|Year : 2022 | Volume
| Issue : 1 | Page : 48-53
Permanent teeth loss: A 5-year retrospective analysis of the patterns and indications of intra-alveolar exodontia in Najran, Kingdom of Saudi Arabia
Ramat Oyebunmi Braimah1, Dawood Ali-Alsuliman2, Harit Kanwar Sharma2, Abdulrazaq O Taiwo3, Adebayo Aremu Ibikunle4, Yahyah Alsalah5, Reham Makrami5, Abdullah S Alwalah5, Mohammed S Alajam5, Abdullrahman Saeed Alalharith2
1 Department of Maxillofacial Surgery, Specialty Regional Dental Center, Medical Village Complex, Najran, Kingdom of Saudi Arabia
2 Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Centre, Medical Village Complex, Najran, Kingdom of Saudi Arabia
3 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, College of Health Sciences, Usmanu Danfodiyo University Sokoto, Sokoto, Nigeria
4 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
5 Specialty Regional Dental Centre, Medical Village Complex, Najran, Kingdom of Saudi Arabia
|Date of Submission||18-Oct-2021|
|Date of Decision||04-Nov-2021|
|Date of Acceptance||17-Nov-2021|
|Date of Web Publication||29-Apr-2022|
Dr. Ramat Oyebunmi Braimah
Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Introduction: Tooth loss is a worldwide public health concern of huge proportion. Problems associated with permanent tooth loss are enormous.
Aim: This study aims to investigate the major reasons and patterns of permanent tooth extraction in a government referral dental center.
Materials and Methods: This retrospective study was conducted on patients who had intra-alveolar extraction of teeth in our facility between January 2016 and December 2020. Sociodemographic data and type of tooth extracted were recorded. Reasons for extraction were classified into the following: caries, failed root canal treatment, failed restoration, periodontitis, prosthodontic, orthodontic, trauma, and over-eruption. Data were stored and analyzed with SPSS for MOS, Version 20.0.
Results and Discussion: A total of 8065 (3248, 0.3%) males and 4817 (59.3%, females) patients presented for teeth extraction during the study period with 11,746 extractions done, giving an average of 1.5 extractions per individual. The age range of 11–102 years with a mean (±standard deviation) of 36.0 (16.6) was observed. The majority of the patients were in the age groups of 21–30 years (1992 (24.7%), then 31–40 years (1773 (22.0%). Caries and its sequelae accounted for the main reasons for tooth mortality. In the mandible, a total of 5321 (45.3%), while in the maxilla, a total of 6425 (54.7%) teeth were extracted. Molars were the most extracted tooth in both jaws (3485 (29.7%))
Conclusions: The current study found that dental caries, and its sequelae, was the main reason for tooth extraction in a Saudi subpopulation, Najran. Molars were the most commonly extracted teeth.
Keywords: Dental caries, indications, Najran, periodontal disease, Saudi Arabia, tooth extraction
|How to cite this article:|
Braimah RO, Ali-Alsuliman D, Sharma HK, Taiwo AO, Ibikunle AA, Alsalah Y, Makrami R, Alwalah AS, Alajam MS, Alalharith AS. Permanent teeth loss: A 5-year retrospective analysis of the patterns and indications of intra-alveolar exodontia in Najran, Kingdom of Saudi Arabia. Saudi J Oral Sci 2022;9:48-53
|How to cite this URL:|
Braimah RO, Ali-Alsuliman D, Sharma HK, Taiwo AO, Ibikunle AA, Alsalah Y, Makrami R, Alwalah AS, Alajam MS, Alalharith AS. Permanent teeth loss: A 5-year retrospective analysis of the patterns and indications of intra-alveolar exodontia in Najran, Kingdom of Saudi Arabia. Saudi J Oral Sci [serial online] 2022 [cited 2022 Aug 15];9:48-53. Available from: https://www.saudijos.org/text.asp?2022/9/1/48/344405
| Introduction|| |
Tooth loss has become a worldwide public health concern of enormous percentage., Tooth extractions comprise the bulk of daily minor oral surgical procedures carried out in both government and private dental practice., Problems associated with permanent tooth loss include psychosocial, mastication, and deglutition dysfunctions, speech difficulties, malnutrition, cancers, and poor quality of life.,,,, Furthermore, cardiovascular disease and cerebrovascular accidents including dose–response relationship have been linked with tooth loss. Also, dementia development has been reported to be more likely in patients with tooth loss.
Literature has reported dental caries and periodontal pathologies as the major community diseases and chief etiologies of tooth loss.,, Other cited reasons for tooth loss include failures of previous endodontic and restorative treatments, orthodontic, trauma, iatrogenic, and combination of any these. Consequently, research on pattern and etiology relating to permanent tooth extraction will generate data that will aid government and s in implementing measures that will improve access to oral health and knowledge.
Worldwide, it has been reported that total tooth loss has affected over 276 million people in 2015 and this expected to increase due to aging population. Studies reporting prevalence and reasons for tooth extraction are still scarce in the Kingdom of Saudi Arabia., In Najran, a southwestern city, no study has reported the pattern and etiologies for permanent teeth extraction in the oral and maxillofacial department of the only referral dental center. Therefore, this study aims to investigate and explore the major reasons and patterns of permanent tooth extraction in Najran, Kingdom of Saudi Arabia.
| Materials and Methods|| |
This 5-year retrospective study was conducted on patients who had intra-alveolar extraction of teeth at the Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran, between January 2016 and December 2020. The center is the only referral hospital located in Najran, Southern Saudi Arabia. The study followed the Helsinki Declaration and was approved by the Ethics and Research Committee of General Directorate of Health Affairs in Najran Region with protocol number KSA: H-l1-N-081.
Patients who were < 11 years old at the time of treatment and transalveolar extraction of the third molars were excluded from the study. Data on the age, gender, year of presentation, type of tooth extracted, restorative status, and reason for extraction were documented. Reasons for extraction were classified into the following: caries, failed root canal treatment, failed restoration, periodontitis, prosthodontic, orthodontic, trauma, and over-eruption.
Statistical analyses were done using the Statistical Package for Social Sciences version 20 (IBM SPSS Statistics for MOS, Version 20.0. Armonk, NY, USA: IBM Corp.). Descriptive analyses and cross-tabulations of variables were done. The level of statistical significance was set at P < 0.05.
| Results|| |
A total of 8065 (3248 (40.3%) males and 4817 (59.3%) females) patients presented for teeth extraction during the study period with 11,746 extractions done, giving an average of 1.5 extractions per individual. The age range of 11–102 years with a mean (±standard deviation) of 36.0 (16.6) was observed [Table 1]. The male/female ratio was 1:1.5. The majority of the patients were in the age groups of 21–30 years (1992, 24.7%), then 31–40 years (1773, 22.0%), then 41–50 years (1135, 14.1%), while the least were >90 years (24, 0.3%) [Table 1].
Caries and its sequelae accounted for the main reasons for tooth loss with statistical significance (χ2 = 3106.48, df = 56, P = 0.000). Caries accounted for 4471 (55.4%) of tooth loss, 2245 (27.8) was as a result of failed root canal treatment, while 435 (5.4%) was because of failed restoration. The least reason for tooth loss was trauma (35, 0.4%)). Other reasons for tooth loss are presented in [Table 2] and [Figure 1]. Tooth 18 was the most extracted tooth (921, 7.8%) followed by tooth 36 (908, 7.7%) (n = 11,746). Other distributions of extracted teeth are shown in [Figure 2].
|Table 2: Distribution of indications for extraction according to the age group of patients|
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|Figure 1: Chart showing indications for tooth extraction according to gender of patients|
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In the mandible, a total of 5321 (45.3%) teeth were extracted consisting of 222 (4.2%) lower right incisors (41 and 42), 129 (2.4%) lower right canine (43), 703 (13.2%) lower right premolars (44 and 45) and 1714 (32.2%) lower right molars (46, 47, and 48), 163 (3.1%) lower left incisors (31 and 32), 60 (1.1%) lower left canine (33), 556 (10.5%) lower left premolars (34 and 35), and 1774 (33.3%) lower left molars (36, 37, and 38) [Figure 3].
In the maxilla, a total of 6425 (54.7%) teeth were extracted comprising 339 (5.3%) upper right incisors (11 and 12), 172 (2.7%) upper right canine (13), 970 (15.1%) upper right premolars (14 and 15), 1910 (29.7%) upper right molars (16, 17, and 18), 195 (3.0%) upper left incisors (21 and 22), 167 (2.6%) upper left canine (23), 901 (14.0%) upper left premolars (24 and 25), and 1771 (27.6%) upper left molars (26, 27, and 28) [Figure 4].
| Discussions|| |
Tooth loss will continue to remain an obstacle in achieving a wide-ranging population oral health worldwide due to its negative consequences.,, In Saudi Arabia, the ministry of health has reported that 18,640 permanent teeth were extracted in the Eastern Province alone in 2019 and this figure continues to increase.
The current study has observed a female predilection which is in agreement with the literature., Better health-seeking behavior of the female gender has been given as the major reason for this observation., However, other studies have reported a male preponderance., Reasons for the reported male predominance have been linked with female anxiety and fear of surgical procedures. The mean age of the patients displayed a statistically significant difference when analyzed with gender as the majority of the patients were in the age group 21–30 years. This observation has been reported in other studies.,, Other studies have reported otherwise as most of their patients were in their fourth decades of life., The reason behind the high prevalence of tooth loss in younger patients in the current study can be attributed to high caries index among children and adolescents in Saudi Arabia.,, Many who seek treatment of these carious lesions are often on a long waiting list in government hospitals that will eventually lead to extractions. Those who seek treatment in private clinics usually do not have adequate restoration and, as such, are destined to fail ab initio resulting in extraction. Unlike other climes where childhood dental caries have been reduced, periodontal problems contribute more to reasons of tooth loss in addition to comorbid conditions that are associated with this age bracket.
The present study re-affirmed previous studies reporting dental caries and its sequelae as the main reason for tooth loss globally and locally.,,, Worldwide, it was reported that 2.3 billion people are affected with dental caries and its sequelae. In the current study, failed root canal treatment and failed restorations which are consequences of caries are the other main reasons for tooth loss. In Saudi populations, poor oral hygiene, high tobacco smoking, high consumption of refined carbohydrates, nonchalant attitude towards dental clinic attendance, and very low dental awareness are factors reported to have increased them to oral diseases and thereafter leading to tooth loss., In other to increase dental awareness in the entire Kingdom, school-based oral health education should be incorporated into the primary, intermediate, and secondary levels to “catch them young.” This has already started in the major cities, and should be extended to every province. In addition, mothers should be enlightened during antenatal care about their oral hygiene. Studies have shown that there is an influence of mothers oral health-care knowledge and awareness on their children.,
Unlike developing countries where there is a lack of dental services being incorporated into primary health-care services, in Saudi Arabia, oral health care is already incorporated into primary health services and all primary health-care centers are fully equipped. However, lack of utilization by the citizens is a major problem. Many Saudi patients preferred to be attended to by specialists, however, this group of professionals are only available in the major hospitals. In the major hospitals, there are long waiting lists for endodontic and restorative treatments such that most teeth that can be salvaged are been referred for extraction.
Unlike previous studies that reported periodontal diseases,, as the second most common reason of tooth loss after dental caries and its sequelae, this present study has reported orthodontic reasons as the second most common reason for tooth extraction. In Najran, there is a high rate of malocclusion; therefore, many extraction cases of the premolars mostly in the younger age group are observed in our clinic. This is in agreement with reports from Madinah and Riyadh., These variations may be due to socioeconomic, type of treatment rendered in government hospitals, and educational status of both parents and the patients. Periodontal diseases were the third most common reason for tooth loss after the fifth decade in the present study. This is in agreement with the literature. In this age bracket, periodontal diseases are common because of poor oral hygiene, smoking, and increase in comorbid medical conditions such as diabetes., Furthermore, the study was conducted in the major government referral center and not in the dispensaries where most extractions are done due to periodontal diseases. Prosthodontic reasons for tooth extraction are not popular in the current study, as its one the least reasons for tooth loss. This particular reason is in clear relationship with patients in the fifth and sixth decades of life, as reported in a previous study. Over-eruption of opposing teeth is a physiologic consequence of extraction of tooth. Due to the absence of opposing force and in addition to the natural eruptive potential of the tooth, there is an affinity for the tooth to erupt above the occlusal plane.
The current study showed that more teeth were extracted in the maxilla (6425, 54.7%) than in the mandible as previously reported by Ahmad et al. However, this contrasts studies from Nigeria where most of the extracted teeth were in the mandible., Studies worldwide have reported mandibular and maxillary molars as the most frequently extracted teeth., While other studies have reported the first permanent molars as the most frequently extracted tooth, the present study has observed upper third molar (#18) as the most extracted tooth and followed by lower right molar (#36). The morphology, eruption timing, deep pits, and fissures that increase susceptibility to plaque and calculus accumulation on molars have been reported as possible reasons. In addition, difficult assess to cleaning of upper last molar may also predispose the upper last molar to caries and eventual tooth loss, as observed in the current study. Community water fluoridation, fissure sealant applications to pits and fissures on molars, and early atraumatic restorative treatment of occlusal caries with glass ionomer cement are cost-effective strategies that will prevent early loss of molars due to caries. Oher measures include twice-daily toothbrushing at sleep time and when waking up, reduction in in-between meals, and regular 6-monthly dental checkups., Anterior teeth were the least frequently extracted in the current study, as reported in previous studies. Easy access to cleaning, buffering actions from submandibular and sublingual salivary glands, and lack of pits/fissures on the anterior teeth may be responsible for this observation. One of the limitations observed in the present study is that the sample population is hospital based and may not reflect the entire Najran region. Multicenter future studies including all the dispensaries and private clinics should be pursued.
| Conclusions|| |
The current study found that dental caries and its sequelae was the main reason for tooth extraction in a Saudi subpopulation, Najran. Molars were the most commonly extracted teeth. Preventive measures targeting mothers and schoolchildren should be vigorously pursued. Furthermore, obstacles to accessing preventive oral care should also be followed actively and removed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Alesia K, Khalil HS. Reasons for and patterns relating to the extraction of permanent teeth in a subset of the Saudi population. Clin Cosmet Investig Dent 2013;5:51-6.
Taiwo OA, Sulaiman AO, Obileye MF, Akinshipo A, Uwumwonse AO, Soremi OO et al.
Patterns and reasons for childhood tooth extraction in Northwest Nigeria. J Pediatr Dent 2014;2:83. [Full text]
Fernández-Barrera MÁ, Medina-Solís CE, Casanova-Rosado JF, Mendoza-Rodríguez M, Escoffié-Ramírez M, Casanova-Rosado AJ, et al.
Contribution of prosthetic treatment considerations for dental extractions of permanent teeth. PeerJ 2016;4:e2015.
Bhayade SS, Mittal R, Chandak S, Bhondey A. Assessment of social, demographic determinants and oral hygiene practices in relation to dental caries among the children attending Anganwadis of Hingna, Nagpur. J Indian Soc Pedod Prev Dent 2016;34:124-7.
] [Full text]
Chen J, Ren CJ, Wu L, Xia LY, Shao J, Leng WD, et al.
Tooth loss is associated with increased risk of dementia and with a dose-response relationship. Front Aging Neurosci 2018;10:415-24.
Gerritsen AE, Allen PF, Witter DJ, Bronkhorst EM, Creugers NH. Tooth loss and oral health-related quality of life: A systematic review and meta-analysis. Health Qual Life Outcomes 2010;8:126-37.
Kossioni AE. The association of poor oral health parameters with malnutrition in older adults: A review considering the potential implications for cognitive impairment. Nutrients 2018;10:E1709.
Cheng F, Zhang M, Wang Q, Xu H, Dong X, Gao Z, et al.
Tooth loss and risk of cardiovascular disease and stroke: A dose-response meta analysis of prospective cohort studies. PLoS One 2018;13:e0194563.
Shi J, Leng W, Zhao L, Deng C, Xu C, Wang J, et al.
Tooth loss and cancer risk: A dose-response meta analysis of prospective cohort studies. Oncotarget 2018;9:15090-100.
Frencken JE, Sharma P, Stenhouse L, Green D, Laverty D, Dietrich T. Global epidemiology of dental caries and severe periodontitis – A comprehensive review. J Clin Periodontol 2017;44 Suppl 18:S94-105.
Ahmad FA, Alrashidi AM, Alajmi B, AlSharrad A. Causes and Patterns of tooth loss among patients attending Riyadh elm university hospital: A cross-sectional study. Oral Health Dent Sci 2019;3:1-5.
Dye BA. Global periodontal disease epidemiology. Periodontol 2000 2012;58:10-25.
Richards W, Ameen J, Coll AM, Higgs G. Reasons for tooth extraction in four general dental practices in South Wales. Br Dent J 2005;198:275-8.
Taiwo OA, Oduola TK, Farouk OM, Braimah RO, Ibikunle AA, Labbo JS, et al.
Pattern and indications for tooth extraction in a tertiary hospital, Kebbi State, Nigeria. Int Res J Med Med Sci 2017;5:30-6.
Kassebaum NJ, Smith AG, Bernabé E, Fleming TD, Reynolds AE, Vos T, et al.
Global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for 195 countries, 1990-2015: A systematic analysis for the global burden of diseases, injuries, and risk factors. J Dent Res 2017;96:380-7.
Gossadi YI, Nahari HH, Kinani HM, Abdelwahab SI, Boreak NM, Abidi NH, et al.
Reasons for permanent teeth extraction in Jizan region of Saudi Arabia. IOSR J 2015;14:86-9.
Aljafar A, Alibrahim H, Alahmed A, AbuAli A, Nazir M, Alakel A, et al
. Reasons for permanent teeth extractions and related factors among adult patients in the Eastern Province of Saudi Arabia. ScientificWorldJournal 2021;2021:1-7.
Guiguimde WP, Bakiono F, Ouedraogo Y, Millogo M, Gare JV, Konsem T, et al.
Epidemiology and clinic of dental extractions in University Teaching Hospital Yalgado Ouedraogo, (Burkina Faso). Odontostomatol Trop 2014;37:32-8.
Taiwo AO, Ibikunle AA, Braimah RO, Sulaiman OA, Gbotolorun OM. Tooth extraction: Pattern and etiology from extreme Northwestern Nigeria. Eur J Dent 2017;11:335-9.
] [Full text]
Oliver MI, Pearson N, Coe N, Gunnell D. Help-seeking behaviour in men and women with common mental health problems: Cross-sectional study. Br J Psychiatry 2005;186:297-301.
Thompson AE, Anisimowicz Y, Miedema B,
Hogg W, Wodchis WP, Aubrey-Bassier K, et al.
The influence of gender and other patient characteristics on health care-seeking behaviour: A QUALICOPC study. BMC Fam Pract 2016;17:38.
Taiwo OA, Alabi OA, Yusuf OM, Ololo O, Olawole WO, Adeyemo WI. Reasons and pattern of tooth extraction among patients presenting at a Nigerian semi-rural specialist hospital. Nig Q J Hosp Med 2012;22:200-4.
Akaji EA, Chukwuneke FN, Okeke UF. Attendance pattern amongst patients at the dental clinic of the university of Nigeria teaching hospital, Enugu, Nigeria. Niger J Med 2012;21:74-7. [Full text]
Saheeb BD, Sede MA. Reasons and pattern of tooth mortality in a Nigerian Urban teaching hospital. Ann Afr Med 2013;12:110-4.
] [Full text]
AlMutiry MB, Eltahir MA. Causes of permanent teeth extraction in relation to age: A study from Qassim Region, KSA. Acta Sci Dent Sci 2020;4:95-9.
Chrysanthakopoulos NA, Vlassi CK. Reasons and risks of permanent teeth extraction. The general dental practice in Greece. Int J Med Dent 2013;3:4.
Al Agili DE. A systematic review of population-based dental caries studies among children in Saudi Arabia. Saudi Dent J 2013;25:3-11.
Alshammari FR, Alamri H, Aljohani M, Sabbah W, O'Malley L, Glenny AM. Dental caries in Saudi Arabia: A systematic review. J Taibah Univ Med Sci 2021;16:643-56.
Quadri MF, Shubayr MA, Hattan AH, Wafi SA, Jafer AH. Oral hygiene practices among Saudi Arabian children and its relation to their dental caries status. Int J Dent 2018;2018:3234970.
Lesolang RR, Motloba DP, Lalloo R. Patterns and reasons for tooth extraction at the Winterveldt clinic: 1998-2002. SADJ 2009;64:214-5, 218.
GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1789-858.
Moradi-Lakeh M, El Bcheraoui C, Tuffaha M, Daoud F, Al Saeedi M, Basulaiman M, et al.
Tobacco consumption in the Kingdom of Saudi Arabia, 2013: Findings from a national survey. BMC Public Health 2015;15:611.
Idris AM, Vani NV, Almutari DA, Jafar MA, Boreak N. Analysis of sugars and pH in commercially available soft drinks in Saudi Arabia with a brief review on their dental implications. J Int Soc Prev Community Dent 2016;6:S192-6.
Al-Shammery A, Baseer MA, Kamel A, Al-Shammery S, Almugerien OM, Alsaffan AD, et al
. Effect of King Salman Center for Children's Health-sponsored school-based oral health education programs on oral health knowledge of government school students in Riyadh city, Saudi Arabia. Saudi J Oral Sci 2018;5:90-7. [Full text]
Tikare S, AlQahtani NA. Oral health knowledge and attitudes of primary school teachers toward school-based oral health programs in Abha-Khamis, Saudi Arabia. Saudi J Oral Sci 2017;4:72-7. [Full text]
Shetty RM, Deoghare A, Rath S, Sarda R, Tamrakar A. Influence of mother's oral health care knowledge on oral health status of their preschool child. Saudi J Oral Sci 2016;3:12-6. [Full text]
Jindal A, Namdev R, Aggarwal G, Singhai P, Asija S, Thukrai H, et al
. Attitude and awareness of expectant and lactating mothers toward infant oral health care in North Indian subpopulation: A cross- sectional study. Saudi J Oral Sci 2018;5:28-34. [Full text]
AlShammery AR. Dentistry in Saudi Arabia and the challenges of Vision 2030. Saudi J Oral Sci 2016;3:59-60. [Full text]
Alyami B. Descriptive epidemiology of dental malocclusion in Najran patients seeking orthodontic treatment. Saudi Dent J 2020;33:481-6. [doi: 10.1016/j.sdentj.2020.10.002].
Al Ameer HM, Awad S. Reasons for permanent teeth extraction in Al-Madinah Al- Munawarah. JAMMR 2017;24:1-6.
Alkadasi BA, Al-Ahmari NM, AL-Dumaini MA, Noman NA, Aldimis AA, Al Moaleem MM, et al
. Etiology and prevalence of permanent tooth extraction among group of Yemeni population. Biosci Biotech Res Comm 2020;13:491-9.
Quteish Taani DS. Periodontal reasons for tooth extraction in an adult population in Jordan. J Oral Rehabil 2003;30:110-2.
Al Dawish MA, Robert AA, Braham R, Al Hayek AA, Al Saeed A, Ahmed RA, et al.
Diabetes mellitus in Saudi Arabia: A review of the recent literature. Curr Diabetes Rev 2016;12:359-68.
Alaboudi AK, Aboalshamat KT, Mahfouz A, Alobodi A, Abualfaraj A. Reasons for teeth extraction in governmental hospitals in Madinah city, Saudi Arabia. J Dent Med Sci 2016;15:1-5.
Livas C, Halazonetis DJ, Booij JW, Katsaros C, Ren Y. Does fixed retention prevent overeruption of unopposed mandibular second molars in maxillary first molar extraction cases? Prog Orthod 2016;17:6.
Nuvvula S, Chava VK, Nuvvula S. Primary culprit for tooth loss!! J Indian Soc Periodontol 2016;20:222-4.
Anyanechi C, Chukwuneke F. Survey of the reasons for dental extraction in eastern Nigeria. Ann Med Health Sci Res 2012;2:129-33.
] [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]