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An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists


 
  Table of Contents    
REVIEW ARTICLE  
Year : 2022  |  Volume : 26  |  Issue : 4  |  Page : 534-540
 

Cytotoxic and genotoxic effects of cigarette and waterpipe tobacco smoking on buccal mucosa: A systematic review and meta-analysis


1 Faculty of Oral Pathology, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia
2 Dental Graduates, College of Dentistry, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia
3 General Dentist, MOH, Thadiq General Hospital, Riyadh, Kingdom of Saudi Arabia
4 General Dentist, MOH, Al-Muzahmiyah General Hospital, Riyadh, Kingdom of Saudi Arabia
5 General Dentist, MOH, Prince Saud Bin Jalawi Hospital, Alahsa, Kingdom of Saudi Arabia

Date of Submission06-Jul-2022
Date of Acceptance14-Nov-2022
Date of Web Publication22-Dec-2022

Correspondence Address:
Nishath S Abdul
Faculty of Oral Pathology, Department of OMFS & Diagnostic Sciences, College of Dentistry, Riyadh Elm University, Riyadh
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomfp.jomfp_292_22

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   Abstract 


Background: Waterpipe tobacco smoking (WTS) is an issue all over the world, although it is particularly prevalent in the Middle East, and Southeast Asia. The genotoxic effects of smoking were reported to be associated with nucleus abnormalities such as micronuclei (MN), karyorrhexis (KR), karyolysis, pyknosis, binucleates, broken eggs, condensed chromatin in exfoliated buccal mucosal cells, and was believed to be associated with apoptosis of cells and was not correlated to the exposure time.
Aim: The aim of this study was to evaluate and compare the cytotoxic and genotoxic effects of cigarette and WTS on buccal mucosa.
Materials and Methods: The pertinent search was done through the computerized literature on MEDLINE, EMBASE, and PUBMED databases, which included case-control, clinical and observational studies regarding the mutagenic effects of cigarettes and WTS in oral tissues. The retraction of data in this study was undertaken from May 2010 to May 2022. A total of 60 articles from the search data were retrieved. This investigation was registered with the research center of Riyadh Elm University for institution review board approval (IRB) and obtained the IRB number “FRP/2021/448/733/707 and the systematic review registration number with respect to PROSPERO is 345417.
Results: After the removal of duplicates, 32 were evaluated for the inclusion and exclusion criteria. Out of 32 articles, twenty studies were evaluated for cytogenetic abnormalities in buccal mucosal cells of waterpipe tobacco smokers (WTS) and cigarette smokers, and 12 were excluded. The mean MN levels in the oral tissues of WTS were more (1.94 ± 0.39) than in non-smokers (1.68 ± 0.35).
Conclusion: Therefore, we conclude that the MN count can be employed as a biomarker and preliminary signal for the identification of changes in oral mucosa among smokers, which develop towards cancer formation.


Keywords: Buccal mucosa, cigarette, cytotoxic, genotoxic, micronuclei, water-pipe


How to cite this article:
Abdul NS, Alrukban NK, Alajmi AM, Bindawoad FA, Almughaiseeb AA, AlGhannam SM. Cytotoxic and genotoxic effects of cigarette and waterpipe tobacco smoking on buccal mucosa: A systematic review and meta-analysis. J Oral Maxillofac Pathol 2022;26:534-40

How to cite this URL:
Abdul NS, Alrukban NK, Alajmi AM, Bindawoad FA, Almughaiseeb AA, AlGhannam SM. Cytotoxic and genotoxic effects of cigarette and waterpipe tobacco smoking on buccal mucosa: A systematic review and meta-analysis. J Oral Maxillofac Pathol [serial online] 2022 [cited 2023 Jan 30];26:534-40. Available from: https://www.jomfp.in/text.asp?2022/26/4/534/364801





   Introduction Top


Micronuclei (MN) frequencies corroborate the commonly recognized idea that the MN are products of early events in human oncogenic pathway development, especially in the oral cavity, which is immediately exposed to cigarettes and WTS.[1],[2],[3],[4],[5],[6] The typical documented stable population with respect to MN frequency is 1–3 per 1000 cells.[7],[8],[9] Brown, J.E et al.[8] recognized that the evidence of genotoxic and cytotoxic effects of smoking on buccal mucosa was very limited and controversial. According to Jensen R.P et al.[10] mutagenic symptoms have been reported to be associated with nuclear dyscrasias. Few studies reported that the mutagenic abnormalities of oral tissues in cigarettes and WTS are > in nonsmokers.[11],[12] Pop A.M et al.[13] reported that diagnostically healthy young tobacco users displayed an increased number of MN in the buccal epithelia, compared to non-smokers, suggesting the existence of histological alterations.

Early detection of cytological and genotoxic damages to the epithelia of cigarette and WTS smokers may assist in increasing longevity. Therefore, the purpose of the present review is to evaluate and compare the mutagenic aspects of cigarettes and WTS on dental epithelia. This investigation will help to detect the early alterations in the buccal mucosa and assess the risk for carcinomas formation in such individuals.[14]


   Materials and Methods Top


Study design

This present systematic review was carried out with a search in the literature that included original full-text articles, cross-sectional, observational, descriptive studies, published from May 2010- May 2022, which evaluated the cytotoxic and genotoxic effects of cigarette and WTS on buccal mucosa.”

Protocol and registration

This investigation was registered with the research center of Riyadh Elm University for institutional review board approval (IRB) and obtained the IRB number “FRP/2021/448/733/707 and the systematic review registration number with respect to PROSPERO is 345417.

Search strategy

The present systematic review of the literature was carried out both electronically and manually. The relevant literature search was carried out through searches of the digitized literature on MEDLINE, EMBASE, and PubMed databases, and manual search irrespective of the date of publication using Medical Subject Headings (MeSH) terms. A total of 32 papers were identified with this method. Various keywords utilized in the search strategy included such as cigarette smoking, waterpipe smoking, cytotoxic, genotoxic, buccal mucosa, exfoliated buccal cells, and periodontal health.

Selection criteria

Initially, titles and abstracts of the records retrieved by the search were assessed in order to exclude those studies that were inappropriate. Retrospective studies were not included. For the remaining studies, full-text articles were recovered that met the inclusion criteria. Selected studies were screened using the STROBE checklist for observational studies.[15]

Inclusion criteria

Study selection was based on the following: (1) Studies published until May 2022 (2) full-text articles published in the English language (3) studies evaluating the cytotoxic effects of cigarette smoking on the buccal mucosa (4) studies evaluating the genotoxic effects of cigarette smoking on buccal mucosa. (5) Studies evaluating the cytotoxic effects of WTS on exfoliated buccal mucosa cells and buccal mucosa (6) studies evaluating the genotoxic effects of WTS on exfoliated buccal mucosa cells and buccal mucosa (7) cross-sectional, observational studies clinical, case-control studies and review articles were included.

Exclusion criteria

The studies that were excluded from the present review were: Studies published before May 2010, studies published in other than the English language, articles having only titles, conference abstracts, editorial letters and retrospective data, cytotoxic and genotoxic studies done in the oral cavity other than in buccal mucosa, animal and plant studies, studies on Nargile and Marijuana were excluded.

Control of bias assessment

The following issues were included in the risk of bias or quality assessment in the present systematic review: (1) Completeness of article information on cytotoxic and genotoxic effects of smoking on the buccal mucosa (2) selective outcome reporting (3) outcome measures (cytotoxic and genotoxic effects of smoking on buccal mucosa) (4) study design and (5) conflict of interest in the conduct of the study.

Collection and data extraction

The search retrieved 60 articles. After the removal of duplicates, 32 articles were identified. After title and abstract screening, 20 studies remained and 12 studies were excluded. Out of 32 studies, 20 studies remained for qualitative analysis and five for the meta-analysis of the primary and secondary outcomes. All authors analyzed the selected studies and critically reviewed the main findings. This review was done according to the guidelines set forth by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).[16]


   Results Top


Study selection and characteristics

The search retrieved 60 articles from the search data. After the removal of duplicates, 32 were evaluated for the inclusion and exclusion criteria. After careful analysis, 20 articles were included[4],[5],[13],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33] and after comprehensive evaluation of the titles, abstracts, resulted in the exclusion of 12 articles[1],[3],[9],[12],[34],[35],[36],[37],[38],[39],[40],[41] The reason for exclusion was due to incomplete articles, conference abstracts, articles other than the English language, retrospective studies, animal studies, editorial letters, studies on Marijuana and Nargile users and studies on blood and saliva, gingiva and those not following inclusion criteria were excluded, as shown in [Figure 1], according to PICO framework.
Figure 1: PRISMA Flow Diagram for data search strategy

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From 20 articles that were evaluated and included in this study, eight studies[5],[22],[23],[24],[26],[29],[31],[33] compared the cytotoxic and genotoxic effect of WTS and conventional and electronic cigarettes on buccal mucosa/exfoliated buccal mucosal cells. Whereas, seven studies were among smokers and non-smokers[4],[17],[19],[20],[21],[25],[28] which compared the cytogenetic abnormalities in desquamated cells of the oral mucosa. The other five studies included those with a smokeless form of tobacco users and smokers of different tobacco products.[4],[18],[27],[13],[30] These studies have mentioned that smoking WTS and cigarettes cause cytotoxic damage to cells by causing an increase in MN compared to non-smokers/controls.

This present review includes studies that were done in different countries such as USA, UK, Brazil, Bosnia, Romania, Iraq, Iran, UAE, Egypt, Jordan, India, and Pakistan as shown in [Table 1]. Meta-analysis of the five articles included as shown in [Figure 2] and the Funnel plot of the odds ratio for publication bias of included articles was shown in [Figure 3]. The meta-analysis results included five articles (Bibars AR et al. 2015[5]; Jackson M, et al. 2020[22]; Javed H et al. 2017[25]; Jalayer Naderi N et al. 2017[23]; Prasad P, et al. 2018[31]) which fulfilled the criteria of inclusion of the comparison of the groups of cigarette smoking and water pipe smoking. The odds ratio favors the vales of water pipe smoking to greatly affect the buccal mucosa cells in these individuals.
Table 1: Summary of studies under our investigation

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Figure 2: Meta analysis of the five articles included

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Figure 3: Funnel plot of odds ratio for publication bias

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   Discussion Top


Different terms are used to describe WTS depending on different regions and cultures. It is known as Shisha, Narghile, and Hookah in different countries. WTS is very common nowadays among young teenagers, especially among college students.[3] It is a frequent practice in Arabic countries and in several Asian ones. It commonly occurs among friends in social situations such as private residences or events that offer primed outlets to consumers for smoking purposes.[2] Most waterpipe smokers believed, that it is less harmful and less addictive than cigarette smoking. The available literature demonstrates that both types of smoking are dangerous, with many similar health impacts. Compared to cigarette users, waterpipe smokers have been discovered to have higher amounts of toxins and teratogenic chemicals that cause malignancies. In vitro investigations indicated that WTS exposure caused mutations in WBCs and oral tissues.[42]

A total of 20 studies were evaluated for cytogenetic abnormalities in the oral tissues of WTS and cigarette smokers in the present review. The MN test is a better indicator of genotoxicity damage and can be used as biomarker for the assessment of DNA damage.[27] Bansal et al.[4] have reported MN is higher in smokeless users than in smokers and non-smokers. Therefore, smokeless tobacco users have an increased risk for cancer due to an increase MN count. This study is similar to the study conducted by Devadoss S et al.[18] & Motgi AA,[27] which reported nuclear abnormalities such as prominent nucleoli and condensed chromatid among smokeless users than in smokers. A study by Da Siva VHP et al.[17] reported that MN incidence was high in the exfoliated cells of buccal mucosa of cigarette smokers than in non-smokers. This is consistent with other studies done by Farhadi et al. S[19] & Shafi FAA.[32] MN originate from chromosome fragments that lag behind at anaphase during nuclear division. MN studies on peripheral blood and exfoliated cells of buccal mucosa were reported by Fenech M et al.[20] and Haveric A et al.[21] MN is higher in the buccal mucosa of smokers than in non-smokers and is associated with duration, age, and intensity of smoking, unlike the MN in lymphocytes, which are not correlated or associated with these factors. Bonassi et al.[7] have reported MN frequency increased in heavy smoking and decreased with the daily intake of fruits. Jalayer NN & Pasha P[23] reported MN count increased in cigarette smokers than in WTS and controls and the mutagenic effects of tobacco smoking were not interlinked to exposure period and duration of smoking, However, WTS was correlated to the exposure time. This statement contradicts El-Setouhy M et al.[6] The MN count findings though contradict Jalayer NN & Pasha P's[23] study and are in agreement with El-Setouhy M et al.[6] & Moghaddam MR et al.[26] MN count not only depends on smoking habits but also on the occupation of the individual Javed H & Ghani N[25] & Fenech M et al.[20] Studies on MN Assay of buccal cells in water pipe smokers (WTS)/Hookah smokers by Nezhad MD et al.[29] & Taghibakhsh M et al.[33] reported that the mean number of MN is higher in WTS. Increased MN count in the buccal cells of cigarette smokers than in betel quid users and e-cigarette smokers.[13],[30],[31]

Limitations

The main drawback of our study is that it is primarily a systematic review with meta-analysis, which causes challenges with hypothesis testing because data on risk factors and outcomes are examined at the same time, although this does not appear to have an impact on our findings. Because the influence of smoking may fluctuate depending on sex, an imbalance in the proportion of males and females in our study sample could be a constraint. Future longitudinal studies are needed to better understand the long-term impact of WTS on the overall well-being of individuals with respect to a larger sample size; however, due to funding constraints and a lack of demographic records, these are challenging to conduct in poor countries.


   Conclusion Top


The present investigation indicated a greater prevalence and count of MN cells in desquamated cells of buccal mucosa of WTS users compared to cigarette smokers and non-smokers among the included studies. Future studies are warranted to assess MN assays in the oral cavity of waterpipe tobacco and cigarette smokers and their correlation with the duration and dose of smoking.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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