|Year : 2016 | Volume
| Issue : 2 | Page : 124-128
Oral submucous fibrosis: A demographic study
Department of Oral Medicine and Radiology, Mithila Minority Dental College and Hospital, Darbhanga, Bihar, India
|Date of Submission||23-Apr-2015|
|Date of Acceptance||14-Nov-2016|
|Date of Web Publication||02-Dec-2016|
Dr. Satish Kumar
Department of Oral Medicine and Radiology, Mithila Minority Dental College and Hospital, Darbhanga, Bihar
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Oral submucous fibrosis (OSF) has the highest malignant potential disorder than any other oral premalignant lesions. It is found in the Asian subcontinent, mostly India, Pakistan, Sri Lanka and Bangladesh. The understanding of the exact role of alkaloids and other etiological agents with respect to pathogenesis will help in the management and treatment modalities. Materials and Methods: A total of 1006 patients of OSF attending the dental outpatient clinic of the Department of Oral Medicine and Radiology over a period of 24 months were selected for the study. A detailed case history and clinical examination was done in visible light. The diagnosis of OSF was difficulty in opening the mouth and associated blanched oral mucosa, with palpable fibrous bands. Other diagnostic features included burning sensation, salivation, tongue protrusion, habits and associated malignant changes. Study was done on the basis of age group, habit duration, frequency of habit, and type of habit. Statistical Analysis Used: Simple correlation analysis was performed. Results: Of the 1006 cases of OSF studied, 422 (41.94%) cases were stage II. Two hundred and twenty six (22.29%) were stage IV, 184 (18.29%) stage III, and 174 (17.29%) stage I. Among the groups divided based on age, Group II (20-30 years age) showed more prevalence than the others. Areca nut (gutkha) was a powerful etiological factor (60.43%) among other etiological factors. Conclusion: In the present study it was concluded that although the prevalence based on duration and frequency of habit was variable, it was found that most of the subjects were having stage II OSF and the severity was more in subjects who were chewing for longer duration and swallowing.
Keywords: Gutkha, habit, oral submucous fibrosis
|How to cite this article:|
Kumar S. Oral submucous fibrosis: A demographic study. J Indian Acad Oral Med Radiol 2016;28:124-8
| Introduction|| |
Oral submucous fibrosis (OSF) is "an insidious, chronic disease affecting any part of the oral cavity and sometimes the pharynx. Although occasionally preceded by and/or associated with vesicle formation, it is always associated with juxta-epithelial inflammatory reaction followed by fibro-elastic change of the lamina propria, with epithelial atrophy leading to stiffness of the oral mucosa and causing trismus and inability to eat." , Worldwide, estimates of OSF show a confinement to Indians and Southeast Asians, with an overall prevalence rate in India of approximately 0.2-0.5%, and a gender prevalence of 0.2-2.3% in males and 1.2-4.57% in females. 
The resulting stiffness of the oral mucosa and deeper tissues progressively limits opening of the mouth and protrusion of the tongue, with difficulties in eating, speaking, and swallowing.  Epithelial atrophy is marked in the advanced stages of the disease. The association with cancer is highly probable but not yet conclusive. In India, 30-40% of all reported cancers are oral cancers.  Use of tobacco and its various forms are one of the major risk factors of oral cancer. In 1990, it was estimated that tobacco caused 3.9 million deaths, demonstrating the rapid evolution of the tobacco epidemic, providing evidence of the size of this hazard, with most of the increase in developing countries.  In this study, prevalence of OSF in the rural and urban population was estimated.
| Materials and Methods|| |
We examined OSF patients in the outpatient department of the Department of Oral Medicine and Radiology during 24 months. OSF patients were divided according to gender. A total of 1006 OSF patients were screened out of a total of 25400 patients. The selected patients were divided into four groups according to their clinical stage. ,
Stage I: Interincisal mouth opening up to or greater than 35 mm, stomatitis and blanching of oral mucosa.
Stage II: Interincisal mouth opening between 25 and 35 mm, presence of palpable fibrous band in buccal mucosa and/or oroparynx, with/without stomatitis.
Stage III: Interincisal mouth opening between 15 and 25 mm; presence of palpable fibrous bands in buccal mucosa and/or or pharynx, and in any other parts of the oral cavity.
Stage IV: Interincisal mouth opening less than 15 mm.
a. Any other stage along with other potentially malignant disorders, e.g., oral leukoplakia, oral erythroplakia, etc.
b. Any other stage along with oral carcinoma.
The OSF patients were divided in four categories on the basis of age groups:
Prevalence of OSF was also recorded on the basis of habit duration and divided in three groups:
- Group I: 10-20 years
- Group II: 20-30 years
- Group III: 30-40 years
- Group IV: 40-50 years.
This study is conducted on the basis of the type of habit and divided in three groups [Table 1]:
- Group A: 2-5 years
- Group B: 5-10 years
- Group C: More than 10 years.
We excluded patients who were suffering from any systemic diseases. Children below the age of 10 years were also excluded from this study.
- Group 1: Guthka, Pan masala
- Group 2: Betal quid
- Group 3: Tobacco, smoking.
| Results|| |
Descriptive statistics and correlation test were performed to determine the P value for each variable. This included the analysis of mean, median and standard deviation (SD), which are presented in [Table 2] [Table 3] [Table 4]. In this study, the total number of OSF patients were 1006 out of a total of 25400 (3.96%). OSF was divided in four stages according to mouth opening. More prevalence was recorded in stage IV (41.94%) than that in stage II (22.99%); however, approximately equal prevalence was observed in stage I (17.29%) and stage III (18.29%) [Table 2].
Prevalence was also recorded on the basis of age groups. There was more prevalence of OSF in group II (42.74%) in comparison to group III (16.69%) and V (16.50%). There was less prevalence in group IV (11.13%) and I (12.92%) in comparison to groups II, III, and V. In Group I, more prevalence was noticed in stage II (46.15%) OSF than stage I (33.84%) OSF. Less prevalence was recorded in stage III (13.84%) OSF and stage IV (6.15%) OSF. In Group II, more prevalence was noticed in stage II (58.60%) OSF than stage III (19.63%); less prevalence was noticed in stage IV (8.13%) and stage I (13.48%). In group III, there was more prevalence of stage II (34.52%) OSF in comparison to stage IV (29.76%). There was more prevalence in stage III (29.19%) in comparison to stage I (9.52%). The prevalence of stage IV (64.07%) OSMF was more than stage III (21.42%) OSF in group IV, however, approximately similar prevalence was recorded in stage II (7.14%) and stage I (5.35%). Finally, in group V, there was more prevalence in stage IV (34.93%) OSF than stage I (30.12%), stage II (26.50%), and stage III (8.43%) OSF (P < 0.0001) [Table 3].
In this study, prevalence of OSF was recorded on the basis of duration of habit. Duration of habit was divided in three groups. Group A consisted of people with a habit duration of 2-5 years. Group B consisted of people with a habit duration of 5-10 years, and Group C consisted of people with a habit duration of more than 10 years. A higher prevalence was recorded in Group A (60.03%) in comparison to Group B (27.03%) and Group C (12.92%). This prevalence was statically significant (P < 0.0001) [Table 4].
An investigation was done on the basis of the frequency of the habit (per day). Frequency of habit was divided in three groups. Group 1 had a habit frequency of 2-5 times/day; group 2 had a habit frequency of 5-10 times/day; and group 3 had a habit frequency of more than 10 times/day. Prevalence was more in Group 1 (47.57%) in comparison to group 3 (28.67%) and group 2 (23.58%). The prevalence was statistically significant (P < 0.0001) [Table 5]. The type of habit prevalence of OSF was also recorded. Based on the type of habits the subjects were divided into four groups. Group A contained those with the habit of gutkha chewing. Group B contained those having habit of betal quid and gutkha, and Group C contained those having habit of tobacco and gutkha; Group D contained those having the habit of smoking and gutkha. Prevalence was more in Group A (60.43%) in comparison to Group C (23.26%). There was less prevalence recorded in Group D (08.54%) in comparison to Group B (07.78%) [Table 6]. According to gender, prevalence of OSF was more in males (95.42%) in comparison to females (4.47%) [Table 7]. In stage IV OSF, Prevalence of leukoplakia (6.16%) was more in comparison to oral cancer [Table 8].
| Discussion|| |
A study from Delhi reported the prevalence of areca nut use to be 11.74% among high school students.  A similar study was done by Goel et al.,  which showed that commercial areca nut consumption was 40% among OSF patients; Ahmad et al.  showed that 69% were consuming gutkha. Other studies have reported an increased prevalence in the consumption of areca nut and areca nut-based products, which are addictive and psychoactive in nature. ,, The findings of Babu et al., among OSF patients in Hyderabad, showed that people were more addicted to gutkha than any other related areca nut and tobacco products such as pan, pan masala and raw areca nut. They found a strong association between gutkha chewing and OSF and pointed that gutkha consumption led to OSF.  The prevalence of OSF was 6.3% and gutkha chewing was the most common abusive habit among OSF patients in the study conducted by Nitin nigam et al.  Similarly, in the present study, habitual gutkha chewing was more prevalent than gutkha with tobacco.
Epidemiological studies on the prevalence of submucous fibrosis have been conducted by Pindborg et al. and Shear et al. Pindborg et al.  examined 35000 urban Indians seeking admission in clinics at dental colleges in Lucknow, Bombay, Bangalore, and Trivandrum and found the following prevalence 055%, 0.5%, 0.2%, and 1.2%, respectively. Shear et al. examined 1000 Indians in South Africa and found a prevalence of 5%.  OSF was recoded in age Group I, III, and V, than Group I and IV. Similar observation was made by Ranganathan et al.,  Borle and Borle,  Anurda et al.,  Sami et al.,  Haider et al., and Hazarey. 
In this study, gutkha chewing with alcohol and smoking (bidi) were causes of stage III and IV OSF and oral leukoplakia (6.16%), as well as oral cancer (3.57%). Alcohol consumption has been associated with elevated risks of oral leukoplakia,  OSF,  and erythroplakia.  Tobacco smoking involves the inhaling of smoke, which may have less contact with the mouth and more contact with the throat and lung compared to tobacco chewing. Smokeless tobacco is an important etiological factor in the cancer of the mouth, lip, tongue, and pharynx. The Indian subcontinent has one of the highest rates of oral cancer in the world. 65% of all cancer in men and 33% of all cancers in women are tobacco related. Annual incidence of oral cancer is said to be 10/10000 of males.  Smoking consumption alone has been found to have no effect in the development of OSF, however, its addition to areca nut consumption can be a risk factor for OSF. 
A male predominance in OSF cases was reported by Sinor et al.  in India. Male predominance in our study can be due to easy accessibility for males to use areca nut and its products more frequently than females in our society along with the changing lifestyles of youngsters. In this study, male patients were more in comparison to females, with a prevalence of 95.42% compared to 4.47% in females.
| Conclusion|| |
The commercially available areca nut and tobacco (gutkha) by products have shown higher severity in terms of clinical staging. The current study found that although habit is variable in the form of duration, frequency; chewing for a longer duration and swallowing without spitting was found to correlate significantly with the severity of clinical staging.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pindborg J, Sirsat S. Oral submucous fibrosis. Oral Surg Oral Med Oral Pathol 1966;22:764.
Rajendran R. Oral submucous fibrosis: Etiology, pathogenesis, and future research. Bull World Health Organ 1994;72:985-96.
Phatak A. Fibrin producing factor in Oral Sub-Mucous Fibrosis. Indian J Otolaryngol Head Neck Surg 1979;31:103-4.
Krishnappa A. Oral submucous fibrosis. Dent J Malaysia Singapore 1967;7:32-9.
Pindborg JJ. Epidemiological studies of oral cancer. Int Dent J 1997;27:172-8.
Reducing Risks, Promoting healthy life can be increased 5-10 years. The World Health Report; 2002.
More CB, Das S, Patel H, Adalja C, Kamatchi V, Venkatesh R. Proposed clinical classification of oral sub mucosa fibrosis. Oral Oncol 2012;48:200-2.
Khada SR, Peabody JW. Tobacco control in India. Bull World Health Organization 2003;81:48-52.
Prabha S, Chandra UM. Areca nut: The hidden Indian 'gateway' to future tobacco use and oral cancers among youth. Indian J Med Sci 2007;61:319-21.
Goel S, Ahmad J, Singh MP, Nahar P. Oral submucous fibrosis: A clinical-histopathological comparative study in population of south Rajasthan. J Carcinogene Mutagene 2012:1:108.
Ahmad MS1, Ali SA, Ali AS, Chaubey KK. Epidemiological and etiological study of oral sub mucosa fibrosis among gutkha chewers of Patna, Bihar. J Indian Soc Pedod Prev Dent 2006:24:84-9.
Sinor PN, Gupta PC, Murti PR, Bhonsle RB, Daftary DK, Mehta FS, et al
. A case-control study of oral submucous fibrosis with special reference to the etiologic role of areca nut. J Oral Pathol Med 1990:19:94-8.
Hazarey VK, Erlewad DM, Mundhe KA, Ughade SN. Oral sub mucosa fibrosis: Study of 1000 cases from central India. J Oral Path Med 2007:36;12-7.
Babu S, Bhat RV, Kumar PU, Sesikaran B, Rao KV, Aruna P, et al
. A comparative clinico-pathological study of oral submucous fibrosis in habitual chewers of pan masala and betel quid. Clin Toxicol 1996;34:317-22.
Nigam NK, Aravinda K, Dhillon M, Gupta S, Reddy S, Srinivas Raju M. Prevalence of oral submucous fibrosis among habitual gutkha and areca nut chewers in Moradabad district. J Oral Biol Craniofac Res 2014:4:8-12.
Pindborg JJ, Mehta FS, Gupta PC, Daftary DK. Prevalence of oral submucous fibrosis among 50,915 Indian villagers. Br J Cancer 1968;22:646-54.
Ranganathan K, Devi MU, Joshua E, Kirankumar K, Saraswathi TR. Oral submucous fibrosis: A case control study in Chennai, South India. J Oral Pathol Med 2004:33:274-7.
Borle RM, Borle SR. Management of oral submucous fibrosis: A conservative approach. J Oral Maxillofac Surg 1991;49:788-91.
Anuradha P, Mishra G. Prevalence of oral sub mucosa fibrosis among people in periurban area in Lucknow city UP. J Indian Assoc Pub Health Dent 2011:18:121-30.
Jang SJ, Chiba I, Hirai A, Hong WK, Mao L. Multiple oral squamous epithelial lesions: Are they genetically related. Oncogene 2001;20: 2235-42.
Hashibe M, Sankaranarayanan R, Thomas G, Kuruvilla B, Mathew B, Somanathan T, et al
. Alcohol drinking, body mass index and the risk of oral leukoplakia in an Indian population. Int J Cancer 2000;88:129-34.
Hashibe M, Sankaranarayanan R, Thomas G, Kuruvilla B, Mathew B, Somanathan T, et al
. Body mass index, tobacco chewing, alcohol drinking and the risk of oral submucous fibrosis in Kerala, India. Cancer Causes Control 2002;13:55-64.
Shah N, Sharma PP. Role of chewing and smoking habits in the etiology of oral submucous fibrosis (OSF): A case control study. J Oral Pathol Med 1998;27:475-9.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]