Smoking and Periodontics

What is the leading cause of preventable disease and death in the US?

Cigarette smoking

What percent of adults use tobacco? what percent are cigs?

47.1 million (19%): cigs are 12.5%

7 main effects of smoking on oral cavity

Discoloration, mucosa, bad breath, sense of smell, sense of taste, saliva, periodontitis

How does smoking affect Mucosa (6)

• heat injury

• Mealnosis

• Nicotine stomatitis

• Keratosis

• Black hair tongue

• SCC

Effect of smoking on Saliva

• increases flow rate

• reduced pH (more acidic)

• Buffering Capacity

• Host response

• Bacteria and Fungi

In smokers, higher prevalence of ?

periodontitis and greater rate of bone lossa

among current smokers, __% of periodontitis attributed to smoking

75%

Odds ratio for periodontitis, heavy smokers have odds ratios that are over __x that of light smokers for attachment loss and bone loss

2 to 7, 2x

Vaping bio effects (5)

• secretion of pro-inflammatory cytokines

• Inhibits commensals and favors growth and biofilm formation

• IL4 suppression further supports colonization with pathogenic bacteria

• Increase inflammatory cytokines in airway epithelial cells

• Inhibits the FC receptor and function of neutrophils

vaping and periodontitis

increase of PD and CAL

decrease of BOP

Smoking on gingival inflammation

• less clinical signs of inflammation + more supragingival calc

• ginigival tissue: fibrotic with rolled margins

  • Decreased inflammatory response to plaque

Smoking is associated with (4)

Aggresive periodontitis, Acute necrotizing ulcerative gingivitis, refractory periodontits, increased risk of attachment/bone loss

Proposed mechanisms (8)

• vascular alterations

• Altered neutrophil function

• Decreased IgG production

• Decreased lymphocyte proliferation

• Increase prevalence of periopathogens

• Altered fibroblast attachment and function

• Difficulty in eliminating pathogens by mechanical therapy

• Negative local effects on cytokine and growth factor production

Smoking and microflora

• Alters composition of bacterial plaque

• Lower oxygen tension = more anaerobic species

• Selective pressure

• Harbor greater numbers of periodontal pathogens

• More difficult to eradicate P gingivalis and T forysthia in pockets

Smoking and Host response (4)

Altered vasculature, decreased wound healing, impaired neutrophil function, decreased antibody production

Altered vasculature with smoking

Vasoconstriction: decreased gingival blood flow, decreased GCF

Decreased wound healing: host response and smoking

• Inhibits gingival fibroblast

• Decrease collagen production

• Impaired re-vascularization of bone and soft tissue

• Impaired expression of Growth factors

Impaired neutrophil function: smoking and host response

Decreased chemotaxis, phagocytosis, adhesion to vascular endothelium

Decreased antibody produciton: smoking and host resposne

• Decreased levels of salivary IgA and serum IgG

• Alters the IgG subclass concentrations (less IgG1)

Strongest modifiable risk in periodontal disease

Plaque, then smoking

smoking and effect on treatment

More oxidative stress in smoker and/or periodontitis

Non-surgical and surgical therapy: effect of smoking

Difference in treatment outcome is more pronounced ?

PD and CAL improvements in smokers are 50-75% of non-smokers

Heavy smokers worse

after surgical treatment

Adjunctive antibiotics in smokers

Clincal improvements, but little clinical relevance (DO NOT REPLACE PROPER NON-SURGICAL PERIODONTAL TREATMENT)

Smokers: soft and hard tissue grafting

Less success with procedures, 50% less improvement

smoking and regeneration

EMD (enamel matrix derivative) is used to provide increased defect fill and cementum formation, but in smokers it is detrimental to new bone formation

Dental implant therapy and smoking

Implants fail at least twice more often, worse with grafted maxillary sinus, also negatively affects ridge augmentation procedures

Implant success rate for past smokers is

similar to those who never smoked

What we do with smokers and implants

consent form, place cover screw vs abutment to cover the tissue to reduce exposure

Smoking status should be considered in?

periodontal diagnosis, prognosis, and treatment planning (grade modifier)

modified treatment plan for smokers

Non-surgical therapy and or resective surgery preferable, or antibiotics (local or systemic)