Prevalence, Habit Pattern, and Awareness on Harmful Effects of Tobacco/Areca Nut Use among Patients Visiting a Tertiary Care Center in Sri Lanka.

S.P. Kalpana Jeewanthi SubasingheBackground The carcinogenicity of tobacco and areca nut is well established worldwide. Areca nut is the fourth most common psychoactive substance identified recently. The effects of areca nut on the autonomic nervous system make the users dependent on the habit which has been an emerging health issue among Sri Lankan adults and adolescents. This study aimed to evaluate the prevalence and patterns of these risk habits among the patients attending a tertiary care center in Sri Lanka, and their awareness of the harmful effects of the habit. Method A hospital-based cross-sectional study was conducted among 512 patients using an interviewer-administered questionnaire. Results The sample consisted of 167 (33%) tobacco consumers. The average age of the initiation of tobacco consumption was 23.66 years (standard deviation ± 8.04). Age ( p = 0.001), gender ( p = 0.001), income ( p = 0.005), and educational level ( p = 0.001) are significantly associated with tobacco consumption. There is a strong likelihood for tobacco consumers to consume areca nut (odds ratio [OR] 30.58, 95% confidence interval [CI] 17.05-54.88) and alcohol (OR 11.16, 95% CI 6.91-17.98) at any stage in their lives. The majority of the tobacco consumers (61%) were smokeless tobacco users. Areca nut consumers are 0.44 times more likely to know its carcinogenic effects than nonconsumers (95% CI 0.28-0.69). Tobacco consumers are more likely to be aware of the harmful effects of tobacco consumption than nonconsumers (OR 1.11, 95% CI 0.45-2.74). Sixty percent have made at least one attempt to quit the habit. Sixty-two percent of the unsuccessful quitters reported the reason as "addiction." Conclusion Prevalence of smokeless tobacco consumption prevails at a high level among Sri Lankans. Tobacco and areca nut users are more likely to be aware of its harmful effects than the nonconsumers but unable to quit the habit due to the psychoactive properties of tobacco and areca nut.

Developments and future prospects of personalized medicine in head and neck squamous cell carcinoma diagnoses and treatments.

BACKGROUND: Precision healthcare has entered a new era because of the developments in personalized medicine, especially in the diagnosis and treatment of head and neck squamous cell carcinoma (HNSCC). This paper explores the dynamic landscape of personalized medicine as applied to HNSCC, encompassing both current developments and future prospects. RECENT FINDINGS: The integration of personalized medicine strategies into HNSCC diagnosis is driven by the utilization of genetic data and biomarkers. Epigenetic biomarkers, which reflect modifications to DNA that can influence gene expression, have emerged as valuable indicators for early detection and risk assessment. Treatment approaches within the personalized medicine framework are equally promising. Immunotherapy, gene silencing, and editing techniques, including RNA interference and CRISPR/Cas9, offer innovative means to modulate gene expression and correct genetic aberrations driving HNSCC. The integration of stem cell research with personalized medicine presents opportunities for tailored regenerative approaches. The synergy between personalized medicine and technological advancements is exemplified by artificial intelligence (AI) and machine learning (ML) applications. These tools empower clinicians to analyze vast datasets, predict patient responses, and optimize treatment strategies with unprecedented accuracy. CONCLUSION: The developments and prospects of personalized medicine in HNSCC diagnosis and treatment offer a transformative approach to managing this complex malignancy. By harnessing genetic insights, biomarkers, immunotherapy, gene editing, stem cell therapies, and advanced technologies like AI and ML, personalized medicine holds the key to enhancing patient outcomes and ushering in a new era of precision oncology.

Bacteriome and mycobiome dysbiosis in oral mucosal dysplasia and oral cancer.

It has long been considered that the oral microbiome is tightly connected to oral health and that dysbiotic changes can be detrimental to the occurrence and progression of dysplastic oral mucosal lesions or oral cancer. Improved understanding of the concepts of microbial dysbiosis together with advances in high-throughput molecular sequencing of these pathologies have charted in greater microbiological detail the nature of their clinical state. This review discusses the bacteriome and mycobiome associated with oral mucosal lesions, oral candidiasis, and oral squamous cell carcinoma, aiming to delineate the information available to date in pursuit of advancing diagnostic and prognostic utilities for oral medicine.

Quality of life of patients treated with robotic surgery in the oral and maxillofacial region: a scoping review of empirical evidence.

BACKGROUND: There is a blooming trend in the application of robotic surgery in oral and maxillofacial care, and different studies had evaluated the quality of life (QoL) outcomes among patients who underwent robotic surgery in the oral and maxillofacial region. However, empirical evidence on the QoL outcomes from these procedures is yet to be mapped. Thus, this study was conducted to evaluate the available scientific evidence and gaps concerning the QoL outcomes of patients treated with robotic surgery in the oral and maxillofacial region. METHODS: This study adopted a scoping review design, and it was conducted and reported based on the Arksey and O'Malley, PRISMA-ScR, and AMSTAR-2 guidelines. SCOPUS, PubMed, CINAHL Complete, and APA PsycINFO were searched to retrieve relevant literature. Using Rayyan software, the retrieved literature were deduplicated, and screened based on the review's eligibility criteria. Only the eligible articles were included in the review. From the included articles, relevant data were charted, collated, and summarized. RESULTS: A total of 123 literature were retrieved from the literature search. After deduplication and screening, only 18 heterogeneous original articles were included in the review. A total of 771 transoral robotic surgeries (TORSs) were reported in these articles, and the TORSs were conducted on patients with oropharyngeal carcinomas (OPC), recurrent tonsillitis, and obstructive sleep apnoea (OSA). In total, 20 different QoL instruments were used in these articles to assess patients' QoL outcomes, and the most used instrument was the MD Anderson Dysphagia Inventory Questionnaire (MDADI). Physical functions related to swallowing, speech and salivary functions were the most assessed QoL aspects. TORS was reported to result in improved QOL in patients with OPC, OSA, and recurrent tonsillitis, most significantly within the first postoperative year. Notably, the site of the lesion, involvement of neck dissections and the characteristics of the adjuvant therapy seemed to affect the QOL outcome in patients with OPC. CONCLUSION: Compared to the conventional treatment modalities, TORS has demonstrated better QoL, mostly in the domains related to oral functions such as swallowing and speech, among patients treated with such. This improvement was most evident within the initial post-operative year.

A Preliminary Study on Early Detection of Oral Cancer with Opportunistic Screening: Insights from Dental Surgeons in Sri Lanka.

In Sri Lanka, opportunistic screening is encouraged as a cost-effective tool to bring down the prevalence of oral cancer, which is the most common cancer among males. The objectives of the study were to determine the practices, attitudes, and level of competency of dental surgeons regarding the early detection of oral cancer and oral potentially malignant disorders (OPMDs) through opportunistic screening. A prospective study was conducted online via a Google form using a pretested, self-administered questionnaire of 22 close-ended questions and 3 open-ended questions. Out of the 137 dental surgeons who responded, 88% (121/137) of the participants believed that screening high-risk target groups would be more effective in the early detection of oral cancer rather than opportunistic screening. Only 64% (88/137) of the participants frequently check for oral cancer and OPMDs when patients visit for dental treatment. Participants recalled an average of 34 patients (4628/137) with clinically suspicious lesions being diagnosed during examination at general dental practice during the past year, and 98% (134/137) of the participants believed that they should receive additional training in order to identify and diagnose clinically suspicious oral OPMDs and oral cancer. Opportunistic screening in general dental practice as an oral-cancer prevention strategy is appreciable, but due emphasis should be given to other prevention strategies such as population screening and screening high-risk target groups. The level of confidence of general dental practitioners in the early detection of oral cancer has to be raised in order to achieve higher standards in oral cancer prevention through opportunistic screening.

Carcinogenic Effects of Areca Nut and Its Metabolites: A Review of the Experimental Evidence.

Oral cancers (OC) are among the most frequent malignancies encountered in Southeast Asia, primarily due to the prevalent habit of betel quid (BQ) and smokeless tobacco use in this region. Areca nut (AN), the primary ingredient in BQ, contains several alkaloids, including arecoline, arecaidine, guvacoline, and guvacine. These have been associated with both the AN abuse liability and carcinogenicity. Additionally, variations in AN alkaloid levels could lead to differences in the addictiveness and carcinogenic potential across various AN-containing products. Recent studies based on animal models and in vitro experiments show cellular and molecular effects induced by AN. These comprise promoting epithelial-mesenchymal transition, autophagy initiation, tissue hypoxia, genotoxicity, cytotoxicity, and cell death. Further, clinical research endorses these undesired harmful effects in humans. Oral submucosal fibrosis, a potentially malignant disease of the oral cavity, is predominantly reported from the geographical areas of the globe where AN is habitually chewed. OC in chronic AN users presents a more aggressive phenotype, such as resistance to anti-cancer drugs. The available evidence on the carcinogenicity of AN based on the findings reported in the recently published experimental studies is discussed in the present review.

Salivary Interleukin Levels in Oral Squamous Cell Carcinoma and Oral Epithelial Dysplasia: Findings from a Sri Lankan Study.

The incidence of oral squamous cell carcinoma (OSCC), and its precursor, oral epithelial dysplasia (OED), is on the rise, especially in South Asia. OSCC is the leading cancer in males in Sri Lanka, with >80% diagnosed at advanced clinical stages. Early detection is paramount to improve patient outcome, and saliva testing is a promising non-invasive tool. The aim of this study was to assess salivary interleukins (lL1ß, IL6, and IL8) in OSCC, OED and disease-free controls in a Sri Lankan study cohort. A case-control study with OSCC (n = 37), OED (n = 30) patients and disease-free controls (n = 30) was conducted. Salivary lL1ß, IL6, and IL8 were quantified using enzyme-linked immuno-sorbent assay. Comparisons between different diagnostic groups and potential correlations to risk factors were assessed. Salivary levels for the three tested interleukins increased from disease-free controls through OED, and were highest in OSCC samples. Furthermore, the levels of IL1ß, IL6, and IL8 increased progressively with OED grade. The discrimination between patients (OSCC and OED) and controls, as assessed by AUC of receiver operating characteristic curves, was 0.9 for IL8 (p = 0.0001) and 0.8 for IL6 (p = 0.0001), while IL1ß differentiated OSCC from controls (AUC 0.7, p = 0.006). No significant associations were found between salivary interleukin levels and smoking, alcohol, and betel quid risk factors. Our findings suggest that salivary IL1ß, IL6, and IL8 are associated with disease severity of OED, and are potential biomarkers for predicting disease progression in OED, and the screening of OSCC.

Image collection and annotation platforms to establish a multi-source database of oral lesions.

OBJECTIVE: To describe the development of a platform for image collection and annotation that resulted in a multi-sourced international image dataset of oral lesions to facilitate the development of automated lesion classification algorithms. MATERIALS AND METHODS: We developed a web-interface, hosted on a web server to collect oral lesions images from international partners. Further, we developed a customised annotation tool, also a web-interface for systematic annotation of images to build a rich clinically labelled dataset. We evaluated the sensitivities comparing referral decisions through the annotation process with the clinical diagnosis of the lesions. RESULTS: The image repository hosts 2474 images of oral lesions consisting of oral cancer, oral potentially malignant disorders and other oral lesions that were collected through MeMoSA® UPLOAD. Eight-hundred images were annotated by seven oral medicine specialists on MeMoSA® ANNOTATE, to mark the lesion and to collect clinical labels. The sensitivity in referral decision for all lesions that required a referral for cancer management/surveillance was moderate to high depending on the type of lesion (64.3%-100%). CONCLUSION: This is the first description of a database with clinically labelled oral lesions. This database could accelerate the improvement of AI algorithms that can promote the early detection of high-risk oral lesions.

Barriers to early detection and management of oral cancer in the Asia Pacific region.

OBJECTIVE: Oral cancer is amenable to early detection but remains a prominent cause of mortality in the Asia Pacific region. This study aimed to identify barriers to early detection and management of oral cancer in the Asia Pacific region. METHODS: A mixed-methods approach was employed triangulating findings from a survey and focus groups. The survey was conducted among seven representative members of the Asia Pacific Oral Cancer Network (APOCNET) across six countries. Focus groups were conducted to gain deeper insights into the findings of the survey. RESULTS: The identified barriers were a lack of national cancer control strategies and cancer registries and the limited availability of trained health care professionals. Overcoming these challenges in the Asia Pacific region where resources are scarce will require collaborative partnerships in data collection and novel approaches for continuous professional training including eLearning. Further, to overcome the lack of trained health care professionals, innovative approaches to the management of oral potentially malignant lesions and oral cancer including telemedicine were suggested. CONCLUSION: The findings of this study should be taken into account when charting national cancer control plans for oral cancer and will form the basis for future collaborative studies in evaluating effective measures to improve oral cancer detection and management in low- and middle-income countries.

Second hand smoking and tobacco use among pregnant women in Yatinuwara Medical Officer of Health (MOH) area in Sri Lanka.

This study was aimed to assess the prevalence and factors associated with second hand smoking (SHS) and tobacco use among pregnant women in Yatinuwara Medical Officer of Health area in Kandy district, Sri Lanka. This was a descriptive cross-sectional study using 390 pregnant women. Data were collected through a pre-tested, self-administered questionnaire. Fifty-four-point four percent were exposed to the SHS. Prevalence of smoking during pregnancy was 0.5% and eight women used smokeless tobacco (SLT). SHS was significantly associated with the age of the mother and family income. Women's age, monthly income, husband's education, husband's occupation, women's age at marriage and trimester of pregnancy were significantly associated with tobacco use. In conclusions, prevalence of SHS was high but tobacco use was low in pregnant women. An effective training program should be designed to educate pregnant women as well as their husbands on adverse effects of tobacco use and SHS during pregnancy.

Evaluation of Successfulness of Capacity Building Programmes on Smokeless Tobacco and Areca Nut Cessation.

BACKGROUND: Prevalence of smoking in Sri Lanka has shown a gradual reduction whilst the use of smokeless tobacco and areca nut exhibits an increasing trend. At present, only a few well-structured smokeless tobacco (SLT)/areca nut (AN) cessation programs have been conducted in Sri Lanka, which is a gross underachievement as betel chewing-related oral squamous cell carcinoma is the most common cancer in Sri Lankan males. As General Dental Practitioners (GDP) do not contribute significantly to SLT/AN cessation activities at present, capacity building programs on SLT/AN control were carried out. The study evaluated the knowledge, attitude and practices  imparted on SLT/AN control among dental surgeons. METHODS: Following a single day capacity building program on smokeless tobacco / areca nut control, two self-administered questionnaires were used to assess the improvement of knowledge and change of attitudes among 663 GDPs. RESULTS: Majority had a good knowledge on harmful effects of SLT but not on areca nut. Knowledge of the current legislation on SLT control in Sri Lanka and carcinogenicity of areca nut was not satisfactory. Almost all agreed that proper counseling leads to patient quitting the habit, a formal training is necessary to conduct tobacco control activities and it should be a part of the regular treatment modalities. More than 80% of the participants support strict legislation. Most important factors leading to poor involvement in tobacco cessation activities were lack of expertise and inadequate educational material and not breach of patient privacy and lack of financial incentives. 20.1% dental surgeons had consumed smokeless tobacco / areca nut products in the past and only a few were current users of tobacco and/or areca nut. CONCLUSIONS: Well planned workshops are efficient in improving knowledge, practices and attitudes of dental surgeons towards SLT/AN cessation.
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Proliferative Verrucous Leukoplakia of the Gingiva: An Early Lesion Refractory to Surgical Excision.

This report describes a case of proliferative verrucous leukoplakia (PVL) of the gingiva with no discernible aetiology, which presented in a 36-year-old female. The initial nonscrapable gingival lesion was treated with CO2 laser ablation, and the histopathological evaluation was carried out. The presence of koilocytic cells in the superficial epithelium led to immunohistochemical investigations with p16 antibody, which showed strong nuclear positivity and slight cytoplasmic positivity in >50% of the cells with >25% confluency. However, it was not possible to confirm the presence of HPV infection with further investigations due to logistic reasons. The lesion recurred twice within a short time despite the surgical resection following the first recurrence. Thus, this paper presents a case of proliferative verrucous leukoplakia, which demonstrated a significant resistance to routine treatment protocols recommended in the management of such lesions.

Economic burden of managing oral cancer patients in Sri Lanka: a cross-sectional hospital -based costing study.

OBJECTIVE: Cancer of the oral cavity is the leading malignancy among males in Sri Lanka, and sixth among women. This study aimed to estimate costs of managing patients with oral cancer (OCA) in Sri Lanka for a 12 month period from diagnosis. DESIGN: Hospital based costing study. SETTINGS: Four selected cancer treatment centres in Sri Lanka. PARTICIPANTS: Sixty-nine OCA patients: 60 were males and 12 had recurrent tumours. OUTCOME: Societal perspectives (healthcare, household and indirect costs) were itemised. Costs to the healthcare system included surgery, Intensive Care Unit (ICU) care, chemotherapy and radiotherapy. Capital costs including apportioned value of land, buildings, equipment and furniture. Household costs consisted of out of pocket expenditure for healthcare and indirect costs of lost income. Costs were estimated from the stage of presentation for treatment to 1 year of follow-up. RESULTS: Mean cost of managing a single stage II OCA patient for 1 year was Sri Lankan rupees (SLR) 58 979 (US$394, at the midyear exchange rate in 2016) to the health system. Mean household cost was SLR 77 649 (US$518). The annual cost of managing a stage III or IV patient was SLR 303 620 (US$2027), with household costs of SLR 71 932 (US$480). CONCLUSIONS: Owing to the high incidence of OCA in Sri Lanka, the economic costs associated with these diseases are enormous, resulting in negative impacts on both the healthcare system and individual families, seriously impacting the country's economy. Policy-makers should take note of this burden and increase steps for prevention and control of this devastating disease.