Systemic Risk Factors - Smoking

Question 1

What is pack years?

What is a high level of nicotine dependence?

Answer 1

• estimate of how much a patient has smoked in their lifetime

Pack years = no.of packs smoked per day X number of years smoked

High level of nicotine dependency: smoking at least 15-20 cigarettes per day, and/or within 30 mins of waking

Half life of nicotine is ~2hrs, overnight nicotine levels drop close to those of a non-smoker

Question 2

What is important in gaining informed consent to a perio patient that smokes?

What is the Prochaska model for smoking cessation?

Answer 2

Patients who smoke must be warned early on (part of informed consent) about the likelihood of having a reduced periodontal treatment outcome

Prochaska model:

• pre-contemplators (not interested)
• contemplators (interested but unready)
• active quitters (making an attempt)

Question 3

What are the 5 A’s in smoking cessation?

Answer 3

Ask: about smoking status

Advise: about the advantages and value of stopping

Assess: how motivated a patient is to stop

Assist: material, help lines, referral

Arrange: monitoring, follow-up and referral

Question 4

What are the 5 R’s for patients who are more resistant to stopping smoking?

Answer 4

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 5

How does smoking affect the oral mucosa?

Staining, plaque and calculus?

Gingiva?

Answer 5

Oral mucosa: oral lesions including oral cancer

• important carcinogens in smoke are pilycyclic aromatic hydrocarbons and N-nitroso compounds

Staining, plaque and calculus:

• black/brown staining on teeth/tongue
• rough surface –> plaque retention may be increased
• smokers have higher plaque scores than non-smokers but is not thought to be due to the smoking itself

Gingiva:

• reduced inflammatory reponse and vascularity which can make the gingiva appear healthy even though there is active disease
• more calculus that non smokers
• increased salivary slow rate as a response to the irritant particulate matter in smoke
• risk factor for necrotising gingivitis

Question 6

What are the biological effects of smoking?

Answer 6

• reduced vascularity
• reduced inflammatory and immune responses
• more pathogenic plaque biofilm
• direct toxic effects on various cell types e.g. fibroblasts
• thermal damage

Question 7

How is vascularity reduced in smokers?

Answer 7

Smoking impairs the vasculature of periodontal tissues:

• fewer large blood vessels and more smaller blood vessels in smokers gingivae
• inflammatory response in smokers gingivae seems to produce less increase in vascularity than in non-smokers
• reduced vascularity results in less gingival redness, less BOP and gewer vessels visible both clinically and histologically in smokers
• may be why smokers have poorer gingival healing

Question 8

What is the rebound effect?

Answer 8

After stopping smoking there is a rapid recovery of both the inflammatory response and vasculature of periodontal tissues (within a few weeks)

• will result in increased BOP
• warn patients about this prior to stopping smoking

Question 9

How does smoking negatively imoact on inflammatory and immune response?

Answer 9

• reduced neutrophil function with impaired chemotaxis, phagocytosis and bacterial killing
• reduced production of salivary IgA
• reduced serum IgG levels
• reduced number of helper T lymphocytes
• higher levels of matrix metalloproteinases (MMPs - collagenases) and prostaglandin which cause tissue breakdown in smokers, compared to non-smokers

Question 10

What is the effect of smoking on a patients gingival crevicular fluid?

Answer 10

• lower resting GCF probably due to the reduced periodontal vascularity and levels of inflammation in smokers
• reduces ability of immunoglobulins and other defence molecules to reach the pocket
• reduces flushing out of the gingival crevice which helps to remove bacteria and their waste

Question 11

How is healing in smokers following RSD affected?

Answer 11

• less pocket depth reduction in smokers as inflammatory swelling makes up less of the pocket depth
• harbour more pathogenic pathogens
• low numbers of fibroblasts and reduced epithelial cell function in addition to reduced host response and reduced vascularity
• therefore periodontal treatment outcomes tend to be poorer in smokers