Do you know what tobacco use is doing to your patient

The Set-Up

“Tobacco use has been associated with a variety of diseases including periodontal diseases. In this article, Dr. Ryder addresses ways in which the dental team can play a significant role in improving the patient’s overall health,” Dr. Peter O. Cabrera, Team Lead

Tobacco use in general and smoking in particular are the most important preventable risks for periodontal diseases. There has been a decline in the use of some tobacco products such as cigarettes in the United States and in other industrialized countries, thanks in part to public health education and smoking restriction laws.  However patients who use tobacco products still pose challenges to the dental practitioner. In addition, while some may believe cigar and pipe smoking are a safer alternative, there is a similar pattern of increased periodontal destruction-as well as comparable risks for other serious illness and conditions. Furthermore, smokeless tobacco users often will present with localized periodontal destruction at the site of tobacco placement. Tobacco users also do not respond as well to periodontal therapies including nonsurgical debridement, open flap debridement, regeneration procedures, periodontal plastic surgery, and implant therapy.

What it does

Several decades ago many clinicians believed the main effects of smoking on periodontal health and the poor response to therapy were mostly because of the misconception that smokers have more bacterial plaque. However smokers with good to excellent plaque control still lose more bone and respond poorly to periodontal therapy, even though smokers show less clinical gingival inflammation. These effects of tobacco on periodontal tissue appear mostly because of a suppression of the body’s ability to fight infection, and perhaps more importantly because of tobacco’s effects on stimulating tissue-destructive inflammation.

Quitting can help

The dental practitioner should be encouraged by the beneficial effects of quitting on periodontal health and the response to therapies. For example, former smokers respond as well as patients who have never smoked to a variety of periodontal therapies. The dental practitioner is uniquely positioned to help prevent the patient from taking up using tobacco products, and in helping your patients who use tobacco to quit. These efforts require patience and reinforcement.

Regrettably, there is an abundance of inducements in the media worldwide to get patients to smoke or use other tobacco products. Strategies by tobacco makers to induce young patients to start using tobacco products are particularly troublesome as it is much more difficult to get a patient to stop using tobacco products when the habit is acquired at an early age. This is mostly because of the effects of habituation with the nicotine found in all tobacco products, which “wires the brain” for tobacco dependence.

What you can do

Many smoking patients will see their dentist/hygienist more often than their physician. This gives the dental practitioner more opportunities and strategies to try to get their tobacco patients to quit. Perhaps the best known strategy for tobacco cessation now taught in almost all dental educational programs is a step by step approach known as the “5A” approach, coupled with some form of nicotine replacement therapy and/or other systemic medications such as a mild antidepressant or a nicotine receptor agonist. In addition, there are several other sources such as telephone quitlines and websites that the dentist/hygienist can use in their tobacco cessation efforts.  

These efforts by the dental practitioner require relatively little additional time in the practice and can result in better long-term (6-12 months) smoking cessation rates in a portion of patients. In addition, multiple attempts, coupled with demonstrations to the patient of the adverse effects of tobacco use, can increase these quit rates. Of particular importance to the dental practitioner is the evidence that quit rates are much higher once a patient experiences a tobacco related disease or condition (such as a heart attack), or is shown clear visible evidence of the damage from tobacco use. The dentist/hygienist can appeal to a patient’s sense of appearance by showing clear visible evidence such as gingival recession, tooth staining, radiographic bone loss, and other soft tissue changes in the mouth.

Those patients who wont quit

For those patients who continue to use tobacco products, the damage to the periodontium and other oral tissues should be minimized. Increased frequency of periodontal recalls and the use of local and/or systemic medications that can dampen the effects of tobacco on stimulating the products of destructive inflammation should be considered. The increased production and/or secretion of these inflammatory products can be partially suppressed by a variety of local or systemic anti-inflammatory agents. Currently antibiotics of the tetracycline family such as minocycline and doxycycline are the most widely used of these medications.

It's not something you can ignore

Despite the decline in the prevalence of the use of tobacco products in many industrialized countries, tobacco will probably remain a major risk for periodontal diseases in the near future. Dentists and hygienists are in a unique position to help the tobacco patient quit. Therefore what the practitioner can do in helping the tobacco patient to quit can be beneficial for the patient’s oral health, overall health, and, when considering the hazards of second-hand smoke, for the general population.

About the author

Dr. Mark Ryder is a Professor and Chair of Periodontology and Director of the Postgraduate program in Periodontology at the University of California, San Francisco, where he has taught for 31 years. He received his dental and specialty training from the Harvard School of Dental Medicine. He has written more than 150 articles, abstracts and book chapters and lectures extensively on diagnosing and treating periodontal diseases..