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 Table of Contents  
Year : 2013  |  Volume : 57  |  Issue : 2  |  Page : 105-108  

Periodontal status among tobacco users in Karnataka, India

1 Assistant Professor, Department of Public Health Dentistry, Amrita School of Dentistry, Edapally, Cochin, Kerala, India
2 Professor, Department of Public Health Dentistry, Amrita School of Dentistry, Edapally, Cochin, Kerala, India

Date of Web Publication15-Jul-2013

Correspondence Address:
Chandrashekar Janakiram
Department of Public Health Dentistry, Amrita School of Dentistry, Edapally, Cochin - 682 041, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-557X.115006

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A cross-sectional study was designed to assess the prevalence of periodontal diseases among tobacco and non-tobacco users. A total of 2,156 dentate subjects were selected in the age group of 35-44 years through multi-stage sampling method. A total of 350 and 175 subjects were selected from household survey from each district in rural and urban areas. Subjects were interviewed for the tobacco usage status, followed by clinical assessment of periodontal status. Prevalence of calculus, periodontal pockets of 4-5 mm depth and loss of attachment of 0-3 mm and 4-5 mm was significantly more frequent among current tobacco users. The subject with smoking and chewing tobacco has an odds ratio (OR) 1.6 (95% confidence intervals [CI] 1.14-2.31) and OR 1.7 (95% CI 1.38-2.28) respectively. The findings contribute to the evidence of smoking as a risk factor for periodontal disease.

Keywords: Chewing, Periodontal disease, Smoking, Tobacco

How to cite this article:
Mohamed S, Janakiram C. Periodontal status among tobacco users in Karnataka, India. Indian J Public Health 2013;57:105-8

How to cite this URL:
Mohamed S, Janakiram C. Periodontal status among tobacco users in Karnataka, India. Indian J Public Health [serial online] 2013 [cited 2023 Mar 23];57:105-8. Available from:

Tobacco use and its association with oral diseases is a major contributor to the global oral disease burden [1] and responsible for up to half of all periodontitis cases among adults. There is no universally agreed upon definition of periodontitis or of disease severity. The Armitage definition has been widely accepted for epidemiological studies," periodontal disease defined as attachment loss of at least 4 mm at one or more sites." [2] Due to various tobacco usage practices, it is important to take in to account the associated diseases caused by tobacco. The earlier studies on tobacco usage pattern and periodontal status mainly have been hospital-based populations because of the convenience. The prevalence assessed among hospital based samples will be different than that assessed among the general population and they are not representative of the general population. The baseline data about the magnitude of dental diseases needs to be from the valid epidemiological data to plan for national or regional oral health promotion programs. The age group of 35-44 years also provides full blown effect of periodontal. [3] The present study was carried out to assess the relationship between tobacco usage and occurrence of periodontal disease among 35-44-year-olds people in Karnataka state.

This cross-sectional analytical study was conducted in four districts of Karnataka state, India, based on agro-climatic zones namely Northern, Central, Southern and Coastal region. [4] A multi-stage sampling design was followed and total of 48 areas with 20 urban and 28 rural areas were selected from four districts. Ethical approval was obtained from the institutional ethical review committee of Yenopaya Dental College and Hospital Mangalore. We calculated the total sample size of 2,100 subjects using formula 4PQ/L [2] , where, p- Prevalence rate, q- Probability level, L- Permissible error in the estimate of p. In our study, α was 0.05 and β was 0.2 with the prevalence (P) of 95% periodontal disease. [4] Minimum of 350 households in rural areas and 175 households in urban areas were selected per district assuming we get minimum one subject from one household. Data was collected from household survey that included examination of periodontal status and exposure ascertainment of selected subjects in their houses. The periodontal status was assessed using community periodontal index in selected subjects in their households using the artificial light (yellow light) according to the criteria defined in basic methods: oral health survey 1997. [3] A pretested questionnaire was prepared containing 19 item questionnaires to elicit the information on the tobacco usage status and also other information such as oral hygiene status, demographic details etc. Tobacco users were classified as follows:

  • Tobacco user: [5] An individual who is currently using tobacco once a day or more often in the form of smoke or smokeless tobacco.
  • Non-tobacco user: [5] An individual who had never used tobacco in the form of smoke or smokeless tobacco.
  • Ex-user: [5] An individual who had been using tobacco more often in the form of smoke or smokeless tobacco and has quit the habit for past 1 year.
  • Occasional user: [5] An individual who is using tobacco occasionally in the form of smoke or smokeless tobacco.

The two day training session was conducted in Department of Community Dentistry, of a Yenopaya dental College Mangalore India. Kappa averaged 0.92 for inter-examiner reliability. The training was a simulation of field examination technique. Data were processed using SPSS 17 (SPSS Chicago). A series of bivariate analysis were performed, which was then followed by a stratified analysis on selected variables.

A total of 2,600 subjects were included out of which 2,156 subjects responded with (the survey with the response rate of 83%). Among the subjects 51.9% were males. The mean age of study population was 39.52 ± 2.75 years. In the present study, 68.9% were tobacco users and 31.1% were non tobacco users. 1.4% of occasional users and 0.5% of ex-users were merged with tobacco and nontobacco users respectively. Among smoking tobacco users, 59.0% and 41.0% were beedi and cigarette smokers respectively. Paan with tobacco consumption (49.7%) was the most popular form of chewing habit among tobacco chewers followed by gutkha use (27.1%), plain tobacco with lime consumption (14.3%) and pan masala with tobacco (8.9%). In the current study, smoking habit was only found among males.

In our study, the prevalence of periodontal disease was almost 100%. The proportion of subjects having calculus was 41.4%. Loss of attachment was present in almost 50% of the study population.

The tobacco users had 2.43 times risk for periodontal disease when compared with non-tobacco users with odds ratio (OR) 2.43 (95% confidence intervals [CI] 2.0-2.97) [Table 1]. The tobacco users were divided into smokers, chewers and both. The risk was highest OR 3.32 (95% CI 2.57-4.30) when individual consumes both forms of tobacco compared to non-tobacco users. Only tobacco smokers and tobacco chewers had a lower risk OR 2.10 (95% CI 1.58-2.68) and OR 2.18 (95% CI 1.73-2.75) respectively compared with non-tobacco users [Table 1].
Table 1: Association of tobacco consumption with the occurrence of periodontal disease

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The association of tobacco smokers and occurrence of periodontal disease was further strengthened by the quantity and duration of consumption. There was a significant risk associated with development of periodontal disease when the subjects smoked 11 or more beedis/cigarettes OR 2.86 (95% CI 2.07-3.96) when compared to those who smoked lesser quantity per day. Among the smokers the subjects who smoked for duration of 10 years or more had 2.35 (95% CI 1.53-3.63)

more risk of developing periodontal disease when compared to those smokers who had the habit for lesser duration [Table 2].
Table 2: Association of periodontal disease according to quantity and duration of tobacco smokers and chewers

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Subjects with the habit of chewing 4-5 packs of tobacco products such as gutkha and betel quid etc. showed twice the risk of periodontal disease OR 2.0 (95% CI 1.66-2.42) compared to non-chewers [Table 2]. Chewing tobacco for a period of more than 10 years showed three times higher risk for periodontal disease OR 2.12 (95% CI 1.50-3.01), compared to those who chewed for less than 10 years OR 1.93 (95% CI 1.60-2.31).

The association of tobacco consumption with severity of periodontal disease has been widely studied, but the earlier studies were unable to quantify the associations mainly because of the design problems and were clinical studies. Hence, our objective was quantifying the risk in terms of frequency, duration and dose relationship between the either forms of tobacco and so that risk can be used for tobacco cessation activity.

The definition of periodontal disease used in this study follows the recommendation that periodontal disease severity is measured based on irreversible attachment loss rather than on reversible pocket depth. [2]

In the present study shows higher prevalence (68.9%) of either forms of tobacco consumption compared to other studies which found 27% and 18% in India. [6] This may be attributed to that the only subjects where maximum numbers of consumers were in the age group of 35-44 years. Due to the low cost of beedis, [7] beedi smoking (59.0%) was the most popular followed by cigarette consumption (41.0%). The rolling of beedis by local self-groups in rural areas may contribute to increased consumption due to easy accessibility. [8]

One of the important findings of study is the higher proportion of tobacco consumers showed the presence of calculus followed by shallow pockets. Previous studies have shown tobacco could increase the accumulation of plaque and subsequent calculus. [9]

The study findings shows the linear relationship between the quantity of consumption of tobacco (chewing and smoking tobacco) and occurrence of periodontal disease. Though, the previous studies shows the relationship between the prevalence of moderate to severe periodontal disease and smoking, but were unable demonstrate any risk estimates. [10]

One of the important findings is the presence of additive statistical interaction between two exposures chewing tobacco and smoking tobacco. The subject with smoking and chewing tobacco has an adjusted risk of OR 1.6 and 1.7 respectively on periodontal disease. The subjects who consume both forms of tobacco have OR 3.29 times of chance of getting periodontal disease compared to nonsmokers. To our knowledge, none of the previous studies has shown the considerable association between the chewing tobacco and periodontal disease in the community based studies.

To conclude, tobacco usage not only contributes to periodontal disease, but spurs the development of oral cancer, smoking cessation should be considered in the treatment of periodontitis and be a part of health prevention in dentistry.

   References Top

1.Tomar SL, Asma S. Smoking-attributable periodontitis in the United States: Findings from NHANES III. National Health and Nutrition Examination Survey. J Periodontol 2000;71:743-51.  Back to cited text no. 1
2.Armitage GC. Periodontal diagnoses and classification of periodontal diseases. Periodontol 2000 2004;34:9-21.  Back to cited text no. 2
3.WHO. Oral Health Surveys-Basic Methods. Geneva: Oral Health Department; 1999. p. 08.  Back to cited text no. 3
4.Dental Council of India. National Oral Health Survey & Fluoride Mapping 2002-2003. Karnataka: Dental Council of India in collaboration with Ministry of Health and Family Welfare, Government of India; 2004. p. 33.  Back to cited text no. 4
5.Harada S, Akhter R, Kurita K, Mori M, Hoshikoshi M, Tamashiro H, et al. Relationships between lifestyle and dental health behaviors in a rural population in Japan. Community Dent Oral Epidemiol 2005;33:17-24.  Back to cited text no. 5
6.Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control 2003;12:e4.  Back to cited text no. 6
7.John RM. Tobacco consumption patterns and its health implications in India. Health Policy 2005;71:213-22.  Back to cited text no. 7
8.Jones L. Tobacco and poverty. 2010. Available from: [Accessed on 2010 Jun 02].  Back to cited text no. 8
9.Mullally BH. The influence of tobacco smoking on the onset of periodontitis in young persons. Tob Induc Dis 2004;2:53-65.  Back to cited text no. 9
10.Mark I. Tobacco use and the periodontal patient. J Periodontol 1996;67:51-6.  Back to cited text no. 10


  [Table 1], [Table 2]

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