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  ط وت ا   قشل   ةيحصلا   ةج ا ع    اتل   دج نماثل   دل 711 Oral health status of male adolescent smokeless tobacco users in Saudi Arabia D.E. Al Agili 1  and H.-K. Park  2,3 ABSTRACT Few studies have evaluated the oral effects of smokeless tobacco use in adolescents. This study described the oral health status of adolescents who were daily users of local smokeless tobacco (  shamma ) in Saudi Arabia. A convenience sample of 270 middle-school male students completed a questionnaire and received an oral examination and a saliva cotinine test. Among the students, 96% had plaque deposits (mean plaque index score 1.66); 41% had gingivitis (mean clinical attachment loss 1.1 mm); 56% had dental caries (mean decayed, missing, filled teeth score 2.1) and 86% had at least 1 mucosal lesion. The levels of plaque, gingivitis, dental caries and periodontitis among smokeless tobacco users were similar to those of most adolescents regardless of tobacco use. Almost 9/10 students had a mucosal lesion that could be related to smokeless tobacco use. Strong measures should be taken to increase students’ awareness of the adverse health effects of tobacco use and to control their access to tobacco. 1 Community Dentistry Division, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia (Correspondence to D.E. Al Agili:  2 Graduate School of Public Health, International Cyber University for Health, Yonsei University, Seoul, Korea.  3 College of Health  Sciences and Nursing, University of Phoenix, Phoenix, Arizona, United States of America. Received: 26/03/12; accepted: 06/05/12 ةوعس   ة رع   ةكل   اخ   د غبت   ومدتس   نذ   يقهرل   ىد   ف   ةص   ةاح ا غنويك   ويه   ، يقعل   ميهر إ   ةيند   ر   ىد      ة   ةاح   ةاسر   ذ   صت  . اخ   دب      ر   دس   ةو   يثأ   انت   ةق   اس   ان   :  ـصل ا   ةحر   ف   ًاط   270      أت   ةئ   ةنع   س   دق  . ةو   ةبر   ة   ف  ) ةّَش ( اخ   دب         ًو   ود   ذ      اسرت    د      ءؤ      % 96      ئان   اك  . ا   تو   اق      ع   او   ل   رج   ،مس   ةدع   ، )       1.1   ر   ات   د   س ( ة   اه    د   هن   % 41      ، ) 1.66   ةن   او   َْنَ   ا   س ( ةن   او   ا  . ةطا   ة   ف   ق   ع   دح   ةآ    د   هن   % 86      ، ) 2.1   وش   ةقا   ون   انس   ا ( نس   ر    د   هن   % 56      ر   ظ   ىد   ا   ة اش   ا   اخ   دب      د   ىد      ع   اه   ن   رن   ة   اه   ةن   او   او   نس  . اخ   دب      دس   إ   ىزت         ،ةطا   ة   ف   ةآ   ط   10   ك   ب      9   ىد   اك  .    دس   ع   رظن   غب .    ع   لوصح   ةا      دس   رئاض   ةص   اث   وح      ب   عو   ىو   از   ةوق   يبدت   ا   جو         احا État de santé bucco-dentaire des adolescents de sexe masculin consommateurs de tabac sans fumée en Arabie saoudite RÉSUMÉ Peu d'études ont évalué les effets bucco-dentaires de la consommation de tabac sans fumée chez les adolescents. La présente étude décrit l'état de santé bucco-dentaire des adolescents qui consommaient quotidiennement du tabac sans fumée (  shamma ) en Arabie saoudite. Un échantillon de proximité de 270 élèves du secondaire de sexe masculin a rempli un questionnaire, puis a fait l'objet d'un examen bucco-dentaire et d'une analyse de la concentration salivaire de cotinine. Sur l'ensemble des élèves participants, 96 % présentaient de la plaque dentaire (score moyen de l'indice de plaque 1,66) ; 41 % souffraient de gingivite (perte d'attache clinique moyenne 1,1 mm) ; 56 % avaient des caries dentaires (indice des dents cariées, absentes ou obturées moyen 2,1) et 86 % étaient atteints d'au moins une lésion de la muqueuse. Les taux de plaque dentaire, de gingivite, de caries et de parodontite chez les consommateurs de tabac sans fumée étaient similaires aux taux observés chez la plupart des adolescents indépendamment de leur consommation de tabac. Près de 9 élèves sur 10 étaient atteints d'une lésion de la muqueuse ayant potentiellement un lien avec la consommation de tabac sans fumée. Des mesures énergiques devraient être prises pour sensibiliser les élèves aux effets indésirables pour la santé de la consommation de tabac et pour contrôler leur accès au tabac  EMHJ  ã Vol. 19 No. 8 ã 2013 Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientale 712 Introduction obacco use is a major prevenable cause o premaure deah and also a common risk acor or several general chronic diseases [1]. Alhough smoking prevenion programmes in developed counries have resuled in a decline in he number o smokers over he pas 3 decades, smokeless obacco use has increased, principally due o is heavy consumpion by male adolescens and  young men [2,3]. Smokeless obacco use causes cancer o he head and neck, oesophagus and pancreas, and many oral diseases such as oral mucosal lesions, leukoplakia and periodonal disease [4,5]. here are 2 major types of smokeless tobacco products: chewing tobacco and snuff. In Saudi Arabia, snuff (  shamma ) use is common and is largely practised in the southern part of the country and by select populations countrywide [6]. Since the production and import of commer-cial smokeless tobacco is prohibited in Saudi Arabia, these products are prepared illegally at home without government inspection or monitoring. Smokeless to- bacco is readily accessible, cheap and its use by adolescents is easily hidden from parents and teachers [7]. Tese factors are likely to contribute to its increasing popularity and use among adolescents. o date, there are no population studies of the prevalence of smokeless tobacco use in Saudi Arabia. In 2010, the authors conducted a study to determine the prevalence of tobacco use among 7th, 8th and 9th grade schoolchildren in Jed-dah, Saudi Arabia. Te results indicated that 10% of these students currently used any tobacco (13% of boys and 7% of girls) and smokeless tobacco use was exclusively practised by 2% of the male students in Jeddah [8]. Studies in other countries have reported substantial oc-currence of oral mucosal lesions, a signifi-cant correlation between gingival index scores and snuff use and an increased risk of gingival recession among adoles-cents [9–12]. Nevertheless, data on the association of dental caries and smoke-less tobacco use are limited. In general, there is no evidence of tobacco-associ-ated dental caries [9–11]. Offenbacher and Weathers in 1985 reported higher decayed, missing, filled teeth (DMF) scores among users only if they had gin-givitis [11]. Although smokeless tobacco is a well known risk indicator associated  with adverse oral health outcomes in adults, few studies have reported statisti-cal differences between adolescent snuff users and non-users. Tis is likely to be a result of the short exposure time to smokeless tobacco products among ado-lescents [13–15]. Currenly, here are no sudies on he oral healh saus o adolescen smokeless obacco users in Saudi Ara- bia. Te aim o his sudy was o describe he oral healh saus o adolescens who use smokeless obacco in Saudi Arabia. Methods Study design In a cross-secional sudy middle-school sudens compleed a sel-adminisered quesionnaire and received a compre-hensive oral examinaion and a saliva coinine es in May 2010. Subjects  A convenience sampling mehod was used o recrui smokeless obacco users only rom public male middle schools in he eas and souh o Jeddah. Tese re-gions are generally recognized as being o low o lower middle socioeconomic class. A oal o 15 schools paricipaed in he sudy. Te schools’ counsellors  were asked o ideniy and prepare a name lis o smokeless obacco users in heir school o enrol in our sudy. From a oal o 391 7h o 9h grade sudens  who were iniially surveyed, 100 su-dens were no smokeless obacco users  based on heir quesionnaire responses. O he 291 who repored smokeless obacco use, only daily users ( n  = 270)  were used in he analysis. Data collection Questionnaire Te sudens compleed a shor quesionnaire specially designed or his sudy beore receiving heir oral examinaion. Quesions abou heir denal/oral healh, oral healh pracices, obacco use and sociodemographic characerisics were included. Oral clinical examination wo rained deniss perormed he oral examinaions. Te sudens were examined a he schools using porable denal chairs, disposable oral examina-ion kis and head lighs or illuminaion.  Williams markings periodonal probe  was used o assess periodonal diseases [16]. Te oral/denal variables were assessed in he ollowing order.Oral hygiene saus: Te oral hygiene saus o sudens was evalu-aed using he plaque index o Silness and Löe [17]. Te presence o plaque deposis was assessed visually on 3 a-cial sies (mesioacial, mid-acial and disoacial) o 12 seleced eeh. Tese  were upper and lower cenral incisors, upper and lower firs premolars, and upper and lower firs molars. Missing cenral incisors were replaced by laeral incisors, missing firs premolars were replaced by second premolars and firs molars were replaced by second molars. Te percenage o sudens wih plaque on any surace o he seleced eeh was calculaed.Probing pocke deph (PPD): PPD  was measured as he disance rom he ree gingival margin o he base o he clinical pocke on he 3 acial sies o he 12 seleced eeh. Te PPD measure-men was rounded o he higher whole millimere [18].Gingival recession: Te disance rom he cemeno-enamel juncion o he ree gingival margin was measured on he same sies o he same 12 eeh. I  was recorded as a negaive value i here  were gingival overgrowh and as a posi-ive value i here was a recession. Gin-gival recession was considered presen  ط وت ا   قشل   ةيحصلا   ةج ا ع    اتل   دج نماثل   دل 713 i he ree gingival margin was locaed apical o he cemeno-enamel juncion. Te measuremen was rounded o he higher whole millimere [18].Clinical atachmen loss (CAL): CAL was calculaed by adding up he recorded values o he disance rom he cemeno-enamel juncion o ree gingival margin and PPD on he 3 sies o he 12 seleced eeh [18].Gingiviis: bleeding on probing (BOP) was recorded ollowing PPD and gingival recession measuremens. BOP was scored as posiive i bleeding  was observed [18]. Dental caries: was scored on all teeth, excluding third molars. Te preva-lence of dental caries was determined by the presence of any untreated cavities in the user’s mouth. In addition, the World Health Organization decayed (D), missing (M), and filled (F) permanent teeth (DMF) index criteria were used in our oral examination [19]. Te stu-dent was questioned about the reason for extraction of any missing teeth to confirm caries as the cause of extraction. ooh wear: ooh wear was consid-ered posiive i here was loss o ooh srucure resuling in smooh, hard de-pressions on he acial suraces adjacen o he cemeno-enamel juncion and/or on occlusal suraces o all eeh [20].ooh sain: ooh sain was record-ed as presen i i was ound on occlusal and/or acial suraces o all eeh [20]. Oral mucosal lesions (OML): abnor-malities of the oral mucosa were catego-rized into 3 degrees according to Greer and Poulson’s criteria [9]: degree 1, a superficial lesion with colour similar to the surrounding mucosa and slight wrin-kling; degree 2, a superficial whitish or reddish lesion with moderate wrinkling; and degree 3, a red or white lesion with obvious thickening and wrinkling [9]. Training and calibration of dental examiners wo eams, each consised o a den-al examiner and a recorder, were rained and calibraed o conduc oral examinaions. Prior o he sudy, a di-dacic insrucional session and 9 hours o clinical raining were conduced. weny (20) middle school male su-dens were invied o he denal school clinics o rain he denal examiners in he recordings o he oral indicaors. In-er- and inraexaminer reliabiliies (per-cenage agreemen) or he recordings o CAL, OML, and denal caries were calculaed. Te inerexaminer reliabiliy or CAL wihin 1 mm and OML were ≥ 95%. Te inerexaminer reliabiliy or denal caries was ≥ 95%. Te inraexam-iner reliabiliy or CAL wihin 1 mm and OML were ≥ 96%. Te inraexaminer reliabiliy or denal caries was ≥ 95%. Cotinine test   A saliva coinine es was done or each suden afer hey had compleed he quesionnaire and beore hey received he oral examinaion. NicAler™ saliva nicoine es was used or esing. I is a semi-quaniaive saliva based es or he deerminaion o in vivo  nicoine consumpion or exposure. Te es was colleced and analysed according o he manuacurer’s insrucions. Each es srip is divided ino 6 reacive chromo graphic (colour change) levels o coinine deecion. Level 1 indicaes a coinine equivalen o 10–30 ng/mL and level 6 indicaes a coinine equiva-len o 2000+ ng/mL. wo denal residens were responsible or collecing saliva and adminisering he es.  Ethical issues Te projec was approved by he ehics commitee o he Deanship o Scienific Research a King Abdulaziz Universiy,  Jeddah, Saudi Arabia. Furhermore, sudy clearance was obained rom he Direcorae o he Deparmen o Educaion and he schools observed heir own policies or inorming parens abou he sudy. Statistical analysis Daa were enered in Microsof  Access   2007   and analysed using SAS  saisi-cal sofware, version 9.2. Descripive saisics in he orm o requencies and means and sandard deviaion (SD)  were compued or paricipans’ demo-graphic daa, oral healh behaviour and saus, and access o denal care and oral healh saus o smokeless obacco users relaed o sie o smokeless obacco use.Many o he surveyed sudens used oher orms o obacco such as cigaretes and waerpipe (  shisha ). Te sudens were classified ino 4 groups o evaluae any differences in oral healh saus beween sudens who used only smokeless obacco and hose who used i in combinaion wih oher orms o obacco. Tese groups were: smoke-less obacco only, smokeless obacco and waerpipe, smokeless obacco and cigaretes, and all ypes o obacco. Te generalized linear model was applied o analyse he difference in oral healh condiions among hese groups. Values o  P   < 0.05 were considered saisically significan.o describe he oral healh saus o smokeless obacco users relaed o he sie o smokeless obacco use, we divided he mouh ino sexans: sexan  A (rom upper righ second molar o upper righ firs premolar), sexan B (rom upper righ cuspid o upper lef cuspid), sexan C (rom upper lef firs premolar o upper lef second molar), sexan D (rom lower lef second molar o lower lef firs premolar), sexan E (rom lower lef cuspid o lower righ cuspid) and sexan F (rom lower lef firs premolar o lower lef second mo-lar). A generalized linear model was used o compare oral healh indicaors among smokeless obacco users by sexans. Values o  P   < 0.05 were consid-ered saisically significan. Results Characteristics of smokeless tobacco users Te mean age o he 270 paricipans  was 15.7 (SD 1.5) years, range 13–20  years. All paricipans were males and  EMHJ  ã Vol. 19 No. 8 ã 2013 Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientale 714 82.0% were o Saudi naionaliy; 42% o sudens were in grade 9, 31.8% in grade 8, and 26.2% in grade 7 (able 1). More han hal o he sudens (54.3%) repored having a low amily income [≤ Saudi riyals (SR) 3000], 28.5% medium income (SR 3001–7000) and 17.2% high income (> SR 7000). Te aver-age daily school allowance was SR 4.7 (range: 0–20). Remarkably, 21.0% and 32.6% o sudens repored ha heir aher and moher respecively were illierae. Furhermore, 7.2% and 6.6% o ahers and mohers respecively had compleed high school and 6.7% and 6% o ahers and mohers respecively had graduaed rom college. Te majoriy o sudens (87.5%) repored ha boh o heir parens were alive and 80% were living wih boh parens. Mos sudens (73%) lived wih heir moher only i heir parens were no living ogeher. Knowledge about and behaviours related to smokeless tobacco use S users were asked abou age a sar-ing S use, knowledge abou S and several behaviours relaed o heir use (able 2). Te mean age a saring S use was 12.6 (SD 2.4) years. On average, users use 6 chews per day, leave a chew abou 11 minues in he mouh, and chew anoher in abou an hour. Nearly a hal (51.3%) o hese sudens uses smokeless obacco during he examinaion period. Ineresingly, only 17.8% knows he conen o smokeless obacco and 3.8% adds waer, pepper, spices or oohpase o he chew, or  wrap i in issue beore use. Oral health status of smokeless tobacco users and their access to dental care Several quesions were asked o evalu-ae sudens’ oral healh behaviour and heir percepions o heir oral healh saus and access o denal care (able 3). A hird o respondens (32.6%) re-pored having a oohache a he ime o he survey. Only 30.5% brushed heir eeh on a daily basis and 16.4% never  brushed. Moreover, a leas one-hird (33.1%) had visied he denis in he pas year and 26.7% had never been o a denis. Among hose who had visied a denis, mos (40.6%) wen or ooh-ache or ooh decay (38.1%). Analysis o he oral clinical examina-ion findings showed ha 96% o hese sudens had plaque deposis on heir eeh and he mean plaque index score  was 1.66 (SD 0.51). Alhough 41% presened wih gingiviis, none o he sudens showed signs o periodonal disease. Te mean CAL was 1.1 (SD 0.37) mm, 1% had gingival recession and he mean pocke dephs ranged rom 1.1–3.4 mm. Te percenages o smokeless obacco users wih < 2 mm, 2–3 mm and > 3 mm pocke dephs Table 1 Demographic data of adolescent smokeless tobacco users in Jeddah (  n =  270) VariableNo.%  Student’s age (years)  a 13145.2144115.4156725.1166725.1174818.018197.11983.02031.1  Student’s nationality  a Saudi219 82.0Non-Saudi48 18.0  Student’s grade 770 26.2885 31.89112 42.0  Student’s daily allowance (SR)  a 0 –238 14.23– 477 28.75– 7125 46.68 –1026 9.7> 102 0.8  School region East 16661.5South 10438.5 Father’s education a Illiterate56 22.3 < High school153 61.0 High school degree18 7.2 > High school249.6  Mother’s education a Illiterate88 34.2 < High school136 53.0 High school degree17 6.6 > High school16 6.2 a  Missing values are not included.


Jul 23, 2017

695 BB ConfigGuide

Jul 23, 2017
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