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Presented by : dr shabeel pn

Smokeless Tobacco Oral Cancer

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Text of Smokeless Tobacco Oral Cancer


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 Zarda


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 & leukoplakia.


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 .


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 carcinoma.

ZARDATobacco leaves + lime+spices boiled in water. Residual tobacco dried & coloured.


Polycyclic aromatic hydrocarbons Nicotine carcinogenesis Nitrosamine Phenol tumour promotion& irritation Benzopyrene Carbon monoxide - impaired oxygen transport Formaldehyde & oxides of N - toxicity


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


Benign tumours-Epithelial origin Papilloma Squamous acanthoma Pigmented cellular nevus Premalignant lesions-Epithelial origin Leukoplakia Leukodema Erythroplakia Intraepithelial carcinoma Oral submucous fibrosis

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 fibroma

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 Multiple myleoma

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 region.


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.


Homogenous Granular/Speckled

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: Onset

is incidious - 25yrs. Site buccal mucosa. Presence of palpable fibrous bands.

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.


common malignancy. Common site exposed surface of skin, face,scalp. Age middle-aged/elderly People with fair complexion-high rate.

Etiology: UV

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.


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.


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.


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 SYNDROME.

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 dimension

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 / Dependence

REFERENCES:Essentials of Preventive and Community Dentistry -3rd edition- Soben Peter. Shafers textbook of Oral Pathology 6th edition Indian Dentist Research and Review.