Tobacco and nicotine use have significant implications for oral and periodontal health. This review explores the profound impact of tobacco products, including cigarettes, smokeless tobacco, and emerging nicotine delivery systems, on oral tissues and periodontal structures. The detrimental effects of tobacco on oral health manifest in various ways, such as increased risk of periodontal disease, delayed wound healing, development of oral cancer, and exacerbation of pre-existing conditions like gingivitis and periodontitis.
Furthermore, nicotine addiction poses challenges for cessation efforts and exacerbates oral health complications. Tobacco cessation intervention for periodontal patients, treatment considerations for periodontal patients, understanding the oral and periodontal implications of tobacco and nicotine is crucial for healthcare professionals to develop effective prevention and treatment strategies, improve patient education, and promote oral health.
ORAL AND PERIODONTAL IMPLICATIONS OF TOBACCO AND NICOTINE PRODUCTS
1. INTRODUCTION
Tobacco use is responsible for nearly 9 million annual global deaths. This is more than any other behavioral risk factor and trailing only high systolic blood pressure among all risk factors in its contribution to human mortality.Tobacco smoke disrupts the functioning of nearly every human organ system, causing most deaths through cancer, heart disease, and noncancer respiratory diseases1. Health risks extend not only to the person using tobacco but to people involuntarily exposed to smoke.Tobacco experimentation typically begins in adolescence, often due to both social influences and tobacco marketing. Later in life, most adult tobacco users find themselves chemically and/or behaviorally dependent on nicotine and unable to quit tobacco use. Yet, despite this well-chronicled destruction, industrially produced tobacco products remain legally sold and marketed in nearly every country, well surpassing US$1 trillion in annual sales.1
Smoked tobacco, and in particular, cigarette smoking, is the most popular method of using tobacco. Smoked tobacco is the most common method for nicotine delivery. Smoked tobacco is available in various forms, such as cigarettes, cigars, pipes, bidis, hookah, and others 2
Tobacco smoke as a product of conventional cigarettes contains a wide variety of harmful, mutagenic and carcinogenic chemicals such as nicotine, carbon monoxide, arsenic, hydrogen cyanide, benzene, reactive radicals, and tobacco-derived nitrosamines 3
The most recent decade has also seen an expanding variety of new or emerging tobacco and/or nicotine products brought to market, most prominently electronic cigarettes . Heated tobacco products and nicotine-containing pouches are other examples of an increasingly diverse product landscape.
Meanwhile, more permissive laws and regulations have broadened access to cannabis (marijuana) products. Cannabis, though not a tobacco product, is frequently consumed in combination with tobacco and by individuals who also use tobacco.Smoke from cannabis products shares many chemical properties with tobacco smoke and has been linked to health problems, including potential cardiovascular and respiratory impairment 1
1.1 CIGARETTES
Cigarette smoking elevates the risk of nearly every oral condition that dental professionals are tasked with treating and diminishes the chances of many dental treatments being successful.1The effects of these cigarette smoke chemicals on the hard and soft tissues of the oral cavity are very well known and documented. Cancer of the oral cavity and pharynx, periodontitis, dental caries, oral pain, and diminished salivary flow are just a few of many conditions found in smokers.
Cigarette smoke significantly affects the immune and circulatory systems, influencing the incidence and progression of periodontal disease through various Pathways3of the oral cavity or pharynx, with evidence supporting a dose-response relationship and synergistic risk with alcohol consumption. In countries where use of chewing tobacco is uncommon, most oral cancer cases are attributable to tobacco smoking,3
Tobacco smoking appears to diminish the reparative capacity of periodontal cells, including fibroblasts, osteoblasts and cementoblasts, reducing the ability to form new tissue and potentially impeding responsiveness to periodontal therapy. Whereas whole tobacco smoke is clearly damaging to oral cells and tissues, deciphering which of the many components of tobacco smoke are most responsible for these effects is challenging. Smoking is associated with worse outcomes following nonsurgical debridement,open surgical debridement, bone grafts, guided tissue regeneration,and periodontal plastic surgery. Smoking is similarly a risk factor for dental implant failure 1
1.2 REVERSE SMOKING
Reverse smoking is a unique style of tobacco use in which the smoker places the lit end of a chutta into his or her mouth while smoking and then inhales the smoke from the lit end. Chuttas are cheroots that have been coarsely processed and range in length from 5 to 9 cm. In Andhra Pradesh’s coastal districts, particularly Visakhapatnam and Srikakulam, reverse chutta smoking is common. Unlike males, who smoke chuttas in either the traditional or reverse manner, women almost exclusively smoke chuttas in the reverse manner, which they regard to be a more feminine form of smoking Reverse smoking has been linked to a variety of oral mucosal changes, ranging from minor changes such as leukoedema, melanosis, and smoker’s palate to more serious potentially malignant illnesses or lesions like leukoplakia and erythroplakia, which can eventually lead to oral cancer. 5
1.3 SMOKELESS (SPIT) TOBACCO
The term smokeless tobacco has been used to cover a wide variety of noncombustible tobacco products that are held in the mouth or chewed.
This includes areca nut products, such as betel quid (paan), gutka, and mainpuri in South and Southeast Asia, where the consumption of these and similar products has been strongly associated with oral cancer.These smokeless products contain high levels of tobacco-specific nitrosamines, believed to be highly carcinogenic 1
1.4 CIGARS AND PIPES
Cigars are the non–cigarette product among adults used most (4% prevalence), and use prevalence among young adults aged 18-24 years is more than threefold higher (14%).when compared with cigarette smokers, cigar/pipe users had lower accumulations of plaque and calculus and less alveolar bone loss. 1
1.5 HOOKAH
Use of a hookah, also referred to as a tobacco waterpipe or narghile, dates back several centuries and is a cultural norm in many countries of North Africa and the Middle East. In other parts of the world, the popularity of hookahs has recently increased, particularly among youth and young adults. Often perceived as less harmful than cigarette smoking, hookah smoke contains levels of volatile organic compounds, ultrafine particles, nicotine, and carbon monoxide matching or exceeding cigarette smoke. Epidemiologic studies have associated hookah use with respiratory and cardiovascular diseases.1
1.6 E- CIGARET TES AND OTHER NOVEL PRODUCTS
E-cigarettes represent a class of battery-powered products that heat a liquid solution, typically containing nicotine, into an inhalable aerosol.E-cigarettes were not developed through the medical pharmaceutical route and are
usually considered a consumer product, similar to tobacco products or, in some regulatory contexts, classified as tobacco products. Although commercial availability and promotion are potentially part of the appeal of these products, there have been many challenges around regulation, product quality, product perceptions, and limited
supporting scientific evidence.important concerns surrounding e-cigarettes include rising use prevalence among youth and young adults, potential risks for cardiovascular and lung health 1
2. Effects of tobacco-related products on oral health
In addition to associations between tobacco product use and many diseases, cigarettes, smokeless tobacco (e.g. chewing tobacco and snus), and other tobacco uses cause specific oral health issues such as oral cancer, oral mucosal lesions, periodontal disease, implant failure, salivary gland hypofunction, dental caries among many other oral diseases and conditions. 2
2.1 Oral cancer
Oral cancer is the eighth most common cause of cancer-related mortality in the world tobacco, smoked or smokeless, causes oral squamous cell carcinoma (OSCC). Cigarettes and other combusted tobacco products are dangerous nicotine delivery devices that contain a complex mixture of tumor promoters, co-carcinogens, and various toxicants that exacerbate the effects of the carcinogens 2
some of the periodontal disease risk factors, particularly tobacco and betel quid use, have also been linked with the etiology of oral cancer. 4
2.2 Oral mucosal lesions
A strong association has been found between tobacco use and mucosal lesions such as leukoplakia, smokeless tobacco keratosis at the site of tobacco placement, nicotinic stomatitis, smoker’s melanosis and erythroplakia. While some of the oral mucosal lesions are non-malignant, it is necessary to further investigate leukoplakia associated with tobacco with a biopsy for the presence of epithelial dysplasia or carcinoma. 2
2.3 Periodontal disease and dental implants
Smokers have higher gingival recession, tooth loss, and pocket depths. compared to non-smokersTobacco smokers display an increased gingival microvascular density with considerable gingival inflammation, suppressed angiogenesis due to local immune suppression, and oxidative stress leading to periodontal disease and increased risk of complications,The implant failure rate was found to be higher among smokers. 2
Cigarette smokers had the highest values of probing depth (PD), gingival recession, plaque and bleeding scores, and clinical attachment loss (CAL); tooth loss was comparable in the cigarette.3
2.4 Dental caries
Nicotine may cause an ecological imbalance and promote colonization and metabolism of Streptococcus mutans, a significant bacterium contributing to dental caries. Smoking influences saliva by lowering the buffer capability, altering its chemical agent and bacterial components, and reducing salivary flow rate thereby promoting the formation of a caries-susceptible environment2
3.TOBACCO CESSATION INTERVENTIONS FOR PERIODONTAL PATIENTS
3.1 The role of dental professionals in tobacco cessation
Dental professionals are well positioned to provide tobacco cessation treatment to their patients. Not only do dental professionals see a large number of tobacco users, but they often have more time with patients and see patients more regularly than other health professionals do.In addition, the negative health effects of tobacco use are often first identified in the oral cavity, underscoring the importance of managing tobacco-related risk factors for the dental professional.It was found that tobacco cessation interventions by dentists and dental hygienists during oral examinations can increase cessation among cigarette smokers and smokeless tobacco users.149 Multiple dental professional organizations not only
promote tobacco cessation in dental practice but characterize it as a professional responsibility to provide tobacco cessation treatment and education to patients. 1
The entire dental team needs to be involved in tobacco cessation, including dental hygienists and assistants. Patients tend to have a better rapport with
dental hygienists and pay more attention to their oral health educational messages. Integration of tobacco cessation by the electronic health record system with automated clinical reminders is a useful tool.2
3.2 Interventions for tobacco cessation in practice
3.2.1 The five R’s approach to tobacco cessation counseling
Images are not included in the preview of the text.
3.2.2.The behavioural change model for tobacco cessation
Images are not included in the preview of the text.
3.2.3Motivational interviewing methods for tobacco using patients
Images are not included in the preview of the text.
3.3 Nicotine replacement therapy
Among the various pharmacotherapies, nicotine replacement therapy (NRT) is the most commonly used. Nicotine is a chemical that acts as an agonist
of nicotinic acetylcholine receptors in the ventral tegmental area of the brain.When stimulated, the nicotinic receptors release dopamine in the nucleus accumbens leading to a sense of reward. NRT products contain pure nicotine and aim to reduce the desire for smoking by increasing nicotine levels in the bloodstream through sources other than cigarette smoke92. Several types of NRT products are available in the market. Nicotine gum, an easily accessible NRT product, is prescribed for 6–12 weeks for a maximum of 6
months. Patients are advised to chew intermittently for 30 minutes and then place it in the oral vestibule for transmucosal absorption. After 2–3 months the dose is tapered or the chewing time is gradually decreased. 2
4.Treatment considerations for periodontal patients
Tobacco use has significant negative effects on oral health and the outcome of almost all therapeutic periodontal procedures. Additionally, cigarette smokers have been shown to be less likely than nonsmokers to follow through with supportive periodontal/peri-implant therapy or periodontal maintenance, further increasing their risk of poor outcomes , Ideally, patients should quit tobacco use successfully prior to any type of periodontal treatment to improve outcomes, such as fewer implant failures and improved wound healing post surgery. However, despite tobacco use being one of the most significant risk factors for poor periodontal outcomes, it is not considered a complete treatment contraindication.
In the event that a patient is unwilling or unable to quit, providers must weigh the risks and benefits of treatment and discuss potential outcomes with the patient prior to making decisions on whether to move forward with treatment.patients must be informed of the risks associated with continued tobacco use and encouraged to make a quit attempt with evidence-based help from their dental provider through direct support or referral to cessation services . 1
5. CONCLUSION
The oral and periodontal implications of tobacco and nicotine products are significant and far-reaching. Tobacco use, whether through smoking or smokeless forms, poses serious risks to oral health, including increased risk of periodontal disease, oral cancer, and delayed wound healing. Nicotine, an addictive component of tobacco, further exacerbates these effects by constricting blood vessels, reducing blood flow, and impairing immune function in the oral cavity.
Dental professionals play a crucial role in educating patients about the detrimental effects of tobacco and nicotine on oral health and overall well-being. Interventions aimed at tobacco cessation, such as counseling, behavioral support, and pharmacotherapy, can help individuals quit smoking or using other tobacco products, thereby reducing their risk of oral diseases. 3
Furthermore, early detection through regular dental check-ups and screenings is essential for identifying oral lesions and abnormalities associated with tobacco use, facilitating timely intervention and treatment.
Tobacco has detrimental effects on oral health. Tobacco users have significantly higher rates of oral cancer, oral mucosal lesions, periodontal disease, dental caries, and implant failure. Dental practice settings provide a unique opportunity in providing tobacco cessation assistance. Oral health providers can refer patients to free evidence-based treatment options such as telephone quitlines, quitsites, and telehealth, and they can use brief educational interventions, behavior counseling, and pharmacotherapy including nicotine replacement therapy. Lack of time and training are the most common barriers faced by dentists while providing tobacco counseling services. Considering the myriad of roles oral healthcare providers can play in tobacco cessation, more conferences, workshops, and research are needed to motivate and educate oral healthcare providers on tobacco cessation services and develop interventions geared towards dental practices. 2
smokers have higher prevalence of tooth discolouration than non-smokers as anticipated.Use of pictures of teeth with tobacco staining as warning messages on tobacco products may be also worth consideration as it was very clear that smokers recognised the deleterious effect of smoking on their dental appearance. 6
Exposure to the nicotine containing aerosol of heated tobacco products in adults is less harmful to periodontal tissues compared to burning tobacco in conventlional cigarettes 3
Tobacco significantly increases the prevalence of oral cancer and aggravates the damage from periodontal disease. 4
Flavored nicotine products could induce microbial dysbiosis in the oral cavity and periodontium, inhibit local innate immune responses, and cause the pathogenesis of periodontitis resulting from the interplay between respiratory microbiota and innate immunity. Furthermore, the favor of menthol facilitates penetration of toxic chemicals, e.g., nitrosonornicotine (NNN) and nicotine, across buccal and foor-of-mouth mucosa, posing the risk to oral soft tissue lesion.7
Reverse smokers are more likely99 to develop precancerous palatal alterations and squamous cell carcinoma of the palate. To make healthy choices, a strong focus on health promotion is required, which includes initiatives that emphasise the need of educating individuals about disease risks. It is necessary to run information campaigns aimed at high‑risk groups in order to influence personal routines and behaviours. Individuals and communities must be empowered to define priorities, make decisions, and plan and implement solutions in order to improve their health. 5
6. REFERENCE
1. Chaffee BW, Couch ET, Vora MV, Holliday RS. Oral and periodontal implications of tobacco and nicotine products. Periodontology 2000. 2021 Oct;87(1):241-53.
2. Gajendra S, McIntosh S, Ghosh S. Effects of tobacco product use on oral health and the role of oral healthcare providers in cessation: A narrative review. Tobacco Induced Diseases. 2023;21.
3. Mišković I, Kuiš D, Špalj S, Pupovac A, Prpić J. Periodontal Health Status in Adults Exposed to Tobacco Heating System Aerosol and Cigarette Smoke vs. Non-Smokers: A Cross-Sectional Study. Dentistry Journal. 2024 Jan 29;12(2):26.
4. Zhang Y, He J, He B, Huang R, Li M. Effect of tobacco on periodontal disease and oral cancer. Tobacco induced diseases. 2019;17.
5. Vinnakota D, Hakkim S, Pellissery MV, Sivasubramanian M, Khan MT, Hoque A, Mashrur AR, Parsa AD, Kabir R. Reverse smoking and its effects among Indian reverse smokers: a scoping review. Journal of Primary Care Dentistry and Oral Health. 2022 Sep 1;3(3):67-74.
6. Alkhatib MN, Holt RD, Bedi R. Smoking and tooth discolouration: findings from a national cross-sectional study. BMC public health. 2005 Dec;5:1-4.
7. Ye D, Rahman I. Emerging oral nicotine products and periodontal diseases. International Journal of Dentistry. 2023 Feb 10;2023.
Frequently Asked Questions About Oral and Periodontal Implications of Tobacco and Nicotine Products
What are the major health risks associated with tobacco use?
Tobacco use is responsible for nearly 9 million annual global deaths and disrupts the functioning of nearly every human organ system, causing deaths through cancer, heart disease, and noncancer respiratory diseases. Risks extend to those involuntarily exposed to smoke.
What are some common forms of smoked tobacco?
Smoked tobacco is available in various forms, such as cigarettes, cigars, pipes, bidis, and hookah.
What harmful chemicals are found in tobacco smoke?
Tobacco smoke contains nicotine, carbon monoxide, arsenic, hydrogen cyanide, benzene, reactive radicals, and tobacco-derived nitrosamines, among other harmful chemicals.
What are some emerging tobacco and nicotine products?
Emerging products include electronic cigarettes (e-cigarettes), heated tobacco products, and nicotine-containing pouches.
What oral health conditions are associated with cigarette smoking?
Cigarette smoking elevates the risk of oral cancer, periodontitis, dental caries, oral pain, and diminished salivary flow, among other conditions. It also diminishes the success of many dental treatments.
What is reverse smoking, and what risks are associated with it?
Reverse smoking involves placing the lit end of a chutta (cheroot) into the mouth. It's linked to oral mucosal changes, potentially malignant illnesses or lesions (leukoplakia, erythroplakia), and oral cancer.
What is smokeless tobacco, and what are the associated health risks?
Smokeless tobacco includes noncombustible products held in the mouth or chewed. These products, including areca nut products like betel quid (paan) and gutka, contain high levels of tobacco-specific nitrosamines and are strongly associated with oral cancer.
How does hookah use compare to cigarette smoking in terms of harmful chemicals?
Hookah smoke contains levels of volatile organic compounds, ultrafine particles, nicotine, and carbon monoxide matching or exceeding cigarette smoke and is associated with respiratory and cardiovascular diseases.
What are the effects of e-cigarettes on oral health?
E-cigarettes pose potential risks for cardiovascular and lung health. There are concerns regarding rising use among youth and young adults, product quality, and limited supporting scientific evidence.
What specific oral health issues are caused by tobacco products?
Tobacco use causes oral cancer, oral mucosal lesions (leukoplakia, smokeless tobacco keratosis, nicotinic stomatitis, smoker’s melanosis, erythroplakia), periodontal disease, implant failure, salivary gland hypofunction, and dental caries.
How does tobacco use affect periodontal disease?
Smokers have higher gingival recession, tooth loss, and pocket depths. Tobacco smokers display increased gingival microvascular density with gingival inflammation, suppressed angiogenesis, and oxidative stress.
How does tobacco use affect dental implants?
The implant failure rate is higher among smokers.
How does smoking influence dental caries?
Nicotine may cause an ecological imbalance and promote colonization and metabolism of Streptococcus mutans. Smoking lowers saliva buffer capability, alters its chemical agent and bacterial components, and reduces salivary flow rate.
What role do dental professionals play in tobacco cessation?
Dental professionals are well-positioned to provide tobacco cessation treatment. Interventions by dentists and dental hygienists can increase cessation among cigarette smokers and smokeless tobacco users. Many dental professional organizations consider it a professional responsibility.
What interventions can be used for tobacco cessation in practice?
The five R’s approach, behavioral change models, and motivational interviewing methods can be used. Nicotine replacement therapy (NRT) is also a common pharmacotherapy.
What are the treatment considerations for periodontal patients who use tobacco?
Patients should ideally quit tobacco use prior to periodontal treatment. If a patient is unwilling or unable to quit, providers must weigh the risks and benefits of treatment and discuss potential outcomes. Patients must be informed of the risks and encouraged to make a quit attempt.
What are the long-term effects of tobacco and nicotine products on oral health?
Long-term tobacco use poses serious risks to oral health, including increased risk of periodontal disease, oral cancer, and delayed wound healing. Nicotine exacerbates these effects by constricting blood vessels, reducing blood flow, and impairing immune function.
What evidence is there that heated tobacco products are less harmful?
Exposure to the nicotine-containing aerosol of heated tobacco products in adults is less harmful to periodontal tissues compared to burning tobacco in conventional cigarettes.
How do flavored nicotine products affect the oral cavity?
Flavored nicotine products could induce microbial dysbiosis in the oral cavity and periodontium, inhibit local innate immune responses, and cause the pathogenesis of periodontitis. Menthol facilitates penetration of toxic chemicals across buccal and floor-of-mouth mucosa.
- Quote paper
- Anonym (Author), 2024, Oral and Periodontal Implications of Tobacco and Nicotine Products, Munich, GRIN Verlag, https://www.hausarbeiten.de/document/1511787
