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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 102-106

Effects of tobacco chewing on periodontal health in Parsa, Nepal: A comparative study

1 Department of Periodontology, M. B.Kedia Dental College, Birgunj, Nepal
2 Department of Oral Pathology, M. B.Kedia Dental College, Birgunj, Nepal
3 Department of Community Dentistry, M. B.Kedia Dental College, Birgunj, Nepal
4 Department of Oral Medicine and Radiology, M. B.Kedia Dental College, Birgunj, Nepal
5 Department of Conservative and Endodontics, M. B.Kedia Dental College, Birgunj, Nepal
6 Department of Prosthodontics, M. B.Kedia Dental College, Birgunj, Nepal
7 Department of Periodontology, The Oxford Dental College, Bengaluru, India

Date of Submission27-Nov-2020
Date of Acceptance22-Feb-2021
Date of Web Publication16-Jul-2021

Correspondence Address:
Rajesh Shah
MB Kedia Dental College, Birgunj
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_164_20

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Background: Tobacco chewing in Nepal has been a part of cultural rituals in different since ages. The tobacco products and by-products are detrimental to oral as well as systemic health. Objectives: The objective of the study was to ascertain the causative effect of chewing tobacco in the periodontal health and to alert the society about the deleterious effects of the chewing tobacco. Methods: A comparative, cross-sectional study was conducted among 300 patients visiting the outpatient department of periodontology and oral implantology. The total study population was divided into two groups: tobacco user and nonuser. The study population was further re-categorized based on the duration of tobacco chewing into two groups. Periodontal health status of the participants was assessed using plaque index, gingival index, clinical attachment loss, and probing depth. Mann–Whitney test was used to compare the difference among the outcome variables. Results: Median score of PI was 1.32 (0.66–2.04), GI was 1.33 (0.70–2.06), CAL was 1.46 (0.98–2.10), and PD was 1.22 (0.59–1.86). The difference in PI, GI, CAL, and PD scores was statistically significant when compared among tobacco users and nonusers (P < 0.001) There was statistically significant difference in PI, GI, CAL, and PD when compared among the patients of age group ≤35 years and >35 years (P < 0.001) and the tobacco users consuming tobacco for ≤10 years and >10 years (P < 0.001). Conclusion: The present study revealed a direct impact of tobacco chewing on the periodontal health, with the severity of symptoms increased with the age and duration of the habit.

Keywords: Oral health, periodontium, tobacco chewing

How to cite this article:
Shah R, Ghosh S, Singh A, Wazir SS, Singh HM, Gupta R, Chaterjee A. Effects of tobacco chewing on periodontal health in Parsa, Nepal: A comparative study. J Dent Res Rev 2021;8:102-6

How to cite this URL:
Shah R, Ghosh S, Singh A, Wazir SS, Singh HM, Gupta R, Chaterjee A. Effects of tobacco chewing on periodontal health in Parsa, Nepal: A comparative study. J Dent Res Rev [serial online] 2021 [cited 2021 Aug 1];8:102-6. Available from: https://www.jdrr.org/text.asp?2021/8/2/102/321535

  Introduction Top

Periodontitis is defined as "an inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms or group of micro-organisms resulting in the progressive destruction of periodontal ligament and alveolar bone with pocket formation, recession, or both."[1] Periodontitis is one of the common inflammatory diseases resulting in untoward mobility and tooth loss in adults. The prime cause of periodontitis is the repeated consumption of tobacco.[2] Tobacco is available in different forms, which can be used primarily in smoking and chewing forms. Other addictable variants include sucking and sniffing form of tobacco.[2],[3] More than 90% of the lung cancer has been attributed to the primary etiology of smoking tobacco, which is also a risk factor for stroke and other cardiovascular diseases.[2],[3]

Tobacco chewing in Nepal has been a part of religious and cultural rituals since ages and has gained a considerable degree of social acceptance.[4] Participants with chewing tobacco have a two-fold higher risk of developing periodontitis than nonusers.[5]

Not only periodontitis but also tobacco is the prime etiological agent for oral and oropharyngeal malignancies.[6] Maternal consumption of tobacco can also lead to preterm low birth weight of the babies.[7] According to the report of a 1987 WHO study group, a smokeless tobacco user can have blood nicotine levels as high as or even higher than those found in tobacco smokers.[8] Smokeless tobacco is available in different forms. Gutkha is a relatively common form of smokeless tobacco which is a composite of powdered tobacco, areca nut, catechu, condiments, and slaked lime. The ultimate fate of smokeless tobacco is not known compared to those produced by smoking.[9]

Cytokines such as interleukin 1 acts a chemoattractants, facilitating recruitment of leukocytes and macrophages at the site of periodontal inflammation and elicits local immune response.[10] The consumption of tobacco in any form affects the differential count of leukocytes, as well as alters the neutrophil chemotaxis, thereby reducing the elimination of periodontal pathogens, further intensifying the effects of periodontitis.[11],[12] The present study was crafted to highlight the detrimental effects of smokeless tobacco on the periodontium to alert the clinicians to look for those symptoms whenever a patient gives a history of tobacco chewing.

  Methods Top

The hospital-based, cross-sectional, comparative study was conducted among 300 patients visiting the outpatient department of periodontology and oral implantology of a private dental college in Nepal. Ethical clearance was obtained from institutional ethical review board, and written consent was obtained from every patient before the investigation. To estimate the sample size, 95% confidence interval (CI) and 95% power was used. For this purpose, GI (tobacco nonusers: 1.35 ± 0.69; tobacco users: 1.52 ± 0.68) from the study by Rizvi et al.[13] was considered, and the calculated sample size was 108 for each group. To increase the sensitivity, validity and considering 15% nonresponse, the sample size was further increased to 150 in each group. Same numbers of 150 patients who do not have the habit of chewing tobacco were included for the comparison. Convenience sampling technique was used to recruit the participants.

Patients varying in the age group ranging from 25 to 45 years were included in the study. The patients with the history of smoking tobacco and alcohol consumption were excluded from the study. Patients with the comorbidities such as diabetes mellitus and hypertension were excluded from this ongoing study. Pregnant and lactating females as well as the patients with the history of periodontal treatment in the last 6 months were also excluded from the study. Socio-demographic data were noted, and oral examination was done.

A questionnaire containing demographic profile and the following mentioned variable was used.

  • Plaque index (PI)[14]
  • Gingival index (GI)[14]
  • Clinical attachment loss (CAL)[15]
  • Probing depth (PD).[15]

The clinical periodontal examinations were carried out manually by single operator using UNC-15 probe (Hu-Friedy, IL, USA). The CAL and PD were measured in four sites (mesio-facial, mid-facial, disto-facial, and palatal/lingual) per tooth, and the average for each individual was calculated. The outcome measures were years of tobacco use, GI, PI, CAL, and PD. All the clinical data were collected by a single investigator. After clinical examination, a pro forma was filled to tabulate the recorded information from the patient.

The obtained data were recorded in Microsoft Excel 2019, and statistical analysis was contemplated in the Statistical Package for the Social Sciences (SPSS) version 21 (SPSS, Inc., Chicago, IL, USA) software. Descriptive statistics, including the mean, median, and standard deviations, were computed for GI, PI, CAL, and PD. Frequency distribution among the study population was calculated. Mann–Whitney test was used to compare the dependent variable among tobacco users and nonusers. P < 0.05 was considered statistically significant at 95% CI.

  Results Top

Three hundred patients participated in the present study, which included 272 males (90.6%) and 28 females (9.4%). The sociodemographic details of the study population are mentioned in [Table 1]. Median score of PI was 1.32 (0.66–2.04), GI was 1.33 (0.70–2.06), CAL was 1.46 (0.98–2.10), and PD was 1.22 (0.59–1.86) [Table 2].
Table 1: Distribution of the study population

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Table 2: Overall mean, median, and standard deviation

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The difference in the median scores of PI (P = 0.181), GI (P = 0.439), CAL (P = 0.64), and PD (P = 0.237) among males and females was statistically insignificant [Table 3].
Table 3: Comparison of overall mean difference among gender (n=300)

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Furthermore, the study population was categorized into two age groups (≤35 years and >35 years). Statistically significant difference in the median score (P < 0.001) of PI, GI, CAL, and PD was observed [Table 4]. Statistically significant difference was noted in the median score (P < 0.001) of PI, GI, CAL, and PD among the tobacco chewers and nonchewers [Table 5]. The tobacco chewers were also categorized in two groups based on the duration of tobacco chewing (≤10 years and >10 years). Significant difference (P < 0.001) was found among the two groups when compared for the median score of PI, GI, CAL, and PD [Table 6].
Table 4: Comparison of overall mean difference based on age category (n=300)

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Table 5: Comparison of overall mean difference based on tobacco use (n=300)

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Table 6: Comparison of overall mean difference based on the years of tobacco use (n=150)

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In tobacco chewers, the overall periodontal health was poor in females compared to males, although the result was not statistically significant. Attrition of tooth was the most common regressive change identified, followed by abrasion in the tobacco chewers. The number of missing tooth was also more in tobacco chewers compared to the participants without the history of tobacco chewing. Among the oral mucosal lesion, the presence of tobacco pouch keratosis was higher, followed by oral leukoplakia and oral submucous fibrosis in the tobacco chewers. These clinical diagnoses were further confirmed by the histopathological findings.

  Discussion Top

Chewing tobacco is not merely a practice, but a part of long-established custom in this part of the globe. Mostly, people start chewing tobacco from very beginning of their life. We have chosen participants above and below 35 years of age because chronic periodontitis become more prevalent in individuals over 35 years of age. The aftermath of chewing tobacco in oral mucosa and periodontium takes time to come into existence; therefore, we have compared the overall periodontal health of the study population with the habit below 10 years and above 10 years.

In the present study, missing teeth was more in tobacco chewers above 35 years, which is in concordance with the institution-based study conducted by Amjad et al.[3] who compared the effects of chewing tobacco on the oral health. Similar results were obtained in the study conducted by Neely et al.[9] which concluded that there is a significant correlation between betel nut use and missing teeth.

GI score was comparatively higher in the tobacco chewers above 35 years and in the individuals with the same habit for more than 10 years. This signifies that tobacco chewing has direct impact on the health of the gingiva and the effects become more profound with increase in the frequency and duration of the habit. Similar results were found by the study conducted by Sumanth et al.[16] Mittal et al.[17] who compared the effect of smoking and tobacco chewing on periodontal disease and nonsurgical treatment outcome and found that gingival inflammation was more in tobacco chewers, whereas the response to nonsurgical periodontal treatment was more suppressed in smokers than tobacco chewers.[17]

In the present study, the CAL was found to be significantly higher in the participants above 35 years of age and in the participants with a tobacco chewing habit for more than 10 years' duration, which is indicative of the fact that it is not merely the habit, but also the age and duration of the habit is directly proportional to the effects caused on the periodontium. Similar result was found by Amjad et al.[3] who reported the presence of periodontal pockets was significantly higher in tobacco chewers. Sumanth et al.[16] compared the periodontal health status in betel quid chewers with or without the use of tobacco and found that the presence of deep periodontal pockets was higher in tobacco and betel quid chewers. Fisher et al.[18] observed that smokeless tobacco users are at a two-fold increased risk of developing periodontal disease than the nonchewer.

The result of our study is in concordance with a comparative study conducted on the consumption of tobacco and periodontal health of rural health population by Chu et al.[19] who observed significantly higher gingival recession and PD in individuals who consumed smokeless tobacco. Rathod et al.[20] conducted a study on the impact of kharra chewing in the periodontal health status of healthy individuals, individuals with chronic periodontitis, and individuals with chronic periodontitis and OSMF, and found that gingival, PI score, and CAL was higher in the individuals with chronic periodontitis with oral submucous fibrosis, suggesting a direct correlation between kharra chewing and overall periodontal health. Similar results are obtained in our study where we found the deterioration in the overall periodontal health with increasing age and duration of the habit of chewing tobacco.[21]

Tobacco chewing brings about the painless loss of gingiva together with alveolar bone destruction, in the area which is in intimate contact with the smokeless tobacco, as outlined by Robinson et al.[19],[20] This occurs as a consequence of enhanced collagen destruction.[22] Excessive consumption of smokeless tobacco makes the oral environment favorable for the colonization of commensals like P. gingivalis and P. intermedia which produces collagenase enzyme causing gingival recession and loss of attachment.[23]

Regular betel quid chewing is significantly associated with radiologic alveolar bone loss, as reported by Hsiao et al.,[24] whereas regular dental check-ups combined with the moderation of unhealthy habits result in improvement of overall periodontal health. In accordance to studies done by Akhter et al.[25] in Bangladeshi population and Goyal et al.[26] in the population in Uttar Pradesh, we also observed the frequency and dose-dependent periodontal disease in betel quid chewers. Oral health education and awareness about the same are a prerequisite for adopting healthy lifestyle practices. A study conducted by Shah et al.[27] where the authors compared the overall oral health status in the first and final year students of Bachelor of Dental Surgery and found that the oral health status of the final year students were better than the 1st year students, as the former ones were much aware of the importance of the oral health by virtue of oral health education, which is a part of their regular curriculum.[27]

Therefore, after the completion of the study, the entire study population was called for giving an orientation on the tobacco and its consequences, where we had 94% attendance in it. It was an audio-visual program, where we gave a talk of different forms of tobacco and its consequences on oral and periodontal health, videos were shown on how showing tobacco causes damage to the entire periodontium. Self-illustrative charts on the local languages were there, and one-to-one discussion was also done. We demonstrated the brushing techniques and emphasized on the need of visiting the dentists twice a year.

The limitation of the present study is that we could not comment on the recovery of the oral and periodontal health post-withdrawal of the habit, which remains as a scope for further research. The present study could not evaluate the mental and emotional health of the subjects at the time of evaluation. The study was confined to the hospital-based patients of Birgunj, Parsa. Further, multicentric studies with increased sample size are required to get a deeper insight on the periodontal health of the tobacco chewers of the population of Nepal.

  Conclusion Top

The present study showed that chewing tobacco is detrimental to the tooth, oral mucosa, and off course periodontium. The results showed that oral mucosal lesions such as tobacco pouch keratosis, leukoplakia, and oral submucous fibrosis were higher in tobacco chewers. Gingival inflammation and CAL were also higher in tobacco chewers, which gradually increased with age and increase in the duration of the habit. The present study can serve as guidance to the clinicians to identify the high-risk population and look for the similar kind of signs, counsel the patients, provide early treatment, and minimize the morbidity as much as possible.

Ethical clearance

Ethical approval was obtained from Institutional Review Committee.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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