by Prof Dr Dasan Swaminathan
Gum (periodontal) disease is an infection of the gums and if left untreated can damage the soft tissues and bone structure that supports your teeth. In severe cases, it can make your teeth fall out.
Plaque biofilm derived from saliva is the primary cause of periodontal disease. Plaque biofilm formation is a continuous process and it accumulates on the teeth surfaces if oral hygiene is not performed satisfactorily to remove it.
The oral cavity is home for more than 700 bacterial species. The bacteria from the oral cavity will contaminate plaque biofilm and if it stays on your teeth for too long, several layers of plaque biofilm and tartar (hardened plaque) will develop. This build-up can lead to gum disease.
Smoking is classified as a contributing factor to periodontal disease. Epidemiological studies have provided evidence that tobacco smokers have poorer oral hygiene than non- smokers, and also have increased quantities of dental calculus.
Most of these differences can be attributed to less favourable tooth brushing habits, particularly evident in male smokers! However, smoking is also associated with a decreased flow of saliva, which may explain the increased tendency to form dental tartar (calculus).
Smoking and gingivitis (inflammation of the soft outer layer of the tooth).
Heavy smokers often present with a thickened, fibrotic appearance of their gum tissues. The rate of plaque accumulation is similar in smokers and non-smokers. However, smokers show less gingival inflammatory change, with less gum bleeding, gum redness and fluid flow from the gums.
Hence, it appears that smoking may suppress the normal immune response to the accumulation of plaque biofilm. The major clinical implication of these findings is that the masking of gum bleeding in smokers may lead to a failure to recognise the presence of periodontal disease. Possible mechanisms for this reduced gum bleeding are the vasoconstriction of gum blood vessels caused by smoking.
Smoking and periodontitis (inflammation of the deeper supporting structures of the tooth).
Recent studies have revealed an association between smoking and more severe periodontitis. Smoking has been shown to be associated with deeper periodontal pockets and eventually these pathologic pocketing will reach the underlying bony structures (alveolar bone) below the soft gum tissues.
The toxic by-product produced by bacteria within the plaque biofilm will travel via the periodontal pocketing reaching into the deeper hard tissues and will cause the destruction and eventual loss of the alveolar bone. These processes will finally culminate in the tooth becoming mobile leading to eventual tooth loss.
There is also evidence that the rate of progression of periodontitis is more rapid among smokers. Possible mechanisms through which smoking alters the expression of periodontal diseases include effects on the composition of plaque biofilm and also effects on the host response.
It has been hypothesised that smoking can reduce oxygen within the tissues (redox potential) which will favour anaerobic micro-organisms which do not require oxygen to survive and multiply, leading to the formation of more pathogenic plaque biofilm. The vasoconstriction will also limit the ability of the tissues to deliver an immune response via the blood supply to tissues.
Some advice to patients:
How Can Gum Disease Be Prevented?
You can help avoid gum disease with good dental habits:
- Brush your teeth twice a day.
- Floss often to remove plaque.
- Use antimicrobial mouth rinses like chlorhexidine if you have any issues with oral hygiene like poor manual dexterity
- See your oral health care provider regularly for check-ups and for management of any gum disease.
What can oral health care providers do to manage gum disease in smokers?
More severe gum disease which may be seen in smokers may require:
- Oral Hygiene instructions on every visit.
- Scaling and deep cleaning below the gum line.
- Root debridement to remove bacterial plaque biofilm and tartar deep in the rootsof the teeth.
- Surgery to help manage gums or bone lost to periodontal disease
- Smoking cessation programme for patients’ who find it very difficult to quit smoking.
In spite of the awareness of the adverse effects of smoking on health, many individuals will continue to be smokers. Many will not be aware of the effects that tobacco may have on their systemic and periodontal health. There is ample evidence in the literature to support advising patients to reduce or stop their smoking as part of the management of gum disease.
Extra care needs to be taken in the periodontal examination of smokers. As had been mentioned earlier, it is likely that visual signs of periodontal disease like bleeding on probing will be masked.
This will entail careful periodontal probing and clinical examination of gum tissues and radiographic examination to reveal the true level of destruction to the supporting structure of the teeth.
Smokers need to be informed prior to the commencement of periodontal treatment that the outcome of their treatment may be compromised if they continue to smoke.
The take home message is that one should try to stop smoking to prevent the many health issues that is a consequence of smoking.
WE