Oral Health and

Tobacco Use

Presented by:Laura Romito, DDS, MSKathy Walker, BA

Learning Objectives After attending the session, participants

should be able to: 1. Identify the effects of tobacco use on

oral hard and soft tissues. 2. Provide information about statewide

tobacco cessation resources. 3. Address marketing of smokeless

tobacco products and increased use of these products especially in rural communities.

Smoking Cigarette Cigar Pipe Hookah

Smokeless (spit) Snuff Chew Snus Dissolvable

Tobacco Products

In years past the tobacco industry used frontier images to convey the image of a “real” man, who worked the land and smoked cigarettes. In fact, the Marlboro Man was well known and synonymous with such an image.

Although these images were not necessarily targeting the rural population, they amplified and helped to

maintain social and cultural norms within rural communities.

The Rural Culture

http://tobaccoeval.ucdavis.edu/documents/culture_rural.pdf

Rural Marketing Such belief systems no doubt relate to the significantly

high rate of smokeless tobacco use currently seen in rural populations, where chewing tobacco is viewed as part of being young and male in rural areas

(Campbell-Grossman et al., 2003) In this manner, the tobacco industry exploits the social

and cultural aspects of smokeless tobacco, most easily demonstrated by the tobacco industry’s past and current sponsorship of sporting events such as

rodeos, bull riding and car racing (Pokhrel et al., 2009).

http://tobaccoeval.ucdavis.edu/documents/culture_rural.pdf

Smokeless Use in Rural Areas

Research shows that smokeless tobacco is most common in rural areas. National surveys reveal that a huge gap exists between smokeless tobacco use among rural and urban residents (Pokhrel et al., 2009; Stevens et al.,

2010). According to the National Survey on Drug Use and

Health (2007), the use of smokeless tobacco is almost three times higher in rural areas compared to those who live in large and small metropolitan areas.

The prevalence of smokeless tobacco is highest among young males aged 18 to 24 living in rural areas (Campbell-Grossman, et al., 2003; Boyle et al., 1999).

http://tobaccoeval.ucdavis.edu/documents/culture_rural.pdf

Sweet Shop versus Tobacco Shop

Can you tell the difference?

Melt-Away Tobacco Strips or Chewing Gum?

Tobacco Orbs or Tic Tac’s?

Chewing Tobacco or Breath Mints?

Tobacco Stick or Orange Stick?

PERCENTAGE OF MIDDLE AND HIGH SCHOOL STUDENTS WHO EVER TRIED FLAVORED TOBACCO PRODUCTS, 2008 IYTS

Middle School6% Smokeless Tobacco9% Cigars8% Black & Mild cigars, Swisher Sweets cigarillos, and/or Phillies Blunt cigars

High School15% Smokeless Tobacco30% Cigars32% Black & Mild cigars, Swisher Sweets cigarillos, and/or Phillies Blunt cigars

CURRENT USE OF TOBACCO PRODUCTS AMONG MIDDLE AND HIGH SCHOOL STUDENTS, 2008 IYTS

Middle School10% Any Tobacco Products4% Cigarettes3% Smokeless Tobacco 4% Cigars

High School31% Any Tobacco Products18% Cigarettes8% Smokeless Tobacco 15% Cigars

Smoking Prevalence Education

GED: 43.2%, College: 10.7% Socioeconomic status

Low SES : ~50% Age

18-24 = 24.4%; > 65=8.6% Ethnicity

Native American: 32% Asian American: 13%

MMWR, 2006Mayo Clinic Foundation, 2008

Cancers, CVD, Respiratory diseases Oral effects

Discoloration of teeth and restorations Coated / hairy tongue Reduced sense of taste and smell Smokers’ melanosis Smokers’ palate Oral Candidiasis Dental Caries Increased implant failure rates Periodontal disease Poor wound healing Leukoplakia Carcinoma

Adverse Effects of Tobacco Smoking

The initial interaction of smoking with the human body occurs most often in

the oral cavity, where it would be expected to

be active and exposure to be intense.

Heavy smokers are 4.7 times more likely to develop prematurely wrinkled faces than

non-smokers

Annals of Internal Medicine (1991)

Smokers have decreased clinical signs of inflammation

Impaired bleeding may indicate a faulty

inflammatory vascular response in response to dental plaque resulting

in alterations in the body’s basic gingival defense mechanism

Smoking & Periodontal Status

Nicotine & CO wound healing Decreased blood flow Immune effects

Increased destructive actions of neutrophils Fibroblast impairment Increased prevalence of potential periodontal

pathogens. Protective antibodies are reduced in smokers,

specifically immunoglobulin G to A. actinomycetemcomitans

Smoking & Gum Disease

J. Perio. 2004;74:196-209

Compared to nonsmokers, smoker’s are 4x more likely to have severe periodontal disease

The average 32 yr old smoker has similar perio attachment loss as a 59 yr old nonsmoker!

Continued smoking is an important cause of impaired healing in all aspects of periodontal

treatment

Linde, et al, “Clinical Periodontology” 2008, 5th Edition, pp. 316-322

PMN action intensified in passive smoking Numabe Y, Ogawa T, Kamoi H, et al. Phagocytic function of salivary PMN after smoking or secondary smoking. Ann Periodontol. 1998; 3(1): 102-7.

Periodontal disease: 1.6x more likely in NS exposed to ETS than NS not exposed Arbes SJ, Jr., Agustsdottir H, Slade GD. Environmental tobacco smoke and periodontal disease in the United States. Am J Public Health. 2001; 91(2): 253-7.

ETS increases periodontal inflammatory responses

Nishida N, Yamamoto Y, Tanaka M, et al. Association between passive smoking and salivary markers related to periodontitis. J Clin Periodontol. 2006; 33(10): 717-23.

Nishida N, Yamamoto Y, Tanaka M, et al. Association between involuntary smoking and salivary markers related to periodontitis: a 2-year longitudinal study. J Periodontol. 2008; 79(12): 2233-40.

Shizukuishi S. Smoking and periodontal disease. Clin Calcium 2007;17(2):226-32.

Does ETS Influence Perio Status?

Implant Failure

Cigarette smoking is an important risk factor for implant failure, especially for those who smoke more than 10 cigarettes a day

Linde, et al, “Clinical Periodontology” 2008, 5th Edition, pp 591, 597

Parental smoking related to caries in young kids (Williams et al, 2000, Sherkin et al 2004)

Active & passive smoking associated with presence of carious permanent teeth (Ayo-Yusef, 2007; Ojima et al 2007)

Possible biological mechanisms Smoking & saliva flow rates & composition Tobacco & the immune system Oral bacteria responses to tobacco

Smoking and Dental Caries

Dental Calculus Cigarette smokers have higher levels of both supra- and sub-gingival calculus than do nonsmokers.

Cessation is accompanied by a reduction in calculus formation

Smoker’s Melanosis

Nicotine Stomatitis

Is strongly associated with reverse smoking, cigar smoking, and a high frequency of pipe and cigarette smoking

Smokeless Tobacco Effects Esthetic Considerations (Stains & Halitosis) Gingival Recession & Bone Loss Abrasion & Dental Caries Hairy Tongue Tobacco Pouch Keratosis Leukoplakia Erythroplakia Squamous cell carcinoma

Gingival Recession and Bone Loss

A positive association exists between ST use and gingival recession, especially among long-term users who also have co-existing gingivitis

Tooth Abrasion & Dental Caries

Sand and grit in ST can significantly wear down occlusal surfaces of teeth

Sugar found in chewing tobacco (especially flavored varieties) can contribute to dental caries

52 M “snuff patch” smokeless tobacco use, 3-

4x daily

Tobacco Pouch Keratosis

Lesion is typically found in vestibule where the tobacco is placed; may extend into the gingiva and buccal mucosa

Most are readily reversible once the habit is discontinued

If lesion persists after one month of cessation, biopsy is recommended

Leukoplakia “A predominantly white lesion of the oral

mucosa that cannot be characterized as any other definable lesion” (WHO, 2003)

20% of oral leukoplakia exhibit dysplastic or cancerous changes; 9-17% will exhibit malignant transformation

Occur mostly where tobacco is held in place Treatment includes biopsies and sometimes

total removal of the lesion

Leukoplakia Is definitely associated with both smoked and smokeless tobacco use.

Is dose related, e.g. positively linked to the frequency, intensity, amount, and length of tobacco use.

Snuff Dipper’s Lesions are Often Reversible

Of 29 subjects using moist snuff, all those who quit (20) showed clinically healthy and histologically normal mucosa after 3-6 months.

J. Oral Pathology (1991) Larsson, Axell, Andersson

Snuff Dipper’s Keratosis

Erythroplakia “Term used to designate a red patch of oral

mucosa that cannot be diagnosed as any specific disease” (Neville, Damm, & White, 2003)

Lesions may be single, multiple, smooth, or pebbly; may be “speckled” with leukoplakia

Mostly affect patients who use tobacco and consume alcoholic beverages

Up to 90% of patients will exhibit severe epithelial dysplasia, carcinoma in-situ, or squamous cell carcinoma

Leading Carcinogens Contained in ST

Tobacco-Specific NitrosaminesPolycyclic Aromatic Hydrocarbons

Radiation-Emitting Polonium

The use of both tobacco and alcohol has a

synergistic effect on the development of OCP

(Oral Cavity and Pharyngeal Cancer),

together causing 80-90% of all new cases of OCP

CancerMMWR 2008; 57 (SS08): 1-33

Carcinoma in-situ and leukoplakia in 50 y o M pipe smoker

Squamous Cell Carcinoma

Cancer of the stratified squamous epithelium Accounts for 90% of all oral cancers “Characterized by the invasion of supporting

connective tissue and adjacent structures by malignant squamous epithelial cells” (Neville, Damm, & White, 2003)

80% of all squamous cell carcinomas develop in tobacco users (smokers & ST)

Most patients are 45+ years of age at onset In ST users, occurs mostly where ST is held

Squamous Cell Carcinoma

Treatment consists of surgery, radiation therapy, or combinations of both

5-year survival rate 75% for patients with localized intraoral

lesions 40% with lymph node involvement 10% with distant metastasis

Patients are at a significant risk for development of a subsequent intraoral cancerous lesion or upper digestive tract cancer

52 y o AA M Cigarette & Pipe User - Oral Carcinoma

61 y o M Epidermoid (SSC) Carcinoma 50 Pk-Yr History

Oral Screenings

All individuals (particularly tobacco users) should receive regular head

& neck cancer screenings & should be taught to

periodically conduct oral self-exams.

Indiana Tobacco Quitline Fax Referral Highly trained professionals FREE coaching sessions Appropriate materials sent to participant 1-800-QUIT-NOW

What Is A Quitline?Telephone-based Cessation ServicesEvidence-based ProactiveQuit Coaches

Highly trained in cognitive behavioral therapy

240 hours of training

Spanish speaking competency (170 other languages)

Educated up to graduate level

Over 50% with 3+ years prior experience in counseling

Four prearranged calls w/coachTen prearranged calls for pregnant womanWeb coach Unlimited call in privileges and access to coachesSupport Materials

The Participant Experience

Meta-analysis of 13 studies shows 56% increase in quit rates compared to self-help

Accessibility― Eliminates many barriers of traditional classes

(having to wait for classes to form, needing transportation)

― Helpful for those with limited mobility and those in rural or remote areas

― Appeal to those who are reluctant to seek help provided in a group setting

Quitline Effectiveness

Benefits Confidential Free National call number 1-800-QUIT-NOW Provides intensive one-on-one counseling Unlimited access as long as necessary HIPAA-compliant entity Assess ability to all tobacco users Call initiated by quit coach if fax referred by

a provider, employer, or organization.

Join The Preferred Network

Promote the Indiana Tobacco Quitline to patients, employees, and/or clients

Begin referring people who are ready to quit to:

1-800-QUIT-NOW

Provider, Employer,

Organization

Fax Referral

Contact InformationLaura Romito, DDS, MSAssociate ProfessorDirector, Nicotine ProgramDepartment of Oral Biology, Rm B19CIndiana University School of Dentistry1121 West Michigan StreetIndianapolis, IN  46202Ph: 317-278-6210Email: lromitoc@iupui.edu

Kathy WalkerFountain/Warren Tobacco Prevention & Cessation ProgramCommunity Action Program, Inc. of Western Indiana418 Washington StreetCovington, IN 47932Ph: 765-793-4881Email: kwalker@capwi.org