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National Journal of Maxillofacial Surgery
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Table of Contents
Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 133-138  

Evidence-based analysis of the effect of smoking on osseointegrated implant outcome

1 Department of Dentistry, King Abdulaziz Medical City, Jeddah, Saudi Arabia
2 Department of Prosthodontics, College of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia

Date of Submission26-Dec-2020
Date of Acceptance25-Feb-2021
Date of Web Publication15-Jul-2021

Correspondence Address:
Dr. Abeer Ali Hadadi
Assistant Consultant, Department of Dentistry, King Abdulaziz Medical City, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njms.NJMS_287_20

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The outcome of the osseointegrated implant is influenced by various conditions, one of which is smoking. Literature shows conflicting results for the association between smoking and implant success. Hence, the study was conducted to assess the effects of smoking on survival and marginal bone loss of osseointegrated implants. Literature search of published articles in Medline, Scopus, Ovid, and Journal of Web till June 2020 were analyzed for the determined outcomes. Revman 5.4 software was used for the analysis of the study. Of the 437 articles screened, nine were chosen for review and analysis. Meta-analytic results showed that implant success rate was better in nonsmokers than smokers (odds ratio = 0.43, 95% confidence interval = 0.26–0.72, P < 0.0001). Smoking habit does seem to affect the implant outcome of survival and marginal bone loss negatively.

Keywords: Bone loss, edentulism, implants, peri-implantitis, smoking tobacco

How to cite this article:
Hadadi AA, Mezied MS. Evidence-based analysis of the effect of smoking on osseointegrated implant outcome. Natl J Maxillofac Surg 2021;12:133-8

How to cite this URL:
Hadadi AA, Mezied MS. Evidence-based analysis of the effect of smoking on osseointegrated implant outcome. Natl J Maxillofac Surg [serial online] 2021 [cited 2023 Jan 27];12:133-8. Available from: https://www.njms.in/text.asp?2021/12/2/133/321448

   Introduction Top

Osseointegrated dental implants are proven successful in treating partial and complete edentulism. Various systemic and local factors influence on the osseointegration maintenance and bone healing.[1] Smoking is considered to be a significant risk factor with regard to implant failure. Smoking habit shows to influence osseointegration in the earlier stages, which is dependent on the surface of implants and individual host genetic responses. Smokers in contrast to nonsmokers have exhibited altered bone composition and structure.[2]

In the previous decade, the surface texture of implants is modified from being smooth to a kind of rough texture, which is expressed as an average roughness of the Sa value of 1–2 _m.[3] This concept has enhanced the implant to bone surface contact, even in smokers. A fluoride incorporated surface was developed in the year 2000, with a moderately rough surface having nanoscale topography.[4] Survival rate and bone remodeling are attributed to osseointegration bought upon by osteoblastic differentiation, platelet activation, surface thrombogenica, and osteoconductive characteristics.

Various studies have assessed smoking habits influencing implant success rates. While a few of them postulated that smoking can enhance the failure of osseointegrated implants, others were not able to arrive at a definitive conclusion. To date, no definite consensus has been arrived thus deterring clinicians to not make any decisions regarding informed clinical decisions while placing implants in smokers. This could be attributed to a variety of factors such as design variability, quality of studies reviewed, and nonspecificity of eligibility criteria. The element of heterogeneity has made it difficult to conclude. Hence, this evidence-based analysis was conducted to explore the effect of smoking on osseointegrated implants, answering the PICO question “Does smoking have any effect on the outcome associated with osseointegrated implants?”

   Materials and Methods Top

Protocol and registration

The PRISMA checklist of systematic reviews and meta-analysis was analyzed for each of the selected articles.[5]

Eligibility criteria

The research question was framed employing the “PICOS” framework. The research question formulated fitted the eligibility criteria.

Population – Smokers with implant placement.

Intervention – Follow-up for a certain period.

Comparison – Nonsmokers who had implant placement.

Outcome – The primary outcome assessed was the survival rate of implants in the oral cavity. A Secondary outcome such as marginal bone loss and soft-tissue involvement was considered wherever found.

Setting – Private practice or hospital settings.

Inclusion criteria

Any study employing cross-sectional, retrospective, or prospective study design with participants placed with osseointegrated dental implants in either of the jaws with subsequent follow-up and articles published in the English language only were included.

Exclusion criteria

Editorials, case reports, commentaries, animal studies, and articles written in a language other than English were excluded. Trials not having a comparison group were also not included.

Information sources

Search engines such as PubMed, Ovid, Embase, Scopus, and Journal on web databases were employed for literature search. Those of the relevant articles were identified, extracted in full through electronic and manual searches.

Search strategy


Key terms used for the search included “Smoking tobacco;” “cigarette smoking;” “osseointegrated implants;” “implant-supported dental prosthesis;” “oral implants;” “endosseous implants;” “oral implants;” “periimplantitis;” “survival rate;” “marginal bone loss.”

Boolean operators

The Boolean operator “OR” was used to complement truncated synonyms in each search attempt. The Boolean operator “AND” made up the sum of each four main search themes to specifically output papers to produce at least one result for each time.

Search limits

Searches incorporated literature until 2020 as the concluding year. Only sources in English were used.

Process of study identification

Endnote X8 was used to import the results of the search data and to remove the duplicates. The screening of abstracts was carried out by the use of the eligibility criteria and for those not excluded, full-text articles were searched for. These were then assessed for inclusion and upon acceptance, underwent data extraction and quality assessment. Articles failing to meet inclusion criteria were excluded.

Data collection

All the titles and the extracts were independently screened by the reviewers and upon a meticulous review of the full-text articles, the data were extracted and documented in a data extraction table, which shows depicting data items evaluated for the review.

Data items

The data extraction table will include Study ID, sample size, follow-up period, implant type, outcome, criteria employed, and study design.

Risk of bias in individual studies

Cochrane Handbook for Systemic Review of Interventions was used for assessing the quality of recruited studies.[6]

Criteria assessed were random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), and selective reporting (reporting bias).

Data synthesis

The total number of success and failures of implants in each study in both smoking and nonsmoking groups was obtained. When present, marginal bone loss was recorded as mean and standard deviation. The heterogeneity level of all studies was evaluated using heterogeneity Cochrane's test and I squared test to determine the percentage of variation because of heterogeneity. A random-effect model was used. Funnel plots were constructed to examine publication bias and for checking symmetry of effect size versus sample size.

Statistical analysis

Data analysis was carried out using RevMan 5.4 software, Cochrane Collaboration, London, United Kingdom.

   Results Top

The search strategy results in a total of 437 articles, of which 101 had to be excluded because of duplication. Further 259 articles had to be excluded as only abstracts were obtained of these articles. A total of 9 articles were included for the systematic review and the same were analyzed for meta-analysis [Figure 1]. The characteristics of the study are enlisted in [Table 1]. Two reviewers performed the data extraction and bias judgment. Any nonagreement between the reviewers was sorted out by seeking expert advice.
Figure 1: Flow chart diagram for article inclusion

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Table 1: Characteristics of the studies included

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Of the 9 studies reviewed, 5 were of retrospective study design, and the rest employed prospective study. The majority of the studies evaluated Branemark implants. Follow-up time ranged from 5 years to the time of implant failure. Low risk of bias was seen in all the included studies [Table 2].
Table 2: Risk of bias in included studies

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A total of 3090 implants in smokers were assessed while 8994 in nonsmokers were followed up to evaluate for failure. Meta-analytic results showed that implant success rate was better in nonsmokers than smokers (odds ratio = 0.43, 95% confidence interval = 0.26–0.72, P < 0.0001), the random-effects model was adopted [Figure 2]. Funnel plots for both survival rate and marginal bone loss showed minimal publication bias [Figure 3],[Figure 4],[Figure 5].
Figure 2: Forest plot showing implant success rate among smokers versus non smokers

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Figure 3: Funnel plot for survival rate among smokers versus non smokers

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Figure 4: Forest plot showing marginal bone loss among smokers versus non smokers

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Figure 5: Funnel plot for marginal bone loss among smokers versus non smokers

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There was no significant difference in marginal bone loss among smokers and nonsmokers [Figure 4].

   Discussion Top

A meta-analysis involving both retrospective and prospective study design was done to comparatively evaluate the survival rate and marginal bone loss among smokers and nonsmokers.

The survival rate amongst nonsmokers was significantly better than smokers at P < 0.001. This is in concordance with the reviews of Moraschini and Barboza[15] and Alfadda[16] The exact pathogenesis affecting this remains unclear. But probably osseointegration gets affected by the chemical constituents present in tobacco affecting the vascularity of surrounding implant tissues, which might result in poor bone loss. Roughly around 3 mg of nicotine and 20–30 ml of CO get inhaled with each cigarette smoke.[17] Nicotine seems to elevate plate aggregation and hamper fibroblastic function along with red blood cells, osteoblast, and macrophages.[18] Furthermore, CO has a greater affinity for hemoglobin competing with oxygen causing the formation of carboxyhemoglobin instead of oxyhemoglobin, which in turn reduces transportation of oxygen, causing hypoxia because of decreased oxygen tension in tissues.

Literature evidence also demonstrates that nicotine enhances pro-inflammatory cytokines expression thus playing an important part in accelerating alveolar bone loss around natural dentition. Increased ranges of pro-inflammatory cytokines are demonstrated in peri-implant sulcus fluid. Nicotine has the potential in suppressing cellular healing response and increasing biofilm accumulation in smokers.[19],[20]

No significant difference in the marginal bone loss was seen between smokers and nonsmokers. This was contradictory to the review of Alfadda[16] where a greater difference was noted between the groups. They justified it with amalgamating effects of tobacco chemicals on bone vascularity.

Publication bias in both the analysis was found to nonsignificant. The risk of bias assessed demonstrated an overall low risk highlighting the higher quality of the studies included.

The studies included in the present analysis employed cross-sectional, retrospective, or prospective study design, which is categorized under Level 2 under the evidence-based criteria assessment of Oxford Center for Evidence-Based Medicine.[21]

Though the choice of osseointegrated implants provides an excellent option for missing teeth replacement, certain other factors have to be considered such as plaque accumulation, peri-implant tissue inflammation, systemic-factors, and occlusal variables, which may influence osseointegration.[22],[23] Furthermore, measuring nicotine levels to assess smoking status is recommended for further research to establish more credibility.

However, the retrospective nature of the studies does carry some limitations. To better appreciate the influence of smoking in the success of osseointegrated implants, prospective, controlled, and randomized studies are needed which are evaluated using clinical and radiographic criteria. Furthermore, the fewer number of eligible studies could have an impact on the study weight.

   Conclusion Top

Smoking proves to be detrimental to survival rate and marginal bone loss in osseointegrated implants. Education regarding the effect of smoking on peri-implant health must be given by the clinicians and reinforced at every phase.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Weyant RJ. Characteristics associated with the loss and peri-implant tissue health of endosseous dental implants. Int J Oral Maxillofac Implants 1994;9:95-102.  Back to cited text no. 1
Sayardoust S, Omar O, Norderyd O, Thomsen P. Clinical, radiological, and gene expression analyses in smokers and non-smokers, Part 2: RCT on the late healing phase of osseointegration. Clin Implant Dent Relat Res 2017;19:901-15.  Back to cited text no. 2
Mendonça G, Mendonça DB, Aragão FJ, Cooper LF. Advancing dental implant surface technology – From micron- to nanotopography. Biomaterials 2008;29:3822-35.  Back to cited text no. 3
Ellingsen J, Johansson C, Wennerberg A, Holmen A. Improved retention and bone-tolmplant contact with fluoride-modified titanium implants. Int J Oral Maxillofac Implants 2004;19:659-66.  Back to cited text no. 4
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009;6:e1000097.  Back to cited text no. 5
Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928.  Back to cited text no. 6
Sánchez-Pérez A, Moya-Villaescusa MJ, Caffesse RG. Tobacco as a risk factor for survival of dental implants. J Periodontol 2007;78:351-9.  Back to cited text no. 7
De Bruyn H, Collaert B. The effect of smoking on early implant failure. Clin Oral Implants Res 1994;5:260-4.  Back to cited text no. 8
DeLuca S, Habsha E, Zarb GA. The effect of smoking on osseointegrated dental implants. Part I: Implant survival. Int J Prosthodont 2006;19:491-8.  Back to cited text no. 9
Maló PS, de Araújo Nobre MA, Ferro AS, Parreira GG. Five-year outcome of a retrospective cohort study comparing smokers vs. nonsmokers with full-arch mandibular implant-supported rehabilitation using the All-on-4 concept. J Oral Sci 2018;60:177-86.  Back to cited text no. 10
Windael S, Vervaeke S, De Buyser S, De Bruyn H, Collaert B. The long-term effect of smoking on 10 years' survival and success of dental implants: A prospective analysis of 453 implants in a non-university setting. J Clin Med 2020;9:1056.  Back to cited text no. 11
Noguerol B, Muñoz R, Mesa F, de Dios Luna J, O'Valle F. Early implant failure. Prognostic capacity of Periotest: Retrospective study of a large sample. Clin Oral Implants Res 2006;17:459-64.  Back to cited text no. 12
Kan JY, Rungcharassaeng K, Lozada JL, Goodacre CJ. Effects of smoking on implant success in grafted maxillary sinuses. J Prosthet Dent 1999;82:307-11.  Back to cited text no. 13
Alsaadi G, Quirynen M, Komárek A, van Steenberghe D. Impact of local and systemic factors on the incidence of oral implant failures, up to abutment connection. J Clin Periodontol 2007;34:610-7.  Back to cited text no. 14
Moraschini V, Barboza ED. Success of dental implants in smokers and non-smokers: A systematic review and meta-analysis. Int J Oral Maxillofac Surg 2016;45:205-15.  Back to cited text no. 15
Alfadda SA. Current evidence on dental implants outcomes in smokers and nonsmokers: A systematic review and meta-analysis. J Oral Implantol 2018;44:390-9.  Back to cited text no. 16
Sherwin MA, Gastwirth CM. Detrimental effects of cigarette smoking on lower extremity wound healing. J Foot Surg 1990;29:84-7.  Back to cited text no. 17
Hukkanen J, Jacob P 3rd, Benowitz NL. Metabolism and disposition kinetics of nicotine. Pharmacol Rev 2005;57:79-115.  Back to cited text no. 18
Ghanem A, Abduljabbar T, Akram Z, Vohra F, Kellesarian SV, Javed F. A systematic review and meta-analysis of pre-clinical studies assessing the effect of nicotine on osseointegration. Int J Oral Maxillofac Surg 2017;46:496-502.  Back to cited text no. 19
Barão VA, Ricomini-Filho AP, Faverani LP, Del Bel Cury AA, Sukotjo C, Monteiro DR, et al. The role of nicotine, cotinine and caffeine on the electrochemical behavior and bacterial colonization to cp-Ti. Mater Sci Eng C Mater Biol Appl 2015;56:114-24.  Back to cited text no. 20
CEBM (Centre for Evidence-Based Medicine). Oxford Centre for Evidence-based Medicine – Levels of Evidence (March 2009). Available from: http://www.cebm.net/index.aspx?o=1025. [Last accessed on 2020 Jul 22].  Back to cited text no. 21
Rocchietta I, Nisand D. A review assessing the quality of reporting of risk factor research in implant dentistry using smoking, diabetes and periodontitis and implant loss as an outcome: Critical aspects in design and outcome assessment. J Clin Periodontol 2012;39 Suppl 12:114-21.  Back to cited text no. 22
Lang NP, Pun L, Lau KY, Li KY, Wong MC. A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Implants Res 2012;23 Suppl 5:39-66.  Back to cited text no. 23


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]

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