Palatal changes in reverse and conventional smokers e A clinical comparative study in South

India

Aim: To evaluate the effect of type of smoking on palatal mucosa in patients attending a
dental institution in South India. Design: A cross-sectional comparative study on palatal
changes in conventional and reverse smokers was performed. A total of 150 patients of
various age groups were selected from the outpatient department with habit of smoking
(reverse and conventional), according to the inclusion and exclusion criteria. The oral
findings were properly examined by qualified dentists and findings were noted on a specified
Proforma. The palatal changes were graded according to the classification given by Ramulu
et al (1972) with few modifications. Fisher‟s exact test and ManneWhitney U-test were used
to determine any significant differences between the groups. Spearman‟s rank correlation
coefficient test was used to determine any significant association between groups. Results:
Out of 150 patients, 86 males & 64 females participated in the study. A statistically
significant female predominance (n ¼ 63/77) was observed in reverse smokers when
compared conventional smokers (n ¼ 1/57). Reverse smokers were observed to have more
severe palatal changes than conventional smokers. In reverse smokers, frequency of smoking
had a significant effect on palatal mucosa than duration of smoking. Conclusion: The present
study has reported an increased prevalence of reverse smoking in female subjects, which
produced deleterious changes in them when compared to con- ventional smokers. Such habit
can be prevented before spreading from one place to another with proper education in the
low socioeconomic community thus preventing oral cancer. Keywords: Oral cancer,
Tobacco, Cigarette smoking, Palate, Leukoplakia.

Introduction : Reverse smoking is a common social practice in some parts of coastal India.
This practice includes smoking of “chutta”, a type of homemade cigar in reverse direction.
The habit of reverse smoking which is common in certain parts of coastal India (Andhra
Pradesh) is called as “Adda Poga”. This habit mainly presents with placing the fired extreme
of cigarette inside the mouth, while the other end is held between teeth and lips. The seal
provided by the lips allow slow inhalation of chutta. Air is supplied to the zone of
combustion through the non heated extreme of chutta. The smoke is expelled from the mouth
and ashes are thrown out or swallowed. The lips keep chutta wet which increases its time of
consumption from 2 to 18 min. The word “chutta” is derived from the Tamil word “churutu”
which means “to roll or fold”. It is made of dried twigs of home grown tobacco and is rolled
crudely in a semi-dried tobacco leaf. The clinical manifestations of the oral mucosa in
patients with reverse smoking habit were reported to vary from con- ventional to non-
smoking individuals. The most commonly affected areas in reverse smokers are palate and
tongue. Saunders (1958) described these palatal changes as a papular leukoplakia in the
palate, caused by tobacco smoke striking the palate more directly than other regions.
Schwartz (1965) also thought that this type of lesion was caused by tobacco. Ramulu et al
(1973) described the changes in palate due to reverse smoking as nicotina stomatitis, but
Gloria J et al (2008) preferred to use the term „palatal keratosis associated with reverse
smoking‟ because, nicotine is not the only etiological factor for intra oral lesions in reverse
smokers, instead heat with various other components of tobacco combustion contribute to the
development of palatal lesions. Various studies on the habit of reverse smoking have focused
on the prevalence and characterization of clinical and histological changes in the oral
mucosa. However, sufficient clinical data comparing the palatal changes in smokers and
reverse smokers is not available. Hence a study was under- taken to evaluate the effect of
type of smoking on palatal mu- cosa, in patients attending a dental institution in South India.

Methods : A total of 150 patients of various age groups were selected from the outpatient
department with habit of smoking (reverse or conventional smoking). The study was
conducted for a period of 6 months. Participants in the study were divided into 2 groups.
Group I (reverse smokers) constituted of subjects having reverse smoking habit. Group II
(conventional smokers) constituted both conventional chutta and cigarette smokers.
Necessary care was taken to include only those smokers who had the habit of smoking from
a minimum of 6 months. Lesions that are not associated with habit of smoking were
excluded. After obtaining permission from the Institutional ethical committee subjects were
selected according to the inclusion and exclusion criteria. All the subjects with reverse
smoking habit were initially counseled and educated regarding the adverse effects of reverse
smoking and necessary care was taken to include all the reverse smokers who visited our
department during this time period. The study procedure was explained to the subjects in the
local language and a written consent was taken. The oral findings were properly examined by
the qualified dentists and findings were noted on a speci- fied Proforma. The palatal changes
were evaluated in subjects according to the grading system proposed by Ramulu et al.6 But
the grading system was purely based on premalignant changes in palate, hence few
modifications were done and a modified grading system was used, which included e no
palatal changes (Grade 0), mild (Grade1), moderate (Grade 2) and severe (Grade 3) form of
lesions along with a 5th category, “palatal carcinoma” (Grade 4). Each grade was defined and
described in Table 1. The collected data was entered in a spreadsheet (Excel 2007, Microsoft
Office) and analyzed using, statistical analysis software (SPSS version 16.01, SPSS. Inc.,
Chicago, 1989e2007). Fisher‟s exact test and ManneWhitney U-test were used to determine
any significant differences between the groups. Spearman‟s rank correlation coefficient test
was used to determine any significant association between groups. Sig- nificance was set at
0.05 level (P < 0.05).

Results : The total study sample constituted of 150 subjects (86 males and 64 females). Out
of 86 male subjects 72 were conventional smokers (56 conventional chutta smokers, 16
conventional cigarette smokers) and 14 were reverse smokers. In a total of 64 female subjects
63 were reverse smokers and only 1 subject reverse smokers was significantly higher in
females (98.4%) when compared to males (16.3%), [p ¼ 0.001 (p < 0.05)]. Clinically the
palatal changes in conventional and reverse smokers were analyzed (Table 2). Maximum
number of sub- jects with conventional smoking habit had mild palatal changes (63%).
Most reverse smokers had moderate (37.7%) and severe palatal changes (31.2%). The palatal
lesions were found to be more severe in reverse smokers than conventional smokers [z ¼
6.270, n ¼ 150, P ¼ 0.000 (P < 0.05)]. Three cases of palatal carcinoma were recorded in the
study. Interestingly all the 3 members were females and reverse smokers. Man- neWhitney
U-test was done to evaluate any difference in the palatal changes in males and females in
reverse smokers. But significant differences were not obtained. When palatal changes were
compared with duration of smoking in reverse smokers, 63.3% of subjects smoking more
than 46 years presented with severe palatal changes (Table 3). Three smokers with palatal
carcinoma were present in 3 different groups, which included smoking habit less than 15
years, 16e30 years and 31e45 years respectively. No significant association was obtained
between palatal changes and duration of smoking in reverse smokers. Pearson corre- lation
test was performed to evaluate any correlation between duration of smoking and palatal
changes in reverse smokers. But no statistically significant correlation was obtained.
Similar results were obtained in conventional smokers. When palatal changes were compared
with frequency of smoking in reverse smokers, significant differences were ob- tained
between groups [p ¼ 0.007 (p < 0.05)]. 100% of the pa- tients who smoke 4 chuttas per day
were in the group of severe palatal changes (Table 4). A weak positive correlation was
obtained between frequency of smoking and palatal changes in reverse smokers [r ¼ 0.382,
P ¼ 0.001 (P < 0.05)]. No significant association was obtained between frequency of
smoking and palatal changes in conventional smokers.
Discussion : The habit of reverse smoking is a peculiar custom in low economic groups
with high frequency in women, especially after 3rd decade of life.1 There are only very few
areas in the world with an unusual presentation of this habit, that seem to spread through
generations. The habit of reverse smoking has been reported from America (the Caribbean
area, Columbia, Panama, and Venezuela), Asia (South India), and Europe (Sardinia).
Pindborg et al and Gavarasana et al reported an increased prevalence of reverse smokers
among females than males. Similar results were obtained in our study where out of 77 reverse
smoking subjects 63 were females. The female predominance in reverse smoking can be
attributed to the following reasons: e (a) They wanted to keep it secret from their husbands.
(b) Generally fishermen and women work in water; hence splashes of water may extinguish
the fire of chutta. (c) To prevent hot ashes falling on children and clothes at the time of
nursing. (d) As a treatment for toothache as it produces soothing sensation. (e) Continued as
tradition from generations. Mercado-Ortiz et al reported an increased incidence of palatal
changes (96.7%) in reverse smokers. The present study also reported 98.7% (76/77) reverse
smokers with palatal changes which was in favor of previous study. An increased tendency
towards development of palatal cancer in reverse smoking has been reported in the
literature. Ramulu et al re- ported oral cancer in 2.4% of the patients who presented nicotinic
stomatitis due to reverse smoking. Similar results were obtained in our study. Out of 77
reverse smokers 3 sub- jects (3.9%) had carcinomatous transformation of palatal lesions. Heat
might be considered as an adjunct for carcinogenic agents. Malik S.K. et al in his study
reported deposition of high concentrations of TPM (total particulate matter) in oro-
pharyngeal region during reverse smoking. The smoke emitted from chutta contains high
concentration of alkaline pH, which facilitates maximum absorption of substances like
nicotine alkaloid, reducing sugars, and nitrogen. The heat produced during reverse smoking
ranges from 300 to 360 C, which acts as co-carcinogen and accelerates neoplastic changes.
The presence of reverse smoking habit as a custom was reported in the regions of Srikakulam
district of Andhra Pra-desh in Indian subcontinent (Reddy et al, 1974). The present study
reports a similar habit of reverse smoking even in the coastal regions of east and west
Godavari districts of Andhra Pradesh. As this habit is practiced since long time in this re-
gion, the smokers usually get exposed to reverse smoking for a prolonged period. Hence the
effect of duration and frequency of reverse smoking were also evaluated in our study. Inter-
estingly we observed that the frequency of smoking had a significant impact on palatal
changes than the duration of smoking. 100% of subjects who smoke 4 chuttas per day
(maximum number of chuttas used by a reverse smoker in our study) were found to have
severe palatal changes. But this cannot be attributed to subjects in the palatal carcinoma
group, as Carcinogenesis can be multifactorial and varies from person to person. Smoking is
a dangerous habit and its effects will be severe in case of reverse smoking. Such habit can be
prevented from spreading one place to another with proper education thus preventing oral
cancer. Our study reported high prevalence of reverse smokers among female subjects.
Interestingly most of these reverse smokers belong to fishermen and agricultural communities
living in village areas near to the coastline of West Godavari district of Andhra Pradesh,
India. There were few differences identified in these two groups (fishermen & agricultural
group) in the way they smoke. They also differ in their reasons for adapting reverse smoking.
Hence there is a need for further research and epidemiological survey per- taining to the habit
of reverse smoking in these 2 groups. Grade 0: No palatal changes. Grade 1: Mild palatal
changes Red circular areas over a slightly raised blanched mucosa of the glandular zone of
the hard palate. Grade 2: Moderate palatal changes Papules of 2e4 mm with central
umbilication less than 2 mm of diameter. Moderate changes include sub-acute to chronic
inflammatory mucosal changes associated with hyperkeratinization and premalignant changes
like leukoplakia. Grade 3: Severe palatal changes Papules greater than 4e5 mm in size
characterized by crater like ulcerations surrounded by keratinization. It is often represented
as a burn type of reaction of the palatal mucosa due to the intense heat of the lightened end
of chutta, associated with hyperkeratosis. Commonly seen in reverse smokers. Grade 4:
Palatal carcinoma Invasive malignant tumor involving palate associated with chronic
ulcerations which are confirmed by biopsy.