Professional Documents
Culture Documents
https://doi.org/10.1007/s11356-018-2120-1
RESEARCH ARTICLE
Abstract
The aim of this cross-sectional study was to evaluate the prevalence of oral mucosal lesions (OMLs) and their association with
crack/cocaine addiction in men. Clinical oral examination was performed in 161 adult male patients at the School of Dentistry of
the Federal University of Bahia, Brazil. Crack/cocaine addiction was determined from the medical records, and all drug-addicted
individuals used both crack and cocaine. All participants (40 crack/cocaine-addicted men and 121 non-addicted men) underwent
a systematic evaluation of the lips, labial mucosa, commissures, buccal mucosa and sulcus, gingiva and alveolar ridge, tongue,
floor of the mouth, and soft and hard palate by a single examiner. Bivariate and regression analyses were conducted to assess for
the presence of OMLs and the association of OMLs with crack/cocaine addiction. OMLs were found in 22 participants with a
significantly greater prevalence in the crack/cocaine-addicted group (25 vs. 9.9%; p = 0.01). The most prevalent types of lesions
in the addicted group were traumatic ulcer and actinic cheilitis (7.5% for each) followed by fistulae associated with a retained
dental root (5%). After adjusting for covariates, crack/cocaine addiction was significantly associated with OMLs (OR = 2.87;
95% CI = 1.08–7.67; p = 0.03). The prevalence of OMLs was higher in crack/cocaine-addicted individuals, and crack/cocaine
addiction was significantly associated with OMLs. A public health program aimed at the early diagnosis and treatment of OMLs
is vital to improving the oral health status of individuals addicted to crack/cocaine.
Keywords Cocaine crack . Cross-sectional study . Illicit drug . Oral mucosa . Prevalence studies . South American
Although few studies have evaluated oral mucosal lesions 1.46 between crack/cocaine-exposed and unexposed individ-
(OMLs) in drug-addicted people, the reported prevalence uals, as previously described (Cury et al., 2017a, b). The in-
across Brazil, China, India, Ireland, and Spain is about 6% clusion criteria were male sex and age 18 year or older. The
(Du et al., 2001; Thavarajah et al., 2006; Rooban et al., exclusion criteria were a diagnosis of systemic disease, such
2008; O’sullivan, 2011; Gupta et al., 2012; Mateos-Moreno as diabetes or immunological disorders, and dependence on
et al., 2013; Da Silva Júnior et al., 2016). The most commonly other illicit drugs. Initially, 120 individuals addicted to crack/
used illicit substances in these studies were cannabis, opioids, cocaine were invited to participate, but only 40 were deemed
heroin, methadone, and benzodiazepines; these studies also eligible to be included in the study. During the months of
included multi-drug users (O’sullivan, 2011; Gupta et al., examining the crack/cocaine-addicted participants, 121 age-
2012; Mateos-Moreno et al., 2013). However, none of these matched non-addicted individuals were also examined and
studies strictly evaluated the presence of OMLs in crack/ included in the study.
cocaine-addicted adults. Periodontal diseases and dental health status were also
Therefore, the present study aimed to evaluate the preva- evaluated in this population and the results have been previ-
lence of OMLs in crack/cocaine-addicted men with the hy- ously published (Cury et al., 2017a, b).
pothesis that crack/cocaine addiction is associated with the
occurrence of OMLs.
Operational procedures
Material and methods Data were collected between June 2013 and June 2014 at
the School of Dentistry of the UFBA. Before clinical ex-
Ethical issues amination, in-person interviews were conducted by a
trained researcher to collect standard data on demographic
This study was conducted in accordance with the World and socioeconomic status (e.g., age, education level,
Medical Association Declaration of Helsinki and was ap- monthly income) as well as other health-related data, in-
proved by the Ethics and Research Committee of the Faculty cluding nicotine (Heatherton et al., 1991) and alcohol de-
of Dentistry of the Federal University of Bahia (UFBA), pendence (Bohn et al., 1995), using structured written
Brazil (protocol 112.869). Written informed consent was ob- questionnaires.
tained from all study participants. Individuals with OMLs
were referred to the stomatology service of the Federal
University of Bahia for biopsies when indicated. Oral mucosa evaluation
Study design and sampling procedures One dentist performed the clinical examinations, assisted by
one trained undergraduate student from the School of
This cross-sectional observational study included 161 con- Dentistry of the UFBA. Before the study, the examiner was
secutive adult male individuals (≥ 18 years old) examined calibrated for accuracy and repeatability using ten participants
at the School of Dentistry of the UFBA. Participants were who were not related to the study. Clinical examinations were
divided into two groups: one comprising 121 non-addicted performed in the School of Dentistry of the UFBA with the
individuals and the other comprising 40 crack/cocaine- individuals seated on a dental chair.
addicted individuals. Addiction to both crack and cocaine Examination of the oral mucosa was performed according
was the exposition factor, and the presence of OMLs was to the World Health Organization criteria (WHO 1997).
the outcome. Clinical examinations included the systematic evaluation of
The principal route of cocaine consumption was intranasal the lips, labial mucosa and sulcus, commissures, buccal mu-
(i.e., snorting) and the principle route of crack consumption cosa and sulcus, gingiva and alveolar ridge, tongue, floor of
was oral (i.e., smoking). Crack and cocaine addiction was the mouth, and soft and hard palate. Color, texture, and any
determined based on the medical records from the Center for abnormalities were evaluated. When an OML was found, the
Psychosocial Care—Alcohol and Other Drugs (UFBA School location, clinical diagnosis, and clinical description were
of Medicine). The center provided care 8 h a day, in non- recorded.
hospital settings. The present individuals received food and Diagnoses of OMLs were performed following a stepwise
psychosocial interventions, such as cognitive behavior thera- protocol that included clinical examination by the field exam-
py, motivational interviewing, and introduction to artistic iners, review of clinical records and photographs by an expe-
work. rienced pathologist, and referral of cases to the stomatology
The representative sample of adults was calculated based service of the UFBA for further clinical examination, treat-
on a significance level of 95%, a power of 80%, and a ratio of ment, and biopsies whenever indicated.
Environ Sci Pollut Res
Table 1 Comparison of general characteristics of the crack/cocaine-addicted and non-addicted participants (N = 161)
N Yes No OR 95% CI p
CI confidence interval, OR odds ratio, n number of persons presenting the condition within the group
a
Chi-squared test
b
Fisher’s exact test (used when the Bn^ was ≤ 5)
In the present study, actinic cheilitis and traumatic ulcer cheilitis, which is caused by chronic and excessive exposure
were the most prevalent type of OML in the crack/cocaine- to ultraviolet radiation from sunlight, has previously been re-
addicted group (7.5%, 3 cases each). The prevalence of actinic ported to be 10.9% in multi-drug users (Mateos-Moreno et al.,
Table 2 Bivariate analysis of the association of oral mucosal lesions with age, education level, income, alcohol/nicotine dependence, and crack/cocaine
addiction
N Yes No OR 95% CI p
CI confidence interval, OR odds ratio, n number of persons presenting the condition within the group
a
Chi-squared test
b
Fisher’s exact test (used when the Bn^ was ≤ 5)
Environ Sci Pollut Res
Table 3 Logistic regression for the relationship between oral mucosal the present population, traumatic agents were removed when-
lesions and crack/cocaine addiction
ever present and the lesions were followed to confirm the
Variables diagnosis.
Melanocytic nevus was the most prevalent lesion in the
OML OR (95% CI) p value non-addicted group (6.6%); however, a lower prevalence
Crack/cocaine addiction 0.02
(2.5%) was reported in the crack/cocaine-addicted group.
Melanocytic nevi were found on the lips, hard palate, and soft
No 1
palate. Epidemiological data is scarce on the prevalence of
Yes 3.03 (1.19–7.69)
melanocytic nevi in users of illicit substances; its development
CI confidence interval, OR odds ratio in both groups may be associated with skin type, ethnicity,
genetic predisposition, and exposure to ultraviolet light
2013). A higher prevalence of actinic cheilitis was expected in (Neville et al., 2015).
the crack/cocaine-addicted group as addicted individuals tend Although more than 70% of men in the crack/cocaine-
to have more sunlight exposure. This is because many drug addicted group were also alcohol- or nicotine-dependent, the
addicts are homeless, and in northeastern Brazil where this frequency and amount of consumption of these substances
study was conducted, sunlight levels are higher (Junqueira may be low, which may explain the lack of association be-
et al., 2011). A higher prevalence of traumatic ulcer (21.5%) tween nicotine and alcohol dependence and OMLs.
has also been described in the socioeconomically disadvan- This study does have some limitations. First, the sample
taged Brazilian population (Vieira-Andrade et al., 2011). size of this study may have been too small. Due to logistical
Traumatic ulcers may be cause by bites, dental apparatuses, and financial constraints, a sampling error of 5% was
tooth brushing, maladapted partial or completely removable employed and no correction factor was used for the sample
dentures, dental caries, malocclusion, and unsatisfactory res- size calculation. The crack/cocaine-addicted men were also
toration. Although the presence of many of these causative less cooperative during oral examination. Many of these par-
factors has not been evaluated, a previous study showed a high ticipants complained of pain and the time needed for the ex-
prevalence of dental caries in the drug-addicted population amination; they were also unable or unwilling to keep their
(Cury et al., 2017a). Therefore, the presence of these factors mouths open during the entire examination and frequently
may explain the occurrence of traumatic ulcers in this study. In asked to leave before completing examinations. Some
Table 4 Prevalence of different types of oral mucosal lesions among the participants
Traumatic ulcer 3 7.5 Tongue (1); alveolar mucosa (1); 0 0.0 – 3 1.8
floor of the mouth (1)
Candidiasis 1 2.5 Hard palate (1) 0 0.0 – 1 0.6
Actinic cheilitis 3 7.5 Buccal mucosa (1); lips (2) 1 0.8 Lips (1) 4 2.4
Melanocytic nevus 1 2.5 Lips (1) 8 6.6 Hard palate (1); lips (6); 9 5.5
soft palate (1)
Amalgam tattoo 1 2.5 Gingiva (1) 0 0.0 – 1 0.6
Fistulae from 2 5.0 Gingiva (2) 3 2.4 Gingiva (3) 5 3.1
retained root
Fibrosis 1 2.5 Alveolar mucosa (1) 0 0.0 – 1 0.6
Desquamation 1 2.5 Gingiva (1); 1 0.8 Gingiva (1) 1 0.6
Gingival 1 2.5 Gingiva (1) 0 0.0 – 1 0.6
hyperplasia
Fissure 1 2.5 Hard palate (1) 0 0.0 – 1 0.6
Total 15 37.5 – 13 10.7 – –
–
n number of persons presenting the condition within the group, N number of persons presenting the condition in both groups
Prevalence = (number of persons presenting the condition/number of examinees within the group) × 100
Overall prevalence = (number of persons presenting the condition/number of examinees in both groups) × 100
Environ Sci Pollut Res
Table 5 Prevalence of oral mucosal lesions at different sites public health program aimed at the early diagnosis and treat-
Site of lesion Crack/cocaine addiction ment of OMLs is vital to improving the oral health status of
crack/cocaine-addicted individuals.
N Yes No
Lips
No 151 (93.8%) 37 (92.5%) 114 (94.2%)
References
Yes 10 (6.2%) 3 (7.5%) 7 (5.8%)
Buccal mucosa
Angelillo IF, Grasso GM, Sagliocco G, Villari P, D’Errico MM (1991)
No 160 (99.4%) 39 (97.5%) 121 (100%) Dental health in a group of drug addicts in Italy. Community Dent
Yes 1 (0.6%) 1 (2.5%) 0 (0%) Oral Epidemiol 19(1):36–37
Tongue Antoniazzi RP, Sari AR, Casarin M, Moraes CMB, Feldens CA (2017)
No 160 (99.4%) 39 (97.5%) 121 (100%) Association between crack cocaine use and reduced salivary flow.
Braz Oral Res 31:e42
Yes 1 (0.6%) 1 (2.5%) 0 (0%)
Blanksma CJ, Brand HS (2005) Cocaine abuse: orofacial manifestations
Gingiva and implications for dental treatment. Int Dent J 55(6):365–369
No 154 (95.7%) 36 (90%) 118 (97.5%) Bohn MJ, Babor TF, Kranzler HR (1995) The Alcohol Use Disorders
Yes 7 (4.3%) 4 (10%) 3 (2.5%) Identification Test (AUDIT): validation of a screening instrument
for use in medical settings. J Stud Alcohol 56(4):423–432
Alveolar mucosa
Cury PR, Oliveira MG, de Andrade KM, de Freitas MD, Dos Santos JN
No 159 (98.8%) 38 (95%) 121 (100%) (2017a) Dental health status in crack/cocaine-addicted men: a cross-
Yes 2 (2.2%) 2 (5%) 0 (0%) sectional study. Environ Sci Pollut Res Int 24(8):7585–7590
Floor of mouth Cury PR, Oliveira MG, dos Santos JN (2017b) Periodontal status in crack
and cocaine addicted men: a cross-sectional study. Environ Sci
No 160 (99.4%) 39 (97.5%) 121 (100%)
Pollut Res Int 24(4):3423–3429
Yes 1 (0.6%) 1 (2.5%) 0 (0%) Da Silva Júnior FJG, Monteiro CFS, Monteiro TAS, Veloso LUP, Lima
Soft palate LAAL, Barbosa LK (2016) Oral changes for poly drug users: mul-
No 160 (99.4%) 40 (100%) 120 (100%) ticenter study. Int Arch Med 9 (146)
Yes 1 (0.6%) 0 (0%) 0 (0%) De Oliveira MGA, Dos Santos JN, Cury PR, da Silva VH, Oliveira NR,
da Costa PR et al (2014) Cytogenetic biomonitoring of oral mucosa
Hard palate cells of crack cocaine users. Environ Sci Pollut Res Int 21(8):5760–
No 158 (98.1%) 38 (95%) 120 (99.2%) 5764
Yes 3 (1.9%) 2 (5%) 1 (0.8%) Dias AC, Araújo MR, Dunn J, Sesso RC, de Castro V, Laranjeira R
(2011) Mortality rate among crack/cocaine-dependent patients: a
12-year prospective cohort study conducted in Brazil. J Subst
Abus Treat 41(3):273–278
participants wanted a dental prosthesis but did not want to be
Du M, Bedi R, Guo L, Champion J, Fan M, Holt R (2001) Oral health
examined. Moreover, the possibility of bias while answering status of heroin users in a rehabilitation centre in Hubei province,
the questionnaires cannot be ruled out for the crack/cocaine- China. Community Dent Health 18(2):94–98
addicted participants, as consumption of these drugs can lead Falck RS, Wamg J, Carlson RG (2008) Among long-term crack smokers,
to cognitive dysfunction. Crack/cocaine-addicted individuals who avoids and who succumbs to cocaine addiction? Drug Alcohol
Depend 98(1–2):24–29
may also be more likely to omit information or make false
Global Drugs Survey GDS (2017). Global overview and highlights.
assertions. Furthermore, the cross-sectional study model does London. Avaliable from: https://www.globaldrugsurvey.com/
not allow a causal inference, since it is not possible to analyze Gupta T, Shah N, Mathur VP, Dhawan A (2012) Oral health status of a
temporal relations between exposure and effect. group of illicit drug users in Delhi, India. Community Dent Health
The results of this study provide guidance for planning 29(1):49–54
Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO (1991) The
preventive and curative oral care for crack/cocaine-addicted
Fagerström Test for Nicotine Dependence: a revision of the
individuals. Further studies with a larger sample size are re- Fagerström Tolerance Questionnaire. Br J Addict 86(9):1119–1127
quired to evaluate other factors associated with OMLs among International Standard Classification of Education ISCED (2011)
drug-addicted individuals and to confirm these results in other Disponível em: www.uis.unesco.org/education/documents/isced-
populations. 2011-en.pdf. Acessed 12 Dec 2016
Junqueira JL, Bönecker M, Furuse C, Morais Pde C, Flório FM, Cury PR,
Araújo VC (2011) Actinic cheilitis among agricultural workers in
Campinas, Brazil. Community Dent Health 28(1):60–63
Conclusion Kapila YL, KASHANI H (1997) Cocaine-associated rapid gingival re-
cession and dental erosion. A case report. J Periodontol 68(5):485–
488
In conclusion, the prevalence of OMLs was higher in crack/ Kayal RA, Elias WY, Alharthi KJ, Demyati AK, Mandurah JM (2014)
cocaine-addicted individuals and crack/cocaine addiction was Illicit drug abuse affects periodontal health status. Saudi Med J
significantly associated with the occurrence of OMLs. A 35(7):724–728
Environ Sci Pollut Res
Kozor R, Grieve SM, Buchholz S, Kaye S, Darke S, Bhindi R, Figtree Pomara C, Cassano T, D'Errico S, Bello S, Romano AD, Riezzo I,
GA (2014) Regular cocaine use is associated with increased systolic Serviddio G (2012) Data available on the extent of cocaine use
blood pressure, aortic stiffness and left ventricular mass in young and dependence: biochemistry, pharmacologic effects and global
otherwise healthy individuals. PLoS One 9(4):e89710 burden of disease of cocaine abusers. Curr Med Chem 19(33):
Majewska MD (1996) Cocaine addiction as a neurological disorder: im- 5647–5657
plications for treatment. NIDA Res Monogr 163:1–26 Rooban T, Rao A, Joshua E, Ranganathan K et al (2008) Dental and oral
Mateos-Moreno MV, Del-Río-Highsmith J, Riobóo-García R, Solá-Ruiz health status in drug abusers in Chennai, India: a cross-sectional
MF, Celemín-Viñuela A (2013) Dental profile of a community of study. J Oral Maxillofacial Pathol 12(1):16–21
recovering drug addicts: biomedical aspects. Retrospective cohort Thavarajah R, Rao A, Raman U, Rajasekaran ST, Joshua E, R. H, Kannan
study. Med Oral Patol Oral Cir Bucal 18(4):671–679 R (2006) Oral lesions of 500 habitual psychoactive substance users
Narvaez JC, Jansen K, Pinheiro RT, Kapczinski F, Silva RA, Pechansky F in Chennai, India. Arch Oral Biol 51(6):512–519
et al (2014) Psychiatric and substance-use comorbidities associated Vieira-Andrade RG, Zuquim Guimarães Fde F, Vieira Cda S, Freire ST,
with lifetime crack cocaine use in young adults in the general pop- Ramos-Jorge ML, Fernandes AM (2011) Oral mucosa alterations in
ulation. Compr Psychiatry 55(6):1369–1376 a socioeconomically deprived region: prevalence and associated fac-
Neville BW, et al (2015) Oral and maxillofacial pathology. Elsevier. tors. Braz Oral Res 25(5):393–400
Disponível em: < https://books.google.com.br/books?id=Qs- World Health Organization WHO (1997) Oral health surveys: basic
JCgAAQBAJ > methods. Genova. 4th
O'Sullivan EM (2011) Prevalence of oral mucosal abnormalities in addic-
Yukna RA (1991) Cocaine periodontitis. Int J Periodontics Restorative
tion treatment centre residents in Southern Ireland. Oral Oncol
Dent 11(1):72–79
47(5):395–399