|Ahead of print publication
Prevalence of oral potentially malignant disorders (OPMD) in adults of Western Maharashtra, India: A cross-sectional study
KM Shivakumar1, Vaishali Raje2, Vidya Kadashetti1
1 Departments of Public Health Dentistry & Oral Pathology and Microbiology, Faculty of Dental Sciences, Krishna Institute of Medical Sciences Deemed to be University, Karad, Maharashtra, India
2 Department of Community Medicine, Krishna Institute of Medical Sciences, Krishna Institute of Medical Sciences Deemed to be University, Malkapur, Karad, Maharashtra, India
|Date of Submission||30-Sep-2020|
|Date of Decision||06-Jan-2021|
|Date of Acceptance||12-Jan-2021|
|Date of Web Publication||25-Oct-2021|
Professor, Department of Community Medicine, Krishna Institute of Medical Sciences, Krishna Institute of Medical Sciences Deemed to be University, Malkapur, Karad - 415 110, Satara (Dist.), Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Oral cavity cancer is estimated to be the third most common malignancy after cancer of cervix and stomach in developing countries.
Objectives: The objective of this study is to investigate the relationship between smoking, alcoholic consumption, betel quid chewing, and OPMD in a prospective manner.
Materials and Methods: A descriptive, cross-sectional study was conducted among 35–55-year-old adults of Western Maharashtra, India. Oral cavity examination as recommended by the American Dental Association specification was followed. Data recorded were transferred from precoded survey pro forma to the computer. The prevalence of OPMD was assessed by determining the percentage of the study population affected. Analysis was done to find out the risk of oral premalignant disorders. The Chi-square (x2) test and adjusted odds ratio (ORs) with 95% confidence interval (CI) were calculated. The Statistical Package for the Social Sciences (SPSS) software version 21.0 was used for the statistical analysis and significance level was set at P < 0.05.
Results: Odds of having OPMD are five times higher for those who smoke (OR = 5.78; 95% CI, [6.18, 7.82]) as compared to those who do not. The odds of suffering from OPMD are about five times higher among those who chew as compared to those who do not (OR = 4.98; 95%CI, [2.91, 7.28]). The mean frequency of tobacco chewing per day and duration in years in participants with OPMDs was significantly higher as compared with normal oral mucosa (P < 0.05 and P < 0.05), respectively, in the use of different tobacco forms.
Conclusion: These findings can be used to design case control or cohort studies to further understand the relation between habits and OPMD.
Keywords: Oral cancer, oral premalignant disorders (OPMDs), smoking, tobacco chewing
|How to cite this URL:|
Shivakumar K M, Raje V, Kadashetti V. Prevalence of oral potentially malignant disorders (OPMD) in adults of Western Maharashtra, India: A cross-sectional study. J Can Res Ther [Epub ahead of print] [cited 2021 Nov 29]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=329188
| > Introduction|| |
Oral cancer is an important component of the worldwide burden of cancer and is eighth most common cancer worldwide. It is a major global health issue. Oral cavity cancer is estimated to be the third most common malignancy after cancer of the cervix and stomach in the developing countries. It is the 12th most common cancer in females and sixth most common cancer in males. The oral and pharyngeal cancer is the 6th most common cancer in the world, with an annual global estimated incidence of 275,000 for oral and 130,300 for pharyngeal cancers in 2002, excluding salivary neoplasms, malignant neoplasms of the nasopharynx, and of the pyriform sinus – two-thirds of these occur in developing countries.,,, Oral cancer has also been one of the top ten causes of death from cancer since 1991 in Taiwan and the death toll for oral cancer in males has been rising at a surprising rate. It is often preceded by “potentially malignant lesions and conditions.”, A recent workshop conducted by the WHO Collaborating Center for Oral Cancer and Precancer in London has recommended the term oral potentially malignant disorders (OPMD). In 2005, the WHO recommended and proposed to use the term “Oral Potentially Malignant Disorders” (OPMDs), which is defined as “the risk of malignancy being present in a lesion or condition either at the time of initial diagnosis or at a future date.” The most common OPMDs with malignant potential include erythroplakia, oral leukoplakia, oral lichen planus, and oral submucous fibrosis.,,,
The global prevalence of OPMD is reported to be between 1% and 5%. A high prevalence of OPMD is reported from South and East Asia with male preponderance and with malignant transformation rates of over 2% per year. The incidence of cancer in the head-and-neck region accounts for 30%–40% of all malignant tumors in India., The prevalence of OPMDs and their malignant transformation rates varies globally.
The main risk factors for OPMDs include tobacco use, alcohol use, and human papillomavirus infection. Chewing of tobacco, smoking, and consumption of alcoholic beverages have become common social habits in India. The prevalence of regular use of alcohol is 4.5% and smoking tobacco is 16.2%. The risk factors which synergistically contribute to potential for malignant transformation include smoking, drinking alcohol, and chewing of tobacco which leads to OPMD., In India, 60%–80% of patients present with advanced stages of the disease as compared to 40% in developed countries. Although OPMD can give rise to oral cancer, the rate of malignant transformation varies with the quantity and duration of tobacco and alcohol use. Therefore, this study aimed to investigate the relationship between smoking, alcoholic consumption, and betel quid chewing on OPMD and its effects in the development of oral cancer.
| > Materials and Methods|| |
A descriptive, cross-sectional study was conducted among 35–55-year-old adults of Western Maharashtra, India. This study was conducted over a period of 1 year from March 2019 to February 2020. These participants were considered as a target population for the study. An ethical approval (Ref No. KIMSDU/IEC/01/2018, dated 01/02/2018) was obtained from the Institutional Ethics Committee of Krishna Institute of Medical Sciences Deemed to be University, Karad, Maharashtra, India. A pilot study was carried out on 50 adults to determine the feasibility of the study. The study participants were selected by using simple random sampling procedures (lottery method), which was followed by house-to-house survey.
Sample size determination
After the pilot study, the prevalence of OPMD was found to be 5% and the sample size (n) was determined by using the following formula:
Where, Z: Standard variate at 95% confidence level
q: Proportion of the population not having this characteristics.
d: Allowable error = 5% of “p”
The sample size was found to be 300. Those participants who are not willing to participate were excluded from the study. A total of 300 adults in the age group of 35–55 years were examined for the study. The purpose of the study was explained in their local language (Marathi) to all the study participants, and an informed consent was obtained. First house was selected in the village by using simple random sampling procedures (lottery method), which was followed by house-to-house survey till we achieve estimated sample size. The recruited study participants were given structured questionnaire, which contains the general information and questions regarding the use of tobacco and any other habits along with details of diet pattern and examination for oral premalignant disorders. Oral cavity examination was done for the presence or absence of OPMD in the oral cavity. A single examiner carried out the examination, and the same was calibrated. Conventional oral examination using normal light is used to check for the presence or absence of oral premalignant disorders based on their clinical features. The cases which required further investigation were referred to the hospital for further diagnosis and treatment.
Examination procedure, examination area, and lighting
Type-III clinical examination as recommended by American Dental Association specification was followed. The clinical examination was carried out under the adequate natural light in school premises or corridors. Sufficient numbers of instruments were carried to the examination place to avoid the interruption during the study. After each day of examination, the entire instruments were autoclaved.
The data recorded were transferred from the precoded survey pro forma to a computer. The statistical average mean, standard deviation was employed to represent the different measurements. The prevalence of OPMD was assessed by determining the percentage of study population affected. The collected data were entered in Microsoft Excel sheet and subjected to the statistical analysis.
The analysis was done to find out the risk of oral premalignant disorders. The Chi-square (x2) test and adjusted odds ratio (ORs) with 95% confidence interval (CI) was calculated. The Statistical Package for the Social Sciences (SPSS) software version 21.0 (version 21.0, Inc., and Chicago, IL, USA) was used for the statistical analysis, and the significance level was set at P < 0.05.
| > Results|| |
[Table 1] shows the distribution of study participants by basic characteristics. The mean age of the participants was 42.55 ± 10.28 years. There were more males (67.74%) in the study population than females (32.26%). 48.39% of the study participants were in the age group of 35–45 years, 51.61% were in the age group of 46–55 years, and there was statistically significant difference has been observed among these gender. About 12.54% of the participants were either degree or diploma holders, and remaining participants have had only school education or were illiterates. Significant difference has been noticed among the education of the study participants. More than 54.49% of the study participants came from families with monthly income between Rs. 4556 and Rs. 7593 per month, whereas <9.68% belonged to families with income <Rs. 4555 per month.
|Table 1: Comparison of sociodemographic characteristics of the study population in relation to oral premalignant disorders|
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[Table 2] shows the overall prevalence of oral premalignant disorders. Oral submucous fibrosis (0.82%), lichen planus (0.11%), leukoplakia (0.75%), erythroplakia (0.1%), discoid lupus erythematosus (0%), epidermolysis bullosa (0.2%), smokeless tobacco keratosis (0.9%), smoker's melanosis (0.5%), and chewer's mucositis (0.75%) were found in our study.
[Table 3] shows the comparison of frequency and duration of tobacco, alcohol, and betel quid usage with respect to the OPMD. The odds of having OPMD are five times higher for those who smoke (OR = 5.78; 95% CI, [6.18, 7.82]) as compared to those who do not. The odds of suffering from OPMD are about five times higher among those who chew as compared to those who do not (OR = 4.98; 95% CI, [2.91, 7.28]). The consumption of alcoholic beverages alone is not significantly associated with the OPMD, i.e., prevalence of OPMD did not differ between those who consumed alcoholic beverages and those who did not. The overall prevalence of smoking, drinking alcoholic beverages, and chewing tobacco was 19.26%, 15.19%, and 20.86%, respectively. The prevalence of smoking was higher among men (69.58%) when compared to women (0.28%). Furthermore, the prevalence of smoking is the highest among the age group of 35–45 (56.9%) years, higher being in the age group of 46–55 years (43.1%). More than 6 out of 10 smokers use unfiltered cigarettes, as compared to the other types, namely filtered cigarette and beedi. In this population, alcohol consumption was more common among men (19.3%) when compared to women (0.19%), with the prevalence being the highest (15.4%) in the age group of 45–55. The brandy, beer, desi daru, and whisky were more prevalent when compared to alcoholic beverages consumed in the study group, namely vodka, wine, and rum. The chewing habit was more prevalent in men (31.6%) as compared to women (13.8%). In women, the chewing habit was more prevalent when compared to the other two habits; wherein, in men it was the smoking habit that was more prevalent. The study participants were more likely to chew pan masala (commercially available product) or Gutkha, (71%) as compared to other products, namely betel quid, betel leaf with areca nut and lime, and unprocessed and processed areca nut alone.
|Table 3: Comparison of frequency and duration of tobacco, alcohol, and betel quid usage with respect to the oral premalignant disorders|
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[Table 4] shows the effects of different predictor variables on the prevalence of OPMD. The mean frequency of tobacco consumption per day and duration in years in participants with OPMDs was significantly higher as compared to with normal oral mucosa (P < 0.05 and P < 0.05), respectively, in the use of different tobacco forms. The mean number of years of betel quid consumption was 7.29 ± 7.96 in participants with OPMDs which was significantly higher as compared to 5.82 ± 3.83 in participants with normal oral mucosa (P < 0.05). The mean mL of alcohol consumption per day was in participants with OPMDs was significantly higher as compared in participants with normal oral mucosa (P < 0.001 and P < 0.001), respectively.
|Table 4: Effects of different predictor variables on the prevalence of oral premalignant disorders|
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| > Discussion|| |
In our study, we have analyzed the risk factors in estimating the prevalence of an OPMD and in identifying the high-risk category population in the development of oral cancer. In our sample, the prevalence of oral lesions was 7%, with the prevalence being greater for males than females. The prevalence of leukoplakia (0.75%), OSF (0.82%), and oral lichen planus (0.11%) in our study population is similar to those found in other previous studies conducted in India.,
The prevalence of alcohol consumption (15.19%) in the study population was higher when compared to the results reported by Neufeld et al. using the Indian National Sample survey sample. However, the prevalence of chewing (20.86%) and smoking (19.26%) was found to be lower. Smoking and chewing were the significant predictors of OPMD in our study population. However, the association between the presence of OPMD and alcohol consumption was not statistically significant.
In our study, it shows that smoking is more prevalent in men when compared to the other two habits of tobacco use. The findings from the our study are in concordance to that of Hashibe et al., with regard to chewing and smoking habit being the significant predictors of OPMD. The consumption of alcohol beverages (any amount) does not prove to be a significant predictor as found in the studies by Hashibe et al. and Gupta et al.,
The health-care workers must be encouraged to perform oral cancer examinations as part of their patient care program and to have knowledge about the early signs of oral cancer and premalignant disorders. The need for continuing educational campaigns at various levels to educate the public about the risk factors and early signs/symptoms should be highlighted.,
Workplace screening programs for the detection of oral malignant and premalignant disorders in these age groups are suitable and cost-effective alternative measure and effective utilization of existing infrastructure and workforce through the involvement of medical and dental hospital in the areas can also help in screening and early diagnosis.
| > Conclusion|| |
The findings from this study can be used to design case control or cohort studies to further understand the relation between habits and OPMD. Studies of this nature could population and which would be most beneficial for providing better oral hygiene programs. Programs to improve oral health should be conducted regularly to promote oral health care in the population. Workplace should be promoted to ban the use and sale of tobacco-related products which would decrease the usage of the product and overall might reduce the prevalence of disease and its severity of the oral premalignant disorders.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Sharada P, Swaminathan U, Nagamalini BR, Kumar KV, Ashwini BK, Lavanya VL. Coalition of E-cadherin and vascular endothelial growth factor expression in predicting malignant transformation in common oral potentially malignant disorders. J Oral Maxillofac Pathol 2018;22:40-7.
] [Full text]
Amarasinghe HK, Johnson NW, Lalloo R, Kumaraarachchi M, Warnakulasuriya S. Derivation and validation of a risk-factor model for detection of oral potentially malignant disorders in populations with high prevalence. Br J Cancer 2010;103:303-9.
Krishna Rao S, Mejia GC, Logan RM, Kulkarni M, Kamath V, Fernandes DJ, et al
. A screening model for oral cancer using risk scores: Development and validation. Community Dent Oral Epidemiol 2016;44:76-84.
Mehrotra R, Pandya S, Chaudhary AK, Kumar M, Singh M. Prevalence of oral pre-malignant and malignant lesions at a tertiary level hospital in Allahabad, India. Asian Pac J Cancer Prev 2008;9:263-5.
Pereira LH, Reis IM, Reategui EP, Gordon C, Saint-Victor S, Duncan R, et al
. Risk stratification system for oral cancer screening. Cancer Prev Res (Phila) 2016;9:445-55.
Lin WJ, Jiang RS, Wu SH, Chen FJ, Liu SA. Smoking, alcohol, and betel quid and oral cancer: A prospective cohort study. J Oncol 2011;2011:525976.
Kumar YS, Acharya S, Pentapati KC. Prevalence of oral potentially malignant disorders in workers of Udupi taluk. South Asian J Cancer 2015;4:130-3.
] [Full text]
Ray JG. Oral potentially malignant disorders: Revisited. J Oral Maxillofac Pathol 2017;21:326-7.
] [Full text]
Warnakulasuriya S, Johnson NW, van der Waal I. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med 2007;36:575-80.
Jeddy N, Ravi S, Radhika T. Screening of oral potentially malignant disorders: Need of the hour. J Oral Maxillofac Pathol 2017;21:437-8.
] [Full text]
Achalli S, Madi M, Babu SG, Shetty SR, Kumari S, Bhat S. Sialic acid as a biomarker of oral potentially malignant disorders and oral cancer. Indian J Dent Res 2017;28:395-9.
] [Full text]
Arakeri G, Rai KK, Boraks G, Patil SG, Aljabab AS, Merkx MAW, et al
. Current protocols in the management of oral submucous fibrosis: An update. J Oral Pathol Med 2017;46:418-23.
Kadashetti V, Shivakumar KM, Chaudhary M, Patil S, Gawande M, Hande A. Influence of risk factors on patients suffering from potentially malignant disorders and oral cancer: A case-control study. J Oral Maxillofac Pathol 2017;21:455-6.
] [Full text]
Reddy KS, Gupta PC. A Report on Tobacco Control in India, Ministry of Health and Family Welfare, Government of India and World Health Organization. New Delhi: Prepared by Word Editorial Consultants; 2004. p. 41-9.
Saraswathi TR, Ranganathan K, Shanmugam S, Sowmya R, Narasimhan PD, Gunaseelan R. Prevalence of oral lesions in relation to habits: Cross-sectional study in South India. Indian J Dent Res 2006;17:121-5.
] [Full text]
Neufeld KJ, Peters DH, Rani M, Bonu S, Brooner RK. Regular use of alcohol and tobacco in India and its association with age, gender, and poverty. Drug Alcohol Depend 2005;77:283-91.
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.
Gupta S, Singh R, Gupta OP, Tripathi A. Prevalence of oral cancer and pre-cancerous lesions and the association with numerous risk factors in North India: A hospital based study. Natl J Maxillofac Surg 2014;5:142-8.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4]