Smoking has significant negative effects on periodontal health and outcomes of periodontal treatment. It increases the prevalence and severity of periodontal disease, affects the pathogenesis by altering the microbiome and inflammatory response, and decreases the response to nonsurgical and surgical periodontal therapies. Dentists play an important role in educating patients on the harms of smoking and counseling those who use tobacco on methods for cessation using pharmacotherapy and behavioral support. Smoking cessation improves periodontal treatment outcomes by allowing the periodontium to recover.

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.