|Year : 2014 | Volume
| Issue : 1 | Page : 21-25
Evaluation of gingival pigmentation in children exposed to and not exposed to environmental tobacco smoking
Shabeer Mohamed Madani, Biju Thomas
Department of Periodontics, A. B. Shetty Institute of Dental Sciences, Derlakatte, Mangalore, Karnataka, India
|Date of Web Publication||19-Mar-2014|
Shabeer Mohamed Madani
Department of Periodontics, A. B. Shetty Institute of Dental Sciences, Derlakatte, Mangalore, Karnataka
Background and Aim: The exposure to environmental tobacco smoke (ETS) has been recognized as a strong contributor to respiratory disorders, lung cancer, peripheral vascular function and death. Increased gingival pigmentation in smokers is established. In children exposed to ETS, an increased incidence of caries and pigmentation of gingiva were documented. In a country like India where no stringent smoke-free policies exist and the presence of joint family systems in rural population, children are at a greater health risk when either one of the family member is a smoker. The potential accumulation in melanin-containing tissues of nicotine and tobacco-specific compounds may be a concern for any individual who is chronically exposed to tobacco smoke. Gingival pigmentation is easy to assess and could be of significant importance while educating parents in terms of their child's health. Thus primary objective of our study is to assess the effects of ETS on gingival pigmentation in children with ≥1 smoker parent or close relatives. Materials and Methods: A total of 228 students between the age group of 6-16 years were selected randomly. The cases included children exposed to ETS who were non-smokers and the controls were not exposed to ETS at home. Pigmentation was assessed using Dummet & Co's pigmentation index and smoking was assessed by interview. Results: The prevalence of pigmentation in subjects not exposed to ETS was found to be 132 (80.5%) subjects in comparison to 32 (19.5%) without any gingival pigmentation. It can also be noted that all the 64 (100%) subjects exposed to ETS had pigmented gingiva. Conclusion: Within the limitations of this cross-sectional observational study, we conclude that there may be a correlation between gingival melanin pigmentation of children exposed to ETS.
Keywords: Epidemiology, gingival pigmentation, passive smoking
|How to cite this article:|
Madani SM, Thomas B. Evaluation of gingival pigmentation in children exposed to and not exposed to environmental tobacco smoking. SRM J Res Dent Sci 2014;5:21-5
|How to cite this URL:|
Madani SM, Thomas B. Evaluation of gingival pigmentation in children exposed to and not exposed to environmental tobacco smoking. SRM J Res Dent Sci [serial online] 2014 [cited 2019 Nov 17];5:21-5. Available from: http://www.srmjrds.in/text.asp?2014/5/1/21/129066
| Introduction|| |
It has been estimated that 30% of the population 15 years or older -47% men and 14% of women-either smoked or chewed tobacco, which translates to almost 195 million people -154 million men and 41 million women in India. However, the prevalence may be underestimated by almost 11% and 1.5% for chewing tobacco among men and women, respectively and by 5% and 0.5% for smoking among men and women, respectively, due to use of household informants. 
Smoking has been accepted as a major risk factor for various diseases including cancers of the lungs, mouth, esophagus bladder, cardiovascular diseases, respiratory diseases and also periodontal diseases.  It has also been seen to cause increased labial and gingival pigmentations. Though active smoking is considered one of the leading causes of preventable deaths world-wide, passive smoking also poses a serious threat to health.
The exposure to environmental tobacco smoke (ETS) has also been described to cause increased gingival pigmentation in smokers.  In children exposed to ETS, an increased incidence of caries and pigmentation of gingiva were documented.  In a country like India where no stringent smoke-free policies exist and the presence of joint family systems in rural population, children are at a greater health risk when either one of the family member is a smoker. The oral, head and neck mucosae in humans are not uniformly colored and several degrees of chromatic variation may be observed in physiologic and pathologic conditions. 
Chronic exposure to smoking causes accumulation of harmful substances like nicotine, cotinine and other volatile components like acrolein and acetaldehyde. Nicotine has the tendency accumulate in higher concentrations in melanin - containing tissues and thus people of Indian sub population are at a higher risk of nicotine accumulation in ETS exposure. Hence gingival pigmentation could be an easy method to assess as well as helpful in educating the parents of the child's health. 
It has been estimated that the gingival pigmentation in Asian population is 34.9%.  Until date, there has only been very few studies done in the Indian population and thus our study aims to assess the gingival pigmentation in children of at least one smoker in the family in the Dakshin Kannada population. We also assessed the prevalence of pigmentation in both ETS exposed as well as non-exposed groups with gender segregation.
| Materials and Methods|| |
The cross-sectional observational study was conducted from various school camps conducted by the A.B. Shetty Memorial Institute of Dental Sciences, Derlakatte, Mangalore. A total of 228 students between the age group of 6 -16 years were selected randomly from March 2013 to May 2013 for the study. The inclusion criteria included children of smoking parents or other family members living together. Subjects selected were non-smokers and the controls were not exposed to ETS at home. We excluded the subjects with a positive history of long-term use of minocycline, antimalarial drugs and subjects with Addison's disease, Kaposi's sarcoma, melanomas, nevi, or amalgam tattoos. The ethical clearance was obtained from the ethical committee of the NITTE University, Derlakatte, Mangalore. Informed consent was taken from the parents/guardians/responsible authority before the study.
Evaluation of smoking status
The smoking status of children and family member were established via an interview by a single examiner. The smoking history of the parents was recorded in pack-years (number of cigarettes per day multiplied by the number of years of smoking).
Evaluation of gingival depigmentation
Gingival pigmentation was assessed by a single blinded examiner and was assessed on the basis of the Dummett Oral Pigmentation Index (DOPI).
DOPI  represents the assignment of a composite numerical value to the total melanin pigmentation manifested on clinical examination of various oral tissues. The criteria are as follows:
0= Pink tissue (no clinical pigmentation),
1= Mild, light brown tissue (mild clinical pigmentation),
2= Medium brown or mixed pink or brown tissue (moderate clinical pigmentation),
3= Deep brown or blue/black tissue (heavy clinical pigmentation).
A total of 228 participants was assessed by a single blinded examiner and grouped on the basis of scores of gingival pigmentation, parental smoking status and gender. Chi-square test was done to assess the significance of the relationship of the study parameters and was done with software SPSS v. 15.0, IBM, Chicago, IL. The significance level was set at 5%.
| Results|| |
Out of the 228 children, 64 (28.1%) subjects were exposed to ETS with at least one smoking member of the family and the rest 164 (71.9%) were not exposed to ETS.
Pearson Chi-Square test was done to compare the GP score with at least one smoker in the family to that of the control yielded a very highly significant difference (<0.001). A GP score of 0 was found in 14% of the subjects (19.5% of children not exposed to ETS and with 0% exposed to ETS), a GP score of 1 was seen with 34.2% of the subjects (46.3% of children not exposed to ETS and with 6.1% exposed to ETS), a GP score of 2 was found with 28.1% of the subjects (29.3% of children not exposed to ETS and with 25% exposed to ETS) and a GP score of 3 observed with 23.7% (4.9% of children not exposed to ETS and with 71.9% exposed to ETS) [[Table 1]1.1 and 1.2], [Figure 1].
|Figure 1: Pie chart showing the prevalence of pigmentation scores in families with smokers and without smokers|
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The prevalence of pigmentation in subjects not exposed to ETS was found to be 132 (80.5%) subjects in comparison to 32 (19.5%) without any gingival pigmentation. It can also be noted that all the 64 (100%) subjects exposed to ETS had pigmented gingiva [Table 2], [Figure 2].
|Figure 2: There is increasing pigmentation and cases of smoking in family. The green bars|
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|Table 2: Prevalence of pigmentation in children of non-smoker family members|
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A total of 12 subject's parents were interviewed for the amount of smoking, since the study was conducted in the school, parents of the rest 216 were not available to be interviewed for the amount of smoking. When the amount of smoking was correlated to the amount of pigmentation observed with the Fisher's exact test it showed no significant results. This could have been due to the lack of sample size to ascertain any particular outcome [[Table 3] 3.1 and 3.2], [Figure 3].
|Figure 3: Correlation of the amount of smoking and pigmentation. Pigmentation of 3 is seen more when smokers are there in family|
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When the pigmentation was segregated with respect to gender it was noticed that in subjects not exposed to ETS, 57 were males and 107 females, of which 10 (17.5%) males and 22 (20.6%) females had no pigmentation and the subjects exposed to ETS had 34 males and 30 females and had 0 subjects with no pigmentation at all [Table 4], [Figure 4].
| Discussion|| |
We detected 85.9% subjects with gingival pigmentation and only 15.1% without pigmentation. It was also observed that pigmentation was absent in 10 boys compared with 22 girls, showing almost twice the predilection of pigmentation in females compared with males. The level of gingival pigmentation in the study population also depends on the genetic and racial basis as physiological pigmentation is observed and has been correlated to be more than that found in a study done in the Japanese population  . It was observed that 28.1% children were exposed to ETS with at least one smoking member of the family and 71.9% were not exposed to ETS in the home environment even though the smoking status in India is 47% men and 14% of women which by itself is an under section. 
Our study also suggests that there is an influence of ETS on gingival pigmentation as the correlation between children of smokers in the family had a significantly higher level of pigmentation observed when compared to that with children not exposed to ETS. These results are in agreement with the study done by Srirangarajan et al. in 2010.  It has been hypothesized that there are mainly 2 mechanisms through which stimulatory substances reach the melanocytes by ETS; firstly it's through directly through the saliva causing effects on the oral epithelium and second mechanism, which is the main cause is through inhaling the smoke and consequently nicotine and its products stimulating an increase in melanocyte activity.  It has been stated that active smoking has a dose dependent causal relationship with gingival pigmentation generally occurring in the maxillary anterior region. ,,,
A case-control study by Hanioka et al. in a Japanese population determined that 61% of children with at least one smoking member in the family. Gingival pigmentation was observed in 71-78% of children. The percentage of smoking parents was higher in children with gingival pigmentation (70-71%) than in those who lacked pigmentation (35%), which suggested that the pigmentation in the gingiva of children was associated with passive smoking. 
We were not able to assess the dose dependent relationship between level of smoking and gingival pigmentation. This was due to the fact that the amount of smoking history was lacking as the parents were not interviewed except for 12 subjects and these 12 subjects showed no statistically significant result.
| Conclusion|| |
Within the limitations of this cross-sectional observational study, we conclude that there may be a correlation between gingival melanin pigmentation of children exposed to ETS.
What this study adds?
This research is helpful in understanding the impact of passive smoking within the household. It also highlights the effects of passive smoking on children and further studies can be conducted to understand the other deleterious effects of smoking.
| References|| |
|1.||Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: Prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control 2003;12:e4. |
|2.||Sridharan S, Ganiger K, Satyanarayana A, Rahul A, Shetty S. Effect of environmental tobacco smoke from smoker parents on gingival pigmentation in children and young adults: A cross-sectional study. J Periodontol 2011;82:956-62. |
|3.||Hanioka T, Tanaka K, Ojima M, Yuuki K. Association of melanin pigmentation in the gingiva of children with parents who smoke. Pediatrics 2005;116:e186-90. |
|4.||Dummett Co, Gupta O.P. The DOPI assessment in gingival pigmentation. J Dent Res. 1966;45:122. |
|5.||Axéll T, Hedin CA. Epidemiologic study of excessive oral melanin pigmentation with special reference to the influence of tobacco habits. Scand J Dent Res 1982;90:434-42. |
|6.||Araki S, Murata K, Ushio K, Sakai R. Dose-response relationship between tobacco consumption and melanin pigmentation in the attached gingiva. Arch Environ Health 1983;38:375-8. |
|7.||Hedin CA, Axéll T. Oral melanin pigmentation in 467 Thai and Malaysian people with special emphasis on smoker′s melanosis. J Oral Pathol Med 1991;20:8-12. |
|8.||Hanioka T, Tanaka M, Tamagawa H, Shizukuishi S. Epidemiologic study of melanin pigmentation in the attached gingiva in relation to cigarette smoking [in Japanese]. J Dent Health 1993;43:40-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]