Periodontal diseases and Smoking


Smoking is associated with severe diseases such as cancer, lung diseases and heart diseases. The connection between smoking and periodontal diseases is less known to the public, despite the fact that the affect of smoking on the supportive tissue has already been proven.

Recent studies show that smoking is a main risk factor in the development of gum disease. Smokers should be aware of the dangers associated with periodontal diseases and the connection between smoking and cancer or heart attacks.

What are periodontal diseases?

Periodontal diseases are infectious diseases caused by bacteria. They are common among the general public and are responsible for most of the tooth extractions performed in dental clinics. Bacteria accumulate around the teeth and form plaque (a layer of bacteria). If plaque is not removed, it can become calcified. As a result, the tooth’s grip is damaged and it can become separated from the gums and jaw, creating a periodontal pocket. As this continues, resorption occurs in the alveolar bone and the tooth loses its grip and falls out. Initially, periodontal disease is manifested in swelling and redness, as well as bleeding when brushing. Usually there is no pain involved in this quiet chronic illness. At this stage periodontal disease can be reversed. In later stages the disease causes discharge, bad breath, bad taste in the mouth, teeth mobility, gaps opening between the teeth and aesthetic problems. In addition to bacteria, other risk factors include smoking, diabetes and hormonal changes. Many treatments are available and depend on the severity of the disease: from maintaining dental hygiene and removing the plaque to more complex surgical treatments.

Smoking and periodontal disease: manifestation in the mouth, the pathological process, practical clinical implications and the positive changes of quitting smoking

1. Manifestation in the mouth

Gums tend to thicken and become fibrous, without a significant edema, regardless of the severity of the disease. Surprisingly, smokers do not complain of bleeding, probably because of disruption to blood flow.

Gum recession and root exposure: teeth appear longer, and are colored yellow and brown because of nicotine. Taste decreases and strong odors are present.

In x-rays, bone resorption is dramatic compared to non-smokers.

More wrinkles are present in the face, and skin is tinted grey.

2. The pathological process: what does smoking affect?

  • Smoking affects the consistency of bacteria in the mouth (bacterial flora). Studies show that aggressive bacteria (pathogens) increase in the mouth and throat of smokers. In healthy patients there is a balance between “normal” bacteria and potential pathogens. This balance may be restored within a few months after the patient has quit smoking.
  •  Smoking damages microcirculation: blood vessels in the gums become narrower due to nicotine accumulation and limited blood flow. This delays the appearance of cells crucial to fending off bacteria.  This is a probable explanation as to why smokers bleed less during brushing despite the progression of the disease.

Today we know that the substances created during the burning of the cigarette are more harmful to the body than the nicotine itself. They are responsible for changes in blood thickness and a tendency to adhere and clot.

To conclude, a smoker’s blood is thicker and flows slower.

  • Smoking affects the immune systems by reducing the production of antibodies and harming white blood cells.
  • Smoking damages the metabolism of fibroblast – the cell responsible for healing wounds. Fibroblast ensures the vitality of the connecting tissue between the teeth and the gums.
  • Smoking encourages calcium loss, resulting in increased bone resorption.

3. The practical clinical implications of smoking in Periodontistry

  • Difficulty in early detection of periodontal disease. Bleeding while brushing is one of the first and only signs indicating periodontal disease, but this symptom is absent in smokers, which leads to late detections.
  • Slow healing of wounds.  Healing is delayed because of changes to blood supplies and to the immune system.
  • Periodontal treatments do not respond properly compared to non-smoking patients. Results are not stable in the long run. Due to faulty microcirculation, microsurgery is not a suitable option.
  • Smoking and transplant acceptance: the osseointegration process of dental implants does occur in smokers, but it’s slower and more fragile. This is manifested in the fast development of Gingivitis around the implants: “Peri-implantitis” and failure in the short and mid runs.

Quitting smoking and hope

All of the studies show that quitting smoking restores dynamics to the vascular system (patients whom quit smoking note the appearance of bleeding gums – a symptom which was not present before). In the very first days after quitting smoking, the same studies show a change for the better in blood flow, which could assist in a successful completion of periodontal treatments.

Treatment approach with smokers

Though several clinics and specialists refuse to treat patients whom smoke due to the low success rate of most treatments, my approach is different:

The smoker is a victim of a tough addiction, and he cannot always face it. The patient is usually stuck in a closed circle which does not allow change. Therefore, the patient shouldn’t be punished. The treatments should be adapted to smokers, while acknowledging their limitations. The patient must be encourages continuously to stop smoking. Usually, intimidating the patient through stories about cancer or cardiovascular diseases is ineffective. Instead, I suggest an honest conversation emphasizing other arguments related to aesthetics and quality of life. We offer a program which improves the patient’s quality of life based on quitting smoking, exorcise and a balanced diet. The initial achievements of the periodontal treatment encourage the smoker to break the unhealthy circle. We, as doctors, act as coachers supporting our patients and helping them regain control of their lives. 

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