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REVIEW ARTICLE
Tobacco smoking and surgical healing of oral tissues:
A review
Balaji SM

Consultant Oral and Maxillofacial

Surgeon and Director, Balaji
Dental and Craniofacial Hospital,
30/1, Kavingar Bharadidasan
Road, Teynampet, Chennai
600 018, India

Received
Review completed
Accepted
PubMed ID

ABSTRACT

: 09-11-07
: 04-12-07
: 04-12-07
: 19075440

It is believed that the crew of Columbus had introduced tobacco from the American India to
the rest of the world, and tobacco was attributed as a medicinal plant. It was often used to avert
hunger during long hours of work. But in reality, tobacco causes various ill effects including
pre-malignant lesions and cancers. This article aims at reviewing the literature pertaining to
the effect of tobacco smoking upon the outcome of various surgical procedures performed in
the oral cavity.
Tobacco affects postoperative wound healing following surgical and nonsurgical tooth extractions,
routine maxillofacial surgeries, implants, and periodontal therapies. In an experimental study,
bone regeneration after distraction osteogenesis was found to be negatively affected by smoking.
Thus, tobacco, a peripheral vasoconstrictor, along with its products like nicotine increases
platelet adhesiveness, raises the risk of microvascular occlusion, and causes tissue ischemia.
Smoking tobacco is also associated with catecholamines release resulting in vasoconstriction
and decreased tissue perfusion. Smoking is believed to suppress the innate and host immune
responses, affecting the function of neutrophils the prime line of defense against infection.
Thus, the association between smoking and delayed healing of oral tissues following surgeries is
evident. Dental surgeons should stress on the ill effects of tobacco upon the routine postoperative
healing to smoker patients and should aid them to become tobacco-free.
Key words: Delayed wound healing, dry socket, effect of tobacco, implant failure, periodontal
therapy, plate exposure, tobacco

Historians believe that the Native Americans began using

tobacco for medicinal and ceremonial purposes before the
rst century B.C. According to a Huron Indian myth,[1] In
ancient times, when the land was barren and the people
were starving, the Great Spirit sent forth a woman to save
humanity. As she travelled over the world, everywhere
her right hand touched the soil, there grew potatoes. And
everywhere her left hand touched the soil, there grew corn.
And in the place where she sat, there grew tobacco.
Tobacco was introduced into India by the Portuguese traders
during 16th century. Tobacco use and production have
greatly increased to such an extent that today India is the
second largest producer of tobacco in the world.[1]
Usage of tobacco harms almost every organ of the body and
has been associated with coronary heart diseases, stroke,
atherosclerosis, respiratory diseases such as COPD, and
pneumonia, and various carcinomas.[1]
Also, usage of tobacco affects oral tissues causing various
Correspondence:
SM Balaji,
E-mail: smbalaji@gmail.com
Indian J Dent Res, 19(4), 2008

344 CMYK

pre-cancerous lesions and carcinomas of the mouth and

pharynx. Smoking tobacco has been attributed to have a
negative effect on the healing process of oral tissues after
surgical and nonsurgical extractions, periodontal procedures,
orthognathic surgeries, and implant therapies. This article
aims at reviewing the effects of tobacco upon the healing
capacity of oral tissues following routine surgical procedures
performed in the oral cavity.

CIGARETTE SMOKING AND WOUND HEALING

Tobacco is a peripheral vasoconstrictor inuencing the rate
at which the oral wound heals.[2] Carbon monoxide and other
chemicals produced during the combustion of tobacco can
reduce the capillary blood ow. A clinical study has shown
that a single cigarette can reduce the peripheral blood
velocity by 40% in one hour.[2]
The mechanism by which smoking may affect wound
healing is unknown. One possible explanation is that the
substances in tobacco and its smoke, particularly nicotine,
cotinine, carbon monoxide, and hydrogen cyanide are
cytotoxic to those cells that are involved in wound healing.
Nicotine increases platelet adhesiveness, raising the risk
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Effect of smoking on surgical healing

of microvascular occlusion, and tissue ischemia. Smoking

is associated with catecholamines release, resulting in
vasoconstriction and decreased tissue perfusion.[3] In the
authors experience, a patient reported with delayed healing
of an ulcer in the lip was found to be a smoker [Figure 1].

DRY SOCKET
Cryer et al ., [4] postulated that smoking is associated
with endogenous catecholamines release resulting in
vasoconstriction and decreased tissue perfusion. Sweet
et al.,[5] had evaluated the relationship between smoking and
localized osteitis in 200 patients, who had 400 mandibular
third molars removed. Information on the number of cigarettes
smoked each day and the postoperative smoking habit of each
patient were recorded. The authors suggest that the heat from
the burning tobacco, and tobacco along with its byproducts
could act as a contaminant in the surgical site together with
the suction applied to the cigarette that might dislodge the clot
from the alveolus interrupting healing of the socket.
According to Meechan et al.,[6] brinolytic activity caused
by smoking reduces alveolar blood supply after dental
extractions and dry socket was found common among
smokers. Incidence of painful socket was analyzed in 3541
extractions performed in 2417 patients. It was observed
that sockets with poor lling of blood postoperatively, were
found more likely to develop painful sockets (P > 0.02).
Postoperative socket lling with blood was signicantly
reduced in smokers compared with nonsmokers (P > 0.01).
The incidence of painful socket in heavy smokers (20
or more cigarettes per day) was higher compared with
nonsmokers (P > 0.05).
Larsen[7] in a prospective study assessed the risk factors
associated with the development of dry socket after
extraction of 138 third molars. Usage of tobacco was found
to signicantly increase the incidence of alveolar osteitis
compared to other factors like age, sex, usage of oral
contraceptives, and increased surgical time.
Al-Belasy et al ., [3] in a study determined the risk of
developing dry socket in water-pipe (shisha) smokers
and found that cigarette and shisha smokers were 3-times
more prone to develop dry socket than nonsmokers. The
authors had observed that smoking on the day of surgery
and increased frequency of smoking increased the incidence
of dry socket.
Lopez Carriches et al.,[8] in their study observed that after
third molar extraction, smokers were more prone to develop
trismus than nonsmokers. However, they did not observe
statistically signicant difference in terms of pain.
In the authors experience, smoking on the day of tooth
extraction seemed to increase the susceptibility to dry socket
345

Balaji

formation [Figure 2].

According to Sweet et al., the suction associated with
cigarette smoking might dislodge the clot from the alveolus
and interrupt healing. However, Alexander denies the fact
that suction during smoking causes physical dislodgement
of the clot.[9] Al-Belasy et al.,[3] believe that dry socket
is caused by destruction of the clot rather than physical
dislodgement. Though the exact mechanism by which
smoking predisposes the socket to become dry remains
unclear, smoking denitely seems to be positively associated
with the occurrence of dry socket.

IMPLANT FAILURE
Though plaque-induced inammation and occlusal loading
are considered as the most important factors inuencing
the prognosis of oral implant treatment, smoking is also an
important factor related to the loss of, and soft tissue changes
around implants.[1013]
Some clinicians believe that smoking is a relative
contraindication for dental implant therapy.[14] De Bruyn
found that the early failures before loading in the maxilla
were higher in smokers (9%) than nonsmokers (2%).[11] Over
an average of a thirty-eight months follow-up, Bain and
Moy[10] reported that implant failure rates were more than
twice as high in smokers (11.28%) as nonsmokers (4.76%).
Effects were more pronounced in the maxillary arch, where
the failure rate for smokers was (16.82%) in the anterior
region as compared to 3.6% in nonsmokers.
Weyant[15] in a large multicentre population-based study,
reported that the usage of tobacco negatively affects periimplant soft tissue health. Another multicentre study was
conducted by Gorman et al.,[12] to analyze the implant
survival at stage-2 surgery in more than 2000 implants placed
in 433 patients in 310 cases. Correlating the results of the
interim analysis, the authors have concluded that smoking
is detrimental to implant success.
Lindquist et al.,[16] studied the association of smoking with
the peri-implant bone loss around mandibular implants in
45 edentulous patients (21 smokers and 24 nonsmokers)
for a period of 10 years after treatment. Information
about smoking habits of patients was collected based on
an interview. Peri-implant bone level was measured on
intraoral radiographs. Though the long-term results of
the implant were good, the mean marginal bone loss was
signicantly greater in smokers (P < 0.001) than nonsmokers,
correlating to the numbers of cigarettes consumed. Based on
a multivariate analysis, smoking was observed as the most
signicant factor affecting the rate of peri-implant bone
loss compared to oral hygiene, and those associated with
occlusal loading. The authors have stressed that smoking
habits should be included in the analysis of implant survival
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Effect of smoking on surgical healing

Balaji

and peri-implant bone loss.

EFFECT OF NICOTINE ON DISTRACTION

OSTEOGENESIS
An experimental study was performed by Cheung
et al.,[17] to evaluate the dose-dependent effect of nicotine
on bone regeneration, using a rabbit model of mandibular
distraction osteogenesis with sham, placebo control,
low-dose nicotine (0.75 g), and high-dose nicotine (1.5 g)
groups. Nicotine was administered with 60 daytime-release
nicotine pellets implanted subcutaneously in the nicotine
groups. When the sacriced animals were subjected to
examination by radiography, computed tomography, and
histological analysis, signicantly lower volume of bone and
chondrocytes were found in the high-dose nicotine group
compared to the low-dose nicotine, sham, and placebocontrol groups. The authors imply that bone formation
following distraction osteogenesis may be compromised by
high-dose nicotine exposure.

Figure 1: Delayed wound healing in a smoker

EFFECT OF SMOKING UPON BONE HEALING

FOLLOWING ROUTINE ORAL SURGICAL
PROCEDURES
Smoking is reported to be an important factor responsible
for postoperative infections leading to plate removal in
orthognathic surgeries and fracture management.
Hollinger et al ., [18] based on an experimental study,
hypothesized that nicotine has a negative effect on bone
healing by diminishing osteoblast function. It also seems to
cause autogenous bone graft morbidity and interferes with
the biomechanical properties of the graft.

Figure 2: A case of dry socket following surgical removal of third molar

in a patient with postoperative history of smoking

Cheynet et al.,[19] in their retrospective study of infectious

complications of 60 mandibular osteotomies, smoking
was observed as the important patient-related risk factor
responsible for postoperative infection.
Levin et al.,[20] observed high degree of complications
following surgeries or implant failures in smokers. The
authors had suggested that the heat released from mainstream cigarette smoke and the toxic by-products of tobacco
such as nicotine, carbon monoxide, and hydrogen cyanide,
could be the risk factors affecting the success of dental
implants and grafting procedures like maxillary sinus
augmentation, etc.
Saldanha et al.,[21] investigated the effect of smoking on
the dimension of alveolar process and radiographic bone
density in 21 patients (11 nonsmokers and 10 smokers)
after nonmolar extractions. Reduction in alveolar height
and radiographic bone density was more pronounced in
smokers than nonsmokers. The authors believe that cigarette
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Figure 3: Wound dehiscence and subsequent plate exposure in

a smoker following open reduction of the fracture of angle of the
mandible
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Effect of smoking on surgical healing

smoking increases bone resorption at the fractured ends,

interfering with the osteoblastic function.
In the authors experience, a male patient treated for fracture
of the mandibular angle, reported with ap laceration and
plate exposure was found to have a history of cigarette
smoking during the postoperative period [Figure 3].

Balaji

2.

3.
4.

The plate was removed since the bone healing was not
compromised. Thus, cigarette smoking may be an important
factor predisposing to wound dehiscence or ap laceration
following surgeries.

5.

INFLUENCE OF SMOKING ON PERIODONTAL

THERAPY

7.

Cigarette smoking is a signicant risk factor for periodontal

diseases and impaired healing after periodontal surgeries.[22]
Unlike usage of smoking tobacco that causes widespread
periodontal destruction, the usage of smokeless tobacco
causes gingival recession at the site of placement.[23]
Many periodontal interventional studies had consistently
demonstrated that smokers do not heal as well as nonsmokers.[24]
Two population-based epidemiological studies done by Tomar
et al.,[25] and Beck et al.,[26] found that periodontitis is more
common in smokers than in nonsmokers. Former smokers had
lower rates of periodontitis than smokers.[25] Smokers were
also reported to have more alveolar bone loss.
A number of clinical studies have compared the response
of smokers and nonsmokers to various types of surgical
and nonsurgical periodontal therapy.[2630] It was found
that smoking has a strong negative impact on regenerative
therapy, [31] including osseous grafting, guided tissue
regeneration,[3134] or a combination of these treatments,[35]
and 80% failure rate in the treatment of furcation
defects.[36] The majority of studies found that gingival
grafting for root coverage is less successful in smokers than
nonsmokers.[3739]

6.

8.

9.
10.
11.
12.

13.
14.
15.
16.
17.
18.
19.

CONCLUSION
20.

Tobacco, apart from being positively associated with

pre-cancerous and cancerous lesions is also reported
to negatively affect the outcome of almost all routine
therapeutic procedures performed in the oral cavity, starting
from simple nonsurgical periodontal therapy to orthognathic
surgeries. Dental surgeons should aid smoking patients to
become tobacco-free, educating the patients by imparting
these adverse effects.

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How to cite this article: Balaji SM. Tobacco smoking and surgical healing of
oral tissues: A review. Indian J Dent Res 2008;19:344-8.
Source of Support: Nil, Conflict of Interest: None declared.

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There is no data on follow-up of these patients.

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