Smokeless Tobacco Use Research Articles

Challenges and Opportunities for Smokeless Tobacco Cessation During Covid 19: learnings from a Feasibility trial in India

The use of smokeless tobacco (SLT) is detrimental at any time, however, its usage during Covid 19 has proved to be more harmful in increasing the spread of the virus. The pandemic has also affected the efforts that were being made for SLT cessation. Understanding the various challenges and facilitating factors of smokeless tobacco cessation during the pandemic is imperative. This paper highlights the key challenges and opportunities of implementing a feasibility trial on SLT cessation amidst Covid 19 in India.

Diverse e-cigarette regulations in the Asia Pacific: A health economic perspective.

Diverse e-cigarette regulations in the Asia Pacific: A health economic perspective.

Effect of Smokeless Tobacco (Maras Powder) on the Epicardial Fat Thickness and Ventricular Repolarization Parameters.

Background and Objectives: Smokeless tobacco (ST) use has recently become an alternative to cigarettes, and it has been concluded that ST is at least as harmful as cigarettes. ST use is thought to play a role in the pathogenesis of arrhythmia by affecting ventricular repolarization. In this study, we aimed to examine the relationships of Maras powder (MP), one of the ST varieties, with epicardial fat thickness and new ventricular repolarization parameters, which have not previously been described. Materials and Methods: A total of 289 male individuals were included in this study between April 2022 and December 2022. Three groups, 97 MP users, 97 smokers, and 95 healthy (non-tobacco), were compared according to electrocardiographic and echocardiographic data. Electrocardiograms (ECG) were evaluated with a magnifying glass by two expert cardiologists at a speed of 50 m/s. Epicardial fat thickness (EFT) was measured by echocardiography in the parasternal short- and long-axis images. A model was created with variables that could affect epicardial fat thickness. Results: There were no differences between the groups regarding body mass index (p = 0.672) and age (p = 0.306). The low-density lipoprotein value was higher in the MP user group (p = 0.003). The QT interval was similar between groups. Tp-e (p = 0.022), cTp-e (p = 0.013), Tp-e/QT (p =0.005), and Tp-e/cQT (p = 0.012) were higher in the MP user group. While the Tp-e/QT ratio did not affect EFT, MP predicted the epicardial fat thickness (p < 0.001, B = 0.522, 95%CI 0.272-0.773). Conclusions: Maras powder may play a role in ventricular arrhythmia by affecting EFT and causing an increase in the Tp-e interval.

The Snuffbox: The Effect of Smokeless Tobacco Use on Scaphoid Fracture Healing.

Smoking has been demonstrated to be a risk factor for nonunion of scaphoid fractures, but it is unclear if chewing tobacco confers similar risk. The purpose of this study was to evaluate rates of bone-related complications after nonsurgical management of scaphoid fractures in smokeless tobacco users compared with matched control subjects and compared with smokers. A retrospective cohort study was conducted using the PearlDiver database. For patients who underwent nonsurgical management of scaphoid fractures, 212 smokeless tobacco users and 6,048 smokers were matched 1:4 with control subjects (n = 848 and 24,192, respectively) and 212 smokeless tobacco users were matched 1:4 with 848 smokers. Rates of bone-related complications within 2 years of initial injury were compared using multivariable logistic regression. From weeks 12 through 104 after initial injury, compared with control subjects who do not use tobacco, the smokeless tobacco cohort demonstrated markedly higher rates of nonunion (5.7% vs 2.7%, OR: 2.07). Compared with control subjects who do not use tobacco, the smoking cohort demonstrated markedly higher rates of nonunion (4.3% vs 2.6%, OR: 1.91), repair of nonunion (1.5% vs 0.9%, OR: 1.87), and four corner fusion and proximal row carpectomy (0.3% vs 0.1%, OR: 3.17). Smokeless tobacco use was markedly underdiagnosed in the adult male cohort of unilateral scaphoid fractures with 2 years of follow-up found in the database (372 of 25,704, 1.45%) relative to Centers for Disease Control estimates for adult male smokeless tobacco use (4.5%) ( P < 0.001). Given the higher rates of nonunion diagnoses after nonsurgical management in this cohort, surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke and consider adding this to the patient's intake history to further identify patients at risk for nonunions. Tobacco cessation counseling is indicated for all tobacco users, including smokeless with scaphoid fractures.

Predictors of Cessation in Men Using a Tobacco Quitline: A Follow-Up Study

Although the effectiveness of tobacco quitline services for people who smoke cigarettes is well established, less is known about other forms of tobacco. This study aimed to compare quit rates and factors contributing to tobacco abstinence in men reporting dual use (smokeless tobacco and one additional combustible tobacco product), smokeless tobacco use only, and cigarette use only. Self-reported 30-day point-prevalence tobacco abstinence at the 7-month follow-up was calculated in males who registered with the Oklahoma Tobacco Helpline and completed a 7-month follow-up survey (N=3,721) (July 2015-November 2021). Logistic regression analysis completed in March 2023 identified variables associated with abstinence in each group. Abstinence was reported by 33% in the dual-use group, 46% in the smokeless-tobacco-use-only group, and 32% in the cigarette-use-only group. Eight or more weeks of nicotine replacement therapy provided by the Oklahoma Tobacco Helpline was associated with tobacco abstinence in men who reported dual use (AOR=2.7, 95% CI=1.2, 6.3) and exclusive smoking (AOR=1.6, 95% CI=1.1, 2.3). The use of all nicotine replacement therapy was associated with abstinence in men who used smokeless tobacco (AOR=2.1, 95% CI=1.4, 3.1) and who smoked (AOR=1.9, 95% CI=1.6, 2.3). The number of helpline calls was associated with abstinence in men who used smokeless tobacco (AOR=4.3, 95% CI=2.5, 7.3). Men in all three tobacco-use groups who fully utilized quitline services showed a greater likelihood of tobacco abstinence. These findings underscore the importance of quitline intervention as an evidence-based strategy for people who use multiple forms of tobacco.

Smokeless Tobacco Use is Associated With Worse Medical and Surgical Outcomes Following Total Hip Arthroplasty

Studies have demonstrated increased complication risk after total hip arthroplasty (THA) in patients who smoke cigarettes. However, it is unclear if smokeless tobacco use confers a similar impact. The purpose of this study was to (1) evaluate rates of postoperative complications after THA in smokeless tobacco users and people who smoke as compared to matched controls, and (2) compare rates of postoperative complications in smokeless tobacco users versus people who smoke. A retrospective cohort study was conducted using a large national database. For patients who underwent primary THA, smokeless tobacco users (n = 950) and people who smoke (n = 21,585) were matched 1:4 with controls (n = 3,800 and 86,340, respectively), and smokeless tobacco users (n = 922) were matched 1:4 with people who smoke (n = 3,688). Rates of joint complications within 2 years and medical complications within 90 days postoperatively were compared using multivariable logistic regressions. Within 90 days of primary THA, smokeless tobacco users demonstrated significantly higher rates of wound disruption, pneumonia, deep vein thrombosis, acute kidney injury (AKI), cardiac arrest, transfusion, readmission and longer length of stay compared to tobacco naïve controls. Within 2 years, smokeless tobacco users demonstrated significantly higher rates of prosthetic joint dislocations and overall joint-related complications compared to tobacco naïve controls. Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. Smokeless tobacco use may be under-diagnosed in patients undergoing elective total hip arthroplasty. Surgeons may consider delineating between smoking and smokeless tobacco use during preoperative medical optimization.

Smokeless Tobacco Use and Cessation Attempts during COVID-19 Lockdown: A Qualitative Study.

Smokeless tobacco (SLT) use among women is widely prevalent in Manipur state accounting for 45% users as per Global Adult Tobacco Survey (GATS)-2 India. Studies from India and elsewhere indicate changes in the way people used SLT during COVID-19 lockdown. This study explores individual and economic influences on SLT consumption and cessation attempts by tribal women in Manipur during the first COVID-19 lockdown (March-June, 2020) in India. Twenty in-depth interviews, both in-person and telephonically, were conducted among tribal women from Imphal west, Manipur, India, who used any SLT, from April to September 2020. Objective of the study was to understand the use, factors associated with consumption, purchasing behaviors, and cessation attempts of SLT during the lockdown. Thematic content analysis was used to identify core themes and codes. Study participants reported of changes in current SLT use during restrictions imposed to contain COVID-19 pandemic in India. Majority reported of reduction or quit attempts in SLT use. Reasons included inaccessibility due to travel restrictions, limited availability and price rise of SLT products, fear of COVID-19, and disposable income for purchase of SLT products. However, a few women reported of increased consumption due to bulk purchasing, or switching to other SLT products as a result of unavailability or price rise of preferred products or to cope up with social isolation caused by the lockdown. Study findings on factors influencing quit attempts and strategies used for reducing SLT use by tribal women in Imphal, Manipur provide valuable insights for development of appropriate intervention for prevention of SLT use among women.

Physical and chemical characterization of smokeless tobacco products in India

The rapid proliferation of smokeless tobacco (SLT) in India has occurred without adequate information on the possible dangers and toxicity of these products. Tobacco flavors as well as nicotine (both protonated and un-protonated) are responsible for health dangers and addiction. The study aimed to offer information on the physical characteristics of commonly used smokeless tobacco products (including microscopic analysis), along with nicotine content (both total and un-protonated), pH, moisture, and flavors. The Standard Operating Procedures (SOPs) validated by the World Health Organization (WHO) recognized Tobacco Testing Laboratory TobLabNet) were applied for the analysis of various constituents of the SLTs. The microscopic analysis indicated that some of the SLT products like khaini were finely processed and available in filter pouches for users’ convenience and prolonged use leading to prolonged retention and addiction potential. Nicotine absorption and availability (both protonated and un-protonated) are affected by moisture and pH. Essences provide a pleasant aroma and flavor, with an increased risk of misuse and other health problems. Few chewing tobacco and Zarda had the lowest levels of un-protonated nicotine (0.10–0.52% and 0.15–0.21%, respectively), whereas Gul, Gudhaku, and Khaini had the highest levels, ranging from 95.33 to 99.12%. Moisture and pH ranged from 4.54 to 50.19% and 5.25–10.07 respectively. Menthol (630.74–9681.42 µg/g) was the most popular flavour, followed by Eucalyptol (118.16–247.77 µg/g) and camphor (148.67 and 219.317 µg/g). SLT’s health concerns and addiction dangers are exacerbated by the high proportion of bioavailable nicotine coupled with flavors. The findings of this study have important implications for the regulation and use of SLT in countries where use of SLT is prevalent.

Oral Candidal Carriage and its Correlation with Salivary Oxidative Stress in Smokeless Tobacco Users

Background: Smokeless tobacco use, particularly the consumption of Naswar, is prevalent in Pakistan and has been associated with various chronic diseases, including oral cancer. Naswar is known to contain toxic heavy metals, carcinogenic substances, and microbial contaminants. This study aims to assess the oral Candida carriage and biofilm formation in Candida albicans isolates from Naswar users and its association with salivary oxidative stress. Methods: A cross-sectional study was conducted involving 150 participants, divided into Naswar users (n=75) and Non-users (n=75). Socio-demographic data, oral health, hygiene practices, and Naswar usage patterns were collected through a standardized questionnaire. Salivary samples were collected, and Candida strains were identified using culture techniques. Salivary oxidative stress was assessed using a DPPH solution-based free radical system. Results: The mean age of participants was 30 ± 7.3 years for Naswar users and 30.2 ± 7.1 years for non-users. No significant differences were observed in oral health and hygiene practices between the two groups. Among Naswar users, the most common type of product used was green moist Naswar (77.3%). Oral Candida carriage was significantly higher in Naswar users, particularly those with fungal infections of C. albicans, C. krusei, or both. These participants also exhibited elevated levels of salivary oxidative stress. Practical Implication: Public health interventions and oral health education programs should be implemented to raise awareness about the risks associated with Naswar and promote good oral hygiene practices among users. Conclusion: This study reveals significant differences in oral Candida carriage and salivary oxidative stress between Naswar users and non-users, indicating potential implications for the oral health of Naswar users. These findings underscore the need for larger prospective studies to validate the detrimental effects of Naswar use. Public health interventions targeting smokeless tobacco users should prioritize oral health promotion and emphasize the risks associated with Naswar consumption. Keywords: Candida species, smokeless tobacco, oral health, oxidative stress

Association of Smoked and Smokeless Tobacco with Tooth Loss

Background: Tooth loss is associated with numerous factors which includes smoking, systemic diseases, age, poor oral hygiene, level of education and socio economic status etc. Association of tobacco and tooth loss is known but relationship of other modes of tobacco i.e. smokeless tobacco (chewable) with tooth loss is in dearth. Aim: To figure out the relationship oftooth loss with smokeless tobacco along with other variables such as presence of tobacco use (both smoked and smokeless), age and gender. Methodology: Three hundred and thirty six participants were included in this study. ‘Controls’ were based on the presence of all teeth and ‘Cases’ were based on one or more than one tooth missing. Participants’ were questioned about use of smokeless tobacco (chewable), presence of tobacco use (both smokeless and smoked), age (&gt; than 30 or &lt; less than 30) and gender (male or female). Results: There was no statistically significance of tooth loss (dependent variable) with any of the independent variables such as smokeless tobacco, age and gender. However presence of tobacco use i.e. both smokeless and smoked has 1 time more chance of tooth loss (OR=1.535) (C.I=0.54-4.335) as compared to absence of tobacco use. Practical implication: This study will figure out the association of tooth loss with use of smokeless tobacco because research in this aspect is insufficient. Results of this study would help in determining smokeless tobacco as a reason of tooth loss. Conclusions: Presence of tobacco use either smokeless or smoked can lead to tooth loss. Keywords: Tooth loss, Smoked and smokeless tobacco, Gender, Age

Comparing Smokeless Tobacco Use between Male-to-Female and Female-to-Male Transgender Adults in the United States

Background: The shifted gender social norms and tobacco cessation advice associated with estrogen therapy as a result of thrombosis risk could be responsible for the tobacco use differences between Male-to-Female (MTF) and Female-to-Male (FTM) transgender adults. Research has established this disparity in cigarette smoking, but none has looked at smokeless tobacco. Aim: This study aimed to compare smokeless tobacco use MTF and FTM transgender adults in the United States. Furthermore, it assessed the other potential determinants of smokeless tobacco use among the transgender population. Methods: The study analyzed data from the 2021 Behavioral Risk Factor Surveillance System (BRFSS), which included 1,070 transgender individuals aged 18 and above (382 MTF and 688 FTM). Gender identity (MTF vs. FTM) was used to predict smokeless tobacco use using logistic regression, adjusting for other socio-demographic and behavioral determinants. Results: The prevalence of smokeless tobacco use among the transgender population was 5.7%, 3.8% among MTF, 6.3% among FTM, and 6.7% among gender non-conforming transgender individuals. FTM transgender individuals were 2.23 times more likely to use smokeless tobacco than MTF transgender individuals. Smokeless tobacco use among MTF and FTM transgender individuals was also significantly associated with being older than 54 years (OR = 1.94), having a high school education or lower (OR = 1.98), living with at least a child (OR = 2.17), a current smoker (OR = 1.78) and a current e-cigarette user (OR = 2.97). Discussion: This study found a significant difference in smokeless tobacco use among transgender subgroups and addressed a critical tobacco knowledge gap among this population.

The global impact of tobacco control policies on smokeless tobacco use: a systematic review

Smokeless tobacco, used by more than 300 million people globally, results in substantial morbidity and mortality. For smokeless tobacco control, many countries have adopted policies beyond the WHO Framework Convention on Tobacco Control, which has been instrumental in reducing smoking prevalence. The impact of these policies (within and outside the Framework Convention on Tobacco Control) on smokeless tobacco use remains unclear. We aimed to systematically review policies that are relevant to smokeless tobacco and its context and investigate their impact on smokeless tobacco use. In this systematic review, we searched 11 electronic databases and grey literature between Jan 1, 2005, and Sept 20, 2021, in English and key south Asian languages, to summarise smokeless tobacco policies and their impact. Inclusion criteria were all types of studies on smokeless tobacco users that mentioned any smokeless tobacco relevant policies since 2005, except systematic reviews. Policies issued by organisations or private institutions were excluded as well as studies on e-cigarettes and Electronic Nicotine Delivery System except where harm reduction or switching were evaluated as a tobacco cessation strategy. Two reviewers independently screened articles, and data were extracted after standardisation. Quality of studies was appraised using the Effective Public Health Practice Project's Quality Assessment Tool. Outcomes for impact assessment included smokeless tobacco prevalence, uptake, cessation, and health effects. Due to substantial heterogeneity in the descriptions of policies and outcomes, data were descriptively and narratively synthesised. This systematic review was registered in PROSPERO (CRD42020191946). 14 317 records were identified, of which 252 eligible studies were included as describing smokeless tobacco policies. 57 countries had policies targeting smokeless tobacco, of which 17 had policies outside the Framework Convention on Tobacco Control for smokeless tobacco (eg, spitting bans). 18 studies evaluated the impact, which were of variable quality (six strong, seven moderate, and five weak) and reported mainly on prevalence of smokeless tobacco use. The body of work evaluating policy initiatives based on the Framework Convention on Tobacco Control found that these initiatives were associated with reductions in smokeless tobacco prevalence of between 4·4% and 30·3% for taxation and 22·2% and 70·9% for multifaceted policies. Two studies evaluating the non-Framework policy of sales bans reported significant reductions in smokeless tobacco sale (6·4%) and use (combined sex 17·6%); one study, however, reported an increased trend in smokeless tobacco use in the youth after a total sales ban, likely due to cross-border smuggling. The one study reporting on cessation found a 13·3% increase in quit attempts in individuals exposed (47·5%) to Framework Convention on Tobacco Control policy: education, communication, training, and public awareness, compared with non-exposed (34·2%). Many countries have implemented smokeless tobacco control policies, including those that extend beyond the Framework Convention on Tobacco Control. The available evidence suggests that taxation and multifaceted policy initiatives are associated with meaningful reductions in smokeless tobacco use. UK National Institute for Health Research.

Alteration of oral bacteriome of smokeless tobacco users and their association with oral cancer

Smokeless tobacco (SLT) is certainly one of the major risk factors associated with oral cancer. Disruption of oral microbiota-host homeostasis contributes to the progression of oral cancer. Here, we profiled SLT users' oral bacterial composition and inferred their functions by sequencing 16S rDNA V3-V4 region and PICRUSt2, respectively. Oral bacteriome of SLT users (with or without oral premalignant lesions), SLT with alcohol co-users, and non-SLT consumers were compared. Oral bacteriome is shaped primarily by SLT use and the incidence of oral premalignant lesions (OPL). A significantly increased bacterial α-diversity was monitored in SLT users with OPL compared to in SLT users without OPL and non-users, whereas β-diversity was significantly explained by OPL status. Overrepresented genera were Prevotella, Fusobacterium, Veillonella, Haemophilus, Capnocytophaga, and Leptotrichia in SLT users having OPL. LEfSe analysis identified 16 genera as a biomarker that were differentially abundant in SLT users having OPL. The functional prediction of genes significantly increased for several metabolic pathways, more importantly, were nitrogen metabolism, nucleotide metabolism, energy metabolism, and biosynthesis/biodegradation of secondary metabolites in SLT users having OPL. Furthermore, HPV-16 and EBV, but not HPV-18, were considerably connected with the SLT users having OPL. Overall, this study provides evidence that SLT utilization and OPL development are associated with oral bacteriome dysbiosis indicating the enrichment of bacterial species known for their contribution to oral carcinogenesis. Therefore, delineating the cancer-inducing bacterial population in SLT users will facilitate the future development of microbiome-targeted therapies. KEY POINTS: • SLT consumption significantly elevates oral bacterial diversity. • Prevalent significant genera are Prevotella, Veillonella, and Haemophilus in SLT users with OPL. • SLT promotes the occurrence of the cancer-inducing bacterial population.

Management of Oral Health Complications Associated with Smokeless Tobacco

This case report highlights the management of oral health complications related to smokeless tobacco use. A 38-year-old male patient presented with decayed teeth and oral mucosal changes resulting from smokeless tobacco consumption. After receiving habit cessation counseling, the patient reported for follow-up. This report discusses the importance of habit cessation counseling and demonstrates how this case contributes to the broader understanding of managing oral health complications associated with smokeless tobacco. It emphasizes the need for tobacco cessation and improved oral hygiene practices in preventing and managing these complications.

The invisible enemy: maternal smokeless tobacco use as a risk factor for low birth weight

The invisible enemy: maternal smokeless tobacco use as a risk factor for low birth weight

Cancer of tongue-our fixed entity

Background: Oral cancer ranks the top three of all cancers in India. This study aimed to determine etiologic factors for squamous cell carcinoma (SCC) of the tongue and its management. Methods: This longitudinal retrospective study was conducted with 30 patients of biopsy- proven SCC of tongue diagnosed in our hospital between the years of 2010-2022. Medical records, including history of abuse of alcohol, betel nuts, tobacco products and human papillomavirus (HPV) infection were recorded. The patients details including tumour size, location, node metastasis, grade, disease recurrence, other primary cancers, delay time until diagnosis, therapy course were noted. Patients were analyzed based on etiology and management undertaken. Results: Among 30 patients with SCC tongue, 25 (83.33%) were males, 5 (16.66%) were females. Smoking was significantly higher in males (20 patients), in those 5 alcoholics. Chronic mechanical trauma was observed in 5 patients. HPV infection was observed in 2 males, 3 females had betel nut chewing habit and use of smokeless tobacco. Among 30 cases alcohol abuse, smoking, chronic mechanical traumas, HPV infection and betel nut chewing appeared as significant etiologic factors of which smoking was the most common etiology (50%). Surgical excision with neck dissection followed by radiotherapy was treatment undertaken in our study patients based on SCC tongue stage. Conclusions: our study concluded that smoking is the most common etiology of SCC tongue, the definitive treatment is surgery combined with radiotherapy based on TNM staging.

Factors Associated with Smoking and Smokeless Tobacco Use, Intention to Quit, and the Number of Cigarettes Smoked among Adults with High Blood Pressure in a Rural District of Bangladesh

The current research is an initial investigation aimed at reporting the factors associated with smoking tobacco, smokeless tobacco (SLT) use, the number of cigarettes smoked, and the intention to quit smoking. A total of 307 adults aged 30 to 75 years with high blood pressure were recruited as part of a cluster RCT from a rural area in Bangladesh. The outcome variables included the number of cigarettes smoked per day, intentions to quit smoking, and SLT use. We used Rasch analysis and regression analysis. A low level of education and older age were associated with smoking tobacco and SLT use, respectively. The 62 smokers smoked 9.6 cigarettes or bidi on average per day, and 54 (87%) knew that smoking was associated with cancer. Overall, 41.6% of farmers compared to 58.9% of employees and 53% of people with no education compared to 75% of people with a higher education intended to quit smoking and SLT use. Our research contributes to the evidence that increasing education increases the intention to quit smoking and identifies population groups that could benefit from targeted public health campaigns. Health education programs are needed to increase motivation to quit smoking, especially among farmers, and to reduce SLT use among women and elderly people.

Smokeless tobacco (snus) use and its correlates among men during 2000-2020 in Finland

Smokeless tobacco (snus) use and its correlates among men during 2000-2020 in Finland

Sociodemographic inequalities in cigarette, smokeless tobacco, waterpipe tobacco, and electronic cigarette use among adolescents in 114 countries: a cross-sectional analysis

Sociodemographic inequalities in cigarette, smokeless tobacco, waterpipe tobacco, and electronic cigarette use among adolescents in 114 countries: a cross-sectional analysis

Patterns and distribution of tobacco use and its association with oral precancerous lesions among the tribes of Odisha

ABSTRACT Background Both smoked and smokeless tobaccos play crucial roles in forming potentially malignant oral disorders. Studies are scant in India, particularly among vulnerable tribal populations. Odisha, with the highest number of tribes in India, stands at the top in smokeless tobacco use among major states. The present study explores tobacco use status among Indian tribes by evaluating the OPMD risks. . Methods A cross-sectional study was carried out among the tribal populations in Odisha. Data was collected pertaining to sociodemographic profile, tobacco use and prevalence of oral potentially malignant disorders (OPMD). The Fagerstrom Test for Nicotine Dependence (FTND) scale was used to evaluate tobacco dependency.. Results The findings revealed that 75.2% of people are tobacco consumers. Half of the studied population consumes Dukuta and Khaini. Maximum people, including 54.2% of youth, fall in the high nicotine dependence category. Additionally, 45.2% of the participants reported mouth lesions, and 27.1% with potentially malignant disorders (PMD). The incidence of tobacco pouches in the studied population is 22.9%, followed by 12.4% leukoplakia lesions. Conclusion A health policy for community-level intervention toward tobacco cessation and early diagnosis of previously undiagnosed OML (oral malignant lesion) and OPMD would be a positive strategy.