[Downloaded free from http://www.ijncd.org on Friday, January 27, 2023, IP: 103.54.0.

5]

Original Article

Smoking and periodontal disease severity, probing pocket

depth and bleeding on probing
Suresh Babu J1, Swarnalatha C1, Ritu Mathur2, Tayf Naif Radhi Alshammari1, Archana Meenakshi3, Asma Alavi4,
Nashwa Alzaki Ali Bushara5, Yasser Riaz Malik5, Abhishek Singh Nayyar6
1
Division of Periodontology, Department of Preventive Dental Sciences, College of Dentistry, University of Ha’il, Ha’il, Kingdom of
Saudi Arabia, 2Department of Periodontology and Implantology, Pacific Dental College and Research Center, Udaipur, Rajasthan, India,
3
Department of Periodontology and Implantology, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India, 4Consultant Dental
Surgeon, Dammam, 5Division of Dental Public Health, Department of Preventive Dental Sciences, College of Dentistry, University of
Ha’il, Ha’il, Kingdom of Saudi Arabia, 6Department of Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital
and Post-graduate Research Institute, Parbhani, Maharashtra, India

ABSTRACT
Background and Objective: The purpose of the present study was to investigate whether severity of disease process differed between
smokers and nonsmokers and to study characteristic differences in pattern of periodontal disease in smokers in a group of known
chronic periodontitis patients.
Materials and Methods: The study included 150 individuals in an age range of 35–60 years wherein periodontal evaluation including
probing pocket depth (PPD) and bleeding on probing (BOP) was performed using Williams’s periodontal probe. For both the
parameters (PPD and BOP), mean scores were calculated from different quadrants of the oral cavity while the results obtained were
subjected to statistical analysis.
Results: The mean percentage of sites that presented with BOP was higher for nonsmokers compared with smokers. Furthermore,
smokers had more number of pockets and pockets with increased PPD. On analysis of buccal and lingual sides, also, it was observed
that smokers had more number of sites with PPD of ≥5 mm than nonsmokers.
Conclusion: From the results, it could be concluded that smoking is associated with more severe periodontal attachment and bone
loss and deeper periodontal pockets.

Keywords: Bleeding on probing, periodontal disease, probing pocket depth, smoking

Introduction smokers, thus, implying a strong association between smoking

and periodontal disease.[9‑11] Furthermore, greater levels of
Periodontitis is the result of complex interrelationships alveolar bone loss, probing pocket depth (PPD), tooth mobility,
between host factors and causative microorganisms with a and tooth loss have been seen in smokers than in nonsmokers.
plethora of risk factors modifying the expression of disease
process.[1‑4] Among proposed risk factors, smoking has been Address for correspondence: Dr. Abhishek Singh Nayyar,
SD Dental College, NH 222, Pathri Road, Parbhani,
found to be associated with an increased prevalence and Maharashtra, India.
severity of periodontal disease.[5‑8] There is, also, evidence in E‑mail: [email protected]
the literature that a disproportionately high number of people
with severe periodontal disease were found to be chronic This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix,
tweak, and build upon the work non‑commercially, as long as appropriate credit is given and
the new creations are licensed under the identical terms.
Access this article online
Quick Response Code
Website: For reprints contact: [email protected]
www.ijncd.org How to cite this article: Babu JS, Swarnalatha C, Mathur R,
Alshammari  TN, Meenakshi A, Alavi A, et al. Smoking and periodontal
disease severity, probing pocket depth, and bleeding on probing. Int J
DOI: Non‑Commun Dis 2021;6:72-6.
10.4103/jncd.jncd_23_21 Submitted: 25-Apr-2021 Revised: 14-May-2021
Accepted: 17-May-2021 Published: 16-Jul-2021

72 © 2021 International Journal of Noncommunicable Diseases | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.ijncd.org on Friday, January 27, 2023, IP: 103.54.0.5]

Babu et al.: Smoking and periodontal disease

Several studies have, also, proposed a common

[12‑15] Statistical analysis
observation that smokers, in general, have proportionately Statistical analysis was done using SPSS version 18.0 (SPSS
more periodontal pockets in anterior than posterior regions Inc., Chicago, IL, USA). For both the parameters (PPD and
than nonsmokers.[16‑18] The purpose of the present study was BOP), mean scores were calculated considering distribution
to investigate whether severity of disease process differed in relation to the upper and lower jaw, and buccal and
between smokers and nonsmokers and to study characteristic lingual sites in anterior, premolar, and molar regions while
differences in pattern of periodontal disease in smokers in a comparisons were made using z‑test (two‑tailed test).
group of known chronic periodontitis patients. P <0.05 was considered statistically significant.

Materials and Methods Results

The present study was designed as a cross‑sectional, Table 1 reveals comparison of nonsmokers and smokers
hospital‑based study to assess association between in relation to mean age, number of teeth and sites
smoking and periodontal disease severity and to affected, and at different levels of PPD wherein it was
investigate whether disease severity differed between
smokers and nonsmokers in a group of chronic Table 1: Comparison of nonsmokers and smokers in relation to
periodontitis patients by assessing PPD and bleeding mean age, number of teeth and sites affected, and at different
on probing (BOP). The study included 150 individuals, levels of probing pocket depth
75 smokers, and 75 nonsmokers, in an age range of Parameters Mean±SD P
35–60 years while individuals recruited in smoker group Nonsmokers Smokers
(n=75) (n=75)
included individuals who smoked ≥10 cigarettes a day
Age (years) 47.0±8.0 46.0±6.0 >0.05
for ≥10 years. Inclusion criteria for the study included
Mean number of teeth 25.0±3.6 25.7±3.8 >0.05
patients who were in good systemic health with chronic Anteriors 11.1±1.5 11.1±1.2 >0.05
generalized periodontitis characterized by ≥5 mm pocket Premolars 7.7±1.6 7.9±1.7 >0.05
depth while patients having past dental history of oral Molars 7.5±2.8 7.2±2.8 >0.05
prophylaxis in the past 6 months, patients who had taken PPD (mm)
antibiotics in the past 3 months, patients with a history 0-3 48.6±19.5 36.8±5.9 <0.05
of any form of systemic disease including cardiovascular 4-5 37.7±12.9 39.3±12.3 >0.05
6-7 15.2±8.2 22.2±10.2 <0.05
diseases, diabetes mellitus, blood disorders, renal and
≥8 9.2±6.5 10.2±5.6 >0.05
hepatic disorders, and pregnant and lactating females were
P<0.05 Statistically significant. SD  ‑  Standard deviation, PPD  ‑  Probing pocket depth
excluded from the study. The individuals were recruited
based on the simple randomization process while the Table 2: Comparison of nonsmokers and smokers in relation to
need for the study was explained to all the participants different levels of probing pocket depth in anterior, premolar,
and a written, informed consent was obtained before and molar regions
their inclusion into the study. Furthermore, approval Variables Mean±SD P
was obtained from Institutional Ethics Committee before Nonsmokers Smokers
the start of the study through letter approval no. SDDC/ (n=75) (n=75)
PPD (mm) in anteriors
IEC/07‑37‑2018. A detailed history was taken for each
0-3 56.0±22.0 41.0±19.0 <0.05
participant followed by clinical examination performed
4-5 31.0±15.0 38.0±16.0 <0.05
as per protocol of Universal Precautions with the help of 6-7 10.0±12.0 16.0±15.0 <0.05
diagnostic instruments under artificial illumination. The ≥8 5.0±7.0 6.0±9.0 >0.05
findings were recorded in a specially designed proforma PPD (mm) in premolars
while periodontal evaluation including PPD and BOP 0-3 44.0±18.0 34.0±15.0 <0.05
was performed on all four quadrants and at six sites per 4-5 38.0±14.0 40.0±15.0 >0.05
tooth using Williams’s periodontal probe. The PPD was 6-7 14.0±8.0 20.0±13.0 <0.05
≥8 6.0±8.5 7.0±9.0 >0.05
measured from the gingival margin to the base of the
PPD (mm) in molars
pocket and BOP recorded as either present or, absent
0-3 22.0±14.5 15.0±9.5 <0.05
when provocation with the probe was done.[19,20] For 4-5 42.0±17.0 43.0±16.0 >0.05
both the parameters (PPD and BOP), mean scores were 6-7 20.0±15.0 35.0±14 <0.05
calculated from different quadrants of the oral cavity while ≥8 18.0±14.5 14.0±12.0 >0.05
the results obtained were subjected to statistical analysis. P<0.05 Statistically significant. SD  ‑  Standard deviation, PPD  ‑  Probing pocket depth

International Journal of Noncommunicable Diseases / Volume 6 / Issue 2 / April‑June 2021 73

[Downloaded free from http://www.ijncd.org on Friday, January 27, 2023, IP: 103.54.0.5]

Babu et al.: Smoking and periodontal disease

observed that mean age, mean number of teeth, and mean nonsmokers and smokers at PPD of ≥5 mm in relation to
percentage of sites affected did not differ significantly the upper and lower jaw in terms of involvement of buccal
between the smokers and nonsmokers, though, mean and lingual sites in anterior, premolar and molar regions
percentage of sites that presented with BOP was higher wherein statistically significant differences were observed
for nonsmokers compared with smokers. Furthermore, at various sites in relation to both upper and lower jaw,
smokers had more number of pockets and pockets with and buccal and lingual sites in anterior, premolar and molar
increased PPD of 4–7 mm than nonsmokers. No significant regions (P < 0.05). In relation to the upper jaw, 48% of sites
difference, though, was detected in the prevalence of in smokers while only 37% of sites in nonsmokers exhibited
pockets with ≥8 mm PPD. Table 2 reveals comparison of pockets with PPD of ≥5 mm. On analysis of buccal and
nonsmokers and smokers in relation to different levels of lingual sides, also, it was observed that smokers had more
PPD in anterior, premolar, and molar regions wherein it number of sites with PPD of ≥5 mm than nonsmokers.
was observed that at all sites, pockets with PPD of 6–7 mm The data, also, revealed that largest difference was found
in relation to the upper jaw in anterior and premolar
were significantly more in smokers than nonsmokers.
regions between smokers and nonsmokers with smokers,
Overall, differences in the prevalence of pockets at PPD
in particular, having more number of pockets with PPD
of  ≥5  mm at all sites including anterior, premolar, and
of ≥5 mm on palatal and lingual sites in upper and lower
molar regions between smokers and nonsmokers were
jaw, respectively.
found to be statistically significant (P < 0.05) [Table 3].
Similarly, Table 4 reveals comparison of nonsmokers and
Discussion
smokers at PPD of ≥5 mm in relation to the upper and
lower jaw, and buccal and lingual sites in anterior, premolar, The present study was planned to investigate whether the
and molar regions while Table 5 reveals comparison of severity of periodontal disease process differed between
smokers and nonsmokers in a group of known chronic
Table 3: Comparison of nonsmokers and smokers at probing
periodontitis patients wherein the findings suggested that
pocket depth of≥5 mm in anterior, premolar, and molar regions
mean percentage of sites that presented with BOP was
Location Mean±SD P
higher for nonsmokers compared with smokers. The findings
Nonsmokers (n=75) Smokers (n=75)
All sites 37.0±19.0 48.0±17.0 <0.05
of the present study were found to be in accordance with
Anteriors 25.0±20.0 34.0±22.0 <0.05 findings of other studies which concluded that smokers had
Premolars 35.0±23.0 45.0±21.0 <0.05 less bleeding on provocation than nonsmokers. Decreased
Molars 54.0±21.0 63.0±16.0 <0.05 gingival BOP in smokers has been explained on the basis
P<0.05 Statistically significant. SD  ‑  Standard deviation of vasoconstriction of peripheral blood vessels induced by

Table  4: Comparison of nonsmokers and smokers at probing pocket depth of≥5 mm in relation to the upper and lower jaw, and
buccal and lingual sites in anterior, premolar, and molar regions
Location Mean±SD
Upper jaw Lower jaw Buccal Lingual
Nonsmokers Smokers P Nonsmokers Smokers P Nonsmokers Smokers P Nonsmokers Smokers P
All sites 35±20 46±18 <0.05 30±20 40±19 <0.05 30±19 41±18 <0.05 39±22 49±20 <0.05
Anteriors 26±24 39±24 <0.05 23±22 34±21 <0.05 24±22 35±22 <0.05 25±24 35±24 <0.05
Premolars 38±27 51±21 <0.05 29±24 37±22 <0.05 29±22 36±21 <0.05 38±25 55±23 <0.05
Molars 56±22 65±18 <0.05 54±23 65±19 <0.05 54±25 60±19 <0.05 58±23 67±19 <0.05
P<0.05 Statistically significant. SD  ‑  Standard deviation

Table  5: Comparison of nonsmokers and smokers at probing pocket depth of≥5 mm in relation to the upper and lower jaw in terms
of involvement of buccal and lingual sites in anterior, premolar, and molar regions
Location Mean±SD
Upper jaw: Buccal Lower jaw: Buccal Lower jaw: Lingual Upper jaw: Palatal
Nonsmokers Smokers P Nonsmokers Smokers P Nonsmokers Smokers P Nonsmokers Smokers P
All sites 40±24 55±22 <0.05 30±22 39±28 <0.05 35±22 44±21 <0.05 42±26 56±24 <0.05
Anteriors 30±30 45±30 <0.05 22±24 33±25 <0.05 18±27 26±23 <0.05 31±30 44±28 <0.05
Premolars 43±28 57±24 <0.05 24±26 29±22 <0.05 35±27 50±31 <0.05 44±31 57±24 <0.05
Molars 59±26 66±22 <0.05 49±27 60±23 <0.05 61±28 67±26 <0.05 57±27 68±24 <0.05
P<0.05 Statistically significant. SD  ‑  Standard deviation

74 International Journal of Noncommunicable Diseases / Volume 6 / Issue 2 / April‑June 2021

[Downloaded free from http://www.ijncd.org on Friday, January 27, 2023, IP: 103.54.0.5]

Babu et al.: Smoking and periodontal disease

cotinine, a by‑product of nicotine metabolism that reduces Ethical approval statement

clinical signs of inflammation including redness, edema, The ethical approval was obtained from Institutional Ethics
and gingival bleeding.[19,21,22] Furthermore, a plethora of Committee before the start of study via letter approval no.
studies have shown an association between smoking and SDDC/IEC/07-37-2018.
in particular, the number of cigarettes smoked per day
and prevalence and severity of periodontal disease with Financial support and sponsorship
observation that individuals smoking >ten cigarettes per Nil.
day and with a habit of longer duration were relatively more
frequent in moderate to advanced periodontitis group with Conflicts of interest
those smoking lesser number of cigarettes or, with shorter There are no conflicts of interest.
duration of habit having lesser severity of disease process.[8,9]
The present study was different from these studies on the References
basis of a detailed analysis of PPD and BOP assessment
1. Page  RC, Schroeder  HE. Pathogenesis of inflammatory periodontal
considering distribution in relation to the upper and lower disease. A summary of current work. Lab Invest 1976;34:235‑49.
jaw, and buccal and lingual sites in anterior, premolar and 2. Socransky SS, Haffajee AD. The bacterial etiology of destructive
molar regions. The findings of the present study suggested periodontal disease: Current concepts. J Periodontol 1992;63:322‑31.
3. Page  RC, Offenbacher  S, Schroeder  HE, Seymour  GJ, Kornman  KS.
that at all sites, pockets with PPD of 6–7 mm were significantly
Advances in the pathogenesis of periodontitis: Summary of developments,
more in smokers than nonsmokers while differences in the clinical implications and future directions. Periodontol 2000 1997;14:216‑48.
prevalence of such pockets at PPD of  ≥5  mm at all sites 4. Burt B, Research, Science and Therapy Committee of the American
including anterior, premolar and molar regions were found Academy of Periodontology. Position paper: Epidemiology of
periodontal diseases. J Periodontol 2005;76:1406‑19.
to be statistically significant (P < 0.05) between smokers
5. Bergström J. Cigarette smoking as risk factor in chronic periodontal
and nonsmokers. Furthermore, on further analysis, it was disease. Community Dent Oral Epidemiol 1989;17:245‑7.
observed that smokers had more number of sites with 6. Haber J, Kent RL. Cigarette smoking in a periodontal practice.
PPD of ≥5 mm than nonsmokers. All these findings were J Periodontol 1992;63:100‑6.
7. Haber J, Wattles J, Crowley M, Mandell R, Joshipura K, Kent RL.
found to be in accordance with finding of previous studies
Evidence for cigarette smoking as a major risk factor for periodontitis.
wherein it was observed that smokers had significantly J Periodontol 1993;64:16‑23.
more pronounced periodontitis characterized by a greater 8. Martinez‑Canut P, Lorca A, Magán R. Smoking and periodontal disease
mean loss of attachment and teeth affected sites than severity. J Clin Periodontol 1995;22:743‑9.
9. Tomar SL, Asma S. Smoking‑attributable periodontitis in the United
nonsmokers.[23‑27] The findings of the present study, also,
States: Findings from NHANES III. National Health and Nutrition
revealed that largest difference was found in relation to the Examination Survey. J Periodontol 2000;71:743‑51.
upper jaw, and in anterior and premolar regions, between 10. Mullally BH. The influence of tobacco smoking on the onset of
smokers and nonsmokers, with smokers, in particular, having periodontitis in young persons. Tob Induc Dis 2004;2:53‑65.
11. Van Dyke TE, Sheilesh  D. Risk factors for periodontitis. J  Int Acad
more number of pockets with PPD of ≥5 mm on palatal and
Periodontol 2005;7:3‑7.
lingual sites in the upper and lower jaw, respectively. All these 12. Ahlqwist M, Bengtsson C, Hollender L, Lapidus L, Osterberg T.
observations were found to be in close accordance with Smoking habits and tooth loss in Swedish women. Community Dent
findings of previous studies which suggested that periodontal Oral Epidemiol 1989;17:144‑7.
13. Krall EA, Dawson‑Hughes B, Garvey AJ, Garcia RI. Smoking, smoking
microflora is modified by smoking which results in varying
cessation, and tooth loss. J Dent Res 1997;76:1653‑9.
patterns of distribution of sites affected by periodontitis 14. Krall EA, Garvey AJ, Garcia RI. Alveolar bone loss and tooth loss in
in smokers than nonsmokers. Various in vitro studies have, male cigar and pipe smokers. J Am Dent Assoc 1999;130:57‑64.
also, reported a shift in bacterial flora in smokers and that, 15. Krall EA, Dawson‑Hughes B, Garvey AJ, Garcia RI. Smoking, smoking
cessation, and tooth loss. J Dent Res 1997;76:1653‑9.
in smokers, there is decreased oxygen tension in periodontal
16. Grossi SG, Genco RJ, Machtei EE, Ho AW, Koch G, Dunford R, et al.
pockets that favors colonization, preferably, by anaerobic Assessment of risk for periodontal disease. II. Risk indicators for alveolar
bacteria.[28‑31] bone loss. J Periodontol 1995;66:23‑9.
17. van der Weijden GA, de Slegte C, Timmerman MF, van der Velden U.
Periodontitis in smokers and non‑smokers: Intra‑oral distribution of
Conclusion pockets. J Clin Periodontol 2001;28:955‑60.
18. Lima FR, Cesar‑Neto JB, Lima DR, Kerbauy WD, Nogueira‑Filho GR.
From the results, it could be concluded that smoking Smoking enhances bone loss in anterior teeth in a Brazilian population:
is associated with more severe periodontal attachment A retrospective cross‑sectional study. Braz Oral Res 2008;22:328‑33.
19. Larson PS, Silvette H. Tobacco: Experimental and Clinical Studies
and bone loss and deeper periodontal pockets with a
(Supplement III). PS Larson, HB Haag, H Silvette (ed): Tobacco:
characteristic intraoral distribution that is suggestive of Experimental and clinical studies; A comprehensive account of the
local effect. world literature. The Williams & Wilkins Co, Baltimore, US; 1961.

International Journal of Noncommunicable Diseases / Volume 6 / Issue 2 / April‑June 2021 75

[Downloaded free from http://www.ijncd.org on Friday, January 27, 2023, IP: 103.54.0.5]

Babu et al.: Smoking and periodontal disease

20. Newbrun  E. Indices to measure gingival bleeding. J  Periodontol 26. Jacob V, Vellappally S, Smejkalová J. The influence of cigarette smoking
1996;67:555‑61. on various aspects of periodontal health. Acta Medica (Hradec Kralove)
21. Gelskey SC. Cigarette smoking and periodontitis: Methodology to assess 2007;50:3‑5.
the strength of evidence in support of a causal association. Community 27. Ojima M, Hanioka T. Destructive effects of smoking on molecular and
Dent Oral Epidemiol 1999;27:16‑24. genetic factors of periodontal disease. Tob Induc Dis 2010;8:4.
22. Bagaitkar J, Demuth DR, Daep CA, Renaud DE, Pierce DL, Scott DA. 28. Bardell D. Viability of six species of normal oropharyngeal bacteria
Tobacco upregulates P. gingivalis fimbrial proteins which induce TLR2
after exposure to cigarette smoke in vitro. Microbios 1981;32:7‑13.
hyposensitivity. PLoS One 2010;5:e9323.
29. Zambon JJ, Grossi SG, Machtei EE, Ho AW, Dunford R, Genco RJ.
23. Bergström J, Eliasson S, Dock J. A 10‑year prospective study of tobacco
Cigarette smoking increases the risk for subgingival infection with
smoking and periodontal health. J Periodontol 2000;71:1338‑47.
24. Machuca  G, Rosales  I, Lacalle  JR, Machuca  C, Bullón P. Effect of periodontal pathogens. J Periodontol 1996;67:1050‑4.
cigarette smoking on periodontal status of healthy young adults. 30. Darby IB, Hodge PJ, Riggio MP, Kinane DF. Microbial comparison of
J Periodontol 2000;71:73‑8. smoker and non‑smoker adult and early‑onset periodontitis patients by
25. Petropoulos G, McKay IJ, Hughes FJ. The association between polymerase chain reaction. J Clin Periodontol 2000;27:417‑24.
neutrophil numbers and interleukin‑1alpha concentrations in gingival 31. Kubota M, Tanno‑Nakanishi M, Yamada S, Okuda K, Ishihara K. Effect
crevicular fluid of smokers and non‑smokers with periodontal disease. of smoking on subgingival microflora of patients with periodontitis in
J Clin Periodontol 2004;31:390‑5. Japan. BMC Oral Health 2011;11:1.

76 International Journal of Noncommunicable Diseases / Volume 6 / Issue 2 / April‑June 2021