A review pooling 13 studies found smokers lose a little more of the bone holding their implants every year. For diabetes, osteoporosis and other health conditions, the research barely existed.
Ask a dentist about implants and smoking and you’ll usually hear about failure rates: smokers lose more implants. Less talked about is what happens to the bone around an implant that stays put. A 2014 review pooled the studies that had measured it and landed on a number. Smokers lost about a sixth of a millimeter more supporting bone each year than non-smokers did.
Small, yes, and drawn from studies that disagreed with one another a lot. It was also the only health-related risk factor with enough research behind it to measure at all.
Key takeaways
- In a 2014 pooled analysis of 13 studies covering 478 smokers and 1,207 non-smokers, smokers lost about a sixth of a millimeter more bone around their dental implants each year than non-smokers.
- That yearly gap is close to the entire 0.2 mm of annual bone loss that widely used implant success criteria allow after an implant’s first year.
- The evidence behind the figure is limited: 12 of the 13 studies were observational, most looked back through old records, and their results varied so much that the authors cautioned against combining them.
- For diabetes, osteoporosis, genetic traits and other health conditions, the reviewers found too few studies to say anything about bone loss around implants.
Later and much larger reviews point the same way for smoking, and current European guidelines recommend tackling smoking and blood-sugar control before implants are placed.
How the review worked
Marco Clementini, then at the University of Rome Tor Vergata, and colleagues in Italy, Spain and Brazil searched three major medical databases through January 2012 for any study tracking bone levels around implants in people with a systemic risk factor: a chronic disease, a genetic trait, long-term drug or alcohol use, or smoking.
They required at least a year of follow-up after the implant got its crown or denture, because bone around a new implant naturally settles in the first few months.
From 1,824 records, 17 studies made the cut, covering 1,883 patients and 5,730 implants. Sixteen were cohort studies, where researchers follow a group of patients forward or dig back through their records. One was a randomized trial. Bone loss was read off X-rays, sometimes small close-up films of a single implant and sometimes panoramic images of the whole jaw.
Smoking was the only thing they could measure
Smoking turned out to be the only risk factor studied often enough to combine. Thirteen studies compared smokers with non-smokers, 478 people in one group and 1,207 in the other. Pooled together, the smokers lost about a sixth of a millimeter more bone around their implants every year.
For context, the implant success criteria set out by Tomas Albrektsson and colleagues in 1986, still among the most widely used, allow an implant to lose less than 0.2 mm of bone a year after its first year in service. On this estimate, smoking by itself uses up most of that allowance before anything else is counted.
“Exposure to smoking had a harmful effect on peri-implant bone loss.”
— Clementini, Canullo and colleagues, International Journal of Oral and Maxillofacial Surgery (2014). https://doi.org/10.1016/j.ijom.2013.11.012
The individual studies were all over the place, though. Fewer than half found a clear difference on their own. In one, heavy smokers lost roughly ten times as much bone as non-smokers, a gap the reviewers put down to that study including only highly dependent smokers. Others found close to nothing. Studies defined light and heavy smoking differently, and most just asked patients how much they smoked.
Everything else on the list, including osteoporosis, diabetes, inflammation-related gene variants and Sjögren’s syndrome, turned up in one or two studies each. That’s too thin to analyze, and the authors didn’t try.
| What was measured | Result | In plain terms |
| Records screened / studies included / studies pooled | 1,824 / 17 / 13 | Smoking was the only factor studied often enough to combine |
| People in the pooled analysis | 478 smokers, 1,207 non-smokers | About 1,700 patients across 13 studies |
| Extra annual bone loss in smokers (WMD, random effects) | 0.164 mm/year (95% CI 0.101 to 0.226), P < 0.001 | About a sixth of a millimeter more each year |
| Heterogeneity | I² = 86%; QH = 89.2, P < 0.001 | The studies disagreed a lot |
| Studies showing a clear effect on their own | 5 or 6 of 13 (paper reports both) | Fewer than half |
| Other systemic factors (osteoporosis, diabetes, IL-1 genes, Sjögren’s, others) | 1 to 2 studies each; not pooled | Too little data to say anything |
| Soft-tissue outcomes (bleeding, plaque, recession) | Rarely reported; none on recession or keratinized tissue | Gum health around implants largely unmeasured |
Source: Clementini et al., Int J Oral Maxillofac Surg 2014;43:323–334, Results, Table 4 and Discussion.
What’s been learned since
When the review came out in January 2014, Derek Richards, a dental public health specialist who then directed the Centre for Evidence-Based Dentistry, pointed to the same weakness on the Dental Elf blog.
“The majority of included studies are retrospective so have a greater risk of bias.”
— Derek Richards, dental public health specialist, The Dental Elf (January 2014), commenting on this review. https://www.nationalelfservice.net/mental-health/review-suggests-that-smoking-may-have-a-harmful-effect-on-peri-implant-bone-loss/
The larger reviews that followed haven’t overturned the direction, though. In 2021, Bruno Ramos Chrcanovic, a prosthodontics researcher at Malmö University in Sweden, and two colleagues pooled 292 studies with roughly 35,500 implants in smokers and 114,600 in non-smokers. Smokers’ implants were more than twice as likely to fail, and smokers averaged about 0.6 mm more bone loss overall. The authors called their own results not robust, given how many studies were retrospective. On failure, though, the smoking effect held steady however long patients were followed.
“…the effect of smoking in implant failures does not fade away with time.”
— Mustapha, Salame and Chrcanovic, Medicina (2021), on their own review of 292 studies. https://doi.org/10.3390/medicina58010039
Smoking also turns up in research on peri-implantitis, the gum-and-bone infection that’s the main biological threat to implants. A 2023 review restricted to cohort studies found smokers had roughly twice the risk. The 2017 World Workshop on classifying periodontal and peri-implant diseases picked out smoking, diabetes and a history of gum disease as the systemic factors with the most solid evidence. And the European Federation of Periodontology’s 2023 clinical guideline recommends assessing every implant patient’s risk profile, including smoking cessation and blood-sugar control in people with diabetes, before treatment starts.
What it means for you
If you’re a patient
Smoking doesn’t automatically rule implants out. One of the longest studies in this review, following patients for up to 20 years, concluded that smoking shouldn’t be an absolute barrier, but that long-term heavy smokers should be told they face more bone loss and a slightly higher chance of late implant loss.
The part you can change is the smoking. Nobody has yet measured how much quitting helps implant bone, or how long before surgery you’d need to stop. It’s still the one item on this list that’s in your hands, and implant specialists writing for the International Team for Implantology stress the dentist’s part in helping with it.
“…the dentist’s role in patient education and smoking cessation guidance.”
— Isabella Neme Ribeiro dos Reis, Nadja Naenni, Giuseppe Romito and Cláudio Pannuti (University of São Paulo and University of Zurich), ITI Blog, writing generally on peri-implantitis risk. https://blog.iti.org/?p=6045
If you have diabetes, osteoporosis or another long-term condition, this review can’t tell you much either way. Later research links poorly controlled diabetes with more peri-implantitis, which is why guidelines stress getting blood sugar in range first. Worth raising at your next check-up, along with whether you’ll get a baseline X-ray to compare against later.
If you’re a dentist
A sixth of a millimeter a year is below what a single X-ray can reliably measure, so the trend only shows up against a clean baseline. The EFP guideline recommends a baseline intra-oral radiograph once initial bone remodeling is complete, and probing at every exam. Recording smoking status, and any change in it, at each recall turns this from a vague warning into something you can track.
What nobody knows yet
Whether quitting before surgery puts a smoker back on a non-smoker’s bone-loss track, and how many weeks or months that takes. How vaping and heated tobacco compare, since nearly all of this research predates them. Whether bone loss climbs with the number of cigarettes; the studies here sorted smokers into categories too inconsistently to tell. And for diabetes, osteoporosis, bone-strengthening drugs and genetic risk, whether any of them change bone levels around implants that otherwise survive. When this review was done, almost nobody had measured it.
The bottom line
Pooling 13 mostly retrospective studies, this review estimated that smokers lose about a sixth of a millimeter more bone around their implants each year than non-smokers, a direction later and larger reviews support even if the exact figure is soft. For every other health condition the reviewers looked at, the honest answer in 2014 was that nobody had measured it well enough to say.
Questions people ask
Does smoking cause bone loss around dental implants?
Smokers consistently show more bone loss around implants than non-smokers. A 2014 review of 13 studies estimated an extra sixth of a millimeter a year, and a 2021 review of 292 studies found about 0.6 mm more on average. These are observational studies, so they show a strong link rather than proof of cause, but the direction has held up.
How much bone loss around a dental implant is normal?
Some bone settling in the first year after an implant is loaded is expected. After that, widely used success criteria from 1986 allow less than 0.2 mm of bone loss per year. On the 2014 estimate, smoking alone accounts for most of that yearly allowance, though X-ray measurements are only precise to roughly the same amount.
Can I get dental implants if I smoke?
Usually, yes. Smoking isn’t generally treated as an absolute barrier, but smokers face higher implant failure rates, more bone loss and roughly twice the risk of peri-implantitis. Current European guidelines recommend addressing smoking before implants are placed. Your dentist can talk through your own risk and whether quitting first makes sense for you.
Do diabetes or osteoporosis affect bone around implants?
The evidence is thin. The 2014 review found only one or two studies each on diabetes and osteoporosis, too few to draw conclusions. Later reviews link poorly controlled diabetes with higher rates of peri-implantitis, and guidelines recommend good blood-sugar control before treatment. How osteoporosis affects bone around implants that survive still hasn’t been well measured.
Will quitting smoking help my dental implants?
Probably, though it hasn’t been measured directly. Researchers who reviewed nearly 300 studies in 2021 called for work on whether quitting around the time of surgery improves results, because nobody knows yet. Given how consistently smoking is linked to bone loss and implant failure, stopping is the one change on the list that’s fully within your control.
Source
Clementini M, Rossetti PHO, Penarrocha D, Micarelli C, Bonachela WC, Canullo L. Systemic risk factors for peri-implant bone loss: a systematic review and meta-analysis. International Journal of Oral and Maxillofacial Surgery. 2014;43(3):323–334. https://doi.org/10.1016/j.ijom.2013.11.012
Published by Elsevier under subscription; not open access. A submitted (preprint) version is listed in the University of São Paulo repository. The authors report no funding and no competing interests.
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