Smoking and Periodontal Disease

• Smoking is a modifiable risk factor for periodontal disease.
• The adverse effects of smoking on periodontal tissues are dose-dependent.
• The level of risk is the number of pack years.

GDC Learning Outcomes

• It is important to explain general and systemic diseases and their relevance to oral health.
• It is important to explain and take account of the impact of patient's periodontal and general health on overall treatment plan and outcomes.

Intended Learning Outcomes

• Learning must include the effects of smoking and periodontal disease.
• Learning must include the adverse effects of smoking on the periodontium.
• Learning must include the harmful chemicals in tobacco.
• Learning must include the reasons why smoking has adverse effects on periodontal health.

The dental relevance

• Taking social history is relevant to assess risk.
• Discussing the impact on periodontal outcomes with patients is relevant.
• Encouraging smoking cessation is relevant.

Smoking and Periodontitis

• Smoking tobacco is linked to an increased risk of periodontitis.
• Periodontitis is the 6th most prevalent disease worldwide and is linked to general well-being.
• In the UK, 14.7% of those aged 18+ smoked cigarettes.
• Those aged 25 to 34 have the highest proportion of smokers at 19%.

Effects of Smoking on the Periodontium

• Smoking is second only to bacterial plaque as a modifiable risk factor for periodontitis.
• Smoking increases the risk for periodontal attachment and/or bone loss by 2 to 8-fold.
• This depends on the definition of disease severity and smoking dose.
• Passive smoking is mildly associated with periodontitis.
• Smoking exacerbates periodontal conditions in susceptible individuals like diabetics.
• Effects of smoking/dose are cumulative (“Pack Years”).
• There is a direct linear relationship between exposure to smoking and alveolar bone loss.
• Smoking is now one of the diagnostic terms in risk factors.

Compared to Non-Smokers, Smokers have:

• Deeper pockets
• More CAL (Clinical Attachment Loss)
• More periodontal bone loss
• More furcation involvement
• More infra-bony defects
• More missing teeth, especially molars
• More recession
• More fibrotic gingivae
• Less BOP (Bleeding on Probing)
• Higher levels of calculus, independent of plaque levels

Periodontal Treatment

• All types of periodontal treatments are less effective in smokers.
• This includes non-surgical, surgical, muco-gingival (recession coverage), and implants.
• Smokers see a 50-75% improvement in clinical parameters compared to non-smokers for surgical/non-surgical treatments.
• Implant failure rate has been reported as 4% over 10 years in non-smokers vs. 15% in smokers.

Smoker Clinical Appearance

• Fibrotic “tight” gingivae occurs with rolled margins.
• Reduced gingival redness and bleeding
• More severe, widespread disease for the same age (non-smoking control).
• Nicotine staining occurs.
• Calculus is present.
• The anterior maxilla and palate are the worst affected areas.

Smoker Clinical Characteristics

• Early onset of disease
• Rapid disease progression.
• Increased severity and extent of disease, pockets, CAL, bone loss
• Increased tooth loss
• Poorer response to Non-Surgical Periodontal Treatment (NSPT)
• Recurrence within one year of surgery
• Increased percentage are refractory to treatment

Smoking and Saliva

• Smoking causes a dry mouth.
• This due to the effect of tobacco smoke on saliva.

Water Pipes

• Water pipes may cause periodontal damage.
• Also referred as hookahs or shishas.
• They are a single or multi-stemmed instrument used for heating or vaporising and then smoking tobacco, cannabis, or hashish.

Reasons for harmful effects of smoking on periodontal health

• Direct damage from toxins
• More periodontopathic bacteria
• Impairment of innate and adaptive host response includes:
• Decrease in IgG production
• Shift towards destructive neutrophil effects, namely oxidative damage
• Negative impact on cytokine and growth factor production
• Effects on tissue repair and healing which causes:
• Decrease in tissue vascularity and angiogenesis
• Inhibition of fibroblast growth as well as attachment / collagen production

Smoking and Periodontium

• Smokers often have less gingival bleeding than non-smokers.
• This is dose-dependent.
• This phenomenon is attributed to the vasoconstriction of nicotine.

Chemicals in Tobacco Smoke

• There are 4,000 chemicals in tobacco smoke.
• Nicotine is an addictive drug that increases heart rate.
• Tar causes brown staining.
• Carbon monoxide is a poisonous gas that lowers the blood's ability to transport oxygen.
• Tar is sticky and stains teeth.
• Carbon monoxide binds to haemoglobin, preventing adequate oxygen carriage, which lowers the blood's oxygen transport ability.

Smoking Cessation

• Smoking cessation improves the prospects for a good periodontal treatment outcome.