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Tobacco Control and Public Health in Eastern Europe
Sumartono, W., Thabrany, H., & Meidyawati, R. (2016). Heavy smoking and severe dental caries in Indonesian men. Tobacco Control and Public Health in Eastern Europe, 6(1), 21-29. doi:http://dx.doi.org/10.6084/m9.figshare.4496771
Heavy smoking and severe dental caries in Indonesian men
Wasis Sumartono, Hasbullah Thabrany, Ratna Meidyawati
BACKGROUND: In Indonesia, the prevalence of dental caries is 85%-99% and 67.4% of males aged 15 years or older are current users of tobacco. The aim of this study was to examine the association between heavy smoking and severe dental caries.
METHODS: The authors used secondary data from Basic Health Research 2007. Respondents were Indonesian males aged 45-54 years (n = 34 534). Decay, Missing, Filled Teeth (DMFT) value was used to define severe dental caries with 31.4% of respondents having DMFT value > 8, the cutoff point of severe dental caries in this study. In addition, the enumerators recorded socio-demographic characteristics (age, socio-economic status, education, and job), tooth brushing and smoking behavior of respondents. Chi-square test was used to compare the prevalence of severe dental caries between heavy smokers (defined as Brinkman Index or BI > 400) and never smokers (BI = 0). The
multivariate logistic regression model was used to estimate adjusted association between heavy smoking and dental caries severity.
RESULTS: The prevalence of severe dental caries among never smokers, light smokers (BI 1-399) and heavy smokers was 24.9%, 32.5%, and 38.7% respectively (p < 0.005). Compared to never smokers, the adjusted ORs of having severe dental caries among light smokers and heavy smokers were 1.45 (95% CI: 1.37-1.53) and 1.70 (95% CI: 1.59-1.81), respectively.
CONCLUSIONS: Smoking is a risk factor of severe dental caries in Indonesian men with dose-and-re-sponse association revealed between the exposure and the outcome. Indonesian dentists, individually and collectively, have to participate in smoking prevention and control more actively.
KEYWORDS: heavy smoking; severe dental caries; Indonesian men; Basic Health Research 2007.
BACKGROUND
Dental caries is the most prevalent oral disease and is a major concern of dental health profession (Moses, Rangeeth & Gurunathan, 2011). On the global map of the spatial distribution of caries among people aged 12 years old, Indonesia belongs to the third or 'low' quartile (1.10 to 1.80) (Moreira, 2012). Though the mean Decay, Missing, Filled Teeth (DMFT) value of Indonesian people at the age of 12 is relatively low, dental caries is a major problem among the oral diseases in Indonesia with a preva-
lence of 85%-99% in 2007 (Agtini, 2009). Dental caries can affect anyone at any age. If untreated, it can lead to pain and discomfort, and finally loss of teeth (Gupta, Gupta, Singh, 2014). Cariogenic bacteria and their by-products that diffuse through the dentin tubules are the most frequent cause of pulp inflammation (Soden, Botero, Hanks, & Nor, 2009). Periapical lesions develop as sequelae to pulp disease (Fernandes & Ataide, 2010).
If left untreated, this odontogenic infection may cause maxillary rhi-nosinusitis (Hoskison, Daniel,
Rowson, & Jones, 2012), masticatory space (Schuknecht, Stergiou & Graetz, 2008), or buccal space abscess (Srinivas, Sumanth, & Chopra, 2009).
Dental caries and odontogenic infections can range in severity from mild buccal space infection to a severe, life-threatening multi-space infection (Gregoire, 2010). That is why the improvement of oral health may have a positive impact on the general health of the population and may diminish mortality (Padilha, Hilgert, Hugo, Bos & Ferrucci, 2008).
Dental caries is a multi-factorial disease that is affected by physical and biological factors, lifestyle and behavior, and social status (Tanaka, Miyake, Sasaki & Hirota, 2012). Dental caries risk factors can be divided into three groups: (1) personal factors, (2) oral environmental factors, and (3) factors that directly contribute to caries development. Personal factors include socio-de-mographic status, income, dental insurance coverage, knowledge, attitudes, oral health literacy, behavior (oral hygiene and smoking), and education (Higham, 2009).
One of the common ways to measure the level of dental health is by counting the total number of teeth decay (D), teeth extracted or missing (M) because of dental caries, and teeth that have been filled (F) (Gordan et al., 2011). Decayed, Missing, Filled (DMF) index is a key measure for the experience of dental caries in the epidemiology of dental disease (Chukwumah et al., 2012; Wellapuli & Amarase-na, 2012; De Clerk et al, 2012).
In Indonesia, 67.4% of men aged 15 years and older were cigarette smokers in 2011 (Ministry of Health Rep. of Indonesia, 2012). Indonesia is the third largest tobacco consumer in the world after China and India (Djutaharta, Thabrany, Sung, Ong & Hu, 2012). In 2013, an average Indonesian aged ten years and older consumed 12.3 cigarettes per day (Badan Litbang Ke-sehatan, Kemenkes R.I., 2013).
However, given the lack of tobacco control policies similar to ones implemented in other countries, tobacco use has not yet been recognized a leading health issue in Indonesia. Although the USA FDA has prohibited import, sales, distribution, and marketing of Indonesian clove cigarettes in order
to protect the health of US young generation from harmful effects of tobacco use (U.S. FDA, 2014; U.S. FDA, 2013), Badan Pen-gawasan Obat dan Makanan (Indonesian FDA) did not do anything similar to protect its own population. While Thailand has become a pioneering country to prohibit tobacco import in order to protect Thai's public health (Frankel, 1996), in Indonesia, there was a tendency of increasing tobacco import from 1990 to 2011 (Wiyono and Ahsan, 2015).
While Brunei Darussalam has induced strong control of tobacco supply by implementing restrictions on tobacco import (Constitution of Brunei Darussalam, 2005), Indonesian president Joko Widodo has allowed Philip Morris - a giant transnational tobacco company -to increase investment in Indonesia (Thabrany, 2015). It is obvious why the rapid reduction in the prevalence of tobacco smoking, which occurred in many other countries, including neighboring countries, did not occur in Indonesia.
In the USA, the Department of Health and Human Services (U.S. DHHS) aimed to enhance the role of health professionals, including dentists, in the control of tobacco epidemic. The enhancement of dentists' role in tobacco control was undertaken by means of increasing tobacco use screening in dental care settings and increasing tobacco cessation counseling in dental care settings. (U.S. DHHS, 2010).
Smoking causes a number of oral conditions such as tooth discoloration (staining), bad breath, and impaired wound healing process (Terrades, Clarke, Mullally, & Stevenson, 2009), periodontal dis-
eases, oral pre-cancer and tumor development (Lamster & Eaves, 2011). In Italy, the prevalence of dental caries was higher in heavy smokers as compared to never smokers (Campus et al., 2011). In Mexico and the U.S., greater exposure to tobacco was significantly associated with a more severe dental caries (DMFT) (Zinser, Irigo-yen, Rivera, Maupomé, Pérez & Velázquez, 2008; Gordan, Mc Edward, Garvan, Ottenga & Harris, 2011).
Therefore, this study aimed to examine the relationship between tobacco use and dental caries in Indonesian men. The primary research question of the study was whether greater exposure to tobacco smoking was associated with severe dental caries. To answer the question, the authors used the data from Basic Health Research (BHR) 2007, the latest population survey which covered dental caries issues. Other factors which are known to be causally related to dental caries and data on which were collected in the BHR were controlled for in this study. These included the site of housing (rural or urban), education (graduate from high school or not), ground water condition (e.g. consuming water with low levels of Fluor), socio-economic status (whether a respondent belongs to the group of underprivileged or rich people), etc.
METHODS
Source of data
Basic Health Research 2007 (BHR 2007), a national health survey conducted by the National Institute of Health Research and Development, Ministry of Health of Republic of Indonesia, was the source of data for this study. Information on socio-demographic characteris-
tics, tooth brushing, smoking behavior, and dental caries experience (DMFT) was obtained by well-trained enumerators. The study involved Indonesian men aged 45-54 years. The study sample included 53,942 individuals.
Recoding socioeconomic status
Data management officers of BHR 2007 have categorized socioeconomic status of BHR 2007 respondents into five categories as follows:
a. Quintile 1 (the poorest);
b. Quintile 2 (the poor);
c. Quintile 3 (moderate);
d. Quintile 4 (the rich);
e. Quintile 5 (the richest).
The authors have collapsed this division into two categories:
a. The rich - quintiles 3 to 5;
b. The underprivileged - quintiles 1 and 2.
Dental caries criteria
Intraoral examination on dental caries was performed with the use of a mouth mirror. Respondents were asked to rinse their mouth before the intraoral examination. A respondent was categorized as having dental caries if the enumerator found decay (D), missing (M) and/or filling (F) in one or more of the teeth. Afterwards, the DMFT score was recorded by the enumerators.
Cutoff point of severe dental caries in this study
Subjects with severe dental caries in a population are defined as those with the top 30% of the population DMFT values (Ditmyer, Dounis, Mobley & Schwarz, 2010). The cutoff point for severe dental caries in this study was defined according
to the method of Malmo University (Malmo University, n.d.) and Leake et al. (Leake, Jozzy & Uswak, 2008):
1. Respondents in the study sample were ranked according to their DMFT values.
2. Approximately one-third of the study sample with the highest DMFT scores were defined as those with severe dental caries.
3. From this calculation, the lowest DMFT value of study participants with severe dental caries equaled 8. That is why the operational definition of severe dental caries in this study is DMFT > 8 (Figure 1).
Classification of smoking exposure
Brinkman index (BI) is an index of smoking exposure and is calculated by multiplying the average number of cigarettes smoked per day by the duration of daily smok-
100
90
80
70
c
(U (J 60
(U
<u > 50
ro
F 40
3
u
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
DMFT
Figure 1. DMFT value frequency distribution and severe dental caries cutoff point of Indonesian males aged 45-54 - Basic Health Research 2007.
ing (in years) (Hamabe et al., 2011). In this study, heavy smoking was defined as having BI>400 (Hu, Sekine, Gaina, Wang & Kagamimori, 2007). Based on their smoking exposure, participants of this study were categorized into three groups: (1) never smokers (BI = 0); (2) light smokers (BI 1399); and (3) heavy smokers (BI>400).
Inclusion and exclusion criteria
Respondents were included in the analysis if data on DMFT indexes were available, and excluded if their smoking exposure (Brinkman index) could not be calculated (example: occasional smokers, former smokers, and regular smokers for whom there was no data on the duration of smoking). The final sample included 34,534 individuals.
Statistical analysis
Chi-square test was used to examine the relationship between the outcome of interest - severe dental caries - and smoking exposure. Bi-variate and multivariable logistic regression models were carried out to estimate unadjusted and adjusted associations between severe dental caries and heavy smoking on 5 percent significance level. Multivariable logistic regression also allowed estimation of adjusted ORs between the outcome of interest and other factors, which are known to be associated with dental caries. Thus, besides the main exposure variable, our final adjusted logistic regression model included the following covariates: ground water condition (whether the study participant lives in 'high-risk area' like in Bangka Island and South Kalimantan, or in the other provinces of Indonesia which are considered a 'safe area'), type of housing (ur-
ban or rural), age, education (in terms of the highest education level achieved by the respondent), main occupation, socioeconomic status, and tooth brushing frequency.
RESULTS
Univariate analysis
From a total of 34,534 respondents who were eligible, only 2.1% lived
Table 1. Sociodemographic characteristics, dental caries severity, tooth brushing behavior and smoking exposure of study participants - Indonesian men aged 45-54 years -Basic Health Research, 2007
_N_%_
Ground water condition
(-)RH2AHLC/ LFC 33,816 97.9
(+)RH2AHLC/ LFC 718 2.1
Type of housing
Urban 15,490 44.9
Rural 19,044 55.1
Age (years)
45-49 18,922 54.8
50-54 15,612 45.2
Socioeconomic Status
Rich 20,982 60.8
Underprivileged 13,552 39.2
Education
SHS - graduated 8,470 24.5
SHS - did not graduate 26,064 75.5
Occupation
Army/ Police/ Gov/ Private Employees 6,232 18.0
Merchants 8,963 26.0
Laborers 5,824 16.8
Farmers/ Fishermen 12,420 36.0
Unemployed 1,095 3.2
Dental Caries Severity (DMFT)
Not severe (0-7) 23,694 68,6
Severe (> 8) 10,840 31.4
Tooth brushing frequency
At least once a day 32,138 93.1
Less than once a day 2,396 6.9
Smoking exposure (Brinkman index)
Never smokers (0) 11,148 32.2
Light smokers (1-399) 15,978 46.3
Heavy smokers (> 400) 7,408 21.5
Total 34,534 100.0
(-) RH2AHLC/ LFC = Provinces where ground water was not Reported to have High Acidity and High Lead Concentration or Low Fluor Concentration
(+) RH2AHLC/ LFC = Provinces where ground water was Reported to Have High Acidity and High Lead Concentration or Low Fluoride Concentration)
in provinces with ground water reported to have high acidity and high lead concentration or low Fluor concentration (RHHA&HLC/ LFC) (Table 1); 44.9% of respondents were living in urban areas; 54.8% were aged 45-49 years, while the rest 45.2% were 50-54 years old.
Based on the highest educational level achieved, the majority or 75.5% of respondents had education lower than Senior High School (SHS), and the rest 24.5% were graduates of SHS or other higher education institutions. The proportions of respondents based on their main occupation were as follows:
(1) farmers or fishermen - 36%;
(2) merchants - 26%; (3) army/police/government/private employee - 18.0%; (4) laborers - 16.8%; and (5) unemployed - 3.2%. From the point of view of socio-economic status, 60.7% of respondents were categorized as rich, and the rest 39.3% respondents were categorized as underprivileged. Severe dental caries (DMFT > 8) was revealed in 31.4% of respondents. Tooth brushing at least once a day was reported by 93.1% of respondents and the rest 6.9% did so less often than once a day. The proportion of never smokers (BI = 0), light smokers (BI 1-399), and heavy smokers (BI>400) was 32.3%; 46.3%; and 21.4%, respectively.
Bivariate analysis
Table 2 shows the results of bivari-ate analysis. The prevalence of severe dental caries in respondents who were never smokers, light smokers, and heavy smokers was 24.9%, 32.5%, and 38.7%, respectively (p<0.005).
Multivariate Analysis
Table 3 shows the results of multi-variate analysis with severe dental caries as the outcome of interest. As compared to never-smokers (BI = 0), the adjusted OR of suffering from severe dental caries in light smokers (BI 1-399) was 1.45 (95% CI: 1.37-1.53), and in heavy smokers (BI>400), the corresponding OR was 1.70 (95% CI: 1.591.81).
DISCUSSION
Main results and their comparison with published literature
This study found that the occurrence of severe dental caries was higher among those with greater smoking exposure. This is consistent with the finding of Campus et al. (2011) in Italy, which revealed that the prevalence of dental caries was higher in heavy smokers as compared to never smokers. The results of this study are also consistent with the finding of Zinser, Irigoyen, Rivera, Maupomé, Pérez & Velazquez (2008) in Mexico, as well as with the findings of Gordan, McEdward, Garvan, Ottenga & Harris (2011) in the USA. Both studies revealed that greater exposure to tobacco was significantly associated with a more severe dental caries expressed as DMFT value.
Potential strengths and weaknesses of the study
This study has several advantages. First, the investigators had access to the data of Basic Health Research 2007, a nationwide community-based study that used a relatively large sample size. As known, larger sample sizes can provide greater precision in estimates
(Gongalves, Paula, Ambrosano, Mialhe & Pereira, 2012; Kelsey, Whittemore, Evans & Thompson, 1996; DSS Research, 2015). Respondents of Basic Health Research 2007 were selected by the Central Bureau of Statistics in such a way that they would represent the population of Indonesia up to the district level.
Secondly, multivariable adjusted logistic regression model was carried out. This allowed estimating adjusted ORs between severe dental caries and heavy smoking, controlling for other covariates in the model.
However, this study had several limitations. First of all, dietary habits or, more precisely, the daily sugar intake covariate was not included in the logistic regression analysis. This was due to the lack of validity and reliability of the data on this matter in Indonesian Basic Health Survey 2007. Secondly, the main focus of this study was to assess the relationship between heavy smoking and dental caries severity regardless of the type of tobacco or cigarettes smoked by respondents. Thus, since the majority of Indonesian men consumed clove (kretek) cigarette, the results of this study could probably be applicable to Indonesian clove cigarette smokers. However, the authors admit that to find out whether heavy smoking might cause severe dental caries, a better study design is needed. One choice is to conduct a prospective cohort study.
Further research
Based on the results of this study, additional research questions were generated. Specifically, further research is needed to find out what proportion of Indonesian dentists perform screening of smoking sta-
tus of their dental patients. Further on, there are no data on what percentage of Indonesian dentists perform smoking cessation counseling. Also, further research is recommended to find out whether giving additional lectures on this
matter to Indonesian dental students can help to increase the percentage of future Indonesian dentists who will perform smoking screening and smoking cessation counseling to their dental patients. Finally, further investigation is
needed to find out what behavior change approaches applied to dental practitioners in Indonesia can increase their participation in smoking screening and smoking cessation counseling.
Table 2. Prevalence and crude odds ratios of severe dental caries (DMFT > 8) in Indonesian men aged 45-54 years by socio-demographic characteristics, tooth brushing behavior and smoking intensity - Basic Health Research 2007
N < 8 (%) DMFT > 8 (%) OR Estimate p-value
Groundwater condition
(-)RH2AHLC/ LFC 33,816 69.0 31.0 1a < 0.005
(+)RH2AHLC/ LFC 718 51.5 48.5 2.09 (1.80-2.42)b
Site of housing*
Urban 15,490 71.5 28.5 1 < 0.005
Rural 1944 66.3 33.7 1.28 (1.22-1.34)
Age (years)*
45-49 18,922 74.4 25.6 1
50-54 15,612 61.6 38.4 1.81 (1.72-1.89) < 0.005
Highest education *
SHS - Graduated 8,470 77.7 22.3 1 < 0.005
SHS - Did not graduate 26,065 65.6 34.4 1.83 (1.73-1.94)
Main Occupation *
Army/Police/Gov/Private Employee 6,232 78.0 22.0 1
Merchants 8,962 69.5 30.5 1.56 (1,45-1.68)
Laborers 5,825 64.5 34.5 1.87 (1.73-2.03) < 0.005
Farmers/ Fishermen 12,420 65.2 34.8 1.89 (1.77-2.03)
Unemployed 1,095 62.4 37.6 2.14 (1.87-2.45)
Socio-Economic Status*
Rich 20,982 70.1 29.9 1 < 0.005
Underprivileged 13,552 66.2 33.8 1.20 (1.14-1.25)
Tooth Brushing Freq*
Every day 32,138 70.1 29.9 1 < 0.005
Not every day 2,396 48.6 51.4 2.48 (2.28-2.70)
Smoking intensity (BI)*
Never smokers (0) 11,148 75.1 24.9 1 < 0.005
Light smokers (1-399) 15,978 67.5 32.5 1.45 (1.38-1.54)
Heavy smokers (>400) 7,408 61.3 38.7 1.90 (1.78-2.03)
*Significantly different from its reference class, p < 0.005 a Reference group
b Numbers in parentheses are 95% confidence intervals (estimation achieved from logistic regression). (-) RH2AHLC/ LFC = Provinces where ground water was not Reported to have High Acidity and High Lead Concentration or Low Fluor Concentration
(+) RH2AHLC/ LFC = Provinces where ground water was Reported to Have High Acidity and High Lead Concentration or Low Fluoride Concentration)
Table 3. Adjusted odds ratios of severe dental caries (DMFT> 8) according to socio-demographic characteristics, tooth brushing behavior and smoking exposure in Indonesian men aged 45-54 years - Basic Health Research, 2007
B
S.E.
DF P-value Adjusted OR Estimate
Ground water condition* (-)RH2AHLC/ LFC (+)RH2AHLC/ LFC Age (years)* 45-49 50-54 Socioeconomic status* Rich
Underprivileged Highest Education* Graduated from SHS Did not graduate from SHS Main occupation*
Army/ Police/ Gov./ Private Employee
Merchants
Laborers
Farmers/ Fishermen Unemployed Tooth brushing Freq. Every day Not every day Smoking exposure (BI) Never smokers (0) Light smokers (1-399) Heavy smokers (s 400)
0.84
0.56
0.05
0.33
0.21 0.26 0.23 0.44
0.75
0.37 0.53
0.078
0.024
0.025
0.037
0.043 0.049 0.045 0.074
0.044
0.029 0.033
<0.001
<0.001
0.039
<0.001
<0.001 <0.001 <0.001 <0.001
<0.001
<0.001 <0.001
1a
2.32 (1.99-2.71)b 1
1.74 (1.66-1.83) 1
1.05 (1.00-1.11) 1
1.39 (1.30-1.50)
1
1.24 (1.14-1.34) 1.30 (1.18-1.43) 1.26 (1.15-1.37) 1.56 (1.35-1.80)
1
2.11 (1.94-2.30) 1
1.45 (1.37-1.53) 1.70 (1.59-1.81)
1
1
1
1
1
*Significantly different from its reference group, p < 0.005 a Reference group
b Numbers in parentheses are 95% confidence intervals (estimation achieved from logistic regression). (-) RH2AHLC/ LFC = Provinces where ground water was not Reported to Have High Acidity and High Lead Concentration or Low Fluor Concentration
(+) RH2AHLC/ LFC = Provinces where ground water was Reported to Have High Acidity and High Lead Concentration or Low Fluoride Concentration)
CONCLUSIONS
This was a secondary analysis of cross-sectional data from Basic Health Survey 2007, a national health survey conducted by the National Institute of Health Research and Development, Ministry
of Health Rep. of Indonesia. The aim of this study was to determine whether there was an association between heavy smoking and severe dental caries. The conducted analysis revealed that heavy smoking is associated with increased severe dental caries in Indonesian men.
Implications for practice
Indonesian dentists, individually and collectively (through Indonesian Dental Association) should be more intensively involved in accomplishment of tobacco control objectives. Together with other
health professional organizations, Indonesian dentists are supposed to contribute to the advancing of Indonesian nation from a smoking nation into a non-smoking one.
ACKNOWLEDGMENTS
The authors would like to express sincere gratitude to Dr. Trihono, MPH, Ph.D., former Head of National Institute of Health Research and Development, Ministry of Health, Rep. of Indonesia for his permission to use BHR 2007 data in this study.
ABOUT THE AUTHORS
Wasis Sumartono, DDS, Ph.D., is affiliated to the Institut Kesehatan Indonesia (IKI) Jakarta and Indonesia Health Institute (IHI) Jakarta, Indonesia; ORCID 0000-0002-9047-735X Email: wsumartono@gmail.com
Hasbullah Thabrany, MD, MPH, Dr.PH, is affiliated to the Center for Social Security Studies Univer-sitas Indonesia (CSSUI), Gedung Program Pasca Sarjana, Jakarta, Indonesia;
ORCID: 0000-0002-6711-2547 Email: hasbullah.thabrany@gmail.com
Ratna Meidyawati, DDS, Ph.D., is affiliated to Department of Conservative Dentistry, Faculty of Dentistry, University of Indonesia, De-pok
ORCID: 0000-0001-6760-5352 Email: meidyawati58@gmail.com
This paper was received: October 29, 2016; accepted: November 20, 2016; published: December 30, 2016.
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