The Case of a Smokeless Tobacco-associated White Lesion

A 46-year-old male was seen at the general practice clinic for routine dental care. The resident noticed a white lesion in the anterior lower vestibule. Although there was a history of smokeless tobacco placement at this site, the patient had quit at least 12 months ago.

The white lesion appeared to be more than just a surface change. It was firm on palpation with approximate dimensions of 10 x 4 mm. Gingival recession adjacent to the site of placement was also noted. 

White lesion at the site of smokeless tobacco placement

The persistence of this lesion despite cessation of habit was a little concerning (smokeless tobacco keratosis disappears within two weeks of changing placement site), so a biopsy was recommended. The histopathology report described the epithelial changes as atypical and the underlying connective tissue as scar tissue.  Since the pathologist's comment on the epithelial changes did not rule out a premalignant process, the patient was told to return for regular follow-ups.

In my opinion, the changes seen in this case were more suggestive of a reactive etiology. Repeated placement had probably resulted in the formation of scar tissue at this site. 

It is extremely rare to develop oral squamous cell carcinoma with Swedish and some American types of smokeless tobacco. But since the risk is there, the American Dental Association maintains smokeless tobacco in its list of oral carcinogens. 

It is also important to understand that the composition of smokeless tobacco is highly variable throughout the world. In places like Sweden, scientific studies have affirmed the safety of smokeless tobacco. It is now recommended as a smoking-cessation aid in these parts. However, in places like Pakistan, the story is very different. Majority of cancers in the northern part of the country are a result of smokeless tobacco (Niswar) use.