WHAT ARE THE CAUSES FOR TOOTH EXTRACTION?

A PROJECT REPORT PRESENTED BY

S.R. GUNAWARDANE (D/07/023) D.M.J.H. DISSANAYAKE (D/07/017) D.E.N. ALWIS (D/07/001)

To the Division of Community Dentistry Faculty of Dental Sciences

In partial fulfillment of the requirement For the award of degree of

Bachelor of Dental Sciences Of the

UNIVERSITY OF PERADENIYA SRI LANKA 2013

CONTENT PAGES

Chapter 01. Introduction 01.1. General Introduction 01.2. Research Background 01.3. Problem Justification 01.4. Literature Review 01.5 Objectives 01.5.1. General Objective 01.5.2. Specific Objective 02. Methodology 02.1. Research Questions 02.2. Study Design 02.3. Study Area 02.4. Inclusion and Exclusion Criteria 02.5. Study Population 02.6. Instruments Used for the Study 02.7. Pilot Study 02.8. Data Collection 02.9. Analysis of Data 03. Results 03.1. Socio- Demographic Data of the Study Population 03.3. Association of Causes of extraction with Socio- Demographic Data 05. Discussion 06. Conclusion 07. Limitation 08. Recommendation References Annexure

Pages 01 01 02 02 03 04 04 04 05 05 05 05 05 05 06 06 06 06 09 09 10 17 21 22 23 24 25

LIST OF FIGURES
Figure 01 - Distribution of reasons for tooth extractions varied in different age groups Figure 02 - Distribution of total extraction and tooth type with Residence Figure 03 - Distribution of Causes of extraction with Residence

Figure 04 - Distribution of tooth extraction in different age groups in rural & urban area Figure 05 - Distribution of reasons for tooth extraction with the level of education Figure 06 - Distribution of causes for extraction and economical state

LIST OF TABLES
Table 01 Table 02 - Reasons for tooth extractions. Results of nationwide studies. - Number and percentage of teeth extractions according to age groups including the proportions of male and Table 03 female.

- Number and percentage of extractions for different reasons for all patients & to male & female

Table 04 Table 05 Table 06

- The relationship between tooth type and the causes of tooth extraction - The relationship between the causes of extraction and residence - Relationships of causes of extraction with Ethnicity

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LIST OF ABBREVIATIONS

WHO FDI Dev. LOF Ortho Perio Prosth R U LA LP UA UP OPD DF

World Health Organization International Dental Federation Developmental Reasons Lack of facilities to preserve the tooth Orthodontic reasons Periodontal reasons Prosthetic reasons Rural Urban Lower anterior Lower posterior Upper anterior Upper posterior Outer Patient Division Degree of Freedom

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ABSTRACT

A cross sectional study was conducted to survey the extractions of permanent and deciduous teeth in Matale, Kurunegala, and Polonnaruwa districts which may reflects the pattern of oral diseases in Sri Lanka. The study was conducted with a convenience sample of 206 subjects having 290 extractions from dental clinics of Teaching Hospital Kurunegala, District General Hospital Matale, and General Hospital Polonnaruwa. The data were recorded by interviewing the dentist and patients using a questionnaire form during two weeks duration including causes of extraction (according to predefined classification) and socio- demographical data. Percentage of six most common causes (caries and its sequale, periodontal problems, eruption problems, prosthetic reasons, orthodontic reasons and other causes which are mainly patient demand for extraction) and few less common conditions were calculated by Minitab version 16, as a whole, separate for male, female, ethnicity, level of education and economical state. Results show that overall 39.66% of teeth were extracted due to advance dental caries where as 28.62% due to periodontal reasons. 11.38% due to eruption problems, 7.59% for other causes which are mainly patient demand for extraction, 6.21% due to trauma, 2.41% due to developmental conditions, 2.07% for prosthetic reasons and 1.38% for orthodontic purposes. It is noticeable 0.69% shows lack of facilities to preserve the tooth. The results of the study indicate that caries is the most frequent reason for tooth extraction in younger population both in urban and rural population with number of extractions due to periodontal reasons were increasing over 40 years of age.

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What are the causes for tooth extraction?

Chapter 01

INTRODUCTION
1.1 General Introduction Understanding the patterns and the causes for tooth loss is important for social, functional, psychological and economic reasons. Dental diseases are major public health problem in developing world which can be prevented and treated if diagnosed early. In developing world preservative treatments such as restorations, endodontic treatments are expensive for economically marginalized communities and extractions may be the easier alternative in terms of finance and time. So formulation of strategies and the planning of dental health service require the surveys and studies investigating the reasons and patterns for tooth loss, in order to achieve WHO (World Health Organization) goals of retaining at least 20 teeth at the age of 80 years in an individuals mouth which has not been achieved yet in many countries. [1] Studies investigating the causes for tooth extractions have been carried out in many countries, mostly in developed industrial Europe. [2] The result of those studies showed that dental caries and periodontal diseases were the most common causes for tooth loss which is presented in Table 1
[2]

which is abstracted from Fouad K Wahab, A survey of reasons

for extraction of permanent teeth in Jordan.

Table 1 : Reasons for tooth extractions. Results of nationwide studies.

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There seems to be an interesting variation in the order of causes of extractions among those countries, while caries accounts for 60% of extractions in Finland, it is only 20.7% in Germany. Also periodontal problems, the highest prevalence 38% was in Japan while the lowest in New Zealand which is 10%. While dental caries and periodontal disease are the most common reasons for tooth extractions, age, gender, socio- economical and attitudinal characteristics tend to influence the tooth loss of population. Studies have shown that subjects of low income and low education are more prone to be edentulous than their counterparts. [3] A study on correlation between gender and reasons for tooth extraction showed more teeth loss in less educated rural male population.
[4]

Some studies reported that, people living in

rural areas have less access to dental services than urban which leads to accumulation of tooth extraction demands in the rural population. [5] 1.2 Research Background Limited number of studies was carried out in Sri Lanka to determine prevalence of oral diseases. A study carried by Prof. Lilani Ekanayake and Dr. R. Perera about the tooth loss in Sri Lankan adults shows the overall prevalence of tooth loss is high among Sri Lankan adults which is 81.6%. [6] Few studies that have been done in the past to assess the reasons for tooth extractions in Sri Lanka reported caries and periodontal reasons are the major reason for tooth extraction. [6], [7] This study also designed to understand the causes and patterns of extraction of permanent and deciduous teeth in relation to socio demographic conditions in Sri Lanka with a convenience sample of subjects from Matale, Kurunegala and Polonnaruwa districts. 1.3 Problem justification Sri Lanka has a total population 20 million according to the WHO estimations.[11] 1375 dentists are working under ministry of health in 2012 and 200 dentists in full time working private dental practices with dentist to population ratio is 1:15000. The study population was consisting of three districts having total population of Polonnaruwa (358,984), Kurunegala (1,460,265) and Matale (441,328). [8]

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The study investigated for causes of tooth extractions were carried out during two week period of duration in Polonnaruwa, Kurunegala and Matale districts, taking account the patients age gender, ethnicity and socio demographical data. Furthermore this study may give an indication about the level of oral hygiene, dental health awareness and an insight in to magnitude of dental problems and their managements. Such data may also be of value to the improvement of dental health care system in the country, hence the purpose of this study. 1.4 Literature review 1) Tooth loss in Sri Lankan adults Perera R, Ekanayake L. The aim of this study is to determine the prevalence and correlation of tooth loss in Sri Lankan adults. This is a descriptive cross-sectional study with the target population of adults above 20 years of age in Colombo district Sri Lanka. Results The overall prevalence of tooth loss was 81.6% while 1.9% of the sample was edentulous. The prevalence rates of tooth loss in the 20-39, 40-59 and >= 60 years old were 71%, 93% and 96%, respectively, while 0%, 1.5% and 11.4% were edentulous in three groups. 2) Reasons for extractions in patients seen in Pak Field Hospital level 3 Darfur, Sudan Ajmal Yousaf, Saad Mahmood, Nasrin Yousaf, Manzoor Ahmed Manzoor This cross sectional study was conducted at Pak Field Hospital Level 3 Darfur Sudan from Jan 2011 till May 2012 to find out the reasons for extractions of teeth in UNAMID troops. 1500 patients from various countries were interviewed and examined. Results Overall 41.2% of the teeth were extracted due to advanced dental caries whereas 34.8% due to periodontal disease, 12.04% due to impactions, 4.4% for prosthetic purposes, 4.3% for orthodontic and 3.2% for other reasons. Advanced caries was the primary cause for extractions in male while impactions and orthodontic causes were the main reasons. Highest numbers of teeth were extracted due to advanced caries in patients from Nigeria (43.5%) and due to periodontal reason from patients of Bangladesh (37.1%) and Nepal (37%).

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3) Reasons for tooth extraction in urban and rural populations of Saudi Arabia Reghunathans Preethanath An epidemiological survey was carried out to ascertain the reasons and the factors that contribute to dental extractions in a rural and an urban population of Saudi Arabia. A total of 820 individuals (400 in an urban area and 420 in a rural area) aged between 20 and 80 years were included in the study. Results Caries and its sequela were responsible for more tooth loss in younger age groups in urban and rural population while extraction consequent to periodontal problem increased with age. As far as the type of tooth extracted, the most frequently extracted were mandibular posterior teeth in rural areas (40.57%) and maxillary posterior teeth in urban areas (56.0%) followed by maxillary anteriors (11.43%) and mandibular anteriors in rural areas (10.0%) respectively, which was statistically significant. Extractions from periodontal problems were more common among those with only primary education while a high frequency of extraction for orthodontic purposes was noticed in urban females with primary education. However extractions from caries followed a uniform pattern in all groups with minimum number of individuals with secondary and tertiary level of education. The observations of the study indicate that caries is the most frequent reason for tooth extraction in young population both in rural and urban populations. Extraction due to periodontal reasons predominated in the age group above 40 years. 1.5 Objectives 1.5.1 General Objective To survey the causes of tooth extraction of permanent and deciduous teeth in Matale, Kurunegala and Polonnaruwa districts which may reflect the patterns of oral diseases in Sri Lanka. 1.5.2 Specific Objective To assess relationship according to Gender Ethnicity Region Education level Economical state

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Chapter 02

METHODOLOGY
2.1 Research Questions Primary: What are the causes for tooth extraction? Secondary: What is the relationship between causes of tooth extraction and certain socio-demographic data? (Gender, Age, Ethnicity, Education Level, Economical state) 2.2 Study Design This is a cross sectional descriptive study. 2.3 Study Area This study was undertaken in three public dental clinics in Kurunegala, Matale, Polonnaruwa districts of Sri Lanka. Those were Teaching Hospital Kurunegala, District General Hospital Matale, General Hospital Polonnaruwa which are under Ministry of Health, Sri Lanka. 2.4 Inclusion and Exclusion Criteria Inclusion criteria Patients who has undergone tooth extraction during period of 23th July 2012 to 06th August 2012 at Teaching Hospital Kurunegala, District General Hospital Matale, and General Hospital Polonnaruwa. Exclusion criteria Patients who has undergone tooth extraction at private dental clinics on respected area. 2.5 Study Population This study was implemented to survey the causes of tooth extraction of permanent and deciduous teeth in Matale, Kurunegala and Polonnaruwa districts. Since the population was large, it has selected a sample population of 206 patients with 290 extractions aged from 574 years, attending to the dental OPD clinics at Teaching Hospital Kurunegala, District General Hospital Matale, and General Hospital Polonnaruwa, with convenience sampling method which is a non-probability sampling method.

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2.6 Instruments Used for the Study After taking informed consent patients data were recorded by survey team in to a questionnaire form which was supervised and corrected by Prof. Lilani Ekanayake, (Professor in Community Dentistry, Faculty of Dental Sciences, University of Peradeniya) including patients age, gender, ethnicity, socio- economic status, educational level. The questionnaire was simply designed in order to take minimum time from the dentist work hours. 2.7 Pilot Study A pilot study was undertaken on 17th June 2012 in dental clinic at Base Hospital Katugastota in Sri Lanka. The purpose of the pilot study was to assess the suitability of the survey instrument and the method used. Prepared questionnaire was tested in pilot study and necessary changes were applied. Using this pilot tested questionnaire (Annexure No 01) the study was conducted in targeted districts. 2.8 Data Collection The data were recorded by interviewing the dentist and patients using a questionnaire form with the above experience. The survey was done between 9am 12am and 2pm 4pm on each day of the survey period as the above period of time showed maximum amount of patients. 2.9 Analysis of Data The data was entered and analyzed using Microsoft Excel 2007 and Minitab version 16. Percentages are shown by bar charts. Chi square test and Goodman Kruskal statistical test are used to test the association between causes for tooth extraction and the selected demographic data. Chi - Square test

Chi - Square test is a statistical test that can be used to test the association between categorical variables.

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Goodman Kruskals Gamma statistical test

Goodman and Kruskal's gamma measures the strength of association of the cross tabulated data when both variables are measured at the ordinal level. It makes no adjustment for either table size or ties. Values range from 1 (100% negative association, or perfect inversion) to +1 (100% positive association, or perfect agreement). A value of zero indicates the absence of association. P- Value

This determines the appropriateness of rejecting the null hypothesis in a hypothesis test by representing the probability of incorrectly rejecting the null hypothesis (H0) when it is actually true. When the significance level (alpha) = 0.05, p -value > 0.05: Do not reject H0 Vs. p -value < 0.05: Reject H0 2.9.1 Dependent variables The causes of tooth extraction were recorded according to the criteria, designed based on those used by Ainamo et al [4], Chen et al [9] Those were 1. Caries and its sequels Teeth requiring extractions because of caries (initial or recurrent) and its consequences, extracted roots remnants where the crown was lost through caries and teeth fracturing due to weakening by caries, failed root canal treatments and fractures of teeth weakened by endodontists. 2. Periodontal diseases Teeth requiring extraction due to periodontitis including pain, loss of function. 3. Trauma Teeth extracted due to or as a result of trauma including mandibular fractures. 4. Eruption problems Partially impacted and fully impacted teeth and those, which are characterized by pericoronitis (persistent inflammation around third molar, which necessitated removal of one or all third molars) 5. Orthodontic treatments Teeth to be removed for orthodontic reasons
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6. Prosthetic treatments Teeth to be removed for prosthetic reasons. 7. Developmental conditions Teeth removed due to developmental conditions, supernumeraries and over retained deciduous. 8. Lack of facilities to preserve the teeth Although the teeth can be preserved by root canal treatment, it leads to extract the teeth due to lack of facilities. 9. Patient preference for extraction and other reasons Patients perceived demand for extraction despite the tooth can be preserved or not and any other reasons which is not encompassed by one of the above category Type of tooth extracted were recorded base on FDI (International Dental Federation) classification.

2.9.2 Independent Variables Gender Male, Female Age The subjects were grouped into eight aged groups from <=10,11-20, 21-30, 31-40, 41-50, 51-60, 61-70, >70. Education level Primary Secondary Tertiary :- No education to Grade 5 school education :- Grade 5 to GCE A/L school Education :- University or higher education

Economical state also classified into a scale according to their monthly gross income as Low Mid High :::<Rs.15,000 Rs.15,000 Rs.30,000 >Rs.30,000

Economical state for the population below 18 years of age was considered as their parents or guardians income state. Education state of population below 5 year of age was considered their parents or guardians education level.

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Chapter 03

RESULTS
3.1 Socio - Demographic Data of the Study Population

Size of the sample Number of extractions According to District: o Kurunegala o Matale o Polonnaruwa According to gender: o Male o Female-

: 206 : 290

77 65 64

(37.38%) (31.55%) (31.07%)

83 123

(40.29%) (59.71%)

According to ethnicity: o Sinhala o Tamil o Muslim

134 27 45

(65.05%) (13.10%) (21.84%)

According to education level: o Primary 80 o Secondary 85 o Tertiary 41 According to residence: o Rural o Urban

(38.83%) (41.26%) (19.90%)

113 93

(54.85%) (45.15%)

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3.2 Association of Causes of tooth extraction with Socio- Demographic Data The number of extracted teeth classified according to the age is described in Table 2. Age Group <=10 11-20 21-30 31-40 41-50 51-60 61-70 >70 Total Male Female 2 0.69% 4 1.38% 13 4.48% 16 5.52% 20 6.90% 31 10.69% 17 5.86% 40 13.79% 25 8.62% 33 11.38% 24 8.28% 25 8.62% 10 3.45% 22 7.59% 6 2.07% 2 0.69% 117 40.35% 173 59.66% DF = 7 P- value = 0.200 Total 6 2.07% 29 10.00% 51 17.59% 57 19.66% 58 20.00% 49 16.90% 32 11.03% 8 2.76% 290 100.00%

Table 4: Number and percentage of teeth extractions according to age groups including the proportions of male and female

The group age 31-40, 41-50 make up about the same proportion of 20% each and represented the highest number of extracted teeth in the present study. Table 2; also shows differences between males and female. In all age groups females experienced significantly more extractions than males. The teeth extracted, about 49% were from patients up to age 40 years and 51% from the patient above the 40 years of age and 69% were from up to 50 years of age. From the 290 teeth extracted during the study, Table 3; shows that number and percentage of extractions for different reasons Gender Caries 45 Male 15.53% 70 Female 24.14% 115 Total 39.67% Table 5: Number male & female Dev. Eruption LOF Ortho Other Perio. 2 19 2 1 4 31 0.69% 6.55% 0.69% 0.35% 1.39% 10.69% 5 14 0 3 18 52 1.72% 4.83% 0.00% 1.00% 6.22% 17.93% 7 33 2 4 22 83 2.41% 11.38% 0.69% 1.35% 7.61% 28.62% and percentage of extractions for different reasons for Prosth Trauma 2 11 0.69% 3.79% 4 7 1.38% 2.41% 6 18 2.07% 6.21% all patients & to

Table 3; shows that about 39.6% were extracted due to caries, 28.6% due to periodontal reasons, 6.21% for trauma, 11.38% for eruption problems, 1.35% for orthodontic reasons and 7.61 for other reasons which is mainly for perceive demand of patients to extraction. It was noticed that 0.69% of extractions reported due to lack of facilities such as root canal treatments to preserve the tooth. In the sample it was reported from Polonnaruwa district which consist of two male patients. The relationship between causes and gender didnt show statistically significant differences with Goodman Kruskal Gamma statistical test (p>0.005).

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Rreasons for tooth extractions varied in different age groups

20
Trauma Prosthetic Periodontal Other Orthodontic LOF Impaction Dev elopmental Caries

15

Total extraction

10

0 Age Group <=10 11-20 21-30 31-40 41-50 51-60 61-70

70<

Figure 1: Distribution of reasons for tooth extractions varied in different age groups

Figure1; shows that the reasons for tooth extractions varied in different age groups; In the 21-30, 31-40 years of age groups shows highest percentage due to caries while 41-50, 6170 years of age groups shows most commonest in periodontal diseases. 51-60 years of age group reported with caries as the most common cause. In <=10 age group has reported developmental problems such as supernumeraries as the most common cause. Orthodontic reasons accounted slightly higher than caries in 11-20 years of age group. Trauma accounted with nearly equal percentage in 11-20, 31-40, 51-60, and 61-70 years of age groups. Patients perceive demand for extraction accounted in a noticeable percentage in every age group in this study population. The relationship between causes and age groups was highly significant statistically with P = 0.001. But the relationship between causes and gender was not statistically significant in this study population.

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Figure 2; shows the relationship between total extraction and tooth type and it also represent relationship with residence (Urban or Rural).
Relationship between total extraction and tooth type , Residence
20

Total Extraction %

15

10

0 Residence Tooth Type

R LA

R LP

R U UA

R UP

Figure 2: Distribution of total extraction and tooth type , Residence

Lower posterior teeth are the most common tooth type which was extracted and upper anterior teeth are the least common tooth type in the study population. In relation to residence lower anterior, lower posterior and upper posterior were most commonly extracted in rural area than urban. In the green colour area indicate that the presence of deciduous and supernumeraries in extracted population. According to the table 4; which represents the relationship between tooth type and the causes of tooth extraction, lower anterior teeth were extracted due to periodontal reasons (18.1%) with more prevalence while upper anterior teeth due to traumatic reasons (5%). Lower posteriors were extracted due to caries as most common reason (23.8%) while upper posteriors also the same (15.3%). Eruption problems reported equal percentage on both upper and lower posterior with 5%. Lower posteriors shows the highest prevalence of causes of extraction (38.7%) and the second was lower anterior (19.6%) in study population. Significant number of posterior teeth was extracted due to orthodontic. On the other hand commonest reason for extraction of the upper and lower posterior teeth was caries.

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LA

LP

UA

UP

All 40.42% 0.00% 11.70% 0.71% 1.42% 7.77% 29.40% 2.13% 6.38% 99.93%

Caries 1 0.36% 67 23.75% 3 1.06% 43 15.25% 114 Developmental 0 0.00% 0 0.00% 0 0.00% 0 0.00% 0 Eruption Problems 0 0.00% 15 5.32% 2 0.71% 16 5.67% 33 LOF 0 0.00% 0 0.00% 1 0.36% 1 0.36% 2 Orthodontic 0 0.00% 0 0.00% 0 0.00% 4 1.42% 4 Other 3 1.06% 12 4.23% 0 0.00% 7 2.48% 22 Periodontal 51 18.09% 12 4.23% 10 3.55% 10 3.55% 83 Prosthetic 0 0.00% 1 0.36% 1 0.36% 4 1.42% 6 Trauma 1 0.36% 2 0.71% 14 4.97% 1 0.36% 18 All 56 19.86% 109 38.58% 31 10.99% 86 30.50% 282 Table 6: The relationship between tooth type and the causes of tooth extraction

Rural

Urban

Total

Caries 60 20.69% 55 18.97% 115 39.66% Developmental 3 1.03% 4 1.38% 7 2.41% Eruption Problems 17 5.86% 16 5.52% 33 11.38% LOF 2 0.69% 0 0.00% 2 0.69% Orthodontic 2 0.69% 2 0.69% 4 1.38% Other 15 5.17% 7 2.41% 22 7.59% Periodontal 48 16.55% 35 12.07% 83 28.62% Prosthetic 4 1.38% 2 0.69% 6 2.07% Trauma 9 3.10% 9 3.10% 18 6.21% All 160 55.17% 130 44.83% 290 100.00% Table 7: The relationship between the causes of extraction and residence (Urban or Rural)

Rural population lost more teeth due to caries (20.7%) and periodontal reasons (16.6%) than urban (18.9%, 1.9%) and this was more prevalent in rural females (21.9%) than females in urban area (18.5%). Urban males presented with more prevalence in caries than urban females (19.7%>18.5%). Difference between tooth loss due to caries and gender was not statistically significant. Generally rural population lost teeth due to periodontal reasons (16.6%) more than urban population (12.1%) as seen in Figure 3:

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Causes of extraction with Residence

20

Total Extraction %

15

10

Residence

0
R U s r ie a C v De R U l ta en Im R U n ti o ac R U F LO O r th od R U tic on O R U er th d R U l ta on P R U ic et th os a Tr R U a um

el o

pm

r io Pe

Figure 3 : Distribution of Causes of extraction with Residence

Due to periodontal reason, rural women and urban women shows almost equal prevalent in tooth loss. Urban women shows almost equal prevalent in tooth loss. Rural male lost more teeth due to same reason than urban males (18.8%, 7.6%). It is interesting in Figure 3 shows equal prevalent in urban and rural areas for orthodontic reason and trauma individually. Patients perceive demand for extraction and other factors were more common in rural area than urban. (5.25%, 2.5%). Concerning the distribution of tooth extraction according to age, the age group with most extracted teeth was 31-40 years of age in rural population and 41-50 years in urban population (Figure 4:). The result also indicated increase in tooth loss in 11-20 years of age group in urban population than rural population which may be due to high amount of sugary food intake in urban children. Tooth loss in rural area, the population above 40 years of age shows great accrescence than rural area.

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35 30 25
Total Extration

Residence R U

20 15 10 5 0 <=10 11-20 21-30 31-40 41-50 Age Group 51-60 61-70 70<

Figure 4: Distribution of tooth extraction in different age groups in rural & urban area,

Table 6: shows relationship of causes of tooth extraction and ethnicity of study population. That relationship shows statistically significant relationship. (P<0.05)

Muslim Sinhala Caries 36 12.41% 67 23.10% Developmental 0 0.00% 6 2.07% Eruption Problems 1 0.35% 29 10.00% LOF 1 0.35% 1 0.35% Orthodontic 1 0.35% 3 1.03% Other 3 1.03% 15 5.17% Periodontal 25 8.62% 38 13.10% Prosthetic 2 0.69% 4 1.38% Trauma 2 0.69% 12 4.14% All 71 24.48% 175 60.34% Table 8: Relationships of causes of extraction with Ethnicity

Tamil 12 1 3 0 0 4 20 0 4 44

4.13% 0.35% 1.03% 0.00% 0.00% 1.38% 6.90% 0.00% 1.38% 15.16%

The relationship between reasons of tooth extraction and the level of education didnt represent significant differences statistically. (Figure5 ;) Also the relationship between causes of extraction and economical state also didnt come up with statistically significant relationship to this population. (Figure 6 ;)

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Causes of tooth extraction with Level of Education

30 25

Total extraction %

20 15 10 5 0 Residence Education Level

R U Primary

R U Secondary

R U Tertiary

Figure 5: Distribution of reasons of tooth extraction with the level of education

Causes of tooth extraction with Income State

30 25

Total Extraction %

20 15 10 5 0 Residence Income State

R HIGH

R LOW

R MID

Figure 6: Distribution of causes of extraction and economical state

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Chapter 04

DISCUSSION
Tooth loss is a fundamental to assessment of oral status in a given population. As untreated dental disease will ultimately end up in tooth loss, it could be considered as a crude estimate of the oral health status of a given population. Prevention of tooth loss is an important goal in oral health care provision due to the increased attention to its psychosocial and functional consequences on the wellbeing of an individual. [10] So for this study, patients who has undergone tooth extraction during period of 23th July 2012 to 06th August 2012, investigated for causes of tooth extractions in Polonnaruwa, Kurunegala and Matale districts. The study was conducted at OPD dental clinics of Teaching Hospital Kurunegala, District General Hospital Matale, and General Hospital Polonnaruwa of Sri Lanka. The sample was collected with the help of dental surgeons in respective districts. The number of subjects identified and interviewed was 206 with 290 extractions. Basic health Statistical data of Polonnaruwa district with a population of 358,984 are approximately, 26 dental surgeons, 10 school dental therapists for one general hospital, 2 base hospitals, 8 district hospitals. In Kurunegala district with a population of 1,460,265 are approximately, 74 dental surgeons, 36 school dental therapists for one teaching hospital, 4 base hospitals, 16 district hospitals. In Matale it was 441,328 approximate populations, 25 dental surgeons, 12 schools dental therapists for one district general hospital, 8 district hospitals. [8] Out of 209 subjects 83 were males and 123 were females. The age range of the study population was 05 74years and majority of them were between 21 50years age. The educational levels of the study population were not satisfactory as 80.09% of subjects have not got tertiary (University of higher) level education, while 41.26% have only got secondary education. Of the study population 65.05% were Sinhalese and 13.10% were Tamils with 21.84% Muslims. Out of the sample 77 were from Kurunegala, 65 from Matale and 64 from Polonnaruwa districts. They were lived in urban areas 45.15% with majority of (54.85%) rural area.

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For the purpose of assessing the causes for tooth extraction by interviewed questioner was administered, which comprised of respective questions to the relevant areas. The pathological reason for tooth extraction was recorded by interviewing the dental surgeon and others were recorded with patient. The survey team expected that the result of the present study may reflect the country as a whole because it covers three major districts in Sri Lanka which represent similar sociodemographic distribution respectively for the country. And this study involves the public dental clinics that contain comprehensive facilities for wide varieties of treatment and to which the majority of population can be easily accessible for their treatment needs. It is believed that the present study therefore reflect the effect of socio- demographical factors as well as patients personal attitudes bear on the treatment carried out by practicing dentist. The correct classification of the causes of tooth extraction was crucial for the validity of this study. Several factors were considered when formulating the system, which confirmed as far as possible to previously used internationally defined criteria. [4], [9] It is also important to remind that an extraction of teeth is not only based on disease related factors. Studies showed that [12] it is substantially influenced by factors related to patient, dentist and environment. These factors may include the dentist philosophy of practice, his experiences as well as patient demand and attitude for extraction and socio- demographic status of both patient and country. Even though the team tried to select centers with comprehensive facilities to cover the demand of patients, it reveals that few situations were reported lack of facilities also leading to tooth extraction which may have possibilities to preserve. It is an important finding that previous studies werent indicated. The observation of this study showed that, caries was the major cause of tooth loss in most of the population, both in urban and rural communities with an increasing in age, the incidence to extract tooth due to periodontal reasons also increased. This is an agreement with several other studies [3], [5] and the results of third national oral health survey. [10] It is reported from third national oral health survey as revealed by the findings approximately quarter (23.41%) of 5-year-old children had deciduous teeth indicated for extraction due to extensive caries. Moreover, on average 0.64 deciduous teeth required to be extracted among 5-year-olds. However, this figure rose to 2.75 when those who had caries only accounted for. Therefore, on average 5-year-old children with carious teeth needed 2.75 deciduous teeth to be extracted due to extensive caries. These findings suggest a notable burden of advanced dental caries with regards to deciduous teeth with implications for intervention. From 12 years onwards the number of persons needing extractions and the number of teeth indicated for extractions increased and reached the maximum at 65-74 years. Adults and elderly reported a considerable need for tooth
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extractions. For example, on average 3.38 teeth needed to be extracted among 35-44 yearold-adults and 4.48 teeth among 65-74 year-old- elderly who had caries respectively. Concerning about the gender variation, although it wasnt significant with statistically, females shows high frequency of caries than males. Most of the researchers and oral health surveys also attributed this fact [3] that in general female teeth erupt earlier than males. Since they were at more risk to exposure risk factors than males, it is logical to assume that female teeth are more viable to get caries. The third national oral health survey indicated that Muslims need more extractions; [10] this study shows Sinhalese with highest frequency of tooth extractions due to caries followed by Muslims and Tamils. It is not confirmed by national oral health survey. This variation may be due to convenience sampling method that used to choose the study sample which lead to be selected with highest amount of Sinhala patients than others. In the national oral health survey, components of periodontal disease measurement reflect both concurrent disease state and historical accumulation of the disease with resultant association with age. Hence, it is obvious to find the highest prevalence of this condition among elderly aged 65-74 years. And in overall there is a considerable burden of some form of periodontal disease among all age groups thus making a cause of concern for improvements. In this study population, periodontal problems were not the major cause of extraction in the younger population. Since at that age, it is less often manifested. With an increase in age, the incidence of periodontal disease also increases, while the prevalence of caries reduces due to stabilization of oral hygiene and nutritional habits. This study confirmed the trend that periodontal diseases is the most frequent reason for tooth extraction in patients over 40 years of age as shown in previous studies. [3] Urban population shows high frequency of extractions due to orthodontic reasons and overall orthodontic and prosthetics like advance dental treatments. High frequency of urban population may suggest a positive motivation for such treatment and low frequency of rural population may suggest lack of knowledge and attitudes towards such treatment options and poor motivation from dentists working on rural area. The study of rural population accounted with more extractions than urban population. In rural area, the dental professionals mainly provide relief from dental pain by tooth extraction rather than attempting any preservative treatment which would involve the retention of such teeth. Restoring teeth may not be in priority in rural area due to lack of information, knowledge and resources. That may lead to rural population to get more extraction than urban. The result also indicated increase in tooth loss in 11-20 years of age group in urban population than rural population which may be due to high amount of sugary food intake in urban children.

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The study shows small amount of patients recorded with extractions due to lack of facilities to preserve the teeth. Even though it was two patients from Polonnaruwa district, it indicated an inequality of resources distribution and maintenance for dental clinics. Patients demand for tooth extractions also reported as noticeable frequency mainly in rural areas. That may indicate the lack of health knowledge about modern dental treatments to rural community. It may due to lack of facilities to access health education programme and poor motivation from dentist working on respective area in relation to modern treatments. It may suggest there should be a strong effort to take reduces this burden. Therefore health educational and health promotional events should be carried out respective area with focusing this matter. And the dentists who work on such areas should be educated and trained to motivate patients towards restorations rather than extractions. The survey team expected to have relationships with level of education and income state in relation to causes of tooth extractions. But it is not represented with statistically significant differences. That may also be due convenience sampling method of sample selection and short period of survey which is only two weeks duration. Since the team expected to survey the geographic variation for causes of tooth extraction, it also couldnt fulfill due to above shortages. Concerning about descriptive analysis of level of education and income state indicated that low level of educations leads to more extractions than its counterparts. It is also indicated high income level of population with minimum frequency of extractions that may be due to their affordability for expensive preservative treatments and also they may have visited to private dental clinics rather than public dental clinics where the survey was carried out. Efforts to preserve more natural teeth of the population should focus on the prevention and treatment of caries and periodontal diseases. Besides the preventive measures, dental education programmes for the population together with dental professionals needs to be implemented, in the purpose of improving oral hygiene and insisting on conservative therapy than extraction. Since the survey team was not expected to record data relation to total number of treatments carried out in respective dental clinics, it has noticed that number of extractions is higher in relation to restorations. That may not be the expectations of dental profession. Therefore it is prefer to suggest carrying studies regarding above factor also which may beneficial to make reliable grading for hospital dental services and clinics.

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Chapter 05

CONCLUSION
This study was conducted to survey the causes of tooth extraction of permanent and deciduous teeth in Matale, Kurunegala and Polonnaruwa districts which may reflect the patterns of oral diseases in Sri Lanka. The results of the study indicate that caries is the most frequent reason for tooth extraction in younger population both in urban and rural population with number of extractions due to periodontal reasons were increasing over 40 years of age.

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Chapter 06

LIMITATIONS
1. According to the survey topic, the target population was patients who have undergone tooth extraction in Sri Lanka. But due to the large number of population in Sri Lanka, time, cost and limitation of resources, the team was selected three major hospitals in Sri Lanka using convenience sampling method in three different districts. Therefore the sample size may not be adequate.

2. Sample was restricted to the limited area due to difficulties in access, lack of human resources, limited time and limited financial status. Therefore the samples were located only three districts in Sri Lanka and it again restricted in to one location in each districts which may not be able to be the best sample to represent the whole population in Sri Lanka. 3. Even though the ideal sampling method was random sampling, due to above mention shortages the team used convenience sampling method which is a nonprobability sampling method. Therefore it may lead to sampling errors. 4. Due to convenience sampling method, the selected sample presented with more Sinhalese that may lead to have an effect on results. 5. There was no recommended classification for the causes of tooth extraction even it was crucial for the validity of this study. 6. During the process of dividing the population in to classes and groups according to socio- demographical factors there were no standard define criteria for that. 7. Due to short duration of survey, there may be errors with the sample that may not represent whole population. 8. Since the survey excluded the patients who have undergone tooth extraction at private dental clinics on respected area, sample may not be representing whole population in order to give variation of results.

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Chapter 07

RECOMMENDATIONS
1. By imparting knowledge on oral health, the survey team suggests to increase the awareness of rural population towards the modern dental treatments.

2.

The team suggests that the programmes should implement to improve dental surgeons attitude towards motivation of patient away from tooth extractions also crucial to reduce tooth loss.

3. The survey team suggests to those who involves in formulation of strategies and the planning of dental health service require to concern of equal distribution of comprehensive facilities for dental treatment need. 4. The result of the study shows high prevalence of tooth loss due to caries and periodontal disease in all age groups with various socio-demographical conditions, it is necessary, implementation of programmes to improve oral hygiene practices and dietary advices in both urban and rural populations.

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REFERENCES
1. Muller F, Naharro M, Carlson GE, What are the prevalence and incidence of tooth loss in the adult and elderly population in Europe? Clin Oral Implants Res. 2008 Mar; 19(3): 326-328 2. Fouad K Wahab, A survey of reasons for extraction of permanent teeth in Jordan. J Saudi Dental. 2001 Dec-Sep; 13(3) 3. Baelum V, Fejerskov O, Manji F. Periodontal diseases in adult Kenyans. J Clin Periodontol. 1988; 15(7):445-52. 4. Ainamo J, Sarkki L, Kuhalampi ML, Palolampi L, Piirto O. The frequency of periodontal extractions in Finland. Community Dent Health. 1984; 1(3):165-72. 5. Manji F, Baelum V, Fejerskov O. Tooth mortality in an adult rural population in Kenya. J Dent Res. 1988; 67(2):496-500. 6. Perepa R, Ekanayake L, Tooth loss in Sri Lankan adults. Int Dent J. 2011 Feb; 61(1) 7-11 7. Final BDS Part I community dentistry project report- 2006. What are the causes for tooth extractions? 8. Census Report 2001 9. Cahen PM, Frank RM and Turlot JC. A survey of the reasons for dental extraction in France. J Dent Res 1985; 64: 1087-1093. 10. National Oral Health Survey 2002-2003 11. WHO; World Health Statistics 2000-2009; 2010; 12. Bailit HL, Braun R, Maryniuk GA and Camp P. Is periodontal disease the primary cause of tooth extraction in adults? J Am Dent Assoc 1987; 114: 40-45.

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Annexure

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Acknowledgement
We express our heartfelt and sincere gratitude to Prof. Lilani Ekanayake, Professor in Community Dentistry, Division of Community Dental Health, Faculty of Dental Sciences who guided us to bring out successful completion of our survey project. Were really appreciate her attention towards us, though she was very busy at the moment.

We thank Dr. Irosha Perera who was Consultant in Community Dentistry, Dental Institute; Colombo gave professional advices and a great support to be successful with this project.

Also our gratitude extend to Mr. Ramesh Soyza, Department of Statistics & computer sciences, Faculty of Science, University of Peradeniya for his helpfulness which given us for statistical evaluations of this project.

Specially, our thanks goes to the Dental Surgeons and staff who actively participated for the interview with lot of enthusiasm. Without their active participation, We will not be able to collect unbiased data for this research.

Also our greatest gratitude

goes to patients who actively participated for

the

interview while having painful mouth. Without their support and participation, We will not be able to collect unbiased data for this research.

Our special and heartfelt gratitude to our dearest parents without their blessings we may not have been typing these words. Thank you for all that you have done for us.

We sincerely extend our gratitude to the staff members of the dental faculty library who helped us to do this study successfully.

We also extend our gratitude to all our undergraduate fellows who helped us to do this study successfully.