The effect of cigarette smoking on the severity of periodontal diseases among adults of Kothamangalam Town, Kerala.

AIMS AND
OBJECTIVES: Smoking is one of the major risk factors for periodontal disease. This study aims at examining the difference in the periodontal status of current smokers, former smokers, and nonsmokers among the adults of Kothamangalam, Kerala. It investigates the association between the level of cigarette consumption and periodontal attachment loss taking into account the effect of age, gender, and oral hygiene.
METHODOLOGY: The study population consisted of 30 subjects and divided into three groups as current, former, and nonsmokers with periodontal disease. All clinical parameters were recorded. Smoking assessment was done using a self-reported questionnaire, and statistical analysis was carried out.
RESULTS: Current smokers had a higher percentage of sites with mean probing depth, and greater mean clinical attachment level than former smokers and nonsmoker. A significant difference (P < 0.05) was found in clinical attachment loss (CAL) between Group I (current smokers) and III (nonsmokers), that shows the increased risk of current smokers for future periodontal destruction. The CAL for current smokers was 5.20 ± 2.440 and for the nonsmokers was 1.50 ± 1.265. A significant difference (P < 0.05) was found in CAL between Group I and III. SUMMARY AND
CONCLUSION: The study revealed a marked association between cigarette smoking and the risk of periodontitis. The increased destruction among current smokers showed a dose-dependent relationship with the amount of cigarette consumption. For former smokers, the duration since quitting smoking was associated with a lower risk for severe periodontitis.

Smoking is a major risk factor of periodontal disease. It is now well established that tobacco use is one of the most important, preventable risk factor in the incidence and progression of periodontal diseases. In addition, tobacco use has a negative adverse effect on the full spectrum of periodontal treatment approaches such as mechanical debridement, local and systemic antimicrobial therapy, periodontal surgery, regenerative therapy, and implants.[1] In the past 30–40 years, groups of investigators have developed several schematic explanations for the complex interplay of the factors that play a role in the progression of periodontal diseases.[2] Although effects of cigarette smoking on the periodontium have been extensively examined, most studies compared the risk of different smoking status; that is, current smokers, and nonsmokers, on the severity or progression of periodontal disease.[3]

Aims and Objectives

This study aims at examining the difference in the periodontal status of current smokers, former smokers, and nonsmokers among the adults of Kothamangalam, Kerala. It investigates the association between the level of cigarette consumption and periodontal attachment loss taking into account the effect of age, gender, and oral hygiene.

Methodology

The patients for this pilot study were selected from the outpatient Department of Periodontology and Oral Implantology clinic of Indira Gandhi Institute of Dental Sciences, Kothamangalam.

Method of Collection

The study population were divided into three groups. Each group consisted of 10 patients [Figure 1].

Figure 1

The groups of population used for the study

Group I: Current smokers: Subjects who had smoked 100 or more cigarettes over their lifetime and smoked at the time of interview

Group II: Former smokers: Subjects who had smoked 100 or more cigarettes in their lifetime but were not currently smoking

Group III: Subjects who had not smoked 100 or more cigarettes in their lifetime.[4]

Criteria for Patient Selection

Inclusion criteria

Systemically, healthy patients in the group between 30 and 50 years were included in the study. All the subjects were explained about the study, and an informed consent was obtained from the patients.

Exclusion criteria

Females

Patients with systemic diseases like diabetes

Third molars were not included while measuring the clinical parameters

Patients who were under antibiotics for past 3 months

Root stumps were avoided.

Clinical Parameters

The subjects were seated in a comfortable position on a dental chair with adequate lighting. A mouth mirror, No. 23 explorer, Williams graduated periodontal probe were the instruments used. Clinical evaluation was done on subjects of all three groups. A detailed medical and dental history was obtained by interview.

All teeth in four quadrants were examined except third molars. Periodontal examinations included oral hygiene status, gingival bleeding, probing pocket depth (PD), and clinical attachment loss (CAL). Probing PD and clinical attachment level were measured on four sites per tooth. Probing PD was assessed as the distance from the marginal gingiva to the base of the pocket. Loss of attachment was measured as the distance in millimeter from the cemento-enamel junction to the bottom of the gingival sulcus. Oral hygiene status was measured using the Simplified Oral Hygiene Index (Greene and Vermillion). The gingival index (Loe and Silness) was used to assess the severity of gingivitis.[5]

Smoking Status Assessment

Smoking status was assessed by a self-reported questionnaire. Participants were asked to estimate the number of cigarettes consumed per day and the number of years they smoked. Smokers were defined as persons who had smoked at least 100 cigarettes in their lifetime. Current smokers were those smoked at the time of examination. Former smokers were persons who had quit smoking at the time of examination. Subjects who quit smoking 1-year or before from the time of examination were included in the study. Smoking exposure was expressed in term of pack-years, which was calculated by the multiplication of the number of packs of cigarettes smoked per day by the number of years smoked.

Statistical analysis

In the current pilot study, subjects were categorized according to their smoking status as current smokers (Group I), former smokers (Group II), nonsmokers (Group III). Mean values were compared among different study groups by using paired t-test. In the present study, P < 0.05 was considered as the level of significance.

Results

A total number of 30 subjects within the age group of 30–50 years participated in this study throughout. The study was carried out among the population of Nellikuzhi, Kothamangalam, Kerala. Clinical parameters such as oral hygiene index-simplified, gingival index, probing PD, and CAL were assessed. Current smokers had a higher percentage of sites with mean probing depth, and greater mean clinical attachment level than former smokers and nonsmokers [Tables 1 and 2]. A significant difference (P < 0.05) was found in CAL between Group I (current smokers) and III (nonsmokers), that shows the increased risk of current smokers for future periodontal destruction. The CAL for current smokers was 5.20 ± 2.440 and for the nonsmokers was 1.50 ± 1.265. A significant difference (P < 0.05) was found in CAL between Group I and III [Table 3 and Figure 2].

Table 1

The mean probing depth and mean CAL between Group I (current smokers) and Group III (nonsmokers)

Table 2

Mean probing depth and mean CAL between Group II (former smokers) and Group III (nonsmokers)

Table 3

Independent samples test

Figure 2

Mean difference in clinical attachment loss between the study groups

Discussion

The impact of smoking on the periodontal disease is characterized by decreased gingival inflammation and bleeding on probing. It causes increased prevalence and severity of periodontal destruction, increased PD, attachment loss, and bone loss leading to tooth loss.[6]

The increased prevalence and severity of periodontal destruction associated with smoking suggests that the host bacterial interactions normally seen in chronic periodontitis are altered, resulting in aggressive periodontal breakdown.[7] It is caused due to changes in the composition of sub-gingival plaque with an increase in the numbers and virulence of pathogenic organisms, host response to the bacterial challenge or both. Smoking causes increased colonization of shallow periodontal pockets by periodontal pathogens. In the immunological level, it causes altered neutrophil chemotaxis and phagocytosis. There is increased levels of tumor necrosis factor-alpha and prostaglandin E2 (PGE2) in gingival crevicular fluid, increased neutrophil collagenase, and elastase.[4] Nicotine increases the secretion of PGE2 by monocytes in response to lipopolysaccharide and also it can create a defect in the chemotaxis of neutrophils causing “chemotactic paralysis.” In the physiological point of view, there is decreased gingival blood vessels with increased inflammation.[8] The current pilot study assessed the difference in the loss of attachment, gingival conditions, and probing PD among the current smokers, former, and nonsmokers. Current smokers had a higher percentage of sites with plaque, increased mean probing PD, and greater mean CAL than former smokers and nonsmokers. A significant difference (P < 0.05) was found in CAL between Group I (current smokers) and III (nonsmokers), that shows the increased risk of current smokers for future periodontal destruction. The CAL for current smokers was 5.20 ± 2.440 and for the nonsmokers was 1.50 ± 1.265. The CAL for current smokers was higher than nonsmokers which shows that smoking increases the risk for future periodontal destruction.[9] Former smokers have less CAL than current smokers that shows quitting smoking reduce the risk of developing periodontitis.[10]

Summary and Conclusion

The present study revealed a marked association between cigarette smoking and the risk of periodontitis among a group of individuals at Nellikuzhi, Kothamangalam. The increased destruction among current smokers showed a dose-dependent relationship with the amount of cigarette consumption.[1112] For former smokers, the duration since quitting smoking was associated with a lower risk for severe periodontitis.

This study also proves a significant difference in CAL between smokers and nonsmokers. Given the evidence that smokers have the worse periodontal disease than nonsmokers, and the magnitude and predictability of clinical improvements after treatment are significantly reduced in smokers, smoking cessation counseling is considered important.[13] Cessation of smoking has been primarily an issue of patient compliance. However, nicotine replacement therapy may help strongly addicted patients.[4]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.