ORAL LESIONS ASSOCIATED WITH USE OF TOBACCO

BY J.MANGAIYARKKARASICRRI

•Stomatitis nicotina•Snuff dipper lesion•Cigarette smoker’s lip lesion

Stomatitis nicotina Smoker’s palate/nicotine palatinus/nicotine stomatitis/stomatitis nicotina palati

The most common effect of smoking are presented clinically as specific white leathered lesions that develops on the hard and soft palate .

Grayish white appearance of palate seen in smoker’s palate

The burning end of the chutta (type of cigar) is being introduced into the oral cavity.

• In many cultures , hand rolled cigarettes and cigars are smoked with the burning end within the mouth.

• This habit is called as ‘reverse smoking ‘ and the lesion associated with it is called reverse smoker palate.

• Reverse smoker palate has a significant potential to develop dysplasia or carcinoma.

Clincal featurs : in heavy cigarette , pipe and cigar smokers.• Prevalence : Range - 0.1 to 2.5%.• Seen in mens with pipe smokers .common in middle age and

elderly adults.

• Common Site :palate ,well developed and prominent on keratinized hard palate.• Onset :initially there is redness and inflammation of the palate.

• With long term exposure to heat, the palatal mucosa become diffusely gray or white ,thickened and fissured.

• Fissures and crakes may appear producing a wrinkled , irregular surface.

• Tonsillar pillars are usually erythematous, numerous slightly elevated papules are noted, usually with punctuate red centers .

• In this lesion red dots can be observed representing ductal orifices of inflamed accessory salivary glands ,which appears as white umbilicated nodule with red center that may be stain brown by deposits of tar.• which can be enlarged and

display metaplasia.

A heavy brown or black tobacco stain may be present on the teeth.

Dried mud appearance: in some cases palatal keratin becomes so thickened that it impart fissure or dried mud appearance.

• This extensive leathery , white change of the hard palate is sprinkled throughout with numerous red papules, which represent inflamed salivary duct openings.

• The gingival mucosa also is keratotic

Histopathologically : it is characterized by -hyperkeratosis ,-acanthosis of palatal epithelium and-mild ,patchy, chronic inflammation of sub epithelial connective tissue and mucosal glands.

Squamous metaplasia of the excretory ducts is usually seen and an inflammatory exudate may be noted within the duct lumina. In cases with popular elevation ,hyperplastic ductal epithelium may be seen near the orifice ,The degree of epithelial hyperplasia and hyperkeratosis appears to correlate positively with the duration and level of heat exposure .Epithelial dysplasia rarely is seen.

Types (clinical)

Etiology : it is due to high temperature rather than chemical composition of smoke.

Mild :consisting of red , dot like opening blanched area,

Severe :marked papules of 5mm or more with umbilication of 2- 3 mm.

Modrate:characterized by well defined elevation with central umbilication,

Palatal changes :Keratosis – diffuse whitening of entire palatal mucosa.Excrescences -1-3mm elevated nodules , often with central red dots corresponding to the opening of palatal mucous glands.Patches –well defined ,elevated white plaque which could qualify for the clinical term leukoplakia ,Red areas- well defined reddening of the palatal mucosa,Ulcerated area- crater-like areas covered by fibrin,Non-pigmented areas- area of palatal mucosa which is devoid of pigmentation.

Diagnosis Clinical diagnosis – history of cigar or pipe smoking and reverse smoking with generalized lesion of palate is key for the diagnosisLaboratory diagnosis –in biopsy epithelium shows acanthosis and hyperkeratosis.epithelium lining of minor salivary gland often shows squamous cell metaplasia and hyperplasia.Differential diagnosis Papillary hyperplasia-the lesion displays cobblestone appearance and in stomatitis nicotina ,there is red center located on the palate of pipe or cigar smokers.The papules of the papillary hyperplasia are focal .Darier’s disease – they appear diffusely on palate in cobblestone pattern.Focal epithelial hyperplasia-it is not common on palate and they are not erythematous.Cowden syndrome-these are multiple papillary nodules commonly seen on gingiva.

ManagementStoppage of habit – it is completely reversible, once the habit is discontinued . If the lesion resolve within 2 weeks of cessation of smoking.

Biopsy-rarely indicated.But biopsy should be performed on any white lesion of the palatal mucosa tat persists after 1 month of discontinuation of smoking habit and it should be considered a true leukoplakia and managed accordingly.

Snuff Dipper Lesion It is also called as snuff pouch, tobacco pouch keratosis,

spit tobacco keratosis, smokeless tobacco keratosis.

Types of smokeless tobacco : Chewing tobacco (used by men in conjunction with

outdoor activity) ,

Moist snuff and Dry snuff (contains nitrosamines and nitrate). Moist stuff is the most popular& the increase in popularity may be

in part to the convenience of small, prepackaged pouches that can be used discretely.

The habit of chewing tobacco is called as smokeless tobacco or spit tobacco use which increases the toxicity of the compounds.

There is definitive association between this form of smokeless tobacco and oral cancer.

Common in young men and high school students.

In India tobacco is combined with - betal leaf, - sliced areca nut and - powered slaked lime.

Grayish lesion seen in buccal vestibule of patient where he uses to keep tobacco.

Etiopathogenesis • Nicotine—the compound N-nitroso-nor-nicotine (NNN), which is derived partly from bacterial action on nicotine during the curing process, is contributed by the action of salivary nitrites, when tobacco is held in the mouth; occurs in greater concentration in snuff tobacco because of the ready absorption of nicotine and other molecules through the oral mucosa.

CLINICAL FEATURES • Location— It occurs in mucosal surface, where snuff is habitually held.. • Teeth—there is brown black extrinsic stain typically present on the enamel , cementum surface of the teeth adjacent to the tobacco use. There is also cervical erosion of teeth with more prevalence of dental caries (because of high sugar content of some brands).

Gingival recession is accompanied by destruction of facial surface of the alveolar bone and correlates well with the quantity of daily uses and duration of the smokeless tobacco habit

• Gingiva and periodontal tissue —there is painless loss of gingival and periodontal tissue in the area of tobacco contact .

HALITOSIS if a frequent finding in chronic users.Localized or generalized wear of occlusal or incisal sufaces especially in those using the product in dusty

environment.

Smokeless tobacco keratosis:

It is white plaque present in the mucosa where chewing tobacco is kept. It is thin, gray or gray-white translucent lesion . Margin of the lesion blends gradually into surrounding mucosa.sometimes mild peripheral erythema is present.

DEVELOPMENT OF THIS LESION is most strongly influenced by• duration, • brand of tobacco used,• early onset of smokeless tobacco use,• total hours of daily use ,• use of different tobacco leaves.• amount of tobacco consumed daily,and• number of sites routinely used for tobacco

placement.

• The altered mucosa typically has a soft velvety feel on palpation and stretching of the mucosa often reveals a distinct ‘pouch’

• Caused by flaccidity in the chronically stretched tissues in the area of tobacco placement, because the tobacco is not in the mouth during a clinical examination , the usually stretched mucosa appears fissured or rippled in a fashion resembling the sand on a beach after an ebbing tide .

• A soft , fissured , gray-white lesion of the lower labial mucosa located in the area of chronic snuff placement.

MILD TOBACCO POUCH KERATOSIS :

• It takes 1 to 5 years to develop.

• once it occurs, however, the keratosis typically remains unchanged indefinitely unless the tobacco contact time is altered.

• In some cases the white lesion gradually becomes thickened to the point of appearing leathery or nodular

SEVERE TOBACCO POUCH KERATOSIS

The World Health Oraganization International Agency for Re-search on cancer established in its report from 2004 that “overall , There is sufficient evidence that smokeless tobacco causes oral cancer & pancreatic cancer in humans and sufficient evidence of carcinogenicity from animals”.

Management • Stoppage of habit—maximum lesion is regress following the cessation of habit.

• Biopsy: Any lesion which remains after 6 months quitting the habit should be send for biopsy.

• Malignant transformation— verrucous carcinoma has been reported to occur from snuff dipper lesion. This is also called as snuff dipper cancer

Seen commonly in smokers of Nonfiltered cigarettes come in short stubby packs, and don't have a filter end.

These filter have tiny , invisible perforations are present. As smoke flows through the filter, quite a bit of air flows through the perforations and mixes in with the smoke.

With each drag, the smoker receives a lot of air and much less smoke, and therefore less tar and nicotine.

Cigarette Smoker’s Lip Lesion

Nonfiltered cigarette

Clinical features: They are generally flat or slightly elevated nodular

white lesion on one or both lips, corresponding to the site at which the cigarette is held and apparently smoked down to an extremely short length.

There is increased redness and stippling of lip in localized area.

Margin has elliptical, circular or irregular borders. Color is pale to white and is slightly elevated with

nodular or papillary shape.

INCREASED STIPPLING AND PALE COLOR LIP IN CHRONIC CIGARETTE SMOKER.

Differential diagnosis : Leukoplakia, lichen planus, mechanical fiction, chemical

burn, chronic lip biting, candidiasis

Treatment : Cessation or reduction of smoking.