Zhang X, Schmitz W, Gelderblom H R, Reichart PA (2001): Shammah-induced oral leukoplaquia-like lesions
Oral Oncol. 37 (7): 609-612.

A Shammah-induced oral leukoplakia-like lesion is described in a 44-year-old Algerian patient, who used this specific chewing tobacco since 33 years. The extended white lesion was located to the right mandibular vestibule and had a homogeneous appearance. Shammah is a chewing tobacco consisting of powdered tobacco leaves with carbonate of lime and other substances. It has been associated with oral cancer in Saudi Arabia. Histologically, acanthosis, hyperortho- and parakeratosis were seen. The spinous cell layer showed large pale staining epithelial cells with pycnotic nuclei. Atypia was not observed, however, an increase in mitotic activity was apparent. The subepithelial infiltrate was mild. Electron microscopy showed changes in the basal membrane with interruptions, duplications and triplications. Follow-up of the patient for 2 years revealed that, whenever, the patient changed the location of application, the white lesion regressed or disappeared within 4-6 weeks. Due to the composition of Shammah, the lesion induced has features of a mucosal burn. In contrast to other smokeless tobacco variants, Shammah seems to cause changes which, according to the small number of reports, may transform into oral cancer. As such, Shammah-induced oral leukoplakia-like lesions may be considered precancerous.