The impact of lifestyles on the periodontal health of adults in Udupi district: A cross sectional study.

OBJECTIVES: (1) To assess the impact of different lifestyle factors on periodontal health of adults. (2) To assess the impact of overall/combined lifestyle variable (calculated by health practice index [HPI]) on periodontal health of adults.
MATERIALS AND METHODS: A cross-sectional study consisting of a structured questionnaire on HPI, oral health-related behavior, and personal habits as well as sociodemographic variables was conducted on 800 subjects aged 20-50 years attending dental outreach set-ups of Manipal College of Dental Sciences, Manipal. Clinical examination for periodontal status was done by recording loss of attachment scores using community periodontal index (FDI/WHO-1982). Statistical analysis was done by bivariate analysis using Chi-square followed by multivariate analysis to obtain adjusted odds ratio with 95% confidence interval.
RESULTS: After adjusting for all the confounding variables in multivariate logistic regression analysis, the variables that showed an independent association with periodontitis were age, location, marital status, smoking, hours of sleep per night, physical activity, and overall poor lifestyles.
CONCLUSION: Our results support studying a combined approach using various lifestyle behaviors for controlling chronic periodontitis. Necessary public health action on conditions which determine unhealthy lifestyle behaviors across population is needed which is possible by patient's involvement in self-care by promoting healthy lifestyles.

INTRODUCTION

Periodontal disease continues to be a significant problem worldwide. It is closely linked to lifestyles and strongly determined by behavioral factors. It is a well-known fact that chronic periodontitis is a multifactorial disorder. The primary ethology is poor oral hygiene which leads to the accumulation of dental plaque, but several other lifestyle factors have important modifying roles in its pathogenesis. Unhealthy lifestyles are found to be associated with a higher prevalence of periodontitis in studies done by Locker et al. and Sakki et al.[12] Better immunity with higher natural killer cells activity was reported among those with healthy lifestyles [3] while unhealthy lifestyles were related to elevated or suppressed immunoglobulin levels.[4]

As the concept of lifestyle highlights the personal characteristics of an individual, it makes it possible to study behavior in a wider sense. The way in which an individual' lives may produce behavioral patterns that are either beneficial or detrimental to health. If health is to be improved, there is a need to investigate various lifestyles as risk factors and actions must be directed toward their rectification. However, an international agreement on standardized methods for measuring lifestyle is lacking. The decision on health associated lifestyle measures depends on the particular research interest. The items that measure lifestyle should be chosen according to the research purpose.[5] Yet, in considering general health behavior, Breslow's seven habits (sufficient sleep, not smoking, moderate alcohol intake, maintaining proper weight, regular exercise, eating breakfast, and not eating between meals) are commonly used.[6]

Not only it is important to investigate the individual lifestyle factors that can affect the periodontal status but also studying about overall lifestyle will help to study the combined influences of various risk factors on health.[7] There are very few studies which have checked the overall effect of the lifestyle of an individual on the periodontal health.[89] To our knowledge, no previous studies in Udupi District of South Karnataka, India, have investigated whether lifestyles of the people can influence their periodontal health status or not. Such analysis should help to elucidate the role of these factors on the prevention and treatment of many chronic problems; one of them is periodontitis. The aim of the study was to assess the different lifestyle factors and an overall/combined lifestyle variable affecting the periodontal health status of the adult population attending dental outreach centers of Udupi District.

MATERIALS AND METHODS

The present study was a cross-sectional study carried out on the subjects of age group 20–50 years attending the dental outreach set-ups of Manipal College of Dental Sciences, Manipal. Ethical approval to conduct the study was obtained from the Ethical Committee of the Institution University. Patients were recruited from the various dental camps organized at randomly selected locations from the Udupi District map. Informed consent was taken from all the participants before the study. The self-administered questionnaires were then distributed to 400 urban and 400 rural subjects; out of those, 780 participants returned the completed questionnaires with the acceptable response rate of 97.5%.

The eligibility criteria that had been used for inclusion of the subjects in the study were those who were willing to participate, between the age group of 20–50 years, and able to read the questionnaire. The subjects those who were not willing to participate, undergoing orthodontic treatment, any medically compromised conditions contraindicating the oral examination such as infective endocarditis and HIV/AIDS were excluded from the study. Individuals with any medical conditions which may influence the periodontal health such as diabetes, pregnancy, anti-inflammatory drugs or tetracycline or Vitamin C supplements from last 6 months, drugs which can cause gingival enlargement, for example, phenytoin (Dilantin), numerous calcium channel blocker agents such as nifedipine, amlodipine, and cyclosporin were also excluded from the study.

A pilot survey of 25 urban subjects and 25 rural subjects was carried out before the commencement of the study to assess their periodontal status. About 48% (n = 12) of the subjects among the urban group and 64% (n = 16) of the subjects among the rural group had periodontal disease. The sample size required to carry out the study was calculated taking confidence level at 95% (Z, standard value of 1.96) and margin of error at 5% (d, standard value of 0.05). Calculating the sample size by the given prevalence, values obtained were 384 and 354, respectively.[10] Therefore, a final sample size of 400 was chosen for each group.

A structured questionnaire was prepared to consist of four parts.

The first part of the questionnaire included respondents' sociodemographic characteristics in terms of age, gender, location, marital status, income/month, education, occupation, and religion.

The second part of the questionnaire was in regards to oral health-related behavior and personal habits such as frequency of dental visits, device of cleaning, frequency of cleaning, method of cleaning, and presence or absence of habits such as tobacco and paan chewing.

The third part of the questionnaire was an “eight-item health practice index (HPI) scale” for the evaluation of the total lifestyle, developed by Morimoto.[3111213] The eight items on the self-administered questionnaire included information regarding smoking, consuming alcohol, eating breakfast, hours of sleep/night, hours of work/day, physical exercise, nutritional balance, and mental stress. Subjects selected one of 2–6 multiple choices of each item, and the answer was classified as indicating either “good” or “poor” health practices according to Morimoto's criteria [Table 1]. The “good” health practices were given the code of 1, and “poor” health practices were coded 0. Each subject was then assigned a total score between 0 and 8 based on number of good health practices and classified into one of the following three categories as poor lifestyles (score = 0–3), moderate lifestyles (scores = 4, 5), and good lifestyle (scores = 6 or higher) [Table 2].

Table 1

Distribution of study participants according to health practice index between the urban and rural groups

Table 2

Overall lifestyles (combined health practice index variable) of the study participants betweenthe urban and rural groups

The fourth part consisted of information on clinical periodontal health status. Loss of attachment (LOA) of periodontal tissues was recorded using the community periodontal index (FDI/WHO-1982). LOA with at least 1 site ≥4 mm was considered case-defining criteria for periodontitis.[14]

Kannada is the regional language of Karnataka; hence, the questionnaire was translated into Kannada language. The validity was checked by a back-translation method, involving blind retranslation into English. The validity of translation was verified by experts in both languages. This was also checked after wording modification, to ensure the functional and conceptual equivalence of the questionnaire.

One trained and calibrated dentist conducted all clinical oral examinations with a trained recorder noting the observations. Before conducting the survey, the training and calibration of examiner were done in Comprehensive Dental Care Centre of Department of Public Health Dentistry, Manipal, under the guidance and supervision of the faculty of the Department. Training for the indices used in the study was done on ten patients with wide-ranging levels of oral disease. Subsequently, a total of twenty patients were examined on two occasions over 2 successive days. Intraexaminer reliability was assessed using kappa statistic, which was in the range of 0.85–0.92 for the indices which reflected a high degree of conformity in the observations. The recorder was instructed in the coding systems of the indices used in the study.

A schedule was prepared for data collection based on an average time of 10–12 min for clinical examination per individual. The study was scheduled for the months of January 2011–April 2011. Twenty to thirty subjects were examined per day. The clinical examination was carried out by the examiner following “Universal Precautions.”

Statistical analysis of the data was done using Statistical Package for Social Sciences (SPSS) version 11.5 (SPSS Inc., Chicago, IL, USA). Bivariate analysis was done using Chi-square test for the categorical variables. Adjusted odds ratio (OR) with 95% confidence interval (CI) was calculated using the multivariate logistic regression analysis. The cutoff level for statistical significance was taken at 0.05. For statistical purposes, LOA scores were categorized into two categories; “LOA score 0” was coded as “LOA-absent” and “LOA scores 1, 2, 3, and 4” were coded as “with at least one tooth site having ≥4 mm LOA.”

This study included 392 subjects from the urban group and 388 subjects from the rural group of the study population. There was an approximately equal distribution of the study sample with respect to gender and age in both urban and rural population [Table 3].

Table 3

Distribution of study population according to the demographic characteristics

RESULTS

Multivariate analysis

To evaluate the independent association of various lifestyle factors with LOA of periodontal tissues, multivariate logistic regression analysis was used. Only those variables which showed a significant relationship with periodontal health in the bivariate analysis were included for multivariate analysis to reduce the confounders. In addition, the dichotomization of education, occupation, income, and method of cleaning was done to overcome the confounding effects. After adjusting for all the confounding variables, the risk factors which were still found to be significantly associated with the prevalence of LOA were age (P < 0.001), location (P = 0.001), marital status (P < 0.001), smoking (P < 0.001), number of sleeping hours per night (P = 0.008), physical activity (P = 0.03), and overall poor lifestyles (P = 0.05). The prevalence of LOA was significantly higher among those who were smokers (adjusted OR = 3.86), had poor sleeping habits (adjusted OR = 1.69), had poor physical activity (adjusted OR = 1.53), were older (adjusted OR = 4.89), located in rural areas (OR = 2.09), and were married (adjusted OR = 5.17) as compared to their counterparts [Table 4]. Participants with poor lifestyles were 2.77 times (95% CI: 1.01–7.61) more likely to have LOA than those with good lifestyles (P = 0.05) [Table 5].

Table 4

Independent association of various components of lifestyle with loss of attachment of periodontal tissues, the results of multivariate regression analysis

Table 5

Independent association of lifestyles (combined health practice index variable) with loss of attachment of periodontal tissues, the results of multivariate regression analysis

DISCUSSION

The present study was done with the objective of assessing the impact of various lifestyle factors and overall lifestyles on the periodontal health of the adults. It included a larger set of variables such as demographics of study subjects, their oral health-related behaviors, personal habits, habits included in HPI, and overall lifestyles (calculated by HPI). The results of the multivariate regression analysis found the following variables, i.e., age, marital status, location, smoking, number of sleeping hours per night, physical activity, and overall poor lifestyles to be independently associated with periodontitis (measured in terms of LOA).

Demographics and periodontitis

Age was found to be significantly associated with periodontitis in the present study which was in accordance with a multitude of studies, for example, Doifode et al.,[15] Al-Sinaidi.[16] and Albandar et al.[17] however, believed that severe periodontal disease in the elderly could be due to cumulative destruction over a lifetime, rather than the influence of age. The effect of age on the progression of periodontitis could therefore be considered negligible when good oral hygiene is maintained. This belief is further supported by Abdellatif and Burt [18] who reported that more than 95% of the cases examined with good oral hygiene in all age groups did not have periodontitis.

Marital status was one of the other demographic variables which showed significant association with periodontitis in our study. Although periodontal destruction (LOA) was seen significantly higher among the married subjects (59.2%) than the unmarried (11.8%), it is greatly assumed that it could be due to the confounding effect of age. A few authors such as Marcenes and Sheiham [19] and Croucher et al.[20] had also reported a similar association.

Location was identified as another significant demographic factor in the present study that may play a role in the progression of periodontal disease. It was inferred that the rural participants had twice the prevalence of periodontitis than the urban participants. This was in line with the reports from the National Oral Health Survey and Fluoride Mapping (2002–2003) by Bali et al.[21] and the study carried out by Shah et al.[22] The lesser periodontal destruction among the urban participants can be attributed to their better oral health-related behavior in the present study. This could be on account of better education, superior occupation, higher income, availability of health care services, and increased awareness among urban population. This finding however did not conform to the findings of Singh and Soni,[23] who reported that urban subjects had higher prevalence of periodontitis as compared to rural subjects.

Personal habits and periodontitis

Smokers were 3.86 times more prone to periodontitis than nonsmokers in the present study. This finding was in uniformity with a majority of studies which considered smoking as a contributing factor to poor periodontal health and a very important risk factor for periodontal diseases.[1724] Smoking suppresses the host-defense system and in turn, promotes periodontal disease progression. On the contrary, Croucher et al.[20] reported that tobacco smoking was not a significant factor for periodontitis.

Alcohol consumption is considered an independent modifiable risk factor for periodontitis.[25] The relation of alcohol consumption with periodontitis was unclear in the multivariate analysis of the present study due to the presence of wide CI between the two. The reason for this could be an inadequate sample of everyday alcohol consumers in our study. As only 16 out of 780 participants reported alcohol consumption every day, it was interesting to find that all sixteen (100%) had LOA of the periodontal tissues. This indicates that daily alcohol consumption may be an important risk factor for periodontitis.

Lack of sleep was identified as another significant lifestyle factor in the present study that may play a role in the progression of periodontal disease. The participants who sleep for 7–8 h/day exhibited less periodontal disease (LOA) than those who sleep for 6 h or lesser a day. This is in accordance with the study conducted by Kibayashi et al.;[26] however, studies that have observed hours of sleep as an independent factor affecting periodontal health are scarce. From this study, we can speculate that shortage of sleep can impair the body's immune response which may lead to the progression of periodontal disease. The other possible explanation could be that lack of sleep can act as a proxy indicator for stress or over-worked conditions.

Lack of physical activity had also demonstrated a significant impact on periodontal disease. Participants who did not perform any form of exercise were 1.53 times more likely to have LOA than those who did. This finding corresponds with the reports presented by Al-Zahrani et al.[27] Similarly, Merchant et al.[28] reported that the benefits of a physically active lifestyle may extend to periodontal health. In contrast, there are studies that have affirmed that physical activity was not associated with periodontitis.[29]

The influence of stress and number of hours of work per day were reduced in the multivariate analysis to an extent that it was not significantly associated with the periodontitis in the present study. This finding differs from studies done by Marcenes and Sheiham [19] Linden et al.,[30] which revealed a significant relationship between periodontal health status and work-related mental demand. Similarly, studies done by Wimmer et al.[31] and Pistorius et al.[32] reported that mental stress may be a contributing factor in periodontal disease. Similar to the study done Aleksejuniené et al.,[33] a link between stress and periodontal health was not found in the present study; however, there is reason to believe that such an association is likely. Lack of association in the current study could be due to social desirability bias which can arise as a result of self-assessment of the levels of stress.

In the present study, in addition to the habits included in the HPI, tobacco chewing, and paan chewing behaviors were also evaluated as these habits are integral to the culture of the study area. However, the association of chewing tobacco was not found significant with the LOA of periodontal tissues of the study subjects, which was in agreement with Sinusas et al.[34] Nevertheless, we believe that smokeless tobacco may be an important risk factor for periodontal disease.[35] Use of smokeless tobacco is known to produce a painless loss of gingival tissues and alveolar bone destruction in the area of chronic tobacco contact as reported by Robertson et al.[36] This is a result of collagen breakdown due to increased release of collagenase.

Overall/combined lifestyle variable

The combined lifestyle variable used in the study represented the aspects of overall lifestyle related to health. The variable was used here to obtain a more comprehensive view than a single characteristic of behavior using the HPI developed by Morimoto.[3] The prevalence of LOA was almost twice among participants with poor lifestyles than that found in participants with good lifestyles. This was congruent with the findings reported by Sakki et al.,[8] Kibayashi et al.,[26] and Gundala and Chava,[37] which also stated that lifestyle had an independent association with periodontal health. The prevalence of periodontitis among those with a healthy lifestyle was significantly lower as compared to those with an unhealthy lifestyle.

Limitations

There was an inherent potential for endogeneity of the covariates arising in the present study. Taking this into account, multivariate regression analysis was carried out in the study. The time and budget limitations made it impractical to assess the whole population using random sampling. Instead, patients were recruited from various dental camps. This process could lead to selection bias and may limit generalizability. However, an attempt to minimize this bias was made by selecting random locations from the district map for organizing these camps. It is recommended that future studies might consider a longitudinal relationship between lifestyle and oral health to explore it further.

CONCLUSION

The concept of lifestyle enhances an overall view of health. The association of lifestyle with periodontitis supports the concept that behavior should be taken into consideration for the prevention of chronic diseases. Public health action on conditions which determine unhealthy lifestyle behaviors across the population is imperative. This however can only be made possible by the patient's involvement in self-care by promoting healthy lifestyles. Negating orally-abusive substance addiction, having breakfast every day, eating a balanced diet, and reducing stress lead to an overall good lifestyle. These factors along with sleeping a minimum of 7–8 h per night and working for 8–9 h and ample daily exercise may help patients improve or protect their oral health for years to come.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.