The Saudi Mouth — Part 2: The Shisha Session

Shisha is the most socially normalized tobacco product in Saudi Arabia — and one of the least discussed in the dental chair. Waterpipe smokers carry a 5.1-fold increased risk of periodontal disease. Here is what the evidence says.

Research

What Happens to Your Patient's Mouth After One Hour of Waterpipe Smoking

There is a conversation most Saudi dentists are not having.

Not because the topic is difficult — but because it has somehow slipped into the background noise of clinical life. The patient sits in the chair. You take a history. Tobacco use: no. Cigarettes: no. And that, in many practices, is where it ends.

But shisha is not cigarettes. And for a significant portion of your patients, the answer to "do you smoke?" is genuinely no — while the answer to "do you smoke waterpipe?" would be yes, several times a week, in a café, with friends, in an environment where it barely registers as a health behavior at all.

That normalization is the clinical problem. And the evidence on what happens inside the mouth during a shisha session is considerably more sobering than most patients — or clinicians — realize.

This is Part 2 of The Saudi Mouth.

How Common Is It?

Before the pathology, the prevalence.

A 2025 survey found daily hookah use reported by 38.8% of participants at Saudi hookah venues, with males and younger adults overrepresented.¹ The Global Youth Tobacco Survey 2022 in Saudi Arabia documented that nearly 1 in 2 adolescents believed waterpipe smoking was harmful — which also means nearly 1 in 2 did not.² A 2025 Frontiers in Public Health study documented current tobacco use across Saudi regions, noting waterpipe use as a prominent pattern among young adults alongside cigarettes and e-cigarettes.³

The Eastern Mediterranean region, including Saudi Arabia, consistently records some of the highest waterpipe smoking prevalence rates in the world — higher than Europe, the Americas, or Africa.⁴

The cultural framing matters. Shisha is social. It is shared. It is associated with hospitality, leisure, and conversation. It is not perceived as a medical risk in the same category as cigarettes. But perception and biology are not the same thing.

What a Session Actually Delivers

One hour of waterpipe smoking exposes the user to approximately 100 to 200 times the smoke volume of a single cigarette.⁴ The water in the pipe does not filter the toxicants to any meaningful degree. The charcoal used for heating adds its own burden — carbon monoxide, polycyclic aromatic hydrocarbons, and particulate matter — independent of the tobacco itself.

A landmark 2025 systematic review and meta-analysis, published in Systematic Reviews (Springer Nature), analyzed 191 observational studies covering 807,174 participants across 24 countries. It found statistically significant associations between waterpipe smoking and an extensive list of adverse health outcomes — including several dental health indicators, as well as lung cancer, gastric cancer, bladder cancer, stroke, and coronary artery disease.⁴

The oral consequences are the focus here — but it is worth making this point to patients: the same session that is damaging their periodontium is also, with each use, incrementally increasing their cardiovascular and oncological risk.

The Periodontal Effect

The most clinically immediate oral consequence of regular waterpipe smoking is periodontal destruction.

A Saudi-specific study of 262 citizens of Jeddah found the relative risk for periodontal disease was 5.1-fold higher in waterpipe smokers compared to non-smokers — notably higher than the 3.8-fold increased risk observed in cigarette smokers in the same population.⁵

Read that again: in this Saudi population, waterpipe smokers had a greater relative risk of periodontal disease than cigarette smokers.

The mechanism is not mysterious. Chronic exposure to tobacco toxicants — whether inhaled from a cigarette or a pipe — dysregulates the host immune response in periodontal tissues. Vasoconstrictive effects of nicotine mask bleeding on probing, leading both patients and clinicians to underestimate disease activity. Oxidative stress impairs fibroblast function and collagen synthesis. The periodontal ligament degrades faster, alveolar bone resorbs earlier, and the clinical picture — when it finally becomes visible — often represents significant accumulated destruction.

The masking of bleeding is particularly important. A waterpipe-smoking patient whose gums do not bleed is not necessarily a patient with healthy gums. They may simply be a patient whose vasoconstrictive tobacco load has suppressed the very sign you rely on to detect disease.

The Mucosal and Oncological Risk

Periodontal disease is the most measurable consequence. But it is not the most serious one.

A 2023 systematic review and meta-analysis published in the Sultan Qaboos University Medical Journal examined 20 studies and found that waterpipe smoking causes cytotoxic and genotoxic effects on oral mucosal cells — including acanthosis, epithelial dysplasia, and hyperparakeratosis — with a pooled risk difference of 0.16.⁶ These are documented cellular-level changes: DNA methylation alterations at 727 genomic locations, p53 expression changes, and nuclear abnormalities — the same early-stage modifications observed in oral carcinogenesis.

The 2025 Springer Nature meta-analysis confirmed statistically significant associations between waterpipe smoking and multiple cancers.⁴ A Saudi-authored systematic review from Taif University confirmed that smoking raises the incidence of periodontitis by 85% (RR 1.845, 95% CI 1.5–2.2), further establishing the dose-response relationship between tobacco exposure and oral tissue destruction.⁷

The practical implication for every dental clinician is straightforward: a thorough soft tissue examination is not optional for waterpipe-smoking patients. The oral mucosa, lateral tongue, floor of mouth, and soft palate must be examined systematically at every recall appointment. Any lesion — white, red, or mixed — that does not resolve within two weeks requires investigation.

Waterpipe smokers are not outside the risk profile for oral mucosal malignancy. They are inside it.

The Caries and Salivary Picture

The periodontal and mucosal consequences receive the most research attention, but waterpipe smoking also affects caries risk through its salivary effects.

Tobacco use — including waterpipe — suppresses salivary flow and alters salivary composition: lower pH, reduced buffering capacity, decreased antimicrobial proteins. The result is an oral environment that is more cariogenic: more acid exposure per sugar challenge, less remineralization between meals, higher counts of cariogenic bacteria over time.

Patients who smoke shisha regularly and consume sweetened beverages — which describes a large proportion of the social shisha-going population — face a compounding risk that standard caries prevention counseling does not always address, because the tobacco component is not being discussed.

The Conversation at the Chair

  1. Reframe your tobacco history question. "Do you use any tobacco products — cigarettes, e-cigarettes, or waterpipe?" catches what "do you smoke?" misses.
  1. Do not minimize waterpipe as "social smoking." The relative risk data does not support that framing. Five-fold increased periodontal risk is not a social behavior — it is a clinical exposure.
  1. Examine soft tissue systematically in every waterpipe-smoking patient, at every recall.
  1. Counsel without moralizing. Most patients have genuinely not been told the oral consequences. A brief, evidence-referenced explanation — "waterpipe smokers have five times the periodontal risk of non-smokers" — lands differently than a general warning.
  1. Document tobacco use type in the clinical record. This matters for treatment planning, prognosis of restorative work, implant candidacy, and recall interval decisions.

A Note on Language

Waterpipe smoking in Saudi Arabia sits in a specific cultural context — one where hospitality and social cohesion are genuinely important values. The goal is not to stigmatize a practice that carries deep social meaning, but to ensure that the people who engage in it have access to the same quality of information about its oral health consequences that they would receive about any other risk factor.

Evidence does not judge. It describes. And what it describes, in this case, is a risk that is real, underrecognized, and highly relevant to Saudi dental practice.

Key Takeaways

  1. Waterpipe smoking is prevalent among Saudi adults and youth — and is significantly underreported in clinical histories because patients do not perceive it as "smoking."
  2. In a Saudi population study of 262 Jeddah residents, waterpipe smokers had a 5.1-fold increased risk of periodontal disease — higher than the 3.8-fold risk in cigarette smokers.
  3. Nicotine-induced vasoconstriction suppresses bleeding on probing, masking disease activity. Absence of bleeding does not mean absence of disease in tobacco users.
  4. A 2023 systematic review confirmed waterpipe causes cytotoxic and genotoxic changes in oral mucosal cells across 20 studies.
  5. A specific tobacco history question is required. "Do you smoke?" will not capture waterpipe users.

References

  1. Social determinants of health and frequency of hookah use among visitors to Saudi hookah venues. IJCMPH. https://www.ijcmph.com/index.php/ijcmph/article/view/14287
  2. Saudi Arabia Global Youth Tobacco Survey 2022. WHO/CDC. https://extranet.who.int/ncdsmicrodata/index.php/catalog/966
  3. Smoking prevalence and emerging tobacco product use in Saudi Arabia. Frontiers in Public Health. 2026. https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2026.1850905/full
  4. Sepidarkish M et al. The waterpipe smoking and human health: systematic review and meta-analysis of 191 observational studies. Systematic Reviews. 2025;14(74). PMID: 40165261. https://pmc.ncbi.nlm.nih.gov/articles/PMC11956342/
  5. Al-Zahrani MS et al. Tobacco smoking and periodontal health in a Saudi Arabian population. Journal of Periodontology. 2006. PMID: 16274311. https://pubmed.ncbi.nlm.nih.gov/16274311/
  6. Grillo R et al. Cytotoxic and genotoxic effects of waterpipe on oral health status: systematic review and meta-analysis. Sultan Qaboos University Medical Journal. 2023;23(1):5–12. PMID: 36865434. https://pmc.ncbi.nlm.nih.gov/articles/PMC9974039/
  7. Alwithanani N. Periodontal disease and smoking: systematic review. Journal of Pharmacy and Bioallied Sciences. 2023. PMID: 37654319. https://pmc.ncbi.nlm.nih.gov/articles/PMC10466628/
  8. Smoking and oral and pharyngeal cancer: a meta-analysis. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC12865294/

The Saudi Mouth is a SaudiDent original series by Dr. Mahmoud H. Al-Johani. Part 1 — Our Children's Teeth: https://saudident.com/blog/our-childrens-teeth-dental-caries-saudi-arabia

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