- Introduction to the effect of smoking on the mouth
- Gum disease and smoking
- Dental implants and smoking
- Smoking, saliva and tooth decay
- Oral cancer
- Other effects of smoking on the mouth
The role of smoking in the development of lung cancer and cardiovascular disease is well known. It also has a part to play in several diseases and lesions in the mouth; the most common being gum disease. The chance of dental implant failure is more common among smokers than among non-smokers, and gum disease around these implants in those who smoke is also more prevalent.
The following oral diseases and conditions are caused by, or can be attributed to smoking:
- Staining of teeth and dental fillings;
- Reduction of the ability to smell and taste;
- Bad breath;
- Smoker’s palate, where the palate becomes white and a number of little spots project from the surface, each bearing a small red spot at the centre that marks the opening of the duct of the gland;
- Smoker’s melanosis, which is associated with cigarette and pipe smoking, and is seen as brown spots inside the mouth;
- Coated tongue, which is the condition wherethere is a coloured layer composed of mainly food particles, bacteria, and debris from epithelium in the mouth;
- Oral thrush, which is a type of fungal infection that occurs in the mouth;
- Gum disease;
- Tooth decay (dental caries);
- The failure of dental implants; and/or
- Oral precancer and cancer.
These lesions most likely result from the:
- Irritants, and toxic and cancer causing compounds found in the smoke;
- Dryness in the mouth following high temperatures of inhaling smoke;
- pH change;
- Change in immune response; and/or
- Change in ability to handle viral and fungal infections.
Have you quit smoking? Or are thinking about trying to quit? Use this tool to see what health benefits you have already achieved and what benefits you can expect in the future if you stick with it. For more information, see Health Benefits of Quitting Smoking Tool.
Cigarette smoking and its relationship with gum disease has been the topic of interest in the last 10-15 years.
Smokers have a 2.5 to 3.5 times greater risk of severe gum disease, which is recognised by the amount of bone lost around a particular tooth due to gum disease. Smokers also tend to lose more teeth than non-smokers.
The effect of smoking on gum disease is also dependent on the amount of cigarettes or cigars consumed (both quantity and duration of smoking).
Some research in previous decades thought that severe gum disease in smokers was caused by poor dental hygiene, and was made worse by smoking. It is now known that smoking, when adjusted for poor dental hygiene still causes more gum disease than in non-smokers.
Three common bacteria are involved in gum disease. Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, and Prevotella intermedia, are all present in higher amounts in smokers than non-smokers.
Although we do not know if there is a greater amount of bacteria in total, there is a lot of research that indicates the type of bacteria in smokers is more likely to cause gum disease. This is due to a higher quantity of “bad” bacteria that is present in smokers.
There is less inflammation and bleeding in smokers than in non-smokers. The reason for this is due to a constriction in blood vessels in the facial area. This constriction does not simply go away once people stop smoking but lasts for a while after smoking has stopped. The reduction in inflammation around the gums may also lead to a false sense of security that the gums are healthy, as one of the indicators dentists use to measure gum health is the amount of inflammation around the gums.
Smoking alters the way the body responds to the bacteria that is in plaque. It reduces the ability of the body to respond well to the bacteria and thus causes gum disease.
There are many compounds in smoke that can cause a reduction in the immune system (e.g. nicotine).
The main way our body responds to bacteria is through inflammation, and neutrophils are the most critical cell in protection against gum disease. Smokers have more neutrophils in the body in total; however fewer neutrophils reach the gums mainly due to the effects of nicotine. As neutrophils cannot control the bacteria as well as usual (due to the fewer amount reaching the gums), there is a much higher chance gum disease will occur.
The destruction of the gums also occurs much faster in smokers due to the presence of a higher number of matrixmetalloproteinases (MMPs), elastase, interleukin-1 and prostanglandin-2. These are components of the body’s immune response that are involved in inflammation, loss of collagen, and loss of bone.
It is clear that nicotine and various compounds in tobacco may impose detrimental effects on the blood system, inflammatory process and immune system. This results in a progression of gum disease, and a poor response to treatment.
Smokers respond less favourably than non-smokers to treatment of any kind to try and control the progression of gum disease. Heavy smokers (smoking > 10 cigarettes per day) in general exhibit a lower degree of healing following treatment for gum disease than ex-smokers and nonsmokers.
The effect of smoking on the gums is reversible to some extent when people stop smoking. Stopping smoking will allow for normal healing and repair of the gum tissues when bacteria are introduced to the area (usually in the form of dental plaque).
Significantly greater proportions of implant failures occur in smokers (failure rate 11%) than in non-smokers (failure rate 5%).
We are not sure exactly why there is a poorer rate of success in smokers compared to non-smokers. However, it has recently been suggested that the increase in the number of implant failures in smokers is not the result of poor healing during the surgical part of the implant, but is due to the exposure of tobacco smoke to the gums around the implant. Peri-implantitis is the name given to gum disease around an implant, and chronic peri-implantitis results in implant failure when left untreated.
Programs designed to stop smoking show considerable promise in improving the success rate of dental implants in smokers, with significant differences in failure rates between:
- Non-smokers and smokers; and
- Smokers who adopted the smoking cessation protocol and those who continue smoking.
Smoking tobacco has the following effects on saliva. Smoking:
- Immediately stimulates salivary flow;
- Does not affect saliva flow rates in the long term;
- In the long-term, slightly reduces pH (makes the mouth more acidic) and buffering power, which means that the chance of getting tooth decay and dental erosion is slightly higher; and
- Is associated with lower amounts of salivary cystatin (thought to contribute to maintaining good dental health).
It is interesting to note that smoking during pregnancy is also associated with a higher chance of tooth decay in preschool children.
Numerous studies in various populations have shown that smokers have a substantially higher risk of oral cancer than nonsmokers. The risk is higher when a greater amount of tobacco smoke is consumed. There is also a clear benefit in cancer risk reduction when people stop smoking.
Although we do not know exactly how smoking causes cancer, the toxic elements of smoking do cause harm to cells, which could easily lead to cancer.
Combining smoking and excessive alcohol intake increases the risk of getting oral cancer, and it has been estimated that 75-90% of all cases of oral cancer are explained by the combined effect of smoking and alcohol use. This could be because:
- Alcohol dissolves certain toxic compounds in tobacco smoke which are linked to cancer; and/or
- Alcohol increases the permeability of the epithelium inside the mouth.
Oral leukoplakia, which can be regarded as “pre-cancer” is far more common in smokers than in non-smokers. Leukoplakia is essentially any white lesion whose cause is not known, and there is a chance that these lesions can become cancer.
For more information, see Oral Cancer.
Smoking causes discolouration of the teeth (more than from the consumption of coffee and tea), dental fillings and dentures. This affects the appearance of the mouth.
Smoking is also a common cause of bad breath and affects the ability for us to be able to taste and smell.
Smoker’s melanosis is associated with cigarette and pipe smoking, and is seen as brown spots inside the mouth. Smoker’s melanosis occurs in 5-21.5% of smokers. The pigmentation in the mouth is a result of tobacco smoke causing:
- Stimulation of melanin production (brown pigment in our skin and mouth); or
- The binding of the melanin to the compounds in tobacco smoke.
The amount of pigmentation is increased in heavy smokers.
Nicotinic stomatitis is seen in the mouth as a number of bumps, which may have red centres, and occurs on the top of the mouth, which looks whitish in appearance overall.
This appearance is due to irritated salivary glands with inflamed ducts, which enter into the mouth. Nicotinic stomatitis is a response to heat (not the chemicals in tobacco); thus, there is no chance of cancer as a direct result of this lesion. Nicotinic stomatitis usually goes away once the person stops smoking. The top of the mouth returns to how it should look within 1-2 weeks of stopping smoking.
Hairy tongue is characterised by an overgrowth of little “hairs” on the tongue known as papillae. The papillae may be stained white, yellow, brown, green, or black depending on the source of the staining. With tobacco use, the color is generally brown or black. This condition is of concern as it does not look very nice, and also may contribute to bad breath.
Kindly written by Dr Akhil Chandra BDSc. (Hons UWA)
Dentist, Whitfords Dental Centre and Editorial Advisory Board Member of the Virtual Dental Centre
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