4: Substance‐Related Disorder

Case 4
Substance‐Related Disorder

Medical History

Patient has a negative medical history and does not take any medication

Social History

Patient reports being a social drinker consuming three to four beers a week. He was recently married and has no children. He uses smokeless tobacco three to four times a week and sometimes chews up to two times a day depending on his work day.

Patient reports that he tries to go to the gym two or three times a week.

He brushes with a soft‐bristled toothbrush twice a day and flosses three to four times a week. He has occlusal composites on the posterior teeth and has completed with professional whitening treatments. He also had orthodontic treatment as a teenager.

Review of the Systems

  • Vital signs
    • Blood pressure: 130/87 mmHg
    • Pulse: 61 beats/min
    • Respiration: 16 breaths/min

Extraoral Exam

Within Normal Limits

Intraoral Exam

  • Mandibular buccal to #18 and #19, vestibular area: evidence of tobacco pouch keratosis, dimensions 12 × 6 mm. Clinical appearance of lesion is wrinkled, white, nonfriable.

Intraoral Images

See Figure 9.4.1 and Figure 9.4.2 for lower left vestibule views.

Image described by caption.

Figure 9.4.1: Lower left vestibule view 01.

Image described by caption.

Figure 9.4.2: Lower left vestibule view 02.

Gingival Examination

  • Generalized 1–3 mm probing depths and localized areas of recession
  • 4 mm pocket on #4 distal‐lingual
  • 4 mm pocket on #31 mesial‐facial
  • See Figure 9.4.3 Periodontal Chart
Image described by caption.

Figure 9.4.3: Periodontal Chart.

Radiographic Examination

  • A full mouth series of radiographs were taken (see Figure 9.4.4)
  • Four existing composite restorations on occlusal surfaces of posterior molars
  • No recurrent or active caries
Image described by caption and surrounding text.

Figure 9.4.4: Full mouth series.


Full record is shown in Figure 9.4.5.

An odontogram displaying hatched region in the occlusal surface of teeth #2, #3, #14, #15, #18, #19, #30, and #31.

Figure 9.4.5: Odontogram.

Dental Hygiene Diagnosis

Problems Related to Risks and Etiology
Usage of smokeless tobacco
Lack of knowledge regarding risks associated with smokeless tobacco use
Dysplasia of the oral cavity
Increased risk for oral cancer
Increased risk of periodontal disease
Increased risk of caries

Planned Interventions

Clinical Education/Counseling Oral Hygiene Instructions
Refer to DDS for pathology diagnosis of affected area
Six‐week re‐evaluation of affected area
Adult prophylaxis
Six‐month periodontal recare visits
Cessation of smokeless tobacco
Explain increased risks of oral dysplasia, caries, and periodontal disease with usage of smokeless tobacco
Monitoring of affected area caused by usage of smokeless tobacco
Importance of fluoride usage in daily home care
Continue usage of soft‐bristled toothbrush using Modified Bass brushing technique
Increase frequency of interdental care
  • A brush biopsy was performed
  • Brush biopsy results:
    • Findings revealed nonhyperplastic cells with negative findings.
    • Evidence showed keratinized tissue
  • Patient was advised to immediately discontinue use of smokeless tobacco and referred to specialist for counseling and cessation.

Treatment Plan

  • Oral hygiene instructions
  • Routine adult prophylaxis
  • Six‐week evaluation of mandibular left vestibular area


There are two forms of smokeless tobacco: snuff, also known as “dip,” and chewing tobacco (Bhattacharyya 2012). All smokeless tobacco products contain the carcinogen N‐nitrosonornicotine (NNN), and it is an accepted cause of oral cancer (Greer 2011; Lee and Hamling 2009). Oral cancer is defined as a term affecting the tissues of the oral cavity or those of the oropharynx, which includes part of the throat and the back of the mouth (“Head and neck cancer” 2011).

The use of smokeless tobacco is associated with dysplasia of the oral cavity and oral squamous cell carcinoma (Greer 2011; Lee and Hamling 2009). Smokeless tobacco can also be associated with periodontal inflammation, gingivitis, and dental caries. There an estimated one‐quarter million new cases of oral cancer worldwide each year attributed to the use of smokeless tobacco, with an estimated increase of 275,000 new cases each year (Balbo et al. 2013; Warnakulasuriya 2009).

In the United States, one in five white adolescent males between the ages of 18 and 25 years old, and 7% of all men, use smokeless tobacco. Smokeless tobacco comes in the form of teabag‐like sachets of moist snuff and is usually placed in the vestibular areas between gingiva and buccal mucosa (CDC 2014; International Agency for Research on Cancer 2007; US Department of Health and Human Services 2012). With long‐term usage, the area that the smokeless tobacco is placed can exhibit a white plaque‐like lesion that cannot be wiped off, sometimes referred to as leukoplakia (Jones et al. 2014). Most leukoplakia lesions are the result of hyperkeratosis, which is the thickening of the keratin layer or a combination of epithelial hyperplasia (thickening of the prickle cell or the spinous layer) and hyperkeratosis (Jones et al. 2014). Epithelial dysplasia and even squamous cell carcinoma may even be seen in a microscopic investigation of leukoplakia (Jones et al. 2014). However, the cytopathology of lesions associated with smokeless tobacco are unique (Carroll 2012). Long‐term use of smokeless tobacco may result in white lesions called “smokeless‐tobacco associated keratosis, rather than leukoplakia because the direct cause of the lesion is known” (Jones et al. 2014). A differential diagnosis, including a biopsy of the area, needs to be established in order to determine the etiology of the lesion.

The global health impact of tobacco use, in smokeless and smoked forms, is significant – it constitutes about 90% of all drug‐caused deaths and is most conspicuous reason of health inequalities (Jarvis and Wardle 2006). Tobacco use also has an impact on economic development, resulting in families spending less money on basic items, such as health care, food, and education (Agbor et al. 2013).

The role of the dental professional is essential in identifying possible patient risks for developing precancerous/cancerous lesions in the oral cavity. Each patient must be provided with a thorough extra/intraoral examination and review of medical and social histories. Recommendations for intervention include: continued monitoring of lesion for any significant changes, possible brush biopsies, or specialist referrals. The patients who present with significant lesions should be put on a frequent recare schedule.

The dental professional has an essential role in eliminating the use of tobacco products. Education of the patient on the risks of tobacco usage is recommended, with an emphasis on the potential detrimental effects on the oral tissues and the oropharynx. Sometimes smokeless tobacco may even be used as a safe alternative to cigarette smoking, which poses a public health threat in many ways (Bhattacharyya 2012). Dental professionals can assist tobacco users to quit by establishing partnerships with patients to promote healthier habits (Rainchuso et al. 2016). When indicated, tobacco cessation programs should also be recommended (Rainchuso et al. 2016).

Smokeless tobacco is often used by professional sports figures at major sporting events (Greer, 2011; Lee and Hamling 2009). The media exposure creates a false impression that tobacco usage is popular and is acceptable, without any detrimental health effects.

In response to the health hazards of smoking tobacco products and as an aid to smoking cessation, advertisement and usage of electronic cigarettes also called e‐cigarettes or electronic nicotine delivery systems are increasing in popularity. These battery‐operated devices often contain nicotine, different flavorings, and other chemicals that can expose the lungs to a variety of chemicals with unknown health effects (NIH 2017). Exposure to electronic cigarettes with nicotine is becoming increasingly common in adolescents and can lead to nicotine addiction and risk to other drugs (Leventhal et al. 2015). E‐cigarettes are now the most commonly used form of tobacco in adolescents in the United States and may serve as an introductory product for adolescents before the use of other tobacco products (NIH 2017).

More research is needed as e‐cigarettes have not been thoroughly evaluated in scientific studies and also to find out whether they may be as effective, as advertised, smoking cessation aids (NIH 2017).

Take‐Home Hints

  1. Smokeless tobacco use is most prevalent in white males, ages 18–25.
  2. Long‐term use of smokeless tobacco is often associated with oral cavity dysplasia and can lead to oral squamous cell carcinoma.
  3. The use of smokeless tobacco can be most associated with erythroplakia.
  4. Smokeless tobacco is most commonly placed on the mandibular buccal vestibular area.
  5. All dental professionals should perform a thorough intraoral examination to identify early signs of oral dysplasia caused by possible use of smokeless tobacco.

Jul 18, 2020 | Posted by in Dental Hygiene | Comments Off on 4: Substance‐Related Disorder

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