ASSOCIATION BETWEEN MIGRAINE FREQUENCY, SLEEP QUALITY, AND STRESS LEVELS AMONG ADULT NEUROLOGY OUTPATIENTS IN PAKISTAN: A CROSS-SECTIONAL STUDY

Jahanzeb  Akhtar; Zia Ur Rehman

Authors

Jahanzeb Akhtar JPMC, Pakistan Author
Zia Ur Rehman International Islamic University Islamabad, Pakistan, Author

Keywords:

Cross-Sectional Studies; Dental Plaque Index; Electronic Nicotine Delivery Systems; Gingival Hemorrhage; Periodontal Diseases; Periodontal Pocket; Young Adult

Abstract

Background: E-cigarettes are increasingly marketed as safer alternatives to conventional tobacco products, particularly among young adults. However, growing evidence suggests that e-cigarette use may adversely impact periodontal health through mechanisms involving inflammation and microbial imbalance. Understanding this relationship is essential for guiding dental practice and public health interventions.

Objective: To determine the prevalence of e-cigarette use among young adult dental patients and evaluate its association with bleeding on probing, probing pocket depth, and plaque index after adjusting for potential confounding variables.

Methods: A cross-sectional investigation was carried out over a five-month period within a dental teaching hospital located in Lahore. Systematic random sampling was used to recruit 420 patients between the ages of 18 and 35 years. Each participant filled out a structured questionnaire that gathered information on demographics, oral hygiene routines, and history of electronic cigarette use. Standardized periodontal examinations were performed by calibrated clinicians to record clinical measures such as bleeding on probing (BOP), probing pocket depth (PPD), and plaque index (PI). All statistical analyses were conducted using SPSS software, version 26.0. Comparisons between groups for categorical and continuous variables were performed using the Chi-square test and independent samples t-test, respectively. To evaluate independent relationships, multivariate linear regression was employed, adjusting for potential confounders including age, sex, socioeconomic status, and oral hygiene habits.

Results: E-cigarette use prevalence was 27.6%. Current users exhibited significantly higher mean BOP (34.2% ± 8.1), deeper PPD (3.8 ± 0.9 mm), and elevated PI (2.4 ± 0.6) compared with non-users (p < 0.001 for all). In multivariate models, e-cigarette use independently predicted worsened periodontal outcomes, with adjusted β-coefficients of 0.29 for BOP, 0.25 for PPD, and 0.31 for PI (p < 0.05).

Conclusion: E-cigarette use among young adults was significantly associated with greater periodontal inflammation, reflected in higher bleeding, deeper pockets, and greater plaque accumulation. These findings highlight the need for integrating e-cigarette risk awareness into dental counseling and preventive care strategies. Longitudinal studies are recommended to confirm causality and assess long-term periodontal impacts.

Author Biographies

Jahanzeb Akhtar , JPMC, Pakistan

Postgraduate Resident Neurosurgery, JPMC, Pakistan
Zia Ur Rehman , International Islamic University Islamabad, Pakistan,

Neuroscience Researcher, International Islamic University Islamabad, Pakistan,

References

1. Alnufaiy B, Alzahrani HG, Lambarte RA, Alghamdi MA, Alali AS, Alanazi WF, et al. The impact of electronic cigarette smoking on periodontal status and proinflammatory cytokine levels: a cross-sectional study. 2025;25(1):775.

2. Isik Andrikopoulos G, Farsalinos K, Poulas KJT. Electronic nicotine delivery systems (ENDS) and their relevance in oral health. 2019;7(4):61.

3. Mišković I, Kuiš D, Špalj S, Pupovac A, Prpić JJDj. Periodontal health status in adults exposed to tobacco heating system aerosol and cigarette smoke vs. non-smokers: A cross-sectional study. 2024;12(2):26.

4. Garcia BdFS, de Barros Nascimento B, Marques EF, de Jesus CBD, Neto ICS, Rocha LST, et al. The use of electronic cigarettes and other tobacco products among university students and their potential relationship with oral health: A cross-sectional study. 2024;155(8):647-56.

5. Pesce P, Menini M, Ugo G, Bagnasco F, Dioguardi M, Troiano GJCoi. Evaluation of periodontal indices among non-smokers, tobacco, and e-cigarette smokers: a systematic review and network meta-analysis. 2022;26(7):4701-14.

6. Al Tameemi ZHF. Smoking Impact on Gingival Crevicular Fluid Cytokine and Periodontal Status, a Systematic Literature Review: Lithuanian University of Health Sciences (Lithuania); 2024.

7. Zhang Q, Wen CJFiPH. The risk profile of electronic nicotine delivery systems, compared to traditional cigarettes, on oral disease: a review. 2023;11:1146949.

8. Shabil M, Khatib MN, Ballal S, Bansal P, Tomar BS, Ashraf A, et al. The impact of electronic cigarette use on periodontitis and periodontal outcomes: a systematic review and meta-analysis. 2024;24(1):1197.

9. Ali D, Kuyunov I, Baskaradoss JK, Mikami TJBOH. Comparison of periodontal status and salivary IL-15 and-18 levels in cigarette-smokers and individuals using electronic nicotine delivery systems. 2022;22(1):655.

10. Alkattan R, Tashkandi N, Mirdad A, Ali HT, Alshibani N, Allam EJIDJ. Effects of Electronic Cigarettes on Periodontal Health: A Systematic Review and Meta-Analysis. 2025.

11. Tanner T. Healthy young adults' oral health and associated factors: cross-sectional epidemiological study. 2015.

12. Xu F, Aboseria E, Janal MN, Pushalkar S, Bederoff MV, Vasconcelos R, et al. Comparative effects of E-cigarette aerosol on periodontium of periodontitis patients. 2021;2:729144.

13. Scherer G, Pluym N, Scherer MJHRJ. Oral health risks in adults who use electronic nicotine delivery systems and oral nicotine pouches: a critical review of the literature and qualitative synthesis of the available evidence. 2024;21(1):229.

14. Ibraheem W, Bokhari AM, Alam MN, Munthiri HA, Arishi HA, Alsabei AKJJoID, et al. Relationship of Periodontal Disease and Electronic Cigarette Usage among Adolescents in Jazan Population, KSA. 2024;17(1):346-51.

15. Suryadevara J. Prevalence of use of tobacco and cannabis products among UCSF dental patients with Periodontal Disease: cross sectional assessment: University of California, San Francisco; 2021.

16. Preshaw P, Chambrone L, Holliday R, Ambalavanan NJN, Edition-E-Book CsCPtSA. Smoking and periodontal disease. 2024;116.

17. Kravchenko B, Lykhota KJBoM, Research B. Health effects of nicotine products on oral tissues: Prevention approaches. 2024;4(6):76-87.

18. Ahad A, Bey A, Khan S, Ahmad MSJJoap, dentistry i. Periodontal status associated with dual habits of smoking and smokeless tobacco use: A cross-sectional study in young adults. 2021;13(2):69.

19. Camoni N, Conti G, Esteves-Oliveira M, Carvalho TS, Roccuzzo A, Cagetti MG, et al. Electronic cigarettes, heated tobacco products, and oral health: a systematic review and meta-analysis. 2023;13(17):9654.

20. Tattar R, Jackson J, Holliday RJE-bd. The impact of e-cigarette use on periodontal health: A systematic review and meta-analysis. 2025:1-7.

21. Tabnjh AK, Alizadehgharib S, Campus G, Lingström PJFiOH. The effects of electronic smoking on dental caries and proinflammatory markers: a systematic review and meta-analysis. 2025;6:1569806.

22. Bielecka-Kowalska NP, Bielicka S, Lewkowicz NJJoP-C, Research C. Effects of tobacco smoking and electronic nicotine delivery systems on oral health-a narrative review. 2022;16(3).