The Prevalence of Smokeless Tobacco Consumption and Its Effects on Gingival and Periodontal Health Among the Adults in the Emirates of Sharjah, UAE – A Cross-Sectional Study

ABSTRACT

Introduction:

Smokeless tobacco (SLT) has been linked with various oral signs and symptoms, such as oral mucosal lesions and gingival and periodontal effects. However, there is limited research on the prevalence of SLT use and its impact on gingival and periodontal health in the adult population of the Emirates of Sharjah.

Aim:

To assess the prevalence of SLT consumption and its effects on gingival and periodontal health in the adult population of the Emirates of Sharjah.

Methods:

The study evaluated 171 dentate patients aged 18–77 years who use SLT or are nonsmokers. Data were collected through a questionnaire on SLT use and periodontal health assessed using plaque index, gingival index (GI), attachment score, and gingival recession (GR). Statistical analysis was done using SPSS 27.0 version.

Results:

Among 390 screened participants, 28 subjects (21 males and 7 females) were SLT users with prevalence of 7.18%. No significant differences were found in plaque index, GI, or periodontal pocket depth. However, SLT users had significantly higher clinical attachment loss scores (mean 4.01 mm, SD 0.35) compared to non-users (mean 1.49 mm, SD 1.12). Significant differences were also observed in GR.

Conclusions:

This study provides insights into the prevalence and impact of SLT use on periodontal and gingival health in UAE adults. SLT usage is associated with a higher risk of periodontitis and gingivitis, indicating the need for awareness and intervention. Further research is required to validate results and consider confounding factors.

INTRODUCTION

Periodontal disorders are immunoinflammatory conditions that affect the tissues that support the teeth and are mostly brought on by particular microbial communities found in the oral biofilm. Even though that plaque microorganisms are what cause periodontal diseases, several risk factors may influence the way the body reacts to microbial aggression.[1,2] Food habits, lifestyle, environmental, and genetic risk factors might affect the outset and/or the development of periodontitis by altering the manifestation of periodontal disease.[3]

Tobacco is considered the plague of modern times, and its utilization is increasing across the globe.[4] Tobacco smoking is related to periodontal disease through an increased prevalence and progression, and the linkage between tobacco consumption and dental and oral health status is well documented; its adverse effect on the periodontium has also gained a lot of attention throughout the years.[5,6,7,8,9]

Tobacco consumption has many adverse effects on the oral cavity whether it’s smokeless tobacco (SLT) or regular tobacco. Many studies have been done over the years to assess the devastating effects of SLT on general oral health.[10,11] SLT has different forms including areca nut, catechu and gutkha, khaini, tobacco lime, gudhaku, etc., which damage the tooth-supporting structures. SLT use has been linked with various oral manifestations, especially in the area of SLT placement. These signs include oral mucosal lesions and gingival-periodontal effects.[12,13,14,15]

A clear correlation between SLT consumption and periodontal attachment loss has not been definitively demonstrated.[8,12,16] Even though the unexpected effect of smoking on periodontal health is copiously recorded,[5,6,9] literature addressing the possible repercussions of SLT products on periodontal health is scanty.[11,17,18] Many studies have been done all over the world in many different countries to address this topic.[10,19] Several studies concluded that SLT affects oral health negatively, by causing gingivitis, loss of clinical attachment, bone resorption, pocket formation (periodontitis), oral keratosis, and oral cancer.[10,19] Some studies, however, have reported no connection between SLT use and interproximal attachment loss.[11,18] The conventional type of SLT consumed in the Gulf region (UAE) is known as Shammah;[18,20] results showed that periodontal pockets were greatly linked with 30 years and above age group, low family income category, former SLT users, and current SLT users.[20]

Nevertheless, no studies have been done in the Middle East, particularly in the UAE, regarding the various types of SLT and its adverse effects (gingival inflammation, interproximal clinical attachment loss (CAL), gingival recession (GR), and periodontal bone loss) on gingival and periodontal health. Hence, the present cross-sectional study aims to assess the prevalence of SLT consumption and its effects on the gingival and periodontal health among the adults in the Emirates of Sharjah.

MATERIALS AND METHODS

Study design

A prospective observational cross-sectional study was conducted to investigate the prevalence of SLT consumption and its effects on gingival and periodontal health among the adults reporting to the University Dental Hospital Sharjah, UAE.

Methodology

Research participants

The participants of the study included adults who reported to the University Dental Hospital, Sharjah, UAE. between December 2022 and March 2023.

Eligibility criteria

The study’s eligibility criteria are as follows: Inclusion criteria pertain to adults aged 18–68 years, who have a minimum of two teeth in each sextant and maintain dentate status. Exclusion criteria encompass individuals with diabetes, toothbrush-induced trauma, noncarious cervical lesions, tobacco smoking, ongoing periodontal treatment, and the use of medications impacting periodontal health.

Ethical considerations

Ethical approval was acquired by the University of Sharjah Research Ethics Committee (Ref. No. 23-01-12-02-S). Before the commencement of the study, participants signed the written consent in English/Arabic/Urdu language explaining the design of the study and declaring that their participation was voluntary.

Research questionnaire

A well-organized questionnaire recorded socio-demographic details including age, family income, and education level. Information about oral hygiene practices namely daily tooth brushing, daily dental flossing, dental visits, mouth rinsing, and SLT status were also collected.

In terms of SLT status, it will be recorded as a nonuser, former user, and current user. The current SLT users will be individuals who used SLT either daily or every now and then; former users were those who consumed no SLT for at least a year; and nonusers were those who have never consumed SLT. Apart from this, frequency of SLT per day, annual duration of SLT use, location, duration of SLT placement in the mouth per minute, and quantity (in packs) of SLT used were included in the questionnaire.

Clinical examination

Recording the clinical parameter

Participants’ gingival status and periodontal condition based on Plaque Index (PI) scores, Gingival Index (GI) scores, Pocket Probing Depth scores (PPD), and CAL were assessed using standardized methods as follows:

The PI: The PI was evaluated using a mouth mirror and plaque-disclosing agent, and then the scores were calculated. When a specific tooth is missing, the closest tooth distal to the missing tooth was evaluated.[6]

GI: The gingival tissue around each tooth is divided into six gingival scoring units namely (mesio-facial papilla, facial margin; disto-facial papilla, mesio-lingual papilla, distolingual, midlingual gingival margin). The teeth and gingiva were dried gently with air or cotton rolls. Each of the included gingival units was examined and the scores were tabulated. A periodontal probe was used to evaluate the bleeding points around the teeth with scoring criteria as: Score 0 – absence of inflammation, Score 1 – mild inflammation, Score 2 – moderate inflammation, and Score 3 – severe inflammation. The GI per tooth was attained by adding up the four scores per tooth. The GI score per person was obtained by adding the GI score per tooth and dividing it by the number of teeth examined.[8]

PPD: Calibrated color-coded University of North Carolina Probe 15 (UNC 15) was used to measure the distance from the base of the sulcus or pocket to the gingival margin by inserting the probe parallel to the long axis of the tooth at six sites all around the tooth (mesiobuccal, midbuccal, distobuccal, midlingual, mesiolingual, and distolingual around all teeth).[7]

GR: GR was determined as positive recession if the gingival margin was located below the cementoenamel junction (CEJ) at the buccal and lingual aspect of all the teeth and as a negative recession if the gingival margin was placed on the crown 1 mm above the CEJ.[8]

CAL: CAL was determined by calculating the distance from a fixed reference point, CEJ, to the base of the pocket or sulcus (calculated automatically in the periodontal chart).

Data collection

Informed consent was signed by all the voluntary participants and a questionnaire was filled by them. Based on the voluntary reports of the SLT users, participants were categorized as (nonuser, former users, and current users). After completing the questionnaire, all the voluntary study population went through clinical examination for GI, PI, PDD, GR, and CAL. The quantity of SLT used will be based on the number of packs or pieces, and the duration and quantity were calculated individually, as well as in combination in cases of combined users. (Combined users are those who use one or more types of tobacco.) The results were tabulated and analyzed statistically.

Statistical analysis

The data entry and analysis were done using SPSS 27.0 version (IBM, USA) and GraphPad Prism 7.0 version (GraphPad Software, USA) by using inferential statistics and descriptive statistics using Student’s unpaired t-test and Chi-square test. ANOVA was used to find the association. P < 0.05 was considered as the level of significance.

RESULTS

Among the 390 participants screened, a total of 28 subjects (21 males and 7 females) were SLT users with a prevalence of 7.18% [Figure 1]. Among the 390 screened participants, only 171 were eligible for further analysis. The included participants involved 120 (70.2%) males and 51 (29.8%) females with a mean age and standard deviation of 35.41 ± 12.41 years.

Figure 1.

Flowchart of the study

There was no notable difference in plaque index score, GI score, and periodontal pocket depth between the SLT users and nontobacco users. However, there was a highly significant difference in the CAL scores between the SLT users with a mean loss of 4.01 mm (D = 0.35) when compared to nontobacco users (mean = 1.49, SD = 1.12 mm). Similarly, there was a significant difference in the GR between SLT users and nontobacco users [Table 1].

Table 1.

Comparison of plaque index (PI) Score, gingival index (GI) Score, periodontal pocket depth (PPD), clinical attachment loss (CAL) scores, and gingival recession (Gr) across the study groups

Parameters	Smokeless tobacco users (n=11)			Nontobacco users (n=160)			Significance
	Mean	SD	SEM	Mean	SD	SEM	t	P
PI Score	1.37	2.25	0.67	1.82	2.02	0.15	0.71	0.47, NS
GI Score	0.64	1.69	0.51	1.65	1.53	0.12	0.03	0.97, NS
PPD	5.18	0.60	0.18	5.01	1.76	0.13	0.31	0.75, NS
CAL Score	4.01	0.35	0.10	1.49	1.12	0.08	7.36	<0.001**
Gingival Recession
GR	No.	%	Total	No.	%	Total	χ 2	p
Positive	8	72.73%	11 (100)	47	29.38%	160 (100)	8.76	0.003*
Negative	3	27.27%		113	70.63%

There was no association found when the CAL was compared with the site of placement of tobacco, frequency, and duration of tobacco use [Table 2]. Similarly, no association was found when the GR was compared with the site of placement of tobacco, frequency, and duration of tobacco use [Figure 2].

Table 2.

Association of clinical attachment loss with the location of tobacco placement, duration of tobacco chewing, and frequency of tobacco chewing

	Participants	CAL Score Mean±SD (mm)	Significance
			F	P
Location of tobacco placement
Lower anterior	1 (9.09%)	3.70±0	2.58	0.16 NS
Lower left buccal	2 (18.18%)	4±0.17
Lower right buccal	3 (27.27%)	3.76±0.29
Upper left	2 (18.18%)	4.36±0.08
Upper right	1 (9.09%)	4.40±0
Other	2 (18.18%)	3.01±0.83
Duration of tobacco chewing
0–2 min	0 (0%)	0±0	0.74	0.50 NS
2–5 min	3 (27.3%)	4.01±0.34
5–10 min	5 (45.5%)	3.93±0.33
>10 min	3 (27.3%)	3.48±1
Total	11 (100%)	3.83±0.56
Location of tobacco placement
1–3 times	5 (45.5%)	3.82±0.26	0.37	0.70 NS
3–5 times	2 (18.2%)	4.14±0.36
5–10 times	0 (0%)	0±0
>10 times	4 (36.4%)	3.69±0.91
Total	11 (100%)	3.83±0.56

Figure 2.

Association of gingival recession with the location of tobacco placement, duration of tobacco chewing, and frequency of tobacco chewing

DISCUSSION

To the best of our insight, this is the first study which is determining the prevalence of SLT consumption and its effects on the gingival and periodontal health among the adults in the Emirates of Sharjah. This study aimed to investigate the prevalence of SLT consumption among adults in the Emirate of Sharjah and to assess the correlation between SLT consumption on gingival and periodontal health considering all the periodontal parameters.

The observed prevalence of SLT consumption among the adults in the Emirates of Sharjah in the present study was 7.18%. A study from India based on the Global Adult Tobacco Survey reported a prevalence of SLT use of 28% among males aged 25–44 years.[21] Another study reported an inclusive SLT use of 8%.[22]

A study conducted in Al Ain, UAE in 2020 reported the prevalence of SLT consumption of 6, 12, and 16% for Indian, Pakistani, and Bangladeshi male participants, respectively.[23] Similar findings were observed in the present study with an overall prevalence of 7.18% (males 5.38% and females 1.8%). The reason for the low SLT prevalence could be due to the shorter duration of data collection, low availability of tobacco products in the UAE compared to other countries, and the barriers in accessing the SLT products in the UAE.[23] However, this value is higher than the reported value of Shamma (the local name of SLT) users in Saudi Arabia (2.0%).[24]

Other suggested reasons for participant dropouts and low prevalence include the following: incomplete data, incomplete questionnaire, eligibility criteria, and strict exclusion criteria.

Previous studies of SLT use by adults showed significant associations between periodontal disease and tobacco use.[8,25,26] In a study using the population-based Third National Health and Nutrition Examination Survey in the USA, results showed that adults currently using SLT are twice as likely to have severe active periodontal disease than adults who never used SLT.[26]

The results showed that according to age distribution, most of the participants were between the ages of 21 and 30, the least number of participants were above the age of 60, and the mean age of participants is 35.41 ± 12.41. Out of 171 participants, 120 (70.2%) of them were male and 51 (29.8%) females. Almost all the participants use a toothbrush and toothpaste to clean their teeth. The distribution of adults according to their frequency of cleaning revealed that 107 participants clean twice daily while 10 only clean thrice a day. Most of the adults in the sample size brush their teeth in a horizontal and vertical manner (58 adults), while the least number of adults use a circular fashion to brush their teeth. In total, 95.3% of the adults in this sample size has mixed food habits, while 4.7% are only vegetarian. Out of the 11 participants who use SLT, most of them use Gutka and Betelnut with tobacco, while none of them use tobacco and lime.

However, the study has some limitations, including a proportionally small sample size and a focus on patients attending a single dental hospital. The study’s findings may not be generalizable to the entire Emirate of Sharjah population, and further research may be needed to validate the results.

CONCLUSIONS

In conclusion, the study provides valuable insights into the prevalence and impact of SLT use on periodontal and gingival health among adults in the UAE population; even though the prevalence of SLT users was low, SLT usage was substantially linked to a higher risk of periodontal and gingival disease, including periodontitis and gingivitis in adults. The study’s findings highlight the need for awareness programs to inform individuals about the harmful outcomes of SLT use on oral health and the importance of early intervention to prevent and manage periodontal and gingival diseases. Further research is needed to validate the study’s results and investigate the impact of confounding factors on periodontal and gingival health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.