Smoking and the Periodontium

Question 1

What are the 5 A’s?

Answer 1

Ask: about the smoking use status
Advise: about the advantages and value of stopping
Assess: how motivated a patient is to stop
Assist: those who wish to stop
Arrange: monitoring, follow-up and referral

Question 2

What are the 5 R’s?

Answer 2

Relevance: of smoking to the individual
Risks: associated with smoking
Rewards: of cessation to be stressed
Road: blocks must be identified
Repetition: repeat at each consultation

Question 3

What are the important carcinogens in smoke?

Answer 3

• polycyclic aromatic hydrocarbons
• N-nitroso compounds

Question 4

How does smoking affect the periodontium clinically?

Answer 4

• causes more staining - black/brown
• higher levels of plaque
• more calculus
• reduction in inflammation
• reduction in bleeding
• gingiva can often appear healthy and mask significant disease
• deeper pocketing
• more bone loss, LOA and recession

Question 5

How does smoking affect the periodontium biologically?

Answer 5

• reduces vascularity (more vasocontriction)
• reduced inflammation and immune responses
• more pathogenic plaque biofilm
• direct toxic effect on various cell types (fibroblasts)
• thermal damage

Question 6

How does the inflammatory and immune response respond to smoking?

Answer 6

Inflammatory and immune responses are reduced in smokers:
- reduced neutrophil function with impaired chemotaxis, phagocytosis and bacterial killing (impaired oxidative burst)
- reduced production of salivary IgA
- reduced serum IgG levels
- reduced number of helper T lymphocytes
- higher levels of matrix metalloproteinases, collagenases and prostaglandin E2 which cause tissue breakdown

Question 6

What are the effects of reduced gingival crevicular fluid in smokers on the periodontium?

Answer 6

Smokers have lower resting GCF flow rates compared to non-smokers resulting in several negative effects:
- reduces ability of immunoglobins and other defence molecules to reach the pocket
- reduces flushing out of the gingival crevice/pocket which helps to remove bacteria and their waste

Question 7

How is the subgingival biofilm affected in smokers?

Answer 7

• biofilm is more diverse with higher levels of pathogenic species and more anaerobic in nature
  Subgingival plaque biofilm in periodontally healthy smokers is more like that found in active deep periodontal pockets

Question 8

What are the 3 main factors in pocket depth reduction in non-smokers following successful periodontal treatment?

Answer 8

• reduction in inflammatory swelling
• improved tissue resistance
• small possible gain in attachment

Question 9

Why are smokers more likely to be left with residual deeper pockets?

Answer 9

Inflammatory swelling accounts for the most reduction in pocket depth, however inflammation makes up less of the pocket depth in smokers
- tendency for less pocket depth reduction and tend to harbour more pathogens

Question 10

Why is healing less successful in smokers?

Answer 10

• tendency for less pocket depth reduction due to less initial inflammation
• lower numbers of fibroblasts and reduced epithelial cell function
• reduced host response and therefore reduced vascularity