Association Between Smoking Habit and Peri-implant Diseases: a Case Control Study

1. Introduction Nowadays, dental implants are a good restorative option for those patients who have lost one or more teeth in order to re-establish function and aesthetics. Nevertheless, dental implants are not free of suffering complications and disease. Peri-implant diseases are inflammatory conditions affecting the tissues surrounding the bone anchored implants, triggered by the presence of peri-implant biofilms in susceptible individuals (Rinke et al., 2011; Roos-Jansåker, Lindahl, et al., 2006; Roos-Jansåker, Renvert, et al., 2006; Schwarz et al., 2017)(Roos-Jansåker, Lindahl, et al., 2006; Roos-Jansåker, Renvert, et al., 2006; Schwarz et al., 2017)(Merli et al., 2014). At the New World Workshop in Periodontology (2017) these terms were revised and it was concluded that peri-implant mucositis is the presence of reversible inflammatory changes in the mucosa around an implant with no signs of loss of supporting bone, while peri-implantitis is the condition of inflammation of the peri-implant tissues involving loss of supporting bone (Renvert et al., 2018).

Peri-implant diseases are prevalent, and its presence has increased over time. As it is reported in the Swedish population, peri-implant mucositis appears in 32% of the patients, whereas peri-implantitis was observed in 45% of the patients (Derks et al., 2016). In addition, a cross-sectional study Spain revealed the presence of peri-implant mucositis in the 24% of patients, while peri-implantitis was found in the 18% (Rodrigo et al., 2018). For that high percentage of peri-implantitis, it seems reasonable to do a patient-specific risk assessment for implant therapy, and there is a clear need to identify an effective method to prevent peri-implant infections. According to the New World Workshop on Periodontology there is strong evidence that history of periodontitis, poor plaque control and lack of regular maintenance is a risk factor for peri-implantitis (Renvert et al., 2018).

Regarding tobacco, there is scientific evidence that affirms it is a risk factor for the periodontal disease progression and its effect on biofilm (Winkelhoff et al., 2001), host response (Palmer et al., 2005), wound healing and periodontal treatment success (Bunæs et al., 2015; Fisher et al., 2008; Kotsakis et al., 2015). It has been reported more presence of some periodontopathogens in smokers in comparison to non-smokers such as B forsythia, P micros, F nucleatum and C rectus; an effect on neutrophil's function, lymphocytes and on the vasculature of the periodontal tissues (Palmer et al., 2005) being more predisposed to periodontal breakdown and recurrence (Bunæs et al., 2015; Fisher et al., 2008; Kotsakis et al., 2015).

Although smoking has been proposed as well, as a risk factor/indicator for peri-implantitis, there is currently no conclusive evidence. The current literature confronts the inconclusive evidence of tobacco for a risk factor. Studies by Schwarz, Roos-Jansaker or Rinke concluded that smoking habit has 2.7 to 31 times more probability to cause peri-implantitis with Odds Ratio (OR) ranging from 2.7 to 31.6 respectively (Rinke et al., 2011; Roos-Jansåker, Lindahl, et al., 2006; Roos-Jansåker, Renvert, et al., 2006; Schwarz et al., 2017)Furthermore, it has been reported by Karoussis and coworkers an incidence of peri-implant diseases of 6% in non-smokers vs 17,9% in smokers. The biologic processes involved in osseointegration and maintenance of peri-implant bone levels could be likely affected by tobacco smoking(Karoussis et al., 2003). However, most of the literature shows (Aguirre-Zorzano et al., 2015; ALHarthi et al., 2018; Canullo et al., 2016; Casado et al., 2013; Dalago et al., 2017; Daubert et al., 2015; de Araújo Nobre et al., 2015; Dvorak et al., 2011; Koldsland et al., 2010, 2011; Marrone et al., 2013; Máximo et al., 2008; Rokn et al., 2017) that there is no association between tobacco smoking and peri-implant diseases . Stacchi and coworkers concluded that there were no sufficient data to assess the role of smoking as a risk factor for implant loss and peri-implantitis. Both implant and patient-based meta-analyses revealed a significantly higher risk of developing peri-implantitis in patients with a history of periodontitis compared with periodontally healthy subjects, but not a statistically significant increased risk for implant loss (Stacchi et al., 2016).

Tobacco contains thousands of different substances and most of them represent harmful effects resulted from the systemic exposure following lung absorption. It also has effects on the oral microbiota, the gingival tissues, the inflammatory and immune response, and the healing capacity of the periodontium (Palmer et al., 2005).