Romanian Journal of Oral Rehabilitation

Vol. 13, No.4 October-December 2021

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withdrawn.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

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 Romanian Journal of Oral Rehabilitation
Vol. 13, No.4 October-December 2021
3.Genetic Factors: Genetic
predisposition may play a role in the
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.
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TYPES OF LEUKOPLAKIA
1. Homogeneous leukoplakia :
This type appears as smooth, white patches
on the 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
2. 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
3. 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
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
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Vol. 13, No.4 October-December 2021
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.
110
- 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.
- 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.
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Vol. 13, No.4 October-December 2021
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.
111
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 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
 Romanian Journal of Oral Rehabilitation
Vol. 13, No.4 October-December 2021
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
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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 micronucleated
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, micronucleated
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 chemopreventive agents. Vitamin
A given at a level of 50,000 IU/week was able
to keep the frequency of micronucleated
mucosal cells at low levels for at least a 12-
month post-treatment period, whereas beta-
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
 Romanian Journal of Oral Rehabilitation
Vol. 13, No.4 October-December 2021
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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