IS SODIUM-CARBONATE IN SNUFF A CAUSATIVE FACTOR FOR ORAL MUCOSAL LESIONS – A CROSSSECTIONAL ANALYSIS
Introduction: Sodium carbonate raise the pH of the snuff to 8–9 in order to facilitate nicotine absorption through the oral mucous membranes. Objective: The objectivity of the present study is to assess the difference between various forms of sodium carbonate in snuff on mucosal conditions
Materials And Methods: The present crosssectional was conducted on 284 participants. Snuff users adding sodiumcarbonate were further splitted into two groups i.e one group using sodiumcarbonate in premixed form ie (already mixed within pouches) and other group adding sodiumcarbonate seperately (freshly mixed). The parametric One way (ANOVA) of variance, Stepwise Regression Analysis and Multiple Logistic Regression Analysis has been done to narrate the relationship between variables of different forms of sodium carbonate in snuff and different oral conditions
Results: The results of the present study reveals highly significant relationship between snuff users using sodium carbonate in freshly mixed (0.001**) form than that of premixed form(p=0.030*).
Conclusion: The present study is dipicting that there seems to be association between the use of sodium carbonate in snuff and oral mucosal lesions.
Key words – smokeless tobacco, snuff, sodiumcarbonate, Oral mucosal lesions.
The prevalance of tobacco in smokeless form is globally spreaded from Sudan and India to scandinavia and USA.1 Among all the forms of smokeless tobacco product (STPs), the snuff is widely used and its more prevailing among the youth.
The use of snuff is based on mechanism that the product directly release nicotine when it is placed in the vestibule between gum and cheek.2 The intake of snuff is very popular in North America, Scandinavia and in some parts of Asia (i.e Bangladesh, Bhutan, India) also in some parts of Africa (e.g Algeria, Sudan,and Nigeria). The snuff is manifestated in two ways ; the loose form and another form in which it is packed in small filter sachets or pouches. The pouch form has gained a lot of popularity in recent times. These pouches are inserted in the vestibule for a duration of approximately 30 minutes resulting in nicotene absorption and then disposed.3 The use of snuff results in dependency due to release of high dosage of nicotine.4 The composition of snuff includes water, tobacco,moist preservatives,taste enhancers(salt) acidifiers and aromas. The tobacco itself is composed of 2500 chemical components in which nicotine is most common, the other components are sodium carbonate, sodiumchloride,TSNA (tobacco specific nitrosamines) and PAH (polycyclic aromatic hydrocarbons)5. The nicotine absorption takes place through mucous membrane by passive diffusion.
One factor that is considered critical for passive diffusion of many drug compounds is the proportion of drug present in the un-ionized or uncharged form.
Un-ionized drugs undergo passive diffusion much more readily than their corresponding ionized forms because of the greater solubility of uncharged molecules in lipophilic cellular membranes. The proportion of drug present in the un-ionized form is determined by the dissociation constant of the drug and the pH of the medium in which the drug is found. This results in a pH dependence for the absorption of many drugs across the oral mucosa and forms the basis for affecting drug delivery via manipulation of the oral pH.7 The nicotine absorption through mucous membrane is directly proportional to pH, so the snuff is buffered to pH of 8-9 by adding sodium carbonate.8 The nicotine dosage in snuff is dependant on the ph level ,amount of nicotine in the product,and size of tobacco cutting.2 Some studies have examined the correlation smokeless tobacco/moist snuff product pH and nicotine absorption ,however we are aware of no studies in which the resulting pHs for mixtures of commercial moist snuff and saliva have been determined.10 The pH is directly proportional and plays a very important role in nicotine absorption. Tobacco smoking has a major impact on many tissues and organs of the body, including the periodontal tissues. Hence the objectivity of the present study is to assess the impact of various forms sodium carbonate present in snuff on oral condition among snuff users in jammu, India .
The present crosssectional study has been conducted in Jammu region to access the impact of different forms of sodium carbonate present in snuff on the oral health status of snuff users.
The current study has been conducted among workers at various construction sites in jammu region. A total of 284 snuff using workers participated in the the study. The subjects were selected through stratified random sampling technique. All the study subject were informed prior to the start of the study and the informed consent was obtained. Ethical approval for conducting the study was obtained from ethical committee of Indira Gandhi Dental College jammu. It took duration of 3 months for conducting this study that is from month of december 2017-february 2018.The subjects who were using snuff regularly from five years and whose age were ranging between 25 years to 60 years were incuded for both genders. Snuff users adding sodiumcarbonate were further splitted into two groups i.e one group using sodiumcarbonate in premixed form ie (already mixed within pouches) and other group adding sodiumcarbonate seperately (freshly mixed)
The present study was carried out in the following pattern
Snuff users ( 284)
With sodium carbonate (282) without sodium carbonate (2)
Premixed (70) Freshly Mixed (212)
Methods Of Data Collection
The examination was done on an ordinary chair with back rest under natural light A pre designed structured questionaire is made to record information regarding general data, type of moist snuff with and without sodium carbonate, duration, and frequency of using moist snuff. The Axell’s index was used to find the degree of severity of oral lesions. Before the start of the study, the two examiners were trained to levels of accuracy and reproducibility for the various clinical parameters to be used.
The armamentarium used in the present study was CPI probe, mouth mirror and explorer, tweezer,which were sterlised properly. The parametric One way ( ANOVA ) of variance, Stepwise Regression Analysis and Multiple Logistic Regression Analysis has been done to narrate the relationship between variables of different forms of sodium carbonate in snuff and different oral conditions.
Results and tables
Table 1: Distribution of Snuff users according to age and gende
Characteristics No. of moist snuff users (n) Percentage (%)
56 and above
n- Number of patients in a particular category
Table-1 Shows the distribution of moist snuff users according to their age and gender. It was seen that consumption of snuff use is more in males and in age group between 26-35 years.
Table 2: Distribution of snuff users according to addition of sodium carbonate
(n) Percentage (%)
No. of snuff users
No. of snuff users without sodiumcarbonate (n)
No. of moist snuff users with sodiumcarbonate (n)
n- Number of patients in a particular category
TABLE 2- Showed number and percentage of snuff users with and without sodium carbonate in both forms that is frshly mixed and premixed.
TABLE 3: Multiple Logistic Regression Analysis Showing sodium carbonate freshly mixed in relation with oral conditions.
Dental lesions Freshly mixed R-Value p- Value Significance
Oral mucosal lesions 312 0.0792 0.001**
Snuff Lesions 312 0.0767 0.051*
Gingival Recession 312 0.681 0.653
Dental Attrition 312 0.528 0.391
Dental Erosion 312 0.016 0.048*
Dental Abrasion 312 0.134 0.750
Burning Sensation 312 0.174 0.571
(p ? 0.05 – Significant, CI = 95 %)
Shows the correlation of oral snuff containing sodiumcarbonate in freshly mixed form using Multiple Logistic Regression Analysis and it was found to be having significant relationship with oral mucosal lesions,snuff lesions and dental erosion.
TABLE 4: Multiple Logistic Regression Analysis Showing sodium carbonate pre mixed in relation with oral conditions.
Dental lesions Pre mixed R-Value p- Value Significance
Oral mucosal lesions
(p ? 0.05 – Significant, CI = 95 %)
Shows the correlation of oral snuff containing sodiumcarbonate in pre-mixed form using Multiple Logistic Regression Analysis and it was found to be having significant relationship with oral mucosal lesions and snuff lesions.
The present cross-sectional study explores the impact of different forms of sodiumcarbonate both in freshly mixed as well as premixed form which is added in snuff and oral condition among snuff users in Jammu City.
This study includes stratified samples of 284 constructing workers using snuff at various construction sites and slums in Jammu on the basis of prevalence of snuff use which is higher among them.
The present study indicates high prevalance of oral-mucosal lesions among snuff users with addition of sodium carbonate both in freshly mixed aswell as in pre-mixed form.
The results of the present study reveals highly significant relationship between snuff users using sodium carbonate(0.001**) in freshly mixed form than that of premixed (0.030*)form. It is due to reason that there is rise in pH and hence more absorption of nicotene due to addition of sodium carbonate in freshly mixed form than that of premixed form packed in pouches or sachets .
The degree of oral lesions is positively correlated with age, frequency, duration of snuff use in studies conducted by Hirsch et al 198211, Mornstad et 1989,12 Anderson et al 1991.13 Moist snuff use may be associated with adverse oral lesions. It has been
seen in our study that use of moist snuff is significantly responsible for causing mucosal changes. Numerous other studies have observed that snus use is associated with a characteristic reaction in the oral mucosa (e.g., Axéll 1976)14,Andersson and Axéll 1989,15 Larsson et al. 1991,16 Mornstad et al. 1989,12 Rolandsson et al. 200617).
This type of lesion has been referred to by various names, including snuff dipper’s
lesion, snuff-induced leukoplakia, or snus-induced lesions. The lesion generally
appears at the location in the mouth where the snus is held. The prevalence of this condition varies widely, and appears to be related to characteristics of the user
(such as age, salivary pH, patterns of tobacco use) and characteristics of the product (nicotine content, loose vs. portion bag, etc.).In addition the degree of lesions seems to increase with increasing pH as well as increasing nicotine concentration according to Mornstad et al 1989,12 Anderson et al .13
The present study also shows that a positive correlation between sodium carbonate both in freshly mix and premixed form and oral mucosal lesions or snuff lesions . It is added to raise the pH of the snuff to 8–9 in order to facilitate nicotine absorption through the oral mucous membranes. This causes local reactions in the gingival tissues and oral musosa exposing to snuff or nicotine resulting in mucosal changes and lesions.18
Mavropoulos et al. (2001) found an increased blood flow in the gingiva and oral mucosa of humans in response to local exposure to nicotine,19 and Petro et al.(2002) reported that smokeless tobacco extract increased IL-2 production and decreased IL-12 production from macrophages.20 In an experimental study, Alpar et al. (1998) showed that the growth of human oral fibroblasts decreased when exposed to nicotine.21
In summary, the observations of the present study indicate that there seems to be association between the use of sodium carbonate in moist snuff and and oral mucosal lesions.
1. Idris et al. 1998, Nichter et al. 2004). Idris, A. M., Ibrahim, S. O., Vasstrand, EN.,Johannessen, A. C., Lillehaug, J. R., Magnusson, B., Wallstro¨m, M., Hirsch, J. M. & Nilsen, R. The Swedish snus and the Sudanese toombak: are they different? Oral Oncology 1998;34,558–566.
2. V Fant, Jack E Henningfield, Richard A Nelson,Wallace B Pickworth, Pharmacokinetics and pharmacodynamics of moist snuff in humans Reginald. Tobacco Control 1999;8:387–392.
3. Peng Li , Jie Zhang , Shi-Hao Sun *, Jian-Ping Xie and Yong-Li Zong , A novel model mouth system for evaluation of In Vitrorelease of nicotine from moist snuff, Chem Cent J. 2013; 7: 176
4. Holm, H., Jarvis, M. J., Russell, M. A. & Feyerabend, C. (1992) Nicotine intake and dependence in Swedish snuff takers. Psychopharmacology 108, 507–511
5. Arun Kumar MS, Mythri S, Shashikanth Hegde, Rajesh KS, Effect of chewing gutkha on oral hygiene, gingival and periodontal status, Journal of Oral Health Research, Volume 3, Issue 3, July 2012.
6. Frithiof, L., Anneroth, G., Lasson, U. & Sederholm, C. (1983). The snuff-induced lesion. A clinical and morphological study of a Swedish material. Acta Odontologica Scandinavica 41, 53–64.
7. Laura A. Ciolino*, Heather A. McCauley, Diane B. Fraser, and Karen A. Wolnik, The Relative Buffering Capacities of Saliva and Moist Snuff: Implications for Nicotine Absorption, Journal of Analytical Toxicology, Vol. 25, January/February 2001
8. Ciolino, L. A., McCauley, H. A., Fraser, D. B. & Wolnik, K. A. The relative buffering capacities of saliva and moist snuff: implications for nicotine absorption. Journalof Analytical Toxicology 2001; 25, 15–25.
9. Bergstro M J, Keilani H, Lundholm C, Radestad U. Smokeless tobacco (snuff) use and periodontal bone loss . J ClinPeriodontol 2006; 33: 549–554. doi: 10.1111/j.1600-051X.2006.00945.x.
10. Laura A. Ciolino, Heather A. McCauley, Diane B. Fraser, and Karen A. Wolnik. The Relative Buffering Capacities of Saliva and Moist Snuff, Journal of Analytical Toxicology; January 2001. 25,1,15–25.
11. Hirsch, J.M., Heyden, G., and Thilander, H. 1982. A clinical, histomorphological and histochemical study of snuff-induced lesions of varying severity. J. Oral Pathol. 11:387-398.
12. Mörnstad, H., Axéll, T., and Sundström, B. 1989. Clinical picture of snuff dipper’s lesion in Swedes. Community Dent. Oral Epidemiol. 17:97-101.
13. Andersson, G., Axéll, T., and Larsson, A. Clinical classification of Swedish snuff dippers lesions supported by histology. J. Oral Pathol. Med. 1991;20:253-257.
14. Axéll, T. A prevalence study of oral mucosal lesions in an adult Swedish population. Thesis. Odontol. Rev. Suppl. 1976; 27:1-103
15. Andersson, G., Axéll, T., and Larsson, A. 1989b. Histologic changes associated with the use of loose and portion-bag packed Swedish moist snuff: A comparative study. J. Oral Pathol. Med. 18:491-497.
16. Larsson, A. Andersson, G., Axéll, T., 1991b. Clinical classification of Swedish snuff dippers lesions supported by histology. J. Oral Pathol. Med. 20:253-257.
17. Rolandsson, M., Hellqvist, L., Lindqvist, L. ; Hugoson, A. (2005) Effects of snuff on the oral health status of adolescent males: a comparative study. Oral Health Prev Dent 3, 77–85.
18. Monte´n U, Wennstro¨m JL, Ramberg P. Periodontal conditions in male adolescents using smokeless tobacco (moist snuff). J Clin Periodontol 2006; 33, 863–868. doi:10.1111/j.1600-051X.2006.01005.x.
19. Mavropoulos, A. Aars, H. ; Brodin, P. (2001) The acute effects of smokeless tobacco (snuff) on gingival blood flow in man. Journal of Periodontal Research 36, 221–26
20. Petro T. M., Andersson L , Gowler J. S, Liu X. J. ; Schwartzbach S. D. Smokeless tobacco extract decreases Il-12 production from LPS-stimulated but increases Il-2 from IFN-gamma-stimulated macrophages. Internationalimmunopharmacology 2002; 345–55.
21. Berna Alpar, Gabriele Leyhausen, Angela Sapotnick, Hüsamettin Günay, W. Geurtsen. Nicotine- induced alterations in human primary periodontal ligament and gingiva fibroblast cultures. Clinical Oral Investigation 1998; 2, 40–46.