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Cigarette smoking has numerous effects on the human body, all of which are almost entirely preventable. According to the Center for Disease Control and Prevention (CDC), cigarette smoking accounts for 1 in 5 deaths in the United States.
Cigarettes contain nicotine, a substance that causes addiction but is not carcinogenic. Nicotine binds to nicotinic acetylcholine receptors in the ventral tegmental area (VTA) of the central nervous system. This binding releases dopamine in the nucleus accumbens, linked to the reward system. The carcinogenic effects are more complex.
Inhaled smoke rapidly diffuses through oral and respiratory mucosal lining, destroying epithelial cells via reactive oxygen species (ROS) that induce DNA damage and activate inflammatory mediators. Chronic use leads to chronic inflammation. Epithelial cells are responsible for expressing toll-like receptors (TLRs) that contribute to cell-mediated immunity. When the epithelium is destroyed by reactive oxygen species, the immune response becomes compromised and results in diminished anti-microbial function. This explains why smokers are at a higher risk for infections and have causal links to several chronic diseases and cancers.
Tobacco smoking is a known risk factor for periodontal disease. Tobacco smoke itself is cytotoxic on gingival fibroblasts. Fibroblasts are unable to produce enough type 1 collagen and fibronectin, and instead produce more collagenase. Collagenase breaks down gingival tissue and compromises the integrity of gingival soft tissue in the oral cavity.
While the prevalence of cigarette smokers has declined, there are new forms of tobacco products on the market now with no known long-term effects to bring awareness to. Hookahs are water pipes used to smoke flavored tobacco.
The smoke contains nicotine, tar, carcinogens, and heavy metals. While hookah is considered a cultural group activity, many are unaware of its harmful effects. One hour of hookah smoking is equivalent to inhaling up to 200 cigarettes. E-cigarettes are battery-powered devices that deliver nicotine through water vapor. Cigarette smokers are known for using these devices to help them quit, but no studies have shown their efficacy and the FDA has not approved of this as a means for tobacco cessation.
Patient D.M., a 63-year-old African-American female, presented to Clinic 5CD-A on May 29, 2018 for a periodic oral evaluation. She was previously seen by a student who graduated from NYUCD in 2018. D.M.’s chief complaint was “I need teeth to chew and eat properly.” The treatment planned for patient D.M. was a maxillary complete denture and a mandibular complete implant overdenture. Because her mandibular complete denture will be converted into an implant overdenture, I was concerned about the effects of her tobacco use on her periodontium throughout her life. She has been smoking 1 pack/day for 40 years, making her tobacco use 40 pack-years. She has, however, tapered down her use to 1-5 cigarettes a week over the past five years. I wanted to investigate the role of tobacco use in her previous loss of teeth, her current bone levels, and the future osseointegration of these implants.
My clinical question was, does cigarette smoking affect periodontal health in adult patients? My PICO included: P for adult patients, I for cigarette smoking, C for no cigarette smoking, and O for periodontal health. I used the Clinical Queries tab in PubMed and searched “smoking AND periodontitis.” I narrowed the 2548 search results down and chose four articles: three systematic reviews/meta-analyses and one retrospective cohort study.
The first article in this literature review is titled, “Impact of Smoking Cessation on Periodontitis: A Systematic Review and Meta-analysis of Prospective Longitudinal Observational and Interventional Studies.” The authors felt there was little known information regarding the effect of smoking cessation on periodontitis and aimed to answer two specific questions:
The first question findings came from observational studies, and the second question from interventional studies. This review narrowed down 2,743 records to include only 6 studies in its meta-analysis. The review concluded that the risk for periodontitis incidence and progression was negligible in quitters versus those who had never smoked tobacco products. Additionally, smokers had an 80% higher risk of periodontitis compared to quitters and never-smokers. When reviewing the effectiveness of smoking cessation on non-surgical therapy (i.e. oral hygiene, prophylaxis, scaling and root planing), the authors found quitters had significantly better responses to these treatments compared to ongoing smokers. For example, quitters had a 0.2mm gain in clinical attachment and 1.1mm reduction in probing depth compared to those who continued smoking. Although the results from these longitudinal studies showed the positive effects of tobacco cessation on periodontal health, there are some key points to note.
Firstly, the systemic inflammation induced by tobacco can last for months to years, and patients are still at risk for irreversible damage. Previous studies have noted that after tobacco cessation, there were persistent elevations in C-reactive protein (CRP) levels, a pro-inflammatory protein highly associated with chronic periodontitis. However, this review found a positive response to periodontal therapy within only twelve months of quitting smoking. A major limitation of this review is the high losses to follow-up in participants, making it difficult for researchers to account for relapses following smoking cessation. This is a major confounder to this review and I believe more research would need to be done to find out the rate of relapse and compare this population to quitters, non-smokers, and current smokers.
The second article in this literature review is titled, “Risk Factors Associated with Post-Loading Implant Loss of Removable and Fixed Implant-Supported Prostheses in Edentulous Jaws.” The purpose of this study was to determine risk factors for implant loss in patients who received implant-supported prostheses, such as the mandibular overdenture that my patient has yet to receive. This retrospective cohort study analyzed 245 dental implants placed in 54 edentulous jaws of 46 Japanese patients at the Niigata University Hospital. The study used five inclusion criteria: implants to be placed in edentulous jaws, rough surface implant, two-year observational and follow-up period, annual follow-ups with necessary radiographs, and patients of the Asian race. The exclusion criteria were: implant loss before osseointegration or provisional restoration placement, and lack of follow-up data and/or medical records prior to April 2015. Although my patient does not fit this inclusion criteria, I still felt that the study was very relevant to her case because she is receiving an implant overdenture on her edentulous mandibular arch. Of the 245 implants placed, a total of 16 were lost due to infection, movement, and/or fracture.
The study results found two clinically significant risk factors associated with these implant losses: maxillary removable restorations (pThe third article in the literature review is titled, “Bone and soft tissue outcomes, risk factors, and complications of implant-supported prostheses: 5-years RCT with different abutment types and loading protocols.” The long-term prognoses of implant-supported partial fixed dental prostheses have not been reviewed, so the authors of this RCT wanted to compare fixation modes to determine risks and complications. The clinical question for this randomized-control trial was, do differential loading protocols and prosthesis connections to implants affect marginal bone loss (MBL) from the time of surgery to five years post-op? The inclusion criteria for this trial were: healthy adults, completed dental treatments (e.g. tooth extraction and bone augmentation 3 and 6 months respectively), and necessary bone levels for three implants to be placed. The exclusion criteria were smoking more than ten cigarettes a day, malocclusion, and bruxism. This narrowed down the patient pool to 50 subjects, 32 women and 18 men who were then randomly placed into a test group or control group. The test group received a provisional bridge 2 days after implant placement and a final bridge 6 months after. The control group received only a final bridge 3-4 months after implant placement.
For the prosthesis after implant placement, both groups were randomly assigned to three different types of prostheses: implant level (IL), machined abutment (AM), or oxidized abutment (AOX). Marginal bone loss (MBL) was measured during recall visits 1 year and 5 years after surgery. After five years, both groups showed an average MBL of 1.92mm. MBL between both groups was not clinically significant. In both groups, however, machined abutments promoted less MBL because the attachment allowed for healthier soft tissue maintenance.
Risk factors identified were buccal soft tissue thickness, previous periodontal disease, smoking The fourth and final article I included in this literature review is titled, “Influence of Involuntary cigarette smoke inhalation on osseointegration: a systematic review and meta-analysis of preclinical studies.” The purpose of this review was to assess if involuntary cigarette smoke inhalation (ICSI) had an effect on implant osseointegration in cortical and cancellous bone. The inclusion criteria listed were: original clinical and experimental studies, implants, a control group that was not exposed to ICSI, and risk factors associated with implant stability. The exclusion criteria were quantitative or qualitative reviews, case reports, case series, commentaries, letters, interviews, and updates. 199 articles came up from the key words searched on the online databases. 180 were excluded because the clinical questions were either too vague or duplicates, and 10 did not met the inclusion criteria. In the end, 9 prospective studies, all conducted in Brazil and on rats. Bone-implant contact (BIC) was analyzed for cortical and cancellous bone, and both analyses showed heterogeneity to not be statistically significant.
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