Home  -  About us  -  Editorial board  -  Search  -  Ahead of print  -  Current issue  -  Archives  -  Instructions  -  Subscribe  -  Contacts  -  Advertise - Login 

 Table of Contents  
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 488-490

Incidental finding of oral white lesions due to tobacco chewing - A case report

1 Department of Orthodontics, University of Alabama Birmingham, Birmingham, AL, USA
2 Department of Oral and Maxillofacial Surgery, University of Alabama Birmingham, Birmingham, AL, USA

Date of Submission09-Apr-2020
Date of Acceptance19-May-2020
Date of Web Publication02-Jul-2020

Correspondence Address:
Dr. Chung How Kau
Department of Orthodontics, University of Alabama Birmingham, 1919 7th Ave South, Birmingham, AL 35294
Login to access the Email id

DOI: 10.4103/ams.ams_114_20

Rights and Permissions

The diagnosis of oral white lesions might be quite challenging. White lesions are only 5% of all oral pathologies. Smokeless tobacco (ST), also known as tobacco chewing, spit tobacco, dip, plug, or chew, is one of the well-documented agents that causes white lesions. The use of ST is associated with a variety of oral cavity lesions, including tooth decay, periodontal disease, tooth loss, leukoplakia, keratosis, oral cancers such as carcinoma-in situ, verrucous carcinoma, and invasive squamous cell carcinoma. The prevalence and severity of lesions are dose related. Therefore, it can be best predicted by the amount, frequency, and duration of ST used. This case report highlights an unusual presentation of an adolescent child presenting in the orthodontic retention phase that was originally misdiagnosed as gingival recession due to treatment. A clinical examination of the oral cavity and careful history taken should be routinely performed in every patient presenting at a dental office.

Keywords: Oral pathology, periodontology, white lesions

How to cite this article:
Buendia AM, Ying Y, Kau CH. Incidental finding of oral white lesions due to tobacco chewing - A case report. Ann Maxillofac Surg 2020;10:488-90

How to cite this URL:
Buendia AM, Ying Y, Kau CH. Incidental finding of oral white lesions due to tobacco chewing - A case report. Ann Maxillofac Surg [serial online] 2020 [cited 2021 Aug 2];10:488-90. Available from: https://www.amsjournal.com/text.asp?2020/10/2/488/288856

  Introduction Top

The diagnosis of oral white lesions may be challenging to many oral health providers (OHPs). Although white lesions represent 5% of all oral pathologies, a number of these lesions carry a substantial risk of malignant transformation. Their malignant potential varies from 0.5% to 100% depending on the course of literature.[1],[2] As a result, white lesions mandate an appropriate, and systematic approach to detection and OHPs play an important role in educating patients, diagnosing oral lesions, and preventing malignancies from developing.

The types of white lesions of the oral cavity vary significantly. Oral leukoplakia (white patch in the oral mucosa) is commonly found in 40%–50% of people who use smokeless tobacco (ST).[3] In ST, the tobacco is usually positioned against the mucosa of the mouth while the user “sucks” on the tobacco juices allowing the nicotine to be absorbed into the bloodstream without being swallowed and also cause DNA damage to the surrounding tissues.[4],[5] This mode of use allows the most dangerous carcinogen chemicals, tobacco-specific nitrosamines present in tobacco, to enter into the human body.[6] In 2001, the American Dental Association mentioned that all forms of consuming tobacco were responsible for >75% of deaths due to oral and pharyngeal cancers. According to the Committee on Energy and Commerce House of Representatives in 2010, millions of people in the United States use ST.[7],[8]

  Case Report Top

A 13-year-old male patient presented for an orthodontic consultation at the Department of Orthodontics, University of Alabama at Birmingham [Figure 1]. He was previously treated successfully and uneventfully with braces for 15 months and moved into retention [Figure 2]. The patient was educated about wearing his retainer and re-called annually for follow-up appointments.
Figure 1: Initial photos. (a-c) Before orthodontic treatment

Click here to view
Figure 2: (a-c) Posttreatment photos

Click here to view

During that 2-year follow-up visit, the patient revealed he did not use his retainer. The intraoral examination showed some Orthodontic relapse to the lower anterior teeth, and localized gingival recession was evident on his right lower free gingival margin extending from the distal surface of the right mandibular canine to the mandibular right central incisor [Figure 3]a and [Figure 3]b. There seemed to be some slightly demarcated white lesions present as compared with normal tissues. In addition, his left vestibule appeared normal [Figure 3]c. From an Orthodontic perspective, there was concern that the previous treatment rendered had resulted in buccal alveolar bone loss and gingival recession due to the non-extraction treatment plan [Figure 4]. Impressions and clinical pictures were taken for a new retainer and careful consultation made with an oral surgeon. On the patient's return, a careful social history was obtained, and it was revealed that the patient was chewing ST just like his parent was. This occurred during his baseball games and some of the games lasted over 4 h.
Figure 3: Follow-up visit. (a and b) Free gingival margin of the young patient showing localized white lesions and gingival recession on the mandibular right side; (c) healthy soft tissue in left side

Click here to view
Figure 4: Anterior crowding relapse. Localized gingival recession and leukoplakia

Click here to view

  Discussion Top

The majority of commercially available tobacco is derived from the species Nicotiana tabacum and Nicotiana rustica. Nicotine is a volatile alkaloid ingredient from those plants and is one of the most addictive drugs available commercially. ST usage is related to bad breath and a variety of oral cavity lesions, including tooth decay, tooth loss, leukoplakia, periodontal disease, keratosis, oral cancers such as carcinoma in situ, verrucous carcinoma and invasive squamous cell carcinoma.

The term “leukoplakia” is used as a provisional or definite diagnosis to classify a white patch in the oral mucosa that cannot be removed by rubbing it. Since 1984, it was decreed to avoid this term as an etiology, except in cases where tobacco was believed to be the cause. Leukoplakia describes “a whitish patch or plaque that cannot be characterized clinically or pathologically as any other disease and it is not associated with any physical or chemical causative agent except the use of tobacco.”[2]

Unlike smokers, who experience widespread periodontal destruction, the most prevalent effects of ST are localized to the site of placement, in the form of gingival recession and white mucosal lesions. In fact, epidemiological studies conducted in 940 individuals demonstrated that lesions are strongly associated with frequency and 85% of them reported to place the tobacco on the mandibular labial or buccal vestibule. These lesions may present in patients who are undergoing orthodontic treatment.[9],[10]

In this case report, the patient presented exactly with a white lesion. However, the age of the patient and the clinical setting (Orthodontic clinic for adolescents) did not preclude the diagnosis of such a lesion. Only after careful examination of the pictures and social history was the diagnosis possible. From the literature described, these lesions often improve with cessation of the habit. As such, a careful social history, clinical records (photographs), and observation were all that was required. In addition to the orthodontic retreatment, patient education and counseling on tobacco use were prescribed.

Research has shown that, when lesions are diagnosed early, the lesion heals and the dysplastic tissue improves and returns to normal. The periodontal disease seen in this report can be stopped, and the involved oral mucosa ultimately reverts to healthy upon cessation of chewing tobacco. However, ST lesions presented in adolescents may be an early indicator of high risk for oral cancer if the patient moves on to tobacco smoking or other forms of smoke inhalation. OHPs should educate patients on the initial stages of an oral lesion, ask specific questions about tobacco use, and encourage them to quit smoking.[11]

  Conclusions Top

Prompt oral diagnosis of white lesions can lead to early intervention leading to successful remission and recovery. OHPs should make a proactive effort to think beyond their specialty to identify white oral lesions and subsequently conduct counseling on the harmful chemicals of this habit ultimately preventing oral cancers.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Axéll T, Pindborg JJ, Smith CJ, van der Waal I. Oral white lesions with special reference to precancerous and tobacco-related lesions: Conclusions of an international symposium held in Uppsala, Sweden, May 18-21 1994. International Collaborative Group on Oral White Lesions. J Oral Pathol Med 1996;25:49-54.  Back to cited text no. 1
Bánóczy J. Oral leukoplakia and other white lesions of the oral mucosa related to dermatological disorders. J Cutan Pathol 1983;10:238-56.  Back to cited text no. 2
Khan Z, Khan S, Christianson L, Rehman S, Ekwunife O, Samkange-Zeeb F. Smokeless Tobacco and Oral Potentially Malignant Disorders in South Asia: A Systematic Review and Meta-analysis. Nicotine Tob Res 2017;20:12-21.  Back to cited text no. 3
Taybos G. Oral changes associated with tobacco use. Am J Med Sci 2003;326:179-82.  Back to cited text no. 4
de Geus JL, Wambier LM, Loguercio AD, Reis A. The smokeless tobacco habit and DNA damage: A systematic review and meta-analysis. Med Oral Patol Oral Cir Bucal 2019;24:e145-e155.  Back to cited text no. 5
Johnson GK, Slach NA. Impact of tobacco use on periodontal status. J Dent Educ 2001;65:313-21.  Back to cited text no. 6
Kallischnigg G, Weitkunat R, Lee PN. Systematic review of the relation between smokeless tobacco and non-neoplastic oral diseases in Europe and the United States. BMC Oral Health 2008;8:13.  Back to cited text no. 7
Wiener RC. Association of smokeless tobacco use and smoking in adolescents in the United States: An analysis of data from the Youth Risk Behavior Surveillance System survey, 2011. J Am Dent Assoc 2013;144:930-8.  Back to cited text no. 8
Jashinsky JM, Liles S, Schmitz K, Ding D, Hovell M. Risk factors for tobacco susceptibility in an orthodontic population: An exploratory study. Am J Orthod Dentofacial Orthop 2017;152:171-7.  Back to cited text no. 9
Sears CR, Hayes C. Examining the role of the orthodontist in preventing adolescent tobacco use: A nationwide perspective. Am J Orthod Dentofacial Orthop 2005;127:196-9.  Back to cited text no. 10
Crews K, Taybos G. Role of dentists in tobacco cessation programs. Hawaii Dent J 2004;35:12-3.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)  

  In this article
  Case Report
   Article Figures

 Article Access Statistics
    PDF Downloaded125    
    Comments [Add]    

Recommend this journal