTS WITH BLEEDING or HIGHER SCORE, CALCULUS or HIGHER SCORE,

SHALLOW POCKETS or HIGHER SCORE, DEEP POCKETS AMONG TOBACCO AND NON-TOBACCO USERS

CPI SCORES CURRENT TOBACCO USERS NON-TOBACCO USERS

HEALTHY 0.82 ± 1.39 0.79 ± 0.91

BLEEDING or HIGHER SCORE 4.17 ± 1.23 4.20 ± 1.07

CALCULUS or HIGHER SCORE 3.28 ± 1.05 4.55 ± 1.27

SHALLOW POCKETS or HIGHER SCORE 1.98 ± 1.29 1.60 ± 1.05

DEEP POCKETS 0.87 ± 1.03 0.30 ± 0.93

Results

50

TABLE 12: PERCENTAGE OF STUDY SUBJECTS WITH VARIOUS FORMS OF TOBACCO USE AND COMMUNITY PERIODONTAL INDEX SCORES IN

KARNATAKA STATE

CPI SCORES TYPE OF

TOBACCO HEALTHY BLEEDING CALCULUS POCKETS 4

to 5 mm POCKETS 6

mm or MORE NOT

RECORDED

SMOKE 0.1 4.25 9.9 10.05 1.8 00

CHEW 00 4.35 21.15 17.2 2.75 0.1

BOTH 00 1.3 10.75 11.0 4.6 0.1

TOTAL 0.1 10.55 41.75 38.25 9.15 0.2

Results

51

TABLE 13: MEAN NUMBER OF SEXTANTS WITH HEALTHY PERIODONTAL TISSUE, BLEEDING or HIGHER SCORE, CALCULUS or

HIGHER SCORE, SHALLOW POKETS or HIGHER SCORE, DEEP POCKETS AMONG VARIOUS FORMS OF TOBACCO USERS

CPI SCORES

SMOKERS MEAN ±

STANDARD DEVIATION

CHEWERS MEAN ±

STANDARD DEVIATION

BOTH MEAN ±

STANDARD DEVIATION

HEALTHY 0.72 ± 1.05 0.58 ± 1.29 0.42 ± 1.20

BLEEDING or HIGHER SCORE

5.23 ± 1.19 5.50 ± 1.6 5.64 ± 1.3

CALCULUS or HIGHER SCORE

3.82 ± 0.85 3.90 ± 1.10 4.82 ± 0.90

SHALLOW POCKETS or

HIGHER SCORE

1.72 ± 1.70 1.60 ± 0.9 2.62 ± 0.98

DEEP POCKETS 0.81 ± 0.50 0.70 ± 0.80 1.51 ± 1.05

Results

52

TABLE 14: PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT FORMS OF SMOKING HABITS AND COMMUNITY PERIODONTAL INDEX SCORE

IN KARNATAKA STATE

COMMUNITY PERIODONTAL INDEX SMOKE

FORM OF TOBACCO HEALTHY BLEEDING CALCULUS

POCKET 4 – 5mm

POCKET 6mm or MORE

NOT RECORDED

TOTAL

CIGARETTE 0.1 4.3 15.6 15.9 3.6 00 39.5

BEEDI 00 5.8 19.8 25.6 9.1 0.2 60.5

TOTAL 0.1 10.1 35.4 41.5 12.7 0.2 100

Results

53

TABLE 15: PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT FORMS OF CHEWING HABITS AND COMMUNITY PERIODONTAL INDEX SCORE

IN KARNATAKA STATE

COMMUNITY PERIODONTAL INDEX CHEWED

FORMS OF TOBACCO BLEEDING CALCULUS

POCKET 4 – 5mm

POCKET 6mm or MORE

NOT RECORDED

TOTAL

PAN WITH TOBACCO 3.8 26.1 16.85 6.6 00 53.3

PAN MASALA

WITH TOBACCO

0.85 3.7 3.1 0.65 00 8.3

GUTKHA 2.45 8.5 13 1.05 0.15 25.15

PLAIN TOBACCO

WITH LIME

1.1 5.85 4.1 2.1 0.05 13.25

TOTAL 8.15 44.05 37.05 10.5 0.2 100

Results

54

TABLE 16: PERCENTAGE OF STUDY SUBJECTS ALONG WITH DURATION OF SMOKING HABITS AND COMMUNITY PERIODONTAL INDEX SCORES

COMMUNITY PERIODONTAL INDEX DURATION

OF SMOKING HEALTHY BLEEDING CALCULUS

POCKET 4 – 5mm

POCKET 6mm or MORE

NOT RECORDED

TOTAL

LESS THAN 1 YEAR

00 0.9 1.9 0.2 0.4 00 3.4

1 to 2 YEARS 00 1.4 2.4 0.8 0.1 00 4.7

2to 5 YEARS 0.1 5.8 12.5 22.6 3.9 00 44.9

5 to10 YEARS 00 1.3 15.0 13.1 5.5 00 34.9

MORE THAN 10 YEARS

00 0.6 4.1 4.5 2.7 0.2 12.1

TOTAL 0.1 10.0 35.8 41.2 12.6 0.2 100

Results

55

TABLE 17: PERCENTAGE OF STUDY SUBJECTS ALONG WITH DURATION OF CHEWING HABITS AND COMMUNITY PERIODONTAL INDEX SCORES

COMMUNITY PERIODONTAL INDEX DURATION

OF CHEWING

HABITS

BL

EE

DIN

G

CA

LC

UL

US

POC

KE

T

4 –

5mm

POC

KE

T

6mm

or

MO

RE

NO

T

RE

CO

RD

ED

TO

TA

L

LESS THAN 1 YEAR 0.35 1.65 2.95 00 00 5.05

1 to 2 YEARS 1.4 10.25 6.75 0.6 00 19.0

2to 5 YEARS 3.25 13.5 13.65 4.6 00 34.95

5 to10 YEARS 1.65 12.1 10.05 4.5 00 28.25

MORE THAN 10 YEARS

1.05 5.1 5.6 0.8 0.2 12.75

TOTAL 7.7 42.65 39 10.5 0.2 100

Results

56

TABLE 18: PERCENTAGE OF STUDY SUBJECTS WITH LOSS OF ATTACHMENT SCORES AMONG TOBACCO USERS AND NON- TOBACCO

USERS

LOSS OF ATTACHMENT (LOA) TOBACCO

USERS AND NON-USERS

LOA 0 to 3mm

LOA 4 to 5mm

LOA 6 to 8mm

LOA 9 to

11mm

LOA 12mm or MORE

NOT RECORED

CURRENT TOBACCO

USERS 31.05 20.95 11.85 1.4 0.1 0.1

NON TOBACCO

USERS 19.15 6.35 6.4 0.6 0.0 0.0

EX-USERS 1.05 0.25 0.05 0.0 0.0 0.0

OCCASIONAL USERS 0.25 0.45 0.0 0.0 0.0 0.0

TOTAL 51.50 28.0 18.3 2.0 0.1 0.1

Results

57

TABLE 19: MEAN NUMBER OF SEXTANTS AFFECTED PER PERSON WITH LOSS OF ATTACHMENT (LOA) SCORES AMONG TOBACCO AND NON-

TOBACCO USERS

LOA SCORES CURRENT TOBACCO USERS

NON – TOBACCO USERS

0 -3 mm 4.27 ± 1.68 4.41 ± 0.98

4 – 5 mm 1.29 ± 1.59 0.87 ± 0.85

6 – 8 mm 0.25 ± 0.94 0.39 ± 0.16

9 – 11mm 0.18 ± 0.57 0.33 ± 0.39

TABLE 20: PERCENTAGE OF STUDY SUBJECTS WITH VARIOUS FORMS OF TOBACCO USE AND LOSS OF ATTACHMENT SCORES IN KARNATAKA

STATE

LOSS OF ATTACHMENT SCORES (LOA)

TYPE OF TOBACCO LOA

0 – 3 mm

LOA 4 – 5 mm

LOA 6 – 8 mm

LOA 9 –11 mm

LOA 12 mm or

MORE

NOT RECORDED

SMOKE 12.85 8.45 4.45 0.35 00 00

CHEW 23.2 15 7.15 0.05 00 0.05

BOTH 11.85 8.25 6.3 1.75 0.2 0.1

TOTAL 47.85 31.7 17.9 2.15 0.2 0.15

Results

58

TABLE 21: MEAN NUMBER OF SEXTANTS WITH LOSS OF ATTACHMENT BY SCORE AMONG VARIOUS FORMS OF TOBACCO USERS

LOA SCORES

SMOKERS MEAN ±

STANDARD DEVIATION

CHEWERS MEAN ±

STANDARD DEVIATION

BOTH MEAN ±

STANDARD DEVIATION

0 -3 mm 2.95 ± 1.61 1.96 ± 1.40 2.22 ± 1.05

4 – 5 mm 2.05 ± 1.27 1.90 ± 1.25 2.08 ± 0.76

6 – 8 mm 0.58 ± 1.07 1.26 ± 1.07 1.18 ± 0.98

9 – 11mm 0.21 ± 0.61 0.57 ± 1.08 0.31 ± 0.46

MORE THAN 12mm

0.20 ± 0.6 0.30 ± 0.8 0.20 ± 0.30

Results

59

TABLE 22: PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT FORMS OF SMOKING HABITS AND LOSS OF ATTACHMENT SCORES IN

KARNATAKA STATE

LOSS OF ATTACHMENT

SMOKE FORM OF TOBACCO

LO

A

0 to

3m

m

LO

A

4 to

5m

m

LO

A

6 to

8m

m

LO

A

9 to

11m

m

LO

A 1

2mm

or

MO

RE

LO

A N

OT

R

EC

OR

DE

D

TOTAL

CIGARETTE 14.8 14.9 7.8 1.9 00 00 39.5

BEEDI 29.5 17.4 11.7 1.3 0.4 0.2 60.5

TOTAL 44.3 32.3 19.5 3.2 0.4 0.2 100

Results

60

TABLE 23: PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT FORMS OF CHEWING HABITS AND LOSS OF ATTACHMENT SCORES IN

KARNATAKA STATE

LOSS OF ATTACHMENT

CHEWED FORMS

OF TOBACCO

LO

A

0 to

3m

m

LO

A

4 to

5m

m

LO

A

6 to

8m

m

LO

A

9 to

11m

m

LO

A 1

2mm

or

MO

RE

LO

A

NO

T

RE

CO

RD

ED

TOTAL

PAN WITH TOBACCO 23.4 14.85 8.95 1.2 0.3 00 48.65

PAN MASALA WITH

TOBACCO 5.15 2.1 1.5 00 00 00 8.75

GUTKHA 10.35 12.6 3.7 0.85 00 0.2 27.65

PLAIN TOBACCO

WITH LIME 5.85 3.6 5.1 0.3 00 0.1 14.9

TOTAL 44.7 33.15 19.2 2.35 0.3 0.3 100

Results

61

TABLE 24: PERCENTAGE OF STUDY SUBJECTS ALONG WITH DURATION OF SMOKING HABITS AND LOSS OF ATTACHMENT SCORES IN

KARNATAKA STATE

LOSS OF ATTACHMENT

DURATION OF

SMOKING LOA 0 to

3mm

LOA 4 to

5mm

LOA 6 to

8mm

LOA 9 to

11mm

LOA 12mm

or MORE

LOA NOT

RECORDED

TOTAL

LESS THAN 1 YEAR

1.4 0.7 0.9 0.4 00 00 3.4

1 to 2 YEARS 2.2 1.6 0.6 0.2 00 00 4.7

2to 5 YEARS 19.8 15.8 8.1 1.2 00 00 44.9

5 to10 YEARS 15.1 12.7 5.4 1.3 0.4 00 34.9

MORE THAN 10 YEARS

5.8 1.2 4.8 0.1 00 0.2 12.1

Results

62

TABLE 25: PERCENTAGE OF STUDY SUBJECTS ALONG WITH DURATION OF CHEWING HABITS AND LOSS OF ATTACHMENT SCORES IN

KARNATAKA STATE

LOSS OF ATTACHMENT

DURATION OF

CHEWING HABITS

LO

A

0 to

3m

m

LO

A

4 to

5m

m

LO

A

6 to

8m

m

LO

A

9 to

11m

m

LO

A 1

2mm

or

MO

RE

LO

A

N

OT

R

EC

OR

DE

D

TOTAL

LESS THAN 1 YEAR

1.65 2.8 0.55 00 00 00 5.05

1 to 2 YEARS 10.8 5.5 2.35 0.3 00 00 19.0

2to 5 YEARS 16.5 12.1 4.2 2.1 00 00 34.9

5 to10 YEARS 12.4 6.15 13.25 0.05 0.3 00 28.25

MORE THAN 10 YEARS

6.2 4.45 1.95 00 00 0.2 12.75

TOTAL 47.6 62.1 18.35 2.55 0.3 0.2 100

Results

63

TABLE 26: PERCENTAGE OF STUDY SUBJECTS WITH ORAL MUCOSAL CONDITIONS AMONG TOBACCO USERS AND NON- TOBACCO USERS

ORAL MUCOSAL CONDITIONS

TOBACCO USERS AND

NON-TOBACCO USERS

MA

LIG

NA

NT

T

UM

OU

RS

LE

UK

OPL

AK

IA

LIC

HE

N P

LA

NU

S

UL

CE

RA

TIO

NS

CA

ND

IDIA

SIS

AB

SCE

SS

CH

EW

ER

S M

UC

OSA

OSM

F

CA

VE

RN

OU

S H

EM

AN

GIO

MA

AC

TIN

IC K

ER

AT

ITIS

CURRENT TOBACCO

USERS 0.05 2.55 0.05 0.1 0.05 0.0 1.2 0.6 0.05 0.05

NON TOBACCO

USERS 0.0 0.55 0.0 0.0 0.0 0.05 0.1 0.2 0.0 0.0

EX-USERS 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

OCCASIONAL USERS 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

TOTAL 0.05 3.1 0.05 0.1 0.05 0.05 1.3 0.8 0.05 0.05

Results

64

TABLE 27: PERCENTAGE OF STUDY SUBJECTS WITH VARIOUS FORMS OF TOBACCO USE AND ORAL MUCOSAL CONDITIONS IN KARNATAKA

STATE


TYPE OF TOBACCO

NO

RM

AL

MA

LIG

NA

NT

T

UM

OU

RS

LE

UK

OPL

AK

IA

LIC

HE

N

PLA

NU

S

UL

CE

RA

TIO

NS

CA

ND

IDIA

SIS

CH

EW

ER

S M

UC

OSA

OSM

F

CA

VE

RN

OU

S H

EM

AN

GIO

MA

AC

TIN

IC

KE

RA

TIT

IS

TOTAL

SMOKE 25.15 0.05 0.5 00 0.05 00 0.1 0.2 00 00 26.1

CHEW 42.8 00 1.8 00 00 0.05 0.6 0.05 0.05 0.05 45.45

BOTH 24.7 00 1.95 0.05 0.05 00 1.05 0.65 00 00 28.5

Results

65

TABLE 28: PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT FORMS OF SMOKING HABITS AND ORAL MUCOSAL CONDITIONS IN

KARNATAKA STATE


SMOKE FORM OF TOBACCO

NO

AB

NO

RM

AL

C

ON

DIT

ION

S

MA

LIG

NA

NT

T

UM

OU

RS

LE

UK

OPL

AK

IA

LIC

HE

N P

LA

NU

S

UL

CE

RA

TIO

N

CH

EW

ER

S M

UC

OSA

OSM

F

TO

TA

L

CIGARETTE 45.65 00 1.8 00 00 0.7 1.0 49.1

BEEDI 46.05 0.1 2.65 0.1 0.3 1.35 0.45 50.9

TOTAL 91.7 0.1 4.45 0.1 0.3 2 1.45 100

Results

66

TABLE 29: PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT FORMS OF CHEWING HABITS AND ORAL MUCOSAL CONDITIONS IN

KARNATAKA STATE


CHEWED FORMS

OF TOBACCO

NO

AB

NO

RM

AL

C

ON

DIT

ION

S

LE

UK

OPL

AK

IA

LIC

HE

N P

LA

NU

S

UL

CE

RA

TIO

N

CA

ND

IDIA

SIS

CH

EW

ER

S M

UC

OSA

OSM

F

CA

VE

RN

OU

S H

EM

AN

GIO

MA

AC

TIN

IC K

ER

AT

ITIS

TO

TA

L

PAN WITH

TOBACCO 44.5 2.3 00 0.1 0.1 1.1 0.45 00 00 48.65

PAN MASALA

WITH TOBACCO

8.2 0.2 00 00 00 0.2 0.1 0.1 00 8.75

GUTKHA 25.1 2.05 00 00 00 0.4 0.1 00 0.1 27.65

PLAIN TOBACCO

WITH LIME

13.25 0.6 0.1 00 00 0.65 0.3 00 00 14.9

TOTAL 91.15 5.2 0.1 0.1 0.1 2.3 0.95 0.1 0.1 100

Results

67

TABLE 30: PERCENTAGE OF STUDY SUBJECTS ALONG WITH DURATION OF SMOKING HABITS AND ORAL MUCOSAL CONDITIONS IN

KARNATAKA STATE


DURATION OF

SMOKING

NO

AB

NO

RM

AL

C

ON

DIT

ION

S

MA

LIG

NA

NT

T

UM

OU

RS

LE

UK

OPL

AK

IA

LIC

HE

N P

LA

NU

S

UL

CE

RA

TIO

N

CH

EW

ER

S M

UC

OSA

OSM

F

TO

TA

L

LESS THAN 1 YEAR

3.2 00 0.2 00 00 00 00 3.4

1 to 2 YEARS 4.1 00 0.5 00 00 0.1 00 4.7

2to 5 YEARS 42.8 00 0.6 0.1 00 0.6 0.8 44.9

5 to10 YEARS 31.7 0.1 1.5 00 0.2 0.6 0.7 34.9

MORE THAN 10 YEARS

10.0 00 1.4 00 00 0.7 00 12.1

Results

68

TABLE 31: PERCENTAGE OF STUDY SUBJECTS ALONG WITH DURATION OF CHEWING HABITS AND ORAL MUCOSAL CONDITIONS IN

KARNATAKA STATE


DURATION OF

CHEWING HABITS

NO

AB

NO

RM

AL

C

ON

DIT

ION

S

LE

UK

OPL

AK

IA

LIC

HE

N P

LA

NU

S

UL

CE

RA

TIO

N

CA

ND

IDIA

SIS

CH

EW

ER

S M

UC

OSA

OSM

F

CA

VE

RN

OU

S H

EM

AN

GIO

MA

AC

TIN

IC

KE

RA

TIT

IS

TO

TA

L

LESS THAN 1 YEAR

5.05 00 00 00 00 00 00 00 00 5.05

1 to 2 YEARS 18.1 0.6 00 00 0.05 0.25 00 00 00 19

2to 5 YEARS 30.95 2.4 0.05 00 00 1.0 0.55 00 00 34.95

5 to10 YEARS 25.6 1.4 00 0.15 00 0.7 0.35 0.05 00 28.25

MORE THAN 10 YEARS

11.45 1.0 00 00 00 0.25 00 00 0.05 12.75

Results

CHART 1: DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO RURAL/URBAN REGIONS

CHART 2: PERCENTAGE OF STUDY SUBJECTS AMONG DIFFERENT TOBACCO USERS AND NON-TOBACCO USERS IN RURAL AND URBAN

AREAS

69

Results

CHART 3: PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT TYPES OF TOBACCO USE IN KARNATAKA STATE

CHART 4: PERCENTAGE OF STUDY SUBJECTS WITH COMMUNITY PERIODONTAL INDEX SCORES IN TOBACCO USERS AND NON-

TOBACCO USERS

70

Results

CHART 5: PERCENTAGE OF STUDY SUBJECTS WITH VARIOUS FORMS OF TOBACCO USE AND COMMUNITY PERIODONTAL INDEX SCORES

IN KARNATAKA STATE

CHART 6: PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT FORMS OF SMOKING HABITS AND COMMUNITY PERIODONTAL

INDEX SCORE IN KARNATAKA STATE

71

Results

CHART 7: PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT FORMS OF CHEWING HABITS AND COMMUNITY PERIODONTAL

INDEX SCORE IN KARNATAKA STATE

72

Results

CHART 8: PERCENTAGE OF STUDY SUBJECTS WITH LOSS OF ATTACHMENT SCORES AMONG TOBACCO USERS AND NON-

TOBACCO USERS

CHART 9: PERCENTAGE OF STUDY SUBJECTS WITH VARIOUS FORMS OF TOBACCO USE AND LOSS OF ATTACHMENT SCORES IN

KARNATAKA STATE

73

Results

CHART 10: PERCENTAGE OF STUDY SUBJECTS WITH DIFFERENT FORMS OF CHEWING HABITS AND LOSS OF ATTACHMENT SCORES IN

KARNATAKA STATE

74

Discussion

75

DISCUSSION

Tobacco consumption is the single largest cause of death in the developed world

and increasing in the less developed countries41. Developing countries also account for

about half of the world’s disease burden to tobacco as measured by DALY’s (WHO) 42.

Tobacco use is a major risk factor for a wide range of pathologies, including oral

cancer, oral mucosal lesions, gingival and periodontal diseases and dental caries. All of

the major forms of tobacco have oral consequences and have been shown to increase the

risk of oral diseases. Evidences suggest that the oral diseases are associated with greater

amounts of tobacco used and longer duration of use.

Results of the present study showed that the prevalence of oral mucosal

conditions was 5.6% in Karnataka state among tobacco and non-tobacco users aged 35-

44 years. The prevalence was considerably higher than the study conducted by Dental

Council of India (2004)39 which was 0.6%.

Pre-cancerous condition in the form of leukoplakia was present in 3.1% of

subjects. The prevalence of leukoplakia was higher when compared to a study conducted

by Mehta et al43, where the prevalence was found to be only 0.2%. The difference in the

prevalence rate may be due to the variations in the representative samples of both the

studies. However in a study conducted by Pindborg et al (1967)44 the prevalence of

Discussion

76

leukoplakia was found to be 3.2% which was in accordance to our study. It is note worthy

that according to a study by Dental Council of India (2004) 39, no cases of leukoplakia

were found in Karnataka state.

In present study oral submucous fibrosis was prevalent in 0.8% of subjects, which

is slightly higher compared to 0.5% prevalence rates found in a study conducted by

Pindborg45.

A single case of malignant tumour was found in present study (0.05%), whereas a

total of nine cases (0.3%) were recorded in a study by Dental Council of India (2004) 39.

Periodontal status was assessed by CPI index. The prevalence of periodontal

disease was found to be 99.8% in the state. Calculus was found in 41.4% of subjects and

shallow pockets in 35.3% of the study population. Deep pockets were recorded in 10% of

the population. The findings were similar to the study by Dental Council

of India (2004)39.

The mean number of sextants with deep pockets or higher was found to be 0.4 ±

0.51 which was similar to the study conducted by Dental Council of India (2004) 39. The

findings show the poor status of periodontal health in the state.

The destructive and degenerative nature of the periodontal disease was assessed

by loss of attachment. Almost half of the study population (49.5%) had loss of attachment

Discussion

77

in the current study, which is in accordance with the study by Dental Council

of India (2004) 39.

In the present study 65.5% of the subjects in Karnataka state used tobacco in one

or the other form. The higher prevalence of tobacco consumption is seen in the present

study compared to a lower prevalence of 27% found in a study by Rani M (2003) 46 and

18% in a study by Dental Council of India (2004) 39. This can again be attributed to

sample size and selection of sample which was according to age in our study.

Higher prevalence of calculus (25.1%), pockets of 4–5mm (28.6%) and deep

pockets of 6 mm or more (6.8%) were observed in current tobacco users compared to

non-tobacco users in the study. There was a significant difference in the periodontal

status with CPI scores and LOA scores among tobacco users and non-tobacco users. This

is in agreement with most of the previous studies (Stoltenberg et al 199347, Schenkein et

al 199548, Gunsolly et al 199849, Al-Bandar et al 200050.)

The prevalence of oral mucosal conditions was found to be more among current

tobacco users (4.7%) compared to non-tobacco users (0.9%). 2.55% of the current

tobacco users had leukoplakia. The prevalence of leukoplakia in non-tobacco users was

just 0.55%. This findings was consistent with other studies conducted by Mehta FS

Discussion

78

(1972) 51, Gupta PC (1989) 52. This clearly indicates that the tobacco usage is one of the

major cause for oral mucosal diseases.

The pattern of tobacco consumption in the state showed that the use of chewed

form of tobacco (44.6%) was most prevalent followed by use of both forms of tobacco

use (28.9%) and smoking form of tobacco alone was found among 26.5% of study

subjects. The study results are in accordance with a study conducted by Rani M (2003)46.

The reason for this can be attributed to the fact that in Karnataka, tobacco consumption in

chewed forms is used by both males and females.

There was statistically significant difference in CPI scores among smokers,

chewers and users of both forms of tobacco. Tobacco chewers had high prevalence of

calculus (21.5%) and also pockets of 4–5mm (17.2%) when compared to tobacco

smokers and users of both forms of tobacco. This may be due to the cumulative effect of

placement of tobacco for longer duration in the mouth and also because of presence of

more irritants in smokeless tobacco products (Walsh MP 2000)24.

The presence of oral mucosal conditions like leukoplakia, OSMF, chewers

mucosa, was found to be more among tobacco chewers (2.65%). This can be probably

due to close proximity of tobacco to the mucosal tissues (Georgia KG et al 2001)27.

Discussion

79

Although one case of cavernous hemangioma was found in the study, the etiology cannot

be associated with tobacco use as it is a congenital anomaly and usually present at birth.

Among the various forms of smoking habits, beedi smoking (60.5%) was the most

popular one in Karnataka state, followed by cigarette consumption (39.5%). The findings

of present study are in accordance to findings by John RM (2005)53. The difference in

consumption pattern here can be probably due to low cost of beedis and also increase in

consumption patterns of smokeless tobacco. Also it is important to note that the majority

of rural populations use beedi in Karnataka.

High prevalence of bleeding, calculus and periodontal pockets were observed

among beedi smokers compared to cigarette smokers. Also to note that there was more

loss of attachment among beedi smokers. This may be due to the presence of more toxic

irritants, high amount of tobacco in beedis and absence of filters in beedis. All these

factors may contribute to increase in periodontal destruction among beedi smokers when

compared to cigarette smokers as mentioned in a report on tobacco habits in India (Mehta

FS 1993)8.

Only one case of (0.05%) malignant tumor was observed in a beedi smoker. The

risk of oral malignancies among beedi smokers is higher considerably than other forms of

tobacco users (Warnakulasuria S 2005)54. However according to study by Dental Council

Discussion

80

of India (2004)39 there were a total of nine cases recorded in the state. The difference can

be attributed to the variation in sample population.

Among the smokeless forms of tobacco usage, use of pan with tobacco was more

prevalent in the present study, followed by gutkha users and usage of plain tobacco with

lime. The findings are slightly higher than the study conducted by Gajalaxmi (2004)55.

Pan with tobacco chewing is an ancient habit in India and also is used as social custom

and this can be attributed as a probable reason for high use of pan with tobacco. The

heavy marketing and advertising of gutkha can also be a contributing factor for its

increasing usage (Sharma R 200456, Prabhu SR 198257).

There was high prevalence of gingival bleeding, calculus and pockets among the

subjects who smoked tobacco for duration of 2 to 5 years. The severity of community

periodontal index scores was higher among the subjects having the habits for past 5 to 10

years. This clearly shows that the duration of smoking habits is related to severity of

periodontal destruction (Bregstrom J 2003) 58.

The same findings were observed among smokeless tobacco users in our study.

There was increase in severity of periodontal diseases and mucosal conditions with

increase in duration of use of smokeless forms of tobacco (Grady D 1990)11.

Discussion

81

The present study showed that tobacco use in any form was harmful to

periodontal health and also caused oral mucosal conditions. The different forms of

tobacco use and also along with duration of use had its significant effect on severity of

oral mucosal and periodontal conditions.

However the present study is associated with its limitations like the gender being

not considered in the study. The rural and urban variations were also not tabulated and

not included as it was beyond the objectives of our study.

Summary and Conclusion

82

SUMMARY AND CONCLUSION

The present study was conducted to find out the oral mucosal and periodontal

status among 35-44-year-old tobacco and non-tobacco users in Karnataka state.

Out of the total 2156 subjects examined, 65.5% of subjects were current

tobacco users. The prevalence of ex-users and occasional users in the current study

was negligible.

Among the tobacco users 26.5% of subjects were smokers and 44.6% of

subjects were chewers and the rest 28.9% of subjects were consumers of both forms

of tobacco.

1. Prevalence of calculus, periodontal pockets of 4 to 5 mm depth and loss of

attachment of 0 to 3mm and 4 to 5 mm was significantly more among

current tobacco users than in non-tobacco users.

2. Leukoplakia was the most common oral mucosal condition in the study

followed by chewers mucosa and oral submucous fibrosis.

3. In the current study, leukoplakia was predominant among current tobacco

users (2.55%). Beedi smokers (2.65%) and chewers of pan with tobacco

(2.3%) had more prevalence of leukoplakia compared to other form of

smoking and chewing habits.

Summary and Conclusion

83

4. Only one case of malignant tumour was recorded in the study and was

present in current tobacco users.

5. Taking into account the various forms of tobacco usage, tobacco chewers

had higher prevalence of gingival bleeding, calculus and periodontal

pockets of 4 to 5 mm when compared to smokers and users of both forms

of tobacco.

6. Among the tobacco smokers, subjects who smoked beedi had

comparatively more bleeding on probing, calculus, periodontal pockets

and loss of attachment than cigarette smokers.

7. Chewing pan with tobacco was the most popular form of chewing habit in

the study. Subjects who chewed pan with tobacco had also presented

themselves with higher prevalence of gingival bleeding, pockets and loss

of attachment.

8. Majority of smokers, chewers and users of both smoked and chewed forms

of tobacco had the habit of consuming tobacco for the past 2 to 5 years.

9. Present study showed that tobacco users having the habit for past 2 to 5

years of duration had higher prevalence of oral mucosal conditions,

gingival bleeding, calculus, periodontal pockets and attachment loss.

Recommendations

84

RECOMMENDATIONS

1. To provide health education to general population particularly in rural areas to

create awareness of tobacco related diseases and also to enhance the knowledge of

harmful effects of tobacco on health.

2. To conduct more screening camps for early diagnosis and treatment of tobacco

related disorders.

3. Dentists should be trained to provide tobacco cessation and counseling in their

place of work.

4. Anti-tobacco campaigns should be extended to reach the rural populations.

5. Strict enforcement of the existing anti-tobacco laws especially in educational

institutions, schools, colleges and public places.

Bibliography

85

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Annexure

93

Questionnaire

DATE: DISTRICT: VILLAGE/URBAN BLOCK:

1. NAME OF THE RESPONDENT: ……………………………….

2. SEX OF THE RESPONDENT: 1. Male 2. female

3. Age: _________ years

4. RELIGION OF THE HOUSEHOLD:

1.Hindu 2.Muslim 3.Sikh 4.Christian 5.Other

5. WHAT IS THE LEVEL OF EDUCATION COMPLETED BY THE

RESPONDENT?

1. Illiterate 2. Primary School 3. Middle School 4. High school

5. Graduate 6. Professional

6. HOW DO YOU CLEAN YOUR TEETH? 1. Finger 2. Tooth Brush 3. Datun 4. Others (Specify)____________________

7. WHAT MATERIAL YOU GENERALLY USE TO CLEAN THE TEETH?

1. Tooth paste 2. Tooth powder 3. Others (specify)_____________________

8. HOW OFTEN DO YOU CLEAN YOUR TEETH IN A DAY?

1. Once 2. Twice 3. Thrice 4. After every meals 5.Don’t clean every day

9. WHAT ARE YOUR TIMINGS OF CLEANING TEETH?

1.Morning – a. before breakfast b. after breakfast

2.Night - a. before dinner b. after dinner

3. Both 4.after every meals 5. Others (specify)__________________

10. HOW OFTEN DO YOU CHANGE YOUR TOOTH BRUSH?

1. 0-3 months 2. 4-6 months 3. More than 6 months 4. not using tooth brush

Annexure

94

11. DO YOU RINSE YOUR MOUTH WITH WATER AFTER MEALS?

1. Never 2. Sometimes 3. Always

12. DO YOU USE TOBACCO?

1. Current user 2. Never user 3. Ex - user

13. DO YOU SMOKE OR CHEW TOBACCO?

1. Smoke 2. Chew 3. Both

14. WHAT DO YOU SMOKE?

1. Cigarettes 2. Beedis 3. Cigars 4. Chillum 5. Hookah

6. Others. (specify) _______________________________

15. HOW MANY NUMBER OF BEEDIS/CIGARETTES/OTHERS DO YOU

SMOKE/DAY?

1. 0 to 3 2. 4 to 5 3. 6 to 10

4. 11 to 20 5. More than 20

16. SINCE HOW LONG HAVE YOU BEEN SMOKING?

1. Less than one year 2. One to two years 3. Two to five years

4. Five to ten years 5. More than ten years

17. WHAT FORM OF TOBACCO DO YOU CHEW?

1. Pan with tobacco 2. Pan Masala with tobacco

3. Other form (specify)___________________________________

18. HOW LONG YOU HAD THE HABIT OF CHEWING TOBACCO?

1. less than one year 2. One to two years 3. Two to Five years

4. Five to ten years 5. More than ten years

Annexure

19. HOW MANY TIMES DO YOU CHEW TOBACCO IN A DAY?

1. Zero to Three times 2. Four to Five times

3. Six to Ten times 4. More than Ten times Oral mucosa: Condition location 0 = no abnormal condition 0 = vermillion border 1 = malignant tumour 1 = commissures 2 = leukoplakia 2 = lips 3 = lichen planus 3 = sulci

95

4 = ulceration( apthous, herpetic, traumatic) 4 = buccal mucosa 5 = acute necrotizing gingivitis 5 = floor of mouth 6 = candidiasis 6 = tongue 7 = abscess 7 = hard and/ or soft palate

8 = other condition(specify if possible) 8 = alveolar ridges/gingiva 9 = not recorded 9 = not recorded Community periodontal index (CPI) 0 = healthy 17/16 11 26/27 1 = bleeding 2 = calculus

3 = pocket 4-5 mm(black band on probe partially visible) 4 = pocket 6 mm or more(black band on probe not visible)

X = excluded sextant 47/46 31 36/37 9 = not recorded Loss of attachment 0 = 0-3mm 17/16 11 26/27 1 = 4-5mm (cementoenamel junction(CEJ) within black band) 2 = 6-8mm (CEJ between upper limit of black band and 8.5mm ring) 3 = 9-11 (CEJ between 8.5mm and 11.5 mm rings)

4 = 12mm or more (CEJ beyond 11.5mm ring) X = excluded sextant 9 = not recorded 47/46 31 36/37

oral mucosal and periodontal ststus among 35-44year old

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