APPENDIX 8
Memorandum by the British Dental Association
(TB 16)
The British Dental Association is one of the
largest dental associations in Europe. It is the trade union and
professional association representing over 20,000 dentists in
the UK. The BDA works to promote the oral health of the public.
It advises dentists on scientific and clinical issues. Dentists
advise patients on the risks of smoking particularly with respect
to oral health, and can help them to try to quit.
There is considerable scientific evidence showing
that tobacco can affect oral health in a number of ways, from
minor aesthetic changes, to gum disease, and fatal cancers1.
In addition to the harmful pathological effects of tobacco use
(both smoking and chewing), smoking is also associated with a
range of unpleasant physical changes in the mouth and teeth. The
largely reversible and easily observed nature of the oral health
effects provide a unique means of monitoring the positive effects
of smoking cessation. There is increasing concern about the sale
of sweetened chewing tobacco (Gutka) to underage children, especially
in the ethnic communities.
Table 1 summarises oral health conditions known
to be induced or associated with tobacco use.
ORAL CANCER
Using the BDA's definition, sites where oral
cancer can occur are the lip, tongue, gum, floor of the mouth,
other unspecified parts of the mouth, oropharynx, hypopharynx
and other and ill-defined sites within lip, oral cavity and pharynx2.
This excludes cancers of the salivary glands and nasopharynx2.
There are currently around 3,400 new cases of oral cancer each
year in the UK and about 1,600 deaths (similar to the number of
deaths from cancer of the uterine cervix which receives much more
public attention), although early detection significantly increases
the chance of survival. The major risk factors for oral cancer
are well established—excess tobacco (both smoking and chewing)
and alcohol use. Between 75 per cent and 90 per cent of all cases
are linked to the combined effects of smoking and alcohol use.
Potentially malignant lesions such as leukoplakia occur six times
more frequently in smokers than in non-smokers.
PERIDONTAL (GUM)
DISEASE
Smokers have an increased prevalence and severity
of peridontis, including greater marginal bone loss, deeper periodontal
pockets, tooth mobility and tooth loss3. These adverse
effects are independent of any other risk factors such as poor
oral hygiene, plaque, calculus and socio-economic factors. Risk
assessments suggest that smokers are at between 2.5 and 6 times
more likely to develop periodontal disease than non-smokers. A
recent study3 has shown that there is a lethal synergy
between nicotine and a bacterial toxin and it may also interact
with other toxins produced by bacteria which cause periodontis.
Nicotine also affects how the immune system reacts which could
exacerbate the effects of the toxin-producing bacteria, as well
as causing localised tissue damage thereby increasing the severity
of the periodontal disease.
CANDIDIASIS
Thrush, or more chronic fungal infections of
the mouth, are common and severe in smokers, and more difficult
to treat.
SMOKERS' PALATE
Heavy pipe smokers often develop a pale or white
hard palate, often combined with multiple red dots4.
This can reverse after stopping smoking.
SMOKERS' MELANOSIS
Increased melanin pigmntation can occur on the
cheeks and attached gums due to heavy smoking4. This
is asymptomatic but can take up to a year before the colour returns
to normal.
OTHER EFFECTS
Smoking causes staining of teeth, dental restorations
and dentures. It also affects taste thresholds, especially for
salt—heavy smokers have been shown to have a 12-14 times
greater salt threshold compared with non-smokers4.
Smoking is also a common cause of bad breath. Smoking has also
been shown to adversely affect wound healing following surgery.
REFERENCES
1 EU Working Group on Tobacco and Oral Health
(1998). Tobacco and oral health. Facts for the dental profession.
A tool for development of information materials and guidelines.
2 `Oral cancer—Guidelines for early
detection'. (1998) BDA. Occasional paper. No. 5.
3 Sayers NM, Gomes BPFA, Drucker DB and
Blinkhorn AS. (1997) Possible lethal enchancement of toxins from
putative periodontopathogens by nicotine; implications for periodontal
disease. J Clin Pathol 50:245-249.
4 Watt R and Robinson M (1999) Helping smokers
to stop: a guide for the dental team. Health Education Authority.
5 Johnson NWJ (1997) Oral cancer: Prevention.
FDJ World 6(6) 10-16.
Table 1
TOBACCO INDUCED AND ASSOCIATED CONDITIONS
ORAL CANCER
Leukoplakia
Homogenous leukoplakia
Non-homogenous leukoplakia (precancer)
Verrucous leukoplakia
Nodular leukoplakia
Erythroleukoplakia
Other tobacco-induced oral mucosal conditions:
Snuff dipper's lesion
Smoker's palate (nicotinic stomatitis)
Smoker's melanonsis
Tobacco-associated effects on the teeth and supporting
tissues
Premature tooth loss
Staining
Abrasion
Periodontal diseases
Acute necrotising ulcerative gingivitis
Other tobacco associated oral conditions:
Calculus
Halitosis
Leukoedema
Chronic hyperplastic candidiasis (candidal leukoplakia)
Median rhomboid glossitis
Hairy tongue
Gingival bleeding
Possible association with tobacco
Oral clefts
Dental plaque
Lichen planus
Salivary changes
Taste and smell
September 1999
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