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Short Communication

Tobacco Pouch Keratosis in a young

individual: A brief description
Preethy Mary Donald, Renjith George,1 Ankita Arora2

Departments of Oral Abstract:

Medicine and Radiology, Smokeless tobacco is used orally or nasally without burning tobacco. This is equally harmful as smokers due
1
Oral Pathology to the tobacco content and can cause oral cancer as well as systemic effects such as nicotinic dependence.
and 2Pedodontics, Many other oral conditions have also been reported in association with smokeless tobacco. This paper presents
Melaka‑Manipal Medical features of tobacco pouch keratosis and aims to highlight the oral effects of smokeless tobacco, management,
College, Malacca, and guidelines for dentists in educating and counselling tobacco users.
Malaysia Key words:
Actinic, counseling, dentists, keratosis, tobacco smokeless, tobacco use disorder

INTRODUCTION appeared normal. Gingival recession was evident,

and his teeth showed tobacco stains and some

T obacco pouch keratosis or smokeless

tobacco‑induced keratosis is the development
of a white mucosal lesion in the area of tobacco
Access this article online contact. The lesion develops on habitual
Website: chewing or snuff dipping tobacco. The lesion
www.jisponline.com is precancerous, and dentists must educate the
DOI: patient about the harmful effects of tobacco and
10.4103/jisp.jisp_109_17 motivate the patient to stop the habit. Here, we
Quick Response Code: highlight oral manifestation of a young male
patient diagnosed with tobacco pouch keratosis.
showed abrasion. His overall oral hygiene was
poor with halitosis. As a part of comprehensive
treatment plan, scaling was done. He was
prescribed with mouthwash for the maintenance
of oral hygiene. The patient was educated about
the ill‑effects of using smokeless tobacco, and we
advised him to gradually stop the habit and was
asked to follow‑up after 1 month.
DISCUSSION

CASE REPORT This case illustrates tobacco pouch keratosis

A 22‑year‑old male patient visited our outpatient
clinic for a complaint of discomfort while eating,
drinking, and speaking. The patient further
added that on self‑examination he felt a rough
surface texture in his left upper vestibule. He
did not experience any pain, burning sensation,
or dysgeusia. His habit history revealed the use
of tobacco since 5 years in combination with
areca nut and betel leaf. He assembles all the
ingredients in a quid form and keeps in his
left vestibule for a span of 4–5 h and then spits
Address for out. On an average, he chews 2–3 quids a day.
correspondence: He does not consume any alcohol. His medical
Dr. Preethy Mary Donald,
Department of Oral
history was non-significant and did not take any
Medicine and Oral medications.
Radiology, Faculty of
Dentistry, Melaka‑Manipal On intraoral examination, a grayish‑white
Medical College, plaque was evident on his left upper vestibule
Jalan Batu Hampar,
extending from distal surface of left canine to
Melaka, Bukit Baru, his upper first molar [Figure 1]. The borders
75150, Malaysia.
were diffuse. Few parts of the lesion showed
E‑mail: pmdrsc30@gmail.
com yellowish encrustations which were deposits of
the ingredients used in the quid. On palpation, the
Submission: 16‑05‑2017 lesion had a wrinkled, thickened, and corrugated
Accepted: 19‑10‑2017 surface texture. However, his right vestibule
© 2018 Indian Society of Periodontology | Published by Wolters Kluwer ‑ Medknow 249
diagnosed in a young individual. This condition
is best described as the development of a
well‑recognized white mucosal lesion in the
area of tobacco contact usually seen in smokeless
tobacco chewers.[1] The term smokeless tobacco is
derived from the fact that tobacco is not burned in
this habit unlike smoking. Many synonyms such
as snuff dipper’s keratosis and smokeless tobacco
keratosis have been proposed for this condition.
A brief description on the types of smokeless
tobacco is shown in Table 1.[2]
The most common location for tobacco pouch
keratosis is in the lower anterior vestibule
followed by posterior vestibule. The lesion
This is an open access article distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
License, which allows others to remix, tweak, and build upon
the work non‑commercially, as long as the author is credited
and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Donald PM,
Renjith G, Arora A. Tobacco pouch keratosis in a
young individual: A brief description. J Indian Soc
Periodontol 2017;21:249-51.
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Donald, et al.: Tobacco pouch keratosis in a young individual

Table 1: A brief description on types of smokeless

tobacco
Types of smokeless Method of consumption and description
tobacco of ingredients
Chewing tobacco/spit Chewed in the form of leaves
tobacco Placed in between the cheek or lower lip
Once chewed, the saliva is spit
Spitless tobacco Finely milled and dissolves orally
The form of tobacco is chewed and spitting
is not required called as “spitless tobacco”
Snuff tobacco Snuffed in the form of fine powdered
tobacco
Available in dry and moist form
Dry form is inhaled through nose and moist
form is placed in between cheek or lower lip

Table 2: Five A’s of smoking cessation

Figure 1: Tobacco pouch keratosis of the left upper vestibule 5A’s Method of Intervention
Ask Document status of tobacco use
appears thickened and corrugated, and as the condition Advice Urge every tobacco user to quit
worsens, it becomes more leathery.[3] Literature reveals that this Assess Is the user willing to quit at the time of visit?
condition has been established as a risk factor for developing Assist Use counseling and pharmacotherapy to help the user
oral carcinoma. However, they are said to have a lower risk to quit if he is willing
Arrange Schedule follow-up preferably within 1st week after
of malignant transformation when compared to leukoplakia. the quit date
Chronic use of smokeless tobacco can result in nicotinic
dependence. Further, researchers have proved that use of
tobacco during adolescence can disrupt brain circuits and affects harmful effects of habitual chewing of smokeless tobacco, and
cognitive abilities, attention deficits, and psychiatric disorders.[4] preventive measures can be taught for a better quality of life.

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. [5]
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.[6] However, there was no evidence of taste
disturbances in our patient.
The Tobacco and Cancer Program of the National Cancer
Institute recommends that all health‑care professionals follow
the 5As guidelines to aid in successful intervention of educating
and counselling tobacco users [Table 2].[7]
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal. The
patients understand that their names and initials will not be
published and due efforts will be made to conceal their identity,
but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.

Management of tobacco pouch keratosis includes complete REFERENCES

cessation of tobacco chewing habit and follow‑up to assess
resolution. If the patient is not willing to stop the habit, we
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temporary relief and resolution can be made. In around 98% of
patients, oral mucosa resumed to normal within 2 to 6 weeks
after stopping the habit. A biopsy should be performed if there
is any evidence of erythema or ulceration to rule out dysplasia
or carcinoma.[8] Nicotine replacement therapy such as nicotine
gum and nicotine patches can be delivered to such patients
which acts as a substitute.[6]
CONCLUSION
Dental professionals play a vital role in early identification of
tobacco‑related conditions. As this condition is more prone
for malignant transformation, such conditions should not
be neglected and the patient has to be educated about the
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Donald, et al.: Tobacco pouch keratosis in a young individual

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