|Year : 2020 | Volume
| Issue : 2 | Page : 149-153
Prevalence of tobacco associated oral mucosal lesions in the population of Mahabubnagar District of Telangana State: A cross-sectional study
Ramesh Kumar Koothati1, D Rama Raju2, Ch Leela Krishna Prasad3, Bhavana Sujanamulk4, Ankit Srivastava5, Kotya Naik Maloth6
1 Department of Oral Medicine and Radiology, Govt Dental College, Vijayawada, Andhra Pradesh, India
2 Department of Oral Medicine and Radiology, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India
3 Department of Oral Medicine and Radiology, Maharana Pratap Dental College, Kothi, Mandhana, Kanpur, Uttar Pradesh, India
4 Department of Oral Medicine and Radiology, Drs Sudha and Nageswara Rao Siddhartha Institute of Dental Sciences, Gannavaram, Vijayawada, Andhra Pradesh, India
5 Department of Oral Medicine and Radiology, Malla Reddy Dental College for Women, Hyderabad, Telangana, India
6 Department of Oral Medicine and Radiology, Mamata Dental College, Khammam, Telangana, India
|Date of Submission||05-Mar-2020|
|Date of Decision||27-Apr-2020|
|Date of Acceptance||01-May-2020|
|Date of Web Publication||27-Jun-2020|
Dr. Ramesh Kumar Koothati
Department of Oral Medicine and Radiology, Govt Dental College, Vijayawada, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: We aimed to evaluate the prevalence of tobacco-associated oral mucosal lesions in Mahabubnagar district of Telangana state in South India. Methodology: A cross-sectional study was conducted in Mahabubnagar district for 6 months on 3200 subjects of both rural and urban people and the study was carried out by conducting camps at the Government Hospitals to assess the prevalence of oral mucosal lesions. People aged from 16 to 75 years, both men and women in same proportions, were included in the study. Results: 750 subjects had the habit of tobacco usage among a total of 3200 subjects. Among the 750 subjects, 225 (30.0%) subjects were being diagnosed with oral mucosal lesions. Of 225 subjects, 6 (2.67%) subjects had erythroplakia, 22 (9.78%) subjects had leukoplakia, 58 (25.78%) subjects had lichenoid reaction, 62 (27.56%) subjects had oral submucous fibrosis (OSMF), 45 (20.0%) subjects had palatal hyperkeratosis, and 32 (14.22%) subjects had tobacco pouch keratosis. Conclusion: From this study, we can conclude that prevalence of oral mucosal lesions was seen in tobacco-related oral habits where palatal hyperkeratosis was found among smokers; similarly OSMF was more among tobacco chewers and potentially malignant disorders were more prevalent in tobacco chewers than smokers.
Keywords: Oral mucosal lesions, smokers, tobacco chewers
|How to cite this article:|
Koothati RK, Raju D R, Krishna Prasad CL, Sujanamulk B, Srivastava A, Maloth KN. Prevalence of tobacco associated oral mucosal lesions in the population of Mahabubnagar District of Telangana State: A cross-sectional study. J Indian Acad Oral Med Radiol 2020;32:149-53
|How to cite this URL:|
Koothati RK, Raju D R, Krishna Prasad CL, Sujanamulk B, Srivastava A, Maloth KN. Prevalence of tobacco associated oral mucosal lesions in the population of Mahabubnagar District of Telangana State: A cross-sectional study. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2020 Jul 7];32:149-53. Available from: http://www.jiaomr.in/text.asp?2020/32/2/149/288135
| Introduction|| |
Oral mucosal lesions associated with tobacco could be because of many etiological factors mainly for the usage of smokeless forms of tobacco, areca nut, betel quid, or alcohol. Tobacco in any form, either smoked or smokeless, can cause a wide spectrum of oral mucosal lesions including potentially malignant disorders and oral cancers. The type and location of the lesion varies with the tobacco used, the way it is consumed, and the frequency, duration of use.
Oral cancer is the most common and lethal lesion among all the oral mucosal lesions associated with tobacco. Oral malignancies are the sixth most common cancers around the globe. Oral cancer is common in men in developing countries. It is the most common form of cancer especially the cause of cancer-related death of men in India. Its high risk in the Indian subcontinent is related to the popularity of pan-tobacco (a combination of betel leaf, lime, arecanut, and sun-cured tobacco) chewing in the region., Oral mucosal lesions associated with tobacco, especially the potentially malignant disorders, leads to oral cancer which is lethal; hence, the early diagnosis of such lesions is important to prevent further complications.
Epidemiological studies are useful for assessing the prevalence, incidence, and severity of a disease. These studies are also useful to determine the risk factors of a disease which help to plan any health-care programs at the primary level to spread awareness, and for early diagnosis and prompt treatment. India has a vast geographic area, divided into many states, which differ in their socioeconomic, educational, and behavioral status. These factors may influence their lifestyle, which affects the oral health status of the individuals. Hence, to obtain nationwide data regarding oral mucosal lesions associated with tobacco, a nationwide survey is required. Another alternative is to conduct surveys at regional level and review data from various regions which may give an understanding of the national scenario.,,
Hence, this study aimed to assess the prevalence of tobacco-related oral habits and tobacco-associated oral mucosal lesions in Mahabubnagar district of Telangana, India; as Mahabubnagar district is one of the backward districts of Telangana state with highest rural population and lowest literacy rate in the state.,
| Materials and Methods|| |
A cross-sectional study was carried out to assess the prevalence of tobacco-associated oral mucosal lesions in Mahabubnagar district of Telangana state in India over a period of 6 months from January to June 2012. A pilot study was done to know the feasibility and to calculate the sample size. Eight clusters were chosen. The final sample size was calculated using the formula for sample size as recommended by WHO:
Where P = prevalence of disease in a population z was to calculate 95% confidence interval, and d = acceptable margin of error (0.05). Therefore, the prevalence of oral habits in our pilot study was 26%. We could however take large sample size, although minimum sample size of 3200 was required for the study.
A “Simple Cluster Random sampling method” was followed in this study and eight clusters were selected from the entire district by following the district map which included four rural clusters and four urban clusters in total.
We selected 3200 subjects based on their tobacco usage; those who had a habit from a minimum of 6 months were included in the study from eight clusters and subjects were selected randomly (400 subjects from each cluster which includes 200 male and 200 female patients). Before commencing the survey, the examiners were trained in the Department of Public Health dentistry for each cluster; however, the final diagnosis was made by principal investigator. Participants were explained about the study and written informed consent was taken from every subject willing to take part in the study. The survey was done by conducting camps at the Government Hospitals at each cluster area. People aged from 16 to 75 years both men and women in same proportions were included in the study.
The oral examination of each subject was done from a standard height, by standing facing the subject slightly toward his or her right side, with the subject comfortably seated in a chair in an upright position with adequate natural light. For proper retraction of the oral tissues, two disposable wooden spatulas were used for each subject. Sometimes torch light was used when the natural light was inadequate for proper visualization of the oral cavity. Data were collected by interviewing the individual subjects regarding various tobacco-related oral habits (either smoking, chewing tobacco or a combination of both). Most of the subjects consumed the commercial variety of betel quid, which included areca nut, piper beetle, fresh leaf, slaked lime, sundried tobacco, catechu, and spices such as cloves and cardamom. Those subjects having a habit of alcohol, any local trauma or irritation and those with infections or any systemic disease, and those not willing to take part in the study were all excluded. The oral examination was performed to check the presence of any tobacco-associated oral lesions. The study protocol included a questionnaire-based interview and oral soft-tissue examination conducted by trained examiners. The questionnaire included details like age, gender, educational status, monthly income, frequency of habit and duration of the habit. The obtained data were noted simultaneously into the proforma which was exclusively designed to fulfill the objectives of this study.
Based on the location, clinical characteristics and histopathological diagnosis, the potentially malignant disorders enlisted were taken. The clinical diagnosis was established based on the criteria as for the diagnosis of oral mucosal diseases according to the WHO guidelines. The investigator was thoroughly trained in understanding different tobacco-related oral habits (such as smoking tobacco or chewing tobacco or both) and its associated oral lesions (such as leukoplakia, erythroplakia, oral submucous fibrosis, palatal hyperkeratosis, tobacco pouch keratosis and lichenoid reaction), to make consistent clinical judgements. Clinical oral examination was done using the Color Atlas of Common Oral Diseases (Langlais et al., 2009) and the established criteria of various authors were taken from a study by Naveen K, et al. The investigator also underwent the “reproducibility test” and the value 0.8 was considered acceptable. All the subjects involved in this study were motivated by the investigator regarding the health consequences and ill effects of tobacco use and the tobacco users were also motivated to quit the habit.
Data were analyzed by using IBM SPSS Statistics for Windows, version 20.0. Categorical variables were compared for proportions among the groups using Chi-square test. A value of P < 0.05 was considered as statistically significant. The results were expressed in numbers and percentages and were depicted in tables.
| Results|| |
In this study, 750 (23.5%) subjects were having the habit of tobacco usage among the total of 3200 subjects. 320 (42.7%) of them had the habit of tobacco smoking, 334 (44.5%) had the habit of tobacco chewing, and 96 (12.8%) had the habit of both tobacco chewing and tobacco smoking [Table 1].
Among the 750 subjects who had the habit of tobacco usage, 225 (30.0%) subjects were being diagnosed with oral mucosal lesions. Of the 225 subjects those who were having tobacco-associated oral lesions, 6 (2.67%) subjects were having erythroplakia, 22 (9.78%) were having leukoplakia, 58 (25.78%) were having lichenoid reaction, 62 (27.56%) were having oral submucous fibrosis (OSMF), 45 (20.0%), were having palatal hyperkeratosis, and 32 (14.22%), were having tobacco pouch keratosis.
Of the 225 subjects those who were having tobacco-associated oral lesions, 28 (12.5%) were having premalignant lesions, 62 (27.5%) were having premalignant conditions, and 135 (60.0%) were having other tobacco-related oral lesions [Table 2].
Of 62 subjects who had the oral mucosal lesions among tobacco smokers, 45 (72.6%) of had benign oral mucosal lesions and 17 (27.4%) had potentially malignant disorders. Of 125 subjects who had the oral mucosal lesions among tobacco chewers, benign lesions were more common which accounts for 58.4% followed by potentially malignant disorders (41.6%). Of 38 subjects who had the oral mucosal lesions among both tobacco smokers and tobacco chewers, potentially malignant disorders were more common which accounts for 55.3% followed by benign oral mucosal lesions (44.7%). When compared these three groups with each lesion, a P value of <0.001 was obtained which was considered as statistically highly significant [Table 3].
|Table 3: Different types of tobacco associated oral mucosal lesions among different forms of tobacco related oral habits|
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Palatal hyperkeratosis was more common among tobacco smokers which accounts for 72.6% followed by leukoplakia (17.7%) and erythroplakia (9.7%). 125 subjects had the oral mucosal lesions among 334 subjects who were having the habit of tobacco chewing. Lichenoid reaction was more common among tobacco chewers which accounts for 36.8% followed by oral submucous fibrosis (35.2%), tobacco pouch keratosis (21.6%), and leukoplakia (6.4%). Of 38 subjects who had the oral mucosal lesions among both tobacco smokers and tobacco chewers, oral submucous fibrosis was more common which accounts for 47.4% followed by lichenoid reaction (44.7%) and tobacco pouch keratosis (13.2%). When compared these three groups with each lesion, a P value of <0.001 was obtained which was considered as statistically highly significant [Table 3].
Palatal hyperkeratosis was more common among Beedi and Chutta smokers, whereas oral submucous fibrosis was more common among tobacco chewers who were having commercial variety, and tobacco pouch keratosis was more common among tobacco chewers who were having non commercial variety. When compared these groups with each lesion, a P value of < 0.001 was obtained which was considered as statistically highly significant. Potentially malignant disorders were more common among tobacco chewers when compared to tobacco smokers [Table 4].
|Table 4: Different types of tobacco associated oral lesions with different forms of tobacco|
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| Discussion|| |
This study was conducted to assess the prevalence of tobacco-associated oral lesions and tobacco-related oral habits in Mahabubnagar district, Telangana, India. This study helps us to analyze the situation of tobacco-associated oral lesions which in turn helps in planning a program to prevent the tobacco-related oral habits and its associated oral lesions such as potentially malignant disorders and oral cancers through early detection and primary prevention.
In this study, 30% subjects were identified with oral mucosal lesions. The findings in this study were higher compared to the other study conducted by Patel P et al. (2011) in North Gujarat where 16.34% of subjects were identified with abnormalities on clinical examination and the reason for more prevalence of oral mucosal lesions may be because of longer duration and high frequency of usage of tobacco.
In this study, high prevalence (37.4%) of oral mucosal lesions was seen in tobacco chewers than tobacco smokers (19.3%). This finding is like the results of the study conducted by Vellappally S, et al. (2008) where they found that the highest prevalence of oral mucosal lesions was present in tobacco chewers (22.7%) followed by regular smokers (12.9%).
In this study, palatal hyperkeratosis was seen only in smokers which accounts for 72.6% of all smokers and our findings are similar to the study conducted by Behura SS et al. (2015) where prevalence of oral lesions were mostly seen in tobacco smokers and the associated lesion such as smoker's melanosis was more in men.
Also in our study highest prevalence of oral submucous fibrosis (27.56%) was seen in tobacco chewers and the result correlating the study conducted by Behura SS et al. (2015) where OSMF was seen more common in tobacco chewers followed by the subjects who have both habits and in a study conducted by Patel P et al. (2011) the percentage of patients suffering from oral submucous fibrosis was 9.7%. In this study, OSMF was high due to the more prevalence in usage of chewing tobacco in the commercial form.
In this study, prevalence of leukoplakia was 9.78% which was higher than previous studies reported by Matthew et al. (2008) and Bhatnagar et al. (2013) which was 2.38% in Uttar Pradesh, India in 2013 and it may be because of more usage of tobacco and tobacco-associated habits in various forms when compared to other studies.
This study was a cross-sectional study, and it provided information on the prevalence of tobacco-related oral habits and tobacco-associated oral lesions among part of Telangana state of South India. Although the sample of the study was more, we could not find the exact site of the tobacco-associated oral mucosal lesion in the oral cavity and duration of the tobacco habits due to low resources such as lack of new-generation diagnostic procedures, imaging devices, and chemotherapies. Further studies with large sample and long-term follow-up are required to test the risk of lesion with each form of tobacco consumed.
| Conclusion|| |
From this study, we conclude that OSMF was more common in tobacco chewers, whereas palatal hyperkeratosis was observed in Chutta and Beedi smokers than cigarette smokers. The potentially malignant disorders were found more in tobacco chewers than smokers, and tobacco pouch keratosis was more common among tobacco chewers who were having non commercial variety. The futuristic studies whether case control or cohort studies for each lesion taking larger sample size would further enhance in evaluating the risk of potentially malignant disorders and oral cancer resulting from smoking and chewing habits of tobacco near Mahabubnagar district.
The study was conducted in area government hospitals at selected clusters. Ethical clearance was obtained from the Institutional Ethical Committee and prior permission was taken from the Superintendent of the area Government Hospital Mahabubnagar district, Telangana state, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]