Journal of Oral Hygiene & Health
Open Access

Periodontitis is a chronic infectious inflammatory disease of the gingiva and structures supporting the teeth. Periodontitis is an infection caused by specific bacteria such as Porphyromonas gingivalis present in the bio film within the periodontal pocket in the susceptible patient. The infection affects the tissues of gingiva and can lead to the destruction of supporting connective tissue and finally result in bone resorption [1]. Periodontitis has been associated with various systemic conditions and many theories have been postulated and numerous diverse paths for the passageway of periodontal pathogens and their products into the systemic circulation have been proposed [1-3]. According to the focal infection theory by Miller it was identified that microorganisms and their products from the dental plaque can access the parts which are adjacent to or distant from the mouth through the bloodstream causing many types of systemic diseases and sometimes can also lead to degenerative conditions [1].

The theory of shared risk highpoints is the concept that the factors causing the risk for development of periodontitis can likewise make the affected individuals at risk for developing other systemic diseases. The consequence is that the occurrence of risk factors increases the probability that these diseases will occur within an individual it could result in either one manifesting, or both diseases occurring at the same time, in an individual. Tobacco smoking is an example of one such environmental risk factor which is implicated with periodontitis, attributes to systemic conditions like heart diseases, respiratory diseases and diabetes, and similarly is the factors of age, stress and male gender. Due to the concept of this shared risk factor, a person with an increased age has a greater possibility to simultaneously have periodontitis, cardiovascular diseases and/ or diabetes, but this is not necessarily because one is contributing factor of the other. Both periodontal diseases and systemic diseases share mutual risk factors including alcohol consumption, smoking of tobacco, male gender and aging [4-6].

In a survey of 1,350 licensed dentists in North Carolina by Paquette et al. [7] it was reported that the common risk factors for periodontitis and systemic diseases are tobacco consumption, alcohol, physical inactivity, smoking, diabetes, genetics and stress. In a cross-sectional study done by Bhatti et al. [8], the association between periodontal disease, smoking, diabetes and coronary heart disease was identified. This study was conducted on 60 male patients having coronary heart disease with periodontitis visiting the University of Dentistry, Lahore, Pakistan. The patients were divided into four groups, group A; which included patients who smoked and had diabetes, group B; which included patients who had diabetes and who did not smoke, group C; included non-diabetic patients who smoked and group D; included non-diabetes patients and who did not smoke. The results of this study showed that the levels of bleeding on probing, periodontal pocket depth and clinical attachment loss were highest among coronary heart disease patients with periodontitis having diabetes and who smoked.

The tremendous increase in the risk factors such as tobacco use, alcohol consumption has been observed in Fiji. Use of behavioural risk factors including the use of alcohol, tobacco and kava are higher among men than compared to the women, however, women are more likely to be overweight or obese (Fiji Country Gender Assessment, 2015) [9]. The overall prevalence of tobacco use among the people in Fiji is 36.6%. The observed mean age for the commencement smoking is approximately 18 years. 77.3% of alcohol drinkers are binge drinkers. Physical activity at leisure is a priority in Fiji. The numbers of individuals who are overweight are 29.9% and obese are 18%. In terms of BMI and abdominal obesity, females are more obese than males. A tremendous increase of obesity with age group up to 30-34 years is observed (The Fiji National strategic plan, 2010-2014) [10]. According to the Global Youth Tobacco Survey (2016) it was reported that total prevalence of use of tobacco among the age 13-15-year olds in Fiji was 9.1% and cigarette smoking among them was 5.1%. In the Fiji Steps Survey (2011) [11] it was reported that among adults age group of 25-64-year olds the prevalence of use of tobacco daily was 16.6%. In semi developed countries like Fiji, a common risk factor approach to prevent the disease from occurring and a comprehensive interdisciplinary approach to manage both disease entities could be beneficial. Despite the increase in use of behavioural risk factors in Fiji no study was done regarding presence of behavioural risk factors among periodontitis patients with systemic disease in Fiji. The main aim of this study was to identify the presence of behavioural risk factors among periodontitis patients with and without systemic disease in the Fiji National University (FNU) Dental Clinics.

This is a descriptive study on periodontitis patients with complete self-reported systemic disease history carried out in two dental clinics operated by FNU. Every periodontitis patient with complete selfreported systemic disease history seen at FNU Dental Clinics from 1st January 2013-31st December 2014 was taken in this study. Before collecting the data, an ethical approval was pursued from the relevant authorities and data collection was done using patient clinical records by the student researcher along with monitoring and evaluation of the clinical co-ordinators and the supervisors. A work plan was used as a guide to help determine the sequence in the study. Any flaws which were identified during the study were discussed with the supervisors.

A total of 369 periodontitis patient records were included in this study. Patient folders were identified by names and were de-identified by serial numbers such as 1, 2, 3 and so on in a study log sheet, to ensure confidentiality is kept at all times. An excel spread sheet was prepared to collect data which contained details on patient serial numbers, self-reported history of systemic disease, demographic variables, selfreported behavioural risk factors, Community Periodontal Index (CPI) scores and severity of periodontitis recordings.

The Data was extracted from patient clinical records and entered in Microsoft Excel and exported to Statistical Package for Social Science (SPSS) version 22 for data cleaning, processing and analysis. All the categorical variables were presented by numbers and percentages and continuous variables in averages and standard deviations. Chi square test was used to determine use of behavioural risk factors (such as use of tobacco, use of alcohol and the use of betel-nut), among the periodontitis patients with and without systemic disease. And Binary logistic regression was used to calculate odds ratio with their 95% Confidence Intervals to define any association between dependent variable and independent variables. A p-value less than 0.05 was considered statistically significant.

As Table 1 shows majority of patients aged 40-64 years old and 57% were female. I-Taukei Fijians constituted 47.4% of the study population, 32.5% were Fijians of Indian Descent and 20.1% represents individuals from other ethnic groups.

Table 1: Demographic characteristics of periodontitis patients.

The behavioural risk factors (use of tobacco, use of alcohol and use of betel-nut) among periodontitis patients with and without systemic disease were summarized in Table 2. Periodontitis patients with systemic disease using tobacco in this study was 35.9% and those who did not use tobacco was 64.1%, however this was not statistically significant. Periodontitis patients with systemic disease consuming alcohol was 39.7% and those who did not consume alcohol was 60.3%, this was statistically significant. Periodontitis patients with systemic disease using betel-nut were 4.7% and who did not use betel-nut was 95.3%, however this was not statistically significant. The study showed that only alcohol consumption was statistically significant (p=0.022).

Table 2: Behavioral risk factors (use of tobacco, use of alcohol, use of betel-nut) among periodontitis patients with and without systemic diseases.

Studies have shown that the use of tobacco has an effect on the periodontal status of the consumers. Smoking results in periodontal destruction by affecting the innate and immune host responses. Smokers have decreased number of lymphocytes which are important in the function of B cell and in the production of antibodies and are manifested by decreased in the levels of the salivary antibodies (IgA) and serum IgG. Impaired IgG response increases the risk of periodontitis. The components of tobacco can impair chemotaxis and/or phagocytosis of oral and peripheral neutrophils [12,13]. The metabolites of nicotine can proliferate into the periodontium and cause an impact in the vasoconstriction advancement, and weaken the functional activity of polymorphs and macrophages. A few research studies have decisively identified any microbiological changes in the tissues of the periodontium attributable to smoking [14]. Previous studies in the epidemiology of periodontal diseases like periodontitis, identified that smoking could be a possible causative factor for the disease. Thus, there have been diverging opinions about the effect of smoking in periodontitis. A study by Mager et al. [15] investigated the relationship between periodontal pathogens and cigarette use. The data used was self-reported smoking data. And it was identified that there is an increased risk to have sub gingival infection with Porphyromonas gingivalis among smokers, however this study did not show any statistical significance. The odds of the presence of A. actinomycetemcomitans among smokers were 3 times more than among the non-smokers. However, Darby et al. [16], in their study utilized polymerase chain reaction techniques in the investigation of the association between cigarette smoking and the occurrence of periodontal pathogens. The study reported no significant differences in the manifestation of any of the periodontal pathogens like Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tanarella forsythensis and Tanarella denticola were observed between smokers and non-smokers.

Use of alcohol can impact the tissues in the periodontium through various mechanisms. One such is its opposing consequence on the host defence system. It is associated with the reduction in adherence, motility, phagocytotic activity and amplified frequency of infections, which are the defective functions of the neutrophils, and the complement deficiency [17]. However, the effect of alcohol is diverging as alcohol can also act as an antimicrobial agent and is identified to have a high action against and inhibiting growth of few pathogens, like Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis in the periodontium [18]. In a study by Tezal et al. [19] of 1,371 patients aged 25 to 74 in the Erie County, New York, United States of America, it was reported that alcohol consumption was associated with moderate periodontitis. Alcohol use has an impact and significant association on the periodontal status. Higher CPI scores was significantly associated with harmful alcohol use in men in a study by Kim et al. [20] on 5291 Korean adults.

Use of betel-nut also known as areca-nut is associated with severe periodontitis. Areca nut or the betel-nut chewing can initiate an inflammatory response and affect the periodontium of its users. The extract of areca nut initiates the factors like prostaglandin E2 (PGE2) production, and activates the concentrations of intracellular calcium, P-38 mitogen- activated protein kinase, and the extracellular signalregulated protein kinase inhibitor which are all responsible for an inflammatory response in the host [21]. A study by Giri et al. [22] reported, chronic periodontitis was aggravated by betel-nut. The researchers of the study utilized a 32-year-old male patient reported in the Department of Periodontics, Manipal College of Dental Sciences, Manipal, India.

In the present study, the number of periodontitis patients that used tobacco was 41.73% (n=154), that used alcohol was 47.7% (n=176) and those that used betel-nut was 6.83% (n=25). The male periodontitis patients showed more use of tobacco (59.7%) and alcohol (58%) than female periodontitis patients (p ≤ 0.001). Similarly, according to the Fiji Country Gender Assessment, (2015) it was reported that men in Fiji show higher usage of tobacco, alcohol, and kava than women. Binge drinking was 17% among younger aged men, compared to the 3% of younger women. Among all the ethnic groups in this study, the I-Taukei Fijians showed highest use of tobacco (63.6%) and alcohol (50%) than the other ethnic groups, this was statistically significant. However, in the use of betel-nut, the other group of ethnicities that is, all the ethnicities excluding the I-Taukei Fijians and Fijians of Indian Descent showed the highest (60%), this was statistically significant. According to a report by Kessaram et al. [23] it was identified that use of alcohol is a leading risk factor in the Pacific Island Countries and Territories for the development of diseases and injuries. In 2004, Fiji was the first developing country among all the countries in the Western Pacific and the third country globally to validate the WHO Framework Convention on Tobacco Control. Educational and health promotional activities and non-smoking campaigns were the other components included in the framework. There has been an incredible advancement in launching and revising tobacco legislation and in creating “Tobacco Free Villages’ in Fiji (Fiji Islands Health System Review, 2011) [11]. Despite this there still remains increased use of tobacco among the Fijian populations. In this study, the age group 15-39-year-olds had the most number of periodontitis patients using betel-nut (62.5%), p=0.001. Studies have stated that use of betel-nut frequently starts at a very young age. Betelnut contains large amounts of sweeteners to conceal its bitterness, and children often consider it as a type of candy. Many people use betel-nut as a mouth freshener [24,25].

The present study did not show any statistically significant association between use of tobacco and use of betel-nut among periodontitis patients with and without systemic disease, however, use of alcohol among the periodontitis patients with and without systemic disease was statistically significant (p=0.022). In a study done by Bhatti et al. [8], the association between periodontal disease, smoking, diabetes and coronary heart disease was reported. This difference is mainly because the present study had self-reported history of tobacco use, alcohol consumption and betel-nut use, the patients had a fixed choice of questions lowering the validity, questions asked could be misunderstood by the patients, there could also be social desirability and patient could be hiding the truth [26]. In a study by Pattnaik et al. [27], it was reported that although smoking is a common risk factor for both periodontal diseases and cardiovascular diseases, the association between periodontal diseases and cardiovascular diseases may be independent of smoking. Similarly, in a study by Kim, [28] among 5,604 Korean adults selected from the sixth (2014) national health nutrition survey, with periodontal pocket depth it was reported that hypertension independently influenced periodontitis of other factors such as smoking, diabetes, use of alcohol. The findings of a study among a U.S. cohort, Beck et al. [29] provided evidence that the observed relationship between periodontitis and heart disease is not only a result of smoking. The results identified increased occurrence of coronary heart disease and subclinical atherosclerosis was linked with the elevated levels of systemic antibodies to the periodontal microbes like Prevotella nigrescens, Actinobacillus actinomycetemcomitans and Capnocytophaga ochracea among the patients who did not smoke.

Among all the other behavioural risk factors such as use of tobacco and betel-nut, only the use of alcohol among periodontitis patients with and without systemic diseases was statistically significant. The study can be utilized by FNU Dental Clinics to improve oral health and raise the awareness of harmful effects of use of behavioural risk factors especially among periodontitis patients with systemic disease. And also, to carry on further research studies to determine the exact cause of the link between periodontitis and systemic diseases.