Indan Journal of Medical Research Indan Journal of Medical Research Indan Journal of Medical Research Indan Journal of Medical Research
  Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login  
  Home Print this page Email this page Small font sizeDefault font sizeIncrease font size Users Online: 2858       

   Table of Contents      
REVIEW ARTICLE
Year : 2018  |  Volume : 148  |  Issue : 1  |  Page : 35-40

Oral health consequences of smokeless tobacco use


1 Department of Oral Medicine, Radiology & Special Care Dentistry, Saveetha Dental College, Saveetha University, Chennai, India
2 WHO Collaborating Centre for Oral Cancer; King's College London, London, UK

Date of Submission12-Nov-2017
Date of Web Publication25-Sep-2018

Correspondence Address:
Dr Saman Warnakulasuriya
WHO Collaborating Centre for Oral Cancer & King's College London, London
UK
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_1793_17

Rights and Permissions
   Abstract 

Smokeless tobacco (SLT) use has many oral effects including oral cancer, leukoplakia and erythroplakia, oral submucous fibrosis (if mixed with areca nut), loss of periodontal support (recession) and staining of teeth and composite restorations. This review was aimed to provide information to identify oral lesions that occur due to the use of smokeless tobacco so that effective interventions can be undertaken to reduce morbidity and mortality from the use of SLT.

Keywords: Chewing tobacco - leukoplakia - oral cancer - smokeless tobacco - submucous fibrosis


How to cite this article:
Muthukrishnan A, Warnakulasuriya S. Oral health consequences of smokeless tobacco use. Indian J Med Res 2018;148:35-40

How to cite this URL:
Muthukrishnan A, Warnakulasuriya S. Oral health consequences of smokeless tobacco use. Indian J Med Res [serial online] 2018 [cited 2020 Jan 26];148:35-40. Available from: http://www.ijmr.org.in/text.asp?2018/148/1/35/242218


   Introduction Top


Tobacco is derived from two main species Nicotiana tabacum and Nicotiana rustica. The most important ingredient from the leaves of these plants is nicotine - a volatile alkaloid. Nicotine is one of the most addictive and stimulant drugs. Nicotine affects all organs, but predominantly, it binds to a central nervous system receptor and increases brain dopamine levels making it an addictive agent. Although nicotine is an addictive, most of the severe health effects of smokeless tobacco use come from other chemicals[1]. The Centers for Disease Control and Prevention analyzed 40 top-selling brands of moist snuff to measure nicotine, moisture, pH, un-ionized nicotine and tobacco-specific nitrosamines (TSNAs), including 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol. The study findings indicated that moist snuff brands in the US varied widely in the content of rapidly absorbed, addictive un-ionized nicotine (500-fold range) and of carcinogenic TSNAs (18-fold range)[2]. Smokeless tobacco (SLT) products in the Indian market are likely to have much more nitrosamine content. This was confirmed in a study on the Indian products: the highest levels of TSNAs were found in certain brands of khaini, zarda and other SLT products. Concentrations of N-nitrosonornicotine (NNN) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) in these products ranged from 1.74-76.9 to 0.08-28.4 μg/g, respectively[3]. The packaging, moisture content and pH of the product influence the content and rapid absorption of chemicals through the oral mucosa. Smokeless tobacco may also contain harmful metals such as arsenic. A recent study indicates that the concentration of arsenic was significantly higher in scalp hair and blood samples of tobacco chewing patients than those of controls[4].

In addition to chewing tobacco leaves, other forms of smokeless tobacco are used in India and other countries. The terminology used for these SLT products and the ingredients in tobacco mixtures used to make these products are shown in [Table 1]. Gutka is the most abundantly consumed SLT form in India. Gutka has now been banned all over India[5], but a more vigorous implementation is necessary. Betel quid used in South Asia often contains smokeless tobacco[6].
Table 1: Types and ingredients of smokeless tobacco (SLT) products

Click here to view


There is greater prevalence of using smokeless tobacco than smoking tobacco in the Indian subcontinent. Use differs by age, gender and social class. Unlike other regions, in South East Asia Region, SLT use among adults is higher than smoking. Among women tobacco users, SLT is the predominant form of tobacco used[6].

Chewing tobacco and other smokeless tobacco products are known to be deleterious to oral health. The oral health effects of smokeless tobacco used in North America has been reviewed earlier[7]. This review is focused on harmful effects of SLT products available in the Indian subcontinent. The effects can be divided into two broad categories: those affecting the dental hard tissues, which include teeth, their supporting periodontium, and the soft tissues, which make up the oral mucosa that lines the oral cavity.


   Oral health consequences of SLT use Top


The main categories of smokeless or chewing tobacco-induced oral mucosal soft-tissue lesions reported are: oral squamous cell carcinoma (SCC) and verrucous carcinoma; oral potentially malignant disorders (OPMDs) (leukoplakia, erythroplakia and erythroleukoplakia); and tobacco pouch lesion [tobacco and lime users' lesion, oral submucous fibrosis (OSF) when mixed with areca nut].


   Oral cancer Top


The evaluation of carcinogenic risks of smokeless tobacco by the International Agency on Research for Cancer (IARC) has confirmed that SLT is carcinogenic to human and the main target organ being the oral cavity where the products are applied locally[8],[9]. The IARC evaluation is based on a large number of epidemiological studies (both case-control and cohort studies) and various experimental studies both in vivo and in vitro. A meta-analysis of published studies[10] reported an adjusted relative risk of 6.19 [confidence interval (CI) 4.16-9.21] from 10 studies for chewing betel quid with tobacco. The population attributable risk of SLT for the development of oral cancer is estimated at 66 per cent to tobacco chewers[10]. Cancers of the oral cavity arise in the lining epithelium of the oral cavity and the two main histological types reported are SCCs and verrucous carcinomas.

Squamous cell carcinoma

Tumours appear as red granular areas, or tend to be exophytic- ulcerative-infiltrative [Figure 1]. Ulcerative lesions have a distinct rolled border (margins). Induration at the margins and base of the tumour is a pathognomonic sign of oral SCC. Buccal involvement is reported to be as high as 80 per cent of the cancers that arise at the site of placement of the tobacco-containing quid, mostly in the lower buccal sulcus or posterior buccal mucosa. Lateral margins of tongue and floor of mouth are also high-risk sites due to pooling to tobacco fluid in this horse-shaped area in the mouth. In late stages, limitation of mouth opening, rigidity of tongue and metastasis to lymph nodes are common. Buccal carcinoma with extraoral fungation is not uncommon.
Figure 1: Oral squamous cell carcinoma in a patient addicted to gutka. Tumour arising from retromolar region has spread to the buccal sulcus. The figure demonstrates features of an exophytic growth with ulceration and necrosis.

Click here to view


Verrucous carcinoma

Verrucous carcinoma (VC) comprised up to 16 per cent of oral cancers in an Indian study[11] with a predilection for commissural, buccal or gingival sites. VC is a slow-growing tumour spreading laterally, is more indolent than conventional SCC. It is a diffuse, exophytic lesion usually covered by leukoplakic (keratotic) patches [Figure 2]. Characteristically, the lesion shows multiple rugae-like folds and deep clefts between them. This tumour has a high potential for local recurrence but not for nodal metastasis[12]. VC could sometimes appear as multifocal tumours due to field cancerization of the oral cavity by chronic SLT use.
Figure 2: Verrucous carcinoma in oral cavity of a patient in a tobacco chewer. This is an advanced tumour with a typical verrucoid appearance.

Click here to view



   Oral potentially malignant disorders (OPMD) Top


Placing tobacco in the oral cavity, namely in the buccal mucosa, gingival sulcus, inner aspect of lower lip, floor of the mouth initially leads to keratotic or hyperkeratotic changes. These changes are localized to the site where tobacco is placed [Figure 3]. Initially, there is a greyish white area which develops at the site of tobacco placement with a wrinkling of the mucosa which is termed as ‘tobacco pouch keratosis’[13]. Pindborg[14] reported some morphological variations in smokeless tobacco-associated lesions in the form of discrete elevated keratinized striae, particularly when involving non-keratinized mucosal sites. These striae gave the appearance to the lesion described as ‘pumice pattern’. A typically wrinkled appearance at the site of placement of the moist snuff and chewing tobacco was described by Axéll et al[15]. Later with prolonged use this area of mucosa changes to more defined conditions referred to as leukoplakia or erythroplakia.
Figure 3: Lower labial sulcus of a patient showing tobacco pouch keratosis in places where the quid has been retained for long periods.

Click here to view


Leukoplakia and erythroplakia

Leukoplakias are usually diagnosed after the fourth decade of life. These are more common in males and are six times more common among SLT users, than among non-tobacco users[16]. Sites of involvement among SLT users are buccal mucosa and lower buccal groves that are commonly affected due to the placement of tobacco quid at these locations.

There are two main clinical types of leukoplakia encountered in clinical practice; homogeneous and non-homogeneous leukoplakia[16]. The distinction is based on surface colour and morphological (thickness and texture) characteristics. Homogeneous leukoplakiasare uniformly flat and thin [Figure 4]. Non-homogeneous varieties comprise three clinical types: (i) Speckled: mixed, white and red (also termed erythroleukoplakia) [Figure 5] but retaining predominantly white in colour; (ii) Nodular: small polypoid outgrowths, rounded red or white excrescences; and (iii) Verrucous or exophytic: wrinkled or corrugated surface appearance.
Figure 4: Oral homogeneous leukoplakia affecting the commisure in a tobacco chewer.

Click here to view
Figure 5: Erythroleukoplakia with candidal infection. This is mixed red and white lesion and has a worse prognosis than homogeneous leukoplakia.

Click here to view


In general, most leukoplakias are asymptomatic. A red component in the leukoplakia (erythroleukoplakia) indicates possible colonization by candida organisms and an increased risk for dysplasia and/or malignancy [Figure 5]. When widespread or multiple patches of leukoplakia are noted the term proliferative verrucous leukoplakia is used [Figure 6]. This is a distinct entity that carries a higher risk for malignant transformation and is fortunately rare. A provisional diagnosis of leukoplakia is made after excluding other conditions that clinically appear white in colour[17].
Figure 6: Proliferative verrucous leukoplakia. Thick white plaques are noted affecting several sites, gingiva, alveolar mucosa, the sulcus and spreading to lower lip.

Click here to view


Erythroplakia clinically appears as a red patch with a velvety or a granular surface and present with well circumscribed clinical margins. Again the diagnosis is made after excluding other conditions that clinically appear red in colour.

Oral submucous fibrosis

OSF is a chronic, insidious disease that affects the submucosa of the oral cavity resulting in progressive limitation of mouth opening which is a hallmark feature of this disease[18]. The disease is solely[6],[9] caused by areca nut and the literature erroneously refers to smokeless tobacco as the causative agent. However, as gutka products contain both SLT and areca nut[19], the disease is common among gutka chewers. Due to an increase in the prevalence of gutka use among young people in India, the OSF was considered as an epidemic[20]. A systematic review[21] of studies reported ORs 2.98 (CI 1.5-3.9); 2.33 (CI 1.9-4.5); 5.08 (CI 3.7-6.4); 3.56 (CI 1.3-4.7); 33 (CI 2.2-46.6); 1.65 (CI 1.2-2.3); 3.33 (CI 2.5-5.3) and 9.25 (CI 3.1-15.5) for between gutka use and prevalence of OSF. [Figure 7] illustrates some of the clinical aspects of OSF. Malignant changes at the site of OPMD may take a couple of years to manifest. Before oral SCC develops, a biopsy taken from the white or red patch may show varying degrees of dysplasia. Some OPMDs may show reversal and may not undergo malignant change[22].
Figure 7: Oral submucous fibrosis, (A) left buccal mucosa, (B) right buccal mucosa, (C) palate. The buccal mucosae show loss of elasticity and fibrous banding. The palatal arch shows fibrosis.

Click here to view



   Effect of smokeless tobacco on teeth Top


Chewing tobacco and use of SLT products cause considerable staining of teeth among users [Figure 8]. Discolouration of the teeth is a common complication of tobacco chewing. The stains bind and penetrate the enamel, dentin, root surfaces causing a brown to black discolouration. Artificial dentures, prosthesis are also discoloured by prolonged tobacco chewing. The coarse abrasives in tobacco products when constantly chewed cause abrasion or tooth wear. Chewing tobacco also increases the incidence of dental caries and thereby causes tooth loss[23]. Epidemiology suggests tobacco users have 67 per cent tooth loss compared to non-users[23]. The high content of sweetening and flavouring agents in tobacco products is responsible for tooth decay.
Figure 8: Tooth staining. These extrinsic stains are due to long term betel quid with tobacco use.

Click here to view



   Effects of SLT on gingiva and periodontal tissues Top


Among smokeless tobacco users, there is an increased gingival recession with exposure of tooth root surface, periodontal pocket formation, plaque and calculus accumulation which leads to periodontitis. The gingival recession is more prominent in the anterior teeth region. A systematic review[21] of three studies among tobacco chewers reported ORs 1.64 (CI 1.2-2.1); 2.20 (CI 1.1-4.9) and 3.56 (CI 1.9-5.50) for periodontal inflammation including gingivitis, gingival recession and periodontal pocketing among tobacco chewers.


   Conclusion Top


Smokeless tobacco predisposes to increased risk of oral cancer and OPMD development in an individual. In addition, it exerts a number of adverse effects on the teeth and adjoining structures. All healthcare providers should assess the patients' tobacco usage habits and actively employ tobacco prevention, cessation and treatment programmes.

Conflicts of Interest: None.

Financial support & sponsorship: None.



 
   References Top

1.
National Cancer Institute and Centers for Disease Control and Prevention. Smokeless Tobacco and Public Health: A Global Perspective. NIH Publication No. 14-7983; 2014.  Back to cited text no. 1
    
2.
Richter P, Hodge K, Stanfill S, Zhang L, Watson C. Surveillance of moist snuff: Total nicotine, moisture, pH, un-ionized nicotine, and tobacco-specific nitrosamines. Nicotine Tob Res 2008; 10 : 1645-52.  Back to cited text no. 2
    
3.
Stepanov I, Hecht SS, Ramakrishnan S, Gupta PC. Tobacco-specific nitrosamines in smokeless tobacco products marketed in India. Int J Cancer 2005; 116 : 16-9.  Back to cited text no. 3
    
4.
Arain SS, Kazi TG, Afridi HI, Talpur FN, Kazi AG, Brahman KD, et al. Correlation of arsenic levels in smokeless tobacco products and biological samples of oral cancer patients and control consumers. Biol Trace Elem Res 2015; 168 : 287-95.  Back to cited text no. 4
    
5.
Chaturvedi P. Resource Centre for Tobacco Free India. Available from: www.rctfi.org/, accessed on May 2, 2013.  Back to cited text no. 5
    
6.
International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans. Betel-quid and areca nut chewing and some areca-nut derived nitrosamines. Vol. 85. Lyon, France: IARC; 2004.  Back to cited text no. 6
    
7.
Walsh PM, Epstein JB. The oral effects of smokeless tobacco. J Can Dent Assoc 2000; 66 : 22-5.  Back to cited text no. 7
    
8.
International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans. Smokeless tobacco and some tobacco specific N-nitrosamines, Vol. 89. Lyon, France: IARC; 2007.  Back to cited text no. 8
    
9.
International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans. Personal habits and indoor combustions, Vol. 100E. Lyon, France: IARC; 2012.  Back to cited text no. 9
    
10.
Guha N, Warnakulasuriya S, Vlaanderen J, Straif K. Betel quid chewing and the risk of oral and oropharyngeal cancers: a meta-analysis with implications for cancer control. Int J Cancer 2014; 135 : 1433-43.  Back to cited text no. 10
    
11.
Rekha KP, Angadi PV. Verrucous carcinoma of the oral cavity: A clinico-pathologic appraisal of 133 cases in Indians. Oral Maxillofac Surg 2010; 14 : 211-8.  Back to cited text no. 11
    
12.
Walvekar RR, Chaukar DA, Deshpande MS, Pai PS, Chaturvedi P, Kakade A, et al. Verrucous carcinoma of the oral cavity: A clinical and pathological study of 101 cases. Oral Oncol 2009; 45 : 47-51.  Back to cited text no. 12
    
13.
Shrestha P, Ikeda N, Fukano H, Takai Y, Mori M. Oral mucosal lesions associated with tobacco and betel-chewing habits: A napalese experience. Dent J Malays 1997; 18 : 23-5.  Back to cited text no. 13
    
14.
Pindborg JJ. Oral cancer and precancer. Bristol: John Wright; 1980.  Back to cited text no. 14
    
15.
Axéll T, Andersson G, Larsson A. Oral mucosal findings associated with chewing tobacco in Sweden - A clinical and histological study. J Dent Assoc S Afr 1992; 47 : 194-6.  Back to cited text no. 15
    
16.
Kramer IR, Lucas RB, Pindborg JJ, Sobin LH. Definition of leukoplakia and related lesions: An aid to studies on oral precancer. Oral Surg Oral Med Oral Pathol 1978; 46 : 518-39.  Back to cited text no. 16
    
17.
Warnakulasuriya S, Johnson NW, van der Waal I. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med 2007; 36 : 575-80.  Back to cited text no. 17
    
18.
Warnakulasuriya S, Kerr AR. Oral submucous fibrosis: A review of the current management and possible directions for novel therapies. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 122 : 232-41.  Back to cited text no. 18
    
19.
Gupta PC, Ray CS. Smokeless tobacco and health in India and South Asia. Respirology 2003; 8 : 419-31.  Back to cited text no. 19
    
20.
Gupta PC. Mouth cancer in India: A new epidemic? J Indian Med Assoc 1999; 97 : 370-3.  Back to cited text no. 20
    
21.
Javed F, Chotai M, Mehmood A, Almas K. Oral mucosal disorders associated with habitual gutka usage: A review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109 : 857-64.  Back to cited text no. 21
    
22.
Warnakulasuriya S, Ariyawardana A. Malignant transformation of oral leukoplakia: a systematic review of observational studies. J Oral Pathol Med 2016; 45 : 155-66.  Back to cited text no. 22
    
23.
Warnakulasuriya S, Dietrich T, Bornstein MM, Casals Peidró E, Preshaw PM, Walter C, et al. Oral health risks of tobacco use and effects of cessation. Int Dent J 2010; 60 : 7-30.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1]


This article has been cited by
1 Systemic toxicity evaluation of novel tobacco products in Caenorhabditis elegans
Haiqing Cai,Yilu Xu,Shen Tang,Xiaobo Yang,Yunfeng Zou,Xinhang Wang,Laiming Mo,Bin Wu,Ziwei Liang,Yunqing Li,Xuejing Wei,Qingqing Ao,Ling Meng,Ning Zhang,Muting Chen,Chunhua Lan,Xiyi Li,Cailing Lu
Toxicology in Vitro. 2019; : 104671
[Pubmed] | [DOI]
2 Circle RNA hsa_circRNA_100290 serves as a ceRNA for miR-378a to regulate oral squamous cell carcinoma cells growth via Glucose transporter-1 (GLUT1) and glycolysis
Xing Chen,Jianjun Yu,Hao Tian,Zhenfeng Shan,Wei Liu,Zhen Pan,Jihao Ren
Journal of Cellular Physiology. 2019;
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
    Oral health cons...
   Oral cancer
    Oral potentially...
    Effect of smokel...
    Effects of SLT o...
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed2052    
    Printed3    
    Emailed0    
    PDF Downloaded491    
    Comments [Add]    
    Cited by others 2    

Recommend this journal