ORIGINAL RESEARCH REPORT

Relating oral hygiene, gingival, and periodontal status

with nicotine dependence among smokers - A cross-
sectional study
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Chibuzor Osediye Boi‑Ukeme, Clement Chinedu Azodo1

Department of Periodontics, School of Dentistry, University of Benin, 1Department of Periodontics, University of Benin, Benin City, Edo State,
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Nigeria

ABSTRACT
Background: The objective was to examine the oral hygiene, gingival, and periodontal status
among smokers and to relate them with nicotine dependence. Methods: The cross‑sectional
study was carried out among smokers and nonsmokers in Benin‑City, Edo State. Data collection
was done through questionnaire and oral examination. The indices applied were Fagerstrom
test, Simplified Oral Hygiene Index (OHI‑S), Gingival Index (GI), Community Periodontal
Index, and tooth mobility index. Results: A total of 40 (20 smokers and 20 nonsmokers)
Submitted: 22-Apr-2019
persons participated in the study. The mean OHI‑S for smokers was 2.87 ± 0.92 while that of
Revised: 26-Apr-2020
Accepted: 31-Jul-2020 nonsmoker was 2.20 ± 0.73 and this was statistically significant (P = 0.015). The mean GI for
Published: 19-Oct-2020 smokers was 1.04 ± 0.36 while that of nonsmoker was 0.80 ± 0.22 and this was statistically
significant (P = 0.018). The mean number of mobile teeth for smokers was 0.15 ± 0.49 while
that of nonsmoker was. 00 ± 0.00 and this was not statistically significant (P = 0.178).
Address for correspondence: One‑quarter (25%) of smokers had score 3 and 4 while only 5% of nonsmokers had were found
Dr. Clement Chinedu Azodo, Shallow and deep pockets were found score 3 and 4. About half (45.0%) of the smokers had
Room 21, 2nd Floor, Department low‑moderate nicotine dependency among the smokers revealed that. Participants with higher
of Periodontics, Prof Ejide Dental nicotine dependence had nonsignificantly poorer oral hygiene, gingival, and periodontal status
Complex, University of Benin than their counterparts. Conclusion: Smokers generally had poorer oral hygiene, gingival, and
Teaching Hospital, PMB 1111, periodontal status as compared to the nonsmokers. Smokers with higher nicotine dependence
Ugbowo, Benin City, Edo State,
did not have poorer oral hygiene, gingival, and periodontal status than their counterparts.
Nigeria.
E‑mail: [email protected] Key words: Nonsmokers, oral health, periodontal disease, smokers

INTRODUCTION diseases and a major cause of tooth loss in Nigeria.[7] Smoking

increases the severity and progression of periodontal
Tobacco in varied forms (smoked or smokeless) is harmful disease and exerts adverse effects on periodontal treatment
to almost every organ in the body and is associated with outcome.[2] It has also been reported that cigarette smoking
multiple diseases thereby reducing quality of life and exerts a strong and chronic effect on the periodontium
longevity. Many chemicals generated when cigarette resulting in lesser gingival bleeding and deeper periodontal
burns are poisonous and potentially carcinogenic and the pockets.[3,4] Tobacco smoking is an important environmental
morbidities from cigarette smoking documented in the risk factor for periodontitis as smokers are five times more
literature are skewed toward general health despite the fact likely to develop severe periodontitis than nonsmokers.[5,6]
that the oral manifestations are glaring and starts early.[1] The other periodontal manifestations of tobacco smoking
Studies have established an etiological link between smoking
and periodontal disease[2‑6] which is one of the main oral This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
Access this article online which allows others to remix, tweak, and build upon the work non‑commercially,
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Website:
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DOI: How to cite this article: Boi-Ukeme CO, Azodo CC. Relating oral
10.4103/jcls.jcls_35_19
hygiene, gingival, and periodontal status with nicotine dependence
among smokers - A cross-sectional study. J Clin Sci 2020;17:127-30.

© 2020 JOURNAL OF CLINICAL SCIENCES | PUBLISHED BY WOLTERS KLUWER - MEDKNOW Page | 127
 Boi‑Ukeme and Azodo: Relating periodontal health with nicotine dependence among smokers

include stained teeth, bad breadth, gingival recession, related to cigarette smoking. It contains 6 items that
attachment loss, dental implant failure, increase in number evaluate the quantity of cigarette consumption, the
of deep pockets, furcation involvement in molar teeth, bone compulsion to use, and dependence. Fagerstrom Test for
loss, and tooth loss.[1,6,8] Nicotine Dependence is scored as follows; yes/no items are
scored from 0 to 1 and multiple‑choice items are scored
Cigarette smoking results in periodontal manifestations from 0 to 3. The items are summed to yield a total score
through local and systemic mechanisms. Cigarette of 0–10. The higher the total Fagerström score, the more
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stains favor plaque retention while nicotine causes intense is the patient’s physical dependence on nicotine.
vasoconstriction of gingival blood vessel and decreases Nicotine dependency among the smokers were categorized
oxygen tension, which may create a favorable subgingival as low dependence (1–2), low‑moderate dependence (3–4),
environment for colonization by anaerobic bacteria.[6,9] Heat moderate dependence (5–7), and (High dependence)
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from cigarette smoke increases calculus formation.[10] Other 8–10. Oral hygiene status was assessed using Oral Hygiene
mechanisms include reduced mobilization and movement Index‑Simplified (OHI‑S) Index,[17] gingival status with
of host defence to the gingiva, decreased healing capacities Gingival Index (GI),[18] periodontal status with Community
in collagen synthesis, inhibition of fibroblast growth and Periodontal Index (CPI),[19] and tooth mobility with Millers
damage to cell membrane.[9‑13] It has also been shown that index.[20] Tooth mobility of Grade 0 which means absence of
both cellular and humoral immune systems are adversely tooth mobility was scored as 0 per tooth while Grade 1–3
affected through its effect on the cytokine network and was scored as 1 per tooth.
suppression of both chemotactic and phagocytic functions
of polymorphonuclear leukocytes in saliva and tissues.[9] Informed consent was obtained from the participants.
Smokers have been shown to respond poorly to periodontal Participation was voluntary. Scaling and root planing
therapy than nonsmokers because smoking impairs healing were done for the participants after the questionnaire
by decreasing the reparative and regenerative potential of administration and clinical examination as incentive
the periodontium and calcium deposition in the alveolar for participation. The obtained data were subjected to
bone.[14,15] Few oral health studies on smokers in Nigeria Chi‑square or Fisher’s exact statistics and independent
that evaluated their response to periodontal treatment t‑test and using IBM SPSS version 21.0 (IBM Corp. Armonk,
or were conducted in a risk group (inmates of prison), New York, United States of America). The statistically
included arrays of periodontal indices but none assessed significant association was set at P < 0.05.
nicotine addiction among the smokers.[14‑16] Even when
neglect of oral hygiene exists in drug addicts. Hence, the RESULTS
objective of this study was to examine the oral hygiene,
gingival and periodontal status among smokers and to A total of 97 (62 tobacco users and 35 nontobacco
relate them with nicotine dependence. users) persons were approached to take part in the
study but only 20 male smokers gave their consent
MATERIALS AND METHODS and 20 age‑matched nonsmokers were consequently
selected giving a total of 40 participants. The mean
This cross‑sectional study was conducted among smokers age of smokers was 39.20 ± 7.26 years while that of
in Benin City between December, 2016 and February, the nonsmokers was 39.10 ± 7.75 years [Table 1].
2017. The smokers aged 18–60 years were approached at Nicotine dependency among the smokers revealed that
varied locations in Benin City and invited to University of 9 (45.0%) had low dependence (1–2), 9 (45.0%) had
Benin Teaching Hospital Outpatient Dental Clinic for the low‑moderate dependence (3–4), 2 (10.0%) had moderate
research. Smokers who came to hospital and gave consent dependence (5–7), and 0 (0.0%) had high dependence)
were included while those who had any known systemic (8–10). The mean OHI‑S for smokers was 2.87 ± 0.92 while
conditions that could influence oral health and did not that of nonsmoker was 2.20 ± 0.73 and this was statistically
give informed consent were excluded from the study. significant (P = 0.015). The mean GI for smokers was
Age‑ and sex‑matched nonsmokers were recruited from 1.04 ± 0.36 while that of nonsmoker was 0.80 ± 0.22 and
the same population. Data collection was done through this was statistically significant (P = 0.018). The mean
interviewer‑administered questionnaire and clinical
examination. The questionnaire elicited information on Table 1: Demographic characteristics of the
demographic characteristics and nicotine dependence of participants
the smokers. Clinical examination was done to determine Characteristics Nonsmokers, n (%) Smokers, n (%)
oral hygiene, gingival health, periodontal status, and tooth Age (years)
mobility. Nicotine dependence of the smokers was assessed 20-40 13 (65.0) 13 (65.0)
using Fagerstroms test which is a standard instrument for 41-60 7 (35.0) 7 (35.0)
assessing the intensity of physical addiction to nicotine. The Mean age 39.10±7.75 39.20±7.26
test provides an ordinal measure of nicotine dependence The mean age of participants 39.15±7.41 years

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 Boi‑Ukeme and Azodo: Relating periodontal health with nicotine dependence among smokers

number of mobile teeth for smokers was 0.15 ± 0.49 of moderate nicotine‑dependent smokers and 44.4% of
while that of nonsmoker was 0.00 ± 0.00 and this was not the low‑moderate dependent smokers had moderate and
statistically significant (P = 0.178). One‑quarter (25.0%) of severe gingival inflammation but this was not statistically
the smokers had poor oral hygiene while one‑tenth (10.0%) significant (P = 0.762). All (100.0%) of the moderate
of the nonsmokers had poor oral hygiene. There nicotine‑dependent smokers had shallow pockets while
was no statistically significant association between 22.2%% of the low‑moderate‑dependent smokers had
oral hygiene status and smoking status (P = 0.246). shallow pockets (11.1%) and deep pockets (11.1%) but
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Four‑tenth (40%) of the smokers had moderate‑to‑severe this was not statistically significant (P = 0.063) [Table 3].
gingival inflammation while all (100.0%) nonsmokers
had mild gingivitis. There was statistically significant DISCUSSION
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association between gingival status and smoking

Findings from this study, using the Fagerstrom
status (P = 0.003). One‑quarter (25%) of the smokers
test showed that the smokers generally had low to
had CPI scores 3 and 4 while only 5% of the nonsmokers
low‑moderate nicotine dependence which contrasted
had CPI scores 3 and 4. There was no statistically
with findings among Indian health and nonhealth‑care
significant association between periodontal status and professional college students where the participants had
smoking status (P = 0.257) [Table 2]. Half (50.0%) of the moderate nicotine dependence.[21] In this study, more
moderate nicotine‑dependent smokers had poor oral smokers (25.0%) had poorer oral hygiene status than
hygiene status while 22.2% of the low and low‑moderate nonsmokers (10.0%). This was not statistically significant
dependent smokers had poor oral hygiene status but this with the categorization of oral hygiene into good, fair, and
was not statistically significant (P = 1.000). Half (50%) poor status but became statistically significant when the
mean values were compared. This finding was similar to
Table 2: Oral hygiene, gingival, and periodontal that of studies conducted in Lagos[12,22] and Ibadan[15,23]
status among the participants Nigeria among smokers. The worse oral hygiene status
Variable Nonsmokers, n (%) Smokers, n (%) Total, n (%) Fisher’s P seen among the smokers may be due to increased calculus
OHI‑S formation and plaque accumulation due to cigarette tar
1.00 2 (10.0) 0 (0.0) 2 (5.0) 0.246 stains in smokers.
2.00 16 (80.0) 15 (75.0) 31 (77.5)
3.00 2 (10.0) 5 (25.0) 7 (17.5) Smokers had significantly more severe (moderate‑to‑severe)
GI form of gingival inflammation than nonsmokers which is
1.00 20 (100.0) 12 (60.0) 32 (80.0) 0.003 in keeping with findings of a study by Arowojolu et al.[23]
2.00 0 (0.0) 7 (35.0) 7 (17.5) finding in a study among smokers and nonsmokers in
3.00 0 (0.0) 1 (5.0) 1 (2.5) Ibadan, Nigeria. Smokers had poorer periodontal status
CPI in terms of shallow pockets (score 3) and Deep pockets
1 1 (5.0) 0 (0.0) 1 (2.5) 0.257 (score 4) than nonsmokers. Poorer periodontal status in
2 18 (90.0) 15 (75.0) 33 (82.5)
terms of shallow pockets and Deep pockets with reports
3 1 (5.0) 4 (20.0) 5 (12.5)
in sextants patterns in smokers in comparison with
4 0 (0.0) 1 (5.0) 1 (2.5)
Total 20 (100.0) 20 (100.0) 20 (100.0)
nonsmokers has been similarly reported by Nwhator
OHI‑S=Simplified Oral Hygiene Index, GI=Gingival Index, CPI=Community
et al.[12] The mean number of mobile teeth for smokers
Periodontal Index was higher than that recorded among nonsmoker which is

Table 3: Relating nicotine dependence with oral hygiene, gingival, and periodontal status among
smokers
Variable Low dependence, n (%) Low‑moderate dependence, n (%) Moderate dependence, n (%) Total, n (%) P
OHIS
2.00 7 (77.8) 7 (77.8) 1 (50.0) 15 (75.0) 1.000
3.00 2 (22.2) 2 (22.2) 1 (50.0) 5 (25.0)
GI
1.00 6 (66.7) 5 (55.6) 1 (50.0) 12 (60.0) 0.762
2.00 3 (33.3) 3 (33.3) 1 (50.0) 7 (35.0)
3.00 0 (0.0) 1 (11.1) 0 (0.0) 1 (5.0)
CPI
2 8 (88.9) 7 (77.8) 0 (0.0) 15 (75.0) 0.063
3 1 (11.1) 1 (11.1) 2 (100.0) 4 (20.0)
4 0 (0.0) 1 (11.1) 0 (0.0) 1 (5.0)
Total 9 (100.0) 9 (100.0) 2 (100.0) 20 (100.0)
OHI‑S=Simplified Oral Hygiene Index, GI=Gingival Index, CPI=Community Periodontal Index

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