Effect of cigarette smoking on periodontai healing foi lowing surgical therapy
Hans Preber and Jan Bergstrom Department of Periodontology, School of Dentistry, Karolinska Institutet, Stockholm, Sweden
Preher H and Bergstrom J: Effect of cigarette smoking on periodontal healing following .surgical therapy. J Clin Periodontol J990; 17: 324-328.
Abstract. The influence of cigarette smoking on the outcotne of surgical therapy was investigated in 54 patients, 24 of whom were smokers. The patients had moderate to severe periodontitis with persisting diseased pockets after nonsurgical therapy. The surgical modality used was the rnodified Widman flap operation and the pockets under scrutitiy were those with an initial probing depth of 4-6 tnm. Re-examination was made 12 months following the completion of surgery. The probing depth reduction at the 12-month follow-up was 0.76 + 0.36 mm (meari + SD) in smokers as compared to 1.27 + 0.43 mm in non-smokers. The difference was statistically significant (P4 mtn) and a repeatedly low plaque index ( 0.05 >0.05 0.05
Figures within parentheses refer to the smokers, excluding 4 patients with plaque index >0.6, « = 20.
(baseline) and 12 months after surgery. The evaluation of changes in probing depth was limited to sites with an initial probing depth of 4-6 mm. The number of teeth remaining, the number of pockets and the mean probing depth in the two subgroups at baseline are presented in Table 1. The number of pockets per patient according to probing depth class is presented in Table 2.
•:' ^
-•
,
•
non-smokers was performed using the Student /-distribution. In all analyses, the patient constituted the unit. Multiple regression analysis was carried out with probing depth reduction as dependent variable and with initial smoking habit and plaque index as predictors. The GLIM programme package was used (Baker & Nelder 1978). Significance was accepted at a /i-level , I j Non-smokers Fig. 3. Frequeney of pockets 4—6 mm exhibiting improved or impaired probing depth 12 months following periodontal surgery. Pooled poekets according to initial probing depth. IMPAIRED
Smoking and periodontal surgery tors which should be considered when interpreting the results, such as blindriess of observations. It is probably not feasible to make the clinical recordings blind with respect to smoking. In order to avoid this fallacy, the clinical examination was performed by observers who were not aware that smoking was one aspect under scrutiny. Therefore, the present results sustain the view that smoking may interfere with the therapeutical outcome following periodontal surgery. Our observations may reflect interference with primary healing events or be considered as evidence of recurrence of disease. Further investigation both in the shortterm and long-term perspective is required for substantiation of an adverse effect of smoking on periodontal healing. Acknowledgements
The authors gratefully acknowledge the Statistical advice of Professor G. Eklund. Department of Cancer Epidemiology, Karolinska Institutet, Stockholm. Financial support was received from Praktikertjanst AB, Stockholm. Zusammenfassung Der Einfluss des Zigareltenraiichens auf die Heilung des Parodont nach chirurgiseher Therapie Bei 54 Paticnten, unlor denen sich 24 Raucher befanden, wurde der Einfluss des Zigarettenrauchens auf den Erfolg chirurgiseher Therapie untersueht. Naeh eingangs vorgenommener, nieht-ehirurgischer Therapie lag bei diesen Patienlen massige bis scliwere Parodonlitis mit persistierenden erkrankten Tasehen vor. Die modifizierte Lappenoperation naeh Widman wurde als, in diesen Fallen indizicrtes, chirurgisches Verfahren angcwandt und bei den zu behandelnden Taschen war die ursprungliche Sondierungsliefe 4-6 mm. 12 Monalc nach dem Abschluss der chirurgischen Behandlung wurde eine Wiederholungsunlersuchung vorgenommen. Die Reduktion der Sondierungsliefen bei der Folgeuntersuchung naeh 12 Monaten belrug bei den Rauchern 0.76 + 0.36 (Miltelwerl + SD), was im Vergleich mil 1.27 + 0.43 bei Nichlrauchern gesehen werden muss. Dieser Untersehied war stalistisch abgesichert (/!< 0.001) ct persistait meme lorsque le facteur plaque ctait pris en consideration. Les resultats indiquent que fumer peut entraver le processus de guerison parodontale.
References Abbott, R. D., Yin, Y, Reed, D. M. & Yano, K. (1986) Risk of stroke in male cigarette smokers. New England Jotirnat of Medicine 315, 717-720. Baker, R. i. & Nelder, J. A. (1978) The GUM system. Release 3. Oxford: Numerical Algoritms Group. Bergstrom, J. & Henrikson, C. O. (1974) Quantitative long-term determinations of the alveolar bone tiiineral mass iti tnan by I'-' absorptiometry (II). Following periodontal surgery. Acta Radiologica. Therapy Physics Biology 13, 489-500. Bergstrom, J. & Floderus-Myrhed, B. (1983) Co-twin control study of the relationship between smoking and some periodontal disease factors. Conmnmity Dentistry and Oral Epidemiology 11, 113-116. Bergstrom, J. & Eliasson, S. (1987) Cigarette smoking and alveolar bone height in subjeets with a high standard of oral hygiene. Journal of Clinical Periodotitology 14, 466-469. Bolin, A., Lavstedt, S., Frithiof, L. & Henrikson, C. O. (1986) Proximal alveolar bone loss in a longitudinal radiographic investigation. IV. Smoking and some other factors inlluencing the progress in a material of individuals with at least 20 remaining teeth. Acta Odontologica Scandinavica 44, 263-269. Doll. R. & Peto, R. (1976) Mortality in relation to smoking. British Medical Jotirnal 2, 1525-1536. Feldman, R. S., Bravocos, J. S. & Rose. C. L. (1983) Association between smoking different tobacco products and periodontal disease indexes. Journal of Periodontology 54. 4S\-487. Herulf, G. (1968) On the marginal alveolar ridge in adults. Svensk Tandtaekare Tidskrift 61, 675-703. Hill, R. W., Ramfjord, S. W., Morrison, E. C , Appleberry, E. A., Caffesse, R. G., Kerry, G. J. & Nissle, R. R. (1981) Four types of periodontal treatment cotnpared
327
over two years. Journal of Periodontotogv 52, 655-662. Isidor, F. & Karring, T. (1986) Long-term effect of sttrgical and non-surgical periodontal treatment. A 5-year clinical study. Journal of Periodontal Research 21, 462-473. Ismail, A. .1., Burt, B. A. & Eklund, S. A. (1983) Epidemiologic patterns of smoking and periodontal disease in the United States. Jourtial of the Atnerican Dental As.mciation 106, 617-621. Kannel, W. B. (1983) An overview of the risk factors for cardiovascular disease. In: Kaplan, A. & Stamler, J. (eds): Prevention of coronary heart disease. London: WB Saunders. Lam, S. K.& Koo, J. (1983) Accurate prediction of duodenal-ulcer healing rate by discriminant analysis. Gastroenlerologv 85, 403-^12. Lavstedt, S. (1975) A tnethodologiealroentgenological investigation on marginal alveolar bone loss. Acta Odontologica Seandinavica 33, Supplement 67. Lindhe, J. & Nyman, S. (1987) Chnieal trials in periodontal therapy. Journal of Periodontal Research 22. 217-221. Lindhe, .1., Westfelt, E., Nyman, S., Socransky, S. S. & Haffajee, A. D. (1984) Longterm effect of surgical/non-surgical treatment of periodontal disease. Journal of Clinical Periodonto/ogy 11, 448-458. Philstrorn, B. L., McHugh, R. B., Oliphant, T. H. & Ortiz-CamposX. (1983) Comparison of surgical and nonsurgical treatment of periodontal disease. A review of current studies and additional results after 6 1/2 years. Journal of Clinical Periodontology 10,524-541. Preber, H. & Bergstrom, J. (1986a) Cigarette smoking in patients referred for periodontal treatment. Scandinavian Journal of Dental Researeh 94, 102-108. Preber, H. & Bergstrom, J. (1986b) The effect of nonsurgical treatment on periodontal pockets in smokers and non-smokers. Journal of Clinical Periodontotogy 13, 319-323. ' Ramljord, S. P & Nissle. R. R. (1974) The modified Widman flap. Journal of Periodontotogy 45, 601-607. Ramljord, S. P., CalTesse, R. G., Morrison, E. C , Hill, R. W., Kerry, G. J., Appleberry, E. A., Nissle, R. R. & Stults, D. L. (1987) 4 modalities of periodontal treatment compared over 5 years. Journal of Clinical Periodontologv 14. 445^53. Rees, T , Liverett, D. & Guy, C. (1984) The effect of cigarette smoking on skin flap survivel in the face lift patient. Plastic Reconstructive Surgery 73, 911-915. Riefkohl, R., Wolfe, ,1., Cox, E. & McCarty, K. (1986) Association between cutaneous ocelusive vascular disease, cigarette smoking and skin slough after rhytidectomy. Plastic Reconstructive Surgery 77, 592-595. Rosling, B., Nyman, S. & Lindhe, J. (1976) Effect of systematic plaque control on
328
Preher & Bergstrom
bone regeneration in intrabony pockets. Journal of Clinical Pcriodontologv 3. 38-53. Shciham, A. (1971) Periodontal disease and oral cleanliness in tobacco smokers. Journal of Pei-iotlonlology 42. 259-263. Silness, J. & Loe, H. (1964) Periodontal disease in pregnancy (II). Correlation between oral hygiene and periodontal condition. Ada Odonlologica Scandinavica 22, 121-135.
Slone, D., Shapiro, S., Rosenberg, L., Kaufman, D. W., Hartz, S. C , Rossi, A. C , Stolley, R D. & Mictinen, O. S. (1978) Relation of cigarette sinoking to myocardial infarction in young women. New England Journal of Medicine 298, 1273-1276. Solomon, H. A., Priorc, R. J. & Bross, J. D. J. (1968) Cigarette smoking and periodontal disease. Journal of the American Denial A.isocialion 11, 1081-1084. Sweet, J. B. & Butler, D. R (1979) The re-
lationship of smoking to localized osteitis. Journal of Oral Surgery 37, 732-735. Address: Hans Preber Department of Periodontology School of Dentistry Karolitiska In.stitutet Box 4064 S-141 04 Huddinge Sweden
Hans Preber and Jan Bergstrom Department of Periodontology, School of Dentistry, Karolinska Institutet, Stockholm, Sweden
Preher H and Bergstrom J: Effect of cigarette smoking on periodontal healing following .surgical therapy. J Clin Periodontol J990; 17: 324-328.
Abstract. The influence of cigarette smoking on the outcotne of surgical therapy was investigated in 54 patients, 24 of whom were smokers. The patients had moderate to severe periodontitis with persisting diseased pockets after nonsurgical therapy. The surgical modality used was the rnodified Widman flap operation and the pockets under scrutitiy were those with an initial probing depth of 4-6 tnm. Re-examination was made 12 months following the completion of surgery. The probing depth reduction at the 12-month follow-up was 0.76 + 0.36 mm (meari + SD) in smokers as compared to 1.27 + 0.43 mm in non-smokers. The difference was statistically significant (P4 mtn) and a repeatedly low plaque index ( 0.05 >0.05 0.05
Figures within parentheses refer to the smokers, excluding 4 patients with plaque index >0.6, « = 20.
(baseline) and 12 months after surgery. The evaluation of changes in probing depth was limited to sites with an initial probing depth of 4-6 mm. The number of teeth remaining, the number of pockets and the mean probing depth in the two subgroups at baseline are presented in Table 1. The number of pockets per patient according to probing depth class is presented in Table 2.
•:' ^
-•
,
•
non-smokers was performed using the Student /-distribution. In all analyses, the patient constituted the unit. Multiple regression analysis was carried out with probing depth reduction as dependent variable and with initial smoking habit and plaque index as predictors. The GLIM programme package was used (Baker & Nelder 1978). Significance was accepted at a /i-level , I j Non-smokers Fig. 3. Frequeney of pockets 4—6 mm exhibiting improved or impaired probing depth 12 months following periodontal surgery. Pooled poekets according to initial probing depth. IMPAIRED
Smoking and periodontal surgery tors which should be considered when interpreting the results, such as blindriess of observations. It is probably not feasible to make the clinical recordings blind with respect to smoking. In order to avoid this fallacy, the clinical examination was performed by observers who were not aware that smoking was one aspect under scrutiny. Therefore, the present results sustain the view that smoking may interfere with the therapeutical outcome following periodontal surgery. Our observations may reflect interference with primary healing events or be considered as evidence of recurrence of disease. Further investigation both in the shortterm and long-term perspective is required for substantiation of an adverse effect of smoking on periodontal healing. Acknowledgements
The authors gratefully acknowledge the Statistical advice of Professor G. Eklund. Department of Cancer Epidemiology, Karolinska Institutet, Stockholm. Financial support was received from Praktikertjanst AB, Stockholm. Zusammenfassung Der Einfluss des Zigareltenraiichens auf die Heilung des Parodont nach chirurgiseher Therapie Bei 54 Paticnten, unlor denen sich 24 Raucher befanden, wurde der Einfluss des Zigarettenrauchens auf den Erfolg chirurgiseher Therapie untersueht. Naeh eingangs vorgenommener, nieht-ehirurgischer Therapie lag bei diesen Patienlen massige bis scliwere Parodonlitis mit persistierenden erkrankten Tasehen vor. Die modifizierte Lappenoperation naeh Widman wurde als, in diesen Fallen indizicrtes, chirurgisches Verfahren angcwandt und bei den zu behandelnden Taschen war die ursprungliche Sondierungsliefe 4-6 mm. 12 Monalc nach dem Abschluss der chirurgischen Behandlung wurde eine Wiederholungsunlersuchung vorgenommen. Die Reduktion der Sondierungsliefen bei der Folgeuntersuchung naeh 12 Monaten belrug bei den Rauchern 0.76 + 0.36 (Miltelwerl + SD), was im Vergleich mil 1.27 + 0.43 bei Nichlrauchern gesehen werden muss. Dieser Untersehied war stalistisch abgesichert (/!< 0.001) ct persistait meme lorsque le facteur plaque ctait pris en consideration. Les resultats indiquent que fumer peut entraver le processus de guerison parodontale.
References Abbott, R. D., Yin, Y, Reed, D. M. & Yano, K. (1986) Risk of stroke in male cigarette smokers. New England Jotirnat of Medicine 315, 717-720. Baker, R. i. & Nelder, J. A. (1978) The GUM system. Release 3. Oxford: Numerical Algoritms Group. Bergstrom, J. & Henrikson, C. O. (1974) Quantitative long-term determinations of the alveolar bone tiiineral mass iti tnan by I'-' absorptiometry (II). Following periodontal surgery. Acta Radiologica. Therapy Physics Biology 13, 489-500. Bergstrom, J. & Floderus-Myrhed, B. (1983) Co-twin control study of the relationship between smoking and some periodontal disease factors. Conmnmity Dentistry and Oral Epidemiology 11, 113-116. Bergstrom, J. & Eliasson, S. (1987) Cigarette smoking and alveolar bone height in subjeets with a high standard of oral hygiene. Journal of Clinical Periodotitology 14, 466-469. Bolin, A., Lavstedt, S., Frithiof, L. & Henrikson, C. O. (1986) Proximal alveolar bone loss in a longitudinal radiographic investigation. IV. Smoking and some other factors inlluencing the progress in a material of individuals with at least 20 remaining teeth. Acta Odontologica Scandinavica 44, 263-269. Doll. R. & Peto, R. (1976) Mortality in relation to smoking. British Medical Jotirnal 2, 1525-1536. Feldman, R. S., Bravocos, J. S. & Rose. C. L. (1983) Association between smoking different tobacco products and periodontal disease indexes. Journal of Periodontology 54. 4S\-487. Herulf, G. (1968) On the marginal alveolar ridge in adults. Svensk Tandtaekare Tidskrift 61, 675-703. Hill, R. W., Ramfjord, S. W., Morrison, E. C , Appleberry, E. A., Caffesse, R. G., Kerry, G. J. & Nissle, R. R. (1981) Four types of periodontal treatment cotnpared
327
over two years. Journal of Periodontotogv 52, 655-662. Isidor, F. & Karring, T. (1986) Long-term effect of sttrgical and non-surgical periodontal treatment. A 5-year clinical study. Journal of Periodontal Research 21, 462-473. Ismail, A. .1., Burt, B. A. & Eklund, S. A. (1983) Epidemiologic patterns of smoking and periodontal disease in the United States. Jourtial of the Atnerican Dental As.mciation 106, 617-621. Kannel, W. B. (1983) An overview of the risk factors for cardiovascular disease. In: Kaplan, A. & Stamler, J. (eds): Prevention of coronary heart disease. London: WB Saunders. Lam, S. K.& Koo, J. (1983) Accurate prediction of duodenal-ulcer healing rate by discriminant analysis. Gastroenlerologv 85, 403-^12. Lavstedt, S. (1975) A tnethodologiealroentgenological investigation on marginal alveolar bone loss. Acta Odontologica Seandinavica 33, Supplement 67. Lindhe, J. & Nyman, S. (1987) Chnieal trials in periodontal therapy. Journal of Periodontal Research 22. 217-221. Lindhe, .1., Westfelt, E., Nyman, S., Socransky, S. S. & Haffajee, A. D. (1984) Longterm effect of surgical/non-surgical treatment of periodontal disease. Journal of Clinical Periodonto/ogy 11, 448-458. Philstrorn, B. L., McHugh, R. B., Oliphant, T. H. & Ortiz-CamposX. (1983) Comparison of surgical and nonsurgical treatment of periodontal disease. A review of current studies and additional results after 6 1/2 years. Journal of Clinical Periodontology 10,524-541. Preber, H. & Bergstrom, J. (1986a) Cigarette smoking in patients referred for periodontal treatment. Scandinavian Journal of Dental Researeh 94, 102-108. Preber, H. & Bergstrom, J. (1986b) The effect of nonsurgical treatment on periodontal pockets in smokers and non-smokers. Journal of Clinical Periodontotogy 13, 319-323. ' Ramljord, S. P & Nissle. R. R. (1974) The modified Widman flap. Journal of Periodontotogy 45, 601-607. Ramljord, S. P., CalTesse, R. G., Morrison, E. C , Hill, R. W., Kerry, G. J., Appleberry, E. A., Nissle, R. R. & Stults, D. L. (1987) 4 modalities of periodontal treatment compared over 5 years. Journal of Clinical Periodontologv 14. 445^53. Rees, T , Liverett, D. & Guy, C. (1984) The effect of cigarette smoking on skin flap survivel in the face lift patient. Plastic Reconstructive Surgery 73, 911-915. Riefkohl, R., Wolfe, ,1., Cox, E. & McCarty, K. (1986) Association between cutaneous ocelusive vascular disease, cigarette smoking and skin slough after rhytidectomy. Plastic Reconstructive Surgery 77, 592-595. Rosling, B., Nyman, S. & Lindhe, J. (1976) Effect of systematic plaque control on
328
Preher & Bergstrom
bone regeneration in intrabony pockets. Journal of Clinical Pcriodontologv 3. 38-53. Shciham, A. (1971) Periodontal disease and oral cleanliness in tobacco smokers. Journal of Pei-iotlonlology 42. 259-263. Silness, J. & Loe, H. (1964) Periodontal disease in pregnancy (II). Correlation between oral hygiene and periodontal condition. Ada Odonlologica Scandinavica 22, 121-135.
Slone, D., Shapiro, S., Rosenberg, L., Kaufman, D. W., Hartz, S. C , Rossi, A. C , Stolley, R D. & Mictinen, O. S. (1978) Relation of cigarette sinoking to myocardial infarction in young women. New England Journal of Medicine 298, 1273-1276. Solomon, H. A., Priorc, R. J. & Bross, J. D. J. (1968) Cigarette smoking and periodontal disease. Journal of the American Denial A.isocialion 11, 1081-1084. Sweet, J. B. & Butler, D. R (1979) The re-
lationship of smoking to localized osteitis. Journal of Oral Surgery 37, 732-735. Address: Hans Preber Department of Periodontology School of Dentistry Karolitiska In.stitutet Box 4064 S-141 04 Huddinge Sweden
