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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 1  |  Page : 44-51

Smoking and its effect on periodontium – Revisited


1 Department of Periodontology and Implantology, Dr. Harvansh Singh Judge Institute of Dental Sciences and Hospital, Panjab University, Chandigarh, India
2 Department of Periodontology and Implantology, BRS Dental College and Hospital, Panchkula, Haryana, India
3 Private Practioner, Chahal Dental Clinic, Chandigarh, India

Date of Web Publication6-Mar-2017

Correspondence Address:
Gurparkash Singh Chahal
150, Sector 11-A, Chandigarh - 161 011
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_96_16

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  Abstract 

Cigarette smoking represents a major preventable cause of human disease. Smokers have significantly elevated risks of all-cause mortality and developing a variety of pathological conditions. A direct causal relationship between smoking exposure and the prevalence and the severity of periodontal disease has been firmly established. Although the direct cause for periodontitis is oral bacterial infection, smoking is arguably the strongest behavioral risk factor for the incidence and progression of periodontitis. Smoking has a deleterious effect on all the aspects of periodontium. Smokers have been shown to respond less well to nonsurgical as well as surgical therapy than nonsmokers. Based on this evidence, dental health professionals should advise patients about tobacco's negative health effects as well as the benefits of quitting tobacco use, and tobacco cessation counseling should be a part of the armamentarium of the dental office.

Keywords: Periodontium, risk factor, smoking


How to cite this article:
Chahal GS, Chhina K, Chhabra V, Chahal A. Smoking and its effect on periodontium – Revisited. Indian J Dent Sci 2017;9:44-51

How to cite this URL:
Chahal GS, Chhina K, Chhabra V, Chahal A. Smoking and its effect on periodontium – Revisited. Indian J Dent Sci [serial online] 2017 [cited 2019 Jan 18];9:44-51. Available from: http://www.ijds.in/text.asp?2017/9/1/44/201643


  Introduction Top


Cigarette smoking represents a major preventable cause of human disease.[1] Tobacco smoke contains over 3800 chemicals, including carbon monoxide, hydrogen cyanide, and reactive oxidizing radicals, and sixty of these chemicals are known or suspected to be carcinogens.[2] Smokers have significantly elevated risks of all-cause mortality and developing a variety of pathological conditions.[1] A direct causal relationship between smoking exposure and the prevalence and the severity of periodontal disease has been firmly established (American Academy of Periodontology 1996, Grossi et al. 1994).[3],[4] According to the National Health and Nutrition Examination Survey III, smokers were four times as likely to have periodontitis as persons who had never smoked after adjusting for age, gender, race/ethnicity, education, and income/poverty ratio. The use of tobacco products, in general, and smoking products, in particular, is the major preventable risk factor for the initiation and progression of periodontal diseases.[5],[6],[7] A meta-analysis of data from six such studies involving 2361 individuals indicated that current smokers were nearly three times more likely to have severe periodontitis than nonsmokers. The detrimental impact of long-term smoking on the periodontal and dentate status of older adults has been clearly demonstrated.[8] The most marked difference between smokers and nonsmokers in probing depths or attachment loss occurs in the maxillary lingual area and mandibular anterior teeth, suggesting a local effect of smoking.[9]

It has also been firmly established that smoking cessation is associated with decreased mortality, lower risk of developing a variety of diseases, and increased life expectancy.[1]


  Clinical Parameters of Periodontium Affected by Smoking Top


Gingival diseases

Gingivitis

Several cross-sectional investigations have indicated that smokers may present with lower levels of gingival inflammation to a specific level of plaque than nonsmokers. This was evidenced using both the gingival index and the dichotomous evaluation of bleeding on probing.[1] Nair et al. followed 27 individuals for 4–6 weeks during a verified successful period of quitting smoking and found bleeding doubled (from 16% to 32%) during this period.[10]

Acute necrotizing ulcerative gingivitis

Pindborg (1947) was one of the first investigators to study the relationship between smoking and periodontal disease. He determined that tar in the smoke exerted a direct irritating effect on the gingiva giving rise to gingivitis and that nicotine could cause contraction of the capillaries, thus interfering with the nutrition of the gingiva which consequently became less resistant to infection.[11]

Periodontitis

Smokers have a higher proportion of sites with deeper probing depths and clinical attachment loss compared with nonsmokers.[4],[12],[13] The observed effects have been confirmed in different studies and in different populations after correcting for a variety of potential confounders.[14]

Cigarette smoking as a risk factor for periodontitis

Although the direct cause for periodontitis is oral bacterial infection, its progression and severity depend on a number of genetic and environmental factors.[14] Several epidemiological studies in different population demonstrate a relationship between smoking and periodontal disease.[15],[16] Cigarette smoking is arguably the strongest behavioral risk factor for the incidence and progression of periodontitis.[17] It is also important to note that although nonsmokers universally respond better to periodontal treatment than do smokers, there is nevertheless substantial evidence of clinical improvement in smokers after treatment, indicating that smoking as a risk factor will compromise rather than prevent tissue healing.[18] Some of the mechanisms by which smoking affects periodontitis are elucidated in [Table 1].[19]
Table 1: How smoking alters the etiology and pathogenesis of periodontal disease

Click here to view



  Effect of Smoking on the Microbiology of Periodontitis Top


Studies have failed to demonstrate a difference in the rate of plaque accumulation of smokers compared with nonsmokers, suggesting that if an alteration in the microbial challenge in smokers exists, it is due to a qualitative rather than quantitative alteration in the plaque.

Several studies report a similar microbial profile of dental plaque in smokers compared with nonsmokers with regard to the ability to detect suspected periodontal pathogens in the subgingival plaque biofilm.[20],[21],[22] However, in smokers, such suspected periodontal pathogens are recovered in shallower areas without clinical periodontal breakdown.[23] More recent studies that utilize molecular techniques capable of characterizing previously unknown bacteria or those that are difficult to culture have provided evidence of distinct microbial profiles and patterns of biofilm colonization in smokers and nonsmokers.[24],[25]

Winkelhoff and Tijhof [26] compared the subgingival microflora of treated and untreated smokers and nonsmokers. They found the most pronounced microbiological characteristics of smokers appeared to be the presence of Bacteroides forsythus, Peptostreptococcus micros, Fusobacterium nucleatum, and Campylobacter rectus in the absence of Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis. In addition, these pathogenic bacteria were more prevalent in the maxilla than the mandible.[27]


  Impact of Smoking on the Physiology Top


The clinical signs of inflammation are less pronounced in smokers when compared with nonsmokers. Although no significant differences in the vascular density of healthy gingiva have been observed between smokers and nonsmokers, the response of the microcirculation to plaque accumulation appears to be altered in smokers when compared with nonsmokers.[28] Fewer crevicular polymorphonuclear neutrophils (PMNs) and less crevicular phagocytosis could conceivably decrease the release of lysosomal enzymes and thus decrease the level of inflammation in the superficial layers of the periodontal tissues. Smoking-induced chronic hypoxia of periodontal tissues causes greater severity of periodontal disease seen in smokers.[29] Trikilis et al. found that subgingival temperatures are lower in smokers than nonsmokers. The decreased subgingival temperature in smokers might reflect the reduced activity of periodontal cell.[30]

Tobacco and some of its components such as nicotine have been found to have adverse effects on cells of the periodontium, including gingival fibroblasts and cells of the immune system. An in vitro study done by Tanur et al. showed that the nature of cell attachment to root surfaces is altered by nicotine.[31] Cigarette smoke condensate may interfere in myofibroblastic differentiation. Results of the study by Silva et al. showed that cigarette smoke, but not nicotine, may significantly alter cell viability, cell migration, and myofibroblastic differentiation in gingival mesenchymal cells.[32]

Nicotine also caused a dose-dependent inhibition of fibronectin and Type I collagen production. The inhibition of collagen production by nicotine was accompanied by ~700 and 400% increase in collagenase activity at nicotine concentrations of 0.075% and 0.05%, respectively. Nicotine may stimulate transcription of the collagenase gene, either directly or through inducing the production of cytokines by the fibroblasts themselves.


  Impact of Smoking on Immunology Top


Periodontitis is associated with an alteration in the host-bacterial balance that may be initiated by changes in the bacterial composition of subgingival plaque, changes in the immune response, or a combination of both elements.[33] A number of studies have shown that cigarette smoking may affect the host response by altering the immune response in local tissue.[8] Smoke exposure impairs f-actin kinetics, resulting in the damage of the neutrophil cytoskeleton (Ryder et al. 1998).[33]

Effect on oral polymorphonuclear neutrophils

Neutrophils, obtained from the peripheral blood or saliva of smokers, have been shown to demonstrate functional alterations in chemotaxis, phagocytosis, and oxidative burst.[34],[35] One possible mechanism for this elevated neutrophil-mediated destruction may simply be the elevation of neutrophils in smokers seen in the peripheral blood which may lead to increased secretion of potentially tissue-destructive products. In addition, nicotine may prolong the lifespan of neutrophils in tissue by delaying the process of programmed cell death (apoptosis).[36]

Effect on monocytes

The effects of nicotine on monocytes were not restricted to inhibition of the production of oxygen radicals. It also interfered with secretion of the pro-inflammatory cytokine, interleukin 1β (IL-1β). In periodontitis, IL-1β activates fibroblasts and osteoclasts to destroy the periodontal ligament and the alveolar bone. Eventually, the immune response to prolonged infection by periodontal pathogens would overwhelm any short-term anti-inflammatory effect of nicotine.[37]

Effect on circulating polymorphonuclear neutrophils

Circulating PMNs from smokers have been shown to have normal phagocytosis but depressed chemotaxis when testing is performed rapidly after cigarette smoking. This effect is lost after overnight abstinence from smoking, suggesting the presence of a labile substance.[38]

Effect on antibody and lymphocyte response

Nicotine and the water-soluble fraction from whole cigarette smoke can suppress the in vitro secondary antibody response.[39] Salivary immunoglobulin A has been found to be significantly decreased in smokers when compared with nonsmokers.[40] Production of antibody essential for phagocytosis and killing of bacteria, specifically IgG2 levels to periodontal pathogens, has been reported to be reduced in smokers versus nonsmokers with periodontitis.[41]

Effect on cytokines, growth factors, and other enzymes

Elevated levels of tumor necrosis factor-α, prostaglandin-E2, neutrophil elastase, and matrix metalloproteinase-8 have been demonstrated in the gingival crevicular fluid (GCF) of smokers.[41] Wendell et al. demonstrated that nicotine can directly stimulate human gingival fibroblast IL-6 and IL-8 production in vitro. In addition, combination of nicotine and lipopolysaccharide had a synergistic response, upregulating inflammatory cytokine production.[42] IL-4 production by peripheral blood mononuclear cells of smokers was significantly higher than that of nonsmokers (Byron et al. 1994).[43] Bergstrom et al. (2001) observed that for patients with periodontitis, the concentration as well as the total amount of GCF, α-2-macroglobulin and α-1-antitrypsin, was lower in smokers as compared to nonsmokers, which led to increased tissue damage due to increased activity of elastase and collagenase.[44]


  How Smoking Effects the Response to Periodontal Therapy Top


Nonsurgical therapy

The majority of clinical research supports the observation that pocket depth reduction is more effective in nonsmokers than in smokers using nonsurgical periodontal therapy, including oral hygiene instruction, scaling, and root planing. In addition, gains in clinical attachment as a result of scaling and root planing are less pronounced in smokers than in nonsmokers.[45],[46],[47],[48],[49],[50],[51] Wan et al. found that at 12 months after nonsurgical therapy, smokers presented with a significantly higher percentage of residual pockets. In addition, smokers showed less probing pocket depth (PPD) reduction in sites with initial PPD ≥5 mm.[52] The inhibitory effect of smoking on treatment response is more pronounced at initially deeper sites.[53]

Studies by Preber and Bergström, Grossi et al. (1997),[47] Renvert et al., Machtei et al., and Jin et al. have shown that probing depth reduction and clinical attachment level improvement in smokers are 50%–75% those of nonsmokers, following nonsurgical and surgical therapy.[47],[53],[54],[55],[56],[57] Darby et al. found that nonsmokers with aggressive periodontitis had significantly greater probing depth reduction (2.4 mm) compared with patients with aggressive periodontitis who smoke (1.3 mm).[58]

It can be concluded that smokers respond less well to nonsurgical therapy than nonsmokers. However, in the presence of excellent plaque control, these differences may be minimized.[8]

Antimicrobial therapy

In a 9-month, placebo-controlled, randomized trial in which smokers and nonsmokers were treated by scaling and root planing with and without sub-antimicrobial doxycycline, Preshaw et al. concluded that adjunctive sub-antimicrobial dose doxycycline enhanced therapeutic outcomes in all groups with smokers taking doxycycline, showing approximately the same magnitude of clinical improvement as nonsmokers on placebo.[18],[59] On the other hand, in studies where adjunctive systemic amoxicillin and metronidazole [60] or locally delivered minocycline microspheres [61] enhanced the results of mechanical therapy, there was a greater difference between the control and experimental treatments within smokers as compared to within nonsmokers. These enhanced results might be due to antimicrobial actions, and, in the case of tetracycline derivatives, anticollagenase activity.[3]

Unique regimens that sequence systemic antimicrobial therapy or combine local antimicrobial delivery with host modulatory therapy might offer clinicians and patients options that address microbial and host response alterations in smokers.[62]

Surgical therapy and soft and hard tissues grafting

The clinical benefit seen in nonsmokers following nonsurgical therapy has also been observed following surgical treatment (Ah et al. 1994).[9],[63] The most impressive report of clinical attachment gain in nonsmokers (5.2 mm) compared with smokers (2.1 mm) was observed by Tonetti et al., who carried out guided tissue regeneration (GTR) of infrabony defects using Gore-Tex membranes and with a follow-up period of 1 year. They also concluded that higher plaque levels that are seen consistently in smokers compared with nonsmokers will also have influenced the clinical outcomes.[64]

Smoking is detrimental to regenerative therapy in interproximal and furcation defects, whether treatment includes osseous grafts alone, membranes alone, or membranes in combination with osseous grafts. Studies by Trombelli et al.[65] and Mayfield et al. (1998) reported that evaluated osseous changes by sound probing or re-entry, vertical bone gain in smokers ranged from 0.1 to 0.5 mm, whereas nonsmokers demonstrated 0.9–3.7 mm improvement.[66] Stavropoulos et al. showed that smoking exerted a detrimental effect on the outcome of GTR treatment of intrabony defects with bioresorbable membranes.[67]

When expanded polytetrafluoroethylene membranes were utilized in GTR procedures at recession sites, smokers had significantly less root coverage (57%) as compared to nonsmokers (78%).[68] The superior blood supply afforded by the subepithelial connective tissue graft might be more resistant to the effects of smoking as compared to the nonresorbable barrier membrane.[3] However, root coverage following thick free gingival graft procedures is reportedly diminished by heavy cigarette smoking and there are conflicting reports on smoking's effect on the success of subepithelial connective tissue grafts.[68]

Implant therapy

Based on a multivariate statistical model adjusted for age, gender, and jaw position, smoking is significantly associated with implant failure.[10] In the studies reviewed, 0%–17% of implants placed in smokers were reported as failures as compared to 2%–7% in nonsmokers, with the majority of studies showing at least twice as many failed implants in smokers.[3]

The largest data set on the influence of smoking on implant success comes from the Dental Implant Clinical Research Group (DICRG) of the Department of Veterans Affairs, which is an 8-year, randomized, prospective clinical study that includes >2900 implants.[69] The 3-year data demonstrated that 8.9% of implants placed in smokers failed as compared to 6% in individuals who had never smoked or had quit smoking. The majority of implant failures in smokers occurred before prosthesis delivery; thereafter, the differences between smokers and nonsmokers tended to disappear.[70]

Several investigators have confirmed that smoking more negatively impacts implants placed in the maxillary arch than in the mandible. The DICRG reported that the percentage of maxillary implant failures among smokers (10.9%) was almost twice that reported for nonsmokers or past smokers (6.4%).[69]

The majority of the existing reports deal with machined titanium surfaces, and early evidence suggests that the currently, more popular roughened surfaces can partially compensate for the negative healing response in smokers.[3] A meta-analysis done by Bain reported that light smoking (average of 12 cigarettes/day) did not affect the success rate of either machined or dual acid-etched surface implants.[71]

Implant therapy in grafted sites

Emerging data indicate that the impact of smoking on implant therapy is more dramatic in grafted maxillary sinuses compared to nongrafted sites. The percentage of implant failures in grafted sinuses in smokers is 1.4–3.9 times greater than that of nonsmokers, with the majority of studies showing at least 2.5 times the number of failed implants in smokers.[3]


  Impact of Smoking Cessation on Periodontal Status and Treatment Outcomes Top


There was no association between number of years since cessation of smoking and changes in mean pocket depth or clinically attachment loss in former smokers. The negative effect of smoking on the subgingival environment and flora appears to be reversible. This is evidenced by the fact that a comparable proportion of former and nonsmokers became negative for P. gingivalis and B. forsythus after mechanical treatment.[47]

In the only longitudinal study to date, Preshaw et al. have reported 12-month data from 10 individuals with periodontitis who quit smoking. The quitters demonstrated a significant reduction in probing depths compared with nonquitters as well as a higher incidence of probing depth reductions of ≥3 mm.[72] Further, the implementation of population-based smoking cessation programs may also have a significant impact on the prevalence and progression of periodontal diseases (Susin et al. 2004).[73]


  Tobacco Counseling – A Component of Periodontal Therapy Top


Nicotine dependence is classified as a chemical addiction by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, 1994 (IV). A useful model brief intervention that uses a five-step approach is recommended by the Agency for Health Care Research and Quality [Table 2].[74],[75]
Table 2: The five “A's” for smoking cessation

Click here to view


If a patient has expressed a sincere interest in quitting, the chances of success are far greater than if the patient is unwilling to quit or wishes to postpone the start of a cessation program. For these patients, before deciding whether to proceed with a smoking cessation program, a Five R's approach has been developed [Table 3].[76],[77]
Table 3: The five R's approach to tobacco cessation

Click here to view


Success is most likely to be achieved when counseling and pharmacological approaches, such as nicotine-replacement therapies [Table 4], are used in combination.[76],[78]
Table 4: First line pharmacotherapies for smoking cessation

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  Conclusion Top


With a growing smoking prevalence, the proportion of tobacco-attributed disease will probably contribute comparably more to total periodontal disease in future years.[10] The American Academy of Periodontology Parameters of Care include tobacco cessation as a part of periodontal therapy and the 2000 Surgeon General's Report on Oral health in America encourage dental professionals to become more active in tobacco cessation counseling.[3]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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