Are We Practicing According to the Evidence?Periodontitis and Smoking: An Evidence-Based Appraisal
Introduction
The awareness of the harmful effects of tobacco smoking on many organs and tissues in the body has gradually increased in the general population and bans on smoking in public places are becoming more and more common in many countries. In dentistry the harmfulness of smoking, surprisingly, has gained only limited concern. In spite of the fact that there is substantial knowledge to verify the effects of smoking on oral tissues, dental care in general has devoted very little time and effort to the information about these untoward effects. One reason for this negligence may be that the effects of smoking on oral and, in particular, periodontal health are insufficiently appreciated or underestimated.
Although the first reports on smoking and its potential effects on periodontal health emanate from the early 1950s, a more thorough understanding or acceptance of smoking as a periodontal health risk began with the appearance of 3 independent publications in 1983.1., 2., 3. Since then, a gradually increasing interest in the relationship between smoking and the periodontal health condition has emerged. Over the past 10 to 15 years smoking has gained scientific acceptance as an important risk factor for destructive periodontal disease. In addition, the potential interference of smoking with the outcome of various periodontal therapies has been addressed in a number of investigations. The objective of the present systematic review, therefore, is to give a critical appraisal of the available literature on the subject to establish an evidence base regarding (1) the relationship between smoking and the periodontal health condition and (2) the influence of smoking on periodontal therapy outcome.
Section snippets
Method
A search in medical databases using MeSH terms related to “smoking” and “periodontal…” resulted in approximately 1050 hits. A further selection including clinical and epidemiological studies in humans alone resulted in a retrieval of 577 titles. A narrowing to include studies that only used measures of the periodontal destruction such as pocket probing depth, attachment level (or attachment loss), bone height (or bone loss), and tooth frequency further reduced the number of titles. Thus,
Population Studies
Overall, the population studies that have addressed the relationship between smoking and periodontitis include 70 cross-sectional,1., 2., 3., 4., 5., 6., 7., 8., 9., 10., 11., 12., 13., 14., 15., 16., 17., 18., 19., 20., 21., 22., 23., 24., 25., 26., 27., 28., 29., 30., 31., 32., 33., 34., 35., 36., 37., 38., 39., 40., 41., 42., 43., 44., 45., 46., 47., 48., 49., 50., 51., 52., 53., 54., 55., 56., 57., 58., 59., 60., 61., 62., 63., 64., 65., 66., 67., 68., 69., 70. 14 case-control,71., 72., 73.
Comments and evidence interpretation of population studies
More than 100 studies including about 90,000 individuals distributed among cross-sectional and case-control as well as cohort studies were included in the present appraisal. Altogether, the analysis shows an overwhelming consistency among study results indicating that the periodontal health condition of smokers is significantly inferior to that of nonsmokers. As the studies were based on data collected in populations from a great number of nations throughout the world—developed as well as
Comments and evidence interpretation of intervention studies
Overall, the results of the intervention studies suggest an inferior therapeutic outcome in smoker patients compared to nonsmoker patients. In 80% of studies the results were statistically significant. The rationale for nonsurgical therapy is to bring about resolution of inflammation by means of eliminating subgingival microbial deposits. When measured in terms of mean PPD reduction or mean CAL gain after a maximum of 9 months, the outcome on the average is less efficient in smokers than in
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