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122]

Original Article

Effect of cigarette smoking on

the periodontal health status: A
comparative, cross sectional study
D. K. Gautam, Vikas Jindal, S. C. Gupta, Amrinder Tuli, Bhanu Kotwal,
Rambhika Thakur

Department of Abstract:
Periodontics, Himachal Context: Survey. Aims: The objective of the study was to evaluate the periodontal health status among cigarette
Dental College, smokers and non cigarette smokers, and oral hygiene measures. Settings and Design: Cross sectional study.
Sundernagar, District Materials and Methods: The study included 400 male (200 cigarette smokers and 200 non smokers) aged 1865
Mandi, Himachal years. The subjects were randomly selected from the patients attending dental outpatient department of civil
Pradesh, India hospital and Himachal Dental College, Sundernagar. Community Periodontal Index (CPI) score was recorded
for each patient and a questionnaire was completed by each patient. Statistical Analysis Used: Chi square and
ttest. Results: Periodontal condition as assessed by CPI score showed that there was statistically significant
difference in the findings between cigarette smokers and nonsmokers. Conclusions: Within the limits of this
study, positive association was observed between periodontal disease and cigarette smoking. It was found that
cigarette smoking was associated with lesser gingival bleeding and deeper pockets as compared to nonsmokers.
Key words:
Community periodontal index, periodontal disease, smoking

Access this article online

INTRODUCTION
Website:
www.jisponline.com
DOI:
10.4103/0972-124X.92575 P eriodontal disease is one of the most common
chronic diseases in adults.[1] It is second only
to dental caries as a cause of tooth loss among
Quick Response Code:
adults in developed countries.[2]
About 80% of myocardial infarctions before the
age of 50 years, and 70% of chronic lung diseases
are caused by tobacco smoking.[3]
Tobacco smoking, mostly in the form of cigarette
smoking, is recognized as the most important
environmental risk factor in periodontitis.[4]
Periodontal diseases are a dynamic phenomenon
with cyclical patterns of progression and
resolution at any given site.[5] Smoking is thought
to impair the immune response and compromises
the periodontal tissues ability to heal, following
Address for a period of disease activity.[6]
correspondence:
Dr. D. K. Gautam,
Department of It has been well demonstrated that there is a
Periodontics, Himachal closeresponse relationship for tobacco use and
Dental College, the risk of the development of oral cancer.[7]
Sundernagar,
District Mandi, The population impact of smoking on
Himachal Pradesh, India. periodontitis also varies according to the
Email: gautam.
devender3@gmail.com
frequency of exposure to tobacco smoking
in populations.[8] Gingival bleeding has been
Submission: 27-07-2010 consistently reported to occur less in smokers
Accepted: 30112011 due to nicotine induced vasoconstriction in
smokers gingiva as well as heavy gingival
keratinization.[9] Pocket depth measurements are
found to be greater in smokers due to increased
alveolar bone loss.[10,11]
Tobacco smoking probably plays a significant role
in the development of refractory periodontitis.[12]
Periodontal breakdown has been shown to be
more severe among current smokers compared
to former smokers. Those who have never
smoked have been observed to have the lowest
risk.[13] Smoking has a strong negative impact on
regenerative therapy, including osseous grafting,
guided tissue regeneration, or a combination of
this treatment.[14]
Josef[15] examined periodontal needs according to
the community periodontal index of treatment
needs (CPITN) and smoking habits. The
results showed that effect of both smoking
and the number of cigarettes smoked had
deleterious effect on periodontal status. Gerad
et al.,[16] concluded that cigarette smoking was
a major environmental factor associated with
accelerated periodontal destruction in young
adults. Palmer et al.,[17] reviewed the potential
biological mechanisms underlying the effects
of tobacco smoking on periodontitis and
concluded that tobacco smoking has widespread
systemic effects, many of which may provide
mechanisms for the increased susceptibility
to periodontitis and the poorer response to

Journal of Indian Society of Periodontology - Vol 15, Issue 4, Oct-Dec 2011 383
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Gautam, et al.: Effect of smoking on the periodontal health status
treatment. Torrungruang,[18] determined the effect of cigarette
smoking on the severity of periodontitis in a crosssectional
study of older Thai adults and concluded that there was a
strong association between cigarette smoking and the risk of
periodontitis.
Ankola et al., conducted a comparative study of periodontal
[19]
status and loss of teeth among smokers and non smokers of
Belgaum city and concluded that smoking was associated
with higher plaque and calculus deposits. Vered et al.,[20]
evaluated the periodontal status and present smoking habits
among a representative sample of young adult Israelis, and
investigated possible associations and concluded that only
7% of the participants demonstrated signs of periodontitis and
most young adults did not smoke.
During periodontitis, cigarette smoking may differentially
affect neutrophil function, generally preventing elimination of
periodontal pathogens, but, in heavy smokers also stimulated
reactive oxygen species release and oxidative stress mediated
tissue damage.[21] Tymkiw et al.,[22] compared the expression
of 22 chemokines and cytokines in gingival crevicular fluid
from smokers and nonsmokers, with periodontitis and
periodontally healthy control subjects, and concluded that
periodontitis subjects had significantly elevated cytokine and
chemokine profiles. Smokers exhibited a decrease in several
proinflammatory cytokines and chemokines and certain
regulators of Tcells and natural killer cells. This reflected
that the immunosuppressant effects of smoking which may
contribute to an enhanced susceptibility to periodontitis.
MATERIALS AND METHODS
Study sample
A cross sectional study design was used. This study included
400 male aged 18 to 65 years attending dental outpatient
department of civil hospital and Himachal Dental College,
Sundernagar. Community Periodontal Index (CPI) was used
as an epidemiological tool. Patients were randomly selected
depending on following criteria.
Inclusion criteria
Over 18 years of age and not older than 65 years of age.
More than 10 natural teeth present.
Exclusion criteria
Chronic systemic pathology, such as diabetes, other
endocrine pathologies, hematological pathologies.
Periodontal health, with no clinical signs of periodontal
inflammation (CPI=0).
Subjects were divided into two groups:
Cigarette smokers
Nonsmokers
Questionnaire
A questionnaire was developed. It included questions on oral
hygiene habits and smoking habits.
Clinical examination
The periodontal examination was conducted using the mouth
mirror and CPITN probe, and the CPI score was recorded.
384 Journal of Indian Society of Periodontology - Vol 15, Issue 4, Oct-Dec 2011
Questionnaire
Patient Name:Sex: M/F
Age:.......................... Address:..
Occupation:
Please give only one answer to each question
1. How often do you brush your teeth each day?
1 2 3 4
After each meal Sometimes
2. How many minutes do you brush your teeth for?
1 2 3 4 Over 4 minutes
3. What type of tooth brushing movements do you employ?
Vertical Horizontal Combined
4. Do you use a mouthwash?
Yes No
If yes, how often?
1/day 2/day
3/day more than 3/day
5. Which secondary methods for plaque control do you use?
Dental floss Interdental brushes
Toothpicks None
6. Do you, or did you use an electric toothbrush?
Yes No
7. On what is your daily diet mainly based?
Potato chips Vegetables
Milk products Meat
8. Do you have bleeding gums?
Yes No
If yes, are these:
Spontaneous Provoked Not constant
9. Do you have any health problems?
Yes No
If yes, please give details.
10. Do you smoke?
Yes No I quit smoking
11. If you are a smoker, how many cigarettes do you smoke daily?
110 cigarettes 1120 cigarettes
2140 cigarettes Over 40 cigarettes
Codes and criteria of CPI index
Code0=No periodontal disease (healthy periodontium).
Code1=Bleeding observed during or after probing.
Code2=Calculus or other plaque retentive factors either seen
or felt during probing.
Code3=Pathological pocket 4 to 5 mm in depth. Gingival
margin situated on black band of the probe.
Code4=Pathological pocket 6 mm or more in depth. Black
band of the probe is not visible.
Ethics
The ethical committee of the Himachal Dental College
approved the study. Patients who agreed to participate signed
an informed consent form. At the conclusion of the study, the
participants were provided with oral health instructions and
a specific periodontal treatment plan.
RESULTS
Young adults under 35 years represented the majority of the
study population, that is 47% of the total sample, 51% were
current cigarette smokers. In the oldest age group (over 55
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Gautam, et al.: Effect of smoking on the periodontal health status

years), only a small proportion (11%) were current cigarette score 4 (P=0.045; cigarette smokers more likely to have deep
smokers [Table 1]. pockets) [Table 4].

The mean age of 37.34 years (SD 12.06) was in the non smoker
group, and mean age of 38.07 years (SD 13.21) was in the
cigarette smoker group [Table 2].
The difference in age in cigarette smokers and non smokers
was not statistically significant [Table 3].
Periodontal condition as measured by maximum CPI score
per person showed that in the group studied, there were
statistically significant differences between cigarette smokers
and non smokers for CPI score of 1 (P=0.007; non smokers more
likely to have gingival bleeding), 2 (P=0.004; cigarette smokers
more likely to have calculus present), CPI score 3 (P=0.001;
non smokers more likely to have shallow pockets), and CPI
According to the selfreported oral hygiene practices, the mean
tooth brushing frequency in cigarette smokers was slightly
higher compared with the non smoker group, but was not
found to be statistically significant [Table 5]. Cigarette smokers
also reported that they brushed their teeth for longer than
non smokers. The tooth brushing time per minute was not
statistically significant in non smoker, and the cigarette smoker
group at 0.05 level of significance [Table 6].
DISCUSSION
It has been estimated that about a third of the male adult
global population smokes. Among the young, one in five
smokes worldwide. Between 80,000 and 100,000 children

Table 1: Study group according to age and cigarette smoking

Age (years) 1865 n (%) <35 n (%) 3544 n (%) 4555 n (%) >55 n (%)
Sample
Total 400 (100) 188 (47) 92 (23) 76 (19) 44 (11)
Nonsmokers 200 (50) 92 (49) 48 (52) 48 (63) 12 (27)
Cigarette smokers 200 (50) 96 (51) 44 (48) 28 (37) 32 (73)
Chi square 0.08 1.174 5.26 9.09
P value 0.77 0.67 0.02 0.00

Table 2: Mean and standard deviation according to age among cigarette smoker and non smoker group
Group n Mean age Std. deviation
Non smokers 200 37.34 12.06
Cigarette smokers 200 38.07 13.21

Table 3: Comparison ttest on age between cigarette smokers and non smokers
Group N Mean age Std. deviation Std. error mean T Df P value
Non smokers 200 37.34 12.06 0.85 0.573 398 0.567
Cigarette smokers 200 38.07 13.21 0.93

Table 4: CPI scores according to reported cigarette smoking

CPI scores Code 1 bleeding (%) Code 2 calculus (%) Code 3 shallow Code 4 deep pocket Total n (%)
pocket 45 mm (%) 6 mm (%)
Non smokers 31 (15.5) 87 (43.5) 56 (28) 26 (13) 200 (100)
Cigarette smokers 14 (7) 116 (58) 29 (14.5) 41 20.5) 200 (100)
Chi square 7.24 8.41 10.89 4.03
P value 0.007** 0.004** 0.001** 0.045*
**Significant at 0.01 level. *Significant at 0.05 level; CPI Community periodontal index

Table 5: Tooth brushing frequency/times per day among cigarette smokers and non smokers
Frequency Cigarette smokers n (%) Non smokers n (%)
Once 167 (83.5) 170 (85.0)
Twice 18 (9.0) 14 (7.0)
Sometimes 10 (5.0) 12 (6.0)
After meal 5 (2.5) 4 (2.0)
Total 200 (100.0) 200 (100.0)
Cigarette smokers vs Non smokers: Chi-sq= 0.82, P=0.9357NS

Table 6: Tooth brushing times/minutes per day

Group N Mean Std. deviation Std. error mean t Df P value
Non smokers 200 2.22 0.83 0.58 0.651 398 0.516
Cigarette smokers 200 2.75 0.86 0.61

Journal of Indian Society of Periodontology - Vol 15, Issue 4, Oct-Dec 2011 385
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Gautam, et al.: Effect of smoking on the periodontal health status
worldwide, starts smoking every day.[19] In the current study,
51% of all smokers were young adults under 35 years of age.
Smoking is on the rise in the developing world, but falling in
developed nations. About 15 billion cigarettes are sold daily or
10 million every minute.[23] Smoking has clearly been implicated
contributing to periodontal breakdown and in impeding
healing of periodontal tissues.[24]
Tobacco smoke contains many cytotoxic substances such
as nicotine, which can penetrate the soft tissue of oral
cavity, adhere to the tooth surface or enter to the blood
stream. Potential molecular and cellular mechanisms in the
pathogenesis of smoking associated periodontal diseases
has been reported and these include, immunosuppression,
exaggerated inflammatory cell responses, and impaired stromal
cell functions of oral tissues. The association between cigarette
smoking and periodontal diseases represent a significant oral
health problem.[25]
The findings in the present study are consistent with the study
of Feldman et al.,[26] showed that smokers with periodontal
disease had less clinical inflammation and gingival bleeding
when compared with non smokers. This may be explained
by the fact that one of numerous tobacco smoke byproducts,
nicotine, exerts local vasoconstriction, reducing blood flow,
edema and acts to inhibit what are normally early signs of
periodontal problems by decreasing gingival inflammation,
redness, and bleeding.
Some in vitro studies provided other possible intimate
mechanisms by which smoking may affect bone metabolism.
Rosa et al.,[27] reported that nicotine increased the secretion of
interlukin6 and tumor necrosis factor alpha in osteoblasts and
production of tissuetype plasminogen activator, prostaglandin
E2, and matrix metalloproteinase, thereby tipping the balance
between bone matrix formation and resorption toward the
latter process, as reported by Katano et al.[28] Receptor activator
of nuclear factorkappa ligand (RANKL) and osteoprotegerin
(OPG) are members of the tumor necrosis factor super family.
RANKL promotes osteoclastic differentiation and activates
bone resorption. In contrast, OPG inhibits osteoclastogenesis
and suppresses bone resorption by inhibition of RANKL.
Another potential mechanism of bone loss in smokers may
be the suppression of OPG production and a change in the
RANKL/OPG ratio. Although bacteria are the primary
etiologic factors in periodontal disease, the patients host
response is a determinant of disease susceptibility.
Smokers appear to have depressed numbers of helper
lymphocytes, which are important to Bcell function and
antibody production.[25]
The combined effect of bacterial colonization and the local
and systemic effect of smoking are responsible for the greater
severity of periodontal destruction in smokers of the current
study. These results of the current study are similar to those
reported by Linden and Mullally,[29] Harber et al.,[30] Schenkein
et al.,[31] and Haffajee.[32] All of these studies have shown that
compared to nonsmokers, young adult smokers have a
higher prevalence and severity of periodontitis. At the same
time, results of the present study showed that the gingival
386 Journal of Indian Society of Periodontology - Vol 15, Issue 4, Oct-Dec 2011
bleeding and gingival inflammatory symptoms appeared to
be suppressed in smokers. These results are parallel to those
reported by Schuller,[33] Bergstrm and Bostrm[34] and Chen
et al.[35]
In this study, we used the CPI as recommended by the World
Health Organization. CPI is not a perfect measure of periodontal
disease and excludes measurement of attachment loss, gingival
recession, alveolar bone level, and other clinical periodontal
parameters. Nevertheless, it was originally proposed as an
appropriate estimation of disease in large epidemiological
surveys and has contributed to an understanding of the
epidemiology of periodontal disease on a global level.[36]
Data from the present study may therefore only offer
an estimation of the prevalence of the moderate or deep
periodontal pocketing, and not of all clinical disease
parameters. The result of this study confirms a consistent
association between smoking and periodontal status.
However, smoking duration was not recorded and this
determinant could not be included in the analyses. It should
be noted that given the small difference between smokers and
non smokers, other factors should have been considered such
as socioeconomic status and stress.
In conclusion, the current study shows that smoking is a
major environmental factor associated with accelerated
periodontal destruction. The progression and excessive loss
of periodontal support in later life depends to a greater extent
upon excessive smoking in youth. The findings highlight the
need for preventive strategies aimed at young individuals,
many of whom take up smoking as a habit, early in life. Dental
public health efforts, therefore, need to include and emphasize
the role of smoking and not only oral hygiene in primary
preventive efforts.
Statistics/data analysis
The association of cigarette smoking and other risk factors for
periodontal status was examined in this comparative, cross
sectional study. The Chisquare test was used to test whether
the variables had normal or nonnormal distribution. The ttest
was used to compare group means.
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How to cite this article: Gautam DK, Jindal V, Gupta SC, Tuli A,
Kotwal B, Thakur R. Effect of cigarette smoking on the periodontal
health status: A comparative, cross sectional study. J Indian Soc
Periodontol 2011;15:383-7
Source of Support: Nil, Conflict of Interest: None declared.

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