Smoking & Oral Health

Smoking and Oral Health

Cigarette smoking is the cause of many major general and oral health problems. The detrimental effects smoking has on your health has been known for some time. Associated life-threatening medical conditions such as lung disease, lung and mouth cancer, heart disease, stroke, impotence, and premature and low birth-weight babies have been well documented.

Smoking is of major interest to dental professionals as it is known to be a significant risk factor for oral cancer and periodontitis. Smoking also has an unfavourable impact on healing and dental treatment outcome.

Epidemiology of Smoking

Tobacco smoking is one of the major risk factors for many illnesses. It is the largest contributor to the burden on the health system.

Data from the Australian Institute of Health and Welfare 2001 show that smoking is prevalent in the Australian population, with nearly half (49%) being current or former smokers. In people 14 years and over, 21% of men and 18% of women smoke daily.

The highest rate of smoking is found in males aged 20-29 years (28%) and the highest rate for females is in the 30-39 years age group (24%). The lowest rate of smoking is found among those aged 60+ years.

It is disturbing that smoking among adolescents (14-19 years) is greater than ever and is still rising, with more females (16%) taking up the habit than males (14%).

The majority of smokers (89%) start in their teenage years; therefore, it is important to target this age group with some prevention strategies.

Smoking as a Risk Factor

Cigarette smoking is a major risk factor for many illnesses such as lung and cardiovascular diseases, poor pregnancy outcomes, and oral diseases including oral cancers and periodontitis.

The role of smoking in the pathogenesis of these diseases is believed to be associated with a deficient host immune function, causing an increased risk of disease and poor wound healing. Smoking also impairs the revascularisation of bone and soft tissues, further impairing healing.

There have been recent studies to indicate that tobacco use may be one of the most significant factors in the development and accelerated progression of periodontal disease. It is also suggested the chemicals present in tobacco slow a patient’s recovery following periodontal treatment or any other type of oral surgery, and as such, makes the success of treatment less predictable.

Studies have highlighted the correlation between smoking and periodontal disease, oral cancer and oral mucosal lesions.

Periodontal Disease

It is estimated that up to 20% of the Australian population suffer from a form of periodontal disease.

Periodontitis is caused by environmental (bacteria) and host related factors. Numerous epidemiological studies have concluded that smoking is also a significant risk factor. Current smokers are 2.5 to 6 times more likely to have periodontitis than non-smokers. Former smokers are almost twice as likely to have periodontitis than people who have never smoked. In terms of severity of periodontal disease, a number of studies have confirmed that smokers are three times more likely to suffer from severe periodontitis compared to non-smokers. There is also evidence that smokers experience greater tooth loss than non-smokers.

Among current smokers there is a dose-response relationship between the number of cigarettes smoked per day and the likelihood of periodontitis – the more cigarettes smoked the greater the chances of developing periodontitis.

Smoking causes irreversible damage to the periodontium; however, the progress of the disease can be stopped and further damage prevented by cessation of smoking. This information can be used as encouragement for smokers to quit the habit. Although the patient, as well as the dental professional, will still need to deal with some dental consequences of smoking, the patient can be reassured that the periodontal disease will not worsen.

Smoking cessation significantly benefits a person’s likelihood of tooth retention, but it may take decades for the rate of tooth loss to return to that observed in non-smokers.

Calculus and Gum Disease

Plaque is a clear sticky film that adheres to your tooth enamel. Once this becomes hardened, it is called calculus, which can only be removed professionally by treatments such as root planing and scaling, using specially designed instruments. Depending on the severity, these treatments may be conducted under a local anaesthetic to clean deep into the area called gum pockets.

As periodontal disease develops, gaps between your teeth and gum pockets can enlarge. If the calculus is not removed from below the gum-line, the bacteria can cause the loss of tissue and bone structure that supports your teeth to deteriorate and may result in tooth loss. Periodontal disease that is left untreated can result in a bacterial infection deep in the gum pocket. Your immune system reacts to this infection in an attempt to rid the body of the bacteria, pus then develops in the pocket, and when there is no way for it to drain, it becomes an abscess.

Gingival Tissue

Gingivitis is modified by several factors including smoking. Gums of smokers show:

• fewer gingival inflammatory changes
• reduced bleeding
• a thickened and fibrotic appearance.

The gingival changes are due to a suppressed immune response to plaque that masks the presence of periodontal disease. It is important that the dental clinician recognises the condition and performs a thorough periodontal examination to detect signs of periodontal disease.

Acute necrotizing ulcerative gingivitis (ANUG) occurs more frequently in smokers. Possible explanations for the increased frequency of ANUG in smokers include the vasoconstriction of gingival blood vessels, reduced activity of leukocytes and proliferation of anaerobic fusospirochaetal microorganisms.

Oral Cancer

Studies continue to provide evidence of the strong correlation between smoking and oral cancer. The risk of oral cancer increases with increasing number of cigarettes smoked per year and number of years a person has smoked. After quitting smoking the risk of cancer reduces.

In Australia 3% of all cancers are oral cancers and the annual death rate from oral cancers is higher than that of cervical cancer. Smokers over 40 years of age who smoked one packet a day for 20 years have 4.4 times the risk of developing mouth cancer. The risk of oral cancers associated with smoking increases further with excessive alcohol consumption.

Because oral cancers in the early stages are often treated successfully by excision, it is important that dental clinicians are able to diagnose the early signs.

Early oral lesions are usually asymptomatic and can present as a small white or red area or an ulceration that does not heal for a prolonged period of time. In the final stages an oral cancer usually becomes symptomatic and widespread, with poor survival prognosis.

Other Oral Mucosal Lesions

There are a number of mucosal lesions associated with smoking including leukoplakia and smokers keratosis.

Oral leukoplakia (white patch) is found six times more frequently in smokers than in non-smokers and is dose related. Smoking cessation or reduction has been found to cause regression or disappearance of the lesion.

Smoker’s keratosis (known as nicotine stomatitis or smoker’s palate) is a common form of keratosis associated with smoking. The prevalence of white patches is not related to the quantity of tobacco consumed but rather to the number of years the person had smoked. The condition rarely progresses into malignancy; however, it is an indicator of significant epithelial changes in the mouth.

Dental Caries

Dental caries is another example of multifactorial disease. The evidence of a causal relationship between smoking and coronal dental caries is inconclusive, but is suggestive of an association between root caries and smoking.

Recent studies have reported an association between environmental tobacco smoke and risk of caries among children. There is insufficient evidence to classify these associations as causal.

Response to Dental Treatment and Healing

Many studies have shown that smoking impairs a patient’s response to periodontal therapy, including both simple and complex (such as guided tissue regeneration or osseous grafting) procedures. Smoking is therefore a contraindication to periodontal therapy. Ninety percent of cases not responsive to periodontal treatment occur in smokers.

Implant Failure

Smoking has been found to be the most significant risk factor for implant failure, which is caused by impaired healing associated with smoking. The failure rate for smokers is 11% compared to 4.8% for non-smokers. Stopping smoking for as short a period as from one week before to eight weeks after the procedure can reduce the failure rate.

Tooth Extractions

Common oral procedures such as tooth extractions, are also known to be affected adversely by smoking. Tobacco smokers have a significantly greater incidence of complications after an extraction, for example alveolar osteitis.

Dental Aesthetics

Discolouration of teeth, restorations or dentures is a common complaint of many smokers. Early decay lesions (white spot lesions) and dentine are prone to discoloration; therefore, the discolouration is even more noticeable if prior white spot lesions are present, dentine is exposed or a patient’s oral hygiene is lacking.

Halitosis (oral malodour), which often creates serious personal and social embarrassment for the affected person, may also be associated with tobacco use.

Smokers as Dental Patients

Tobacco smoking is recognised as the risk factor or the risk indicator for many oral diseases; therefore, assessment of a smoking habit should become part of every dental examination. It is important to be aware of the length of the habit (number of years smoked) as well as the severity (number of cigarettes smoked per day).

It is not uncommon for smokers to underestimate their smoking habits when talking about the number of cigarettes they smoke.

Smoking habit assessment is very important as it helps the clinician to:

• understand the patient’s present and future risk of dental diseases
• assess the prognosis and possible complications of any dental treatment that may be carried out
• prepare an appropriate treatment plan
• explain to the patient treatment options and the limitations associated with smoking
• keep the patient’s expectations at a realistic level.

No dental treatment will be successful and long-lasting if the patient is unaware of his or her role in the maintenance phase of the treatment.

The Dentist’s Role in Smoking Cessation

Smoking is a complex behavioural and psychological issue that must be dealt with in all aspects of health care including dentistry. Dental professionals should not only be able to diagnose smoking related diseases, but should play an active role in both preventing the initiation of smoking and in smoking cessation.

The ‘five As’ principle of smoking cessation is being promoted by Quit Australia and can be easily adapted to any dental surgery environment.

Patient Awareness

The majority of smokers are aware of smoking being a risk factor for many general health problems.

Many smokers are however not aware of the wide range of dental consequences of smoking. It is the role of the dental clinician to bring this issue to patients’ attention and ensure that an in-depth explanation is given. If this information is not given to the patient, it may be perceived as ‘supervised neglect’.

In spite of an increased awareness of the adverse effects of smoking on oral health, many patients will continue to be smokers; however, they will better understand the reasons for a possibly less than optimal outcome of dental treatment and prognosis.

Failure of some patients to act on advice on smoking cessation should not discourage the dental clinician to continue providing this type of service to patients. Quitting is a process and not a single event. On average, at least five or six attempts to quit are made by a smoker before being successful, and all attempts need to be perceived as a learning experience for all involved.

Ready to Quit?

For help quitting smoking, visit the Smoking Quitline: www.quitnow.gov.au

Your dental team can also help. Ask us about referring you to Sara Dobson at I Quit 4 Life, a specialist quit smoking service that uses advanced hypnosis and NLP to help you quit cigarettes in just 60 minutes — with a lifetime guarantee. Call Sara on 0437 774 250, email sara@iquit4life.com or visit www.iquit4life.com. Offices in Cairns & Innisfail. Download the IQuit4Life_A4 Flyer

Further Information

Dental Practice Education Research Unit Dental School, The University of Adelaide, South Australia 5005 Phone (08) 8303 5438 | Email dperu@adelaide.edu.au Website: www.adelaide.edu.au/socprev-dent/dperu

Source: Colgate Dental Education Program — A joint program by Colgate Oral Care and The University of Adelaide. Special Topic No. 1.