ISSN 0975-8437

INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(1): 25-28

RESEARCH PAPER

Intraoral distribution of oral melanosis and cigarette smoking in a Pakistan

population
Muhammad Nadeem, Rabia Shafique, Ali Yaldram, Rodrigo Lpez

Abstract
Aims: To assess the intraoral distribution of oral melanosis and its association with cigarette
smoking. Material and methods: A cross sectional study conducted during June 2009 in Karachi, Pakistan
involving 378 adult volunteers aged 18-35 years attending a dental camp organized by Liaquat College of
Medicine and Dentistry. A total of 440 subjects consulted in the outpatient department and 378 (86%)
fulfilled the inclusion criteria and participated in the study. Information on demographic factors and
dimensions of cigarette smoking was obtained using a questionnaire. Each subject received a clinical
examination for the presence of melanosis on the buccal- lingual mucosa, gingiva, palatal tissue, and floor
of the mouth. Statistics: Analyses included 2 statistics, the differences between proportions and the
corresponding 95% confidence intervals for the differences between groups. Results: Both, the duration of
smoking in years (2= 24.6; P<0.001); the severity of smoking (2=68.6; P<0.001); and the type of
cigarette (2=25.6; P<0.001) were significantly associated with the occurrence of melanosis. Among
smokers, melanosis was more frequently found on the buccal mucosa (2=35.1; P<0.001); whereas among
non-smokers the lingual mucosa was more frequently affected (2=0.02; P=0.53). Conclusion: There is a
significant dose response relationship between oral melanosis and cigarette smoking.
Key words: Melanocytes;Melanosis; Pakistan; Smoking.
Received on: 21/07/2010
Accepted on: 13/10/2010
Introduction
The results of several studies have
consistently suggested a strong association
between melanin pigmentation of the gingiva
and smoking (1-5) and the results from crosssectional studies indicates that the prevalence
estimates for this type of pigmentation ranges
between 21% and 90% among cigarette smokers
(1,6). The term smokers melanosis was coined
by Hedin back in 1977 (7) and it has been
hypothesized that this condition may be due to
the physical effect of tobacco smoke on the oral
tissues by heat and/or the direct effect of nicotine
stimulating melanocytes located along the basal
cells of the epithelium to produce more
melanosomes, thus resulting in increased
deposition of melanin (2,8).
While several authors have investigated
the
intraoral
distribution
of
melanin
pigmentation (1,2,4,6,9,10), most focus has been
invested on the gingival tissues and smoking
(2,6,10) and it is unclear whether the oral
mucosa can be affected in a similar manner and
whether the distribution of the lesions is different
among non-smokers. In addition to this, while
the results of several studies suggest the
existence of a dose response in the relationship
between melanin pigmentations and smoking,
with heavy cigarette smokers presenting more
frequently with pigmentations than mild smokers
(1,4,10) and with subjects who have smoked

cigarettes for longer periods of time presenting

more frequently with melanin pigmentations
than subjects who have been exposed for shorter
periods of time (1,4,10), to the best of our
knowledge, the potentially influential role of the
type of cigarette smoked has not been
investigated.
The aims of this study were to
investigate the association between selected
dimensions of exposure to cigarette smoking and
oral melanosis and to explore the intra-oral
distribution of melanin pigmentations according
to smoking status in a young adult population of
volunteers attending a free dental camp in
Gulshan Town, Karachi, Pakistan for general
dental checkups.
Materials and methods
The Department of Community
Dentistry and Periodontology of the Liaquat
College of Medicine and Dentistry in Karachi,
Pakistan organized a dental camp in which
people could consult for routine dental checkups
at the Darul Sehat hospital during the month of
June 2009. The hospital covers the rural and
urban areas of Gulshan Town and counts with
clinical facilities that provided the opportunity
for conducting this cross-sectional study. The
exercise did not include acute consultations due
to pain or infections and was restricted to
intraoral examination and advice to the

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participants on how to improve and maintain

their oral health. Participants were also informed
on the presence of caries and/or need for dental
scaling.
Study population: A total of 440
subjects aged 18-35 years consulting for checkups were invited to participate in the study.
Exclusion criteria included self-reported
diabetes, self-reported hypertension, selfreported complains of bleeding gums, having
received radiation therapy, having clinical signs
of oral carcinoma, and history of pan and/or betel
nut use. From the group of eligible subjects, 2
were excluded due to alcoholism, 20 because
they presented with diabetes or hypertension, 27
were not excluded because of pan and/or betel
nut consumption, and 5 were excluded due to
concomitant oral carcinoma and/or exposure to
radiation therapy. A total of 8 individuals did not
want to participate in the study thus leaving 378
(86%) volunteers. The dimensions of cigarette
smoking investigated included the type of
cigarettes smoked (with or without filter), the
duration of smoking in years (< 5 years, 5 to 9
years, 10 to 14 years and >14 years), and the
number of cigarettes smoked. A subject was
considered a cigarette smoker if she smoked at
least one cigarette every day. No attempts were
made to identify ex-smokers.
Sample Size: The sample size estimated
for the study (n=323) was originally calculated
considering a precision of 5%, a 95% level of the
confidence interval, and assuming a 50%
prevalence in the underlying referral population.
Ethical Considerations: The study protocol was
approved by the Department of Research and
Ethics of the Liaquat College of Medicine and
Dentistry Karachi and written informed consent
was provided by each participant.
Variables: All participants filled a selfadministered
questionnaire
containing
information on age, gender, smoking status
(current smoker/no smoker); the duration of
smoking in years (< 5yrs, 5-9 yrs, 10-14 yrs and
Smokers (n=103)

> 14 yrs); and the type of cigarettes smoked

(with or without filter).
Clinical outcome: A trained oral
pathologist (AY) and a dentist (MN) who had
been calibrated against the pathologist conducted
all the clinical examinations. The examiners
were blinded to information on smoking habits.
Each participant was examined for the presence
of melanosis in five areas of the mouth: 1) the
buccal mucosa; 2) the lingual gingiva; 3) the
buccal gingiva; 4) the hard and soft palate; and
5) the floor of the mouth. The term oral
pigmentation is frequently applied to a wide
range of lesion or conditions featuring a change
of colour of oral tissue. Lesions not associated
with an accumulation of melanin pigment (e.g.,
Fordyce spots) were not classified as pigmented
lesions (11). The presence of oral melanosis was
dichotomized (Yes/No). . For the purpose of the
present analysis, the site with most prominent
melanin pigmentation was considered at the
individual level.
Statistical Analysis: We used 2 statistics to
compare overall differences between groups, the
differences between proportions and the
corresponding 95% confidence intervals for the
differences between groups.
Results
The study group comprised 103smokers
and 275 non-smokers and a total of 1,890 sites
were examined for the presence of melanin
pigmentation. There were 40 (38.8%) pigmented
sites among smokers and 26 (9.5%) sites affected
among non-smokers.
Intraoral distribution of melanin
pigmentation according to smoking status:
Among smokers, pigmentations were most
frequently found in the buccal mucosa (17.5%),
while among non-smokers the lesions were more
frequent in the lingual mucosa (5.5%). The
second largest number of pigmented sites in
smokers was found in the gingival area (7.8%)
(Table 1).

Non-Smokers (n=275)

Diff

95% CI

2 statistic

Buccal

N
18

%
17.5

n
4

%
1.5

16

[9.5;24.5]

P<0.001, 2=35.10

Lingual

5.8

15

5.5

0.4

[-4.2;7.0]

P=0.53, 2= 0.02

Gingival

7.8

1.1

6.7

[2.4;13.5]

P=0.002, 2= 11.82

Palatal

5.8

0.7

5.1

[1.4;11.4]

P=0.006, 2= 9.4

Floor of the Mouth

1.9

0.7

1.2

[-1.1;6.1]

P=0.300, 2= 1.06

Sites

Total
40
38.8
26
9.5
29.4
[19.7;39.5]
Diff= Differences between proportions
95% CI= 95% confidence intervals for the differences between groups
2= Chi square statistics
Table 1.- Intraoral distribution of melanin pigmented sites according to smoking status

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Distribution of melanin pigmentation according

to the duration of smoking: The highest numbers
of pigmented sites were observed in individuals
who had smoked more than 14 years (67.5%).
The occurrence of melanin pigmentation was
similar for individuals who had smoked between
5 to 9 years and for those who had smoked 10 to
14 years (12.5%). The occurrence of pigmented
sites was significantly associated with the
duration of smoking in years (=24.56,
p<0.001) (Table 2).
Pigmented
Smoker
(n=40)
n
%
3
7.5
5
12.5
5
12.5
27
67.5

Duration
of Smoking
<5 years
5-9 years
10-14 years
>14 years

Non Pigmented
Smokers
(n=63)
n
%
11
17.5
9
14.3
30
47.6
13
20.6

(2= 24.56, df= 3, p<0.001)

df=degrees of freedom
2= Chi square statistics
Table 2.- Distribution of melanin pigmentation among
smokers according to the duration of smoking in years

Distribution of melanin pigmentation

according to the number of cigarettes smoked per
day: Subjects reporting to smoke less than 10
cigarettes a day were considered to be mild
smokers. Subjects reporting to smoke 10 or more
cigarettes a day were considered to be heavy
smokers (4). The occurrence of pigmented sites
was significantly higher among heavy smokers
(=68.63, p<0.001) (Table 3).
Severity
of
Smoking

Pigmented
Smoker
(n=40)

Non
Pigmented
Smokers
(n=63)
n
%

Diff

95% CI
for the
difference

N
%
Mild
Smokers
[-88.4;7
17.5
61 96.8
(<10
79.3 63.0]
cigarettes)
Heavy
Smokers
33 82.5
2
3.2
79.3 [63.0;88.4]
(10or
more)
(2= 68.63, df= 1, p<0.001)
Diff= Differences between proportions
95% CI= 95% confidence intervals for the differences
between groups
2= Chi square statistics
Table 3.- Distribution of melanin pigmentation among
smokers according to the number of cigarettes smoked daily

Distribution of melanin pigmentation

according to the type of cigarettes smoked:
Subjects smoking cigarettes without filter were
significantly more likely to present with melanin
pigmentations (=25.56, p<0.001) than did
subjects smoking filtered cigarettes (Table 4).

Type of
cigarette

Pigmented
Smoker
(n=40)

Non
Pigmented
Smokers
(n=63)
n
%

Diff

95% CI
for the
difference

n
%
Filtered
[-62.3;16 40.0 55
87.3
cigarettes
47.3
28.7]
Nonfiltered
24 60.0
8
12.7 47.3 [28.7;62.3]
cigarettes
(x2= 25.56, df= 1, p<0.001)
Diff= Differences between proportions
95% CI= 95% confidence intervals for the differences
between groups
2= Chi square statistics
Table 4.- Distribution of melanin pigmentation among
smokers according to the type of cigarettes smoked

Discussion
To the best of our knowledge, this is the
first study examining the association between
smoking habits and intraoral distribution of
melanosis in an adult Pakistan population. The
results of this study confirm previous reports
suggesting the existence of a dose-response
relationship between exposure to cigarette
smoking and the occurrence of oral melanin
pigmentations both when exposure is measured
as the number of cigarettes smoked (1,2,4,10)
and the duration of cigarette smoking in years
(1,4,10).
The intraoral distribution of melanin
pigmentations differed for smokers and nonsmokers, with smokers presenting most
frequently with pigmentations on the buccal
mucosa whereas non-smokers presented most
frequently with pigmentations on the lingual
mucosa. This finding is in agreement with
previous findings reported for a Nigerian
population (4), but deviate from the results of
other studies in which the attached gingiva has
been found to be the most common location for
pigmentations among Swedish (1), Thai and
Malaysian (6), and Turkish (9) smokers.
Our finding on the statistically
significant association between the type of
cigarette smoked (non-filtered) and higher
frequency of melanin pigmentation is novel for
the oral sites investigated but is in agreement
with the results of a previous study concerning
reverse smoking suggesting that palatal
mucosal changes are more frequent among users
of non-filtered cigarettes (12). Our finding on the
type of cigarette smoked may reflect an
additional dimension of the severity of exposure
to smoking. However, this should be interpreted
with caution because the habit of smoking
cigarettes without filter may also be related to
unknown determinants of melanin pigmentation

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e.g., socio-economic position, which can

therefore confound the reported association.
A limitation of this study is the
inclusion of volunteers for dental check-ups
because this strategy for selecting participants in
a study is more likely to overestimate the
occurrence of oral melanosis and other oral
conditions because people with self-perceived
oral conditions are more likely to consult than
what would be expect for subjects in the
underlying population of Karachi. However,
while this may affect prevalence estimates, it is
not likely to affect the results of the associations
found in the study. It can also be seen as a
limitation that no attempts were made to
indentify
ex-smokers.
However,
the
disappearance of melanosis after reducing or
quitting smoking has been reported in the
literature (8) and we do not expect that earlier
exposure to smoking among ex-smokers affects
the results of this cross-sectional investigation.
Conclusion
Smokers presented more frequently
with oral melanin pigmentations than nonsmokers and the relationship suggested a doseresponse effect. Oral melanosis among smokers
was most commonly found on the buccal mucosa
and subjects smoking non-filtered cigarettes
were more commonly affected.
Acknowledgments
The authors appreciate the support received
from the Liaquat College of Medicine and Dentistry
Research Centre, in Karachi in the person of Professor
Navid Rashid Qureshi and the input received from
Darul Sehat Hospital during the organization of the
dental camp. The statistical advice received from
Professor Nazeer Khan is greatly appreciated.
Authors Affiliations: 1. Dr. Muhammad Nadeem,
M.I.P.H, Department of Periodontology/Community
Dentistry, 2. Dr. Rabia Shafique, B.D.S, Department
of Oral Surgery, 3. Dr. Ali Yaldram, M.Sc,
Department of Oral Pathology, Liaquat College of
Medicine & Dentistry, Dental Block, Darul Sehat
Hospital, Karachi, Pakistan 4. Dr. Rodrigo Lpez,
D.D.S, Ph.D., Department of Periodontology, Faculty
of Health Sciences, Aarhus University, Denmark.
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Address for Correspondence
Dr. Muhammad Nadeem, M.I.P.H,
Department of Periodontology,
Liaquat College of Medicine & Dentistry,
Dental Block, Darul Sehat Hospital,
Karachi, Pakistan.
Email: dr_nt01@hotmail.com

Source of Support: Liaquat College of Medicine & Dentistry, Conflict of Interest: None Declared

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