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Reasons for permanent tooth extraction in the North of Afghanistan
Journal of Dentistry (2006) 34, 48–51
www.intl.elsevierhealth.com/journals/jden
Reasons for permanent tooth extraction in the North of Afghanistan Da’ameh Da’ameh* Division of Periodontology, Dental Corps, Royal Medical Services, P.O. Box 107, Rusaifa 13710, Jordan Received 3 September 2004; received in revised form 18 January 2005; accepted 3 February 2005
KEYWORDS Tooth extraction; Reasons; Caries; Periodontal disease
Summary Objectives: The aim of this study was to study the pattern of and reasons for permanent tooth extraction in a group of Afghan patients attending a dental clinic in the North of Afghanistan. Methods: A simple clinical survey was done in Afghan population sample that has undergone or planned for tooth extraction. Results: A total of 184 permanent teeth were extracted from 123 patients ranging in age from 9 to 62 years during the three-month study period. Males were 54.5% while females formed 45.5%. Overall, caries was the most frequent reason for tooth extraction (59.2%), followed by periodontal disease (35.3%), surgical indications (4.9%) and patient request (0.5%). Caries was the main reason for tooth loss up to 50 years of age. However, periodontal disease became the principal reason in 51 years old and over. Posterior teeth represented the highest percentage (84.2%) of extraction. Conclusions: Both caries and periodontal disease were the main reasons for tooth extraction in the North of Afghanistan, so that proper oral health system including efficient programs focusing on prevention and treatment of these diseases should be created and developed. Q 2005 Published by Elsevier Ltd.
Introduction Oral health requires the retention of permanent teeth as long as possible because our teeth are important for chewing, smiling, and speaking. Equally, loss of these teeth will adversely affect our quality of life: biologically, psychologically and socially, therefore extraction of permanent teeth
* Tel./fax: C962 5 3751417. E-mail address: [email protected]
0300-5712/$ - see front matter Q 2005 Published by Elsevier Ltd. doi:10.1016/j.jdent.2005.02.009
should only be carried out if strongly recommended as part of a carefully planned dental treatment. In Afghanistan, health sector, as all other sectors is in a state of collapse with a severe shortage in human and material resources; this is since more than two decades of violent conflicts that have torn the country apart. Human resources for health are: 19 physicians, three dentists, two pharmacists and 22 nurses and midwives per100,000 populations.1 The oral health manpower—in specific—is only192 dentists and 268 chair-side assistants all over the country.2 Moreover, no published studies on oral/dental health status in Afghanistan where found in electronic databases except an assignment
Reasons for permanent tooth extraction in the North of Afghanistan report of the prevalence of dental caries by Leous P 1991.2 The report showed dft index for 3–4, and 5–6 years age groups to be 3.4 and 2.0, respectively, while DMFT for 7–12, 13–15 and 35–44 age groups were 2.9, 3.8 and 8.3. Mazar-i-Sharif is the largest city in the North of Afghanistan. People come to it from the various rural surrounding areas and therefore it has a heterogeneous society but with no definitive known demographic profile in terms of number of population, age, socioeconomic status, etc. This study is the first in Mazar-i-Sharif to investigate the pattern of and reasons for permanent teeth extraction and to assess dental needs and treatment.
Materials and methods A simple clinical survey was performed at the dental clinic of the Jordanian Military Field Hospital in Mazar-i-Sharif into which the people come seeking free and updated medical as well as dental care. All patients who came seeking extraction of permanent teeth during the study period (December 2002–February 2003) were included. The aims of the study were described for each patient and a consent form was signed. Data were collected by the only dentist available in the hospital, who made the diagnosis and provided the treatment. Age and gender of the patients in addition to teeth extracted or planned for and the main reason for extraction seen by
Table 1
49
the dentist according to certain criteria (Table 1) were recorded. Data were entered into the PC using SPSSw (version 10) software and descriptive statistics were applied.
Results A total of 184 teeth were either extracted or planned for from 123 patients with a mean of 1.5 teeth per person. Certain demographic data of patients are shown in Table 2. The patients’ age range was from 9 to 62 years while the median age was 33.0. Patients were mostly males (54.5%), while females formed 45.5%. Female patients had 77 teeth extracted or planned for, comprising 41.8% of the total teeth extracted. Males having their teeth extracted were most commonly in the 21–30-year age group (57.5%) while females were in the 31–40-year age group (51.4%). Out of 123 patients, 30 patients have undergone multiple teeth extraction. It was more in males compared to females, 60 and 40% respectively and increased with age. Dental caries accounted for the majority of extractions (59.2%), while extractions due to periodontal disease (PD) and surgical reasons (35.3 and 4.9%, respectively) were less. Patient request accounted for the remaining (0.5%) while none of the extractions were due to orthodontic, pre-prosthetic, or other reasons. Caries was the main reason for extraction in both males and females (Fig. 1). It accounted for 64.5% of extractions in males and 51.9% of extractions in
Criteria for extraction categories.
Extraction reason
Criteria
Caries
Initial and recurrent caries, all sequelae of caries including extraction of roots where the crown was lost through caries and teeth fracturing due to weakening by caries. Failed root treatment where the tooth was initially root treated because of caries Where pain, loss of function or pocketing due to periodontal disease requires that the tooth be extracted Teeth extracted to prevent or correct malocclusion, be they impacted, incompletely erupted or supernumerary Teeth which are extracted because their removal facilitates a better prosthetic restoration Teeth lost as a result of trauma (including jaw fractures), pericoronitis, unerupted or partially impacted teeth and oral mucosal lesions Teeth extracted because the patient prefers extraction to other treatments or requests a clearance and dentures. Also in this category extractions performed due to the patient’s behavior or fear which prevents conservative care being carried out If the reasons for extracting a tooth are not encompassed by the above categories the reason should be stated clearly
Periodontal disease Orthodontic Pre-prosthetic Surgical Patient request
Others
50
D. Da’ameh
Table 2
Patient’s characteristics.
Gender: Female Male Age: %20 21–30 31–40 41–50 51–60 60C
No. of patients
(%)
No. of teeth extracted
(%)
56 67
45.5 54.5
77 107
41.8 58.2
10 40 37 30 5 1
8.1 32.5 30.1 24.4 4.1 0.8
11 61 51 50 10 1
6 33.2 27.7 27.2 5.4 0.5
Figure 2 Percentage distribution of extraction reasons in each age group.
Discussion
Percentage of teeth extracted
females. By contrast, PD was the reason for greater percent of extraction in females than in males (36.4 and 34.6%, respectively). Within the different age groups, caries accounted for most of tooth extractions carried out or planned for up to 50 years of age (Fig. 2). However, among patients of 51 years and older, PD has become the dominant reason? Moreover, all teeth removed due to surgical indications were removed between the age 21 and 30 years. The teeth most frequently extracted were mostly posteriors (155) comprising 84.2% of teeth in contrast to only 29 anterior teeth. It is worthy of note that posterior teeth were mostly extracted because of caries whereas anterior teeth were lost more due to PD. Extraction of posterior teeth because of caries was common between 21 and 40 years of age, while periodontal extraction of all teeth types was more frequent over 31 years of age. However, extraction of anterior teeth was rare in patients 20 years old or less.
70 Females Males
60 50 40 30 20 10 0
Caries
Perio Surgical Extraction reasons
Request
Figure 1 Percentage distribution of extraction reasons for females and males.
The results of this study should be interpreted with caution as the sample size is small and the study was done in one area in Afghanistan, which is, Mazar-i-Sharif, so it is not necessarily representative of the Afghan population. What’s more is that patients under study are a selected Afghan subpopulation seeking free and updated dental treatment. In our patient sample, there were more men than women; this might be due to cultural restrictions on mobility of Afghan women in all parts of Afghanistan, or could be explained by differences between sexes regarding how much aesthetics is important. None of the extractions performed in this study were due to orthodontic or pre-prosthetic reasons. This is because these therapeutic procedures are financially and technically demanding, especially in a country like Afghanistan where people thrive to eat and live in peace rather than looking for replacement of missing teeth or improvement of appearance. Multiple tooth loss was higher in men compared to women. This is probably because men prefer tooth extraction rather than restorative options as they are exposed to financial and security pressures leaving them with insufficient time to attend the dental clinic seeking complicated restorative treatment. Our finding that caries was the leading reason for extraction may be attributed to the pattern of attendance to dental clinic where our sample populations are irregular patients with cultural and financial barriers to dental care. Also, the persistence of caries as the main cause of tooth loss in older age groups, reported here, could be due to the failure of long-standing restorations rather than the appearance of new carious lesions, since dental caries is a disease of the young. This suggests
Reasons for permanent tooth extraction in the North of Afghanistan the need for regular check-ups, to maintain restorations throughout life and thus minimizing tooth extraction as a whole. Posterior teeth were extracted more than anterior teeth, mostly due to caries, may be because posterior teeth are more involved in mastication and thus exposed to a greater risk of caries. Anterior teeth in the contrary are more accessible for complicated restorative and endodontic treatment and extraction of these teeth may also be delayed as long as possible for aesthetic concerns. Furthermore, anterior teeth, which escape extraction due to caries in young patients perhaps because they are relatively resistant to caries, but still ultimately susceptible to PD, will be lost as the patient becomes older. In conclusion, reasons for tooth extraction in the present study reflect the extent and severity of
51
caries and PD as the most common reasons for tooth loss in the North of Afghanistan. Therefore, improvement in oral health, particularly prevention of dental caries and proper periodontal assessment and treatment, is of paramount importance if patients are to maintain a healthy and functional dentition throughout life. Moreover, further larger studies are recommended to see whether there are variations in tooth extraction patterns between different parts of Afghanistan, and to monitor changes in extraction patterns over time.
References 1. http://www.who.int/GlobalAtlas/DataQuery/ViewData.asp. 2. Leous P. Oral health care in Afghanistan—assignment report;1991 WHO/Geneva.
www.intl.elsevierhealth.com/journals/jden
Reasons for permanent tooth extraction in the North of Afghanistan Da’ameh Da’ameh* Division of Periodontology, Dental Corps, Royal Medical Services, P.O. Box 107, Rusaifa 13710, Jordan Received 3 September 2004; received in revised form 18 January 2005; accepted 3 February 2005
KEYWORDS Tooth extraction; Reasons; Caries; Periodontal disease
Summary Objectives: The aim of this study was to study the pattern of and reasons for permanent tooth extraction in a group of Afghan patients attending a dental clinic in the North of Afghanistan. Methods: A simple clinical survey was done in Afghan population sample that has undergone or planned for tooth extraction. Results: A total of 184 permanent teeth were extracted from 123 patients ranging in age from 9 to 62 years during the three-month study period. Males were 54.5% while females formed 45.5%. Overall, caries was the most frequent reason for tooth extraction (59.2%), followed by periodontal disease (35.3%), surgical indications (4.9%) and patient request (0.5%). Caries was the main reason for tooth loss up to 50 years of age. However, periodontal disease became the principal reason in 51 years old and over. Posterior teeth represented the highest percentage (84.2%) of extraction. Conclusions: Both caries and periodontal disease were the main reasons for tooth extraction in the North of Afghanistan, so that proper oral health system including efficient programs focusing on prevention and treatment of these diseases should be created and developed. Q 2005 Published by Elsevier Ltd.
Introduction Oral health requires the retention of permanent teeth as long as possible because our teeth are important for chewing, smiling, and speaking. Equally, loss of these teeth will adversely affect our quality of life: biologically, psychologically and socially, therefore extraction of permanent teeth
* Tel./fax: C962 5 3751417. E-mail address: [email protected]
0300-5712/$ - see front matter Q 2005 Published by Elsevier Ltd. doi:10.1016/j.jdent.2005.02.009
should only be carried out if strongly recommended as part of a carefully planned dental treatment. In Afghanistan, health sector, as all other sectors is in a state of collapse with a severe shortage in human and material resources; this is since more than two decades of violent conflicts that have torn the country apart. Human resources for health are: 19 physicians, three dentists, two pharmacists and 22 nurses and midwives per100,000 populations.1 The oral health manpower—in specific—is only192 dentists and 268 chair-side assistants all over the country.2 Moreover, no published studies on oral/dental health status in Afghanistan where found in electronic databases except an assignment
Reasons for permanent tooth extraction in the North of Afghanistan report of the prevalence of dental caries by Leous P 1991.2 The report showed dft index for 3–4, and 5–6 years age groups to be 3.4 and 2.0, respectively, while DMFT for 7–12, 13–15 and 35–44 age groups were 2.9, 3.8 and 8.3. Mazar-i-Sharif is the largest city in the North of Afghanistan. People come to it from the various rural surrounding areas and therefore it has a heterogeneous society but with no definitive known demographic profile in terms of number of population, age, socioeconomic status, etc. This study is the first in Mazar-i-Sharif to investigate the pattern of and reasons for permanent teeth extraction and to assess dental needs and treatment.
Materials and methods A simple clinical survey was performed at the dental clinic of the Jordanian Military Field Hospital in Mazar-i-Sharif into which the people come seeking free and updated medical as well as dental care. All patients who came seeking extraction of permanent teeth during the study period (December 2002–February 2003) were included. The aims of the study were described for each patient and a consent form was signed. Data were collected by the only dentist available in the hospital, who made the diagnosis and provided the treatment. Age and gender of the patients in addition to teeth extracted or planned for and the main reason for extraction seen by
Table 1
49
the dentist according to certain criteria (Table 1) were recorded. Data were entered into the PC using SPSSw (version 10) software and descriptive statistics were applied.
Results A total of 184 teeth were either extracted or planned for from 123 patients with a mean of 1.5 teeth per person. Certain demographic data of patients are shown in Table 2. The patients’ age range was from 9 to 62 years while the median age was 33.0. Patients were mostly males (54.5%), while females formed 45.5%. Female patients had 77 teeth extracted or planned for, comprising 41.8% of the total teeth extracted. Males having their teeth extracted were most commonly in the 21–30-year age group (57.5%) while females were in the 31–40-year age group (51.4%). Out of 123 patients, 30 patients have undergone multiple teeth extraction. It was more in males compared to females, 60 and 40% respectively and increased with age. Dental caries accounted for the majority of extractions (59.2%), while extractions due to periodontal disease (PD) and surgical reasons (35.3 and 4.9%, respectively) were less. Patient request accounted for the remaining (0.5%) while none of the extractions were due to orthodontic, pre-prosthetic, or other reasons. Caries was the main reason for extraction in both males and females (Fig. 1). It accounted for 64.5% of extractions in males and 51.9% of extractions in
Criteria for extraction categories.
Extraction reason
Criteria
Caries
Initial and recurrent caries, all sequelae of caries including extraction of roots where the crown was lost through caries and teeth fracturing due to weakening by caries. Failed root treatment where the tooth was initially root treated because of caries Where pain, loss of function or pocketing due to periodontal disease requires that the tooth be extracted Teeth extracted to prevent or correct malocclusion, be they impacted, incompletely erupted or supernumerary Teeth which are extracted because their removal facilitates a better prosthetic restoration Teeth lost as a result of trauma (including jaw fractures), pericoronitis, unerupted or partially impacted teeth and oral mucosal lesions Teeth extracted because the patient prefers extraction to other treatments or requests a clearance and dentures. Also in this category extractions performed due to the patient’s behavior or fear which prevents conservative care being carried out If the reasons for extracting a tooth are not encompassed by the above categories the reason should be stated clearly
Periodontal disease Orthodontic Pre-prosthetic Surgical Patient request
Others
50
D. Da’ameh
Table 2
Patient’s characteristics.
Gender: Female Male Age: %20 21–30 31–40 41–50 51–60 60C
No. of patients
(%)
No. of teeth extracted
(%)
56 67
45.5 54.5
77 107
41.8 58.2
10 40 37 30 5 1
8.1 32.5 30.1 24.4 4.1 0.8
11 61 51 50 10 1
6 33.2 27.7 27.2 5.4 0.5
Figure 2 Percentage distribution of extraction reasons in each age group.
Discussion
Percentage of teeth extracted
females. By contrast, PD was the reason for greater percent of extraction in females than in males (36.4 and 34.6%, respectively). Within the different age groups, caries accounted for most of tooth extractions carried out or planned for up to 50 years of age (Fig. 2). However, among patients of 51 years and older, PD has become the dominant reason? Moreover, all teeth removed due to surgical indications were removed between the age 21 and 30 years. The teeth most frequently extracted were mostly posteriors (155) comprising 84.2% of teeth in contrast to only 29 anterior teeth. It is worthy of note that posterior teeth were mostly extracted because of caries whereas anterior teeth were lost more due to PD. Extraction of posterior teeth because of caries was common between 21 and 40 years of age, while periodontal extraction of all teeth types was more frequent over 31 years of age. However, extraction of anterior teeth was rare in patients 20 years old or less.
70 Females Males
60 50 40 30 20 10 0
Caries
Perio Surgical Extraction reasons
Request
Figure 1 Percentage distribution of extraction reasons for females and males.
The results of this study should be interpreted with caution as the sample size is small and the study was done in one area in Afghanistan, which is, Mazar-i-Sharif, so it is not necessarily representative of the Afghan population. What’s more is that patients under study are a selected Afghan subpopulation seeking free and updated dental treatment. In our patient sample, there were more men than women; this might be due to cultural restrictions on mobility of Afghan women in all parts of Afghanistan, or could be explained by differences between sexes regarding how much aesthetics is important. None of the extractions performed in this study were due to orthodontic or pre-prosthetic reasons. This is because these therapeutic procedures are financially and technically demanding, especially in a country like Afghanistan where people thrive to eat and live in peace rather than looking for replacement of missing teeth or improvement of appearance. Multiple tooth loss was higher in men compared to women. This is probably because men prefer tooth extraction rather than restorative options as they are exposed to financial and security pressures leaving them with insufficient time to attend the dental clinic seeking complicated restorative treatment. Our finding that caries was the leading reason for extraction may be attributed to the pattern of attendance to dental clinic where our sample populations are irregular patients with cultural and financial barriers to dental care. Also, the persistence of caries as the main cause of tooth loss in older age groups, reported here, could be due to the failure of long-standing restorations rather than the appearance of new carious lesions, since dental caries is a disease of the young. This suggests
Reasons for permanent tooth extraction in the North of Afghanistan the need for regular check-ups, to maintain restorations throughout life and thus minimizing tooth extraction as a whole. Posterior teeth were extracted more than anterior teeth, mostly due to caries, may be because posterior teeth are more involved in mastication and thus exposed to a greater risk of caries. Anterior teeth in the contrary are more accessible for complicated restorative and endodontic treatment and extraction of these teeth may also be delayed as long as possible for aesthetic concerns. Furthermore, anterior teeth, which escape extraction due to caries in young patients perhaps because they are relatively resistant to caries, but still ultimately susceptible to PD, will be lost as the patient becomes older. In conclusion, reasons for tooth extraction in the present study reflect the extent and severity of
51
caries and PD as the most common reasons for tooth loss in the North of Afghanistan. Therefore, improvement in oral health, particularly prevention of dental caries and proper periodontal assessment and treatment, is of paramount importance if patients are to maintain a healthy and functional dentition throughout life. Moreover, further larger studies are recommended to see whether there are variations in tooth extraction patterns between different parts of Afghanistan, and to monitor changes in extraction patterns over time.
References 1. http://www.who.int/GlobalAtlas/DataQuery/ViewData.asp. 2. Leous P. Oral health care in Afghanistan—assignment report;1991 WHO/Geneva.