Mucosal Lesions Related to Toombak Dipping in the Sudanese

Background: Mucosal changes related to smokeless tobacco dipping appear to be influenced by many factors; including duration of dipping, frequency of dipping, chemical ingredients of the dipped stuff, in addition to possible genetic and racial factors. In the Sudan the habit of using smokeless tobacco (Toombak) is very common, and it is associated with pathological mucosal changes classified into five distinct clinical presentations: Presentation I; wrinkling with slight discoloration, Presentation II; Café au lait discoloration (Brownish discoloration), Presentation III; smoke-white discoloration, Presentation IV; grizzle discoloration, and Presentation V; cotton-white discoloration. Material and Methods: In this observational prospective study, a survey of oral cancer across 16 different localities was held in the Sudan. A total of 285 Toombak dippers agreed to be examined and of them 161 patients were found to have Toombak dipper-lesions. The clinical presentations of these lesions were identified and recorded into 5 different presentation categories. Furthermore, 64 specimens were cut and stained with Haematoxylin and Eosin (H&E). Microscopic diagnosis was obtained using both WHO-5-Point grading classification and the binary system. The history of the time span was matched with the related clinical and microscopic findings. Results: Regarding the 161 cases; the lower vestibule was the preferred dipping site in 75(46.6%) cases. The average Age of Commencement (AoC) was 24.5 years. The average Estimated Contact Hours (ECH) was 22,338 ± 40,824 hours; equal to 2.55 contact years in lifetime. The dominant mucosal clinical presentation was wrinkling with/without slight discolouration; found in 54 cases, and accounting for 33.6% of the sample. Of the 64 specimens, 51 cases showed hyperkeratosis, 11 cases showed mild dysplasia and the remaining three cases showed severe dysplasia; two cases were cotton- white presentations, and one case was a grizzle presentation. Conclusion: Twenty per cent of Toombak dippers-lesions showed dysplastic cells. The grizzle and the cotton- white clinical presentations are associated with high-risk dysplasia. A significant relationship was found between the clinical presentation and the AoC. No significant relationship was found between the clinical presentation and the Impact of Time Duration (TD), in terms of life-time duration of dipping, number of dippings/day, dip-duration and the Estimated Contact Hours (ECH).