Introduction {#section1-2374373518788851}
============

Despite all the efforts of both governmental and nongovernmental organizations to improve oral health, oral disease burden is still high globally, especially in developing countries. Among the major barriers that have been consistently echoed by several authors as militating against the desired improvement in oral health is individual attitude and oral health behavior ([@bibr1-2374373518788851],[@bibr2-2374373518788851]).

Health attitude has been defined as "opinions, feelings, and associated beliefs toward individual health," while health behavior refers to "behavior patterns, actions, and habits that relate to health maintenance, restoration, and improvement" ([@bibr3-2374373518788851]). Health behaviors can be broadly classified into health-enhancing or health-impairing behaviors. It has been established that behavior and behavioral modification can be used to influence health outcomes.

Baxter ([@bibr4-2374373518788851]) examined the relationship between health behaviors and health outcomes and demonstrated its role in morbidity and mortality. Connor and Norman stated that significant mortality is caused by behavior of individual, but such behaviors are modifiable and this change can influence health outcomes ([@bibr5-2374373518788851]). They reported that health-improving behaviors are associated with low morbidity and high subsequent long-term survival ([@bibr5-2374373518788851]).

Patients utilizing dental services can be grouped into nonattenders, problem-oriented attenders, and regular attenders ([@bibr6-2374373518788851]). Regular dental visit has been shown to be one of the effective ways of maintaining good oral health ([@bibr7-2374373518788851] [@bibr8-2374373518788851]-[@bibr9-2374373518788851]). Attitude to routine use of dental services is poor globally, but worse in developing countries ([@bibr1-2374373518788851],[@bibr10-2374373518788851]).

Studies have demonstrated poor oral health to be associated with problem-oriented dental service use ([@bibr11-2374373518788851],[@bibr12-2374373518788851]), and Jamieson and Thomson ([@bibr10-2374373518788851]) in a prospective cohort study in New Zealand reported a definite association between long-term routine dental services use and better oral health outcomes. The impact of utilization of dental services on oral health has been examined in several dental specialties ([@bibr1-2374373518788851],[@bibr2-2374373518788851],[@bibr9-2374373518788851]), but to the best of our knowledge, none has been reported from an oral surgery clinic.

Tooth mortality is a reflection of cumulative effect of past disease and practice pattern ([@bibr13-2374373518788851]). Pattern of tooth loss has been generally regarded as one of the most important measures needed for assessing the standards, availability, and utilization of both curative and preventive dental care in a given population ([@bibr14-2374373518788851]). This study aims to find out the effects of dental health attitude and behavior on tooth mortality in a cohort of adults attending the surgery clinic for extraction in 2 health facilities in southwestern Nigeria.

Patients and Methods {#section2-2374373518788851}
====================

This is a cross-sectional study conducted in a cohort of adult patients who presented for tooth extraction at the University College Hospital (UCH), dental clinic Ibadan and Oyo state Government dental center, Ibadan between December 2014 and August 2015. The study data were collected using a semistructured questionnaire after obtaining informed consent for participation in the study and the dental extraction procedure. Study participants included 446 consecutive adult patients (16 years and above) who had an extraction of one or more permanent teeth at any of the study centers during the study period. Patients who declined to participate in the study were excluded. The data collected included the age, gender, socioeconomic status, highest educational attainment, type and number of teeth removed, indications for tooth extraction, oral hygiene practice, and pattern of previous dental clinic attendance. The ethical approval for the study was obtained from the University of Ibadan UI/UCH Ethical Review Committee (UI/EC/17/0568). For the purpose of this study, pattern of dental clinic attendance (visiting status) was grouped into 3: regular attenders, in-trouble attenders, and nonattenders (adapted from Taiwo and Noah, 2006) using the following criteria ([@bibr6-2374373518788851]):

a.  Time interval since last visit.

b.  Purpose of visit; whether it was solely for maintenance of dental health or cure of symptoms.

c.  Intention to visit the dental clinic again.

An attender whose last visit was within the last 1 year, whose purpose of visit was solely to maintain dental health, and who intends to visit the dental clinic again was accepted as a regular attender. Visits made for the purpose of checkups, fluoride application against caries, and professional cleaning (scaling and polishing) were regarded as health maintenance purposes.

An attender whose last visit was more than a year was regarded as an in-trouble attender. An attender even though the visit was within 1 year was regarded as in-trouble if the purpose of his visit was for cure of symptoms and had no intention of visiting the dental clinic again. Attenders who have never visited the dental clinic before were classified as nonattenders.

All the extraction procedures were done aseptically under local anesthesia. Tooth delivery was by intra-alveolar forceps extraction for fully erupted teeth and transalveolar extraction (surgical disimpaction) for impacted teeth.

Statistical Analysis {#section3-2374373518788851}
--------------------

Data entry and analysis were done using the SPSS for Windows Inc (Chicago, Illinois) version 19.0. Results were presented as frequency tables and diagrams. Variables were subjected to univariate and multivariate logistic regression to evaluate their relationship with tooth extraction and dental habit. Categorical variables were tested using the Pearson χ^2^ test to examine the relationship between tooth loss and specific patients' characteristics as well as various factors that may affect utilization of dental services. Univariate and multivariate logistic regression analyses were used to identify factors affecting dental habit and dental service utilization. Variables achieving a *P* value of ≤.05 are considered statistically significant.

Results {#section4-2374373518788851}
=======

A total of 453 respondents, consisting of 212 males (46.6%) and 241 females (53.2%), made up the study participants. There were 239 nonattenders, 196 in-trouble attenders, and only 18 regular attenders ([Figure 1](#fig1-2374373518788851){ref-type="fig"}). Majority of the participants in each category (81.6%, 80.6%, and 72.2%, respectively) were resident in Ibadan. The age group 31 to 50 years accounted for 40.2% of the patients, while those over 70 years were less than 10% of the participants. One hundred twenty-seven patients who had attained tertiary education formed the majority (64.8%) of the in-trouble attenders, and this was statistically significant (*P* = .02). However, 59.4% of the participants were low earners or were not in any gainful employment ([Table 1](#table1-2374373518788851){ref-type="table"}).

![Pattern of attendance.](10.1177_2374373518788851-fig1){#fig1-2374373518788851}

###### 

Distribution of Study Subjects Based on Status of Attendance and Age and Socioeconomic Standing.

![](10.1177_2374373518788851-table1)

  Dental Visiting Status        Regular Attender, n (%)            In-Trouble Attender, n (%)   Nonattender, n (%)   *P* Value
  ----------------------------- ---------------------------------- ---------------------------- -------------------- -----------
  Gender                                                                                                             
   Male                         11 (5.19)                          86 (40.57)                   115 (54.25)          .314
   Female                       7 (2.90)                           110 (45.64)                  124 (51.45)          
  Residence                                                                                                          
   Inner Ibadan city            13 (3.55)                          158 (43.17)                  195 (53.28)          .536
   Outer Ibadan city            4 (5.00)                           29 (40.00)                   39 (55.00)           
   Outside Ibadan               1 (6.67)                           9 (60.00)                    5 (33.33)            
  Age group                                                                                                          
   16-30                        4 (3.48)                           40 (34.78)                   71 (61.74)           .091
   31-50                        4 (2.20)                           86 (47.25)                   92 (50.55)           
   51-70                        6 ([@bibr5-2374373518788851].31)   49 (43.36)                   58 (51.33)           
   70 and above                 4 (9.30)                           21 (48.84)                   18 (41.86)           
  Educational level                                                                                                  
   No formal education          1 ([@bibr7-2374373518788851].14)   6 (42.86)                    7 (50)               .020
   Primary school education     4 (12.12)                          12 (36.37)                   17 (51.51)           
   Secondary school education   4 (2.74)                           51 (34.93)                   91 (62.33)           
   Higher education             9 (5.63)                           127 (79.37)                  24 (15.00)           
  Occupational earning level                                                                                         
   High earner                  6 (4.48)                           70 (52.24)                   58 (43.28)           .058
   Intermediate earner          4 (8.00)                           18 (36.00)                   28 (56.00)           
   Low earner                   5 (3.94)                           45 (35.43)                   77 (60.63)           
   No gainful employment        3 (2.11)                           63 (44.37)                   76 (53.52)           

Four hundred two (88.7%) of the participants cleaned their teeth with toothbrush and tooth paste, while only 7 participants used chewing stick alone as teeth cleaning aid. Majority of the participants (79.2%) cleaned their teeth once daily, while 19% cleaned their teeth more than once daily; this was statistically significant (*P* = .001). In all, 71.7% of participants took carbonated drinks occasionally, while 8.8% took more than once a day, and 7.3% do not take carbonated drinks at all ([Table 2](#table2-2374373518788851){ref-type="table"}). Dental caries and its sequelae were the commonest reason for visiting the dental clinic in all attenders. Five (28%) out of 18 regular attendees required multiple extractions ([Table 3](#table3-2374373518788851){ref-type="table"}). Caries was the commonest primary presentation and indication for extraction ([Figures 2](#fig2-2374373518788851){ref-type="fig"} and [3](#fig3-2374373518788851){ref-type="fig"}).

###### 

Distribution of Study Subjects Based on Oral Hygiene Measures.

![](10.1177_2374373518788851-table2)

  Dental Visiting Status                                                     Regular Attender, n (%)            In-Trouble Attender, n (%)   Nonattender, n (%)   *P* Value
  -------------------------------------------------------------------------- ---------------------------------- ---------------------------- -------------------- -----------
  Cleaning aid                                                                                                                                                    
   Tooth brush and tooth paste                                               17 (4.23)                          172 (42.80)                  213 (52.97)          .913
   Chewing stick                                                             0 (0)                              3 (42.86)                    4 (57.14)            
   Chewing brush, tooth paste + chewing stick                                1 (2.27)                           21 (47.73)                   22 (50)              
  Frequency of tooth brushing                                                                                                                                     
   Twice or more daily                                                       7 ([@bibr8-2374373518788851].14)   50 (58.14)                   29 (33.72)           .000
   Once daily                                                                9 (2.51)                           143 (39.83)                  207 (57.66)          
   Irregular sometimes less than once daily                                  2 (25.00)                          3 (37.50)                    3 (37.50)            
  Consumption of carbonated drinks, sweetened beverages, and energy drinks                                                                                        
   Once a day                                                                3 (5.45)                           22 (40.00)                   30 (54.55)           .612
   More than once a day                                                      2 (5.00)                           20 (50.00)                   18 (45.00)           
   Occasionally                                                              10 (3.08)                          140 (43.07)                  175 (53.85)          
   Does not take                                                             3 (9.09)                           14 (42.42)                   16 (48.49)           

###### 

Distribution of Study Subjects Based on Dental Health-Care Usage.

![](10.1177_2374373518788851-table3)

  Dental Visiting Status                         Regular Attender   In-Trouble Attender   Nonattender   *P* Value
  ---------------------------------------------- ------------------ --------------------- ------------- -----------
  Indications for extraction                                                                            
   Dental caries and its sequelae                8                  111                   159           .108
   Periodontal disease                           5                  43                    39            
   Endo-perio lesions                            1                  3                     4             
   Prosthetic reasons                            0                  2                     0             
   Impaction/eruption problems                   1                  11                    11            
   Failed root canal treatment                   0                  8                     0             
   Trauma                                        3                  15                    19            
   Supernumerary/supplemental teeth              0                  1                     4             
   Orthodontic reasons                           0                  2                     1             
   Patients request                              0                  0                     2             
  Pattern of extraction                                                                                 
   Single extraction                             13                 177                   212           .067
   Multiple extraction                           5                  19                    27            
  Previous dental visit                                                                                 
   First dental visit                            0                  4                     235           .001
   Has had dental visit before                   18                 196                   235           
  Willingness to visit the dental clinic again                                                          
   Yes 6 months or less                          16                 103                   70            .001
   Yes 1 year or less                            2                  10                    11            
   Not sure                                      0                  59                    139           
   Never                                         0                  22                    15            

![Primary complaint of patients who presented for dental extraction.](10.1177_2374373518788851-fig2){#fig2-2374373518788851}

![Indications for extraction in 453 patients.](10.1177_2374373518788851-fig3){#fig3-2374373518788851}

Discussion {#section5-2374373518788851}
==========

Published works have shown that the routine use of dental services is poor globally, although worse in developing nations, and that most patients present at the dental clinic majorly for treatment of symptoms ([@bibr1-2374373518788851],[@bibr2-2374373518788851],[@bibr10-2374373518788851],[@bibr15-2374373518788851]). Majority of our respondents were making their first contact with a dental clinic at the time of the extraction, which corroborates the findings from previous studies that majority of dental service users are problem oriented ([@bibr1-2374373518788851],[@bibr8-2374373518788851],[@bibr10-2374373518788851]). Adegbembo ([@bibr2-2374373518788851]) in a study in Ibadan, southwestern Nigeria, reported that only 9% of household had utilized dental services the previous year. In another study in Nigeria, Taiwo and Noah reported 55.6% nonattenders, 33.3% in-trouble attenders, and 11.1% regular attenders among their study participants ([@bibr6-2374373518788851]). In the present study, only 3.9% of our study participants were regular attenders, the remaining were either nonattenders (52.8%) or in-trouble attenders (43.3%). The lower percentage of regular attenders in this study could be due to selection bias this is because this study was carried out in oral surgery clinic among patients presenting for mainly for extraction of teeth unlike the other studies that were done among patients attending the dental clinic for various reasons. Most of the regular attenders are likely to have other forms of treatments apart from extraction. This is corroborated by earlier studies that reported more restorative and periodontal treatment in regular attenders than infrequent attenders among which a high rate of tooth loss was common ([@bibr8-2374373518788851],[@bibr16-2374373518788851],[@bibr17-2374373518788851]).

Less than 10% of our study participants belong to the age group of 70 years and above in agreement with a previous study that has reported an inverse relationship between age and dental service utilization ([@bibr18-2374373518788851]) but in contrast to the reported use of general health-care services ([@bibr19-2374373518788851],[@bibr20-2374373518788851]). The low percentage of elderly respondents found in this study could be due to lower life expectancy in Nigeria. Average life expectancy in Nigeria is 56.8 years ([@bibr21-2374373518788851]), creating a situation in which fewer people above the age of 70 years are seen among the populace. As previously documented, other possible factors limiting the use of dental services by the elderly include functional barriers, immobility, presence of other chronic diseases, disability, and limited financial resources ([@bibr20-2374373518788851]).

Caries (61.4%) and periodontal disease (19.2%) accounted for the highest cause of extraction in agreement with previous reports ([@bibr22-2374373518788851],[@bibr23-2374373518788851]). Caries and periodontal disease are largely preventable causes of extraction when diagnosed at the early (asymptomatic) stage at regular attendance. Unfortunately, in-trouble attenders and nonattenders tend to attend late and only when there is pain at which stage other treatment options apart from extraction are either not appealing or not affordable ([@bibr22-2374373518788851]). This is reflected in this study where pain was the commonest complaint. It is therefore not surprising that majority of these patients had extractions in the oral surgery clinic.

Distance and availability of health facility have been documented as one of the barriers to seeking treatment ([@bibr24-2374373518788851]). Although this study did not document the distance patients had to travel to reach the health facility, the finding in this study does not suggest distance to be a major factor responsible for the poor attendance pattern as comparable percentages of all the categories of attenders live in Ibadan. Ibadan is a cosmopolitan city and has both government and private dental facilities located in different parts of the city such that they are accessible to the populace. This finding is in agreement with the studies of Adegbembo ([@bibr2-2374373518788851]) and Goel et al ([@bibr25-2374373518788851]) that reported poor utilization of dental services despite availability and accessibility; this was attributed to poor oral health attitudes. Therefore, other factors apart from distance may be responsible for the poor health-seeking behavior among our study participants.

High education levels have been previously reported to be associated with better health-seeking behavior ([@bibr26-2374373518788851],[@bibr27-2374373518788851]); however, we found no positive correlation between oral health seeking behavior and level of education among our study participants. Majority of in-trouble attenders had higher levels of education. Education is expected to improve health-seeking behavior on the premise that there will be better access to information, which will improve their knowledge about health, thereby motivating them to make a change. However, evidence have also shown that giving information alone may not lead to measurable change in behavior since a complex interaction between several factors may determine health-seeking behavior ([@bibr28-2374373518788851]). As opined by Kakatka et al ([@bibr29-2374373518788851]), successful motivation requires more than information but also paying attention to individual reasons restricting behavior. In Nigeria, there are so many graduates without any gainful employment ([@bibr21-2374373518788851]); this raises the possibility of financial restrictions to positive health-seeking behavior influenced by education.

Majority of our participants were low-income earners or were not in any gainful employment; this agrees with the study of Ahmed et al that reported socioeconomic indicators as the single most pervasive determinant of health-seeking behavior ([@bibr19-2374373518788851]). A similar study in Nigeria suggested that their study population placed more priority on farming than oral health ([@bibr30-2374373518788851]). Previous studies have documented socioeconomic disadvantage as a barrier to oral care, thereby contributing to social discrepancies in oral health status ([@bibr31-2374373518788851],[@bibr32-2374373518788851]). In a society with high levels of poverty and where oral health is considered not life threatening, people use their resources for other apparently more pressing needs until the dental symptoms become unbearable. Helman surmised this behavior by concluding that, "people do not consult a doctor when they are sick simply because they cannot afford it" ([@bibr33-2374373518788851]).

This study did not look at oral health knowledge; however, from the result obtained in the oral health habit, it may be inferred that oral health knowledge was deficient among majority of our study participants. This agrees with Gilbert et al who reported more preventive behaviors among regular attenders than nonattenders ([@bibr16-2374373518788851]). Although majority of the participants use toothbrush, only few of them brush more than once daily. Oral health preventive studies have unequivocally demonstrated the beneficial effect of twice daily toothbrushing on improving oral health ([@bibr34-2374373518788851] [@bibr35-2374373518788851]--[@bibr36-2374373518788851]); this is one of the main oral health information given to patients during dental consultations. This type of information that may lead to improved knowledge and possible behavioral change is more likely to be achieved through routine dental visit. Reinforcement of information at routine dental visit can contribute to change in habit and behavior that ensures sustainability. Preventive oral health practices like twice-daily toothbrushing were poor among our participants as only 19% brush their teeth more than once daily in agreement with the study of Gilbert et al ([@bibr16-2374373518788851]). Information does not always lead to change of habit; it is possible that some regular attenders still have poor oral health practices despite regular exposure to oral health education. Therefore, they become candidates for tooth extraction and form part of the study participants contributing to the high percentage of poor preventive practices noted.

Contrary to previous studies that reported less extractions in regular attenders ([@bibr8-2374373518788851],[@bibr17-2374373518788851]), we did not find any significant difference in the number of extractions needed between the different categories of attenders. This could however be due to the fact that only relatively few regular attenders were involved in this study. Another possibility for the observed trend in the present study is that some of the indications for multiple extractions among regular attenders were for aesthetic reasons like orthodontic and prosthetic reasons and not necessarily because of pathology in the oral tissues.

Regular attendance has the potential for preventing tooth loss by improving oral health. Each dental attendance and consultation serves as a source of reinforcement of good oral practices until it becomes a habit. Even in people who previously had some poor oral attitude and behavior, the regular reinforcement at each routine visit may help to contribute to change in habit and behavior that ensures sustainability.

Conclusion {#section6-2374373518788851}
==========

The result obtained in this study suggests that majority of the patients who present for extraction of teeth had poor oral health habits and were problem oriented, despite their high educational attainment and availability of dental services. Socioeconomic disparities and poor dental habits appear to be part of the major factors responsible for poor dental behavior among the study subjects.

**Declaration of Conflicting Interests:** The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

**Funding:** The author(s) received no financial support for the research, authorship, and/or publication of this article.

**Olalere Omoyosola Gbolahan** is a senior lecturer in the department of Oral and Maxillofacial Surgery, College of Medicine, University of Ibadan, Nigeria. His research interests are maxillofacial traumatology, dentoalveolar Surgery and TMJ diseases.

**Abiodun Olubayo Fasola** is a Professor of Oral and Maxillofacial surgery and Dean of the faculty of Dentistry, College of Medicine University of Ibadan, Nigeria. His research interests are maxillofacial traumatology, TMJ abnormalities and bioethics. He has numerous peer reviewed articles.

**Timothy Olukunle Aladelusi** is a Lecturer in the department of Oral and Maxillofacial Surgery, College of Medicine, University of Ibadan, Nigeria. His research interest is dentoalveolar surgery, maxillofacial oncology and reconstruction.
