OBJECTIVES: This systematic review aimed to investigate the effect of tobacco smoking and smoke-free products as risk factors for dental implants. MATERIALS AND METHODS: Three databases were searched to identify studies reporting on the risk of implant failure/survival in tobacco smokers or smoke-free users as compared to non-smokers in studies with ≥ 1 year of follow-up post-implant loading. Data on biological complications and radiographic peri-implant crestal bone loss (CBL) were also collected. Meta-analyses computed the Odds Ratio (OR) of implant survival with its confidence interval by applying the DerSimonian and Laird's random effect method, with p set at < 0.01. RESULTS: Forty-five articles reporting on 44 studies were included, 41 of which reported on the effect of cigarette smoking, with a follow-up from 1 to up to 17 years. Overall, a significantly reduced implant survival both at implant and patient level was indicated in cigarette smokers (OR = 0.40, 95% CI 0.27; 0.61, p < 0.001 and OR = 0.43, 95% CI 0.20; 0.90, p = 0.02, respectively). An increased CBL of 0.64 mm (95% CI 0.29; 0.99, p < 0.001) was also suggested in cigarette smokers, and the majority of studies reported a higher incidence of peri-implantitis. Insufficient data are available for smoke-free users. CONCLUSIONS: Although tobacco smoking is not considered an absolute contraindication for implant therapy, evidence indicates that it has a detrimental effect on peri-implant tissues, leading to an increased risk of implant failure and crestal bone loss. Individual behavioural counselling for smoking cessation should always be integrated in the treatment plan of patients receiving implant-supported rehabilitations. TRIAL REGISTRATION: PROSPERO number: CRD42024628116.
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