Comparison of clinical periodontal status among habitual smokeless-tobacco users and cigarette smokers

Smokeless tobacco and periodontitis: A systematic review with meta-analysis

AIM

The present systematic review with meta-analysis aimed to investigate the global association between smokeless tobacco (SLT) use and periodontitis, considering significant effect size variation based on the income levels of countries.

METHODS

We searched seven databases to identify studies that assessed the prevalence of periodontitis in adult SLT users compared to non-users. The quality of studies was evaluated using the 10-item risk-of-bias tool, and publication bias was addressed through the trim-and-fill method. Sensitivity analysis utilized the leave-one-out approach. Meta-analysis and meta-regression, stratified by country income, SLT type, and smoking status, employed robust variance estimation.

RESULTS

From an initial pool of 484 studies, 29 studies met the selection criteria and were subjected to qualitative synthesis. Subsequently, data from 19 studies were included in the meta-analysis. SLT users exhibited a nearly threefold greater likelihood of periodontitis compared to non-users (OR = 2.99; 95% CI: 2.10, 4.27; p < .01). The pooled estimate did not vary significantly based on the type of SLT used or concurrent smoking. However, the odds of periodontitis varied according to the economic level of the country; the pooled estimate was higher in high-income countries (OR = 1.69; 95% CI: 1.20, 2.37; p < .01) and even higher in lower-middle-income and lower-income countries (OR = 3.91; 95% CI: 2.66, 5.77; p < .01).

CONCLUSIONS

Smokeless tobacco users have a higher likelihood of developing periodontitis. This study underscores global disparities in the SLT-periodontitis relationship, highlighting the need for targeted interventions, particularly in economically challenged areas where SLT use is largely unregulated.

Comparison of severity of periodontal clinical parameters among naswar/snuff users: Cross sectional study

Background

Naswar is a moist, non-chewable, and smokeless tobacco product ensconced in the buccal vestibule or floor of the mouth. Consumption of naswar is very popular in South Asia, especially Pakistan. This cross-sectional study compared the periodontal clinical parameters amongst mild, moderate, and severe naswar users.

Methods

318 naswar users, categorized into three equal groups (n = 106) severe naswar users, moderate naswar users, and mild naswar users were drawn for this study. Bleeding on probing, pocking depth, gingival recession, and attachment loss were assessed using the UNC-15 probe and compared among the three groups of naswar users. Data analysis was done with the help of SPSS. Statistical significance was deliberated at p value ≤0.05.

Results

28.9 ± 7.6 years was the mean age presentation. The mean % of bleeding on probing score was 61.95% in severe naswar users, 56.62% in moderate naswar users, and 51.23% in mild naswar users with a p-value of 0.001*. In severe, moderate, and mild naswar users the probing pocket depth (4-6mm) were 35.14%, 30.95%, and 23.21% respectively. 26.78% severe naswar users were having mean percentage for probing pocket depth (>6m) followed by moderate naswar users (17.26%) and mild naswar users (17.26%) with a significant p-value (0.001*). Clinical attachment loss (CAL) was 2.50 percent in light naswar users, 3.0 percent in moderate naswar users, and 4.25 percent in severe naswar users. Clinical attachment loss (CAL) was 2.50 percent in light naswar users, 3.0 percent in moderate naswar users, and 4.25 percent in severe naswar users. Severe naswar users had a high mean percentage of gingival recession (23.21%), whereas light 13.67 percent and moderate 14.88 percent naswar users had a smaller difference.

Conclusions

Clinical periodontal parameters were more worsen in heavy naswar users compared to moderate and light naswar users.

Novel Insight into the Mechanisms of the Bidirectional Relationship between Diabetes and Periodontitis

Periodontitis and diabetes are two major global health problems despite their prevalence being significantly underreported and underestimated. Both epidemiological and intervention studies show a bidirectional relationship between periodontitis and diabetes. The hypothesis of a potential causal link between the two diseases is corroborated by recent studies in experimental animals that identified mechanisms whereby periodontitis and diabetes can adversely affect each other. Herein, we will review clinical data on the existence of a two-way relationship between periodontitis and diabetes and discuss possible mechanistic interactions in both directions, focusing in particular on new data highlighting the importance of the host response. Moreover, we will address the hypothesis that trained immunity may represent the unifying mechanism explaining the intertwined association between diabetes and periodontitis. Achieving a better mechanistic insight on clustering of infectious, inflammatory, and metabolic diseases may provide new therapeutic options to reduce the risk of diabetes and diabetes-associated comorbidities.

Association between Smokeless Tobacco Use and Risk of Periodontitis in Asian Countries: A Systematic Review and Meta-Analysis

BACKGROUND

Individual studies conducted in Asian countries have reported higher risk of periodontitis among smokeless tobacco (SLT) users in comparison to non-users. Therefore, a systematic review was conducted to summarize the available evidence on this topic.

METHODS

Prominent electronic databases were searched using pre-decided MeSH terms and keywords. Screening of titles and abstracts, full text reading, quality assessment and data extraction was done by two investigators independently. The Newcastle-Ottawa scale was used for risk of bias assessment of eligible studies. Meta-analysis was performed for four periodontal outcomes (periodontal pocket depth, loss of attachment, clinical attachment level and gingival recession). A sensitivity analysis was also performed.

RESULTS

Of the 546 citations, 367 were screened for eligibility. Finally, 89 studies were shortlisted for full text reading, of which, 36 were found eligible for qualitative analysis. Most of the studies were conducted in India (n=22), were of cross-sectional design (n=33), utilized purposive sampling and 24 studies were included for meta-analysis (n=28) and done on hospital-based population (n=26). Only 13 (37.1%) studies achieved a score of more than 50% (5/10 stars) on quality assessment scale. SLT users had higher odds of greater periodontal pocket depth greater than 4 mm (OR=3.64), gingival recession (OR=1.71) and loss of attachment 4-5 mm (OR=2.83) and mean difference of 1.7 mm for Clinical Attachment Level compared to non-users.

CONCLUSION

The studies included in this review suggests that SLT users have poorer periodontal health in comparison to non-users. But most of this evidence comes from cross-sectional studies. Longitudinal studies with rigorous methodology are required to support this elucidation. Registration: This systematic review protocol has been registered in PROSPERO (CRD42019122964).

Periodontal status associated with dual habits of smoking and smokeless tobacco use: A cross-sectional study in young adults

Background. Tobacco smoke is an established risk factor for periodontitis. However, few studies have evaluated the periodontal status of smokeless tobacco (SLT) users, while that of individuals with dual habits has largely been unexplored. Therefore, the current study aimed to find if the periodontal status in individuals with dual habits of smoking and SLT use is different from those with any single habit.Methods. Four groups (A: exclusive smokers, B: exclusive tobacco chewers, C: individuals with dual habits, and D: non-users of tobacco), each comprising 75 males in the age group of 20 to 35 years, were selected. Along with the history of tobacco use, a modified oral hygiene index (OHI), gingival index (GI), probing depth (PD), and the number of teeth with gingival recession (GR) were recorded. The data were assessed using the Chi-squared test, one-way ANOVA, and logistic regression. Statistical significance was set at P<0.05.Results. Group C exhibited the highest mean OHI scores, with 94.66% of participants having poor oral hygiene (OHI>3.0). The prevalence of severe gingivitis (GI>2.0) was significantly lower among exclusive smokers (group A) and those with dual habits (group C) compared to the other two groups. As much as 60% of group C participants had average PD in the range of 4-6 mm, while deeper average PD (>6 mm) was most common among smokers. The highest risk of having a tooth with GR was also associated with the dual habit (OR = 4.33, 95% CI = 3.24 - 5.76) compared with the non-users.Conclusion. While both forms of tobacco were associated with poor periodontal status, the additive effect of smoking and SLT use was evident in almost all the parameters, more so with poor oral hygiene and the prevalence of gingival recession. These findings emphasize that individuals with dual habits have an additional risk for periodontal destruction.

Tobacco Use and Periodontal Disease-The Role of Microvascular Dysfunction

Periodontal disease consists in highly prevalent wide-ranging inflammatory conditions that affect the supporting apparatus of teeth. Tobacco use is the most important risk factor for periodontal disease as it increases disease severity and periodontal surgery complications. Tobacco use is harmful for the vasculature by causing microvascular dysfunction, which is known to negatively affect periodontal disease. To the author's knowledge this paper is the first comprehensive review on the mechanisms by which tobacco use affects oral microcirculation and impacts the pathophysiology of periodontal disease. In healthy subjects, acute nicotine administration or tobacco use (smoking/smokeless forms) increases the blood flow in the oral mucosa due to local irritation and increased blood pressure, which overcome neural- and endocrine-mediated vasoconstriction. Chronic tobacco smokers display an increased gingival microvascular density, which is attributed to an increased capillary recruitment, however, these microcirculatory units show higher tortuosity and lower caliber. These morphological changes, together with the repetitive vasoconstrictive insults, contribute to lower gingival perfusion in chronic smokers and do not completely regress upon smoking cessation. In periodontal disease there is considerable gingival inflammation and angiogenesis in non-smokers which, in chronic smokers, are considerably suppressed, in part due to local immune suppression and oxidative stress. Tobacco exposure, irrespective of the form of use, causes long-term microvascular dysfunction that increases the risk of complications due to the natural disease course or secondary therapeutic strategies.

Current status of periodontitis and its association with tobacco use amongst adult population of Sunsari district, in Nepal

BACKGROUND

Tobacco products are considered significant, but preventable factors related to initiation and progression of periodontal diseases. We assessed the prevalence of periodontitis and evaluated its association with tobacco use and other factors amongst the adult population of Sunsari district in eastern Nepal.

METHODS

A community-based, cross-sectional study was conducted in rural municipalities in the province one of eastern Nepal. A total of 440 adults were interviewed with a set of a pre-tested semi-structured questionnaire. Data on social demographics, adverse oral habits followed by periodontal clinical examination were recorded. Prevalence of periodontitis was assessed by a case definition provided by CDC-AAP. Univariate and multivariate logistic regression analysis was done to measure the association between tobacco use and other factors with periodontitis.

RESULTS

The overall prevalence of periodontitis was found to be 71.6%. Majority (85.4%) of tobacco users had periodontitis and they were significantly associated with the disease and its severity. The study identified age groups, 45-65 years (AOR = 7.58, 95% CI 3.93-14.61), plaque accumulation (AOR = 1.01, 95% CI 1.00-1.02), smoking (AOR = 3.14, 95% CI 1.36-7.27), khaini users (smokeless tobacco, AOR = 2.27, 95% CI 1.12-4.61) and teeth loss (AOR = 2.02, 95% CI 1.21-3.38) as the significant factors associated with periodontitis.

CONCLUSION

The prevalence of periodontitis is high in the surveyed rural adult population. Cigarette smoking along with the use of smokeless tobacco in the form of khaini were identified as significant factors associated with periodontitis.

Interventions to prevent periodontal disease in tobacco-, alcohol-, and drug-dependent individuals

Substance abuse affects more than one sixth of the world's population. More importantly, the nature of the abuse and the type of addictive substances available to individuals is increasing exponentially. All substances with abusive potential impact both the human immuno-inflammatory system and oral microbial communities, and therefore play a critical role in the etiopathogenesis of periodontal diseases. Evidence strongly supports the efficacy of professionally delivered cessation counseling. Dentists, dental therapists, and hygienists are ideally placed to deliver this therapy, and to spearhead efforts to provide behavioral and pharmacologic support for cessation. The purpose of this review is to examine the biologic mechanisms underlying their role in disease causation, to understand the pharmacologic and behavioral basis for their habituation, and to investigate the efficacy of population-based and personalized interventions in prevention of periodontal disease.

Perception of health professions students of their role model status in Toombak cessation: A cross-sectional study from Sudan

INTRODUCTION

Health professionals are to play an essential and effective role in tobacco control. Toombak is a popular form of smokeless tobacco, locally made and used among Sudanese. It is associated with oral and systemic health hazards, particularly oral cancer. This study was set out to assess health professions students' perception of their status as future role models for their patients and the public regarding Toombak use cessation and to explore socio-cognitive covariates of perceived role model status.

MATERIALS AND METHODS

A cross-sectional study was conducted in 2013-2014 using a self-administered questionnaire among health professions students enrolled in Medicine, Pharmacy, Dentistry and Nursing colleges in Khartoum state, Sudan. A total of 1530 participants were recruited from colleges using a cluster stratified sampling procedure.

RESULTS

The majority of the participants (88.2%) were 19-22 year old, females showed predominance (66.1%). Most of the participants (69.7%) scored good knowledge of Toombak-related therapies. The majority (97%) had a positive attitude towards banning Toombak use in public. Half of the participants (50.4%) confirmed availability of Toombak control policy in their college, while 66% reported receiving training in Toombak cessation. Only 9.2% of the participants reported that they have ever used Toombak; among them, 69.5% were current daily users. Less than half (47.8%) reported a positive perception of their status as a role model. Logistic regression model revealed that tobacco cessation training, availability of college policy and positive attitudes towards banning Toombak use in public were strong predictors of with a positive perception of role model status.

CONCLUSION

Imposing Toombak control policies within colleges combined with formal training in cessation methods, would reinforce the positive perception of health professions students as a role model, particularly the students themselves seem to be ready for such systematic training.

Permanence of Modifications in Oral Microcirculation in Ex-Smokers

Background

The aim of this study was to assess the long-term effects of smoking and to investigate the permanence of this damage to the oral microcirculation.

Material/Methods

We recruited 75 patients and divided them into 3 groups: group 1 was composed of 25 healthy non-smokers, group 2 was composed of 25 healthy current smokers, and group 3 was composed of 25 healthy ex-smokers. Video-capillaroscopic examination was performed on all patients.

The video-capillaroscopic investigation was performed on patients in sitting position, always with the same light source, at the same room temperature (23°C), in the morning, with the same operator (GAS), and was repeated many times for every area under investigation. An enlargement of 200× allowed us to explore point-by-point all the morpho-structural characteristics of the capillaroscopic field. For non-parametric data, we evaluated the visibility of the loops and their position in relation to the surface of the mucosa. The evaluated parametric data were length of capillary loop, diameter of the loop, capillary tortuosity, and capillary density.

Results

Our study clearly shows there was no remission of vascular damage, even 13 years after smoking cessation.

Conclusions

Our research shows that that the effects of smoking are still visible in ex-smokers, even at 13 years after cessation and also that ex-smokers are still subject to the risk of oral pathologies in the interval of time that we considered.

Comparison of periodontal inflammatory parameters among habitual gutka-chewers and naswar-dippers: a split-mouth retrospective clinical study

OBJECTIVE

The aim of the present split-mouth retrospective study was to compare the clinical periodontal parameters among gutka-chewers and naswar-dippers.

METHODS

A structured questionnaire was used to record demographic information. Jaw quadrant in which, gutka or naswar were placed were defined as "test-sites". The remaining jaw quadrants were designated as "control-sites". Clinical [plaque index (PI), bleeding on probing (BOP), probing pocket depth (PPD) and clinical attachment loss (CAL)] and radiographic [alveolar bone loss (ABL)] parameters were compared among gutka-chewers and naswar-dippers in the test- and control sites. Data were analysed using non-parametric Wilcoxon signed rank test followed by post hoc analyses with the Bonferroni correction. p < .05 were considered statistically significant.

RESULTS

Seventy-five gutka-chewers and 72 naswar-dippers with mean ages of 45.2 ± 0.8 years and 47.3 ± 2.8 years, respectively were included. Gutka-chewers and naswar-dippers were consuming their respective smokeless tobacco product 10.2 times and 8.5 times daily for 15.1 ± 2.7 and 12.3 ± 3.4 years, respectively. Among gutka-chewers and naswar-dippers, scores of PI, BOP, PPD ≥4 mm, CAL and ABL were significantly higher in the test-sites compared with their respective control-sites (p < .01).

CONCLUSIONS

Periodontal inflammatory parameters were poorer in the test-sites among gutka-chewers and naswar-dippers compared with the control-sites.

Greater Sensitivity of Oral Fibroblasts to Smoked Versus Smokeless Tobacco

BACKGROUND

Smokers have an increased incidence and severity of periodontal disease. Although cigarette smoke contains >4,000 chemical components that could affect periodontal tissues, less is understood about the effect of smokeless tobacco. Therefore, this study compares the effects of cigarette smoke extract (CSE) and smokeless tobacco extract (STE) on cell survival and motility of periodontal ligament (PDL) and gingival fibroblasts in vitro.

METHODS

PDL and gingival fibroblasts were exposed to various concentrations of CSE, STE, or nicotine alone. Viable cells were labeled with calcein acetoxymethyl, visualized using fluorescent microscopy, and quantified using a fluorescence multi-well plate reader. In vitro wounding and collagen gel contraction assays were used to assess cell motility.

RESULTS

Both gingival and PDL fibroblasts displayed reduced cell viability with increasing concentrations of CSE and STE. Based on relative nicotine content, CSE was significantly more cytotoxic than STE. PDL fibroblasts were also more sensitive to both CSE and STE compared with gingival fibroblasts. Finally, sublethal doses of CSE reduced cell motility and gel contraction, whereas STE had less effect. Nicotine alone ≤0.5 mM had little to no effect in any of these assays.

CONCLUSIONS

Many of the underlying effects of tobacco products on periodontal tissues may be due to direct inhibition of normal fibroblast function. CSE is found to be more deleterious to the function of both PDL and gingival fibroblasts than STE. PDL fibroblasts appear to be more sensitive to CSE and STE than gingival fibroblasts. Therefore, cigarette smoke may have more profound effects than smokeless tobacco.