Oral lesions
Effects on the oral mucosa
Summary
The use of Swedish snus and the incidence of dental caries and periodontal disease and various non-carcinogenic oral conditions have been investigated in multiple studies. It is evident that Swedish snus possesses multiple physio-chemical properties, such as pH, chemical composition, particle size and moisture content, that can affect the oral mucosa and in certain cases cause snus lesions. Whether these lesions will result in cancer has attracted scientific attention for a long time.
Important research results on Swedish snus:
- It is unclear whether use of Swedish snus causes dental caries.
- Use of Swedish snus causes reversible inflammation in the gingival mucosa (gingivitis) in some individuals at the site where the pinch is placed. There seems not to be any association between the use of snus and periodontitis (loosened teeth).
- Gingival recessions are more common in users of loose snus than in users of portion-packed snus and are irreversible.
- Snus use causes benign changes in the oral mucosa (snus dipper’s lesions).
- These changes arise at the site where the pinch is placed.
- There is an association between the degree of oral mucosal lesion and consumption factors such as daily duration, daily consumption and number of years.
- When snus users reduce their daily consumption or when users of loose snus switch to portion-packed snus the degree of oral mucosal lesions decrease both from a clinical and a histological perspective.
- The degree of oral mucosal lesion increases both with increasing pH and nicotine content.
- Snus lesions are reversible, i.e. the oral mucosa reverses to normal condition after cessation of snus use.
- Users of portion-packed snus have less pronounced snus lesions than users of loose snus.
- Epidemiological data do not indicate any association between snus use and serious dysplastic oral mucosal changes or pre-carcinogenic effects in the oral cavity. These results agree well with the fact that no tumours or dysplasia have been found in the oral cavity among 500 snus users who have been examined annually for several years.
Advanced
Dental caries and periodontal disease
The association between use of Swedish snus and dental health, i.e. dental caries, tooth wear and tooth loss (parodontitis) has been described in three descriptive studies. Even if the results indicate that there is an association between snus use and these damages, caution should be exercised in interpreting the data since the effects of diet and mouth hygien have not been controlled for (Hirsch et al., 1991, Ekfeldt et al., 1990, Johansson et al., 1994)
In a recently published cross-sectional study, the relationship between tobacco use and prevalence of periodontal disease was investigated. There was a significant association between smoking and periodontal disease compared to never-smoking, but there was no significant association between current snus use and periodontal disease compared to never use (Wickholm et al., 2004).
Use of snus may cause inflammation of the buccal mucosa in certain individuals. This disease is reversible at an early stage. Use of snus can also cause gum recession (gingivitis), damages that are irreversible and occur more commonly in users of loose snus than in users of portion-packed snus (Andersson and Axéll, 1989a; Frithiof et al., 1983; Modéer et al., 1980).
Mucosal lesions
The association between the use of snus and the prevalence and severity of snus lesions is described in a large number of descriptive studies. Five of these studies describe the type of oral lesions occurring in a group consisting of 252 construction workers (Andersson, 1991a). Several articles deal with the association between the prevalence of snus use and oral lesions in a large population study comprising 30000 individuals (Axéll, 1976).
A mucosal change, snus lesion, is found in almost all snus users at the site of the gum where the pinch is placed. The degree of oral lesion is positively correlated with daily duration, daily consumption and number of years of active snus use (Hirsch et al., 1982; Mörnstad et al., 1989; Andersson et al., 1991b). Andersson et al. (1989b) found that portion packed snus results in less pronounced changes of the mucosa than loose snus. In addition, the degree of lesions seems to increase with increasing pH as well as increasing nicotine content (Mörnstad et al., 1989; Andersson et al., 1995).
Oral lesions caused by snus are reversible, i.e. the oral mucosa reverses to its original condition in individuals, who have quit the use of snus (Larsson et al., 1991). Frithiof et al. (1983) reported that these lesions were almost entirely reversed 14 days after quitting the use of snus even in individuals, who had used snus for decades.
Larsson et al. (1991) examined histological oral mucosal changes in a group consisting of 252 Swedish snus users. They found that 29 of these individuals, who were all users of loose snus, had dysplastic changes in the epithelium. In a follow-up 3-6 months later normal tissues were found in those 20 individuals, who had quit the use of snus and no dysplastic changes were found in those individuals, who had switched to portion-packed snus or reduced their consumption. These results agree well with the fact that no tumours or dysplastic changes have been found in the oral mucosa of those 500 snus users, who have annually been examined for several years (Ahlbom et al., 1997).
REFERENCES
Ahlbom et al., 1997. Hälsorisker med snus. SoS-rapport 11: 17-19. Andersson, G. and Axéll, T. 1989a. Clinical appearance of lesions associated with the use of loose and portion-bag packed Swedish moist snuff: A comparative study. J. Oral Pathol. Med. 18:2-7. Andersson, G., Axéll, T., and Larsson, A. 1989b. Histologic changes associated with the use of loose and portion-bag packed Swedish moist snuff: A comparative study. J. Oral Pathol. Med. 18:491-497. Andersson, G. 1991a. Snuff-induced changes associated with the use of loose and portion-bag-packed Swedish moist snuff. A clinical, histological and follow-up study. Swed. Dent. J. Suppl. 75:1-89. Andersson, G., Axéll, T., and Larsson, A. 1991b. Clinical classification of Swedish snuff dippers lesions supported by histology. J. Oral Pathol. Med. 20:253-257. Andersson, G., Axéll, T., and Curvall, M. 1995. Reduction in nicotine intake and oral mucosal changes among users of Swedish oral moist snuff after switching to a low-nicotine product. J. Oral Pathol. Med. 24:244-250. Axéll, T. 1976. A prevalence study of oral mucosal lesions in an adult Swedish population. Thesis. Odontol. Rev. Suppl. 27:1-103. Ekfeldt, A., Hugoson, A., Bergendal, T., and Helkimo, M. 1990. An individual tooth wear index and an analysis of factors correlated to incisal and occlusal wear in an adult Swedish population. Acta Odontol. Scand. 48:343-349. Frithiof, L., Anneroth, G., Larsson, U., and Sederholm, C. 1983. The snuff-induced lesion. A clinical and morphological study of a Swedish material. Acta Odontol. Scand. 41:53-64. Hirsch, J.M., Heyden, G., and Thilander, H. 1982. A clinical, histomorphological and histochemical study of snuff-induced lesions of varying severity. J. Oral Pathol. 11:387-398. Hirsch, J.M., Livian, G., Edward, S., and Norén, J.G. 1991. Tobacco habits among teenagers in the city of Göteborg, Sweden, and possible association with dental-caries. Swed. Dent. J. 15:117-123. Johansson, I., Tidehag, P., Lundberg, V., Hallmans, G. 1994. Dental status, diet and cardiovascular risk factors in middle-aged people in Sweden. Comm. Dent. Oral Epidemiol. 22:431-436. Larsson, A., Axéll, T., and Andersson, G. 1991. Reversibility of snuff dippers lesion in Swedish moist snuff users: A clinical and histologic follow-up study. J. Oral Pathol. Med. 20:258-264. Modéer, T., Lavstedt, S., and Åhlund, C. 1980. Relation between tobacco consumption and oral health in Swedish school children. Acta Odontol. Scand. 38:223-227. Mörnstad, H., Axéll, T., and Sundström, B. 1989. Clinical picture of snuff dipper's lesion in Swedes. Community Dent. Oral Epidemiol. 17:97-101. Wickholm, S., Söder, P.-Ö., Rosaria, M., Söder, B., and Klinge, B. 2004. Periodontal disease in a group of Swedish adult snuff and cigarette users. Acta Odontol. Scand. 62:333-338.
Hirsch, J.M., Heyden, G., and Thilander, H. 1982. A clinical, histomorphological and histochemical study of snuff-induced lesions of varying severity. J. Oral Pathol. 11:387-398.
Hirsch, J.M., Livian, G., Edward, S., and Norén, J.G. 1991. Tobacco habits among teenagers in the city of Göteborg, Sweden, and possible association with dental-caries. Swed. Dent. J. 15:117-123.
Larsson, A., Axéll, T., and Andersson, G. 1991. Reversibility of snuff dippers lesion in Swedish moist snuff users: A clinical and histologic follow-up study. J. Oral Pathol. Med. 20:258-264.
Modéer, T., Lavstedt, S., and Åhlund, C. 1980. Relation between tobacco consumption and oral health in Swedish school children. Acta Odontol. Scand. 38:223-227.
Mörnstad, H., Axéll, T., and Sundström, B. 1989. Clinical picture of snuff dipper's lesion in Swedes. Community Dent. Oral Epidemiol. 17:97-101.
