Oral Effects of Smokeless Tobacco

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Oral Effects of Smokeless Tobacco

• Lourdes Vazquez, RDH, MS, ECP

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Two Main Types of Smokeless Tobacco

• Chewing Tobacco
• Snuff

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Smokeless Tobacco

• Chewing Tobacco
• Loose leaf
• Processed cigar type tobacco loosely packed in
  small strips

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Smokeless Tobacco

• Chewing Tobacco
• Plug
• Small oblng blocks of semi-soft tobacco
• Place tobacco next to the gingival/buccal mucosa

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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

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Smokeless Tobacco

• Snuff
• Dry
• Placed in oral cavity or sniffed through the nose

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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

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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

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Symptoms of NicotineToxicity

• Nausea
• Vomiting
• Diarrhea
• Abdominal pain
• Sweats
• Flush
• dizziness

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Effects of Nicotine Toxicity

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

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Nicotine Toxicity

• Interferes with birth control pills
• Infertility
• Impotence

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Nicotine Dependence

• Physiologic
• Psychologic
• Behavioral

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Behavioral Dependence

• Social use patterns
• Ritualistic triggers
• Behavioral habits

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Physiologic Dependence

• Withdrawal
• Tolerance

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Nicotine Withdrawal Symptoms

• Anxiety
• Irritability
• Poor concentration
• Restlessness
• Craving
• GI problems
• Headaches
• drowsy

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Adverse Medical Consequences

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

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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

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Central Nervous System (CNS)

• Vascular Disease
• Cerebrovascular Accidents
• TIAs
• Stroke

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Central Nervous System

• Receptors of nicotine in the CNS
• Adiction

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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

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Health Consequences of Nicotine Exposure

• Nicotine intoxication
• Accelerated coronary and peripheral vascular
  disease
• Stroke
• Hypertension
• Of greatest concern

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Complications

• Delayed wound healing
• Reproductive or perinatal disorders (low birth
  weight, prematurity, spontaneous abortion)
• Peptic ulcer disease
• Esophageal reflux
• Of great concern

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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

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Cardiovascular Disease

• Heart rate acceleration
• Promote atherosclerotic vascular disease
• Aggravate hypertension by causing
  vasoconstriction
• Acute cardiac ischemia (angina, myocardial
  infarction, even sudden death)

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Hypertension

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

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Lipids

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

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Diabetes

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

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MAJOR RISK

• HEAD AND NECK DISEASE

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SMOKELESS TOBACCO LESIONS (STLs)

• 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.

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HARD TISSUES

• Effects on teeth Discoloration of the teeth and
  receding gingiva

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ATTACHED GINGIVA

• Recession of gingival margin
• Loss of attachment
• Tooth abrasion
• Hyper keratinized soft tissues

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Periodontal Disease

• 3-5 of diseased gingival and periodontal tissue
  becomes oral cancer

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Potent Carcinogens

• Nitrosamines
• Polycyclic aromatic hydrocarbons
• Radiation-emitting polonium

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Abnormal Changes at Cancerization site

• Clinically
• Leukoplakia
• Erythroplasia
• Dysplasia
• Carcinoma in situ

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Hyper Keratosis
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Oral Leukoplakia
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Leukoplakia

• Under the tongue

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Oral leukoplakia/Cancer under the upper lip

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

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TONGUE

• Cancer under the tongue

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FLOOR OF THE MOUTH

• Cancer behind the teeth

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Papillary Squamous Cell Carcinoma of lower gingiva
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Precancerous Lesion
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Cancerous Lesion/Vestibule
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Vericous Carcinoma
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Cancer of the cheek with erosion of tissue
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Cancer/Smokeless Tobacco
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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

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Dentists

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

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ROLES OF THE DENTAL PROFESSION

• ORAL CANCER SCREENING
• Non-invasive procedure
• No discomfort
• No pain
• Inexpensive

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ClinicallyWhat to look for?

• Head and Neck examination
• Intraoral examination

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INTRAORAL EXAMINATION

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

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Oral Examination
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Intra-oral examination
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Base and borders of the tongue
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Pharynx, Soft Palate, Pilars.
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Buccal Mucosa
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Ventral
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Vermillion Borders
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Discovery and Diagnosis

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

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DISCOVERY DIAGNOSIS

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

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DIGITAL PALPATION OF THE NECK

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

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OTHER DIAGNOSTIC AIDS

• LIGHTS
• DYES
• OTHER TECHNIQUES APPEARING IN THE MARKET.

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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

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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.

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Brush Biopsy
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Tissue sample
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Early Cancerous Lesions
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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

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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?

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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

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Referral

• Dental specialist periodontist
• Oral medicine specialist

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Confirmation of the Disease

• By the pathologist is obtained
• Referral of patient to a proper medical
  intervention, Oncologist

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Continued help after diagnosis

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

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ALTERNATIVES TO QUITING
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PROGRAMS AND SUPPORT GROUPS