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To the Editor: The use of objective biomarkers can help to quantify exposure to environmental tobacco smoke (ETS).¹ For instance, we have reported that cotinine concentrations in cord serum can be used to assess exposure to prenatal ETS in newborns during a period of several days,² and that nicotine concentrations in hair were related to infant exposure to ETS over a period of months.³ The presence of nicotine and cotinine in meconium has been associated with chronic exposure to ETS during fetal life.⁴ In this study we investigate whether nicotine and cotinine concentrations in deciduous teeth are related to cumulative tobacco exposure from fetal life to the time the tooth is lost.

Methods.
Children were recruited by word of mouth at a public primary school in Rome, Italy. Parents gave written consent to participate in the study and answered a questionnaire regarding smoking habits. Average value of nicotine daily intake by one or both parents and children's daily exposure to nicotine were calculated as described previously.² The presence of other smokers in the children's environment was also assessed.

Each child donated a deciduous superior incisor, lost in the previous months. Donated teeth were washed and organic washing was assayed to ascertain contamination from external nicotine. Subsequently, nicotine and cotinine were extracted from powdered teeth by organic solvent and analyzed by gas chromatography and mass spectrometry.⁵ The homogeneity of nicotine and cotinine content were verified in those cases in which the donated teeth were pairs of 2 superior incisors (n = 3). A univariate linear regression analysis was conducted to assess a dose-response relationship between childhood exposure to ETS and log-transformed values of nicotine and cotinine concentrations in teeth.

Results.
Teeth from 35 children (mean [SD] age, 7.4 [0.6] years) from nonsmoking and smoking parents were examined. External nicotine contamination was negligible, and the concentrations of analytes were similar (difference, <5%) in the 3 matched pairs of superior incisors. Nicotine concentration in teeth (Table 1) statistically discriminated between children exposed and not exposed to parental smoking even during pregnancy, as measured by questionnaire, by the average value of parental daily consumption of nicotine and by average levels of exposure to tobacco smoke during childhood. Cotinine concentrations in teeth, although showing a trend similar to those of nicotine, did not have a statistically significant relationship to ETS.

View this table: [in this window] [in a new window] Table. Association Between Child Exposure to Environmental Tobacco Smoke and Levels of Nicotine and Cotinine in Teeth

Comment.
Aligne et al⁶ recently reported an association between ETS and risk of dental caries among children. The authors speculated that levels of serum cotinine might provide a good estimate of exposure to tobacco smoke in infancy. There is no biomarker, however, that accounts for cumulative exposure to ETS during the whole childhood. Our data suggest that concentrations of nicotine in teeth may be a promising noninvasive tool for monitoring and categorizing cumulative exposure to environmental tobacco smoke during the entirety of childhood. It is possible that nicotine reaches the inside of the tooth by systemic circulation and can be accumulated together with lesser amounts of its metabolite, cotinine, during fetal life.

AUTHOR INFORMATION
Funding/Support: This study was supported in part by Progetto N. 1 "Area Progetto Droga" from Istituto Superiore di Sanità, Rome, Italy, and Fondo de Investigaciones Sanitarias (FIS-00/0021-01), Spain.

Acknowledgment: We thank the Gianni Rodari primary school of Rome, Italy, for help with recruitment of children for this study.

Oscar Garcia-Algar, MD, PhD; Oriol Vall, MD, PhD
Paediatric Service
Hospital del Mar
BarcelonaSpain

Jordi Segura, PhD; Jose Antonio Pascual, PhD; David Diaz, BSc
Unit of Pharmacology

Laura Mutnoz, BSc
Institut Municipal d'Investigaciao: Mgedica(IMIM)
PompeuFabraUniversity
Barcelona

Piergiorgio Zuccaro, PhD

Roberta Pacifici, PhD; Simona Pichini, PhD
Istituto Superiore diSanitaa(ISS)
Rome, Italy

1. Jaakkola MS, Jaakkola JJ. Assessment of exposure to environmental tobacco smoke. Eur Respir J. 1997;10:2384-2397. ABSTRACT 2. Pichini S, Basagaña X, Pacifici R, et al. Cord serum cotinine as a biomarker of fetal exposure to cigarette smoke at the end of pregnancy. Environ Health Perspect. 2000;108:1079-1083. ISI | PUBMED 3. Pichini S, Altieri I, Pellegrini M, Pacifici R, Zuccaro P. The analysis of nicotine in infants' hair for measuring exposure to environmental tobacco smoke. Forensic Sci Int. 1997;84:253-258. FULL TEXT | PUBMED 4. Ostrea EM, Knapp K, Romero A, Montes M, Ostrea AR. Meconium analysis to assess fetal exposure to nicotine by active and passive maternal smoking. J Pediatr. 1994;124:471-476. FULL TEXT | ISI | PUBMED 5. Shin HS, Kim JG, Shin YJ, Jee SH. Sensitive and simple method for the determination of nicotine and cotinine in human urine, plasma and saliva by gas chromatography-mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci. 2002;769:177-183. PUBMED 6. Aligne CA, Moss ME, Auinger P, Weitzman M. Association of pediatric dental caries with passive smoking. JAMA. 2003;289:1258-1264. FREE FULL TEXT

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;290:196-197.

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