Both smoking and the use of smokeless tobacco can significantly affect a person’s oral health.  Oral cancer and periodontal (gum) disease are among the most serious oral health problems associated with tobacco use. Other oral health conditions associated with tobacco use include tooth decay, bad breath (halitosis) and stains on the teeth.

Smoking can cause cancer to develop anywhere in the mouth or the pharynx (upper part of the throat behind the mouth). Use of smokeless tobacco or a water pipe (hookah) is just as dangerous to a person’s oral health as any other form of smoking. Any tobacco product may cause cancer because tobacco contains many carcinogenic agents. These chemicals damage cells in the lining of the mouth, pharynx and larynx (voice box). Signs and symptoms of oral cancers vary depending on the location of the cancer, and may begin as abnormal white or red patches in the mouth.

Use of tobacco is among the leading risk factors for developing gum disease. About half of all cases of gum disease among adults in the United States may be attributed to smoking. People who use tobacco also increase their risk of tooth decay and tooth loss. In addition, smokeless tobacco often contains sugar that can promote decay, as well as sand and grit that can wear down the teeth.

Researchers are unclear as to exactly why tobacco causes gum disease. However, many suspect that the chemicals in tobacco interfere with the body’s ability to fight disease and promote healing. People who develop gum disease as a result of using tobacco products may experience symptoms such as swollen, red or sensitive gums. They also may experience gum pain or gums that bleed when brushing or flossing teeth.

Patients who have concerns about their oral health will likely visit a dentist or physician. In either case, an examination of the patient’s mouth, head and neck will likely be performed and a thorough medical history obtained, including any family history of cancer, gum disease or other illnesses. Patients may be asked about their tobacco use, and may undergo additional testing if cancer or gum disease is suspected.  

Treatment depends on the cause of the oral health problem. Treatment options for patients with gum disease include use of antibiotics, scaling, root planing, and gum surgery to clean diseased gum pockets. Treatment options for patients with oral cancer include surgery, radiation therapy and chemotherapy.

Tobacco use has many negative effects on a person’s oral health. People who smoke or use smokeless tobacco are particularly at risk of developing oral cancer or periodontal (gum) disease. Tooth decay, tooth loss, bad breath (halitosis) and stains on the teeth are additional oral health conditions associated with tobacco use.

Oral cancer is perhaps the most significant threat to a tobacco user’s oral health. Each year, physicians diagnose more than 30,000 new cases of cancer of the oral cavity and pharynx (upper throat at the back of the mouth), and about 8,000 deaths occur. The five-year survival rate for oral cancers is 50 percent, and treatment methods can significantly alter facial appearance, according the U.S. Centers for Disease Control and Prevention.

About 90 percent of people with mouth cancer and some types of throat cancer have used tobacco, according to the American Cancer Society. All forms of tobacco are dangerous, including cigars, pipes, cigarettes, hookahs and other, more exotic forms. Smokers are six times more likely than nonsmokers to develop oral cancer. Using smokeless tobacco increases the risk of developing cancers of the cheek, gums or inner surface of the lips by nearly 50 times.

Smoking can cause cancer to develop anywhere in the mouth or pharynx. Pipe smoking also has an added risk of causing cancer in the area of the lips that comes into contact with the pipestem. Smokeless or chewing tobacco is associated with cancers of the tongue, cheek, gums and inner surface of the lips. This cancer can begin within a few years of regular use of smokeless tobacco and tends to spread quickly. Unless it is caught early, major surgery is often needed to remove part of the mouth, jaw and tongue.

Smoking is among the leading risk factors for developing gum disease, a bacterial infection that erodes tissue that supports the teeth. This can lead to receding gums, which increases the risk of tooth decay and sensitivity. Gum disease that becomes chronic can lead to loss of teeth. About half of all cases of gum disease among adults in the United States may be attributed to smoking. In addition, tobacco use retards the mouth’s ability to heal, making it less likely that treatments for gum disease will be effective. Even passive (secondhand) smoking can increase the risk of gum disease & other oral health problems.

People who smoke and have gum disease are likely to suffer from failed dental restorations. Gum disease causes bone loss and receding gums that can affect the strength and durability of crowns and implants. Certain cosmetic procedures such as porcelain veneers are less likely to be successful in tobacco users.

Other oral health problems associated with use of tobacco products include:

• Tooth decay. Use of tobacco products, including smokeless tobacco, increases tartar buildup and decreases saliva production (or dries out the area where smokeless tobacco sits in the mouth), which can lead to decay. Chewing tobacco often contains sugar for flavoring, as well as sand and grit that can wear down the teeth. Smokeless tobacco also provides an ideal environment for bacteria to grow, feeding on food particles and other debris for hours at a time.
  
  
• Delayed healing. People who use tobacco products heal more slowly after tooth extraction or other forms of oral surgery.
  
  
• Other problems. Smokers are more likely to require a root canal treatment than nonsmokers, according to the National Institutes of Health. Conditions such as bad breath and stains on the teeth and tongue also are associated with use of tobacco products. Tobacco use can also reduce a person’s sense of taste. People who use smokeless tobacco may experience a bacterial coating of the tongue known as black hairy tongue.

Use of tobacco products causes oral cancer because tobacco contains carcinogenic toxins, including nitrosamines. These chemicals damage cells in the lining of the mouth, pharynx (upper throat at the back of the mouth) and larynx (voice box). Damage to these cells may cause them to malfunction and to rapidly multiply as cancer cells. Many of the chemicals found in tobacco also damage DNA. When functional, DNA tells the cells how to grow and repair the damage.

Researchers are still unclear as to exactly why use of tobacco causes conditions such as periodontal (gum) disease. However, many suspect that chemicals in tobacco interfere with the body’s ability to fight disease and promote healing. It is also believed that chemicals in tobacco hamper the flow of blood to the gums, which slows down the healing process. Over time, this damages the attachment of bone and soft tissue to the teeth, and causes receding gums.

Poor dental care – such as failure to brush and floss regularly – in addition to tobacco use can exacerbate oral health problems. Poorly fitting dentures can trap particles of tobacco, increasing the risk of oral cancer and other oral health problems.

People who develop periodontal (gum) disease as a result of using tobacco products may experience symptoms such as swollen, red or sensitive gums. They also may experience gum pain or gums that bleed when brushing or flossing teeth.

Other symptoms associated with gum disease include:

• Bad breath (halitosis) that does not go away after brushing
  
  
• An abscess or pus on the gums, indicating infection
  
  
• Receding gums that make the teeth look longer
  
  
• Periodontal pockets (deep spaces between the teeth and gums)
  
  
• Loose or shifting teeth

Even though smokers are more likely to experience gum disease than nonsmokers, they may be less likely to experience symptoms such as bleeding and reddened gums because tobacco interferes with blood flow to the gums. This can give the patient a false sense of security about their dental health.

People who develop oral cancer from tobacco use may experience varying signs and symptoms depending on the location of the cancer. The onset and severity of the symptoms may also vary depending on the site of the cancer within the mouth or throat. For the majority of individuals, the symptoms appear gradually over time.  

Lip cancers may be detected earlier than other oral cancers because of their highly visible location. Many oral cancers are not detected until the symptoms become more advanced. When detected early, many oral cancers can be successfully treated. Some conditions that may indicate early signs of oral cancer include:

• Leukoplakia. Causes lesions that look like thick, white patches of tissue in the mouth or throat. Leukoplakia is most often a noncancerous condition caused by chronic irritation, such as tobacco use. However, in a small percentage of cases, it can lead to oral cancer. Signs of leukoplakia can develop in as little as a year after beginning tobacco use. White lesions on the sides of the tongue of the floor of the mouth should be checked by a dentist because they are the most common sites for oral cancer.
  
  
• Erythroplakia. Condition that causes raised red lesions in the mouth or throat. These lesions may bleed easily if scraped and may become cancerous. Tobacco and alcohol use are associated with the development of erythroplakia.
  
  
• Dysplasia. A precancerous condition in the mouth or throat that may be preceded by either leukoplakia or erythroplakia. Characteristics of this condition include a white or red area of tissue in the mouth or throat. It is most often caused by tobacco use, but may be caused by other mouth irritants (such as poor–fitting dentures).

The most common signs and symptoms of oral cancer include:

• Sore in the mouth or on the lips that does not heal or bleeds easily
  
  
• Pain in the mouth that does not go away
  
  
• Lump or thickening in the cheek or on the lip
  
  
• Red or white patch on the gums, tongue or lining of the mouth
  
  
• Persistent bad breath

Symptoms of more advanced oral cancer include:

• Difficulties chewing and swallowing
  
  
• Problems moving the tongue or jaw
  
  
• Loosening of the teeth or pain around teeth and jaw
  
  
• Numbness around tongue or other areas of the mouth
  
  
• Weight loss

Patients who have concerns about their oral health will likely visit a dentist or physician. In either case, an examination of the patient’s head, neck and mouth will likely be performed and a thorough medical history obtained, including any family history of periodontal (gum) disease, cancer or other illnesses. The physician also will likely ask about tobacco use that may be related to the patient’s symptoms.

In diagnosing gum disease, a dentist or hygienist will examine the gums to identify signs of inflammation. A tiny probe may be used to measure the depth of any periodontal pockets. When the gums are healthy, the depth of these pockets is between 1 and 3 millimeters (mm). Spaces larger than 3 mm may indicate gum disease.

Dental x-rays may also be used to look for signs of bone loss. If gum disease is suspected, the dentist may refer the patient to a periodontist, a dentist who specializes in the diagnosis and treatment of gum disease.

Because smokers are less likely to experience certain symptoms (e.g., bleeding or reddened gums) associated with gum disease than nonsmokers, it is important for anyone who smokes to schedule regular dental examinations and cleanings with a dentist.

If a dentist or physician suspects oral cancer, the patient’s mouth, tongue and lips will be closely examined. Because there is an increased risk of secondary cancers in the head and neck area for individuals with oral cancer, the pharynx (upper throat at the back of the mouth), larynx (voice box), nose region and lymph nodes in the neck may also be examined. A biopsy, which involves taking a small piece of tissue and having it analyzed in a laboratory, may be necessary if an oral lesion looks suspicious.

Treatment will depend on the cause of the oral health problem. Typically, periodontal (gum) disease results in widespread infection of the gums that requires treatment by a dentist or periodontist. Examples of such treatments include use of antibiotics, scaling, root planing or gum surgery. Gum surgery may involve reflecting the gums away from the bone, cleaning diseased gum pockets and stitching them back into place, or grafting soft tissue from another area of the mouth to replace diseased gum tissue.

Treatment of gum disease in people who use tobacco can be difficult to perform successfully. It is crucial that patients avoid using tobacco while undergoing treatment. Failure to do so will impact the effectiveness of treatment. Gum disease often improves greatly after quitting smoking.

Treatment for oral cancer varies depending on a number of factors, including the general health of the patient and the location and stage of cancer. The patient's age, family and peer support and the ability to tolerate certain medications or procedures also affect the treatment plan.

The best way to prevent tobacco-related oral health problems is to avoid using tobacco in the first place. People who use tobacco products often can significantly lower their risk of oral health problems by quitting tobacco use.

For example, studies indicate that smokers who quit for more than a decade have significantly lower rates of periodontal (gum) disease, similar to rates experienced by nonsmokers. People who cut back on smoking also appear to lower their risk of gum disease, compared to those who smoke more heavily.

People who use tobacco are urged to talk with their dentist or physician about aids – such as medications or support groups – that can help them quit.

Regular visits to a dentist are crucial to identifying early signs of oral health conditions, when they are most treatable. All patients should have dental examinations and professional cleanings at least twice yearly. This is especially important for those who smoke.

Preparing questions in advance can help patients to have more meaningful discussions regarding their conditions. Patients may wish to ask their doctor the following questions related to tobacco and oral health:

1. How can I tell if smoking is damaging my teeth?
   
   
2. Will proper brushing and flossing help reduce damage to my oral health caused by smoking?
   
   
3. How will you diagnose my condition?
   
   
4. How significant is my condition?
   
   
5. What are the advantages of seeing a periodontist?
   
   
6. What are my treatment options? What are the risks associated with these options?
   
   
7. Will I have to see the dentist more frequently due to my tobacco use?
   
   
8. Where can I find out about aids that can help me quit using tobacco?
   
   
9. How long will it be before I see improvements in my oral health after I quit using tobacco?
   
   
10. What is my long-term prognosis?