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Strive-The Student View Hookah and Effects on Oral Health There’s a new fad around, and everyone’s taking a puff. Hookah (shisha), a water pipe, was once only used at social gatherings where men sat around and smoked fruit-flavored, sweet-scented tobacco. This practice has expanded through the spread of restaurants, lounges and cafés that offer the option of smoking to their customers. Its popularity began in the Middle East and spread to Europe, and it is gaining quickly throughout America. Today, this “smoking the hookah” practice has not only continued with Middle Eastern men, but has spread to young professionals, youth and college students, who include it as a part of their social weekend outings. Even though the hookah has been accepted socially, these smokers have limited information about the effects it has on their oral health.
There are many myths about the effects of hookah. Many believe that it is more dangerous to our health or comparable to cigarettes, while others see it as a clean way to smoke without the risk factors. Dental professionals need to look to the research to clarify the risk factors associated with smoking the hookah so they can better educate their patients and dispel deceptive beliefs. A study that appeared in the November issue of the Journal of Periodontology showed the relative risks of periodontal disease in hookah smokers. Researchers from the Karolinska Institute in Stockholm studied 262 adults, ranging from 17 to 60 years old, in Saudi Arabia where hookah smoking is very common. The study concluded that 20 percent of participants had signs of periodontal disease, evident by generalized redness and inflammation. The incidence of periodontal disease was 30 percent in water pipe smokers, 24 percent in cigarette smokers and eight percent in nonsmokers.[1] Although researchers have found that the impact of smoking a water pipe is as great as that of cigarette smoking, many believe that smoking the hookah pipe is safe because the tobacco smoke passes through the water, which filters out the toxins before the smoker inhales it. According to Kenneth A. Krebs, DMD, president of the American Academy of Periodontology, “even though the smoke is filtered by the water, inhalation of toxic substances is similar to or even greater than that of cigarette smoking.” The report from Karolinska Institute states that water pipe smoking included the same toxins as cigarette smoking, such as carbon monoxide and tar. Carbon monoxide is a highly toxic gas and can be very harmful, as it reduces oxygen delivery to the body’s vital organs and tissues. Since hookah smoking is a time to socialize, it is used over a longer duration, often 40-45 minutes, rather than 5-10 minutes it takes to smoke a cigarette. This increases the exposure to these toxic substances. According to the World Health Organization (WHO) advisory, even after passing through the water, the tobacco smoke produced still contains high levels of toxic compounds, including carbon monoxide and carcinogens. The water does absorb some of the nicotine, yet hookah smokers can still be exposed to a sufficient dose to cause an addiction.[2] It is possible that the reduced concentration of nicotine will end up in smokers inhaling a greater amount, thereby exposing them to higher levels of the toxic substances. Sana S. Al-Mutairi and his colleagues at Kuwait University School of Medicine analyzed the concentration of nicotine and cotinine, a product of nicotine, in the urine samples of 77 hookah smokers, 75 cigarette smokers and 16 healthy nonsmokers. After studies were made, chronic respiratory problems were reported among the hookah smokers. Bronchitis was also reported at a younger age, when compared to cigarette smokers.[3] Additionally, intra-oral findings in hookah smokers are similar to those in cigarette smokers. These findings include coated tongue, halitosis and staining. In cases of periodontal disease, gingival tissue repair is delayed after treatment increasing the risk for aggressive periodontitis. To many, because shisha smoke seems less harsh than cigarette smoke, they perceive it as less toxic. Even though the research studies have demonstrated the negative effects associated with smoking the hookah these smokers are uninformed. Dental professionals play a large role in educating patients about the risks of smoking and oral disease. Another habit that has been adopted in the Middle East and in the West when smoking hookah is drinking alcoholic beverages. The inclusion of alcohol adds to the social atmosphere portrayed by smoking the hookah. This combination of tobacco and alcohol use has been linked to the increase of neoplasms in the oral cavity, pharynx and larynx.[4] Neoplasm is defined as any new and abnormal growth, specifically one in which cell multiplication is controlled and progressive.[4] The interaction of tobacco and alcohol may increase the effects of the alcohol. Understanding this correlation is important when addressing overall health. Conclusion In general, smoking anything is not beneficial to our health. Further studies are needed to determine specific risk factors associated with smoking the hookah. There is a misconception among current hookah smokers who believe that smoking the hookah is safe because toxins are filtered out by the water. For years, I have known about the hookah pipe and its origin. It has been a part of Middle Eastern culture and folklore that has spread to others through acceptance of this social smoking custom. Those who are engaged in this globalized tradition put their health at risk. Addressing the factors involved by differentiating between its social and relaxation benefit, and advising about its potential harm, are important for us as health professionals. It is essential that every dental professional understands the risks involved and is aware of hookah smoking’s popularity throughout the younger population. This information will help dental professionals address concerns for the patient’s health and play a significant role in creating awareness. Awareness will allow the patients to make healthier decisions. It is our responsibility to assist these patients in modifying their behaviors before irreversible disease occurs. References
Rula Kameel Kassis is a senior dental hygiene student at SUNY Farmingdale in New York. After graduation, while working as a dental hygienist, she will continue her education at University of Michigan, Ann Arbor. Her incentive comes from the love and support of her amazing parents, and the encouragement of her instructors. She is very dedicated and hopes to play a big role in the dental hygiene community. Laura Mueller-Joseph, RDH, BSDH, MS, EdD, was the faculty mentor for this column.
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By Rula Kameel Kassis
Readers should be aware of what a hookah consists of to better understand the process in which patients are engaging when they follow this new trend. The components of a hookah pipe include a glass base, mostly filled with water, connected by a tube to a bowl at the top. The tobacco is placed in the bowl and covered with burning charcoal. The smoker draws from a hose that is connected to the base. The air is drawn through the tobacco and passed through the water before it is inhaled. The bowl of the hookah is filled with a type of tobacco that is sweetened with molasses, honey or fruit. There is a great variety of hookah flavors, including grape, pink lemonade and apple. Its popularity may be due to the selection of flavors that can satisfy anyone’s taste buds.
