Introduction
According to the data statistics by the World Health Organization, in 2018, there were more than seven million people who are the victims of chronic tobacco smoking, leading to significant systemic disease development and predisposing them to mortality every year. The dental implants primarily fuse to the alveolar bone by maintaining bone-implant contact through the phenomenon of osseointegration or fusion to the bone. This successful phenomenon determines the dental implants' long-term success rates.
The most common question that arises in people, whether they are addicted to smoking or it may be just another detrimental habit they possess, is whether dental implants are successful in these individuals or not. The answer based on the research and documented evidence accumulated through dental literature indicates that the upregulation of pro-inflammatory cytokines (cells present at the site of inflammation), especially interleukin-1, is responsible for aggravating localized tissue damage as well as alveolar bone resorption. These can be inflammatory reactions as well, due to which the smoker develops peri-implantitis or peri-implant mucositis (an Inflammatory lesion of the soft tissue that leads to loss of bone around an osseointegrated implant). That disturbs the functions of dental implant stability or anchorage.
Hence, it has been recognized as a significant factor for dental implant failure. This means that in chronic smokers, it can severely impact the localized peri-implant tissue of contact and the underlying alveolar bone, which would impede the effective osseointegration of the dental implant. Though smoking is a prevalent habit and behavior worldwide, the negative or detrimental effects are numerous concerning both oral and systemic health.
Which Are the Systemic and Oral Diseases for Which Smoking Is a Risk Factor?
The detrimental effects of smoking on general health in the long term that are linked to systemic diseases are given below. These systemic diseases in chronic smokers enlisted below do have the potential to interfere again, in turn, with the phenomenon of osseointegration and cause dental implant instability or failure in the long run. They are;
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Heart stroke or cardiovascular disease.
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Cancers.
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Coronary heart disease.
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Low birth weight infants or stillbirth in the pregnant smoker.
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Pneumonia.
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Atherosclerosis.
In terms of detrimental impact on the oral tissues or in the oral cavity, smoking is a risk factor for the conditions given below;
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Periodontitis or periodontal disease.
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Oral cancers.
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Precancerous lesions of the oral cavity.
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Root caries.
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Delayed extraction site healing.
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Delayed oral wound healing.
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Taste derangement or alteration of taste sensation.
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Staining dental restorations.
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Staining of tooth enamel.
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Periimplantitis or periimplant mucositis.
According to the reviews of traditional medicine and dental literature in the field of implant dentistry, the exact mechanisms regarding the failure of dental implants in smokers remain elusive. However, there are several proposed hypotheses or mechanisms that are widely accepted by dental implantologists as to the mechanism of action through nicotine that renders implant failure.
How Does Smoking Affect Dental Implants?
The success and failure of dental implants depend on certain lifestyle factors, characteristics of the implant, the skill of the clinician, and the location of the implant. Research has found that the factors related to the patient are more important than the factors related to implants.
The smoking habit of a patient affects the implant at different stages, like before, during, and after the procedure.
Before the Procedure of Implantation:
During the preparation of the implantation procedure, one or more teeth are to be extracted, and during the extraction, the tooth socket is exposed. This socket may turn into a dry socket because of the smoking habit. A dry socket is considered to be slow healing, as the blood clot is not formed effectively at the site of the extraction or in the socket. Blood clots are important to protect the nerve endings and bone present underneath. These are helpful in the growth of new bone and tissues.
Chemicals inhaled during smoking may slow down the healing process and tend to infect the surgical site. The clot formed in the surgical site may get dislodged due to smoking, making it vulnerable to infection by bacteria.
During the Implantation Procedure:
It was observed from the research that smoking can affect the implant during the procedure, causing it to fail. A Spanish study has noticed that 15.8 % of implant failure among smokers when compared to 1.4 % among nonsmokers. The reason is smoking, which affects the new bone and tissue growth.
Heavy smokers exhibit gum disease and jaw bone deterioration. Bone loss can be a major risk for implant failure.
Research has found that smoking habits affect the gum tissue, especially during the period between the placement of the implant and prosthesis. This is because the soft tissue around the implant gets irritated and infected by the tobacco smoke. This is one of the reasons for implant failure.
After Implant Surgery:
Smoking affects the implant even after the surgery. Smoking increases the inflammation and resorption of the bone. Smoking affects after the procedure of implant surgery by increasing the inflammation and resorption of the bone. This affects the success of the bone grafts used. It was noted by researchers that marginal bone loss is higher among smokers when compared to nonsmokers. It was observed that individuals who smoke and have poor oral hygiene with implants are three times likelier to experience bone loss after ten years when compared to nonsmokers.
Smoking affects the gum tissue. It damages the blood vessels in the mouth, affects the blood flow to the tissues that support the implant, and results in the dryness of the mouth. These lead to the failure of the implant.
Tips for Minimizing Implant Failure:
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Maintaining Good Oral Hygiene: Adopting regular brushing and flossing of teeth may help in maintaining good oral hygiene and be successful in removing bacteria from the mouth. Incision sites must be cleaned by using mouth rinses or salt water to clean.
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Sticking to Soft Food: During the healing process of the implant sticking to soft food is important to avoid the disturbances that are caused by using solid foods.
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Avoiding Smoking: Smoking interferes with the healing process by affecting the bones and soft tissues. Hence, it should be avoided to minimize implant failure.
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Follow-up: Post-operative instruction should be followed to avoid failure of implants. Regular visits and follow-up care are to be taken promptly.
Can Smokers Get Dental Implants?
Some smokers can have dental implants whereas others may not be fit to have them. Dentists can decide by examining the oral health status of a person. Some may need treatment before undergoing the procedure like bone loss to be treated with bone grafts, tartar and plaque to be removed, and gum disease to be treated. Smoking should be avoided completely till the healing process is completed.
Caring for Dental Implants If One Smokes:
Dentists may instruct the person to avoid smoking at least one week before the procedure. This can help the gum tissues to come back to their normal health. They may be instructed to avoid smoking for two months after the surgery. This helps in the healing process of the implant and allows osseointegration of bone with an implant.
After surgery, avoid rinsing, and touching the site with fingers and tongue to be done. This helps in avoiding the dislodgement of blood clots. The use of straw must be avoided. Post-operative instructions are to be followed.
The person must follow good oral hygiene practices every day. Regular visits to the dentist can help avoid complications.
What Is the Difference in Osseointegration Between a Non-smoker and a Smoker?
In a normal osseointegration phenomenon for a successful dental implant, the implant contacts the bone without deposition of any fibrous tissue. Also, this phenomenon is influenced by local oral factors such as the presence and functionality of the preosteoblasts that differentiate into osteoblast cells. The osteoblasts are, in fact, responsible for the secretion of the extracellular matrix that results in calcification between the bone-implant surface (BIC). The cells around successful dental implants exhibit anchorage, adhesion, proliferation, and differentiation into osteoblasts.
In smokers, there is primarily the formation of fibrous tissue that may be deposited at this interface between the bone and implant, forming a coagulum. In addition, the nicotine in tobacco or any cigarette product will usually release nitrosamine compounds, carbon dioxide, ammonia, aldehydes, benzene, etc., that correlate directly with bone resorption, rendering the dental implant unstable primary anchorage in the bone. The negative impact of cigarette contents is also due to the carbon monoxide element that acts as a potent inhibitor of oxygen. The red blood cells that carry oxygen are not only depleted of sufficient oxygen, but these compounds mentioned above inhibit enzyme systems in the oral cavity that are essential for normal oxidative metabolism (like hydrogen cyanide).
How Does Nicotine Cause Microvascular Constriction?
Nicotine has the detrimental ability to activate the voltage-gated calcium channels that regulate bone metabolism and fusion to the dental implant by severe changes in the intracellular calcium ion levels. The major effect studied in dental research is "the phenomenon of microvascular obstruction."
By the vasoconstrictive effect of nicotine exerted over the blood cells and the nutrients, ideally available at the bone-implant junction, interference is created due to a reduction in blood flow as well as nutrients post-implant insertion. It is one of the reasons why dental implants would possibly fail at a very early stage, even in a few months, in severe smokers. The evidence of the inhibition of immune T cells and B cells is also considered a bioactive factor for implant failure through peri-implant disease.
According to the evidence presented by the "human microbiome project," smokers developed an ecological succession of bacterial flora specific to peri-implant mucositis and peri-implant disease development that eventually results in "fibro-osseous" integration instead of "osseointegration."
Conclusion
Smoking is not a strict contraindication, but it is a risk factor for implant failure. When implant therapy is being considered, a person's smoking history should be gathered. This information should include how long the person has smoked, how much they have smoked in the past, and how much they smoke now. Dentists should strongly advise smokers to give up smoking before undergoing any implant-related surgery or dental implantation, pointing out that smoking might raise problems and lower the success rate of these treatments. In high-risk scenarios, the clinician must determine whether or not to begin implant therapy; nonetheless, if treatment is chosen to begin, the patient's informed permission is required.
