Oral mucosal smokeless tobacco lesions among adolescents in the United States

The presence of oral smokeless tobacco lesions among adolescents may be an early indicator of increased risk for oral cancers. Data from the 1986-1987 National Survey of Oral Health in US School Children were used to examine the cross-sectional relationship between the use of tobacco and alcohol and the presence of white or whitish oral soft-tissue lesions. The sample included 17,027 schoolchildren (aged 12 to 17 years) who provided information on the use of snuff, chewing tobacco, cigarettes, and alcohol and who received oral clinical examinations. Smokeless tobacco lesions were detected in 1.5% of students (projects to about 300,000 nationally), including 2.9% of males and 0.1% of females. These lesions were more prevalent among whites (2.0%) than among African-Americans (0.2%) or Hispanics (0.8%). Modeling with multivariate logistic regression revealed that, among white males, current snuff use was the strongest correlate of lesions [odds ratio (OR) = 18.4; 95% confidence interval (CI) = 8.5-39.8], followed by current chewing tobacco use [OR = 2.5; 95% CI = 1.3-5.0]. Lesions were strongly associated with duration, monthly frequency, and daily minutes of use of snuff and chewing tobacco. These data suggest that snuff may be a stronger risk factor than chewing tobacco for smokeless tobacco lesions, but the use of either of these forms of oral tobacco exhibits a dose-response relationship with the occurrence of lesions. We found little evidence that the use of alcohol or cigarettes may increase the risk of smokeless tobacco lesions. Preventing smokeless tobacco lesions and their possible malignant transformation may be best accomplished among adolescents by preventing the use of snuff and chewing tobacco.

Prevalence of smokeless tobacco use and clinical oral leukoplakia in a military population

The purpose of this study was to determine the prevalence of smokeless tobacco use and clinical leukoplakia in a specific military population. Two hundred fourteen soldiers participated in this study. Each participant completed a questionnaire-type survey regarding tobacco use and received an annual-type dental examination that included extra-oral and intra-oral examination of hard and soft tissues and counseling regarding the risks associated with the use of tobacco. More than 50% of the participants were between the ages of 18 and 24. Survey response indicated that 7.0% used smokeless tobacco, 29.0% smoked cigarettes, and 7.9% used both cigarettes and smokeless tobacco. Leukoplakia was seen in 4 of the current smokeless tobacco users. Difficulty in cessation was experienced by 10 of 32 smokeless tobacco users; 5 continue to use smokeless tobacco. Due to the concentration of users in the 18 to 24 age group, efforts toward detection and reduction of smokeless tobacco use should be focused on junior ranks and younger age groups.

Oral cancer: a retrospective study of 100 Danish cases

One hundred Danes with oral cancer who were collected consecutively from 1986 to 1991 were evaluated retrospectively. The study included subjective and objective observations in 56% men and in 44% women. M:F ratio was 1.2:1. Fifty percent of the patients were non-smokers. Nine percent were women who did not drink alcohol. Ten percent of the patients were between 40 and 49 years of age, 20% between 50 and 59 years, 35% were between 60 and 69 years and 20% between 70 and 79 years of age. This may reflect a tradition of early drinking and smoking. Doctor's delay was the cause of delayed referral in 14% of the cases while 72% of the patients were the cause themselves for the delayed referral.

Oral lesions in Thai heterosexual AIDS patients: a preliminary study

OBJECTIVE

To study the types of oral lesions in Thai heterosexual AIDS patients.

DESIGN

Cross-sectional study and single centre.

SETTING

Medical ward of the Prince of Songkla University Hospital, Thailand, from June 1994 to May 1995.

SUBJECTS

Heterosexual AIDS patients who had been admitted because of opportunistic infections and/or neoplasms.

MAIN OUTCOME MEASURES

Types of oral lesions, opportunistic systemic diseases present and drugs in use, as well as the lymphocyte count, were recorded in each patient. Mycological investigations by the oral rinse technique were also performed.

RESULTS

41 patients were examined (32 male, 9 female; aged 19-53 years, median 29 years). Oral lesions were found in 35 (85%) patients as follows: oral candidiasis (31), hairy leukoplakia (3), aphthous ulcer (3), linear gingival erythema (2), non-Hodgkin's lymphoma (2) and histoplasmosis (2). CANDIDA ALBICANS: was isolated in 31 patients. There was correlation between the clinical signs of oral candidiasis and the colony-forming units of Candida (Mann-Whitney U test; two-tailed P = 0.0007).

CONCLUSIONS

Oral candidiasis was the most common lesion. It is of interest that non-Hodgkin's lymphoma was the only neoplasm detected. We conclude that oral lesions among Thai heterosexual AIDS patients may differ from those in other countries.

Development of oral lesions in human immunodeficiency virus-infected transfusion recipients and hemophiliacs

The authors used multivariate repeated-measures transition models to identify risk factors for two oral lesions related to human immunodeficiency virus (HIV)-candidiasis and hairy leukoplakia-in 152 HIV-infected blood transfusion recipients and hemophiliacs. Subjects were examined for occurrences of these lesions every 6 months from July 1985 through March 1993, yielding 1,076 study visits. It was found that, after adjustment for the CD4:CD8 T-lymphocyte ratio, patients with a history of candidiasis in the previous 18 months were at high risk of lesion recurrence. This risk increased with the number of prior episodes and with the recency of the episode(s). A history of hairy leukoplakia was less predictive of persistence of that lesion after adjustment for significant risk factors (including candidiasis and use of antifungal agents at the current examination, a low CD4:CD8 cell ratio, and age less than 40 years). The authors also found a high coprevalence of candidiasis and hairy leukoplakia in these subjects. These results suggest that HIV-infected patients with oral candidiasis should be carefully monitored for subsequent episodes over the next 12-18 months, and patients with either oral candidiasis or hairy leukoplakia and a low CD4:CD8 cell ratio should be carefully examined for the other type of lesion as well.

Cytogenetic damage in exfoliated oral mucosal cells and circulating lymphocytes of patients suffering from precancerous oral lesions

One hundred patients suffering from oral submucous fibrosis (OSF), oral leukoplakia (OL) and oral lichen planus (OLP) were studied for the cytogenetic damage in oral mucosal cells and in circulating lymphocytes along with their habit patterns. It was observed that OSF was largely associated with betel nut containing masticants while OL was associated with chewing or smoking habit. It was further observed that their exfoliated oral mucosal cells had significantly higher numbers of micronucleated (Mn) cells as compared to these of healthy normal subjects without any chewing or smoking habit. Similar cytogenetic damage in the form of increased sister chromatid exchanges (SCE) was observed in circulating lymphocytes indicating that the carcinogenic agents produce damage not only in target tissue but also in other host cells such as circulating lymphocytes.

Prevalence of oral leukoplakia in 1000 Berliners

OBJECTIVE

The aim of this study was to determine the prevalence of oral leukoplakia and other oral white lesions in an urban population of non-referred patients to a department of oral surgery in the city of Berlin.

DESIGN

A total of 1000 patients over the age of 16 were evaluated for oral leukoplakia and other oral white lesions. Age, sex, and smoking as well as alcohol habits were recorded.

RESULTS

Of 506 men (50.6%) and 494 women (49.4%), 0.9% showed oral leukoplakia. Men were more frequently affected (1.6%) than women (0.2%). Patients of older age groups were more frequently affected than younger patients. Other white oral lesions were recorded such as leukoedema (8.3%), smoker's palate (0.1%), frictional white lesions (2.6%) and lichen planus (0.6%) with equal distribution between men and women.

CONCLUSION

The prevalence of oral leukoplakia in this limited group of urban patients was low, however comparable to that of other neighbouring west European countries. Association with tobacco and alcohol consumption was demonstrated as in most other studies.

Prevalence study of oral white lesions with special reference to a new definition of oral leucoplakia

In this survey, the experiences with and implications of a revised definition of oral leucoplakia are described. One of the new aspects of the revised definition is the distinction between a provisional, clinical diagnosis and a definitive one for which histopathological examination is required. A prevalence study of white lesions of the oral mucosa among a selected population of 1000 consecutive patients from the Netherlands showed a prevalence of a provisional and definitive diagnosis of oral leucoplakia of 0.6 and 0.2%, respectively. For uniform reporting, a recently proposed classification and staging system has been used to stage leucoplakias with a definitive diagnosis. The use of the revised definition of oral leucoplakia, as well as the classification and staging system, seem very suitable for epidemiological studies.

Influence of dose and cessation of kiraiku, cigarettes and alcohol use on the risk of developing oral leukoplakia

Data from a previously-reported study of oral leukoplakia-associated risk factors in a Kenyan population were further analyzed to determine the influence of dose and cessation. Specifically, risk analysis was made with respect to kiraiku (a traditional Kenyan type of home-made, hand-rolled tobacco product), cigarettes, and commercial beer. The relative risk (RR) of oral leukoplakia among those who smoked > 10 cigarettes was 14.7, as compared to 6.7 among those who smoked < or = 10 cigarettes. With regard to duration, the RR increased from 7.4 in those who had smoked for < or = 15 years to 10.8 in those who had smoked for > or = 30 years. Among those who had quit smoking, RR value was significant only in ex-kiraiku smokers (RR = 4.9, 95% confidence interval (CI) = 2.3-20.4) and was dependent on both the duration of smoking and duration since quitting. For commercial beer, the RR was significant in consumers of > 10 bottles per drinking day (RR = 4.2, 95% CI = 1.0-3.9) and in those whose who drank for > or = 5 days per month (RR = 3.8, 95% CI = 1.0-15.1). Duration of beer consumption did not significantly influence the RR of oral leukoplakia. The RR in ex-beer consumers was not statistically significant. These findings suggest a dose-dependent association between oral leukoplakia and the use of tobacco and alcohol, in which the number of cigarettes smoked, the quantity of beer consumed, and the frequency of consumption were more important than the duration of use of these products. Furthermore, while oral leukoplakia due to cigarette smoking may regress completely, those due to kiraiku may persist for more than 10 years after cessation of these habits.

Palatal changes associated with reverse smoking in Filipino women

OBJECTIVE

To determine baseline data for the presence or absence of reverse-smoking and conventional smoking associated oral palatal mucosal changes in women.

DESIGN

A cross-sectional evaluation of the clinical and cytological changes associated with the condition.

SETTING

Nine rural barangays in Cabanatuan City, Philippines.

SUBJECTS AND METHODS

Nine-one volunteer women smokers (61 reverse and 30 conventional) were examined clinically and photographically. Smears were also taken from three areas and the palate to investigate the cytology of palatal mucosal epithelium.

MAIN OUTCOME MEASURES

Variations in colour, texture and topography of the palatal mucosa; determination of epithelial cell characteristics and inflammatory cell populations present in the lesions.

RESULTS

Clinical findings showed that subjects could be grouped into three categories: Group A subjects showed pigmentation and some erythema only; Group B subjects included those with ulceration, marked erythema and non-descript mucosal roughening; Group C subjects (comprising the majority of reverse smokers) exhibited various combination of leukoplakia, fissuring, thickening and pigmentation of the palatal mucosa. Additional features, including nodularity, erythema, prominence and reddening of minor salivary gland duct openings were also occasionally observed in this group. Cytologic analysis revealed that, within each smoking group, there was a significant site-dependent difference in the predominant epithelial cell type present.

CONCLUSIONS

This study reports the first systematic description of reverse smoking associated palatal mucosal changes in Filipino women. It also provides a basis for classification of the palatal mucosal changes among reverse smokers.

Oral mucosal changes and associated factors among male industrial workers with or without access to subsidized dental care

Oral mucosal changes and associated factors were studied among male industrial workers in southern Finland. Two groups, with or without access to an employer-provided dental benefit scheme, were compared. A multiple-choice questionnaire followed by clinical examinations was completed by 325 (81%) subsidized workers and 174 (69%) controls. In both groups 52% of the subjects had some oral mucosal change, and there were no significant differences between the groups in the location distribution of the changes. Smoking was significantly associated with redness of the oral mucosa (p < 0.001), coating (p < 0.001), and leukoplakia (p < 0.01), whereas denture wearing was associated with ulcers (p < 0.05), hyperplasia (p < 0.001), and redness (p < 0.001). Among denture wearers non-acceptable dentures were significantly associated with hyperplasia (p < 0.001). The subsidized group had better dentures, although this did not significantly benefit their oral mucosal status.

Metabolites of a tobacco-specific nitrosamine, 4-(methylnitrosamino)- 1-(3-pyridyl)-1-butanone (NNK), in the urine of smokeless tobacco users: relationship between urinary biomarkers and oral leukoplakia

Two metabolites of the carcinogenic tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone were quantified in the urine of smokeless tobacco users. The metabolites are 4-(methylnitrosamino) -1-(3-pyridyl)-1-butanol (NNAL) and [4-(methylnitrosamino)-1-(3-pyridyl) but-1-yl]-beta-O-D-glucosiduronic acid (NNAL-Gluc). The study population consisted of 47 male nonsmokers, of whom 23 were snuff dippers, 13 were tobacco chewers, 3 were users of both products, and 8 were nonusers. The levels of NNAL-Gluc in urine ranged from 0.14-30.3 pmol/mg creatinine with a mean +/- SD of 3.47 +/- 5.86, whereas the levels of NNAL ranged from 0.02-8.73 pmol/mg creatinine with a mean +/- SD of 0.92 +/- 1.59. The mean levels of NNAL-Gluc and NNAL were not significantly different from those measured in a previous study of smokers. The levels of NNAL-Gluc were significantly higher in snuff dippers than in tobacco chewers. The ratio of NNAL-Gluc:NNAL was higher in snuff dippers than in tobacco chewers or smokers. There was no indication of two phenotypes of the NNAL-Gluc:NNAL ratio in smokeless tobacco users, in contrast to previous observations in smokers. Of the 39 smokeless tobacco users in this study, 16 presented with oral leukoplakia. When the total levels of NNAL-Gluc, NNAL, or NNAL-Gluc + NNAL were divided into tertiles, there was a significant association between the presence of leukoplakia and increasing levels of these metabolites; a similar relationship was found between urinary cotinine and leukoplakia. The results of this study demonstrate that there is significant uptake of carcinogenic nitrosamines in smokeless tobacco users, and that such products are not harmless alternatives to cigarettes. Moreover, the urinary biomarkers NNAL-Gluc, NNAL, and cotinine were associated with the presence of leukoplakia, which provides biochemical support for the role of smokeless tobacco products as a cause of oral leukoplakia.

Prevalence of oral mucosal lesions in a Kenyan population with special reference to oral leukoplakia

The prevalence of oral leukoplakia and related lesions in a Kenyan rural population was determined in a systematic house to house survey of individuals aged 15 years and above. Among the 803 individuals examined, the following prevalence of lesions was observed: leukoedema (26%), melanosis (12.7%), leukoplakia (10.6%), palatal keratosis (6.4%), frictional keratosis (5.5%), pre-leukoplakia (4.1%), borderline leukoplakia (2.4%), cheek/lip biting (1.3%), and snuff dippers lesion (0.4%). 48.6% of the subjects had at least one of these lesions. Statistically significant preponderance was demonstrated for oralleukoplakia, palatalkeratosis, leukoedema and frictional keratosis among males and melanosis among females. With regard to clinical classification of oral leukoplakia, the prevalence was 10% for homogeneous and 0.6% for nonhomogeneous lesions. On the basis of aetiological classification; the prevalence was 8.3% for tobacco associated and 2.2% for idiopathic leukoplakia. 22.5% of leukoplakia lesions biopsied had evidence of epithelial dysplasia. In view of the premalignant potential of oral leukoplakia, our findings suggest a need for greater attention towards prevention and control of this lesion in the study community.

The association between oral leukoplakia and use of tobacco, alcohol and khat based on relative risks assessment in Kenya

A case-control study was conducted to determine the significance of tobacco, alcohol and khat (Catha edulis) chewing habits in the development of oral leukoplakia among Kenyans aged 15 yr and over. In a house-to-house survey, 85 cases and 141 controls matched for sex, age and cluster origin was identified and compared for these risk factors. Smoking unprocessed tobacco (Kiraiku) with a relative risk (RR) of 10.0 (95% confidence interval (CI) = 2.9-38.4) and smoking cigarettes (RR = 8.4; 95% CI = 4.1-17.4) were the most significant factors. While the RR associated with smoking cigarettes alone was 4.5 (95% CI = 1.9-10.8), smoking of both products (RR = 15.2) suggested probable synergy or additive effects. Oral leukoplakia in 18 cases could not be attributed to smoking tobacco. Commercial beer, wines and spirits were relatively weak, but statistically significant, risk factors. Traditional beer, khat and chilies were not significantly associated with oral leukoplakia.

Tobacco use and cancer. A reappraisal

With approximately six million users, smokeless tobacco has received considerable scrutiny as a risk factor for oral cancer. We review the relationship between smokeless tobacco use, keratosis, and oral cancer. Several features of smokeless tobacco keratosis, including the natural history, clinical presentation, and biologic behavior, differentiate it from other leukoplakias that exhibit greater malignant potential. Previous research has demonstrated that the relative risk of oral cancer with smokeless tobacco use is 4.2, about half of the risk from smoking (relative risk = 10 to 15). Mortality data from populations with sustained high-frequency smokeless tobacco use do not support the mistaken prediction of an epidemic of oral cancer with increasing smokeless tobacco use. In fact, the risks of smokeless tobacco use compare so favorably with those of smoking that smokers who switch to smokeless tobacco reduce their risks for all tobacco-related illnesses including oral cancer. Although some criticize this proposal as less than an ideal solution for the nation's smokers, full adoption of this strategy would eventually save over 400,000 lives each year.

Effect of cessation of tobacco use on the incidence of oral mucosal lesions in a 10-yr follow-up study of 12,212 users

OBJECTIVE

To study the effect of cessation of tobacco use on the incidence of lichen planus, leukoplakia and other oral mucosal lesions.

DESIGN

A 10-yr cohort study in a rural population of Ernakulam district, Kerala, India.

MATERIAL AND METHODS

Some 12,212 tobacco users were interviewed and examined in a baseline survey and re-examined annually for 10 years. At each examination they were exposed to health educational programs to encourage them to quit their tobacco use. The incidence rates were calculated using person-years method among those who stopped their tobacco use and all others.

RESULTS

A total of 77,681 person-years of observation accrued among men and 32,544 among women. Among men 6.5% of these and among women 14.4% were in the stopped category. The incidence of oral lichen planus did not show any consistent association with cessation of tobacco habits (incidence ratio 1.35) but for leukoplakia there was a substantial drop in the incidence after cessation (incidence ratio 0.31). Several other tobacco-associated oral mucosal lesions such as oral lichen planus-like lesion, smoker's palate, preleukoplakia, central papillary atrophy of the tongue and leukoedema showed either zero, or very small incidence, after cessation.

CONCLUSION

The reported association between tobacco use and lichen planus appears to be indirect but for all other lesions it is direct. The cessation of tobacco use led to a substantial fall in the incidence of leukoplakia and other lesions implying a reduced risk for oral cancer after cessation of tobacco use.

Prevalence study of oral mucosal lesions in a selected Cambodian population

The aim of this study was to investigate the epidemiology of oral mucosal lesions in a selected Cambodian population to obtain pilot data useful in planning an oral health data base for the country. Due to unstable conditions in Cambodia, the validity of population data related to present census information is highly questionable. Therefore, prior to this investigation a census registration was carried out using local health workers as registrars in nine villages of a commune. In the period July 4-31, 1991, a total of 1319 individuals (953 women, 366 men, 15-99 yr) were examined by one oral surgeon in the nine villages of Kok Trop Commune, Kandal Stung District, southwest of the capital Phnom Penh. Clinical diagnoses were based on WHO criteria. Information on smoking habits, betel nut chewing habits, and alcohol use was collected by 4 Khmer dental personnel. In total, 71 lesions were recorded in 64 (4.9%) individuals. Leukoplakia was found in 1.1%, lichen lesions in 1.8%, candidosis in 1.4%, submucous fibrosis in 0.2%, cancer in 0.1% and other diagnoses in 0.8%. The prevalence of leukoplakia was 2.2% and 0.6% among men and women respectively, a statistically significant difference (P < 0.05). There were significantly more smokers (P < 0.01) among subjects with leukoplakia (64.3%) than among those without this lesion (28.6%). All subjects with lichen lesions were women. The age-adjusted relative risk for developing lichen among betel nut chewers as compared to non-chewers was 3.3.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of mouth self-examination in the control of oral cancer

This study was planned to evaluate the feasibility of mouth self-examination (MSE). Some 450 college students distributed to 9000 households a brochure describing the risk factors of oral cancer, the appearance of premalignant and malignant lesions of the oral cavity and the methods of MSE with pictures. All subjects with tobacco habits and/or aged 30 years or over were asked to read the brochure carefully and to report to the clinic conducted in their locality on fixed days, if they suspected an abnormality while practising MSE. Out of the approximately 22,000 eligible subjects, 8028 (36%) practised MSE. Among the 247 subjects reporting to the clinics seven (3%) had oral cancer and 85 (34%) had oral precancerous lesions; the others had either benign lesions or normal anatomical variations. Six of the seven subjects with oral cancer had stage I disease, five of whom accepted treatment and were alive disease-free 5 years later. The detection rates of oral cancer compared favourably with the previously reported detection rates using trained health workers. Although this study demonstrated that MSE is feasible, larger studies are required to evaluate whether health education could result in a sustained practice of MSE resulting in reduction in incidence of and mortality from oral cancer.

Skin cancer and warts in immunosuppressed renal transplant recipients

Non-melanoma skin cancer (NMSC) is increasingly recognised as a complication of long-term immunosuppression and has been particularly studied in renal transplant recipients (RTR). A population study of renal transplant recipients has been performed with analysis of those features contributing to a high rate of detection of NMSC, such that 40% patients with fair skin have NMSC 5 years after transplantation. 90% of the total patient population have warts 5 years after transplantation, many being atypical and in sun-exposed sites. Therefore, contributory factors in these patients include not only the global immunosuppression, ultraviolet radiation (UVR)-induced mutagenesis and photoimmunosuppression, but also the widespread presence of human papillomavirus (HPV) infection, including the unusual epidermodysplasia verruciformis (EV)-associated cutaneous oncogenic HPV.

Oral manifestations of HIV infection in homosexual men and intravenous drug users. Study design and relationship of epidemiologic, clinical, and immunologic parameters to oral lesions

This article describes the baseline findings from a study designed to compare the oral manifestations of HIV infection in homosexual men and intravenous drug users. Both seropositive and seronegative persons were studied. A standard examination instrument was developed to record indexes of oral disease as well as to record the presence of oral lesions. The two groups differed in terms of education, race, socioeconomic status, employment status, housing, and smoking experience. The prevalence and type of oral lesions differed in the two seropositive groups. In seropositive homosexual men, white lesions on the tongue (28.4%) predominated; whereas for the seropositive intravenous drug users, oral candidiasis (43.0%) and gingival marginal erythema (33.3%) were most often detected. We also observed that seronegative intravenous drug users displayed a greater number of oral lesions than seronegative homosexual men. For seropositive homosexual men, lesion presence was significantly associated with decreased levels of CD4; positive associations were seen with current smoking, antiviral drug use, and antibiotic use, and a negative association was observed with current employment. In contrast, only exposure to antiviral drugs was significantly correlated with lesion presence for seropositive intravenous drug users. This baseline analysis from our longitudinal study suggests clear differences in oral manifestations of HIV infection between seropositive homosexual men and intravenous drug users and between seronegative homosexual men and intravenous drug users. Among other parameters, it is apparent that lifestyle, access to health care, and the condition of the oral cavity before infection influence the development of oral lesions in persons with HIV infection.

Surveying smokeless tobacco use, oral lesions and cessation among high school boys

We surveyed 821 Iowa teenage boys to establish patterns of smokeless tobacco use, occurrence of oral lesions and the effect of lesions on attitudes about quitting, current use and plans for future use. Results suggest that young ST users who currently have a lesion or have experienced lesions may be particularly receptive to discussion of quitting options and other information about ST health effects. Dentists and other oral health professionals should initiate ST intervention when establishing a lesion history or on discovering a lesion at examination.

Prevalence study of tongue lesions in a Hungarian population

The aim of the study was to assess the prevalence of tongue lesions in a district population, in Budapest, called regularly for X-ray lung examinations. Oral examinations of 7820 individuals were performed, 42% were over 60 yr of age, 42.9% were men and 57.1% women. Tongue alterations were found in 18.52% of the examined individuals, more frequently in women than in men. Lingua fissurata has been diagnosed in 8.8%, geographic tongue in 3.0% of the examined subjects. Atrophic lesions of the tongue were found in 6.37%, among them 5.42% central papillary atrophy (median rhomboid glossitis): 0.35% of the total sample. Manifest clinical symptoms of oral Candidiasis were found in 2.15% of the total sample, and in 4.28% of patients with tongue lesions. The occurrence of oral leukoplakia and lichen in patients with tongue lesions was respectively 0.47 and 0.07%. The prevalence of tongue alterations was consistent with the literary data, the oral screening attached to the X-ray lung examinations proved to be useful in detecting changes of the oral mucosa.

Toward assessing trends in oral mucosal lesions: lessons learned from oral cancer

Trend data on oral mucosal lesions are limited. The literature is comprised of a large number of studies documenting the prevalence of various lesions in different populations. Trend data on cancers of the oral cavity and pharynx are the exception. An overview of the international epidemiologic studies of these cancers is provided. General conclusions across studies and countries for trend data of these cancers cannot easily be drawn, since variations exist in data collection methods, risk factors, and other characteristics of the study populations. This paper also reviewed the available prevalence data for oral mucosal lesions in general as well as data on leukoplakia, recurrent herpes labialis, and recurrent aphthous ulcers. A few studies of the incidence of leukoplakia are described. In order to explore the potential for future trend data on oral mucosal lesions, this paper discusses issues related to the feasibility and structure of monitoring these lesions. Criteria that could be used to identify which conditions should be monitored in the future were discussed, such as, those that present a public health problem, those that are sentinel events for serious conditions, and infectious lesions. Once lesions are identified, it is clear that international consensus for diagnostic criteria of these lesions is needed in order to permit comparisons to be made among studies. Finally, strategies for monitoring these conditions and factors that may affect future trends are reviewed.

[The psychopathological aspects of oral lichen planus (OLP)]

The etiopathology of oral lichen planus (OLP) is still uncertain. It is probably caused by a T lymphocytes cell-mediated autoimmune reaction. This reaction, caused by different pathogenic noxae, develops in subjects with a specific genetic pattern (HLA-DR on the keratinocytes) and some psychic attitude (higher Hamilton anxiety scale (HAS) and Hamilton depression scale (HDS) scores. In literature a psychic component has been often mentioned in OLP etiopathology. This work is a case-control study of replication: it aims to evaluate the importance of psychopathologic trait in patients affected by OLP. The study has been carried out on 16 patients (7 male and 9 female--average age 56) with OLP histologically confirmed. Before biopsy, they had been tested with: General health questionnaire (GHQ). Hamilton anxiety scale (HAS). Hamilton depression scale (HDS) with melancholia scale (MES). We have also studied a survey group of 14 patients affected by leukoplakia and neoplasms of the oral cavity (12 males and 2 female--average age 51). Before biopsy the survey group has been tested with the same questionnaire faced by the studied group. We chose the survey group as follows. Patients with leukoplakia show such similar lesions to OLP that the diagnosis is often histological; as far as patients with oral cavity tumours are concerned we hypothesized a more than usual anxious and depressed behaviour. We compared the score of the OLP patients to the one of the survey group patients using the "One-way Analysis of Variance" (ANOVA) method. The results confirmed that the patients with OLP showed very high scores in HAS and HDS, while the survey group scores were significantly lower.(ABSTRACT TRUNCATED AT 250 WORDS)

Chemoprevention of oral leukoplakia and chronic esophagitis in an area of high incidence of oral and esophageal cancer

This intervention trial carried out in Uzbekistan (former USSR) in an area with a high incidence of oral and esophageal cancer involved random allocation of 532 men, 50 to 69 years old, with oral leukoplakia and/or chronic esophagitis to one of four arms in a double-blind, two-by-two factorial design, with active arms defined by the administration of (a) riboflavin; (b) a combination of retinol, beta-carotene, and vitamin E; or (c) both. Weekly doses were 100,000 IU of retinol, 80 mg of vitamin E, and 80 mg of riboflavin. The dose of beta-carotene was 40 mg/d. Men in the trial were followed for 20 months after randomization. The aim of the trial was to determine whether treatment with these vitamins or their combination could affect the prevalence of oral leukoplakia and/or protect against progression of oral leukoplakia and esophagitis, conditions considered to be precursors of cancer of the mouth and esophagus. A significant decrease in the prevalence odds ratio (OR) of oral leukoplakia was observed after 6 months of treatment in men receiving retinol, beta-carotene, and vitamin E (OR = 0.62; 95% confidence interval (CI): 0.39 to 0.98). After 20 months of treatment, no effect of vitamin supplementation was seen when the changes in chronic esophagitis were compared in the four different treatment groups, although the risk of progression of chronic esophagitis was lower in the subjects allocated to receive retinol, beta-carotene and vitamin E (OR = 0.65; 95% CI: 0.29 to 1.48) A secondary analysis not based on the randomized design revealed a decrease in the prevalence of oral leukoplakia in men with medium (OR = 0.45; 95% CI: 0.21 to 0.96) and high (OR = 0.59; 95% CI: 0.29 to 1.20) blood concentrations of beta-carotene after 20 months of treatment. Risk of progression of chronic esophagitis was also lower in men with a high blood concentration of beta-carotene, odds ratios being 0.30 (95% CI: 0.10 to 0.89) and 0.49 (95% CI: 0.15 to 1.58) for medium and high levels, respectively. A decrease in risk, also statistically not significant, was observed for high vitamin E levels (OR = 0.39; 95% CI: 0.14 to 1.10). These results were based on levels of vitamins in blood drawn after 20 months of treatment.

Oral manifestations of HIV infection: a Panamerican perspective

This paper presents a preliminary approach to the study of the oral manifestations of HIV infections in the region of the Americans. A general description of the lesions encountered is provided together with a review of the prevalence of the different manifestations in some countries of the Americas. Oral candidiasis was the most common oral lesion identified. Among oral candidiasis lesions differences were noted in relation to the frequency of the clinical forms seen. Hairy leukoplakia was the second most frequent lesion in almost all studies, with the exception the Peruvian study, where the most prevalent oral condition was xerostomia. The numbers of cases of HIV-gingivitis and HIV-periodontitis found in the countries of the Americas were lower than the cases in USA. Other oral manifestations of HIV infections seen were: Kaposi's sarcoma, oral erythema, labial herpetic infection. It is concluded that still more studies are needed, oral health professionals need additional training in the detection and treatment of lesions, and information needs to be systematized and standardized such that it is possible to make accurate comparisons among regions and countries. Recommendations are included to improve this situation.

Risk of preneoplastic and neoplastic events in operated oral leukoplakias

We retrospectively analysed 167 consecutive patients with oral leukoplakias operated on by CO2 laser resection in the Day Hospital of the Istituto Nazionale Tumori in Milan from January 1981 to December 1988, with post-operative histological examination negative for cancer. Within 5 years there were 69 patients with at least one unfavourable event. First unfavourable events were: 31 local relapses, 27 new leukoplakias, 5 oral carcinomas and 6 other neoplasms elsewhere. To identify possible prognostic factors we recorded age, sex and history of previous oral leukoplakias or head and neck cancers; also number, site, size and type of lesion; as well as tobacco and alcohol consumption and oral hygiene. The Cox regression model was employed to compare disease-free survival between different patient groups, both by univariate and multivariate analysis. From this analysis it emerges that age of operated patients and size of resected lesion are significantly predictive for development of relapses, new leukoplakias and carcinomas.

Occurrence of oral leukoplakia and lichen planus in diabetes mellitus

The occurrence of oral leukoplakia and lichen planus in 1600 patients with diabetes mellitus (815 type 1: insulin-dependent, 761 type 2: non-insulin-dependent)-under care at the International Medicine Department-was studied. Precancerous lesions and conditions were diagnosed and grouped according to internationally accepted criteria. The prevalence of oral leukoplakia in diabetic patients was 6.2%, as compared to 2.2% in the healthy controls, that of oral lichen was 1.0% in the test-, and 0.0% in the control group. Leukoplakia and lichen both showed the highest occurrence in the second year of established diabetes, and their prevalence was higher among insulin-treated diabetics. Smokers were more often affected, by both kind of lesions, oral lichen showed a more frequent association with candidiasis. The prevalence of oral leukoplakia and lichen in diabetes mellitus patients was higher, than average ratios in population samples from the same country.

The prevalence of hairy leukoplakia in HIV seropositive and HIV seronegative immunocompromised patients

The prevalence of hairy leukoplakia was determined among 176 symptomatic HIV seropositive patients seen at the outpatient department of the Institute of Tropical Medicine in Antwerp, Belgium. Moreover, systematic tongue biopsies were performed during postmortem examination of 21 patients with AIDS, 100 HIV seronegative immunocompromised patients with haematologic or other malignancies and 100 HIV seronegative non-immunocompromised patients who died at the University Hospital Antwerp. Hairy leukoplakia was observed in 52 (29.5%) of the outpatients, but only in one (5%) of the AIDS patients in the postmortem study (P = 0.03). An explanation for this difference may be that significantly more AIDS patients who died had received either acyclovir or ganciclovir during the 3 months prior to the postmortem examination than the HIV seropositive outpatients during the 3 months prior to examination. Hairy leukoplakia occurred more often in Caucasian homosexual men with HIV infection (38%) than among heterosexual Africans with HIV infection (17%) (P = 0.06). Hairy leukoplakia was observed in none of the HIV seronegative patients.

Nass use, cigarette smoking, alcohol consumption and risk of oral and oesophageal precancer

In a cross sectional study, conducted in Uzbekistan, an area with a high incidence of oral and oesophageal cancer, 1569 men were interviewed regarding use of nass quid, cigarette smoking and alcohol drinking. All subjects in the study had an oral examination, and oesophagoscopy was performed in 1344 men. Nass use and cigarette smoking emerged as independent risk factors for oral leukoplakia. The prevalence odds ratio (OR) for life-time nass intake equivalent rose from 1.0 in never-users to 5.17 [95% confidence interval (CI), 3.10-8.61] in the highest category; for total pack-years of cigarettes smoked the risk rose from 1.0 in never-smokers to 10.03 (95% CI, 4.9-20.6) in the highest category. There was a significant trend in risk (P < 0.001), for both factors. In the group with oral leukoplakia, the effect of nass use and cigarette smoking appeared to be additive. Cigarette smoking was also found to be an independent risk factor for oesophageal lesions and was significantly associated with chronic oesophagitis. The risk of chronic oesophagitis in the group with the highest pack-years of cigarettes smoked was approximately double that among non-smokers [Odds ratio (OR) = 2.47; 95% CI 1.34-4.56]. There was a weak association between nass use and oesophageal pathology: the highest life-time intake equivalent was associated with an OR of 1.56 (95% CI 1.09-2.23). Alcohol intake was not found to be independently associated with the presence of oral and oesophageal precancerous lesions.

Prevalence study of oral precancerous lesions within a complex screening system in Hungary

Previous epidemiological studies, performed in conjunction with compulsory lung screening examinations, showed good results in detecting oral lesions in Hungary, where the mortality rate of oropharyngeal cancer has increased by more than 30% in the past decade. Oral examinations were performed on a district population sample in Budapest, called regularly for X-ray lung examinations. Precancerous lesions and conditions were diagnosed and grouped according to internationally accepted criteria. Oral examinations of 7820 individuals were performed: 42.9% in men and 57.1% in women; 42% of all examined subjects were over 60 yr of age. Oral leukoplakia was diagnosed in 104 cases (1.3%). Histologic examination revealed squamous cell carcinoma in one case. About 70% of oral leukoplakias occurred in men and 30% in women. Oral lichen was diagnosed in six cases (0.08%). The prevalence of smokers was 86.5% in the leukoplakia group as compared with with 29% in the non-lesion group. The new organizational screening model seems to function well in the "risk group" of elderly persons, especially in the early diagnosis of oral cancer and precancerous lesions.

HIV and periodontal health. A study of military personnel with HIV

In 230 military personnel who were seropositive for the human immunodeficiency virus, the prevalence of viral and fungal infections in the mouth was clearly related to the degree of immune dysfunction as measured by T4-lymphocyte counts. The relation between periodontal health and T4 counts was less clear. Tobacco use was related to the increased occurrence of both mucosal lesions and periodontal diseases.

Oral leukoplakia and adolescent smokeless tobacco use

The recent increase in smokeless tobacco (ST) use has prompted investigators to assess the health effects of ST use. This study attempted to evaluate the prevalence of oral leukoplakia among adolescent users and to determine factors associated with its presence. During their annual physical examination, 1116 teenaged football players (567 black, 546 white) answered a 34-question survey and received an oral screening examination. Results indicated that 0.5% of nonusers, 1.5% of previous users, and 13% of current users had clinically evident oral leukoplakia. Factors statistically associated with higher leukoplakia rates included history of ST use, regular ST use, years of ST use, and the weekly quantity consumed. Factors not associated included use of alcohol, use of cigarettes, type of ST used, and hours of ST use. One brand of snuff was found to be associated with a relative risk of leukoplakia higher than that of another brand of snuff. Overall, in ST users oral leukoplakia was six times more likely to develop than in nonusers. Earlier ages of ST use may lead to greater periods of use (in years) and to possible increases in deleterious long-term health effects in current adolescents.

Epidemiologic studies of oral mucosal conditions--methodologic issues

The methods used in the international English-language literature of epidemiologic investigations of oral mucosal conditions were reviewed. Methods used to study leukoplakia, lichen planus, recurrent herpes labialis, recurrent aphthous ulcers, geographic tongue and candidiasis are highlighted. In addition, studies of the full range of pathologies documented in a population were reviewed. The methodologic issues raised by the epidemiologic literature as well as those to be considered for future studies of oral mucosal conditions are presented. Emphasis is placed on study population selection, diagnostic criteria development, type and training of examiners, risk factor assessment and issues related to data collection, analysis and reporting.

Oral mucosal health and disease in institutionalized elderly in Brazil

During the last decade, many studies in Europe and North America have evaluated oral conditions and dental needs in the elderly. Similar information does not exist in Brazil. The aim of this study was to determine the prevalence of oral health and disease in elderly persons living in an institution in the city of Piracicaba, State of São Paulo, Brazil. Of 350 elderly persons, 134 males and 136 females were interviewed and clinically examined. Less than one half had healthy mouths. 58.9% of the examined individuals showed one or more lesions in the oral mucosa, the most frequent being denture-induced stomatitis (20.0%). Fibrous hyperplasias (11.8%) and angular cheilitis (9.3%) were fairly common. Gender, use and degree of hygiene of the denture were factors statistically significantly contributing to prevalence of denture stomatitis. Precancerous lesions such as leukoplakia (3.0%), actinic cheilitis (2.6%) were uncommon but three cases of squamous carcinoma (1.1%) were revealed. This study emphasizes the need for regular oral examinations of the elderly by personnel trained in oral diagnosis.

[The clinical and histopathological findings in 110 cases of leukoplakia of the oral cavity]

The authors value the distribution of some parameters such as age, sex, life habits, kind of clinical diagnosis and its relation to histological diagnosis in a population of 110 patients heterogeneous for rank and provenance. After describing the kind of casualty department aid, they explain the meaning of the word leukoplakia and underline the difficulties of clinical diagnosis: the macroscopic appearance of the white patch (according to WHO definition) is often comparable to other oral diseases either classified as precancerous lesions or not.

The prevalence of oral lesions in HIV-infected homosexual and bisexual men: three San Francisco epidemiological cohorts

To establish the prevalence of HIV-related oral lesions, we performed oral examinations of members of three San Francisco epidemiological cohorts of homosexual and bisexual men over a 3-year period. Hairy leukoplakia, pseudomembranous and erythematous candidiasis, angular cheilitis, Kaposi's sarcoma, and oral ulcers were more common in HIV-infected subjects than in HIV-negative subjects. Among HIV-infected individuals, hairy leukoplakia was the most common lesion [20.4%, 95% confidence interval (CI) 17.5-23.3%] and pseudomembranous candidiasis was the next most common (5.8%, 95% CI 4.1-7.5%). Hairy leukoplakia, pseudomembranous candidiasis, angular cheilitis and Kaposi's sarcoma were significantly more common in patients with lower CD4 lymphocyte counts (P less than 0.05). The prevalence of erythematous candidiasis and Kaposi's sarcoma increased during the 3-year period. Careful oral examinations may identify infected patients and provide suggestive information concerning their immune status.

Chronic hyperplastic candidosis and secretor status

A prospective study was undertaken of 22 patients with chronic hyperplastic candidosis and 50 age and sex matched individuals with no evidence of oral mucosal disease. Specifically the relationship between the inherited ability to secrete blood group antigens in saliva and chronic hyperplastic candidosis was investigated. The proportion of non-secretors of blood group antigens was significantly higher in patients with chronic hyperplastic candidosis (68%) compared to the control subjects (38%). The inability to secrete blood group antigens in saliva may therefore be a risk factor in the development of, or persistence of chronic hyperplastic candidosis.

Oral lesions in Mexican HIV-infected patients

One hundred and twenty-five HIV-infected patients, of whom 49 (39%) were at early stages of the infection (CDC-II & III) and 76 (61%) in CDC IV, were prospectively examined. In 100 (80%) one or more oral mucosal lesions were observed; candidiasis (51%) and hairy leukoplakia (43%) were the commonest. Erythematous candidiasis was more often seen (35%) than the pseudomembranous type (16%), and appeared with the higher values at early than later stages. The prevalence of hairy leukoplakia, oral hyperpigmentation and xerostomia were incremented in groups CDC-IV. Pseudomembranous candidiasis and exfoliative cheilitis increased significantly with severity of disease. Our study demonstrates that oral alterations associated to HIV are a frequent finding, both at early (76%) and late (83%) stages of the infection in Mexican patients.

Periodontal effects associated with the use of smokeless tobacco

This report describes periodontal findings from a comprehensive study of smokeless tobacco use in professional baseball players. Subjects consisted of 1,094 players, coaches, and training staff of seven major league and their associated minor league teams. Before being examined, subjects completed questionnaires on patterns of smokeless tobacco use (validated by blood chemistry studies), rinsed their mouths under supervision, and were cautioned not to discuss their use of tobacco with the dental examiners. They then received a complete oral examination that included recording of all mucosal abnormalities, missing teeth, caries, extrinsic stain, attrition, Plaque Index, Gingival Index, pocket depth, attachment loss, and gingival recession. More than 50% of team members reported using smokeless tobacco, and 39% reported use during the current week. Among current week users, 46% had oral mucosal lesions, located primarily in the mandible at sites where the smokeless tobacco quid was placed. The use of smokeless tobacco was not necessarily associated with severe forms of periodontal disease, and the presence of poor oral hygiene and gingivitis in these users was not related to the development of oral lesions. However, sites adjacent to mucosal lesions in smokeless tobacco users showed significantly greater recession and attachment loss than in sites not adjacent to lesions in users or comparable sites in non-users.

[Oral hairy leukoplakia in patients with HIV infection]

Oral hairy leukoplakia is a new clinicopathological entity. Little is known about its etiology, pathogenesis and natural history. It is considered a specific marker of HIV infection, although it has been also reported in HIV-negative patients. The etiology appears related to Epstein-Barr virus. Hairy leukoplakia has a characteristic clinical and histopathological aspect, but it is not specific. Because hairy leukoplakia may be easily confused with other lesions of the tongue, the dentist should be very careful in making the final diagnosis. Hairy leukoplakia is usually asymptomatic and treatment is not necessary. In cases of extensive lesions or psychological intolerance of the patient, useful drugs are acyclovir and vitamin A derivatives.

Oral candidiasis and hairy leukoplakia correlate with HIV infection in Tanzania

We report a detailed study on oral lesions and their association with the WHO revised provisional case definition of AIDS as well as serologic signs of HIV infection among 186 patients in Dar Es Salaam, Tanzania. The patient material consisted of 39 hospitalized suspected AIDS patients, 44 medical nonsuspected patients, 53 dental outpatients, and 50 patients with sexually transmitted diseases. The male:female ratio was 2.1:1 on average. Oral examination was done without knowledge of the HIV status of the patients. Among 39 suspected AIDS patients 97% had WHO AIDS criteria and 90% were seropositive for HIV. Among the 147 patients not suspected of having AIDS 18 (12%) had AIDS criteria and 15% had serologic evidence of HIV infection. The presence of WHO AIDS criteria correlated significantly with the presence of HIV antibodies, but not with HIV antigen. Oral lesions were found in 54% of those with AIDS criteria and 52% of HIV-infected patients, as compared to 3% and 6% of the patients without AIDS criteria and HIV infection, respectively (p less than 0.01). Among patients with AIDS atrophic candidiasis occurred in 21%, pseudomembranous candidiasis in 23%, hairy leukoplakia in 36%, herpetic stomatitis in 2%, Kaposi's sarcoma in 4%, and nonspecific ulcer in 4%. The presence of oral lesions had a high predictive value for presence of AIDS criteria as well as for presence of HIV infection in this hospital setting. All patients should have a thorough oral examination and the presence of the aforementioned oral lesions should lead to testing for HIV infection.

Oral findings in elderly nursing home residents in selected countries. 2. Soft tissue lesions and denture wearing habits

This paper demonstrated that 38% of the 610 examinees at seven institutions in four countries have soft tissue lesions. Seventy to eighty percent of the detected lesions were of the erythematous type. This incidence was found at institutions with and without attending dentists, in denture and non-denture users, in dependent and independent patients. Tissue lesions in denture wearers were four times as many as in non-denture wearers. The percentage of inflammatory lesions in both denture and non-denture wearers was considerably higher at institutions with no attending dental personnel when compared with those with dental care facilities. Where patients depended on the staff and/or their relatives for their personal hygiene, a sharp increase in pathological findings was seen when compared to independent dwellers. The nursing staff and the relatives know very little about the oral problems of the elderly residents. There was no uniform policy about telling patients when to wear their removable dentures and patients did not always follow instructions when they were given. Many patients sleep with their upper denture while the lower one is removed for the night. Patients sometimes sleep in the dentures and sometimes remove one or both dentures for varying periods of time. The high percentage of soft tissue lesions and erratic denture wearing habits point to neglect and insufficient oral care toward the geriatric population studied.

Prevalence of oral lesions among HIV-infected intravenous drug abusers and other risk groups

To study the prevalence of oral manifestations, we examined 217 patients infected with the human immunodeficiency virus (HIV). Most of our patients were intravenous drug abusers (IVDAs) (65%). Other risk categories were represented by IVDAs who were also male homosexuals or bisexuals (11%), male homosexuals and bisexuals (16%), sexual partners of HIV-infected patients (5%), and hemophilic persons and recipients of blood transfusions (3%). Forty-six patients were women and 171 were men, with a median age of 27 years (range, 11 to 65 years). At the time of first examination, 38% of patients had asymptomatic HIV infection, 36% had lymphadenopathy syndrome, 17% had AIDS-related complex, and 9% had AIDS. Oral manifestations were observed in 89 (41%) patients. Of these, 15 had asymptomatic infection, 23 had lymphadenopathy syndrome, 27 had AIDS-related complex, and 24 had AIDS. Increasing severity of disease was significantly associated with higher prevalence of oral lesions (p less than or equal to 0.0001). Candidiasis was the most common oral lesion, followed by hairy leukoplakia. Kaposi's sarcoma, melanotic macules, herpes labialis, condyloma acuminatum, perioral molluscum contagiosum, and bacterial glossitis due to Escherichia coli infection were found in a small number of patients. Results of culture for fungi, available for 203 patients, revealed that 51% of patients with positive Candida cultures had clinical evidence of candidiasis. Our study demonstrates that oral lesions are also important signs of HIV infection among IVDAs. Early diagnosis of these manifestations is becoming increasingly significant in the practice of dentistry.

Smokeless tobacco use among Native American school children

Seven published and two unpublished surveys of Native American school children's use of smokeless tobacco (ST) are reviewed. The surveys represent school children in the States of South Dakota, Montana, Nebraska, Washington, Arizona, New Mexico, and Alaska. This review describes and discusses the survey methods, prevalence, duration, and intensity of ST use, and ST health effects documented in these studies. Prevalence of regular ST use ranges from 18 percent in kindergartners through 6th graders to 55.9 percent among 9th and 10th graders. In two studies that surveyed kindergartners, regular use was reported at 13 percent in one study and 21 percent in the other. Comparisons to use by non-Native Americans, as reported in surveys, demonstrate the severity of the problem in Native American communities. There appear to be three significant findings related to Native American ST use: (a) young age of onset of ST use, (b) similar prevalence of use among adolescent boys and girls, and (c) higher overall prevalence of ST use when compared to non-Native American populations. Acceptance of the habit, peer pressure, and addiction seem to be contributing to the high ST use in Native American communities.