THE FOLLOWING OPTIONAL SET OF SLIDES SHOW SOME OF THE ORAL MANIFESTATIONS OF ATODA. SLIDES WERE ADAPTED FROM SMOKING AND YOUR MOUTH AND THE IMPACT OF TOBACCO USE OR ORAL DISEASE AND CONDITIONS BY ARDEN G. CHRISTEN D.D.S., M.S.D., M.A., INDIANA UNIVERSITY SCHOOL OF DENTISTRY
This 32-year-old woman has a clinically healthy, clean mouth and no overt dental disease. As a nonsmoker, her breath is nonoffensive and her teeth are unstained by tobacco tars. The gingival tissues surrounding the crowns of her teeth are firmly attached and salmon-pink in color. Her gums do not bleed and her tongue is uncoated.
Chronic smoked usage causes a number of undesirable aesthetic side effects that have interpersonal implications. This slide shows a 39-year-old male smoker who has combined tobacco and coffee stains on the necks of his lower teeth. These discolorations developed within a few months after his teeth were cleaned and polished in the dental office. The dark staining of fingers, dentures, dental fillings, teeth, and nasal hair are common effects of smoking tobacco.
This slide exemplifies the classic signs of smoking-related periodontitis: swollen, irritated, boggy, hyperemic gingiva; visible plaque and debris with calculus formation; loss of interdental papilla; and deep pocketing. Scientific evidence strongly indicates that quitting smoking greatly decreases the acceleration of periodontal disease and reduces the rate and incidence of bone and tooth loss. However, periodontal diseases are not "cured" when tobacco use is discontinued.
In smokers, the gingiva tends to bleed less than it does in nonsmokers, in spite of the fact that smokers generally have higher levels of dental plaque. Impaired gingival bleeding, which may
result from a smoker's tendency to develop a faulty inflammatory vascular response, is a sign that the body's basic gingival defense mechanisms have been damaged. These circumstances may delay the diagnosis and treatment of periodontal disease.
Smokers frequently use candy or breath mints in a futile attempt to avoid having offensive breath. This 23-year-old man was concerned that the front surfaces and biting edges of his back right teeth were "melting away." The major cause of this tooth erosion was his daily habit of sucking fruit-flavored candy breath mints containing citric acid. He had been using these mints for 10 years in an attempt to mask halitosis odors produced by his cigarette smoking. It has been well- documented that citric acid and sugar combined can readily destroy tooth enamel.
Tobacco uses have been implicated as a complicating factor in the development of periodontal disease (destruction of supporting tissues surrounding teeth). Smoking tobacco promotes the proliferation of anaerobic bacteria within the periodontal pocket, when it is associated with poor oral hygiene.
Smokers have noticeably increased levels of pocketing, bone loss and dental calculus leading to destructive periodontitis. It is prevalent 2 1/2 - 3 times greater among smokers than non-smokers at all ages and both sexes.
Smoker's palate is shown in a 41-year-old man who had smoked a pipe heavily for the previous year (6 to 10 pipefuls per day). The corncob pipe he smoked was so hot that it caused several small, bilateral ulcers (burns), seen here on his palate. The patient commented that the roof of his mouth was frequently "sore." This diffuse palatal keratosis is characterized by multiple, white, slightly elevated papules, that resemble a cobblestone street. The openings of the minor salivary glands appear as red spots. This condition is most strongly associated with pipe smoking, reverse smoking (i.e., holding the lit end of a cigarette or cigar inside the mouth), heavy cigar smoking, and conditions that produce greater heat in the oral cavity than cigarette smoking.
"Hairy tongue," pictured in this 33-year-old pipe smoker is almost exclusively seen among heavy smokers. The condition is characterized by the development of elongated, thick, densely matted, and stained hairlike filaments which represent a profuse overgrowth of the filiform papilla. As a result, the tongue's coating can become white, brown, black, or any of these combinations. The elongated papilla develop when the particulate matter and gases in tobacco smoke prevent the surface cells from sloughing normally. As more bacteria and food debris become trapped between this piled-up keratin, a burning sensation on the tongue, as well as severe halitosis, tends to develop. Predisposing factors that can cause "Hairy tongue" include: the long-term use of oxygenating mouthwashes or antibiotics, the presence of gastrointestinal disease, or situations were patients are immunocompromised.
This 57-year-old man, a cigar smoker for 16 years, has leukoplakia in the commissural area inside of his cheek. He habitually holds a cigar in the corner of his mouth for hours at a time. Oral leukoplakia is a white patch on the oral mucosa that can neither be easily scraped off nor classified as any other diagnosable disease entity (eg, moniliasis, lichen planus, etc).
Although leukoplakia is not seen exclusively in tobacco users, it has been definitely associated with smoking. The tobacco-leukoplakia is dose related, i.e., it is linked to the frequency (intensity), amount, and length of tobacco use. It has been reported that 2% to 6% of oral leukoplakias undergo malignant transformation. Usually, tobacco-related leukoplakias are related to localized irritation caused by direct contact with any forms of tobacco or their by-products, which contain more than 4,000 chemical components. While most oral leukoplakias are benign and represent a simple irritational build-up of keratin (i.e., a callous formation), those lesions that persist more than 30 days after tobacco cessation must be biopsied to rule out the presence of oral cancer.
This 50-year-old retiree has a somewhat benign-appearing combination red and white lesion on his lower lip. A pipe smoker for 20 years, he used four bowls of tobacco per day and habitually held the pipe stem between his lips in the location where these lesions developed. A closer evaluation and subsequent diagnostic biopsy (lip shave) revealed the presence of carcinoma-in-situ. Lesions of this nature are easily missed during an oral examination. Patients with carcinoma of the lip usually present early, and their prognosis is good. Cancer of the lower lip is especially seen in male Caucasians who smoke and who live in sunny climates.
Epidermoid (squamous cell) carcinoma is shown in a 61-year-old man, a long-term alcoholic who had been a two-pack-a-day cigarette smoker for 25 years. (He died 6 months later of metastatic lung cancer.) Smokers have a significantly higher risk of developing cancer of the mouth, larynx, pharynx, and esophagus than do nonsmokers. According to the American Cancer Society, approximately 30,800 new oral cancer cases and 8,150 oral cancer-related deaths are reported annually in the United States. Smoked form of tobacco contain thousands of dangerous chemical substances, including many cancer-producing agents, such as tars (aromatic hydrocarbons), radioactive polonium, and nitrosamines. Any form of smoking which is combined with habitual drinking (i.e., consuming over 7 ounces of alcohol daily) significantly increases the risk of developing multiple head and neck primary carcinomas. After accomplishing 5 years of smoking cessation, former smokers' risks for developing recurrent cancers of the oral cavity and esophagus have been reduced by 50%. Further reduction takes place as abstinence continues.
This slide shows the diagram of a mouth with teeth and says: "You Should be checking for more than just cavities: Some of your patients have a more serious problem--drug abuse. And you have the opportunity to identify and help them--because you are the health care professional they see most often. Make the commitment. DRUG ABUSE...be part of the solution." (To obtain a Partnership for a Drug Free America poster, order from Drug-Free America Campaign, 211 E. Chicago Ave, Chicago, IL 60611.)
