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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 52-58

Reasons for permanent tooth extraction and the current status of the existing teeth among patients visiting dental clinics in Guntur, Andhra Pradesh: A cross-sectional study


Department of Public Health Dentistry, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Nijampatnam P. M. Pavani
Department of Public Health Dentistry, Sibar Institute of Dental Sciences, Takkelapadu, Guntur, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_18_18

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  Abstract 


Introduction: Tooth loss impairs the quality of life, often substantially, and affects the well-being of the person as missing teeth can interfere with chewing ability, diction, and esthetics. Aim and Objectives: The aim of the present research was to investigate the reasons for extractions of permanent teeth and the current status of the existing teeth in adult patients visiting dental clinics in Guntur. Methodology: Places where the dental services are available were stratified. One government general hospital (GGH) in Guntur where dental services are available and one teaching-based private dental institution (Sibar Institute of Dental Sciences [SIDS]) were included in the study. Fifteen private clinics were randomly selected from a total of 107 dental clinics present in Guntur city. The estimated sample size was 746. It was rounded off to 750 for the purpose of convenient segregation. The survey pro forma prepared included demographic information along with clinical examination. Discussion: The highest (2.92) mean number of teeth to be extracted was seen in SIDS followed by GGH (1.94), and the difference in all the three types of clinics was statistically significant (P = 0.000). Post hoc test showed significant difference between private dental clinics and SIDS, private teaching dental institution and the other two types of clinics, and GGH and SIDS. Conclusion: It was revealed from the study that dental caries and periodontitis are the most common reasons for extraction.

Keywords: Dental clinics, permanent teeth, reasons of extraction


How to cite this article:
Pavani NP, Srinivas P, Devaki T, Chandu VC, Kothia NR, Yaddanapalli SC. Reasons for permanent tooth extraction and the current status of the existing teeth among patients visiting dental clinics in Guntur, Andhra Pradesh: A cross-sectional study. Indian J Oral Health Res 2018;4:52-8

How to cite this URL:
Pavani NP, Srinivas P, Devaki T, Chandu VC, Kothia NR, Yaddanapalli SC. Reasons for permanent tooth extraction and the current status of the existing teeth among patients visiting dental clinics in Guntur, Andhra Pradesh: A cross-sectional study. Indian J Oral Health Res [serial online] 2018 [cited 2019 May 24];4:52-8. Available from: http://www.ijohr.org/text.asp?2018/4/2/52/257147


  Introduction Top


Oral health in general implies preservation of the permanent dentition teeth for as long as reasonably possible, in order to support the basic day-to-day functions such as mastication, speech, and laugh.[1] Tooth loss impairs the quality of life, often substantially, and affects the well-being of the person. Missing teeth can interfere with chewing ability, diction, and esthetics. Low self-esteem related to tooth loss can not only hinder an individual's ability to socialize, hamper the performance of work and daily activities, and lead to absence from work,[2] but also affect the overall quality of life of an individual. Oral health goals recommended by the WHO for the year 2020 have stated that there should be an increase in the number of individuals with functional dentitions (21 or more natural teeth) at ages 35–44 and 65–74 years.[3] Nevertheless, extraction of tooth, which is the terminal event in the life of a tooth and is a frequent episode in individuals with uncared and neglected oral cavity, is a common phenomenon in the world.[4] To our knowledge from indexed literature, there are no studies that have investigated the cause of tooth mortality among individuals from Guntur, India. Therefore, the aim of the present research was to investigate the reasons for extractions of permanent teeth and the current status of the existing teeth in adult population sample of various clinics of Guntur and their associations with sociodemographic variables. Assessment of the reasons for tooth loss and oral health status in this population helps in proper planning of oral health programs to reduce the oral disease burden in the community.

Aim and objectives



  1. To elicit the reasons for extraction of permanent teeth in adult patients visiting various dental clinics of Guntur, Andhra Pradesh
  2. To assess the current status of the remaining teeth.



  Methodology Top


Study area

Guntur city is the headquarters of Guntur district, which is one of the 13 districts in the South Indian state of Andhra Pradesh. The city is a municipal corporation and an inclusive part of the neo capital region of Andhra Pradesh, under the jurisdiction of Andhra Pradesh Capital Region Development Authority. As per the provisional reports of Census India, population of Guntur in 2011 was 647,508; of which males and females were 320,720 and 326,788, respectively. Although Guntur city has a population of 647,508, its urban/metropolitan population is 670,073 of which 331,435 are males and 338,638 are females – a sex ratio of approximately 1019 females per 1000 males, higher than the national average of 940/1000.[5] Urban agglomeration of the city is projected to have a population of approximately 1,028,667.[6] The city is famous for its exports, including chilies, pepper, cotton, and tobacco. It is the largest producer of chilies in India. The average literacy rate of Guntur city is 80.40%, of which male and female literacy is 85.74% and 75.21%, respectively.[5] The region of Guntur is one of the medical hubs in India. It boasts major medical facilities (superspecialty hospitals) and related research institutions. The government general hospital (GGH) in Guntur, which spreads over an area of 10.85 acres, provides free health care to people across the coastal districts. Guntur district has one teaching dental institution, i.e., SIBAR Institute of Dental Sciences (SIDS), which provides services for low cost and conducts free camps throughout the district. According to the data provided by A.P Doctor's guide, there are 107 private dental clinics in Guntur.[7]

Study setting and population

The present study was conducted in adult patients attending dental clinics of Guntur, Andhra Pradesh.

Study design

A cross-sectional study.

Pilot study

A pilot study was conducted for 3 weeks, and the number of extractions per day was recorded. The results of the pilot study showed that 35.8% of patients attending GGH, 42.83% of patients attending SIDS, and 28.6% of patients attending private dental hospital underwent extraction over this 3-week period. Therefore, the prevalence of dental extractions was found to be 39%.

Sample size derivation from the prevalence rate of dental extractions

Prevalence of dental extractions obtained from the pilot study (39%) was taken for the estimation of sample size. Absolute level of precision (d), which specifies the width of the confidence interval, was kept as 5.[8] The sample size was calculated according to the formula mentioned below.



Therefore, the estimated sample size was found to be 746.

Sampling technique

Places where the dental services are available were stratified. Since there was only one GGH in Guntur where dental services are available and one teaching-based private dental institution (SIDS), they were included in the study. Fifteen private clinics were randomly selected from a total of 107 dental clinics present in Guntur city. The estimated sample size was 746. It was rounded off to 750 for the purpose of convenient segregation. The estimated sample was segregated into 250 patients from GGH, 200 from private dental clinics, and 300 from teaching-based dental institution (SIDS) based on the respective prevalence of extraction observed at these clinics in the pilot study. Data were collected once a week for a period of 1 year.

Inclusion criteria

  1. Patients undergoing extraction in clinics where consent was obtained
  2. Patients who were willing to participate.


Exclusion criteria

Patients who were not willing to participate.

Consent from concerned authorities of clinics

Prior permission was taken from the superintendent of GGH, principal of SIDS, and practitioners in selected private dental clinics.

Consent from patients

Prior permission was taken from each patient before the start of the study.

Method of collection of data

The survey pro forma prepared included demographic information, number and type of teeth to be extracted, reason for extraction, by whom the decision had been made (by doctor or by patient), Community Periodontal Index (CPI), loss of attachment (LOS),[9] dentition status, and treatment needs.[10] The pro forma was prepared in English, and the investigator had interviewed the patients in the regional language Telugu. Clinical examination for the existing tooth status was done using the WHO's basic Oral Health Survey pro forma 1997. Type III American Dental Association (ADA) examination[11] was done using a mouth mirror, CPI probe, and adequate illumination.

Methods of statistical analysis

Data were compiled using Microsoft Excel software and analyzed using statistical package for social sciences software version-20. The data were subjected to both descriptive and inferential statistics. Descriptive data were presented in frequency tables. For the evaluation of nominal data, cross tabs with Pearson's Chi-square test were applied. Parametric statistics (one-way ANOVA or unpaired t-tests) were used to compare the mean number of teeth to be extracted and the mean number of teeth retained after scheduled extraction with different independent variables. Wherever necessary, Bonferroni post hoc test was used along with ANOVA to compare means between different groups.


  Results Top


The study sample comprised 750 adults, aged 18–90 years, with a mean age of 42.16 ± 15.82 years. Out of the total patients, 42.8% (321) were male and 57.2% (429) were female. The ratio of females to males is higher in Guntur, which was reflected in the characteristics of the study population. Similar observations were seen in the studies done by Kalauz et al.,[12] Nair et al.,[13] and Upadhyaya et al.[1] [Table 1] shows the mean number of extractions with their age group and predominant reasons for extraction. In patients below 40 years of age, the common reason for tooth extractions was caries, and in patients above 40 years of age, periodontitis was the common cause for tooth extractions. [Table 2] shows gender-wise distribution of the study patients based on reason for extraction and who had made the decision. All the reasons showed significant difference between males and females.
Table 1: Mean number of extractions with age group and predominant reasons for extraction

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Table 2: Gender-wise distribution of the study participants based on reason for extraction and by whom the decision had been made

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[Table 3] shows that the highest (2.92) mean number of teeth to be extracted was seen in SIDS followed by GGH (1.94), and the difference in all the three types of clinics was statistically significant (P = 0.0001). Post hoc test showed significant difference between private dental clinics and SIDS, private teaching dental institution and the other two types of clinics, and GGH and SIDS. [Table 4] shows no statistically significant difference between the mean number of retained teeth after a scheduled extraction per patient by type of clinic.
Table 3: Difference in the mean number of teeth to be extracted per patient by type of service center available with multiple pairwise comparison

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Table 4: Difference in the mean number of retained teeth after a scheduled extraction per patient by type of service center attended

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[Table 5] shows tooth-wise distribution of crown status of the study population. A total of 847 teeth in the maxilla and 1202 teeth in the mandible were decayed. Four teeth in the maxilla and nine teeth in the mandible were filled with decay; 59 teeth in the maxilla and 65 teeth in the mandible were filled with no decay; 863 teeth in the maxilla and 985 teeth in the mandible were missed as a result of caries; 542 teeth in the maxilla and 663 teeth in the mandible were missed because of other reasons; 29 teeth in the maxilla and 13 teeth in the mandible were having bridge abutment, special crown, or veneer; 141 teeth in the maxilla and 153 teeth in the mandible were unerupted; and 35 teeth in the maxilla and 15 teeth in the mandible were with trauma (tooth fractures).
Table 5: Distribution showing crown status of the study population

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[Graph 1] shows that, in the maxilla, the highest number of teeth extracted constituted 3rd molars (156 teeth) followed by 1st molars (140 teeth), whereas in the mandible, 1st molars (217 teeth) followed by 3rd molars (193 teeth) were the most commonly extracted teeth.



[Table 6] and [Table 7] show the distribution of study patients according to the highest CPI score; most (54.9%) of them had 2 (calculus) as the highest score and 57.5% had the highest percentage of LOS score as score 1 (0–3 mm pocket). Periodontal status at individual level assessed by CPI score and LOS score with age group showed statistically significant value at P = 0.00.
Table 6: Periodontal status at individual level assessed by the highest community periodontal index score with age group

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Table 7: Periodontal status at individual level assessed by the highest loss of attachment score with age group


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  Discussion Top


The mean number of extractions due to dental caries was higher among younger ages, i.e., <40 years (1.11 ± 0.38), when compared to >40 years (0.98 ± 0.27), whereas the mean number of extractions due to periodontal disease was higher among people >40 years of age (1.67 ± 0.62) when compared to those <40 years (0.41 ± 0.13). This is in agreement with the other studies by Quteish Taani,[14] Sayegh et al.,[15] and Jovino-Silveira et al.[16]

The number of extractions was higher in females with both dental caries and periodontal diseases as the reasons for extraction. This can be attributed to a number of facts, including early tooth eruption in girls in comparison to boys, differences in dental attendance due to lack of financial independence on the part of females, fear of dentists among males and females, and difference in dietary pattern between homemakers and working man.[17],[18],[19] However, no proper consensus could be derived on the gender-based reasons for the extraction of teeth as previous studies in the literature show differing results, with some studies highlighting more tooth loss in females due to caries, while the others demonstrating more tooth loss in males due to caries. Some studies[20],[21],[22],[23] showed that females lost more teeth due to caries and males lost due to periodontitis. However, a study by McCaul et al.[24] showed that males lost more teeth due to caries and females lost more teeth due to periodontitis. In a majority of cases, dentists took the decision of extraction. All the reasons for extraction showed statistical significance (P ≤ 0.05) when checked with gender and who has made the decision of extraction.

The mean number of teeth to be extracted per patient was more (2.92) in patients attending SIDS, followed by GGH (1.94) and private dental clinics (1.81), which is highly statistically significant (P = 0.000). Bonferroni post hoc test results confirmed a statistically significant value with some groups, i.e., private dental clinics with SIDS, GGH with SIDS, and SIDS with both private dental clinics and GGH. Because of free or lower treatment prices, many of the patients who were in lower socioeconomic status (SES) prefer attending SIDS and GGH. In government sectors, extractions were a dominant part of treatment and irrespective of their dental needs, this may be because of heavy flow of patients, shortage of workforce, lack of infrastructure, and lack of time for the dentists,[25],[26] but in the teaching dental hospital (SIDS), in the process of imparting good practical knowledge to the students, each patient is thoroughly checked and all other teeth were treated along with their chief complaint.

The mean number of teeth retained after a scheduled extraction was more (26.30) in patients attending private dental clinics, followed by SIDS (25.13) and GGH (24.97), with no statistically significant difference (P = 0.181). The possible explanation is that the patients of private dental clinics are good at affording conservative treatment because many of them belong to upper middle class of SES. The reason for higher percentage of tooth loss in low-income group patients might be poverty, ignorance, and lack of knowledge about dental care.[27] The above reasons lead to delayed and irregular visits to dental surgeons for treatment and in such circumstances, dentists will not be in a position to do much of the reparative and preventive treatments. It is more likely that the dental surgeon would advise extraction to a patient of lower SES as the patient could not spend more money on conservative or restorative procedures because of economic reasons. This is compounded by lack of facilities in government hospitals for specialized restorative treatments to preserve teeth.[28]

Maxillary crown status of the study population showed 847 decayed teeth; 4 teeth were filled with decay; 59 were filled with no decay; 863 were missed as a result of caries; 542 were missed with some other reasons; no teeth were having fissure sealant; 29 teeth were with bridge abutment, special crowns, or veneer; 142 teeth were unerupted; 35 teeth were with trauma; and 3 were not recorded. Mandibular crown status of the study population showed 1202 decayed teeth; 9 teeth were filled with decay; 65 were filled with no decay; 985 were missed as a result of caries; 663 were missed with some other reasons; no teeth were having fissure sealant; 13 teeth were with bridge abutment, special crowns, or veneer; 153 teeth were unerupted; 15 teeth were with trauma; and 3 were not recorded. Decayed, Missing, and Filled Teeth score for mandibular teeth was more when compared to that of maxillary teeth.

In the maxilla, the highest number of teeth extracted was 3rd molars (156 teeth) followed by 1st molars (140 teeth), whereas in the mandible, 1st molars (217 teeth) followed by 3rd molars (193 teeth) were the most commonly extracted teeth. When compared to the other types of teeth, i.e., premolars, canines, and incisors, molars were the most commonly extracted teeth. Among molars, lower molars were extracted more commonly compared to upper molars. Similar results have been reported in the literature by Oginni et al. in lIe-lfe,[29] Al-Sharafat et al.,[30] and Alomari et al.[31] However, these findings were in contrast with the study done by Thomas and Al-Maqdassy,[32] where the most frequently teeth extracted were the upper molars followed by the lower molars. Among all the molars, mandibular 1st molars (217 teeth) were most commonly indicated for extraction in the present study. Similar findings were reported in the study done by Al-Shammari et al.[33] This could be explained by the early eruption of permanent first mandibular molars which predispose them to dental decay, unique and noncleansing occlusal morphology, more involved in mastication, neglect during mixed dentition period, and poor attention paid while brushing as these teeth are not in the esthetic zone.

CPI scores of the study population showed that majority (54.9%) of the individuals were with a highest score of 2, i.e., calculus followed by the highest score 0, i.e., healthy (22.5%). Nearly 11.8% of them had the highest bleeding score, 4.9% were with 4–5 mm pockets, 0.1% were not recorded, and 4.7% were excluded. LOS score showed that majority (57.5%) of the individuals were with a score of 0, i.e., 0–3 mm. A score of 2 was observed in 23.3% of the participants, i.e., 6–8 mm, followed by a score of 1 among 11.3% of the participants, i.e., 4–5 mm. Almost 2.0% of the patients were found to have a score of 3, i.e., 9–11 mm, whereas 1.1% were recorded with a score of 4, i.e., 12 mm or more, 0.1% were not recorded, and 4.7% were excluded.

The present study findings are in accordance to the known fact that, as age increases, CPI and LOA scores also increase. Individuals in the younger age groups (<20, 20–29, and 30–39) were found to have more healthy scores. Individuals with highest bleeding score were more in the age groups of 20–29 and 30–39; calculus score was high in the age groups of 30–39, 40–49, 50–59, and 60–69; 4–5 mm pockets were more in the age groups of 40–49, 50–59, and 60–69; and 6 mm or more pockets were more in the age group of 70–79. Periodontal status at individual level assessed by the highest CPI score with age groups showed statistically significant value of χ2 = 0.00. LOA scores also showed the same trend as that of CPI score: majority of individuals in young age groups were with score 0 (20–29, 30–39, and 40–49); individuals having 4–5 mm pockets were high in the middle age groups (30–39, 40–49, and 50–59); 6–8 mm pockets were more in the age groups of 40–49, 50–59, and 60–69; 9–11 mm pockets were more in the age groups of 40–49, 60–69, and 70–79; 12 mm or more pockets were found only in the age groups of 40–49, 50–59, and 60–69. In both CPI and LOA scores, individuals with highest excluding sextants were in the age groups of 60–69 and 70–79 as it was in these age groups that more number of teeth were missing. Periodontal status at individual level assessed by the highest LOA score with age groups showed statistically significant difference of χ2 = 0.00.


  Conclusion Top


On the whole, the present study revealed that dental caries is the principal cause for tooth loss followed by periodontitis. Moreover, a lot of oral health problems were observed in the study population, which requires treatment options other than extraction, the provision of which improves the oral health status. Advances in oral health science and knowledge have not yet benefitted developing countries to the fullest extent possible. The major challenges of the future will be to translate knowledge and experience of disease prevention into action programs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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