Oral cavity is recurrently subjected to a series of alterations with increase in age, life style related changes, local and systemic, environmental variations. Changes in the mucosa of oral cavity can be seen secondary to traumatic, inflammatory, infectious, genetic, hormonal, mechanical, chemical and other numerous factors. Consumption of tobacco in any form can lead to a numerous health problems affecting various body systems. These may result in pulmonary diseases, cardiovascular diseases, gastroenteral diseases, various malignancies along with multitude of oral mucosal changes [1]. Consumption of tobacco is reported to be the second leading reason of mortality globally and causing around 5 million deaths yearly [2]. The number is expected to increase and reach the value of 8.4 million approximately by the year 2020 [3,4]. The clinical appearance, location and frequency of the oral changes are related to the various ways and forms in which tobacco is consumed. It has been reported that over 300 products can be found in tobacco smoke or in saliva as the water-soluble components [5]. Long term use of tobacco and consumption of alcoholic beverages along with poor dietary and nutritional status are known to be the prime factors leading to 90 percent head and neck malignancy cases. In industrialized countries, smoking is proved to be the leading cause of 40-45 percent of all cancer deaths among males, around 90-95 percent deaths secondary to pulmonary cancers, approximately 85 percent of deaths due to oral malignancy, and around 35 percent of deaths due to underlying cardiovascular diseases [6]. Long term use of smoked and smokeless tobacco found to produce severe effects on oral soft tissues and hard tissues. These changes may be seen secondary to the carcinogen itself or as a result of protective mechanism of the oral cavity [7]. The strong correlation between malignancies of the oral cavity with usage of tobacco is well established and reported in literature. Consumption of tobacco, the nature, frequency and duration is determined by various factors, such as, attitude of the individual, social and economic factors, availability, local medias, education status, etc [8]. Similar to other part of the world, in Saudi Arabia a prevalence of 21.1% of smoking in males and 0.09% was observed in females in 1999 and in 2009 a prevalence of 11.6%-52.3% was noted all over the country from various studies, which shows a significant increase in the use of tobacco [9]. In the 1st International Islamic Conference of Ulemas on Drugs, Narcotics and Liquors held in (Saudi Arabia1982, a resolution prohibiting the use of tobacco in any of its forms, its cultivation, manufacturing, trading, selling or promoting it in any way has been passed. There are numerous Fatwas (decrees) that prohibits use of tobacco and smoking, if the local population adheres to these Fatwas, they will eradicate a major cause for cancer [10,11].
To the best of our knowledge only few studies have been carried out in Kingdom of Saudi Arabia, correlating the tobacco habits and oral mucosal changes. The main objective of this cross-sectional study was to determine the prevalence of the oral mucosal changes in tobacco using males. To know the correlation between the oral mucosal changes and the type of tobacco usage, its frequency and duration.
Materials and Methods
Individuals aged, 18 and above, who had the habit of using tobacco (smoked or chewed forms) were included in the study. The study was carried out from December 2011 to November 2014. Subjects who were unwilling to give the complete habit details were excluded. The cohort of the present study constituted 536 male patients attending the Out Patient Department with tobacco associated habits. Females were not included in the study, as the study was carried out in a University for male students. Ethical clearance was obtained from the institutional ethical committee. All the subjects were informed regarding the study and an informed consent was obtained. Following which they were interviewed for their adverse habits and examined for the presence of any oral lesions.
Along with patient’s demographic details, information regarding the type of habit, duration, frequency, site of placement, period of contact was recorded. The subjects were then clinically examined using mouth mirrors under artificial illumination. All the changes were diagnosed and categorised in accordance with various international recommendations and criteria [12–14].
Statistical Analysis
Descriptive statistical analysis was carried out in the present study. Significance was set at 5% level of significance (p<0.05). Chi-square test was used to find the significance association between two attributes on categorical scale and the Z-proportionality tests was used to find the significance difference between two parameters with proportion rates. Data were analysed using SPSS, version 21.0 (SPSS Inc., Chicago, Illinois, USA).
Results
The study included total number of 536 male patients reported with tobacco habits in the age group of 18–65 years. Out of the 536 subjects with history of tobacco smoking and chewing habits, 386 (72%) showed changes in oral mucosa at the time of the study. 69% of patients were found to be using tobacco in the form of smoking and 31% of patients were using smokeless tobacco [Table/Fig-1].
Distribution of patients according to habits
| Habits | N | % |
|---|
| Smoking | 370 | 69 |
| Smokeless | 166 | 31 |
| Total | 536 | 100 |
[Table/Fig-2] represents the Prevalence of oral lesions, smokers melanosis was seen with a maximum prevalence (43.28%) as compared to a minimum of leukoplakia (3.17%) followed by, leukoedema (27.05%), smoker’s palate (22.76%), lichenoid lesion (15.30%) and lichenplanus (6.00%).
Prevalence of oral lesions
| Lesions | N | % |
|---|
| Smoker's melanosis | 232 | 43.28 |
| Leukoedema | 245 | 27.05 |
| Smoker’s palate | 122 | 22.76 |
| Tobacco induced keratosis | 90 | 16.8 |
| Lichenoid lesion | 82 | 15.3 |
| Lichenplanus | 32 | 6.0 |
| Leukoplakia | 17 | 3.17 |
Distribution of the oral lesions according to site [
Table/Fig-3]
Site wise distribution of the oral lesions
| Site | N | % |
|---|
| Buccal mucosa | 113 | 29.27 |
| Commissures | 81 | 20.98 |
| Labial mucosa | 50 | 12.95 |
| Palatal mucoas | 42 | 10.88 |
| Buccal vestibule | 38 | 9.84 |
| Gingiva and alveolar mucosa | 27 | 6.99 |
| Retromolar areas | 23 | 5.95 |
| Tongue | 8 | 2.07 |
| Floor of mouth | 4 | 1.03 |
In the present study, a maximum 29.27% of patients had lesion at buccal mucosa and a minimum 1.03% of patients had lesion at floor of mouth, followed by commissures (20.98%), labial mucosa (12.95%), palatal mucosa (10.88%), buccal vestibule (9.84%), gingiva and alveolar mucosa (6.99%), retromolar areas (5.95%) and at the tongue (2.07%).
Prevalence of lesion in relation to type of tobacco usage [
Table/Fig-4]
Prevalence of lesion in relation to type of tobacco usage
| Lesions | Types of tobacco usage | Z-value | p-value |
|---|
| Smoking | Smokeless |
|---|
| Smoker's melanosis | 232 (43.28 %) | 0 | 10.2054 | 0.00001* |
| Leukoedema | 86 (16.44 %) | 59 (11.00%) | 1.6420 | 0.1006 |
| Smoker’s palate | 122 (22.76 %) | 0 (00) | 6.6951 | 0.00001* |
| Tobacco induced keratosis | 19 (3.54%) | 71(13.24 %) | -4.1987 | 0.00001* |
| Lichenoid lesion | 34 (6.34 %) | 48 (8.95) | -1.0845 | 0.2782 |
| Lichenplanus | 15 (2.79 %) | 17 (3.17 %) | -0.2421 | 0.8087 |
| Leukoplakia | 6 (1.11 %) | 11 (2.05 %) | -0.8561 | 0.3919 |
Chi-square= 319.8292 p = 0.00001*
A significant association was observed between lesions and type of tobacco usage among the present study (chi-square=319.8292, p=0.00001). A significant difference was observed between smoking tobacco usage and smokeless tobacco usage in relation to smoker's melanosis (Z=10.2054, p=0.00001) smoker’s palate (Z=6.6951, p=0.00001) and tobacco induced keratosis (Z=-4.1987, p=0.00001) at 5% level.
Association between frequency of tobacco usage and oral lesions [
Table/Fig-5]
Association between frequency of tobacco usage and oral lesions
| Lesions | Frequency |
|---|
| <5 times/day | 5-10 times/day | >15 times/day |
|---|
| Smoker's melanosis | 103 (19.21 %) | 78 (14.55 %) | 51 (9.70 %) |
| Leukoedema | 59 (11.00 %) | 46 (8.58 %) | 40 (7.46 %) |
| Smoker’s palate | 37 (6.90 %) | 39 (7.27 %) | 46 (8.58 %) |
| Tobacco induced keratosis | 20 (3.73 %) | 32 (5.97 %) | 38 (7.08 %) |
| Lichenoid lesion | 35 (6.52 %) | 18 (3.35 %) | 29 (5.41 %) |
| Lichenplanus | 14 (2.61 %) | 8 (1.49) | 10 (1.84 %) |
| Leukoplakia | 4 (0.74 %) | 5 (0.93 %) | 8 (1.49 %) |
Chi-square= 30.0121, p = 0.0003
Out of total samples, 19.21% who were consuming tobacco at least <5 times had smokers’s melanosis as compared to 14.55 % who were consuming tobacco 5-10 times and 9.70 % of those who consumed tobacco >15 times per day. Similarly, 11.00% of leukoedema was seen in those who consumed tobacco <5 times as compared to 8.58 %, seen in subjects who consumed tobacco 5-10 times and 7.46 % those using tobacco >15 times per day. Incidence of leukoedema decreased in subjects with an increased frequency of tobacco usage. Smokers palate was seen in 6.90%, who consumed tobacco <5 times as compared to 7.27% who were consuming tobacco 5-10 times and 8.58 % of subjects using tobacco >15 times per day. Association between frequency of tobacco usage and oral lesions was found to be statistically significant (chi-square=30.0121, p = 0.0003).
Association between duration of tobacco usage and oral lesions [
Table/Fig-6]
Association between duration of tobacco usage and oral lesions
| Lesions | Duration |
|---|
| 1-5 year | 5 to 10 years | 10 to 15 years | >1 5 years |
|---|
| Smoker's melanosis | 22 (4.10 %) | 43 (8.02 %) | 65 (12.12 %) | 102 (19.02 %) |
| Leukoedema | 14 (2.61 %) | 25 (4.66%) | 42 (7.83%) | 64 (11.94%) |
| Smoker’s palate | 12 (2.23 %) | 19 (3.54%) | 38 (7.08%) | 53 (9.88%) |
| Tobacco induced keratosis | 14 (2.61%) | 13 (2.42%) | 28 (5.22%) | 35 (6.52%) |
| Lichenoid lesion | 31 (5.78%) | 26 (4.85%) | 19 (3.54%) | 6 (1.11%) |
| Lichenplanus | 11 (2.05%) | 7 (1.30) | 10 (1.86%) | 4 (0.74%) |
| Leukoplakia | 0 (0.00 %) | 3 (0.55%) | 6 (1.11 %) | 8 (1.49%) |
Chi-square= 79.3470, p = 0.00001
The duration of tobacco usage and oral lesions was found to be statistically significant (Chi-square= 79.3470, p = 0.00001). All the lesions except lichenoid reaction and lichenplanus were found to be more prevalent in subjects who used tobacco for more than 15 years.
Discussion
This is the first research carried out in Aljouf province of Saudi Arabia, regarding the tobacco usage and its associated oral mucosal changes. In the present study 69% of patients were found to be using tobacco in the form of smoking and 31% of patients were using smokeless tobacco, which was in contrast to the study be Sujata et al., where 39.2% used smoked tobacco and 28.1% used smokeless tobacco [15]. Use of smokeless tobacco was found among 22.8% and 21.2% of population in the different region of Saudi Arabia [9,16]. The prevalence of oral mucosal changes seen in the study population was 72 %, which was less in comparison with an another similar study conducted in other part of Saudi Arabia by Safia Ali Al-Attas et al., but the changes were very much high in comparison with studies from different part of world [9,15–17]. In this study smoker's melanosis was the most common lesion (43.28%), whereas Safia Ali Al-Attas et al., noticed smokers melanosis as second most common lesion (36.1%) followed by hairy tongue as the most common lesion (49.9%) [9]. Sujata et al., observed smoker's melanosis in 13.4% of male subjects which was very low when compared to the results of present study [15]. Sadeq A Al-Maweri et al., observed fissured tongue (41.9%) as the most common lesion found in males in their study [18]. The second most common lesion in our subjects was leukoedema with a prevalence of 27.05% which was very high in comparison to the results of Sadeq A Al-Maweri et al (4.8 %) [18], Sujata et al., (8.1%) [13], Patil et al., (0.84 %) [17]. Smoker's palate was seen in 22.76% subjects of present study, which was less in comparison with Safia Ali Al-Attas et al., who detected smokers palate in 28.9% of subjects [9], wheras Sujata et al., noticed smokers palate in 6.0% and Patil et al noticed in 1.9% which was very less when compared to present study [15,17]. It has been stated that premalignant lesions and conditions like leukoplakia, erythroplakia, lichenpanus, oral submucous fibrosis etc., may progress in oral malignancy if they are not prevented and treated at earlier stages. To achieve this objective, awareness regarding the prevalence of these lesions and conditions is necessary. Leukoplakia (3.17%) was the least common lesion which was noticed in this study wheras Sujata et al., and Patil et al., noticed that leukoplakia was the most common lesion in the tobacco users in their respective studies [15,17]. Safia Ali Al-Attas et al., observed leukoplakia in 2.3 % of subjects [9] and Sadeq A Al-Maweri et al., seen in 0.7% of male patients [18]. None of the subjects in the present study had hairy tongue, oral submucous fibrosis, erythroplakia and malignant changes which were found in other studies [9,15–17]. Rarity of oral submucous fibrosis may be due to no or minimal usage of areca nuts by this population. As stated in the previous studies, duration and frequency of habits had a positive influence in the development of oral changes. Subjects who used tobacco for more than 15 times per day for more than 10 years were seen with maximum number of oral changes, which was in accordance with other studies by Yen AM et al., [19] Aruna et al., [20] and Sujata et al., [15]. In the present study, buccal mucosa was the most frequent site for the occurrence of oral changes followed by commisures and floor of the mouth being least involved, Patil et al., found that even though buccal mucosa was the common site for oral lesions but the labial mucosa was second common and alveolar mucosa was least common [17]. Studies in literature suggest that the use of smokeless tobacco leads to a spectrum of oral cavity lesions, including leukoplakia, speckled leukoplakia, erythroplasia, tobacco-associated keratosis, carcinoma in situ and squamous cell carcinoma (SCC), whereas the results of this study show that majority of the mucosal changes were seen in the subjects who were smoking tobacco except for premalignancies, which were more prevalent in subjects who chewed the tobacco [14,15,21,22].
Local irritation effect from tobacco and its products is thought to be prime reason for development of oral changes in the tobacco users. Reports in the literature established that lichenoid lesions may be seen due to combination of dryness of oral mucosa and exposure to chemical and mechanical irritation [23].
Limitations
The major limitation of this is study was the inclusion of only male patients in the sample and selection of sample only from localised province of Saudi Arabia. The details regarding the frequency and duration of the tobacco habits may biased as it is totally dependent on the self report of patients.
Conclusion
The results of the present study conclude that use of tobacco can be positively correlated to the occurrence of various benign, premalignant and malignant oral changes. Studies covering a larger geographic region correlating the demographic details, socio- economic factors, influence of cessation of habits and involvement of both sexes as sample subjects may prove more beneficial. The results of this study also signify the importance of examining the oral mucosa of the patients with the habits of tobacco usage. This study aids in creating awareness among the public regarding the about the deleterious effects of tobacco and may motivate them for cessation of tobacco use.