Abstract
Purpose
Dental caries are an emerging public health problem in developing countries in the last two decades. However, there is a paucity of data on dental caries in northwest Ethiopia. This study investigated the prevalence of dental caries and associated factors in northwest Ethiopia.
Patients and Methods
A hospital-based cross-sectional study was conducted in 368 patients who visited the University of Gondar Comprehensive Hospital Dental Clinic. A systematic random sampling technique was used to select the samples. Data were collected by three qualified dental surgeons using a pre-designed questionnaire modified from a WHO oral health survey and the clinical examination was done using the WHO dental caries diagnosis guideline. Data analysis was done using SPSS 20. Descriptive data were presented in tables and logistic regression analysis was done to identify the possible predisposing factors using odds ratios with 95% confidence interval.
Results
The prevalence of dental caries in this study was 23.64% (95% CI: 19.30, 28.00) with a significant difference between females (30.56%) and males (17.02%). Being female (AOR=2.15 (95% CI: 1.31, 3.52), poor oral hygiene practice (AOR=2.44 (95% CI: 1.46, 4.07), being diabetic (AOR=8.15 (95% CI: 3.2, 20.75), low educational level (AOR=1.81 (95% CI: 1.05, 3.1), low monthly income (AOR=3.05 (95% CI: 1.54, 6.02) and halitosis (AOR=10.98 (95% CI: 5.68, 2.24) were significantly associated with dental caries. The mean DMFT score was 1.095±0.24 (SD). The majority of the DMFT (70.59%) was due to decay, while filled tooth accounted for only 2.17% of the DMFT. The DMFT score was higher in females (0.625), urban residents (0.85), and those with montly income of ≤2500 Ethiopian birr (0.86). The mean DMFT was 0.13.
Conclusion
The prevalence of dental caries in the study participants was 23.64% andwas higher in males than females and in diabetic patients. Female gender, poor tooth brushing habits, diabetes mellitus, and halitosis were significant predictors associated with dental caries.
Keywords: dental caries, tooth decay, DMFT, predisposing factors, oral hygiene practice
Background
Dental caries is a bacterial infectious disease of the hard tissue of the tooth by the interaction of cariogenic bacteria and easily fermentable carbohydrates.1 Dental caries is one of the major orofacial problem and indicator of the burden of oral health throughout the globe.2,3 Even if, the prevalence of dental caries varies from country to country, it is a fact that the disease has a wide geographic distribution, high prevalence, and graded severity.2,4 The prevalence was higher in minority and economically poor community.5
Dental caries affects the quality of life of the affected patients and highly affect the economy of the individual and society. The presence of carious tooth affects work performance, eating and speaking and also impair the growth and development.6,7
In the last two decades, the prevalence of dental caries has declined in developed countries,8 while it showed a dramatic increase in the developing countries due to unaffordability of the dental services, and unavailability of dental clinics in rural settings.9 A national survey done in Malawi showed 49.0% of 35–44 years adults had dental caries and the prevalence becomes 49.2% in 65–74 years. Moreover, the mean DMFT was raised as age increases from 12 years (DMFT=0.67) to 65–74 years (DMFT=6.87).10 A study done in Eritrea showed 78% of the participants had dental caries and the prevalence of dental caries in Ethiopia was ranged from 36.3%-78.2%.11,12 Another study conducted in Turkey revealed females were 1.83 times at risk of developing dental caries.13 Lower socioeconomic status has a significant effect on the occurrence of dental caries in adults.11
The emerging of increased consumption of fermentable carbohydrates, low level of awareness about oral health, poor tooth brushing habits, and scarcity of dental centers are the possible factors for the increased prevalence of dental caries in developing countries.14,15 Moreover, change in way of life, eating habits, and socio-demographic factors also increase the prevalence of dental caries.7,13,16,17
To date, there is a paucity of data on the prevalence and associated factors of dental caries in the study area. Due to this, the present study aimed to determine the prevalence of dental caries and associated factors in patients who visited the dental clinic of the University of Gondar specialized hospital.
Patients and Methods
Setting
This cross-sectional study was done at the University of Gondar comprehensive Hospital dental clinic from September 1, 2019-December 31, 2019. University of Gondar specialized hospital provides health care services over 5 million people and it’s located 750km from Addis Ababa, the capital city of Ethiopia. The dental clinic is one of the Specialty clinics in the hospital that provides inpatient and outpatient dental health services for the population in the area.
Study Participants
All populations in the catchment area were the source population for the study and those who were 6 and above and visited the dental clinic of the University of Gondar would be included in the study. Patients with 6 and above years were examined for dental caries. All patients who visited the dental clinic within the study period and signed the consent form were included and examined for the presence of dental caries.
Exclusion Criteria
Critically ill patients
A patient with a dental emergency
Patients refused to sign the consent
Sampling Technique and Procedure
A sample size of 368 participants was selected using the single population proportion formula
N= Z2p (1-p)
d2
With the following assumptions; The prevalence of dental caries (P) to be 78.2% as estimated in Debre tabor hospital, Ethiopia,11 confidence level (CI) of 95%, marginal error (d=5), and non-response rate of 10%.
Sampling Procedure
Systematic random sampling would be used (k=4). The first participant was selected by a simple random method.
Data Collection
A structured questionnaire, modified from WHO oral health survey 2013,18 was prepared and a face to face interview was conducted in the dental clinic. The interview questionnaire was developed in English, translated into the local language of Amharic, and back into English. Two dental professionals reviewed the questionnaire for its clearness, sensitivity to culture, and the presence of appropriate words to the community. A pilot study was done in 40 patients before the administration of data collection. The data collected were socio-demographic characteristics, tooth brushing habits, dietary habits, and other medical conditions. The PI trained the data collectors for 2 days on how to approach, interview, maintaining confidentiality, and research ethics. A day to day supervision was made by the PI to check the completeness of the questionnaires.
Intra-Oral Examination
The intra-oral examination was done according to the WHO oral health survey guideline18 using dental probes, dental mirrors, and tissue forceps. A patient was considered to be carious if a lesion in a pit or fissure or on the smooth tooth surface had a detectable softened floor, or undermined enamel. A Tooth was considered to be missing because of caries if a person gave a history of pain and/or the presence of the cavity before extraction. The severity or experience of dental caries was evaluated by using the mean DMFT (permanent tooth) and dmft (primary dentition). The dentist did an intra-oral dental x-ray when it was indicated.
Data Analysis
Each questionnaire was checked for completeness before fed into a computer. The study variables were coded and entered into Epi-Info version 7 and transferred to SPSS version 20 for analysis. Descriptive statistics were computed. The association between the independent variables and dental caries was initially investigated using bivariate analysis and those with a p-value of ≤0. 25 were included in the multivariable analysis. Results were presented using OR with its 95% CI.
Ethical Consideration
Ethical approval was sought from the University of Gondar ethical review board (IRB) before the commencement of the study. Besides, a study permit was acquired from the University of Gondar Department of Dentistry. Written consent was obtained from the participants, and written assent was taken from parents or legal guardians for under 18 years. All patients with pain were managed as an emergency during their visit to the dental clinic.
Results
Socio-demographic characteristics of the participants
The mean age of the study participants was 30±14.766 SD years and 1/3rd of the participants were within the age group of 20–29 years (37.2%). Out of 368 participants, 180 (48.9%) were females. The majority of the study participants were orthodox (89.7%), and from urban residents (78.8%).
More than 2/3rd of the participants (73.6%) had a monthly income of ≤2500 Ethiopian birr and 77.4% of the participants had formal education (Table 1).
Table 1.
Socio-Demographic Characteristics of the Patients Attended University of Gondar Comprehensive Hospital Dental Clinic (n=368)
| Variable | Number | Percent | |
|---|---|---|---|
| Age (years) | <20 | 68 | 18.5 |
| 20–29 | 137 | 37.2 | |
| 30–39 | 92 | 25.0 | |
| 40–49 | 26 | 7.1 | |
| ≥50 | 45 | 12.2 | |
| Gender | Male | 188 | 51.1 |
| Female | 180 | 48.9 | |
| Marital status | Single | 169 | 45.9 |
| Married | 184 | 50.0 | |
| Divorced | 15 | 4.1 | |
| Occupation | Farmer | 54 | 14.7 |
| Student | 128 | 34.8 | |
| Governmental employee | 68 | 18.5 | |
| NGO-employee | 9 | 2.4 | |
| Merchant/Personal business | 109 | 29.6 | |
| Religion | Orthodox | 330 | 89.7 |
| Muslim | 23 | 6.3 | |
| Protestant | 8 | 2.2 | |
| Catholic | 7 | 1.9 | |
| Residency | Urban | 290 | 78.8 |
| Rural | 78 | 21.2 | |
| Monthly income | ≤2500 ETB | 271 | 73.6 |
| >2500 ETB | 97 | 26.4 | |
| Educational status | Has no Formal education | 83 | 22.6 |
| Has formal education | 285 | 77.4 | |
Oral hygiene practice of the participants
More than 2/3rd (73.1%) of the participants had tooth brushing habit and of them, 31.0% had no fixed time to brush their teeth. Only 7.5% of the participants brushed their teeth twice/day. A traditional tooth brushing stick (“Mefakia”) (48.7%%) and a toothbrush with paste (49.8%) were the commonly used materials by the participants (Table 2).
Table 2.
Oral Hygiene Habits and Practice of the Participants (Self-Reported)
| The Habit of Tooth Brushing | Number | Percentage | |
|---|---|---|---|
| Toothbrush | Yes | 269 | 73.1 |
| No | 99 | 26.9 | |
| Frequency of tooth brushing | ≥3 times/day | 4 | 1.5 |
| Twice/day | 20 | 7.4 | |
| Once/day | 76 | 28.3 | |
| Irregularly | 169 | 62.8 | |
| Time of tooth brushing | Before bed | 11 | 4.1 |
| Morning | 117 | 43.5 | |
| Both in the morning and before bed | 27 | 10.0 | |
| No fixed time | 114 | 42.4 | |
| Material for tooth brushing | Mefakia (traditional stick) | 131 | 48.7 |
| Toothbrush with paste | 134 | 49.8 | |
| Charcoal | 4 | 1.5 | |
Dietary habits, Smoking habits, and other systemic diseases
The majority of the study participants (74.2%) had consumed fermentable carbohydrates. Hot drinks (Tea and coffee) and soft beverages were commonly used carbohydrates by the participants (Table 3).
Table 3.
Carbohydrate Intake, Smoking and Presence of Other Chronic Medical Illness Among the Study Participants
| Frequency | Percentage | ||
|---|---|---|---|
| Carbohydrate consumption | Yes | 273 | 74.2 |
| No | 95 | 25.8 | |
| Type of carbohydrate taken | Candy | 24 | 8.8 |
| Soft beverages | 78 | 28.6 | |
| Chewing gum | 33 | 12.1 | |
| Tea | 112 | 41.0 | |
| Others | 26 | 9.5 | |
| Smoking habits | Yes | 23 | 8.4 |
| No | 337 | 91.6 | |
| Frequency of smoking | Sometimes | 12 | 52.2 |
| Once/day | 4 | 17.4 | |
| 3 times/day | 4 | 17.4 | |
| >3 times/day | 3 | 13.0 | |
| Diabetic mellitus patient | Yes | 22 | 5.9 |
| No | 346 | 94.1 | |
| History of hypertension | Yes | 11 | 3.0 |
| No | 357 | 97.0 | |
Twenty-three (8.4%) participants were smokers, 5.9% were diabetic patients (DM) and 3% were hypertensive patients (Table 3).
Prevalence of Dental Caries
The prevalence of dental caries was 23.64% (95% CI: 19.30, 28.00) and the lower 1st molar was the commonly affected (56.7%) tooth. Females had a higher prevalence of dental caries than Males (30.6% vs 17.0%) and the prevalence was higher in rural residents than the urban residents (30.8% vs 21.7%, p=0.095). The prevalence was high in a patient with halitosis (42.26%), DM (68.2%), and malocclusion (40.0%) (Table 4).
Table 4.
Prevalence of Dental Caries Based on the Sociodemographic Characteristics and Other Factors
| Variables | Dental Caries | |||
|---|---|---|---|---|
| Yes No (%) | No No (%) | P value | ||
| Gender | Male | 32(17.0) | 156(83.0) | 0.002 |
| Female | 55(30.6) | 125(69.4) | ||
| Age (years) | <20 | 16 (23.5) | 52(76.5) | 0.477 |
| 20–29 | 32 (23.4) | 105(76.6) | ||
| 30–39 | 27(29.3) | 65(70.7) | ||
| 40–49 | 4 (15.4) | 22 (84.6) | ||
| ≥50 | 8(17.8) | 37(82.2) | ||
| Marital status | Single | 36(21.3) | 133(78.7) | 0.033 |
| Married | 51 (27.7) | 133(72.3) | ||
| Divorced | 0 (0.0) | 15(100) | ||
| Educational status | Has no formal education | 27(32.5) | 56(67.5) | 0.061 |
| Has formal education | 60(21.1) | 225(78.9) | ||
| Occupation | Farmer | 12(22.2) | 42(77.8) | 0.013 |
| Student | 32(25.0) | 96(75.0) | ||
| Governmental employee | 8(11.8) | 60(88.2) | ||
| NGO-employee | 0(0) | 9(100) | ||
| Merchant/personal business | 35(32.1) | 74(67.9) | ||
| Religion | Orthodox | 75(27.7) | 255(77.3) | 0.098 |
| Muslim | 4(17.4) | 19(82.6) | ||
| Protestant | 1(12.5) | 7(87.5) | ||
| Catholic | 7(100) | 0(0) | ||
| Residency | Urban | 63(21.7) | 227(78.3) | 0.095 |
| Rural | 24 (30.8) | 54(69.2) | ||
| Monthly income | ≤25,000 ETB | 76(28.0) | 195(72.0) | 0.000 |
| > 2500 ETB | 11(11.3) | 86(88.7) | ||
| Tooth brushing habits | Yes | 51(18.9) | 218(81.1) | 0.001 |
| No | 36(36.4) | 63(63.6) | ||
| Consumption of sugary foods | Yes | 71(26.0) | 202(74.0) | 0.045 |
| No | 16(16.8) | 79(83.2) | ||
| Smoking habits | Yes | 8(34.8) | 15(65.2) | 0.429 |
| No | 63(23.0) | 211(77.0) | ||
| Has Diabetic mellitus | Yes | 15(68.2) | 7(31.8) | 0.000 |
| No | 72(20.8) | 274(79.2) | ||
| Hypertension history | Yes | 5(45.5) | 6(54.5) | 0.049 |
| No | 82(22.9) | 275(77.1) | ||
| Halitosis | Yes | 75(43.6) | 97(54.4) | 0.000 |
| No | 12(6.1) | 184(93.9) | ||
| Malocclusion | Yes | 8(40.0) | 12(60.0) | 0.072 |
| No | 79(22.7)) | 269(77.3) | ||
Decayed, Missed and Filled Tooth (DMFT)
The mean DMFT of the study participants was 1.095±0.24 (SD). The decayed part accounts for 70.59% of the DMFT value and it’s lonely contributes 0.78 of the mean DMFT. Filled tooth accounts only 2.17% of the mean DMFT. The DMFT score was higher in females (0.625), urban residents (0.85), and monthly income of ≤2500 Ethiopian birr (0.86) The mean dmft was 0.13 (Table 5).
Table 5.
The Mean DMFT Scores Based on Sex, Residency and Monthly Income of the Participants
| Characteristics | Permanent Dentition (DMFT) | Primary Dentition (dmft) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Decayed | Missed | Filled | DMFT | Decayed | Missed | Filled | Dmft | ||
| Gender | Male | 126 | 43 | 4 | 0.47 | 25 | 15 | 0 | 0.11 |
| Female | 162 | 64 | 4 | 0.63 | 0 | 6 | 0 | 0.02 | |
| Residency | Urban | 225 | 81 | 8 | 0.85 | 20 | 14 | 0 | 0.08 |
| Rural | 63 | 26 | 0 | 0.24 | 5 | 7 | 0 | 0.05 | |
| Monthly income | ≤2500ETB* | 223 | 87 | 8 | 0.86 | 8 | 6 | 0 | 0.04 |
| >2500ETB* | 65 | 20 | 0 | 0.23 | 17 | 15 | 0 | 0.09 | |
| Mean DMFT | 1.09±0.24 | Mean dmft | .13 | ||||||
Note: *ETB: Ethiopian birr.
Logistic Regression Analysis
The factors which had a significant association in the bivariate analysis entered into the multivariable logistic regression model as independent variables for the outcome of dental caries.
The analysis found a significant association between dental caries and gender (AOR=2.15 (1.31 3.52), P=0.002), low educational status (AOR=1.81 (1.05,3.1), P=0.036), monthly income of <2500 Ethiopian birr (AOR=3.05 (1.54, 6.02), P=0.000), poor tooth brushing habit (AOR=2.44 (95% CI: 1.46, 4.07, P=0.004) presence of self-perceived halitosis (AOR=10.98 (5.68, 21.24),P=0.000) and a patient on diabetes mellitus (DM) (AOR=8.15 (3.2, 20.75),P=<0.0001). A patient with a known hypertension history was 2.79 times at risk of developing dental caries, however, the association was not significant (P=0.13) (see Table 6).
Table 6.
Multivariate Analyses of Variables Associated with Dental Caries Among Patients Visited the Dental Clinic of the University of Gondar Comprehensive Hospital, Gondar, Ethiopia, 2019
| Variables | Dental Caries | AOR (95% CI) | P-value | ||
|---|---|---|---|---|---|
| No (%) | Yes (%) | ||||
| Gender | Male | 156 (82.9) | 32 (17.1) | 1 | 0.002 |
| Female | 125 (69.4) | 55(30.6) | 2.15 (1.31 3.52) | ||
| Educational status | No formal education | 56(66.7) | 27 (33.3) | 1.81(1.05,3.1) | 0.036 |
| Has formal education | 224(78.9) | 60 (21.1) | 1 | ||
| Monthly income | ≤2500 ETB | 195(71.9) | 76(28.1) | 3.05(1.54, 6.02) | 0.000 |
| >2500 ETB | 86(88.7) | 11(11.3) | 1 | ||
| Tooth brushing habits | Yes | 218 (81.0) | 51(19.0) | 1 | 0.004 |
| No | 63 (63.6) | 36 (36.4) | 2.44(95% CI: 1.46, 4.07, | ||
| Halitosis | Yes | 97(57.7) | 71(42.3) | 10.98 (5.68, 21.24) | 0.000 |
| No | 180(93.8) | 12(6.2) | 1 | ||
| History of DM | Yes | 7(31.8) | 15(68.2) | 8.15(3.2, 20.75) | 0.0001 |
| No | 274 (79.2) | 72(20.8) | 1 | ||
| History of HTN | Yes | 6 (54.5) | 5(45.5) | 2.79(0.83, 9.39) | 0.13 |
| No | 275(77.0) | 82(23) | 1 | ||
Discussion
This study attempted to investigate the prevalence of dental caries among patients attended the University of Gondar Comprehensive Hospital dental clinic. The overall prevalence of dental caries was 23.64% (95% CI: 19.30, 28.00) which was consistent with a study done in Bahir Dar (21.8%),19 and Nigeria (25.3%),20 and lower than the study done in Debre tabor Hospital (78.2%), Gondar (36.3%),12 Addis Ababa (47.4%),21 Axsum (35.4%),22 Finote Selam (48.5%),23 Sudan (42%),24 Kosovo (72.80%)25 and Eritrea (78%).26 This difference might be due to the study population variation and the sociodemographic difference between the countries.
The present study found that dental caries were high in females where females are 2.15 times at risk of developing dental caries (AOR=2.15 (1.31 3.52), p=0.002) which is consistent with a study done in Turkey27 and Canada.28 The high prevalence of dental caries in females might be due to the earlier eruption of a tooth in Girls, frequent Snacking by females, and pregnancy.
The prevalence of dental caries was higher in lower- income than higher-income participants (AOR=3.05 95% CI: 1.54, 6.02). The difference in the prevalence of dental caries according to the socioeconomic status was observed in a study done in Debre Tabor (AOR = 8.43, 95% CI, 2.6, 27.2).11 The high prevalence might be due to the unaffordability of dental services and oral hygiene maintaining materials.
A significantly higher prevalence of dental caries was recorded in participants with poor oral hygiene practice than among a subject who had a habit of tooth brushing (AOR=2.44, 95% CI: 1.46, 4.07), which coincides with the results of Finote Selam,23 Bahir Dar19 and Debre Tabor.11 More than 2/3rd (73.1%) of the study participants had tooth brushing habits. However, only 7.5% of the participants brushed their teeth twice/day.
This study found a higher prevalence of dental caries among DM patients than non-DM patients, which is similar to a previous study.29 A patient with true halitosis was 10.98 times at risk of developing dental caries than a patient without halitosis (AOR=10.98 (5.68, 21.24)). The high prevalence of dental caries might be due to the presence of poor oral hygiene practice and calculus accumulation in patients with self-perceived halitosis.
The mean DMFT of the present study was 1.095 where the decayed part accounts for 70.59% of the DMFT values and the filled tooth accounts only 2.17% of the mean DMFT which is relatively similar to a study done in Jimma30 and Finote Selam.23 However, this result is lower compared with a study done in Eritrea (DMFT= 2.50 (±2.21)),26 Kenya (DMFT= 3.9),31 Uganda (DMFT=4.71),32 and Turkey (11.44).27
Limitations
This study had some inherent limitations. First, the study focused on patients who attended the dental clinic and we hope they have some sort of knowledge of dentistry. Even if there are a lot of factors that affect the occurrence of dental caries, we only targeted individual-level factors. So, the coming researchers should focus on factors such as; service providers, barriers, and community water fluoridation.
Strengths of the Study
The first strength was study participants were selected randomly in a systematic way and this reduces the selection bias. The second was the questionnaire was adapted from WHO oral health survey 5th edition and we make some modifications and the pre-test was done on 10% of the participants before the actual study.
Conclusion
The prevalence of dental caries in the study participants was 23.64%, higher in females than males and in diabetic patients. Female gender, poor tooth brushing habits, diabetes mellitus, and halitosis were significant predictors associated with dental caries. To reduce the prevalence of dental caries and minimize its impact on the population oral health education should be given at school level and community-based oral health education programs should be designed.
Acknowledgments
Our earnest gratitude goes to the University of Gondar Institutional Review Board (IRB) for their review and approval of this research paper. Our sincere gratitude and appreciation is also forwarded to data collectors and participants, without their involvement, it wouldn’t have been realized.
Funding Statement
There was no external funding for this research.
Abbreviations
AOR, adjusted odds ratio; DMFT, Decayed, Missed and Filled tooth; OR, Odds Ratio; SD, Standard Deviation; SPSS, Statistical package for social sciences; WHO, World Health Organization.
Data Sharing Statement
All the related data are available within the manuscript.
Ethics Approval and Consent to Participate
Ethical clearance was obtained from the University of Gondar IRB office. Before the commencement of the study, a formal letter was given to the department of dentistry. Written consent was obtained from each study participant after explaining the purpose of the study. Parent or legal guardian provided written informed consent (assent) for participants under the age of 18 years. All the participants were informed about the confidentiality of their information. (IRB number: V/P/RCS/05/149/2019).
Author Contributions
All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; gave final approval of the version to be published, and agree to be accountable for all aspects of the work.
Disclosure
The authors report no conflicts of interest in this work.
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