Critical analysis of the published literature about the effects of narghile use on oral health

Figures & data

Table 1 Study designs and characteristics of included subjects in published studies aiming to evaluate the effects of narghile use on periodontal health (clinical, radiological, and microbiological studies)

First author	Baljoon (16)	Natto (17)	Natto (18)	Natto (19)	Natto (20)	Bibars (21)
Town (country)	Jeddah (Saudi Arabia)	Jeddah (Saudi Arabia)	Jeddah (Saudi Arabia)	Jeddah (Saudi Arabia)	Jeddah (Saudi Arabia)	Irbid (Jordan)
Study design	Cross-sectional Comparative	Cross-sectional Comparative	Cross-sectional Comparative	Cross-sectional Comparative	Cross-sectional Comparative	Cross-sectional Comparative
Recruitment method	Announcements/newspaper	Announcements/newspaper	Announcements/newspaper	Announcements/newspaper	Announcements/newspaper	Flyers (cafés; restaurants and university campus)
Name of the smoking mode	Water-pipe	Water-pipe	Water-pipe	Water-pipe	Water-pipe	Waterpipe
Inclusion criteria	>20 teeth	≥25 Y	>20 teeth	>20 teeth	>20 teeth	NR
Non-inclusion criteria	Pregnancy Unhealthy	NR	Pregnancy Unhealthy	Pregnancy Unhealthy	Pregnancy Unhealthy	Chronic systemic diseases Endocrine or hematological pathologies Pregnancy Dental scaling within the last 6 months Orthodontic appliance
Exclusive-NS	Yes	Yes	Yes	Yes	Yes	Yes
Calculated sample size	No	No	No	No	No	No
Number	117	76	80	117	58	72
Age (Y)	39 (37–41)^a 17–60^b	39.4^c 25–70^b	17–60^b M: 38 (36–41)^a‡ F: 39 (34–44)^a‡ TS: 38.5^c	17–60^b M: 39 (37–41)^a F: 38 (34–43)^a	39 (36–41)^a	27±9^d* 18–60^b
Number of years of smoking	NR	NR	NR	NR	NR	NR
Type of tobacco	NR	NR	NR	NR	NR	NR
Method of narghile-use quantification	RY	NR	RY	RY	NR	NW
Quantity of used tobacco	57 (48–66)^a RY 44%: <40 RY 56%: ≥40 RY	NR	36 (27–44)^a RY 40%: <27 RY 60%: ≥27 RY	57 (48–66)^a RY 44%: <40 RY 56%: ≥40 RY	NR	3.4^c NW
Last narghile (h)	NR	NR	NR	NR	NR	NR
Explorations	Clinical examination (four sites [buccal, mesial, distal, lingual] for all the teeth) Radiographic examination	Clinical examination Radiographic examination	Clinical examination (four sites [buccal, mesial, distal, lingual] for all the teeth)	Clinical examination (four sites [buccal, mesial, distal, lingual] for all the teeth) Radiographic examination	Clinical examination Bacteriological study	Clinical examination (four sites [buccal, mesial, distal, lingual] for 6 teeth)
Questionnaires	Standardized	Standardized	Standardized	Standardized	Standardized	Non-standardized
Comparison with active CS	n=72 37 (35–39)^a Y 230 (193–268)^a CY 37 subjects: <170 CY 52 subjects: ≥170 CY	n=49 36.7^c Y 25–70^b	n=50 36.5^c Y 210 (169–251)^a CY	n=72 M: 36 (34–38)^a Y F: 38 (34–43)^a Y 230 (193–268)^a CY 37 subjects: <170 CY 52 subjects: ≥170 CY	n=35 37 (34–40)^a Y	n=30 34±10^d Y 14.1^c CD
Comparison with healthy non-S	n=99	n=70 34.4^c Y 25–70^b	n=78 33.2^c	n=99 M: 38 (35–41)^a F: 35 (32–39)^a	n=80 40 (35–41)^a Y	n=38 32±11^d Y
Comparison with MS	n=67 33 (31–35)^a Y 174 (141–207)^a CY 24 (18–30)^a RY	n=49 38.1^c Y 25–70^b Y	n=54 37.1^c Y 1.91 (154–229)^a CY 17 (10–6)^a RY	n=67 M: 33 (31–35)^a Y F: 32 (28–37)^a Y 174 (141–207)^a CY 24 (18–30)^a RY	n=25 33 (30–37)^a Y	n=50 28±10^d Y 1.9^c NW 10.6^c CD
Main results	VD prevalence and severity are greater in NS and CS than in non-S Similar associations of VD with narghile or cigarette smoking Narghile use exerts a negative impact on the periodontal bone	Gingival health is compromised by narghile use	Association between narghile use and PD manifestations	Narghile use is associated with PBH reduction	No major differences were observed between CS, NS, and non-S regarding the occurrence of PM	NS were significantly more likely to have PD

CD, cigarette/day; CS, cigarette smokers; CY, cigarette-years; F, female; M, male; NS, narghile smokers; non-S, non-smokers; NR, not reported; NW, narghile/week; PBH, periodontal bone height; PD, periodontal disease; PM, periodontal microflora; RY, run-years; VD, vertical defect; Y, years.

^aData are mean (95% confidence interval); ^bdata are range (minimum–maximum); ^cdata are mean; ^ddata are mean±SD.

Significant differences: *NS vs. CS; ^‡NS vs. MS. No significant difference was found between NS vs. non-S.

Table 2 Study designs and characteristics of included subjects in published studies aiming to evaluate the effects of narghile use on oral mucosa (clinical and histological studies)

First author	El-Hakim (8)	Al-Belasy (9)	Ali (10)	El-Setouhy (11)	Dangi (12)	Al-Attas (13)	Seifi (14)	Al-Amrah (15)
Town (country)	Cairo (Egypt) Al Khobar (Saudi Arabia)	Mansoura (Egypt)	NR (Yemen)	Qalyubia (Egypt)	Haryana (India)	Jeddah (Saudi Arabia)	Babol (Iran)	Jeddah (Saudi Arabia)
Study design	Case-series	Longitudinal Comparative	Cross-sectional Comparative	Cross-sectional	Cross-sectional Descriptive	Cross-sectional Descriptive	Cross-sectional Comparative	Cross-sectional Comparative
Recruitment method	Patient consultants	Patient consultants	Patient consultants	Randomized sample of households	NR	Population clusters	Cafes Entertainment centers Dental students Medical sciences students	Coffee shops Resting areas
Name of the smoking mode	Goza Shisha Hubble-bubble	Shisha Water pipe Hookah	Water-pipe Mada'a	Waterpipe	Hookah	Shisha Moasel	Waterpipe Hookah	Waterpipe Gouza Shisha Hubble-bubble Narghile Hookah
Inclusion criteria	NR	Healthy No drugs Unilateral high mesioangular Impactions+exposed occlusal surfaces	Using qat daily on only one side of the mouth for ≥10 Y	>18 Y Male Current NS (at least once per/week and smoked <100 cigarettes in their life) Never smokers	NR	>18 Y	20–40 Y	Healthy Male Adult
Non-inclusion criteria	NR	MS Former smokers Medication use Recent antibiotic use Need for antibiotic prophylaxis	Unhealthy Systemic disease	Female	Pregnancy Child Diagnosis of oral cancer prior to entry the study	Non-S	Systemic disease Alcohol use Fixed or removable partial denture PS Oral mucosa lesion	Alcohol use Medications use
Exclusive-NS	No Case 2 was an occasional CS	Yes	No	No	No	No	Yes	Yes
Calculated sample size	No	No	No	No	No	Yes	No	No
Number	3	100	11	128	163	228	40	20
Age (Y)	61 23 20	29^a 22–39^b	45±9^c 22–55^b	47±14^c†	45–95^b	34.9^a	30.15±6.02^c 20–40^b	37.5^a 28–65^b
Number of years of smoking	Case 1:>20 Y Case 2: 3 Y	NR	NR	70 subjects≤14 Y 58 subjects >14 Y	NR	NR	NR	NR
Type of tobacco	Moassel Tomback	NR	NR	NR	NR	Moassel	NR	Moassel Jurak
Method of narghile use quantification	NR	ND	NR	HW HD	NR	NR	NW	ND
Quantity of used tobacco	Case 1: twice a day≥ 20 Y Case 2: twice a day for 3 Y Case 3: regular smoker 4 Y	30%: 1–3 ND 37%: 4–6 ND 17%: 7–9 ND 16%: 10 to12 ND	NR	54%: ≤28 HW 46%: >28 HW 52%: ≤4 HD 48%: >4 HD	NR	NR	1–3 NW 20–80 min 3–5 Y	1–4 ND .>15 min
Last narghile (h)	NR	NR	NR	NR	NR	NR	NR	NR
Explorations	Clinical examination Lesion biopsy	Clinical examination	Clinical examination Histological study: two biopsies (chewing and contralateral sides)	Clinical examination Genetic study	Visual-tactile-examination	Clinical conventional oral examination	Clinical oral examination Histological study (cytological smear samples from three different areas)	Histological study: collection of buccal cells The comet assay
Questionnaires	NR	Non-standardized	Non-standardized	Non-standardized	NR	Non-standardized	Non-standardized	NR
Comparison with active CS	No	n=100 27^a Y 20–38^b Y	n=11 38±12^c Y 24–58^b Y Heavy smokers (>20 CD)	No	No	No	n=40 30.32±5.69^c Y 20–40^b Y 3–30^b CY	No
Comparison with healthy-Non-S	No	n=100 (100 M/0 F) 28^a Y 20–37^b Y	n=11 32±10^c Y 22–58^b Y	n=78 53±11^c Y	No	No	n=40 30.30±5.83^c Y 20–40^b Y	n=20
Comparison with MS	No	No	No	No	No	No	No	No
Main results	Narghile use may predispose to OC.	NS have three times the risk of non-S for developing DS Increased frequency of smoking either cigarettes or narghile results in increased DS incidence Patients who smoke either cigarettes or narghile the day of surgery are at a significantly greater risk of developing DS	Histopathologic changes in the oral mucosa of both sides: no significant differences between the three groups	TMN and CMN: higher in NS vs. non-S	Narghile use is associated with higher risk of SL	Narghile use is associated with SL while CT was positively associated with these lesions	Narghile use is effective in creating some quantitative cytometric alterations in oral mucosa	Narghile use causes DNA damage in buccal cells
		than are the patients who do not smoke postoperatively or who smoke the second day after surgery DS in smokers appears to favor a systemic etiology rather than a direct effect of heat/smoke or suction on the extraction socket	Pathologic changes of the oral mucosa were related mainly to takhzeen al-qat

CD, cigarette/day; CMN, number of cells containing micronuclei; CT, chewing tobacco; CY, cigarette-years; DNA, deoxyribonucleic acid; DS, dry-socket; HD, hagar/day; HW, hagar (narghile tobacco unit)/week; MS, mixed smokers; ND, narghile/day; NS, narghile smokers; non-S, non-smokers; NR, not reported; NW, narghile/week; OC, oral cancer; PS, passive smoker defined as individuals who were exposed to cigarette smoke at home or work; SL, suspicious lesions; TMN, total number of micronuclei; Y, years.

^aData are mean; ^bdata are range (minimum–maximum); ^cdata are mean±SD.

Significant differences: ^†NS vs. Non-S. No significant difference was found between NS vs. CS or NS vs.MS.

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