Oral Health
and
Tobacco Use
Presented by:
Laura Romito, DDS, MS
Kathy Walker, BA
Learning Objectives
 After
attending the session, participants
should be able to:
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1. Identify the effects of tobacco use on
oral hard and soft tissues.
2. Provide information about statewide
tobacco cessation resources.
3. Address marketing of smokeless tobacco
products and increased use of these
products especially in rural communities.
Tobacco Products
 Smoking
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Cigarette
Cigar
Pipe
Hookah
 Smokeless
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(spit)
Snuff
Chew
Snus
Dissolvable
The Rural Culture
 In years past the tobacco industry used frontier images to
convey the image of a “real” man, who worked the land and
smoked cigarettes. In fact, the Marlboro Man was well known
and synonymous with such an image.
 Although these images were not necessarily targeting the rural
population, they amplified and helped to
maintain social and cultural norms within
rural communities.
http://tobaccoeval.ucdavis.edu/documents/culture_rural.pdf
Rural Marketing
 Such belief systems no doubt relate to the significantly high
rate of smokeless tobacco use currently seen in rural
populations, where chewing tobacco is viewed as part of
being young and male in rural areas
(Campbell-Grossman et al., 2003)
 In this manner, the tobacco industry exploits the social and
cultural aspects of smokeless tobacco, most easily
demonstrated by the tobacco industry’s past and current
sponsorship of sporting events such as
rodeos, bull riding and car racing
(Pokhrel et al., 2009).
http://tobaccoeval.ucdavis.edu/documents/culture_rural.pdf
Smokeless Use in Rural Areas
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Research shows that smokeless tobacco is most common
in rural areas. National surveys reveal that a huge gap
exists between smokeless tobacco use among rural and
urban residents (Pokhrel et al., 2009; Stevens et al., 2010).
According to the National Survey on Drug Use and Health
(2007), the use of smokeless tobacco is almost three times
higher in rural areas compared to those who live in large
and small metropolitan areas.
The prevalence of smokeless tobacco is highest among
young males aged 18 to 24 living in rural areas (CampbellGrossman, et al., 2003; Boyle et al., 1999).
http://tobaccoeval.ucdavis.edu/documents/culture_rural.pdf
Sweet Shop versus Tobacco Shop
Can you tell the difference?
Melt-Away Tobacco Strips
or Chewing Gum?
Tobacco Orbs or Tic Tac’s?
Chewing Tobacco or Breath Mints?
Tobacco Stick or Orange Stick?
PERCENTAGE OF MIDDLE AND HIGH SCHOOL
STUDENTS WHO EVER TRIED FLAVORED TOBACCO
PRODUCTS, 2008 IYTS
Middle School
6% Smokeless Tobacco
9% Cigars
8% Black & Mild cigars, Swisher Sweets cigarillos, and/or Phillies
Blunt cigars
High School
15% Smokeless Tobacco
30% Cigars
32% Black & Mild cigars, Swisher Sweets cigarillos, and/or Phillies
Blunt cigars
CURRENT USE OF TOBACCO PRODUCTS AMONG
MIDDLE AND HIGH SCHOOL STUDENTS, 2008 IYTS
Middle School
10% Any Tobacco Products
4% Cigarettes
3% Smokeless Tobacco
4% Cigars
High School
31% Any Tobacco Products
18% Cigarettes
8% Smokeless Tobacco
15% Cigars
Smoking Prevalence
 Education

GED: 43.2%, College: 10.7%
 Socioeconomic

status
Low SES : ~50%
 Age
 18-24
= 24.4%; > 65=8.6%
 Ethnicity


Native American: 32%
Asian American: 13%
MMWR, 2006
Mayo Clinic Foundation,
2008
Adverse Effects of Tobacco Smoking
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Cancers, CVD, Respiratory diseases
Oral effects
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Discoloration of teeth and restorations
Coated / hairy tongue
Reduced sense of taste and smell
Smokers’ melanosis
Smokers’ palate
Oral Candidiasis
Dental Caries
Increased implant failure rates
Periodontal disease
Poor wound healing
Leukoplakia
Carcinoma
The initial
interaction of
smoking with
the human
body occurs
most often in
the oral cavity,
where it would
be expected
to be active
and exposure
to be intense.
Heavy smokers are 4.7 times
more likely to develop
prematurely wrinkled faces
than non-smokers
Annals of Internal Medicine (1991)
Smokers have decreased
clinical signs of
inflammation
Impaired bleeding may
indicate a faulty
inflammatory vascular
response in response to
dental plaque resulting in
alterations in the body’s
basic gingival defense
mechanism
Smoking & Periodontal Status
 Nicotine
& CO wound healing
 Decreased blood flow
 Immune effects
 Increased destructive actions of neutrophils
 Fibroblast impairment
 Increased prevalence of potential periodontal
pathogens.
 Protective antibodies are reduced in smokers,
specifically immunoglobulin G to
A. actinomycetemcomitans
Smoking & Gum Disease
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
Compared to nonsmokers, smoker’s
are 4x more likely to have severe
periodontal disease
The average 32 yr old smoker has
similar perio attachment loss as a 59
yr old nonsmoker!
J. Perio. 2004;74:196-209
Continued smoking is an
important cause of
impaired healing in all
aspects of periodontal
treatment
Linde, et al, “Clinical Periodontology” 2008, 5th Edition, pp. 316-322
Does ETS Influence Perio Status?
 PMN
action intensified in passive smoking
Numabe Y, Ogawa T, Kamoi H, et al. Phagocytic function of salivary PMN after
smoking or secondary smoking. Ann Periodontol. 1998; 3(1): 102-7.
 Periodontal
disease: 1.6x more likely in NS
exposed to ETS than NS not exposed Arbes SJ,
Jr., Agustsdottir H, Slade GD. Environmental tobacco smoke and periodontal disease
in the United States. Am J Public Health. 2001; 91(2): 253-7.
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ETS increases periodontal inflammatory
responses
Nishida N, Yamamoto Y, Tanaka M, et al. Association between passive smoking and
salivary markers related to periodontitis. J Clin Periodontol. 2006; 33(10): 717-23.
Nishida N, Yamamoto Y, Tanaka M, et al. Association between involuntary smoking
and salivary markers related to periodontitis: a 2-year longitudinal study. J
Periodontol. 2008; 79(12): 2233-40.
Shizukuishi S. Smoking and periodontal disease. Clin Calcium 2007;17(2):226-32.
Implant Failure
Cigarette smoking is an
important risk factor for
implant failure, especially
for those who smoke more
than 10 cigarettes a day
Linde, et al, “Clinical Periodontology” 2008, 5th Edition,
pp 591, 597
Smoking and Dental Caries
 Parental
smoking related to caries in young kids
(Williams et al, 2000, Sherkin et al 2004)
 Active
& passive smoking associated with presence
of carious permanent teeth (Ayo-Yusef, 2007;
Ojima et al 2007)
 Possible
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biological mechanisms
Smoking & saliva flow rates & composition
Tobacco & the immune system
Oral bacteria responses to tobacco
Dental Calculus
Cigarette smokers have
higher levels of both supraand sub-gingival calculus than
do nonsmokers.
 Cessation is accompanied
by a reduction in calculus
formation

Smoker’s Melanosis
Nicotine Stomatitis
Is strongly associated
with reverse smoking,
cigar smoking, and a
high frequency of pipe
and cigarette smoking
Smokeless Tobacco Effects
 Esthetic
Considerations (Stains & Halitosis)
 Gingival Recession & Bone Loss
 Abrasion & Dental Caries
 Hairy Tongue
 Tobacco Pouch Keratosis
 Leukoplakia
 Erythroplakia
 Squamous cell carcinoma
Gingival Recession and Bone
Loss
A
positive association exists
between ST use and gingival
recession, especially among
long-term users who also have
co-existing gingivitis
Tooth Abrasion & Dental Caries
 Sand
and grit in ST can significantly wear down
occlusal surfaces of teeth
 Sugar found in chewing tobacco (especially
flavored varieties) can contribute to dental
caries
52 M “snuff patch” smokeless
tobacco use, 3-4x daily
Tobacco Pouch Keratosis
 Lesion
is typically found in vestibule where
the tobacco is placed; may extend into
the gingiva and buccal mucosa
 Most are readily reversible once the habit
is discontinued
 If lesion persists after one month of
cessation, biopsy is recommended
Leukoplakia
 “A
predominantly white lesion of the oral
mucosa that cannot be characterized as any
other definable lesion” (WHO, 2003)
 20% of oral leukoplakia exhibit dysplastic or
cancerous changes; 9-17% will exhibit
malignant transformation
 Occur mostly where tobacco is held in place
 Treatment includes biopsies and sometimes
total removal of the lesion
Leukoplakia
Is definitely associated with
both smoked and smokeless
tobacco use.
 Is dose related, e.g. positively linked

to the frequency, intensity, amount, and
length of tobacco use.
Snuff Dipper’s Lesions are
Often Reversible
Of 29 subjects using moist snuff, all
those who quit (20) showed
clinically healthy and
histologically normal mucosa after
3-6 months.
J. Oral Pathology (1991) Larsson, Axell, Andersson
Snuff Dipper’s Keratosis
Erythroplakia
“Term used to designate a red patch of oral
mucosa that cannot be diagnosed as any
specific disease” (Neville, Damm, & White, 2003)
 Lesions may be single, multiple, smooth, or
pebbly; may be “speckled” with leukoplakia
 Mostly affect patients who use tobacco and
consume alcoholic beverages
 Up to 90% of patients will exhibit severe epithelial
dysplasia, carcinoma in-situ, or squamous cell
carcinoma

Leading Carcinogens
Contained in ST
Tobacco-Specific
Nitrosamines
Polycyclic Aromatic
Hydrocarbons
Radiation-Emitting Polonium
The use of both tobacco and
alcohol has a synergistic
effect on the development of
OCP (Oral Cavity and
Pharyngeal Cancer), together
causing 80-90% of all new
cases of OCP Cancer
MMWR 2008; 57 (SS08): 1-33
Carcinoma in-situ and leukoplakia in 50 y o M pipe smoker
Squamous Cell Carcinoma
 Cancer
of the stratified squamous epithelium
 Accounts for 90% of all oral cancers
 “Characterized by the invasion of supporting
connective tissue and adjacent structures by
malignant squamous epithelial cells” (Neville,
Damm, & White, 2003)
 80%
of all squamous cell carcinomas develop in
tobacco users (smokers & ST)
 Most patients are 45+ years of age at onset
 In ST users, occurs mostly where ST is held
Squamous Cell Carcinoma
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Treatment consists of surgery, radiation
therapy, or combinations of both
5-year survival rate
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75% for patients with localized intraoral lesions
40% with lymph node involvement
10% with distant metastasis
Patients are at a significant risk for
development of a subsequent intraoral
cancerous lesion or upper digestive tract
cancer
52 y o AA M Cigarette & Pipe User - Oral Carcinoma
61 y o M Epidermoid (SSC) Carcinoma 50 Pk-Yr History
Oral Screenings
All individuals
(particularly tobacco users)
should receive regular head
& neck cancer screenings
& should be taught to
periodically conduct oral
self-exams.
Indiana Tobacco Quitline
 Fax
Referral
 Highly trained professionals
 FREE coaching sessions
 Appropriate materials sent to participant
 1-800-QUIT-NOW
What Is A Quitline?
Telephone-based Cessation Services
Evidence-based
Proactive
Quit Coaches
Highly trained in cognitive behavioral therapy
240 hours of training
Spanish speaking competency (170 other languages)
Educated up to graduate level
Over 50% with 3+ years prior experience in counseling
Four prearranged calls w/coach
Ten prearranged calls for pregnant woman
Web coach
Unlimited call in privileges and access to coaches
Support Materials
The Participant Experience
Quitline Effectiveness
 Meta-analysis of 13 studies shows 56% increase in
quit rates compared to self-help
 Accessibility
―
Eliminates many barriers of traditional classes
(having to wait for classes to form, needing transportation)
―
Helpful for those with limited mobility and those in rural
or remote areas
―
Appeal to those who are reluctant to seek help provided
in a group setting
Benefits








Confidential
Free
National call number 1-800-QUIT-NOW
Provides intensive one-on-one counseling
Unlimited access as long as necessary
HIPAA-compliant entity
Assess ability to all tobacco users
Call initiated by quit coach if fax referred by
a provider, employer, or organization.
Join The Preferred Network
Promote the Indiana
Tobacco Quitline to
patients, employees,
and/or clients
Begin referring people
who are ready to quit to:
1-800-QUIT-NOW
Fax Referral
Contact Information
Laura Romito, DDS, MS
Associate Professor
Director, Nicotine Program
Department of Oral Biology, Rm B19C
Indiana University School of Dentistry
1121 West Michigan Street
Indianapolis, IN 46202
Ph: 317-278-6210
Email: lromitoc@iupui.edu
Kathy Walker
Fountain/Warren Tobacco Prevention & Cessation Program
Community Action Program, Inc. of Western Indiana
418 Washington Street
Covington, IN 47932
Ph: 765-793-4881
Email: kwalker@capwi.org