Oral Effects of Smokeless Tobacco

Lourdes Vazquez, RDH, MS, ECP

Two Main Types of Smokeless Tobacco

Chewing Tobacco Snuff

Smokeless Tobacco

Chewing Tobacco Loose leaf

Processed cigar type tobacco loosely packed in small strips

Smokeless Tobacco

Chewing Tobacco Plug

Small oblng blocks of semi-soft tobacco Place tobacco next to the gingival/buccal

mucosa

Smokeless Tobacco

Snuff (finely ground tobacco) Moist

Used by dipping Placing it between the gum and the cheek or

under the upper or lower lip

Smokeless Tobacco

Snuff Dry

Placed in oral cavity or sniffed through the nose

Smokeless Tobacco Use

The highest rate of smokeless tobacco users is found in: 8-17 year old white male People in the North-Central and South-

Central states Blue collar occupations

Nicotine Effects on the CNS

Stimulating effects Seen with low dose of nicotine Affecting the brain at the cortex and

Locus ceruleus Reward like effects

Seen with high dose of nicotine levels Affecting the brain in the Limbic system

Symptoms of NicotineToxicity

Nausea Vomiting Diarrhea Abdominal pain Sweats Flush dizziness

Effects of Nicotine Toxicity

Perinatal Exposure Hypoxemia of fetus Spontaneous abortion Placental disruption Preterm delivery Decreased milk production

Nicotine Toxicity

Interferes with birth control pills Infertility Impotence

Nicotine Dependence

Physiologic Psychologic Behavioral

Behavioral Dependence

Social use patterns Ritualistic triggers Behavioral habits

Physiologic Dependence

Withdrawal Tolerance

Nicotine Withdrawal Symptoms

Anxiety Irritability Poor concentration Restlessness Craving GI problems Headaches drowsy

Adverse Medical Consequences

Many problems affecting different systems in the body Central Nervous System Heart Disease Hypertension Lipids Diabetes

Effects of smokeless Tobacco

Physiological effects of Nicotine Cardiovascular System Central Nervous System Endocrine System

Oral cancer Cancer risk of cheek and gum may

reach nearly fiftyfold among long-term snuff users

Central Nervous System (CNS)

Vascular Disease Cerebrovascular Accidents

TIA’s Stroke

Central Nervous System

Receptors of nicotine in the CNS Adiction

Dependence on Smokeless Tobacco

U.S. Surgeon General(1986):”Geven the nicotine content of smokeless tobacco, its ability to produce high and sustained blood levels of nicotine, and the well-established data implicating nicotine as an addictive substance, one may deduce that smokeless tobacco is capable of producing addiction in users”

Health Consequences of Nicotine Exposure

Nicotine intoxication *Accelerated coronary and

peripheral vascular disease Stroke Hypertension

*Of greatest concern

Complications

Delayed wound healing *Reproductive or perinatal disorders

(low birth weight, prematurity, spontaneous abortion)

Peptic ulcer disease Esophageal reflux

*Of great concern

Heart Disease

Smokeless tobacco causes similar effects as those seen in smoking Increase in heart rate (30% higher) Increase in blood pressure Less cardiovascular risk than smoking

possibly due to lack of carbon monoxide and related compounds

*Cardiovascular Disease

Heart rate acceleration Promote atherosclerotic vascular

disease Aggravate hypertension by causing

vasoconstriction Acute cardiac ischemia (angina,

myocardial infarction, even sudden death)

Hypertension

Blood pressure levels are affected by: High sodium levels Nicotine Licorice , which causes sodium

retention

Lipids

According to an article published in the American Journal of Public Health (1989) Smokeless tobacco users had 2.5 times

increase in cholesterol

Diabetes

Smokeless tobacco as well as Cigarette smokers have increase insulin levels which suggests a link wiht insulin resistance

MAJOR RISK

HEAD AND NECK DISEASE

SMOKELESS TOBACCO LESIONS (STL’s)

Appear as changes in color and texture of the oral mucosa

Are the most prevalent oral soft tissue lesions among adolescents in the U.S.

HARD TISSUES

Effects on teeth: Discoloration of the teeth and receding gingiva

ATTACHED GINGIVA

Recession of gingival margin

Loss of attachment Tooth abrasion Hyper keratinized

soft tissues

Periodontal Disease 3-5% of diseased gingival and

periodontal tissue becomes oral cancer

Potent Carcinogens

Nitrosamines Polycyclic aromatic hydrocarbons Radiation-emitting polonium

Abnormal Changes at Cancerization site

Clinically: Leukoplakia Erythroplasia Dysplasia Carcinoma in situ

Hyper Keratosis

Oral Leukoplakia

Leukoplakia

Under the tongue

Oral leukoplakia/Cancer under the upper lip

A portion of leukoplakias can under go transformation to dysplasia and further to cancer.

TONGUE

Cancer under the tongue

FLOOR OF THE MOUTH

Cancer behind the teeth

Papillary Squamous Cell Carcinoma of lower gingiva

Precancerous Lesion

Cancerous Lesion/Vestibule

Vericous Carcinoma

Cancer of the cheek with erosion of tissue

Cancer/Smokeless Tobacco

Role of Oral Health Professionals in Cessation Counseling: Survey Findings

73-item survey mailed to 1,064 dentists in Central Ohio

529 responded 9% were effective at getting

patients to quit 71% willing to provide educational

pamphlets 6% would consider to prescribe

nicotine gum

Dentists

Results indicate the need for further education in tobacco and cessation counseling for dentists.

ROLES OF THE DENTAL PROFESSION

ORAL CANCER SCREENINGNon-invasive procedure

No discomfortNo pain

Inexpensive

Clinically…What to look for?

Head and Neck examination Intraoral examination

INTRAORAL EXAMINATION

Where to look? Site of Smokeless Tobacco Placement Vestibular area Attached Gingiva Oral mucosa Tongue Floor of the mouth Hard tissues

Oral Examination

Intra-oral examination

Base and borders of the tongue

Pharynx, Soft Palate, Pilars….

Buccal Mucosa

Ventral

Vermillion Borders

Discovery and Diagnosis

Any sore, discoloration, induration, prominent tissue, horseness which does not resolve within a two week’s period on its own, with or without treatment, should be considered for further examination or referral.

DISCOVERY & DIAGNOSIS

Result from Visual and manual examination Systematic visual exam of all the soft

tissues of the mouth

DIGITAL PALPATION OF THE NECK

INCLUDING THE THYROID AND SURROUNDING LYMPH NODES SURROUNDING THE ORAL CAVITY.

OTHER DIAGNOSTIC AIDS

LIGHTS DYES OTHER TECHNIQUES APPEARING IN

THE MARKET.

BIOPSY

ONLY MEANS OF DIAGNOSIS OF ORAL CANCER MAY BE THROUGH BIOPSY.

How long has the suspicious lesion been present? Herpes simplex ulceration Aphthous lesions

14 days

BIOPSY BRUSH

Easy, painless, accurate diagnosis of soft tissue abnormalities.

Not designed to provide the information, specifically cellular architecture that a punch or incisional biopsy would provide.

Will allow us to know whether a malignancy exists or not through minimal and inexpensive procedure.

Brush Biopsy

Tissue sample

Early Cancerous Lesions

Conventional biopsy

A positive result from the brush biopsy needs to be followed by a conventional biopsy.

Often the only way to diagnose oral lesions and diseases

Most are performed at a hospital

POINTS TO CONSIDER PRIOR TO MUCOSAL BIOPSY

Why is biopsy being taken? What information is required from the

pathologist? Is the biopsy to exclude malignancy? Is the biopsy incisional or excisional? Will the specimen be required to be

orientated? Is a fresh specimen required?

Information to accompany mucosal biopsies

Patient demographic data Description of the clinical appearance of

the lesion and suspected diagnosis The site of the biopsy The relationship of the lesion to

restorations, particularly amalgam A detailed drug history Medical history including blood dyscrasias Smoking and alcohol consumption

Referral

Dental specialist: periodontist Oral medicine specialist

Confirmation of the Disease

By the pathologist is obtained Referral of patient to a proper

medical intervention, Oncologist

Continued help after diagnosis

Preparing the patient for treatment through proper management of oral tissues before, during and after treatment.

ALTERNATIVES TO QUITING

PROGRAMS AND SUPPORT GROUPS