ADVERSE ORAL HABITS AND PERIODONTAL HEALTH STATUS: A CROSS SECTIONAL CLINICAL STUDY.

Mukhatar Ahmed Javali 1 , Rakan Saed Safar Althobaiti 2 , AbdulHkeem Ali Salim AlQarni 3 , Foziah Abdullah Al Asmari 3 , Abdullah M A Alkanad 4 and Elyas Ali A Asiri 2 . 1. Associate Professor.Department of PCS. King Khalid University, College of Dentistry. Abha – KSA. 2. Intern Doctor, King Khalid University, College of Dentistry. Abha – KSA. 3. Dental Student, King Khalid University, College of Dentistry, Abha KSA 4. MOH, General Practitioner,Al Madha General hospital , Khamis Mushait KSA. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 10 November 2018 Final Accepted: 12 December 2018 Published: January 2019


Introduction:-
Periodontal disease is a pathological inflammation of the gum and bone support surrounding the teeth. The two most common periodontal diseases are gingivitis and periodontitis, inflammation affecting the bone and tissues around the teeth.
Periodontal disease is the main cause of loss of tooth and is considered one of the two major dangers to the oral health 1 . Although bacterial plaque is the primary causative factor in pathogenesis of periodontitis, development and progression of it is associated with presence of risk factors which include oral hygiene, specific environmental and genetic predisposition 2 . Smoking 3 and stress 4 are well-established risk factors for periodontal disease.
Tobacco consumption is a major risk factor for morbidity and mortality 5 .Smoking and smokeless tobacco are two forms of tobacco consumption. Smokeless tobacco (ST) comprises a great variety of products and mixtures that contain tobacco as the principle constituents and is used either orally or nasally. ST mixtures differ according to their geographic location of use and the nature of chemicals added to them 6 (Samman et al., 1998).
In Kingdom of Saudi Arabia (KSA), present facts on tobacco consumption are deficient. Some studies reported that tobacco consumption has increased in this region 7, 8 . However, there are few studies from KSA that reported smoking status. 9,10, 11 . In a national level STEPwise approach of survey on tobacco consumption in KSA  Shammah is a snuff-dipping form of ST prepared by mixing powdered tobacco, calcium oxide, ash, black pepper, oils, and flavors (Scheifele et al., 2007) 15 . This formula of ST is obtainable in various varieties and is grouped according to color and composition. Some forms of shammah are used as white, black, and gray powder (Agili and Park, 2012) 16 .
Smokers have both increased prevalence and more severe extent of periodontal disease than in nonsmokers 17 . The greater severity of periodontal destruction may be due to the increase in the rate of periodontal disease progression 18 . Various data provide strong support that the risk of developing periodontal disease as measured by clinical attachment loss and alveolar bone loss increases with increased smoking 19 .
Adverse oral habits such as bruxism are considered as risk factor for periodontal disease. Bruxism can have unpleasant and harmful effects on periodontium causing gingival recession, occlusal wear and trauma from occlusion 20 . Abnormal occlusal forces can cause changes in the alveolar bone and periodontal connective tissue both in the presence and in the absence of periodontitis 21 .
Only few studies are done in KSA with respect to prevalence of oral parafunctional habits and its influence on periodontium. Murshid Z et al 22 in their study found that prevalence of breathing disorders, bruxism, thumb-sucking and clenching habits were 20.2%. 30.2%, 16.7% and 13.6%, respectively. Bruxism was more prevalent in boys (33.1%) than girls (23.7%). Other studies reported nail-biting habit was highly prevalent among the study participants (27.2%), followed by mouth breathing during sleeping (13.8%), thumb sucking (7.4%), and teeth clenching (6.0%) 23 .
The aim of the our study was two-fold: (1) to investigate the prevalence of adverse oral habits and (2) to find its association with the periodontal status among saudi sub population of age between 15-65 years of southern region.

Material And Methods:-
A cross sectional study was conducted at the OPD of Periodontics, College of Dentistry, King Khalid University among new patients referred from Intern clinic for oral prophylaxis or phase 1 periodontal therapy. The study was conducted between March to June 2018 in patients between the ages of 15 to 65 years. 330 patients consented to participate and hence were included in the study. Ethical approval was sought from the institutional scientific committee. It was carried out in accordance with the code of ethics in the Declaration of Helsinki.
Patients excluded were individuals who gave history of any systemic conditions, or were taking any type of medication, periodontal therapy in last 6 months, systemic antibiotics within last 3 months along with pregnant and lactating mothers.

Characteristics of study participants
Complete description of the characteristics of study participants was collected according to major age strata to enable an understanding of the reasons that may account for observed differences in prevalence across studies. In this study, age was categorized as less than or equal to 25 years (I), 26-40 (II), 41-60 (III) and above 60 years (IV). A single examiner was employed for the questionnaire and periodontal examinations to avoid bias. Probing pocket depth (PPD) (distance from FGM to the base of sulcus or periodontal pocket) were measured using a William's graduated periodontal probe placing parallel to the long axis of the tooth at each site. Each measurement was rounded to the lower whole millimeter. Clinical Attachment Loss (CAL) was calculated same using the William's graduated periodontal probe as the distance between cemento-enamel junction (CEJ) to base of pocket. Severity of periodontitis was defined as shallow when probing depth was less than or equal to 5 mm and deep when probing depth was more than 5 mm. CAL was divided into mild(1 to 2mm), moderate (3 to 4mm) and severe (equal or more than 5mm). Gingival index (GI) and plaque index (PI) were also recorded in these patients.

Data analysis
The collected data from patients were subjected to appropriate statistical analysis using SPSS software for Windows, Version 16.0 (SPSS Inc., Chicago, IL, USA). Frequency distribution and percentage were calculated as summary measures for editing the data. Chi-square test was used for finding significant proportion difference in various types of adverse oral habits among the participants. A calculated P value less that 0.05 is statistically significant.

Results:-
Overall 330 patients gave consent to participate in the study, out of which 170 (51.5%) were female and 160 (48.5%) were male as shown in Table 1. Also Table 1 shows the age-wise distribution of the study participants. The age of patients as categorized were < 25(n=50), 26-40 (n=126); 41-60 (n=143) and >60 years old (n=11). Frequency distribution and percentage of different adverse oral habits in these patients are shown in Table 2. It was found that 232/330 (70.3%) had no adverse oral habits while 1/330 (0.3%) had habit of using shamah, 56/330 (17%) smoking, 5/330 (1.5%) shisha, 7/330 (2.1%) chewing tobacco, 23/330 (7%) bruxism and 6/330 (1.8%) of nail biting habit. Table 3 shows frequency distribution and percentage of PI, GI, PPD and CAL in these patients. In patients with all types of adverse oral habits or no habits who participated in the study, majority (69.7% and 86.1%) had PI and GI of score 2 respectively. Mean probing pocket depth showed varying results 128/330 (38.8% ) normal PPD upto 3mm, 200/330 (60.6%) 3 to 5mm(Shallow) and 2/330 (0.6%) more than 5mm (Deep).Mean CAL also showed similar pattern as PPD no CAL in 37/330 (11.2%), mild 45/330 (13.6%), moderate 183/330 (55.5%) and severe in 65/330 (19.7%) among the participants. Table 4 shows frequency distribution and percentage of periodontal status according to different adverse oral habits in the study participants. It was found that participants with adverse oral habit had PI (230/ 69.7%) and GI (284/86.1%) score of 2. With respect to mean PPD and mean CAL the participants with adverse oral habits had shallow pocket depth and moderate attachment loss. With respect to mean CAL there was statistically significant with p value 0.038. Table 5 shows frequency distribution and percentage of adverse oral habits according to age groups and gender among the participants. It shows that male participants showed significantly increased prevalence of tobacco consumption. Among female participants 11.8% had bruxism and 3.5% nail biting habit. Parafunctional habits were found to be higher in female participants. Significant association was found among type of adverse oral habit and gender. Table 6 shows the frequency distribution and percentage of mean PPD and CAL according to age groups and gender among the participants. It was found that participants in the middle age groups showed more of shallow PPD and moderate CAL. Statistically significant association was found between gender and mean PPD. With respect to gender more number of participants had shallow PPD and moderate CAL. Statistically significant association was found between age groups, gender and mean CAL.

Discussion:-
To the best of our knowledge, this study is the first of its kind that explore the prevalence of adverse oral habit and its association with the periodontal status among saudi sub population of age between 15 -65 years. Bacterial plaque is the primary cause of periodontal disease but many factors such as adverse oral habits play an important role as risk factor promoting the accumulation of plaque or progression of periodontal disease.
In this study, the number of patients consented to participate were almost equal, male (48.5%) and female (51.5%).The most prevalent adverse oral habit was the smoking (17%) and then the bruxism (7%) among the participants. The overall prevalence of tobacco use was 20.9%; the prevalence of smoking (17%), shammah (0.3 ), shisha (1.7% ) and tobacco chewing were 2.1% respectively. 34.4% of male participants were current smokers and the prevalence of the tobacco usage increased subsequently in the old age groups as compared to that in the younger age groups. The prevalence of smoking in our study was almost same to those which were reported by Jarallah JS et al. 9 which is a lower than our estimate of 17 %.
Male tend to smoke much more than female in most of the countries of the region. In our study also the smoking among female participants was lower compare to male. This results are similar to reported by Jaralla et al 9  Tobacco consumption is associated with suppression of gingival inflammation caused by plaque accumulation. The relative risk of causing periodontal disease is 5.1 fold higher with smokers compared to non-smokers 26 . In our results we found that 48.2% smokers had shallow PPD, 57.1% moderate and 32.1% severe CAL. Whereas with tobacco chewing habit it was 57.1% shallow PPD and 71.4% moderate CAL.
In this study the frequency distribution and prevalence of bruxism (7%) and nail biting was 1.8% among the participants. 11.8% of female participants had habit of bruxism compare to male with 1.9%. This finding was lower to results of Murshid Z et al 22 who reported 30.2% in their study and more prevalent with 33.1% in male than girls 23.7%, which is opposite to our results. Aloumi A et al 23 in their study reported 27.2% prevalence of nail bitting which in our study is much lower of 1.8%. The results of our study also found that 69.9% of participants with habit of bruxism had shallow PPD and 43.5% had moderate CAL.
Studies have reported prevalence of periodontal disease to be nearly 100% in adults 27,28 . However; there is a considerable range in the findings of different epidemiological studies. In this study, higher proportion of patients showed shallow mean PPD in middle age group and moderate mean CAL among same age group with statistically significant P value of .007. The results of our study were in concordance with the studies done by Hetland L et al 29 with similar results of shallow probing pocket depth more prevalent in middle age group.
Oral health education should focus on improving knowledge, attitude and removing obstacles to daily oral health care. One must aim at ascertaining and enhancing the psychological features that portray dental behaviors. Motivation and education plays critical role in altering attitude of patient and it should be the first step in treating any patient.
Our study has some limitations. First, our study is cross-sectional and hence we cannot consider causation. Second, many of our behavioral information, such as smoking are self-reported.

Conclusion:-
The findings of this study provide an insight into the periodontal health status among the patients with adverse oral habits like tobacco consumption, bruxism or nail biting. More significantly, the results of our study will help in planning oral health promotion programs and tobacco consumption habits cessation counseling sessions and stress management at regular interval which will help to prevent periodontal disease occurrence and progression.    .0008* .136 ns ns=not significant; *=significant when p (less than 0.05)