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Q ui by N ht pyrig ORIGINALoARTICLE N ot C for Pu bli Related to Tobacco Use tand cation ess c e en Study on Swiss Arm...

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pyrig ORIGINALoARTICLE N ot C for Pu bli Related to Tobacco Use tand cation ess c e en Study on Swiss Army Recruits

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Oral Mucosal Findings Alcohol Consumption: A Involving Self-Reported and Clinical Data

Reto Morgera/Christoph A. Ramseierb/Terry D. Reesc/Walter B. Bürgina/ Michael M. Bornsteina,d

Purpose: The aim of the present study was to assess the oral mucosal health status of young male adults (aged 18 to 24 years) in Switzerland and to correlate their clinical findings with self-reported risk factors such as tobacco use and alcohol consumption. Materials and Methods: Data on the oral health status of 615 Swiss Army recruits were collected using a standardised selfreported questionnaire, followed by an intraoral examination. Positive clinical findings were classified as (1) common conditions and anatomical variants, (2) reactive lesions, (3) benign tumour lesions and (4) premalignant lesions. The main locations of the oral mucosal findings were recorded on a topographical classification chart. Using correlational statistics, the findings were further associated with the known risk factors such as tobacco use and alcohol consumption. Results: A total of 468 findings were diagnosed in 327 (53.17%) of the 615 subjects. In total, 445 findings (95.09%) were classified as common conditions, anatomical variants and reactive soft-tissue lesions. In the group of reactive soft-tissue lesions, there was a significantly higher percentage of smokers (P < 0.001) and subjects with a combination of smoking and alcohol consumption (P < 0.001). Eight lesions were clinically diagnosed as oral leukoplakias associated with smokeless tobacco. The prevalence of precursor lesions in the population examined was over 1%. Conclusions: Among young male adults in Switzerland, a significant number of oral mucosal lesions can be identified, which strongly correlate with tobacco use. To improve primary and secondary prevention, young adults should therefore be informed more extensively about the negative effects of tobacco use on oral health. Key words: alcohol consumption, epidemiology, oral lesions, oral mucosal alterations, tobacco use, young adults Oral Health Prev Dent 2010; 8: 143–151.

espite the efforts taken by the World Health Organization (WHO) to encourage epidemiological studies on oral lesions (WHO, 1980), the number of publications on oral mucosal findings remains

D a

Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern, Bern, Switzerland.

b

Department of Periodontology, School of Dental Medicine, University of Bern, Bern, Switzerland.

c

Departement of Periodontics, Texas A&M University Health Science Center, Baylor College of Dentistry, Dallas, TX, USA.

d

Dental Services of the Swiss Army, Bern, Switzerland.

Correspondence: Dr Michael M. Bornstein, Department of Oral Surgery and Stomatology, Freiburgstrasse 7, CH 3010 Bern, Switzerland. Tel: +41 31 632 25 45/66. Fax: +41 31 632 98 03. Email: [email protected]

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Submitted for publication: 09.10.08; accepted for publication: 06.01.09.

limited (Kleinman et al, 1991). In Switzerland, there have been four epidemiological studies so far addressing oral health aspects: one study carried out in 1970 at the Swiss military base in Zurich and the other three in 1974, 1985 and 1996 at the Swiss military base in Thun. Within the framework of interdisciplinary surveys on oral health status, these investigations primarily focused on the prevalence of caries (Jaeggi et al, 1999; Menghini et al, 2001) and periodontal disease (Curilovic et al, 1972, 1980; Germann et al, 1973; Joss et al, 1992; Lang et al, 2001; Rothlisberger et al, 2007). Furthermore, these studies were able to document a long-term reduction in caries and an improvement in the periodontal health of young 143

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At the Swiss Army base for mechanised and armoured troops in Thun, Switzerland, 628 recruits

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Swiss male adults. However, similar studies investigating the prevalence of oral mucosal lesions are lacking in Switzerland. Epidemiological investigations of oral mucosal alterations in general have been limited to specific lesions (e.g. leukoplakia) with the same clinical appearance (Axell, 1987) or comparable aetiology (Mornstad et al, 1989). Moreover, the distribution of oral lesions was frequently examined in selected populations within a particular institution or in populations with exposure to a specific risk factor (Axell et al, 1990; Ikeda et al, 1995; Zain et al, 1997). In 1976, Axell investigated the prevalence of oral lesions in a Swedish population of 30,118 subjects with an average age of 43 years. In his study, he identified 60 different oral mucosal findings, some of which showed a remarkably high prevalence: Fordyce’s spots (82.80%), leukoedema (49.07%) and geographic tongue (8.45%). In a comparable study from the United States, Bouquot (1986) summarised the distribution of oral mucosal findings in a cohort of 23,616 individuals. The prevalence of alterations in the oral mucosa from his sample (average age 55.90 years) was 10.30% (i.e. 3783 oral mucosal findings among 2824 subjects). In two recent studies, the prevalence of alterations in the oral mucosa ranged from 27.90% (Shulman et al, 2004) to 61.60% (Kovac-Kovacic and Skaleric, 2000). Shulman et al (2004) found a significant increase in the number of oral mucosal alterations as a function of age, gender, ethnicity, tobacco use and the wearing of removable prosthetics. The primary objective of the present study was to determine the prevalence and topographical locations of oral mucosal findings in 18- to 24-year-old male adults from Switzerland. As presented in a similar survey in 1985 (Joss et al, 1992), the ethnicity and socioeconomic status of recruits at the Swiss Army base in Thun, Switzerland, represent a typical distribution in the young Swiss male population. Therefore, data on the oral health status of these recruits were collected using a standardised selfreported questionnaire, followed by an intraoral examination. The secondary objective of the present study was to evaluate the correlations between alterations found and the known risk factors such as tobacco use and alcohol consumption.

pyrig No Co t fo rSD: aged 18 to 24 years (mean: 20.0 years; Pu 0.91) were selected on the basis of the availability ofbltheir ica section during the period of detailed basic militarytion t drafted into training in the third week after being e ss e n c e

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active service. The examination and data collection were performed following the guidelines of the World Medical Association Declaration of Helsinki (version 2002; www.wma.net/e/policy/b3.html). The present study was carried out with the ethical approval of the Swiss Army Dental Corps. Care was taken to select a sample representative of the young Swiss male population based on the information obtained from the Swiss Federal Statistical Office (SFSO, 2006) with regard to different languages and geographical distribution of the Swiss population. The examinations were performed in cohorts of 20 recruits, totaling about 90 subjects per day for seven working days. The examinations included an assessment of the prevalence of dental caries based on clinical and radiographic evaluation, an inspection of the oral cavity for oral mucosal alterations and halitosis, an assessment of erosive lesions of the hard structures of all teeth, and an evaluation of the functional aspect of the masticatory system.

Methods Prior to clinical examination, the subjects were asked to fill out a self-reported questionnaire that included personal data, subjective oral health information, history of tobacco use (cigarette smoking) and alcohol consumption. The history of tobacco use was recorded in pack-years. A pack-year was defined as the consumption of one pack (20 manufactured cigarettes) per day over a period of 1 year. Subsequently, all of the subjects were clinically examined by an experienced oral medicine specialist following a standardised protocol based on the guidelines of the WHO (Kramer et al, 1980). Following an extraoral examination, a systematic intraoral examination was performed on all subjects using the following instruments: two dental mirrors (Deppeler steel mirror FB1, Deppeler, Rolle, Switzerland), a dental explorer (Deppeler Probe DH 2, Deppeler), a wooden tongue depressor (Appli-set, Applimed, Châtel-St-Denis, Switzerland) and sterile, folded compresses (MediSet, IVF Hartmann, Neuhausen, Switzerland). All of the oral mucosal alterations found were correlated with their particular intraoral locations and transferred to a second recording sheet for the topographical classification of oral mucosal findings (Roed-Petersen and Renstrup, 1969). The clinical Oral Health & Preventive Dentistry

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The clinical diagnosis of oral mucosal lesions was made on the basis of the clinical appearance and the diagnostic criteria presented by Axell (1976). No biopsies were taken nor laboratory tests performed. The terms ‘fibromatous lesion/mesenchymal neoplasia’ and ‘papillomatous lesion/epithelial neoplasia’, for example, lesions suspected to be associated with a human papillomavirus infection, refer to the clinical diagnosis in the absence of a pathohistological verification. Therefore, irritation fibroma was classified as a reactive lesion when the presence of a causative mechanical factor was evident. In the absence of such a factor, the lesion was declared as a neoplastic fibroma or fibromatous lesion—taking into consideration that without a histopathological examination, other benign neoplasias could be present—and categorised into the ‘benign tumour lesions’ group. For every subject in whom at least one potentially premalignant lesion was identified, further data were recorded, including queries about the presence of risk factors such as tobacco use and alcohol consumption. Furthermore, all of the subjects with one or more lesions of this kind were given detailed information on the premalignant nature of the lesion, the possible aetiology and the prognosis, together with a recommendation for a biopsy and regular follow-up visits.

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1) Common conditions and anatomical variants: this group comprises frequent soft- and hard-tissue findings without clinical pathology (e.g. fissured tongue or torus mandibularis) (Antoniades et al, 1998). 2) Reactive lesions: this group includes mucosal alterations caused by exogenous or endogenous irritant factors (Huber, 2006). 3) Benign tumour lesions. 4) Premalignant lesions: this group includes soft-tissue lesions that were clinically diagnosed as having the potential to become cancerous (Warnakulasuriya et al, 2007).

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findings were assigned to the following classes of oral mucosal alterations:

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Fig 1 Number of subjects reporting alcohol consumption or tobacco use out of 615 subjects included in the analysis.

Descriptive part: the Excel spreadsheets were used for the descriptive analysis of all data collected on the types and locations of the alterations identified. Analytical part: the data were processed and analysed using the SASâ statistics package (SAS/STATâ, version 8, SAS Institute, Cary, NC, USA). Frequency tables were generated for the occurrence of all the alterations and their locations. The probability of the occurrence of both an individual finding and an alteration at a particular location was calculated performing logistic regression and Fisher’s exact test in subjects exposed to either tobacco, alcohol or both. Similarly, the data from the self-reported questionnaire on oral mucosal alterations were analysed as a function of tobacco use and/or alcohol consumption.

RESULTS Population The age of the 628 subjects ranged from 18 to 24 years (mean: 20.0 years; SD: 0.91). The percentage of recruits from the French-speaking and the Germanspeaking cantons of Switzerland was 23.88% (n = 150) and 76.11% (n = 478), respectively. Thirteen recruits had to be excluded from the analysis because of their failure either to complete the questionnaire or to take part in the oral examination.

Statistical analysis

Tobacco use

The data collected using both the self-reported questionnaires and the clinical examinations were entered on Excel spreadsheets for statistical analysis (Microsoftâ Excel 2004, Microsoft, Redmond, WA, USA).

From the total of 615 recruits included in the analysis, 31.38% (n = 193) were smokers (Fig 1), with 44.04% (n = 85) reporting a 1- to 2-pack-year history, 47.67% (n = 92) reporting a 3-pack-year history and 8.29% (n = 16) reporting a 4-pack-year history or

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Only 13.85% of the subjects reported alterations of their oral mucosa. These subjects revealed recurring aphthous lesions (9.43%) and herpes labialis (4.42%). In the group of 58 subjects reporting recurring aphthous lesions, the percentage of smokers and the number of subjects with a history of alcohol consumption were significantly lower (P < 0.01) than in the overall study population.

Overall clinical findings No oral mucosal alterations were observed in 288 subjects (46.83%). This subgroup was further divided into (1) 206 non-smokers and 82 smokers or (2) 117 subjects with a history of alcohol consumption and 171 with no history of alcohol consumption. Among the remaining 327 recruits diagnosed with oral mucosal findings, a total of 468 alterations were identified (Table 1). This figure reveals a prevalence of at least one alteration in 53.17% of the subjects examined. Most of the alterations found (95.09%; n = 445) were classified as common conditions and anatomical variants (46.58%; n = 218) or reactive lesions (48.50%; n = 227). The benign tumour lesions accounted for just slightly > 2.99% (n = 14). Finally, nine premalignant lesions were found (1.92% prevalence of all detected lesions) (Table 1).

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Of all the recruits questioned, 60.98% (n = 375) revealed a history of alcohol consumption (Fig 1), almost 40% of the recruits reported not to consume alcohol on a regular basis; 24.88% (n = 153) reported a history of both alcohol consumption and smoking. Finally, 32.52% (n = 200) reported neither regular alcohol consumption nor tobacco use in the questionnaires.

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above. No statistically significant difference in the percentage of smokers was observed between the French–Italian-speaking and the German-speaking recruits. An interest to quit smoking was expressed only by 59.07% (n = 114) of smokers.

pyrig No Co tf r P found (Table 1). These alterations were mostooften ub and in the buccal plane (linea alba, leukoedema lica Fordyce’s spots) and the tongue (fissured tongue,tion t geographic tongue and hairy tongue). eInss13 e e n csub-

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jects (four smokers and nine non-smokers), both geographic tongue and fissured tongue were demonstrated. In subjects with suspected ethnic pigmentation, 19 were non-smokers and only 12 recruits were smokers reporting a history of < 1 pack-year.

Reactive lesions Reactive lesions constituted the largest group of all lesions found. A total of 227 (48.50%) reactive lesions were diagnosed in the entire population, while lesions associated with a mechanical irritation accounted for the highest proportion of all oral mucosal findings within this group (Table 1). A total of 227 reactive lesions were identified in 128 non-smokers and 99 in smokers. The percentage of smokers in this group was significantly higher (P < 0.001) than the number of smokers in the general population. A total of 25 tobacco-associated reactive benign alterations (23 smoker’s melanosis and 2 leukokeratosis nicotina palati/smoker’s palates) were diagnosed. All of the subjects presenting with these lesions reported an average of > 3 packyears. Apart from an increased use of tobacco, these subjects reported increased consumption of alcohol, reaching statistical significance in comparison with the entire study population (P < 0.05). Within the entire study population, a total of 15 aphthous lesions (12 in non-smokers and 3 in smokers) were found. Herpes labialis was not present in any of the recruits examined. Mycotic lesions were diagnosed only in four subjects (all of whom were smokers), presenting as a median rhomboid glossitis in the clinical examination.

Benign tumour lesions Of the 14 (2.99%) benign tumour lesions (e.g. fibromatous lesion and papillomatous lesion) identified in the study population (4 in non-smokers and 10 in smokers), a significantly higher percentage of smokers presented with a clinically diagnosed papillomatous lesion (n = 3; P < 0.001) (Table 1).

Common conditions and anatomical variants

Premalignant lesions

Common conditions and anatomical variants accounted for a high percentage (46.59%; n = 218)

In nine of the recruits examined (prevalence 1.46%), a premalignant lesion was detected (eight subjects

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Common conditions and anatomical variants Soft tissue Linea alba (intercalary line) Fordyce’s spots Lingua geographica (geographic tongue) Lingua plicata (fissured tongue) Ethnic pigmentation Leukoedema Lingua villosa (hairy tongue) Hard tissue (exostosis) Torus mandibularis Torus palatinus Total Reactive lesions Reactive hyperplasia Irritation fibroma Mechanical/chemical irritation Scar tissue Cheek and lip biting (morsocatio lab/bucc) Piercing-related lesion ‘Mucocele’ Angular cheilitis Tobacco-associated benign reactive alterations Smoker’s melanosis Leukokeratosis nicotina palati Aphthae (minor, major) Mycotic lesions Glossitis rhombica media Total Benign tumour lesions Soft-tissue lesions Fibromatous lesion/mesenchymal neoplasia Papillomatous lesion/epithelial neoplasia Miscellaneous Total Premalignant lesions Oral leukoplakia (OL) Oral lichen planus (OLP) Total Total of all oral mucosal findings

56 41 38 28 21 6 3

19 12 9 8 2 4 2

37 29 29 20 19 2 1

44** 24 20 16 8 3 1

12** 17 18 12 13 3 2

21 4 218

6 1 63

15 3 155

13 1 130

8 3 88

5

1

4

2

3

133 31 8 4 2

47 10 6* 2 1

86 21 2* 2 1

87 18 5 3 2

46 13 3 1 0

23 2 15

23*** 2** 3

0*** 0** 12

19 2 7

4 0 8

4 227

4*** 99***

0*** 128***

3 148

1 79

3 3 8 14

2 3*** 5 10

1 0*** 3 4

2 3 3 8

1 0 5 6

8 1 9 468

2 0 2 174

6 1 7 294

3 1 4 290

5 0 5 178

with oral leukoplakia [OL] and one subject with suspected oral lichen planus [OLP]). The predominant OLP localised on the lateral margin of the tongue was identified as the asymptomatic papular-reticular type. In all eight subjects with OL (five of whom were assigned to the same platoon), homogeneous Vol 8, No 2, 2010

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pyr Co etigal No Morger t fo rP Table 1 Overview of all 468 oral mucosal findings in 327 recruits and their distribution according to smoking or alcohol ub lica consumption (*P < 0.05; **P < 0.01; ***P < 0.001) tio n te alcohol Overall Smoking Non-smoking Alcohol No ss e n c e consumption consumption

leukoplakia was found in the maxillary anterior vestibule. Upon further enquiry, all of the subjects with suspected OL reported regular consumption of smokeless tobacco (ST). The site of application (anterior maxillary vestibule) of the ST was congruent with the location of the OL found. Six recruits with 147

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Table 2 Topographical distribution of the 468 oral mucosal lesions diagnosed, in consumption (*P < 0.05; **P < 0.01)

pyrig No Co t fo r relation to smoking andPalcohol ub lica ti teNo alcohol on Alcohol ss e n c e consumption consumption n

Overall

Smoking

Non-smoking

Mandible Labial mucosa Dorsal and lateral borders of the tongue Keratinised mucosa Vestibular mucosa Floor of the mouth Total

108 89 47 10 10 264

39 29 24** 3 7* 102

69 60 23** 7 3* 162

69 50 30 4 6 159

39 39 17 6 4 105

Maxilla Keratinised mucosa Labial mucosa Hard palate Vestibular mucosa Soft palate Total

26 20 13 12 4 75

12 6 7 3 2 30

14 14 6 9 2 45

16 13 10 5 3 47

10 7 3 7 1 28

127 2 129

41 1 42

86 1 87

82 2 84

45 0 45

this type of ST-associated lesion reported no history of smoking.

Topographical distribution Oral mucosal findings were most frequently diagnosed at the buccal plane (n = 127), labial mucosa of the mandible (n = 108), and dorsal and lateral borders of the tongue (n = 89) (Table 2). A total of 69.23% (n = 324) of alterations were found at all three locations. Of the 127 alterations diagnosed at the buccal plane, 72.44% (n = 92) were classified as linea alba (n = 56) or Fordyce’s spots (n = 36). A total of 89 findings were detected on the dorsal and lateral borders of the tongue. The following alterations located on the tongue accounted for approximately one-third of all common conditions and anatomical variants: fissured tongue, geographic tongue and hairy tongue. In 13 subjects, both fissured tongue and geographic tongue were demonstrated. In the present study, a significantly higher proportion of smokers were found with alterations localised only within the keratinised mucosa of the mandible (P < 0.01) or on the floor of the mouth (P < 0.05). There was no significant correlation between a history of alcohol consumption and an alteration at a particular location. 148

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DISCUSSION In Switzerland today, an average of 25% of 14- to 19year-olds smoke cigarettes regularly (27% of males and 23% of females), while the figure rises steeply with increasing age (Keller et al, 2005). In an additional study based on the data obtained between 1993 and 2003, the prevalence of 20-year-old male smokers was assessed (Mohler-Kuo et al, 2006). The latter study showed an increase in daily and weekly tobacco use from 37.1% to 46.7% over the past 10 years. In the present study, however, the prevalence of smokers was lower (31.38%; n = 193). An alarming trend has further been noticed with regard to the daily consumption of alcohol by adolescents and young adults, which ranged from 24.3% in 1986 to 40.5% in 2002 (Mohler-Kuo et al, 2006) and a high percentage of young Swiss with episodes of excessive alcohol consumption (‘binge drinking’) reported by a study in collaboration with the Swiss military (Daeppen et al, 2005). Owing to the differences observed in the methodology used for data collection among the aforementioned studies, the results of the findings can only be compared with caution to that of alcohol consumption and tobacco use in the present study. Whereas the investigators collected quantitative Oral Health & Preventive Dentistry

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data, Mohler-Kuo et al (2006) reported the frequency of consumption (annually, monthly, weekly and daily). It is recommended for future studies that investigators use standardised data collection methods to allow their data to be compared with those of other researches in the field. The overall prevalence of the intraoral findings (53.17%) recorded in the present study is higher than the 10.30% reported by Bouquot (1986), the 11.83% reported in a representative study from northern Germany (average age 49.00 years) examining 4210 subjects (Splieth et al, 2007) or the 27.9% shown by Shulman et al (2004), where geographic, hairy and fissured tongue were also included. In contrast, a number of epidemiological studies that similarly account for ‘common conditions and anatomical variants’ or ‘reactive lesions’ report comparable prevalence rates (Kovac-Kovacic and Skaleric, 2000; Garcia-Pola Vallejo et al, 2002). Different patient selection criteria or populations examined, varieties of alterations involved and subjective/individual inclusion criteria applied may explain why prevalence rates reported in the above-mentioned studies have to be compared with caution (Pentenero et al, 2008). In the present study, the majority of oral mucosal findings were classified as ‘common conditions and anatomical variants’ (46.59%, n = 218) or ‘reactive lesions’ (48.50%, n = 227). The prevalence of geographic tongue (38 findings in 615 subjects; 6.18%) was found to be higher in the present study than in all other epidemiological studies (Bouquot, 1986; Kovac-Kovacic and Skaleric, 2000; Shulman et al, 2004; Splieth et al, 2007), except for the Swedish study that was carried out by Axell (8.5%) (Axell, 1976). In the present study, however, geographic tongue was found in 13 (46.43%) out of 28 recruits in whom a fissured tongue was also demonstrated. The simultaneous and frequent prevalence of geographic tongue and fissured tongue on the basis of a genetic predisposition had previously been described in the literature (Hume, 1975; Salonen et al, 1990; Shulman and Carpenter, 2006). Between 1988 and 1994, Shulman and Carpenter examined 16,833 subjects aged 18 years and above. In their study population, the prevalence of geographic tongue was found to be 1.8%. No significant differences could be observed between the different age groups; however, a significantly higher prevalence of geographic tongue was found in subjects with a fissured tongue (Shulman and Carpenter, 2006). In the present study, reactive lesions exhibited the highest prevalence (48.50%, n = 227) of all

pyr Co etigal No Morger t fo rP lesions diagnosed. In this group, a significantly u subhigher percentage of smokers (P < 0.001) and b lica jects with a combination of the known risk factors tion te such as tobacco use and alcohol consumption ss e n c e (P < 0.001) was found in comparison with the general population. The number of tobacco-associated benign reactive lesions (23 smoker’s melanosis and 2 leukokeratosis nicotina palati/smoker’s palates) was relatively high in view of the comparatively young age of the subjects examined. When all oral findings were taken into account, this number corresponded with a prevalence of 4.00% in the entire study population (smoker’s melanosis: 3.7% and smoker’s palate: 0.3%). In a representative Swedish study sample of 920 subjects aged 20 years and above, the prevalence of smoker’s melanosis was found to be 4.8% (n = 44) (Salonen et al, 1990). Out of the 23 cases of smoker’s melanosis in the present study, 11 lesions were identified in the keratinised mucosa of the anterior mandible or maxilla. In the present study population, a significantly higher proportion of smokers was found with alterations localised on the floor of the mouth (P < 0.05). In a recent study examining the history of tobacco smoking and the presentation of oral squamous cell carcinoma involving the posterolateral tongue and floor of the mouth, a strong association was observed between the two parameters (Schmidt et al, 2004). Since about 25% of the examined recruits reported a history of smoking and drinking, primary preventive efforts need to be taken urgently. Despite best efforts, if smoking levels remain unchanged and alcohol consumption increases, the increase in cancer development in the oral cavity is likely to be greater than at any other site in the upper aero-digestive tract, including cancer of the pharynx (Franceschi et al, 1999). During the clinical examinations of the present study, 15 aphthous lesions (12 in non-smokers and 3 in smokers) were diagnosed. This figure represents a prevalence of 2.44% in the entire study population. However, 58 subjects (47 non-smokers and 11 smokers) reported the regular occurrence of aphthae in the questionnaire. This value would represent a prevalence of 9.43%. Interestingly, both the percentage of smokers and the percentage of recruits with a history of alcohol consumption were significantly lower in the ‘aphthae’ group than in the remainder of the population examined. RiveraHidalgo et al (2004) reported a significantly increased predisposition to aphthous lesions in non-smokers. The phenomenon of a lower prevalence of aphthae in smokers reaching statistical significance was also observed in previous studies 149

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(Axell and Henricsson, 1985; Salonen et al, 1990; Tuzun et al, 2000). The reason for the inhibitory effect of smoking on aphthae formation remains unknown (Tuzun et al, 2000). In the present study, eight lesions were clinically defined as OL. According to the WHO Collaborating Centre for Oral Cancer and Precancer, OL can be characterised by the following aetiological factors: tobacco-related OL, ST-related OL and idiopathic OL (Napier and Speight, 2008). All of the eight lesions were clinically defined as leukoplakias associated with ST. This value represents a prevalence of > 1% for so-called precursor lesions in this population. A comparable prevalence of 1.63% (n = 205) was reported in an evaluation of NHANES III data obtained from 17,235 individuals in 2004 (Shulman et al, 2004). However, two randomly selected studies with male populations in Sweden reported significantly higher figures: Axell reported a prevalence of 15.90% in 1976 (Axell, 1976), whereas Salonen and co-workers found 14.50% in 1990 (Salonen et al, 1990). The 10-fold difference among these populations may be explained by the different proportion of ST users, including geographic or cultural differences, age of the population and methods of diagnosing oral lesions. In the present study, the consumption of ST was not assessed using the self-reported questionnaire. Therefore, there may be limitations regarding the information available on the use of ST in the entire study sample even though the use of ST was recorded from those subjects presenting clinical manifestations of leukoplakia-like lesions during the clinical examination. A systematic review analysing 33 epidemiological studies in Europe and the United States reported a strong dose-related effect of ST users associated with OL (Kallischnigg et al, 2008). An experimental study examining 3051 male U.S. Air Force basic military trainees showed a 97.5% regression of the OL after 6 weeks of stopping ST use (Martin et al, 1999). Whereas in a series of 138 Danes (63 females and 75 males), it was observed that in those who abstained from smoking for 3 months, 56% of lesions regressed or disappeared, while in those who quit smoking permanently, 78% of lesions regressed or disappeared after a year (RoedPetersen, 1982). These studies demonstrate the enormous impact of tobacco on the development and manifestation of an OL. A study from the Netherlands noted that the longer the period of follow-up of an OL, the higher the incidence of malignant transformation (Schepman et al, 1998). Consequently, having a precursor lesion at the age of 20 years could present—in association with risk factors (tobacco

pyrig No Co t fo rthe consumption)—an important cofactor for Pu develbli opment of a malignant transformation. ca The present study is the first in Switzerland con-tion cerning oral mucosal findings in youngte male adults ss e n ce

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regarding self-reported and clinical findings. A significant number of oral mucosal alterations can be identified, which strongly correlate with tobacco use. To improve primary and secondary prevention, young adults should therefore be informed more extensively on the negative effects of tobacco use on oral health. In future studies using a self-reported questionnaire, data on ST use should be gathered systematically in addition to the smoking history. Both systemic and local effects of ST have not yet been explored as extensively as the negative impact of cigarette smoking.

ACKNOWLEDGEMENTS The cooperation of Colonel Kurt Jäger, Chief of the Dental Services of the Army (ZDA), and the technical support of the Pharmacy of the Swiss Army are greatly appreciated. Thanks are also due to the officers, subofficers and recruits of the Recruit School Pz Trp RS 21-2. Many thanks are due to the Surgeon General of the Swiss Army, Div. Gianpiero Lupi. The authors would like to express their special gratitude to Lieutenant-Colonel Niklaus P. Lang for the organisation and supervision of the present investigation in the summer of 2006 in Thun, Switzerland.

REFERENCES 1. Antoniades DZ, Belazi M, Papanayiotou P. Concurrence of torus palatinus with palatal and buccal exostoses: case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:552–557. 2. Axell T. A prevalence study of oral mucosal lesions in an adult Swedish population. Odontol Revy 1976;27:1–103. 3. Axell T. Occurrence of leukoplakia and some other oral white lesions among 20,333 adult Swedish people. Community Dent Oral Epidemiol 1987;15:46–51. 4. Axell T, Henricsson V. The occurrence of recurrent aphthous ulcers in an adult Swedish population. Acta Odontol Scand 1985;43:121–125. 5. Axell T, Zain RB, Siwamogstham P, Tantiniran D, Thampipit J. Prevalence of oral soft tissue lesions in out-patients at two Malaysian and Thai dental schools. Community Dent Oral Epidemiol 1990;18:95–99. 6. Bouquot JE. Common oral lesions found during a mass screening examination. J Am Dent Assoc 1986;112: 50–57. 7. Curilovic Z, Helfenstein U, Renggli HH, Saxer UP, Schmid MO, Lutz F. Clinical periodontal findings in a group of Swiss youths. Soz Praventivmed 1980;25:139–148. 8. Curilovic Z, Renggli HH, Saxer UP, Germann MA. The condition of the periodontium in a group of Swiss recruits. SSO Schweiz Monatsschr Zahnheilkd 1972;82:437–451. 9. Daeppen JB, Anex F, Leutwyler J, Gammeter R, Darioli R, Pecoud A. Binge drinking in 19 year old men. Swiss Med Wkly 2005;135:179–183.

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