3.11 Dental diseases

Last updated: May 2020
Suggested citation: Purcell, K 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; 2020. 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 that supports the teeth—these tissue structures are 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

 A large study in the United Kingdom of 9,657 participants in the National Adult Dental Health survey found that non-smokers were more likely to rate themselves as having 'good oral health' compared with smokers (75% versus 57% respectively).2 Smokers were also twice as likely to attend the dentist symptomatically compared with non-smoker who were more likely to have regular dental visits. Disadvantaged smokers were also more likely to attend the dentist symptomatically and perceive they had poorer oral health.2

Periodontitis, dental caries and peri-implant pathology are three common chronic oral health conditions and smoking is a risk factor for all three. It has been estimated that preventing uptake of smoking could result in a potential reduction of 37% in periodontitis, 7% in dental caries, and 39% of cases of failure of tooth implants.3


3.11.1 Periodontitis

Periodontal disease (gum disease or periodontitis) is the inflammation of tissues surrounding the tooth. It affects the gum, ligaments and bone, and is caused by bacterial infection. As people age, the risk of periodontitis increases.4

Periodontal disease is associated with substantial morbidity and health care costs. 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 Australian adults affected by periodontitis due to their smoking.5 Data from the US National Health and Nutrition Survey in 2017 estimates that just under half of adults over 30 years of age (46.3%) had periodontal disease.6

Smoking causes periodontitis.1 A systematic review and meta-analysis of six studies in 2017 found that current smoking increased the risk of developing periodontitis by 80% compared with ex-smokers and never smokers.7 Those who had quit smoking had a similar risk to never smokers.7 A 2018 meta-analysis of 14 prospective longitudinal studies found that smoking has a negative effect on both the incidence and progression of periodontitis.8 Smokers also experience greater severity9 and a more rapid progression of periodontal disease than non-smokers.7, 9 Smokers have a poorer response to periodontal therapy than non-smokers.7, 9 Quitting smoking is beneficial, as non-surgical periodontal treatment outcomes improve after smoking cessation.7

The precise means by which smoking causes periodontitis have not been determined, but several 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 can also result in oxidative stress and changes to the immunoinflammatory systems which may also play an important role in the development of periodontitis.9

Smoking can also alter the balance of bacterial species in the mouth10 and has a negative effect on the quality of saliva in a long term smokers mouth. The saliva of smokers is thicker than non-smokers and the amount of saliva decreases significantly with long-term smoking and increasing age.11 Smokers also had a lower (more acidic) salivary pH compared with non-smokers which makes them more susceptible to oral and dental disease.12 Long-term smokers often have poorer oral hygiene compared with never smokers which compounds the problem.11 The balance of bacteria in the mouth can be restored following smoking sustained cessation. After ten years, smokers had the same balance of bacterial species as non-smokers.10

Smoking also results in poorer bone regeneration after surgical treatment aimed at replacing all missing tissues of the periodontium. A 2011 meta-analysis found significantly less bone gain in smokers than non-smokers after such treatment.13 Smoking also appears to inhibit the healing process following periodontal treatment by impacting on periodontal ligament stem cells.14

Exposure to secondhand smoke may also have harmful effects on periodontal health. A 2015 cohort study of 1,164 Japanese adults found that the risk for periodontal disease in men was significantly increased among current smokers and subjects exposed to secondhand smoke.15 A 2019 retrospective clinical study found that waterpipe users as well as smokers are vulnerable to peri-implant soft tissue inflammation and bone loss following dental implant procedures compared with those who have never smoked.16

Some of the negative effects of smoking on periodontal tissue can be reversed following sustained smoking cessation, therefore advice to quit should be an integral part of oral health advice.9

3.11.2 Dental caries

Dental caries (cavities) occur 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 Systematic review evidence suggests that smoking promotes the growth of bacterial microorganisms in the mouth that increase the risk of dental caries.17 The presence of nicotine enhances the growth of some of these bacteria, and smoking behaviour also influences the components of saliva. Together these changes promote an environment that makes smokers more susceptible to the formation of caries.17

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.18 Data from a US National Health and Nutrition survey of more than 5,000 women published in 2009 found that smoking is a risk factor for untreated caries and decayed, missing and filled permanent tooth surfaces.19 A 2019 systematic review and meta-analysis of eleven studies also found a positive association between tobacco smoking and dental caries.20 A 2019 prospective observational study of young adults in Sweden found that smoking, but not the use of moist Swedish snuff showed a statistically significant relationship with development of dental caries over a three year period.21

A 2014 cross-sectional study of 8,537 young adults in Finland also confirms that smoking is associated with other oral health risk behaviours such as eating sweet food, frequent snacking, consuming energy drinks and low brushing prevalence which can increase the risk of requiring restorative dental treatment.22

3.11.3 Tooth loss

The main biological causes of tooth loss (edentulism) are periodontal disease and caries.23 As outlined above, smoking has been linked to both.

There is a strong association between smoking and tooth loss.24-26 A systematic review found significant associations between smoking and tooth loss in each of the six cross-sectional and two cohort studies considered.27 A 2015 large cohort study in Germany of more than 23,000 participants also found that cigarette smoking is associated with higher prevalence of tooth loss.23 A 2018 meta-analysis of four cohort studies found that smokers had more than three times the risk of tooth loss compared with non-smokers among those participating in periodontal maintenance therapy.24 Two Japanese studies also found that smoking was associated with the number of missing teeth.28, 29

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.30

Most studies report that the duration and intensity of smoking are important factors influencing the risk of tooth loss.23-26, 30 Ten years or more of smoking is associated with tooth loss and this effect appears to be strongest among men who are current smokers and weakest among females who were ex-smokers.31 There is a dose response relationship, with heavy smoking (>15 cigarettes per day) associated with a three times higher risk of tooth loss in men and more than twice the tooth loss in women younger than 50 years of age compared with never smokers.23

Sustained smoking cessation is associated with a reduction in tooth loss.23, 25 Some studies have reported that the risk of tooth loss in a smoker will approximate that of a never smoker (depending on age and gender) after ten years,23, 31 while others report a reduction in this risk after twenty years or more of cessation.25, 28 The Australian ‘45 and up study’ found that the risk of being edentulous was still higher than that of never smokers 30 years after quitting.30

The relationship between smoking and tooth loss is apparent even among adults who have had access to subsidised dental care during their lifetime.26 A 2015 cohort study in Finland of almost 2,000 adults found a clear relation between the intensity and the duration of smoking and tooth loss, even though the adults in this study had access to subsidised dental care and reported good oral health.26

The Australian ‘45 and Up study’ also study suggested environmental tobacco smoke for six or more hours a week might also increase the risk of edentulism.30 An unmatched case-control study from Pakistan of 376 subjects found that smokers and users of smokeless tobacco had an increased risk of tooth loss.32

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 disease33 and the success of prosthetic implants for missing teeth.34

Smokers appear to have an increased risk implant failure compared with non-smokers following dental implant procedures.35, 36 A 2007 meta-analysis of 29 studies found a higher risk of implant failures and complications in smokers compared with non-smokers.34 A 2015 meta-analysis examined 19,836 implants placed in smokers and 60,464 implants placed in non-smokers.37 There was a failure rate of 6.35% in smokers (1259 failures) and 3.18 % failure in non-smokers (1923 failures).37 Smokers also have a greater risk of marginal bone loss36-38 and higher rate of postoperative infections following implant procedures.37

Cigarette smoke can also cause significant discoloration of dental composite resins used for dental restoration.39 A 2009 meta-analysis of seven studies found that root-coverage procedures for people with periodontal disease were less successful in smokers than non-smokers.33

Advice from dentists about quitting can be effective in encouraging quit attempts among smokers and may have benefits in reaching smokers who may not be in regular contact with other parts of the health system40 —refer Chapter 7, Section 7.10.4 for further details.  

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated July 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: https://www.cdc.gov/tobacco/data_statistics/sgr/2004/index.htm.

2. Csikar J, Kang J, Wyborn C, Dyer TA, Marshman Z, et al. The Self-Reported Oral Health Status and Dental Attendance of Smokers and Non-Smokers in England. PLoS ONE, 2016; 11(2):e0148700. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26863107

3. Nobre MA and Malo P. Prevalence of periodontitis, dental caries, and peri-implant pathology and their relation with systemic status and smoking habits: Results of an open-cohort study with 22009 patients in a private rehabilitation center. Journal of Dentistry, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28750777

4. Australian Institute for Health and Welfare. Oral health and dental care in Australia 2015. Canberra: AIHW, 2016. Available from: https://www.aihw.gov.au/reports/dental-oral-health/oral-health-dental-care-in-australia-2015.

5. 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

6. Vogtmann E, Graubard B, Loftfield E, Chaturvedi A, Dye BA, et al. Contemporary impact of tobacco use on periodontal disease in the USA. Tobacco Control, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26880744

7. Leite FRM, Nascimento GG, Baake S, Pedersen LD, Scheutz F, et al. Impact of smoking cessation on periodontitis: A systematic review and meta-analysis of prospective longitudinal observational and interventional studies. Nicotine and Tobacco Research, 2018:nty147-nty147. Available from: http://dx.doi.org/10.1093/ntr/nty147

8. Leite FRM, Nascimento GG, Scheutz F, and Lopez R. Effect of Smoking on Periodontitis: A Systematic Review and Meta-regression. American Journal of Preventive Medicine, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29656920

9. Nociti FH, Jr., Casati MZ, and Duarte PM. Current perspective of the impact of smoking on the progression and treatment of periodontitis. Periodontology 2000, 2015; 67(1):187-210. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25494601

10. Preidt R. Smoking triggers big changes in mouth bacteria, study finds, in Health Day2016. Available from: http://consumer.healthday.com/cancer-information-5/misc-tobacco-health-news-666/smoking-triggers-big-changes-in-mouth-bacteria-709469.html.

11. Petrusic N, Posavac M, Sabol I, and Mravak-Stipetic M. The Effect of Tobacco Smoking on Salivation. Acta Stomatologica Croatica, 2015; 49(4):309-15. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27688415

12. Grover N, Sharma J, Sengupta S, Singh S, Singh N, et al. Long-term effect of tobacco on unstimulated salivary pH. J Oral Maxillofac Pathol, 2016; 20(1):16-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27194856

13. 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

14. Ng TK, Huang L, Cao D, Yip YW, Tsang WM, et al. Cigarette smoking hinders human periodontal ligament-derived stem cell proliferation, migration and differentiation potentials. Sci Rep, 2015; 5:7828. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25591783

15. Ueno M, Ohara S, Sawada N, Inoue M, Tsugane S, et al. The association of active and secondhand smoking with oral health in adults: Japan public health center-based study. Tob Induc Dis, 2015; 13(1):19. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26225132

16. Alahmari F, Javed F, Ahmed ZU, Romanos GE, and Al-Kheraif AA. Soft tissue status and crestal bone loss around conventionally-loaded dental implants placed in cigarette- and waterpipe (narghile) smokers: 8-years' follow-up results. Clinical Implant Dentistry and Related Research, 2019. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30884091

17. Wu J, Li M, and Huang R. The effect of smoking on caries-related microorganisms. Tob Induc Dis, 2019; 17:32. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31516475

18. 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: https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm

19. 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: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1752-7325.2009.00128.x

20. Jiang X, Jiang X, Wang Y, and Huang R. Correlation between tobacco smoking and dental caries: A systematic review and meta-analysis. Tob Induc Dis, 2019; 17:34. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31516477

21. Petersson GH and Twetman S. Tobacco use and caries increment in young adults: a prospective observational study. BMC Research Notes, 2019; 12(1):218. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30971314

22. Tanner T, Kamppi A, Pakkila J, Jarvelin MR, Patinen P, et al. Association of smoking and snuffing with dental caries occurrence in a young male population in Finland: A cross-sectional study. Acta Odontologica Scandinavica, 2014; 72(8):1017-24. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25141188

23. Dietrich T, Walter C, Oluwagbemigun K, Bergmann M, Pischon T, et al. Smoking, Smoking Cessation, and Risk of Tooth Loss: The EPIC-Potsdam Study. Journal of Dental Research, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26243734

24. Vieira TR, Martins CC, Cyrino RM, Azevedo AMO, Cota LOM, et al. Effects of smoking on tooth loss among individuals under periodontal maintenance therapy: a systematic review and meta-analysis. Cadernos de Saude Publica, 2018; 34(9):e00024918. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30281706

25. Carson SJ and Burns J. Impact of smoking on tooth loss in adults. Evidence-based Dentistry, 2016; 17(3):73-74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27767106

26. Simila T and Virtanen JI. Association between smoking intensity and duration and tooth loss among Finnish middle-aged adults: The Northern Finland Birth Cohort 1966 Project. BMC Public Health, 2015; 15(1):1141. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26576994

27. Hanioka T, Ojima M, Tanaka K, Matsuo K, Sato F, et al. 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

28. Yanagisawa T, Marugame T, Ohara S, Inoue M, Tsugane S, et al. Relationship of smoking and smoking cessation with number of teeth present: JPHC Oral Health Study. Oral Diseases, 2009; 15(1):69. Available from: https://pubmed.ncbi.nlm.nih.gov/19744265

29. Yanagisawa T, Ueno M, Shinada K, Ohara S, Wright FA, et al. Relationship of smoking and smoking cessation with oral health status in Japanese men. Journal of Periodontal Research, 2010; 45(2):277-83. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19744265

30. 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: https://pubmed.ncbi.nlm.nih.gov/20884927

31. Simila T, Auvinen J, Timonen M, and Virtanen JI. Long-term effects of smoking on tooth loss after cessation among middle-aged Finnish adults: the Northern Finland Birth Cohort 1966 Study. BMC Public Health, 2016; 16(1):867. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27557640

32. Qureshi FH, Hamid S, Khan SM, and Qureshi AH. Effect of tobacco use on tooth loss among patients visiting the out-patient dental department of a tertiary care hospital in Pakistan. J Pak Med Assoc, 2018; 68(6):841-847. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29887612

33. 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: https://pubmed.ncbi.nlm.nih.gov/19255173

34. Strietzel F, Reichart P, Kale A, Kulkarni M, Wegner B, et al. 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: https://pubmed.ncbi.nlm.nih.gov/17509093/

35. Veitz-Keenan A. Marginal bone loss and dental implant failure may be increased in smokers. Evidence-based Dentistry, 2016; 17(1):6-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27012565

36. Alfadda S. Current Evidence on Dental Implants Outcomes in Smokers and Non-Smokers: A Systematic Review and Meta-Analysis. Journal of Oral Implantology, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29864381

37. Chrcanovic BR, Albrektsson T, and Wennerberg A. Smoking and dental implants: A systematic review and meta-analysis. Journal of Dentistry, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25778741

38. Mumcu E and Dayan SC. Effect of Smoking and Locations of Dental Implants on Peri-Implant Parameters: 3-Year Follow-Up. Med Sci Monit, 2019; 25:6104-6109. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31414668

39. Zhao X, Zanetti F, Majeed S, Pan J, Malmstrom H, et al. Effects of cigarette smoking on color stability of dental resin composites. American Journal of Dentistry, 2017; 30(6):316-322. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29251454

40. Ordell S and Ekback G. Smoking cessation and associated dental factors in a cohort of smokers born in 1942: 5 year follow up. International Dental Journal, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30009445