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Oral lesions in patients consuming dierent
types of smokeless tobacco. A literature review.
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Lesiones orales en pacientes consumidores de diferentes
tipos de tabaco no inhalados. Revisión de la literatura.
Elsy Lorena Jerez1 Ashmita Nagrani2 Eduardo Arosemena3
1. Professor, Interamerican University of Panama, Panama City, Panama. / lorenajerez@hotmail.com
2. Dental Surgeon Student, Interamerican University of Panama. Panama City, Panama. / ashmitanagrani@hotmail.com
3. Professor, Interamerican University of Panama, Panama City, Panama. / arosemenadoss@yahoo.com
https://doi.org/10.59334/
Recibido: 2023-04-25
Aceptado: 2023-07-03
Abstract
Introduction:
Smokeless tobacco (ST) is widely consumed around the world, with products such as gutkha and paan masala being
particularly common. These products typically contain areca nut, which is known for its carcinogenic properties and negative
effects on oral health. In addition, tobacco is a key ingredient in ST and has been linked to a range of general and dental
health issues, particularly among younger populations. Aim: The purpose of this article is to review the literature about ST and
its repercussion on the oral health, specically the dental and periodontal effects.
Method:
This research was based on a systematic review of articles published between January 2009 and March 2023, aided
by PubMed, Scielo, and Google Scholar search engines. Conclusions: Some studies have shown that ST and areca nut
components can be particularly dangerous for people with cardiovascular disease and diabetes. Additionally, tobacco
has a signicant impact on periodontal and dental health, with pathological lesions that may lead to malignant disorders.
Peer pressure and stress are common reasons for ST addiction. As such, promoting the intention to quit this habit should be
repeatedly emphasized to avoid the negative consequences of these products.
Key Words:
smokeless tobacco, gutkha, areca nut, diabetes, cardiovascular disease, periodontal disease, dental caries, intraoral lesions.
Introduction
The worldwide tobacco outbreak has caused
a wide range of health effects and is the main
cause of oral cancer. It’s been considered the
most consequential threat to human health
globally. Over the time, the use of various types
of tobacco has escalated in Asia, primarily in
India.
Additionally, it has been observed in Asian
immigrant communities in Europe, North and
Central America. (Pandey et al. 2019).
Tobacco use has prompted around 800,000
deaths annually, for which the majority were
led by smokeless tobacco (ST) products such
as betel, snuff, gutkha (paan masala), and
mishri. (Agrawal et al. 2020) These products are
an important factor in the causes of addiction
and death in the Indian population. ST persists
as the most pervasive form of tobacco usage
after cigar, cigarettes, and electronic cigarette.
(Willis et al. 2014).
Its use has shown an immense surge in the
young population worldwide and adolescents
Jerez, E. L., Nagrani, A., & Arosemena, E. (2024). Oral lesions in patients consuming different types of smokeless tobacco. A literature review. Odontología Vital, 2(41), 27-42. https://doi.org/10.59334/
ROV.v2i41.564
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and young individuals are inclined to these
habits quickly by the inuence of friends and
relatives. Furthermore, this group has the
tendency of trying the products for fun without
having any knowledge of the consequences
and effects of the diverse products containing
tobacco. (A’yun et al. 2022).
One of the most common forms of ST use is
the gutkha (or betel quid), Its main ingredient is
the areca nut (seed of the areca palm), it also
contains crushed tobacco, slaked lime (calcium
hydroxide paste) and catechu (extract from
the acacia plant). This is also blended with
sweeteners and avoring agents. Gutkha is
placed between the cheek and gum and can be
chewed or sucked. The consumer may spit the
saliva out or swallowed the product. (Harini et al.
2022).
This product has made a substantial headway
within a lower socioeconomic status population
as an alternative for smoking. Consumption
has increased throughout the years, possibly,
because of the great amount of publicity
placement under many brands, and as a result
of the reasonable cost in local markets. (Shukla
et al. 2020).
On the other hand, the strategic plan of selling
gutkha in small shops and kiosks near malls
and schools, has enabled the accessibility and
effortless spread of this addiction in young
individuals and children in India. (Srivastava.
2014).
Furthermore, gutkha provides the same effects
of cigarettes as it also contains nicotine, so
it may be used as a replacement for them. It
has been clearly demonstrated that the use
of cigarettes, gutkha or any other product
containing tobacco, is difcult to quit, and
consequently, is creating an addiction among its
users. (Banerjee et al. 2013).
The essential element of gutkha, areca nut
is the seed of the areca fruit from the tropical
palm areca tree which is found greatly in
parts of South Asia. (Gupta et al. 2015). The
main ingredient of gutkha is known to be
a human carcinogen. It contains several
constituents, such as tannins, that act as
stimulants and alkaloids, especially arecoline.
Areca nut is consumed by roughly 600 million
people globally, most of them belong to low
socioeconomic status. In the same manner as
gutkha, areca nut is placed between the gum
and cheek (Do et al. 2022).
Another option is snuff, which is known as a
type of ST made of nely ground or shredded
tobacco leaves. It can have various types of
avors and scents and it is also positioned
between the gum and cheek or behind the
upper or lower lip. It has been related to heart
illness, gum disease and other health problems.
(Harini et al. 2022).
Tobacco-specic nitrosamines, which appear
during the curing and processing of tobacco,
are available in all commercial tobacco
products, including smokeless tobacco, cigarette
smoke, and cigar smoke.
There are seven tobacco-specic
nitrosamines found in unburned, cured
tobacco, but only three of them have
received attention: N’-nitrosonornicotine
(NNN), 4-(methylnitrosamino)-1-(3-pyridyl)-
1-butanone (NNK), and its main metabolite 4
-(methylnitrosamino)-1-(3-pyridyl)-1-butanol
(NNAL). There is evidence for their endogenous
synthesis, mainly via the nitrosation of
nornicotine. Cured and processed tobacco
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are the essential sources of tobacco-specic
nitrosamines, which are fabricated when
tobacco alkaloids react with nitrite. Two
tobacco-specic nitrosamines NNN and NNK,
with mean concentrations of 1901 ng/g and 523
ng/g, respectively, are the most carcinogenic
(Sankla et al. 2017).
NNN and nicotine are both found in ST products.
It must be pointed out that NNN is expected to
have a signicant role as a cause of cancer,
and an important fact to understand is that the
nitrosation of nicotine may lead to the formation
of NNN. (Hecht et al. 2022).
The purpose of this article is to review the
literature about ST and its repercussion on the
oral health, specically the level of effect on the
dental and periodontal side.
Methodology
A bibliographic search was conducted on
PubMed, Google Scholar and Scielo, for articles
published between January 2009 to March 2023
on the effects of the consumption of paan and
gutkha on oral cavity. The use of smokeless
tobacco in association with topics such as:
• Gutkha,
• Areca nut,
• Ingredients,
• Placement site,
• Association with oral cancer,
• Periodontal status,
• Oral lesion on the oral cavity,
• Effects on the mucosa,
• Periodontal and bone level,
• Dental caries
were added to the inclusion criteria in this
investigation. Key words relating to conventional
cigarettes, electronic cigarettes, articles not
completed, and articles published before 2009
were excluded.
Results
A considerable amount of people consume
various types of smokeless tobacco products
worldwide, most often gutkha and betel quid.
These users are very susceptible to developing
oral and general health problems. ST combines
several components, the most important
being areca nut, which is known to produce
carcinogenic and toxic chemicals in the body.
The most serious health repercussion of ST is
oral cancer. Moreover, different effects will be
mentioned and explained regarding general
health, intraoral lesions, dental and periodontal
status. (Shukla et al. 2020).
Systemic Diseases
It is well established that the usage of tobacco
increases the risk of developing cardiovascular
disease. It may cause effects such as:
increment of myocardial workload, coronary
vasoconstriction, reduction of the oxygen-
carrying capacity of the blood and induction
of hypercoagulable state. ST products contain
nicotine, hydrocarbons, nitrosamines, aldehydes,
alkaloids, and metal.
ST usage can produce more durable and
sustained levels of nicotine, unlike cigarette
smoking, which delivers peaks in nicotine level.
In the other hand, acute cardiovascular effects
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are common with ST products. These include an
increase in heart rate and blood pressure levels.
(Shaik et al. 2020) Over the past two decades,
substantial evidence has been gathered
concerning the possible association between
tobacco and the development of systemic
diseases such as diabetes. Health risks due to
smoking have been reported to be higher for
people diagnosed with diabetes than for the
general population. Studies have stated the
effect of ST usage over diabetes, glucose levels,
glucose intolerance, insulin levels and insulin
intolerance.
Intraoral Lesions
Tobacco use is increasing rapidly. It is most
popular with young adults as an alternative
to smoking. ST products contain various
carcinogen chemicals which are associated
with different types of oral cancer.
As ST is placed intraorally, it can induce
to changes in the oral cavity resulting in
pathological lesions. (Jyoti et al. 2012) The
oral effects of ST are seen primarily where the
product has been placed. If these intraoral
lesions are not managed at an early stage, it is
most likely to develop oral cancer. The presence
of dysplastic changes cannot be predicted, and
a biopsy must be done on the suspected site. (Le
et al. 2022)
The term precancer can be attributed to benign
mucosal alterations that can lead to malignant
lesions. Prime prevention of general and oral
diseases consists of recognition and correct
diagnosis of potential malignancies. (Asthana
et al. 2019) The World Health Organization
(WHO) differentiated between conditions and
precancerous lesions. The team outlined a
precancerous lesion as an altered tissue in
which cancer is more likely to develop. Such
lesions are considered potential malignant
disorders, for example: leukoplakia, erythroplakia,
oral submucous brosis and lichen planus.
(Warnakulasuriya et al. 2022).
Leukoplakia was dened by the WHO as
a white patch or plaque that cannot be
characterized clinically or pathologically as other
diseases.
The pivotal microscopic feature is the presence
of epithelial dysplasia. This lesion can be divided
under two types of diagnosis: homogenous and
non-homogenous. Homogenous leukoplakia
lesions are uniformly at and thin and can
display shallow cracks in the surface keratin.
Non-homogenous leukoplakia present mixed
white and red areas although it holds a
dominant white character. They are associated
with a specic oral site. People who consume
gutkha are affected more often on the buccal
mucosa where the gutkha is placed. Detection
and management of this lesion can prevent the
progression of oral cancer.
Although, the presence of epithelial dysplasia
is a feasible indicator of malignant potential.
Lesions with epithelial dysplasia are 10 times
more prone to malignant transformation. (Souza
et al. 2009)
Erythroplakia is dened as any lesion of the
oral mucosa that displays as bright red velvety
plaques that cannot be characterized clinically
or pathologically as any other denable
condition. Even though it is not as common as
leukoplakia, it is much more likely to develop into
dysplasia or carcinoma.
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A biopsy is mandatory in all cases of
erythroplakia. The favorable way to manage this
lesion would be surgery and regular follow-ups
complemented by habit reduction. Erythroplakia
should be treated soon after diagnosis.
(Athukorala et al. 2021)
Oral submucous brosis (OSF) is a chronic
disorder that develops by brosis of the lining
mucosa of the upper digestive tract involving
the oral cavity, and oropharynx. The oral mucosa
hardens because of the brosis of the lamina
propria leading to a reduction of the mouth’s
opening range.
OSF is related to the consumption of areca
nuts, particularly in chewers of this product.
Consuming it may lead to oral cancer. (Singh et
al. 2011) OSF occurs across all the intraoral cavity,
and it can even extend to the pharynx and
esophagus.
Clinically, marked mucosal blanching is
observed, prominently in the early stages.
Additionally, a diagnostic feature is the presence
of palpable brous bands in the buccal mucosa
and in the lips. Patients might feel a burning
sensation and hyper- or diminished salivation
and speech defects. OSF is known to be difcult
to manage.
Several treatments have been suggested,
such as surgical options, although there is no
conrmed treatment to restore the normal
texture of the oral mucosa and reduce the risk of
cancer development. (Athukorala et al. 2021)
Lichen planus is mainly a dermatological
disorder in which various mucosal surfaces
may be involved. The oral mucosa is more
frequently affected than other mucosal sites.
It is known to be probably related to immune
system malfunctioning. Tobacco use seems to
play a role in its development. This oral lesion
has shown a great association with gutkha,
paan masala and ST products as well. However,
tobacco use is not regarded as an etiological
factor for this lesion.
Oral lichen planus is diagnosed when a pale,
reticular or lace like pattern of striae on the oral
mucosa or tongue is observed. Other clinical
forms of this disorder are the erosive and
ulcerative type. This alteration may lead to oral
cancer. (Srivastava. 2014)
Other types of lesions in the oral cavity
associated with the use of ST is tooth decay.
Dental caries is the most prevalent disease
to man, affecting more than 2 billion people
worldwide. Tobacco consumption alters the
dental composition. It has shown that nicotine
increases biolm formation and bacterial
adherence.
Studies show that chewing tobacco and
smoking can promote signicant health
risk factors for dental caries. Reports have
acknowledged that ST users have a higher
caries incidence. This could be a consequence
of the degenerative effect of tobacco on salivary
glands.
It can also inhibit the buffering capacity of
saliva, making the person vulnerable to cavities.
In addition, ST products containing areca nut
have also been observed to produce tooth wear,
dental sensitivity, and halitosis. Figure 1 shows the
effects of each ingredient of ST. (Bhavsar et al.
2022).
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Catechu Salked Line Tobacco (TSNA)
Phenols Alkaline Medium Periodontitis
injury
Oxidate Stress
Reactive Oxigen Species
Premalignant Lesions
Malignant Lesions
Apoptosis DNA DamageCell Proliferation
Choronic Inflammation Cytochome Production
Abrasion / attrition
Phenols Dental Caries Local Trauma
Areca Nut (ASNA)
Figure 1. Mechanism of gutkha carcinogenicity. (Sankla et al. 2017)
Reports have revealed a relationship between
tobacco and periodontal disease. The
consumption of gutkha has been linked with
periodontitis and bone decay. (Verma et al. 2019)
Periodontal disease is an inammatory illness
of the supporting tissue of the teeth caused by
microorganisms and resulting in the progressive
destruction of periodontal ligament and alveolar
bone. (Dave et al. 2023) Smokers have a higher
susceptibility to periodontitis and are less prone
to gingivitis.
Possibly because smoking interferes with the
inammatory and immune responses. Smokers
are almost 6 times more likely to develop
periodontal destruction. (Shah et al. 2021)
The impact of ST products is quite high on all
periodontal health indicators such as calculus,
plaque and gingival index, gingival recession,
clinical attachment loss, furcation, mobility,
pocket depth, and formation of lesions. (Mishra
et al. 2013) The hardness of the areca nut and
the interaction among the various components
of chewing products with periodontal tissues
might be the reason of poor periodontal health
in gutkha chewers. (Hsiao et al. 2015)
Areca nut contains alkaloids (arecoline), and
this may play a signicant role in periodontal
disease in combination with oral hygiene,
general health, and dental status. (Kulkarni et
al. 2016) The diverse changes in health and oral
cavity for gutkha users are listed on Table 1.
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Table 1.
Effect of gutkha on health. (Sankla et al. 2017)
Clinical Changes Functional Changes
Extra Oral Intra Oral
Sunken cheek Whitening of the oral mucosa Varying degree of trismus
Stiff cheek Reduced and stiff oral aperture Speech
Pseudo-proptosis Bald tongue Swallowing
Multiple perioral skin folds Discoloration of the
commissure Reduced salivary outow
Pseudo malar prominence Retracted erythematous soft
palate and uvula Dysphagia
Forward pointing uvula Hearing
Loss of tonsillar bulge Poor oral hygiene
Oral melanosis
Chronic non healing ulcers
Oral submucosa brosis
Calculus
Discoloration of tooth
Dental caries
Attrition/Erosion
Extreme sensitivity in teeth
Gingivitis
Periodontitis
Loss of gingival sulcus
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Table 2.
Studies reporting effects of tobacco chewers
Reference Country
or Region Study Design Exposure Effects
A’yun et al. 2022 West Nusa
Tenggara
Cross-Sectional
Survey
Chewers vs
non chewers
Signicant relationship between
betel chewing with periodontal
status
Bhavsar et al.
2022 India Cross-Sectional
study
Chewers vs
non chewers
Higher prevalence of dental
caries in gutkha users
Harini et al. 2022 India Case Control Chewers vs
non chewers OSF
Le et al. 2022 New York,
USA
Retrospective
study
Users’ vs
nonusers
High risk of oral lesions, bruxism
and frequent consumption of
sugary beverages and snacks
Warnakulasuriya
et al. 2022 Taiwan Cross-Sectional Chewers vs
non chewers
Oral cancer with betel quid
chewing
Ahad et al. 2021 Asia Cross-Sectional
Survey
Users’ vs
nonusers
Users have poor oral hygiene
and severe gingivitis
Anand et al. 2021 India Cross-Sectional
Survey
Users’ vs
nonusers
Periodontal destruction
signicant in ST users
Athukorala et al.
2021 Asia Literature Chewers vs
non chewers
Areca nut chewers associated
with withdrawal symptoms, peer
pressure and behavior
Dave et al. 2021 India Case Control Chewers vs
non chewers
Periodontal index and
attachment loss
Shah et al. 2021 Nepal Comparative Chewers vs
non chewers
High presence of missing teeth
in tobacco chewers
Shaik et al. 2021 India Experimental Chewers vs
non chewers
Signicant increase in plasma
glucose levels, total cholesterol
and decrease in lipoprotein
Agrawal et al.
2020 India Cross-Sectional
Survey
Chewers vs
non chewers
Clinical inammation if gingiva
was greater in placement sites
of ST
Do et al. 2020 Georgia,
USA Focus Group Users’ vs
nonusers
Addiction and gutkha use have
affected children
Table 2. Shows some of the literature that has been published in the last decade addressing the
effects related to gutkha and areca nut with its repercussions in the oral health in chewers.
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Shukhla et al.
2020
Ranchi,
India
Cross-Sectional
study
Chewers vs
non chewers
Signicant changes were
observed in serum IgA and IgG
levels in chewers
Asthana et al.
2019 India Literature Users’ vs
nonusers
High association between oral
cancer and ST
Pandey et al. 2019 India Prospective
Survey
Chewers vs
non chewers
Cause of oral, esophageal,
pancreatic and lung cancer
Verma et al. 2019 Delhi, India Cross-Sectional
Survey
Chewers vs
non chewers
ST use related to periodontitis,
bone misfortune and tooth
misfortune
Niaz et al. 2017 Asia Bibliographic Chewers vs
non chewers
Periodontal inammation,
increased arterial blood
pressure and heart rate
Rizvi et al. 2017 India Cross-Sectional
Survey
Chewers vs
non chewers
Elevated destruction in
plaque, gingival and calculus
index, pocket probing depth,
recession, and furcation
Sankla et al. 2017 India Literature Chewers vs
non chewers
High concentration of nicotine
responsible for addiction
Goyal et al. 2016 India Cross-Sectional
Survey
Chewers vs
non chewers
Consumed ST due to
advertisements and good taste
Kulkarni et al.
2016 India Cross-Sectional
Survey
Chewers vs
non chewers Plaque index higher in ST users
Singh et al. 2016 India Cross-Sectional
Survey
Users’ vs
nonusers
High percentage of recession
and clinical attachment loss in
gutkha users
Gutpa et al. 2015 India Literature Users’ vs
nonusers Oral cancer and leukoplakia
Hsiao et al. 2015 Taiwan Cross-Sectional
Survey
Chewers vs
non chewers
Plaque and gingival index, bleed
on probing, probing depth,
clinical attachment loss
Kumar et al. 2014 India Case Control Chewers vs
non chewers
Leukoplakia, erythroplakia,
reverse smoking, lichen planus
and OSF
Smita et al. 2014 New York,
USA Focus Group Users’ vs
nonusers
Social and cultural inuences
on tobacco related health
disparities
Warad et al. 2014 India Cross-Sectional
Survey
Chewers vs
non chewers
High relation with pocket
probing depth, gingival index,
and clinical attachment loss
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Willis et al. 2014 USA Experimental Chewers vs
non chewers
Organ system toxicity, critical
circulating hormone and
enzyme levels
Mallikarjuna et al.
2013 India Case Control Users’ vs
nonusers
Staining of teeth, irritation,
burning sensation and bad
breath
Mishra et al. 2013 India Literature Chewers vs
non chewers
ST is considered as a signicant
risk factor in implant patients
Jyoti et al. 2012 India Case Control Chewers vs
non chewers
Micronucleus frequency
incremented in chewers
Singh et al. 2011 India Cross-Sectional
Survey
Chewers vs
non chewers
Great association with plaque,
gingival and calculus index,
recession, mobility, furcation,
and lesions
Auluck et al. 2009 Canada Literature Chewers vs
non chewers
Oral cancer, oral precancerous
lesions
Souza et al. 2009 India Comparative Chewers vs
non chewers
Lesion such as OSF, leukoplakia,
erythroplakia, nicotine
stomatitis, palatal lesions,
actinic keratosis, and tobacco
pouch keratosis
Potentaally
Malignant lessions
Others
Periodontal
Disease
Oral
Cancer
Dental
Caries
19%13%
52% 13%
13%
Graph 1. Effects of gutkha in the health
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In Graph 1, a distribution can be observed
relating to the effects of gutkha and paan with
its consequences in the oral cavity reported by
the 31 articles referred to by Table 2. It was found
to have a high relation with periodontal disease
like gingivitis, periodontitis, bleeding on probing,
gingival recession, clinical attachment loss,
furcal lesions, increase in biolm index, calculus
index, and pocket probing depth. Periodontal
disease was a predominant problem among
chewers of gutkha and was mentioned in 51.61%
of the articles. In Graph 1, the slice referring to
others includes effects such as: bruxism, bad
breath, staining in teeth, esophageal, pancreatic
and lung cancer, increased arterial blood
pressure and heart rate.
Potentially malignant oral lesion among chewers
showed a 19.36%, and included: OSF, leukoplakia,
erythroplakia, nicotine stomatitis, palatal lesions,
actinic keratosis, tobacco pouch keratosis,
reverse smoking, and lichen planus.
Discussion
Gutkha is the most consumed presentation of ST,
especially in countries like India. It contains many
carcinogens, among them is nicotine which is
presumed to be the cause of addiction to this
product. Other carcinogens found in gutkha are
areca nut, catechu, and tobacco. (Auluck et al.
2009) Tobacco affects the general health, as it
can increase arterial blood ow and heart rate.
The consumption of ST has proven to cause
intraoral lesions that can develop to oral cancer.
These injuries cause dysplastic changes in the
mucosa which result in alterations in periodontal
and dental status. (Niaz et al. 2017)
It is noteworthy that several studies have
reported that areca nut components generate
reactive oxygen species (ROS) in the oral cavity
of chewers. However, saliva has the potential to
inhibit the production of these ROS and other
free radicals from the constituents of the betel
quid. Moreover, paan and gutkha consumption
can expose users to various oral mucosal
disorders.
Impaired glycemic status has been associated
with an increased production and accumulation
of ROS in body tissues, including the
periodontium. Thangjam and Kondaiah 2009,
demonstrated, in an experimental study, that the
oxidative stress induced by arecoline alters the
inammatory processes in human keratinocytes.
Additionally, paan and gutkha chewers have
been found to exhibit reduced salivation and
mucus formation, which decreases the normal
microora of the oral cavity and makes the oral
cavity more vulnerable to pathogens such as
Aspergillus species.
This reduced salivation may also allow
pathogens to accumulate in the supragingival
and subgingival areas, thus increasing
periodontal inammation in gutkha chewers
compared to non-chewers. (Javet et al. 2008,
Mavropoulos et al. 2001, Avasn et al. 2004, Tseng
et al. 2008, Liu et al. 2006, Ohnishi et al. 2009,
Shevalye et al. 2012, Javet et al. 2012)
Javed, 2015 conducted a study with the aim of
evaluating the clinical periodontal parameters
and the levels of IL-1β, IL-6, MMP-8 and MMP-9
in total saliva in patients who habitually chew
gutka and non-consumer patients. Forty-ve
gutka chewers and forty-ve control subjects
were included.
The researchers recorded periodontal
parameters, including plaque index (PI), bleeding
on probing (BOP), probing depth (PD) > 3 mm,
clinical attachment loss (AL), marginal bone
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loss (MBL) and the number of missing teeth.
The authors established that periodontal
inammatory conditions worsen, and levels
of IL-6, IL-1β, MMP-8, and MMP-9 in saliva were
higher among gutka chewers than nonchewers.
This nding is consistent with previous studies
conducted by Nair et al. 1990, Jeng et al. 1999,
and Javet et al. 2008, these authors suggested
that slaked lime (aqueous calcium hydroxide),
an essential ingredient in gutka, is associated
with oral mucosal inammation.
Furthermore, extracts from areca nut, which
contains arecoline as the main component,
have been found to inhibit the growth of
cultured gingival keratinocytes and periodontal
broblasts. These results may help explain
why gutka-chewers experience more severe
periodontal conditions and oral symptoms than
non-chewers.
Previous studies have stated that the effect of
smoking and ST use on the periodontal status
can be reasoned on two factors: alterations in
host tissue and response of periodontal ora.
(Warad et al. 2014) Also, the occurrence of
gingival recession has been associated with
site placement of ST product in the oral cavity.
(Ahad et al. 2021) The most common reason
given by users was peer pressure, general stress,
and advertisements. The studies have proven
that young people are the most liable to this
addiction.
Methods to quit this habit should be
implemented by health workers, relatives, and
the community. (Anand et al. 2021)
Conclusion
With the articles investigated, we conclude that
the consumption of tobacco has taken a huge
toll worldwide. The widespread of ST products
such as gutkha and paan masala has affected
all age groups. It is clear that the habit of using
tobacco without smoking produces results that
are distinct from those resulting from the sole
application of any one habit.
Even with the worst levels of oral hygiene, those
with this behavior showed the least amount
of gingival irritation. People with the frequent
habit had signicantly more teeth with gingival
recession than any other group, although
having slightly shallower periodontal pockets
overall. Therefore, it would seem that stopping
the use of smokeless tobacco in Asia should be
given top priority in order to prevent periodontal
disease. Oral cancer rates are increasing due
to the use of smokeless tobacco products,
especially among the lower socioeconomic
levels. It is crucial to reduce the adverse health
effects, by improving public health campaigns
and enhancing the access for the affected
individuals.
Therefore, programs should be implemented to
control the use of ST products, and to establish
appropriate data management, monitoring, and
to evaluate health systems.
Conicts of interest:
The authors declare that they have no conicts
of interest.
Funding:
No funding was received to assist with the
preparation of this manuscript.
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