title: Tobacco smoking and periodontal health in a Saudi Arabian population.
abstract: OBJECTIVE
  Tobacco smoking exerts a harmful effect on the periodontal tissues manifested by periodontal pockets, attachment loss and periodontal bone loss. Current evidences on the effects of tobacco on periodontal health mainly concern cigarette smoking. In view of the increasing popularity of water pipe smoking in Arabian countries and reports confirming that water pipe smoking has health effects similar to those of cigarette smoking, there is a need for a better understanding of the potential harm of this smoking habit. The present thesis was carried out in order to explore whether water pipe smoking is associated with periodontal health in a manner similar to cigarette smoking.
  
  
  METHODS
  Residents in Jeddah City, Saudi Arabia, were invited to participate in the study by means of announcements in two daily newspapers. 355 individuals, 100 women and 255 men (17-60 years) responded to a standardized questionnaire and digital panoramic dental radiographs were taken. The questionnaire included information about oral hygiene practices, dental care and smoking habits. Of these subjects, 262 (73%) also volunteered for clinical examination, including assessments of oral hygiene, gingival inflammation and probing depth. Subgingival microbial test was carried out in 198 individuals for the detection of 12 different bacterial species most commonly associated with periodontal disease using the checkerboard DNA-DNA hybridization technique. Participants were stratified into water pipe smokers 33%, cigarette smokers 20%, smokers of both water pipe and cigarettes (mixed smokers 19%) and non-smokers 28%.
  
  
  RESULTS
  Tobacco smoking is associated with a suppression of the gingival bleeding response to plaque accumulation. A suppressive effect was observed in both cigarette and water pipe smokers compared to non-smokers (Study I). Both cigarette and water pipe smoking were associated with the presence of more than 10 pockets of > or = 5 mm probing depth. The relative risk for periodontal disease was 5.1-fold and 3.8-fold increased in water pipe and cigarette smokers, respectively, compared to non-smokers (p < 0.01). The relative risk associated with heavy smoking was about 8-fold elevated in water pipe smokers and 5-fold elevated in cigarette smokers, suggesting an exposure-response effect (Study II). Tobacco smoking was associated with a reduction of the periodontal bone height. The reduction was of similar magnitude in water pipe smokers and cigarette smokers. The relative risk of periodontal bone loss of more than 30% of the root length was 3.5-fold and 4.3-fold elevated in water pipe and cigarette smokers, respectively, compared to non-smokers (p < 0.01). The relative risk associated with heavy smoking was 7.5-fold elevated in water pipe smokers and 6.3-fold elevated cigarette smokers (Study III). Further more, cigarette smokers, water pipe smokers and non-smokers exhibited similar periodontal microflora (Study IV).
  
  
  CONCLUSIONS
  Tobacco smoking is associated with inferior periodontal health. The impact of water pipe smoking is of largely the same magnitude as that of cigarette smoking. The association between tobacco smoking and an inferior periodontal health seems to be independent of the subgingival microflora. Water pipe smoking habit should be considered in periodontal health.
authors.affiliation: Department of Periodontology, Institute of Odontology, Karolinska Institutet, Stockholm, Sweden. Suzan.Natto@ofa.ki.se
authors.forename: Suzan Bakur
authors.initials: SB
authors.lastname: Natto
mesh_terms: D000293:Adolescent; D000328:Adult; D016301:Alveolar Bone Loss / Q000000981:diagnostic imaging / Q000209:etiology*; D005260:Female; D005881:Gingiva / Q000382:microbiology; D006090:Gram-Negative Bacteria / Q000302:isolation & purification; D006801:Humans; D008297:Male; D008875:Middle Aged; D009910:Oral Hygiene; D010510:Periodontal Diseases / Q000000981:diagnostic imaging / Q000209:etiology* / Q000382:microbiology; D010512:Periodontal Index; D011859:Radiography; D012307:Risk Factors; D012529:Saudi Arabia; D012907:Smoking / Q000009:adverse effects*; D011795:Surveys and Questionnaires