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Four classes of disturbance occur: Mechanical disturbance the negative pressure created when inhaling can destabilize the forming clot Thermal disturbance combustion heat alters surface physiology and dries exposed tissue Chemical disturbance gases and particulates contact raw tissue before epithelial sealing Vascular disturbance nicotine modifies microcirculation dynamics at the wound interface smoke after tooth extraction is not necessarily that it will destroy the wound in theatrical fashion it is that it degrades conditions in which optimal wound organization is already fragile and newly built