SMOKELESS TOBACCO & ORAL CANCERPresented by :
dr shabeel pn
INTRODUCTIONTobacco is responsible for a significant amount of
morbidity & mortality among middle aged adults. India has one
of the highest rates of oral cancer in the world. Tobacco-related
cancers - 1/2 of all cancers - men & 1/4 th among women. Oral
cancer - 1/3rd total cancer ; 90% - tobacco chewers. Men are
affected 2-3 times than women due to higher use of alcohol &
tobacco and higher exposure to sunlight . Tongue & intra-oral
cancer - equal in both as chewing tobacco among women is common.
Effects of tobacco use, heavy alcohol consumption , and poor diet
together explain over 90% of head & neck cancers.
What Is Smokeless Tobacco?
Smokeless tobacco / spit tobacco / chewing tobacco. Mainly two
forms: snuff and chewing tobacco. Snuff - users "pinch" or "dip"
between their lower lip and gum. Chewing tobacco - users put
between their cheek and gum. The tobacco juice is sucked and chewed
- nicotine absorbed into the bloodstream through the oral tissues.
No need to swallow.
Chewed : gutkha, pan, mawa, mainpuri tobacco, khaini, zarda
Applied on gums and teeth : mishri, gudhaku, bajjar, tooth paste
Inhaled : snuff
TYPES Gutkha Khaini Mainpuri tobacco Mawa Mishri Paan Snuff
Leads to Oral sub-mucous fibrosis (SMF). Main component -
arecanut along with tobacco.
Paste of tobacco + slaked lime & is used with arecanut.
Mixed with the thumb to make the mixture alkaline-premolar region
of mandibular groove.
Tobacco+ slaked lime + finely cut arecanut + camphor + cloves.
Mainly-Uttar Pradesh. High incidence of oral cancer &
Gujarathi preparation made from shavings of arecanut, tobacco
and slaked lime. Sold by tobacco vendors in cellophane papers tied
like a small ball.
Mixed & chewed excessively and kept in mandibular
groovecauses oral cancer.
Prepared by roasting tobacco on a hot metal
plate-blackpowdered-used with catechu. Used to clean teeth. Common
in women leads to low birth wt. babies .
PAN (BETEL QUID) WITH TOBACCO
Most common-ancient habit. Betel leaf + arecanut + slaked lime +
catechu. Arecanut-vital component-drastically affects oral health.
Contains nitrosamines-carcinogenic. Pan masala - mainly contains
tobacco - causes oral cancer.
Finely powdered air-cured & fire-cured tobacco leaves. Used
orally/nasally. Carried in a metal container-a twig is dipped into
itplaced in oral vestibule. Causes oral squamous cell
ZARDATobacco leaves + lime+spices boiled in water. Residual
tobacco dried & coloured.
CONSTITUENTS OF TOBACCO
Polycyclic aromatic hydrocarbons Nicotine carcinogenesis
Nitrosamine Phenol tumour promotion& irritation Benzopyrene
Carbon monoxide - impaired oxygen transport Formaldehyde &
oxides of N - toxicity
EFFECTS OF TOBACCO
Oral cancer Cracking & bleeding lips & gums. Receding
gums tooth falls out. Increased heart rate, high B.P, irregular
heartbeats greater risk of heart attacks. When pregnant women
smoke, carbon monoxide and nicotine passes into their lungs and
bloodstream, reducing the oxygen supply to their unborn baby
leading to: - asthma attacks, chest infections and colds in later
life - premature birth - underweight birth.
Oral cancer refers to cancer of the mouth , lips, tongue, floor
& roof of the mouth, cheek & the gums. Cancer from chewing
tobacco does not remain in the mouth itself & it spreads to the
stomach,esophagus & bladder.
ETIOLOGY & RISK FACTORSGenetic factors Dental factors
Occupational risks Tobacco use Alcohol Mouthwash Viral & fungal
infections Diet & nutrition
CLASSIFICATION OF ORAL CANCEROUS LESIONS
Benign tumours-Epithelial origin Papilloma Squamous acanthoma
Pigmented cellular nevus Premalignant lesions-Epithelial origin
Leukoplakia Leukodema Erythroplakia Intraepithelial carcinoma Oral
Malignant tumours-epithelial origin Basal cell carcinoma
Epidermoid carcinoma Carcinoma of lip, tongue, floor of mouth,
gingiva, buccal mucosa, palate, maxillary sinus Verrcous carcinoma
Adenoid squamous cell carcinoma Malignant melanoma
Benign tumours - connective tissue origin Fibroma Giant cell
Peripheral central ossifying granuloma Lipoma Hemangioma Myxoma
Chondroma Codmans tumour Osteomas Malignant tumours of connective
tissue Fibrosarcoma Kaposis sarcoma Ewings sarcoma
Chondro/Osteosarcoma Non-Hodkins lymphoma Burkitts lymphoma
RED & WHITE / PRECANCEROUS LESIONS Leukoplakia Erythroplakia
Oral lesions- tobacco/alcohol Carcinoma-in-situ Bowens disease Oral
submucous fibrosis Actinic keratosis Discoid lupus erythematosis
Dyskeratosis congenita Lichen planus Lichenoid reactions
Leukokeratosis/white patch formed by keratinization/ thickening
of the mucosa. Most common malignant lesion of the oral mucosa.
Raised white part of the oral mucosa measuring 5cm / more which
cannot be scraped off & which cannot be attributed to any other
diagnosable diseases. Definable white lesions:
Hyperplastic candidiasis Hairy leukoplakia Tobacco-induced
/smokers palate Tobacco-associated Idiopathic leukoplakia
Highest prevalence in Ernakulam
ETIOLOGY: Smoking Spirits Spices Sepsis Sharp tooth edge
Syphilis CLINICAL FEATURES:
Age: after 30yrs. Strong male predominance. Site: buccal
mucosa,commissures,tongue,alveolar mucosa,etc Yellowish-white
changes to brownish-yellow. Types: Homogenous Ulcerated Nodular
LEUKODEMAResembles early leukoplakia Opaque appearance of buccal
mucosa grayish white Common in occlusal line bicuspid&molar
Erythroplasia of Queyrat Red
patch Rare-most imp. precancerous lesion. More dangerous than
its white kin. Bright red velvety plaques cannot be characterized
clinically/pathologically as due to any other condition. No sex
predilection. Occur in 6th&7th decades. ETIOLOGY & CLINICAL
FEATURES: Smoking & alcohol abuse-same.
Malignant transformations: Preleukoplakia Leukodema Smokers
ORAL SUBMUCOSIS FIBROSIS (OSF) Chronic,progressive,scarring
disease. A chronic mucosal condition affecting any part of the
oral mucosa characterized by mucosal rigidity of varying intensity
due to fibro - elastic transformation of the juxta epithelial
connective tissue layer. Etiology: Pan chewing Clinical features:
is incidious - 25yrs. Site buccal mucosa. Presence of palpable
Cheek mucosa & tongue become fibrosed-loses its elasticity.
Opening of mouth restricted Blanching of oral mucosa - impaired
vascularity. Difficult to tolerate both spicy & hot foods. Pain
on palpation at areas of submucosal fibrotic bands.
Prevalent in Ernakulam- Kerala.
BASAL CELL CARCINOMA Most
common malignancy. Common site exposed surface of skin,
face,scalp. Age middle-aged/elderly People with fair
radiation-shorter wavelength-more Chronic sun exposure X-ray
exposure / arsenic.
Clinical features: Age
after 40yrs Sex male:female=3:2 More in fair skin individuals ,
rare in dark. Common in middle third of face. Does not arise in the
oral mucosa arrives by invasion & infiltration from a skin
surface. Begins as a small, elevated papule ulceratesheals-crusts
down-develops a rolled border.
EPIDERMOID CARCINOMA /SQUAMOUS CELL CARCINOMA
Most common malignant neoplasm of oral cavity.
Tobacco Alcohol Syphilis Nutritional deficiencies Sunlight
Trauma , sepsis Viruses-EBV,CMV, immunocompromised.
Clinical features: Mainly-ulcerated
& indurated margin Occurs as carcinoma of lip , tongue,
floor of mouth, gingiva,etc.
CARCINOMA IN SITU Intra-epithelial
carcinoma. Cancer which involves only the place in which it
began & that has not spread. Early - stage tumour. eg: Bowens
disease. Common site- floor of mouth , tongue , lips. More common
in males /elderly.
DISCOID LUPUS ERYTHEMATOSIS( DLE)
A chronic , scarring , atrophy producing, photosensitive
dermatosis. Red-atrophic , white - keratotic , red - telangiectatic
zones provide a characteristic appearance. Sites - cheeks, gingiva,
labial mucosa, lip. Age 3rd& 4th decades.
LICHEN PLANUS /LICHEN RUBBER PLANUS
Common mucocutaneous disease. Affects skin /mucosa /both. Causes
bilateral white striations, papules/plaques on the buccal mucosa,
tongue & gingiva.
Epidemiology: Prevalent in Ernakulam. Clinical features: Common
site in oral cavity buccal mucosa.
Affects all racial groups/older people. Flat papules covered by
grayish white lines WICKHAMS STRIAE. Association of lichen planus,
diabetes & vascular hypertension triad - GRINSPANS
FORMS OF LICHEN PLANUSReticular form Plaque form Erosive form
Annular & Linear form
STAGING OF CANCER TNM CLASSIFICATION- 3 main parameters: T -
extent of the primary tumour N - condition of regional lymph nodes.
M - absence/presence of distant metastasis. New parameters: P -
Pathology & S - Site of the tumour
T- primary tumour Tx primary tumour cannot be assessed To no
evidence of primary tumour Tis - carcinoma in situ T1 tumour 2cm /
less in greatest dimension T2 tumour >2cm but not more than 4cm
in greatest dimension T3 tumour >4cm in greatest dimension T4
tumour invades adjacent structures N regional lymph nodes Nx
regional lymph nodes cannot be assessed N0 no lymph nodes N1
metastasis in a single ipsilateral lymph node,3cm/less in greatest
N2 metastasis in a single ipsilateral lymph node, >3cm but
not >6cm in greatest dimension,or in multiple ipsilateral lymph
nodes , none >6cm in greatest dimension N2a metastasis in a
single ipsilateral lymph node ,>3cm ,but not >6cm in greatest
dimension N2c - metastasis in bilateral / contralateral lymph
nodes, none >6cm in greatest dimension N3 metastasis in a lymph
node >6cm in greatest dimension M distant metastasis Mx presence
of distant metastasis cannot be assessed M0 - no distant metastasis
M1 - distant metastasis
PREVENTION & CONTROL OF ORAL CANCER3 wellknown approaches to
public health: Regulatory / legal approach Service approach
Educational approach Regulatory approach : Health warning displays.
Ban on tobacco advertisements. Service approach : Active search for
the disease & its treatment. Educational approach : 4 stages
Awareness Initiation /Experimentation Habituation Maintenance /
REFERENCES:Essentials of Preventive and Community Dentistry -3rd
edition- Soben Peter. Shafers textbook of Oral Pathology 6th
edition Indian Dentist Research and Review.