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withdrawn.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 development of
leukoplakia, as certain individuals may be

1
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
mucous membranes of the mouth, tongue, or
throat. The patches may vary in size and can
1
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 3. Leukoplakia patients:
typically contains one or both of the basic - Altered levels of specific biomarkers
ingredients: tobacco and/or areca nut, in raw or associated with inflammation and oxidative
processed forms. At a workshop in Kuala stress, such as interleukins (IL-6, IL-8), tumor
Lumpur, it was recommended to categorize necrosis factor-alpha (TNF-α), and
quids into clear delineations based on their malondialdehyde (MDA).
contents: areca nut quid, tobacco quid, and - Changes in salivary proteomic profiles,
tobacco and areca nut quid. Additionally, betel
including variations in the expression levels of
quid specifically refers to any quid wrapped in
proteins involved in cell adhesion,
a betel leaf, making it a distinct variety of
differentiation, and apoptosis.
quid.5
Biochemical changes of saliva in tobacco
4. Oral cancer patients:
chewers tobacco smokers, alcohol
- Elevated levels of various biomarkers
consumers, leukoplakia and oral cancer
associated with carcinogenesis, such as matrix
patients:The biochemical composition of
metalloproteinases (MMPs), vascular
saliva can be significantly altered in
endothelial growth factor (VEGF), and
individuals who engage in tobacco use, alcohol
epidermal growth factor receptor (EGFR).
consumption, and those with oral leukoplakia
or oral cancer. Here are some notable changes: - Altered expression of salivary microRNAs
(miRNAs) implicated in tumor progression
and metastasis.
1. Tobacco chewers/smokers:
- Decreased levels of certain tumor
- Elevated levels of nicotine and its
suppressor proteins, such as p53 and E-
metabolites may be present.
cadherin, and increased levels of oncoproteins
- Increased concentrations of cotinine, a
like c-Myc and Cyclin D1.
metabolite of nicotine, can be found.
- Reduced antioxidant capacity due to
These changes in salivary biochemistry reflect
decreased levels of antioxidants such as
the systemic effects of tobacco use, alcohol
glutathione and vitamins C and E.
consumption, and the pathophysiological
- Higher levels of certain enzymes linked to
processes associated with leukoplakia and oral
oxidative stress, such as myeloperoxidase.
cancer. Monitoring these biomarkers in saliva
may aid in early detection, risk assessment,
2. Alcohol consumers:
and monitoring of disease progression in
- Elevated levels of ethanol and its
affected individuals. 6
metabolites, such as acetaldehyde.
- Changes in the salivary microbiota,
Salivary IL-6 levels in oral leukoplakia with
including alterations in bacterial diversity and
dysplasia and its clinical relevance to
increased levels of potentially pathogenic
tobacco habits and periodontitis: The study
bacteria.
investigated IL-6 levels in patients with
- Decreased salivary flow rate, leading to dry
leukoplakia and coexisting periodontitis,
mouth (xerostomia) and reduced buffering
periodontitis patients without leukoplakia, and
capacity.
healthy controls. Results showed elevated IL-6
levels in leukoplakia with coexisting

1
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
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.
1
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-
carotene administered at 60 mg/week was less
effective in maintaining the protective effect.10
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.

CONCLUSION
This study explored the association between
chewing mixtures and oral cancer incidence
among groups from various geographical

1

REFERENCES
1.Rich AM, Hussaini HM, Nizar MAM,
Gavidi RO, Tauati-Williams E, Yakin M and
Seo B (2023) Diagnosis of oral potentially
malignant disorders: Overview and
experience in Oceania. Front. Oral. Health
4:1122497. Doi: 10.3389/froh.2023.1122497
2.
https://www.brighamandwomens.org/assets/
BWH/surgery/oral-medicine-and-dentistry/
pdfs/oral-leukoplakia-bwh.pdf
3.Sergio Gandolfo, Crispian Scully, Marco
Carrozzo,(2006) Oral Medicine:Churchill
Livingstone,
ISBN 9780443100376,
https://doi.org/10.1016/B978-0-443-10037-
6.50013-2
4.Maymone MBC, Greer RO, Kesecker J,
Sahitya PC, Burdine LK, Cheng AD,
Maymone AC, Vashi NA. Premalignant and
malignant oral mucosal lesions: Clinical and
pathological findings. J Am Acad Dermatol.
2019 Jul;81(1):59-71. Doi:
10.1016/j.jaad.2018.09.060. Epub 2018 Nov
14. PMID: 30447325.
1
5.Girja KP, Sundharam BS, Krishnan PA, Devi
CS. Biochemical changes of saliva in tobacco
chewers tobacco smokers, alcohol consumers,
leukoplakia and oral cancer patients. Indian J
Dent Res. 2002 Apr-Jun;13(2):102-7. PMID:
12420576.
6. Girja KP, Sundharam BS, Krishnan PA,
Devi CS. Biochemical changes of saliva in
tobacco chewers tobacco smokers, alcohol
consumers, leukoplakia and oral cancer
patients. Indian J Dent Res. 2002 Apr-
Jun;13(2):102-7. PMID: 12420576.
7.Sharma M, Bairy I, Pai K, Satyamoorthy K,
Prasad S, Berkovitz B, Radhakrishnan R.
Salivary IL-6 levels in oral leukoplakia with
dysplasia and its clinical relevance to tobacco
habits and periodontitis. Clin Oral Investig.
2011 Oct;15(5):705-14. Doi: 10.1007/s00784-
010-0435-5. Epub 2010 Jun 19. PMID:
20563615.
8.Teni T, Pawar S, Sanghvi V, Saranath D.
Expression of bcl-2 and bax in chewing
tobacco-induced oral cancers and oral lesions
from India. Pathol Oncol Res. 2002;8(2):109-
14. Doi: 10.1007/BF03033719. PMID:
12172574.
9. Stich HF, Anders F. The involvement of
reactive oxygen species in oral cancers of betel
quid/tobacco chewers. Mutat Res. 1989
Sep;214(1):47-61. Doi: 10.1016/0027-
5107(89)90197-8. PMID: 2671701.
10. Stich HF, Mathew B, Sankaranarayanan R,
Nair MK. Remission of oral precancerous
lesions of tobacco/areca nut chewers following
administration of beta-carotene or vitamin A,
and maintenance of the protective effect.
Cancer Detect Prev. 1991;15(2):93-8. PMID:
2032261.
1