Beware! Smoking masks the signs of gum disease until it gets serious

Research has found that periodontitis progresses more quickly in smokers, compared to non-smokers, resulting in faster destruction of the bone that holds our teeth in place. — Prof Dr DASAN SWAMINATHAN

Gum (periodontal) disease is an infection of the gums and can damage the soft tissues and bone structure that support your teeth.

In severe cases, it can make your teeth fall out.

Gum disease starts with bacteria that originate from a sticky, white film called plaque, which can be found on your teeth.

Plaque is derived from saliva and gets contaminated by the abundant bacteria that are present in the oral cavity.

Plaque accumulates on the teeth if you do not clean them satisfactorily.

If the bacteria within plaque stays on your teeth for too long, several layers of plaque and tartar, or dental calculus (hardened plaque), will develop.

This build-up leads to early gum disease, known as gingivitis.

If the disease is allowed to get worse, your gums will pull away from your teeth and form spaces (i.e. periodontal pockets) that can get infected with the bacteria found in plaque.

This is severe gum disease and is called periodontitis.

The bone and tissue that hold your teeth in place can break down, and your teeth may loosen and need to be pulled out.

Epidemiological studies have provided evidence that tobacco smokers have poorer oral hygiene than non-smokers, as well as increased quantities of tartar.

These differences can be attributed to less regular tooth-brushing habits, which is particularly evident in male smokers!

However, smoking is also associated with a decreased flow of saliva, which may explain the increased tendency of those with this habit to form tartar.

Masking the symptoms

Heavy smokers often present with thicker, harder and pale-looking gum tissue.

The rate of plaque accumulation is similar in smokers and non-smokers.

However, smokers show less gingival inflammatory changes, with less gum bleeding, gum redness and reduced liquid flow from within the gum tissues.

This liquid found in the gums is known as gingival crevicular fluid.

Hence, it appears that smoking may suppress the body’s normal immune response to the accumulation of plaque.

The reduced gum bleeding might also be due to the narrowing of gum blood vessels caused by smoking.

The main implication of this finding is that the lack of gingival bleeding in smokers may lead to a failure to recognise the presence of periodontal diseases in them.

And this would allow the gingivitis to progress further to periodontitis as a lack of diagnosis naturally means a lack of treatment.

More aggressive bacteria

Recent studies have revealed an association between smoking and more severe periodontitis.

After allowing for the effects of oral hygiene and the patient’s age, smoking has been shown to be associated with deeper periodontal pockets and more loss of bone that holds the teeth in the jaws.

There is also evidence that the rate of progression of periodontitis is more rapid among smokers.

Possible mechanisms through which smoking affects the progress of periodontal diseases include its effects on the composition of plaque, as well as its effects on the body’s response to the disease.

It has been hypothesised that smoking can reduce oxygen within the tissues.

This affects the type of bacteria that can survive deeper within the gum tissues inside the periodontal pockets.

In this situation, the oxygen in the superficial, or more exposed, gum area will be used up by the aerobic bacteria found there.

Aerobic bacteria are those that require oxygen to survive.

This then allows for the multiplication and dominance of anaerobic bacteria – i.e. bacteria that do not need oxygen to survive – in the deeper areas of the periodontal pockets.

Compared to the aerobic bacteria in the superficial areas of the gum margins, the anaerobic bacteria in the deeper areas are more aggressive and can cause increased destruction to the soft and hard tissues that support the teeth.

Again, the bacteria are transmitted from plaque on the teeth to the gums, if the plaque is not removed via proper oral hygiene habits.

The narrowing of the blood vessels found in gum tissues as a result of smoking also prevents the body’s immune defence mechanism – comprising white blood cells – from reaching into the gum tissues.

This allows the anaerobic bacteria to multiply rapidly and cause more destruction within the gum tissues.

Preventive steps

You can help avoid gum disease with good dental habits such as:

• Brushing your teeth twice a day.
• Flossing often to remove plaque.
• Seeing your oral health professional regularly for check-ups and for professional management of any gum disease.
• Not smoking, or quitting if you do smoke.

Oral health professionals can also help to manage gum disease – especially severe cases – in smokers by:

• Providing clear instructions and reminders on how to maintain their oral hygiene on every visit.
• Scaling and performing deep cleaning below the gum line.
• Doing root-cleaning (better known as root debridement) to remove plaque and tartar deep in the roots of the teeth.
• Performing surgery to help heal bone or gums lost to periodontitis.
• Helping patients access smoking cessation programmes for those 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 gum health.

There is ample scientific evidence to support advising smokers to reduce or stop their smoking as part of the management of gum disease.

Oral health professionals also need to take extra care during the periodontal examination of smokers.

This is as many of the more visual signs of periodontal disease are likely to be masked due to the lack of gum bleeding.

However, careful periodontal probing and examination of radiographs will reveal the true level of destruction to the supporting soft and hard tissues of the teeth.

Smokers also need to be informed prior to the commencement of periodontal treatment that the outcome of such treatment may be compromised if they continue to smoke.

Professor Dr Dasan Swaminathan is a dental surgeon and periodontist. For more information, email [e-mail]. The information provided is for educational and communication purposes only, and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.