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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 79-83

Effectiveness of nicotine replacement therapy with tooth-whitening agent on smokers dependence and tooth stain: An interventional study


1 Department of Public Health Dentistry, Karpaga Vinayaga Institute of Dental Sciences, Kanchipuram, Tamil Nadu, India
2 Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Submission09-Oct-2018
Date of Acceptance27-Jul-2019
Date of Web Publication13-Nov-2019

Correspondence Address:
Dr. K Indrapriyadharshini
Department of Public Health Dentistry, Karpaga Vinayaga Institute of Dental Sciences, Kanchipuram - 603 308, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_49_18

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  Abstract 


Introduction: Smoking cessation with an added tooth-whitening effect in nicotine replacement therapy (NRT) may increase motivation to quit smoking. The aim of this study was to evaluate the effectiveness of NRT-whitening agent in tooth stain reduction, being a motivational factor for smoking cessation among smokers.
Materials and Methods: A pilot interventional study was conducted among thirty participants from June 2017 to August 2017. NRT-tooth whitening gum was distributed accordingly. Exhaled carbon monoxide (CO) was measured using CO breath analyzer, and extrinsic tooth stain score was assessed using the modified Lobene Stain Index at baseline, 2nd, 3rd, and 4th week. Analysis of intensity and area score for tooth stain, cigarettes consumption, and CO level comparison at baseline, 2nd, 3rd, and 4th week was performed using the Friedman test. Correlation between CO value and stain reduction value was performed using Pearson correlation test.
Results: The difference in mean change in stain index scores, cigarettes consumption, and CO level between baseline and 4th week was statistically significant (P = 0.001). With regard to correlation between stain index score and CO value, statistically significant difference was found between total stain index value for lingual surface and CO value at 4th week(P = 0.00).
Conclusion: The present study results provide evidence that the NRT-tested chewing gums can contribute to a better overall oral hygiene by removing the stain on the tooth surface, thereby motivate smokers to abstain from the habit.

Keywords: Nicotine replacement therapy-tooth-whitening agent, stain reduction, tobacco abstinence


How to cite this article:
Indrapriyadharshini K, Iyer K, Madankumar P D. Effectiveness of nicotine replacement therapy with tooth-whitening agent on smokers dependence and tooth stain: An interventional study. Int J Oral Health Sci 2019;9:79-83

How to cite this URL:
Indrapriyadharshini K, Iyer K, Madankumar P D. Effectiveness of nicotine replacement therapy with tooth-whitening agent on smokers dependence and tooth stain: An interventional study. Int J Oral Health Sci [serial online] 2019 [cited 2019 Dec 15];9:79-83. Available from: http://www.ijohsjournal.org/text.asp?2019/9/2/79/270885




  Introduction Top


Smoking is one of the greatest causes of illness and premature death in developed and developing countries.[1] Tobacco smoke is a cocktail of several toxic chemicals of which more than sixty are known to bind and mutate DNA, responsible for nicotine addiction. Tobacco smoke is a complex and dynamic chemical mixture whose composition varies with tobacco type and preparation. In addition to the chemicals that directly contribute to its mutagenic and carcinogenic effects, tobacco smoke also contains chemicals such as nicotine responsible for its addiction.[2]

Globally, tobacco kills 6 million people every year and more than 80% of these deaths occur in the developing world. It is a known risk factor for 6–8 leading causes of death worldwide. According to the Global Adult Tobacco Survey India Report (2009–2010), more than one-third (35%) of adults in India use tobacco in some form, with 68.7 million users of only smokers.[3] According to the World Health Organization, India is home to 12% of world's smokers, there are approximately 120 million smokers in India, of which 900,000 people die every year due to smoking and related illness as of 2009.[4] As of 2015, the number of men smoking tobacco is 108 million. From the year 1998 to –2015, there is a 36% increase in the prevalence of smokers.[5]

In the oral cavity, smoking can lead to oral mucosal lesions, oral cancer, periodontal disease, and consequent tooth loss. However, perhaps, the most visible and immediate dental manifestation seen by the public is tooth stain. Tooth stain may, therefore, have a deleterious effect on individual's appearance, which in turn may result in social disadvantage for smokers.[6]

Nicotine replacement therapy (NRT) is the most widely used effective treatment for tobacco dependence. NRT came into existence, which temporarily replaces much of the nicotine from tobacco to improve motivation to avoid tobacco and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence.[7] It increases the chance of quitting smoking by about 50%–70%. The majority of smokers who try to quit do so without assistance, though only 3%–6% of quit attempts without assistance are successful.[8] Development of nicotine replacement products with oral benefits could provide smokers with additional motivation to quit smoking.

Availability of NRT with stain removal or tooth-whitening activity would provide an opportunity for dentists to illustrate some early measurable benefits of smoking cessation, reinforce smokers' commitment to quit, and support them on the path to a stable state of not smoking. The combination of high-pH buffers (sodium bicarbonate and sodium carbonate) and an abrasive agent (calcium carbonate) in conjunction with salivary stimulation resulting from the gum flavor (xylitol) and chewing action is likely to have a positive impact on stained teeth, while the gum is being used for smoking cessation. According to the literature, other studies performed with commercial whitening gums demonstrated a reduction in the stain index from week 2 onward.[9] The hypothesis tested in this study was that a nicotine replacement gum removes more stain and that being a motivational factor for smoking cessation among tobacco smokers.


  Materials and Methods Top


Study participants

A pilot interventional study was conducted among thirty bus drivers at Chennai from the June 2017 to August 2017. The study protocol was approved, and the ethical clearance was obtained from the Institutional Review Board, Ragas Dental College and Hospital, Chennai. A convenience sampling method was used to recruit the participants. The participants who consented to participate were recruited for the study. The participants who were current smokers and aged 20–60 years were enrolled in the study.

Inclusion criteria were a minimum of at least 10 of the 12 anterior teeth present and scorable. Teeth that were grossly carious, fully crowned, or extensively restored on the facial or lingual surfaces, and with intrinsic stains were not included in the study. Participants with a history of alcohol consumption and pan chewers were not included in the study. Participant who has Fagerstrom nicotine dependence score >3 was enrolled in the study.

Exclusion criteria included participants with orthodontic appliances, a history of temporomandibular disorders, and any systemic complications.

Study interventions

Details of the demographic characteristics, smoking history, and past medical history were recorded. All the consenting individuals were provided questionnaire of Fagerstrom nicotine dependence scale to assess nicotine dependence and readiness to quit scale to assess motivation level. At baseline, exhaled carbon monoxide (CO) was measured using CO breath analyzer. Extrinsic tooth stain score was assessed using modified Lobene Stain Index which scores eight sites per tooth, four facial and four lingual or palatal. The stain score per tooth site was determined by multiplying the score for stain intensity (scores 0–3) by that for stain area (scores 0–3).[10]

Eligible participants received brief smoking cessation/reduction support and information about the use of NRT – tooth whitening agent. Nicotine replacement gum-tooth whitening was distributed accordingly. All participants were instructed to use the chewing gum for 4 weeks and to quit smoking the day after enrollment.

Follow-up

At all visits after baseline, smoking status and use of study treatment (gum) were checked. The trial comprised four visits: baseline (entry visit), 2nd week, 3rd week, and 4th week (study end). The assessment of extrinsic tooth stain was done at 2nd week, 3rd week, and 4th week using modified Lobene Stain Index. Nicotine dependence was biochemically verified by measuring the level of CO in exhaled air at 2nd week, 3rd week, and 4th week. Details of any adverse events were asked at all visits.

Data analysis

Data collected in the study were entered in Microsoft Excel spreadsheet, and a master table was prepared. The data were analyzed using IBM Statistical Package for the Social Sciences for windows version 20.0 software(IBM Corp., Armonk, NY). Analysis of self-reported cigarettes consumption and CO level comparison at baseline, 2nd week, 3rd week, and 4th week was performed using Friedman test. Analysis of intensity and area score for tooth stain was performed using Friedman test. Post hoc analysis was done with Wilcoxon signed-rank test and Bonferroni correction (P<0.008 – *statistically significant). Correlation between CO value and stain reduction value was performed using Pearson correlation test.


  Results Top


Of the thirty participants who expressed interest to participate in the study, 40% were in precontemplation stage; 30% were in active stage; 10% were in preparation stage and maintenance stage; and 5% were in contemplation stage, passive–action stage, respectively, assessed based on the readiness to quit scale.

[Table 1] shows the distribution based on intensity (I) and area (A) score for tooth stain among the participants at baseline, 2nd, 3rd, and 4th week. At baseline, the mean stain index scores for intensity were 20.85 ± 16.91 (labial), 66.55 ± 26.58 (lingual), and area were 18.35 ± 13.44 (labial), 65.20 ± 25.00 (lingual), respectively. The level of stain index was lower at 4th week with a mean reduction of 6.85 ± 6.29 (labial) 20.85 ± 16.48 (lingual) for intensity and 6.90 ± 6.61 (labial), 20.90 ± 14.38 (lingual) for area, respectively. The total stain index area score at baseline was found to be 575.65 ± 588.40 (labial), 4724.20 ± 2998.68 (lingual), and at 4th week was found to be 81.95 ± 101.65 (labial), 642.55 ± 825.63 (lingual), respectively. The difference in mean change in stain index scores between baseline and 4th week was statistically significant (P = 0.001). The mean change in stain index scores from baseline indicates a stain reduction among the participants.
Table 1: Distribution based on intensity and area score for stain among the study participants at baseline, 2nd, 3rd, and 4th week

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Distribution based on cigarette count and CO value among the study participants at baseline, 2nd, 3rd, and 4th week is shown in [Table 2]. At baseline, participants smoked an average of 4.6 ± 2.501 cigarettes, and their CO value mean was found to be 9.45 ±5.463, respectively. At the 4th-week analysis, participants smoked an average of 1.15 ± 2.049 cigarettes, and their CO value mean was found to be 4.65 ± 2.477. There was statistically significant difference at baseline and 4th week for both the secondary outcome variables (P = 0.001).
Table 2: Distribution based on cigarette count and CO value among study participants at baseline, 2nd, 3rd, and 4th week

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Post hoc analysis was performed to know the significant difference between the time intervals for both CO value and tooth stain index which was found to be statistically significant.

With regard to correlation between stain index score and CO value [Table 3], statistically significant difference was found between 4th-week total stain index value for lingual surface and 4th-week CO value (P = 0.00).
Table 3: Correlation between carbon monoxide value and stain reduction value

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  Discussion Top


The evidence that NRT helps to stop smoking is now well established, and many clinical guidelines recommend NRT as a first-line treatment for people seeking pharmacological help to stop smoking.[11] Effective smoking cessation requires positive reinforcement for decreasing the nicotine dependence. The goal of NRT-tooth whitening agent is to replace nicotine obtained from cigarette smoking, and thereby reduce the urge to smoke and ease the transition from cigarette smoking to abstinence;[7] augmented by tooth stain reduction and enhancing the esthetic impact. The purpose of this study was to investigate, whether 2 mg NRT-tooth-whitening agent could serve as a deterrent factor in smoking and helps abstain among current smokers.

The present study found a reduction in tooth stain intensity, based on the area and total stain of both maxillary and mandibular teeth. The reduction in the stain score (all surfaces) suggests that NRT gum with tooth-whitening agent has an inhibitory effect on stain formation and also has a high impact on removal of extrinsic stains, which correlates with the study conducted by Whelton et al. 2012.[9] It is worth noting that, NRT gum with tooth-whitening agent showed statistically significant stain reduction from baseline to 4th week in the study population.

The use of 2 mg NRT gum with tooth-whitening agent did contribute smokers reduce their cigarette consumption with mean reduction from 4.6 ± 2.501 to 1.15 ± 2.049 as observed in this study, and this finding corroborate with a study conducted by Wennike et al. in 2003 which reported that there was a significantly higher smoking reduction rate (mean 31.0 ± 11.1–39.5 ± 19.7) in daily cigarette smoking among active gum users than placebo.[12]

A significant reduction in CO level from baseline to 4th week was also observed in the study population (P< 0.001) which can be attributed to reduced cigarette smoking after the intervention with NRT. This finding coincides with the evidence from a systematic review by Hughes, where studies have shown that a reduction in cigarette consumption also led to a reduction in expired CO levels.[13]

Findings with respect to correlation between 4th-week CO level and 4th-week stain index value, was found to be a positively correlated (P< 0.012*) on lingual surface of teeth evaluated. This could be primarily attributed to salivary flow from the tip of lingual papilla as well as the abrasive action of this gum more on newly formed stain.

The results of this study suggest that stain removal and tooth whitening are added benefits of using the NRT tooth-whitening agent. These findings may offer an added incentive for smokers to quit smoking.[9] Aesthetic consciousness could be of significance in the antismoking campaigns or interventions; this can be particularly important when participants are more likely to be dissatisfied with their smoking-related tooth stains.[14] Information from this study highlights the advantage of improvement in the cosmetic effect as a motivational factor for helping participants reduce or quit smoking. However, this result has to be interpreted with the following limitation. The study does not conclusively attribute the reduction of smoking frequency solely to the motivational effect of NRT-tooth-whitening gum. This could be clarified if this study had been approached in mixed-method both qualitatively and quantitatively to explore the reason behind motivation. The preliminary findings regarding an increase in motivation to quit through stain reduction should be investigated in future randomized control studies with appropriate control groups and inclusion of larger sample size to elucidate causality.


  Conclusion Top


The present study results provide evidence that the NRT-tested chewing gums can contribute to a better overall oral hygiene by removing the stain on the tooth surface, hence increasing the tooth-whitening quotient. This effect might be stressed by health-care professionals when advising their patients to stop smoking. Since there is increased esthetic consciousness among the population, the use of NRT-tooth-whitening agent will help as an adjuvant to motivate smokers to abstain from the habit.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Moore D, Aveyard P, Connock M, Wang D, Fry-Smith A, Barton P. Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: Systematic review and meta-analysis. BMJ 2009;338:b1024.  Back to cited text no. 1
    
2.
Valayil JM. Cigarette smoking and nicotine addiction. Austin J Lung Cancer Res 2016;1:1002.  Back to cited text no. 2
    
3.
World Health Organization. Global Adult Tobacco Survey. India: World Health Organization; 2009-2010. Available from: http://www.searo.who.int/tobacco/data/india_rtc_reports/en/. [Last accessed on 2018 Aug 21].  Back to cited text no. 3
    
4.
Chandrupatla SG, Tavares M, Natto ZS. Tobacco use and effects of professional advice on smoking cessation among youth in India Asian Pac J Cancer Prev 2017;18:1861-7.  Back to cited text no. 4
    
5.
Mishra S, Joseph RA, Gupta PC, Pezzack B, Ram F, Sinha DN, et al. Trends in bidi and cigarette smoking in India from 1998 to 2015, by age, gender and education. BMJ Glob Health 2016;1:e000005.  Back to cited text no. 5
    
6.
Alkhatib MN, Holt RD, Bedi R. Smoking and tooth discolouration: Findings from a national cross-sectional study. BMC Public Health 2005;5:27.  Back to cited text no. 6
    
7.
Wadgave U, Nagesh L. Nicotine replacement therapy: An overview. Int J Health Sci (Qassim) 2016;10:425-35.  Back to cited text no. 7
    
8.
Rigotti NA. Strategies to help a smoker who is struggling to quit. JAMA 2012;308:1573-80.  Back to cited text no. 8
    
9.
Whelton H, Kingston R, O'Mullane D, Nilsson F. Randomized controlled trial to evaluate tooth stain reduction with nicotine replacement gum during a smoking cessation program. BMC Oral Health 2012;12:13.  Back to cited text no. 9
    
10.
Macpherson LM, Stephen KW, Joiner A, Schäfer F, Huntington E. Comparison of a conventional and modified tooth stain index. J Clin Periodontol 2000;27:854-9.  Back to cited text no. 10
    
11.
Le Foll B, Melihan-Cheinin P, Rostoker G, Lagrue G; Working Group of AFSSAPS. Smoking cessation guidelines: Evidence-based recommendations of the French health products safety agency. Eur Psychiatry 2005;20:431-41.  Back to cited text no. 11
    
12.
Wennike P, Danielsson T, Landfeldt B, Westin A, Tønnesen P. Smoking reduction promotes smoking cessation: Results from a double blind, randomized, placebo-controlled trial of nicotine gum with 2-year follow-up. Addiction 2003;98:1395-402.  Back to cited text no. 12
    
13.
Hughes JR. Reduced smoking: An introduction and review of the evidence. Addiction 2000;95 Suppl 1:S3-7.  Back to cited text no. 13
    
14.
Vallittu PK, Vallittu AS, Lassila VP. Dental aesthetics – A survey of attitudes in different groups of patients. J Dent 1996;24:335-8.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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