Table 8.
ST use and endpoints relevant to periodontal and gingival disease – evidence from the USA
| Study | Endpoint | Time of exposure | Statistic | Exposeda | Unexposeda | Nb | Summary of statistical testsc |
| Ernster 1990 [34] | Plaque | Snuff ever | % | 25.8 | 29.7d | 154 | OR 0.82 (0.65–1.03) |
| Ernster 1990 [34] | Plaque | CT ever | % | 30.2 | 29.7d | 52 | OR 1.02 (0.72–1.46) |
| Wolfe 1987 [30] | Calculus | ST current | %e | 21.6 | 20.5f | - | "Virtually no difference" |
| Offenbacher 1985 [29] | Gingivitis | ST use | % | 72.0 | 77.1 | 54 | OR 0.76 (0.44–1.32) |
| Cummings 1989 [31] | Gingivitis | ST current | % | 35.3 | 33.3 | 6 | OR 1.09 (0.15–7.80) |
| ST former | % | 50.0 | 33.3 | 1 | OR 2.00 (0.08–51.6) | ||
| CT current | % | 33.3 | 33.3d | 3 | OR 1.00 (0.11–8.95) | ||
| Snuff current | % | 28.6 | 33.3d | 4 | OR 0.80 (0.10–6.25) | ||
| Robertson 1997 [38] | Severe gingivitis | ST current | % | - | - | - | "Prevalence equally distributed" |
| ST former | % | - | - | - | "Prevalence equally distributed" | ||
| Wolfe 1987 [30] | Gingival bleeding | ST current | %e | 6.2 | 7.1f | - | "Virtually no difference" |
| Ernster 1990 [34] | Gingival bleeding | Snuff ever | % | 5.9 | 8.8d | 35 | OR 0.64 (0.43–0.96) |
| Ernster 1990 [34] | Gingival bleeding | CT ever | % | 9.9 | 8.8d | 17 | OR 1.13 (0.65–1.96) |
| Offenbacher 1985 [29] | Gingival recession | ST use | % | 60.0 | 14.1 | 45 | OR 9.15 (5.40–15.5)g |
| Wolfe 1987 [30] | Gingival recession | ST current | mean %e | 0.4 | 0.6f | - | "Virtually no difference" |
| Creath 1988 [32] | Gingival recession | Snuff ever | % | 0.3 | 0.0 | 1 | No significant difference |
| Cummings 1989 [31] | Gingival recession | ST current | % | 41.2 | 16.7 | 7 | OR 3.50 (0.33–36.9) |
| ST former | % | 50.0 | 16.7 | 1 | OR 5.00 (0.15–167) | ||
| CT current | % | 55.6 | 16.7d | 5 | OR 6.25 (0.50–77.5) | ||
| Snuff current | % | 35.7 | 16.7d | 4 | OR 2.78 (0.25–30.9) | ||
| Ernster 1990 [34] | Gingival recession | Snuff ever | % | 26.4 | 13.8d | 158 | OR 2.24 (1.73–2.90)h |
| Ernster 1990 [34] | Gingival recession | CT ever | % | 11.0 | 13.8d | 19 | OR 0.77 (0.46–1.29) |
| Robertson 1997 [38] | Gingival recession | ST use | % | - | - | - | ST users had "significantly more recession" |
| Christen 1979 [46] | Gingival recession | ST current | % | 50.0 | - | 7 | - |
| Robertson 1997 [38] | Gingival recession increase | ST use | mean (mm) | 0.36 | No change | - | Not tested |
| Creath 1988 [32] | Rolled gingival margins | Snuff ever | % | 3.1 | 3.4 | 9 | OR 0.91 (0.42–1.99) |
| Ernster 1990 [34] | Pocket depth | ST use | % ≥ 4 mm | - | -d | - | No significant difference |
| Robertson 1997 [38] | Pocket depth | ST use | % | - | - | - | No significant difference |
| Wolfe 1987 [30] | Attachment loss | ST current | %e | 3.9 | 3.3f | - | "Virtually no difference" |
| Ernster 1990 [34] | Attachment loss | Snuff ever | % | 10.7 | 4.4d | 64 | OR 2.63 (1.75–3.93)h |
| Ernster 1990 [34] | Attachment loss | CT ever | % | 4.7 | 4.4d | 8 | OR 1.07 (0.49–2.32) |
| Beck 1995 [24] | Attachment loss (new lesions)i | ST use | % | - | - | - | OR 2.99 (p = 0.001)j |
| Beck 1995 [24] | Attachment loss (lesion progression)k | ST use | mean | - | - | - | No associationl |
| Greer 1983 [27] | Periodontal degenerationm | ST use | % | 25.6 | - | 30 | - |
| Poulson 1984 [28] | Periodontal degenerationm | ST use | % | 26.8 | - | 15 | - |
| Sinusas 1992 [36] | Periodontal diseasen | ST use | % | 19.3 | 21.2 | 17 | OR 0.89 (0.42–1.87) |
| Fisher 2005 [43] | Periodontal diseaseo | ST current | % | 9.8 | 4.3 | 29 | OR 2.1 (1.2–3.7)p |
| Fisher 2005 [43] | Periodontal diseaseo | ST former | % | 9.1 | 4.3 | 38 | OR 1.5 (0.9–2.6)p |
a Where possible exposure is classified as "current" or "former" with exposure given as "use" only where the source paper did not clearly distinguish how former users were considered. The corresponding non-exposure is never or non-use to the same type of ST, except where indicated
b Number of exposed subjects with endpoint (where available)
c Tests are unadjusted for any potential confounding variable, except where stated. Where necessary ORs and 95% CIs are calculated from the data provided in the source paper
d Unexposed is ST never
e % of sites affected
f Unexposed is ST non-current
g The OR for gingival recession is 20.7 if gingivitis is present and 1.13 if it is not present
h The authors also reported an increase in snuff users after adjustment for age, race, cigarette smoking, alcohol consumption and dental hygiene practice
i During the whole year follow-up period
j Adjusted for income, soft tissue reaction and history of pain
k Increase in depth over a one year period
l ST did not appear as an independent risk factor, following backward elimination, in a logistic regression model involving multiple sociodemographic, psychological, medical, environmental, behavioural and oral variables
m Defined as gingival recession with apical migration of the gingival to or beyond the cementoenamel junction, with or without clinical evidence of inflammation
n Gingival recession or gingival thickening and erythema
o Severe active periodontal disease, defined as having at least one tooth with 6 mm or more attachment loss, and bleeding in the same tooth
p Adjusted for smoking, age, diabetes, minority status, gender and visiting dentist in the past year. Similar estimates of 2.1 (1.0–4.4) for current ST and 1.5 (0.5–4.3) for former ST are given for never smokers, and of 2.1 (1.0–4.2) for current ST and 1.3 (0.7–2.7) for former ST are given for interproximal severe active periodontal disease