Factors Associated with Exposure and Caries of Root Surface among Sample of Pakistani Patients Visiting a University Hospital


Rabia Ali1                            BDS
Farhan Raza Khan2        BDS, MS, MCPS, FCPS                                  



1) To determine the frequency of root caries among patients visiting dental clinic of the Aga Khan University Hospital.

2) To determine the association of root caries with gender, xerostomia, smoking, betel nut and sugar intake.

METHODOLOGY: A cross-sectional study was conducted at Aga Khan University Hospital. Patients above 30 years of age who visited dental clinics with gum recession or root surface caries with or without root filling were included. Information was gained on age, sex, brushing habits, malocclusion, use of systemic medications, xerostomia etc. Intraoral examination was done on all teeth excluding third molars. The variables of interest were the frequency of root surfaces exposed (RE), root surface carious (RC) and root surface already restored (RR). The unit of analysis for root surface caries was the individual tooth.

RESULTS: A total of 4080 root surfaces of 40 subjects (25 males and 15 females) were examined. Mean age was 55.6 years (±11.4 SD). About 805 (19.7%) surfaces were found to be exposed. Around 137 (3.35%) surfaces were carious and only 18 (0.44%) were restored. Eighteen subjects had root caries on less than 2 surfaces; fourteen subjects had root caries on 3-5 surfaces and there were eight subjects with more than 5 carious surfaces. Most common type of gum recession found was Miller’s Class III (60%). Xerostomia was observed in 16 (40%) subjects. Diabetes, hypertension and other co-morbids were observed in 17 subjects. Chi square test (or Fisher exact test) was applied to determine association of RE and RC with other variables. The level of significance was kept at 0.05.

CONCLUSIONS: The most common gum recession pattern observed in our study was deep and wide (Miller’s Class III). One fifth of the subjects had extensive RC (> 5 surfaces). RE was found to be associated with age and use of betel nuts (p< 0.01) while RC was seen more in females and was associated with high sugar intake (p=0.02).

KEYWORDS: Root caries, gum recession, root surfaces exposure.

HOW TO CITE: Ali R, Khan FR. Factors Associated with Exposure and Caries of Root Surface among Sample of Pakistani Patients Visiting a University Hospital. J Pak Dent Assoc 2016; 25(3): 81-86.

Received: 26 June 2016, Accepted: 27 September 2016


Root caries (RC) has become an important dental problem because people are living longer and keeping their teeth longer1,2. As patients grow older, their gums recede and root surface are exposed. The root exposure (RE) makes the surface susceptible to RC3 . An increased retention of natural teeth means more adults at risk of dental caries (coronal and root), and the complexity of  these restorations may require additional skills, as well as involving medical considerations when treating older adults4 . Furthermore, the prevalence of gingival recession, xerostomia, use of removable partial dentures and other risk factors leads to a high susceptibility to RC in the older adult population. In fact, RCis more prevalent among older adults than any other age group and has been found to be a main risk factor for tooth loss in older adults5 .

Globally, proportion of the population over 65 years of age who are dentate is increasing. The prevalence of root caries lesions was reported by various studies as ranging from 36% to 67%6-10. Hellyer reported the prevalence of 88.4% in peopleaged 55 years and above.11Imazatoreported that 39% of the subjects had one or more decayed roots3.

With more elderly retaining their natural teeth, the need to understand the nature and cause of root surface lesion is of great importance. Preventive measure that includes proper oral hygiene, plaque control, fluoride therapy and avoidance of removable dentures are required prior to and after dental treatment.

There is ample evidence showing that periodontal disease increases with age due to its cumulative nature. Thus most elderly patients may have some gingival recession and alveolar bone loss, which predisposes them to RC12. In other words; an increased number of RE surfaces in an individual would increase the susceptibility of RC.

Gingival recession is a pre-requisite for RC13. There are various risk factors associated with RC, which include poor oral hygiene, periodontal disease, cariogenic diet, previous RC experience, xerostomia, multiple medications and missing teeth or use of removable dentures.

One of the most important contributing factors to RE among southasian population (including Pakistan) is an increase prevalence of betelnut (arecanut) chewing14. Although, betelnut is known for its pathologic effects on buccal mucosa leading to submucus fibrosis15 (relative risk:154.0). However, the link between betelnut and gum recession has also been established16 (odds ratio: 1.73). The objectives of our study were to determine the frequency of RE and RC among patients visiting our university dental clinic and to explore the association of RE and RC with factors such as gender, xerostomia, smoking, betel nut use and sugar intake.


It was a cross-sectional study conducted at AKUH dental clinics. Non-probability convenience sampling was done to include adult patients above 30 years, irrespective of their RC, RE or RR status. Patients with history of orthodontic treatment, fixed prosthetic treatment or head and neck cancer radiotherapy were excluded.

Written informed consent in Urdu language was taken. Study proforma had two parts. The first part was a questionnaire which gained information on age, gender, brushing habit, salivary condition and dietary habits of the patients.

The second part consisted of information from intraoral examination including occlusion, gum recession and root surface assessment for exposure, caries and restorations. Radiographs were not taken because of practical limitations. The study protocol was approved by the Aga Khan University ethical review committee (Ref#3381-Sur-ERC-14). RE was ascertained on clinical assessment using routine dental examination instruments. RC was labeled if there was a surface break detected on the root surface, irrespective of the color change. RR was confirmed on clinical and radiographic examination. One trained dentist (RA) carried out the clinical examination on all subjects. However, 4 subjects (5%) participants were assessed by the second examiner and the inter-examiner reliability turned out to be >90 %. Thus, the information obtained on RC, RE and RR was consistent.

Data Analysis

SPSS version 19.0 was used for the data analysis. Means and standard deviations for quantitative variables such as age and frequency distributions for categorical variables [such as number of root exposed (RE), root caries (RC) and root restored (RR)] were computed. Chi square test (or Fisher exact test) was applied to determine association of RE and RC with other variables. The level of significance was kept at 0.05.


Our sample comprised of 40 participants (25 males and 15 females) with mean age of 55.6 ± 11.4 years. A total of 1120 teeth (4080 root surfaces) were assessed, out of which 805 were found to be RE surfaces, 18 were RR and 137 were RC (Table 1).The most common brushing frequency found was twice daily as reported by 23 patients. The most common brushing technique was either horizontal strokes or a combination of vertical and horizontal strokes 14 patients each. Most common cleaning method reported by patients was manual brushing. The type of brush used commonly was medium consistency (Table 2). Nine patients reported use of betel nuts with most common frequency of 4-8 times per day Fig. (1).

In our sample, 33 patients were non-smokers while 6 patients reported a frequency of 1 pack a day. The most common frequency of intake of carbonated drinks was more than four times per month in 18 patients and that of sugar intake was 2-4 times per day in 23 patients. Three patients reported use of alcohol (>2 times per week).

The most common gum recession pattern was Class III, as observed in 24 patients Fig. (2). Table 3 shows that age and the use of betel nut was significantly associated with RE (p≤0.05), whereas female gender and the intake of sugars were significantly associated with RC (p≤0.05).

Table 1. Frequency distribution of root exposure (RE), root caries (RC) and root restorations (RR).
Fig. (1). Frequency distribution of Pan/Chaliya intake (n=40).
Table 2. Distribution of oral Hygiene related factors (n= 40).
Fig. (2). Frequency distribution of gingival recession (n=40 subjects).
Table 3. Factors associated with root exposure (RE) and root caries (RC).


RC has been and continued to be a major problem for the older adults, ultimately putting them at greater risk for periodontal disease and tooth loss. Tooth loss in turn is the most significant oral health related negative variable of quality
of life for the elderly.17

We observed age and use of betel nuts are associated with RE. Our study is in accordance with a study conducted by Qasim et al. 1 and Marino et al.4 as they also found age to be associated with RE. These studies reported the mean age of 69.3 years of dentate participants with RE.2 The association of betel nut with RE was a finding that is only consistent with studies done on south Asian subjects. This is mainly attributed to the betel nut chewing which is a common cultural practice in this region. Studies done on other population do not show this association14-16.

Our results were in harmony with the above mentioned studies as we also observed that smoking showed no association with RE. We did not find any association of sugar intake with root RE. This is in accordance with the studies by
Qasim et al.1 and Du et al.18 Similarly for xerostomia and bruxism, no association with RE could be observed. One explanation may be that we had a small sample size where only limited participants presented with xerostomia and bruxism. Alternatively, a misclassification bias of labeling of categorizing such subjects into normal category have had diluted the actual association.
We have analyzed the data separately for root surface exposure (RE) versus root surface caries (RC) as shown in Table 2. The former condition represents a risk factor for latter. However, presence of RC is an irreversible marker of damage to the tooth root structure.
When the association of the variables and development of RC was assessed, the results were mixed. Most of the studies showed an association of age with RC but we failed to determine that1,3,4. However, with respect to gender, our results were consistent with the others1,17. An important finding was association of sugar intake and RC. This is probably due the fact that an exposed dentin has poor protection against carious attack and is vulnerable towards caries development. The strengths of our study were that an important clinical problem was addressed and both RE and RC were taken into account. In addition to patient level data, we captured root surface level data as well. The limitations of our study were low sample size and cross-sectional study design. Stratified analysis was not possible due to limited sample size. Salivary flow rate was also not ascertained.


We found that the proportion subjects presenting with RE, RC and RR were 19.7%, 3.4% and 0.45% respectively. RE was associated with increase in age and use of betel nuts, while RC was associated with high sugar intake.


None declared.


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1. Chief Resident, Operative Dentistry, Aga Khan University, Karachi, Pakistan
2. Consultant, Operative Dentistry, Aga Khan University, Karachi, Pakistan
Corresponding author: “Dr. Rabia Ali” < rabia.ali@aku.edu >