Smoking is very diffused and can be considered a world wide epidemic. In 2012 roughly 44 million American were smokers, with 9 million people suffering from a severe smoking-related disease and almost half a million deaths attributable to smoking and exposure of secondhand smoking each year. Tobacco kills up to a half of its users. Globally, smoking accounts for 1 in 5 deaths among men 30 years old and older and 1 to 20 deaths among women 30 years old and older (WHO 2013).

Smoking is harmful to almost every part of the body. It is associated with multiple diseases that reduce life expectancy and quality of life (lung cancer, heart disease, stroke, bronchitis, and cancers of the oral cavity among all). Almost half of long-term smokers will die early as a result of smoking, and those who die before the age of 70 years will lose an average of 20 years of life (Doll 1994). Tobacco smoke contains thousands of dangerous chemicals (carbon monoxide, ammonia, formaldehyde, hydrogen cyanide are some) and many substances that can lead to cancer.

Smoking and Periodontal Disease

Besides the effect on the general health, smoking is the major risk factor for periodontal disease. It affects the occurrence, the magnitude, and severity of disease. Studies demonstrated that, on average, smokers were 4 times more prone to periodontitis as compared with persons who had never smoked. Former smokers were 1.7 times more likely to have periodontitis than persons who had never smoked. Is important to understand that that approximately 42% of periodontitis cases in the US adult population are linked to current smoking and that approximately 11% to former smoking (Tomar 2000).

Smoking can be deceiving. Smokers wouldn’t see many signs of inflammation in their gums (redness and bleeding gums), but they would hide higher incidence of bone loss deep pockets and increased chances to loose teeth if compared to non-smoking individuals. People may think that her gum status is not bad but they would be wrong. The effect of smoking is slow and subtle.

Fig 1. Global Smoking Prevalence. Percentage of smokers among world adult population. North America shows prevalence between 20 to 25%.

Periodontal Therapy

Numerous studies have indicated that current smokers do not respond as well to periodontal therapy as nonsmokers or former smokers do. The pocket depth reduction and gain of tissue destroyed by periodontitis is more effective in nonsmokers than in smokers after nonsurgical and surgical periodontal therapy (including oral hygiene instruction, scaling, and root surface debridement)*.

Research showed that short- and long-term outcomes of implant therapy in smokers increased the risk of implant failure* (implant loss, implant bone loss, mobility, pain, and periimplantitis). Overall, the risks for implant failure in smokers appears to be approximately double the risk for failure in nonsmokers.

Even with more intensive maintenance therapy given every month for 6 months after surgery (Scabbia 2001) smokers had deeper and more residual pockets than nonsmokers. Smokers also tend to experience additional tissue destruction than nonsmokers after therapy (MacFarlane 1992, Magnusson 1996). Tobacco smoking is associated with tooth loss even when regular recall maintenance care was performed (Chambrone 2010).

FIG 2 a and b








Fig 2. (a) Smoker subject affected by periodontal disease. Notice the bleeding, inflammation and tobacco staining.


(b) Outcome of non-surgical therapy alone and smoking cessation. Tissues appear healthy, pockets were reduced and no bleeding was present. The teeth are now ready for esthetic improvement.


Strategies to Quit*

There are some ways for a smoker to quit. These are listed in order of success.

1. Willpower Alone
This is the least effective method of smoking cessation, with only 3% of smokers managing to quit after 12 months.
2. Self-Help Materials
3. Brief Intervention Program
4. Nicotine Replacement Therapy. Success rate at 12 months is 10% to 20%. Nicotine replacement therapy generally doubles the success rate of smoking cessation (patches, gums, nasal spray, 
5. Other Methods. Intensive counseling, motivational interviewing, behavioral therapy, hypnosis, and acupuncture.

In conclusion, smoking is the major risk factor for periodontitis, and smoking cessation should be considered as a strong part of periodontal therapy in smokers.
Smoking cessation should be treated as a priority for the management of periodontitis in smokers. The result of smoking cessation improves periodontal health and increases the success of therapy delivered by the hygienist and periodontist.

*Carranza’s Clinical Periodontology. 12th edition.

– Lorenzo Mordini DDS, MS

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