Periodontal effects associated with the use of smokeless tobacco

This report describes periodontal findings from a comprehensive study of smokeless tobacco use in professional baseball players. Subjects consisted of 1,094 players, coaches, and training staff of seven major league and their associated minor league teams. Before being examined, subjects completed questionnaires on patterns of smokeless tobacco use (validated by blood chemistry studies), rinsed their mouths under supervision, and were cautioned not to discuss their use of tobacco with the dental examiners. They then received a complete oral examination that included recording of all mucosal abnormalities, missing teeth, caries, extrinsic stain, attrition, Plaque Index, Gingival Index, pocket depth, attachment loss, and gingival recession. More than 50% of team members reported using smokeless tobacco, and 39% reported use during the current week. Among current week users, 46% had oral mucosal lesions, located primarily in the mandible at sites where the smokeless tobacco quid was placed. The use of smokeless tobacco was not necessarily associated with severe forms of periodontal disease, and the presence of poor oral hygiene and gingivitis in these users was not related to the development of oral lesions. However, sites adjacent to mucosal lesions in smokeless tobacco users showed significantly greater recession and attachment loss than in sites not adjacent to lesions in users or comparable sites in non-users.     

Oral mucosal lesions found in smokeless tobacco users

The risk for oral mucosal lesions associated with use of smokeless tobacco among 1,109 professional baseball players during spring training in 1988 was investigated. Leukoplakia was very strongly associated with use of smokeless tobacco in this population of healthy young men. Of the 423 current smokeless tobacco users, 196 had leukoplakia compared to seven of the 493 nonusers (OR = 60.0, 95% CI = 40.5-88.8). The amount of smokeless tobacco used (in hours per day that smokeless tobacco was held in the mouth), recency of smokeless tobacco use (hours since last use), type (snuff versus chewing tobacco), and brand of snuff used were significantly associated with risk for leukoplakic lesions among smokeless tobacco users. Ninety-eight leukoplakic areas in 92 subjects were biopsied and examined microscopically. All lesions were benign, but one specimen had mild epithelial dysplasia. The long-term significance of leukoplakia in smokeless tobacco users and their relation to oral cancer is not clear.     

Histopathology of smokeless tobacco lesions in professional baseball players. Associations with different types of tobacco.

We examined 142 biopsy specimens of smokeless tobacco-associated oral mucosal lesions from 133 professional baseball players. Four types of epithelial change were observed in the specimens: hyperparakeratosis, hyperorthokeratosis, pale surface staining, and basal cell hyperplasia. These types of epithelial change were associated with the type of smokeless tobacco used (snuff or chewing tobacco) but not with the duration (years) or amount (hours per day) of use. The thickness of hyperkeratosis in a specimen correlated directly with the amount of smokeless tobacco use. The use of snuff was more frequently associated with development of oral mucosal lesions than was the use of chewing tobacco, and snuff appeared to cause a greater variety and severity of epithelial change than did chewing tobacco.     

Prevalence of spit tobacco use across studies of professional baseball players.

A review of published data, together with previously unpublished information, shows that the use of spit tobacco among professional baseball players continues to be alarmingly high. In spite of efforts to make players aware of the harmful effects, approximately 35 percent to 40 percent of professional baseball players still use spit tobacco, and about half of those have associated lesions. However, current efforts of the National Spit Tobacco Education Program, Major League Baseball, the Professional Baseball Athletic Trainers Society and the Major League Baseball Players Association are expected to result in a significant reduction in spit tobacco use in this population in the next decade.     

Assessment of risk factors for oral leukoplakia in West Virginia

OBJECTIVE: To assess risk factors associated with oral leukoplakia in a US population with high use of smoked tobacco and smokeless tobacco. METHODS: The RJ Gorlin Leukoplakia Tissue Registry was used to identify individuals with oral leukoplakia in West Virginia, USA. This case-control study consisted of 90 cases with oral leukoplakia and 78 controls with periapical cysts. Univariate-univariable (one dependent variable and one independent variable) and univariate-multivariable (one dependent variable and multiple independent variables) logistic regression modeling quantified the association between oral leukoplakia and potential explanatory variables. RESULTS: Unadjusted measures of association indicate that those with oral leukoplakia were more likely to be older [odds ratio of crude: OR(Crude) = 2.72; 95% confidence interval (CI): 1.45-5.11], more likely to currently use smokeless tobacco (OR(Crude) = 3.16; 95% CI: 1.10-9.07), and more likely to currently use snuff (OR(Crude) = 8.32; 95% CI: 1.83-37.80). Individuals currently using smokeless tobacco or currently using snuff were more likely to have oral leukoplakia [adjusted odds ratio, OR(Adj) = 9.21 and 30.08; 95% CI: 1.49-57.00 and 2.67-338.48, respectively], after simultaneously adjusting for age, gender, currently using smoked tobacco, currently using alcohol daily, and dental prostheses use. CONCLUSIONS: Generalizability is an issue when studying risk factors associated with oral leukoplakia because of geographical variations in the composition of smokeless tobacco (i.e. betel, lime, ash, and N-nitrosamines) and cultural variations in the use of tobacco (i.e. reverse smoking). Snuff was the main smokeless tobacco product currently used in West Virginia, and was strongly associated with oral leukoplakia, after adjusting for potential explanatory variables.     

Reduction of Langerhans cells in smokeless tobacco-associated oral mucosal lesions

Localized absence of epithelial Langerhans cells (LC) has been shown to affect systemic immune responses, allow microbial colonization and play a possible role in carcinogenesis. Because use of smokeless tobacco is associated with abnormal oral mucosal changes and development of carcinoma, we examined lesion and control specimens from 17 current users of smokeless tobacco to determine whether lesions showed changes in LC number or antigen expression. We identified LC by immunohistochemistry with antibodies to the antigens T6, HLA-DR, HLA-DQ, and HLA-DP. Lesion specimens contained fewer LC (means of 6 LC/mm and 10 LC/mm2) than did the corresponding control specimens (means of 14 LC/mm and 30 LC/mm2), and in each pair of lesion and autologous control specimens the reduction in LC was on average 58% (range, 3% to 95%). There were no apparent differences between lesion and control specimens in the number of LC expressing each of the four marker antigens. Reductions in LC occurred in all types of smokeless tobacco-associated lesions, regardless of increased epithelial thickness or changes in keratinization. Our data indicate that smokeless tobacco reduces the number of Langerhans cells at its site of contact with the oral mucosa.     

Smokeless tobacco use prevents aphthous stomatitis.

Aphthous stomatitis is a common, recurrent, painful ulcerative condition of the oral mucosa. Cigarette smoking has been reported to protect against aphthous ulcers. To determine whether smokeless tobacco use also protects against aphthous ulcers, we examined the oral mucosa in 1456 professional baseball players, about half of whom were smokeless tobacco (ST) users. After controlling for the confounding effects of age, race, cigarette smoking, alcohol consumption, and dental hygiene practices, ST use was found to significantly reduce the risk of aphthous ulcers among these healthy young men (odds ratio = 0.4; p = 0.04). It has been suggested that cigarette smoking prevents aphthous ulcers by causing increased keratinization of the oral mucosa, and ST may protect by the same mechanism. Alternatively, a component of tobacco that is systemically absorbed might be responsible for protecting against aphthous ulcers. If the mechanism that protects ST users against aphthous ulcers is systemic, then nicotine is the likely protective factor.     

Dental injury and its prevention in Swiss rugby

Abstract – Objectives: Rugby players are at a high risk of sustaining dental injury because of the high number of tackles implicit to the game. This study aimed to determine the frequency of injuries sustained by players in the Swiss rugby league. Methods: During the 2010/11 season, 517 rugby players from 19 clubs were questioned about dental trauma as well as the use of mouthguards and other forms of body protection. The level of awareness about tooth avulsion and replantation was also assessed. Participants included athletes from four different leagues; National (155), Premier (122), Women’s (90) and Juniors (150). Results: Of the 517 players taking part in the survey, 54.4% had sustained at least one serious injury and 39.5% had sustained a facial injury. One hundred and thirty‐nine athletes (37.3%) had observed another player sustain a dental injury during a game, whilst 35 (6.8%) had personally sustained one or more dental injuries. Dental injury rate was considerably higher amongst forwards than backs. Four hundred and fifty‐six players (88.2%) wore a mouthguard of which three‐quarters were tailor‐made. Three hundred and thirteen players (60.5%) were aware that an avulsed tooth can be replanted; however, only 27 (5.2%) had heard of the tooth rescue boxes. These results demonstrate that, whilst general injuries occur with regularity in rugby, dental injuries are not amongst the most common forms. This is almost certainly attributable to the high level of mouthguard usage. Particularly for players in the junior league, in which the use of mouthguards was lowest, the risk of dental injury may be reduced by an increased level of education about tooth protection. Conclusions: To this end, an increased awareness about and usage of tooth rescue boxes would be desirable. It would seem sensible to make the wearing of mouthguards compulsory in contact sports such as rugby.     

Smokeless tobacco use among adult patients who visited family practice clinics in Karachi, Pakistan

Background:  Use of smokeless tobacco (SLT) is significantly associated with poor oral health and cancers. The objectives of this study were to estimate the proportion of use and the knowledge about SLT in relation to oral cancer and its differentials by socio-demographic and patient's diagnostic categories. This study also aimed to assess the SLT user's attitude and practices for its use.
Methods:  In a cross-sectional study, 502 adult patients (≥15 years) were randomly interviewed in family practice clinics in Karachi, Pakistan. SLT use was considered as usage of any of the following: betel quid (paan) with tobacco, betel nuts with tobacco (gutkha), and snuff (naswar).
Results:  Overall, 52.4% subjects had used SLT at least in one form. More males were using SLT than females ( P  = 0.03). Similarly, higher proportion of patients with gastro-intestinal diseases were using SLT compared with other diagnostic categories ( P  = 0.004). Knowledge about the oral carcinogenic effect of SLT was higher among men and those who had schooling of >10 years ( P  < 0.001). This knowledge was also higher in patients with non-communicable and infectious diseases. Among SLT users, 31.3% tried to quit this habit but failed. The majority of users started using SLT before the age of 15 years; 40.2% and 30.8% started after being inspired by media advertisements and friends/peer pressure, respectively.
Conclusions:  In this study, over half of the patients were using SLT in various forms and had poor knowledge about its hazards. We suggest that there is a need for socially and culturally acceptable educational and behavioral interventions for control of SLT usage.     

P.L. 99-252–Implications for Dentists and Their Clinical Practice

This paper is one of a series attempting to determine the impact of Public Law 99-252, the Comprehensive Smokeless Tobacco Health Education Act of 1986, on decreasing smokeless tobacco use. Potential indicators are discussed that could be used by the dental profession to determine the efficacy of the profession's involvement in existing and future prevention and cessation efforts relative to this law. In this review, six major areas are considered for measuring declines in smokeless tobacco use relative to the role of the dental health practitioner. These areas encompass the following: (1) the dental profession's knowledge of smokeless tobacco health hazards, (2) dental practitioners' involvement in measuring changes in use patterns, (3) the influence dentists have with their patients and community in decreasing smokeless tobacco use, (4) the general attitude and intention to quit on the part of dental patients, (5) active governmental involvement efforts, and (6) health effects of smokeless tobacco that might be used for identifying decreasing smokeless tobacco use. Within each of these six broad categories, more specific indicators for measuring the impact of P.L. 99-252 relative to the dental profession were considered.     

Oral mucosal changes and nicotine disposition in users of Swedish smokeless tobacco products: a comparative study

The purpose of this study was to investigate the uptake and metabolism of nicotine by smokeless (oral) tobacco users and to find out if the less pronounced clinical changes in the oral mucosa in users of portion-bag packed oral moist snuff ( snus ) compared with the changes in the mucosa of loose snus users are correlated to exposure and uptake of tobacco constituents. 54 habitual users of smokeless tobacco were selected for the study: 22 loose snus users, 23 users of portion-bag packed snus and 9 users of chewing tobacco. In accordance with previous findings, less pronounced clinical changes in the oral mucosa were recorded in portion-hug users compared with loose snus users. The clinical findings observed in the oral mucosa of users of chewing tobacco were leukoedema and slight clinical " snus changes". The average intake of nicotine (measured as nicotine equivalents excreted during 24 h) for snus users was 35 mg, and was 50% higher for users of chewing tobacco. The average steady-state saliva cotinine concentration was about 300 ng ml for both categories of snus users, which is similar to that found in smokers, while the average concentration found in users of chewing tobacco was 50% higher. There was a good correlation between saliva cotinine concentration and the 24 h intake of nicotine. The average excretion profile of nicotine was similar in all three groups of smokeless tobacco users, being on average: nicotine 8%, nicotine-Glca 3%, cotinine 8%, cotinine 9%, 3'hydroxycotinine 42%, 3'hydroxycotinine-GlcA 19%, nicotine-N -oxide 9%, and cotinine-N-oxide 3%. The clinical severity of buccal mucosal changes correlated neither with the markers for exposure (i.e. nicotine and tobacco specific nitrosamines extracted from the tobacco) nor with the biological markers for uptake of tobacco constituents (i.e. nicotine equivalents excreted during 24 h and saliva cotinine concentrations).     

Smokeless tobacco (shamma) and oral cancer in Saudi Arabia

Oral use of smokeless tobacco has been associated with the development of oral cancer. Shamma is a preparation of smokeless tobacco. Previous investigators in the Kingdom of Saudi Arabia (KSA) have reported a relationship between their patients with oral cancer and a history of using shamma. The purpose of this study was to explore the possible relationship between a smokeless tobacco preparation (shamma) and oral cancer, among the provinces of the KSA. Tumor Registry (TR) data from the King Faisal Specialist Hospital and Research Centre (KFSH&RC) were reviewed for the period from 1976 to 1995. A total of 26510 Saudi cancer patients were referred over this 20-year period. The frequency of oral cancer was investigated, specifically for those primary sites located near the habitual placement of this smokeless tobacco product. Notably, 35.4% of these oral cancers were referred from one province - Jizan. The percentage of oral cancer cases from this province is significantly higher than the percentage of total malignant cases referred to KFSH&RC from this province, and the Saudi population of this province when compared to the whole of the KSA. These data suggest that there is a relationship between the factors smokeless tobacco product (shamma), frequency of oral cancer, and Jizan province: oral cancer appears to be more common in this province where shamma is also common.     

Smokeless Tobacco Habits and Oral Mucosal Lesions in Dental Patients

As part of a smokeless tobacco (ST) intervention study, we collected data on tobacco use habits and oral health for 245 male ST users aged 15 to 77. The study sample was identified during routine dental office visits and represents a relatively diverse population of patients. Oral health data collection included grading the clinical appearance of oral mucosal lesions using Greer and Poulson's classification system, as well as identifying and recording the primary anatomic location of ST placement. Results show that 78.6 percent of ST users had observable oral lesions, 23.6 percent of which were in the most clinically advanced category (degree III). Of the lesions noted, 85 percent were in the same location the patient identified as his primary area of smokeless tobacco placement. In a comparison sample of 223 non-ST-users with the same age distribution, only 6.3 percent had observable lesions. A multiple logistic regression model for ST users showed that lesion presence and severity were most significantly related to current frequency of ST use.     

Tobacco use among young North American aboriginal athletes

Tobacco use remains a major cause of preventable illness and death in North America. Although reported smoking rates have decreased, they remain high among the young and among Aboriginal people. As part of an oral health promotion project, a convenience sample of 163 Aboriginal athletes participating in the 2002 North American Indigenous Games completed a self-administered questionnaire addressing tobacco use and knowledge of tobacco effects. Mean age of athletes was 19.6 years (SD 7.4); most were male and Canadian citizens. Only 22 participants reported current smoking; past use of tobacco was more common, with 58 reporting a history of smoking. Although age was not associated with current smoking, older athletes were significantly more likely (p 相似文献   

Penetration of N-nitrosonornicotine (NNN) across oral mucosa in the presence of ethanol and nicotine

The effects of ethanol concentrations of 5, 15, 20, 25, 27, 30 and 50% on the penetration of the tobacco-specific carcinogen, nitrosonornicotine (NNN), across porcine oral mucosa were examined using an in vitro perfusion system. Concentrations of ethanol of 25% and above significantly increased the permeability of oral mucosa to NNN, although this increase ceased with 50% ethanol, possibly due to a fixative effect. Nicotine is a consistent component of smoked and smokeless tobacco; the presence of 0.2% nicotine significantly increased the permeability of oral mucosa to NNN and 2% nicotine caused a further increase. Combined use of nicotine and ethanol significantly increased the penetration of NNN across oral mucosa over that of ethanol alone until the concentration of ethanol reached 50%. The results of this study suggest that the synergy between tobacco and alcohol in the etiology of oral cancer may be explained, at least in part, by the local permeabilizing effects of alcohol on the penetration of tobacco-specific (and other) carcinogens across oral mucosa.     

Tobacco control: an issue twinned with oral cancer control

Oral cancer is a silent crisis in India. Thirty per cent of all cancers are oral cancer, and approximately 17% of all cancers in men and 10.5% of all cancers in women are oral cancer. Approximately 70,000 new cases are reported annually and 46,000 oral cancer‐related deaths occur each year in India; furthermore, the number of cases is rapidly increasing. With this crescendo there may be an estimated 100,000 new cases by 2020, which is insurmountable, especially in emerging economies like India. This astronomical increase is a direct result of tobacco usage. The Global Adult Tobacco Survey performed in 2010 (GATS‐2010) reported that approximately 274.5 million people in India use tobacco in various forms. Increasing use of smokeless tobacco, especially by women and children, is of major concern. The World Health Organisation has identified tobacco control and oral cancer control measures as a health priority. However, prevention of tobacco use in India is a great challenge owing to low overall literacy rates and to greater prevalence among people in lower socio‐economic strata. Addressing this problem requires a multidisciplinary approach. This paper presents a situational analysis of oral cancer in India and the role of tobacco in making it the epicentre of the disease, and focuses on the role of dental care‐givers in influencing and promoting tobacco‐control programmes and early detection of oral cancer.     

Epidemiologic study of the association between alcohol habits and oral leukoplakia

In a house-to-house survey in Ernakulam district, Kerala State, 10914 individuals were interviewed for their tobacco and alcohol habits and examined for the presence of oral leukoplakia. Very few females (1.6%) were found to be alcohol users and they were excluded from further analysis. Among 7604 males, 30.4% used alcohol regularly, 25.4% occasionally and 44.2% were non-users. The prevalence of leukoplakia was significantly higher among regular (5.7%) and occasional (3.9%) users than among non-users (2.9%) of alcohol. Alcohol usage was found to be related to age as well as tobacco habits. The prevalence of leukoplakia was higher among alcohol users in each age-group as well as in each tobacco habit category. After age-adjustment the difference between alcohol users and non-users, although reduced, remained significant. For most tobacco habit categories the trend remained similar after age-adjustment except for the mixed habits group, for which there was a reversal of the trend. The alcohol habit may, perhaps, produce discernible effects only in association with other 'weak' etiological risk factors, such as a single tobacco habit of smoking or chewing rather than a 'strong' etiologic factor such as the mixed habits of chewing and smoking.     

The prevalence of smokeless tobacco use among adolescent male athletes

In assessing the prevalence and perceptions of use of smokeless tobacco among adolescent male athletes, several findings have public health implications. Almost a third of the sample had tried smokeless tobacco and 8% were current users. Racial differences between blacks and whites were remarkable. Differences in income strata and urban/rural settings were not significant. Peer influence was the major factor that initiated smokeless tobacco use. Abnormal mucosal findings were much more prevalent in those who had dipped smokeless tobacco than in those who had not. Most significant was a prevalence of oral leukoplakia in 5.2% of those who had ever dipped, which was 50 times that of nondippers. Using smokeless tobacco for more than 2 years or using more than three tins per week seemed to be of possible predictive value regarding the incidence of oral leukoplakia. Fifteen percent of current users had observable leukoplakia. Components necessary for effective intervention/prevention programs were elucidated with an emphasis on an increased role by dentists and other health professionals.     

Oral health effects of smokeless tobacco use in Navajo Indian adolescents

Recent reports have suggested that the use of smokeless tobacco is increasing in adolescents, and is particularly high in Native Americans, causing concern about possible effects on oral health. In this study, 226 Navajo Indians, aged 14-19, were interviewed regarding their use of smokeless tobacco (ST), cigarettes, and alcohol. Midbuccal and mesiobuccal sites on all fully erupted permanent teeth (excluding third molars) were examined for the presence of gingival bleeding, gingival recession, calculus, and loss of periodontal attachment. The oral mucosa was examined for evidence of leukoplakia. 64.2% (145) of the subjects (75.4% of the boys and 49.0% of the girls) were users of ST. Of these, over 95% used snuff alone or in combination with chewing tobacco. 55.9% used ST one or more days per week. 52.2% consumed alcohol, usually beer or wine, and 54.0% smoked cigarettes. 25.5% (37) of the users and 3.7% (3) of the non-users had leukoplakia. The duration (in years) and frequency of ST use (days per week) were highly significant risk factors associated with leukoplakia. However, the concomitant use of alcohol or cigarettes did not appear to increase the prevalence of these lesions. No consistent relationship was observed between the use of ST and gingival bleeding, calculus, gingival recession, or attachment loss, either when comparing users to non-users or when comparing the segment where the tobacco quid was habitually placed to a within-subject control segment. In view of these results, there is little doubt that smokeless tobacco is significantly related to the etiology of leukoplakia. As some evidence exists that smokeless tobacco use is a significant risk factor associated with oral carcinoma, intervention programs to discourage the use of smokeless tobacco by adolescents should be a public health priority.     

Effects of smokeless tobacco on the periodontal, mucosal and caries status of adolescent males

The use of smokeless tobacco (ST) products, such as snuff and chewing tobacco, was investigated in a school population of 565 males with a mean age of 13.8 years. All students completed a tobacco usage questionnaire and were given intraoral examinations by a team of dentists to determine the possible relationship of ST usage to the presence of gingivitis, gingival recession, mucosal pathology and caries. The overall prevalence of ST usage was 13.3%, which was much higher than the 1.4% prevalence of cigarette smoking. Pairwise chi square analysis revealed that there was no relationship between ST usage and the prevalence of gingivitis, but that the prevalence of gingival recession was significantly elevated in ST users, P < 0.001. The odds of having gingival recession were 9 times greater in the students using smokeless tobacco as compared to healthy, non-user cohorts. ST usage did not affect the prevalence of gingival recession in students without gingivitis. The frequency of occurrence of soft tissue pathology was significantly elevated, about 6-fold in students who used smokeless tobacco, as compared to non-users. P < 0.01. This was principally due to the increased prevalence of while mucosal lesions in smokeless tobacco users. However, there was no attributable risk for mucosal pathology in ST users who were free of gingivitis. Similarly, the use of smokeless tobacco was associated with a 1.6-fold elevation in mean DMF in students with gingivitis, P < 0.001, but this increase in caries experience was not seen in ST users who were free of gingivitis. In summary, in students with clean mouths that were free of gingivitis, the use of smokeless tobacco was not associated with a change in the prevalence of gingival recession, mucosal pathology, or in the mean DMF score. In contrast, smokeless tobacco usage was a significant risk factor in individuals with co-existing gingivitis, associated with a marked increase in the prevalence of gingival recession, mucosal pathology and caries experience.