|Year : 2015 | Volume
| Issue : 4 | Page : 544-548
Serum lipid profile as a prognostic marker in oral submucous fibrosis
Kamala Rawson1, Basavaraj N Kallalli2, Pavan Gujjar3, Shruthi T Patil4, Sridevi Bhoi5, Jyoti Zingade4
1 Department of Oral Medicine, Rama Dental College, Kanpur, Uttar Pradesh, India
2 Department of Oral Medicine and Radiology, Hazaribag College of Dental Sciences, Hazaribag, Jharkhand, India
3 Department of Oral Pathology, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India
4 Department of Oral Medicine and Radiology, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India
5 Department of Oral and Maxillofacial Surgery, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India
|Date of Submission||28-Sep-2015|
|Date of Acceptance||10-Mar-2016|
|Date of Web Publication||19-Aug-2016|
Dr. Kamala Rawson
Professor, Department of Oral Medicine and Radiology, Rama Dental College, Lakhanpur, Kalyanpur, Kanpur - 208 024, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Oral submucous fibrosis (OSMF) is the most prevalent precancerous condition in India, with high prevalence rates found in North Gujarat. In spite of the high prevalence and its potential to undergo malignant transformation, this condition has not been widely investigated with respect to the serum lipid levels. The changes in lipid profile have long been associated with cancer as lipids play a key role in the maintenance of cell integrity. Aim: To investigate the alterations and clinical significance of serum lipid profiles in OSMF patients. Materials and Methods: A total of 50 subjects were included in the study and divided into two groups. Group I consisted of 40 clinically diagnosed OSMF subjects and group II consisted of 10 healthy subjects. After taking a thorough history, clinical examination, and informed consent, all the patients were sent for lipid profile estimation, which consisted of (i) serum total cholesterol (TC), (ii) low density lipoprotein (LDL) cholesterol, (iii) high density lipoprotein (HDL) cholesterol, (iv) very low density lipoprotein (VLDL) cholesterol, and (v) serum triglycerides (TG). Results: The serum lipid levels were significantly lower in patients with OSMF than in the controls, which was most evident in stage IV OSMF. From the present results, it is evident that the level of serum lipids decreases with the progression of the disease. Conclusion: This study suggests that decrease in lipid levels may be considered as a useful marker in the early diagnosis of oral premalignant conditions like OSMF.
Keywords: Lipid profile, oral submucous fibrosis, premalignant condition
|How to cite this article:|
Rawson K, Kallalli BN, Gujjar P, Patil ST, Bhoi S, Zingade J. Serum lipid profile as a prognostic marker in oral submucous fibrosis. J Indian Acad Oral Med Radiol 2015;27:544-8
|How to cite this URL:|
Rawson K, Kallalli BN, Gujjar P, Patil ST, Bhoi S, Zingade J. Serum lipid profile as a prognostic marker in oral submucous fibrosis. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2023 Jan 28];27:544-8. Available from: http://www.jiaomr.in/text.asp?2015/27/4/544/188751
| Introduction|| |
Oral submucous fibrosis (OSMF) is the most common potentially malignant disorder in Asian countries. In India, the prevalence rate is high with the malignant transformation rate being 7-13%.  OSMF is defined as "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 fibroelastic changes of the lamina propria with epithelial atrophy leading to stiffness of mucosa and causing burning sensation and inability to eat." , The etiology of OSMF is multifactorial. Areca nut chewing is one of the most important causative factors. Along with this, ingestion of chillies, genetic and immunologic processes, and nutritional deficiencies serve as predisposing factors. ,, OSMF is diagnosed clinically, though additional investigations are required for early diagnosis and better prognosis. 
Various biochemical markers are available for the detection of potentially malignant disorders. Serum lipid profile is one such important marker. Lipids are major cell membrane components essential for various biologic function, cell growth, and cell division. Lower level of lipids may indicate rapidly dividing cells in malignancy. This can serve as a marker in early neoplastic changes, disease prognosis, and follow-up cases. ,, Cell membrane is essential for cell survival as well as biological functions. It is believed that areca nut carcinogens induce fibrosis leading to generation of free radicals and reactive oxygen species, which are responsible for the high rate of oxidation/peroxidation of polyunsaturated fatty acids. This peroxidation further releases peroxide radicals. This affects the essential constituents of the cell membrane and might be involved in carcinogenesis. ,,,, Alteration of serum lipid profile plays a vital role in the pathogenesis of OSMF. Hence, the aim of the present study was to evaluate the alteration of serum lipid profile in OSMF and to compare and correlate the serum lipid levels in different stages of OSMF.
| Materials and Methods|| |
A total 50 subjects in the age range of 20-50 years were selected from the Department of Oral Medicine and Radiology. All the subjects were divided into two groups. Group I consisted of 40 OSMF subjects and group II consisted of 10 healthy controls. The 40 OSMF patients were subdivided into four stages according to Khanna et al. (1995). Their classification is as follows [Figure 1]a and b:
|Figure 1: Figures showing (a) reduction in mouth opening and (b) blanching of buccal mucosa|
Click here to view
- Stage I: Patients with burning sensation, excessive salivation, normal mouth opening
- Stage II: Burning sensation, buccal mucosa - marble like, blanched, and mouth opening - 26-35 mm
- Stage III: Burning sensation, buccal mucosa pale, blanched, vertical fibrous bands palpable, mouth opening - 15-25 mm
- Stage IV: Burning sensation, tongue movements are restricted, shrunken uvula, and mouth opening 2-15 mm
Patients who were suffering from OSMF and had the habit of areca nut chewing were included in the study. Patients with syst emic diseases like obesity, uncontrolled diabetes mellitus, thyroid disorder, liver dysfunction, malabs orption syndrome, and cardiac patients were excluded from the study. Thorough history taking and clinical examination were carried out and recorded in a specific proforma. Ethical clearance was obtained for the study. Purpose of the study was explained and informed consent was taken from the patients. They were recalled on the next day with minimum 12 h of fasting for blood examination for complete lipid profile.
Five milliliters of intravenous blood was collected from the most prominent vein of right cubital fossa and stored in the test tubes. Centrifugation was done for about 4-5 min at 2500 rpm and the serum collected was stored at 4°C. The values for total cholesterol (TC), triglycerides (TG), high density lipoprotein (HDL), low density lipoprotein (LDL), and very low density lipoprotein (VLDL) were estimated using Roche Cobas III autoanalyzer [Figure 2]. All the variables of the study were statistically analyzed using SPSS version 22. Student's t-test was used to compare the serum lipid profile in control and OSMF groups. Analysis of variance (ANOVA) was used to assess statistical significance of difference between all the groups of OSMF.
| Results|| |
The present study consisted of 50 subjects in the age range of 20-50 years. Among these, maximum prevalence of stage I was found in patients of age 20-30 years while stage IV was found in patients of age 40-50 years [Table 1]. There was a male predominance of 80% among the OSMF patients [Table 2].
|Table 1: Table showing the distribution of four stages of OSMF in the three age groups |
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Comparison of mean serum lipid profile in control group and OSMF group
On comparing the mean serum lipid profile in the control group and OSMF group, the values of serum lipid profile in the control group were: TC, 184.21 mg/dl; TG, 162.43 mg/dl; LDL, 120.19 mg/dl; HDL, 47.12 mg/dl; and VLDL, 31.3 mg/dl. While in the OSMF group, the values were: TC, 142.4 mg/dl; TG, 93.36 mg/dl; LDL, 91.08 mg/dl; HDL, 34.2 mg/dl; and VLDL, 15.8 mg/dl. All the lipid profile variables were significantly decreased in the OSMF group compared to the control group, with P < 0.0001 [Table 3] and Graph 1.
|Table 3: Table showing significantly decreased lipid profile variables in OSMF group compared to the control group |
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Comparison of mean serum lipid variables in different stages of OSMF
In the present study, we also compared the mean serum lipid variables in different stages of OSMF. TC values in different stages of OSMF were: stage I, 170.58 mg/dl; stage II, 152 mg/dl; stage III, 132 mg/dl; and stage IV 120 mg/dl. TG values in different stages of OSMF were: Stage I, 138.93 mg/dl; stage II, 124 mg/dl; stage III, 68. 2 mg/dl; and stage IV, 51 mg/dl. LDL values in different stages of OSMF were: Stage I, 110 mg/dl; stage II, 101.78 mg/dl; stage III, 81.1 mg/dl; and stage IV, 74 mg/dl. HDL values in different stages of OSMF were: Stage I, 40.41 mg/dl; stage II, 37 mg/dl; stage III, 32 mg/dl; and stage IV, 27 mg/dl. VLDL values in different stages of OSMF were: stage I, 26.01 mg/dl; stage II, 17 mg/dl; stage III, 13 mg/dl; and stage IV, 9.5 mg/dl. All the variables were found to be significantly decreased from stage I to stage IV OSMF (P < 0.0001) [Table 4] and Graph 2. So, the results reveal that as the disease progresses, serum lipid profile values decrease.
|Table 4: Table showing significant decrease in all the variables from stage I to stage IV OSMF |
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| Discussion|| |
OSMF was first described by Pindborg in 1966. It is regarded as a potentially malignant disorder. ,, It is characterized by a juxta-epithelial inflammatory reaction followed by fibroelastic change in the lamina propria and associated epithelial atrophy. This leads to restricted mouth opening, resulting in trismus leading to restriction of food consumption, difficulty in maintaining oral health, as well as impairs the ability to speak. The fibroelastic changes are due to abnormal accumulation of collagen in the subepithelial layers, resulting in dense fibrous bands in the mouth. ,,,,
Serum cholesterol undergoes early and significant changes in some malignancies. Low levels of cholesterol in the proliferating tissues and in blood compartments could be due to the rapidly dividing cells in malignancies. Several prospective and retrospective studies have shown an inverse association between blood lipid profiles and different cancers. ,,,,,,,
Cholesterol is an amphipathic lipid and, as such, is an essential structural component of all the cell membranes and the outer layer of plasma lipoproteins. It is present in the tissues and in plasma lipoprotein either as free cholesterol or combined with a long-chain fatty acid. Cholesterol cannot dissolve in the blood. It has to be transported to and from the cells by carriers called lipoproteins. ,,,,,
There are three main categories of lipoproteins:
- VLDL: These are lipoproteins that carry cholesterol from the liver to organs and tissues in the body. They are formed by a combination of cholesterol and TG. VLDL is heavier than LDL, and is associated with atherosclerosis and heart disease. The normal range for VLDL is 10-35 mg/dl. 
- LDL: It is also known as "bad cholesterol." LDLs are produced by the liver and carry cholesterol and other lipids (fats) from the liver to different areas of the body like muscles, tissues, organs, and the heart. High levels of LDL indicate increase in the risk of heart disease. LDL levels less than 100 mg/dl are considered optimal. 
- HDL: HDL is considered the "good" cholesterol. HDL is produced by the liver to carry cholesterol and other lipids (fats) from the tissues and organs back to the liver. Normal HDL level ranges between 40 and 60 mg/dl. 
The present study was conducted to evaluate the alteration in serum lipid profile in OSMF and to compare it in different stages of OSMF. The study consisted of 50 subjects with the age range of 20-50 years. There was a male predominance of 80% and the patients had an addiction to areca nut. This is in accordance with previous research. Mehrotra et al.  conducted a study on 65 OSMF subjects with the age range of 20-60 years and compared them with normal subjects. The serum lipid levels were found to be decreased with the mean values (in mg/dl) being: TC 125.68, TG 130.14, LDL 90.61, and HDL 32.58, whereas in the present study, similar correlations were found with the mean values (in mg/dl) being TC 142.4, TG 93.36, LDL 91.08, and HDL 34.2. In the previous study, values of serum lipid profile were significantly decreased in OSMF patients with the P value being <0.05, whereas in the present study, the P value was <0.001.
Ajai et al.  conducted a study for estimation of serum lipid profile in 45 OSMF patients with the age range of 20-60 years. They compared the serum lipid profiles in OSMF and control groups, and also in different stages of OSMF. Their study showed significant reduction in serum lipid levels as the disease progressed, with P < 0.0001. These findings were similar to those of the present study. The mean serum lipid profile values (in mg/dl) of their study were: TC, 151.07; TG, 94.18; LDL, 95.15; HDL, 37.8; and VLDL, 18.11, which were comparable to the present study wherein the mean values (in mg/dl) were: TC, 142.4; TG, 93.36; LDL, 91.08; HDL, 34.2; and VLDL, 15.08.  The result of the present study is consistent with the previous study. They also compared mean serum lipid profile in different stages of OSMF, which showed constant decrease in all lipid variables from stage I to stage IV with P < 0.01, which is similar to the present study.
Patel et al.  carried out a similar study on 184 head and neck cancer patients, 153 patients with oral precancerous condition, and 52 controls. A significant decrease in plasma TC and HDL was observed in cancer patients (P = 0.008 and P = 0.000, respectively) as well as in patients with oral premalignant condition (OPC) (P = 0.014 and P = 0.000, respectively), as compared to the controls. The plasma VLDL and TG levels were significantly lower in cancer patients as compared to the patients with OPC (P = 0.04) and controls (P = 0.059). So, they concluded that there was an inverse relationship between plasma lipid levels and head and neck malignancies as well as OPC. The lower levels of plasma cholesterol and other lipid constituents in patients might be due to their increased utilization by neoplastic cells for new membrane biogenesis. These findings were similar to those of the present study (P < 0.0001).
Lohe et al.  conducted a study on 70 oral cancer and 70 precancerous condition patients for the evaluation of serum lipid profile levels. They found that there was a significant decrease in TC, HDL, VLDL, and TG in oral cancer group and a significant decrease in TC and HDL in oral precancer group, as compared to the controls, with a P < 0.005. They concluded that there is an inverse relationship between serum lipid profile and oral cancer and oral precancer. These findings were similar to those of the present study (P < 0.0001). The findings strongly warrant an in-depth study of alterations in serum lipid profile in OSMF patients, where there is an inverse relationship between serum lipid profiles as the disease progresses.
| Conclusion|| |
The present study was carried out to evaluate the alteration in serum lipid profile and to correlate different clinical stages of OSMF. The results of the study reveal that there is a decrease in the serum lipid variables with the progression of disease. OSMF is a potentially malignant disorder affecting the oral cavity with the highest rate of malignant transformation. So, early detection of OSMF is very important. Serum lipid profile is a relatively inexpensive and easily available method which helps in assessment of the disease severity. Lower levels of the lipid profile may be considered as a useful biochemical marker for better prognosis of OSMF. A much larger study sample and long-term follow-up of cases with periodic estimation of lipid profile would be needed to establish the correlation of transformation from a precancerous state to malignancy.
We thank STATSMASTER TEAM ([email protected]il.com) for their valuable statistical support for this research work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]