Journal of

Original Article Preventive Medicine

J Prev Med Public Health 2023;56:357-367 • https://doi.org/10.3961/jpmph.22.417 & Public Health
pISSN 1975-8375 eISSN 2233-4521

Association Between Tobacco Smoking and Dental Caries

in the Indonesian Population: Results of a National Study
in 2018
Lelly Andayasari1, Rofingatul Mubasyiroh1, Iin Nurlinawati1, Irna Sufiawati2
National Research and Innovation Agency, Bogor, Indonesia; 2Faculty of Dentistry, Padjadjaran University, Bandung, Indonesia
1

Objectives: The 2018 Basic Health Research (RISKESDAS), conducted by the Ministry of Health of the Republic of Indonesia showed a
high prevalence of dental caries (88.8%) in Indonesia and suggested that smoking tobacco was associated with an increased risk of
dental caries. This study analyzed the association between tobacco smoking and dental caries in the Indonesian population.
Methods: This was a cross-sectional analysis of secondary data collected from RISKESDAS 2018. The study population included 35 391
Indonesians aged ≥10 years from all 34 provinces. The decayed, missing, and filled teeth (DMFT) index was used to measure dental
caries. Smoking status was assessed qualitatively based on smoking activity, and the level of smoking exposure was assessed based
on the Brinkman index. A multivariable logistic regression analysis was employed to examine the relationships of smoking status and
smoking exposure levels with the DMFT index.
Results: Of the population aged ≥10 years, 36% had a DMFT≥8 (females: 37.5%, males: 33.9%). Almost one-fourth (23.4%) were cur-
rent smokers, and 4.1% were ex-smokers. Furthermore, 26.4% had a Brinkman index ≥400, indicating heavy smoking. According to
the multivariate analysis, current smoking status was associated with the risk of DMFT≥8 in males (adjusted odds ratio [aOR], 1.40;
95% CI, 1.27 to 1.55; p<0.001) and overall (aOR, 1.07; 95% CI, 1.00 to 1.14; p=0.037). In females, ex-smoking was associated with a
41% higher risk of DMFT≥8 (aOR, 1.41; 95% CI, 1.07 to 1.84; p=0.014). Heavy smoking was associated with a higher risk of DMFT≥8
in males (aOR, 1.38; 95% CI, 1.25 to 1.52; p<0.001) and females (aOR, 1.24; 95% CI, 1.03 to 1.50; p=0.022).
Conclusions: Tobacco smoking was associated with dental caries in the Indonesian population.

Key words: DMFT index, Dental caries, Tobacco, Smoking, Indonesia

INTRODUCTION the elderly. Its global prevalence has elevated it to a significant

public health concern, given its preventability and widespread
Dental caries, the most prevalent non-communicable dis- occurrence. Dental caries can lead to pain, difficulty eating
ease worldwide, affects individuals of all ages, from infants to and sleeping, and chronic systemic infection. It impacts not
only a vast number of people across all age groups, but also
Received: September 22, 2022 Accepted: June 27, 2023
individuals of all socioeconomic statuses, affecting their
Corresponding author: Lelly Andayasari
National Research and Innovation Agency, Jalan Raya Bogor KM. 46, health, well-being, and social interactions [1]. According to the
Cibinong, Bogor 16915, Indonesia Global Burden of Disease Study 2019, dental and oral health
E-mail: [email protected] issues, particularly dental caries, afflict nearly half of the global
This is an Open Access article distributed under the terms of the Creative Commons population, equating to approximately 3.58 billion people [2].
Attribution Non-Commercial License (https://creativecommons.org/licenses/by-
The Basic Health Research (Riskesdas) report of 2018 revealed
nc/4.0/) which permits unrestricted non-commercial use, distribution, and repro-
duction in any medium, provided the original work is properly cited. that the prevalence of dental caries in Indonesia stands at

Copyright © 2023 The Korean Society for Preventive Medicine 357

Lelly Andayasari, et al.

88.8% [3]. Dental caries arises from the production of acido- METHODS
genic bacterial acids. These acids form and proliferate in
plaque biofilms and fermentable sugars, leading to progres- Study Design and Participants
sive tooth damage [4]. If left untreated, dental caries can cause This study represents an extended analysis of the cross-sec-
significant pain and discomfort, ultimately resulting in tooth tional Community Indonesian Health Survey, also known as
loss [2,5]. Basic Health Research (Riskesdas), conducted in 2018. The re-
Dental health is intimately tied to quality of life, encompass- search measured indicators such as health status, which in-
ing a range of factors such as demographic elements, psycho- cluded dental conditions, and risk factors, which encompassed
logical aspects, oral hygiene practices, oral health behaviors, health behavior. The study population comprised all house-
and socioeconomic status [6]. Dental caries is a multifactorial holds across 34 provinces and 514 districts/cities in Indonesia,
disease influenced by physical and biological elements, life- as derived from the 2018 National Socioeconomic Survey (Na-
style choices, oral health habits, and social standing [7]. The tional Statistics Bureau) sample frame database, which was
prevalence of dental caries is associated with lifestyle factors, conducted in March 2018. To select 30 000 census blocks and
including dietary habits such as sugar consumption [8]. Recent ten households, a method known as probability proportional
studies have shown that dental caries is associated with smok- to size was employed. This method involved systematic sam-
ing [9,10] and tooth brushing [11]. Dental caries is also associ- pling with the highest implicit stratification of education com-
ated with a higher body mass index [12] and metabolic syn- pleted by the head of household in each census block. Data
drome [13]. Given the high number of patients with dental were gathered from all individuals, regardless of age, in the
caries, the cost of treatment represents a significant health selected households. As a result, data were collected from
burden. The global economic impact of dental caries is esti- 1 091 528 individuals of all ages across 282 654 successfully in-
mated to be around US dollar (USD) 442 billion annually, with terviewed households. A dental and oral examination was in-
USD 298 billion going towards treatment costs and USD 144 cluded as a subsample of the Riskesdas 2018, providing a na-
billion related to lost workdays [14]. tional level of representation. This dental and oral examination
While the risk of developing dental caries spans all age was successfully conducted in 19 553 households across 2490
groups, most studies on this topic have focused primarily on census blocks out of a targeted 25 000 census blocks in 26
children or toddlers. Numerous risk factors influence the prev- provinces [3].
alence of dental caries in children, including diet, oral hygiene, The inclusion criteria for this study were respondents aged
feeding practices, low birth weight, hereditary enamel defects, 10 years and over who underwent dental examinations and
maternal education, family knowledge of dental and oral had smoking behavior data, as well as information on other
health, attitudes and practices, household income level, socio- covariates. Out of the 37 026 participants who were 10 years
cultural, environmental, and economic factors [15]. There have or older, 4076 did not have dental examinations, and 2441 did
been several studies on dental caries in age groups other than not have complete smoking data, making it impossible to cal-
children and toddlers [10,12-14], but research on individuals culate their Brinkman index. Therefore, the final sample con-
over the age of 10 remains limited. This study, therefore, ex- sisted of 35 391 individuals.
plored the determinants of dental caries in the Indonesian
population, ranging in age from 10 years to over 65 years. It Data Collection
not only described the incidence of dental caries in this age The subjects of this study were males and females aged
group, the respondents’ backgrounds, and proper tooth brush- 10 years and older, who were surveyed in the Indonesian Health
ing techniques, but also examined consumption and smoking Study. The gathered data encompassed demographic details,
behaviors, with separate analyses based on sex. All factors results of dental and oral examinations, and information on
contributing to caries were incorporated into a multivariate lo- health-related behaviors. Trained health professionals conduct-
gistic regression analysis. This research represents an in-depth ed face-to-face interviews with the respondents in their homes.
analysis of data from national studies conducted in Indonesia Dental and oral examinations were performed by dentists at
in 2018. specified health facilities.
A dentist conducted an intraoral examination utilizing a

358
 Tobacco Smoking and Dental Caries

mouth mirror, probe, and sterile tweezers. Prior to the exami- the participants (elementary school or less, middle school, high
nation, respondents were instructed to rinse their mouths. Re- school, and college or above) [19]. Occupations were catego-
spondents were classified as having dental caries if cavities (D), rized as follows: army/police/government/private employees,
missing teeth (M), or fillings (F) were detected in one or more merchants, laborers, unemployed, and others. Geographic lo-
teeth (T). Subsequently, the dentist recorded the DMFT score. cation was divided into two categories: rural and urban. Socio-
The gathered data were documented in a paper questionnaire economic quintiles were determined based on the index of
before being inputted into a computer. To guarantee data qual- household goods ownership, and were divided into 5 groups:
ity, a designated individual at the district/city level supervised quintile 1 (highest) to quintile 5 (lowest). Proper toothbrush-
the data collection process in the field. ing behavior was categorized as either “yes” or “no.” A “yes” re-
The dependent variable of this study was the DMFT status at sponse indicated that toothbrushing was done after breakfast
the time of the examination. Subjects were classified as having and before bed, while a “no” response indicated the opposite.
severe dental caries if they fell within the top 30% of the pop- Food consumption patterns were determined based on frequen-
ulation in terms of DMFT values [16]. The cut-off point for se- cy of consumption, as follows: up to 2 times per week, and from
vere dental caries in this study was determined according to 3 times a week to more than once per day.
the methods of the University of Malmo and Leake et al. [17].
Participants in the study were ranked according to their indi- Statistical Analysis
vidual DMFT scores. Those comprising approximately the top A descriptive analysis was carried out to illustrate the sam-
third of the sample, with the highest DMFT scores, were iden- ple distribution based on various characteristics. The chi-
tified as having severe dental caries. The lowest DMFT score square test was utilized in the data analysis to investigate the
among these participants was 8. Consequently, for the pur- correlation between severe dental caries and smoking expo-
poses of this study, severe dental caries was operationally de- sure. Multivariate logistic regression models were employed to
fined as a DMFT score ≥8. estimate the association between the dental caries severity
In this study, the primary independent variable was smoking (DMFT) with smoking exposure and smoking status at the 5%
activity, evaluated both qualitatively (smoking status: never significance level. Multivariate logistic regression also allows
smoked, ex-smoker, and active smoker) and quantitatively the estimation of the adjusted odds ratio (aOR) between the
(amount of cigarette exposure). The Brinkman index (BI) was desired outcome and the covariate factors. The covariates in
used to classify smoking exposure. The BI is a measure of smok- the multivariate model were variables with p-values less than
ing exposure, calculated by multiplying the average number 0.05 in the bivariate stage for the overall, male, and female
of cigarettes smoked per day by the number of years the indi- patterns, respectively. The covariates included in the overall
vidual has been smoking. For the purposes of this study, heavy model are age, education level, occupation, geographic loca-
smokers were defined as those with a BI of 400 or more [18]. tion, proper toothbrushing habits, and consumption of sweet
Based on their exposure to cigarettes, participants were cate- foods, soft drinks, and energy drinks. For the male model, the
gorized into three groups: (1) never smoked (BI, 0); (2) light covariates were age, education level, occupation, geographic
smokers (BI, 1-399); and (3) heavy smokers (BI≥400). location, proper toothbrushing habits, and consumption of
In addition to the dependent and independent variables, we sweet foods, sweetened drinks, soft drinks, and energy drinks.
also included covariate variables. These variables consisted of In the female model, the covariates were age, education level,
demographic characteristics such as sex, age, level of educa- occupation, and consumption of sweet foods, soft drinks, and
tion, occupation, geographic location, and socioeconomic energy drinks. All analyses were conducted using SPSS version
quintiles. Other variables included proper toothbrushing be- 15.0 (SPSS Inc., Chicago, IL, USA).
havior, and the consumption of sweet foods, sweetened drinks,
soft drinks, and energy drinks. The respondents’ ages at the Ethics Statement
time of the study were categorized into the following groups: The Commission of Health Research granted ethical clear-
10-14 years, 15-24 years, 25-34 years, 35-44 years, 45-54 years, ance for this study (National Institute of Health Research and
55-64 years, and 65 years and older. Education levels were clas- Development, Indonesian Ministry of Health No. LB.02.01/2/
sified based on the highest level of schooling completed by KE.267/2017).

359
Lelly Andayasari, et al.

RESULTS Table 1. Continued from the previous

Characteristics Overall Male Female
Table 1 shows that the majority of the research sample was Occupation
drawn from the productive age group of 25-54 years old, ac- Army/police/government/ 3295 (9.3) 2044 (14.1) 1251 (6.0)
counting for 55.7% of the total. The sample was predominant- private employees
Merchants 4569 (12.9) 2531 (17.4) 2037 (9.8)
ly female (59.0%) and comprised elementary school graduates
Laborers 8379 (23.7) 5148 (35.5) 3231 (15.5)
(51.7%). The sample was almost evenly split between the un-
Unemployed 17 426 (49.2) 4179 (28.8) 13 247 (63.4)
employed (49.2%) and laborers (23.7%). Nearly half of the sam-
Others 1722 (4.9) 608 (4.2) 1115 (5.3)
ple was classified as wealthy (44.6%), and a significant majori-
Geographic location
ty resided in urban areas (64.9%). Furthermore, 23.4% of the
Urban 22 970 (64.9) 9319 (64.2) 13 651 (65.4)
sample were current smokers, while 4.1% were former smok-
Rural 12 420 (35.1) 5190 (35.8) 7230 (34.6)
ers. Notably, 26.4% of the sample fell into the heavy smoking
Socioeconomic quintiles
category, with a BI exceeding 400. Quintile 1 (highest) 8680 (24.5) 3659 (25.2) 5021 (24.0)
Table 2 demonstrates that 36.0% of the population had a Quintile 2 7097 (20.1) 2880 (19.9) 4216 (20.2)
DMFT score ≥8, with a slightly higher prevalence in females Quintile 3 6321 (17.9) 2595 (17.9) 3726 (17.8)
(37.5%) compared to males (33.9%). The proportion of indi- Quintile 4 6685 (18.9) 2709 (18.7) 3976 (19.0)
viduals with a DMFT score ≥8 increased with age, for both Quintile 5 (lowest) 6608 (18.7) 2666 (18.4) 3941 (18.9)
males and females. Heavy smokers were more likely to have a Proper behavior of brushing teeth
DMFT score above 8 (41.8%), with 41.1% of these being male Yes 22 328 (63.1) 9580 (66.0) 12 748 (61.0)
and 53.7% being female when considered separately. The dis- No 13 063 (36.9) 4215 (34.0) 7617 (39.0)
tribution of DMFT scores ≥8 was fairly even across all educa- Smoking status
tion levels, but was most prevalent in the group that had nev- Never smoker 25 668 (72.5) 5417 (37.3) 20 251 (97.0)
er attended school or had no formal education. For males, a Ex-smoker 1451 (4.1) 1199 (8.3) 252 (1.2)
DMFT score ≥8 was primarily observed in laborers and other Smoker 8272 (23.4) 7894 (54.4) 378 (1.8)
similar occupations. The same was true for females, where a Smoking exposure (Brinkman index)
DMFT score ≥8 was most common among workers, entrepre- Never smokers 25 668 (72.5) 5417 (37.3) 20 251 (97.0)
neurs, and other similar groups. Individuals residing in rural Light smokers 382 (1.1) 281 (1.9) 102 (0.5)

areas were more likely to have a DMFT score ≥8 than those Heavy smokers 9341 (26.4) 8812 (60.7) 529 (2.5)
Consumption of sweet foods
Table 1. Socio-demographic characteristics of Indonesians Never to 2 times/wk 13 941 (39.4) 5556 (38.3) 8385 (40.2)
aged 10 years and older – Basic Health Research, 2018 3 times/wk to ≥1 time/day 21 450 (60.6) 8953 (61.7) 12 496 (59.8)
Characteristics Overall Male Female Consumption of sweetened drinks

Age (y) Never to 2 times/wk 9086 (25.7) 2559 (17.6) 6527 (31.1)
10-14 3269 (9.2) 1663 (11.5) 1606 (7.7) 3 times/wk to ≥1 time/day 26 305 (74.3) 11 950 (82.4) 14 355 (68.7)
15-24 5896 (16.7) 2474 (17.1) 3421 (16.4) Consumption of soft drinks
25-34 6574 (18.6) 2384 (16.4) 4190 (20.2) Never to 2 times/wk 33 644 (95.1) 13 406 (92.4) 20 237 (96.9)
35-44 7009 (19.8) 2696 (18.6) 4313 (20.7) 3 times/wk to ≥1 time/day 1747 (4.9) 1103 (7.6) 644 (3.1)
45-54 6109 (17.3) 2490 (17.2) 3619 (17.3) Consumption of energy drinks
55-64 3916 (11.1) 1703 (11.7) 2213 (10.6) Never to 2 times/wk 34 207 (96.7) 13 652 (94.1) 20 555 (98.4)
≥65 2618 (7.4) 1099 (7.6) 1519 (7.3) 3 times/wk to ≥1 time/day 1184 (3.3) 857 (5.9) 327 (1.6)
Level of education Dental caries severity (DMFT)
Elementary school 18 288 (51.7) 7190 (49.6) 11 098 (53.1) <8 22 641 (64.0) 9591 (66.1) 13 050 (62.5)
Middle school 6876 (19.4) 2686 (18.5) 4190 (20.1) ≥8 12 750 (36.0) 4918 (33.9) 7832 (37.5)
High school 8307 (23.5) 3806 (26.2) 4501 (21.6) Total 35 391 (100) 14 509 (41.0) 20 882 (59.0)
College 1920 (5.4) 827 (5.7) 1093 (5.2)
Values are presented as number (%).
(Continued to the next) DMFT, decayed, missing, and filled teeth.

360
 Tobacco Smoking and Dental Caries

Table 2. DMFT conditions according to characteristics and sex– Basic Health Research 2018
Overall Male Female
Characteristics p-value p-value p-value
DMFT<8 DMFT≥8 DMFT<8 DMFT≥8 DMFT<8 DMFT≥8
Age (y) <0.001 <0.001 <0.001
10-14 3065 (93.7) 205 (6.3) 1555 (93.5) 108 (6.5) 1509 (94.0) 97 (6.0)
15-24 5289 (89.7) 607 (10.3) 2256 (91.2) 218 (8.8) 3033 (88.6) 389 (11.4)
25-34 4907 (74.6) 1667 (25.4) 1839 (77.1) 545 (22.9) 3068 (73.2) 1122 (26.8)
35-44 4393 (62.7) 2616 (37.3) 1809 (67.1) 887 (32.9) 2584 (59.9) 1729 (40.1)
45-54 3020 (49.4) 3089 (50.6) 1247 (50.1) 1243 (49.9) 1773 (49.0) 1846 (51.0)
55-64 1347 (34.4) 2569 (65.6) 616 (36.2) 1088 (63.8) 731 (33.0) 1482 (67.0)
≥65 621 (23.7) 1996 (76.3) 269 (24.5) 830 (75.5) 352 (23.2) 1167 (76.8)
Level of education <0.001 <0.001 <0.001
Elementary school 10 835 (59.2) 7452 (40.8) 4469 (62.2) 2721 (37.8) 6367 (57.4) 4731 (42.6)
Middle school 4893 (71.2) 1983 (28.8) 1984 (73.9) 702 (26.1) 2908 (69.4) 1281 (30.6)
High school 5703 (68.6) 2605 (31.4) 2611 (68.6) 1195 (31.4) 3091 (68.7) 1410 (31.3)
College 1210 (63.0) 710 (37.0) 527 (63.7) 300 (36.3) 684 (62.6) 409 (37.4)
Occupation <0.001 <0.001 <0.001
Army/police/government/private 2305 (70.0) 990 (30.0) 1422 (69.6) 622 (30.4) 884 (70.7) 367 (29.3)
employees
Merchants 2669 (58.4) 1900 (41.6) 1552 (61.3) 979 (38.7) 1117 (54.8) 921 (45.2)
Laborers 4580 (54.7) 3799 (45.3) 2902 (56.4) 2246 (43.6) 1678 (51.9) 1553 (48.1)
Unemployed 12 103 (69.5) 5323 (30.5) 3372 (80.7) 807 (19.3) 8731 (65.9) 4516 (34.1)
Others 984 (57.1) 738 (42.9) 343 (56.5) 264 (43.5) 640 (57.5) 474 (42.5)
Socioeconomic quintiles 0.121 0.360 0.349
Quintile 1 (highest) 5498 (63.3) 3183 (36.7) 2384 (65.2) 1275 (34.8) 3114 (62.0) 1907 (38.0)
Quintile 2 4587 (64.6) 2510 (35.4) 1913 (66.4) 967 (33.6) 2673 (63.4) 1543 (36.6)
Quintile 3 4103 (64.9) 2217 (35.1) 1754 (67.6) 841 (32.4) 2350 (63.1) 1376 (36.9)
Quintile 4 4280 (64.0) 2405 (36.0) 1788 (66.0) 921 (34.0) 2492 (62.7) 1484 (37.3)
Quintile 5 (lowest) 4178 (63.2) 2435 (36.8) 1752 (65.7) 914 (34.3) 2421 (61.4) 1520 (38.6)
Geographic location <0.001 <0.001 0.137
Urban 14 890 (64.8) 8080 (35.2) 6309 (67.7) 3010 (32.3) 8581 (62.9) 5070 (37.1)
Rural 7751 (62.4) 4669 (37.6) 3282 (63.2) 1908 (36.8) 4469 (61.8) 2761 (38.2)
Proper behavior of brushing teeth 0.689 0.041 0.695
Yes 14 484 (64.9) 7844 (35.1) 6390 (66.7) 3190 (33.3) 8094 (63.5) 4655 (36.5)
No 7701 (65.1) 4131 (34.9) 2887 (68.5) 1329 (31.5) 4815 (63.2) 2802 (36.8)
Consumption of sweet foods <0.001 0.001 0.002
Never to 2 times/wk 8715 (62.5) 5226 (37.5) 3579 (64.4) 1977 (35.6) 5136 (61.3) 3249 (38.7)
3 times/wk to ≥1 time/day 13 926 (64.9) 7524 (35.1) 6012 (67.2) 2941 (32.8) 7914 (63.3) 4582 (36.7)
Consumption of sweetened drinks 0.973 0.046 0.980
Never to 2 times/wk 5814 (64.0) 3272 (36.0) 1735 (67.8) 824 (32.2) 4080 (62.5) 2447 (37.5)
3 times/wk to ≥1 time/day 16 827 (64.0) 9478 (36.0) 7856 (65.7) 4094 (34.3) 8970 (62.5) 5384 (37.5)
Consumption of soft drinks <0.001 <0.001 <0.001
Never to 2 times/wk 21 308 (63.3) 12 336 (36.7) 8725 (65.1) 4682 (34.9) 12 583 (62.2) 7654 (37.8)
3 times/wk to ≥1 time/day 1333 (76.3) 414 (23.7) 866 (78.6) 236 (21.4) 467 (72.5) 177 (27.5)
Consumption of energy drinks <0.001 <0.001 0.024
Never to 2 times/wk 21 797 (63.7) 12 410 (36.3) 8971 (65.7) 4682 (34.3) 12 826 (62.4) 7729 (37.6)
3 times/wk to ≥1 time/day 844 (71.3) 339 (28.6) 620 (72.4) 236 (27.6) 224 (68.5) 103 (31.5)
(Continued to the next page)

361
Lelly Andayasari, et al.

Table 2. Continued from the previous page

Overall Male Female
Characteristics p-value p-value p-value
DMFT<8 DMFT≥8 DMFT<8 DMFT≥8 DMFT<8 DMFT≥8
Smoking exposure (BI) <0.001 <0.001 <0.001
Never (0) 16 913 (65.9) 8754 (34.1) 4165 (76.9) 1252 (23.1) 12 749 (63.0) 7502 (37.0)
Light smoker (1-399) 293 (76.7) 89 (23.3) 237 (84.6) 43 (15.4) 56 (54.9) 46 (45.1)
Heavy smoker (≥400) 5435 (58.2) 3906 (41.8) 5189 (58.9) 3623 (41.1) 245 (46.3) 284 (53.7)
Smoking status <0.001 <0.001 <0.001
Never 16 913 (65.9) 8754 (34.1) 4165 (76.9) 1252 (23.1) 12 749 (63.0) 7502 (37.0)
Ex-smoker 775 (53.4) 676 (46.6) 655 (54.6) 544 (45.4) 120 (47.6) 132 (52.4)
Smoker 4953 (59.9) 3320 (40.1) 4772 (60.5) 3122 (39.5) 181 (47.9) 197 (52.1)
Total 22 641 (64.0) 12 750 (36.0) 9592 (66.1) 4918 (33.9) 13 050 (62.5) 7831 (37.5)
Values are presented as number (%).
DMFT, decayed, missing, and filled teeth; BI, Brinkman index.

living in urban areas. DISCUSSION

The results of the multivariate logistic regression, as shown
in Tables 3 and 4, indicate that active smokers generally had a Smoking habits in Indonesia are on the rise, with a signifi-
6.8% increased risk of having a DMFT score ≥8 (aOR, 1.07; cant increase observed year after year (Riskesdas, 2018). The
95% CI, 1.00 to 1.14; p=0.037). This trend was also observed in 2012 Indonesia Demographic and Health Survey analysis re-
male smokers (aOR, 1.40; 95% CI, 1.27 to 1.55; p<0.001), and vealed that males smoked more than females [20]. Consequent-
male ex-smokers (aOR, 1.18; 95% CI, 1.01 to 1.38; p=0.034). ly, the analysis was conducted separately for each sex to yield
Females who had previously smoked (ex-smokers) had a 41% more accurate results. The findings indicated that severe den-
increased risk of having a DMFT score ≥8 (aOR, 1.41; 95% CI, tal caries (DMFT≥8) were associated with factors such as age,
1.07 to 1.84; p=0.014). Among males, heavy smoking was as- occupation, consumption of sweet foods, soft drinks, and smok-
sociated with a 38% increased risk of having a DMFT score ≥8 ing habits in both males and females. However, geographic lo-
(aOR, 1.38; 95% CI, 1.25 to 1.52; p<0.001), while in females, cation and the consumption of sweetened drinks were only
the risk was increased by 24% (aOR, 1.24; 95% CI, 1.03 to 1.50; associated with males.
p=0.022). The probability of having a DMFT score ≥8 increas- This study revealed a correlation between DMFT and age,
es with age, both overall and when broken down by sex. Oc- with older age groups experiencing a higher incidence of den-
cupations other than army, police, government, or private sec- tal caries. Research on DMFT in children has demonstrated a
tor employees were associated with a higher risk of having a relatively high percentage that increases with age. A study
DMFT score ≥8, particularly in the overall sample and among conducted in Saudi Arabia also indicated that dental caries is a
males. Consumption of sweet foods was linked to a higher risk significant public health issue among children [6]. This is par-
of having a DMFT score ≥8, both overall and when analyzed tially attributed to increasingly complex consumption patterns
by sex. Similarly, the consumption of sweet drinks is associat- as children age. Numerous studies have established a link be-
ed with a higher risk, especially among males. tween an individual’s diet, particularly the consumption of
Multivariate analysis, segmented by age group, revealed that sugary foods and beverages, and dental caries. The primary
smokers were more likely to experience DMFT scores ≥8 within risk factor for dental caries is the consumption of sugary foods
the age group of 25-34 years, 35-44 years, and 55-64 years. and drinks, which can double the risk of developing this condi-
However, both former smokers and heavy smokers were more tion [15]. The lack of availability of high-quality food and the
likely to experience DMFT scores ≥8 within the age group of proliferation of sugary and fatty foods that are low in energy
35-44 years and 55-64 years. Light smokers, however, were and nutrients are among the factors driving changes in con-
more likely to experience these scores within the 35-44 years sumption behavior patterns [21]. This study also found that, in
age group (Table 4). addition to sugary foods, soft drinks contribute to dental car-
ies. Male respondents who frequently consumed energy

362
 Tobacco Smoking and Dental Caries

Table 3. Multivariate logistic regression smoking status and DMFT status ≥8

Variables Overall p-value Male p-value Female p-value
Smoking status
Never smoker 1.00 (reference) 1.00 (reference) 1.00 (reference)
Ex-smoker 0.97 (0.86, 1.09) 0.568 1.18 (1.01, 1.38) 0.034 1.41 (1.07, 1.84) 0.014
Smoker 1.07 (1.00, 1.14) 0.037 1.40 (1.27, 1.55) <0.001 1.19 (0.96, 1.48) 0.191
Age (y)
10-24 1.00 (reference) 1.00 (reference) 1.00 (reference)
15-24 1.90 (1.60, 2.25) <0.001 1.47 (1.13, 1.92) 0.005 2.04 (1.61, 2.59) <0.001
25-34 5.72 (4.88, 6.71) <0.001 4.54 (3.45, 5.98) <0.001 5.83 (4.66, 7.29) <0.001
35-44 10.00 (8.56, 11.69) <0.001 7.36 (5.61, 9.65) <0.001 10.62 (8.52, 13.24) <0.001
45-54 17.05 (14.58, 19.94) <0.001 14.97 (11.45, 19.58) <0.001 16.52 (13.25, 20.60) <0.001
55-64 31.35 (26.68 36.85) <0.001 25.34 (19.38, 33.14) <0.001 32.14 (25.59, 40.36) <0.001
≥65 51.71 (43.57, 61.37) <0.001 43.92 (33.11, 58.25) <0.001 52.63 (41.39, 66.91) <0.001
Level of education
Elementary school 1.00 (reference) 1.00 (reference) 1.00 (reference)
Middle school 1.05 (0.94, 1.18) 0.398 1.04 (0.86, 1.25) 0.700 1.00 (0.86, 1.16) 0.979
High school 0.97 (0.86, 1.10) 0.677 0.84 (0.69, 1.02) 0.077 1.04 (0.89, 1.22) 0.600
College 0.97 (0.87, 1.09) 0.634 1.05 (0.88, 1.25) 0.613 0.94 (0.81, 1.09) 0.427
Occupation
Army/police/government/ 1.00 (reference) 1.00 (reference) 1.00 (reference)
private employees
Merchants 1.20 (1.08, 1.33) 0.001 1.14 (1.00, 1.31) 0.055 1.16 (0.98, 1.38) 0.075
Laborers 1.19 (1.08, 1.32) 0.001 1.16 (1.01, 1.33) 0.032 1.11 (0.95, 1.31) 0.194
Unemployed 1.29 (1.17, 1.42) <0.001 1.35 (1.14, 1.61) 0.001 1.09 (0.94, 1.26) 0.250
Others 1.31 (1.15, 1.50) <0.001 1.20 (0.97, 1.48) 0.091 1.16 (0.96, 1.40) 0.117
Geographic location
Urban 1.00 (reference) 1.00 (reference) -
Rural 1.00 (0.94, 1.05) 0.874 1.11 (1.01, 1.21) 0.029 -
Proper behavior of brushing teeth
Yes - 1.00 (reference) -
No - 0.97 (0.89, 1.06) 0.509 -
Consumption of sweet foods
Never to 2 times/wk 1.00 (reference) 1.00 (reference) 1.00 (reference)
3 times/wk to ≥1 time/day 1.19 (1.14, 1.26) <0.001 1.18 (1.08, 1.29) <0.001 1.17 (1.10, 1.25) <0.001
Consumption of sweetened drinks
Never to 2 times/wk - 1.00 (reference) -
3 times/wk to ≥1 time/day - 1.23 (1.09, 1.38) <0.001 -
Consumption of soft drinks
Never to 2 times/wk 1.00 (reference) 1.00 (reference) 1.00 (reference)
3 times/wk to ≥1 time/day 0.77 (0.67, 0.88) <0.001 0.71 (0.59, 0.85) <0.001 0.90 (0.73, 1.11) 0.332
Consumption of energy drinks
Never to 2 times/wk 1.00 (reference) 1.00 (reference) 1.00 (reference)
3 times/wk to ≥1 time/day 1.03 (0.89, 1.20) 0.667 1.09 (0.91, 1.32) 0.345 0.94 (0.71, 1.24) 0.669
Values are presented as adjusted odds ratio (95% confidence interval).
DMFT, decayed, missing, and filled teeth.

drinks were more likely to develop dental caries than those content in sugar, which can linger on the teeth and provide a
who did not. This could be attributed to the high carbohydrate breeding ground for bacteria [1,14].

363
Lelly Andayasari, et al.

Table 4. Multivariate logistic regression smoking exposure (Brinkman index) and DMFT status ≥8
Variables Overall p-value Male p-value Female p-value
Smoking exposure (Brinkman index)
Never (0) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Light smoker (1-399) 0.94 (0.72, 1.23) 0.674 0.94 (0.65, 1.36) 0.731 1.42 (0.93, 2.18) 0.106
Heavy smoker (≥400) 1.05 (0.99, 1.12) 0.078 1.38 (1.25, 1.52) <0.001 1.24 (1.03, 1.50) 0.022
Age (y)
10-24 1.00 (reference) 1.00 (reference) 1.00 (reference)
15-24 1.90 (1.61, 2.26) <0.001 1.50 (1.15, 1.96) 0.003 2.04 (1.61, 2.59) <0.001
25-34 5.74 (4.89, 6.72) <0.001 4.56 (3.46, 6.00) <0.001 5.83 (4.66, 7.29) <0.001
35-44 10.00 (8.55, 11.69) <0.001 7.32 (5.58, 9.60) <0.001 10.63 (8.53, 13.25) <0.001
45-54 17.04 (14.57, 19.93) <0.001 14.88 (11.38, 19.47) <0.001 16.51 (13.24, 20.59) <0.001
55-64 31.20 (1.61, 2.26) <0.001 24.80 (18.96, 32.44) <0.001 32.15 (25.60, 40.38) <0.001
≥65 51.40 (1.61, 2.26) <0.001 42.61 (32.14, 56.51) <0.001 52.67 (41.42, 66.96) <0.001
Level of education
Elementary school 1.00 (reference) 1.00 (reference) 1.00 (reference)
Middle school 1.06 (0.93, 1.19) 0.342 1.06 (0.88, 1.27) 0.559 1.00 (0.86, 1.16) 0.993
High school 0.98 (0.87, 1.10) 0.728 0.85 (0.70, 1.03) 0.099 1.04 (0.89, 1.22) 0.610
College 0.98 (0.87, 1.09) 0.680 1.06 (0.89, 1.26) 0.526 0.94 (0.81, 1.09) 0.424
Occupation
Army/police/government/ 1.00 (reference) 1.00 (reference) 1.00 (reference)
private employees
Merchants 1.20 (1.08, 1.33) 0.001 1.14 (0.99, 1.30) 0.071 1.16 (0.98, 1.38) 0.075
Laborers 1.20 (1.08, 1.32) 0.001 1.16 (1.01, 1.33) 0.035 1.11 (0.95, 1.31) 0.193
Unemployed 1.29 (1.17, 1.42) <0.001 1.35 (1.13, 1.60) 0.001 1.09 (0.94, 1.26) 0.245
Others 1.31 (1.150, 1.50) <0.001 1.20 (0.97, 1.49) 0.089 1.16 (0.96, 1.40) 0.117
Geographic location
Urban 1.00 (reference) 1.00 (reference) -
Rural 1.00 (0.94, 1.05) 0.905 1.11 (1.01, 1.22) 0.022 -
Proper behavior of brushing teeth
Yes - 1.00 (reference) -
No - 0.97 (0.89, 1.06) 0.495 -
Consumption of sweet foods
Never to 2 times/wk 1.00 (reference) 1.00 (reference) 1.00 (reference)
3 times/wk to ≥1 time/day 1.19 (1.14, 1.26) <0.001 1.18 (1.08, 1.28) <0.001 1.17 (1.10, 1.25) <0.001
Consumption of sweetened drinks
Never to 2 times/wk - 1.00 (reference) -
3 times/wk to ≥1 time/day - 1.24 (1.10, 1.38) <0.001 -
Consumption of soft drinks
Never to 2 times/wk 1.00 (reference) 1.00 (reference) 1.00 (reference)
3 times/wk to ≥1 time/day 0.77 (0.67, 0.88) <0.001 0.71 (0.59, 0.85) <0.001 0.90 (0.73, 1.11) 0.325
Consumption of energy drinks
Never to 2 times/wk 1.00 (reference) 1.00 (reference) 1.00 (reference)
3 times/wk to ≥1 time/day 1.04 (0.89, 1.21) 0.637 1.10 (0.91, 1.32) 0.333 0.94 (0.71, 1.24) 0.664
Values are presented as adjusted odds ratio (95% confidence interval).
DMFT, decayed, missing, and filled teeth.

The dietary choices people make are shaped by a multitude and occupation. Our research indicates that education and oc-
of intricate factors, including socioeconomic status, education, cupation significantly impact DMFT scores. Both males and fe-

364
 Tobacco Smoking and Dental Caries

males who have never received formal education exhibit the ence of microbes to tooth surfaces and oral epithelial cells. A
highest percentage of DMFT. Furthermore, labor-intensive oc- reduced sIgA concentration is a risk factor for dental caries in
cupations correspond with the highest percentage of DMFT. both children and adults. The immunosuppressive properties
These findings align with previous studies that have identified of smoking, which are dose-dependent, are evident in the re-
a correlation between education and dental health, with those duced concentration of sIgA in the saliva of adult smokers and
only having primary education experiencing a 25% increased children exposed to secondhand smoke.
risk, and illiteracy correlating with the highest risk. This signifi- Amylase plays a vital role in streptococcal colonization and
cant correlation is closely tied to the formation of attitudes and metabolism, which contributes to the development of dental
perceptions, as well as the influence of the family environment caries. It functions as a receptor on the pellicle, providing a
on dental and oral health [15]. surface for bacteria to attach to the tooth. Prior research has
Numerous epidemiological studies worldwide have estab- indicated that individuals who smoke tend to have higher con-
lished a strong correlation between smoking and the incidence centrations of salivary amylase. This enzyme can elevate the
of periodontitis and dental caries [9,10,22]. Smoking heightens pH level of dental plaque, thereby encouraging the coloniza-
the risk of gum disease and oral cancer. It can also lead to tooth tion of oral microbiota and heightening the risk of caries [29].
discoloration (staining), bad breath, and interference with the There are limitations to this study. We carried out a popula-
wound-healing process in periodontal disease. A study con- tion-based cross-sectional study, the results of which cannot
ducted in Scotland demonstrated that children born to moth- establish a cause-and-effect relationship between dental car-
ers who smoked during pregnancy have a higher prevalence ies and tobacco smoking in the Indonesian population. As such,
of caries compared to those born to non-smoking mothers [13]. we recognize the need for a more robust study design to as-
In Portugal, smoking has been identified as a risk factor for certain whether heavy smoking could potentially lead to se-
dental caries, with a 7% reduction in caries incidence observed vere dental caries. A prospective cohort study could be one
when exposure to cigarettes is avoided [23]. A systematic re- such option.
view by Benedetti et al. [24] further corroborates that tobacco
smoking is closely associated with an increased risk of caries. CONFLICT OF INTEREST
In Indonesia, dental caries are more prevalent among heavy
smokers compared to those who have never smoked [25]. This The authors have no conflicts of interest associated with the
observation is consistent with the findings of Sumartono et al. material presented in this paper.
[25], which also indicated a higher incidence of dental caries
among individuals with greater exposure to cigarettes. For FUNDING
smokers, the mouth and teeth are the initial points of contact
with tobacco. The constituents of cigarettes subsequently pro- None.
mote the proliferation of carcinogenic microorganisms. These
bacteria, known to instigate caries, generate acid in the oral ACKNOWLEDGEMENTS
cavity by breaking down fermentable carbohydrates through en-
zyme secretion or metabolism, leading to further demineral- The authors thank the Head of the National Institute of Health
ization of dental hard tissues. Given that about 7000 distinct Research and Development, Ministry of Health, the Republic
molecules are inhaled from cigarettes, it is challenging to pin- of Indonesia, for permission to use Basic Health Research 2018
point which component has the most substantial impact on data in this study.
caries-associated bacteria [9].
Previous research has demonstrated that smoking can di- AUTHOR CONTRIBUTIONS
minish the buffering capacity of saliva, leading to a decrease
in salivary pH [26]. In addition, smoking also affects the con- Conceptualization: Andayasari L, Mubasyiroh R, Sufiawati I,
centration of salivary proteins such as salivary secretory IgA Data curation: Mubasyiroh R, Andayasari L. Formal analysis:
(sIgA) and amylase [27,28]. sIgA plays a crucial role in defend- Mubasyiroh R, Andayasari L, Sufiawati I. Funding acquisition:
ing against oral and dental diseases by inhibiting the adher- None. Methodology: Mubasyiroh R, Andayasari L, Nurlinawati I.

365
Lelly Andayasari, et al.

Visualization: Sufiawati I. Writing – original draft: Andayasari L, 428-434.

Mubasyiroh R. Writing – review & editing: Andayasari L, Nurlinawa- 11. Kumar S, Tadakamadla J, Johnson NW. Effect of toothbrushing
ti I, Mubasyiroh R, Sufiawati I. frequency on incidence and increment of dental caries: a sys-
tematic review and meta-analysis. J Dent Res 2016;95(11):
ORCID 1230-1236.
12. Alswat K, Mohamed WS, Wahab MA, Aboelil AA. The associa-
Lelly Andayasari https://orcid.org/0000-0003-0244-1048 tion between body mass index and dental caries: cross-sec-
Rofingatul Mubasyiroh https://orcid.org/0000-0001-5416-9512 tional study. J Clin Med Res 2016;8(2):147-152.
Iin Nurlinawati https://orcid.org/0000-0002-2479-615X 13. Iwasaki T, Hirose A, Azuma T, Ohashi T, Watanabe K, Obora A,
Irna Sufiawati https://orcid.org/0000-0002-2506-5105 et al. Associations between caries experience, dietary habits,
and metabolic syndrome in Japanese adults. J Oral Sci 2019;
REFERENCES 61(2):300-306.
14. Guracho TT, Atomssa EM, Megersa OA, Tolossa T. Determinants
1. Moynihan P. Sugars and dental caries: evidence for setting a of dental caries among adolescent patients attending hospi-
recommended threshold for intake. Adv Nutr 2016;7(1):149- tals in West Wollega Zone, Western Ethiopia: a case-control
156. study. PLoS One 2021;16(12):e0260427.
2. Institute for Health Metrics and Evaluation. Global Burden of 15. Yousaf M, Aslam T, Saeed S, Sarfraz A, Sarfraz Z, Cherrez-Ojeda
Disease Study 2019 (GBD 2019) data resources; 2020 [cited I. Individual, family, and socioeconomic contributors to dental
2023 Mar 22]. Available from: https://ghdx.healthdata.org/ caries in children from low- and middle-income countries. Int
gbd-2019. J Environ Res Public Health 2022;19(12):7114.
3. Agency of Health Research and Development (Indonesia). In- 16. Ditmyer M, Dounis G, Mobley C, Schwarz E. A case-control study
donesia Basic Health Research 2018; 2021 [cited 2021 Apr 28]. of determinants for high and low dental caries prevalence in
Available from: https://ghdx.healthdata.org/record/indone- Nevada youth. BMC Oral Health 2010;10:24.
sia-basic-health-research-2018. 17. Leake J, Jozzy S, Uswak G. Severe dental caries, impacts and
4. Yon MJ, Gao SS, Chen KJ, Duangthip D, Lo EC, Chu CH. Medical determinants among children 2-6 years of age in Inuvik Region,
model in caries management. Dent J (Basel) 2019;7(2):37. Northwest Territories, Canada. J Can Dent Assoc 2008;74(6):
5. Gupta P, Gupta N, Singh HP. Prevalence of dental caries in rela- 519.
tion to body mass index, daily sugar intake, and oral hygiene 18. Suzuki N, Nakano Y, Yoneda M, Hirofuji T, Hanioka T. The effects
status in 12-year-old school children in Mathura city: a pilot of cigarette smoking on the salivary and tongue microbiome.
study. Int J Pediatr 2014;2014:921823. Clin Exp Dent Res 2022;8(1):449-456.
6. Benedict M, Mavole J, Mutungi M. The role of dental health 19. Park HJ, Lee JH, Park S, Kim TI. Changes in dental care access
education on the quality of life among adolescents in Kibra upon health care benefit expansion to include scaling. J Peri-
sub-county, Nairobi city county, Kenya. Int J Soc Dev Concerns odontal Implant Sci 2016;46(6):405-414.
2019;7:107-122. 20. Timban I, Langi FF, Kaunang WP. Determinant of smoking in
7. Tanaka K, Miyake Y, Sasaki S, Hirota Y. Dairy products and cal- Indonesia analysis of the 2012. KESMAS 2018;7(5):1-11 (Indo-
cium intake during pregnancy and dental caries in children. nesian).
Nutr J 2012;11:33. 21. Mobley C, Marshall TA, Milgrom P, Coldwell SE. The contribu-
8. Peres MA, Sheiham A, Liu P, Demarco FF, Silva AE, Assunção MC, tion of dietary factors to dental caries and disparities in caries.
et al. Sugar consumption and changes in dental caries from Acad Pediatr 2009;9(6):410-414.
childhood to adolescence. J Dent Res 2016;95(4):388-394. 22. Zhang J, Yu J, Dou J, Hu P, Guo Q. The impact of smoking on
9. Wu J, Li M, Huang R. The effect of smoking on caries-related subgingival plaque and the development of periodontitis: a
microorganisms. Tob Induc Dis 2019;17:32. literature review. Front Oral Health 2021;2:751099.
10. Bernabé E, Delgado-Angulo EK, Vehkalahti MM, Aromaa A, 23. Bernabé E, MacRitchie H, Longbottom C, Pitts NB, Sabbah W.
Suominen AL. Daily smoking and 4-year caries increment in Birth weight, breastfeeding, maternal smoking and caries tra-
Finnish adults. Community Dent Oral Epidemiol 2014;42(5): jectories. J Dent Res 2017;96(2):171-178.

366
 Tobacco Smoking and Dental Caries

24. Benedetti G, Campus G, Strohmenger L, Lingström P. Tobacco 27. Parsaie Z, Rezaie P, Azimi N, Mohammadi N. Relationship be-
and dental caries: a systematic review. Acta Odontol Scand tween salivary alpha-amylase enzyme activity, anthropomet-
2013;71(3-4):363-371. ric indices, dietary habits, and early childhood dental caries.
25. Sumartono W, Thabrany H, Meidyawati R. Heavy smoking and Int J Dent 2022;2022:2617197.
severe dental caries in Indonesian men. Tob Control Public 28. Monea M, Vlad R, Stoica A. Analysis of salivary level of alpha-
Health East Eur 2016;6(1):21-29. amylase as a risk factor for dental caries. Acta Med Transilvani-
26. Ahmadi-Motamayel F, Falsafi P, Goodarzi MT, Poorolajal J. Com- ca 2018;23(1):93-95.
parison of salivary ph, buffering capacity and alkaline phos- 29. Culp DJ, Robinson B, Cash MN. Murine salivary amylase pro-
phatase in smokers and healthy non-smokers: retrospective tects against Streptococcus mutans-induced caries. Front Physi-
cohort study. Sultan Qaboos Univ Med J 2016;16(3):e317-e321. ol 2021;12:699104.

367