Pattern of Dental Diseases among

Patients at a Tertiary Care Hospital

A Hospital based Cross-Sectional Study

Submitted By:
Batch C, 4th year MBBS Session (2019-2020)
Department of Community Medicine
Sheikh Zayed Medical College, Rahim Yar Khan

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 Submitted By:
Batch C, 4th year MBBS Session (2019-2020)
Department of Community Medicine
Sheikh Zayed Medical College, Rahim Yar Khan

Name of Student: _______________________________

Class Roll Number: ______________________________
University Roll Number: __________________________
Signature of Student: _____________________________
Signature of Supervisor: __________________________

Supervisor
Prof. Dr. Hafiz Muhammad Yar Malik
HEAD OF DEPARTMENT OF COMMUNITY MEDICINE

Co Supervisor
Dr. Ghulam Mustafa, Associate Professor
DEPARTMENT OF COMMUNITY MEDICINE

SHEIKH ZAYED MEDICAL COLLEGE, RAHIM YAR KHAN

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 Batch C, 4th Year MBBS (2019-2020)

Sr. No Name Roll No.

1 Saniya Kamal 01
2 Aliya Kamal 08
3 Rameen Rabia 15
4 Shumaila Qadir 18
5 Zohaib Asif 32
6 Muhammad Hamza Maqsood 39
7 Kashaf Maryam 41
8 Saba Asad 44
9 Asmara Sattar 46
10 Aniqah Mehmood 49
11 Zarbakht 50
12 Hira Israr 66
13 Tayyaba Anwar 90
14 Sonia Akbar 113
15 Muqaddas Habib 120
16 Dilruba Khan 133
17 Younas Iqbal 141
18 Kainat Naqi 147
19 Hafiz Muhammad Irfan Ameer Khan 148
20 Ali Nawaz 149
21 Sajjal Mahmood 166
22 Ghulam Awais 173
23 Muhammad Zubair Abbas 175
24 Ayaz Ahmed Qazi 176
25 Muhammad Faizan Raza 197
26 Tahreem Fayyaz 206
27 Muhammad Ahmad 207

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 TABLE OF CONTENTS

Sr. No. Contents Page Number

1 Abstract 7

2 Introduction 9

3 Objectives 19

4 Methodology 21

5 Results 24

6 Discussion 36

7 Conclusion 41

8 References 43

9 Annexure 48

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ABSTRACT

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 Abstract

Background: Dental diseases are one of the most prevalent diseases globally. The oral health is
described as a structural, functional, aesthetic, psychosocial and physiologic state of well-being and
necessary for quality of life and general health of an individual. Oral diseases are believed most
significant public health issue owning to their high incidence and main social impact system. Dental
caries is most prevalent oral disease. Objective: To assess frequency of dental diseases among
patients at a tertiary care hospital, sex distribution of patients with dental diseases reporting at dental
section of a tertiary care hospital and health seeking behavior among dental diseases patients.
Methodology: Study design: Cross sectional study. Study site: OPD of Dental section of Sheikh
Zayed Medical College/Hospital, Rahim Yar Khan. Study duration: From September to November,
2020. Sample size: 300 patients. Sampling technique: Random sampling technique. Study subjects:
All the patients attending Dental OPD of Sheikh Zayed Medical College/Hospital Rahim Yar Khan.
Inclusion criteria: Patients having dental diseases of any age and patients of either sex. Exclusion
criteria: Patients who did not willing to participate in study. Study variables: Age, sex, monthly
family income (PKR), residence (Rural/Urban), Education of patient, duration of dental disease,
name of dental disease, comorbidities, recommended treatment and treatment availed. Data
collection: Data was collected by using a predefined and pretested questionnaire having information
regarding the study variables. Ethical approval was sought from the Institutional Review Board.
Data Analysis: The data was entered in the SPSS version 20, analyzed and results were presented as
mean, median, percentage, standard deviation and tabulation. Results: In our study, there were 160
(53.3%) patients with dental caries, 4 (1.3%) with trauma, 41(13.7%) with broken down root, 14
(4.7%) with calculus, 12 (4%) with periodontal disease, 14 (4.7%) with gingivitis, 6 (2%) with
malaligned teeth, 1 (0.3%) with staining, 48(16%) with other diseases. There were 119 (39.7%)
males and 181 (60.3%) females. Our study shows 69(23%) patients had duration of disease less than
a month, 71(23.7%) had duration of disease between 2 to 6 months, 67(22.3%) had duration of
disease between 7 to 12 months, 93(31%) had duration of disease more than 1 year. Conclusion:
Our study showed that most common dental diseases reported at OPD of a tertiary care hospital
were, dental caries, broken down root, gingivitis, calculus, and periodontal disease. Females and
patients from urban areas were most commonly involved in late reporting of dental health problems.

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INTRODUCTION

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 Introduction

Health is a condition of physical, mental, social well-being and not merely the absence of illness or
infirmity. (1) Dental disease is one of the most prevalent diseases globally. (2) The oral health is
described as ―it is a structural, functional, aesthetic, psychosocial and physiologic state of well-
being and necessary for quality of life and general health of an individual. (3) Oral hygiene plays a
considerable role in oral health maintenance. Inadequate oral hygiene is a major risk factor for the
development of oral diseases. (4) Oral hygiene is a practice of keeping teeth and mouth clean to
avoid dental issues, particularly bad breadth, gingivitis and dental caries. The main reason of
keeping oral hygiene is to protect the plaque buildup, sticky layer of the bacteria and food that
appears on teeth. (5) More than 80 percent persons are affected by dental plaque, making it most
communicable disease present among people. (6)
Oral diseases are believed most significant public health issue owning to their high incidence and
main social impact system. (7)

Dental caries is most prevalent oral disease. It is a chronic sugar dependent communicable disease,
affecting the calcified tissue of tooth and causing demineralization of inorganic part with later
damage of organic material. Carious tooth can never return to its original condition, although it is
treated. (8) Maintenance of oral hygiene has an imperative role in the formation of caries. Due to
poor oral hygiene the risk of caries can be increased. Carbohydrates boost the chance of tooth decay.
The most harmful are sticky foods as they stay on teeth. Recurrent snacking enhances the time that
acids are in exposure with tooth surface therefore it is a risk factor as well. (9) Other causes include
lack of sufficient fluorides. Fluoride helps in preventing tooth decay through making teeth extra
resistant to the acids generated by plaque. (10) Dental caries is believed a leading public health
dilemma worldwide owing to its high incidence and considerable social impact. (11) WHO (World
Health Organization) highlights that 60% to 90% of adults and school children have experienced
dental caries worldwide, with the disease being most widespread in Latin American and Asian
countries. (12) Globally, the prevalence of dental caries in 20-64 years age groups is 92% while in
20-30 year group is 85.58. (13) A study conducted in Iraq demonstrated that prevalence of caries is
more among females (84.61%) than males (71.63%). As per Pathfinder Research carried out in
collaboration with World Health Organization in Pakistan, 52% cases in 12-15 years age group and
70% in 35-64 years age group had dental caries. The incidences of dental caries enhanced with age.
(14) One more study performed in Karachi demonstrated 51% prevalence of caries in 3-6 years age
group. (15) A study undertaken in Lahore showed 60.90% prevalence of dental caries in 3-8 years
age group. (16) A study undertaken in Ayub medical college in Abbotabad showed 58% prevalence
of caries in 25 – 35 years group. (17)

Students are separate portion of the population differentiated by a particular age and certain way of
the life. (18) The entire level of health in young people student life is affected by numerous factors,

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for example, raised psycho-emotional stress and inadequate social and hygienic conditions. The
reliance of increase of the dental disease prevalence from rhythm of the life, level of hygienic
culture, education, medical care and dietary habits has been recognized in several investigations.
(19) The most useful technique to maintain health during study period is medical examination which
allows to reveal symptoms of the teeth and gums lesions during early phases and provides total
recovery about diagnosed deformities. (20) A recent study regarding oral health of students and
development of medical programs has been explained by several authors. (21) This part of
population deserves special attention because it is enough large and has a great potential health
dentition. (18) Females are considered pillars of the society because they have to train future
children. Hence there is great need to provide knowledge to the females regarding dental caries and
oral hygiene, who are entering in family generation phase, as by boosting oral hygiene most
prevalent disease i.e. dental caries could be prevented. Therefore present study aims to know the
frequency of dental caries and associated oral hygiene practices in female college students.

Periodontal diseases comprise a wide range of inflammatory conditions that affect the supporting
structures of the teeth (the gingiva, bone and periodontal ligament), which could lead to tooth loss
and contribute to systemic inflammation. (22) It begins as gingivitis (chronic inflammation of the
gums caused by dental plaque), which can be easily treated if action is taken early. If left untreated,
gingivitis can progress to periodontitis, a more serious infection that destroys tooth-supporting
tissues and bone. Unlike gingivitis, the damage caused by periodontal disease is irreversible and
permanent. It can have a huge impact on well-being and quality of life. Periodontal disease can lead
to serious consequences such as problems with chewing, speaking and tooth loss. (23)

Oral and oropharyngeal cancer grouped together is the sixth most common cancer in the world. (24)
They are the largest group of those cancers which fall into the head and neck cancer category.
Common names for it include such things as mouth cancer, tongue cancer, tonsil cancer, and throat
cancer. This includes those cancers that occur in the mouth itself, (salivary gland cancers, tongue
cancers, mucosal soft tissue cancers), in the very back of the mouth known as the oropharynx,
(primarily tonsil and tonsillar crypt and base of tongue), and on the exterior lips of the mouth. (25)
People with human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency
syndrome (AIDS), are at special risk for oral health problems. Oral manifestations are the earliest
and most important indicators of HIV infection. Seven cardinal lesions: oral candidiasis, hairy
leukoplakia, Kaposi sarcoma, linear gingival erythema, necrotizing ulcerative gingivitis, necrotizing
ulcerative periodontitis and non-Hodgkin lymphoma are strongly associated with HIV infection and
have been identified internationally. (26) Other lesions reported in some articles are human
papillomavirus infection, hyperpigmentation, oral submucous fibrosis, xerostomia, herpes zoster,
histoplasmosis, carcinoma, penicilliosis marneffei, exfoliative cheilitis, HIV salivary gland disease,
perioral molluscum contagiosum, staphylococcus aureus infections, and petechiae. (27) Traumatic
orodental injuries are common dental public health problems that have complex aetiology and
significant impact on those affected. They can be painful, distressing, disfiguring, permanent and

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expensive to treat, and often require long‐term management. (28) Orodental trauma includes injuries
to the teeth (i.e. Enamel infraction or fracture, Enamel – dentin fracture and, Enamel - dentine - pulp
- fracture, Crown - root fracture, Root fracture, Fracture of the mandibular or maxillary alveolar
socket wall), supporting structures (i.e. Concussion, Subluxation, Lateral luxation, Extrusive or
Intrusive luxation, Avulsion), gingiva and oral mucosa (i.e. Abrasion, Contusion, Laceration, Soft
tissue avulsion). (29)

Cleft lip is the failure of fusion of the frontonasal and maxillary processes, resulting in a cleft of
varying extent through the lip, alveolus, and nasal floor. Likewise, the failure of fusion of the palatal
shelves of the maxillary processes, results in a cleft of the hard and/or soft palates. (30) Cleft lip and
cleft palate are among the most common birth defects. (31) Cleft lip and cleft palate can occur on
one side (unilateral cleft lip and/or palate) or on both sides (bilateral cleft lip and/or palate). Because
the lip and the palate develop separately, it is possible for the child to have a cleft lip, a cleft palate,
or both cleft lip and cleft palate. (32)

Cancrum oris or noma (from the Greek nomein-to devour) is a gangrenous affection of the mouth,
especially attacking children in whom the constitution is altered by bad hygiene and serious illness
especially from eruptive fevers, beginning as an ulcer of the mucous membrane with edema of the
face extending from within out, rapidly destroying the soft tissues and the bone and almost always
quickly fatal. (33) The mortality of noma is high and the survivors harbor such facial deformities
that they are often rejected from society and family life. (34) Everyone has bacteria in their mouth.
After eating or drinking foods with sugar, bacteria in your mouth turn sugar into acid. Plaque starts
forming on your teeth soon after eating or drinking anything sugary. This is why regular brushing is
important. Plaque sticks to your teeth, and the acid in plaque can slowly erode tooth enamel. Enamel
is a hard, protective coating on your teeth that protects against tooth decay. As your tooth enamel
weakens, the risk for decay increases.

Everyone is at risk for cavities, but some people have a higher risk.

Risk factors include:

• Too many sugary or acidic foods and drinks, a poor oral hygiene routine, such as failing to
brush or floss daily, not getting enough fluoride, dry mouth.
• Eating disorders, such as anorexia and bulimia.
• Acid reflux disease, which can result in stomach acid wearing down your tooth enamel.
Cavities develop more often in the back teeth, according to the Mayo Clinic. These teeth have
grooves and openings that can trap food particles. Also, these teeth are sometimes harder to reach
when brushing and flossing. (35)

Dental caries is initiated by the non-hemolytic viridans streptococci (36), termed mutans
streptococci, most commonly Streptococcus mutans and Streptococcus sobrinus. These organisms

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are not present in newborns but appear as primary dentition erupts. DNA analysis confirms that
transmission occurs usually from mother to child, probably through shared food implements (37).
The organisms thrive on sucrose, which they convert into organic acids and sticky polysugar
(dextrans), which adheres the organisms to tooth surfaces (38). Oral sites that are not regularly
disturbed, such as fissures and contact areas, thereby become susceptible to dental decay. Tooth
structure is in chemical equilibrium with saliva under neutral pH. Increasing acidity to pH 5.4 by
exposing plaque to sugar causes a net efflux of calcium and phosphorus from the enamel into saliva
(39). Initially, crystals of surface hydroxyapatite dissolve, leaving behind an organic matrix of the
sparse intercrystalline material. When neutrality is reestablished through salivary dilution and
buffering, hydroxyapatite reforms on the matrix. However, an undisturbed plaque colony limits the
effects of saliva, even as colonies maintain a low pH at the underlying tooth surface. When
dissolution has proceeded to the point that the matrix collapses, a cavity forms. When cavitation
extends through the enamel to the dentin, the caries process shifts as proteolytic organisms,
particularly Lactobacillus species, exploit the more organic substrate (38).

Older people frequently have dentin exposed near the gingiva, and root caries initiates there. Root
caries is started by mutans streptococci, and there is early involvement of proteolytic Actinomyces
species, including Actinomyces viscosus, Actinomyces odontolyticus, and Actinomyces naeslundii.
Root caries is relatively uncommon before the age of 30 years, but it rapidly increases in incidence
in the succeeding decades of life. In contrast, the attack rate of enamel caries remains stable
throughout a person's life (40).

Without dental treatment, natural progression of caries follows 1 of 2 paths. In younger people, tooth
pulp begins to be affected when caries invades dentin (41). Dental pulp consists of capillaries,
nerves, and connective tissue surrounded by osteoblast-like cells (odontoblasts) that secrete the
precalcified matrix that will become additional dentin. Odontoblasts have thin cellular processes
extending the thickness of dentin. When tooth structure is lost as a result of caries, odontoblastic
processes, now less insulated from the mouth, expand and contract more readily in response to oral
environmental shifts (e.g., hot, cold, sweets, air), and sensory nerves in the pulp's odontoblastic layer
transmit the sensation of pain (42). As caries progresses, bacteria irritate the cellular processes and
trigger an inflammatory reaction in pulp. In the closed space of the pulp chamber, an increase in
tissue pressure causes severe pain (toothache) and, ultimately, pulp necrosis. Commonly, oral debris
occluding the cavity forces the inflammatory process to extend out to the root apex. From there,
infection spreads through bone and into soft tissue.

It is more common for untreated caries in older people to have a self-limiting course. Odontoblasts,
as described above, add dentin onto the walls of the pulp chamber to the extent that diminished
chamber size in advanced age is perceptible on dental radiographs (43). Analogous processes reduce
the number and diameter of dentinal tubules (44). As a result, acute dental pain is an uncommon
complaint in older people (45). Greater tooth destruction occurs before the dental pulp is affected,
because the dentin is thicker. Loss of tooth structure reduces shelter for bacterial colonies, and
natural salivary defenses are able to arrest the process. The microorganisms associated with dental

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abscess and cellulitis are generally not the microorganisms associated with caries but are anaerobic
species from deep within the gingival sulcus that thrive in debris-filled pulp chambers. Infections are
most commonly combinations of ≥3 obligate anaerobes (such as Peptostreptococcus species,
Porphyromonas gingivalis, Prevotella intermedia, and Prevotella melaninogenica) and
Fusobacterium nucleatum. Less commonly identified are the facultative anaerobes Streptococcus
milleri, Streptococcus sanguis, and Actinomyces species (46). Two distinct types of disease of the
periodontium are of interest in older humans. Nonspecific gingivitis is a reversible inflammation of
the gums adjacent to the teeth that is caused by presence of bacterial plaque (47). Improved oral
hygiene resolves the condition, although, in older people, inflammation forms faster in response to
plaque and resolves more slowly when plaque is removed (48). Adult periodontitis occurs when an
inflammatory reaction to gingival pathogens extends into the epithelial attachment between the tooth
and the bone and into the bone itself. As the plaque colonies that cause gingivitis mature, they
become depleted in gram-positive organisms and cocci, and they begin to favor obligate anaerobes
over facultative species (49). Clinically, tissues become red and edematous and gums bleed upon
brushing; the flow of sulcular fluid increases and becomes enriched in lymphocytes and phagocytes
(50). Histologic findings include vasculitis and lymphocytic infiltration of the gingiva and the
junctional epithelium (i.e., the sulcus base tissue) (47). Gingivitis can remain in the state described
for months and years and will not progress to periodontitis, unless changes in local conditions or
generalized host susceptibility occur (51). When the host/pathogen balance tips, the lymphocytic
nature of the gingivitis inflammatory infiltrate changes to a plasma cell lesion as pathogens evade
neutrophils and elaborate proteolytic collagenase and hyaluronidase (50) that degrade junctional
epithelium. The specific pathogens that are most commonly implicated are P. gingivalis and
Bacteroides forsythus (52), which are transmitted both vertically and horizontally—that is, between
parents and children (52) and between spouses (53), respectively.

In response to the invasion of the junctional epithelium, an antibody reaction is initiated and may
successfully limit disease. But, if the antibody response is inadequate, deeper bacterial penetration
results in monocytic activation with elaboration of cytokines and other inflammatory mediators.
Fibroblasts and macrophages in turn secrete matrix metalloproteinases that destroy collagen,
glycosaminoglycans, and bone (50). The process is painless, although the host may note a
disagreeable taste or odor. Bony support of the tooth is lost as the sulcus base migrates toward the
end of the tooth root. Initially, the height of gingiva on the tooth is unchanged, resulting in
deepening of the sulcus (now termed the ―periodontal pocket‖). The pocket's bacterial population
becomes dominantly anaerobic (54). Clinical and epidemiologic evidence indicates that the
preceding description applies, in most cases, to relatively brief (duration, days to weeks) disease
episodes, followed by much longer periods during which host defenses dominate (55). Over years
and decades, measurable loss of osseous support around teeth occurs; in the most extreme case,
affected teeth are exfoliated. More than 95% of dentate adults older than 50 years of age show clear
evidence of this process (hence the use of ―growing long in the tooth as a metaphor for aging),
although only 20% such adults at any given point in time will show signs consistent with active
periodontal destruction (56).

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Several preventive strategies for dental caries are available. These include plaque removal and diet
modification and the use of fluorides and tooth sealants. Fluoride: There is ample and convincing
scientific evidence of the effectiveness of fluoride in reducing dental caries. Fluoride can be
administered in treated drinking water, in dietary supplements, or can be applied directly to the teeth
by the individual or by professionals. The most effective and efficient method of exposing teeth to
fluoride is to consume it in drinking water. A recent symposium speaker on caries prevention stated:
Water fluoridation involves a minimum per capita outlay for a tremendous saving in the cost of
replacing decayed and missing teeth. As such, it is one of the few bargains available in health care.
(57). Approximately half of the American people have drinking water that is either naturally
fluoridated or has had fluoride added. Children who from birth have drunk fluoridated water have,
on the average, 50 to 70 percent less teeth decay than those who have not. (58) Loss of first
permanent molars can be reduced as much as 75 percent; and caries on the proximal surfaces of
upper incisor teeth can be reduced 95 percent. The economic benefits of fluoridation vary with such
factors as the age of the subjects when fluoridation was initiated, the total number of years they have
been drinking fluoridated water, and the size of the city. A conservative estimate, based on number
of tooth surfaces saved, is an annual saving in treatment costs of $11 to $16 per capita, resulting in
an average cost-benefit ratio of approximately 1:50 after 12 to 15 years of fluoridation [59]. In other
words, for every dollar spent on water fluoridation, 50 dollars are saved in treatment costs. One of
the advantages of community water fluoridation is that it does not require active cooperation from-
individuals for its benefits to be conferred. Children in such communities receive fluoride from birth,
which is expected to maximize the benefit. A recent report to Congress by the General Accounting
Office stated that the U.S. Public Health Service was not actively promoting fluoridation. (60)
Subsequently, the Public Health Service, through the Center for Disease Control, has increased its
efforts to promote community water fluoridation. There is a need to educate the public on the
benefits of fluoridation. A national survey revealed that 76 million adults--about 51 percent of the
adult population--do not know what fluoridation is. About 45 million adults served by public water
systems do not even know that the water they drink is fluoridated.

The fluoridation of school water supplies is effective in rural communities that lack a central water
supply. But because children do not attend school until some of their permanent teeth are partially or
fully mineralized, the benefits of school water fluoridation are less than for community fluoridation.
School water is usually fluoridated at levels higher than the concentration recommended for
community fluoridation, because children consume only part of their daily intake of water at school.
The maximum benefit reported has been a 10 to 40 percent reduction in caries. The approximate cost
per person is $1.50 a year, with a cost-benefit ratio of 1:5.3 (one dollar spent for fluoridation saves
$5.30 in dental costs). This figure varies with the size of the school; fluoridation is more efficient for
larger schools and requires no individual compliance. Dietary supplements of fluoride, in tablet
form, can effectively reduce caries. It has been estimated that a 50 to 70 percent reduction in caries
results from ingestion of fluoride tablets from birth. When tablets are administered at school, the
caries-inhibiting effect has been estimated at 20 to 40 percent. A six-year clinical trial of chewable
fluoride tablets administered at school showed that children who chewed one tablet a day during the

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school year had 28 percent fewer cavities than a control group. Administration of tablets at home is
less effective for lack of parental compliance.

Dental caries is usually treated by removing the decayed portion and reconstructing the tooth. Teeth
have limited capacity for self-repair, therefore carious lesions become worse with time. The type of
treatment depends on how early it is instituted. Reconstructive services fall into three main
categories--fillings, inlays and onlays, and crowns. The filling materials generally are silver
amalgam for posterior teeth, tooth colored composite resins for anterior teeth, and cast gold
inlays/onlays for teeth that have lost substantial amounts of tooth structure. A full crown is the
treatment of choice when there is little or no supporting enamel remaining after the decay is
removed. If the destruction caused by the decay has affected the tissues of the pulp chamber,
endodontics (root canal therapy) may be needed if the tooth is to be retained. When the most
extensive treatment (root canal filling and a crown) cannot be performed, the tooth must be
extracted. The dental treatment then consists of replacing the lost tooth or teeth with either
removable partial dentures or fixed bridges. Partial dentures usually are held in place by means of
clasps on the adjacent natural teeth. The loss of all teeth calls for full dentures. Because treatment of
dental caries increases in complexity as the disease process advances, prevention of disease or early
diagnosis and treatment are important. (57)

Plaque bacteria play a major role in the etiology of both dental caries and periodontal diseases. Since
natural mechanisms do not adequately clean teeth, a combination of professional cleaning and
personal oral hygiene practices (tooth brushing, flossing, water pressure devices and gingival
stimulators) is recommended to control dental plaque. This combined approach can reduce the
incidence of periodontal diseases by 90 percent. But there are many gaps in the knowledge related to
plaque control. Plaque may form anew on teeth 24 hours after cleaning; it is not clear how often it
must be removed to control or prevent disease. It has been shown in one study that subjects who
removed all traces of plaque from teeth every two days can maintain healthy gingiva. However, the
subjects' teeth and gums were in excellent condition at the beginning of the study and their teeth
were checked after each brushing to be sure plaque had been completely removed. There is
additional evidence that supervised self-administered oral hygiene procedures are effective in
reducing plaque and gingival inflammation and that plaque control is important for the success of
periodontal treatment.

Teaching people to brush and floss their teeth correctly and motivating them to do it regularly
without supervision has proved to be difficult. Formal classroom instruction in dental health for
children generally has failed to produce long-term behavioral changes. The New York City Health
Department recently terminated a 50-year-old program of classroom instruction in dental health for
elementary and junior high school children because it failed to reverse a 20-year decline in the
number of children seeking or receiving dental treatment annually. (53) More encouraging results
have appeared in studies of instruction and motivation techniques combined with professional dental
care. In one three-year study and experimental group of young adults was given a professional
prophylaxis at two, four, six, and nine months during the first year, at three-month intervals during

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the second year, and at four-month intervals during the third year. They were also instructed
repeatedly about personal oral hygiene and periodontal disease, both individually and in groups. A
control group was given annual examinations and told to continue with their usual oral hygiene
practices.

The oral hygiene score of the control group increased (worsened) at more than four times the rate of
the experimental group. Gingival inflammation scores were significantly lower and loss of epithelial
attachment was significantly less in the experimental group. A follow-up examination 32 months
after the end of the original study found that subjects in the experimental group continued to show
cleaner teeth, less gingival inflammation, and less detachment of tissues than subjects in the control
group. A future alternative to the mechanical cleaning of teeth may be the use of vaccines or
antimicrobial agents to eliminate plaque, although clinical trials of antimicrobials so far have yielded
ambiguous results. At present, however, it would seem that an organized and supervised program of
activities aimed specifically at the prevention of periodontal diseases may be the most effective
method of prevention. Such a program should consist of multiple components, each of which has
some scientific evidence that would suggest its inclusion. The clinical objective of such a preventive
program would be to facilitate the removal of bacteria, plaque, and calculus from the teeth.

The high prevalence of periodontal diseases among youths provides support for the need for
professional intervention to prevent periodontal diseases. Among youths 12 to 17 years of age, for
example, 32 percent have periodontal disease and 6 percent of those show evidence of destructive
periodontal disease. Data from the National Nutrition Survey, primarily of lowincome families,
show that 55 percent of children in junior high school and 65 percent of all high school students
have periodontal disease.. In seven cases of every 100 persons so afflicted, the disease had reached
an advanced and destructive stage. (57) Thus, because calculus is present in a fairly high proportion
of youths, and because there is evidence of destructive (irreversible) periodontal diseases occurring,
it would seem prudent to interfere with the progression of the disease in this age group by means of
periodic, thorough oral prophylaxis. Because the need for such prophylaxis at specific intervals is
not universal, this treatment might be limited to those with the greatest need. The literature on
prevention suggests that a combination of professional cleaning and personal oral hygiene practices
can reduce the incidence of the periodontal diseases. However, reliance on individual behavior alone
to control the bacterial plaque associated with periodontal diseases has not been shown to be
effective. Therefore supportive professional attention to remove calcified plaque and reinforce
personal oral hygiene habits seem to be necessary components of a successful program to prevent
periodontal diseases.

The intent of the treatment of periodontal diseases is to interrupt, arrest, or reverse the progressively
destructive process of the bacterial colonizations that are the precipitating causes of periodontal
diseases. In more advanced diseases, an attempt is made to arrest the progression of the periodontal
pockets which lead to the loss of the supporting bone. Treatments of more advanced clinical states of
periodontal diseases are aimed at rearranging the forces on the periodontal attachment apparatus

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which consists of the root cementum, supporting bone, and the periodontal ligament (the connective
tissue contents of the space between the bone and root cementum).

The specific treatments and the order in which they are given will vary from patient to patient, but
the stages in the process often include: Thorough prophylaxis and the establishment of a program of
oral hygiene in order to control or eliminate gingival inflammation; thorough root planing and
gingival curettage, reevaluation of the patient's ability to maintain oral hygiene as a condition for
more extensive treatments, restoration of carious lesions that are related specifically to gingival
health, extraction of teeth beyond treatment because of periodontal destruction, periodontal surgery
and occlusal adjustment.

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OBJECTIVES

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 Objectives

The objectives of this research were to;

• Assess the frequency of dental diseases among patients at a tertiary care hospital.

• Assess the sex distribution of patients having dental diseases, reporting at dental section of a

tertiary care hospital.

• Determine the health seeking behavior among dental diseases patients.

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METHODOLOGY

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 Methodology

Study design: Cross sectional study

Study site: This study was conducted in OPD of Dental section of Sheikh Zayed Medical
College/Hospital, Rahim Yar Khan

Study duration: From September to November, 2020.

Sample size: A total of 300 patients were selected in this study.

Sampling technique: Study subjects were selected by random sampling technique.

Study subjects: All the patients attending Dental OPD of Sheikh Zayed Medical College/Hospital
Rahim Yar Khan

Inclusion criteria:

• Patients having dental diseases of any age.

• Patients of either sex.

Exclusion criteria:

• Patients who did not willing to participate in study.

Study variables:

Age, sex, monthly family income (PKR), residence (Rural/Urban), education of patient, duration of
dental disease, name of dental disease, comorbidites, recommended treatment and treatment availed.

21 | P a g e
Data collection:

Data was collected by using a predefined and pretested questionnaire having information regarding
the study variables. Each patient following the inclusion and exclusion criteria was informed about
the purpose of data collection and his/her consent was obtained before starting data collection.

Ethical approval:

Ethical approval was sought from the Institutional Review Board.

Data Analysis:

The data was entered in the SPSS version 20, and analyzed. Numerical variables like age, monthly
family income (PKR), duration of disease were presented as mean, median, mode and standard
deviation. Whereas, categorical variables sex, residence, education, frequency of dental disease and
comorbidites were presented as percentages. Duration of diseases in categories was compared with
reference to residence, sex and monthly family income, by using chi square test. P value of 0.05 or
less was taken as significant.

22 | P a g e
RESULTS

23 | P a g e
 Results

This study was conducted to assess the pattern of dental diseases presenting in the outpatient
department of dental section in a tertiary care hospital and to find out the frequency of dental
diseases in patients and to correlate the association between disease frequency and numerous factors
to see the behavioral approach of patients towards the management of these diseases.

Table I: Statistics of age and monthly family income

Value Age in years Monthly family

income Rs

Mean 31.6 18874

Std. Error of Mean 0.8 1200

Median 30 15000

Mode 30 15000

Std. Deviation 15 20784

According to table I, mean age was 31±15 years, median was 30 and mode was 30. Mean
monthly family income was Rs. 18874±20784, median was Rs. 15000 and mode was
15000.

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Table II: Statistics of duration of disease

Value Duration in days

Mean 580

Std. Error of Mean 107

Median 365

Mode 365

Std. Deviation 1856

According to table II, mean duration of disease was 580±1856 days, median was 365
days and mode was 365 days.

Table III: Gender Wise Distribution of Patients

Gender Number Percentage

Male 119 39.7

Female 181 60.3

Total 300 100

Table III shows there were 119 (39.7%) males and 181 (60.3%) females.

25 | P a g e
Table IV: Residence Wise Distribution of Patients

Residence Number Percentage

Rural 126 42

Urban 174 58

Total 300 100

Table IV shows there were 126 (42%) rural patients and 174 (58%) urban patients.

Table V: Education based Distribution of Patients

Education Number Percentage

Illiterate 87 29

Primary 97 32.3

Matric 79 26.3

Graduate 33 11

Postgraduate 4 1.3

Total 300 100

Table V shows among the patients, there were 87 (29%) illiterate, 97 (32.3%) were
primary passed, 79 (26.3%) matric passed, 33 (11%) graduated, 4 (1.3%) post-graduated.

26 | P a g e
Table VI: Disease Wise Distribution of Patients

Disease Number Percentage

Dental caries 160 53.3

Trauma 4 1.3

Broken Down Root 41 13.7

Calculus 14 4.7

Periodontal disease 12 4.0

Gingivitis 14 4.7

Malaligned Teeth 6 2

Satining 1 0.3

Others 48 16

Total 300 100

Table VI shows there were 160 (53.3%) patients with dental caries, 4 (1.3%) with trauma,
41(13.7%) with broken down root, 14 (4.7%) with calculus, 12 (4%) with periodontal
disease, 14 (4.7%) with gingivitis, 6 (2%) with malaligned teeth, 1 (0.3%) with staining,
48(16%) with other diseases.

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Table VII: Recommended Treatment Wise distribution of patients

Treatment Number Percentage

RCT 69 23

Filling 28 9.3

Extraction 116 38.7

Others 87 29

Total 300 100

According to table VII, 69 (23%) patients were recommended RCT, 28(9.3%) were
recommended filing, 116(38.7%) were recommended extraction, 87 (29%) were
recommended other options.

Table VIII: Treatment Availed Wise distribution of patients

Availed Number Percentage

Yes 250 83.3

No 50 16.7

Total 300 100

According to table VIII, 250 patients (83.3%) availed treatment while 50 (16.7%) did not
availed treatment.

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Table IX: If yes from whom treatment availed

Availed Number Percentage

No 50 16.7

From Doctor 223 74.3

From Quack 27 9

Total 300 100

Table IX shows that out of 300 patients 50(16.7 %) did not opted for treatment and 223
(74.3%) opted treatment from a doctor and 27 (9%) opted treatment from a quack.

Table X: Distribution of Comorbidities among patients

Comorbidity Numbers Percentage

None 228 76.0

Diabetes Mellitus 23 7.7

Hypertention 24 8.0

Hepatitis 12 4.0

Others 13 4.3

Total 300 100.0

Table X shows 228 (76%) patients had no comorbidity, 23(7.7%) had diabetes mellitus,
24(8%) had hypertention, 12(4%) had hepatitis, and 13(4.3%) had other comorbidities.

29 | P a g e
Table XI: Distribution of Diseases in Affected Teeth Quadrant
Quadrant Numbers percentage

Upper Right 49 16.3

Upper Left 48 16.0
Lower Right 98 32.7
Lower Left 62 20.7
Generalized 43 14.3
Total 300 100.0

Table XI shows 49(16.3%) patients had affected tooth in upper right quadrant, 48(16.0%)
patients had affected tooth in upper left quadrant, 98(32.7%) patients had affected tooth
in lower right quadrant, 62(20.7%) patients had affected tooth in lower left quadrant, and
43(14.3%) patients had generalized disease involvement.

Table XII: Duration of disease wise distribution of patients

Duration Numbers Percentage

Less Than a Month 69 23.0

2-6 Months 71 23.7

7-12 Months 67 22.3

More than 1 Year 93 31.0

Total 300 100.0

Table XII shows 69(23%) patients had duration of disease less than a month, 71(23.7%)
had duration of disease between 2 to 6 months, 67(22.3%) had duration of disease
between 7 to 12 months, 93(31%) had duration of disease more than 1 year.

30 | P a g e
Table XIII: Monthly family income vise distribution of patients

Monthly family Numbers Percentage

income (Rs.)
≤18000 185 61.7
18001-40000 99 33.0
≥40001 16 5.3
Total 300 100.0

Table XIII shows there are 185(61.7%) patients with monthly family income less than
18000, 99(33%) patients with monthly family income from 18001 to 40000 and 16(5.3%)
patients with monthly family income more than 40000.

31 | P a g e
 Table XIV: Gender versus duration of disease

Duration of diseases

Gender Total P
Less than 2-6 months 7-12 More than value
one month months one year

Male 36 (30.3%) 25 (21%) 25 (21%) 33(27.7%) 119(39.7%)

Female 33(18.23%) 46(25.42%) 42(23.2%) 60(33.15%) 181(60.3%) 0.11

Total 69 (23%) 71(23.7%) 67(22.3%) 93 (31%) 300(100%)

Table XIV shows that out of 119 males from 300 patients, 36 (30.3%) males had duration
of disease less than 1 month, 25 (21%) males had duration of disease between 2-6
months, 25 (21%) males had duration of disease between 7-12 months and 33 (27.7%)
had duration of disease more than 1 year. Out of 181 females, 33 (18.23%) females had
duration of disease less than 1 month, 46 (25.42%) females had duration of disease
between 2-6 months, 42 (23.2%) females had duration of disease between 7-12 months
and 60 (33.15%) had duration of disease more than 1 year.

32 | P a g e
 Table XV: Monthly family income versus duration of disease

Monthly Duration of diseases

family
Total P
income Less than 2-6 months 7-12 More than
value
(Rs.) one month months one year

≤18000 185(61.7%)
44(23.8%) 38(20.5%) 43(23.2%) 60(32.4%)

18001- 99(33%)
22(22.2%) 26(26.3%) 20(20.2%) 31(31.3%)
40000
0.40

≥40000 16(5.3%)
3 (18.8%) 7 (43.7%) 4 (25%) 2 (12.5%)

Total 300 (100%)

69 (23%) 71(23.7%) 67(22.3%) 93 (31%)

Table XV shows that out of 185 from 300 patients with monthly family income less than
18000, 44 (23.8%) had duration of disease less than 1 month, 38 (20.5%) had duration of
disease between 2-6 months, 43 (23.2%) had duration of disease between 7-12 months
and 60 (32.4%) had duration of disease more than 1 year. Out of 99 from 300 patients
with monthly family income between 18001-40000, 22 (22.2%) had duration of disease
less than 1 month, 26 (26.3%) had duration of disease between 2-6 months, 20 (20.2%)
had duration of disease between 7-12 months and 31 (31.3%) had duration of disease
more than 1 year and out of 16 from 300 patients with monthly family income more than
40000, 3 (18.8%) had duration of disease less than 1 month, 7 (43.7%) had duration of
disease between 2-6 months, 4 (25%) had duration of disease between 7-12 months and 2
(12.5%) had duration of disease more than 1 year

33 | P a g e
 .

Table XVI: Residence versus duration of disease

Duration of diseases

Residence Total P
Less 2-6 months 7-12 months More than value
than one one year
month

Rural 126 (42%)

29(23%) 30 (23.8) 34 (27%) 33 (26.2)

Urban 174 (58%)

40(23%) 41(23.6%) 33 (19%) 60(34.4%) 0.29

Total 93 (31%) 300(100%)

69(23%) 71 (23.7%) 67(22.3%)

Table XVI shows that out of 126 rural patients from 300, 29 (23%) had duration of
disease less than 1 month, 30 (23.8%) had duration of disease between 2-6 months, 34
(27%) had duration of disease between 7-12 months and 33 (26.2%) had duration of
disease more than 1 year. Out of 174 urban patients, 40 (23%) had duration of disease
less than 1 month, 41 (23.6%) had duration of disease between 2-6 months, 33 (19%)
males had duration of disease between 7-12 months and 60 (34.4%) had duration of
disease more than 1 year.

34 | P a g e
DISCUSSION

35 | P a g e
 Discussion

This study was conducted to assess the pattern of dental diseases presenting in the
outpatient department of dental section in a tertiary care hospital and to find out the
frequency of dental diseases in patients and to correlate the association between disease
frequency and numerous factors to see the behavioral approach of patients towards the
management of these diseases. According to our study, mean age of the patients was
31±15 years, median was 30 and mode was 30. Mean monthly family income was Rs.
18874±20784, median was Rs. 15000 and mode was 15000. Mean duration of disease
was 580±1856 days, median was 365 days and mode was 365 days. A study conducted in
China to investigate the characteristics of dental care-seeking behaviors and related
socio-demographic factors in a middle-aged and elderly population in northeast China.
That was a cross-sectional study of 1188 subjects, including 792 middle-aged (35–
44 years-old) and 396 elderly (65–74 years-old) residents of northeast China. In that
study information on dental care-seeking behaviors and socio-demographic
characteristics was collected during face-to-face structured interviews conducted between
May and June 2010. In that study, a greater proportion of middle-aged participants
reported a need for dental visits compared with the elderly participants (75.8 % vs.
60.9 %; P < 0.01). This is in comparison to our study, where mean age of patients was
31±15 years, as did more urban that rural residents. This is in comparison to our study
where there were there were 126 (42%) rural patients and 174 (58%) urban patients. That
study also showed that the majority of individuals in both the middle-aged and elderly
groups obtained for dental care at their own expense, and they predominantly chose
private dental clinics. Ridit analyses showed that education level and income were
significantly associated with oral care in both middle-aged and elderly people (Ps < 0.05).
In addition, logistic regression analysis indicated that rural residence was negatively
associated with dental visits in both middle-aged (odds ratio = 0.649, 95 % confidence
interval: 0.447–0.884) and elderly (odds ratio = 0.604, 95 % confidence interval: 0.394–
0.924) individuals. (61)

In our study, among the patients, there were 87 (29%) illiterate, 97 (32.3%) were primary
passed, 79 (26.3%) matric passed, 33 (11%) graduated, 4 (1.3%) post-graduated. Our
study shows there were 160 (53.3%) patients with dental caries, 4 (1.3%) with trauma,

36 | P a g e
41(13.7%) with broken down root, 14 (4.7%) with calculus, 12 (4%) with periodontal
disease, 14 (4.7%) with gingivitis, 6 (2%) with malaligned teeth, 1(0.3%) with staining,
48(16%) with other diseases.

A previous study with aims to assess the dental and oral problems and to find out the
determinants of oral health seeking behaviour among elderly population of Al-Jouf
province, Saudi Arabia, was conducted, on 892 patients showed that out of total 892
elderly persons included, 51.79% were males and 48.21 were females, this is in contrast
to our study where there were 119 (39.7%) males and 181 (60.3%) females. The most
common oral problem was missing tooth (78.69%) followed by gum problems (74.21%).
The difference in the distribution of male and females or association between the type of
care and gender and distribution for choosing a health care source was found to be
statistically significant (p < 0.05). (62)

A study in Pakistan with aim to assess the dental health care seeking behavior among
patients visiting the dental clinics of a tertiary care hospital in Karachi, Pakistan. (63)
Majority (35%) presented with toothache. However in our study most common dental
health issue was dental caries (53%), the reason behind this may be that we assessed
dental disease while in that study they assessed symptom of pain. A significant
proportion of patients (71%) informed that they visit a dentist only when a problem
arises. Significant variation was found among patients regarding awareness of frequency
and importance of seeking regular dental care. Poor awareness, attitudes and behavior
was noted among patients visiting the dental clinics of tertiary care setting in Pakistan.
This poor behavior seems to be a regional pattern in south-east Asia. (63)

In our study, 69 (23%) patients were recommended RCT, 28(9.3%) were recommended
filing, 116(38.7%) were recommended extraction, 87 (29%) were recommended other
options and out of 300 patients 50(16.7 %) did not opted for treatment and 223 (74.3%)
opted treatment from a doctor and 27 (9%) opted treatment from a quack.

Our study showed that 228 (76%) patients had no comorbidity, 23(7.7%) had diabetes
mellitus, 24(8%) had hyper-tension, 12(4%) had hepatitis, and 13(4.3%) had other
comorbidities. In another study conducted in Japan in order to assess the relationship
between dental diseases in elderly people living in nursing homes and the associated co-

37 | P a g e
morbidities in 2017, 41% patients had dementia. Previous literature as well as the current
results, indicate that dental decay is problematic in the elderly population, and periodic
dental care may have a positive impact on health status. We also focused on other
comorbidities. Of these, hypertension, heart disease, and arthritis were significantly
associated with the number of present and normal teeth. (64)

Our study showed 69(23%) patients had duration of disease less than a month, 71(23.7%)
had duration of disease between 2 to 6 months, 67(22.3%) had duration of disease
between 7 to 12 months, 93(31%) had duration of disease more than 1 year. In contrast to
another study conducted in Galicia (north-west of spain), analysis of the interval since the
last visit to the dentist showed small differences between age groups, with approximately
30% of schoolchildren reporting a dental visit less than 1 month previously. This figure
was lower for the 15-year-old group whose results indicate an increase in the positive
attitude towards dental visits, with an increase in their regularity among older age groups.
In general, a significant association between caries history and recent dental visits is
widely accepted in the literature with children receiving dental attendance in recent
months tending to have a higher DMFT. An interesting finding in our study is that at age
15, individuals who went to the dentist more than 6 months previously registered less
caries history than those who went within the previous 3 months. (65)

Current study showed that that out of 119 males from 300 patients, 36 (30.3%) males had
duration of disease less than 1 month, 25 (21%) males had duration of disease between 2-
6 months, 25 (21%) males had duration of disease between 7-12 months and 33 (27.7%)
had duration of disease more than 1 year. Out of 181 females, 33 (18.23%) females had
duration of disease less than 1 month, 46 (25.42%) females had duration of disease
between 2-6 months, 42 (23.2%) females had duration of disease between 7-12 months
and 60 (33.15%) had duration of disease more than 1 year.

Our study showed that showed that out of 185 from 300 patients with monthly family
income less than 18000, 44 (23.8%) had duration of disease less than 1 month, 38
(20.5%) had duration of disease between 2-6 months, 43 (23.2%) had duration of disease
between 7-12 months and 60 (32.4%) had duration of disease more than 1 year. Out of 99
from 300 patients with monthly family income between 18001-40000, 22 (22.2%) had
duration of disease less than 1 month, 26 (26.3%) had duration of disease between 2-6

38 | P a g e
months, 20 (20.2%) had duration of disease between 7-12 months and 31 (31.3%) had
duration of disease more than 1 year and out of 16 from 300 patients with monthly family
income more than 40000, 3 (18.8%) had duration of disease less than 1 month, 7 (43.7%)
had duration of disease between 2-6 months, 4 (25%) had duration of disease between 7-
12 months and 2 (12.5%) had duration of disease more than 1 year. In comparison to a
previous study conducted in Baqai dental college in Karachi which highlighted that
attitudes towards oral health depends on the socioeconomic status of the patients. In the
presence of high-socio economic status, better oral health is experienced, and lower
dental caries rates are observed. The dental visits are important as oral diseases can be
diagnosed, managed, and even avoided on time, and personal oral hygiene guidelines can
be constantly reminded to dental practice visitors. That study reported that 69(21.1%) of
the patients from average monthly income often visits dental clinics once in 3 months and
258(78.9%) visited once in 6 months. It has been reported that people from low
socioeconomic status were less likely to have dental visits to a dental care specialist. (66)

39 | P a g e
CONCLUSION

40 | P a g e
 Conclusion

This study showed that most common dental diseases reported at Outpatient department of a tertiary
care hospital were, dental caries followed by broken down root, gingivitis, calculus, and periodontal
disease. Females and patients from urban areas were most commonly involved in late reporting of
dental health problems.

41 | P a g e
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42 | P a g e
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ANNEXURE

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Serial No ___________

Questionnaire
Pattern of Dental Diseases at a tertiary care Hospital
Age: ______________ years Gender: Male Female Transgender

Monthly Family Income: _____________ Rs. Residence: Rural Urban

Education: Illiterate Primary Matric Graduate Undergraduate Postgraduate

• Type of Disease \ Diagnosis:

Dental Caries Gingivitis

Trauma Broken Down Root

Impaction Staining
Calculus Malaligned Teeth
Periodontal Disease Others: ______________

• Recommended Treatment:

RCT(Root Canal Treatment) Filling

Extraction Minor Surgical Procedure
Others: _________________

• Duration of disease: ____________ years

• Treatment availed \ opt :
YES NO
• If Yes then: Hakeem Doctor Quack

• Associated Medical Condition:

Diabetic Hypertensive
Ischemic Heart Disease Hepatitis
Hypertensive
Gastrointestinal Disease Others: ______________
• Affected Tooth:
Hypertensive

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