|Year : 2014 | Volume
| Issue : 2 | Page : 54-58
Prevalence oral mucosal lesions among moist snuff users in Jodhpur, India
Amarpreet Singh, Susan Thomas, Rushabh Dagli, Geetika Arora Bhateja, Rinki Hans, Akanksha Sharma
Department of Public Health Dentistry, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India
|Date of Web Publication||4-Feb-2015|
Department of Public Health Dentistry, Vyas Dental College and Hospital, Kudi Haud, Pali Road, Jodhpur - 342 001, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: Use of smokeless tobacco in any form is the greatest threat to the global health today. It increases the risk of oral cancers, induces oral lesions at the site where tobacco is placed, and fosters nicotine addiction and dependence. The objective of the present study is to assess the relationship between moist snuff and oral mucosal lesions among individuals using moist snuff in Jodhpur, Rajasthan, India. Materials and Methods: A cross-sectional study was designed to assess the oral lesions among 384 moist snuff users in Jodhpur. Data collection was do ne by using pre-designed questionnaire, which included information regarding general data, type of moist snuff with and without calcium carbonate, duration and frequency of using moist snuff. The Axell's index was used to find the degree of severity of oral lesions. Dental abrasion, gingival recession, dental attrition, and dental erosion were also recorded. The parametric one-way analysis of variance (ANOVA) and stepwise regression analysis were done to narrate the relationship between variables of snuff use and oral mucosal conditions. Results: It was found that there was a significant correlation between the amount (P = 0.007, SD ± 1.348), frequency (P = 0.002, SD ± 1.348), and duration (P = 0.002, SD ± 1.348) of snuff use with oral mucosal lesions. Conclusion: The results reveal an association between the use of moist snuff and oral mucosal lesions.
Keywords: Oral mucosal lesions, snuff, snuff lesions
|How to cite this article:|
Singh A, Thomas S, Dagli R, Bhateja GA, Hans R, Sharma A. Prevalence oral mucosal lesions among moist snuff users in Jodhpur, India. J Health Res Rev 2014;1:54-8
|How to cite this URL:|
Singh A, Thomas S, Dagli R, Bhateja GA, Hans R, Sharma A. Prevalence oral mucosal lesions among moist snuff users in Jodhpur, India. J Health Res Rev [serial online] 2014 [cited 2019 Dec 11];1:54-8. Available from: http://www.jhrr.org/text.asp?2014/1/2/54/150804
| Introduction|| |
The tobacco plant is thought to have originated in the mainland between North and South America. Its cultivation probably dates back at least 5000 years; tobacco seeds were discovered during archaeological excavations in both Mexico and Peru around 3500 BC. American Indians were probably the first people to smoke, chew, and snuff tobacco as early as in 1400. The Indians inhaled powdered tobacco through a hollow Y-shaped piece of cane or pipe by placing the forked ends into each nostril and the other end near the powdered tobacco. This instrument was called a "tobago0" or "tobaca." The word was later changed by the Spaniards to "tobacco."  The use of smokeless tobacco is widespread, from Sudan and India to Scandinavia and the USA.  Although there are several forms of smokeless tobacco, the moist snuff form is most popular among young people and appears to incorporate the most extensive engineering for nicotine dosage control, so that when the product is placed between gum and cheek, the product itself becomes a primary determinant of nicotine intake. 
Moist snuff is a sub-category of oral smokeless tobacco products (STPs), which is popular in North America, Scandinavia (where it is known as Snus), South Asia (e.g. Bangladesh, Bhutan, and India), and parts of Africa (e.g. Algeria, Sudan, and Nigeria). It is mainly available in two forms: A loose form of compacted tobacco and a form with portions of the tobacco sealed in small sachets termed "pouches." A pouch is usually placed between the upper jaw and gum, resulting in absorption of nicotine. It is typically held in the mouth for approximately 30 min before being discarded. Recently, the "pouch" form is becoming increasingly popular. 
The national sample survey 55th round (1999-2000) analysis in India showed that the tobacco consumption in smokeless form including moist snuff is 27%. It had been observerved that in India, over a 100 million people smoke "bidis," about 25 million smoke "cigarettes," and the number of "non smokers" is fairlyclose to total number of "smokers." In the whole of India, smokeless tobacco use is found among one third (38.1%) of men and one third (9.9%) of women according to the third round of "National Family Health Survey" (2005-2006).
Use of smokeless tobacco in any form, such as loose leaf chewing tobacco, dry snuff, moist snuff, plug chewing tobacco, fine cut tobacco, etc., is the greatest threat to the global health today. It increases the risk of oral cancers, induces oral lesions at the site where tobacco is placed, fosters nicotine addiction and dependence, and contributes to systemic vascular diseases. 
The use of moist snuff is steadily increasing, the currently estimated prevalence being 20% for men and 3% for women in Sweden. This can be compared with a smoking prevalence of 17% and 18% for men and women, respectively. Thus, among men, snuff use is as common as cigarette smoking. In addition, snuff use is on the rise, whereas smoking rates are declining. Like other STPs, snuff is rapidly delivering high doses of nicotine, which leads to dependence. 
The moist snuff contains water, tobacco, moist preservatives, taste enhancers (salt), acidifiers, and aromas. At the same time, it must be pointed that there are around 2500 chemical components identified in tobacco among which nicotine is most common; the other components are sodium carbonate, sodium chloride, tobacco-specific nitrosamines (TSNA), and polycyclic aromatic hydrocarbons (PAH). 
Nicotine is readily absorbed via the mucosal membrane by passive diffusion.  The uptake of nicotine from snuff is dependent on the amount of nicotine, the pH, and the buffering capacity.  Sodium carbonate is added to increase the pH of the snuff to 8-9, in order to facilitate nicotine absorption through the oral mucus membranes. The nicotine content of moist snuff varies between 5 and 11 mg/g for the various brands on the market.  The nicotine-dosing potential of moist snuff is determined by at least three factors: The amount of nicotine in the product, the pH level of the product, and the size of the tobacco cutting. 
Tobacco smoking has a major impact on many tissues and organs of the body, including the periodontal tissues. A number of studies of various designs performed in many countries over the last decades unanimously demonstrate that the periodontal health of smokers is greatly inferior to that of non-smokers.  Localized oral manifestations, such as gingival recessions and mucosal lesions (snuff dipper's lesion) at the site of snuff placement, are common in users of moist snuff. 
A literature search on whether the use of other tobacco products, e.g. smokeless tobacco (snuff), may have adverse effects similar to those of smoking discloses comparatively few studies. 
Hence, the objective of the present study is to assess the relationship between moist snuff and oral mucosal lesions among individuals using moist snuff in Jodhpur, Rajasthan, India.
| Materials and methods|| |
A cross-sectional study was designed to assess the oral health status of moist snuff users in Jodhpur.
This study was conducted in two randomly selected areas of Guda Bishnoi and Salawas areas of Jodhpur. A total of 384 participants were selected by stratified random sampling technique. Information about the scope and aims of the project was explained to all subjects and their consent was done. Approval for the study protocol was obtained from the ethical committee of Vyas Dental College and Hospital. The study was done for a period of 2 months, i.e., from December 2013 to January 2014.
Inclusion criteria included patients of both genders using moist snuff regularly since 2 years and in the age group ranging between 18 and 65 years.
Methods of data collection
Data collection was done by using a pre-designed questionnaire which included information regarding general data, type of moist snuff with and without calcium carbonate, and duration and frequency of using moist snuff.
A house-to-house survey was conducted in Guda Bishnoi and Salawas areas of Jodhpur. The snuff users were identified and their clinical examination was carried out on an ordinary chair with back rest under natural light and artificial light, if required. Gingival index of Sillness and Loe was used to assess gingival status, dentition status index was used to determine dental caries status, and periodontal status was rec orded using community periodontal index (CPI) and Loe index was used to record periodontal status . The Axell's index was used to find the degree of severity of oral lesions. Dental abrasion, gingival recession, dental attrition, and dental erosion were also recorded.
The clinical examination was carried out by using sterilized instruments such as CPI probe, mouth mirror, and explorer.
Examiner and examination
Dental examination was carried out by a well-trained examiner and he was assisted by a recorder who was also a dentist and well versed with the questionnaire and clinical examination recording. The examination of the subjects was done under natural light source.
The parametric one-way analysis of variance (ANOVA) and stepwise regression analysis were done to narrate the relationship between variables of snuff use and oral mucosal conditions.
| Results|| |
[Table 1] shows the oral hygiene measures of snuff users and it is observed that 70% of snuff users use toothbrush and toothpaste for brushing and 90% of snuff users brush once in a day.
|Table 1: Distribution of moist snuff users according to their oral hygiene practice|
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[Table 2] shows that 19.6 snuff users are smoking along with using snuff.
[Table 3] shows that more than 53.7% of the snuff users take 3-4 packets of snuff per day, 38.6% of the snuff users consume snuff 5-8 times in a day, and 27% of the snuff users are using snuff for 1-5 years duration.
|Table 2: Distribution of moist snuff users according to their adverse habits|
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|Table 3: Distribution of moist snuff users according to the amount, frequency, and duration of snuff use|
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[Table 4] shows that among all snuff users, 51% were having leukoplakia and 31.2% showed the presence of ulcerations, and 1.8% showed Oral submucous fibros is lesions. A total of 38.2% of the snuff users were having grade 2 snuff lesions.
[Table 5] shows the correlation between amount of snuff use and dental conditions among snuff users (one-way ANOVA test) and it is found that there was a significant correlation between amount of snuff use and oral mucosal lesions.
|Table 5: Relation between amount of snuff and oral mucosal lesions among moist snuff users (one-way ANOVA test)|
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[Table 6] shows the correlation between frequency of snuff use and dental conditions among snuff users (one-way ANOVA test) and it is found that there was a significant correlation between frequency of snuff use with oral mucosal lesions, gingival recession, and dental abrasion.
|Table 6: Relation between frequency of snuff and dental conditions among moist snuff users (one-way ANOVA test)|
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[Table 7] shows the correlation between duration of snuff use and dental conditions among snuff users (one way ANOVA test) and it is found that there was a significant relationship between duration of snuff use with oral mucosal lesions, snuff lesions, gingival recession.
|Table 7: Relation between duration of snuff and dental lesions among moist snuff users (one-way ANOVA test)|
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[Table 8] shows the correlation of oral mucosal lesion using stepwise regression analysis and it is found that oral mucosal lesion has a significant relationship with age, amount, frequency, and duration of snuff containing sodium carbonate freshly mixed and sodium carbonate premixed, and mouth rinse.
[Table 9] shows the correlation of oral snuff lesion using stepwise regression analysis and it is seen that oral snuff lesion has a significant relationship with age, duration, sodium carbonate freshly mixed and sodium carbonate premixed, and mouth rinse.
| Discussion|| |
Moist snuff (snus) is a coarser tobacco product in a moist form. Moist snuff is produced with the combination of tobacco leaves, water, and salt.  Use of moist snuff has become increasingly popular in several countries including India. The highest consumption, predominantly in the form of moist snuff (khaini), has increased in certain age groups, mainly among men, the traditional users. The habit is especially gaining popularity in adolescents. 
The present cross-sectional study explores the relationship between smokeless tobacco in the form of moist snuff (khaini) and its impact on oral health. This study includes stratified samples of 382 (snuff users) selected by a house-to-house survey conducted in the Guda Bishnoi village of Jodhpur, which is approximately 25 km from the main city of Jodhpur, on the basis of prevalence of snuff use which is higher in this region. The tribal community of Bishnoi inhabits the village. Guda Bishnoiyan, spread over 36,578.4 bighas, has a population of 8434. The study was performed by a well-trained examiner assisted by a recorder who is also a dentist and well versed with the questionnaire and clinical examination recording. The parametric one-way ANOVA and stepwise regression analysis were used to narrate the relationship between variables of snuff use and oral health conditions.
Oral mucosal changes or snuff lesions were site dependent among moist snuff users and were commonly seen in the buccal vestibule where the snuff is placed. This could be because the moist snuff remains stationary in the vestibule and generates very little juice.
The degree of oral lesions was positively correlated with age, frequency, and duration of snuff use in studies conducted by Hirsch et al.,  Mornstad et al.,  and Anderson et al.  Moist snuff use may be associated with adverse oral lesions. It has been found in our study that use of moist snuff is significantly responsible for producing mucosal changes. Numerous other studies have observed that snus use is associated with a characteristic reaction in the oral mucosa (e.g. Axéll 1976,  Andersson et al 1989,  Frithiof et al, 1983  Larsson et al. 1991,  Mornstad et al. 1989,  Roosar et al. 2006, Hirsch et al. 1982,  Hugoson A  , Rolandsson et al. 2006  ).
This type of lesion has been referred to by various names, including snuff dipper's lesion, snuff-induced leukoplakia, and snus-induced lesions. The lesion generally appears at the location in the mouth where the snus is held. The prevalence of this condition varies widely and appears to be related to the characteristics of the user (such as age, salivary pH, patterns of tobacco use) and characteristics of the product (nicotine content, loose vs. portion bag, etc). 
In addition, the degree of lesions seems to increase with increasing pH as well as increasing nicotine concentration according to Mornstad et al.  and Anderson et al. 
The present study also shows that a positive correlation exists between sodium carbonate and oral mucosal lesions or snuff lesions. It is added to increase the pH of the snuff to 8-9 in order to facilitate nicotine absorption through the oral mucus membranes. This causes local reactions in the gingival tissues and oral musosa which is exposed to snuff or nicotine, resulting in mucosal changes and lesions.  Mavropoulos et al.  found increased blood flow in the gingiva and oral mucosa of humans in response to local exposure to nicotine, and Petro et al.  reported that smokeless tobacco extract increased interleukin (IL)-2 production and decreased IL-12 production from the macrophages. In an experimental study, Alpar et al. showed that the growth of human oral fibroblasts decreased when exposed to nicotine. 
In summary, the observations of the present study indicate that there seems to be association between the use of smokeless tobacco in the form of moist snuff (khaini) and oral mucosal lesions and gingival recessions. The present observations also indicate that moist snuff leads to risk for periodontal disease. For a complete understanding of a possible effect, however, further longitudinal studies are advocated.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]