Introduction

The World Health Organisation has studies which suggest that tobacco and smoking kill at least half of its users who don't quit. It is 8 million tobacco users and 1.3 million who are subjected to secondary smoke. 

Smoking affects all the organs of our body in various ways. 

• The cardiovascular system:

Atherosclerosis is a condition where the inner lining of the blood vessels is hardened by cholesterol plaque deposits and fibrous changes in the smooth muscle of the arteries. This hardens the arteries, and their elasticity is reduced. When one of the plaque fragments dislodges, it may get carried further downstream and occlude one of the smaller blood vessels. This, in turn, increases the chances of a stroke if the fragment occludes an artery in the brain or a heart attack if the coronary artery is blocked.

• The respiratory system:

Chronic Obstructive Pulmonary Disease (COPD) is commonly found in smokers. There is chronic inflammation in the alveoli of the lung, which leads to increased mucin production. Also, the body’s attempt to limit the inflammation is seen by the loss of elasticity of the lung tissues. This leads to gas entrapment and further distress when exercising and gradually even at rest.

• Cancer:

There is an increased risk of lung cancer, throat cancer and cancers of the alimentary canal in smokers. Though the risk reduces when smoking is stopped, there is still a significant amount of risk in smokers than in non-smokers.

• Gastric Ulcer

Plaque and its composition

The pellicle, which is a glycoprotein, is formed as a thin layer over all the surfaces of the teeth whenever we eat food. It does not contain bacteria, but the glycoproteins act as food for the already existing oral bacteria. When the pellicle starts becoming organised, it is termed plaque. Plaque contains bacterial colonies, which can cause inflammation in the gums, leading to gingivitis. Plaque is 80% water and 20% solids, which comprises bacterial colonies and food particles.

When plaque is retained over a longer period of time on the tooth surfaces, calcium from the saliva is deposited into it, hardening it. This hardened plaque is called tartar or calculus.

What is tartar?

Mineralised and organised plaque is called tartar. It is a layer of chalky white or yellowish deposits on the teeth which do not come out by brushing or flossing. It may also take up the colour of the foods that it is continuously subjected to, like tea, coffee, and smoking. The composition of tartar is uniform, though the bacterial composition may vary. 

There is always a layer of unmineralised or unorganised plaque on the surface of tartar. Due to the bacterial colonies thriving in it, there is constant inflammation in the gums, which leads to redness and bleeding. This condition is termed gingivitis.

Untreated gingivitis can lead to periodontitis, which can further weaken the tooth. The tartar cannot be removed by simple brushing and flossing. A visit to the dentist for scaling and polishing of teeth becomes mandatory.

The tartar can also take up stains of the consumed food, aka tea, coffee, smoking, etc.

The most effective approach to prevent tartar buildup is by consistently disrupting plaque formation through regular brushing and flossing.

Importance of oral hygiene in preventing tartar buildup

Tartar and plaque contain organised bacterial colonies that cause constant irritation to the gums. The redness and bleeding from the gums that ensues is termed gingivitis. Untreated gingivitis rapidly turns to periodontitis due to the deposition of plaque and the invasion of the periodontal ligament by the bacteria in the plaque. This can lead to loosening of the teeth and subsequent loss of teeth.

Why smokers are at a higher risk of tartar buildup

Smoking acts at various levels on the body tissues. It acts mainly by the following modes:

1. Vasoconstriction:

The frequency of smoking and the individual's body composition play an important role in determining the tissue response. The nicotine in the smoke stimulates the sympathetic nervous system. Nicotine also makes the nervous system very dependent on the habit. It releases catecholamines, which act on the alpha receptors of the blood vessels. This also affects the blood supply to the gums, which masks any bleeding due to inflammation. The first symptom of gingivitis is bleeding from the gums. The patient will not realise due to the severity of the gum disease, until it's too late to reverse the damage.

2. Decreased immunity:

Polymorphonucleocytes cells are the first line of defence of the body against bacterial invasions. They mobilise from the peripheral circulation to the site of inflammation and destroy bacteria by phagocytosis. The solution of the tobacco smoke concentrate acts on the motility of these polymorphonuclear cells, so they're no longer able to reach the breach site, and the bacterial infection becomes severe. 

3. Tissue damage:

Cigarette smoke activates the release of elastase ( a coenzyme released by neutrophils). Elastase breaks down elastin, which is a key component of connective tissue. This leads to severe tissue damage. Mild gingivitis or periodontitis can escalate to a severe condition as the bacterial infection can pass easily through the fragile tissues. 

Consequences of tartar buildup in smokers

The various studies done on smokers and the habit have led to the following findings:

1. Tobacco consumption led to a longer time to improve gum inflammation after professional cleaning of the teeth is done
2. Smokers have more supragingival calculus than non-smokers
3. Smokers who smoked more than 20 cigarettes a day had higher levels of nicotine and metabolites, increasing the severity of periodontal disease
4. Crevicular fluid levels are higher in smokers
5. Smoking generates nicotine nitrosamines, polycyclic aromatic hydrocarbons, and volatile organic compounds that act negatively on the mucous membranes and the oral cavity
6. The risk of periodontitis is greatest in patients who smoke more than 10 cigarettes a day for more than 8 years
7. Implant failure rates are 2.5 times higher in smokers than in non-smokers
8. Smokers have a greater chance of recurrence of periodontal disease even after it has been treated completely
9. Smoking results in a loss of oral microflora required for a healthy mucosa- namely Neisseria, Streptococcus, L.mirabilis, r.area, H.parainfluenzae, Aggregatibacter, Kingella, Fusobacterium and Capnocytophaga

Prevention and management

Looking at the amount of devastation that can be caused by smoking, smokers are advised to take proactive steps to reduce the frequency of smoking.

1. Quitting:

Trying to quit smoking with the use of nicotine patches and nicotine gum is advised. Reducing the number of daily cigarettes gradually can also help. Close friends and relatives should be informed about the decision to quit smoking so that they can help too. Distractions like music and reading can help when the urge is too strong.

2. Oral hygiene practices:

• Brushing twice a day will help prevent plaque formation, disrupt the bacterial colonies and prevent tartar buildup.
• Gargling after having food: food debris can be a source of nutrition for the already existing plaque. Gargling will remove any larger food particles, grossly cleaning the mouth.
• Flossing twice a day is the best way to keep plaque at bay. Thread floss or water floss can work equally well to get the desired results.
• Limiting intake of sugary and refined foods will drastically bring down the bacterial count in the mouth and also help prevent tooth decay.
• Use medicated mouthwashes whenever required 
• Regular checkups with the dentist
• Ultrasonic teeth cleaning, when advised by your dentist

Conclusion

Quitting smoking will be the best decision that a smoker can make to improve their overall health and to protect their teeth and gums. One step at a time, one can overcome.