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  Periodontics    Tobacco Use and Periodontal Disease

Cigarette smoking and periodontal diseases: etiology and management of disease.
Ann Periodontol. 1998 Jul;3(1):88-101.
Tonetti MS.

Cigarette smoking has long been suspected to be associated with a variety of oral conditions including periodontal diseases. Experimental evidence accumulated over the last 2 decades has indicated that cigarette smoking is probably a true risk factor for periodontitis. This environmental exposure has been associated with 2- to 3-fold increases in the odds of developing clinically detectable periodontitis. Smokers have both increased prevalence and more severe extent of periodontal disease, as well as higher prevalence of tooth loss and edentulism, compared to non-smokers. The greater severity of periodontal destruction may be partly accounted for by the reported increases in the rate of periodontal disease progression. The noxious effect of smoking has been shown to be dose dependent and to be particularly marked in younger individuals; in these subjects, up to 51% of the observed risk of periodontitis was associated with smoking. Much of the literature has also indicated that smokers affected with periodontitis respond less favorably to both non-surgical, surgical, and regenerative periodontal treatments. The success rate of dental implants has also been shown to be compromised in smokers. Furthermore, longterm studies have pointed out that smoking was associated with recurrence of periodontitis during periodontal maintenance; the effect appeared to be dose dependent, with heavy smokers (> 10 cigarettes/day) presenting with higher levels of disease progression. The indication that previous smokers have lower levels of risk for periodontitis compared to current smokers is considered to be the strongest available evidence that smoking cessation will result in improved periodontal health and that smoking cessation counseling should be an integral part of periodontal therapy and prevention. So far, however, no randomized controlled clinical trial establishing the effect of smoking cessation and/or reduction on the periodontal outcomes has been reported. Given the present state of uncertainty about the periodontal benefits, but in light of the established general health gains for the patient that could be derived from a smoking cessation program, practitioners are incorporating smoking cessation counseling as an integral part of periodontal therapy. Furthermore, smoking status represents a key parameter to assess the periodontal risk of an individual subject and therefore to make evidence-based clinical decisions.

Association between cigarette smoking, bacterial pathogens, and periodontal status.
J Periodontol. 1993 Dec;64(12):1225-30.
Stoltenberg JL, Osborn JB, Pihlstrom BL, Herzberg MC, Aeppli DM, Wolff LF, Fischer GE.

The purposes of this study were to determine if: 1) an association exists between cigarette smoking and signs of periodontal disease after controlling for the confounding variables of age, sex, plaque, and calculus; 2) the prevalence of 5 bacteria commonly associated with periodontal disease differs between smokers and non-smokers; and 3) the presence of any of these bacteria or smoking are associated with a mean proximal posterior probing depth > or = 3.5 mm. Plaque, calculus, gingivitis, and probing depth were measured at the proximal surfaces of all teeth in one randomly selected posterior dental sextant in 615 adults. Subgingival plaque was sampled from the same sites and assayed for the presence of Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Prevotella intermedia, Eikenella corrodens, and Fusobacterium nucleatum. A subsample of non-smokers (n = 126), who were similar to smokers (n = 63) with respect to age, sex, plaque, and calculus, was randomly drawn from the original sample. These two groups were then compared on the basis of clinical and microbial parameters. The results indicated that the odds of having a mean probing depth > or = 3.5 mm were 5 times greater for smokers than the non-smoker subsample (odds ratio = 5.3; 95% CI = 2.0 to 13.8). No statistically significant difference in the prevalence of any of the bacteria was found between smokers and the non-smoker subsample. Based on logistic regression analyses of each of the 5 bacteria and smoking, mean probing depth > or = 3.5 mm was significantly associated with the presence of A. actinomycetemcomitans, P. intermedia, E. corrodens, and smoking (P < 0.05).

Cigar, pipe, and cigarette smoking as risk factors for periodontal disease and tooth loss.
J Periodontol. 2000 Dec;71(12):1874-81.
Albandar JM, Streckfus CF, Adesanya MR, Winn DM.

BACKGROUND: Our purpose was to test the hypotheses that cigar and pipe smoking have significant associations with periodontal disease and cigar, pipe, and cigarette smoking is associated with tooth loss. We also investigated whether a history of smoking habits cessation may affect the risk of periodontal disease and tooth loss. METHODS: A group of 705 individuals (21 to 92 years-old) who were among volunteer participants in the ongoing Baltimore Longitudinal Study of Aging were examined clinically to assess their periodontal status and tooth loss. A structured interview was used to assess the participants' smoking behaviors with regard to cigarettes, cigar, and pipe smoking status. For a given tobacco product, current smokers were defined as individuals who at the time of examination continued to smoke daily. Former heavy smokers were defined as individuals who have smoked daily for 10 or more years and who had quit smoking. Non-smokers included individuals with a previous history of smoking for less than 10 years or no history of smoking. RESULTS: Cigarette and cigar/pipe smokers had a higher prevalence of moderate and severe periodontitis and higher prevalence and extent of attachment loss and gingival recession than non-smokers, suggesting poorer periodontal health in smokers. In addition, smokers had less gingival bleeding and higher number of missing teeth than non-smokers. Current cigarette smokers had the highest prevalence of moderate and severe periodontitis (25.7%) compared to former cigarette smokers (20.2%), and non-smokers (13.1%). The estimated prevalence of moderate and severe periodontitis in current or former cigar/pipe smokers was 17.6%. A similar pattern was seen for other periodontal measurements including the percentages of teeth with > or = 5 mm attachment loss and probing depth, > or = 3 mm gingival recession, and dental calculus. Current, former, and non- cigarette smokers had 5.1, 3.9, and 2.8 missing teeth, respectively. Cigar/pipe smokers had on average 4 missing teeth. Multiple regression analysis also showed that current tobacco smokers may have increased risks of having moderate and severe periodontitis than former smokers. However, smoking behaviors explained only small percentages (<5%) of the variances in the multivariate models. CONCLUSION: The results suggest that cigar and pipe smoking may have similar adverse effects on periodontal health and tooth loss as cigarette smoking. Smoking cessation efforts should be considered as a means of improving periodontal health and reducing tooth loss in heavy smokers of cigarettes, cigars, and pipes with periodontal disease.

Dental patient awareness of smoking effects on oral health: Comparison of smokers and non-smokers.

J Dent. 2005 Aug 5
Al-Shammari KF, Moussa MA, Al-Ansari JM, Al-Duwairy YS, Honkala EJ.

OBJECTIVES: The negative effects of cigarette smoking on oral health are well established, yet few studies assessed patient awareness of such effects. The aim of this study was to examine differences in dental patient knowledge and awareness of the effects of smoking on oral health between smokers and non-smokers. METHODS: Adult patients from 12 dental centers in Kuwait were asked to complete a 14-point self-administered structured questionnaire on the effects of smoking on oral health in this cross-sectional survey. Significant associations between oral health knowledge, smoking status, and sociodemographic variables were examined with univariate analysis and logistic regression. RESULTS: A total of 1012 subjects participated (response rate=84.3%). The prevalence of smoking was 29.3%. Fewer smokers than non-smokers thought that oral health and smoking are related (92.2% vs. 95.8%; P=0.020), and that smoking affected oral cancer (52.4% vs. 66.8%; P< 0.001), periodontal health (72% vs. 78%; P=0.040), or tooth staining (86.1% vs. 90.9%; P=0.018). Logistic regression analysis showed smokers to be significantly less aware of the oral health effects of smoking than non-smoking patients (OR=1.51; 95% CI: 1.05-2.16; P=0.025). CONCLUSION: Smoking dental patients are significantly less aware of the oral health effects of smoking than non-smokers. Comparative studies in other populations may be warranted to ascertain the validity of these results.

The effect of quitting smoking on chronic periodontitis.

J Clin Periodontol. 2005 Aug;32(8):869-79.
Preshaw PM, Heasman L, Stacey F, Steen N, McCracken GI, Heasman PA.

OBJECTIVES: To evaluate longitudinally the effect of smoking cessation on clinical and radiographic outcomes following non-surgical treatment in smokers with chronic periodontitis. MATERIAL AND METHODS: Forty-nine smokers with chronic periodontitis who wished to quit smoking were recruited. Full-mouth probing depths, bleeding and plaque data were recorded at baseline, 3, 6 and 12 months. Clinical attachment levels were recorded at target sites and subtraction radiography was used to assess bone density changes. Patients received non-surgical periodontal therapy during the first 3 months and supportive periodontal care over the remainder of the study. Smoking cessation counselling was provided according to individual need. RESULTS: After 12 months, of patients with complete data, 10 had continuously quit smoking (20% of the original population), 10 continued smoking and six were oscillators (those patients who quit and then relapsed). There were no differences between the groups following treatment with respect to mean clinical or radiographic parameters. Analysis of probing depth reductions between baseline and month 12, however, and comparing quitters with the other two groups combined, demonstrated a significant difference in favour of quitters (p<0.05). Furthermore, quitters were significantly more likely to demonstrate probing depth reductions > or =2 and > or =3 mm than non-quitters and oscillators (p<0.05). CONCLUSION: Quitting smoking has an additional beneficial effect in reducing probing depths following non-surgical treatment over a 12-month period.

Periodontal diseases, tobacco and pregnancy

J Gynecol Obstet Biol Reprod (Paris). 2005 Apr;34 Spec No 1:3S74-83.
Boutigny H, Boschin F, Delcourt-Debruyne E.

This review summarizes the impact of tobacco on the periodontium of pregnant women and the effects of periodontal diseases combined with tobacco on the pregnancy. Periodontal diseases (gingivitis and periodontitis) are gram-negative anaerobic infections. Smokers are 2-7 times more likely to develop periodontal disease than non-smokers. Tobacco, an environmental factor, undermines the host response and may facilitate the development and progression of periodontal disease. Recent epidemiological studies suggest that maternal periodontal diseases would be a risk factor of pre-term deliveries or pre-term low birth weight (PLBW). Cigarette smoking during pregnancy leads to peri-natal morbidity and mortality and it is associated with reduced birth-weight. Tobacco during pregnancy also amplifies the risk of PLBW directly and via periodontal diseases. This article highlights the etio-pathogenic interrelations between periodontal diseases and tobacco as risk factors of PLBW. The blood dissemination of periodontal bacteria and the effects of cytokines like TNF-alpha, Il-1, produced during periodontal infections could explain these obstetrical adverse events. The concept of diagnosing and treating a periodontal disease in a pregnant woman to minimizes the deleterious effects of this infection on systemic conditions represents an unprecedented challenge. Moreover, periodontist have the opportunity to take part in smoking cessation program for pregnant women.

Long-term effect of smoking on vertical periodontal bone loss.

J Clin Periodontol. 2005 Jul;32(7):789-97.
Baljoon M, Natto S, Bergstrom J.

OBJECTIVES: The objective of the present study was to investigate the influence of smoking on vertical periodontal bone loss over 10 years. MATERIAL AND METHODS: The study base consisted of a population that was examined on two occasions with a 10-year interval, including 91 individuals, 24 smokers, 24 former smokers, and 43 non-smokers. The assessment of vertical bone loss was based on full sets of intra-oral radiographs from both time points. The severity of vertical bone loss was expressed as the proportion of proximal sites with vertical defects per person. RESULTS: The 10-year increase in the proportion of vertical defects was statistically significant in all groups (p<0.001) and, in addition, significantly associated with smoking (p<0.05). In particular, the difference between smokers and non-smokers was significant (p<0.01) whereas former smokers did not differ from non-smokers. Moreover, the 10-year vertical bone loss was significantly greater in heavy exposure smokers than in light exposure smokers suggesting an exposure-response effect (p<0.01). Compared with non-smokers the unadjusted 10-year relative risk was 2.3-fold increased in light exposure smokers and 5.3-fold increased in heavy exposure smokers (p<0.05). CONCLUSIONS: The present observations indicate a significant long-term influence of smoking on vertical periodontal bone loss, yielding additional evidence that smoking is a risk factor for periodontal bone loss.

Smoking And Periodontal Disease: Study Shows Yet Another Reason Why Quitters Are Winners
American Academy Of Periodontology

Smoking may be responsible for more than half of the cases of periodontal disease among adults in this country, according to a new study published in the Journal of Periodontology. The study found that current smokers are about four times more likely than people who have never smoked to have advanced periodontal disease. However, 11 years after quitting, former smokers' likelihood of having periodontal disease was not significantly different from those who had never smoked.

Researchers analyzed government health data on 13,650 people aged 18 and older who had their teeth. This is the first study to estimate the proportion of periodontal disease cases that can be attributed to cigarette smoking.

"Cigarette smoking may well be the major preventable risk factor for periodontal disease," said the study's lead researcher, Scott Tomar, D.M.D., Dr.P.H., of the Division of Oral Health at the Centers for Disease Control and Prevention (CDC). "The good news is that quitting seems to gradually erase the harmful effects of tobacco use on periodontal health."

The study also found that there is a dose-response relationship between cigarettes smoked per day and the odds of periodontitis. "Smokers who smoked less than a half a pack per day were almost three times more likely than nonsmokers to have periodontitis. Those who smoked more than a pack and a half per day had almost six times the risk," explains Tomar.

A recent online survey of periodontists conducted by the AAP found that the vast majority of periodontists routinely (79 percent) or most of the time (14 percent) advise their patients to quit smoking.

"Everyday periodontists see the destruction smoking causes in the mouths of their patients," said Jack Caton, D.D.S., M.S., president of the American Academy of Periodontology. "I hope the staggering statistics from this study will compel even more dental care providers to get involved in tobacco cessation efforts."

Tobacco's negative effect on periodontal health is well documented. Smoking interferes with healing, making smokers more likely to not respond to treatment and to loose teeth. "Tobacco use reduces the delivery of oxygen and nutrients to gingival tissue," explains Robert Genco, D.D.S., Ph.D., editor of the Journal of Periodontology. "Smoking impairs the body's defense mechanisms, making smokers more susceptible to an infection like periodontal disease."

In addition to being a major cause of tooth loss, periodontal disease has been linked to increased risk of heart disease, stroke, poorly controlled diabetes, respiratory disease and premature babies.