2

Smoking & Periodontitis

Richard SnoadBDS,FDS, MGDS RCS

Periodontal Specialist

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Objectives

• Periodontitis Overview

• Secondary Environmental Modifier– Smoking

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Aetiology of Periodontal

Disease

Pathogens Environmental

Modifiers

Genetic

Modifiers DISEASE

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Disease Expression

• Susceptible Host

• Pathogens Present

• Virulence Expressed

• Host Threshold Reached

80% of disease concentrated in 20% of

patients

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Homozygous Twins

Michalowicz et al. 1991

Homozygous Twins

Michalowicz et al. 1991 “More than 50% of variation due to Genotype”

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Biological

Risk Factors

Behavioural

Risk Factors

Sex Hormones

Systemic

Diseases

Genetic

Susceptibility

Specific Bacteria

Host

Metabolic Changes

(IL-1)

Anatomic Changes

Medicine

Dentistry

Oral Hygiene

Stress

Smoking

(After Newman 1999)

Genetic

Osteoblast

Macrophage

Osteoclast

Fibroblast

Bone resorption

CollagenaseIL -1beta

TNFalpha

IL- 6

Guidelines• RISK ASSESSMENT (NICE 2004)

– Oral Medicine

– Periodontitis*• Aetiology

• Diagnosis

• Prognosis

• Treatment Plan

– Caries

*National Health Service. National Institute for Clinical Excellence guideline: Dental recall: recall interval between routine dental examinations. NICE 2004 (Oct)

www.nice.org.uk/CG019NICEguideline.

UK Epidemiology ADHS 1998

• SPECIALIST CARE 8% (“Complexity 3”)

• AT SOME RISK 30% (“Complexity 2”)

– SMOKING

– SYSTEMIC

• ADHS 2012

– 50% increase

• Downhill cases

• 6mm pockets

LOSS OF CT ATTACHMENT

&

SUPPORTING ALVEOLAR

BONE

“Slight Periodontitis” Armitage 2004

Environmental modifier: Diabetes

JAVED et al. 2007

Meta Analysis

Baljoon et al 2005

• Dose relationship

• >10 per day

• 5.3 x greater

• <10 per day

• 2.3 x greater

• “Heavy Smoker”

10 cigarettes

/day

Environmental modifier: Smoking

Meta Analysis

Baljoon et al 2005

• Mechanism

• Reduced

• Blood flow

• BV lumen

• Bone quality

• PMNLS 50%

• Cyanide HCn

• Topical effect

• Effects

• Accelerated LOA

• Maxilla worst

• Topical HCn

• Less healing

• More damage

• Bleeding absent

Plaque not bleeding in smokers

6 14

3 2

58 7 1 2 3 4 5 6 7 8

UPPER BLEEDING

R L

Buccal

Palatal

Lingual

Buccal

DATE: 10/10/2010 Target = 20%

Achieved: 35 /128 Percentage = 27%

PATIENT: Mrs Smith

6 14

3

258 7 1 2 3 4 5 6 7 8

LOWER BLEEDING

6 14

3 2

58 7 1 2 3 4 5 6 7 8

UPPER BLEEDING

R L

Buccal

Palatal

Lingual

Buccal

DATE: 10/10/2010 Target = 20%

Achieved: 35 /128 Percentage = 27%

PATIENT: Mrs Smith

6 14

3

258 7 1 2 3 4 5 6 7 8

LOWER BLEEDING

Smoking Clinical Problems

• Gingivitis absent

– Early warning

• Deeper pockets

– Some BOP

• Greater bone loss

– For age

• Worse response

– Periodontics

• Incl. regenerative

• Surgery (NO!)

– Maintenance studies

• Rebound PPDs/BOP

– Within 2 years

Smoker’s Periodontitis

• Haber 1993

– Fibrous response

– No gingivitis

– Deeper pockets

– Resistant to trtmt

– Rebound pocketing

– Rebound BOP

Smoker’s Periodontitis

• Haber 1993

– Fibrous response

– No gingivitis

– Deeper pockets

– Resistant to tx

– Rebound pocketing

– Rebound BOP

Smoker’s Periodontitis

• Haber 1993

– Present later

– Greater destruction

Smoker’s Periodontitis

• Haber 1993

– Present later

– Greater destruction

• ANUG

– Stress effects

– Coping with stress!

Smoker’s Periodontitis

• Haber 1993

– Present later

– Greater destruction

• Worse pal maxilla

• HCn poison PMNLs

Oral Cancer Risk

• 100x

• Smoking/Alcohol

• Danger sites

– Hard/Soft Palate

border

– Floor of mouth

Stopping smoking - the process

Maintainers

Contented

smokers

Contemplators

Relapsers

Ready to quit

Smoking cessation intervention

Increase in % of smokers abstinent for 6+ months:

Very brief advice (3 minutes) by clinician 2

Brief advice (up to 10 minutes) 3

Adding NRT to brief advice 6

Intensive support (e.g. smokers clinic) 8

6% = 190,000 people

Smith S.E. et al 1998 BDJ

11% quit rate at 9 months