Smoking and its influence on Periodontium and Periodontal Health Enlists mechanism of nicotine addiction, its ill effects on individual aspects of the oral cavity and ways to quit smoking to improve health

1. Smoking &
Periodontium
Dr. Rinisha Sinha
MDS Part I
Department of Periodontology

2. Gaining an Insight
• Periodontal diseases are a group of conditions affecting the
supporting structures of the dentition.
• The multifactorial risk factors are :
 Bacterial colonisation
 Age
 Gender
 Socioeconomic status
 Genetic predisposition
 certain Systemic conditions
 SMOKING

3. “Tobacco Smoking” is a significant risk factor for
Periodontal Diseases

4. Constituents of Tobacco Smoke
• Composed of more than 400 toxic, mutagenic, carcinogenic
chemical constituents.
• Nicotine – the most active compound in smoke, having a
half life of 2-3 hrs, is responsible for its addictive potential.

5. Mechanism of Nicotine Addiction
Nicotine : Highly active Pshycoactive Tertiary Amine
In brain, it stimulates release of Dopamine and neurotransmitter into CNS neuronal clefts
Repeated exposure causes proliferation of nicotine acetylcholine receptors on post
synaptic neurons
Intraneuronal changes occur that alters gene expression
With repeated exposure, CNS stimulation by Nicotine gradually reduces and more
nicotine becomes necessary to ward off withdrawal symptoms
Continuous periodoc closing with nicotine becomes a necessity for individual
function normally
Nicotine has a predilection for the brain and other nervous tissue. It acts on nicotinic
acetylcholine receptor, specially the ganglionic type nicotinic receptor and the CNS
nicotinic recptors.

6. Classification of a Smoker
According to the Centre for Disease Control (CDC)
and prevention

7. According to the
number of cigarettes smoked per day

8. Pharmacology of Tobacco Smoke Products
• Tobacco smoke has two distinct phases
Vapor Phase
Contains CO2 upto
5% of CO
Particulate Phase
It is in the form of
aerosol, has liquid
droplets and solid
submicroscopic particles.
Tar droplets of the free
substance are
suspended on these tar
particles.

9. Measurement of Exposure
Simple
Question
Sophisticated
Questionnaire
Biochemical
Analysis
• Exhaled CO in
breath
• Cotinine in Saliva,
Plasma or Serum
and Urine

10. Brown or Black
stains on the
tooth surface
caused by Tar
products

11. Effects on saliva
• Increased rate of flow of Saliva
- Murray in 1776
Salivation in smoker : Reflex phenomenon
due to irritant particulate matter in the smoke

12. Effects on
Calculus formation
More Calculus in Smokers
More Calculus in
Pipe Smokers
due to higher pH
of pipe smoke
An increased
calcium
concentration
in fresh saliva in
smokers
following
smoking
Reference : Feldman RS, Alman JE, Chauncey HH et al; 1987

13. Effects of Smoking
on Gingivitis

14. Effects on clinical signs of Inflammation
Reduced clinical signs of
Inflammation
Nicotine causes
vasoconstriction in the
peripheral blood vessels.
Hence, reduces clinical
signs of gingivitis
Reduction in clinical signs of
gingivitis in smokers is
independent of plaque levels
Reference : Bergstrom J, Preber H et al ; 1983, 1986, 1989

15. Effect on gingival epithelium
• Heavy Smokers : Thickened, fibrotic
apperance of the gingival tissue
• Greyish discoloration and
hyperkeratotitc gingiva
• Keratotic, Hyperkeratotitc,
Hyperplastic gingiva
• Prolonged use of tobacco :
Benign Smokers Keratosis
Leukoplakia
Reference : Creath CJ, Cutter G, Bradley DH et al ; 1991

16. Effect on gingival bleeding
• Reduced bleeding on
probing
• Nicotine stimulates
sympathetic ganglia, which
releases
neurotransmitters,
including catecholamines,
a potent vasoconstrictor.
Catecholamines
Reference : Bergstrom J, Preber H, Daneilsen B et al ; 1988, 1990

17. Effects on Gingival crevicular Fluid
DecreasedsecretionofGCFinSMOKERS
Peripheral
Vasoconstriction
Decreased Blood
Flow
Decreased GCF
Production
WHY ?
Reference : Bergstrom J, Preber H ; 1983, 1986, 1989

18. Effects of Smoking on Periodontitis
• prevalence and severity of
periodontal destruction
• pocket depth, attachment
loss, and bone loss
• rate of periodontal
destruction
• prevalence of severe
Periodontitis
• tooth loss
Reference : Johnson GK, 2004

19. Effects on
Host-Immune Response
Immunology
Altered neutrophil
chemotaxis, phagocytosis, and
oxidative burst
Increased Neutrophil
collagenase and Elastase in
Gingival Crevicular Fluid
Increased
production of
PGE2 by
monocytes
Reference : Locker D, Leake JL; 1993

20. Effects on Microbiology
• No effect on rate of plaque accumulation
• Increased level of periodontal pathogens
in deep periodontal pockets
Lowered
oxidation-
reduction
potential
Increase in
Anaerobic
Plaque
bacteria
Such as
P. gingivalis,
A. Actinomycetemcomitans
T. denticola
Reference : Hanioka T, Tanaka M, Ojima M et al; 2000

21. Decreased
- Clinical response to
root-surface debridement
- Reduction in pocket
depth
- Gain in clinical
attachment levels
- Negative impact on
smoking with level of
Increased
- Pocket depth and
attachment loss during
maintenance therapy
- Disease recurrence in
smokers
- Need for retreatment in
smokers
- Tooth loss in smokers
Effects on response to Periodontal
Therapy
Non-Surgical Surgery and Implants
Decreased
• Pocket-depth reduction
• Gain in attachment
levels
• Root coverage after
grafting procedures for
localised gingival
recession
• Pocket depth reduction
after bone-graft
procedures
Increased
• Deterioration of
furcations after surgery
• Riak for implant failure
and periimplantitis
Mainenance Care

22. Acute necrotizing ulcerative gingivitis and smoking
• More frequently in smokers
• Mechanism :
Reduced activity of leukocytes
+
Proliferation of anaerobic,
fusospirochetal micro-organisms
Vasoconstriction of gingival blood
vessels

23. Smoking Cessation
• The guidelines for health care providers include the FIVE “A’s”
Reference : Johnson GK, Hill M ; 2004

24. Nicotine containing
nicotine replacement
agents
Non - nicotine
containing nicotine
replacement agents
• Nicotine Patch :
Habitrol, Nicoderm
• Gum : Nicorette
• Chantix
(varenicline
tartrate)
• Zyban
(buproprion
hydrochloride)
• Inhaler : Inhaler
Nicotrol
• Nasal spray :
Nicotrol NS

25. Conclusion
• Tobacco smoking has got adverse effects on various
aspects of periodontal health.
• The toxic substances present in tobacco smoke are
one of the risk factors for periodontal disease
progression.
• Studies have also shown the adverse effects of
smoking on healing after non-surgical or surgical
periodontal therapy.
• Cessation of smoking has favourable effects on
healing and maintenance of periodontal health

26.  Carranza’s
Clinical
Periodontol
ogy : 10th
Edition
 Periobasics :
A textbook of
Periodontics
and
Implantology
 Journal of
Pharmaceuticals
and Scientific
Innovation
Grover Harpreet S. Et al :
Smoking and Periodontal Diseases