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An Introduction to Substance Use Disorders for Dental Professionals

Course Number: 545

Oral Implications of Cigarettes and Cigar Use/Abuse

Various conditions result from chronic smoking. Among them are:

Black Hairy Tongue: Elongated; black, brown, yellow or white papillae form in response to the solid and gaseous wastes of tobacco being trapped on the tongue’s surface. Slowed cell sloughing adds to this syndrome. Food and bacteria may be trapped in the papillae and cause halitosis .

Stain & Calculus: While saliva flow is generally reduced in chronic smokers, the act of smoking stimulates serous saliva flow. This can increase calculus production. Stain is generally present. The combination of stain and calculus may compromise the periodontal health of most smokers.

Gingival and Periodontal Diseases: Conditions such as necrotizing ulcerative gingivitis (NUG) is prevalent in smokers. Scientific evidence clearly shows smokers have more severe periodontal diseases than do non-smokers. Continued smoking is likely to compromise the success of periodontal therapy. More refractory periodontal patients are smokers (90%) when compared to the general population (25%).

In 2017, the American Academy of Periodontology introduced their new staging and grading system to guide comprehensive treatment planning and allow for a personalized approach to patient care (Figure 3). The grading system takes into consideration the smoking status and number of cigarette’s the patient utilizes daily.

Charts from the AAP showing the Periodontal Staging and Grading system.

Figure 3. Staging and Grading Periodontitis.

Additional Oral Changes: Smokers may also experience candidiasis, nicotine stomatitis, smoker’s keratosis, pigmentation changes, and xerostomia (Figure 4).

Photo showing nicotine stomatitis.

Figure 4. Nicotine Stomatitis.

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Root Canals: 28-year study showed cigarette smokers are 70% more likely to need root canal therapy than non-smokers. Smoking impairs the body's response to infection, exacerbates bone loss throughout the skeleton, induces a chronic systemic inflammatory response, and causes vascular problems. Any of these pathways can potentially affect the health of the tooth pulp and surrounding bone tissue.33

Sinusitis: The incidence of acute or chronic inflammation of the nasal lining of both the maxillary and frontal sinuses occurs 75% more often among smokers than non-smokers. This is attributed to the chemical compounds in the tobacco.

Ability to Heal: Nicotine is a vasoconstrictor and reduces blood flow to the tissues, causing delayed wound healing, especially in the mouth where smoke lingers. Dry sockets are four times more prevalent among smokers. Typically, dry sockets occur when the addicted smoker returns to their habit too soon after an oral surgery, disrupting the delicate clot in a postoperative extraction socket.

Leukoplakia: A precancerous lesion of the oral soft tissue that consists of a white patch or plaque that cannot be scraped off (Figure 5). It is often associated with tobacco use. It can persist in an area with no pain or irritation. These areas can develop into more serious lesions and should be examined carefully during a meticulous oral evaluation. Some leukoplakia will regress if tobacco use is discontinued.

Photo showing leukoplakia under tongue.

Figure 5. Leukoplakia Under Tongue.

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Squamous Cell Carcinoma: This is the most common oral cancer linked to cigarette smokers and can occur anywhere in the mouth. It is most commonly found on the lateral borders of the tongue, the ventral surface of the tongue or floor of the mouth. Squamous cell carcinoma has a favorable prognosis if it is detected within two years of onset. If not detected early, approximately 50% will die as a direct result of the cancer or complications (Figure 6).

Photo showing squamous cell carcinoma of the tongue.

Figure 6. Squamous Cell Carcinoma of the Tongue.

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Other Cancers: Cigarette smoking harms nearly every organ in the body. It has been conclusively linked to cancers of the mouth, pharynx, larynx, esophagus, lung, stomach, pancreas, cervix, kidney, and bladder, as well as acute myeloid leukemia. Tobacco-related cancers account for about one-third of all cancer deaths. The overall rates of death from cancer are twice as high among smokers as non-smokers, with heavy smokers having rates that are four times greater than those of non-smokers. Foremost among the cancers caused by tobacco use is lung cancer. Cigarette smoking has been linked to about 90% of all cases of lung cancer, the number one cause of cancer deaths among both men and women.