Oral Squamous Cell Carcinoma in Background of Oral Submucous Fibrosis: A Case Report.

Oral submucous fibrosis (OSMF) is a well-recognized, potentially malignant disorder of the oral cavity that can affect any part of the oral mucosa, characterized by mucosal rigidity of varying intensity caused by fibro elastic transformation of the juxta epithelial layer of connective tissue. OSMF occurs in Indians and other population of the Indian subcontinent with certain oral habits. Betel quid chewing is a popular oral habit with potential links to the occurrence of oral cancer. In patients with submucous fibrosis, the oral epithelium becomes atrophic and thereby becomes more vulnerable to carcinogens. Since the ingredients of betel quid, tobacco are crucial for tumor initiation, promotion and progression, exposure to these toxicants simultaneously has been shown to markedly potentiate the oral cancer incidence in OSMF patients. The rate of malignant transformation of OSMF has been estimated to be 2-10%. Most cases with malignant transformation in OSMF have occurred gradually over a long period of time. This paper presents a case of oral submucous fibrosis turning into malignancy in a 34-year-old male patient.

Rising incidence of oral cancer in Ahmedabad city.

CONTEXT: In 1999, an increase in mouth cancer incidence among young men (<50 years) in urban Ahmedabad was reported to be occurring along with decreasing mouth cancer incidence in older age groups and increasing oral submucous fibrosis incidence associated with areca nut consumption among young men in Gujarat. The aim was to investigate whether the increase in the incidence mouth cancer that had started among young men in the 1990s was continuing. SETTINGS AND DESIGN: Ahmedabad urban population, comparison of reported mouth cancer cases in the population across four time period. METHODS: Age‑specific incidence rates of mouth cancer (International Classification of Diseases [ICD]‑9:143–5; ICD‑10:C03–06) in five year age groups among men aged ≥15 years for the city of Ahmedabad for years 1985, 1995, 2007 and 2010 were extracted from published reports. For comparison, lung cancer (ICD‑9:169; ICD‑10:C33–C34) rates were also abstracted. STATISTICAL ANALYSIS USED: A cohort approach was used for further analysis of mouth cancer incidence. Age adjusted incidence rates of mouth and lung cancer for men aged ≥15 years were calculated and compared. RESULTS: The age specific incidence rates of mouth cancer among men increased over the 25‑year period while lung cancer rates showed a net decrease. Using a cohort approach for mouth cancer, a rapid increase in younger age cohorts was found. CONCLUSIONS: Mouth cancer incidence increased markedly among men in urban Ahmedabad between 1985 and 2010, apparently due to increasing consumption of areca nut products, mawa and gutka. Gutka has now been banned all over India, but a more vigorous implementation is necessary.

Argyria an unrecognized cause of cutaneous pigmentation in Indian patients: A case series and review of the literature.

Argyria is an uncommon grey-blue pigmentation of skin and mucous membranes caused by prolonged silver exposure. The impetus behind this review is our experience with cases of generalized argyria resulting from a uniquely Indian socio-cultural practice and belief that it is under reported. Our objective is to increase the awareness for this esoteric entity through a review of the pertinent literature and to highlight clinical and histological features using our four well worked-up cases as examples.

Evaluation of DNA damage in oral precancerous and squamous cell carcinoma patients by single cell gel electrophoresis.

Context: Single cell gel electrophoresis (SCGE) or "comet assay" is a rapid and very sensitive fluorescent microscopic method for detecting various forms of DNA damage at individual cell level. Aims: The aim of the present study was to detect the extent of DNA damage in oral cancer, oral submucous fibrosis (OSMF) and leukoplakia in comparison to normal individual. Settings and Design: A total of 44 consecutive patients with oral cancer (n=26), leukoplakia (n=12) and OSMF (n=6) and 10 healthy normal volunteers with normal oral epithelia (controls) were recruited from Dr. R. Ahmed Dental College and Hospital and were assessed for the extent of DNA damage using SCGE following clinical diagnosis. Materials and Methods: Peripheral blood was collected by venepuncture and comet assay was performed using SCGE. Mean tail length was compared between diagnostic groups and between different oral habit groups using t-tests and analysis of variance (ANOVA). Pearson's product moment correlation was used to examine the linear association between the extent of DNA damage and oral habit pack-years. Scheffe's pair-wise test was employed to adjust for multiple comparisons. Results: None of the controls were associated with any oral habits. Mean (±SD) tail lengths (in mm) for cancer (24.95 ± 5.09) and leukoplakia (12.96 ± 2.68) were significantly greater than in controls (8.54 ± 2.55, P<0.05). After adjustment, well-, moderately, and poorly differentiated carcinomas had significantly greater tail length than controls. Whereas the extent of DNA damage in cancer cases was significantly greater in leukoplakia than in compared to OSMF (11.03 ± 5.92), the DNA damage in latter was not different from controls. DNA damage for people with any oral habit (19.78 ± 7.77) was significantly greater than those with no habits (8.54 ± 2.55; P<0.0001). Conclusions: DNA damage measured by SCGE is greater in leukoplakia and squamous cell carcinoma, but not in OSMF. Deleterious oral habits are also associated with greater DNA damage.

Matrix metalloproteinase-1 expression in oral submucous fibrosis: An immunohistochemical study.

Context: Oral submucous fibrosis (OSF) is a form of pathological fibrosis affecting the oral mucosa. There is compelling evidence to implicate the habitual chewing of areca nut with the development of OSF. Because collagens are the major structural components of connective tissues, including oral submucosa, the composition of collagen within each tissue needs to be precisely regulated to maintain tissue integrity. Arecoline stimulates fibroblasts to increase the production of collagen by 150%. Aim: As the role of collagenase is implicated in cleaving the collagen under physical conditions, this study was carried out to evaluate the role of collagenase-1 (matrix metalloproteinase [MMP]-1) in a pathologic condition like OSF. Settings and Design: A total of 40 patients were included in the study, comprising of 30 OSF as Group 1 and 10 normal buccal mucosa tissue as Group 2. Materials and Methods: Both the groups were stained for MMP-1 by the immunohistochemical method using the streptavidin HRP-biotin labeling technique. MMP-1 expression intensity in the epithelium and connective tissue was decreased in Group 1 when compared to Group 2. Statistical Analysis Used: Chi-square test of association was used to determine the difference in the expression of MMP-1 between OSF and normal buccal mucosa and among different histological gradings of OSF. Results: The results were statistically significant. However, there was no statistically significant difference between the expression of MMP-1 among different histological grades of OSF in Group 1.

Comparative study of clinicofunctional staging of oral submucous fibrosis with qualitative analysis of collagen fibers under polarizing microscopy.

Objective : The aim of the study was to assess the severity of the disease in oral submucous fibrosis (OSF), correlate the clinical, functional staging with histopathological staging, and analyze collagen distribution in different stages of OSF using the picrosirius red stain under polarizing microscopy. Materials and Methods : The study included randomly incorporated 50 subjects, of whom 40 were patients with OSF, and 10 were in the control group. Clinical, functional staging in OSF cases was done depending upon definite criteria. A histopathological study was conducted using the hematoxylin and eosin stain and picrosirius red stain. Collagen fibers were analyzed for thickness and polarizing colors. Furthermore, clinical, functional, and histopathological stages were compared. Statistical Analysis : Descriptive data which included mean, SD, and percentages were calculated for each group. Categorical data were analyzed by the chi-square test. Multiple group comparisons were made by one-way ANOVA followed by Student's t-test for pairwise comparisons. For all tests, a P-value of 0.05 or less was considered for statistical significance. Results : As the severity of the disease increased, clinically, there was definite progression in subjective and objective symptoms. Polarized microscopic, examination revealed, there was a gradual decrease in the green-greenish yellow color of the fibers and a shift to orange red-red color with increase in severity of the disease. Thereby, it appeared that the tight packing of collagen fibers in OSF progressively increased as the disease progressed from early to advanced stages. We observed that the comparison of functional staging with histopathological staging was a more reliable indicator of the severity of the disease. Conclusion : In the present study, we observed that mouth opening was restricted with advancing stages of OSF. The investigation also points to the importance of assessing the cases of OSF, especially with regard to functional and histological staging in planning the treatment.

The prevalence of oral mucosal lesions in alcohol misusers in Chennai, south India.

AIMS AND OBJECTIVES: This study was conducted to assess the prevalence of various oral mucosal lesions (OML) among alcohol misusers attending a rehabilitation center in Chennai, south India. MATERIALS AND METHODS: Qualified dental surgeons examined 500 consecutive alcohol misusers at Ragas Dental College and Hospital and TTK Hospital, India. Thorough history and oral findings were recorded in a pre-determined format. Data entry and statistical analysis were done using SPSS 10.0.5beta. The variables for this study were OML, Oral Hygiene Index (OHI), age, smoking, and alcohol misuse (type and units consumed and duration of misuse). RESULTS: Of the 500 patients, 77% were in the 25-44 years old age group and 84% were married. The mean age of initiation of alcohol misuse was 34 years. In addition to alcohol, 72% smoked tobacco and 96% used other psychoactive substances. The mean alcohol use duration was 12.6 years. A total of 25% of the study group had at least one OML. The common oral lesions were smoker's melanosis (10.2%), oral submucous fibrosis (8%), and leukoplakia (7.4%). Those who misused spirits had a higher incidence of OML than those who misused beer or both. Patients with fair oral hygiene had an odds ratio (OR) of 2.96 for OML compared with an OR of 2.08 for those who had OML with good oral hygiene. CONCLUSION: This study indicates that subjects who misuse alcohol have poor oral hygiene and are at risk for the development of periodontal disease and OML. This survey indicates that oral examination and treatment should be a part of the standard care for alcohol misusers at rehabilitation centers.

Utilizing dental colleges for the eradication of oral cancer in India.

Dental education in India has grown in such a way that it ranks first in the world in having the highest number of dental schools. There are 240 dental schools all over the country. Paradoxically, even with this large number of dentists and dental institutions, India contributes to the highest number of incident cases of oral cancer. In India, oral cancer burden approximates to 20-30% of all cancers. The plausible reason for this high incidence of oral cancer could be expounded on the fact that there exists a high usage of tobacco within the country. The evidence for the high prevalence of using chewable tobacco products, especially in the youth, was recently reported in the Global Youth Tobacco Survey. This increasing usage of chewing tobacco and related products will further accrue to the mortality and morbidity figures in the near future. To effectuate a breakthrough in the existing situation, the work force of dental schools could be capitalized on. The aim of this article is to present the burden of oral cancer in the country and identify trends in the prevalence of tobacco usage, which if continues could alert an epidemic of oral cancer in the near future; and how dental schools in the country can be utilized for preventing this upcoming epidemic.

Oral submucous fibrosis: a clinico-histopathological study in Chennai.

BACKGROUND: Oral submucous fibrosis (OSF) is a precancerous condition associated with the use of areca nut in various forms. There are very few reports to correlate the clinical stage to histopathological grading in OSF. MATERIALS AND METHODS: A hospital-based study was conducted on 75 OSF cases who visited our hospital in Chennai from 2000-2003. A detailed history of each patient was recorded along with a clinical examination. Biopsy was performed for histopathological correlation. Clinical stage of the disease in terms of the ability to open one's mouth was correlated with histopathological grading. RESULTS: The male to female ratio of OSF cases was 6:1. All forms of areca nut products were associated with OSF. Chewing of paanmasala was associated with early presentation of OSF as compared to chewing of the betel nut. Out of 57 cases, which were in clinical stage II, 91.2% had histological grading of I and II in equal proportions and 8.8% had histological grade III. Out of 13 cases that showed a clinical stage of III, 52% showed a histological grade of II, 40% grade III and 8% grade I. CONCLUSION: In the present study, there was no direct correlation between clinical stages and histopathological grading. The possibility of difference in the severity and extent of fibrosis in different regions of the oral mucosa and involved muscles were considered as contributory factors for this variation.

Dental caries and periodontitis associated with betel quid chewing: analysis of two data sets.

BACKGROUND: Not much research evidence concerning the relationship between betel quid chewing and oral health has been established although betel quid chewing is a common practice among people in many Asian countries including rural areas of Thailand. OBJECTIVE: The present study employed two existing data sets to evaluate the association between betel quid chewing and oral diseases. MATERIAL AND METHOD: The study populations for phase I comprised a total of 796 females, aged 30-89 years, residing in five districts of Khon Kaen province, Thailand during 1990-91. In phase II, there were 2,253 females, aged 31-86 years, residing in Chonnabot district, Khon Kaen province, Thailand during 1992-94, respectively. The data were obtained through oral examination and interview. The analyses employed descriptive, bivariate, and multivariable logistic regression. RESULTS: Findings from final multivariable logistic regression models revealed the inverse relationship between betel quid chewing and dental caries adjusting for other variables. In addition, results from the final multivariable logistic regression models predicting periodontitis showed that betel quid chewing was directly associated with periodontitis in the presence of several confounding factors. The consistent findings from both data sets suggest that although betel quid chewing may reduce dental caries, it was directly related to periodontitis and enhanced the possibility of increasing tooth loss. CONCLUSION: Therefore, preventive programs aiming at discouraging Thai people from chewing betel quid should be established to preserve favorable oral health.

Epidemiological and etiological study of oral submucous fibrosis among gutkha chewers of Patna, Bihar, India.

An etiological and epidemiological study of oral submucous fibrosis (OSMF) has been done in Patna, Bihar. Total 157 cases of OSMF and 135 control subjects were selected for study in the period of 2002-2004. It was observed that Male:Female ratio was 2.7:1. The youngest case of OSMF was 11 year old and the oldest one was 54 years of age. Maximum number of cases were belonging to 21-40 years of age and they were belonging to low or middle socioeconomic class. Most of the OSMF cases used heavy spices and chillies, where as control mild spices and chillies. Gutkha was the most commonly used by the OSMF cases only 3 per cent did not use any gutkha or other areca nut product where as 80 per cent control did not have any chewing habit. The OSMF cases used gutkha and other products 2-10 pouches per day and kept in the mouth for 2-10 minutes and they were using since 2-4 years. Most of the OSMF cases kept gutkha in the buccal vestibule or they chewed and swallowed it, only a small number of patients chewed and spitted it out. It was also observed that OSMF developed on one side of the buccal vestibule where they kept the chew and other side was normal.

Effect of habitual arecanut chewing on resting whole mouth salivary flow rate and pH.

BACKGROUND: Resting whole mouth salivary flow rate (SFR) and pH play a significant role in pathogenesis of various oral diseases and conditions. AIM: To observe the effect of habitual use of arecanut and various arecanut containing products (AN) on SFR and pH. DESIGN: Cross sectional. SETTING: Outpatient Department of Dental College. PARTICIPANTS: AN chewers and non-chewers attending Dental college. MEASUREMENTS: SFR and pH. VARIABLES: Type, frequency, duration and exposure time of AN, Smoking and Alcohol habit. MATERIALS AND METHODS: Subjects study was divided into chewers (n=110) and non- chewers (n=50). The SFR (expressed in mL/10min) and pH measured. RESULTS: The difference between the mean SFR for chewers and non-chewers was not statistically significant. The difference between mean pH of chewers and non-chewers was statistically significant. (P=0.02). Difference in pH was statistically significant among the different types of AN chewers (P=0.024). With chewing raw AN, an increase in frequency and exposure time increased SFR and pH respectively. In processed AN chewers, increase in duration and frequency of consumption increased SFR and decreased pH respectively. For chewers with betel quid with tobacco, increase in duration was significantly associated with decrease in salivary pH. CONCLUSION: SFR and pH are altered in AN chewers, rendering the oral mucosa vulnerable to the toxic effects of AN.

Chewing of betel, areca and tobacco: perceptions and knowledge regarding their role in head and neck cancers in an urban squatter settlement in Pakistan.

The link of betel, areca and chewable tobacco with head and neck cancers is clearly established. Fifty eight percent of the global head and neck cancers occur in South and Southeast Asia, where chewing of betel, areca and tobacco are common. This study was carried out to establish the pattern of use of Paan, Chaalia, Gutka, Niswar, Tumbaku and Naas among population of squatter settlement of Karachi and to determine the perceptions and knowledge regarding their role in the etiology of head and neck cancers. It was a cross-sectional study, performed at Bilal colony in Karachi. Through systematic sampling, 425 subjects [a male and female from a household] were interviewed with a structured questionnaire. Knowledge regarding etiology of head and neck cancers was classified in ordinals of "good", "some" and "poor", for each substance separately, while practices were classified into "daily user", "occasional user" and "never user". About 40% of the participants were chewing at least one item [betel, areca or tobacco products] on daily basis. This prevalence was 2.46 times higher among males than females and 1.39 times higher among adolescents than adults. At least 79% of the participants were classified as having poor knowledge about the carcinogenicity of each of these items. Knowledge increased with age and level of education. Health hazards of these items were poorly recognized and about 20% perceived at least one of these items to be beneficial. Positive attitudes were seen regarding the steps to curb the production, business and consumption of these substances. In conclusion, prevalence of chewing of betel, areca and tobacco among adults and adolescents is high. Deficiency in knowledge and wrong perception of favorable effect of chewing products is common. Besides curtailing the availability of chewing products, correct knowledge regarding its ill-effects should be inculcated among population to decrease the burden of head and neck cancers.

Cytomorphometric analysis of the buccal mucosa of tobacco users.

OBJECTIVE: This study has been carried out to assess the effect of tobacco smoking and of betel quid chewing with tobacco on buccal mucosa by cytomorphometry, in a south Indian population. STUDY DESIGN: Cellular diameter (CD) and nuclear diameter (ND) of exfoliated buccal squames obtained from clinically normal appearing buccal mucosa of tobacco smokers, betel quid with tobacco chewers, and those with a combined habit, stained by the Papanicolaou method, were measured. Non-users served as negative controls and oral squamous cell carcinomas in tobacco users served as positive controls. One way ANOVA test of the values obtained followed by multiple range comparison with Tukey-HSD procedure (at p=0.05) was carried out. RESULTS: A statistically significant reduction in CD and increase in ND in smokers and those with a combined habit were observed. CONCLUSION: The use of tobacco in the form of smoking influences the cytomorphology of buccal mucosa.

Pan masala advertisements are surrogate for tobacco products.

BACKGROUND: Pan masala is a comparatively recent habit in India and is marketed with and without tobacco. Advertisements of tobacco products have been banned in India since 1st May 2004. The advertisements of plain pan masala, which continue in Indian media, have been suspected to be surrogate for tobacco products bearing the same name. The study was carried out to assess whether these advertisements were for the intended product, or for tobacco products with same brand name. MATERIALS AND METHODS: The programme of a popular television Hindi news channel was watched for a 24-h period. Programmes on the same channel and its English counterpart were watched on different days to assess whether the advertisements were repeated. The total duration of telecast of a popular brand of plain pan masala (Pan Parag) was multiplied by the rate charged by the channel to provide the cost of advertisement of this product. The total sale value of the company was multiplied by the proportion of usage of plain pan masala out of gutka plus pan masala habit as observed from a different study, to provide the annual sale value of plain pan masala product under reference. RESULTS: The annual sale value of plain Pan Parag was estimated to be Rs. 67.1 million. The annual cost of the advertisement of the same product on two television channels was estimated at Rs. 244.6 million. CONCLUSION: The advertisements of plain pan masala seen on Indian television are a surrogate for the tobacco products bearing the same name.