SMOKELESS TOBACCO & ORAL CANCER

Presented by :

dr shabeel pn

INTRODUCTION
Tobacco 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.

Consumption   

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

GUTKHA 


Leads to Oral sub-mucous fibrosis (SMF). Main component - arecanut along with tobacco.

KHAINI 


Paste of tobacco + slaked lime & is used with arecanut. Mixed with the thumb to make the mixture alkaline-premolar region of mandibular groove.

MAINPURI TOBACCO 
 

Tobacco+ slaked lime + finely cut arecanut + camphor + cloves. Mainly-Uttar Pradesh. High incidence of oral cancer & leukoplakia.

MAWA  

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.

MISHRI  



Prepared by roasting tobacco on a hot metal plate-blackpowdered-used with catechu. Used to clean teeth. Common in women ²leads to low birth wt. babies .

PAN (BETEL QUID) WITH TOBACCO 
   

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.

SNUFF 
  

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.

ZARDA
Tobacco leaves + lime+spices ² boiled in water.  Residual tobacco ²dried & coloured. 

CONSTITUENTS OF TOBACCO
´ ´ ´ ´ ´ ´ ´

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

EFFECTS OF TOBACCO
´ ´ ´ ´ ´

Oral cancer Cracking & bleeding lips & gums. Receding gums ²tooth 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  

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 FACTORS
Genetic factors Dental factors Occupational risks Tobacco use Alcohol Mouthwash Viral & fungal infections Diet & nutrition

CLASSIFICATION OF ORAL CANCEROUS LESIONS 

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 Codman·s tumour Osteomas Malignant tumours of connective tissue Fibrosarcoma Kaposis sarcoma Ewings sarcoma 

Chondro/Osteosarcoma Non-Hodkins lymphoma Burkitt·s lymphoma Multiple myleoma 

RED & WHITE / PRECANCEROUS LESIONS  Leukoplakia  Erythroplakia  Oral lesions- tobacco/alcohol  Carcinoma-in-situ  Bowen·s disease  Oral submucous fibrosis  Actinic keratosis  Discoid lupus erythematosis  Dyskeratosis congenita  Lichen planus  Lichenoid reactions

LEUKOPLAKIA
´ ´ ´

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 /smoker·s palate Tobacco-associated Idiopathic leukoplakia

EPIDEMIOLOGY :
´

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: ² Homogenous ² Ulcerated ² Nodular

LEUKODEMA
Resembles early leukoplakia ´ Opaque appearance of buccal mucosa ²grayish white ´ Common in occlusal line ² bicuspid&molar region.
´

ERYTHROPLAKIA 

Erythroplasia of Queyrat
² ´Red

²patchµ ² Rare-most imp. precancerous lesion. ² More dangerous than its white kin.  Bright red velvety plaques ²cannot be characterized clinically/pathologically as due to any other condition. ² No sex predilection. ² Occur in 6th&7th decades. 
ETIOLOGY & CLINICAL FEATURES: ° Smoking & alcohol abuse-same. 

TYPES:
¹ ¹

Homogenous Granular/Speckled

Malignant transformations:
« Preleukoplakia « Leukodema « Smoker·s

palate 

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 ² epithelial connective tissue layer. « Etiology: Pan chewing « Clinical features:
² Onset

is incidious - 2²5yrs. ² Site ² buccal mucosa. ² Presence of palpable fibrous bands.

«

« « « «

Cheek mucosa & tongue become fibrosed-loses its elasticity. Opening of mouth ² restricted Blanching of oral mucosa - impaired vascularity. Difficult to tolerate both spicy & hot foods. Pain on palpation at areas of submucosal fibrotic bands. 

Epidemiology:
«

Prevalent in Ernakulam- Kerala. 

BASAL CELL CARCINOMA
² Most

common malignancy. ² Common site ² exposed surface of skin, face,scalp. ² Age ² middle-aged/elderly ² People with fair complexion-high rate.

Etiology:
² UV

radiation-shorter wavelength-more ² Chronic sun exposure ² X-ray exposure / arsenic.

Clinical features:
« Age

² after 40yrs « Sex ²male:female=3:2 « More in fair skin individuals , rare in dark. « Common in middle ² third of face. « Does not arise in the oral mucosa ²arrives by invasion & infiltration from a skin surface. « Begins as a small, elevated papule ²ulceratesheals-crusts down-develops a rolled border. 

EPIDERMOID CARCINOMA /SQUAMOUS CELL CARCINOMA
«

Most common malignant neoplasm of oral cavity.

Etiology: 
     

Tobacco Alcohol Syphilis Nutritional deficiencies Sunlight Trauma , sepsis Viruses-EBV,CMV, immunocompromised.

Clinical features:
² Mainly-ulcerated

& indurated margin ² Occurs as carcinoma of lip , tongue, floor of mouth, gingiva,etc. 

CARCINOMA IN SITU
² Intra-epithelial

carcinoma. ² Cancer which involves only the place in which it began & that has not spread. ² Early - stage tumour. eg: Bowen·s disease. ² Common site- floor of mouth , tongue , lips. ² More common in males /elderly. 

DISCOID LUPUS ERYTHEMATOSIS( DLE)
‡

‡

‡ ‡

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 ² 3rd& 4th decades.

LICHEN PLANUS /LICHEN RUBBER PLANUS
² ² ²

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 ²WICKHAM·S STRIAE. Association of lichen planus, diabetes & vascular hypertension triad - GRINSPAN·S SYNDROME.

‡ 

FORMS OF LICHEN PLANUS
Reticular 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: ´Pµ - Pathology & ´Sµ - Site of the tumour

´ ´ ´ ´ ´ ´ ´ ´ ´ ´ ´ ´

¶T·- primary tumour Tx ² primary tumour cannot be assessed To ² no evidence of primary tumour Tis - carcinoma in situ T1 ² tumour 2cm / less in greatest dimension T2 ² tumour >2cm but not more than 4cm in greatest dimension T3 ² tumour >4cm in greatest dimension T4 ² tumour invades adjacent structures ¶N· ² regional lymph nodes Nx ² regional lymph nodes cannot be assessed N0 ² no lymph nodes N1 ² metastasis in a single ipsilateral lymph node,3cm/less in greatest dimension

N2 ² 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 ² 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 ² metastasis in a lymph node >6cm in greatest dimension M ² distant metastasis Mx ² presence of distant metastasis cannot be assessed M0 - no distant metastasis M1 - distant metastasis 

PREVENTION & CONTROL OF ORAL CANCER
3 well²known approaches to public health:  Regulatory / legal approach  Service approach  Educational approach Regulatory approach : Health ² warning displays. Ban on tobacco advertisements. Service approach : Active search for the disease & its treatment. Educational approach : 4 stages ² Awareness Initiation /Experimentation Habituation Maintenance / Dependence 

REFERENCES:
Essentials of Preventive and Community Dentistry -3rd edition- Soben Peter. Shafer·s textbook of Oral Pathology ² 6th edition Indian Dentist Research and Review.

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