During the last decades, there has been an increased trend in narghile use globally
(1, 2). It has been considered as a global threat and given the status of an epidemic
by public health officials (3).
Several reviews were written concerning the health effects of narghile use, especially
cardiorespiratory (2–7). As dentists are almost certain to encounter narghile smokers
(NS) amongst their patients, it is important to inform the dental team of the significantly
detrimental impacts of narghile use on oral health. However, to the best of the authors’
knowledge, no review has raised its oral health effects. Nevertheless, data regarding
its effects on oral health are few. We searched MEDLINE and SCOPUS on June 30, 2015,
using the combination of the following keywords: (‘narghile’ or its different synonyms)
and (‘oral lesions’ or ‘oral cancer’ or ‘dry socket’ or ‘periodontium’). Only 16 studies
(8–23) were found. The studies of Ashril and Al-Sulamani (22) and Natto (23) were
not retained since their full texts were not retrieved. Direct contact with authors
(mail or postal addresses) failed to obtain a copy of their manuscripts. When looking
into the abstract of Natto study (23), having the same title as a previous one by
the same team (18), it seems like a synthesis of their previous studies (17–20). Therefore,
only 14 studies were retained (8–21). Tables 1 and 2 display their designs and main
results. There is a high risk that narghile use may have harmful effects on oral cavity.
However, several methodological limitations were noted in the 14 retained studies.
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-sectionalComparative
Cross-sectionalComparative
Cross-sectionalComparative
Cross-sectionalComparative
Cross-sectionalComparative
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
PregnancyUnhealthy
NR
PregnancyUnhealthy
PregnancyUnhealthy
Pregnancy
Unhealthy
Chronic systemic diseasesEndocrine or hematological pathologiesPregnancy
Dental scaling within the last 6 monthsOrthodontic 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
17–60b
39.4c
25–70b
17–60b
M: 38 (36–41)a
‡
F: 39 (34–44)a
‡
TS: 38.5c
17–60b
M: 39 (37–41)a
F: 38 (34–43)a
39 (36–41)a
27±9d
*
18–60b
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 RY44%: <40 RY56%: ≥40 RY
NR
36 (27–44)a RY40%: <27 RY60%: ≥27 RY
57 (48–66)a RY44%: <40 RY56%: ≥40 RY
NR
3.4c 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 examinationBacteriological 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=7237 (35–39)a Y230 (193–268)a CY37 subjects: <170 CY52 subjects: ≥170 CY
n=4936.7c Y25–70b
n=5036.5c Y210 (169–251)a CY
n=72M: 36 (34–38)a Y
F: 38 (34–43)a Y230 (193–268)a CY37 subjects: <170 CY52 subjects: ≥170 CY
n=3537 (34–40)a Y
n=3034±10d Y14.1c CD
Comparison with
healthy non-S
n=99
n=7034.4c Y25–70b
n=7833.2c
n=99M: 38 (35–41)a
F: 35 (32–39)a
n=8040 (35–41)a Y
n=3832±11d Y
Comparison with MS
n=6733 (31–35)a Y174 (141–207)a CY24 (18–30)a RY
n=4938.1c Y25–70b Y
n=5437.1c Y1.91 (154–229)a CY17 (10–6)a RY
n=67M: 33 (31–35)a YF: 32 (28–37)a Y174 (141–207)a CY24 (18–30)a RY
n=2533 (30–37)a Y
n=5028±10d Y1.9c NW10.6c 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.
a
Data are mean (95% confidence interval);
b
data are range (minimum–maximum);
c
data are mean;
d
data 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-sectionalComparative
Cross-sectional
Cross-sectionalDescriptive
Cross-sectional Descriptive
Cross-sectionalComparative
Cross-sectionalComparative
Recruitment method
Patient consultants
Patient consultants
Patient consultants
Randomized sample of households
NR
Population
clusters
Cafes Entertainment centersDental studentsMedical sciences students
Coffee shopsResting areas
Name of the
smoking mode
GozaShishaHubble-bubble
ShishaWater pipeHookah
Water-pipeMada'a
Waterpipe
Hookah
ShishaMoasel
WaterpipeHookah
WaterpipeGouzaShishaHubble-bubbleNarghileHookah
Inclusion criteria
NR
HealthyNo drugsUnilateral high mesioangular Impactions+exposed occlusal surfaces
Using qat daily on only one side of the mouth for ≥10 Y
>18 YMaleCurrent NS (at least once per/week and smoked <100 cigarettes in their life)Never
smokers
NR
>18 Y
20–40 Y
HealthyMaleAdult
Non-inclusion criteria
NR
MSFormer smokersMedication useRecent antibiotic useNeed for antibiotic prophylaxis
UnhealthySystemic disease
Female
PregnancyChildDiagnosis of oral cancer prior to entry the study
Non-S
Systemic diseaseAlcohol useFixed or removable partial denture PSOral mucosa lesion
Alcohol useMedications
use
Exclusive-NS
NoCase 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)
612320
29a
22–39b
45±9c
22–55b
47±14c
†
45–95b
34.9a
30.15±6.02c
20–40b
37.5a
28–65b
Number of years
of smoking
Case 1:>20Y Case 2: 3 Y
NR
NR
70 subjects≤14 Y58 subjects >14 Y
NR
NR
NR
NR
Type of tobacco
MoasselTomback
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 YCase 2: twice a day for 3 YCase 3: regular smoker 4 Y
30%: 1–3 ND37%: 4–6 ND17%: 7–9 ND16%: 10 to12 ND
NR
54%: ≤28 HW46%: >28 HW52%: ≤4 HD48%: >4 HD
NR
NR
1–3 NW20–80 min3–5 Y
1–4 ND.>15 min
Last narghile (h)
NR
NR
NR
NR
NR
NR
NR
NR
Explorations
Clinical examinationLesion biopsy
Clinical examination
Clinical examinationHistological study: two biopsies (chewing and contralateral sides)
Clinical examinationGenetic study
Visual-tactile-examination
Clinical conventional oral examination
Clinical oral examinationHistological study (cytological smear samples from three
different areas)
Histological study: collection of buccal cellsThe comet assay
Questionnaires
NR
Non-standardized
Non-standardized
Non-standardized
NR
Non-standardized
Non-standardized
NR
Comparison with active CS
No
n=10027a Y
20–38b Y
n=1138±12c Y24–58b YHeavy smokers (>20 CD)
No
No
No
n=4030.32±5.69c
Y 20–40b Y3–30b CY
No
Comparison with healthy-Non-S
No
n=100(100 M/0 F)28a Y20–37b Y
n=1132±10c Y22–58b Y
n=7853±11c Y
No
No
n=4030.30±5.83c
Y 20–40b 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 DSIncreased 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 than are the patients who do not smoke postoperatively
or who smoke the second day after surgeryDS in smokers appears to favor a systemic
etiology rather than a direct effect of heat/smoke or suction on the extraction socket
Histopathologic changes in the oral mucosa of both sides: no significant differences
between the three groupsPathologic changes of the oral mucosa were related mainly
to takhzeen al-qat
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
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.
a
Data are mean;
b
data are range (minimum–maximum);
c
data are mean±SD.
Significant differences:
†
NS vs. Non-S. No significant difference was found between NS vs. CS or NS vs.MS.
The first limitation concerns the ‘narghile’ synonyms. Narghile is the generic name
for any method of tobacco use featuring the passage of smoke through water before
being inhaled (2, 6). In the literature, the name of this mode of smoking depends
on the country of origin and includes several terms: goza, shisha, water pipe, water-pipe,
waterpipe, hubble-bubble, mada'a, moassel, narghile, and hookah (Tables 1 and 2).
One error, of a methodological nature, is to group under one universal entity (‘waterpipe’,
particularly in one word) different types of pipes which are actually used with different
smoking products in different contexts (24). This error is not only a scientific reductionism
but also a nominalism that has fuelled world confusion (2, 6). Two examples of such
confusion were highlighted by Chaouachi (25, 26).
The second limitation concerns the study sample sizes. The number of NS included in
the retained studies varied from 3 (8) to 228 (13) subjects, and only one study (13)
has calculated the required sample size. The calculation of the sample size is a statistically
central point since determining its finest size for a study guarantees enough power
to distinguish statistical significance and is a serious step in the design of a planned
research procedure (27). In the future and accordingly, similar studies should comprise
a suitable calculated sample size (27).
The third limitation concerns the applied medical questionnaires. Five studies (16–20)
applied standardized questionnaires, however, without citing any reference. Six others
(9, 11–14, 21) applied non-standardized questionnaires and three (8, 10, 15) did not
mention how patients’ information was selected. It is interesting to note that there
is a pressing need to standardize items in epidemiological questionnaires used in
studies addressing the narghile use (28).
The fourth limitation concerns the applied inclusion and non-inclusion criteria. Four
remarks concerning this issue should be raised. 1) Only nine studies (9, 14–21) included
exclusive-NS (ENS). In the case-series study (8), there were two ENS and one mixed
smoker (MS, cigarette and narghile). Only one study (14) has excluded passive smokers.
Ignoring the profile of volunteers participating in the trial (often ex-cigarette
smokers [CS] who start narghile use) is a methodological mistake (29). For that reason,
only ENS should be evaluated in the NS group (2, 6). 2) The inclusion of elders (16–21)
may introduce a bias because the prevalence of periodontal diseases (PD) increases
with age (30). 3) One key information that could be addressed as a non-inclusion criterion,
particularly in studies performed in Saudi Arabia (16–20), is about chewing stick
called ‘miswak’, which is widely used there (31). It seems that ‘miswak use’ was at
least as successful as tooth brushing in reducing plaque and gingivitis, and that
its antimicrobial effect is advantageous for prevention/treatment of PD (32). 4) One
major limitation noted in the study of El-Setouhy et al. (11), aiming to investigate
the genotoxic effect of narghile smoke on oral mucosa, was the inclusion of a high
percentage (53%) of NS reporting exposure to agriculture pesticides, since the last
augments the micronuclei frequency in exfoliated oral cells (33).
The fifth limitation concerns the recruitment methods reported only in six studies
(16–21). In 12 studies (9, 10, 12–21), subjects were selected by a convenience sample.
As in any study using convenience samples for their relative ease of access volunteers,
there was a possibility of volunteer bias.
The sixth limitation concerns narghile use. Four remarks concerning this issue should
be raised. 1) Five methods of narghile-use quantification (run-years for ‘narghile
runs smoked per days’בyears duration’; narghile week [number of narghile per week];
narghile day [number of narghile per day]; hagar week [number of hagars smoked weekly];
and hagar day [number of hagars smoked daily]) were cited in eight studies (Tables
1 and 2). In front of the confusion about how to quantify narghile use, a specific
international codification is immediately needed (6). 2) Information about the type
of used tobacco was specified only in three studies (8, 13, 15). The lack of information
about the different types of used narghile tobacco makes comparison difficult, because
in the case of tombak or jurak, in comparison to tabamel, the pattern is different
(6). In the future, the used narghile tobacco (moassel or tabamel, tombak, jurak)
should be noted to allow comparisons between studies. 3) The level of exposure to
narghile tobacco, mentioned only in seven studies, was very large and several definitions
were applied to define light/heavy narghile exposures (Tables 1 and 2). This situation
makes comparison between studies difficult. In the future, like as done for cigarette
smoking, it is recommended to standardize the way in which narghile use is quantified.
4) Information about the last narghile use was lacking in all studies. This information
is important in order to avoid confusion between the chronic and acute effects (4,
5) of narghile use even in oral health.
The seventh limitation concerns the number of implicated examiners, reported only
in 10 studies (Tables 1 and 2). Despite the measurement of interobserver reproducibility
(16, 18, 19) and the conduction of training sessions (12, 13), the duplicity/multiplicity
of examiners may influence the precision of measurements. In future studies, where
more than one examiner will be implicated, error of measurements and data reproducibility
(34) should be noted.
The eighth limitation concerns the control groups (CS; non-smokers [non-S]; MS; non-NS)
included in 10 studies (Tables 1 and 2). Two studies, aiming to evaluate the prevalence
of oral mucosa suspicious lesions, have included smokers of narghile and other forms
of tobacco (12, 13). It is important to highlight that the subjects included in the
study of Ali (10) were all smokers of takhzeen al-qat and the non-NS group of Dangi
et al. (12) included bidi and chewing tobacco users. These are two confusion factors
concerning the effect of narghile use on oral mucosa (10, 12). In addition, the authors
wondered what would be the scientific merit of including an MS group (n=25) in the
study analyzing the periodontal microflora without presenting and/or commenting their
data (20).
The ninth limitation concerns the applied clinical approaches. Three examples can
be highlighted. 1) The discrepancy between effects of narghile use on periodontal
health could be explained by the number of sites of clinical recordings: all teeth
except the third molar (18) or only six representative teeth (21). 2) Al-Belasy did
not specify the difficulty of the surgery, the oral hygiene, the preoperative infection,
and the surgeon experience, which influence the dry socket incidence (35).
In conclusion, future studies should be made more rigorous by taking into account
the various factors discussed here. Extensive epidemiological well-designed studies,
preferably longitudinal, are needed to assess the effect of narghile use on oral tissues.
Mehdi Khemiss
Department of Dental Medicine Fattouma Bourguiba Hospital University of Monastir Monastir,
Tunisia
Sonia Rouatbi
Laboratory of Physiology Faculty of Medicine of Sousse University of Sousse Sousse,
Tunisia Department of Physiology and Functional Exploration Farhat Hached Hospital
Sousse, Tunisia
Latifa Berrezouga
Department of Dental Medicine Fattouma Bourguiba Hospital University of Monastir Monastir,
Tunisia Department of Medical Microbiology–Immunology Faculty of Dental Medicine University
of Monastir Monastir, Tunisia
Helmi Ben Saad
Laboratory of Physiology Faculty of Medicine of Sousse University of Sousse Sousse,
Tunisia Department of Physiology and Functional Exploration Farhat Hached Hospital
Sousse, Tunisia Email: helmi.bensaad@rns.tn