|Ahead of print publication
Correlation of periodontal parameters to various types of smokeless tobacco in tobacco pouch keratosis patients: A cross-sectional study
Gowri Pandarinath Bhandarkar1, Kushal V Shetty2, Ashaya1, Kamakshi Jha1, Kulkarni Arati1, Tanya Thomas1
1 Department of Oral Medicine and Radiology, A. J. Institute of Dental Sciences, Mangalore, Karnataka, India
2 Department of Pedodontia, A. J. Institute of Dental Sciences, Mangalore, Karnataka, India
Gowri Pandarinath Bhandarkar,
Department of Oral Medicine and Radiology, A. J. Institute of Dental Sciences, Kuntikana, Mangalore - 575 004, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Tobacco practice in relation with oral diseases is a foremost cause for the global oral disease burden and is accountable for up to 50% of all periodontitis cases among adults. The present cross-sectional study was undertaken to evaluate the local effects of various types of smokeless tobacco on periodontal health in tobacco pouch keratosis (TPK) patients in Mangalore city in the state of Karnataka.
Materials and Methods: A total of 345 TPK patients were evaluated of which all were smokeless tobacco users. All the patients were clinically examined for different clinical periodontal parameters such as stains, gingival recession (GR), periodontal pocket, furcation involvement, and mobility and local effects of various types of smokeless tobacco on periodontal health in TPK sites were recorded.
Results: The prevalence of GR was of 87.5%. Haathichaap was the most common smokeless tobacco used (35.9%) closely followed by nonpackaged type (loose tobacco) (19.4%). This was followed by Madhu (14.2%). Likewise, periodontal parameters were observed more in these patients in decreasing order.
Conclusion: The results of the present study agree strongly with other smokeless tobacco user studies in terms of the strong association between GR and smokeless tobacco placement. The present cross-sectional study indicates that TPK lesions are positively associated with periodontal diseases. It is important to raise awareness of both oral cancer and periodontal risks and inform about its possible health consequences thereby working towards an improvement of oral and general health and related quality of life in these patients.
Keywords: Gingival recession, periodontal health, periodontal parameters, smokeless tobacco types, tobacco pouch keratosis
|How to cite this URL:|
Bhandarkar GP, Shetty KV, Ashaya, Jha K, Arati K, Thomas T. Correlation of periodontal parameters to various types of smokeless tobacco in tobacco pouch keratosis patients: A cross-sectional study. J Can Res Ther [Epub ahead of print] [cited 2019 Oct 16]. Available from: http://www.cancerjournal.net/preprintarticle.asp?id=268780
| > Introduction|| |
Tobacco practice is a universal public health problem. A powerful and immediate satisfaction to its users is delivered by tobacco in its innumerable forms for the past 500 years leading to pharmacological, psychological, emotional, and social gratifications. Tobacco chewing practice typically entails keeping pinch of powdered tobacco in the gingivobuccal sulcus and sucking on it and is gaining popularity; also described as real tobacco pleasure without even lighting up. Smokeless tobacco (SLT) has now become the answer to this dilemma of the general public not being able to smoke while working in occupations or such locations as well as considering its monetary savings compared to smoking cigarettes. Peer pressure plays a vital role in introducing to SLT use. The euphoriant effect of nicotine on the body is the most common factor of all tobacco practice making a person dependent on nicotine. The first organic carcinogen, nitrosonornicotine is isolated from unburned tobacco and is also found in chewing tobacco in high concentrations between 0.3 and 90 ug.
Although tobacco practices lead to various systemic disorders, oral malignant, and potentially malignant lesions, a variety of oral health disorders such as poor periodontal health and tooth loss, it has also been proposed as a major behavioral risk factor by evolving data.,, Epidemiological and clinical studies with demographic variations have shown the effect of SLT on oral tissues exclusively on periodontal health in different parts of the world.
Previous case reports, studies in the US, Sweden have observed increased association of gingival recession (GR) with oral SLT habits. Studies in India, Bangladesh, and Thailand also observed a strong association between oral SLT use and severe periodontal disease.,
Periodontitis is an inflammatory disease of tooth-supporting structures resulting due to specific microorganisms or their groups existing in dental plaque and is one of the foremost reasons for tooth loss, particularly in older individuals.,
A significant increase in the consumption of SLT has been documented through the last decades parallel to the decline in cigarette smoking observed. Today, though the highest prevalence is found among the youngsters, in the past the use of SLT was most common among the elderly.
Adjacent to the areas where the tobacco quid is held, discolored teeth, GR, advanced periodontal destruction, and tooth loss were documented.,,
In SLT users, the harmful effects of SLT use were demonstrated more in mandibular teeth leading to tooth loss. GR and attachment loss was a result of noxious constituents from the SLT product remaining in contact with the gingival tissues for longer durations at tobacco placement sites. This was particularly seen on the buccal surfaces of the anterior teeth and molars, which were more likely with continued contact to SLT product caused by its retention at the mandibular buccal or anterior labial vestibule.
In India, oral SLT products available commercially cause tissue injury owing to their mutagenic and carcinogenic properties. They comprise more than 4,000 toxic ingredients namely alkaloids such as nicotine, tobacco-specific nitrosamines, phytosterols such as cholesterol, heterocyclic hydrocarbons, pesticides, alkali nitrites, radioactive substances, and toxic metals such as lead, cadmium, and arsenic.
They also contain polycyclic hydrocarbons, aldehydes, heavy metals, and polonium 10 all having the potential to cause harm.
In North India, betel quid with tobacco, zarda, gutkha, khaini, and toombak are highly prevalent and consumed by keeping directly in buccal and labial vestibules without kindling the product.
SLT is normally used orally (sucked or chewed) or through nasal route.
SLT has revealed the serious impact on oral mucosal tissues.
The SLT keratosis (tobacco pouch keratosis [TPK]) is a distinctive white plaque formed on the mucosa in direct contact with snuff or chewing tobacco. Its progress depends on habit duration, the brand of tobacco used, early onset of SLT practice, total hours of daily use, amount of tobacco consumed daily as well as number of sites habitually used for keeping tobacco. The lesion is limited to parts in direct contact with spit tobacco. It appears as a thin, gray or gray-white, almost “translucent” plaque with border merging slowly into the surrounding mucosa.
On palpation, the altered mucosa is soft and velvety and stretching it frequently unveils a distinct “pouch” (tobacco pouch) owing to flaccidity in the constantly stretched tissues in the area of tobacco placement. This stretched mucosa seems fissured or rippled like the sand on a beach after an ebbing tide.
Very few studies indicate the association of different types of SLT on various periodontal parameters.
Due to the high prevalence of SLT use in India, there is a need for a study to better understand the effects of the different types of SLT products on periodontal tissues.
Previous studies evoked a necessity to categorize patients based on the type of tobacco product which vary in their contents as a result differing in their effects on the teeth and the periodontal tissues.
Singh et al. had done a study to evaluate the effects of commonly used SLT types on periodontal health in Lucknow, India.
Hence, the present cross-sectional study was undertaken to evaluate the effect of various types of SLT on periodontal health in TPK patients.
The basis for this cross-sectional study was to examine the consequence of localized effects of various types of frequently used SLT on periodontal health in TPK patients of Mangalore city.
| > Materials and Methods|| |
The patients attending the outpatient department of oral medicine and radiology from January 2015 to March 2018 were selected. A total of 345 dentate patients with 28 natural teeth in the age group of 10–75 years with a presence of clearly identifiable TPK (both males and females) who were otherwise systemically healthy were evaluated.
All the patient details and information such as name, age, gender, demographics, occupation, and SLT use (type, i.e., brand name, duration of use in years, frequency of use [number of packs]), site, and duration of SLT placement in the mouth were recorded. Informed consent was obtained from all the patients. The study protocol was approved by the Institutional Human Ethics Committee. This work has been carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki).
Patients who were edentulous/under medication/presented a history of undergoing any form of periodontal treatment/with systemic disorders/lack of TPK/presence of any other mucosal lesions were excluded from the study.
All patients were examined orally under artificial illumination using mouth mirror, explorer, cotton plier with cotton, Naber's probe, and William's graduated periodontal probe for TPK in various parts of the oral cavity and associated periodontal parameters.
The following parameters were assessed:
- TPK was diagnosed as per clinical examination
- The location, extent, and specific teeth adjacent to the keratosis were recorded and examined for periodontitis diagnosed in accordance with the criteria followed by American Academy of Periodontology and clinical findings of GR, mobility of tooth (M), and furcation involvement (FI), were recorded as well as probing pocket depth (PPD) at all six points
- Total number of teeth present in the mouth.
Outcome variables were periodontal parameters (GR, PPD, FI, M). Descriptive variables were age, gender of the patient, tobacco duration, frequency, and brand. Descriptive statistics (mean ± standard deviation [SD]) were the age of the patient and duration of tobacco.
The qualitative variables in the demographic data, i.e., gender, periodontal parameters, frequency and brand of tobacco were presented as percentage and proportion, and quantitative data (age of the patient and duration of tobacco) were presented as mean and SD.
The data observed from the procedures were entered into Excel sheet, tabulated, analyzed, and descriptive (mean, SD, proportions, and percentages) and inferential (Chi-square test to analyze the association between risk factor and the outcome) statistics were done using computer software SPSS (Statistical Package for the Social Sciences) version 21 (IBM, Chicago, USA). The level of significance P at different confidence levels were interpreted as follows: P >0.05 not significant, P < 0.05 statistically significant, P < 0.01 highly significant, and P < 0.001 very highly significant with a confidence interval of 95%.
| > Results|| |
The present cross-sectional study analyzed the local effects of various types of SLT on periodontal health of TPK patients for which 345 patients were evaluated. All of them were SLT users and were aware of the harmful consequences of tobacco (oral cancer).
The results of the present study revealed that the use of SLT was associated with a significantly higher risk for the development of GRs, followed by periodontal pocket, mobility, and FI in TPK patients. A total of 345 patients were analyzed out of which 344 (99.7%) were male, and 1 (0.3%) was a female. All of them were using some type of SLT.
The age of the patients in the present study ranged from 18 to 75 years. The mean age of the study population was 31.580 + 9.9411 years reporting an average duration of 5.54 + 5.62 years of ST use. Among 345 patients, the number of patients in the age group of 11–20 years were 21 (6.1%); 21–30 years were 171 (49.6%); 31–40 years were 98 (28.4%); 41–50 years were 35 (10.1%); 51–60 years were 17 (4.9%); 61–70 years were 2 (0.5%); and 71–80 years were 1 (0.3%) [Figure 1]. The peak incidence of TPK patients, i.e., 49.6% was observed in the age group of 21–30 years whereas the minimum incidence of 0.3% was observed in the age group of 71–80 years. A prevalence of GR of 87.5% was observed in our study. In the mandible, 36.2% (n = 125) had TPK lesion on the left side; 28.1% (n = 97) had it in the anterior labial vestibule; 14.2% (n = 49) had it on the right side; and 7% (n = 24) had on both right and left sides. Similarly in the maxilla, 5.2% (n = 18) had TPK lesion on the left side; 5.2% (n = 18) had it in the anterior labial vestibule; 0.9% (n = 3) had on both right and left side; 1.5% (n = 5) had on the right side; and 1.7% (n = 6) had TPK lesions in multiple sites (combination) [Figure 2]. [Table 1] and [Table 2] present periodontal clinical parameters with patients stratified by duration in years as well as frequency per day of ST use. The duration of habit in years showed that 71% had the habit of tobacco consumption for <5 years; 20.3% had for 5–10 years and 8.7% had for more than 10 years. Chi-square test showed significant association between the duration of ST use in years and GR (P = 0.05); stains (P = 0.006); mobility (P = 0.00); and periodontal pocket (0.00) [Table 1].
|Table 1: Cross-tabulation of the duration of tobacco consumption and periodontal status|
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|Table 2: Cross-tabulation of the frequency of tobacco consumption and periodontal status|
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The frequency of tobacco consumption showed that 95.9% consumed tobacco for 1–5 times/day and 4.1% consumed tobacco for more than 5 times/day. Cross tabulation of the frequency of tobacco consumption and periodontal status showed no significant association with GR (P = 0.83); stains (P = 0.81); mobility (P = 0.77); periodontal pocket (P = 0.73); and FI (P = 0.7) [Table 2].
GR and stains were the most common observations at the TPK site. Of 345 patients, 87.5% had GR, 87.2% had stains, 58.0% had periodontal pockets, 35.7% had mobility, and 17.7% had FI at the TPK site [Figure 3].
All the patients claimed that they placed ST in the vestibules for about 5–10 min before spitting it out. Among the different varieties of SLT consumed, Haathichaap was the most common SLT used (35.9%) closely followed by nonpackaged type (loose tobacco) (19.4%). This was followed by Madhu (14.2%). Mirage was the least commonly used (.3%) followed by Rajanigandha and Ompuri (1.4% each) [Figure 4]. Few patients used more than one type of SLT. The incidence of GR, stains, periodontal pocket, mobility and FI were likewise higher in the patients who chewed Haathichaap followed by nonpackaged which is followed by Madhu. Khaini, Swagath, and Ghutka had comparatively lesser effects on periodontal health.
Cross-tabulation of GR and tobacco brand showed maximum patients having GR (n = 121) were consuming Haathichaap. Chi-square test was statistically significant– (χ = 64.75; P = 0.000) [Table 3].
Cross-tabulation of stains and tobacco brand showed maximum patients having stains (n = 121) were consuming Haathichaap. Chi-square test was statistically significant (χ = 52.69; P = 0.000) [Table 4].
Cross-tabulation of periodontal pocket and tobacco brand showed maximum patients having pockets (n = 95) were consuming Haathichaap. Chi-square test was statistically significant– (χ =53.09; P = 0.000) [Table 5].
| > Discussion|| |
Even with great feats in the oral health of the general public globally, glitches still persists in the developing countries, one among them being India. Historically, dental caries and periodontal diseases have been the most significant global oral health burdens.
The increase in the prevalence of periodontal diseases leading to pain, infections and compromised mastication is definitely of high concern. SLT practice is quite common in many parts of India. This deep-seated practice is supposed to be a custom among the population. Besides, the general notion that SLT is less harmful than smoking, people also assume that chewing tobacco relieved them from dental pain and halitosis as a result of which dental effects of such habits might be more prevalent in Indians.
SLT practice is a well-known environmental risk factor for various systemic diseases including oral cancer and periodontal disease.
The present cross-sectional study indicates that TPK is positively associated with the periodontal diseases and is in strong agreement with other SLT studies in terms of the strong association between GR and ST placement.
SLT practice leads to increased GR in the mandibular teeth as a result of localized effects of tobacco products on the tissues at the site of placement., The strength of association between SLT and periodontal disease is dependent on the fact that SLT products used in India has a variety of ingredients besides tobacco, for instance, betel quid, areca nut, slaked lime, catechu, and spices. Their methods of preparation to adds to alteration of toxicity of these ingredients thus making it hard to detect the specific effects of tobacco on periodontal tissues. Furthermore, the different chemical composition of these different commercial products has different effects on periodontal tissues. SLT products available in India probably have higher pH, total nicotine and unionized nicotine.
Thus, product-specific data regarding the effect of SLT on periodontal health in TPK patients of Mangalore city was considered.
A frequent local change in the area of tobacco contact is the typical painless loss of gingival tissues. This GR is related to the quantity of daily consumption and duration of the SLT practice leading to the destruction of the facial surface of the alveolar bone. Long-term use may lead to localized or generalized attrition of the teeth along with a brown-black extrinsic tobacco stain typically found on the enamel and cementum surfaces adjacent to the tobacco placement site.
It was observed that as the duration of years and frequency of tobacco chewing with betel nut increases, periodontal parameters increased as compared to the betel quid chewers alone thereby confirming the harmful effects of tobacco on periodontal health.
The present study also measured the effect of time, i.e., duration in years and frequency of SLT use per day.
Stratification of patients was done based on the age of the patient, TPK sites, type of ST product used, duration of ST use in years and frequency of ST use per day to better understand the effects of ST use on the periodontium.
SLT is viewed as rather acceptable forms of tobacco consumption as compared to smoking and individuals are familiarized to such practices at a very young age as a part of their lifestyle. Ill-education, poverty and rural areas of habitation are to be blamed. As a result, the prevalence of SLT use is seen more in the younger age groups which is an important demographic feature.
The age in the present study ranged from 18 to 75 years indicating the early start of the habit as a consequence of the easy availability of these commercial tobacco products. The peak incidence of SLT use was found in the second decade of life (49.6%). This is similar to observations made by Singh et al. Occupational stress and the belief that certain occupational tasks such as driving buses and lorries at night necessitating more concentration could be carried out with ease with tobacco use might have led to an increased prevalence seen in this age group. Furthermore, peer group pressure among the young adults and macho appeal of a certain Bollywood actor advertising Vimal and Rajanigandha were the explanations provided by the patients in our study. All most all of the TPK patients were males as there was only one female; in our study, this higher male preponderance is probably due to the fact that the males were placing tobacco in the vestibule for protracted period of time due to their occupational commitments such as bus drivers compared to females who probably spat it out immediately or it may be also that females with TPK had limited access to health care which is probably due to the social mindset which gave dental treatment a low priority and so patients would not report accounting for low prevalence of females in our study. It is also possible that females in the recent years are more concerned about their general health and choose not to use tobacco and thus did not report with TPK lesions.
Chu et al. observed consistent results with respect to the strong association between buccal recession and ST use despite methodological and population differences.
In the present study, maximum locational use was seen in the mandibular left buccal vestibule closely followed by the anterior labial vestibule. The site of lesion matched with the location of use in all the cases (100%). This is in agreement with Anand et al.
The incidence of GR, stains, periodontal pocket, mobility and FI were higher in the TPK site as compared to the non-TPK sites where tobacco was not placed and confirms various published data revealing the destructive/injurious effects of SLT on periodontal tissues.,,, The easy availability and ease of handling of commercial tobacco products have made them popular in recent years. Both duration and frequency of SLT consumption considerably compromised periodontal health.,,, Among the various types of SLT use, Haathichaap was used by majority of our TPK patients closely followed by nonpackaged (loose tobacco), and Madhu and these patients had comparatively low periodontal health. Khaini, Swagath, and Ghutka had lesser effect on periodontal health compared to other SLT types.
Absorption of nicotine (the principal alkaloid) through the oral mucosa from SLT products impairs the immune system and wound healing thereby playing a significant role in the destruction of the periodontium. There will be vasoconstriction and diminished angiogenesis. The neutrophil function is affected by causing increased shedding of adhesion molecules and modification of f-actin kinetics which brings about decreased migration of neutrophils, preventing phagocytosis as well as oxidative killing. Furthermore, there is decreased proliferation and function of T-lymphocytes, reduced phagocytosis as well as manufacture of pro-inflammatory cytokines and oxygen radicals by monocytes. It increases TNF-α(tissue-destructive cytokine) levels, decreases antibody levels to periodontal pathogens and impairs attachment of human periodontal ligament fibroblasts.
The development of recessions is probably as a result of mechanical and/or chemical trauma to gingiva. This chemical injury to thin areas of gingiva led to the loss of marginal gingiva chronically exposed to SLT in sites with alveolar dehiscence resulting due to the thin underlying alveolar bone at buccal sites.
| > Conclusion|| |
The patients should be educated about the harmful effects of tobacco, its possible health consequences and counseled to stop the habit and if needed any help, put on nicotine replacement therapy. They should be referred for periodontal therapy as soon as possible to avoid further damage to the periodontium.
Tobacco cessation interventional programs in dental care settings are crucial in periodontal therapy protocol of these patients.
Dentists should teach self-examination skills to SLT users who refuse to quit as a minimum health care interventional measure. Hence, potentially dangerous signs and symptoms could be detected at an early stage.
The limitation of the study is a small sample size. Future studies should be done with a better design including more periodontal parameters such as bleeding on probing and attachment loss.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]