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Oral Health and Tobacco Use

Oral Health and Tobacco Use. Presented by: Laura Romito, DDS, MS Kathy Walker, BA. Learning Objectives. After attending the session, participants should be able to: 1. Identify the effects of tobacco use on oral hard and soft tissues.

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Oral Health and Tobacco Use

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  1. Oral Health and Tobacco Use Presented by: Laura Romito, DDS, MS Kathy Walker, BA

  2. Learning Objectives • After attending the session, participants should be able to: • 1. Identify the effects of tobacco use on oral hard and soft tissues. • 2. Provide information about statewide tobacco cessation resources. • 3. Address marketing of smokeless tobacco products and increased use of these products especially in rural communities.

  3. Tobacco Products • Smoking • Cigarette • Cigar • Pipe • Hookah • Smokeless (spit) • Snuff • Chew • Snus • Dissolvable

  4. The Rural Culture • In years past the tobacco industry used frontier images to convey the image of a “real” man, who worked the land and smoked cigarettes. In fact, the Marlboro Man was well known and synonymous with such an image. • Although these images were not necessarily targeting the rural population, they amplified and helped to • maintain social and cultural norms within • rural communities. http://tobaccoeval.ucdavis.edu/documents/culture_rural.pdf

  5. Rural Marketing • Such belief systems no doubt relate to the significantly high rate of smokeless tobacco use currently seen in rural populations, where chewing tobacco is viewed as part of being young and male in rural areas • (Campbell-Grossman et al., 2003) • In this manner, the tobacco industry exploits the social and cultural aspects of smokeless tobacco, most easily demonstrated by the tobacco industry’s past and current sponsorship of sporting events such as • rodeos, bull riding and car racing • (Pokhrel et al., 2009). http://tobaccoeval.ucdavis.edu/documents/culture_rural.pdf

  6. Research shows that smokeless tobacco is most common in rural areas. National surveys reveal that a huge gap exists between smokeless tobacco use among rural and urban residents (Pokhrel et al., 2009; Stevens et al., 2010). • According to the National Survey on Drug Use and Health (2007), the use of smokeless tobacco is almost three times higher in rural areas compared to those who live in large and small metropolitan areas. • The prevalence of smokeless tobacco is highest among young males aged 18 to 24 living in rural areas(Campbell-Grossman, et al., 2003; Boyle et al., 1999). Smokeless Use in Rural Areas http://tobaccoeval.ucdavis.edu/documents/culture_rural.pdf

  7. Sweet Shop versus Tobacco Shop Can you tell the difference?

  8. Melt-Away Tobacco Strips or Chewing Gum?

  9. Tobacco Orbs or Tic Tac’s?

  10. Chewing Tobacco or Breath Mints?

  11. Tobacco Stick or Orange Stick?

  12. PERCENTAGE OF MIDDLE AND HIGH SCHOOL STUDENTS WHO EVER TRIED FLAVORED TOBACCO PRODUCTS, 2008 IYTS Middle School 6% Smokeless Tobacco 9% Cigars 8% Black & Mild cigars, Swisher Sweets cigarillos, and/or Phillies Blunt cigars High School 15% Smokeless Tobacco 30% Cigars 32% Black & Mild cigars, Swisher Sweets cigarillos, and/or Phillies Blunt cigars

  13. CURRENT USE OF TOBACCO PRODUCTS AMONG MIDDLE AND HIGH SCHOOL STUDENTS, 2008 IYTS Middle School 10% Any Tobacco Products 4% Cigarettes 3% Smokeless Tobacco 4% Cigars High School 31% Any Tobacco Products 18% Cigarettes 8% Smokeless Tobacco 15% Cigars

  14. Education • GED: 43.2%, College: 10.7% • Socioeconomic status • Low SES : ~50% • Age • 18-24 = 24.4%; > 65=8.6% • Ethnicity • Native American: 32% • Asian American: 13% Smoking Prevalence MMWR, 2006 Mayo Clinic Foundation, 2008

  15. Adverse Effects of Tobacco Smoking The initial interaction of smoking with the human body occurs most often in the oral cavity, where it would be expected to be active and exposure to be intense. • Cancers, CVD, Respiratory diseases • Oral effects • Discoloration of teeth and restorations • Coated / hairy tongue • Reduced sense of taste and smell • Smokers’ melanosis • Smokers’ palate • Oral Candidiasis • Dental Caries • Increased implant failure rates • Periodontal disease • Poor wound healing • Leukoplakia • Carcinoma

  16. Heavy smokers are 4.7 times more likely to develop prematurely wrinkled faces than non-smokers Annals of Internal Medicine (1991)

  17. Smokers have decreased clinical signs of inflammation

  18. Impaired bleeding may indicate a faulty inflammatory vascular response in response to dental plaque resulting in alterations in the body’s basic gingival defense mechanism

  19. Smoking & Periodontal Status • Nicotine & CO wound healing • Decreased blood flow • Immune effects • Increased destructive actions of neutrophils • Fibroblast impairment • Increased prevalence of potential periodontal pathogens. • Protective antibodies are reduced in smokers, specifically immunoglobulin G to A. actinomycetemcomitans

  20. Smoking & Gum Disease • Compared to nonsmokers, smoker’s are 4x more likely to have severe periodontal disease • The average 32 yr old smoker has similar perio attachment loss as a 59 yr old nonsmoker! J. Perio. 2004;74:196-209

  21. Continued smoking is an important cause of impaired healing in all aspects of periodontal treatment Linde, et al, “Clinical Periodontology” 2008, 5th Edition, pp. 316-322

  22. Does ETS Influence Perio Status? • PMN action intensified in passive smoking Numabe Y, Ogawa T, Kamoi H, et al. Phagocytic function of salivary PMN after smoking or secondary smoking. Ann Periodontol. 1998; 3(1): 102-7. • Periodontal disease: 1.6x more likely in NS exposed to ETS than NS not exposed Arbes SJ, Jr., Agustsdottir H, Slade GD. Environmental tobacco smoke and periodontal disease in the United States. Am J Public Health. 2001; 91(2): 253-7. • ETS increases periodontal inflammatory responses • Nishida N, Yamamoto Y, Tanaka M, et al. Association between passive smoking and salivary markers related to periodontitis. J Clin Periodontol. 2006; 33(10): 717-23. • Nishida N, Yamamoto Y, Tanaka M, et al. Association between involuntary smoking and salivary markers related to periodontitis: a 2-year longitudinal study. J Periodontol. 2008; 79(12): 2233-40. • Shizukuishi S. Smoking and periodontal disease. Clin Calcium 2007;17(2):226-32.

  23. Implant Failure Cigarette smoking is an important risk factor for implant failure, especially for those who smoke more than 10 cigarettes a day Linde, et al, “Clinical Periodontology” 2008, 5th Edition, pp 591, 597

  24. Smoking and Dental Caries • Parental smoking related to caries in young kids (Williams et al, 2000, Sherkin et al 2004) • Active & passive smoking associated with presence of carious permanent teeth (Ayo-Yusef, 2007; Ojima et al 2007) • Possible biological mechanisms • Smoking & saliva flow rates & composition • Tobacco & the immune system • Oral bacteria responses to tobacco

  25. Dental Calculus • Cigarette smokers have higher levels of both supra- and sub-gingival calculus than do nonsmokers. • Cessation is accompanied by a reduction in calculus formation

  26. Smoker’s Melanosis

  27. Nicotine Stomatitis Is strongly associated with reverse smoking, cigar smoking, and a high frequency of pipe and cigarette smoking

  28. Smokeless Tobacco Effects Esthetic Considerations (Stains & Halitosis) Gingival Recession & Bone Loss Abrasion & Dental Caries Hairy Tongue Tobacco Pouch Keratosis Leukoplakia Erythroplakia Squamous cell carcinoma

  29. Gingival Recession and Bone Loss A positive association exists between ST use and gingival recession, especially among long-term users who also have co-existing gingivitis

  30. Tooth Abrasion & Dental Caries Sand and grit in ST can significantly wear down occlusal surfaces of teeth Sugar found in chewing tobacco (especially flavored varieties) can contribute to dental caries

  31. 52 M “snuff patch” smokeless tobacco use, 3-4x daily

  32. Tobacco Pouch Keratosis Lesion is typically found in vestibule where the tobacco is placed; may extend into the gingiva and buccal mucosa Most are readily reversible once the habit is discontinued If lesion persists after one month of cessation, biopsy is recommended

  33. Leukoplakia “A predominantly white lesion of the oral mucosa that cannot be characterized as any other definable lesion” (WHO, 2003) 20% of oral leukoplakia exhibit dysplastic or cancerous changes; 9-17% will exhibit malignant transformation Occur mostly where tobacco is held in place Treatment includes biopsies and sometimes total removal of the lesion

  34. Leukoplakia • Is definitely associated with both smoked and smokeless tobacco use. • Is dose related, e.g. positively linked to the frequency, intensity, amount, and length of tobacco use.

  35. Snuff Dipper’s Lesions are Often Reversible Of 29 subjects using moist snuff, all those who quit (20) showed clinically healthy and histologically normal mucosa after 3-6 months. J. Oral Pathology (1991) Larsson, Axell, Andersson

  36. Snuff Dipper’s Keratosis

  37. Erythroplakia “Term used to designate a red patch of oral mucosa that cannot be diagnosed as any specific disease” (Neville, Damm, & White, 2003) Lesions may be single, multiple, smooth, or pebbly; may be “speckled” with leukoplakia Mostly affect patients who use tobacco and consume alcoholic beverages Up to 90% of patients will exhibit severe epithelial dysplasia, carcinoma in-situ, or squamous cell carcinoma

  38. Leading Carcinogens Contained in ST • Tobacco-Specific Nitrosamines • Polycyclic Aromatic Hydrocarbons • Radiation-Emitting Polonium

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