A Clinical Analysis of Impact of Water-pipe Smoking on Periodontal Ligament Attachment Loss


Ambrina Qureshi1                  BDS, M.Phil
Sidra Farooqui2                       BDS
Hina Qureshi3                    MBBS, FCPS, MCPS


Water-pipe smoking appears to be stimulated by unfolded assumptions of relatively safety compared to cigarettes, as well as the social nature of the activity. Commercial marketing, often with implicit or explicit safety related claims, may also be contributing to the spread of water-pipe smoking across the globe.

Material and Methods:

Cross-sectional analytical study conducted among 13-19 years old students going to a private secondary school; were divided into two groups one who smoked water-pipe and the others who does not smoke. A structured and validated self-administered questionnaire was used to collect base-line data related to the knowledge, attitude and practice of water-pipe tobacco smoking. It was then followed by clinical dental examination using Plaque, gingival, modified papillary bleeding and clinical attachment loss. Data was entered and analyzed using Statistical Package for Social Sciences (SPSS).


Among 320 subjects, 154 subjects were water pipe tobacco smokers while 166 subjects were non water pipe tobacco smoker. While, upon clinical examination of subjects only clinical attachment loss was found to be significant with the p-value of 0.000.


Therefore, in aspect to periodontal health, water-pipe tobacco smoking does have an impact on the periodontal status. Suggesting that the disease progression occurs as episodic burst of activity with periods of remission.


water-pipe tobacco smoking; private secondary school; Karachi.


In modern era, smoking through water pipe (commonly known as “Shisha”) has increased and gained universal popularity.1 There is an emergent global evidence that this trend is much accentuated among youth 2 than among adults 3 and school children are no exception. Although, there are few studies reported from South East Asian countries about water pipe smoking, but their main focus was only to observe prevalence of the problem and so far nothing beyond that.4-6 Although existing data is limited, yet it is worth noting that water-pipe smoking-associated health risks are deleterious.1 An analysis of mainstream water-pipe smoke, which was inhaled by the users, shows large amounts of carcinogens, hydrocarbons and heavy metals, including 36 times the amount of tar as in cigarette smoke.7 Contrary to ancient lore and popular belief, the smoke that emerge from water-pipe contains numerous toxicants known to cause lung cancer,8 heart disease, low birth-weight 9 and periodontal disease.10 Non pooled data of four cross sectional studies 10-13 conducted among adult Saudi population groups only, suggested 3-5 fold chances that water pipe tobacco smoking may cause periodontal disease. Although the quality of the evidence was low, still considering the overall impact of tobacco smoking on deleterious health effects, 14, 15 there was a need to explore more knowledge on such an association. Thus, the purpose of this study was to evaluate effects of water-pipe tobacco smoking on the periodontal tissue and oral hygiene among youth.

Materials and Method

A cross-sectional analytical study was conducted among secondary and O’ Level school children aged 13-19 years old. Three private secondary schools situated in a particular town of Karachi Metropolitan city were purposely selected based on their easy access to “Shisha Pubs”. After seeking ethical approval, study protocols were described to the schools’ administrations and a written signed permission was obtained prior to data collection. Consent letters were sent to students and their parents, where required, through respective school administrations and collected on the day of data collection.

A structured and validated self-administered questionnaire adapted from another study 16 was used to collect base line data as well as data related to water-pipe smoking knowledge, attitude practices among water-pipe smoking group. This study tool included inquiry about the water-pipe smoking (yes/no), on the basis of which, subjects were divided into two groups. Water-pipe smokers who smoked daily or occasionally were included in Group A; whereas, Group B included those who never smoked at any time in their lives. Subjects in both groups having any kind of dental prosthesis were excluded from the study. Also those individuals who were under any antibiotic coverage and had any kind of physical / mental disability jeopardizing manual dexterity were excluded from the study. Non-consenting individuals were also excluded from the study. Subjects who claimed to be regular smokers were requested to further answer the questions related to starting age, awareness, duration, frequency, length and factors leading to water-pipe smoking.

Dental examination was then conducted by single trained and calibrated examiner on mobile dental units under day time sun-light, wearing personal protective equipment and using sterilized mouth mirror and periodontal probe. The Indices used to assess the oral hygiene and periodontal status were Plaque Index (PI), Loe and Silness Gingival Index (GI), as previously been used by our department, 17 Modified Papillary Bleeding Index (MPBI) and Clinical Attachment Loss (CAL).18 During the dental examination, papillary bleeding was initially recorded on the buccal surface of four index teeth (16, 26, 36 and 46). Plaque and gingival index were then inspected on the four surfaces (buccal, lingual, mesial, and distal) of the six index teeth (16, 12, 24, 36, 32 and 44). Probing on each index teeth was started from the distal side of the buccal surface towards the mesial side and then likewise on the lingual surface from its mesial side to distal, hence for each index tooth four readings were recorded and the mean was calculated. During probing procedure probe was placed in gingival sulcus and the maximum recording was noted for each surface of the respected index tooth. Same protocol was followed to measure CAL on six index teeth. Lastly, scores were given for each of the four conditions (plaque, gingival inflammation, bleeding and CAL) as 0= normal/ healthy, 1= mild, 2= moderate and 3= severe. Intra-Examiner reliability for all four indices was accomplished on 10% of the total sample count selected from same schools that were not included in the study data. Kappa statistics was used to achieve > 80% of Intra-Examiner reliability for all four Indices.

Data was entered and analyzed using Stata 11.0. Descriptive statistics was used to determine mean age of smokers and nonsmokers and frequency and percentages were calculated to assess gender differences in both groups. Frequency and percentages were also calculated to assess different categories of oral conditions (assessed through plaque, gingival, bleeding and CAL Indices) in both the groups and for questionnaire responses among smokers only. Chi-square Test was applied to assess any relationship between categories of oral indices and the two study groups with < 5% level of significance.


During base-line data collection a total of 320 subjects were recruited from three selected schools out of which, 154 were included in Group A as water-pipe smokers and 166 in Group B as non-smokers. With a mean age of 16 years, most of these subjects were males in both the groups (Group A= 87%; Group-B= 70%) as compared to females (Table 1). Table 1 also shows distribution of oral indices categories in both groups where an overall observation is “mild” level of oral health and less of “moderate” and “severe” level among both the groups. Table 2 reveals water-pipe smoking related responses self-reported by subjects of Group A (n= 154), that is, only water-pipe smokers. It is worth noticing here that 100% of these smokers were well aware of health consequences of shisha smoking.

Chi-2 Test results are shown in Table 3 where no significant relationship is observed between oral health indices (PI, PBI and GI) and the study groups except in case of CAL.


It is worth discussing initially the descriptive results of self-reported responses from water pipe smokers. It must be escalated that despite of 100% awareness regarding health consequences of shisha smoking, smokers continued this practice majorly for pleasure seeking purpose and as a popular activity amongst friends and other gatherings. Sharing it with their friends and majority of them keeping it for 15-30 minutes suggest that this age group particularly take out time from their academic hours in haste to seek comfort off pressure. As compared to cigarette smoking it is readily acceptable and has become part of social gatherings. Young adult’s water pipe smoking is the leading preventable cause of future morbidity and mortality. Programs should be organized by government and Nongovernmental organizations to increase the awareness of smoking hazards especially among young students. Another strategy by government could be the banning of water pipe smoking restaurants, its advertising and raising taxes on all tobacco products. Health professionals can also play a role in advising not only against cigarette smoking but also strongly against water pipe smoking.

This study observed no significant difference in PI, GI and MPBI between the two study groups. One the other hand, it affirms the strength of association between waterpipe smoking and human tissue destruction20 as evident clinically by significant periodontal tissue attachment loss (CAL) like in other similar recent studies.21, 22

It is important to understand the historical context of periodontal diseases that more than 70% of the adult population suffers from one or the other level of periodontal disease23 with greater prevalence in developing than higher income areas.24 It was universally known that periodontal diseases progress at continuous stride throughout life unless treated well; the phenomenon known as “linear progression theory”. Based on this phenomenon probably was the introduction of several periodontal disease related indices that record scores based on worsening of periodontal condition from plaque to significant bone loss and tooth mobility.25 Modern experimental models de-accentuated this particular theory and suggested intermittent short bursts of destructive activity lead by longer periods of remission, known as “burst theory” of periodontal disease. However, recently it has been extrapolated that both these theories were nothing but mere artifacts as a result of “low-level” evidence, and therefore, not the actual natural history of this disease.26 Consequently, these theories disagree with the concept of periodontal disease as a result of “multi-factorial causes of disease”, where involvement of local environment and host susceptibility are no exception. This may be the reason that despite of low plaque level and gingivitis, CAL was still found statically significant attributable to waterpipe tobacco smoking. On the contrary, due to low sample size it may be one of our limitations.

Clinical laboratory investigation 27 conducted among smokers show that the use of tobacco impacts oral and systemic health through revascularization impairment and production of pro inflammatory cytokines, such as interleukin (IL)-1, IL-6, IL-8, tumor necrosis factor-α (TNF-∞), as well as transforming growth factor-β (TGF-β), thereby increasing bone resorption and tissue destruction. Similarly, water-pipe smoke which is said to release 4-73 fold increased toxic metabolites in air than cigarettes smoke alone28 is understood to be producing more destructive inflammatory markers and cytokines in blood. A review examining the relationship between tobacco smoking and peri-implantitis concordantly suggested that smoking causes marginal bone loss and thus increasing the risk of implant failure among them.29 At the same time, it is also studied that these chemokines may exert negative effects on protective elements of immune system with reduced production of antioxidants, neutrophils and prostaglandins also resulting in activation of tissue destructive enzymes.30 Although, by itself these cytokines and markers may not be the only “sufficient cause” for CAL of periodontal tissues, but inconsistent results observed between water-pipe smoking and other gingival indicators (PI, MBPI and GI) in this study suggest that despite of having reduced plaque and even without sufficient inflammatory response bone tissue destruction may take place resulting in CAL. This may be partially understood by examining the situations where dry socket is commonly observed among smokers through increased fibrinolytic activity thereby reducing alveolar blood supply after tooth extraction.31, 32 These inconsistent and paradoxical results observed among water-pipe smokers in terms of CAL and other gingival indicators (PI, MBPI and GI) is in correspondence with what is already suggested by Mishra and Mishra33 and Mubeen et al. 34 A recent study, on the other hand, observed a comparatively increased prevalence of gingival bleeding and inflammation among smokers (both cigarette and water pipe) than periodontal recession and pockets among the same study group suggesting that tobacco may include the very first signs of gingival inflammation as well.35 However, this result may not be reliable enough as the authors admit that the study participants were not sufficiently educated to follow good oral hygiene practices which may be the reason that gingival inflammation and bleeding was more prevalent among them.


Even though occasionally pulled, water-pipe smoking and its relationship with periodontal CAL is found highly significant and calls for an alarming situation suggesting that similar tissue destruction may be manifested in other parts of the human system. However, due to lack of studies pertinent to effects of water-pipe smoking on health it is suggested that more scientific researches where temporality may be established be conducted and so as to be conclusive that this relationship may not be due to chance. Besides, it is recommended that public health professionals must take part in spreading awareness regarding harmful effects of waterpipe smoking even more than what may be caused by cigarette smoking alone. Furthermore, it is highly recommended that specific efforts be made for advocacy involving government regulatory bodies to take concrete steps against smoking at restaurants and cafes and close such cafes, especially those in the vicinity of educational institutes.

Author’s Contribution

Sidra Farooqui and Ambrina Qureshi have worked on the concept and the design of the study. Intellectual content and literature search was done by all the three authors. Data acquisition was done by sidra farooqui. Data analysis has been done by Ambrina Qureshi & Hina Qureshi. Manuscript preparation and review has been done by Sidra Farooqui, Ambrina Qureshi and Hina Qureshi. Sidra Farooqui and Ambrina Qureshi are responsible for the integrity of the work as a whole.


Declared none.


  1. Akl EA, Gaddam S, Gunukula SK, Honeine R, Jaoude PA, Irani J. The effects of waterpipe tobacco smoking on health outcomes: A systematic review. Int J Epidemiol 2010; 39(3): 834-857. (DOI: 10.1093/ije/dyq002)
  2. Rice VH. Water Pipe Smoking Among the Young: The Rebirth of an Old Tradition. Nurs Clin North Am 2012; 47(1): 141-148.
  3. Akl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, et al. The prevalence of water pipe tobacco smoking among the general and specific populations: a systematic review. BMC Public Health 2011, 11: 244. (DOI: 10.1186/1471-2458-11-244).
  4. Basir F, Khan MS, Ahmed B, Farooq W, Virji RN. The Frequency of Shisha (Waterpipe) Smoking in Students of Different Age Groups. J Coll Physicians Surg Pak 2014; 24 (4): 265-268.
  5. Haroon M, Munir A, Mahmud W, Hyder O. Knowledge, attitude, and practice of water-pipe smoking among medical students in Rawalpindi, Pakistan J Pak Med Assoc 2014; 64(2): 155-158.
  6. Habibullah S, Ashraf J , Taseer I H, Javed R, Naz S, Arain GM, et al. Prevalence of Shisha Smoking in College, University and Madarsa Students Aged 20-25 Years in Pakistan. Pak J Med Res 2013; 52(1): 3-7.
  7. Videtic GM, Stitt LW, Dar AR, Kocha WI, Tomaik AT, Truong PT, et al. Continued cigarette smoking by patients receiving concurrent chemo radio therapy for limited stage small cell lung cancer is associated with decreased survival. J Clin Oncol 2003; 21(8): 1544-1549.
  8. Hazelton WD, Luebeck EG, Heidenreich WF, Moolgavkar SH. Analysis of a historical cohort of Chinese tin miners with arsenic, radon, cigarette smoke, and pipe smoke exposures using the biologically based two-stage clonal expansion model. Radiat Res 2001; 156: 78-94.
  9. Nuwayhid IA, Yamout B, Azar G, Kambris MAK. Narghile (hubble bubble) smoking, low birth weight, and other pregnancy outcomes. Am J Epidemiol 1998; 148: 375-83. (DOI: 10.1093/ oxfordjournals.aje.a009656).
  10. Natto S, Baljoon M, Bergstrom J. Tobacco smoking and periodontal health in a Saudi Arabian population. J Periodontol 2005; 76: 1919-26.
  11. Natto S, Baljoon M, Abanmy A, Bergstorm J. Tobacco smoking and gingival health in a Saudi Arabian population. Oral Health Prev Dent 2004; 2(4): 351-7.
  12. Natto S, Baljoon M, Bergstrom J. Tobacco smoking and periodontal bone height in a Saudi Arabian population. J Clin Periodontol 2005; 32: 1000-6.
  13. Baljoon M, Natto S, Abanmy A, Bergstrom J. Smoking and vertical bone defects in a Saudi Arabian population. Oral Health Prev Dent 2005; 3(3): 173-82.
  14. Jogezai U, Maxood A, Khan NA. Comparison of periodontal health status of smokers versus non-smokers. J Ayub Med Coll Abbottabad 2013; 25(1-2).
  15. Liu KZ, Hynes A, Man A, Al-Sagheer A, Singer DL, et al. Increased local matrix metalloproteinase-8 expression in the periodontal connective tissues of smokers with periodontal disease. Biochimica et Biophysica Acta 2006; 1762(8): 775-780. (DOI: 10.1016/j.bbadis.2006.05.014).
  16. Jawaid A, Zafar A M, Rehman TU, Nazir MR, Ghafoor ZA, Afzal O, et al. Knowledge, attitude and practices of University students regarding waterpipe smoking in Pakistan. Int J Tuberc Lung Dis 2008; 12(9): 1077-1084.
  17. Malik AS, Shaukat MS, Qureshi A, Abdur R. Comparative effectiveness of chewing stick and toothbrush: A randomized clinical trial. North Am J Med Sci 2014; 6: 333-7.
  18. Foia L, Toma V, Surlin P. Diabetes Mellitus Impact on Periodontal Status in Children and Adolescents, Periodontal Diseases – A Clinician’s Guide, Dr. Jane Manakil (ed), ISBN: 978-953-307-818- 2, In Tech 2012. (DOI: 10.5772/26635) [Available from: http: //www.intechopen.com/books/periodontal-diseases-a-clinician-sguide/diabetes-mellitus-impact-on-periodontal-status-in-childrenand-adolescents]. Accessed on: 11-09-2015.
  19. Mehmood A, Aftab A. Shisha Smoking: Ban or not to be ban in Pakistan? Escala Res 2014; 3(1): 4-6.
  20. Kabour OF, Alzoubi KH, Bani-Ahmad M, Dodin A, Eissenberg T, et al. Acute exposure to waterpipe tobacco smoke induces changes in the oxidative and inflammatory markers in mouse lung. Inhal Toxicol 2012; 24(10): 667-675.
  21. Javed F, Al-Kheraif AA, Rahman I, Millan-Luongo LT, Feng C, Yunker M, et al. Comparison of Clinical and Radiographic Periodontal Status Among Habitual Waterpipe Smokers and Cigarette Smokers. J Periodontol 2015; 0(0): 1-9.
  22. Bibars AR, Obeidat SR, Khader Y, Mahasneh AM, Khabour OF. Oral Health Prev Dent 2015; 13(3): 253-259.
  23. Kelly JE, Van Kirk LE. Periodontal disease in adults, United States 1960-1962. Vital Health Stat 1965; 11: 12.
  24. Ramfjord SP, Emslie RD, Greene JC, Held AJ, Waerhaug J. Epidemiological studies of periodontal diseases. Am J Public Health 1968; 58: 1713-1722.
  25. Burt BA. The role of epidemiology in the study of periodontal diseases. Periodontol 2000 1993; 2: 26-33.
  26. Teles R, Teles F, Frias-Lopez J, Paster B, Haffajee A. Lessons learned and unlearned in periodontal microbiology. Periodontol 2000 2013; 62(1): 95-162.
  27. Flouris AD, Poulianiti KP, Chorti MS, Jamurtas AZ, Kouretas D, Owolabi EO, et al. Acute effects of electronic and tobacco cigarette smoking on complete blood count. Food Chemic Toxicol 2012; 50(10): 3600-3603.
  28. St. Helen G, Benowitz NL, Dains KM, Havel C, Peng M, Jacob P. Nicotine and Carcinogen Exposure after Water Pipe Smoking in Hookah Bars. C Cancer Epidemiol Biomarkers Prev 2014; 23: 1055.
  29. Kasat V, Ladda R. Smoking and dental implants. J Int Soc Prev Communit Dent 2012; 2(2): 38-41.
  30. Mortaz E, Redegeld FA, Sarir H, Karimi K, Raats D, Nijkamp FP, et al. Cigarette smoke stimulates the production of chemokines in mast cells. J Leukoc Biol 2008; 83: 575-580.
  31. Giorgetti APO, Neto JBC, Casati MZ, Sallum EA, Junior FHN. Cigarette smoke inhalation influences bone healing of postextraction tooth socket: a histometric study in rats. Braz Dent J 2012; 23(3): 228-234.
  32. Saldanha JB, Casati MZ, Neto FH, Sallum EA, Nociti FH Jr. Smoking may affect the alveolar process dimensions and radiographic bone density in maxillary extraction sites: a prospective study in humans. J Oral Maxillofac Surg 2006; 64: 1359-1365.
  33. Mishra S, Mishra MB. Tobacco: Its historical, cultural, oral, and periodontal health association. J Int Soc Prevent Communit Dent 2013; 3(1): 12-18.
  34. Mubeen K, Chandrashekhar H, Kavitha M, Nagarathna S. Effect of Tobacco on Oral Health- an Overview. J Evol Med Dent Sc 2013; 2 (20): 3523- 3534.
  35. Rasouli-G AA, Behrad D, Afshin K, Yadollah SS, Amirreza R, Siamak Y. Effect of Hubble-Bubble Smoking on Oral Health. Bull. Env Pharmacol Life Sci 2014; 3(12): 52-59.

1 Associate Professor, Department of Community Dentistry, Dr Ishrat-ulEbad khan Institute of Oral Health Sciences, Dow University of Health Sciences Karachi, Pakistan
2 MDS Trainee, Dow University of Health Sciences Karachi, Pakistan
3 MDS Trainee, Dow University of Health Sciences Karachi, Pakistan
*Corresponding author: “Dr Ambrina Qureshi < ambrina.qureshi@duhs.edu.pk >