Original article
Association between alcohol consumption and periodontal disease among older Nigerians in plateau state: a preliminary study E. Samuel. Akpata1, Abiola. A. Adeniyi1, Cyril. O. Enwonwu2, Oyeladun. A. Adeleke3 and Emmanuel. C. Otoh3 1
Faculty of Dentistry, Lagos State University, College of Medicine, Lagos, Nigeria; 2University of Maryland, Baltimore, MD, USA; 3Regional Centre for Oral Health Research and Training Initiatives (RCORTI) for Africa, Jos, Nigeria
Gerodontology 2014; doi: 10.1111/ger.12173 Association between alcohol consumption and periodontal disease among older Nigerians in plateau state: a preliminary study Objective: To report the periodontal status of older adults in Plateau State, Nigeria, and determine its Association with alcohol consumption. Background: Periodontal disease is common among Nigerians, and the prevalence increases with age. The role that alcohol consumption plays in the occurrence of the disease among Africans is uncertain. Materials and methods: Sample selection was performed using a multistage cluster sampling technique among older adults in Plateau State, Nigeria. Interviews, using structured questionnaires, were conducted for each of the participants. Clinical examinations were then carried out to determine the occurrence of periodontal disease, assessed by clinical attachment loss and probing depth. Results: The prevalence of periodontal disease was 79%, being severe in 46% of the population. Almost half of the participants (46.7%) examined were still actively consuming alcohol, among which 48% reported a history of intoxication. There was no statistically significant relationship between periodontal disease and the frequency of alcohol consumption, or quantity consumed on each occasion. However, alcohol consumption was highly correlated with periodontal disease among those who reported intoxication from the drink (r = 0.095; p = 0.033). A history of intoxication with alcohol was the only significant predictor of periodontal disease, after adjusting for age and gender. Conclusion: Periodontal disease was highly prevalent among older Nigerians in this study. Apart from those who reported intoxication from alcohol, there was no statistically significant relationship between the prevalence of periodontal disease and the frequency of alcohol consumption or the quantity consumed on each occasion. Keywords: alcohol consumption, periodontal disease, elderly, Nigerians. Accepted 30 October 2014
Introduction Periodontal disease refers to a group of diseases affecting the tooth-supporting structures known as the periodontium. It contributes significantly to the burden of oral diseases globally1, especially in developing countries where access to oral health care is limited. The prevalence and severity of periodontal disease is thought to increase with age, as such the highest occurrence is often observed among the elderly in many communities2–4. The
prevalence of the disease among elderly Nigerians is high and is estimated to be 73.9%5. An understanding of the risk factors for the occurrence of periodontal disease is critical for its prevention and management. Several risk factors have been identified for the development of the disease, and these include the composition of subgingival bacterial plaque1 as well as tobacco use6. Diabetes has also been associated with periodontal disease, the relationship being postulated to be two way1,2. The role of alcohol consumption alone, or
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
1
2
E. S. Akpata et al.
in combination with smoking, has been investigated as well6,7. Tobacco smoking has been identified as an independent risk factor for developing periodontal disease, especially when combined with alcohol use. The effect of alcohol alone on periodontal disease is still being investigated. However, some recent research reports indicate that excessive alcohol consumption may be an independent risk factor for severe periodontal disease8,9. There is limited information on alcohol consumption in many Third World countries including Nigeria, although in many of the communities, there appears to be widespread use of locally brewed alcoholic drinks. Furthermore, information on the relationship between alcohol consumption and the occurrence of periodontal disease in these countries appears to be scarce. The aim of this study was to evaluate the association between alcohol consumption and the occurrence of periodontal disease among elderly Nigerians. This research was part of a larger study of oral health among a representative sample of older adult Nigerians10.
Materials and methods
and the participants were recruited from households with the aid of members of the Community Development Committees. Only one person was recruited from each family. Ethical considerations Before commencement of the study, letters were written to the Chairpersons of all the selected LGAs, through their Directors of Primary Health Care. In the letters, the aims and objectives of the research were explained, and their consent and support for the study was sought. Approval for the study was also obtained from the State Institutional Review Board. Each participant signed an informed consent form. For most of the participants interviewed in the rural areas, explanation of the content of the consent form was given in Hausa, the predominant local language, and a thumb print in ink on the consent form by illiterate participants was accepted, instead of a signature, as the mark of consent to participate in the study. According to the National Bureau of Statistics, Abuja, Nigeria, almost half of the adult population is illiterate11.
Study location and sampling
Questionnaire study
The selection of the participants in this research project has been described elsewhere10. The sample was obtained from Plateau State, located in the north central geo-political zone of Nigeria. According to the 2003 estimate, the state has a population of 3.9 million, of which approximately 10% are aged 50 years and above. Administratively, it is divided into three senatorial districts (North, Central and South), comprising 17 local government areas (LGAs). Sample selection was performed using a multistage cluster sampling technique. Three LGAs were randomly selected from each of the three senatorial districts. The headquarters of each LGA was chosen as the urban-⁄semi-urban area, and another locality adjoining the headquarters randomly selected as the rural area, making a total of two localities selected from each of the nine LGAs. From the selected LGAs, 500 Nigerians aged 50 and above were randomly selected from households. The number of participants selected from each LGA was proportional to the population of the urban and rural areas. We continued to select those who were eligible, until we reached the number required from each LGA. Prior to selection of the participants, the Chairpersons and the Directors of Health in the LGAs were consulted,
Interviews, using structured questionnaires, were conducted for each of the participants. The domains in the interviewer-administered questionnaire included personal data, oral hygiene habits and questions to assess alcohol consumption patterns. The participants were asked about their history of alcohol consumption, frequency and the average amount consumed at each occasion. The illiterate participants were interviewed in Hausa and the others in English. Clinical examination A clinical dental examination was conducted immediately after administration of the questionnaire. The participants were examined while seated on a chair, with a wall as headrest, under natural lighting conditions. Clinical examinations were conducted to determine the teeth present and the occurrence of periodontal disease according to the methods recommended by the World Health Organization12. To determine the presence of periodontal disease, the clinical attachment loss as well as the periodontal probing depth (PPD) or pocket depth was measured on three locations on each tooth: mesiobuccal (MB), buccal (B) and lingual (L).
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
Alcohol and periodontitis in older Nigerians
The definition of periodontal disease was based on the Centers for Disease Control/American Academy of Periodontology13 definitions as follows: • Severe periodontitis: the presence of two or more interproximal sites with clinical attachment loss of at least ≥6 mm, not on the same tooth, and the presence of one or more interproximal sites with a probing depth of ≥5 mm. • Moderate periodontitis: the presence of two or more interproximal sites with clinical attachment loss of ≥5 mm occurring at two or more different teeth or two or more interproximal sites with a probing depth of ≥5 mm, not on the same tooth. • Mild periodontitis: the presence of two or more interproximal sites with clinical attachment loss of ≥4 mm occurring at two or more different teeth. Two dental surgeons, who were calibrated against each other, carried out the clinical examinations, and recordings for both examiners were by the same dental hygienist recruited from the Regional Centre for Oral Health Research and Training Initiative for Africa (RCORTI), Jos. Each of the examiners practiced the clinical examination until acceptable intraexaminer reproducibility was achieved. Interexaminer level of agreement in the measurement of pocket depth was 0.58 at participant level. Statistical analysis The data management and analysis were carried out, using the statistical software SPSS-PC version 17.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were presented as frequency, percentages, means and standard deviations. One hundred and fifty US dollars, the average working-class monthly wage in Nigeria, was chosen as the threshold for the income variable. For the purpose of data analysis, the periodontal disease was classified thus: group 1 included participants with mild or no periodontal disease, while group 2 comprised participants with moderate or severe periodontal disease. With respect to the level of alcohol consumption, the participants were categorised into two groups: (i) teeter-totters and occasional drinkers who consumed less than 600 ml of alcohol a day, and (ii) daily drinkers who consumed more than 600 ml daily, including those who reported intoxication from the drinks. Chi-squared statistical test was used to determine association between categorical variables, while Spearman’s correlation coefficient was used to determine relationship between alcohol consumption and occurrence of periodontal
3
disease. Logistic regression analyses were carried out to identify the most significant predictor of periodontal disease. The probability level of p < 0.05 was considered significant.
Results A total of 500 persons were included in this survey; there were slightly more men than women. A majority (91.2%) had either no formal education or received only primary school education (Table 1). Alcohol consumption patterns Only about one-third of the respondents (37.4%) had never taken alcohol; 46.7% were still actively taking alcohol while the remaining had stopped alcohol consumption (Table 1). Majority (65.5%) started consuming alcohol while in their teens, 27.2% between age 21 and 30 years, 3.0% between 31 and 40 years and only 0.9% started consuming alcohol in their forties. The commonest type of alcohol consumed was a local alcoholic brew called ‘burukutu’ (72.3%), followed by a combination of beer/locally brewed gin (12.5%), then by beer alone (8.2%). Only 1 person (0.2%) consumed the locally brewed gin exclusively. The remaining respondents consumed other drinks such as palm wine and other combinations of alcohol (Table 2). Almost half of those who reported still consuming alcohol (49.1%) did so on a daily basis. The amount of alcohol consumed at each occasion varied with highest proportion of persons (27.6%) consuming an average of 201–400 ml on each occasion. Almost half of those consuming alcohol (48.3%) recollected at least one occasion when alcohol consumption resulted in intoxication that hampered their daily functioning, suggesting binge drinking. On the other hand, 79.2% of the participants reported they had never used tobacco in any form. Tobacco use was weakly correlated with alcohol consumption, although the association was significant (r = 0.103; p = 0.011). The two variables, however, did not exhibit multicollinearity. Prevalence and severity of periodontal disease Using the criteria described above, 79.2% of the study participants had periodontal disease, of which 14.7% was classified as mild periodontitis, 38.6% moderate periodontitis and 46.7% severe periodontitis, respectively. The mean PPD ranged from 1.28 to 5.85 with overall mean of 2.018 (SD = 1.30). The proportion of sites with PPD of
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
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E. S. Akpata et al.
Table 1 Descriptive study of the general characteristics of the study population (n = 500). Severity of periodontal disease (PD)
Variable Gender Female Male Age in years 50–64 years >65 years Education None/Primary Secondary or higher Monthly income $150 Previous dental visit Within last 2 years >2 years ago Diabetes Yes No Alcohol consumption Current Former Never Tobacco use Current Former Never Location Rural Urban Total
No PD/Mild PD
Moderate PD
Severe PD
No
No
%
No
%
No
90 37.5 72 72 27.7 81 v2= 6.285 p-value = 0.043*
30.0 31.2
78 107
32.5 41.1
240 260
48.0 52.0
101 35.8 90 61 28.0 63 v2= 6.606 p-value = 0.037*
31.9 28.9
91 94
32.3 43.1
282 218
56.4 43.6
146 32.0 141 16 36.4 12 v2= 0.813 p-value = 0.414
30.9 27.2
169 16
37.1 36.4
456 44
91.2 8.8
155 31.9 149 7 50.0 4 v2= 2.340 p-value = 0.310
30.7 28.6
182 3
37.4 21.4
486 16
97.2 2.8
6 20.7 11 156 33.1 142 v2= 2.003 p-value = 0.367
37.9 30.1
12 173
41.4 36.7
29 471
5.8 94.2
11 37.9 7 151 32.1 146 v2= 0.718 p-value = 0.698
24.2 31.0
11 174
37.9 36.9
29 471
5.8 94.2
75 46.6 74 29 18.0 22 57 35.4 57 v2= 1.285 p-value = 0.864
48.4 14.4 37.3
83 28 72
45.4 15.3 39.3
232 79 186
46.7 15.9 37.4
9 22.0 16 18 28.6 20 135 34.1 117 v2= 3.115 p-value = 0.539
39.0 31.7 29.5
16 25 164
39.0 39.7 41.4
41 63 396
8.2 12.6 79.2
28 37.8 20 134 31.5 133 v2= 1.237 p-value = 0.539 162 32.4 153
27.0 31.2
26 159
35.1 37.3
74 426
14.8 85.2
30.6
185
37.0
500
100.0
%
Total %
*
Significant.
5 mm and above also ranged from 0% to 68.75% with mean of 15.02% (SD = 16.25%). Only gender and age were significantly associated (p > 0.05) with the severity of periodontal disease (Table 1). Relationship between periodontal disease and alcohol consumption Periodontal disease was not significantly related to consumption of alcohol, frequency of
consumption and quantity consumed at each occasion (Table 2). There was a statistically significant correlation between a history of being intoxicated and the severity of periodontal disease (r = 0.095; p = 0.033). However, the correlation between frequency of consumption and quantity consumed at each occasion was not significant. Table 3 shows direct logistic regression analyses to assess the impact of different independent variables (history and frequency of alcohol
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
Alcohol and periodontitis in older Nigerians
5
Table 2 Association between alcohol consumption, tobacco use and occurrence of periodontal disease. Periodontal disease
Alcohol consumption No/low alcohol consumption Chronic alcohol consumption Type of alcohol consumed None Beer Burukutu Beer/gin Other combinations Frequency of consumption Never Occasionally Daily Intoxicated Yes No Ever used tobacco Yes No Total
No PD/Mild PD
Moderate PD
Severe PD
Total
No
No
No
%
No
115 33.9 101 29.8 47 29.2 52 32.3 v2= 1.124 p-value = 0.570
123 62
36.3 38.5
336 161
67.8 32.2
0.039 (0.390)
87 32.5 79 29.5 9 47.4 2 10.5 50 29.8 56 33.3 9 31.0 9 31.0 7 43.8 7 43.8 v2= 8.601 p-value = 0.197
102 8 62 11 2
38.1 42.1 36.9 38.0 12.4
268 19 168 29 16
53.6 3.8 33.6 5.8 3.2
0.026 (0.559)
87 32.5 79 29.5 42 35.6 40 33.9 33 28.9 34 29.8 v2= 3.319 p-value = 0.506
102 36 47
38.1 30.5 41.2
268 118 114
53.6 23.6 22.8
0.014 (0.759)
27 24.1 39 34.8 135 34.8 114 29.4 v2= 4.551 p-value = 0.103
46 139
41.1 35.8
112 388
22.4 77.6
0.095 (0.033)*
25 25.3 34 34.3 137 34.2 119 29.7 v2= 2.898 p-value = 0.235 162 32.4 153 30.6
40 145
40.4 36.2
99 401
19.8 80.2
0.76 (0.090)
185
37.0
500
100.0
%
%
%
Spearmans correlation coefficient (p-value)a
*
Significant. Periodontal disease recoded into present or absent.
a
consumption, amount of alcohol consumed, as well as the history of binge drinking and alcohol use) on the likelihood of developing periodontal disease. Hosner and Lomeshow test indicated that all models explored were worthwhile p > 0.05. Age and gender were significantly associated with occurrence of periodontal disease in all the models tested. However, when we controlled for the effect of age, gender, education, income, previous dental visit and history of medical illness (Table 4), only two predictors were statistically significant, namely age (p = 0.025) and history of binge drinking (p = 0.023).
Discussion The Federal Republic of Nigeria ranks among thirty countries with the highest per capita consumption of alcohol globally14,15. This is the first study to investigate the impact of alcohol
consumption on periodontal health among older adults in Nigeria, the most populous country in Africa. Rural and semi-urban communities in Plateau State, North Central Nigeria, provided the randomly selected study samples. Plateau State shares many demographic characteristics with many communities in the rest of the country. The results from the present study may therefore be extrapolated to other parts of Nigeria. Our study showed that periodontal disease was highly prevalent among the participants, an observation consistent with earlier reported findings among elderly persons in Nigeria5,16. The observation was not surprising as the prevalence of periodontal disease generally increases with age2. Additionally, periodontal disease is the most prevalent oral health problem among Nigerian adults, and this is attributed partly to widespread poor oral hygiene practices17,18.
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
0.826 0.826 0.716
0.041*
1.075 (0.567–2.038) 1.075 (0.567–2.038) 1.129 (0.588–2.167)
1.931 (1.026–3.633)
1.469 (0.871–2.478) 0.149 v2= 10.059 p = 0.122 0.563
0.227 0.319
1.416 (0.805–2.488) 1.466 (0.691–3.115)
0.051
0.471 0.297 0.609
0.194 0.194
0.040*
0.333 0.229 0.814
0.183 0.183
0.039*
0.816 0.816 0.863
0.217 0.838
1.134 (0.650–1.981) 0.657 v2= 24.547 p = 0.006 0.310
0.027*
0.804 .804 0.867
1.086 (0.566 –2.083) 1.086 (0.566–2.083) 1.059 (0.542–2.067)
2.072 (1.086–3.954)
0.195 0.764
p-value
1.668 (0.770–3.613) 1.136 (0.492–2.624)
Model 5 Odds Ratio p-value (95% CI)
1.174 (0.674–2.045) 0.571 v2= 22.971 p = 0.028* 0.690
1.969 (1.035–3.744)
1.080 (0.564–2.066) 1.080 (0.564–2.066) 1.061 (0.544–2.068)
1.631 (0.750–3.546) 1.092 (0.471–2.528)
Model 4 Odds Ratio p-value (95% CI)
1.173 (0.674–2.040) 0.572 v2= 20.662 p = 0.008* 0.336
1.958 (1.030–3.722)
1.471 (0.674–3.205) 1.605 (0.743–3.460) 1.083 (0.557–2.107)
1.475 (0.833–2.611) 1.475 (0.833–2.611)
Mzxodel 3 Odds Ratio p-value (95% CI)
1.364 (0.803–2.316) 0.251 v2= 16.946 p = 0.018* 0.940
1.884 (0.997–3.561)
1.326 (0.615–2.857) 1.499 (0.700–2.857) 1.187 (0.616–2.287)
1.458 (0.826–2.577) 1.458 (0.826–2.577)
Model 2 Odds Ratio p-value (95% CI)
Model 1, unadjusted model; Model 2, adjusted for age; Model 3, adjusted for age and gender; Model 4, adjusted for age, gender, educational status and income level; Model 5. adjusted for age, gender, medical problems (heart disease, diabetes) and previous dental attendance. * Statistically significant.
Alcohol consumption (ref: never) Former Current Frequency of consumption (ref: never) Occasionally Daily Amount of alcohol consumed per week Intoxicated (suggest binge drinking) Tobacco use Model fit Hosmer and Lomeshow p-value
Model 1 Odds Ratio (95% CI)
Table 3 Logistic regression of the association between alcohol consumption, tobacco use and periodontal status.
6 E. S. Akpata et al.
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
Alcohol and periodontitis in older Nigerians
7
Table 4 Logistic regression predicting the likelihood of periodontal disease in the study population. 95% CI for Odds ratio Variable Age Sex Educational status (Ref: None) Primary only Secondary Tertiary Income Previous dental visit Positive history of medical condition Alcohol consumption (ref: never) Former Current Frequency of consumption (ref: never) Occasionally Daily Amount of alcohol consumed per week Intoxicated (suggest binge drinking) Tobacco use
B
SE
Wald
df
p
Odds ratio
Lower
Upper
0.023 0.379
0.010 0.232
5.015 2.673
1 1
0.025* 0.102
1.023 1.460
1.003 0.927
1.043 2.299
0.098 1.114 0.182 0.181 0.691 0.198
0.260 0.817 0.593 0.530 0.492 0.233
0.143 1.858 0.094 0.117 1.973 0.720
1 1 1 1 1 1
0.705 0.173 0.759 0.733 0.160 0.396
0.906 3.047 0.833 1.199 0.501 0.820
0.545 0.614 0.260 0.424 0.191 0.519
1.508 15.123 2.667 3.390 1.314 1.296
0.455 0.07
0.403 0.436
1.275 0.027
1 1
0.259 0.869
1.576 1.074
0.715 0.457
3.472 2.527
0.160 0.160 0.161 0.759 0.070
0.338 0.338 0.350 0.334 0.287
0.226 0.226 0.210 5.174 0.060
1 1 1 1 1
0.635 0.635 0.647 0.023 0.807
1.174 1.174 1.174 2.136 1.073
0.606 0.591 0.591 1.111 0.611
2.275 2.275 2.332 4.108 1.884
Model v2= 39.173 p = 0.002* Hosmer and Lomeshow p-value = 0.961.
Several studies have reported increased prevalence and severity of periodontal disease among individuals who consume alcohol4,8,9,19,20. Proffered explanations for this relationship include impairment of neutrophil function by alcohol21. Additionally, experimental animal studies suggest suppression of bone turnover and stimulation of bone resorption by alcohol22. Another explanation is that alcohol consumption may promote neglect of adequate oral hygiene practices, thereby resulting in increased risk for periodontal tissue destruction23. Regardless of the type of alcohol and the frequency of consumption, our results demonstrated that the relationship between moderate alcohol intake and the prevalence as well as severity of periodontal disease was not statistically significant. This observation contrasts with reports from other studies7–9, which suggest a clear relationship between alcohol consumption and periodontal disease. The differences in results between various studies may be attributed partly to differences in assessment and definition of periodontal disease. The natural progression of inflammatory periodontal disease in humans is often hampered by the multifactorial nature of the disease, including confounding factors like smoking, dietary practices, use of medications and several age-related metabolic processes24,25. Smoking and abuse of other
tobacco products are often associated with alcohol consumption. Smoking contributes very significantly to the incidence of advanced periodontal disease in humans26. As indicated in an earlier report10, very few of our study participants (
Association between alcohol consumption and periodontal disease among older Nigerians in plateau state: a preliminary study E. Samuel. Akpata1, Abiola. A. Adeniyi1, Cyril. O. Enwonwu2, Oyeladun. A. Adeleke3 and Emmanuel. C. Otoh3 1
Faculty of Dentistry, Lagos State University, College of Medicine, Lagos, Nigeria; 2University of Maryland, Baltimore, MD, USA; 3Regional Centre for Oral Health Research and Training Initiatives (RCORTI) for Africa, Jos, Nigeria
Gerodontology 2014; doi: 10.1111/ger.12173 Association between alcohol consumption and periodontal disease among older Nigerians in plateau state: a preliminary study Objective: To report the periodontal status of older adults in Plateau State, Nigeria, and determine its Association with alcohol consumption. Background: Periodontal disease is common among Nigerians, and the prevalence increases with age. The role that alcohol consumption plays in the occurrence of the disease among Africans is uncertain. Materials and methods: Sample selection was performed using a multistage cluster sampling technique among older adults in Plateau State, Nigeria. Interviews, using structured questionnaires, were conducted for each of the participants. Clinical examinations were then carried out to determine the occurrence of periodontal disease, assessed by clinical attachment loss and probing depth. Results: The prevalence of periodontal disease was 79%, being severe in 46% of the population. Almost half of the participants (46.7%) examined were still actively consuming alcohol, among which 48% reported a history of intoxication. There was no statistically significant relationship between periodontal disease and the frequency of alcohol consumption, or quantity consumed on each occasion. However, alcohol consumption was highly correlated with periodontal disease among those who reported intoxication from the drink (r = 0.095; p = 0.033). A history of intoxication with alcohol was the only significant predictor of periodontal disease, after adjusting for age and gender. Conclusion: Periodontal disease was highly prevalent among older Nigerians in this study. Apart from those who reported intoxication from alcohol, there was no statistically significant relationship between the prevalence of periodontal disease and the frequency of alcohol consumption or the quantity consumed on each occasion. Keywords: alcohol consumption, periodontal disease, elderly, Nigerians. Accepted 30 October 2014
Introduction Periodontal disease refers to a group of diseases affecting the tooth-supporting structures known as the periodontium. It contributes significantly to the burden of oral diseases globally1, especially in developing countries where access to oral health care is limited. The prevalence and severity of periodontal disease is thought to increase with age, as such the highest occurrence is often observed among the elderly in many communities2–4. The
prevalence of the disease among elderly Nigerians is high and is estimated to be 73.9%5. An understanding of the risk factors for the occurrence of periodontal disease is critical for its prevention and management. Several risk factors have been identified for the development of the disease, and these include the composition of subgingival bacterial plaque1 as well as tobacco use6. Diabetes has also been associated with periodontal disease, the relationship being postulated to be two way1,2. The role of alcohol consumption alone, or
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
1
2
E. S. Akpata et al.
in combination with smoking, has been investigated as well6,7. Tobacco smoking has been identified as an independent risk factor for developing periodontal disease, especially when combined with alcohol use. The effect of alcohol alone on periodontal disease is still being investigated. However, some recent research reports indicate that excessive alcohol consumption may be an independent risk factor for severe periodontal disease8,9. There is limited information on alcohol consumption in many Third World countries including Nigeria, although in many of the communities, there appears to be widespread use of locally brewed alcoholic drinks. Furthermore, information on the relationship between alcohol consumption and the occurrence of periodontal disease in these countries appears to be scarce. The aim of this study was to evaluate the association between alcohol consumption and the occurrence of periodontal disease among elderly Nigerians. This research was part of a larger study of oral health among a representative sample of older adult Nigerians10.
Materials and methods
and the participants were recruited from households with the aid of members of the Community Development Committees. Only one person was recruited from each family. Ethical considerations Before commencement of the study, letters were written to the Chairpersons of all the selected LGAs, through their Directors of Primary Health Care. In the letters, the aims and objectives of the research were explained, and their consent and support for the study was sought. Approval for the study was also obtained from the State Institutional Review Board. Each participant signed an informed consent form. For most of the participants interviewed in the rural areas, explanation of the content of the consent form was given in Hausa, the predominant local language, and a thumb print in ink on the consent form by illiterate participants was accepted, instead of a signature, as the mark of consent to participate in the study. According to the National Bureau of Statistics, Abuja, Nigeria, almost half of the adult population is illiterate11.
Study location and sampling
Questionnaire study
The selection of the participants in this research project has been described elsewhere10. The sample was obtained from Plateau State, located in the north central geo-political zone of Nigeria. According to the 2003 estimate, the state has a population of 3.9 million, of which approximately 10% are aged 50 years and above. Administratively, it is divided into three senatorial districts (North, Central and South), comprising 17 local government areas (LGAs). Sample selection was performed using a multistage cluster sampling technique. Three LGAs were randomly selected from each of the three senatorial districts. The headquarters of each LGA was chosen as the urban-⁄semi-urban area, and another locality adjoining the headquarters randomly selected as the rural area, making a total of two localities selected from each of the nine LGAs. From the selected LGAs, 500 Nigerians aged 50 and above were randomly selected from households. The number of participants selected from each LGA was proportional to the population of the urban and rural areas. We continued to select those who were eligible, until we reached the number required from each LGA. Prior to selection of the participants, the Chairpersons and the Directors of Health in the LGAs were consulted,
Interviews, using structured questionnaires, were conducted for each of the participants. The domains in the interviewer-administered questionnaire included personal data, oral hygiene habits and questions to assess alcohol consumption patterns. The participants were asked about their history of alcohol consumption, frequency and the average amount consumed at each occasion. The illiterate participants were interviewed in Hausa and the others in English. Clinical examination A clinical dental examination was conducted immediately after administration of the questionnaire. The participants were examined while seated on a chair, with a wall as headrest, under natural lighting conditions. Clinical examinations were conducted to determine the teeth present and the occurrence of periodontal disease according to the methods recommended by the World Health Organization12. To determine the presence of periodontal disease, the clinical attachment loss as well as the periodontal probing depth (PPD) or pocket depth was measured on three locations on each tooth: mesiobuccal (MB), buccal (B) and lingual (L).
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
Alcohol and periodontitis in older Nigerians
The definition of periodontal disease was based on the Centers for Disease Control/American Academy of Periodontology13 definitions as follows: • Severe periodontitis: the presence of two or more interproximal sites with clinical attachment loss of at least ≥6 mm, not on the same tooth, and the presence of one or more interproximal sites with a probing depth of ≥5 mm. • Moderate periodontitis: the presence of two or more interproximal sites with clinical attachment loss of ≥5 mm occurring at two or more different teeth or two or more interproximal sites with a probing depth of ≥5 mm, not on the same tooth. • Mild periodontitis: the presence of two or more interproximal sites with clinical attachment loss of ≥4 mm occurring at two or more different teeth. Two dental surgeons, who were calibrated against each other, carried out the clinical examinations, and recordings for both examiners were by the same dental hygienist recruited from the Regional Centre for Oral Health Research and Training Initiative for Africa (RCORTI), Jos. Each of the examiners practiced the clinical examination until acceptable intraexaminer reproducibility was achieved. Interexaminer level of agreement in the measurement of pocket depth was 0.58 at participant level. Statistical analysis The data management and analysis were carried out, using the statistical software SPSS-PC version 17.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were presented as frequency, percentages, means and standard deviations. One hundred and fifty US dollars, the average working-class monthly wage in Nigeria, was chosen as the threshold for the income variable. For the purpose of data analysis, the periodontal disease was classified thus: group 1 included participants with mild or no periodontal disease, while group 2 comprised participants with moderate or severe periodontal disease. With respect to the level of alcohol consumption, the participants were categorised into two groups: (i) teeter-totters and occasional drinkers who consumed less than 600 ml of alcohol a day, and (ii) daily drinkers who consumed more than 600 ml daily, including those who reported intoxication from the drinks. Chi-squared statistical test was used to determine association between categorical variables, while Spearman’s correlation coefficient was used to determine relationship between alcohol consumption and occurrence of periodontal
3
disease. Logistic regression analyses were carried out to identify the most significant predictor of periodontal disease. The probability level of p < 0.05 was considered significant.
Results A total of 500 persons were included in this survey; there were slightly more men than women. A majority (91.2%) had either no formal education or received only primary school education (Table 1). Alcohol consumption patterns Only about one-third of the respondents (37.4%) had never taken alcohol; 46.7% were still actively taking alcohol while the remaining had stopped alcohol consumption (Table 1). Majority (65.5%) started consuming alcohol while in their teens, 27.2% between age 21 and 30 years, 3.0% between 31 and 40 years and only 0.9% started consuming alcohol in their forties. The commonest type of alcohol consumed was a local alcoholic brew called ‘burukutu’ (72.3%), followed by a combination of beer/locally brewed gin (12.5%), then by beer alone (8.2%). Only 1 person (0.2%) consumed the locally brewed gin exclusively. The remaining respondents consumed other drinks such as palm wine and other combinations of alcohol (Table 2). Almost half of those who reported still consuming alcohol (49.1%) did so on a daily basis. The amount of alcohol consumed at each occasion varied with highest proportion of persons (27.6%) consuming an average of 201–400 ml on each occasion. Almost half of those consuming alcohol (48.3%) recollected at least one occasion when alcohol consumption resulted in intoxication that hampered their daily functioning, suggesting binge drinking. On the other hand, 79.2% of the participants reported they had never used tobacco in any form. Tobacco use was weakly correlated with alcohol consumption, although the association was significant (r = 0.103; p = 0.011). The two variables, however, did not exhibit multicollinearity. Prevalence and severity of periodontal disease Using the criteria described above, 79.2% of the study participants had periodontal disease, of which 14.7% was classified as mild periodontitis, 38.6% moderate periodontitis and 46.7% severe periodontitis, respectively. The mean PPD ranged from 1.28 to 5.85 with overall mean of 2.018 (SD = 1.30). The proportion of sites with PPD of
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
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E. S. Akpata et al.
Table 1 Descriptive study of the general characteristics of the study population (n = 500). Severity of periodontal disease (PD)
Variable Gender Female Male Age in years 50–64 years >65 years Education None/Primary Secondary or higher Monthly income $150 Previous dental visit Within last 2 years >2 years ago Diabetes Yes No Alcohol consumption Current Former Never Tobacco use Current Former Never Location Rural Urban Total
No PD/Mild PD
Moderate PD
Severe PD
No
No
%
No
%
No
90 37.5 72 72 27.7 81 v2= 6.285 p-value = 0.043*
30.0 31.2
78 107
32.5 41.1
240 260
48.0 52.0
101 35.8 90 61 28.0 63 v2= 6.606 p-value = 0.037*
31.9 28.9
91 94
32.3 43.1
282 218
56.4 43.6
146 32.0 141 16 36.4 12 v2= 0.813 p-value = 0.414
30.9 27.2
169 16
37.1 36.4
456 44
91.2 8.8
155 31.9 149 7 50.0 4 v2= 2.340 p-value = 0.310
30.7 28.6
182 3
37.4 21.4
486 16
97.2 2.8
6 20.7 11 156 33.1 142 v2= 2.003 p-value = 0.367
37.9 30.1
12 173
41.4 36.7
29 471
5.8 94.2
11 37.9 7 151 32.1 146 v2= 0.718 p-value = 0.698
24.2 31.0
11 174
37.9 36.9
29 471
5.8 94.2
75 46.6 74 29 18.0 22 57 35.4 57 v2= 1.285 p-value = 0.864
48.4 14.4 37.3
83 28 72
45.4 15.3 39.3
232 79 186
46.7 15.9 37.4
9 22.0 16 18 28.6 20 135 34.1 117 v2= 3.115 p-value = 0.539
39.0 31.7 29.5
16 25 164
39.0 39.7 41.4
41 63 396
8.2 12.6 79.2
28 37.8 20 134 31.5 133 v2= 1.237 p-value = 0.539 162 32.4 153
27.0 31.2
26 159
35.1 37.3
74 426
14.8 85.2
30.6
185
37.0
500
100.0
%
Total %
*
Significant.
5 mm and above also ranged from 0% to 68.75% with mean of 15.02% (SD = 16.25%). Only gender and age were significantly associated (p > 0.05) with the severity of periodontal disease (Table 1). Relationship between periodontal disease and alcohol consumption Periodontal disease was not significantly related to consumption of alcohol, frequency of
consumption and quantity consumed at each occasion (Table 2). There was a statistically significant correlation between a history of being intoxicated and the severity of periodontal disease (r = 0.095; p = 0.033). However, the correlation between frequency of consumption and quantity consumed at each occasion was not significant. Table 3 shows direct logistic regression analyses to assess the impact of different independent variables (history and frequency of alcohol
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
Alcohol and periodontitis in older Nigerians
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Table 2 Association between alcohol consumption, tobacco use and occurrence of periodontal disease. Periodontal disease
Alcohol consumption No/low alcohol consumption Chronic alcohol consumption Type of alcohol consumed None Beer Burukutu Beer/gin Other combinations Frequency of consumption Never Occasionally Daily Intoxicated Yes No Ever used tobacco Yes No Total
No PD/Mild PD
Moderate PD
Severe PD
Total
No
No
No
%
No
115 33.9 101 29.8 47 29.2 52 32.3 v2= 1.124 p-value = 0.570
123 62
36.3 38.5
336 161
67.8 32.2
0.039 (0.390)
87 32.5 79 29.5 9 47.4 2 10.5 50 29.8 56 33.3 9 31.0 9 31.0 7 43.8 7 43.8 v2= 8.601 p-value = 0.197
102 8 62 11 2
38.1 42.1 36.9 38.0 12.4
268 19 168 29 16
53.6 3.8 33.6 5.8 3.2
0.026 (0.559)
87 32.5 79 29.5 42 35.6 40 33.9 33 28.9 34 29.8 v2= 3.319 p-value = 0.506
102 36 47
38.1 30.5 41.2
268 118 114
53.6 23.6 22.8
0.014 (0.759)
27 24.1 39 34.8 135 34.8 114 29.4 v2= 4.551 p-value = 0.103
46 139
41.1 35.8
112 388
22.4 77.6
0.095 (0.033)*
25 25.3 34 34.3 137 34.2 119 29.7 v2= 2.898 p-value = 0.235 162 32.4 153 30.6
40 145
40.4 36.2
99 401
19.8 80.2
0.76 (0.090)
185
37.0
500
100.0
%
%
%
Spearmans correlation coefficient (p-value)a
*
Significant. Periodontal disease recoded into present or absent.
a
consumption, amount of alcohol consumed, as well as the history of binge drinking and alcohol use) on the likelihood of developing periodontal disease. Hosner and Lomeshow test indicated that all models explored were worthwhile p > 0.05. Age and gender were significantly associated with occurrence of periodontal disease in all the models tested. However, when we controlled for the effect of age, gender, education, income, previous dental visit and history of medical illness (Table 4), only two predictors were statistically significant, namely age (p = 0.025) and history of binge drinking (p = 0.023).
Discussion The Federal Republic of Nigeria ranks among thirty countries with the highest per capita consumption of alcohol globally14,15. This is the first study to investigate the impact of alcohol
consumption on periodontal health among older adults in Nigeria, the most populous country in Africa. Rural and semi-urban communities in Plateau State, North Central Nigeria, provided the randomly selected study samples. Plateau State shares many demographic characteristics with many communities in the rest of the country. The results from the present study may therefore be extrapolated to other parts of Nigeria. Our study showed that periodontal disease was highly prevalent among the participants, an observation consistent with earlier reported findings among elderly persons in Nigeria5,16. The observation was not surprising as the prevalence of periodontal disease generally increases with age2. Additionally, periodontal disease is the most prevalent oral health problem among Nigerian adults, and this is attributed partly to widespread poor oral hygiene practices17,18.
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
0.826 0.826 0.716
0.041*
1.075 (0.567–2.038) 1.075 (0.567–2.038) 1.129 (0.588–2.167)
1.931 (1.026–3.633)
1.469 (0.871–2.478) 0.149 v2= 10.059 p = 0.122 0.563
0.227 0.319
1.416 (0.805–2.488) 1.466 (0.691–3.115)
0.051
0.471 0.297 0.609
0.194 0.194
0.040*
0.333 0.229 0.814
0.183 0.183
0.039*
0.816 0.816 0.863
0.217 0.838
1.134 (0.650–1.981) 0.657 v2= 24.547 p = 0.006 0.310
0.027*
0.804 .804 0.867
1.086 (0.566 –2.083) 1.086 (0.566–2.083) 1.059 (0.542–2.067)
2.072 (1.086–3.954)
0.195 0.764
p-value
1.668 (0.770–3.613) 1.136 (0.492–2.624)
Model 5 Odds Ratio p-value (95% CI)
1.174 (0.674–2.045) 0.571 v2= 22.971 p = 0.028* 0.690
1.969 (1.035–3.744)
1.080 (0.564–2.066) 1.080 (0.564–2.066) 1.061 (0.544–2.068)
1.631 (0.750–3.546) 1.092 (0.471–2.528)
Model 4 Odds Ratio p-value (95% CI)
1.173 (0.674–2.040) 0.572 v2= 20.662 p = 0.008* 0.336
1.958 (1.030–3.722)
1.471 (0.674–3.205) 1.605 (0.743–3.460) 1.083 (0.557–2.107)
1.475 (0.833–2.611) 1.475 (0.833–2.611)
Mzxodel 3 Odds Ratio p-value (95% CI)
1.364 (0.803–2.316) 0.251 v2= 16.946 p = 0.018* 0.940
1.884 (0.997–3.561)
1.326 (0.615–2.857) 1.499 (0.700–2.857) 1.187 (0.616–2.287)
1.458 (0.826–2.577) 1.458 (0.826–2.577)
Model 2 Odds Ratio p-value (95% CI)
Model 1, unadjusted model; Model 2, adjusted for age; Model 3, adjusted for age and gender; Model 4, adjusted for age, gender, educational status and income level; Model 5. adjusted for age, gender, medical problems (heart disease, diabetes) and previous dental attendance. * Statistically significant.
Alcohol consumption (ref: never) Former Current Frequency of consumption (ref: never) Occasionally Daily Amount of alcohol consumed per week Intoxicated (suggest binge drinking) Tobacco use Model fit Hosmer and Lomeshow p-value
Model 1 Odds Ratio (95% CI)
Table 3 Logistic regression of the association between alcohol consumption, tobacco use and periodontal status.
6 E. S. Akpata et al.
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
Alcohol and periodontitis in older Nigerians
7
Table 4 Logistic regression predicting the likelihood of periodontal disease in the study population. 95% CI for Odds ratio Variable Age Sex Educational status (Ref: None) Primary only Secondary Tertiary Income Previous dental visit Positive history of medical condition Alcohol consumption (ref: never) Former Current Frequency of consumption (ref: never) Occasionally Daily Amount of alcohol consumed per week Intoxicated (suggest binge drinking) Tobacco use
B
SE
Wald
df
p
Odds ratio
Lower
Upper
0.023 0.379
0.010 0.232
5.015 2.673
1 1
0.025* 0.102
1.023 1.460
1.003 0.927
1.043 2.299
0.098 1.114 0.182 0.181 0.691 0.198
0.260 0.817 0.593 0.530 0.492 0.233
0.143 1.858 0.094 0.117 1.973 0.720
1 1 1 1 1 1
0.705 0.173 0.759 0.733 0.160 0.396
0.906 3.047 0.833 1.199 0.501 0.820
0.545 0.614 0.260 0.424 0.191 0.519
1.508 15.123 2.667 3.390 1.314 1.296
0.455 0.07
0.403 0.436
1.275 0.027
1 1
0.259 0.869
1.576 1.074
0.715 0.457
3.472 2.527
0.160 0.160 0.161 0.759 0.070
0.338 0.338 0.350 0.334 0.287
0.226 0.226 0.210 5.174 0.060
1 1 1 1 1
0.635 0.635 0.647 0.023 0.807
1.174 1.174 1.174 2.136 1.073
0.606 0.591 0.591 1.111 0.611
2.275 2.275 2.332 4.108 1.884
Model v2= 39.173 p = 0.002* Hosmer and Lomeshow p-value = 0.961.
Several studies have reported increased prevalence and severity of periodontal disease among individuals who consume alcohol4,8,9,19,20. Proffered explanations for this relationship include impairment of neutrophil function by alcohol21. Additionally, experimental animal studies suggest suppression of bone turnover and stimulation of bone resorption by alcohol22. Another explanation is that alcohol consumption may promote neglect of adequate oral hygiene practices, thereby resulting in increased risk for periodontal tissue destruction23. Regardless of the type of alcohol and the frequency of consumption, our results demonstrated that the relationship between moderate alcohol intake and the prevalence as well as severity of periodontal disease was not statistically significant. This observation contrasts with reports from other studies7–9, which suggest a clear relationship between alcohol consumption and periodontal disease. The differences in results between various studies may be attributed partly to differences in assessment and definition of periodontal disease. The natural progression of inflammatory periodontal disease in humans is often hampered by the multifactorial nature of the disease, including confounding factors like smoking, dietary practices, use of medications and several age-related metabolic processes24,25. Smoking and abuse of other
tobacco products are often associated with alcohol consumption. Smoking contributes very significantly to the incidence of advanced periodontal disease in humans26. As indicated in an earlier report10, very few of our study participants (
