|Year : 2016 | Volume
| Issue : 4 | Page : 383-388
Assessment of periodontal status in smokeless tobacco chewers and nonchewers among industrial workers in North Bengaluru
Dinta Kathiriya1, R Murali2, Madhusudan Krishna3, Y Shamala2, Mansi Yalamalli2, A Vinod Kumar4
1 Department of Public Health Dentistry, Karnavati School of Dentistry, Gandhinagar, Gujarat, India
2 Department of Public Health Dentistry, Krishnadevaraya College of Dental Science, Bengaluru, Karnataka, India
3 Department of Public Health Dentistry, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India
4 Department of Public Health Dentistry, Royal Dental College, Chalissery, Kerala, India
|Date of Web Publication||15-Dec-2016|
C-302, Swagat Flamingo, Sargasan Cross Roads, Gandhinagar - 382 421, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: More than one-third of the tobacco consumed in India is of smokeless form. While the smokeless tobacco (ST) products have been strongly associated with oral cancer, the association between ST and periodontal disease is less clear. The present study was conducted on industrial workers because in premises, there is a ban on smoking tobacco and hence workers tend to consume more of ST products. Aim: The aim of this study is to assess periodontal status in ST chewers and nonchewers among industrial workers in North Bengaluru. Materials and Methods: A cross-sectional analytical study was conducted on 800 industrial workers (400 ST chewers and 400 nonchewers) of North Bengaluru. Information regarding ST habits was obtained using the Global Adult Tobacco Survey questionnaire, followed by clinical examination to assess periodontal status using the community periodontal index and attachment loss. The comparison between chewers and nonchewers was done using Pearson's Chi-square test. Logistic regression analysis was used to estimate the difference of periodontal status and loss of attachment (LOA) between chewers and nonchewers. Results: ST chewing habit was observed the maximum (46.5%) among age group 25–44 years. Most of male chewers had habit of chewing gutkha followed by khaini, and majority of the female chewers were using khaini followed by betel nut quid. A significantly higher prevalence of bleeding on probing and calculus was found among nonchewers. ST chewers had 2.06 (95% confidence interval [CI]: 1.55–2.75) times more risk of developing periodontal pockets and 2.23 (95% CI: 1.68–2.98) times more risk of having LOA when compared with nonchewers. Conclusions: ST has deleterious effects on the periodontium. Hence, it is one of the important risk factors for periodontal disease.
Keywords: Periodontal disease, risk factor, smokeless tobacco
|How to cite this article:|
Kathiriya D, Murali R, Krishna M, Shamala Y, Yalamalli M, Kumar A V. Assessment of periodontal status in smokeless tobacco chewers and nonchewers among industrial workers in North Bengaluru. J Indian Assoc Public Health Dent 2016;14:383-8
|How to cite this URL:|
Kathiriya D, Murali R, Krishna M, Shamala Y, Yalamalli M, Kumar A V. Assessment of periodontal status in smokeless tobacco chewers and nonchewers among industrial workers in North Bengaluru. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2021 Oct 22];14:383-8. Available from: https://www.jiaphd.org/text.asp?2016/14/4/383/195848
| Introduction|| |
Tobacco use is a major public health problem globally and a major preventable cause of death and disability. The World Health Organization estimates 4.9 million deaths that are annually attributed to tobacco. This figure is expected to raise to 10 million in 2030, with 7 million of these deaths occurring in developing countries, mainly India. The state of the epidemic of tobacco use in India was described in the Global Adult Tobacco Survey (GATS), an internationally standardized survey designed to track tobacco use around the world. According to that, India faces diverse epidemics of tobacco use. There are currently about 240 million tobacco users aged 15 years and above in India.
Smokeless tobacco (ST) chewing warranties special attention in India because of its popularity and widespread social acceptance. The major factors that persist to encourage people to use smokeless form of tobacco are its low price, ease of purchase, and the widely held misconception of purported medicinal value in curing toothache, headache, and in decreasing hunger. Furthermore, in contrast to smoking, there is no taboo against using ST.
While the ST products have been strongly associated with oral cancer, the association between ST and periodontal disease is less clear. Gingival recession has been reported in ST users by many but not all clinical surveys. There is insufficient evidence to support consistent association between ST and periodontal disease.
The lifestyle, socioeconomic status, and the standard of living of industrial workers are different from the rest of the population. Poverty, language barriers, and poor education contribute different lifestyle that encourages addictive tobacco habits. As there is a ban on smoking tobacco in most of the industrial premises, workers tend to consume more of ST products. Therefore, they form a special group who could be at a higher risk of periodontal breakdown. Thus, a study was conducted to assess periodontal status in ST chewers and nonchewers among industrial workers in North Bengaluru.
| Materials and Methods|| |
A cross-sectional analytical study was conducted in 12 small scale industries of North Bengaluru selected by simple random sampling method. Ethical clearance was obtained from the Institutional Review Board. Approval for conducting the study was solicited and obtained from the respective authorities of industries. Informed consent was obtained from each individual before conducting interview and clinical examination.
A pilot study was conducted among forty ST chewers and forty nonchewers using GATS questionnaire  through guided interview to determine feasibility of the study. The sample size determination was carried out using the formula N = (Zα + Zβ)2 × p × q × 2/d 2 (Where Zα = value for Z at significant level when α [0.05] =1.96, Zβ = Z value for β error = 0.84, P = anticipated population proportion [“safest choice”] = 0.50, and q = [1 − P] = 0.50). After calculating, the sample size came around 392 per group, which was rounded off to 400, and the similar number of 400 participants for nonchewers was included in the study.
The study population was divided into two groups. One group comprised habitual chewers of ST products (ST chewers) and the other group did not consume tobacco in any form (nonchewers). Individuals aged 15 years and above, who currently chew ST for a minimum period of 12 months, were included in the study. Inclusion criteria for nonchewers were aged 15 years and above without any smoking, alcohol, or tobacco chewing habits. Individuals suffering from any obvious systemic disease that may influence the periodontal status were excluded from the study. The study participants were selected from industries to cover sample size in each group based on the criteria of the study. In the present study, adequately matched nonchewers were interviewed and examined from the same industry.
The principal investigator was trained and calibrated intra-examiner (kappa = 0.84) reliability. Data collection comprised interviewing the study participants regarding demographic details and various tobacco-related habits using GATS questionnaire  in English language. Each participant was interviewed regarding the ST use by principal examiner, and questionnaire was filled by principal examiner. It was followed by clinical examination to assess periodontal status using the community periodontal index (CPI) and attachment loss. Interviews and oral examinations were scheduled in the working hours of the industries to ensure the presence of workers. At a time, only five workers were called which did not disturb industry's work schedule. There were no dropouts from consent to interview and examination.
Statistical analysis was done using the statistical package - SPSS version 20 (Armonk NY: IBM Crop.). The comparison between chewers and nonchewers was done using Pearson's Chi-square test. Bivariate analysis between ST habits, duration, and frequency with periodontal status was assessed using Chi-square test. Logistic regression analysis was used to estimate the difference of periodontal status and loss of attachment (LOA) between chewers and nonchewers. Statistical significance was set at P < 0.05 for the study.
| Results|| |
A total of 800 participants (male 588; female 212) were examined in this study, 400 ST chewers and 400 nonchewers, ranging between ages of 15 and 64 years.
ST chewing habit was observed the maximum (46.5%) among age group 25–44 years [Figure 1]. Among 400 ST users, the most commonly used product was gutkha (35.5%) followed by khaini (32.5%) whereas 0.5% of participants used betel nut only. Participants used combination of products also [Figure 2]. Most of male chewers had habit of chewing gutkha followed by khaini, and majority of the female chewers were using khaini followed by betel nut quid [Figure 3].
|Figure 2: Type of smokeless tobacco product usage among the study participants|
Click here to view
|Figure 3: Distribution of smokeless tobacco chewers according to gender and chewing habits|
Click here to view
According to CPI scores, 4.5% of ST chewers and 5.8% of nonchewers had bleeding on probing (CPI score 1); 46.3% of chewers and 56.8% of nonchewers had calculus (CPI score 2). Pocket depth of more than 4–5 mm (CPI score 3) was found in 48.0% of chewers and 32.0% of nonchewers whereas pocket depth of 6 mm or more (CPI score 4) was found only in chewers (1.3%).
There was a significant difference between CPI score for ST chewers and nonchewers (Chi-square = 44.691, P < 0.001) [Table 1]. ST chewers had 2.06 (95% confidence interval [CI]: [1.55–2.75]) times more risk of developing periodontal pockets than nonchewers. The difference was statistically significant (P < 0.001) [Table 2].
|Table 1: Distribution of smokeless tobacco chewers and nonchewers according to the community periodontal index score|
Click here to view
|Table 2: Logistic regression analysis of periodontal pockets between smokeless tobacco chewers and nonchewers|
Click here to view
About 47.3% of chewers and 31.0% of nonchewers presented a LOA of 4–5 mm (LOA score 1). Only 4% of ST chewers were having a LOA of 6–8 mm (LOA score 2), and 1% of the nonchewers had LOA of 6–8 mm (LOA score 2). There was a significant difference between LOA score of ST chewers and nonchewers (Chi-square = 33.394, P < 0.001) [Table 3]. ST chewers had 2.23 (95% CI [1.68–2.98]) times more risk of having LOA when compared with the nonchewers. The difference was statistically significant (P < 0.001) [Table 4].
|Table 3: Distribution of smokeless tobacco chewers and nonchewers according to the loss of attachment scores|
Click here to view
|Table 4: Logistic regression analysis of loss of attachment between smokeless tobacco chewers and nonchewers|
Click here to view
| Discussion|| |
This study was conducted to determine the patterns of various types of ST chewing habits and to assess periodontal status among ST chewers and nonchewers.
In the current study, among 400 ST chewers, 46.5% of study participants were in the age group of 25–44 years, and 37.3% of the study participants were in the age group of 15–24 years [Figure 1]. This finding is similar to the one observed by Ahmad et al. with most participants belonging to the age group of 21–41 years, but unlike the present study, Ariyawardana et al. reported that age range of 41–51 years had maximum participants (57.7%) with the habit. The reason that 25–44 years old study participants consuming more ST in comparison to the rest of the age groups could be attributed to the increased family responsibilities and the pressure to achieve financial independence at this stage of their lives. In addition, the long working hours and increased stress levels may also contribute to high consumption of ST.
Information collected regarding the age of habit initiation revealed that 4.25% had started chewing ST below the age of 15 years. In the present study, minimum age of initiation of habit was 10 years, which is similar to the one reported by Ahmad et al. in Patna, Bihar, in which age of initiation of habit was 11 years. Easy availability of ST products and peer group influence could be the possible reasons for initiation of the habit at an early age.
Among 400 ST users, the most commonly used product was gutkha, chewed by 35.5% of study participants, followed by 32.5% were khaini users [Figure 2]. Ahmad et al. observed that most participants were chewing gutkha followed by pan. A possible explanation for this observation in the present study could be the advent and easy availability of attractive, conveniently packed sachets that can result in “hassle-free” chewing and addiction to the participants.
In this study, it was found that majority of male chewers had habit of chewing gutkha followed by khaini [Figure 3]. Similar finding was found in the study conducted by Hazarey et al. where a significant increase for gutkha and kharra/mawa chewing was found in men when compared with women. In the present study, majority of the female chewers were using khaini followed by betel nut quid [Figure 3]. Similar finding was reported in the study conducted by van Wyk (1993) who studied South Africans of Indian origin and found that most of the women preferred to consume pan which caused less severe oral mucosal lesions compared to the males who chewed only areca nut and tobacco products.
In the current study, it was found that bleeding on probing and calculus was more among nonchewers as compared to chewers [Table 1]. This finding was in contrast to the reports of Amarasena et al., in which increased calculus formation had been reported in areca nut chewers. In other study conducted by Al-Kholani, it was found that the oral hygiene status of nonchewers was significantly better than that of chewers. The reason for more calculus in nonchewers in the present study could be poor oral hygiene practices among nonchewers.
Chewers experienced more periodontal destruction of the periodontium than nonchewers [Table 2] which is similar to the findings of studies conducted by Waerhaug  and Ling et al.
Among the ST chewers, 48.0% had pocket depth 4–5 mm when compared to nonchewers where 16.6% of participants had a pocket depth of 4–5 mm. This result is similar to the finding reported by Kumar et al., in which less than half (46%) of the ST chewers had a periodontal pocket of 4–5 mm when compared to nonchewers (10%). In the current study, 47.3% presented with LOA of 4–5 mm, whereas among nonchewers, 31.0% had LOA of 4–5 mm [Table 3]. This finding is similar to study reported by Kumar et al., in which 66% had LOA of 4–5 mm in ST chewers and 24% had LOA of 4–5 mm in nonchewers. The hardness of the areca nut and interactions of the various ingredients presents in the chewing products with periodontal tissues might be responsible for the poor periodontal status of chewers. Areca nut, which contains alkaloids such as arecoline, might have a significant causative role in periodontal diseases along with other variables such as the level of oral hygiene, dietary factors, general health, and dental status.
In the present study, there was a higher prevalence of attachment loss in older age groups than in younger age groups, which was a similar finding by Baelum et al., suggesting that age could be a factor affecting such changes.
Limitations of the study could be, all data on the use of ST were based on self-reports from participants, collected by guided interviews. In this mode of questionnaire administration, it is expected that some young people might tend to avoid reporting behaviors that they perceive to be socially unacceptable. If ST use was underreported, this would lead to misclassification of respondents on exposure, and the estimated association between the use of ST products and the presence of oral mucosal lesions could be biased. Since this was a cross-sectional study, the lack of temporality is an inherent limitation.
It is recommended from the current study that as the ST accounts for such a high proportion of oral mucosal lesions and periodontal disease, controlling tobacco use is of immense important if we are to make progress in reducing the burden of tobacco-related oral diseases. Regulatory actions are therefore warranted to control the manufacture, marketing, and the consumption of ST products that contain areca nut and/or tobacco, gutkha, khaini, etc., People are aware about the health hazards of tobacco and merely that is not sufficient to stop them from starting or from continuing the habit. There is also a need to develop multifactorial tobacco quitting strategies focusing on early age intervention. Special efforts are needed to educate the adolescent population using available modalities such as oral health exhibition and oral health outreach programs.
| Conclusions|| |
Most of male chewers had habit of chewing gutkha followed by khaini, and majority of the female chewers were using khaini followed by betel nut quid. A significantly higher prevalence of bleeding on probing and calculus was found among nonchewers whereas the chewers were experiencing more periodontal destruction than the nonchewers. ST chewers had 2.06 times more risk of developing periodontal pockets than nonchewers. There was a higher prevalence of attachment loss in older age groups than in younger age groups. It was found that ST chewers had 2.23 times more risk of having LOA when compared with the nonchewers. Based on the results, it was concluded that ST has deleterious effects on the periodontium. Hence, ST is one of the important risk factors for periodontal disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Global Youth Tabacco Survey Collaborative Group. Tobacco use among youth: A cross country comparison. Tob Control 2002;11:252-70.
Schwartz RL, Wipfli HL, Samet JM. World No Tobacco Day 2011: India's progress in implementing the framework convention on tobacco control. Indian J Med Res 2011;133:455-7.
Reddy KS, Gupta PC. Tobacco Control in India. New Delhi: Ministry of Health and Family Welfare, Government of India; 2004.
Ansari ZA, Bano SN, Zulkifle M. Prevalence of tobacco use among power loom workers – A cross-sectional study. Indian J Community Med 2010;35:34-9.
Muttapppallymyalil J, Sreedharan J, Divakaran B. Smokeless tobacco consumption among school children. Indian J Cancer 2010;47 Suppl 1:19-23.
Position paper: Tobacco use and the periodontal patient. Research, Science and Therapy Committee of the American Academy of Periodontology. J Periodontol 1999;70:1419-27.
Ariyawardana A, Sitheeque MA, Ranasinghe AW, Perera I, Tilakaratne WM, Amaratunga EA, et al.
Prevalence of oral cancer and pre-cancer and associated risk factors among tea estate workers in the central Sri Lanka. J Oral Pathol Med 2007;36:581-7.
Global Adult Tobacco Survey Collaborative Group. Global Adult Tobacco Survey (GATS): Core Questionnaire with Optional Questions, Version 2.0. Atlanta, GA: Centers for Disease Control and Prevention; 2010.
World Health Organization. Oral Health Surveys: Basic Methods. 5th
ed. Geneva: World Health Organization; 2013.
Ahmad MS, Ali SA, Ali AS, Chaubey KK. Epidemiological and etiological study of oral submucous fibrosis among gutkha chewers of Patna, Bihar, India. J Indian Soc Pedod Prev Dent 2006;24:84-9.
Hazarey VK, Erlewad DM, Mundhe KA, Ughade SN. Oral submucous fibrosis: Study of 1000 cases from central India. J Oral Pathol Med 2007;36:12-7.
van Wyk CW, Stander I, Padayachee A, Grobler-Rabie AF. The areca nut chewing habit and oral squamous cell carcinoma in South African Indians. A retrospective study. S Afr Med J 1993;83:425-9.
Amarasena N, Ekanayaka AN, Herath L, Miyazaki H. Tobacco use and oral hygiene as risk indicators for periodontitis. Community Dent Oral Epidemiol 2002;30:115-23.
Al-Kholani AI. Influence of khat chewing on periodontal tissues and oral hygiene status among Yemenis. Dent Res J (Isfahan) 2010;7:1-6.
Waerhaug J. Prevalence of periodontal disease in Ceylon. Association with age, sex, oral hygiene, socio-economic factors, vitamin deficiencies, malnutrition, betel and tobacco consumption and ethnic group. Final report. Acta Odontol Scand 1967;25:205-31.
Ling LJ, Hung SL, Tseng SC, Chen YT, Chi LY, Wu KM, et al.
Association between betel quid chewing, periodontal status and periodontal pathogens. Oral Microbiol Immunol 2001;16:364-9.
Kumar MS, Mythri S, Hegde S, Rajesh KS. Effect of chewing gutkha on oral hygiene, gingival and periodontal status. J Oral Health Res 2012;3:26-31.
Baelum V, Pisuithanakan S, Teanpaisan R, Pithpornchaiyakul W, Pongpaisal S, Papapanou PN, et al.
Periodontal conditions among adults in Southern Thailand. J Periodontal Res 2003;38:156-63.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]