This document discusses the effects of smoking on periodontium. It begins with an introduction and overview of how smoking affects the oral environment and periodontal tissues. It then covers the classification of smokers, constituents of tobacco smoke and their mechanisms of action in damaging tissues. The effects of smoking include increased periodontal pathogens, impaired healing, decreased inflammation and blood flow. Smoking also negatively impacts the response to periodontal treatments and increases risk of recurrence. However, smoking cessation can help recovery of tissues and positive treatment outcomes through improved circulation, microbial shifts and immune response. The document concludes with steps for smoking cessation programs and pharmacotherapy options.

1. SMOKING AND
PERIDONTIUM
Submitted by
Nahala beevi
Final year BDS

3. Flow chart
 Introduction
 Classification
 Constituents of tobacco
 Mechanism of action
 Effects of smoking
 Smoking cessation
 conclusion

4. INTRODUCTION
Smoking is identified as an independent environmental risk factor for development
and progression of periodontal diseases. In 1947 Pinborg for the first time identified
potential cause relationship between smoking and periodontal disease
Tobacco smoking hampers the oral environment and ecology ,the vasculature, the
inflammatory and immune responses and homeostasis and healing potential of the
periodontal tissue .this favors the growth of periodontal pathogen and subsequent
periodontal diseases
The WHO predicts that tobacco death in India may exceed 1.5 million annually
by2020

5. CLASSIFICATION
 According to center for disease control and preventive ,the smokers are classified
as
Current smokers ; smoked 100 cigarettes in their life time, smoked at the time of
interview
Former smoker ;smoked 100 cigarette in their life time but not currently smoking
Non smokers; Those who had not smoked more than or equal to 100 cigaretes
According to number of cigarette smoked per day
Heavy smoker
Light smokers

6. PACK YEAR
 The amount a person had smoked over along period of time is measured by
number of pack year ,it is calculated by
Number of cigarettes smoked /day
Number of years
person has smoked

7. CLINICAL FEATURES OF ORAL TISSUES ASSOCIATED WITH
SMOKING
 The marginal gingiva tends to be fibrotic with a rolled margin
 There is often recession in mandibular and maxillary anterior segment with
resultant open embrasures
 Smoking produces black or brown stain on the tooth surface
 More supra gingival calculus deposits
 Heavy smokers may have greyish discoloration and hyperkeratosis of gingiva
 Nicotinic stomatitis is frequently observed in the palatal mucosa of heavy
smokers
 A unique form of cancer called chutta or palatal cancer occur due to reverse
smoking

9. CONSTITUENTS OF TOBACCO SMOKE
Particulate phase
nicotine
cotinine
Gas phase
carbon monoxide
ammonia
dimethyl nitrosamine
formaldehyde
hydrogen cyanide
acrolein

10. Tobacco contains over 4,000chemicals, many of
which are harmful
 . These include:
 Benzene - solvent used in fuel manufacture
 Formaldehyde - highly poisonous, colorless liquid used to preserve dead bodies
 Ammonia - chemical found in cleaning fluids. Used in cigarettes to increase the
delivery of nicotine
 Hydrogen cyanide -poisonous gas used in the manufacture of plastics, dyes
 pesticides. - Often used as a fumigant to kill rats Cadmium - extremely poisonous
metal found in batteries Acetone - solvent found in nail polish remover

11. Nicotine & cotinine
 It inhibits the apoptosis of in certain cell lines(fibroblast and osteoclast)
 Exaggerates immune system activities
 Nicotine retards growth of gingival fibroblasts reduces fibronectin & collagen
increases collagen breakdown Other actions are: •raise blood pressure
•stimulants •vasoconstriction •psychological - social dependency •physical
dependency - craving

12. CARBON MONOXIDE-ACTIONS
 •Carbon monoxide is a poisonous gas found in car fumes, which reduces the
amount of oxygen carried in the blood. •Oxygen is vital for the body’s organs to
function efficiently. • The reduction in oxygen changes the consistency of the
blood, making it thicker and putting the heart under increased strain as it pumps
blood around the body

13. TAR-actions
 Tar contains many substances proven to cause cancer. •Irritants found in tar
damage the lungs causing narrowing of the tubes(bronchioles) and damaging the
small hairs (cilia) that protect the lungs from dirt and infection

14. Plaque and
oral flora
Homeostasis
and healing
potential
Periodontal
tissues
Systemic
health
Immune
response
Tobacco
Smoking

15. Interaction between smoking and the
other factors
smoking
Periodontal
destruction
Poor general health
attitude and
behavior
Impaired healingPoor systemic health
Increased
periodontal
pathogenic flora
Aggressive
periodontal
destruction
Poor plaque control
immunosuppression

16. Mechanism of action of tobacco- plaque
 Due to the increased redox potential chances of colonization of anaerobic bacteria
 Formation of advanced glycation end product by smoke helps in the growth of
microorganism-Eggert2001
 Higher prevalence of orange and red complex including
 Eikenella nodatum
 Fusobacterium nucleatum
 Prevotella intermedia
 Peptostreptococcus micros
 Prevotella nigrescens
 Treponema denticola
 Porphyromonas gingivalis

17. Other contributing factors
 increased salivary blood flow
increased organic components

18. On periodontal tissues- gingiva
Hyperkeratinisation
Decreased blood due to vasoconstriction by nicotine
Decreased capillaries
Increased Interleukins and PGE2
Loss of cell integrity of fibroblast
Decrease collagen production
Increase collagenase production
SUPPRESSION OF NORMAL INFLAMMATORY PROCESS

19. Effect of smoking
 Effects of smoking on the prevalence and severity of periodontal disease
Periodontal disease Impact of smoking
Gingivitis
Periodontitis
- Decrease in gingival inflammation
and bleeding on probing
- Increase prevalence and severity of
periodontal destruction
- Increase pocket depth attachment
loss and bone loss
- Increase periodontal destruction

20. Periodontal disease Impact of smoking
Periodontitis - Increase prevalence of severe
periodontitis
- Increase tooth loss
- Increase prevalence with increased
number of cigarette smoke per day
- Decrease prevalence in smoking
cessation

21. Effects of smoking on the etiology and
pathology of periodontal diseases
Etiological factors Impact of smoking
Microbiology
Immune inflammatory response
No affect on rate of plaque accumulation
Increase colonization of shallow
periodontal pathogens
Increase level of periodontal pathogens in
periodontal pockets
Altered neutrophil chemotaxis
,phagocytosis, and oxidative burst
Increase tumor necrosis, factor alpha and
prostaglandin E2 in gingival crevicular
fluid

22. Etiological factors Impact of smoking
physiology
Increase neutrophil collagenase and
elastase in gingival crevicular fluid
Production of prostaglandin E2 by
monocyte response to lipopolysaccharide
Decrease gingival inflammation and
gingival blood vessel
Gingival crevicular fluid flow and
on probing with increase inflammation

23. Etiological factor Impact of smoking
Physiology Sub gingival temperature
Increase time needed to recover from
local anesthesia

24. Effect of smoking on response to periodontal
therapy
Therapy Effects of smoking
Non surgical
Surgery implants
Decrease clinical response to root
surface debridement
Decrease in pocket depth
Decrease in gain in clinical
levels
Decrease negative impact of smoking
with increase level of plaque control
Decrease pocket depth reduction and
decrease in gain in attachment level
after surgery

25. Therapy Effects of smoking
Increase deterioration of furcation after
surgery
Decrease gain in clinical attachment
level
Decrease bone fill
Increase recession
And increase membrane exposure
tissue regeneration
Decrease root coverage after grafting
procedure for localized gingival
recession
Decrease pocket depth reduction after
bone graft procedure
Increase risk for implant failure and
periimplantitis

26. Therapy Effects of smoking
Maintenance care Increase pocket depth and attachment
loss during maintenance therapy
Increase disease recurrence in smokers
Increase need for recurrence in smokers
Increase need for retreatment in smokers
Increase tooth loss in smokers after
surgical therapy

28. Effects of smoking cessation on
periodontal treatment outcomes
 Smoking cessation positively influences the periodontal treatment outcomes
 The benefits of smoking cessation on the periodontium is likely to be mediated
through various pathways
 a shift towards a less pathogenic microbial flora
 The recovery of the gingival microcirculation
 Improvement in certain aspect of immune inflammatory response

29. Basic steps of smoking cessation program
 ASK ; ask to identify the tobacco use status of the patient
 ADVICE ;patient should be advised that smoking cessation should be
beneficial
 ASSESS ;recognizing the patients interest and readiness to attempt
tobacco cessation
 ASSIST ;helps to those who are ready with their problem skill and with
pharmacotherapy
 ARRANGE ;arrange follow up support through out the quitting
process

30. pharmacotherapy
 Nicotine replacement therapy
 Nicotine gum ;release nicotine via chewing and buccal absorption
 Nicotine patch
 Non nicotine pharmacotherapy
 Bupropion ; for withdrawal syndrome

31. CONCLUSION
 Cigarette smoking is a major risk factor for periodontitis and also effects the
extend and severity of disease
 Smoking cessation positively affect the periodontal treatment outcome

33. Reference
Textbook of clinical periodontology–carranza
Textbook of periodontology and oral implantology - Dilip G Nayak, Ashitha
uppoor,Mahesh CP

34. THANK YOU