Oral Effects of Smokeless Tobacco

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    Oral Effects of SmokelessTobacco

    Lourdes Vazquez, RDH, MS, ECP

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    Two Main Types of SmokelessTobacco

    Chewing TobaccoSnuff

    http://www.maxillofacialcenter.com/images/SnuffDental.jpg
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    Smokeless Tobacco

    Chewing TobaccoLoose leaf

    Processed cigar type tobacco looselypacked in small strips

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    Smokeless Tobacco

    Chewing TobaccoPlug

    Small oblng blocks of semi-soft tobaccoPlace tobacco next to the gingival/buccalmucosa

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    Smokeless Tobacco

    Snuff (finely ground tobacco)Moist

    Used by dippingPlacing it between the gum and the cheek orunder the upper or lower lip

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    Smokeless Tobacco

    Snuff Dry

    Placed in oral cavity or sniffed through thenose

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    Smokeless Tobacco Use

    The highest rate of smokelesstobacco users is found in:

    8-17 year old white malePeople in the North-Central and South-Central statesBlue collar occupations

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    Nicotine Effects on the CNS

    Stimulating effectsSeen with low dose of nicotine

    Affecting the brain at the cortex andLocus ceruleus

    Reward like effectsSeen with high dose of nicotine levels

    Affecting the brain in the Limbic system

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    Symptoms of NicotineToxicity

    NauseaVomiting

    DiarrheaAbdominal painSweats

    Flushdizziness

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    Effects of Nicotine Toxicity

    Perinatal ExposureHypoxemia of fetus

    Spontaneous abortionPlacental disruptionPreterm deliveryDecreased milk production

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    Nicotine Toxicity

    Interferes with birth control pillsInfertility

    Impotence

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    Nicotine Dependence

    PhysiologicPsychologic

    Behavioral

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    Behavioral Dependence

    Social use patternsRitualistic triggers

    Behavioral habits

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    Physiologic Dependence

    WithdrawalTolerance

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    Nicotine Withdrawal Symptoms

    AnxietyIrritability

    Poor concentrationRestlessnessCravingGI problemsHeadachesdrowsy

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    Adverse Medical Consequences

    Many problems affecting differentsystems in the body

    Central Nervous SystemHeart DiseaseHypertensionLipids

    Diabetes

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    Effects of smokeless Tobacco

    Physiological effects of NicotineCardiovascular SystemCentral Nervous SystemEndocrine System

    Oral cancer

    Cancer risk of cheek and gum mayreach nearly fiftyfold among long-termsnuff users

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    Central Nervous System (CNS)

    Vascular DiseaseCerebrovascular Accidents

    TIAs Stroke

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    Central Nervous System

    Receptors of nicotine in the CNSAdiction

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    Dependence on Smokeless Tobacco

    U.S. SurgeonGeneral(1986):Geven the nicotinecontent of smokeless tobacco, itsability to produce high andsustained blood levels of nicotine,and the well-established dataimplicating nicotine as an addictivesubstance, one may deduce thatsmokeless tobacco is capable of producing addiction in users

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    Health Consequences of NicotineExposure

    Nicotine intoxication*Accelerated coronary andperipheral vascular diseaseStrokeHypertension

    *Of greatest concern

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    Complications

    Delayed wound healing*Reproductive or perinatal disorders

    (low birth weight, prematurity,spontaneous abortion)Peptic ulcer diseaseEsophageal reflux

    *Of great concern

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    Heart Disease

    Smokeless tobacco causes similareffects as those seen in smoking

    Increase in heart rate (30% higher)Increase in blood pressureLess cardiovascular risk than smokingpossibly due to lack of carbon

    monoxide and related compounds

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    *Cardiovascular Disease

    Heart rate accelerationPromote atherosclerotic vascular

    diseaseAggravate hypertension by causingvasoconstrictionAcute cardiac ischemia (angina,myocardial infarction, even suddendeath)

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    Hypertension

    Blood pressure levels are affectedby:

    High sodium levelsNicotineLicorice , which causes sodiumretention

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    Lipids

    According to an article published inthe American Journal of PublicHealth (1989)

    Smokeless tobacco users had 2.5 timesincrease in cholesterol

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    Diabetes

    Smokeless tobacco as well asCigarette smokers have increaseinsulin levels which suggests a linkwiht 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 andtexture of the oral mucosa

    Are the most prevalent oral softtissue lesions among adolescents inthe 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 marginLoss of attachmentTooth abrasionHyper keratinizedsoft tissues

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    Periodontal Disease3-5% of diseased gingival andperiodontal tissue becomes oralcancer

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    Potent Carcinogens

    NitrosaminesPolycyclic aromatic hydrocarbons

    Radiation-emitting polonium

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    Abnormal Changes at Cancerizationsite

    Clinically:LeukoplakiaErythroplasiaDysplasiaCarcinoma 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 theupper lip

    A portion of leukoplakias canunder go

    transformation todysplasia andfurther to cancer.

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    TONGUE

    Cancer under thetongue

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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 inCessation Counseling: Survey Findings

    73-item survey mailed to 1,064dentists in Central Ohio529 responded9% were effective at gettingpatients to quit71% willing to provide educational

    pamphlets6% would consider to prescribenicotine gum

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    Dentists

    Results indicate the need for furthereducation in tobacco and cessationcounseling for dentists.

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    ROLES OF THE DENTALPROFESSION

    ORAL CANCER SCREENINGNon-invasive procedure

    No discomfortNo pain

    Inexpensive

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    ClinicallyWhat to look for?

    Head and Neck examinationIntraoral examination

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    INTRAORAL EXAMINATION

    Where to look? Site of SmokelessTobacco Placement

    Vestibular areaAttached GingivaOral mucosaTongue

    Floor of the mouthHard 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 whichdoes not resolve within a twoweeks period on its own, with orwithout treatment, should beconsidered for further examination

    or referral.

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    DISCOVERY & DIAGNOSIS

    Result from Visual and manualexamination

    Systematic visual exam of all the softtissues of the mouth

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    DIGITAL PALPATION OF THE NECK

    INCLUDING THE THYROID ANDSURROUNDING LYMPH NODESSURROUNDING THE ORAL CAVITY.

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    OTHER DIAGNOSTIC AIDS

    LIGHTSDYES

    OTHER TECHNIQUES APPEARING INTHE MARKET.

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    BIOPSY

    ONLY MEANS OF DIAGNOSIS OFORAL CANCER MAY BE THROUGHBIOPSY.How long has the suspicious lesionbeen present?

    Herpes simplex ulceration

    Aphthous lesions14 days

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    BIOPSY BRUSH

    Easy, painless, accurate diagnosisof soft tissue abnormalities.Not designed to provide theinformation, specifically cellulararchitecture that a punch orincisional biopsy would provide.Will allow us to know whether amalignancy exists or not throughminimal 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 brushbiopsy needs to be followed by aconventional biopsy.Often the only way to diagnose orallesions and diseasesMost are performed at a hospital

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    POINTS TO CONSIDER PRIOR TOMUCOSAL BIOPSY

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

    Is the biopsy to exclude malignancy?Is the biopsy incisional or excisional?Will the specimen be required to beorientated?Is a fresh specimen required?

    f l

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    Information to accompany mucosalbiopsies

    Patient demographic dataDescription of the clinical appearance of the lesion and suspected diagnosis

    The site of the biopsyThe relationship of the lesion torestorations, particularly amalgamA detailed drug historyMedical history including blood dyscrasiasSmoking and alcohol consumption

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    Referral

    Dental specialist: periodontistOral medicine specialist

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    Confirmation of the Disease

    By the pathologist is obtainedReferral of patient to a propermedical intervention, Oncologist

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    Continued help after diagnosis

    Preparing the patient for treatmentthrough proper management of oraltissues before, during and aftertreatment.

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    ALTERNATIVES TO QUITING

    PROGRAMS AND SUPPORT

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    PROGRAMS AND SUPPORTGROUPS