Smoking & its effects on periodontium

smoking and its effects on periodontium

1. SMOKING & ITS EFFECTS ON PERIODONTIUM DR. K.S. STELIN (HOD) DR. MARIYAM MOMIN DR. PARUL ANEJA I YEAR PG DEPARTMENT OF PERIODONTOLOGY & ORAL IMPLANTOLOGY.

2. CONTENTS Introduction Historical background of tobacco Forms of tobacco Constituents of tobacco Challenge of assessing smoking status E ffects of smoking on the prevalence & severity of periodontal diseases Effects of smoking on the etiology & pathogenesis of periodontal diseases Effects of smoking on the response to periodontal therapy Role of a dentist in patient education Guide to counseling for tobacco cessation Use of pharmacotherapy Counseling those unwilling to quit Effects of smoking cessation on periodontal treatment outcomes Conclusion References.

3. INTRODUCTION Smoking is highly prevalent & can be considered as an epidemic in both developing & developed nations. In India 28.6% (266.8 million) adults – aged 15 & above are smokers & 3.7% (34.4 million) are occasional users. According to the Global Adult Tobacco Survey 2 (GATS2), every 3 rd adult in rural areas& every 5 th adult in urban areas use tobacco in some form or the other. Smoking is harmful to almost every organ in the body & is associated with multiple diseases that reduce life expectancy & quality of life.

4. HISTORICAL BACKGROUND OF TOBACCO

5. The National Household Survey of Drug & Alcohol Abuse conducted in 25 states in India in 2002 reported that 55.8% of males aged 12-60 years currently use tobacco. According to the National Epidemiological Oral Health Survey & Fluoride Mapping of the Dental Council of India (1994), about 23-24%, more males, across age groups reported smoking tobacco in the country. 40-45% smokers (more males) beedi – rural areas cigarette – urban areas

6. Tobacco preparations Tobacco is derived from the species of the plant of genus Nicotiana of the potato family. Carl Linnaeus in 1753 had named the genus of the tobacco plant ‘ Nicotiana ’ after the French ambassador to Portugal, Jean Nicot . Major varieties include: Nicotiana Rustica Nicotiana Tabacum

7. The tobacco leaves are subjected to different types of curing, for example: Flue curing Fire curing Sun curing

8. Tobacco may be chewed, smoked, sucked or sniffed. The carcinogenic role of tobacco is related to what type of tobacco product, the way in which it is used & its use in combination with other substances, In western countries, chewing tobacco is available in various forms which include: Naswar (Pakistan & Afghanistan)

9. In India, tobacco is used in various ways which include: Smoked tobacco Reverse smoking Smokeless tobacco

10. The various smoking habits prevailing in India are the following: Bidi Chillum Chutta Cigarette Dhumti Hookah Hookli

11. The various forms of smokeless tobacco used in India are the following: Khaini Manipuri tobacco Mawa Mishri Paan

12. Snuff Zarda Gutka Pan masala Gudakhu

13. Constituents in tobacco Tobacco smoke is estimated to contain over 4000 compounds, many of which are pharmacologically active, toxic, mutagenic & carcinogenic. Tobacco smoke comprises a gaseous phase & a solid (particulate) phase. Gas phase contains carbon monoxide, ammonia, formaldehyde, hydrogen cyanide and many other toxic & irritant compounds including more than 60 known carcinogens such as benzopyrene & dimethylnitrosamine . Particulate phase includes nicotine, “tar” (itself made up of many toxic chemicals), benzene & benzopyrene .

14. All dental patients must be asked about their smoking status or tobacco usage. Current smoking status is the minimal information that must be recorded (e.g., “Patient is currently smoking X cigarettes per day”), but the importance of cumulative exposure to cigarette smoke means that is more appropriate to record pack-years of smoking.

15. Challenge of assessing smoking status Current Smokers: Ask about current smoking & past smoking. Pack-years = Number of packs smoked per day × Number of years of smoking. Former Smokers: Ask patients about their past smoking. Former smokers should always be congratulated for their achievement in quitting, but it is also very important to document the following: How much they used to smoke? How many years they smoked? When they quit? Is the patient’s reponse accurate?

16. When is a smoker not a smoker? Smokers have smoked ≥100 cigarettes in their lifetime & currently smoke. Former Smokers have smoked ≥100 cigarettes in their lifetime & do not currently smoke. Non-smokers have not smoked ≥100 cigarettes in their lifetime & do not currently smoke.

17. Effects of smoking on the Prevalence & Severity of Periodontal diseases. Periodontal Disease Effects of Smoking Gingivitis Gingival inflammation & bleeding on probing Periodontitis Prevalence & severity of periodontal destruction. Pocket depth, attachment loss, & bone loss. Rate of periodontal destruction Prevalence of severe periodontitis Tooth loss Prevalence with increased number of cigarettes smoked per day Prevalence & severity with smoking cessation. Periodontal Disease Effects of Smoking Gingivitis Periodontitis

18. Effects of smoking on the Etiology & Pathogenesis of Periodontal diseases, Etiologic Factor Effects of Smoking Microbiology complexity of the microbiome & colonization of periodontal pockets by periodontal pathogens. Immune-Inflammatory response Altered neutrophil chemotaxis , phagocytosis and oxidative burst Tumor necrosis factor – α & prostaglandin E2 in GCF Neutrophil collagenase & elastase in GCF Production of prostaglandin E2 by monocytes in response to lipopolysaccharides . Physiology Gingival blood vessels with inflammation GCF flow & bleeding on probing with inflammation Subgingival temperature Time needed to recover from local anesthesia. Etiologic Factor Effects of Smoking Microbiology Immune-Inflammatory response Physiology

19. Effects of Smoking on the Response to Periodontal Therapy Therapy Effects of Smoking Nonsurgical Clinical response to root surface debridement Reduction in probing depth Gain in clinical attachment levels Negative impact of smoking with level of plaque control. Surgery & implants Probing depth reduction & gain in clinical attachment levels after access flap surgery Deterioration of furcations after surgery Gain in clinical attachment levels, bone fill, recession & membrane exposure after GTR Root coverage after grafting procedures for localized gingival recession Probing depth reduction after bone graft procedures Risk for implant failure & peri-implantitis . Maintenance care Probing depth & attachment loss during maintenance therapy Disease recurrence in smokers Need for retreatment in smokers Tooth loss in smokers after surgical therapy Therapy Effects of Smoking Nonsurgical Surgery & implants Maintenance care

20. Guide to counselling for tobacco cessation

21. Use of Pharmacotherapy Given the difficulties faced by people attempting to stop tobacco se, treatments have been developed to help them by lessening the intensity of withdrawal symptoms. There are two main types of pharmacotherapy for tobacco use cessation: Nicotine replacement therapies (NRT) Antidepressants.

22. Nicotine replacement therapy (NRT)

23. Basic principles for prescribing NRTs Medical supervision is important. Use a lower dose for less dependent tobacco users. A combination of products can be helpful. This must be done with caution, as nicotine toxicity may develop with a combination of products or if patient has not yet quit using tobacco. Some users may have side-effects. Contraindications : Pregnancy, lactation, CVD, endocrine disorders, inflammation of mouth& throat, oesophagitis , gastric ulcers, diabetes

24. Nicotine withdrawal symptoms Craving for tobacco Depressed mood Insomnia Irritability Frustration Anxiety Difficulty in concentration Restlessness Decreased heart rate Increased appetite & weight gain.

25. 2. Antidepressants They function as anti-craving medications. Antidepressants for tobacco use cessation: First-line therapies Buproprion SR Selegeline Second line therapies Clonidine Nortryptiline

26. Counselling those unwilling to quit

27. Key counselling concepts A Non- judgemental attitude Caring Empathy Listening Raising awareness Prompting self evaluation Offering support while emphasizing personal responsibility Asking open-minded questions Clarifying Reflecting feelings Summarizing Affirming Eliciting self-motivational statements Setting realistic goals Responding to tricky questions Tailoring messages to patient’s state of change

28. Effects of Smoking Cessation on Periodontal Treatment Outcomes Smoking cessation positively influenced periodontal treatment outcomes. The benefit of smoking cessation on the periodontium is likely to be mediated through various pathways such as shift toward a less-pathogenic microbiome , the recovery of the gingival microcirculation & improvements in certain aspects of the immune-inflammatory responses.

29. Conclusion Smoking is a major risk factor for periodontitis, & smoking cessation should be an integral part of periodontal therapy among patients who smoke. Smoking cessation should be considered a priority for the management of periodontitis in smokers.

30. References Carranza’s Clinical Periodontology – 10 th Edition . Essentials of Public Health Dentistry ( Soben Peter) – 5 th Edition

31. Thank you.