UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2024.e4166
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Braz Dent Sci 2024 Jan/Mar;27 (1): e4166
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
The impact of traditional smokers versus electronic cigarette
smokers on periodontal parameters in iraqi males
O impacto do uso de cigarros tradicionais versus uso de cigarros eletrônicos nos parâmetros periodontais em homens
iraquianos
Alyamama Mahmood ALWAN1 , Sarah Ihsan AL-KARAWI1 , Ghasaq Asim ABDUL-WAHAB1
1 - Mustansiriyah University, College of Dentistry, Oral Surgery and Periodontology Department. Baghdad, Iraq.
How to cite: Alwan AM, Al-Karawi SI, Abdul-Wahab GA. The impact of traditional smokers versus electronic cigarette smokers on
periodontal parameters in iraqi males. Braz Dent Sci. 2024;27(1):e4166. https://doi.org/10.4322/bds.2024.e4166
ABSTRACT
Objective: To compare the effects of vaping and cigarette smoking and indicate their impact on periodontal health.
Material and Methods: A total of 90 subjects divided into three groups. Group I: 30 Traditional cigarettes smoker
who have smoked up to 10 cigarettes, Group II: 30 electronic cigarettes subjects who have been using vape at
least one year and never smoke, and Group III: 30 subjects who have no smoking history. Using a mirror and a
periodontal probe, periodontal parameters (plaque index, gingival index, probing depth and clinical attachment
loss) were used to evaluate periodontal health. Results: The ndings showed that the periodontal parameters
had a highly signicant differences at P ≤ 0.01 between traditional and electronic smoking groups. While clinical
attachment loss demonstrated non-signicant difference P ≥ 0.05 in comparison between electronic cigarettes
and the group who never smoke. Conclusion: The results of this study suggested that traditional cigarettes
and electronic cigarettes both had unfavorable impact on periodontal health status, never the less quit smoking
showed positive impacts on periodontal parameters.
KEYWORDS
Cigarette; Periodontitis; Periodontium; Smoking; Vape.
RESUMO
Objetivo: O objetivo foi comparar os efeitos do uso do cigarro eletrônico e do cigarro convencional, indicando seus
impactos na saúde bucal. Material e Método: 90 indivíduos foram divididos igualmente em três grupos: Grupo
I, usuários de cigarro convencional que fumaram até 10 cigarros por dia; Grupo II: usuários de cigarro eletrônico
que utilizam este por pelo menos há 1 ano e não fumavam antes disso; Grupo III: usuários sem qualquer história
de hábitos tabagistas. Utilizando um espelho bucal e uma sonda periodontal, parâmetros periodontais (índice de
placa, índice gengival, profundidade de sondagem e perda de inserção clínica) foram coletados para avaliar a
saúde periodontal. Resultados: As evidências mostraram que os parâmetros periodontais apresentaram diferença
signicativa (P ≤ 0.01) entre os grupos I e II. Conclusão: Os resultados deste estudo sugerem que tanto o uso
de cigarro convencional como o de cigarro eletrônico possuem impactos desfavoráveis na saúde periodontal, e
que a cessação do uso destes mostraram impactos positivos nos parâmetros periodontais.
PALAVRAS-CHAVE
Cigarro; Periodontite; Periodonto; Tabagismo; Vaping.
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Braz Dent Sci 2024 Jan/Mar;27 (1): e4166
Alwan AM et al.
The impact of traditional smokers versus electronic cigarette smokers on periodontal parameters in iraqi males
Alwan AM et al. The impact of traditional smokers versus electronic cigarette
smokers on periodontal parameters in iraqi males
INTRODUCTION
Periodontal disorders have multiple causes,
including interactions between the human
body and microbial plaque and an accelerated
immune-inammatory response [1,2]. The most
frequent and important independent risk factor
for periodontal disease that has an ability
to influence the host immune-inflammatory
response is smoking [3]. Traditional cigarette
smoking is now recognized as a signicant risk
factor for periodontitis [4].
By reducing the production of cytokines
and inammatory mediators, causing oxidative
stress, and impairing gingival vascular function,
smoking changes the immune response of the
host [5].
According to epidemiological research,
smoking significantly increases the chance of
developing periodontal disorders. Smokers
obviously accumulate more dental calculus
than non-smokers. Additionally, smoking is
linked to an increased risk of alveolar bone loss,
periodontal pocket formation, and periodontal
attachment loss [6].
Nicotine is one of the tobacco components.
The primary action in vasoconstrictive action is
the gingivae’s end-arterial vasculature as well as
other substances in tobacco can also result in tissue
necrosis and ulceration, which are symptoms of
periodontal disease. Nicotine stops gingival
broblasts from growing and prevents them from
producing collagen and bronectin. The ability
of oral leukocytes, particularly neutrophils, to
migrate and phagocytose may be minimized, and
they might have a role in the inactivation of tissue
proteinase enzyme inhibitors [7,8]. A masking
effect of tobacco smoking on the symptoms of
gingival inammation may give smokers a false
sense of being assured about their health of the
gingival tissue [9].
In recent years, electronic cigarettes
(E-cigarettes) have gained great popularity as
a replacement for traditional cigarettes [10,11].
Previous studies have revealed that using
E-cigarettes as an alternative for tobacco smoking
may be helpful for a short duration but its use for
longer time may conceivably develop the risk of
periodontal disease [6].
E-cigarettes are battery-operated, handheld
devices [12] that create aerosols. An aerosol is
a mixture made up of tiny particles and droplets
of fluid that have been delayed in a gaseous
medium [13].
In order for E-cigarettes to operate effectively,
a mixture of propylene glycol, glycerol, nicotine,
and other avoring ingredients must be heated
to produce vapors that provide nicotine that
is inhaled. Potentially, these ingredients have
adverse oral health outcomes. Electronic
cigarettes use e-liquids, which possess an easier
composition when compared with traditional
tobacco products [14]. These liquids heat up in
the device and condensate into a viscous aerosol
when the smoker inhales them. While some of the
aerosol adheres to oral cavity structures, others
are absorbed into the bloodstream [15].
Now there are more than 10,000 commercial
formulations of e-liquid available. These
formulations make up the majority of A bases,
nicotine, and avors, which have a negative effect
on oral health [16].
Medical and public debate surrounds the
safety of E-cigarettes and their use as an alternative
to tobacco consumption. However, E-cigarettes
are probably going to be more safe than cigarette
smoking, according to a recent assessment by the
Royal College of Physicians [17]. But still, users
of E-cigarettes have mentioned unpleasant side
effects such as dry mouth, sensitive teeth, and
mouth ulcers [18].
Therefore, it is necessary to determine if
vaping is safer than smoking, and it is vital to
look at any probable links between electronic
cigarettes and periodontal disease. Therefore,
the present study aimed to investigate the
relationship between electronic cigarettes and
traditional cigarettes and compere their effects
on periodontal health status among Iraqi adults.
MATERIAL AND METHODS
At the Department of Periodontology, the
investigation was done between 2022 and 2023.
A total of 90 males between the ages of 27 and
40 underwent a clinical evaluation and completed
questionnaires about their smoking history. Forms
for informed consent were completed by each
participant after being informed of the objectives
and methods of the study. The Ethics Committee
at the University granted the necessary clearance.
Three groups of participants were formed,
as follows:
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Braz Dent Sci 2024 Jan/Mar;27 (1): e4166
Alwan AM et al.
The impact of traditional smokers versus electronic cigarette smokers on periodontal parameters in iraqi males
Alwan AM et al. The impact of traditional smokers versus electronic cigarette
smokers on periodontal parameters in iraqi males
• Group I: The traditional cigarette
(T-cigarette) smokers’ group, consisted of
30 smoker subjects; who were dened as
those who have smoked up to 10 cigarettes
per day for at least 12 months.
• Group II: The electronic cigarette
(E-cigarette) users’ group, consisted of 30
subjects; who were dened as those who
stated they had never smoked in any way
before and had been using E-cigarettes solely
at least one year.
• Group III: Never-smokers (control) group
are those who claim to have never used any
kind of smoking.
Patients’ clinical exams assessed their plaque
index (PLI) [19], gingival index (GI) [20],
probing depth (PD), and clinical attachment
loss (CAL). A Williams periodontal probe was
used for measuring each clinical parameter.
With the exception of third molars, six locations
around each tooth were used to collect clinical
periodontal measures. The following criteria
were used to diagnose the patients as having
periodontitis: Pocketing >3 mm is shown at
2 teeth with buccal or oral CAL 3 mm, or their
CAL was discovered at 2 non-adjacent teeth [21].
The following were the inclusion criteria: (a)
Vaping individuals without a history of tobacco
use who use just E-cigarettes. (b) Cigarette
smokers are those who smoke up to 10 cigarettes
per day for at least a year. (c) Those never smoked
or used any other tobacco product.
The exclusion criteria were: (a) Cigar, pipe,
and/or water pipe smoking (b) Completely
edentulous individuals; (c) Those who have
systemic diseases, such as autoimmune disorders,
diabetes, hepatitis B and C, renal disorders,
acquired immune deficiency syndrome, and
cardiac disorders (d) Third molars; (e) Individuals
who indicated they had periodontal therapy
within the previous six months; and (f) People
who claimed to have taken antibiotics steroids,
non-steroidal anti-inammatory medications, or
antibiotics in the three months before .
Statistical analysis
In this study, descriptive statistics in the form
of means and standard deviation were generated
using the computer program IBM® SPSS® version
27. Independent sample t-tests and a one-way
analysis of variance (ANOVA) test were employed
as statistical tests to compare groups generally.
Additionally, the means of the three groups were
compared applying the calculation for the least
significant difference (LSD) Additionally, the
level of highly signicantly (HS) was accepted at
P ≤ 0.01, the level of signicance (S) was accepted
at P <0.05, the level of non-signicant (NS) was
accepted at P ≥ 0.05.
RESULTS
Clinical evaluations of each group were
conducted, and the data were statistically
analyzed. Table I shows the mean, minimum,
maximum value, and standard deviations (±SD)
of age and clinical parameters for all participants.
Table II illustrates the mean values and ±SD
of periodontal parameters of the three study
groups, it was clearly shown that T-cigarettes
group had the higher mean among the study
groups followed by E-cigarettes group. While the
control group showed the minimum mean value.
For intergroup comparisons ANOVA test
among groups was performed; showed that there
was highly signicant difference both between
and within groups for PLI, GI, PD and CAL, as
shown in Table III.
In addition, the results of LSD testing
revealed a highly signicant difference between
the T-cigarettes, E-cigarettes, and non-smokers
groups for PLI, GI, and PD at P ≤ 0.01 for each
Table I - Descriptive statistical results of age and the clinical parameter of all participants
Minimum Maximum Mean SD±
Age 25 45 34.69 6.02
PLI 0.02 3 0.84 0.58
GI 0.01 3 0.88 0.65
PD 0 5.01 1.91 2.11
CAL 0 3.6 1.03 1.45
PLI: Plaque index, GI: Gingival index, PD: Probing depth, CAL: Clinical attachment loss, SD: Standard deviation.
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Braz Dent Sci 2024 Jan/Mar;27 (1): e4166
Alwan AM et al.
The impact of traditional smokers versus electronic cigarette smokers on periodontal parameters in iraqi males
Alwan AM et al. The impact of traditional smokers versus electronic cigarette
smokers on periodontal parameters in iraqi males
of the multiple comparisons between each pair
of groups. For CAL, however, there was a highly
signicant difference between the T-cigarettes,
E-cigarettes and control group at P≤ 0.01 and
non-signicant difference between E-cigarettes
and control group at P≥ 0.05 [Table IV].
Table IV - Least significant difference test to compare the means of clinical parameter among groups
Index Groups MD SE
P
Significance
PLI T-cigarette E-cigarette 0.72 0.096 0.000 *HS
Control 1.06 0.096 0.000 *HS
E-cigarette Control 0.34 0.096 0.001 *HS
GI T-cigarette E-cigarette 0.92 0.09 0.000 *HS
Control 1.32 0.09 0.000 *HS
E-cigarette Control 0.39 0.09 0.000 *HS
PD T-cigarette E-cigarette 2.27 0.34 0.000 *HS
Control 4.01 0.34 0.000 *HS
E-cigarette Control 1.73 0.34 0.000 *HS
CAL T-cigarette E-cigarette 2.98 0.06 0.000 *HS
Control 3.04 0.06 0.000 *HS
E-cigarette Control 0.06 0.06 0.342 NS
P
≥0.05 (NS), *
P
≤0.01 (HS). 95% confidence interval. NS: Nonsignificant, HS: High significant, PLI: Plaque index, GI: Gingival index, PD: Probing
depth, CAL: Clinical attachment loss, MD: Mean difference, SE: Standard error, P: P-value.
Table II - Descriptive statistical results of the clinical parameter of each group
Groups
PLI GI PD CAL
Mean ±SD Mean ±SD Mean ±SD Mean ±SD
T-cigarette 1.44 0.60 1.63 0.54 4.01 1.13 3.04 0.29
E-cigarette 0.71 0.19 0.70 0.23 1.73 2.02 0.06 0.36
Control 0.37 0.14 0.31 0.15 0 0 0 0
PLI: Plaque index, GI: Gingival index, PD: Probing depth, CAL: Clinical attachment loss, SD: Standard deviation.
Table III - ANOVA Test for Clinical Parameters between Groups
Index ANOVA SS
df
MS F
P
Significance
PLI
Between Groups 17.87 2 8.93
63.66 0.000 *HSWithin Groups 12.21 87 0.14
Total 30.08 89
GI
Between Groups 27.65 2 13.82
111.31 0.000 *HSWithin Groups 10.80 87 0.12
Total 38.45 89
PD
Between Groups 243.28 2 121.64
67.87 0.000 *HSWithin Groups 155.91 87 1.79
Total 399.2 89
CAL
Between Groups 181.67 2 90.83
1246.21 0.000 *HSWithin Groups 6.34 87 0.073
Total 188.01 89
*P≤0.01 (HS). 95% confidence interval. HS: High significant, PLI: Plaque index, GI: Gingival index, PD: Probing depth, CAL: Clinical attachment
loss SS: Sum of squares,
df
: Degree of freedom, MS: Mean square, F and P: Statistical Expressions.
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Braz Dent Sci 2024 Jan/Mar;27 (1): e4166
Alwan AM et al.
The impact of traditional smokers versus electronic cigarette smokers on periodontal parameters in iraqi males
Alwan AM et al. The impact of traditional smokers versus electronic cigarette
smokers on periodontal parameters in iraqi males
DISCUSSION
The American Academy of Periodontology
lists smoking as a risk factor that may have an
impact on periodontal tissue [22]. There are
an estimated 65 million users of E-cigarettes
worldwide, and their use is growing [23].
According to our research, those who
smoke or vape have a higher risk of developing
periodontal disease than those who aren’t
smokers.
T-cigarette smokers demonstrated higher
plaque index readings than E-cigarette users.
The greater prevalence of PLI among tobacco users
may be related to that cigarette smokers showed
an increase risk of producing adherent biolms
than E-cigarette users or non-smokers [24-26].
Due to the adverse effect of smoking on salivary
glands that resulted in increased salivary viscosity,
causing them to secrete primarily mucosal
saliva. Changes in the composition of saliva,
such as in the immunoglobulins and enzymes,
might responsible for defense mechanisms
alterations that possibly resulted in the plaque
formation [27,28].
In another hand, gingival index showed
a higher value in E-cigarette users than the
non-smokers. Due to the increased suppressive
impact on E-cigarettes bleeding can be linked to
the nicotine content of E-liquid [29]. According
to recent research, using E-cigarettes causes
DNA damage, oxidative stress and inammatory
reactions [30,31]. Also in vitro studies reveled
that the avoring agents that are associated with
the aerosol of E-cigarettes have been proved
to enhance DNA injury and promote several
inammatory proteins such as cyclooxygenase
and prostaglandin E2 in gingival cells [32,33].
T-cigarette smokers had a higher probing
depth means when compared with the E-cigarette
users. This demonstrated that frequent tobacco
use enhances oxidative stress in periodontal
tissues and can lead to alveolar bone loss and
periodontal disease if left uncontrolled or
untreated [34,35].
Regarding clinical attachment loss, the
current study findings showed that the mean
CAL in T-cigarette smokers was higher than that
of non-smokers and E-cigarette users. These
variations in CAL among study groups could
be attributed to changes in the composition of
subgingival plaque, the virulence of subgingival
bacteria, and modications in the host response,
all of which increase the resorption of bone
and deterioration of periodontium [36,37].
Nicotine present in tobacco products could
influence the collagen tissues negatively by
raising collagenase production, inhibiting
gingival broblast development, and decreasing
collagen and bronectin production [38].
CONCLUSION
The result of this study concludes that
tobacco cigarettes and electronic cigarettes
have a negative effect on periodontal health.
But on the other hand, electronic cigarettes
demonstrated a lesser impact than tobacco on
periodontal parameters, which possess an easier
composition when compared with traditional
tobacco products.
Our research showed that smoking cessation
appeared to have a positive impact on periodontal
indicators and that T- and E-cigarettes both
had negative impacts. The negative impact of
e-cigarettes was comparable to that of T-cigarettes;
however, it was less severe with regard to PD.
Our data suggest that additional lengthy research
is required to properly comprehend the impact
of E-cigarette use on periodontitis.
Author’s Contributions
AMA: Conceptualization, Methodology,
Investigation, Resources, Software, Writing –
Original Draft Preparation, Project Administration.
SIAK: Conceptualization, Methodology,
Formal Analysis, Investigation, Resources,
Writing – Review & Editing, Visualization. GAAW:
Conceptualization, Methodology, Investigation,
Validation, Resources, Writing – Review &
Editing, Supervision, and Funding Acquisition.
Conict of Interest
The authors have no conicts of interest to
declare.
Funding
This research did not receive any specic
grant from funding agencies in the public,
commercial, or not-for-prot sectors.
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Alwan AM et al.
The impact of traditional smokers versus electronic cigarette smokers on periodontal parameters in iraqi males
Alwan AM et al. The impact of traditional smokers versus electronic cigarette
smokers on periodontal parameters in iraqi males
Regulatory Statement
This study was conducted in accordance with
all the provisions of the local human subjects’
oversight committee guidelines and policies of
the research ethics committee our institute. The
approval code for this study is: MUOSU-202116.
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Sarah Ihsan Al-Karawi
(Corresponding address)
Mustansiriyah University, College of Dentistry, Baghdad, Iraq
Email: saraihsan@uomustansiriyah.edu.iq, sarahkurwi@gmail.com
Date submitted: 2023 Nov 24
Accept submission: 2024 Mar 27
