Journal of Medical Biomedical and Applied Sciences J Med Biomed App Sci 7 (11), 294–299 (2019) ISSN (O) 2349-0748

Oral Changes Due to Tobacco Consumption: A Diagnostic Perspective

Dr. Rekha Jayaram1, Dr. Usha Jambunath2 , Dr. Anitha3 1. Consultant oral physician and maxillofacial radiologist at “RJ Dental Specialists” Bangalore 2. Consultant oral physician and maxillofacial radiologist at “Ujwal Dantalaya”, Bangalore 3. Consultant oral physician and maxillofacial radiologist at “RJ Dental Specialists” Bangalore

DOI: 10.15520/jmbas.v7i11.201 Accepted 15 November 2019; Received 28 September 2019; Publish Online 20 November 2019 Reviewed By: Dr. Daniel V.

Abstract Tobacco use is a major public health challenge and has established risk factor for various oral changes.The adverse effects on oral and general health of tobacco are well documented and on average, cigarette smokers die ten years younger than non-smokers.(1)The excessive use of tobacco products has been associated with various in the oral cavity. A routine intraoral examination by a dental health professional can reveal most of these lesions at an early stage, and early intervention may prevent serious sequelae. The literature search for the present review was conducted utilizing various search engines and electronic databases such as PubMed and MEDLINE with the search words “smokers”, “tobacco”, “oral cavity”, “lesions” . In this article we have made an attempt to review the key to diagnosis of various changes in the oral cavity associated with tobacco. Keywords: tobacco, smokers, smokeless, oral cavity, precancer

1. Introduction attractive, and inexpensive sachets of betel quid substitutes containing a flavored and sweetened dry Tobacco is one of the legal consumer products that mixture of areca nut, catechu, and slaked lime with can harm everyone exposed to it. Although tobacco tobacco (gutkha) or without tobacco (pan masala), is the single most preventable cause of death in the often claiming to be safer products, have become world today,its use is common throughout the world widely available and are increasingly used by young due to low prices and inconsistent public policies people, particularly in India.(28) against its use.(2) Tobacco is chewed and smoked in various forms especially in india. Tobacco is For easy understanding, the changes in the oral used in the following forms: cavity due to tobacco usage and its diagnosis can Smoke - Preparation of bidis, Cigar / cheroot / be dealt as following: chutta, Reverse Chutta Smoking, Chilums, Hookah, Hookli smoker 1. Teeth: Tooth Discolouration, Deposits ,Tooth Smokeless - Pan (betel quid) with tobacco, Mawa, Mainpuri tobacco, Khaini 2.Gingiva : Periodontitis, Acute Necrotising Application over the teeth and the gingiva - Ulcerative (Anug) Gudhaku, Bajjar, Creamy, Snuff.(3) 3.: Palatal , Ulcerations, Nicotinic In most areas, betel quid consists of tobacco, areca , Excresence, Hyperpigmentation nut, slaked lime, catechu, and several condiments, wrapped in a betel leaf. In recent years, small, 4. .: ,(OSMF) Tobacco Pouch Keratosis

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,Inflammation Of The Minor Salivary Glands, Periodontitis: Smokers have been associated with Smokers Melanosis, deeper pockets and greater attachment loss, more pronounced radiographic evidence of furcation Others: Delayed Healing Process, Implant Failures involvement, and increased alveolar bone and Halitosis. loss.(9)Smoking exerts a strong, chronic, and dose- dependent suppressive effect on gingival bleeding 2. Discussion on probing. Bleeding on probing is less evident in India is the second largest consumer of tobacco in smokers than nonsmokers, indicating its effect on the world, second only to China.The prevalence of gingival blood vessels. The mechanism by which tobacco use among adults (15 years and above) is smoking suppresses gingival bleeding is not 35%. The prevalence of overall tobacco use among understood exactly.(8) males is 48 percent and that among females is 20 percent. Nearly two in fi ve (38%) adults in rural Anug: Smoking has long been considered an areas and one in four (25%) adults in urban areas etiologic factor in acute necrotizing ulcerative use tobacco in some form.(24)The excessive use of gingivitis (ANUG). Tar in the smoke has a direct tobacco products has been associated with various irritating effect on gingiva giving rise to gingivitis lesions in the oral cavity. Any product which and nicotine causes contraction of capillaries, thus contains tobacco is not safe for human health. There interfering with the nutrition of the gingiva which are more than twenty-five compounds in smokeless consequently becomes less resistant to tobacco which have cancer causing activity but the infection.(15) It has an acute clinical presentation Use of smokeless tobacco has been linked with with the distinctive characteristics of rapid onset of higher risk of oral cancer. Smokeless tobacco interdental gingival necrosis, gingival pain, contains tobacco-specific nitrosamines (TSNAs), bleeding, and halitosis.(16) polonium, formaldehyde, cadmium, lead, and Tooth Abrasion: and the use of benzo[a]pyrene, which are carcinogenic agents.(27) smokeless tobacco are commonly associated with . The active ingredient for addiction is nicotine, a tooth abrasion.(4,5) Abrasion from pipe smoking naturally occurring drug found in all the different occurs on the occlusal surfaces in association with forms of tobacco. Nicotine sustains tobacco placement of the pipe stem, whereas abrasion from addiction by acting on nicotinic cholinergic smokeless tobacco usually occurs on the vestibular receptors in the brain to trigger the release of surface opposite the wad of smokeless tobacco, but dopamine and other neurotransmitters(34). The may involve the occlusal surfaces if the tobacco is patients with systemic diseases like diabetes and chewed . Abrasion may result in hypertension have the higher risk of developing hypersensitivity, pulp exposure or apertognathia these oral changes on tobacco consumption. The (open bite). Apertognathia develops in pipe smokers different ways in which tobacco is used lead to and usually occurs unilaterally on the smoker’s considerable variation in appearance, site and favourite side. (6) frequency of the lesions associated with the tobacco habit. The clinical appearance and diagnosis of Palatal changes is specific to populations these tobacco associated conditions of the oral who smoke with the lighted end of the cigars or cavity are reviewed here. cigarettes inside the mouth, producing changes in the palatal mucosa. The largest number of reverse And Deposits: Tobacco from smokers are found in certain areas of India, but this cigarettes, cigars, pipes, and chewing tobacco habit is also practiced in some Latin American causes tenacious dark brown and black stains that countries, in Sardinia and in the Philippines. The cover the cervical one third to midway on the palatal changes consist of several components such tooth.(7). Staining is caused by the tar and nicotine as elevated white patches, red areas, ulcerations and in the cigarettes.(14) There is also a strong and hyper- or non-pigmented areas. These components independent impact of on occur independently, but more often, they coexist. subgingival calculus deposition leading to the gum Palatal cancers arise in this region with pre-existing disease called periodontitis.(13) palatal changes; hence they are considered as precancerous.(26) But there is no acceptable explanation why the soft palate escapes getting

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either stomatitis nicotina or carcinoma in whitening of the palatal mucosa which may be mild, reverse smokers.(22) moderate or severe in intensity. It may occur independently or coexist with other Palatal Ulcerations: Ulcerated areas are components.(25) characterized by crater-like ulcerations with deposits of fibrin often surrounded by Inflammation of Minor Salivary Glands: keratinization. Ulcerations form only 2% of the Ulcerative of the minor palatal components. They represent a "burn" type has not been mentioned in the literature so far. reaction of the palatal mucosa from the intense heat There is only one case reported wherein the of the lighted end of chutta.(3) inflammation of the minor salivary gland openings due to smoking and some kind of traumatic Smokers Palate or Nicotina Stomatitis: Refers to irritation could result in ulceration in the lower well-defined diffuse or focal greyish black .(23) pigmentation of the palatal mucosa due to increased melanin production by melanocyte. This Leukoplakia: Schepman et al. found that smokers pigmentation is limited to the and has have 6 times higher risk of developing leukoplakia regular margins . It is produced due to increased than non-smokers, despite lesions of non-smokers melanin deposition as a protective reaction to heat having a greater probability to evolve into and its antioxidant properties against toxic products cancer(21) . Leukoplakia is being recognized by produced during combustion of tobacco within the two forms: Homogeneous and the non- oral cavity.(11,12) homogeneous type. Homogeneous leukoplakia has predominantly white lesion of uniform flat, thin Clinical Grading of Smokers Palate: Mild (Grade appearance, smooth, wrinkled or corrugated surface I): Consisting of red, dot-like opening on blanched throughout the lesion, whereas non-homogeneous area. leukoplakia has been a mixture of white-and-red lesion that may be either irregularly flat, nodular, or Moderate (Grade II): Characterized by well- verrucous.(20) defined elevation with central umbilication. Oral Submucous Fibrosis (OSMF): OSMF is a Severe (Grade III): Marked by papules of 5 mm or chronic, insidious disease that affects the more with umbilication of 2-3 mm.(36) submucosa of the oral cavity resulting in Smokers Melanosis: IT IS a benign limited progressive limitation of mouth opening which is a melanin pigmentation occurring in the attached hallmark feature of this disease. The disease is

gingiva of tobacco smokers.(18) Through the solely caused by areca nut and the literature stimulation by polycyclic amines, smoking causes erroneously refers to smokeless tobacco as the the activation of melanocytes to produce melanin. causative agent. However, as gutka products contain These manifestations of pigmentation are both Smokeless tobacco and areca nut, the disease considered normal and generally no treatment is is common among gutka chewers. The buccal recommended except for aesthetic purposes. mucosa, the toungue and the show loss of Tobacco cessation has been reported to be sufficient elasticity, the palatal mucosa shows fibrosis.(35) in eliminating pigmentation(17) Tobacco Pouch Keratosis: It is characterized by Excrescence: Excrescences are 1–3 mm elevated one or more of the following characteristics: area, often with central red dots marking the orifices Change in color, wrinkled appearance, thickening of of the palatal mucosal glands. There may be many the mucosa, scrapable or non-scrapable epithelial of these painless popular lesions in the glandular surface, and a presence of ulceration(10) part of the hard palatal mucosa and are not present Quid Induced Keratosis: The buccal mucosa in the soft palate or in the anterior half or third of the hard palate and will not extend up to the characteristically shows either bilaterally or unilaterally, ill-defined, whitish-gray discoloration alveolar margin.(19) Mehta et al. in 1977 stated that excrescences were transient in nature and tend to that can be rubbed off at the site of quid placement(10) regress with the discontinuation of the habit. PALATAL KERATOSIS: it is the Diffuse

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Oral Cancer: Smoking and use of chewed forms of after a cigarette has been extinguished, but the tobacco are the most common causes of oral cancer. chemicals that also remain in the mouth affects on The timely diagnosis of oral cancer relies on a bacteria in the mouth. These sulphur-producing detailed clinical history and a comprehensive bacteria feed on proteins, and produce chemicals clinical examination for detection of any abnormal known as “volatile sulphur compounds causing tissue. Early disease is usually symptomatic and halitosis. The nicotine in tobacco reduces saliva incidentally detected wheras advanced stage is flow and some smokers can get dry mouth frequently painful. In more advanced disease, symptoms.(33) ulceration may be a common finding which may be accompanied by pain (30). Pain is pronounced in 3. Conclusion tumors of the tongue due to its mobility and inherently sensitive nature. Advanced tumors that Although the oral cavity is accessible through visual infiltrate the soft tissue and bone of the examination, still oral mucosal lesions are periodontium result in tooth mobility wheras large diagnosed behindhand, so early diagnosis and tumors involving the posterior oral cavity cause treatment are crucial for the efficacious breathing and /or speech impediments. Additional management of patients with oral premalignant clinical features include bleeding, parasthesia, lesions and conditions. Health professionals and referred pain which may be mistaken especially oral physicians and general dentists for earache.(29) should also take part in advancing the agenda of in the community. Dentists have an Delayed Healing of Socket Post Extraction: The important role in tobacco control as they can association between cigarette smoking and delayed directly see the harmful effects of tobacco in the healing is well recognized in clinical practice. mouth. Slower healing has been observed clinically in smokers with wounds resulting from trauma or surgical procedures. The documented effects of the References toxic constituents of cigarette smoke--particularly nicotine, carbon monoxide, and hydrogen cyanide-- 1. Ferrante M, Saulle R, Ledda C, Pappalardo R, suggest potential mechanisms by Fallico R, La Torre G, Fiore M. Prevalence of which smoking may undermine expeditious wound smoking habits, attitudes, knowledge and beliefs repair. Nicotine is a vasoconstrictor that reduces among Health Professional School students: a cross- nutritional blood flow to the skin, resulting in tissue sectional study. Annali dell'Istituto superiore di ischemia and impaired healing of injured tissue. sanitÃ. 2013;49:143-9. Smokers should be advised to stop smoking prior to any surgery (31) 2. Koothati RK, Reddy GV, Ramlal G, Prasad LK, Kumar VJ, Pokala A. An epidemiological study of Implant Failures: Failure rate of implants is more tobacco-related oral habits in Mahabubnagar district in smokers compared to nonsmokers and is directly of Telangana, India. Journal of Indian Academy of proportional to tobacco use. In smokers, implant and Radiology. 2017 Jul failure is more in maxilla as compared to 1;29(3):205. and significant numbers of implants fail after second-stage surgery and also marginal bone loss 3. Nishi Mishra, Shrivardhan K, Jayesh Rai, Nitin and incidence of peri-implantitis is more after Awasthi. Tobacco related lesions of oral cavity- a implant placement. Implants placed in grafted review. International Journal of Contemporary maxillary sinuses of smokers fail two times more Medicine Surgery and Radiology. 2017;2(1):25- 28. compared to that in nonsmokers. To increase implant survival in smokers, it is advised to stop the 4. Bowles WH, Wilkinson MR, Wagner MJ, habit 1 week prior to and up to 2 months after Woody RD. Abrasive particles in tobacco products: implant placement.(32) a possible factor in dental . J Am Dent Assoc 1995; 126:327-31. Halitosis: The bad breath in smokers is due to the chemical composition of tobacco. Not only do the lungs retain a measure of this tobacco smoke even

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Journal of Medical Biomedical and Applied Sciences, Vol 7 Iss 11, 294–299 (2019)