smoking and its effects on periodontium

1. SMOKING & ITS EFFECTS ON
PERIODONTIUM
DR. K.S. STELIN (HOD) DR. MARIYAM MOMIN
DR. PARUL ANEJA I YEAR PG
DEPARTMENT OF PERIODONTOLOGY & ORAL IMPLANTOLOGY.

2. CONTENTS
• Introduction
• Historical background of tobacco
• Forms of tobacco
• Constituents of tobacco
• Challenge of assessing smoking status
• Effects of smoking on the prevalence & severity of periodontal
diseases
• Effects of smoking on the etiology & pathogenesis of periodontal
diseases
• Effects of smoking on the response to periodontal therapy
• Role of a dentist in patient education
• Guide to counseling for tobacco cessation
• Use of pharmacotherapy
• Counseling those unwilling to quit
• Effects of smoking cessation on periodontal treatment outcomes
• Conclusion
• References.

3. INTRODUCTION
• Smoking is highly prevalent & can
be considered as an epidemic in
both developing & developed
nations.
• In India 28.6% (266.8 million)
adults – aged 15 & above are
smokers & 3.7% (34.4 million) are
occasional users.
• According to the Global Adult
Tobacco Survey 2 (GATS2), every
3rd adult in rural areas& every 5th
adult in urban areas use tobacco
in some form or the other.
• Smoking is harmful to almost
every organ in the body & is
associated with multiple diseases
that reduce life expectancy &
quality of life.

4. HISTORICAL BACKGROUND OF
TOBACCO

6. • The National Household Survey of Drug &
Alcohol Abuse conducted in 25 states in India in
2002 reported that 55.8% of males aged 12-60
years currently use tobacco.
• According to the National Epidemiological Oral
Health Survey & Fluoride Mapping of the Dental
Council of India (1994), about 23-24%, more
males, across age groups reported smoking
tobacco in the country.
• 40-45% smokers (more males)
beedi – rural areas
cigarette – urban areas

7. Tobacco preparations
• Tobacco is derived from the species of the plant of
genus Nicotiana of the potato family.
• Carl Linnaeus in 1753 had named the genus of the
tobacco plant ‘Nicotiana’ after the French
ambassador to Portugal, Jean Nicot.
• Major varieties include:
Nicotiana Rustica Nicotiana Tabacum

8. • The tobacco leaves are subjected to different types
of curing, for example:
Flue
curing
Fire curing Sun curing

9. • Tobacco may be chewed, smoked, sucked or sniffed.
• The carcinogenic role of tobacco is related to what type of
tobacco product, the way in which it is used & its use in
combination with other substances,
• In western countries, chewing tobacco is available in various
forms which include:
Naswar
(Pakistan &
Afghanistan)

10. • In India, tobacco is used in various ways which
include:
- Smoked tobacco
- Reverse smoking
- Smokeless tobacco

11. • The various smoking habits prevailing in India are the
following:
Bidi Chillum Chutta
Cigarette Dhumti Hookah Hookli

12. • The various forms of smokeless tobacco used in
India are the following:
Khaini Manipuri tobacco Mawa
Mishri Paan

13. Snuff Zarda
Gutka Pan masala Gudakhu

14. Constituents in tobacco
• Tobacco smoke is estimated to contain over 4000
compounds, many of which are pharmacologically
active, toxic, mutagenic & carcinogenic.
• Tobacco smoke comprises a gaseous phase & a
solid (particulate) phase.
• Gas phase contains carbon monoxide, ammonia,
formaldehyde, hydrogen cyanide and many other
toxic & irritant compounds including more than
60 known carcinogens such as benzopyrene &
dimethylnitrosamine.
• Particulate phase includes nicotine, “tar” (itself
made up of many toxic chemicals), benzene &
benzopyrene.

15. • All dental patients must be asked about their
smoking status or tobacco usage.
• Current smoking status is the minimal
information that must be recorded (e.g., “Patient
is currently smoking X cigarettes per day”), but the
importance of cumulative exposure to cigarette
smoke means that is more appropriate to record
pack-years of smoking.

16. Challenge of assessing smoking status
Current Smokers:
- Ask about current smoking & past smoking.
Pack-years = Number of packs smoked per day
× Number of years of smoking.
Former Smokers:
- Ask patients about their past smoking. Former
smokers should always be congratulated for their
achievement in quitting, but it is also very important
to document the following:
- How much they used to smoke?
- How many years they smoked?
- When they quit?
Is the patient’s reponse accurate?

17. When is a smoker not a smoker?
• Smokers have smoked ≥100 cigarettes in their
lifetime & currently smoke.
• Former Smokers have smoked ≥100 cigarettes in
their lifetime & do not currently smoke.
• Non-smokers have not smoked ≥100 cigarettes
in their lifetime & do not currently smoke.

18. Effects of smoking on the Prevalence &
Severity of Periodontal diseases.
Periodontal
Disease
Effects of Smoking
Gingivitis ↓ Gingival inflammation & bleeding on
probing
Periodontitis ↑ Prevalence & severity of periodontal
destruction.
↑ Pocket depth, attachment loss, &
bone loss.
↑ Rate of periodontal destruction
↑ Prevalence of severe periodontitis
↑ Tooth loss
↑ Prevalence with increased number of
cigarettes smoked per day
↓ Prevalence & severity with smoking
cessation.

19. Effects of smoking on the Etiology &
Pathogenesis of Periodontal diseases,
Etiologic Factor Effects of Smoking
Microbiology ↑ complexity of the microbiome & colonization of
periodontal pockets by periodontal pathogens.
Immune-Inflammatory
response
Altered neutrophil chemotaxis, phagocytosis and
oxidative burst
↑ Tumor necrosis factor –α & prostaglandin E2 in
GCF
↑ Neutrophil collagenase & elastase in GCF
↑ Production of prostaglandin E2 by monocytes in
response to lipopolysaccharides .
Physiology ↓ Gingival blood vessels with ↑ inflammation
↓ GCF flow & bleeding on probing with ↑ inflammation
↓ Subgingival temperature
↑ Time needed to recover from local anesthesia.

20. Effects of Smoking on the Response to Periodontal
Therapy
Therapy Effects of Smoking
Nonsurgical ↓ Clinical response to root surface debridement
↓ Reduction in probing depth
↓ Gain in clinical attachment levels
↓ Negative impact of smoking with ↑ level of plaque
control.
Surgery & implants ↓ Probing depth reduction & ↓ gain in clinical attachment
levels after access flap surgery
↑ Deterioration of furcations after surgery
↓ Gain in clinical attachment levels, ↓ bone fill, ↑ recession
& ↑ membrane exposure after GTR
↓ Root coverage after grafting procedures for localized
gingival recession
↓ Probing depth reduction after bone graft procedures
↑ Risk for implant failure & peri-implantitis.
Maintenance care ↑ Probing depth & attachment loss during maintenance
therapy
↑ Disease recurrence in smokers
↑ Need for retreatment in smokers
↑ Tooth loss in smokers after surgical therapy

21. Guide to counselling for tobacco
cessation

22. Use of Pharmacotherapy
• Given the difficulties faced by people attempting to
stop tobacco se, treatments have been developed
to help them by lessening the intensity of
withdrawal symptoms.
• There are two main types of pharmacotherapy for
tobacco use cessation:
1. Nicotine replacement therapies (NRT)
2. Antidepressants.

23. Nicotine replacement therapy (NRT)

24. Basic principles for prescribing NRTs
• Medical supervision is important.
• Use a lower dose for less dependent tobacco
users.
• A combination of products can be helpful. This
must be done with caution, as nicotine toxicity
may develop with a combination of products or
if patient has not yet quit using tobacco.
• Some users may have side-effects.
Contraindications: Pregnancy, lactation, CVD,
endocrine disorders, inflammation of mouth&
throat, oesophagitis, gastric ulcers, diabetes

25. Nicotine withdrawal symptoms
• Craving for tobacco
• Depressed mood
• Insomnia
• Irritability
• Frustration
• Anxiety
• Difficulty in
concentration
• Restlessness
• Decreased heart rate
• Increased appetite &
weight gain.

26. 2. Antidepressants
• They function as anti-craving medications.
Antidepressants for tobacco use cessation:
First-line therapies
• Buproprion SR
• Selegeline
Second line therapies
• Clonidine
• Nortryptiline

27. Counselling those unwilling to quit

28. Key counselling concepts
A Non-judgemental attitude
Caring
Empathy
Listening
Raising awareness
Prompting self evaluation
Offering support while emphasizing personal
responsibility
Asking open-minded questions
Clarifying
Reflecting feelings
Summarizing
Affirming
Eliciting self-motivational statements
Setting realistic goals
Responding to tricky questions
Tailoring messages to patient’s state of change

29. Effects of Smoking Cessation on
Periodontal Treatment Outcomes
• Smoking cessation positively influenced
periodontal treatment outcomes.
• The benefit of smoking cessation on the
periodontium is likely to be mediated through
various pathways such as shift toward a less-
pathogenic microbiome, the recovery of the
gingival microcirculation & improvements in
certain aspects of the immune-inflammatory
responses.

30. Conclusion
• Smoking is a major risk factor for periodontitis,
& smoking cessation should be an integral part
of periodontal therapy among patients who
smoke.
• Smoking cessation should be considered a
priority for the management of periodontitis in
smokers.

31. References
• Carranza’s Clinical Periodontology – 10th
Edition.
• Essentials of Public Health Dentistry (Soben
Peter) – 5th Edition

32. Thank you.