Oral Manifestations of Dipping Tobacco – A Fatal Addiction

Objectives: Dipping tobacco, traditionally known as wet snuff, is associated with a variety of inflammatory to dysplastic changes in oral mucosa. Easy availability, low cost and lack of awareness in users make it a potentially hazardous addiction all over the world. This study was therefore designed, for the first time in Pakistan, to observe the clinico-cytological changes in the oral cavity of habitual wet snuff users.
Methods: After detailed oral examination of n=300 male subjects taking wet snuff for at least 1 year duration, oral smears were prepared and examined microscopically using routine and special stains (Haematoxylin & Eosin, Papanicolaou, Giemsa).
Results: Subjects were grouped according to age (<30 years:43%, >30 years:57%), dosage of snuff (mild:8%-moderate:26%-heavy:66%) and duration of usage (<5 years:35%, 5-10 years:45%, >10 years:20%).
Mean age was 35.19±11.8 years. Oral lesions included snuff dippers keratosis and mucositis (100%-each) followed by xerostomia (74%), gingivitis (61%), oral pigmentation (50.3%), leukoplakia (40%), erythroplakia (31%) and chronic periodontitis (30%). Oral submucous fibrosis and ulcers were seen in none.
On cytological examination, inflammation (62%), nuclear atypia (46%), micronuclei (34%) and dysplastic changes (6% grade 1, 2% grade 2) including hyperchromasia and atypical mitoses within the oral squamous cells were observed. When clinico-cytological variables were compared, frequency of cytological changes increased with increasing age. Nuclear atypia was significantly associated with the dose of snuff (p=0.014), duration of snuff usage (p=0.001), periodontitis (p=0.032) and micronuclei (p=0.012). Similarly, a significant association between dysplasia and dose of snuff (p=0.021), leukoplakia (p=0.008) and inflammation (p=0.026) was observed.
Conclusions: Oral lesions including the dysplastic changes in dipping tobacco users call for rigorous approach for routine screening and creating awareness among this high risk population that subsequently will improve their clinical outcome. Also a pragmatic national policy for snuff usage and provision of adequately tested material is pivotal.