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Smoking and its impact on oral health

Research

06 Sep 2014

Dr. Xavier Calvo.

Smoking is a habit that is extremely damaging to health and that continues to be widespread throughout society. It is the leading preventable cause of premature death in the world, and it is estimated that in 2020 it will be directly related to some 10 million deaths, mainly in developing countries1

According to the most recent INE (Spanish National Institute of Statistics) 2011-12 survey data, approximately 1 in every 3 adults in Spain is a regular smoker. 

The mechanism of action of tobacco smoke and its components can be seen both at the local and at the systemic level. At the local level, the mouth is the gateway for tobacco smoke to enter our bodies, and therefore is a direct irritant on oral mucosa. Nicotine also has direct effects on the gums. At the systemic level, smoking alters the innate and adaptive defense mechanisms and interferes with multiple cellular processes. 

Smoking is associated with a long list of systemic diseases and disorders, several of which have an impact on oral health. A clear example of these impairments is delayed oral wound healing, whether these are caused by accidents or periodontal surgery and tooth extraction2. Smoking can also cause bad breath, from the odour of tobacco itself or from changes in the bacterial microbiota in the oral cavity3

Nevertheless, the main oral diseases associated with smoking and which we will discuss in this article are periodontal disease and oral cancer. 

Smoking and periodontal disease 

Smoking is the leading environmental risk factor and the second most important modifiable risk factor, following plaque control, for periodontal disease development4. One of the mechanisms by which smoking favours its development seems to be the reduction and impairment of immune defenses against periodontal pathogens. Smokers tend to show increased peripheral blood monocytes with impaired functionality. Impaired phagocytic activity can lead to poor pathogen elimination from the oral cavity. 

Also, B- lymphocytes and T-lymphocytes, when exposed to tobacco smoke, show reduced capacity for proliferation and production of immunoglobulins that protect against oral pathogens5

A typical characteristic of smoking-related periodontal disease is tooth-support tissue destruction, with signs of bone loss, periodontal pocket formation and, on occasion, tooth loss. 

Smoking increases the risk for periodontal disease by 5 to 20 times, depending on the definition of disease, compared to non-smokers6. This increase depends on the time of tobacco smoke exposure. The cause may be related to changes in the oral microbiota or vascular and inflammatory phenomena. Nicotine and carbon monoxide from tobacco smoke also have a negative impact on wound healing6. Smokers have an increased prevalence of periodontal diseases, as well as a higher incidence of tooth loss7.

Most studies also show that smokers with periodontitis respond less favourably to periodontal treatment, whether surgical or non-surgical, and regenerative and mucogingival surgery is not recommended in these patients. Long-term studies have proven that smokers have a higher probability of experiencing periodontal disease recurrence during the periodontal maintenance phase, while people who smoke more than 10 cigarettes per day show the most severe disease progression7

Some studies have even shown that second-hand smoke can have greater periodontal effects, although this is more difficult to determine. Smokers also are at higher risk for experiencing dental implant-related complications, both on the short and the long term. 

Smoking and oral cancer 

Tobacco in all of its different forms and uses is, along with alcohol consumption and certain nutritional deficiencies, the leading cause of oral cancer. Tobacco cigarettes contain over 60 carcinogenic combustion products, capable of binding to and impairing DNA. They also increase oxidative stress on tissues, and in turn, the release of free radical species that damage proteins, lipids, carbohydrates and DNA itself. 

Studies have shown that the risk for oral cancer in smokers is 3 to 5 times higher than in non-smokers, that the effect is dose-dependent and that this dramatically increases when alcohol consumption is added to the equation8

Lesions that can be detected in the mouth, and that are at higher risk of becoming malignant, include leukoplakias, described as whitish patches that cannot be scraped off, that form part of the epithelium and that are growing. These are mainly caused by tobacco and are precursors of oral cancer in approximately 10% of all cases. 

Conclusion 

In short, we must keep in mind that the mouth is particularly susceptible to the effects of smoking and that the risk of suffering from highly disabling diseases such as periodontitis or even deadly such as oral cancer, greatly multiplies among smokers. Therefore, the role of healthcare professionals is crucial for encouraging smokers to reduce their consumption or to quit smoking altogether. 

About the Author

Medical Advisor at DENTAID

Bibliography

  1. World Health Organization report on the global tobacco epidemic 2013. 
  2. Meechan JG, Macgregor ID, Rogers SN, Hobson RS, Bate JP, Dennison M. “The effect of smoking on immediate post-extraction socket filling with blood and on the incidence of painful socket”. Br J Oral Maxillofac Surg. 1988 Oct;26(5):402-9. 
  3. Cortelli JR, Barbosa MD, Westphal MA. “Halitosis: a review of associated factors and therapeutic approach”. Braz Oral Res. 2008;22 Suppl 1:44-54 
  4. Johnson GK, Guthmiller JM. “The impact of cigarette smoking on periodontal disease and treatment”. Periodontology 2000, Vol. 44, 2007, 178–194 
  5. Barbour SE, Nakashima K, Zhang JB, Tangada S, Hahn CL, Schenkein HA, Tew JG. “Tobacco and smoking: environmental factors that modify the host response (immune system) and have an impact on periodontal health”. Crit Rev Oral Biol Med. 1997;8(4):437-60. 
  6. Bergström J. “Tobacco smoking and chronic destructive periodontal disease”. Odontology. 2004 Sep;92(1):1-8. 
  7. Tonetti MS. “Cigarette smoking and periodontal diseases: etiology and management of disease”. Ann Periodontol. 1998 Jul;3(1):88-101. 
  8. Johnson NW, Jayasekara P, Amarasinghe AA. “Squamous cell carcinoma and precursor lesions of the oral cavity: epidemiology and aetiology”. Periodontol 2000. 2011 Oct; 57(1):19-37. 

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