Smoking and periodontal
disease
CONTENTSIntroductionConstituents of tobacco smoke Mechanism of toxicityTobacco as a risk factorEffect of smoking on :
Plaque and oral floraPeriodontal tissuesImmunology
Smoking and systemic statusEffect of smoking on periodontal therapyTobacco cessationConclusionReferences
INTRODUCTION
INTRODUCTION Tobacco smoking - detrimental habit
In India Population
MalesFemales
- 1.1 billion
53%
47%
0.00%5.00%
10.00%15.00%20.00%25.00%30.00%35.00%
MalesFemales
Prevalence rate of smokers
NHFS 98-99
NHFS 05-06
25%29%
3.2% 2.8
%
Introduction
Deaths due to cancer
Other causesDue to smoking
Deaths due to habit
Series150 %
30 %
Death rate0%
10%20%30%40% 32%
6%
M F
Introduction
Different methods of tobacco smoking
Passive
Beedi
Cigars
Hookahs
Pipes
Cigarettes
Introduction
Heavy smokers> 20 / day
Former smokersQuit within the last 10 years
Light smokers< 20 / day
Risk factor for systemic diseases
Susceptibility to coronary artery disease: 2-4 times
Introduction
Introduction
Smoking and periodontal disease
Long-term chronic exposure
in prevalence and progression
Passive smoking – 30% of disease susceptibility
Introduction
Tobacco
smoking
Plaque and oral
flora
Periodontal
tissuesHomeostasis and
healing potentia
l
Systemic health
Immune respons
e
CONSTITUENTS OF TOBACCO SMOKE
CONSTITUENTS OF TOBACCO SMOKE
Complex mixture of substances – over 4000 known constituents
Phenols and cyanides – antibacterial and toxic properties
Constituents
Gaseous phase and particulate phase
Tar and nicotine yields reduced due to use of filters
Dose of tobacco intake – depends on the way an individual smokes
Constituents
Biochemical analyses of cotinine (Wall et al 1988)
Measurements are more reliable – longer half life of 14-20 hours (Jarvis et al 1988)
Cotinine concentrations of regular smokers
Resting plasma nicotine levels : 5–50 ng/ml
Plasma and salivary levels
~ 300 ng/ml (14 ng/ml – 1000
ng/ml)
Urine concentrations ~ 1500 ng/ml
Constituents
Absorption of nicotine Rapidly absorbed into blood - 30% in free
form Lipid-soluble Inhalation of tobacco smoke
Constituents
Action on organs blood pressure heart rate respiratory rate skin temperature Vasodilatation at other body sites
Constituents
Oral mucosa Slowly
From cigarette smoke pH 5.5 not well absorbed
From cigar and pipe smoke pH 8.5 good absorption
(Benowitz 1988)
MECHANISMS OF TOXICITY
MECHANISMS OF TOXICITY
Vascular alteration
antibody production(IgG2P7)
Immunosuppressive effect
Physical subgingival environment
Nicotine on root surfaces
bacterial adhesion to epithelial cells
Mechanisms of toxicity
Impaired immune response
Anaerobic subgingiv
al infection
Connective tissue
cytotoxicity
Impaired wound healing
in severity
of periodontal disease
TOBACCO AS A RISK FACTOR
TOBACCO AS A RISK FACTOR Based on Hill’s criteria (1965) for causation,
reviewed by Gelskey (1999)
Biologic plausibility
Strength of association
Consistency Specificity
Temporality Biologic gradient
Analogy
EFFECT OF SMOKING ON PLAQUE
Plaque developmentOral floraSubgingival microfloraCalculus formationConclusion
EFFECT OF SMOKING ON PLAQUE
Effect of smoking on plaque development
Higher prevalence of dental plaque in smokers(Kristoffersen 1970, Preber et al 1980)
In contrast, smoking did not appear to increase the amount of plaque (Alexander 1970, Sheiham 1971)
Experimental gingivitis models – rate of plaque formation was similar (Bastiaan & Waite 1978, Bergstrom 1981)
Effect of smoking on plaque
Effect of smoking on the oral flora
No significant trend for smokers to harbor putative pathogens (Mager et al 2003, Lie et al 1998b)
Increased counts of exogenous flora – E. coli and C. albicans – have been reported in smokers
Effect of smoking on plaque
Effect of smoking on the subgingival microflora
Cross-sectional investigations
No influence of smoking on the occurrence of any species
Zambon et al 1996 - higher prevalence of A. actinomycetemcomitans, T. forsythensis and P. gingivalisRisk of infection with T. forsythensis – 2.3 times
Mager 2003 – A. actinomycetemcomitans
Effect of smoking on plaque
Prevalence of B. forsythus and P. nigrescens maxilla > mandible (Haffajee
2001)
Cigarette smoking lowers redox potential increase in anaerobic bacteria
Eggert 2001 – effects of CO
Enhancing growth of anaerobes
Formation of advanced
glycation end products by
smoke
Effect of smoking on plaque
Effect of smoking on calculus formation
More supragingival calculus deposits (Bergstrom 1999)
Significantly more with pipe smokers than cigarette
Reason: salivary flow rates
calcium concentration, organic components
Effect of smoking on plaque
Conclusions
Numerous species in oral cavity Varied sampling methods Common known species often investigated
Trend: Greater numbers of pathogens not correlating with plaque levels
EFFECT OF SMOKING ON PERIODONTAL TISSUES
GingivaGingival blood flow Gingival vasculature Gingival inflammation and bleedingOxygen tension in gingival tissueGingival and PDL fibroblastsPeriodontitisWound healingConclusion
EFFECT OF SMOKING ON PERIODONTAL TISSUES
Effect of smoking on gingiva
Changes in the epithelium - hyperkeratotic, hyperplastic
Greyish discoloration of the gingiva
Increased amounts of IL-1, IL-6 and PGE2 (Johnson et al 1996)
Effect of smoking on periodontal tissues
Smoking – predisposing factor for ANUG
use of tobacco frequency of ANUG (Rowland 1999)
Reason: Tar in the smoke irritating effect on gingivaNicotine vasoconstriction of capillaries (Lindeboom 2005)
Effect of smoking on periodontal tissues
Effect of smoking on gingival blood flow
Infusion of nicotine
• gingival blood flow• Recovery below
baseline levels
Transient decrease
(Clarke et al 1981)
Laser Doppler Flow study
• Gingival blood flow ~25%
• Maintained for 5 min• Gradually declined
to baseline values
Transient increase
(Baab & Oberg 1987)
Effect of smoking on periodontal tissues
Reason:Nicotine Vasoconstrictive property
In some cases, smoking-induced elevation in blood pressure overcomes vasoconstrictive effect of smoking.
Smoking decreases gingival blood flow
Effect of smoking on periodontal tissues
Bergstrom et al 1983
Nicotine
Sympathetic ganglia catecholaminesα - receptors
vasoconstrictionPeripheral blood vessels –
periodontium gingival bleeding
Vasoconstriction
Keratinization
Effect of smoking on periodontal tissues
Morozumi et al 2004 - following quitting At 3 days – significant increaseAt 4-8 weeks - small increases occurred
Effect of smoking on periodontal tissues
Effect on the gingival vasculature
number of vessels endothelial ICAM-1 expression
(Rezavandi et al 2002)
not accompanied by an equivalent increase in vascularityInflammation
-
Effect of smoking on periodontal tissues
Gingival inflammation and bleeding
Smokers experienced less gingival bleeding (Bergstrom & Floderus- Myrhed 1983)
NHANES III : Dose–response effect (Dietrich et al 2004)
Quit-smoking program – improvement in parameters(Nair et al 2003) Rapid recovery of the inflammatory response
Effect of smoking on periodontal tissues
gingival redness
Fewer gingival vessels
GCF
Less bleeding
sites
Suppression of the normal inflammatory
response
(Bergstrom 1986)
Effect of smoking on periodontal tissues
Oxygen tension in the gingival tissues
Carbon monoxide – reduces O2 tension (Scott et al 2001)
Oxygen saturation of haemoglobin – lower in healthy gingiva, higher with inflammation (Hanioka et al 2000b)
Pocket oxygen tensionSmokers Non-smokers
~ 21.9 mm Hg ~ 33.4 mm Hg
Effect of smoking on periodontal tissues
Effect on fibroblasts
Nicotine affects Production of collagenous, non-
collagenous proteins (Giannopoulou 2001) Cell orientation and attachment (Raulin et al
1988)
Effect on human gingival fibroblasts
Nicotine HGF
(Wendell 2001)
IL-6
IL-8
P. gingivalis
Effect of smoking on periodontal tissues
25–100 ng/ml of nicotine Orientation of cells lost (Tanur et al 2000)
10–75 g/ml of nicotine Inhibition of proliferation of gingival
fibroblasts production of type 1 collagen and
fibronectin collagenase activity in the culture media Cytoplasmic vacuolation Attachment disrupted (Tipton and Dabbous
1995)
Effect of smoking on periodontal tissues
Effect of acrolein and acetaldehyde Inhibited cell attachment and cell
proliferation (Cattaneo et al 2000, Poggi et al 2002)
EM changes:o Disruption of cell orientation o Presence of large vacuoles and residual
bodies o Reduction in cell viability o Disruption of the cytoskeletal structures
Effect of smoking on periodontal tissues
Root surface of tooth Alters fibroblast attachment Integrin expression Decrease collagen production Increase collagenase production
Nicotine levels could be reduced following root planing (Cuff et al 1989)
Effect of smoking on periodontal tissues
Effect on PDL fibroblasts
Dose-dependent inhibition
< 10 g/ml – no significant effect 100 ng/ml-2 g/ml – inhibition of
proliferation > 1mg/ml – vacuolation
(Giannopoulou et al 1999)
High concentrations (5–25mM) - cytotoxicity (Chang et al 2002)
Effect of smoking on periodontal tissues
Periodontitis
Relative risk for smokers : 3.97 former smokers : 1.68
Odds ratio – 1.5-7.3
Cigar and pipe smokers - severity of disease intermediate between current cigarette smokers and nonsmokers
Effect of smoking on periodontal tissues
Deeper probing depths and a larger number of deep pockets (Feldman et al 1983, Bergstrom et al 2000a)
Twin study - greater degree of alveolar bone loss and tooth loss in smokers (Bergstrom in 1983)
More attachment loss including more gingival recession (Grossi et al 1994, Haffajee & Socransky 2001a)
More teeth with furcation involvement (Mullally & Linden 1996)
Effect of smoking on periodontal tissues
Wound healing
Initial short-term healing after therapy (up to 6 weeks) Reduced cell function Reduced host defense response Reduced vascularity
Medium to longer term healing (3 months - 1 year) Cellular and tissue differences
Effect of smoking on periodontal tissues
Poorly functioning fibroblasts gingival tissue adaptation impaired
Poor healing
Persistence of infection
Predisposition to disease
Effect of smoking on periodontal tissues
Conclusions
Long-term chronic effect
Impairing the vasculature and revascularization
Following abstinence, the vasculature does return to a near- normal state
Smoking and periodontal
disease
CONTENTSIntroductionConstituents of tobacco smoke Mechanism of toxicityTobacco as a risk factorEffect of smoking on :
Plaque and oral floraPeriodontal tissuesImmunology
Smoking and systemic statusEffect of smoking on periodontal therapyTobacco cessationConclusionReferences
EFFECT OF SMOKING ON IMMUNOLOGY AND HOST
RESPONSEPMN functionLymphocyte functionGCFCytokinesOther factorsConclusion
EFFECT OF SMOKING ON IMMUNOLOGY AND HOST
RESPONSEEffect on PMN function
Systemic neutrophilia No effect on oral and sulcular neutrophils Reduction in numbers (Eichel & Shahrik 1969,
Pauletto et al 2000)
Effect of smoking on immunology and host response
Express several receptors
Metabolites of Endogenous smoke factors
34 subtype of nicotinic receptors
(Benhammou et al 2000)
IL-8, ICAM-1, TNF-
Effect of smoking on immunology and host response
PMN functi
on
Degradative
protease formation
Neutrophil respirator
y burst
PMN migration
and chemotaxi
s
Neutrophil priming
Effect of smoking on immunology and host response
Degradative protease formation from PMN
elastase activity and MMP-8 activity – refractory periodontitis (Soder B 1999)
Lower elastase concentrations in GCF PMNs are less functional (Wolff et al 1994) or are present in reduced quantities
Effect of smoking on immunology and host response
Neutrophil respiratory burst “Respiratory burst” – O2-dependent
phagocytosis
Cigarette smoke constituents may inhibit the respiratory burst (Drost et al 1992, Sorensen et al 2004)
Nicotine IL-8 ROS, particularly ONOO- (Iho et al 2003)
Metallothionein – protective roleResponses – enhanced or
suppressed ?
Effect of smoking on immunology and host response
Neutrophil migration and chemotaxis
Tobacco smoke exposure may impair f-actin kinetics
Hampers neutrophil motility and migration(Ryder et al
2002)
Neutrophil migration expression of adhesion integrins expression of selectins
Effect of smoking on immunology and host response
Neutrophil chemotaxis and phagocytosis (Seow et al 1994)
Dose-dependent suppression o Low concentrations – stimulatory to fMLP o High concentrations - inhibitory
Neutrophils respond to multiple chemotactic
stimuli
Results depend upon the experimental
system used
Effect of smoking on immunology and host response
Neutrophil priming (hyper-reactivity) Koethe et al 2000, Matheson et al 2003
Cigarette smoke condensate (CSC)
2-fold increase in fMLP-receptor expression
Subsequent stimulation with fMLP
Cells ‘‘primed’’
2-fold increase in superoxide and elastase release
Hyperinflammatory response
Effect of smoking on immunology and host response
Neutrophil priming capabilities for TNF-alpha (Gustafsson 2000, Bostrom et al 1998b)
HEALTH DISEASE
Effect of smoking on immunology and host response
Conclusions
Neutrophils - critical role
Effect of smoking on immunology and host response
Smoking And Lymphocyte Function
Immune system recognize antigens response
Lymphocytes
T lymphocyte
sNK cells
B lymphocyte
s
Effect of smoking on immunology and host response
T lymphocytes
Leucocytosis (Corre et al 1971, Hughes et al 1985)
Loos et al 2004 Non-smokers, light smokers or heavy
smokers Total leucocyte count - highest in heavy
smokers Increased neutrophil numbers
Effect of smoking on immunology and host response
Animal studies - chronic exposure of rats Vapour phase – no significant changes Particulate phase - confers
immunosuppressive properties
Nicotine, Benzo(a)pyrene,
Benzo(a)anthracene
Immunosuppressive
(Geng et al 1995, 1996)
Tobacco glycoprotein, Metals
Immunostimulatory
(Francus 1988, Brooks 1990)
Net effect - dependent upon dose and
duration
Effect of smoking on immunology and host response
T cell function – controversial
Reduction in proliferative response of lymphocytes to mitogens (Chang et al 1990, Johnson et al 1990)
No significant differences between control subjects, periodontitis patients and smoking status (Loos et al 2004)
Effect of smoking on immunology and host response
B cells and Immunoglobulins
B cells + Cytokines Plasma cells (Th-derived)
Chronic exposure to nicotine Impairment of antigen-mediated T cell signalling Inhibits antibody-forming cell responses
Immunosuppression(Sopori et al 1998)
Effect of smoking on immunology and host response
sIgG levels are reduced in smokers – IgG2 (Fredriksson 1999)
Effects of cigarette smoking on serum IgA and IgM classes – controversial
Smoking decreases salivary IgA
IgE is greatly elevated in smokers
Reduced antibody levels to periopathogens
Effect of smoking on immunology and host response
B cell function Decrease in proliferative response to B cell
mitogens and antigens (Sopori et al 1989) Smoking cessation, function returns to
normal (Reynolds et al 1991)
Combustion by-products - B cell function Tobacco glycoprotein - potent B cell
mitogenNet effect – depends on properties of
tobacco
Effect of smoking on immunology and host response
Natural killer (NK) cells
Antibody-dependent cellular cytotoxicity Analogous to cytotoxic T cells Produce chemokines and cytokines
Reduced activity in smokers (Tollerud et al 1989)
Reversible on smoking cessation (Meliska et al 1995)
Effect of smoking on immunology and host response
Conclusions
Inconsistencies and variations in findings
Inadequate knowledge of antigens and responses
Effect of smoking on immunology and host response
Gingival Crevicular Fluid GCF nicotine concentrations - 300 times that
of plasma (20ng/ml)
Lower resting GCF flow rate (Persson et al 1999)
Reduced GCF flow Defense mechanism hampered
Less flushing – removal of microbes and waste products
Effect of smoking on immunology and host response
Episode of smoking transient increase in GCF flow rate (McLaughlin et al 1993)
Quit-smoking programme – flow rate greater at 5 days postquitting (Morozumi et al 2004)
Effect of smoking on immunology and host response
Cytokines
Cytokine overproduction detrimental host response disease
Higher levels of TNF- (Bostrom et al 1998)
Dose-dependent effect of smoking on IL-1, IL-8, and MCP-1 levels (Kuschner et al 1996)
Effect of smoking on immunology and host response
Higher levels of IL-8, lower levels of IL-4 (Giannopoulou et al 2003)
IL-1 levels half of that found in non-smokers (Petropoulos et al 2004)
IL-6, IL-1 - no significant differences (Bostrom et al 2000)
Effect of smoking on immunology and host response
TGF- IGFIFN
IL-1, -6, -8TNF-
PG
The balance between protection and destruction is
mediated largely by the type of cytokine pattern
secreted by these cells.
Effect of smoking on immunology and host response
Other Factors
2-macroglobulin and 1-anti-trypsin levels Lower concentrations in heavy smokers
(Persson 2001)
ICAM-1 levels (Fraser et al 2001)
Smokers Non-smokers
Serum 331 ng/ml 238 ng/mlGCF 83 ng/ml 212 ng/ml
Effect of smoking on immunology and host response
Conclusions Logic – factors associated with tissue
destruction should be higher
However, lower levels with most cytokines
Clinically, low levels of inflammation observed
May indicate higher levels of activity
GCF could be an end product of the destructive
process
SMOKING AND SYSTEMIC STATUS
SMOKING AND SYSTEMIC STATUS
Smoking + systemic factors = risk of disease
Erie County study In diabetics, more periodontal attachment loss Odds ratio for attachment loss - 30 times more
o Diabetes and heavy smoking o > 45 years of ageo P. gingivalis or T. forsythensis
Postmenopausal women AIDS / HIV +ve
Smoking and systemic status
Gene polymorphisms
IL-1 genotype & smokers
(McGuire & Nunn, 1999)
bleeding on probing (Lang 2000)
probing depth and attachment loss
Risk factor Risk of tooth loss
IL-1 positive genotype 2.7Smoking 2.9 IL-1 positive + smoking 7.7
Smoking and systemic status
N-acetyltransferase 2 (NAT2)
Tobacco smoke Arylamines Detoxification Immunosuppressant
Polymorphism rapid or slow acetylators
Severe periodontal conditions – slow acetylators
NAT2 genotype-positive bone loss (Kocher 2002)
NAT2
Smoking and systemic status
Cytochrome P450 and glutathione S-transferase enzymes
Neutralization of toxic substances
Polymorphism risk of periodontitis
EFFECT OF SMOKING ON PERIODONTAL THERAPY
Non-surgical therapyAntimicrobial therapySurgical therapyTissue graftsImplant therapy Maintenance therapyRecurrent/refractory disease
EFFECT OF SMOKING ON PERIODONTAL THERAPY
Non-surgical therapy
Non-surgical therapy is less effective in smokers and non-smokers
Less reduction in probing depth Smaller levels of gain in clinical attachment
Effect of smoking on periodontal therapy
Grossi et al 1996 – 3-month study Pocket depth reduction - 1.29 vs 1.76 mm
Good plaque control – differences are less significant
Smokers respond less well to nonsurgical therapy
Effect of smoking on periodontal therapy
Antimicrobial therapy
Antimicrobial therapy as an adjunct
Widely used host modulators - tetracycline antibiotics Anti-inflammatory Anti-collagenase activity Anti-oxidant
Enhanced results with: Locally delivered minocycline microspheres
Effect of smoking on periodontal therapy
Little effect of systemic metronidazole (Soder et al)
Systemic amoxicillin and metronidazole – better results
Effect of smoking on periodontal therapy
Surgical therapy
Smokers treated with surgical periodontal therapy Less probing depth reduction Smaller gains in CAL Less gain in bone height
Kaldahl 1996 – 7-year follow up Deterioration of furcation areas
Level of recession - worse in smokers (Martinez-Canut et al 1995, Gunsolley et al 1998)
Effect of smoking on periodontal therapy
Tissue grafts Heavy cigarette smoking decreases the
amount of root coverage
Harris’ study (n=100) CT with partial thickness pedicle graft Light smokers - 97%
Heavy smokers- 99%Non-smokers - 98%
CT graft - more resistant to effects of smoking
Effect of smoking on periodontal therapy
Smoking - negative impact on outcomes of GTR, DFDBA
GTR with ePTFE membrane Smokers - 57% Non-smokers - 78%
Trombelli et al 1997
Effect of smoking on periodontal therapy
Implant therapy
Bain 1993 – 6-year follow-up studySuccess rate - > 95% (non-smokers)
< 89% (smokers)
Implant failure is 2.5 times greater (Wilson 1999)
Smoking cessation - 1/3rd as many failures as compared to smokers
Effect of smoking on periodontal therapy
Light smoking - no effect on machined or dual acid-etched surface implants (Bain 2002)
Maxillary implants risk for peri-implantitis Failures – twice more
Lindquist et al 1996 - 15-year longitudinal study Greater marginal bone loss around
mandibular implants
Effect of smoking on periodontal therapy
Maintenance therapy
2 times the risk of losing teeth
Scabbia 2001 - more residual pockets
Effects of smoking on treatment outcomes - long lasting
Effect of smoking on periodontal therapy
Recurrent/refractory disease
Smokers do not respond favorably recurrent or continuing disease
MacFarlane et al 1992 – 90% of subjects who showed poor results were smokers
Effect of smoking on periodontal therapy
Conclusion
Smoking detrimental effect on periodontal therapy
TOBACCO CESSATIONIntervention models for dental practice
1.Brief2.Comprehensive3.Pharmacotherapy
Relapse preventionEffect of cessation on PDL status and treatment
outcomes
TOBACCO CESSATION
Tobacco is harmful to health
Success long-term abstinence 6 months
Tobacco Cessation
Brief Intervention Program Agency for Health Care Research and Quality
(Fiore MC et al 2000)
Brief Interventi
on Program
ASK
ADVISE
ASSESS ASSIST
ARRANGE
Tobacco Cessation
Comprehensive Intervention Program
Expanding the scope of intervention
Expanding the five A’s1. Ask2. Advise3. Assess4. Assist (2-14% effectiveness)5. Arrange
Tobacco Cessation
Pharmacotherapy Nicotine replacement therapies
Others Sustained-release bupropion Clonidine, nortriptyline
OTC products
Nicotine chewing gum
Lozenges Patches
On prescriptions
Nasal sprays
Inhalers
Tobacco Cessation
Tobacco Cessation
Indications
Patient’s health history Current nicotine exposure Past experience with cessation
Tobacco Cessation
Nicotine replacement and combinations
< 20 / day – patch – 7–22 mg for 4 weeks or longer> 20 / day – combination; patch + other products
No use of any other form of tobacco when on a cessation program
Bupropion – 1st 3 days : 150 mg OD upto 7-12 weeks : BID Safe upto 6 months
Tobacco Cessation
Relapse prevention
Withdrawal symptoms after tobacco cessation
Relapse – high
Long-term abstinence
Alternate treatment modalities
Tobacco Cessation
Effect of cessation on PDL status and treatment outcomes
Rate of bone and attachment loss slows
Disease severity – intermediate
Former smokers respond to therapy similar to never smokers (Kaldahl et al 1996)
Bain 2002 - implant failures
CONCLUSIONAs an environmental factor, smoking
interacts with the host and the bacterial challenge, resulting in an increased susceptibility to periodontitis and poorer response to treatment.
Recent guidance suggest that dental practices should assess the smoking status of patients and motivate smokers towards quitting.
REFERENCES Jan Lindhe, Niklaus P. Lang, Thorkild Karring. 5th
Edition. Clinical Periodontology and Implant Dentistry. Blackwell Munksgaard 2008.
Rose LE, Genco RJ, Cohen DW, Mealy BL. Periodontal Medicine. B.C. Decker Inc 2000.
Palmer RM, Wilson RF, Hasan AS, Scott DA. Mechanisms of action of environmental factors – tobacco smoking. J Clin Peridontol 2005; 32 (Suppl. 6): 180–195.
Ana Pejčić, Radmila Obradović, Ljiljana Kesić, Draginja Kojović. Smoking and periodontal disease a review. Medicine and Biology Vol.14, No 2, 2007, pp. 53–59.
References
Georgia K. Johnson, Margaret Hill. Cigarette smoking and the periodontal patient. J Periodontol 2004; 75: 196–209.
Francisco Rivera-Hidalgo. Smoking and periodontal disease. Periodontology 2000, Vol. 32, 2003, 50–58.
D.F. Kinane and I.G. Chestnutt. Smoking and Periodontal Disease. CROBM 2000 11: 356.
Newman MG, Takei HH, Klokkevold PR, Carranza FA. Carranza’s Clinical Periodontology. 10th Edition. Saunders Elsevier 2007.
References
Mark I. Ryder. The influence of smoking on host responses in periodontal infections. Periodontology 2000, Vol. 43, 2007, 267–277.
Boström L, Bergström J, Dahle´n G, Linder LE. Smoking and subgingival microflora in periodontal disease. J Clin Periodontol 2001; 28: 212–219.
Antonella Labriola, Ian Needleman & David R. Moles. Systematic review of the effect of smoking on nonsurgical periodontal therapy. Periodontology 2000, Vol. 37, 2005, 124–137.
Vivian I. Binnie. Addressing the topic of smoking cessation in a dental setting. Periodontology 2000, Vol. 48, 2008, 170–178.
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Find out• Smokeless tobacco• Different forms of smoking• Plasma/GCF/urine levels of tobacco• NNN – nitrosonornicotine• Effect of smoking on maintenance therapy• Add from carranza…genco???• Format• Read soben peter• Add contents of smoke from SP• Elastase levels• Functions of elastase, ICAM-1• Lindhe treatment aspect• Carranze perio therapy