269
Vol. 52, No. 5, Fall 1992
Smokeless Tobacco Habits and Oral Mucosal Lesions in Dental Patients Sally Jo Little, RDH, MS Victor J. Stevens, PhD Pierre A. Lachance, BS Kaiser Permanente Center for Health Research 3800 N. Kaiser Center Drive Portland, OR 97227-1098 Herbert H. Severson, PhD Oregon Research Institute Eugene, OR Murray H. Bartley, DDS, PhD Oregon Health Sciences University Portland. OR Edward Lichtenstein PhD Oregon Research Institute Eugene, OR Joseph R. Leben, DMD Kaiser Permanente Dental Care Plan Portland. OR Abstract
As part of a smokeless tobacco (ST) interventionstudy, we collected data on tobacco use habits and oral health for 245 male ST users aged 15 to 77. The study sample was identified during routine dental office visits and represents a relatively diverse population of patients. Oral health data collection included grading the clinical appearance of oral mucosal lesions using Greer and Poulson 's classificationsystem, as well as identifying and recording the primary anatomic location of STplacement. Results show that 78.6percent of ST users had observablg oral lesions, 23.6 percent of which were in the most clinically advanced category (degree 111)- Of the lesions noted, 85 percent were in the same location the patient identified as his primary area of smokeless tobacco placement. In a comparison sample of 223 non-ST-users with the same age distribution, only 6.3 percent had observable lesions. A multiple logistic regression model for ST users showed that lesion presence and severity were most significantly related to current frequency of ST use.
Key Words: smokeless tobacco, oral leukoplakia, Send correspondence and reprint requests to Ms. Little. Manuscript received:6/10/91; returned to authors for revision: 9/19/91; accepted for publication:1/28/92.
J Public Health Dent 1992;52(5):269-76
leukokeratosis,preventive dentistry, dental health education.
Although significant progress has been made in reducing cigarette consumption in the United States (11, use of smokelesstobacco (moistsnuff and chewing tobacco)has been on the increase, especially among young males (2). Many users adopt the habit in the mistaken belief that smokeless tobacco (ST) will not harm their health. Until recently, tobacco companies reinforced this illusion by using sports personalities and outdoor sports in their advertising (3). However, the 1986 Surgeon General's Report concludes that ST is not a safe alternative to smoking (2). Many ST users develop changes in the oral mucosa at the location in which tobacco is held (4-9). At the clinical level these mucosal changes may include alterations in color, texture, and contour, and at the histological level development of inflammation, vacuolizations, epithelial atrophy, acanthosis, hyperorthokeratosis, or hyperparakeratosis (lCL151. In some individuals these changes progress to epithelial dysplasia or even squamous cell carcinoma (2,16-18). Several studies of relatively young populations have shown alarmingly high rates of keratotic lesions among ST users in the United States. Greer et a]. (19), studying a
270
sample of 117 teenagers, found that approximately 43 percent of ST users had developed mucosal lesions within three years of initiating the habit. Similarly, a , OO professional baseball players recent study of over 1O showed that almost half of the ST users had detectable oral lesions (20). Other domestic studies have reported that 23-46 percent of their ST-using populations manifested mucosal lesions (5,6,21-23).European studies have reported a somewhat lower incidence of ST-related mucosal lesions (12), although the content of foreign ST varies from domestic ST and in some studies the classification criteria for mucosal lesions differed from those employed in US studies (15,24). This paper presents data on tobacco use and the location and seventy of clinically apparent mucosal lesions in a diverse group of patients seen in a large general dental practice. Unlike ST users in previous domestic studies, this group was heterogeneous in terms of age, educational status, and tobacco use patterns, and therefore represents the patient mix typically seen in dental practices. Methods Data for this study were collected as part of a larger cancer control research program funded by the National Cancer Institute (25). To simplify this report, only those procedures directly related to oral health assessments and tobacco use are described here. Subjects. The subjects for this study were drawn from the patient population of the Kaiser Permanente Dental Care Program (KPDCP), a closed-panel dental HMO servingmore than 130,000members in northwest Oregon and southwest Washington. Because a previous survey of KPDCP patients showed that about 5 percent of the male patients, but none of the female patients, were current users of ST (26), only males were recruited for the current study. Recruitment consisted of asking male patients aged 15 years and older to complete a waitingroom questionnaire on tobacco use and agree to answer further study-related questions at a later date. A total of 245 patients who had used ST during the previous week were identified for an oral health assessment (current ST use was defined as any use during the previous week). The age distribution of this group was: 17 percent aged 15 to 19,33 percent aged 20 to 29,22 percent aged 30 to 39,18 percent aged 40 to 49, and 11 percent aged 50 or older. Regarding educational achievement, 5 percent of the subjects had completed eight years or less of schooling, 11percent had between nine and 11years of schooling, 31 percent had completed high school, 32 percent had some college, and 21 percent were college graduates. Data were collected at the routine dental hygiene clinic visit. At the end of patient recruitment for the ST study, an age-proportional sample of 177 non-ST users was also identified using similar procedures. Males 15 and older
Journalof Public Health Dentistry
completed a tobacco-habits questionnaire in the reception room. Those who had not used ST within the previous two years were examined. Assessment Procedures. Clinic receptionists attached the research forms to the subjects’ dental charts, thereby cuingthe dental hygienist and dentist to collect the oral health data. During the soft-tissue evaluation, the hygienist completed a data collection form including location and severity grade of soft-tissue lesions. The dentist was subsequently asked to confirm the grading of these lesions. Hygienists knew that the patients were ST users at the time of the assessments, but were blind to the patient’s tobacco use patterns and habitual ST placement. After completing the lesion form, the hygienist asked the patient to identify where he habitually placed tobacco in his mouth. Clinical Grading of ST-associated Soft-tissue Lesions. Given the age range and the type of ST predominantly used by our research population, we chose the Greer and Poulson (19) three-grade classification method, a modification of the original four-grade method for classifying lesions created by Axel1 and colleagues (12).The clinically identified lesions were drawn to scale on an anatomical diagram and then graded to indicate clinical severity (seeFigure 1):Grade I = a superficial lesion with color similar to that of the surrounding mucosa with slight wrinkling and no obvious thickening. Grade I1 = a superficial whitish or reddish lesion with moderate wrinkling and no obvious thickening. Grade I11 = a red or white lesion with intervening furrows of normal mucosal color, obvious thickening and wrinkling. Any lesions that fell inbetween grades were scored to the lesser grade and when no ST lesion was found a zero was recorded. Any soft-tissue oral lesions that had other obvious etiology were excluded, such as cheek biting, scar tissue, Fordyce granules, or interdental (linea alba) and retramolar hyperkeratosis. All areas of the mouth were viewed under good lighting and gauze was used to dry the tissue before observation. Training. Both dental hygienists and dentistsattended a two-hour training session on data collection prior to the beginning of the study. Training included slides and instruction on assessing and grading ST-related soft-tissue lesions according to Greer and Poulson’s classification system. The trainer was a dental hygienist with education and experiencein research, ST cessation counseling, and dental public health. Data collection procedures were standardized further by having each data collection form include a written description of the procedures and color photographs of lesions at each stage (5). Each week during the study the data forms were reviewed by the research coordinator to ensure quality control throughout the study. Statistical Procedures. Data were analyzed using SAS version 6.06.
Vol. 52, No. 5, Fall 1992
271
FIGURE 1 Oral Lesion Data Collection Form
DATASET 3885 KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
HR #:
SMOKELESS TOBACCO DATA CHART
DATE.
STEP A.
- ORAL LESIONS -
1. SEVERITY SCORE
-
Dry anatomic locations with gauze Record severity score in the boxes below as follows
0
-
No keratotic lesion found A superficial lesion with color similar to that of the surrounding mucosa with slight wrinkling and no obvious thickening 2 - A superficial whitish or reddish lesion with moderate wrinkling and no obvious thickening 3 - A red or white lesion with intervening furrows of normal mucosal color, obvious thickening and wrinkling 1
TO@ =LACE
SEVERITY SCORE TOBACCO 'LACEMENT
LINGUAL
TOBACCO
'LACEMENT SEVERITY SCORE
SEVERITY SCORE TOBACCO 'LACEMENT
.
FACIAL ~
2. ANATOMIC LOCATIONS: Draw location and dimensions of lesion on this diagram in RED Confirm lesion with dentist
Journal of Public Health Dentistry
272
FIGURE 2 Prevalence and Severity of Lesions by Duration of ST Use (&40.5, P
Vol. 52, No. 5, Fall 1992
Smokeless Tobacco Habits and Oral Mucosal Lesions in Dental Patients Sally Jo Little, RDH, MS Victor J. Stevens, PhD Pierre A. Lachance, BS Kaiser Permanente Center for Health Research 3800 N. Kaiser Center Drive Portland, OR 97227-1098 Herbert H. Severson, PhD Oregon Research Institute Eugene, OR Murray H. Bartley, DDS, PhD Oregon Health Sciences University Portland. OR Edward Lichtenstein PhD Oregon Research Institute Eugene, OR Joseph R. Leben, DMD Kaiser Permanente Dental Care Plan Portland. OR Abstract
As part of a smokeless tobacco (ST) interventionstudy, we collected data on tobacco use habits and oral health for 245 male ST users aged 15 to 77. The study sample was identified during routine dental office visits and represents a relatively diverse population of patients. Oral health data collection included grading the clinical appearance of oral mucosal lesions using Greer and Poulson 's classificationsystem, as well as identifying and recording the primary anatomic location of STplacement. Results show that 78.6percent of ST users had observablg oral lesions, 23.6 percent of which were in the most clinically advanced category (degree 111)- Of the lesions noted, 85 percent were in the same location the patient identified as his primary area of smokeless tobacco placement. In a comparison sample of 223 non-ST-users with the same age distribution, only 6.3 percent had observable lesions. A multiple logistic regression model for ST users showed that lesion presence and severity were most significantly related to current frequency of ST use.
Key Words: smokeless tobacco, oral leukoplakia, Send correspondence and reprint requests to Ms. Little. Manuscript received:6/10/91; returned to authors for revision: 9/19/91; accepted for publication:1/28/92.
J Public Health Dent 1992;52(5):269-76
leukokeratosis,preventive dentistry, dental health education.
Although significant progress has been made in reducing cigarette consumption in the United States (11, use of smokelesstobacco (moistsnuff and chewing tobacco)has been on the increase, especially among young males (2). Many users adopt the habit in the mistaken belief that smokeless tobacco (ST) will not harm their health. Until recently, tobacco companies reinforced this illusion by using sports personalities and outdoor sports in their advertising (3). However, the 1986 Surgeon General's Report concludes that ST is not a safe alternative to smoking (2). Many ST users develop changes in the oral mucosa at the location in which tobacco is held (4-9). At the clinical level these mucosal changes may include alterations in color, texture, and contour, and at the histological level development of inflammation, vacuolizations, epithelial atrophy, acanthosis, hyperorthokeratosis, or hyperparakeratosis (lCL151. In some individuals these changes progress to epithelial dysplasia or even squamous cell carcinoma (2,16-18). Several studies of relatively young populations have shown alarmingly high rates of keratotic lesions among ST users in the United States. Greer et a]. (19), studying a
270
sample of 117 teenagers, found that approximately 43 percent of ST users had developed mucosal lesions within three years of initiating the habit. Similarly, a , OO professional baseball players recent study of over 1O showed that almost half of the ST users had detectable oral lesions (20). Other domestic studies have reported that 23-46 percent of their ST-using populations manifested mucosal lesions (5,6,21-23).European studies have reported a somewhat lower incidence of ST-related mucosal lesions (12), although the content of foreign ST varies from domestic ST and in some studies the classification criteria for mucosal lesions differed from those employed in US studies (15,24). This paper presents data on tobacco use and the location and seventy of clinically apparent mucosal lesions in a diverse group of patients seen in a large general dental practice. Unlike ST users in previous domestic studies, this group was heterogeneous in terms of age, educational status, and tobacco use patterns, and therefore represents the patient mix typically seen in dental practices. Methods Data for this study were collected as part of a larger cancer control research program funded by the National Cancer Institute (25). To simplify this report, only those procedures directly related to oral health assessments and tobacco use are described here. Subjects. The subjects for this study were drawn from the patient population of the Kaiser Permanente Dental Care Program (KPDCP), a closed-panel dental HMO servingmore than 130,000members in northwest Oregon and southwest Washington. Because a previous survey of KPDCP patients showed that about 5 percent of the male patients, but none of the female patients, were current users of ST (26), only males were recruited for the current study. Recruitment consisted of asking male patients aged 15 years and older to complete a waitingroom questionnaire on tobacco use and agree to answer further study-related questions at a later date. A total of 245 patients who had used ST during the previous week were identified for an oral health assessment (current ST use was defined as any use during the previous week). The age distribution of this group was: 17 percent aged 15 to 19,33 percent aged 20 to 29,22 percent aged 30 to 39,18 percent aged 40 to 49, and 11 percent aged 50 or older. Regarding educational achievement, 5 percent of the subjects had completed eight years or less of schooling, 11percent had between nine and 11years of schooling, 31 percent had completed high school, 32 percent had some college, and 21 percent were college graduates. Data were collected at the routine dental hygiene clinic visit. At the end of patient recruitment for the ST study, an age-proportional sample of 177 non-ST users was also identified using similar procedures. Males 15 and older
Journalof Public Health Dentistry
completed a tobacco-habits questionnaire in the reception room. Those who had not used ST within the previous two years were examined. Assessment Procedures. Clinic receptionists attached the research forms to the subjects’ dental charts, thereby cuingthe dental hygienist and dentist to collect the oral health data. During the soft-tissue evaluation, the hygienist completed a data collection form including location and severity grade of soft-tissue lesions. The dentist was subsequently asked to confirm the grading of these lesions. Hygienists knew that the patients were ST users at the time of the assessments, but were blind to the patient’s tobacco use patterns and habitual ST placement. After completing the lesion form, the hygienist asked the patient to identify where he habitually placed tobacco in his mouth. Clinical Grading of ST-associated Soft-tissue Lesions. Given the age range and the type of ST predominantly used by our research population, we chose the Greer and Poulson (19) three-grade classification method, a modification of the original four-grade method for classifying lesions created by Axel1 and colleagues (12).The clinically identified lesions were drawn to scale on an anatomical diagram and then graded to indicate clinical severity (seeFigure 1):Grade I = a superficial lesion with color similar to that of the surrounding mucosa with slight wrinkling and no obvious thickening. Grade I1 = a superficial whitish or reddish lesion with moderate wrinkling and no obvious thickening. Grade I11 = a red or white lesion with intervening furrows of normal mucosal color, obvious thickening and wrinkling. Any lesions that fell inbetween grades were scored to the lesser grade and when no ST lesion was found a zero was recorded. Any soft-tissue oral lesions that had other obvious etiology were excluded, such as cheek biting, scar tissue, Fordyce granules, or interdental (linea alba) and retramolar hyperkeratosis. All areas of the mouth were viewed under good lighting and gauze was used to dry the tissue before observation. Training. Both dental hygienists and dentistsattended a two-hour training session on data collection prior to the beginning of the study. Training included slides and instruction on assessing and grading ST-related soft-tissue lesions according to Greer and Poulson’s classification system. The trainer was a dental hygienist with education and experiencein research, ST cessation counseling, and dental public health. Data collection procedures were standardized further by having each data collection form include a written description of the procedures and color photographs of lesions at each stage (5). Each week during the study the data forms were reviewed by the research coordinator to ensure quality control throughout the study. Statistical Procedures. Data were analyzed using SAS version 6.06.
Vol. 52, No. 5, Fall 1992
271
FIGURE 1 Oral Lesion Data Collection Form
DATASET 3885 KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
HR #:
SMOKELESS TOBACCO DATA CHART
DATE.
STEP A.
- ORAL LESIONS -
1. SEVERITY SCORE
-
Dry anatomic locations with gauze Record severity score in the boxes below as follows
0
-
No keratotic lesion found A superficial lesion with color similar to that of the surrounding mucosa with slight wrinkling and no obvious thickening 2 - A superficial whitish or reddish lesion with moderate wrinkling and no obvious thickening 3 - A red or white lesion with intervening furrows of normal mucosal color, obvious thickening and wrinkling 1
TO@ =LACE
SEVERITY SCORE TOBACCO 'LACEMENT
LINGUAL
TOBACCO
'LACEMENT SEVERITY SCORE
SEVERITY SCORE TOBACCO 'LACEMENT
.
FACIAL ~
2. ANATOMIC LOCATIONS: Draw location and dimensions of lesion on this diagram in RED Confirm lesion with dentist
Journal of Public Health Dentistry
272
FIGURE 2 Prevalence and Severity of Lesions by Duration of ST Use (&40.5, P
