3.11 Dental diseases

Last updated: March 2015 
Suggested citation: Hurley, S, Greenhalgh, EM & Winstanley, MH. 3.11 Dental diseases. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2015. Available from http://www.tobaccoinaustralia.org.au/3-11-dental-diseases


The oral cavity is the first part of the anatomy to be exposed to mainstream smoke in smokers and, as described in Chapter 3, Section 3.5.1, smoking causes oral cancers. Smoking also damages the soft and hard tissue structures that support the teeth, known as the periodontium.1 The periodontium includes the gingiva and the ligaments that attach the tooth root to the jaw. The gingiva is the soft tissue covering the gums and overlapping the teeth; it protects the root surfaces of the teeth. Gingivitis is an inflammation of the gingiva, triggered by the build-up of plaque, leading to reddening of the gums, bleeding and swelling. Untreated gingivitis can lead to chronic periodontitis, an inflammation of the gingiva and the adjacent tooth attachment apparatus. Plaque on the teeth spreads below the gum line behind the gingiva, triggering an inflammatory response. A range of symptoms, including bleeding, swelling, gum recession and separation of the gingiva from the surface of the tooth, lead to further infection. This in turn can lead to bone loss, loosening of teeth, development of abscesses in soft tissue and bone, a greater risk of decay of the exposed root surfaces of the tooth (root surface caries) and tooth loss.1

3.11.1 Periodontitis

Smoking causes periodontitis. Increased tobacco use and longer duration of smoking are associated with more severe disease and a higher risk of dental damage. Cessation appears to reduce the risk.1-5

Analysis of the Australian National Survey of Adult Health (2004–2006) suggested that about 32% of moderate to severe periodontitis is due to smoking. This extrapolates to an estimated 700 000 adults affected by periodontitis due to their smoking.6

The precise means by which smoking causes periodontitis have not been determined, but three mechanisms have been suggested. First, smoking may increase the quantity of plaque and the likelihood that bacterial pathogens colonise the plaque. Second, smoking impairs the body's immune response, making the smoker more susceptible to bacterial infection and also impairing the regeneration and repair of periodontal tissues. Third, the vasoconstrictive effect of tobacco smoke and nicotine may reduce gingival blood flow and impair oxygen and nutrient delivery to gingival tissue.1

Smoking also results in poorer bone regeneration after surgical treatment aimed at replacing all missing tissues of the periodontium. A meta-analysis found statistically significant less bone gain in smokers than non-smokers after such treatment.7

3.11.2 Dental caries

Dental caries (cavities) is a disease that occurs when acids produced by bacteria dissolve the hard enamel of the tooth surface. It is then possible for bacteria to penetrate the tooth and reach the pulp tissue. Pain, infection and the need for tooth extraction can result.1

The 2014 US Surgeon General’s report found that smokers are more likely to have dental caries, missing teeth due to decay, or fillings, although more research is needed to establish smoking as a cause.8 Data from a US national healthy survey of more than 5,000 women found that smoking is a risk factor for untreated caries and DMFS: decayed, missing (due to disease) and filled permanent tooth surfaces.3

3.11.3 Tooth loss

The main biological causes of tooth loss (edentulism) are periodontal disease and caries. As outlined above, smoking is linked to the risk of both.

A systematic review found significant associations between smoking and tooth loss in each of the six cross-sectional and two cohort studies considered.9 Most studies found a dose-response relationship and a decrease in the risk of tooth loss for former smokers.

The Australian '45 and Up Study' investigated the association between smoking and the chance of being edentulous (having no teeth remaining) in approximately 100 000 residents of New South Wales. Smokers had a 2.5-fold higher risk of being edentulous compared with never smokers. The more and the longer people smoked, the higher their risk. Former smokers had lower risk than current smokers but the chance of being edentulous was still higher than that of never smokers 30 years after quitting.10 A Japanese study also found that smoking was associated with the number of missing teeth.11 The Australian study suggested environmental tobacco smoke might also increase the risk of edentulism.10

3.11.4 Complications and failure of dental procedures

Because of the established adverse effects of smoking on the oral cavity, researchers have investigated the impact of smoking on the outcome of surgical procedures for periodontal disease12 and the success of prosthetic implants for missing teeth.13

A meta-analysis published in 200713 and an evaluation of implants in almost 500 patients published in 201014 found that smoking approximately doubles the risk of implant failure. A review by the Massachusetts Dental Society noted that in a cross-sectional study of 109 patients, the prevalence of implant loss in smokers was 15.3%, compared with 2% in non-smokers.15 The review also cited studies reporting that smoking increases the risk of peri-implantitis and that implants failed earlier in patients who smoked more, and concluded that smoking is a relative contraindication to implant placement.

Root-coverage procedures for people with periodontal disease were less successful in smokers than non-smokers.12 The US Surgeon General concluded that the evidence suggests that smoking compromises the survival of dental implants, but more research is needed to confirm it as a cause of dental implant failure.8

Relevant news and research

For recent news items and research on this topic, click here.(Last updated March 2020)


1. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/index.htm

2. Al-Habashneh R, Al-Omari M and Taani D. Smoking and caries experience in subjects with various form of periodontal diseases from a teaching hospital clinic. International Journal of Dental Hygiene 2009;7(1):55–61. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1601-5037.2008.00349.x/abstract

3. Iida H, Kumar JV, Kopycka-Kedzierawski DT and Billings RJ. Effect of tobacco smoke on the oral health of US women of childbearing age. Journal of Public Health Dentistry 2009;69(4):231–41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19453866?ordinalpos=15&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVBrief

4. Zini A, Sgan-Cohen HD and Marcenes W. Socio-economic position, smoking, and plaque: a pathway to severe chronic periodontitis. Journal of Clinical Periodontology 2010;38(3):229–35. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21198768

5. Vered Y, Livny A, Zini A and Sgan-Cohen H. Periodontal health status and smoking among young adults. Journal of Clinical Periodontology 2008;35(9):768–72. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1600-051X.2008.01294.x/abstract

6. Do LG, Slade GD, Roberts-Thomson KF and Sanders AE. Smoking-attributable periodontal disease in the Australian adult population. Journal of Clinical Periodontology 2008;35(5):398-404. Available from: http://dx.doi.org/10.1111/j.1600-051X.2008.01223.x

7. Patel R, Wilson R and Palmer R. The effect of smoking on periodontal bone regeneration: a systematic review and meta-analysis. Journal of Periodontology 2011;[Epub ahead of print] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21627463

8. US Department of Health and Human Services. The health consequences of smoking - 50 years of progress. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Available from: http://www.surgeongeneral.gov/library/reports/50-years-of-progress

9. Hanioka T, Ojima M, Tanaka K, Matsuo K, Sato F and Tanaka H. Causal assessment of smoking and tooth loss: a systematic review of observational studies. BMC Public Health 2011;11(1):221. Available from: http://www.biomedcentral.com/content/pdf/1471-2458-11-221.pdf

10. Arora M, Schwarz E, Sivaneswaran S and Banks E. Cigarette smoking and tooth loss in a cohort of older Australians: the 45 and up study. Journal of the American Dental Association 2010;141(10):1242–9. Available from: http://jada.ada.org/cgi/content/full/141/10/1242

11. Yanagisawa T, Marugame T, Ohara S, Inoue M, Tsugane S and Kawaguchi Y. Relationship of smoking and smoking cessation with number of teeth present: JPHC Oral Health Study. Oral Diseases 2009;15(1):69. Available from: http://onlinelibrary.wiley.com/store/10.1111/j.1601-0825.2008.01472.x/asset/j.1601-0825.2008.01472.x.pdf?v=1&t=ghzos013&s=b4b8ac23f7fe9512cdc8dfe6c9b59e989b1b6ee1

12. Chambrone L, Chambrone D, Pustiglioni F, Chambrone L and Lima L. The influence of tobacco smoking on the outcomes achieved by root-coverage procedures: a systematic review. Journal of the American Dental Association 2009;140(3):294–306. Available from: http://jada.ada.org/cgi/reprint/140/3/294.pdf

13. Strietzel F, Reichart P, Kale A, Kulkarni M, Wegner B and Küchler I. Smoking interferes with the prognosis of dental implant treatment: a systematic review and meta-analysis. Journal of Clinical Periodontology 2007;34(6):523–44. Available from: http://www3.interscience.wiley.com/journal/118533327/abstract

14. Anner R, Grossmann Y, Anner Y and Levin L. Smoking, diabetes mellitus, periodontitis, and supportive periodontal treatment as factors associated with dental implant survival: a long-term retrospective evaluation of patients followed for up to 10 years. Implant Dentistry 2010;19(1):57–64. Available from: http://journals.lww.com/implantdent/pages/articleviewer.aspx?year=2010&issue=02000&article=00009&type=abstract

15. Snider T, Cottrell D and Batal H. Summary of current consensus on the effect of smoking on implant therapy. Journal of the Massachusetts Dental Society 2011;59(4):20–2. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=21446616