What is Pathologic Manifestations of Smokeless Tobacco?

Tobacco use is quickly growing worldwide, with cigarette smoking being a key reason for death and avoidable diseases in the United States. In 2019, according to the Centers for Disease Control and Prevention, about 2 out of 100 adults aged 18 or older reported using tobacco products that didn’t involve smoking, like chew or snuff. This is roughly equivalent to nearly 6 million adults, most of whom use these products every day. The study found that 2.4% of all adult women and 4.7% of all men used these tobacco products. They have been marketed as alternatives to smoking cigarettes.

Smokeless tobacco – the kind you don’t smoke but place in your mouth – contains assorted cancer-causing chemicals. These include polynuclear hydrocarbon benzo[a]pyrene (a chemical found in coal tar and tobacco smoke), nicotine, and tobacco-specific N-nitrosamines that are linked to cancers of the food pipe, stomach, and mouth. Because smokeless tobacco is put directly in the mouth, these harmful substances may lead to abnormal changes in the mouth’s inner lining. Health problems related to using these products can include changes in the skin inside the mouth (smokeless tobacco keratosis), white patches in the mouth (leukoplakia), red patches in the mouth (erythroplakia), a slow-growing type of cancer that looks like a wart (verrucous carcinoma), and a common type of mouth cancer (squamous cell carcinoma).

What Causes Pathologic Manifestations of Smokeless Tobacco?

Smokeless tobacco keratosis is a condition that is triggered by continued irritation caused by smokeless tobacco rubbing against the lining of the mouth, leading to a hardening of the skin, also known as keratosis. The rate at which this occurs depends on how often you use it, the quantity used, and even the specific brand.

Leukoplakia, characterized by white patches in the mouth, can be caused by several factors including the use of tobacco, alcohol, betel nut/sanguinaria (a type of plant), exposure to ultraviolet (UV) radiation, harmful microorganisms, or trauma (injuries).

Erythroplakia, a condition marked by red patches in the mouth, is commonly linked with tobacco use and alcohol intake, and in some cases, chewing betel quid, a type of chewable substance.

Verrucous carcinoma is a less-aggressive form of a skin cancer called squamous cell carcinoma. While the exact cause is not known, it has been linked to factors like the Human Papillomavirus (HPV), smoking, poor mouth cleanliness, presence of lichenoid lesions (small white patches or bumps on the skin), or chewing tobacco.

Squamous cell carcinoma, a type of skin cancer, can be caused by various factors. However, smoking and alcohol consumption are seen as major risk factors, because they have an amplifying effect on the development of this cancer. In fact, the use of these substances is associated with 90% of all reported cases.

Risk Factors and Frequency for Pathologic Manifestations of Smokeless Tobacco

Smokeless tobacco keratosis is a condition that affects 15% of chewing tobacco users and 60% of snuff users. A study found that it was the most common pre-cancerous disorder in their study group, found in over half of the people they examined.

Leukoplakia usually affects people over the age of 40, with the average age of onset being 60. About seven out of ten of these sores are found on the lower lip line, inside the cheeks, or on the gums.

A disorder called erythroplakia, which generally affects middle-aged and elderly people, is present in roughly 0.2% of patients.

Verrucous carcinoma, which mostly affects females, is another type of oral cancer that makes up 2 to 12% of all cases. It typically shows up around the age of 62.

Oral cancer is two to three times more common in men than women across most ethnic groups.
Head and neck cancers represent nearly 700,000 of all cancer diagnoses per year.
Of all the oral cancers diagnosed every year, squamous cell carcinoma makes up about 90%.

Image of erythrolakia extending through the posterior aspect of the mouth

Signs and Symptoms of Pathologic Manifestations of Smokeless Tobacco

Smokeless tobacco keratosis looks like a white, wavy sore in the mouth where tobacco is usually placed. It starts as a white film and eventually turns into a hard pouch over time.

Leukoplakia is a white patch or sore that cannot be described clinically or pathologically as any other disease. These sores get their white color from a thickened layer of tough tissue.

Erythroplakia is a red patch or sore that cannot be identified as any other condition based on clinical examination. They are usually distinguishing red, symptomless patches with a velvet-like texture. Sometimes, these sores can display a mix of erythroplakia and leukoplakia, called erytholeukoplakia. Although less common, erythroplakia and erytholeukoplakia are more often malignant, with most case studies showing abnormal cell growth or localized cancer. They are mostly found on the floor of the mouth, tongue, and soft-roof of the mouth.

Verrucous carcinoma appears as a widespread, clearly marked, painless sore with irregular growths. The sores are generally white but can appear pink depending on the amount of tough tissue produced and the enlargement of underlying blood vessels. They typically occur along the inner lower lip, on the gums, the tongue, and the hard palate. Their location often corresponds with where tobacco is usually placed.

Squamous cell carcinoma can be recognized ordinarily by deep sores with raised edges in areas where there is a higher risk, such as the back lateral part of the tongue or the floor of the mouth.

Testing for Pathologic Manifestations of Smokeless Tobacco

The diagnosis of smokeless tobacco keratosis is often made through physical examination and discussion with the patient. This condition usually shows up as a wrinkled or “corrugated” patch on the inside of the mouth. If the doctor finds such a patch, they’ll ask the patient about their use of smokeless tobacco to confirm if it’s linked to the issue.

Leukoplakia, a white or gray patch that develops on the inside of the mouth or throat, also needs careful examination. It’s significant because more than a third of oral cancers begin as leukoplakia. The doctor will try to identify what’s causing the patch to help decide on the best treatment.

Erythroplakia, or red patches in the mouth, may look like other benign or harmless patches, but it could also be a sign of cancer. The underlying small blood vessels in the mouth tissue give these patches their red color. If there’s no clear cause for these patches, they must be biopsied or sampled to check if there’s dysplasia (abnormal cells) or cancer present.

Verrucous carcinoma, a type of low-grade (slow-growing) squamous cell carcinoma or skin cancer, also requires close evaluation. It’s possible for this type of cancer to be missed or misdiagnosed.

Finally, squamous cell carcinoma, a type of skin cancer that can manifest in various ways, needs thorough examination and the patient’s detailed history. By understanding a patient’s habits, doctors can assess their risk for developing oral cancer.

Treatment Options for Pathologic Manifestations of Smokeless Tobacco

If you’re using smokeless tobacco and develop a condition known as “smokeless tobacco keratosis,” it usually goes away if you quit. An early step in addressing this condition is to change the spot where you put the tobacco in your mouth. Your doctor will then check the affected area after two weeks to see how it’s improving. Early and moderately developed skin abnormalities will typically disappear during this time. More severe changes may take longer to improve or might be at risk of becoming cancerous. It’s important to discuss quitting tobacco use with your doctor, as switching the spot where you put tobacco can increase the risk of abnormal tissue changes in other parts of your mouth.

Leukoplakia, which looks like a thick, white patch inside your mouth, needs to be treated as if it could become cancerous. The risk of it turning into cancer is higher compared to normal unaffected tissue in your mouth.

Erythroplakia, a flat, red patch that may have a velvety texture inside your mouth, is treated based on a detailed analysis of tissue sample under a microscope. If this analysis reveals any abnormal growth or changes in cells (dysplasia), the next step is usually a complete surgical removal, followed by regular check-ups with your doctor, as there’s a high chance of the condition coming back or affecting multiple areas in your mouth.

One in five people with verrucous carcinoma, a type of slow-growing cancer that often appears as a white patch, will develop a more common and serious type of skin cancer called squamous cell carcinoma. That’s why early treatment is crucial. The preferred treatment is surgery to remove the cancer, taking a little bit of the normal tissue around it to lessen the chance of the cancer returning.

Similarly, squamous cell carcinoma, which is a common type of skin cancer, is usually treated by surgical removal aiming to get rid of all the cancerous tissue. It’s also essential to discuss lifestyle changes with your doctor to lower your risk of the cancer returning or a new one forming.

There are several conditions that we need to consider and rule out when diagnosing specific oral abnormalities commonly associated with smokeless tobacco use:

Smokeless Tobacco Keratosis:

Frictional keratosis
Leukoplakia
Squamous cell carcinoma

Leukoplakia:

Leukoedema
Linea alba
Morsicatio buccarum/linguarum
Squamous cell carcinoma

Erythroplakia:

Mucositis
Candidiasis
Psoriasis
Vascular lesions
Squamous cell carcinoma

Verrucous Carcinoma:

Proliferative verrucous leukoplakia
Verruca vulgaris
Squamous papilloma

Squamous Cell Carcinoma:

Erythroleukoplakia
Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE)
Oral manifestation of deep fungal infection

What to expect with Pathologic Manifestations of Smokeless Tobacco

The outlook for smokeless tobacco keratosis, a condition often found in people who use chewing tobacco, is generally good but depends largely on the patient. More advanced cases may need additional examination and monitoring, including a biopsy, to watch for any signs of possible cancerous changes.

Leukoplakia, which appears in the mouth as white patches or spots, has an uncertain prognosis because it is based only on symptoms presented, not a specific test. Since leukoplakia can sometimes turn into cancer, they are considered precancerous until a more benign diagnosis can be confirmed.

Erythroplakic lesions, or red spots in the mouth, also have an uncertain prognosis, as they often come with some form of epithelial dysplasia or abnormal growth of cells.

Verrucous carcinoma, similar to a less severe variant of squamous cell carcinoma (skin cancer), also has an uncertain prognosis. Surgery can usually remove the lesion, but there’s a high risk of the condition reoccurring if the patient continues high-risk behaviors.

Squamous cell carcinoma of the mouth often has a poor outlook even with advancements in treatment. The key to improving survival chances lies in early detection and treatment, as well as identifying and eliminating risk factors. Oral cancers’ survivability rate over five years is around 50%. So, it is very crucial to hault activities that are leading to these conditions and have regular checkups.

Possible Complications When Diagnosed with Pathologic Manifestations of Smokeless Tobacco

Smokeless tobacco keratosis is a condition caused by the usage of smokeless tobacco. This issue will not get better unless the person using the tobacco decides to reduce their use or stop altogether. Hence, it’s crucial to educate patients on the potential risks and encourage them to consider quitting.

The conditions known as Leukoplakia and erythroplakia are both diagnosed in a clinical setting, but to provide a clear diagnosis, a biopsy is required.

On the other hand, verrucous carcinoma and squamous cell carcinoma are both serious diseases. They should be treated quickly to improve the patient’s wellbeing and quality of life. The stage of the disease can determine the level of treatment needed. This could range from extensive surgery to chemotherapy or radiation. All these treatments can have a significant impact on a person’s day-to-day life.

Common Conditions and Treatments:

Smokeless tobacco keratosis: Treatable by reducing or stopping tobacco use
Leukoplakia and erythroplakia: Diagnosed with a biopsy
Verrucous carcinoma and squamous cell carcinoma: Serious diseases requiring quick treatment that might include extensive surgery, chemotherapy, or radiation

Preventing Pathologic Manifestations of Smokeless Tobacco

Using smokeless tobacco can potentially lead to various health issues, including those discussed previously. These problems can be avoided by quitting smokeless tobacco. It’s important for people to understand the health risks associated with continuing to use smokeless tobacco. There are also programs available that help people stop using tobacco. These programs are designed to improve both oral health (the health of your mouth) and systemic health (the overall health of your body).

Frequently asked questions

The prognosis for pathologic manifestations of smokeless tobacco varies depending on the specific condition: - Smokeless tobacco keratosis: The outlook is generally good, but more advanced cases may require additional examination and monitoring, including a biopsy, to watch for signs of possible cancerous changes. - Leukoplakia: The prognosis is uncertain because it is based on symptoms presented, not a specific test. Since leukoplakia can sometimes turn into cancer, it is considered precancerous until a more benign diagnosis can be confirmed. - Erythroplakia: The prognosis is uncertain, as it often comes with abnormal cell growth. - Verrucous carcinoma: Surgery can usually remove the lesion, but there is a high risk of recurrence if high-risk behaviors continue. - Squamous cell carcinoma: The prognosis is poor, and early detection and treatment are crucial for improving survival chances. The five-year survival rate for oral cancers is around 50%.

Smokeless tobacco can cause pathologic manifestations such as smokeless tobacco keratosis, which is triggered by continued irritation caused by the tobacco rubbing against the lining of the mouth. This leads to a hardening of the skin, known as keratosis. The rate at which this occurs depends on factors such as frequency of use, quantity used, and specific brand.

The signs and symptoms of pathologic manifestations of smokeless tobacco include: - Smokeless tobacco keratosis: It appears as a white, wavy sore in the mouth where tobacco is usually placed. It starts as a white film and eventually turns into a hard pouch over time. - Leukoplakia: It is a white patch or sore that cannot be described clinically or pathologically as any other disease. These sores have a white color due to a thickened layer of tough tissue. - Erythroplakia: It is a red patch or sore that cannot be identified as any other condition based on clinical examination. These sores are usually distinguishing red, symptomless patches with a velvet-like texture. Sometimes, they can display a mix of erythroplakia and leukoplakia, called erytholeukoplakia. Erythroplakia and erytholeukoplakia are more often malignant, with most case studies showing abnormal cell growth or localized cancer. They are mostly found on the floor of the mouth, tongue, and soft-roof of the mouth. - Verrucous carcinoma: It appears as a widespread, clearly marked, painless sore with irregular growths. The sores are generally white but can appear pink depending on the amount of tough tissue produced and the enlargement of underlying blood vessels. They typically occur along the inner lower lip, on the gums, the tongue, and the hard palate. Their location often corresponds with where tobacco is usually placed. - Squamous cell carcinoma: It is recognized by deep sores with raised edges in areas where there is a higher risk, such as the back lateral part of the tongue or the floor of the mouth.

The types of tests that are needed for the pathologic manifestations of smokeless tobacco include: - Physical examination and discussion with the patient - Biopsy or sampling of patches to check for abnormal cells or cancer - Analysis of tissue samples under a microscope - Surgical removal of affected areas, with a little bit of normal tissue around it - Regular check-ups with the doctor to monitor the condition and prevent recurrence or new growths.

The other conditions that a doctor needs to rule out when diagnosing Pathologic Manifestations of Smokeless Tobacco are: - Frictional keratosis - Leukoedema - Linea alba - Morsicatio buccarum/linguarum - Mucositis - Candidiasis - Psoriasis - Vascular lesions - Proliferative verrucous leukoplakia - Verruca vulgaris - Squamous papilloma - Erythroleukoplakia - Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) - Oral manifestation of deep fungal infection

The side effects when treating pathologic manifestations of smokeless tobacco include: - Potential risk of abnormal tissue changes in other parts of the mouth when switching the spot where tobacco is placed - High chance of the condition coming back or affecting multiple areas in the mouth for erythroplakia, requiring regular check-ups with the doctor - Potential risk of verrucous carcinoma developing into a more common and serious type of skin cancer called squamous cell carcinoma - Impact on a person's day-to-day life due to extensive surgery, chemotherapy, or radiation for treating verrucous carcinoma and squamous cell carcinoma

An oral and maxillofacial surgeon or an oral pathologist.

Smokeless tobacco keratosis affects 15% of chewing tobacco users and 60% of snuff users.

The pathologic manifestations of smokeless tobacco are treated based on the specific condition. Smokeless tobacco keratosis usually goes away if you quit using tobacco, and changing the spot where you put the tobacco in your mouth can help improve the condition. Leukoplakia, which is a thick, white patch inside the mouth, needs to be treated as if it could become cancerous. Erythroplakia, a flat, red patch, is treated with a detailed analysis of tissue samples, and if abnormal growth or changes are found, surgical removal is usually recommended. Verrucous carcinoma and squamous cell carcinoma, both types of skin cancer, are usually treated with surgical removal to eliminate the cancerous tissue. Lifestyle changes may also be discussed to lower the risk of recurrence or new cancer formation.

The pathologic manifestations of smokeless tobacco include changes in the skin inside the mouth (smokeless tobacco keratosis), white patches in the mouth (leukoplakia), red patches in the mouth (erythroplakia), verrucous carcinoma (a slow-growing type of cancer that looks like a wart), and squamous cell carcinoma (a common type of mouth cancer).