smokeless tobacco and tobacco pouch keratosis

SMOKELESS TOBACCO AND TOBACCO POUCH KERATOSIS- A brief discussion. Dr. Pooja Bansal, Aman Kumar, Kratika Gupta, Mohd. Asad Arafat Abstract: Smokeless tobacco is used orally or nasally without burning tobacco. This is equally harmful as smokers due to the tobacco content and in recent times smokeless tobacco use has increased rapidly. This paper presents features of tobacco associated tobacco pouch keratosis and aims to highlight the oral effects of smokeless tobacco, management, and guidelines for dentists in educating and counselling tobacco use. Aim - As a reference for cases related to smokeless tobacco use, its management and also states about the importance of proper and early diagnosis of tobacco pouch keratosis. INTRODUCTION development of gingivitis, gingival recession and attachment loss, halitosis, reduction of taste, and Tobacco use is rapidly increasing globally.[1] In abrasion of teeth. Smokeless tobacco keratosis is a 2019, according to the CDC, two in every hundred reversible alteration of the oral mucosa in adults aged 18 years older report smokeless immediate contact with a smokeless tobacco tobacco use, correlating to nearly 6 million adults, product (chewing tobacco, moist snuff, dry snuff). with most users reporting daily use. Smokeless The characteristic appearance is a gray/white tobacco has been promoted as an alternative to mucosal discoloration with a wrinkled or fissured smoking.[2] surface texture. The most common locations are the lower labial or buccal vestibule, where the Smokeless tobacco contains various chemical product is held. Gingival recession around teeth in carcinogens, such as the polynuclear hydrocarbon the area of contact is frequently seen.[6] benzopyrene, nicotine, and tobacco-specific N- Smokeless tobacco keratosis presents in 15% of nitrosamines, which are associated with cancers of chewing tobacco users and 60% of snuff users.[7] the oesophagus and the stomach, and mouth.[3] As smokeless tobacco is placed intraorally, these Fig: Photo of buccal vestibule exhibiting compounds can lead to dysplastic changes in the hyperkeratosis from smokeless tobacco. oral mucosa. Pathologic lesions associated with ( Courtsey - Heather Olmo, DDS, MS) these products include smokeless tobacco keratosis, leukoplakia, erythroplakia, verrucous carcinoma, and squamous cell carcinoma. [4] DISCUSSION : Description: Many carcinogens have been found in smokeless tobacco and the major causative agent being tobacco‑specific nitrosamines, and other agents include nitrosamino acids, polycyclic aromatic hydrocarbons, aldehydes, and different types of metals. In addition to the risk of oral cancer, smokeless tobacco has been associated with the development of gingivitis, gingival recession and attachment loss, halitosis, reduction of taste, and abrasion of teeth. Smokeless tobacco keratosis is a

Etiology: Reactive mucosal change in response to appearance of the epithelium (the mucosa) and as habitual use of smokeless tobacco products. the condition worsens, it becomes more leathery.[4] Genetic Basis :- Examples of smokeless tobacco – > Gutkha > Khaini > mawa > paan ,etc > Carcinogenic Constitution of tobacco- Evaluation: Smokeless tobacco keratosis can be Courtsey - ( Shaefer’s textbook of oral pathology) diagnosed with clinical examination and patient interview. If a corrugated buccal mucosa is noted, Histopathology- Smokeless tobacco keratosis may the patient should be questioned regarding the use presents with a non-specific appearance, with of smokeless tobacco. In addition, the clinician hyperkeratotic and/or acanthotic squamous should determine if the location where the patient epithelium. Intracellular oedema and increased places the tobacco correlates with the lesion sub-epithelial vascularity may also be noted. Of identified. [4] The most common location for note, parakeratin chevrons above or within the tobacco pouch keratosis is in the lower anterior superficial epithelial layers can generally be vestibule followed by posterior vestibule.[8] visualized. Therefore, histologic examination of these lesions should evaluate for epithelial Pathophysiology- Smokeless tobacco keratosis dysplasia.[4] results from chronic irritation from the placement of smokeless tobacco, usually in the buccal Fig- Courtsey -Mona Hassan Ahmed Hassan ( journal of vestibule. This irritation results in the deposition of american science 10(4):24-30 excess fibrinlike material throughout the submucosa and an increase in keratin production, which results in the characteristic white corrugated appearance of the epithelium (the mucosa) and as the condition worsens, it becomes more

Treatment: Management of tobacco pouch Distribution of subjects depending on site of keratosis includes complete cessation of tobacco quadrants having oral lesion due to tobacco chewing habit and follow-up to assess consumption :- resolution.[9] Smokeless tobacco keratosis will typically self-resolve with cessation of the habit.[4] [13] If the patient is not willing to stop the habit, we can ask the patient to switch the site of chewing, Oral health consequences of SLT use - and hence, a temporary relief and resolution can >Oral cancer be made.[9] In around 98% of patients, oral The evaluation of carcinogenic risks of mucosa resumed to normal within 2 to 6 weeks smokeless tobacco by the International Agency after stopping the habit. A biopsy should be on Research for Cancer (IARC) has confirmed performed if there is any evidence of erythema or that SLT is carcinogenic to human and the ulceration to rule out dysplasia or carcinoma. main target organ being the oral cavity where Nicotine replacement therapy such as nicotine gum the products are applied locally.[11] and nicotine patches can be delivered to such >Squamous cell carcinoma patients which acts as a substitute.[8]  Tumours appear as red granular areas, or Prognosis: Smokeless tobacco keratosis has a tend to be exophytic- ulcerative- guarded but good prognosis; however, the infiltrative . Ulcerative lesions have a resolution is highly patient-dependent. More distinct rolled border (margins). advanced lesions may require biopsy and further Induration at the margins and base of the monitoring for potential malignant changes.[4] tumour is a pathognomonic sign of oral SCC. Buccal involvement is reported to be Complication: Smokeless tobacco keratosis is the as high as 80 per cent of the cancers that direct result of a habit, and consequently, if a arise at the site of placement of the patient is not willing to cease or even reduce their tobacco-containing quid, mostly in the use of smokeless tobacco, the lesion and the lower buccal sulcus or posterior buccal discomfort associated will not resolve. Therefore, mucosa. patients should be appropriately counselled. [4] DATA ANALYSIS - Distribution of subjects based on tobacco consumption depending on age:- [13]

>Verrucous carcinoma OTHERS TYPE Verrucous carcinoma (VC) comprised up to 16 per >Carcinoma of tongue- cent of oral cancers in an Indian study11 with a Tongue carcinoma comprises between 25%and predilection for commissural, buccal or gingival 50% of all intraoral cancers.[12] sites. VC is a slow-growing tumour spreading laterally, is more indolent than conventional SCC. CONCLUSION : It is a diffuse, exophytic lesion usually covered by leukoplakic (keratotic) patches[12] Oral potentially malignant disorders (OPMD) - Dental professionals play a vital role in early Placing tobacco in the oral cavity, namely in the identification of tobacco-related conditions. As buccal mucosa, gingival sulcus, inner aspect of this condition is more prone for malignant lower lip, floor of the mouth initially leads to transformation, such conditions should not be keratotic or hyperkeratotic changes. These neglected and the patient has to be educated changes are localized to the site where tobacco is about the harmful effects of habitual chewing of placed smokeless tobacco, and preventive measures can be taught for a better quality of life. Initially, there is a greyish white area which develops at the site of tobacco placement with a wrinkling of the mucosa which is termed as ‘tobacco pouch keratosis [11] >Leukoplakia - Leukoplakias are usually diagnosed after the fourth decade of life. These are more common in males and are six times more common among SLT users, than among non-tobacco users16. Sites of involvement among SLT users are buccal mucosa and lower buccal groves that are commonly affected due to the placement of tobacco quid at these locations. [13] >Oral submucous fibrosis OSF is a chronic, insidious disease that affects the submucosa of the oral cavity resulting in progressive limitation of mouth opening which is a hallmark feature of this disease. The disease is solely caused by areca nut and the literature erroneously refers to smokeless tobacco as the causative agent.

REFERENCES:- 1. Cornelius ME,Wang TW, Jamal A, Loretan CG, Neff LJ, Tobacco Product Use Among Adults- United States,2019, Morbidity and Mortality weekly reort ,2020 Nov 20 ; [PubMed PMID- 33211681] 2. Walsh PM,Epstein JB, The oral effects of smokeless tobacco. Journal (Canadian Dental Association). 2000 Jan; [ PubMed PMID- 10680329] 3. Hoffmann D,Brunnemann KD,Prokopczyk B,Djordjevic MV, Tobacco-specific N-nitrosamines and Arecaderived N-nitrosamines: chemistry, biochemistry, carcinogenicity, and relevance to humans. Journal of toxicology and environmental health. 1994 Jan; [PubMed PMID: 8277523] 4. McKinney R, Olmo H, Pathologic Manifestations of Smokeless Tobacco,; 2021 Nov 1st, Bookshelf ID: NBK573058PMID: 34424631 [StatePearl Publishing] 5. Walsh PM, Epstein JB. The oral effects of smokeless tobacco. J Can Dent Assoc 2000; 66:22-5. 6. Molly S. Rosebush, K. Mark Anderson and Yeshwant B. Rawal, Pre cancer and Cancer, Diagnosis and Management of Oral Lesions and conditions, Diagnosis and Management of Oral Lesions and conditions, 19th Feb, 2014, .DOI: 10.5772/57597 7. Rimal J,Shrestha A,Maharjan IK,Shrestha S,Shah P, Risk Assessment of Smokeless Tobacco among Oral Precancer and Cancer Patients in Eastern Developmental Region of Nepal Asian Pacific journal of cancer prevention : APJCP. 2019 Feb 26; [PubMed PMID: 30803200] 8. Sahitha R. Effects of smokeless tobacco, betel quid and areca nut on oral mucosa. IOSR J Dent Med Sci 2014;13:8-11. 9. Mortazavi H, Baharvand M, Mehdipour M. Oral potentially malignant disorders: An overview of more than 20 entities. J Dent Res Dent Clin Dent Prospects 2014;8:6-14. 10. Donald PM, George Renjith, Arora A, Tobacco Pouch keratosis in young individual, Journal of Indian society of Periodontology;Vol 21,issue 23, May-june 2017 . 11. Oral health consequences of smokeless tobacco use - by Muthukrishnan, Arvind1; Warnakulasuriya, Saman.Indian Journal of Medical Research: July 2018 - Volume 148 - Issue 1 - p 35-40 12. Preethy Mary Donald, George Ranjith,Ankita Arora ;Tobacco Pouch Keratosis in a young individual: A brief description , 2017 May-June 21(3),Pubmed Central , PMID- 29440796 13. Oral and Maxillofacial Medicine (3rd EDITION) The basis of Diagnosis and Treatment,page286 .