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.     

Oral tissue alterations associated with the use of smokeless tobacco by teen-agers. Part I. Clinical findings

The use of smokeless tobacco appears to be finding its way onto middle school, high school and college campuses as a socially acceptable and popular habit. Numerous reports in the literature have described the oral changes that appear to be associated with the use of smokeless tobacco in adults. Such information is unavailable for the lower age groups. A study was therefore undertaken to determine the prevalence and frequency of oral hard- and soft-tissue alterations associated with the use of smokeless tobacco in a teen-age population. High school students in grades 9 to 12 were evaluated on a random basis. From a total sample of 1,119 students, 117 users of smokeless tobacco were identified. Four distinct lesions associated with smokeless tobacco use were identified clinically: (1) hyperkeratotic or erythroplakic lesions of the oral mucosa, (2) gingival or periodontal inflammation, (3) a combination of oral mucosal lesions and periodontal inflammation, and (4) cervical erosion of the teeth. Among the smokeless tobacco users, 113 were boys and 4 were girls. Fifty-seven (48.7 percent) of the users had soft-tissue lesions and/or periodontal inflammation or erosion of dental hard tissues. Ninety-nine of the 117 users were Caucasian, 6 were Hispanic, 1 was black, 1 was Asian, 1 was an American Indian, and 6 failed to identify an ethnic origin. Use ranged from one to twenty "dips" per day, with an average time per dip of 30 minutes. Most users had been dipping for an average of 2 years, and twelve different tobacco brands were identified.     

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.     

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.     

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.     

Smokeless tobacco: a potential hazard to infants and children

During the past several years, there has been a growing interest and concern relative to the increased use of smokeless tobacco, especially use among young people. Dentistry is concerned, in particular, with the oral hazards that are associated with smokeless tobacco. Accidental ingestion of poisonous substances is a significant problem among children. A case is reported illustrating the potential hazard of nicotine poisoning in an infant that resulted from an accidental ingestion of a smokeless tobacco-related product.     

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 less than 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 less than 0.01. This was principally due to the increased prevalence of white 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 less than 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.     

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.     

Evaluating the Impact of P.L. 99-252 on Decreasing Smokeless Tobacco Use

Literally, Public Law 99-252 (otherwise known as the Comprehensive Smokeless Tobacco Health Education Act of 1986) includes provisions that are informational in nature. Implicitly, however, this law is considered part of the federal effort in disease prevention and health promotion. This paper reviews the societal and legislative context of that act and presents a plan to evaluate the impact of this law on decreasing smokeless tobacco use. The uniqueness of this plan is its incorporation of nine disciplinary perspectives in the derivation of indicators to measure process, impact, and outcome measures for decreasing smokeless tobacco use. A basic prevention strategy is suggested by this interdisciplinary approach. In addition, specific lessons could be applied from the history of successes in public health to decreasing smokeless tobacco use.     

Smokeless tobacco use and cancer of the upper respiratory tract

The most recent epidemiologic review of the cancer risks associated with smokeless tobacco use appeared in 1986, when 10 studies were available. This review describes 21 published studies, 20 of which are of the case-control type. We characterize each study according to the specific anatomic sites and according to the type of smokeless tobacco products for which it provides relative risks of cancer. The use of moist snuff and chewing tobacco imposes minimal risks for cancers of the oral cavity and other upper respiratory sites, with relative risks ranging from 0.6 to 1.7. The use of dry snuff imposes higher risks, ranging from 4 to 13, and the risks from smokeless tobacco, unspecified as to type, are intermediate, from 1.5 to 2.8. The strengths and limitations of the studies and implications for future research are discussed.     

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.     

Smokeless tobacco cessation guidelines for health professionals in England

Smokeless tobacco is used in the UK predominantly by members of the Indian, Pakistani and especially Bangladeshi communities. The most commonly used form is tobacco mixed with lime and additional psychoactive compounds, most notably areca nut. The resulting "quid" is chewed or held in the mouth. Studies from Asia indicate that use of this kind of product is linked with an increased risk of oral cancers and possibly low birth-weight infants. There is little high quality research evaluating interventions to promote cessation of smokeless tobacco use, especially of the forms used in the UK. However, what evidence there is suggests that advice to stop coupled with behavioural support and counselling may increase long-term abstinence rates by some 5-10%. It seems appropriate therefore to recommend that dentists, GPs and other relevant health professionals should routinely assess and record smokeless tobacco use in patients belonging to relatively high prevalence groups, that they ensure that smokeless tobacco users know the potential health risks (as well as the health risks of smoking) and that they advise them to stop and keep a record of the outcome. Dental professionals should also examine the oral cavity of smokeless tobacco users for lesions when the opportunity arises. Patients expressing an interest in stopping should be referred to specialist smoking cessation services for behavioural support and specialists in areas of high smokeless tobacco use will need to ensure that they are sufficiently knowledgeable and their services sufficiently accessible to these users. There is insufficient evidence to recommend the use of nicotine replacement therapy or bupropion to aid smokeless tobacco cessation. Research is needed in the UK to quantify the personal and population health risks from smokeless tobacco, the benefits of stopping, the effectiveness of interventions aimed at promoting cessation and patterns of use, knowledge and attitudes of users.     

Tobacco cessation and nicotine replacement therapy for dental practice

Addictive tobacco use is the single greatest cause of disease and premature death in America today, responsible for more than 430,000 deaths annually. Smoked and smokeless tobacco intake have profound ill effects on oral tissues, especially those tissues associated with periodontal structures. This article describes the interactive aspects of addictive cigarette smoking and presents specific clinical and systems-based tobacco cessation interventions that can be utilized by health care providers. These programs offer a structured, multifaceted, and behavioral-based approach that includes the utilization of nicotine replacement therapy (NRT), monitoring and follow-up. The health care professional must consider all medical contraindications before using tobacco cessation medications.     

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.     

Implications of smokeless tobacco use in athletes

After almost falling into obscurity, smokeless tobacco use began to increase almost simultaneously with the reduction in cigarette smoking that was influenced by the Surgeon General's first Report on Smoking and Health in 1964. Consumption of smokeless tobacco was stimulated by media promotion using professional athletes; and large numbers of impressionable male teenagers, assuming that it was a safe alternative to smoking, began to use this product, particularly snuff. The nicotine content of smokeless tobacco is equivalent to that of cigarettes and, therefore, will produce habituation and addiction. It may also expose the long-term user to a number of adverse physiologic effects on the cardiovascular system that are similar to those attributed to smoking. Smokeless tobacco contains N-nitrosamines that have a potential carcinogenic effect on the tissues with which they come into contact in the oral cavity. A hazard of short-term use is irreversible gingival recession. The contact of snuff with the oral mucosa can produce leukoplakia that is readily visible and will alert the dentist. The dental professional team must actively strive to prevent initiation of smokeless tobacco use and assist with cessation of this habit.     

Measuring the Impact of P.L. 99-252: an Economist''s View

This paper examines ways in which standard economic analysis may be used to predict and evaluate the impact of P.L. 99-252, the Comprehensive Smokeless Tobacco Health Education Act of 1986. Simple supply and demand models are used to illustrate the range of possible effects of the act. Analysis indicates that the act should reduce demand, though the magnitude of the impact can only be determined empirically. Given that the act affects only one of the principal determinants of demand, consumer preferences, the impact may be rather limited in magnitude. The impact on supply is more ambiguous, but it is possible that restrictions on advertising might lower the smokeless tobacco producers' costs in ways that would lead to an increase in supply. Several suggestions for empirical measurement of impact are made. Three other issues are identified and discussed: potential negative consequences of the act's required health warnings (as a liability defense for firms); the importance of point of view in dealing with the costs of smokeless tobacco use; and a comparison of the act to alternative strategies to reduce smokeless tobacco use, such as taxation.     

The oral effects of smokeless tobacco

Smokeless tobacco use has increased rapidly in North America. This form of tobacco use has many oral effects including leukoplakia, oral cancer, loss of periodontal support (recession), and staining of teeth and composite restorations. Systemic effects such as nicotine dependence, transient hypertension and cardiovascular disease may also result from smokeless tobacco use. This paper aims to guide dental practitioners in identifying oral lesions that occur due to the use of smokeless tobacco and also offer guidelines on how to counsel patients who express a desire to stop using smokeless tobacco products.     

Comparative patterns of smokeless tobacco usage among major league baseball personnel

The purpose of this study was to survey major league baseball personnel in order to determine the prevalence, cultural distribution and factors influential in, and the level of knowledge of individuals regarding the harmful effects of smokeless tobacco usage. During the 1987 preseason/season, 25 of 26 baseball teams in the American and National Leagues participated in the survey. The players (46%) "dipped" or "chewed" more than the managers/coaches (35%) followed by the trainers (30%). Current usage of smokeless tobacco was highest among Caucasian athletes (50%) followed by Hispanic athletes (33%) and then Black athletes (30%). Among the baseball players surveyed who currently use smokeless tobacco, 58% started during the ages 18 to 22. This study indicates that although baseball personnel are fully aware of the harmful effects of smokeless tobacco usage, current use of smokeless tobacco in major league baseball is high. Additionally, baseball personnel start "dipping" or "chewing" smokeless tobacco at an early age and continue this practice for long periods.