I smoke: can I have implants?

The effect of smoking in the mouth is not just stains and bad breath. The part that matters for implants starts in the bloodstream. Nicotine narrows the blood vessels. The vessels that supply the gums and the surface of the jawbone are fine vessels to begin with; when they narrow, less blood reaches the area. The cells, oxygen and nutrients a wound needs in order to close are carried there by the blood. In the days after surgery there is a wound in your mouth that we are waiting to close, and how fast it closes depends directly on this.

The second mechanism is carbon monoxide. Smoke carries a gas that binds to the haemoglobin in the blood far more tightly than oxygen does. It takes the place where oxygen would bind. The result is that even if the amount of blood stays the same, the oxygen it carries falls. Wound healing depends on oxygen from start to finish. Because the vessels narrow and the oxygen level falls at the same time, smoking slows healing down from two directions at once.

The third is the defence cells. Smoke disrupts the work of the immune cells in the tissues of the mouth and of the cells that produce new tissue. That is why, in a smoker's mouth, gum inflammation both starts more easily and is harder to shift. The US National Institute of Dental and Craniofacial Research names tobacco use as the most important risk factor for gum disease and states clearly that tobacco delays healing.

The most insidious part of the picture is that the bleeding disappears. Unhealthy gums bleed when you brush; that bleeding is the earliest warning a patient gets. Because nicotine narrows the blood vessels, a smoker's gums bleed less. The patient thinks 'it is not bleeding, so there is no problem', while the inflammation is quietly progressing. This is one of the most important reasons we schedule check-ups closer together for patients who smoke. What you cannot notice, we find by measuring.

Then there is direct contact. When you smoke, the smoke and heat pass right over the healing area, and the sucking action can dislodge the fresh blood clot. This is why smokers are more likely to lose the blood clot from the socket after a tooth extraction; this is painful and also prolongs healing. It is also why we ask you to avoid anything that involves sucking in the first days after surgery, including drinking through a straw.

Now let us look at how this relates to implants. A conventional implant is placed in the soft, spongy bone inside the jaw, and you wait for months for osseointegration, as that bone bonds with the implant surface. Osseointegration is a process that depends on the blood supply, in other words on blood flow, and that is exactly where smoking does the most harm. The strategic implant, on the other hand, locks mechanically into the hard outer layer of the jaw, the cortical bone. It is this mechanical lock that provides anchorage from the first day. Months of waiting for osseointegration and bone grafting are not part of the plan. That is why, for a patient who smokes, the window in which the risk is at its highest stays narrower.

This does not mean smoking stops mattering. Closing the soft tissue, and keeping the gum around the implant healthy for years, are still largely in your hands. We have written this page not to put you off, but to show clearly what your side of the work is.

The lists below become clear after the examination and CBCT scan. Seeing yourself in the second list does not mean the door is closed; some items do not mean 'no' but 'let's sort this out first'.

The sequence is built around your mouth. In this sequence, smoking has its own heading; it is not a form question that gets asked and then skipped over.

1. 1

   Send us your images

   If you have a panoramic X-ray or a CBCT scan, send it through the form. The images are read by the dentist who will carry out your treatment; the first reply is written by the dentist, not an assistant. There is no need to come in; we reply within one working day.

2. 2

   We ask how much you smoke

   How many a day, for how many years, and whether you use e-cigarettes or shisha. We do not ask this to judge you; your answer directly determines how much preparation your mouth needs and how often your check-ups are.

3. 3

   Assessing the gums and bone

   Gum pocket measurements, the condition of your remaining teeth and any roots that need to be removed go into the plan. The 3D CBCT scan shows where the hard outer layer is, how thick it is and how sound it is; this image makes the decision.

4. 4

   We set the smoke-free window together

   Stopping a week before surgery, staying away for the eight weeks after. Once the dates are confirmed, we fit the window into your calendar. If you need support such as nicotine patches or gum, we discuss it in advance.

5. 5

   You receive the plan in writing

   How many implants, in which jaw, with what bridgework, and which steps the preparation of your mouth involves are all shared in writing. In the same document, you can also see how your check-up schedule is made more frequent because you smoke.

6. 6

   Three clinical days

   If you agree with the plan, the surgery and the fitting of the fixed teeth are spread over three clinical days. You leave the clinic with your fixed teeth. You know what will happen on which day before you arrive.

7. 7

   More frequent check-ups

   For patients who smoke, we shorten the time between check-ups. The reason is simple: because nicotine suppresses gum bleeding, you do not see the early warning sign, so we have to measure. We give you the check-up schedule in writing.

'I cannot stop' is not a sentence that ends the treatment. The routes below are ones our patients actually use; we choose together which one suits you.

We are not writing this to frighten you, but so that you can ask the right questions, whichever clinic you go to.

The sequence below applies to patients treated with strategic implants. What changes for a patient who smokes is not the stages of healing, but how often the check-ups are and the discipline needed in the first weeks.

1. The week before surgery

   This is where the smoke-free window begins. Carbon monoxide clears from the blood quickly; even a week's break noticeably improves the oxygen reaching the tissues. If you are going to use nicotine replacement, go into this week prepared.

2. Three clinical days

   Once the examination and planning are complete, the surgery and the fitting of the fixed teeth are spread over these days. You leave the clinic with your fixed teeth. Some swelling and tenderness during these days is normal.

3. The first week

   The swelling goes down. We ask you to eat soft foods, avoid hard and hot foods, brush the area gently and avoid anything that involves sucking. If you have stitches, they are removed during this period. This is the week when healing is at its most fragile.

4. Eight weeks

   It takes weeks for the soft tissue to settle and for the gum around the implants to take shape; that is why we extend the smoke-free window over this period. We increase the chewing load gradually.

5. Check-ups and the long term

   We give you the check-up schedule and the bridgework maintenance instructions in writing; for patients who smoke, the intervals are shorter. Interdental cleaning, regular professional cleaning and yearly imaging are what make this treatment last.

We do not give figures on this page, because an accurate figure can only be given once the CBCT scan has been reviewed. Send us your scan, and we will set out the scope in writing, item by item. These are the items that determine the total:

Number of implants and which jaw

Whether it is one jaw or both, how many implants are planned and where they will be placed have a direct effect on the total.

Preparing the mouth

In the mouths of long-term smokers, teeth that need extracting, gum inflammation that needs treating and roots that need removing come up more often. These steps are added both to the plan and to the timeline.

Bridgework

The material of the fixed teeth and the laboratory work have a direct effect on the total. We tell you the brand of the material we use in writing, from the outset.

How frequent the check-ups are

For patients who smoke, we schedule check-ups more often. We write into the plan how many check-ups we expect and what they cover; it does not turn up later as an extra item.