ORIGINALARTICLE  
LOCALIZED GINGIVAL RECESSION ASSOCIATED WITH SMOKELESS TOBACCO PLACEMENT  
IN THE ORAL CAVITY: A PAIRED COMPARISON STUDY  
Bushra Jabeen1, Muhammad Yasir Ilyas2, Rabia Arshad3, Salik Rasool4, Hira Musharraf5  
How to cite this article  
ABSTRACT  
OBJECTIVES  
Jabeen B, Ilyas MY, Arshad R, Rasool  
S, Musharraf H. Localized Gingival  
This study aimed to identify the association between smokeless tobacco  
consumption and localised gingival recession in the oral cavity.  
METHODOLOGY  
Recession Associated with Smokeless  
Tobacco Placement in the Oral Cavity:  
A Paired Comparison Study. J  
Gandhara Med Dent Sci.  
A paired comparison study was conducted in the Oral Diagnosis  
Departments of Dow University of Health Sciences between 2019 and 2022.  
In the convenience sampling, 380 participants provided informed consent,  
and data were collected using a closed-ended questionnaire. Gingival  
recession was evaluated using the CPITN probe (community periodontal  
index of treatment needs) procedure with Miller's classication. Data was  
analysed with SPSS 26 for descriptive and analytical statistics.  
RESULTS  
2026;13(2):98-103  
https://doi.org/10.37762/jgmds.13-2.786  
Date of Submission: 10-09-2025  
Date Revised:  
Date Acceptance:  
10-03-2026  
10-03-2026  
2MSC Prosthodontics, Department of  
Prosthodontics, Dow University of  
Health Sciences, Karachi  
The gingival recession was more prevalent on the side exposed to chewing  
3Professor, Department of Pharmacology, tobacco (p=0.019). Variables such as age and smoking also showed  
Dow International Dental College, Dow  
statistically signicant results with gingival recession (P<0.001). Binary  
University of Health Sciences, Karachi  
logistic regression analysis demonstrated that chewing tobacco habits were  
signicantly associated with gingival recession (B = 1.063, SE = 0.265, Wald  
= 16.151, p < 0.001). The odds ratio indicated that individuals with a  
chewing tobacco habit had 0.345 times the odds of the outcome compared  
with those without the habit.  
4Associate Professor, Department of  
Pathology, Dow International Dental  
College, Dow University of Health  
Sciences, Karachi  
5Assistant Professor, Department of  
Prosthodontics, Dow International  
Dental College, Dow University of  
Health Sciences, Karachi  
CONCLUSION  
Smokeless tobacco consumption is strongly associated with gingival  
recession.  
Correspondence  
KEYWORDS: Smokeless Tobacco, Chewing Tobacco, Oral Tobacco,  
Gingival Recession, Receding Gums  
1Bushra Jabeen, Associate Professor,  
Department of Prosthodontics, Dow  
International Dental College, Dow  
University of Health Sciences, Karachi  
:
+92-333-2172183  
:
bushra.jabeen@duhs.edu.pk  
INTRODUCTION  
Pakistan Demographic and Health Survey 2017–18  
found that 3.4% of women and 14.6% of men aged 15-  
The apical displacement of the gingival margin from  
the cement-enamel junction is known as gingival  
recession, a common oral health condition.1 Gingival  
recession can be a consequence of chronic oral and  
periodontal diseases, which can even lead to signicant  
tooth loss.2 Gingival recession is also linked to multiple  
systemic diseases such as diabetes, hypertension, and  
heart issues.3,4 Products like chewing tobacco, snu,  
betel quid with tobacco, and paan are all considered  
smokeless tobacco (SLT).5 People who use SLT are  
more likely to get high levels of nitrosoproline, nitroso-  
diethanol-amine, and other nitrosamines, which can  
49 use SLT in some capacity. In Pakistan, betel quid  
with tobacco (paan), gutka, naswar, dry packet,  
mawa/mainpuri, and betel nut are the most widely used  
forms of SLT. Over the past few decades, appealing  
sachets of SLT, particularly betel quid and Gutka  
alternatives, have become more popular and accessible.  
Despite being cleverly marketed as having risks to oral  
health, the young and old, as well as some immigrants,  
continue to use them. SLT has been shown to impose a  
high socioeconomic cost on society and the country;  
this burden can be reduced through awareness  
campaigns and targeted policymaking.11 The purpose of  
this study was to determine whether tobacco use was  
linked to localised gingival recession in the oral cavity.  
This study also assisted in evaluating several  
demographic and socioeconomic factors related to  
dental recession and participants' preferences for the  
type of smokeless tobacco they used, as no such  
cause signicant chemical harm to gingival and  
8
mucosal tissues, leading to gingival recession.  
It is  
estimated that 600,000,000 individuals chew SLT  
worldwide. In Pakistan, regular use of SLT in the forms  
of paan, betel nut, gutka, niswar, and khaini/tumbaku is  
accepted and regarded as a typical cultural custom.9 The  
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J Gandhara Med Dent Sci  
98  
Localized Gingival Recession Associated with Smokeless  
gingiva, Class II gingival recession that extends to or  
comprehensive study has been conducted in our local  
population.  
beyond the junction of mucosa and gingiva, with no  
periodontal attachment loss. Class III gingival recession  
that extends to or beyond the junction of mucosa and  
gingiva with periodontal attachment loss in the  
interdental area or malalignment of the teeth. Class IV  
gingival recession that extends to or beyond the muco-  
gingival junction with severe bone or soft-tissue loss in  
the interdental area and/or severe malpositioning of the  
teeth.13 A single trained examiner performed all clinical  
examinations. Statistical analysis was performed using  
SPSS 26, and the data were subjected to descriptive and  
analytical statistics.  
METHODOLOGY  
A paired-comparison design study was conducted from  
February to March 2022 to compare the exposed side of  
the oral cavity due to smokeless tobacco use and its  
association with gingival recession at the Oral  
Diagnosis Department of all dental colleges of Dow  
University of Health Sciences. (Ishrat-ul-Ibad Khan  
Institute of Oral Health Sciences, Dow Dental College,  
and Dow International Dental College). The ethical  
certificate  
reference  
number  
is  
Ref  
No.  
RESULTS  
DIKIOHS/PROJ-APPROVED/2018/09-19, Dated: 19-  
09-2018. The sample size was calculated using  
OpenEpi with a gingival recession frequency of 43.51%  
in our community, a 95% condence interval, and a 5%  
Out of the 380 study population, 245 (64.4%) were  
males, and 135 (35.5%) were females. Most  
participants were in the 28-37 age group (54.47%).  
Males had more gingival recession on the exposed site  
than females, though the dierence was not statistically  
significant. Most of the study participants were paan  
consumers (31.8%) and kept the tobacco pouch at the  
right upper posterior area of the oral cavity (43.6%).  
(Table 1) Three fty-six (93.6%) of the samples  
showed eight times more prevalence of gingival  
recession on the exposed side than the non-exposed side  
of the oral cavity. Most of the participants had a habit  
of tobacco chewing 10-13 times a day (37.3%), and  
almost 80% had tooth sensitivity in the exposed area.  
(Table 2) The association between chewing tobacco  
habits and gingival recession was assessed using the  
McNemar test. A signicant dierence was observed  
between the tobacco-exposed and non-exposed sides of  
the oral cavity (p = 0.019), indicating that gingival  
recession was more prevalent on the side exposed to  
chewing tobacco. Variables such as age and smoking  
also showed statistically signicant results with  
gingival recession. (Table 3) Binary logistic regression  
was conducted to examine the association between  
smoking habit and gingival recession, yielding smoking  
as a nonsignicant predictor (B = 0.071, SE = 0.309,  
Wald = 0.053, p = 0.817). The odds ratio suggested that  
smokers had 1.07 times higher odds of gingival  
recession than non-smokers, but this association was  
not statistically signicant. (Table 4a) Binary logistic  
regression analysis demonstrated that chewing tobacco  
habits were signicantly associated with gingival  
recession (B = 1.063, SE = 0.265, Wald = 16.151, p <  
0.001). The model explained 6.4%–8.6% of the  
variance in gingival recession. The odds ratio indicated  
that individuals with a chewing tobacco habit had 0.345  
times the odds of the outcome compared with those  
without the habit. (Table 4b)  
12  
margin of error, yielding a minimum of 378 samples.  
Before the commencement of the study, the examiner  
received training for the assessment of gingival  
recession using Miller's classication and the use of the  
Community Periodontal Index of Treatment Needs  
(CPITN) probe under the supervision of a periodontist.  
To ensure consistency of clinical measurements, intra-  
examiner reliability was evaluated by re-examining a  
subset of patients at dierent times, and satisfactory  
12  
agreement was achieved.  
For this study, 380  
participants were enrolled with convenience sampling  
who provided informed consent, including both genders  
and smokeless tobacco users for years, dentate or  
partially dentate males and females between 18 and 50  
years of age. Edentate patients, cigarette smokers, or  
patients with any systemic disease were excluded from  
the study. Participants with systemic diseases were  
excluded to control for confounding variables, as  
systemic conditions may independently inuence  
periodontal status and gingival recession. Data was  
collected using a closed-ended questionnaire.13 For this  
study, the exposed site was dened as the intraoral  
location where the participant habitually placed  
smokeless tobacco (most commonly the buccal  
vestibule or gingivobuccal sulcus). This information  
was obtained through the questionnaire and patient self-  
report. The unexposed site was defined as the  
contralateral side of the oral cavity where tobacco  
placement was not reported. 380 patients were  
evaluated for gingival recession on tobacco on both  
exposed and unexposed sites of the oral cavity with the  
CPITN probe (community periodontal index of  
treatment needs) procedure using Miller's classication  
in every patient. According to Miller, there are four  
classes of gingival recession. Class I gingival recession  
that does not extend to the junction of mucosa and  
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Localized Gingival Recession Associated with Smokeless  
Table 1: Socioeconomic details of the participants (N=380)  
Gingival Recession  
Variable  
n
%age  
tobacco-exposed site  
tobacco-unexposed site  
Teeth Sensitivity  
356  
42  
93.6  
11.1  
Gender  
Male  
245  
135  
64.4  
35.5  
Female  
Age  
tobacco-exposed site  
tobacco-unexposed site  
Tooth Mobility  
tobacco-exposed site  
tobacco-unexposed site  
Grading of GR on the tobacco-exposed site  
Grade 0  
Miller’s Class 1  
Miller’s Class 2  
Miller’s Class 3  
Grading of GR on the tobacco-unexposed site  
Grade 0  
306  
40  
80.5  
10.5  
18 – 27 Years Old  
28 – 37 Years Old  
38 – 50 Years Old  
Education Level  
None  
91  
207  
82  
23.9  
54.4  
21.5  
131  
16  
34.5  
4.2  
47  
36  
90  
78  
110  
19  
12.3  
9.4  
23.6  
20.5  
28.9  
5.0  
24  
6.3  
Primary  
192  
132  
32  
50.5  
34.7  
8.4  
Middle  
Matric  
Graduation  
Master  
363  
00  
05  
02  
95.5  
00  
1.3  
0.5  
Profession  
Unemployed  
Employed  
Self Employed  
Dental Visits  
Never Visited  
Every Three Months  
Every Six Months  
Every Year  
Miller’s Class 1  
Miller’s Class 2  
Miller’s Class 3  
152  
149  
79  
40  
39.2  
20.7  
Table 3: Variables Associated with Gingival Recession in the Oral  
Cavity  
Characteristics  
211  
27  
47  
95  
55.5  
7.1  
12.3  
25  
Gingival Recession  
p- value  
Yes  
No  
Chewing Tobacco  
0.019*  
Yes  
No  
92  
60  
36  
68  
Table 2: Chewing habits and dental details of the patients  
(N=380)  
Smoking  
Yes  
P<0.001*  
34  
118  
22  
82  
n
%age  
No  
Type of Chewing Tobacco  
All  
Gender  
Male  
Female  
Age  
10  
121  
91  
15  
89  
21  
08  
17  
2.6  
0.08  
137  
77  
40.74±12.96  
92  
74  
Pan  
31.8  
23.9  
3.9  
Guttka  
Bettelnutt  
Snu/niswar/khaini  
pan and gutka  
Gutka and khain/snu/niswar  
Guttka/pan  
Khaini/niswar/snu  
Pan and Khaini/niswar/snu  
bettlenutt/khaini and niswa  
33.24±10.11  
P<0.001*  
Note: McNemar's test and Paired sample T test applied,  
* statistically signicant p-value (p < 0.05)  
23.4  
5.5  
2.1  
4.4  
Table 4A: Binary Logistic Regression Analysis of Smoking Habit  
as a Predictor of Gingival Recession  
Predictor  
Variable  
Smoking Habit  
Constant  
B
SE  
Wald p-value OR  
03  
05  
0.7  
1.3  
(Exp B)  
1.074  
1.439  
0.071  
0.364  
0.309 0.053 0.817  
0.144 6.409 0.011  
Site of Chewing Tobacco in the Oral Cavity  
Upper right anterior  
Upper right posterior  
Upper left posterior  
Lower right anterior  
Lower right posterior  
Lower left posterior  
Sleeping Habits with Tobacco  
in the Oral Cavity  
48  
166  
86  
16  
60  
04  
56  
12.6  
43.6  
22.6  
4.2  
Note: The cut-off value for predicted probabilities was  
0.5. OR = odds ratio; SE = standard error.  
15.7  
0.1  
Table 4B: Logistic Regression Analysis for the Association  
Between Chewing Tobacco Habits and Gingival Recession  
Predictor  
Variable  
Chewing  
Tobacco Habits  
Constant  
14.7  
B
SE  
Wald p-value OR  
(Exp B)  
0.345  
Duration of Use of Tobacco in years intervals  
1.063 0.265 16.151 <0.001  
0-4 years  
5-7 years  
8-12years  
13-17years  
18-22 years  
23-25years  
25-28years  
Frequency of Use of Tobacco in intervals  
2-4 times a day  
5-8 times a day  
10-13 times a day  
15-18 times a day  
19-20 times a day  
21-25 times a day  
26-30 times a day  
79  
20.7  
30.5  
28.9  
13.6  
5.2  
0.02  
0.5  
116  
110  
52  
0.125 0.177 0.499  
0.480  
1.133  
DISCUSSION  
20  
01  
As is known since ancient times, smokeless tobacco is  
considered an essential component of many South  
Asian societies and, despite occasional misinformation,  
is valued for its numerous therapeutic advantages.13 Our  
findings showed that the majority of people enjoy  
chewing snu keepers, paan, and gutka separately  
regularly. According to a survey conducted among  
adults and adolescents in Karachi, Pakistan, 40% of the  
02  
30  
69  
142  
82  
42  
14  
01  
7.8  
18.1  
37.3  
21.0  
11.0  
3.6  
0.02  
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J Gandhara Med Dent Sci  
100  
Localized Gingival Recession Associated with Smokeless  
population chewed at least one type of smokeless  
tobacco product daily, including betel, areca nut, and  
paan, snu, betel quid, or gutka. According to the poll,  
over 60% of men and 38% of women chew smokeless  
tobacco from an early age, which is similar to our  
results.14 A Taiwanese epidemiological survey found  
that men chew smokeless tobacco at a higher rate than  
women (9.8 versus 1.6 per cent), which is not consistent  
with our statistics, as no signicant dierence occurred  
on a gender basis in our study. 15 The reason could be  
that tobacco chewing is a tradition rather than a habit in  
some cultural classes. Our data also shows that more  
young individuals consume smokeless tobacco, and  
similar ndings are stated in another survey claiming  
that Karachi has a greater incidence of oral disorders in  
the severity of loss of attachment at the tobacco pouch  
25  
keratosis side.  
In addition, Muthukrishnan declared  
that dental mobility on the exposed side is high (91 per  
cent) compared to the unexposed side (31 per cent),  
which is likewise high according to another study.  
Gingival recession and tooth sensitivity are closely  
related, especially on the tobacco-exposed side of the  
oral cavity. This is because, as the tooth loses gingiva  
due to bone and root surface exposure, it becomes more  
26  
sensitive.  
Ahad documented that the highest risk of  
gingival recession is associated with the dual habit of  
both smoking and tobacco use. These ndings  
emphasise that individuals with dual habits have an  
additional risk for periodontal destruction.27 The results  
of the analysis demonstrated that chewing tobacco  
habits are signicantly associated with gingival  
recession. An even stronger association has been  
observed with SLT chewing compared with cigarette  
smoking for gingival recession in our study. Trullenque  
also identied that the smoking of any kind increases  
youth, as the young population is indulging in such  
16  
activities, and numbers are growing each day.  
Such  
habits are additionally related to many oral health  
issues.17 The geographic predominance of these facts is  
correlated with the frequency of 58% of head and neck  
pathologies worldwide occurring in South Asia,  
particularly in Karachi, Pakistan. According to time  
trend research, the incidence of both deadly and non-  
fatal diseases of the oral cavity is gradually increasing  
gum issues with probing pocket depth (≥4 mm) in late  
28  
adolescence and young adulthood.  
Thwin also  
conducted his oral health survey on the periodontal  
status and risk factors, concluding that gingival  
recession and gingivitis are 38-44% compounded with  
periodontal complications among tobacco chewers and  
smokers in older adults. 29  
in Pakistan, particularly in Karachi, due to  
18  
inappropriate addictions and habits.  
A
survey  
conducted in Pakistan revealed that almost 40% of  
tobacco chewers have signicant gingival recession  
19  
LIMITATIONS  
(98%).  
Gingival recession was high among second-  
decade Indian gutka consumers. There were reports of  
surveys indicating a high prevalence of tobacco-related  
oral diseases in the second and third decades. 20, 21 The  
duration and frequency of smokeless tobacco use  
during the day were also identied as important factors  
in our study. Once we considered the age to start SLT,  
60% of participants in our study started smoking and  
tobacco chewing at a young age, 22. Similarly, most of  
the members in the study were using tobacco for 5-7  
years. According to another research, those who have  
been using smokeless tobacco for more than 15 years  
Our research is a small sample-sized study conducted  
only in an urban area. As the use of tobacco is  
increasing in both rural and urban settings, among all  
ages, across all ethnic groups and genders, such studies  
must be conducted to get a clear status of the condition.  
Additionally, multiple seminars and programs should  
be organized to raise awareness of this important issue.  
CONCLUSIONS  
Smokeless tobacco has been strongly associated with  
gingival recession, with 8 times the risk in the exposed  
area of the oral cavity.  
have a higher incidence of oral disease and are more  
23  
likely to have it than those who do not.  
Our study  
demonstrated a higher chance of gingival recessions in  
the tobacco-introduced sites of the oral cavity. Similar  
to our results in a study by Kopperud, Snus (moist  
tobacco)- induced gingival lesions were observed more  
frequently (79.2%) among daily snus users. The odds of  
dental retraction were 34% higher with each year of  
snus use. Most of the adolescents had snus-induced  
CONFLICT OF INTEREST: None  
FUNDING SOURCES: None  
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24  
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Localized Gingival Recession Associated with Smokeless  
AUTHORS CONTRIBUTION  
Bushra Jabeen- Concept & Design; Data Acquisition; Drafting  
Manuscript; Final Approval  
Muhammad Yasir Ilyas - Concept & Design; Data Acquisition;  
Drafting Manuscript; Final Approval  
Rabia Arshad - Concept & Design; Data Acquisition; Data  
Analysis/Interpretation;  
Revision; Final Approval  
Drafting  
Manuscript;  
Critical  
Salik Rasool - Concept & Design; Data Acquisition; Data  
Analysis/Interpretation; Drafting Manuscript; Final Approval  
Hira Musharraf - Concept & Design; Data Acquisition; Data  
Analysis/Interpretation; Drafting Manuscript; Final Approval  
The authors accept responsibility for all aspects of the work  
and will ensure that any concerns regarding the accuracy or  
integrity of any part are properly investigated and resolved.  
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103