J Bagh College Dentistry Vol. 33(3), September 2021 The estimation of the 23 The estimation of the viable count of mutans streptococcus in waterpipe smokers and cigarette smokers Ausama A Fathallh (1), Maha A Mahmood (2) https://doi.org/10.26477/jbcd.v33i3.2950 ABSTRACT Background: Waterpipe and cigarette are two products of tobacco consumption; tobacco use has detrimental effects on the oral cavity. Numerous studies around the world have reported a significant relationship between smoking and increase dental caries and viable count of cariogenic bacteria, Materials and Methods: unstimulated saliva was collected from 84 subjects and divided equally into three groups: waterpipe smokers, cigarette smokers, and non-smokers. All of the participants are adult male aged between 25-60 years; dental caries was measured by use DMFT index, while S.mutans and S.sobrinus were isolated by using a selective medium SB 20M (Sugar bacitracin-20 modified) agar Results: The present study showed a significant (p≤0.01) higher DMFT, DT, MT, and FT among cigarette smokers group than both waterpipe smokers and non-smokers groups. The viable count of S mutans was significantly (p≤0.01) higher in the cigarette smokers group followed by the waterpipe smokers group and then the non-smoker's group, while the viable count of S sobrinus showed no statistical differences (P>0.05) between groups. The correlation of DMFT with S.mutans, and S sobrinus count were significantly positive (p ≤0.05) in the cigarette smokers group only. Conclusion: Dental caries increase in cigarette smokers, where the DMFT and S mutans viable count are less affected by waterpipe than cigarette smoking. A positive correlation is found between DMFT and mutans streptococcus count only in cigarette smokers Keywords: Waterpipe, tobacco, S.mutans, S sobrinus, SB 20M. (Received: 9/7/2021, Accepted: 8/8/2021) INTRODUCTION Tobacco is a product that grows commercially in many countries. Studies suggest that tobacco's first use was by Maya people in the center of America in the first centuries BC. With the migration of Maya to the Mississippi Valley started spreading to the south of America. Native Americans afterward, Portuguese and Spanish navigators served to spread various kinds of tobacco to be used throughout the world, (1,2) Another level of tobacco use started when cigarette had been invented; it fired this dramatic increase in tobacco using (3). There is a difference form of tobacco consuming either smoking like waterpipe, cigarette, non-smoking chewing tobacco like snuff /naswar (roasted and finely powdered for inhalation (1). One of the most common use and most favored product of tobacco is cigarette, more than six trillion cigarettes are produced annually and about one billion smokers consume these products in the world (4). (1) Master Student, Department of dentistry, Al-Israa university college, Baghdad, Iraq. (2) Professor, Department of Basic sciences, College of Dentistry, University of Baghdad. Corresponding author's e-mail: drausamaalubaidi@gmail.com Another type of tobacco consumption is waterpipe which has different designs according to regional and cultural reasons; it also has different names, narghile in east Mediterranean countries like Turkey and Syria, shisha in Egypt, and hookah in India (5). Recently waterpipe tobacco usae is spreading rapidly worldwide, with reports of more youth being waterpipe users compared to adults. In many areas of the world (6), the highest prevalence of smoking waterpipe is in Arab countries of Africa, the eastern Mediterranean plus Southeast Asia and rises in European countries. It appears higher among youth than adults (7,8). In the middle of the twenty century, widely read and admitted scientific reports decided that smoking is the major cause of lung cancer (9). Evidence exhibits that the use of tobacco in all its types substantially raises the risk of premature death from many chronic diseases (10). Smoking has many adverse effects on oral health in addition to the contribution in the development of lung cancer and cardiovascular disease. There is plenty of evidence that it has a strong impact on the mouth; it may develop some oral diseases such as periodontal disease, dental caries, oral candidosis, implant failure, oral precancer, and cancer (11). https://doi.org/10.26477/jbcd.v33i3.2950 J Bagh College Dentistry Vol. 33(3), September 2021 The estimation of the 24 Dental caries or decay can be defined as the most widely distributed infectious, chronic and multifactorial disease. It is the result of interactions over time between oral bacteria that produce acid, a substrate, that the bacteria can metabolize, and many host factors that include teeth and saliva (12). The mechanism of action of the caries process happens by the production of a weak acid by cariogenic bacteria such as Streptococcus and Lactobacillus, as a result of the fermentation process of carbohydrate which leads to a decrease in local pH below the critical value and demineralization of the tooth surface (13,14). Studies have strong evidence that emphasizes this significant association between the degree of caries activity and the salivary levels of Streptococcus mutans (15,16). S. mutans is considered as the main component of the oral microbiota and one of the key elements of the dental plaque. (17), Although S.sobrinus is a minor component, S.mutans usually predominates; but both are causative pathogens of dental caries and strongly implicated in plaque or oral biofilm formation (18). Mutans streptococci detection is typically dependent on selective media, growth on Mitis Salivarius Agar (MS), colony morphology, and Biochemical features (19). The SB-20M medium is also a selective medium that is efficient for the identification and direct morphological recognition of S mutans, S.sobrinus (20). In addition to their hazards to general health, tobacco use has detrimental effects on the oral cavity both soft and hard tissue, about half a million oral cancer recorded in 2002 around the world with tobacco as the main cause. A clear relationship was observed with periodontal disease, and also it is associated with the increase of dental caries and is considered as a risk factor (21). Numerous epidemiological reports all around the world have recorded a near association between smoking and dental caries. In Portugal, a study confirms smoking as a risk factor for tooth decay. Further, avoiding exposure to smoking leads to a 7% reduction in caries occurrence. (22). Research in Scotland found that if a pregnant woman smokes cigarettes, her infant can have a higher prevalence of caries than a child born to a non-smoking mother (23). Microbial analysis of saliva showed that there was a substantial increase in the microbial load of S.mutans among tobacco users which might increase the caries severity; however, the association between smoking and S.mutans growth is controversial. Some research has revealed a positive relationship between smoking and S.mutans growth as nicotine in tobacco has been shown to enhance the adhesion of S.mutans to the acquired pellicle and increase biofilm formation and thus increase the incidence and severity of dental caries. (24,25). On the other hand, one recent study shows that tobacco consumers had fewer caries than healthy adults, which was contrary to several previous studies.(26) Supposing that smoking tobacco helps to reduce caries, this was supported by the presence of a higher concentration of Thiocyanate (SCN). In the blood and saliva of the smoker, Thiocyanate is a constituent of tobacco smoke which has caries inhibiting effect (27,28). MATERIALS AND METHODS This comparative study consisted of 84 males aged between 25 to 60 years old. The study consisted of 56 smokers subjects divided into waterpipe smokers group (28), and cigarette smokers group (28), and 28 non-smoker subjects as a control group. The study included subjects who smoke more than five times weekly for waterpipe smokers, while more than 10 cigarettes daily for cigarette smokers, all those with systemic diseases, such as (diabetes mellitus, chronic heart disease), or taken antibiotics within the last 3 months; or had periodontal treatment during the last 6 months were excluded. Oral examination of each subject was carried out following criteria recommended by World Health Organization, 2013 (29), the subjects were examined while seated on a dental chair. The clinical examination of dental caries was conducted using a dental explorer and mouth mirror. Unstimulated saliva was collected from subjects in the early morning between 8-10 am. The subject was asked to avoid eating or drinking for three hours before the procedure of saliva collection, then asked to wash his mouth with distilled water for one minute and to relax for five minutes directly before starting saliva collection. Subjects were also asked to spit saliva into the sterilized cups that possess graduations (30). J Bagh College Dentistry Vol. 33(3), September 2021 The estimation of the 25 RESULTS Table 1 :showed that the median values of DMFT, DT, MT, and FT (8.0, 2.5, 1.0, 3.5 ) respectively were higher among cigarette smokers group than both waterpipe smokers and non-smokers groups; all these differences were statistically highly significant (P ≤ 0.01). Although the median value of DT and MT were equal (1.5, 0.0) respectively in both the waterpipe smokers group and non-smokers group, the mean rank values of DT and MT were higher in the waterpipe group (38.018, 37.143), respectively than non-smokers group (35.78, 33.929) with a non-significant differences (P>0.05) between both groups as clarified by Mann-Whitney test. The median of DMFT and FT were higher in the non-smoker's group (3.5, 1.0 respectively) than in waterpipe smokers group (3.0, 0.0), with a non- significant difference (P>0.05) in DMFT, and statistically highly significant (p≤0.01) in FT. Regarding the viable count of S.mutans results showed that median values of S.mutans calculated in (CFU/ml) were higher in the cigarette smokers group (23.00), followed by the waterpipe smokers group (12.50) and then non-smokers group (11.65). These differences were statistically highly significant (p≤0.01). Mann-Whitney test clarified that despite that the median value of colony count in the waterpipe group was higher than the non- smoker's group, statistically there were no significant differences (P>0.05) between them. According to S.sobrinus viable count (CFU/ml), the results showed that mean rank values in the cigarette smokers group (47.732) have the higher value followed by the non-smoker's group (40.054) and waterpipe smokers group (39.714), but statistically, there were no significant differences (P>0.05). In table 2, results showed that the correlation of DMFT with S.mutans and S.sobrinus viable count, was a weak positive correlation in the non- smoker's group and the waterpipe smokers group, with a non-significant statistical difference (P>0.05), whereas in the cigarette smokers group the correlations was statistically significant. It was moderate positive with S.mutans count (P ≤0.01) and weak positive with S.sobrinus ( P ≤0.05). Table 1: The differences between, waterpipe smokers, cigarette smokers and non-smokers groups considering DMFT index and viable count of mutans streptococcus Variables Groups Descriptive statistics Group difference Median Mean Rank KWH test p-value Groups Mann-Whitney U test p-value DT Control 1.5 35.786 9.362 0.009 Control Waterpipe 377 0.800 Waterpipe 1.5 38.018 Cigarette 219 0.004 Cigarette 2.5 53.696 Waterpipe Cigarette 251.5 0.019 MT Control 0 33.929 16.907 0.000 Control Waterpipe 364.5 0.587 Waterpipe 0 37.143 Cigarette 179.5 0.000 Cigarette 1 56.429 Waterpipe Cigarette 214.5 0.002 FT Control 1 39.964 32.945 0.000 Control Waterpipe 224.5 0.004 Waterpipe 0 25.589 Cigarette 153.5 0.000 Cigarette 3.5 61.946 Waterpipe Cigarette 86 0.000 DMFT Control 3.5 32.750 33.633 0.000 Control Waterpipe 356 0.550 Waterpipe 3 30.589 Cigarette 83 0.000 Cigarette 8 64.161 Waterpipe Cigarette 94.5 0.000 S.mutans count x 10 5 (CFU/ml) Control 11.65 29.839 32.970 0.000 Control Waterpipe 355 0.543 Waterpipe 12.50 33.696 Cigarette 74.5 0.000 Cigarette 23.00 63.964 Waterpipe Cigarette 108.5 0.000 S.sobrinus count x 10 5 (CFU/ml) Control 4.00 40.054 1.954 0.376 Control Waterpipe 387 0.934 Waterpipe 4,00 39.714 Cigarette 318.5 0.226 Cigarette 5.00 47.732 Waterpipe Cigarette 319 0.229 DMFT= decay, missing, filling tooth, SFR= salivary flow rate, P ≤ 0.01 highly significant, P≤0.05 Significant, P>0.05 Non-significant J Bagh College Dentistry Vol. 33(3), September 2021 The estimation of the 26 Table 2: correlation of DMFT index with S mutans, S sobrinus P≤ 0.01 highly significant, P≤0.05 Significant, P>0.05 Non-significant DISCUSSION Although the oral cavity contains numerous types of microorganisms, the present study has chosen S.mutans and S.sobrinus as these two cariogenic bacteria are the most common dental pathogens responsible for the development of caries. In this study, Sucrose-bacitracin, 20 Modified (SB-20M) culture medium was used to culture the aforementioned bacteria, as a selective medium is reliable for detection and direct morphological differentiation of S.mutans and S.sobrinus. Results showed that dental caries increased in cigarette smokers and that median values of DT, MT, FT and, DMFT, were significantly higher among cigarette smokers than waterpipe smokers and non-smokers, These results were in agreement with the former studies (25, 31, 32) and could be due to smoking influences on saliva as it reduced the buffer capability, changing its chemical agent and bacterial components, as well as the existence of nicotine in tobacco which enhances the adhesion of S.mutans to the acquired pellicle and increases biofilm formation that increases the incidence of dental caries (33, 34). On the other hand, results also revealed that the median value of DT and MT were slightly higher in waterpipe group than the non-smokers but without significant differences. Similarly, previous researches assumed that waterpipe smokers were more susceptible to the development of dental caries than non-smoker because of high scores of plaque and calculus indices (35,36), while FT was higher in control groups than waterpipe smokers in the present work. This result agrees with the results of Sahib et al., (2018) (37). The present work showed that median of S mutans viable count (CFU/ml) in cigarette smokers group have the highest value followed by waterpipe smokers group and then non-smokers groups with significant differences and this may be explained by the effect of nicotine and tar which improves the growth and attachment of S. mutans (38,39). The result of the present study disagrees with another previous study that found that the number of S.mutans in the saliva is not related to the smoking status (40). Furthermore, the current results showed that median values of S.sobrinus count in cigarette smokers group had the higher value followed by waterpipe smokers group and non-smokers groups but statistically there were no significant differences. This corresponds with the previous study which recorded higher counting levels of S.sobrinus in smokers than non-smokers (41). This slight increase in colony count of S sobrinus in cigarette smokers may be due to the same aforementioned reason that leads to an increase in S.mutans as both S.mutans and S. sobrinus share several traits and virulence factors (42). It can be concluded that waterpipe smokers are less affected by dental caries when compared with cigarette smokers. This could be due to the lower daily nicotine exposure which is equivalent to 10 cigarettes, for daily smoking and equal to 2 cigarettes per day in non-daily smoking (43). Moreover, the addition of artificial flavoring; like honey, glycerin and other flavors in the preparation of Moassel contributed to lowering the nicotine level of each gram of moassel (44). On the other hand, the correlation of dental caries with S.mutans and S.sobrinus revealed that the relationship of DMFT with S.mutans count was positive non-significant in the non-smokers group and waterpipe smokers group, while it was significantly positive in the cigarette smokers group. This agrees with other previous studies which showed a positive association of caries scores with S.mutans (45-49), Additionally, this study noted a positive non- significant relationship of DMFT with S sobrinus count in non-smokers group and waterpipe smokers group, while it was positive significant in the cigarette smokers group, and this agree with a recent study (50). This positive correlation with S.mutans and S.sobrinus could be due to the role of mutans streptococcus in the initiation of dental caries as both of these bacteria are well-known primary cariogenic microorganisms associated with dental caries (51). 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J Dent Res.. 2017 Jul;96(7):807-14.. المستخلص والال النرجيلة ان خلفية: حيث ، التبغ استهالك من نوعان من سجائر العديد أفادت وقد ، الفم تجويف على ضارة آثار له التبغ تعاطي الدراسات حول العالم بوجود عالقة كبيرة بين التدخين وزيادة تسوس األسنان والعدد الحيوي للبكتيريا المسببة للتسوس ومدخني السجائر ركيلة ناال شخًصا وقسم بالتساوي إلى ثالث مجموعات من مدخني 84ب غير المحفز من المواد والطرق: تم جمع اللعا عاًما ، وتم قياس تسوس األسنان باستخدام 60-25وغير المدخنين ، جميع المشاركين هم من الذكور البالغين الذين تتراوح أعمارهم بين SB 20Mباستخدام وسط انتقائي المكورات المسبحية الميوتنس و المكورات المسبحية السوبرينوس .تم عزل بينما ، DMFTمؤشر J Bagh College Dentistry Vol. 33(3), September 2021 The estimation of the 29 أظهرت النتي ارتفاعجة: الحالية مقارنة FT و MT و DT و DMFT (p≤0.01).رامؤث االدراسة السجائر مدخني مجموعة بين أعلى في و (p≤0.01)كان العدد القابل للحياة من المكورات المسبحية الميوتنس مؤثر حيثركيلة وغير المدخنين.نبمجموعات مدخني اال المسبحية ثم مجموعة غير المدخنين ، بينما لم يظهر العدد الحيوي اللمكوراتركيلة ناال مجموعة مدخني السجائر تليها مجموعة مدخني ذات فروق و المكورات المسبحية الميوتنس و DMFTكانت العالقة بين و (P>0.05) لة إحصائية بين المجموعاتدالالسوبرينوس في مجموعة مدخني السجائر فقط. (p ≤0.05) موجبة معنويا المكورات المسبحية السوبرينوس يلة من أقل تأثراً بالنرك المكورات المسبحية الميوتنسعدد و DMFT الحيث : زيادة تسوس األسنان في مدخني السجائر ،االستنتاجات . وعدد العقديات الطافرة فقط في مدخني السجائر DMFTعالقة إيجابية بين و يوجد تدخين السجائر ، Creative Articles Published by Journal of Baghdad College of Dentistry is licensed under a .Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/