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Environmental Science and Pollution Research

https://doi.org/10.1007/s11356-018-2120-1

RESEARCH ARTICLE

Association between oral mucosal lesions and crack and cocaine


addiction in men: a cross-sectional study
Patricia Ramos Cury 1 & Nara Santos Araujo 2 & Maria das Graças Alonso Oliveira 2 & Jean Nunes dos Santos 2

Received: 17 November 2017 / Accepted: 24 April 2018


# Springer-Verlag GmbH Germany, part of Springer Nature 2018

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

Introduction the most reportedly used drug (77.8%) followed by ecstasy


(33.5%). Cocaine is the third most reportedly used drug
The use of illicit substances worldwide has increased consider- (29.5%) and, together with methamphetamine, crack is the
ably over the last several decades, and drug use is now consid- eleventh most reportedly used drug (5.9%) followed by opium
ered to be a public health problem due to the systemic and (3.7%) and heroin (2.4%) (Global Drugs Survey GDS, 2017).
behavioral consequences (Dias et al., 2011; Narvaez et al., Crack/cocaine use is associated with violent behaviors that
2014). According to the Global Drug Survey 2017, it is esti- harm both the user and the society in which they live. Crack/
mated that 250 million people worldwide (0.6% of the global cocaine addiction can develop rapidly and has many adverse
population) aged 15 to 64 years use some type of illicit drug and health effects, such as cardiovascular disease, cirrhosis, toxic-
have drug-related disorders, including addiction. Cannabis is ity, blood-borne bacterial and viral infections, and mental dis-
orders (Majewska, 1996; Falck et al., 2008; Pomara et al.,
Responsible editor: Philippe Garrigues 2012; Kozor et al., 2014). Crack/cocaine consumption has
also been associated with oral manifestations, such as an in-
* Patricia Ramos Cury crease in the decayed teeth index (Angelillo et al., 1991; Cury
patricia.cury@ufba.br
et al., 2017a, b), dental erosion (Kapila and Kashani, 1997),
hyposalivation (Antoniazzi et al., 2017), periodontitis (Yukna,
1
Department of Periodontics, School of Dentistry, Faculdade de 1991; Kapila and Kashani, 1997; Kayal et al., 2014; Cury
Odontologia, Federal University of Bahia, Av. Araújo Pinho, 62. et al., 2017b), and gingival lesions (Blanksma and Brand,
Canela, Salvador, Bahia 40110-150, Brazil
2005). Exposure to crack and cocaine has also been associated
2
Department of Oral Pathology, School of Dentistry, Federal with chromosomal breakage and the death of oral mucosa
University of Bahia, Av. Araújo Pinho, 62. Canela,
Salvador, Bahia 40110-150, Brazil cells (Oliveira et al., 2014).
Environ Sci Pollut Res

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

Data analysis p = 0.04) and income (OR = 7.7, 95% CI = 3.03–19.90,


p < 0.001) were significantly lower in the addicted group.
The statistical analysis included 161 participants (40 crack/ Alcohol dependence was also significantly more prevalent in
cocaine-addicted individuals and 121 non-addicted individ- the addicted group (OR = 0.61, 95% CI = 0.45–0.83, p ≤
uals). The prevalence of OMLs was calculated and compared 0.03), whereas the prevalence of nicotine dependence was
between the two groups using a chi-square test. similar between both groups (OR = 1.06, 95% CI = 0.94–
According to the median, age was categorized as 19 to 1.19, p ≤ 0.25).
34 years or ≥ 35 years. Education level was categorized as ≥ Bivariate analysis showed that OMLs were significantly
9 years (completion of elementary and middle school) or < associated with crack/cocaine addiction (OR = 3.02, 95%
9 years of education (International Standard Classification of CI = 1.19–7.68, p = 0.01) and a low education level (OR =
Education (ISCED) 2011). Socioeconomic status was catego- 2.66, 95% CI = 1.02–6.93, p = 0.04) (Table 2). After adjust-
rized as a monthly income of < 284 or ≥ 284 US dollars (i.e., ment for education level, only crack/cocaine addiction (OR =
the minimum wage in Brazil). Individuals were classified as 2.87, 95% CI = 1.08–7.67, p = 0.03) was associated with the
either nicotine-dependent or non-dependent (Fagerstrom Test occurrence of OMLs. The odds of having an OML were 2.87
for Nicotine Dependence score ≥ 6 (Heatherton et al., 1991)) times higher in the crack/cocaine-addicted group compared
and either alcohol-dependent or non-dependent (Alcohol Use with the non-addicted group (Table 3).
Disorders Identification Test score ≥ 8 (Bohn et al., 1995)). As shown in Table 4, ten different types of lesions were
To assess the variables associated with OMLs, a chi-square diagnosed clinically. In the addicted group, 15 lesions (37.5%)
test or Fisher’s exact was used initially. Next, a stepwise lo- were detected, and the most prevalent types of lesions were
gistic regression was used, adjusting for the covariates that traumatic ulcer and actinic cheilitis (7.5% for each) followed
showed p < 0.10 in the bivariate model (education level and by fistulae associated with a retained dental root (5%). In the
crack/cocaine addiction). The odds ratios (OR) and 95% con- non-addicted group, 13 lesions (10.7%) were detected, and the
fidence intervals (CI) were then calculated. most prevalent type of lesion was melanocytic nevus (6.6%
P values < 0.05 were considered statistically significant. each) followed by fistula associated with a retained dental root
Data analysis was performed using SPSS software version (2.4%) and actinic cheilitis and desquamation (0.8% for each).
14.0 (SPSS Inc., Chicago, IL, USA). Table 5 shows the prevalence of OMLs at different sites. In
the addicted group, the most commonly affected areas were
the gingiva (10%), lips (7.5%), and floor of the mouth and
Results hard palate (0.8% for each); in the non-addicted group, the
most affected areas were the lips (7%) and gingiva (2.5%).
Two hundred eighty individuals (120 crack/cocaine-addicted
and 160 non-addicted individuals) were invited to participate
on the study. After the examination for eligibility and partic- Discussion
ipation agreement, only 161 individuals (40 crack/cocaine-
addicted individuals and 121 non-addicted individuals) could There is a paucity of data related to the oral health of drug-
be included in the study and in the data analysis. addicted individuals. Access to this population for research
Table 1 displays the general characteristics of participants purposes is difficult due to the social stigma associated with
in both groups. The mean age of participants in both the illicit drug use. However, drug users attending a drug addic-
addicted and non-addicted group was 33 years. The age range tion treatment clinic, as in the present study group, are more
of participants was 18 to 57 years in the addicted group and 18 accessible. The Center for Psychological Care—Alcohol and
to 60 years in the non-addicted group. The mean duration of Other Drugs of the UFBA provided an opportunity to inves-
crack/cocaine use was 14 years, and the most common route tigate OMLs in this population.
of administration was intranasal (55%) followed by oral The present study found a significantly higher prevalence
(45%). Most addicted individuals had < 9 years of education of OMLs in crack/cocaine-addicted participants (25%) than in
(67.5%) and an income lower than US $259.00 per month non-addicted participants (9.9%). Furthermore, crack/cocaine
(85%) and were alcohol- (100%) and nicotine-dependent addiction was the only factor associated with the occurrence
(71%). The prevalence of OML in addicted individuals was of OMLs after adjusting for education level. The association
25%. between OMLs and crack/cocaine addiction described in this
OMLs were more prevalent in the crack/cocaine-addicted paper is supported by the findings of previous studies on
group (OR = 3.02, 95% CI = 1.19–7.68, p = 0.01). There was multi-drug users (Rooban et al., 2008; Gupta et al., 2012).
no significant difference in the age of the participants between Moreover, these results confirm the original hypothesis that
the two groups (OR = 0.91, 95% CI = 0.43–1.90, p = 0.08). crack/cocaine addiction is significantly associated with
However, education level (OR = 2.95, 95% CI = 1.38–6.27, OMLs.
Environ Sci Pollut Res

Table 1 Comparison of general characteristics of the crack/cocaine-addicted and non-addicted participants (N = 161)

Variables Crack/cocaine dependence

N Yes No OR 95% CI p

Age (years) 0.91 0.43–1.90 0.80a


18–34 years 98 (60.9%) 15 (37.5%) 73 (60.3%)
≥ 35 years 63 (39.1%) 25 (62.5%) 48 (39.7%)
Educational level (years) 2.95 1.38–6.27 0.04a
≥9 84 (52.2%) 13 (32.5%) 71 (58.7%)
<9 77 (47.8%) 27 (67.5%) 50 (41.3%)
Income 7.7 3.03–19.90 < 0.001a
≥ US$ 284.00 76 (47.2%) 6 (15%) 70 (57.9%)
< US$ 284.00 85 (52.8%) 34 (85%) 51 (42.1%)
Alcohol dependence 0.61 0.45–0.83 0.03b
No 10 (28.6%) 0 (0%) 10 (33.5%)
Yes 25 (71.4%) 9 (100%) 16 (61.5%)
Nicotine dependence 1.06 0.94–1.19 0.25b
No 9 (13.4%) 5 (29.4%) 4 (8%)
Yes 58 (86.6%) 12 (70.6%) 46 (92%)
Oral mucosal lesions 3.03 1.19–7.68 0.01
No 139 (86.3%) 30 (75%) 109 (90.1%)
Yes 22 (13.7%) 10 (25%) 12 (9.9%)

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

Variables Oral mucosal lesion

N Yes No OR 95% CI p

Age (years) 0.69 0.26–1.80 0.45a


18–34 years 98 (60.9%) 15 (68.2%) 83 (59.7%)
≥ 35 years 63 (39.1%) 7 (31.8%) 56 (40.3%)
Educational level (years) 2.66 1.02–6.93 0.04a
≥9 84 (52.2%) 7(31.8%) 77 (55.4%)
<9 77 (47.8%) 15 (68.2%) 62 (44.6%)
Income 2.11 0.81–5.49 0.12a
≥ US$ 284.00 76 (47.2%) 7 (31.8%) 69 (49.6%)
< US$ 284.00 85 (52.8%) 15 (68.2%) 70 (50.4%)
Alcohol dependence 0.68 0.54–0.86 0.35b
No 10 (28.6%) 0 (0%) 10 (31.3%)
Yes 25 (71.4%) 3 (100%) 22 (68.8%)
Nicotine dependence 0.59 0.05–5.99 0.52b
No 9 (13.4%) 1 (20%) 8 (12.9%)
Yes 58 (86.6%) 4 (80%) 54 (87.1%)
Crack/cocaine dependence 3.03 1.19–7.68 0.01a
No 121 (75.2%) 12 (54,5%) 109 (78.4%)
Yes 40 (24.8%) 10 (45.5%) 30 (21.6%)

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

Oral mucosal Addicted Non-addicted


lesions
n Prevalence Location n Prevalence Location Total, Overall
(%) (%) N prevalence
(%)

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%)
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