ROLE OF TOBACCO USE IN THE

DEVELOPMENT AND PROGRESSION OF

LEUKOPLAKIA

Abstract: The increase in cancer mortality throughout the world justifies the study of its causes and development.
Tobacco use is implicated in the development of oral cancer, and oral leukoplakia as well. The aim of the study was
to give an overview of the connection between tobacco use and oral leukoplakia, considering the epidemiologic
patterns of tobacco habits, the prevalence of smoking in oral leukoplakia, and the effect of smoking on clinically
healthy oral mucosa. In the data, strong evidence has been found for the role of smoking in the development of both
oral cancer and oral leukoplakia.Cross-sectional studies show a higher prevalence rate of leukoplakia among
smokers, with a dose-response relationship between tobacco use and oral leukoplakia, and intervention studies show
a regression of the lesion after stopping the smoking habit.

Keywords: LEUKOPLAKIA, TOBACCO, BETEL QUID

excluded before the clinical diagnosis of
INTRODUCTION leukoplakia is made.1
Leukoplakia is “a clinical term for a white
plaque of questionable risk after having
excluded other known diseases or disorders
that carry no increased risk for cancer” . It is a
common condition, found to be present in
about 4% of the global
population.Overall,homogeneous leukoplakia
carries only a low risk of malignant
transformation but recent systematic reviews
have shown a pooled transformation
prevalence approaching 10% , so full
investigation and ongoing review of patients
with leukoplakia are essential, if practicable.
To fulfil the definition, it is important to
exclude, as far as possible, a frictional cause,
since frictional keratoses are essentially a
hyperplastic response and as such should
resolve once the initiating stimulus is
withdrawn. This might involve smoothing a
sharp cusp or wearing a bite splint to alter
cheek or tongue chewing habits. In addition to
frictional keratosis, other lesions-listed by
Warnakulasuriya et al. 2020 that may present
as oral mucosal white patches need to be
PATHOPHYSIOLOGICAL ASPECTS OF
LEUKOPLAKIA
While the exact pathophysiology of
leukoplakia is not fully understood, several
factors are believed to contribute to its
development:
1.Chronic Irritation: Persistent
irritation of the oral mucosa, often due to
factors such as tobacco use, alcohol
consumption, rough dental surfaces, or ill-
fitting dentures, can lead to the formation of
leukoplakic lesions.
2.Epithelial Hyperplasia: Chronic
irritation can induce hyperplastic changes in
the epithelial cells of the oral mucosa,
resulting in the thickening and proliferation
of the epithelial layer, which manifests as
white patches.
3.Genetic Factors: Genetic
predisposition may play a role in the

1
development of leukoplakia, as certain
individuals may be more susceptible to the
effects of chronic irritation.
4.Inflammatory Response:
Inflammation may contribute to the
pathogenesis of leukoplakia, as chronic
irritation can trigger an inflammatory
response in the oral mucosa, leading to tissue
damage and abnormal cell growth.
5.Viral Infections: In some cases,
viral infections such as human papillomavirus
(HPV) may be associated with the
development of leukoplakia, although the
exact mechanisms are not fully understood.
It is accepted that the interactions between the
oral epithelium and the underlying tissues
have clinical significance due to the fact that
such interactions would control cell
proliferation and cell migration during the
healing of oral lesions and would also play a
role in restoring tissue morphology from
postoperative conditions. On the other hand,
in a number of conditions, the epithelial
changes may be due to alterations in the
subepithelial connective tissue
leukoplakia.Overall, leukoplakia is
considered a potentially premalignant
condition, as some lesions have the potential
to progress to oral cancer over time. Regular
monitoring and management of leukoplakic
lesions are important to detect any malignant
transformation early and to prevent further
complications.
TYPES OF LEUKOPLAKIA
Homogeneous leukoplakia: This type
appears as smooth, white patches on the
1
mucous membranes of the mouth, tongue, or
throat. The patches may vary in size and can
develop anywhere in the oral cavity. They
often have a uniform texture and color.3
Nodular leukoplakia: Nodular leukoplakia
presents as raised, white lesions that may have
a rough or pebbled surface. These nodules can
vary in size and may be solitary or multiple.
They are typically found on the tongue or
inside the cheeks.4
Speckled leukoplakia: Also known as
erythroleukoplakia, this type manifests as a
mixture of white and red patches on the
mucous membranes. The white areas are
composed of keratinized tissue, while the red
areas indicate underlying inflammation or
vascular changes. Speckled leukoplakia can
be more concerning as it may indicate a
higher risk of dysplasia or malignancy.4
Verrucous leukoplakia: Verrucous
leukoplakia has a wart-like or verrucous
appearance, often with a rough surface
texture. These lesions may be white or have a
mixture of white and red areas. Verrucous
leukoplakia is less common but can be more
aggressive than other types, with a higher
potential for malignant transformation.4
These types of leukoplakia can vary in
appearance and clinical significance. While
some cases may be harmless, others may be
precancerous or indicative of underlying
health issues. It's crucial for individuals with
any signs of leukoplakia to undergo
evaluation by a healthcare professional for
proper diagnosis and management.
Oral mucosal lesions associated with betel
quid, areca nut and tobacco chewing habits.
The term “quid” refers to a substance or
mixture placed in the mouth or chewed,
remaining in contact with the mucosa. It
typically contains one or both of the basic
ingredients: tobacco and/or areca nut, in raw or
processed forms. At a workshop in Kuala
Lumpur, it was recommended to categorize
quids into clear delineations based on their
contents: areca nut quid, tobacco quid, and
tobacco and areca nut quid. Additionally, betel
quid specifically refers to any quid wrapped in
a betel leaf, making it a distinct variety of
quid.5
Biochemical changes of saliva in tobacco
chewers tobacco smokers, alcohol
consumers, leukoplakia and oral cancer
patients:The biochemical composition of
saliva can be significantly altered in
individuals who engage in tobacco use, alcohol
consumption, and those with oral leukoplakia
or oral cancer. Here are some notable changes:
1. Tobacco chewers/smokers:
- Elevated levels of nicotine and its
metabolites may be present.
- Increased concentrations of cotinine, a
metabolite of nicotine, can be found.
- Reduced antioxidant capacity due to
decreased levels of antioxidants such as
glutathione and vitamins C and E.
- Higher levels of certain enzymes linked to
oxidative stress, such as myeloperoxidase.
2. Alcohol consumers:
- Elevated levels of ethanol and its
metabolites, such as acetaldehyde.
- Changes in the salivary microbiota,
including alterations in bacterial diversity and
increased levels of potentially pathogenic
bacteria.
1
- Decreased salivary flow rate, leading to dry
mouth (xerostomia) and reduced buffering
capacity.
3. Leukoplakia patients:
- Altered levels of specific biomarkers
associated with inflammation and oxidative
stress, such as interleukins (IL-6, IL-8), tumor
necrosis factor-alpha (TNF-α), and
malondialdehyde (MDA).
- Changes in salivary proteomic profiles,
including variations in the expression levels of
proteins involved in cell adhesion,
differentiation, and apoptosis.
4. Oral cancer patients:
- Elevated levels of various biomarkers
associated with carcinogenesis, such as matrix
metalloproteinases (MMPs), vascular
endothelial growth factor (VEGF), and
epidermal growth factor receptor (EGFR).
- Altered expression of salivary microRNAs
(miRNAs) implicated in tumor progression
and metastasis.
- Decreased levels of certain tumor
suppressor proteins, such as p53 and E-
cadherin, and increased levels of oncoproteins
like c-Myc and Cyclin D1.
These changes in salivary biochemistry reflect
the systemic effects of tobacco use, alcohol
consumption, and the pathophysiological
processes associated with leukoplakia and oral
cancer. Monitoring these biomarkers in saliva
may aid in early detection, risk assessment,
and monitoring of disease progression in
affected individuals. 6
Salivary IL-6 levels in oral leukoplakia with
dysplasia and its clinical relevance to
tobacco habits and periodontitis: The study
investigated IL-6 levels in patients with
leukoplakia and coexisting periodontitis,
periodontitis patients without leukoplakia, and
healthy controls. Results showed elevated IL-6
levels in leukoplakia with coexisting
periodontitis and periodontitis patients
compared to healthy controls (P < 0.001).
Within the leukoplakia group, IL-6 levels
increased with dysplasia severity. Tobacco use
was associated with elevated salivary IL-6. IL-
6 was highlighted as a marker for leukoplakia
with dysplasia, emphasizing tobacco's
independent risk.7
Expression of bcl-2 and bax in chewing
tobacco-induced oral cancers and oral
lesions from India:The study investigated the
expression of apoptosis-regulating proteins
bcl-2 and bax in oral squamous cell
carcinomas (OSCC) and premalignant lesions
in Indian patients, primarily associated with
chewing tobacco habits. They found
overexpression of cytoplasmic bcl-2 in 56%
and bax in 43% of OSCCs. Premalignant oral
lesions, including leukoplakias and potentially
malignant disorders, also exhibited aberrant
expression of bcl-2 (16%) and bax (55%).
While some oral cancers demonstrated
concurrent deregulation of p53 and bcl-2
(30%), and p53, bcl-2, and bax (14%), none of
the oral lesions showed deregulation of all
three genes simultaneously. Interestingly, a
subset of oral lesions showed overexpression
of bax in the absence of p53 and bcl-2
proteins. Positive nodal status correlated
significantly with bcl-2 expression and co-
expression of p53 and bcl-2 in oral cancers.
Survival analysis revealed higher survival rates
in patients with p53-negative tumors compared
to p53-positive tumors. These findings suggest
frequent overexpression of apoptosis
regulators in oral cancers and early events in
oral carcinogenesis, highlighting the potential
1
roles of bcl-2 and p53 in tumorigenesis by
evading apoptosis and allowing additional
genetic alterations to accumulate.8
Role of p53: The role of p53, a tumor
suppressor gene, in leukoplakia is significant.
Mutations in p53 can lead to uncontrolled cell
growth and contribute to the development of
leukoplakia. P53 acts as a guardian of the
genome, regulating cell cycle progression,
DNA repair, and apoptosis (programmed cell
death). When p53 function is impaired, cells
with damaged DNA can accumulate,
potentially leading to the formation of
leukoplakia lesions and, in some cases,
progression to cancer. Therefore, studying p53
expression and mutations in leukoplakia can
provide insights into its pathogenesis and
potential for malignant transformation.9
REMISSION OF ORAL
PRECANCEROUS LESIONS OF
TOBACCO/ARECA NUT CHEWERS
FOLLOWING ADMINISTRATION OF
BETA-CAROTENE OR VITAMIN A, AND
MAINTENANCE OF THE PROTECTIVE
EFFECT
Research has shown that the administration of
beta-carotene or vitamin A can lead to the
remission of oral precancerous lesions in
tobacco and areca nut chewers. Furthermore,
the protective effect of these supplements can
be maintained over time. Beta-carotene and
vitamin A are known for their antioxidant
properties, which can help counteract the
oxidative stress and DNA damage caused by
tobacco and areca nut consumption.
Additionally, these supplements may support
immune function and promote the
differentiation of abnormal cells, contributing
to the regression of precancerous lesions.
However, it’s essential to consult a healthcare
professional before starting any
supplementation regimen, as individual
responses may vary, and proper dosing is
crucial for safety and efficacy.
Designs of intervention trials are based on
results from a multitude of disciplines. In this
study, a comparative analysis of various
chewing mixtures used by groups from
different geographical locations (Guam, Peru,
Taiwan, the Philippines, and India) and their
link to oral cancer incidences was used to
trace the ingredients responsible for oral
carcinogenesis among chewers. The
usefulness of applying intermediate endpoints
in intervention trials was examined by
comparing the response of micronucleated
mucosal cells and oral leukoplakia of chewers
of tobacco-containing betel quids to the twice
weekly administration of beta-carotene (180
mg/week), vitamin A (100,000 IU/week or
200,000 IU/week), and beta-carotene (180
mg/week) plus vitamin A (100,000 IU/week).
A reduced frequency of micro nucleated
mucosal cells and remission of leukoplakias
resulted following a 3- to 6-month treatment.
The development of new leukoplakias was
also inhibited. The various endpoints differed
in degree and time course to the
administration of beta-carotene and vitamin A.
Following termination of the beta-carotene or
vitamin A administration, micro nucleated
cells and leukoplakia recurred in the oral
cavity of chewers who continued this habit
throughout the trial period. Attempts were
made to maintain the protective effect
achieved by the treatment with relatively high
doses of the chemo preventive agents. Vitamin
A given at a level of 50,000 IU/week was able
to keep the frequency of micro nucleated
mucosal cells at low levels for at least a 12-
month post-treatment period, whereas beta-
1
carotene administered at 60 mg/week was less
effective in maintaining the protective effect.10
CONCLUSION
This study explored the association between
chewing mixtures and oral cancer incidence
among groups from various geographical
locations. Intervention trials were conducted to
assess the efficacy of beta-carotene and
vitamin A in reducing micronucleated mucosal
cells and remitting leukoplakias in tobacco-
containing betel quid chewers. Results showed
a decrease in micronucleated cells and
leukoplakias following 3- to 6-month
treatment, with inhibition of new leukoplakia
development. However, recurrence occurred
upon cessation of treatment among continued
chewers. Maintenance of the protective effect
was attempted using high doses of
chemopreventive agents, with vitamin A
(50,000 IU/week) showing better efficacy than
beta-carotene (60 mg/week) in sustaining
reduced micronucleated cells over a 12-month
post-treatment period. It investigated the role
of p53 expression in patients with leukoplakia
and carcinoma of the tongue, focusing on its
association with tobacco use.
Immunohistochemistry was employed to
assess p53 expression. Notably, all patients
with leukoplakia of the tongue were male
tobacco users. This suggests a potential link
between tobacco use and the leukoplakia.
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