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CHAPTER TWO

LITERATURE REVIEW

The majority of oral health problems are essentially avoidable and treatable in their early stages

(WHO, 2020). The most common orofacial conditions include dental caries, periodontal disease,

oral malignancies, oral symptoms of HIV, oro-dental trauma, cleft lip and palate, and noma

[severe gangrenous disease starting in the mouth mostly affecting children] (WHO, 2020). This

literature was reviewed under the following subheadings:

2.1 Concept of Orofacial Disease

Orofacial disease refers to the diseases that affect the oral cavity and the face. The oral cavity is

an essential part of the body and contributes to total health and well-being. Recent studies show

that poor oral health is inimical to general health and that some systemic diseases can affect oral

health (Bratthall et al., 2006). Orofacial diseases are among the most prevalent diseases

worldwide and have serious health and economic burdens, greatly reducing quality of life for

those affected (Peres et al., 2019). The most prevalent and consequential orofacial diseases

globally are dental caries, periodontal disease, tooth loss, and malignancies of the lips and oral

cavity (Peres et al., 2019). Although orofacial diseases are largely preventable, they persist with

high prevalence, reflecting widespread social and economic inequalities and inadequate funding

for prevention and treatment, particularly in low-income and middle-income countries [LMICs]

(Osuh et al., 2022). As with most non-communicable diseases (NCDs), oral conditions are

chronic and strongly socially patterned. Children living in poverty, socially marginalized groups,

and older people are the most affected by orofacial diseases, and have poor access to dental care

(Peres et al., 2019).

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In many LMICs, orofacial diseases remain largely untreated because the treatment costs exceed

available resources (Osuh et al., 2022). The personal consequences of chronic untreated oral

diseases are often severe and can include unremitting pain, sepsis, reduced quality of life, lost

school days, disruption to family life, and decreased work productivity (Peres et al., 2019). The

costs of treating oral diseases impose large economic burdens to families and health-care

systems. Oral diseases are undoubtedly a global public health problem, with particular concern

over their rising prevalence in many LMICs linked to wider social, economic, and commercial

changes (Osuh et al., 2022). By describing the extent and consequences of oral diseases, their

social and commercial determinants, and their ongoing neglect in global health policy, we aim to

highlight the urgent need to address oral diseases among other NCDs as a global health priority

(Osuh et al., 2022; Peres et al., 2019).

2.2 Common Orofacial Disease

According to Oyapero et al. (2020) about 3.5 billion people worldwide are burdened by orofacial

disease such as severe periodontal disease, edentulism, severe tooth loss (having between 1 and 9

remaining teeth), and untreated dental caries in the deciduous and permanent dentitions. Studies

show that untreated dental caries in permanent teeth is the most common health condition in the

world, affecting nearly 2.5 billion people. Untreated caries in deciduous teeth affects nearly 573

million children. Severe periodontal disease affects about 538 million while tooth loss affects

nearly 276 million people worldwide (WHO, 2022, Wen et al., 2021, Kassebaum et al., 2017).

Oral cancer is the eighth most frequent cancer in the world, affecting 1–10 cases per 100,000 in

several countries (Tobin & Ajayi, 2017). Dental traumatic injuries have increased from 16% to

40% among 6-year-olds and 4% to 33% among 12–14-year-olds in industrialized countries.

Increased road traffic accidents (RTA), dangerous playgrounds, and violence have all been
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implicated (Tobin & Ajayi, 2017). Interpersonal violence and RTA have created a comparable

situation in developing countries like Nigeria (Tobin & Ajayi, 2017). In Africa, the morbidity of

orofacial disease is increasingly being recognized as a major public health challenge. It has been

reported that nearly 400 million people suffer from some form of oral disease in Africa (WHO,

2017). In Nigeria, the morbidity of orofacial disease varies from one part of the country to

another and is associated with various socio-demographic factors like age, gender, and socio-

economic status (Arowojolu et al., 2016). The following are some common oral diseases and

conditions:

2.2.1 Dental caries

This is the chemical dissolution of the mineralized portion of the teeth by the action of bacterial

plaque on susceptible teeth surfaces over time leading to cavitation of the teeth (Akpata, 2004).

Dental caries is one of the most common microbe-mediated oral diseases in human beings (Chen

et al., 2020).

2.2.1a. Etiology of dental caries

Currently, the accepted etiology of caries is based on a four-factor theory that includes oral

microorganisms, oral environment, host, and time. Excessive exposure to dietary carbohydrates

leads to the accumulation of acid-producing and acid-resistant microorganisms in the mouth.

Dental caries is driven by dysbiosis of the dental biofilm adherent to the enamel surface (Chen et

al., 2020).

2.2.1b Management of dental caries

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Effective preventive methods include inhibiting the cariogenic microorganisms, treatment with

an anti-biofilm agent, and sugar intake control. The goal is to reduce the total amount of biofilm

or the levels of specific pathogens. Natural products could be recommended for preventing

dental caries, since they may possess fewer side effects in comparison with synthetic

antimicrobials (Chen et al., 2020).

2.2.2 Periodontal disease

Periodontal disease refers to a group of oral health problems that affect the periodontium

including the gingivae, periodontal ligament, and alveolar bone. These problems might be

limited to the gingiva (gingivitis) or spread to the periodontal ligament space and alveolar bone

(periodontitis). Periodontitis can cause tooth mobility, pathologic migration, and ultimately tooth

loss (Popoola et al., 2015). Periodontal disease can manifest clinically at any age. However,

studies show that gingivitis occurs mostly in children and adolescents while periodontitis is more

common in adults (Popoola et al., 2015).

2.2.2a. Etiology of periodontal disease

There is a high prevalence of periodontal disease worldwide, and knowing the etiology is key to

its management (Vargas et al., 2015). The occurrence of periodontal disease is related to oral

hygiene status and socioeconomic class (Popoola et al., 2015, Akpata, 2004). Biofilms that

colonize the oral cavity are among the most complex of nature. Besides pathogenic

microorganisms, genetic and environmental factors contribute to the development of this disease.

Periodontal disease can be increased by several risk factors such as smoking, systemic diseases,

medications such as steroids, antiepileptics, drugs for cancer therapy, poor placement of dental

bridges, dental crowding, lack of teeth, pregnancy and contraceptive use (Vargas et al., 2015).
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2.2.2b Management of periodontal disease

Periodontal disease can be prevented by maintaining good oral hygiene, avoiding harmful

practices like smoking, consumption of healthy diet, and regular visit to the dentist (Vargas et

al., 2015). There are many ways of treating periodontal disease depending on the stage of the

disease, the way the patient responds to previews treatments and the patient oral health. Some of

these treatments include professional dental cleaning, scaling and root planing, antibiotic therapy

and surgical procedures. Lately, the dental community was in search of new non-invasive

treatments to restore oral health like the use of natural products such as plants; their components

have been in use for treatment and cure of diseases all around (Vargas et al., 2015).

2.2.3 Oral cancer

Oral cancer is the sixth most common malignancy in the world. It is a preventable disease,

related to behavioral and lifestyle factors, including tobacco and alcohol (Day et al., 2003). Oral

cancer is of major concern in Nigeria primarily because of the prevalent oral habits of tobacco

chewing, smoking, and alcohol consumption and the fact that oral cancer management and

prognosis is very poor especially because patients present late (Kumar et al., 2016). Despite

recent advances in cancer diagnoses and therapies, the 5-year survival rate of oral cancer patients

has remained at a dismal 50% in the last few decades (Kumar et al., 2016).

2.2.3a. Etiology of oral cancer

Development of oral or head and neck squamous cell carcinoma (HNSCC) and minor salivary

gland carcinomas is influenced by both these factors namely tobacco, alcohol, diet and nutrition,

viruses, radiation, ethnicity, familial and genetic predisposition, oral thrush, immunosuppression,
 6

use of mouthwash, syphilis, dental factors, occupational risks, and mate [tea-like beverage

consumed in South America and in parts of Europe] (Kumar et al., 2016).

2.2.3b Management of oral cancer

Prevention and early detection of oral cancer remain the goals of national efforts to reduce the

impact of this disease on the public (Day et al., 2003). Surgical treatment is the mainstay of

therapy for patients with oral cancer, particularly in advanced stages of cancer. External beam

radiation therapy and brachytherapy have been used successfully as the primary modality for

treating patients with early-stage oral cancer, and they are the standard of care for use as

adjuvant therapy in postoperative cases of patients with advanced stage oral cancer (Day et al.,

2003). There is an emerging trend for the use of chemotherapy in combination with radiation

therapy and surgery for patients with advanced, recurrent, and metastatic head and neck cancer,

although evidence is limited regarding survival benefit when used for treating patients with oral

cavity carcinoma (Day et al., 2003). Any report on the treatment of oral cancer is incomplete

without consideration of functional and aesthetic outcomes, particularly addressing speech,

swallowing, masticatory efficiency, and dental rehabilitation. Future generations will continue to

fight these dreadful diseases until scientists and clinicians are provided the opportunities to

expand efforts to prevent, detect (early), and eradicate oral and other head and neck cancers (Day

et al., 2003).

2.2.4 Cleft lips and palate (CL/P)

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Cleft lips and/or palate is the most prevalent congenital craniofacial abnormality whose

management requires intensive resources due to the complex nature of the condition

(Akinmoladun et al., 2017). Cleft lip and palate represent a major public health problem due to

the possible associated life-long morbidity, complex etiology, and the extensive

multidisciplinary commitment required for intervention. It affects about 1.5 per 1000 live births

(250,000 new cases per year) worldwide, with tremendous variations across geographic areas

and ethnic groups. It is considered a debilitating condition that is associated with significant

feeding, hearing, speech, and psychological impairments (Allam et al., 2014).

2.2.4a. Etiology of cleft lips and palate

CL/P is etiologically heterogeneous with both genetics and environmental contributions. With

the advent of the genomics era and advances in both quantitative and molecular analysis

techniques, there have been great improvements in the identification of causative genetic

mutations and associations underlying syndromic forms of CL/P (Allam et al., 2014).

2.2.4b Management of cleft lips and palate

Management normally includes surgical intervention, speech therapy, mixed dentition

orthodontics, and nutritional support (Allam et al., 2014). The wide surgical, dental, speech,

social, and medical involvement emphasize the importance of understanding the underlying

determinants of these defects to allow optimizing the treatment options and predicting the long-

term course of the affected individual’s development (Allam et al., 2014). Optimal and early

surgical intervention is necessary and folic acid supplementation proved to be a highly efficient

preventive strategy. However, there are still many challenges to be addressed for cleft care

especially in the developing parts of the world (Allam et al., 2014).

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2.2.5 Noma

Noma, otherwise known as cancrum oris is an infection of the oral cavity that spreads quickly

and primarily affects children. It is thought to have originated in Sub-Saharan Africa over the

past ten years and is connected to the region's residents' low socioeconomic status (Bello et al.,

2019). The exact impact or cumulative consequences of noma as measured by financial cost,

mortality, morbidity, or other indicators are unknown. Although this disease is often neglected, a

high prevalence of children is at the risk of developing advanced noma (Farley et al., 2020).

2.2.5a Etiology of noma

The causative agent of noma is unknown. It seems unlikely that a single infectious agent (virus

or bacteria) is responsible for the disease (WHO, 2017). It would be more appropriate to speak

of factors that contribute to the onset of the disease, or its determinants. Noma is the result of

complex interactions in immunosuppressed children living in extreme poverty (WHO, 2017). In

addition to known factors such as malnutrition, coinfections - measles and malaria - and poor

oral hygiene, a number of social and environmental factors such as maternal malnutrition and

closely-spaced pregnancies that result in offspring with increasingly weakened immune systems,

could be strongly related to the onset of the disease (WHO, 2017).

2.2.5b Management of noma

Noma is a serious debilitating disease that usually leaves its victims disfigured. However, if the

infection is treated properly during the early stages of the disease, it can be prevented from

progressing to full blown noma. In order to limit the extent of the damage, treatment must be

started noma as soon as it is recognized. The longer the delay, the lower the survival rate, and the
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worse the physical and psychological trauma will be for the child (WHO). Treatments include

drug, surgical, nutritional, speech and other supportive therapies.

2.2.6 Oro-dental trauma

Dental trauma is relatively common and can occur secondary to falls, fights, sporting injuries, or

motor vehicle accidents. Because many clinicians work in a community-based environment

where there is no dentist on call for emergencies, they may find themselves forced to deal with

acute dental injuries in such situations (Glendor, 2009).

2.2.6a Etiology of oro-dental trauma

The risk for oro-facial trauma is increased by oral factors (like increased overjet with protrusion),

environmental determinants (material deprivation) and human behavior [risk-taking children,

children being bullied, emotionally stressful conditions, obesity and attention-deficit

hyperactivity disorder] (Glendor, 2009). The chances of experiencing dental trauma are also

increased by other factors such as the presence of illness, learning difficulties, physical

limitations and inappropriate use of teeth. A recent cause of dental trauma that is of particular

interest is oral piercing (Glendor, 2009).

2.2.6b Management of oro-dental trauma

The treatment depends on the nature of the trauma. Injuries to the mouth and teeth should be

examined by a dentist, especially if a tooth or teeth have become loose or sustained damage. In

some cases, when a tooth is visibly damaged, the neighboring teeth may also have injuries that

are not necessarily visible unless detected by a dental exam (Glendor, 2009).
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i. For chipped or fractured teeth, a tooth-colored filling may be recommended to replace the

lost part of the tooth. If a significant part of the crown has been lost, an artificial crown or

cap may be offered instead (Glendor, 2009).

ii. If the pulp is exposed, a root canal may be needed.

iii. Injuries to the back teeth, including fractured cusps, may require a root canal and full

coverage crown.

iv. More serious injuries such as split teeth may require the tooth to be removed completely.

v. Dislodged (luxated) teeth should be restabilized by the dentist and root canal

treatment may be needed (Glendor, 2009).

vi. Children under the age of 12 may not need root canal treatment, as their teeth as still

developing and may be able to heal on their own. The dentist will monitor them carefully

to see if any additional treatment is needed (Glendor, 2009).

vii. Teeth that have been knocked out (avulsed) may be replanted if you act quickly. You

should see your dentist or an endodontist immediately – if you receive treatment within

30-40 minutes, there is a good chance you will save the tooth; any longer than this and

the odds diminish considerably. If the tooth can be found, handle it carefully by the

crown – don’t touch the root! The dentist will place it back in its socket and a stabilizing

splint will be placed for a few weeks, after which you may require root canal treatment

(Glendor, 2009).

viii. In some cases, such as if the knocked-out tooth cannot be found, or if it is not treated

soon enough, other treatment options to replace the tooth may be discussed (Glendor,

2009).

2.2.7 Malocclusion
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Malocclusion means the teeth are not aligned properly. Occlusion refers to the alignment of teeth

and the way that the upper and lower teeth fit together (bite) (Akpata, 2004). Malocclusion is the

most common reason for referral to an orthodontist. Most malocclusion is mild enough not to

require treatment (Akpata, 2004).

2.2.7a Etiology of malocclusion

Malocclusion is most often hereditary. It may be caused by a difference between the size of the

upper and lower jaws or between the jaw and tooth size. It causes tooth overcrowding or

abnormal bite patterns. The shape of the jaws or birth defects such as cleft lip and palate may

also be reasons for malocclusion (Akpata, 2004). Other causes include:

i. Childhood habits such as thumb sucking, tongue thrusting, pacifier use beyond age 3, and

prolonged use of a bottle

ii. Extra teeth, lost teeth, impacted teeth, or abnormally shaped teeth

iii. Ill-fitting dental fillings, crowns, dental appliances, retainers, or braces

iv. Misalignment of jaw fractures after a severe injury

v. Tumors of the mouth and jaw (Akpata, 2004).

2.2.7b Management of malocclusion

Very few people have perfect teeth alignment. However, most problems are minor and do not

require treatment (Akpata, 2004). Malocclusion is the most common reason for referral to an

orthodontist. The goal of treatment is to correct the positioning of the teeth. Correcting moderate

or severe malocclusion can: i) Make teeth easier to clean and decrease risk of dental caries and

periodontal diseases. ii) Eliminate strain on the teeth, jaws, and muscles (Akpata, 2004). This
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lessens the risk of tooth fracture and may reduce symptoms of temporomandibular disorders

(TMD). Treatments may include:

i. Braces or other appliances: Metal bands are placed around some teeth, or metal, ceramic,

or plastic bonds are attached to the surface of the teeth. Wires or springs apply force to

the teeth. Clear braces (aligners) without wires may be used in some people.

ii. Removal of one or more teeth: This may be needed if overcrowding is part of the

problem.

iii. Repair of rough or irregular teeth: Teeth may be adjusted down, reshaped, and bonded or

capped. Misshapen restorations and dental appliances should be repaired.

iv. Surgery: Surgical reshaping to lengthen or shorten the jaw is needed in rare cases. Wires,

plates, or screws may be used to stabilize the jaw bone (Akpata, 2004).

It is important to brush and floss the teeth daily and have regular visits to a general dentist.

Plaque builds up on braces and may permanently stain teeth or cause dental caries if it is not

properly removed (Akpata, 2004).

2.2.8 Dental stains (Tooth discoloration)

Tooth discoloration (also referred to as tooth staining) is among the most frequent reasons

patients seek professional dental care. This is because esthetic appeal is regarded as a very

essential attribute to man’s overall view of himself and of others. The appearance of teeth and

ones’ smile contributes immensely to their overall confidence (Kaluvu, 2010). However, tooth

discoloration has proven to be a major setback and efforts to comprehend the etiology, effect and

management of tooth discoloration have been made by dental practitioners, cosmetic

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organization and other health-based organizations; with the sole aim of proffering an effective

and lasting solution to what has become a dental health challenge (Kaluvu, 2010). Manuel et al.

(2010), noted that tooth discoloration can be histologically classified based on the location of the

stains, as either extrinsic or intrinsic. Extrinsic discoloration lies on the tooth surface or in the

acquired pellicle, while the intrinsic discoloration occurs when the chromogens are deposited

within the bulk of the tooth, which maybe of local or systemic origin. Colgate (2019), added that

a third class of tooth discoloration termed “age-related discoloration” is a combination of both

extrinsic and intrinsic factors.

2.2.8a Etiology of dental stains

According to Sruthy et al. (2013), the causes of extrinsic staining can be divided into two

categories;

i. Direct extrinsic tooth staining: Those compounds which are incorporated into the

pellicle and produce a stain as a result of their basic color. Direct extrinsic tooth staining

has a multi-factorial etiology with chromogens derived from dietary sources or habitually

placed in the mouth.

ii. Indirect extrinsic tooth staining: Those which lead to staining caused by chemical

interaction at the tooth surface.

Rajendran and Sundaram (2014) explained that extrinsic stains can be caused by:

a) Dental plaque which may become stained by chromogenic bacteria such as

Actinomyces species.
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b) Dental calculus: plaque if neglected eventually calcifies, and leads to formation of

a hard deposit on the teeth, especially around the gingival margin. The color of

calculus varies, and may be grey, yellow, black or brown.

c) Tobacco: Tar in smoke from tobacco products (and also smokeless tobacco

products) tends to form a yellow-brown-black stain around the necks of the teeth

above the gingival margin.

d) Certain foods and drinks such as vegetables, that are rich with carotenoids or

xanthonoids as well as colored liquids like sports drinks, cola, coffee, tea and red

wine.

e) Betel chewing

f) Certain topical medications: Chlorhexidine binds to tannins, meaning that

prolonged use in persons who consume coffee, tea or red wine is associated with

extrinsic staining (i.e., removable staining) of teeth (Scully, 2013). Also,

cetylpyridinium chloride (CPC), which is found in many antimicrobial

mouthwashes, can result in staining due to dead bacterial residue (Scully, 2013).

g) Antibiotics: Tetracycline and its derivatives are capable of intrinsic discoloration.

However other antibiotics may form insoluble complexes with calcium, iron and

other elements that cause extrinsic staining (Summitt, 2006).

Heasman (2013) noted that some tooth stains are of idiopathic origin. However, Sruthy et al.

(2013), listed the causes of intrinsic stains as: a. Alkaptonuria b. Congenital erythropoietic

porphyria c. Congenital hyperbilirubinaemia d. Amelogenesis imperfecta e. Dentinogenesis

imperfecta f. Tetracycline staining g. Fluorosis h. Enamel hypoplasia i. Pulpal hemorrhagic

products j. Root resorption k. Ageing

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2.2.8b Management of dental stains

Manuel et al. (2010) said that the treatment of tooth discoloration consists of identifying the

etiology and implementing the required therapy. Oral prophylaxis involving the use of

prophylactic paste applied with a rotating cup brush may remove many extrinsic stains. For more

stubborn extrinsic and intrinsic stain, various bleaching techniques may be attempted. Bleaching

can be performed externally, termed night guard bleaching or vital tooth bleaching, or intra-

coronally in root-filled teeth, called non-vital tooth bleaching (Colgate, 2019). Teeth discolored

by dental caries or dental materials require the removal of the caries or restorative materials,

followed by proper restoration of the tooth. Partial (e.g., laminate veneers) or full-coverage

dental restorations may be used to treat generalized intrinsic tooth discoloration in which

bleaching is not indicated or in which the esthetic results of bleaching fail to meet the patient's

expectations. Colgate (2019), explained that many stains are permanent unless the teeth are

treated with a bleaching gel. Discoloration can often be removed by applying a bleaching agent

to the enamel of the teeth. With a technique called "power bleaching," the dentist applies a light-

activated bleaching gel that causes the teeth to get significantly whiter in about 30 to 45 minutes.

The bleaching gels designed for use at home are not as strong as those applied by the dentist, so

the process takes longer — usually two to four weeks. Whitening toothpastes may remove minor

stains, but they are not very effective in most cases.

Colgate (2019), further said that brushing the teeth after every meal and rinsing the mouth with

water after having wine, coffee or other drinks that can stain the teeth will help to prevent some

stains. Regular cleanings by a dental therapist will also help to prevent surface stains. Intrinsic

stains that are caused by damage to a nerve or blood vessel in the pulp of a tooth can sometimes

be prevented by having root canal treatment, which removes organic material before it has a
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chance to decay and darken. However, teeth that undergo root canal treatment may still darken.

Intrinsic stains in children can be prevented by avoiding water that contains a high fluoride

concentration (Colgate, 2019).

2.3 Empirical review of relevant literatures

2.3.1 Literature review on dental caries

Numerous studies on the prevalence of dental caries in Nigeria show that the disease appears to

be on the increase, especially among certain segments of urban dwellers (Akpata, 2004).

However, in most epidemiological surveys, the average of decayed, missing, and filled teeth

(DMFT) is less than 4 in both children and young adults (Akpata, 2004). There has been a

significant prevalence of caries in Nigeria (Folayan et al., 2014) but the prevalence varies by

study location, ranging from 11.2% to 48.0% in urban areas like Benin (Okeigbemen, 2004),

Enugu (Okoye et al., 2010), Lagos (Sofola et al., 2014), and Ibadan, (Denloye et al., 2005) to

between 13.9% and 17.4% in the semi-urban area of Ile-Ife (Adekoya–Sofowora et al., 2006,

Ozeigbe & Esan, 2013). Caries is more common in urban than rural areas; in Northern Nigeria

than Southern Nigeria; and in deciduous teeth than permanent teeth (Folayan et al., 2014).

Recent studies show a similar prevalence rate of caries among Nigerians. A study by Idowu et

al. (2021) among nurses (aged 19-64 years old) at the University of Jos Teaching Hospital,

Plateau State, Nigeria, revealed a caries prevalence of 43.8% with a mean DMFT of 2.06 ± 2.46.

The study also noted a low secondary prevention and low restorative index (Idowu et al., 2021).

In a study among primary school children in Southeast Nigeria, Onyejaka et al. (2021) reported a

caries prevalence of 22.7% with a mean DMFT and dmft scores of 0.10 and 0.45, respectively.

In another study by Akinyamoju et al. (2018) among school children in rural communities, in
 17

Southwest Nigeria, the prevalence of dental caries was 12.2% with a mean DMFT/dmft of 0.2 ±

0.7. In Port Harcourt Nigeria, a prevalence rate of 12.6% was found among primary school

children with a prevalence of 10.2% and 15% among private and public primary school pupils

respectively (Eigbobo et al, 2017).

Many studies have reported that the first permanent molars and the first primary molars are more

frequently affected by caries due to their morphological and functional characteristics, as well as

the conditions that surround newly erupted permanent molars (Onyejaka et al., 2021). However,

a study by Desai et al. (2014) noted that the second molars were more affected by dental caries

than the first molars. Similarly, Akpata (2004) reported that caries prevalence in second

permanent molars is higher than in first permanent molars. This trend is attributed mostly to

dietary change. The study opined that if the first permanent molars have attained a high level of

maturation before being subjected to increased cariogenic diets, caries prevalence will be lower

in the first than in the more recently erupted second permanent molars. Moreover, non-

cariogenic bacteria could colonize fissures of first permanent molars exposed to less cariogenic

diets in childhood and making it difficult for cariogenic bacteria to displace them later in life

(Desai et al., 2014). Nonetheless, if an individual is exposed to highly cariogenic diets in

childhood, cariogenic bacteria such as Streptococci mutans may become the primary colonizers

of the pits and fissures, making the tooth more vulnerable to caries. In this case, the prevalence

of caries will be higher in first permanent molars than in second permanent molars. Therefore,

caries in the first permanent molars at an early age in a Nigerian may indicate that the child is

highly susceptible to caries and thus, needs pits and fissure sealant (Desai et al., 2014).

2.3.2 Literature review on periodontal disease

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In Nigeria, periodontal disease is very common and studies show a relatively high occurrence of

deep pockets in young Nigerians. Periodontal disease affects about 15-58% of Nigerians aged 15

years and above (Akpata, 2004). Periodontal disease is a major oral health concern in Nigeria

and has been described as “a grave socio-economic problem in Black Africa” (Umoh & Azodo,

2012). It is the second most prevalent oral disease and a leading cause of tooth mortality among

adults (Umoh & Azodo, 2012).

An earlier study on periodontal diseases in Ile-Ife found an 84.2% prevalence among 3-20 years

old (Akpata, 2004), whereas a more recent study in Benin City found a 99.2% prevalence among

5-19 years old (Odai et al., 2009). Both studies found a significant prevalence of gingivitis and

extensive calculus deposits, but no indication of periodontal tissue injury. A high level of

gingivitis and periodontal illnesses was identified in a study of institutionalized mentally

challenged Nigerians utilizing the Community Periodontal Index of Treatment Needs (CPITN),

with 92.9% of assessed sextants implicated in periodontal tissue alterations (Popoola et al.,

2015). In a similar study of the Iranian population, comparable findings were made (Popoola et

al., 2015). A study comparing public and private school students indicated that private school

students had less calculus and gingivitis (Igbinosa et al., 2018). This shows that dental hygiene

was better when the socioeconomic level was greater. Only 17.8% of Nigerian children aged 11

to 14 had good oral hygiene, while 50.4% had fair oral hygiene (Popoola et al., 2015). Igbinosa

et al. (2018) found a gender difference in oral hygiene, with the females having a better hygiene

level than the males.

2.3.3 Literature review on oral cancer

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Due to a paucity of data or underreporting, the prevalence of cancer in Nigeria is unknown

(Popoola et al., 2013). Only 1% of the literature in a review of cancer registry updates from

throughout the globe came from Africa, compared to 34% and 42% from Europe and Asia,

respectively. Over 50% of cancer patients reside in poor countries with less than 10% of the

resources for cancer care and control (Popoola et al., 2013). There are currently 11 cancer

registries in Nigeria, all of which are poorly funded and housed in different tertiary hospitals.

They all generate data from hospitals. There are no databases that are community or population-

based (Okoh & Okoh, 2017).

There are varying prevalence rates of oral cancer in different geopolitical zones in Nigeria. In a

15-year study from North Central Nigeria, oral cancers accounted for 7.6% of head and neck

cancers, with carcinomas, sarcomas, and lymphomas accounting for 81.5%, 16.7%, and 1.8% of

the cases, respectively (Okoh and Okoh, 2017). In Gombe State, North Eastern Nigeria, oral

cancer accounts for 19.5% of all head and neck cancers (Akinmoladun et al., 2013), In

Maiduguri, an average rate of 20 occurrences of oral cancer per year was reported (Okoh &

Okoh, 2017).

In Enugu, South Eastern Nigeria, oral malignancies made up 2.7% of all cancer patients

diagnosed at the University of Nigeria Teaching Hospital (UNTH) Enugu over six years (Okoh

& Okoh, 2017). In Benin, South-South Nigeria, Okoh et al. (2015) reported a prevalence of

18.7% in the University of Benin Teaching Hospital (UBTH) throughout a 25-year retrospective

study. In Calabar, Bassey et al. (2015) recorded a prevalence of 25.1%. In Ile Ife, South-West

Nigeria, oral malignancies accounted for 36.8% of all cancer cases. In a study on all patients who

presented with cancer arising in the oral cavity and nearby structures at the Lagos University
 20

Teaching Hospital (LUTH) over 15 years reported a prevalence rate of 9.67% of all cancers

(Okoh & Okoh, 2017).

Low socioeconomic groups are less aware of oral cancer. Hence, they often present when the

condition has advanced resulting in a poor prognosis (Omitola et al., 2017). This unfortunate

state of late presentation is a result of ignorance, poverty, a lack of skilled medical personnel to

make an accurate diagnosis and refer patients, as well as the exorbitant cost of medications when

they are available (Omitola et al., 2017). Only about 23% of graduating dental students in South-

South Nigeria had a decent understanding of oral cancer, according to a survey on their

knowledge and practices (Okoh & Enabulele, 2015). Even though the graduating dental students

were able to identify alcohol and tobacco use as risk factors for oral malignancies, they were

often less aware of other risk factors including poor nutrition, sunshine, and oral Human

Papilloma Virus (HPV) infection (Okoh & Enabulele, 2015).

It is well known that as people age, their chances of developing cancer increase (Okoh & Okoh,

2017). This might be because aging causes an increased level of free radical reactions.

Additionally, it is believed that the ability of the immune system to monitor cancer declines with

age due to the immune system's supposedly declining capacity to eradicate abnormal cells. A

review of squamous cell carcinoma of the oral cavity in Lagos discovered that the prevalence

peaked in the third and fifth decades of life, with 40% of cases occurring in patients under the

age of 40. (Okoh & Okoh, 2017). In Enugu and Lagos, salivary gland cancers typically first

appeared in people 40 years of age or older (Okoh & Okoh, 2017). However, several studies

have noted incidences of oral cancer in people above the age of 40. According to Okoh et al.

(2015), the average age of oral cancer cases in Benin was 51 years, with the seventh decade of

life having the highest incidence rate of squamous cell carcinoma.

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Squamous cell carcinoma incidence peaked in the sixth and seventh decades, according to a

study done in Calabar, whereas Burkitt's lymphoma and rhabdomyosarcoma were seen in the

first decade (Bassey et al., 2015). While orofacial sarcomas and lymphomas were primarily

identified in slightly younger age groups, orofacial carcinomas were reported most frequently in

older age groups (Bassey et al., 2015). 75% of oral carcinomas occur in patients over the age of

40. Patients with lymphomas were much younger than those with sarcomas, whereas those with

carcinoma were older than those with sarcomas and lymphomas (Okoh & Okoh, 2017).

Males are more likely than females to develop oral cancer, but the ratio is changing (Scully,

2013). The majority of studies in Nigeria have revealed that men are more likely than women to

develop oral cancer (Okoh & Okoh, 2017). In Maiduguri, North-East Nigeria, Okoh and Okoh

(2017) discovered a male-to-female ratio of 3:4 and opined that the relative higher

preponderance of females in their study may be attributed to the rising exposure of females in

North-Eastern Nigeria to carcinogens like tobacco and alcohol.

2.3.4 Literature review on cleft lips and palate

A study by DaCosta et al. (2022) at the Lagos University Teaching Hospital showed that even

though the majority of parents of children with clefts and adult patients attending the institution's

cleft clinic had a positive attitude toward orthodontic treatment, they had little knowledge of

orthodontics and the orthodontic care necessary for patients with clefts. A survey by Butali et al.

(2014) which pooled data from the largest cleft treatment centers across the six geopolitical

zones in Nigeria showed that the prevalence rate is 0.5 per 1000. Males are usually more affected

than females and the majority of the patients present before the age of 2 years (James et al.,

2020).
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2.3.5 Literature review on noma

In Nigeria, most epidemiological reports on noma have come from the country's northwestern

region. However, across north-central Nigeria, a sizable number of cases of noma and post-noma

abnormalities notable for epidemiological representation have been observed (Bello et al., 2019).

A study by Bello et al. (2019) showed that the estimated incidence of noma in the north-central

zone is 8.3 per 100,000, ranging from 4.1 to 17.9 per 100,000 in different states and it had a

period prevalence of 1.6 per 100000 at-risk population, which included all cases seen throughout

the study period. In Northwestern Nigeria, Adeniyi and Awosan (2019) found a significant

prevalence of noma (8.3 %), especially in children between the ages of 1 and 5 years.

2.3.6 Literature review on oro-dental trauma

Traumatized anterior teeth are common among Nigerians. In a study carried out among 6–21-

year-old Nigerians, 12-14% of the sample had traumatized anterior teeth, but only 9% had

coronal fracture, a majority of which involved only the enamel (Akinyamoju et al., 2018). In a

study carried out among 12-year-old Nigerians, approximately 11% had traumatic dental

injuries. Overjet greater than 3mm and incompetent lips were predisposing factors (Akinyamoju

et al., 2018). The prevalence of traumatized primary teeth is quite high, being approximately

31% in a study carried out at Ile-Ife in the south- western part of Nigeria (Akinyamoju et al.,

2018). In another study at a teaching hospital at Ibadan in the same part of the country, the

prevalence of traumatized primary teeth was highest in children aged 4–5 years, and there was no

significant difference between boys and girls (Akinyamoju et al., 2018).

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2.3.7 Literature review on malocclusion

In a study of 11– 26-year-old Nigerians, Akpata (2004) reported the prevalence of Angle class II

malocclusion to be 8-10%, a level much lower than found in Europe and North America. On the

other hand, class III molar relationship was observed in 8-18% of the sample, a level much

higher than found in Western countries. Similarly, Isiekwe (1983) reported class II malocclusion

in 15% of the subjects, while class III malocclusion accounted for 8%; crowding occurred in

15% of the population, mostly in the anterior region. In a survey carried out to assess the need

for orthodontic treatment among rural Nigerians, 13% of the population was in objective need of

orthodontic treatment. Furthermore, girls were found to have more attractive dental appearance

and less orthodontic treatment need than boys (Akpata, 2004).

2.3.8 Literature review on dental stains

A study by Kaluvu (2010), revealed that majority of the respondents (94.7%) showed a positive

attitude to tooth discoloration and to those affected by it. 91.4% of the respondents shared the

belief that discolored tooth can be whitened with 72.8% of them showing familiarity with office

and home bleaching as a form of tooth whitening. The study also showed that the respondents

had sufficient knowledge regarding tooth discoloration. Majority of them had heard of the term

tooth discoloration prior to the day of investigation. The respondents showed awareness of the

association of drugs, age, disease and diet to tooth discoloration. However, a great majority did

not understand the dentist’s role in the causation of tooth discoloration. Of the 151 respondents

that participated in the study, majority were males 84(55.6%) while 67(44.4%) were females.

This is contrary to the notion that women are more likely to seek dental treatment than men as

they are usually more concerned with their oral hygiene and dental appearance. The respondents
 24

ranged in age from 13-72 years with majority being in the 20-29 age groups. This is explained by

the fact that younger individuals are more prone to oral and dental disease than the elderly due to

lifestyle changes and diet. Hence, are more likely to be found in dental clinics and hospitals than

the elderly. Majority of the respondents heard of the term tooth discoloration from the internet

(40.6%), with 28.6% obtaining the information from friends. 14.3% heard about it from their

dentists with 5.3% reading about tooth discoloration from magazines. The remaining 11.3%

obtained the information from other sources.

A study conducted by Ibiyemi et al. (2017), on pattern of tooth discoloration and care-seeking

behavior among adolescents in an underserved rural community in Nigeria showed that of the

384 participants, 167 (43.9%) had discolored teeth while 127 (33.1%) perceived that they had

discolored teeth. Extrinsic stains were the major cause of tooth discoloration in both anterior and

posterior teeth (18%-84%) except in upper anterior teeth where enamel hypoplasia was the major

cause (20%-30%). Among participants who perceived that they had tooth discoloration, 81.9%

mentioned that they did not know that the discoloration can be treated. Older participants had

more discolored teeth than their counterparts. Participants who had anterior or intrinsic tooth

discoloration sought care more often than those with posterior or extrinsic tooth discoloration.

Also, a study by Alkhatib and Bedi (2004) on prevalence of self-assessed tooth discoloration in

the United Kingdom revealed that half of the study population perceived their tooth color to be

normal and 6% perceived that they had severe discoloration; the remainder reported that they

have levels of tooth discoloration between these two extremes. Satisfaction with tooth color

decreased with increased discoloration. Sex, age, income and smoking, had statistically

significant effects on the prevalence of perceived discoloration. The study equally showed that

half of the people in the study perceived themselves to have tooth discoloration. Results suggest
 25

that the general public is concerned about dental appearance in terms of tooth color, indicated by

public dissatisfaction with relatively mildly discolored teeth. Findings suggest that a further

increase in the demand of tooth whitening services and cosmetic dentistry in general is likely.