Smokeless tobacco use prevents aphthous stomatitis Deborah Grady, MD, a,b Virginia L. Ernster, PhD,” Linda Stillman, John Greenqm, DMD, PhD,” San Francisco, Cal6 UNIVERSITY
OF CALIFORNIA-SAN
IIIPH,~ and
FRANCISCO
Aphthous stomatitis is a common, recurrent, painful ulcerative condition of the oral mucosa. Cigarette smok.ing has been reported to protect against aphthous ulcers. To determine whether smokeless tobacco use also protects against aphthous ulcers, we examined the oral mucosa in 1456 professional baseball players, about half of whom were smokeless tobacco (ST) users. After controlling for the confounding effects of age, race, cigarette smoking, alcohol consumption, and dental hygiene practices, ST use was found to significantly reduce the risk of aphthous ulcers among these healthy young men (odds ratio = 0.4; p = 0.04). It has been suggested that cigarette smoking prevents aphthous ulcers by causing increased keratinization of the oral mucosa, and ST may protect by the same mechanism. Alternatively, a component of tobacco that is systemically absorbed might be responsible for protecting against aphthous ulcers. If the mechanism that protects ST users against aphthous ulcers is systemic, then nicotine is the likely protective factor. (ORAL SURG ORAL MED
ORAL PATHOL
1992;74:463-5)
A phthous stomatitis
is a common, recurrent, painful ulcerative condition of the oral mucosa. Cigarette smoking has been reported to protect against recurrent aphthous ulcers. l-4 One study suggested that smokeless tobacco (ST) use reduces the prevalence of recurrent aphthous ulcers, but that report was based on self-reported history of recurrent oral ulcers and did not control for other potentially confounding factors such as age, sex, race, and alcohol use.5 To determine whether ST use (chewing tobacco and snuff) prevents aphthous ulcers, we examined the oral mucosa in 1456 professional baseball pla.yers, about half of whom were ST users. METHODS
Details of the methods of this study have been previously published.6 Briefly, during spring training in 1989 and 1990, we studied members of seven professional baseball teams that conduct spring training in Arizona. Subjects completed a questionnaire that inSupported by grant 5 PO1 DE08547-02 from the National for Dental Research. aDepartment of Epidemiob3gy and Biostatistics, School cine. bDepartment of Medicine, School of Medicine. CDepartment of Stomatology, School of Dentistry. 7113135819
Institute
eluded demographic data and information on ST use, cigarette smoking, alcohol consumption, and dental hygiene (teeth cleaned at a dental office within prior year). Current ST use was defined as self-reported ST use within the past week. Oral examinations were performed by examiners who had been extensively trained to establish uniformity in all procedures.7 Before entering the examination area, subjects rinsed the mouth twice to remove any tobacco residue and were asked not to discuss their ST use status with the examiner. Aphthous ulcers were defined as welldemarcated, rounded ulcers covered by a gray, white, or yellowish fibrinous exudate and surrounded by a red inflammatory zone. Chi-square tests were performed to assessthe association between presence of aphthous ulcers and ST use, age, race, cigarette smoking, alcohol consumption, and dental hygiene. To control for potential confounding, logistic regression analysis was performed with all variables as predictors and aphthous ulcers as the outcome. The logistic model calculates an odds ratio (OR) for each predictor variable that is adjusted for each of the other variables in the model.
of Medi-
RESULTS
Subjects were 1456 men between the ages of 17 and 63 years, of whom 37% (n = 545) had used ST within 463
464
Grady et al.
le 1. Prevalence of aphthous ulcers by age, race, cigarette smoking, hygiene No. of Variable
subjects
alcohol consumption,
and dental
No. (%) with aphthous ulcers
Univariate OR
p value*
18 (2.8) 7 (1.3)
1.0 0.5
0.07
2 (1.5) 20 (2.1) 3 (2.8)
1.0 1.5 1.9
0.78
20 (2.5) 5 (2.5) 0 (0)
1.0 1.0 t
25 (2.2) 0 (0)
1.0 t
0.46
5 (2.3) 19 (2.2) 1 (1.8)
1.0 0.9 0.8
0.97
18 (1.8) 6 (3.6)
1.0 2.0
0.14
ST use Nonuser 643 Current user 545 Age Cur)
OF CALIFORNIA-SAN
IIIPH,~ and
FRANCISCO
Aphthous stomatitis is a common, recurrent, painful ulcerative condition of the oral mucosa. Cigarette smok.ing has been reported to protect against aphthous ulcers. To determine whether smokeless tobacco use also protects against aphthous ulcers, we examined the oral mucosa in 1456 professional baseball players, about half of whom were smokeless tobacco (ST) users. After controlling for the confounding effects of age, race, cigarette smoking, alcohol consumption, and dental hygiene practices, ST use was found to significantly reduce the risk of aphthous ulcers among these healthy young men (odds ratio = 0.4; p = 0.04). It has been suggested that cigarette smoking prevents aphthous ulcers by causing increased keratinization of the oral mucosa, and ST may protect by the same mechanism. Alternatively, a component of tobacco that is systemically absorbed might be responsible for protecting against aphthous ulcers. If the mechanism that protects ST users against aphthous ulcers is systemic, then nicotine is the likely protective factor. (ORAL SURG ORAL MED
ORAL PATHOL
1992;74:463-5)
A phthous stomatitis
is a common, recurrent, painful ulcerative condition of the oral mucosa. Cigarette smoking has been reported to protect against recurrent aphthous ulcers. l-4 One study suggested that smokeless tobacco (ST) use reduces the prevalence of recurrent aphthous ulcers, but that report was based on self-reported history of recurrent oral ulcers and did not control for other potentially confounding factors such as age, sex, race, and alcohol use.5 To determine whether ST use (chewing tobacco and snuff) prevents aphthous ulcers, we examined the oral mucosa in 1456 professional baseball pla.yers, about half of whom were ST users. METHODS
Details of the methods of this study have been previously published.6 Briefly, during spring training in 1989 and 1990, we studied members of seven professional baseball teams that conduct spring training in Arizona. Subjects completed a questionnaire that inSupported by grant 5 PO1 DE08547-02 from the National for Dental Research. aDepartment of Epidemiob3gy and Biostatistics, School cine. bDepartment of Medicine, School of Medicine. CDepartment of Stomatology, School of Dentistry. 7113135819
Institute
eluded demographic data and information on ST use, cigarette smoking, alcohol consumption, and dental hygiene (teeth cleaned at a dental office within prior year). Current ST use was defined as self-reported ST use within the past week. Oral examinations were performed by examiners who had been extensively trained to establish uniformity in all procedures.7 Before entering the examination area, subjects rinsed the mouth twice to remove any tobacco residue and were asked not to discuss their ST use status with the examiner. Aphthous ulcers were defined as welldemarcated, rounded ulcers covered by a gray, white, or yellowish fibrinous exudate and surrounded by a red inflammatory zone. Chi-square tests were performed to assessthe association between presence of aphthous ulcers and ST use, age, race, cigarette smoking, alcohol consumption, and dental hygiene. To control for potential confounding, logistic regression analysis was performed with all variables as predictors and aphthous ulcers as the outcome. The logistic model calculates an odds ratio (OR) for each predictor variable that is adjusted for each of the other variables in the model.
of Medi-
RESULTS
Subjects were 1456 men between the ages of 17 and 63 years, of whom 37% (n = 545) had used ST within 463
464
Grady et al.
le 1. Prevalence of aphthous ulcers by age, race, cigarette smoking, hygiene No. of Variable
subjects
alcohol consumption,
and dental
No. (%) with aphthous ulcers
Univariate OR
p value*
18 (2.8) 7 (1.3)
1.0 0.5
0.07
2 (1.5) 20 (2.1) 3 (2.8)
1.0 1.5 1.9
0.78
20 (2.5) 5 (2.5) 0 (0)
1.0 1.0 t
25 (2.2) 0 (0)
1.0 t
0.46
5 (2.3) 19 (2.2) 1 (1.8)
1.0 0.9 0.8
0.97
18 (1.8) 6 (3.6)
1.0 2.0
0.14
ST use Nonuser 643 Current user 545 Age Cur)
