Painful refractory erosive tongue lichen planus with malignant transformation.

We present a recent case of long standing erosive tongue lichen planus successfully treated by wide excision and reconstruction with a submental artery island flap. Erosive Lichen Planus is a progressive indolent potentially malignant condition that tends to end up with severe somatic or even neuropathic pain and malignant changes towards its final stages as elaborated in the presented commentary.

Next-Generation Sequencing in Cancer.

OBJECTIVE: In this article, we provide a gestalt idea about NGS technologies and their applications in cancer research and molecular diagnosis. BACKGROUND: Next-generation sequencing (NGS) advancements like DNA sequencing and RNA sequencing allow uncovering of genomic, transcriptomic, and epigenomic scenes of individual malignant growths. An assortment of genomic abnormalities can be screened at the same time, for example common and uncommon variations, auxiliary variations like insertions and deletions, copy-number variation, and fusion transcripts. CONCLUSION: NGS innovations together with bioinformatics investigation, which extend our insight, are progressively used to analyze multiple genes in a cost-effective way and have been applied in examining clinical cancer samples and offering NGS-based molecular diagnosis. APPLICATION: NGS is progressively significant as a device for the diagnosis of cancers.

Risk-Based Selection of Individuals for Oral Cancer Screening.

PURPOSE: We evaluated proof of principle for resource-efficient, risk-based screening through reanalysis of the Kerala Oral Cancer Screening Trial. METHODS: The cluster-randomized trial included three triennial rounds of visual inspection (seven clusters, n = 96,516) versus standard of care (six clusters, n = 95,354) and up to 9 years of follow-up. We developed a Cox regression-based risk prediction model for oral cancer incidence. Using this risk prediction model to adjust for the oral cancer risk imbalance between arms, through intention-to-treat (ITT) analyses that accounted for cluster randomization, we calculated the relative (hazard ratios [HRs]) and absolute (rate differences [RDs]) screening efficacy on oral cancer mortality and compared screening efficiency across risk thresholds. RESULTS: Oral cancer mortality was reduced by 27% in the screening versus control arms (HR = 0.73; 95% CI, 0.54 to 0.98), including a 29% reduction in ever-tobacco and/or ever-alcohol users (HR = 0.71; 95% CI, 0.51 to 0.99). This relative efficacy was similar across oral cancer risk quartiles (P interaction = .59); consequently, the absolute efficacy increased with increasing model-predicted risk-overall trial: RD in the lowest risk quartile (Q1) = 0.5/100,000 versus 13.4/100,000 in the highest quartile (Q4), P trend = .059 and ever-tobacco and/or ever-alcohol users: Q1 RD = 1.0/100,000 versus Q4 = 22.5/100,000; P trend = .026. In a population akin to the Kerala trial, screening of 100% of individuals would provide 27.1% oral cancer mortality reduction at number needed to screen (NNS) = 2,043. Restriction of screening to ever-tobacco and/or ever-alcohol users with no additional risk stratification would substantially enhance efficiency (43.4% screened for 23.3% oral cancer mortality reduction at NNS = 1,029), whereas risk prediction model-based screening of 50% of ever-tobacco and/or ever-alcohol users at highest risk would further enhance efficiency with little loss in program sensitivity (21.7% screened for 19.7% oral cancer mortality reduction at NNS = 610). CONCLUSION: In the Kerala trial, the efficacy of oral cancer screening was greatest in individuals at highest oral cancer risk. These results provide proof of principle that risk-based oral cancer screening could substantially enhance the efficiency of screening programs.

Prognostic Implications of DNA Repair, Ploidy and Telomerase in the Malignant Transformation Risk Assessment of Leukoplakia.

BACKGROUND: Although leukoplakia shows a higher risk for malignant transformation to oral cancer, currently there are no clinically relevant biomarker which can predict the potentially high risk leukoplakia. This study aimed to investigate the genetic alterations such as DNA ploidy, telomerase expression and DNA repair capacity as predictive markers of malignant transformation risk of leukoplakia. METHODS: The study was initiated in September 2005 and patients were followed up to March 2014. Two hundred patients with oral leukoplakia, 100 patients with oral cancer and 100 healthy, age and sex matched adults with normal oral mucosa as controls were recruited. The DNA ploidy content was measured by high resolution flow cytometry, level of telomerase expression was identified by TRAP assay and intrinsic DNA repair capacity was measured by mutagen induced chromosome sensitivity assay of cultured peripheral blood lymphocytes. The Chi-square test or Fisher's Exact test was used for comparison of categorical variables between biomarkers. A p value less than or equal to 0.05 was considered as statistically significant. Analysis was performed with SPSS software version 16. Logistic regression was used to find the association between the dependent and three independent variables. RESULTS: There was significant difference in the distribution of ploidy status, telomerase activity and DNA repair capacity among control, leukoplakia and oral cancer group (p<0.001). When the molecular markers were compared with histological grading of leukoplakia, both DNA ploidy analysis and telomerase activity showed statistical significance (p<0.001). Both aneuploidy and telomerase positivity was found to coincide with high-risk sites of leukoplakia and were statistically significant (p.

Effectiveness of School based Awareness Programmes against Tobacco among Users and Non- Users- A Cross- Sectional Study from Rural Kerala, India.

Background: Known is the fact that adult tobacco users mostly had their initiation into the habit during the adolescence period. The current study was conducted to evaluate the impact of awareness programmes among adolescent students in rural Kerala, India, in terms of knowledge enhancement on tobacco hazards. Methods: A total of 10 high schools and higher secondary schools from one educational sub district were selected using multi stage sampling design. Male students in the age group 13-19 years studying in class IX and X (high school category) and class XI and XII (higher secondary school) were included in the study. The effectiveness was assessed using pre and post training evaluation forms based on mean knowledge scores. Results: 1,114 students participated by filling both the forms (mean age 15.6, SD 1.3). The response rate was 92.8%. The prevalence of 'current users' in the study was 4.3% (95% CI 3.11- 5.49). Overall difference in mean knowledge scores among study subjects was evident when pre and post training responses were compared (p<0.001). The difference in knowledge scores was evident among 'never users' of tobacco before and after the awareness programmes (p<0.0001). However, no significant difference in mean scores was observed among 'ever users' of tobacco (p = 0.584), age groups of ever users (p=0.208), students of high schools (p = 0.242) and higher secondary schools (p= 0.994). Comparison of never, ever and current users revealed significant difference between 'never' and 'current' users (p = 0.001). However, no such difference was observed between 'ever' and 'current' users (p =0.138) and 'ever' versus 'never' users (p =0.099). Conclusion: The study was useful to improve knowledge among school students in general. However, newer strategies have to be tested to understand the best possible measures for tobacco awareness training among adolescent tobacco users.

Evaluation of Nurse Practitioner Strategies to Promote Adherence to Childhood Obesity Clinical Guidelines.

The significant trend of the obesity epidemic leading to treatment of expensive, lifelong illnesses, especially among Hispanic children, confirms the need for efforts to increase provider adherence to clinical guidelines. This Quality Improvement Project was designed to examine how a practice intervention influenced provider adherence to childhood obesity guidelines among Hispanic children. The practice intervention, based on a unique practice model, consisted of provider awareness, provider involvement, and collaborative support by the researcher. Statistically significant results were obtained regarding guideline adherence. The practice model developed for implementing guidelines in this study will be of benefit to other clinicians. The main project outcome was that the model resulted in significant changes in practice patterns and increased provider adherence to aspects of childhood obesity clinical guidelines. The Practice Improvement Model should be replicated in other settings to evaluate its contribution to improved adherence to any clinical practice guideline.

Tobacco and Alcohol Use and the Impact of School Based Antitobacco Education for Knowledge Enhancement among Adolescent Students of Rural Kerala, India.

Objectives. Limited information is available on adolescent tobacco and alcohol use in rural Kerala, the southernmost state in India. The study was conducted to estimate the prevalence of tobacco and alcohol use among adolescent school students and further to understand the extent of knowledge pertaining to tobacco before and after conducting awareness programmes in schools. Methods. A cross-sectional study was conducted in 10 government schools of rural Thiruvananthapuram district of Kerala state based on a multistaged sampling design. Using a pretested semistructured questionnaire, prevalence and patterns of tobacco use by students and their households, as well as students' knowledge on tobacco hazards before and after delivering antitobacco messages, were collected. Results. The overall prevalence of self-reported ever users of tobacco in the current academic year was 7.4% (95% CI 5.86-8.94), while that of ever alcohol users was 5.6% (95% CI 4.25-6.95). Knowledge assessment scores revealed a significant increase in the mean knowledge scores after posttraining evaluation (mean score = 10.34) when compared to pretraining evaluation (mean score = 9.26) (p < 0.0001). Conclusion. Apart from antitobacco awareness programmes, strict monitoring of trade of tobacco and alcohol products near educational institutions has to be conducted consistently to curb the problem.

A Randomized Double-Blind Placebo-Controlled Phase IIB Trial of Curcumin in Oral Leukoplakia.

Oral leukoplakia is a potentially malignant lesion of the oral cavity, for which no effective treatment is available. We investigated the effectiveness of curcumin, a potent inhibitor of NF-κB/COX-2, molecules perturbed in oral carcinogenesis, to treat leukoplakia. Subjects with oral leukoplakia (n = 223) were randomized (1:1 ratio) to receive orally, either 3.6 g/day of curcumin (n = 111) or placebo (n = 112), for 6 months. The primary endpoint was clinical response obtained by bi-dimensional measurement of leukoplakia size at recruitment and 6 months. Histologic response, combined clinical and histologic response, durability and effect of long-term therapy for an additional six months in partial responders, safety and compliance were the secondary endpoints. Clinical response was observed in 75 (67.5%) subjects [95% confidence interval (CI), 58.4-75.6] in the curcumin and 62 (55.3%; 95% CI, 46.1-64.2) in placebo arm (P = 0.03). This response was durable, with 16 of the 18 (88.9%; 95% CI, 67.2-96.9) subjects with complete response in curcumin and 7 of 8 subjects (87.5%) in placebo arm, demonstrating no relapse after 6 months follow-up. Difference in histologic response between curcumin and placebo was not significant (HR, 0.88, 95% CI, 0.45-1.71; P = 0.71). Combined clinical and histologic response assessment indicated a significantly better response with curcumin (HR, 0.50; 95% CI, 0.27-0.92; P = 0.02). Continued therapy, in subjects with partial response at 6 months, did not yield additional benefit. The treatment did not raise any safety concerns. Treatment of oral leukoplakia with curcumin (3.6 g for six months), thus was well tolerated and demonstrated significant and durable clinical response for 6 months. Cancer Prev Res; 9(8); 683-91. ©2016 AACR.

Long term effect of visual screening on oral cancer incidence and mortality in a randomized trial in Kerala, India.

OBJECTIVES: We studied oral cancer incidence and mortality and the impact of compliance to repeat screening rounds during a 15-year follow-up in a cluster-randomized controlled trial in Trivandrum district, Kerala, India. METHODS: Healthy individuals aged 35 and above in seven clusters randomized to the intervention arm received four rounds of oral visual inspection by trained health workers at 3-year intervals, and those in six clusters randomized to the control arm received routine care during 1996-2005 and one round of visual screening during 2006-2009. Screen-positive persons were referred for diagnosis and treatment. Oral cancer incidence and mortality were compared between the study arms by intention to treat analysis. RESULTS: Of the 96,517 eligible subjects in the intervention arm, 25,144 (26.1%) had one, 22,382 (23.2%) had two, 22,008 (22.8%) had three and 19,288 (20.0%) had four rounds of screening. Of the 95,356 eligible subjects in the control group 43,992 (46.1%) received one round of screening. Although the 12% reduction in oral cancer mortality in all individuals did not reach statistical significance, there was a 24% reduction in oral cancer mortality (95% CI 3-40%) in users of tobacco and/or alcohol in the intervention arm after 4-rounds of screening; there was 38% reduction in oral cancer incidence (95% CI 8-59%) and 81% reduction in oral cancer mortality (95% CI 69-89%) in tobacco and/or alcohol users adhering to four screening rounds. CONCLUSION: Sustained reduction in oral cancer mortality during the 15-year follow-up, with larger reductions in those adhering to repeated screening rounds support the introduction of population-based screening programs targeting users of smoking or chewing tobacco or alcohol or both in high-incidence countries.

Socio-economic factors & longevity in a cohort of Kerala State, India.

BACKGROUND & OBJECTIVES: Even though Kerala State is well-known for its egalitarian policies in terms of healthcare, redistributive actions and social reforms, and its health indicators close to those of high-resource countries despite a poor per-capita income, it is not clear whether socio-economic disparities in terms of life expectancy are observed. This study was therefore carried out to study the impact of socio-economic level on life expectancy in individuals living in Kerala. METHODS: A cohort of 1,67,331 participants aged 34 years and above in Thiruvananthapuram district, having completed a lifestyle questionnaire at baseline in 1995, was followed up for mortality and cause of death until 2005. Survival estimates were based on the participants' vital status and death rates were calculated separately for men and women and for several socio-economic factors, stratified by age. RESULTS: At 40 years, men and women were expected to live another 34 and 37 years, respectively. Life expectancy varied across the participants' different socio-economic categories: those from high income households with good housing conditions, materially privileged households and small households, had a 2-3 years longer life expectancy as compared to the deprived persons. Also, those who went to college lived longer than the illiterates. The gaps between categories were wider in men than in women. INTERPRETATION & CONCLUSIONS: Socio-economic disparity in longevity was observed: wealthy people from Kerala State presented a longer life expectancy.

Non-Hodgkin's lymphoma of the hard palate.

Non-Hodgkin's lymphoma usually involves lymph nodes, but can involve extranodal sites. Oral lymphomas are relatively rare and often difficult to diagnose in a clinical setting. A case of non-Hodgkin's lymphoma of the hard palate who had undergone external beam radiation therapy and was found to be well one year following treatment is reported.

A two-sex model for the influence of heavy alcohol consumption on the spread of HIV/AIDS.

The HIV/AIDS epidemic, one of the leading public health problems to have affected sub-Sahara Africa, is a multifaceted problem with social, behavioral and biological aspects. In the absence of a cure, behavioral change has been advocated as an intervention strategy for reversing the epidemic. Empirical studies have found heavy alcohol consumption to be a fueling factor for HIV/AIDS infection and progression. Previously [20], we formulated and analyzed a one-sex deterministic model to capture the dynamics of this deadly interaction. But, since alcohol drinking habits, consequent risky sexual practices, alcohol-induced immune suppression, etc., can be different for men and women, the primary objective of our present paper is to construct a two-sex model aimed at shedding light on how both sexes, with varying heavy alcohol consumption trends, contribute differently to the HIV/AIDS spread. Based on numerical simulations, supported by the UNAIDS epidemiological software SPECTRUM and using the available data, our study identifies heavy drinking among men and women to be a major driving force for HIV/AIDS in Botswana and sub-Sahara Africa and quantifies its hazardous outcomes in terms of increased number of active TB cases and economic burden caused by increased need for AntiRetroviral Therapy (ART). Our simulations point to the heavy-drinking habits of men as a major reason for the continuing disproportionate impact of HIV/AIDS on women in sub-Sahara Africa. Our analysis has revealed the possibility of the phenomenon of backward bifurcation. In contrast to the result in some HIV vaccination models [52], backward bifurcation in our model is not removed by replacing the corresponding standard incidence function with a mass action incidence, but is removed by merging the two susceptible classes of the same sex into one, i.e., by ignoring acquisition of, and ongoing recovery from, heavy-drinking habits among the susceptible population.

Effect of tobacco chewing, tobacco smoking and alcohol on all-cause and cancer mortality: a cohort study from Trivandrum, India.

OBJECTIVE: To study the risk of all-cause, cancer and tobacco-related cancer mortality associated with tobacco chewing, tobacco smoking and alcohol use. DESIGN: Prospective community-based cohort study initiated in 1996. PARTICIPANTS: 167343 adult subjects, aged 34 and older, living in 13 panchayaths (rural municipal administrative units) in South India, were regularly followed-up for a mean duration of 6.5 years. MAIN OUTCOME MEASURES: Mortality from all-causes, all cancer and tobacco-related cancer. RESULTS: The mortality risks associated with chewing (and 95% confidence intervals), after adjusting for age, sex, socio-economic and dietary variables, and for other habits, were 0.90 (0.86-0.94) for all-cause, 1.07 (0.94-1.22) for cancer and 1.22 (1.04-1.44) for tobacco-related cancer; with smoking the respective mortality risks were 1.31 (1.24-1.39), 1.63 (1.37-1.94) and 1.68 (1.36-2.08); and with alcohol use the risks were 1.13 (1.06-1.20), 1.32 (1.11-1.57) and 1.47 (1.19-1.80), respectively. Reduced risk of all-cause mortality by chewing was observed only in the 60-84 years old group (0.90 (0.85-0.94)), and detrimental effects of chewing on cancer mortality were shown in the young and middle-age groups: 34-39 years old (1.33 (0.67-2.65)), and 40-59 years old (1.26 (1.03-1.55)). CONCLUSION: Tobacco in any form and alcohol uses were harmful and a higher quality of life could be achieved by avoiding these habits. Given the demographic, epidemiological and economic transitions and changes in pattern of tobacco and alcohol use in India, the health loss from the tobacco and alcohol will grow even larger, unless effective interventions and policies to reduce these habits are implemented.

Diffuse reflection spectroscopy: an alternative to autofluorescence spectroscopy in tongue cancer detection.

Laser-induced autofluorescence (LIAF) and diffuse reflection spectroscopy (DRS) are two emerging noninvasive optical tools that have shown immense potential to detect oral cavity pre-cancer. In a recent study, we have used spectral ratio reference standards (SRRS) of LIAF intensity ratios F500/F635, F500/F685, and F500/F705 for grading of tissues belonging to sites other than dorsal side of tongue (DST), lateral side of tongue (LST), and vermillion border of lip (VBL) that exhibited similar spectral shape for normal and abnormal tissues. This led to dismal diagnostic accuracies, and for the three LIAF-SRRS, normal tissue values were often misclassified as squamous cell carcinoma (SCC), which means that the true negatives were being wrongly identified as true positives. This study examines the applicability of the site-specific diffuse reflection spectral intensity ratio (R545/R575) of the oxygenated hemoglobin bands to classify different DST lesions and compares the results obtained with those obtained using LIAF-SRRS. DRS-SRRS of R545/R575 differentiated benign hyperplastic DST tissues from normal tissue with a sensitivity of 86% and specificity of 80%, which were indistinguishable using LIAF-SRRS. Further, in distinguishing hyperplastic tissues from premalignant dysplastic lesions, DRS-SRRS gave a sensitivity of 90% and a specificity of 86%, as compared to sensitivity of 89% and specificity of 72% shown by the three LIAF-SRRS together. The diagnostic accuracy and statistical adequacy of the two techniques were assessed by receiver operating characteristic curve (ROC-Curve) analysis. Three LIAF ratios gave a low overall ROC area under curve (ROC-AUCs) of 0.521, whereas the DR ratio (R545/R575) has shown an improved accuracy of 0.970 in differentiating different tissue types. While distinguishing hyperplastic from dysplastic tissues, the DR ratio gave a higher discrimination accuracy of 0.9. Based on these findings, it can be concluded that the DRS-SRRS technique by virtue of its low cost and higher diagnostic accuracies could be a viable alternate to LIAF-SRRS for in vivo screening of tongue pre-cancers and grading of different tissue types.

Alcohol intake and oral cavity cancer risk among men in a prospective study in Kerala, India.

OBJECTIVE: The aim of the study was to evaluate the role of alcohol drinking and patterns of consumption in oral cancer incidence and mortality in a cohort study using data from the Trivandrum Oral Cancer Screening Study, India. METHODS: At baseline, the study participants completed a lifestyle questionnaire including items on frequency and duration of alcohol consumption. They were followed up for oral cancer incidence and mortality. Data from 32 347 subjects, of whom 134 eventually developed oral cancer, were analysed to estimate risk of oral cancer incidence and mortality according to drinking patterns, using a Cox regression model adjusted for age, religion, education, occupation, body mass index (BMI), standard of living index, chewing habits, smoking habits, and vegetable and fruit intake. RESULTS: Current and past drinkers were each associated with significantly increased risk of developing oral cancer. The hazard ratio increased significantly by 49% (95% CI = 1-121%) among current drinkers and 90% (95% CI = 13-218%) among past drinkers. A significant dose-response relationship between intake frequency, duration and oral cancer risk (incidence and mortality) was observed. CONCLUSIONS: As with other lifestyle factors, alcohol intake plays an important role in oral carcinogenesis in this population, and understanding this role is relevant to developing public health policies targeting at-risk population.

Cost-effectiveness of oral cancer screening: results from a cluster randomized controlled trial in India.

OBJECTIVE: To evaluate oral cancer screening by visual inspection. METHODS: A cluster randomized controlled trial was initiated in Trivandrum district, Kerala, India. Of 13 population clusters, seven were randomly allocated to three rounds of screening between 1996 and 2004, while standard care was provided in six (control arm). An activity-based approach was employed to calculate costs associated with various components of the screening trial. Information on the resources used and on clinical events in each trial arm was derived from trial databases. Total costs for each cluster were estimated in 2004 United States dollars (US$). The incremental cost per life-year saved was calculated for all eligible individuals and for high-risk individuals (i.e. tobacco or alcohol users). FINDINGS: The proportion of oral cancers detected at an early stage (i.e. stage I or II) was higher in the intervention arm than the control arm (42% versus 24%, respectively). The incremental cost per life-year saved was US$ 835 for all individuals eligible for screening and US$ 156 for high-risk individuals. Oral cancer screening by visual inspection was performed for under US$ 6 per person. CONCLUSION: The most cost-effective approach to oral cancer screening by visual inspection is to offer it to the high-risk population. Targeted screening of this group will ensure that screening can be offered at a reasonable cost in a limited-resource setting.

Body mass index, weight change and mortality risk in a prospective study in India.

BACKGROUND: Although the detrimental effect of overweight and obesity has been extensively reported in Western populations, little is known on the association between body weight, weight change and mortality in Asian populations whose weight distribution and mortality differ considerably from the West. METHODS: A cohort of 75 868 subjects aged 35 years and above, participants of the Trivandrum Oral Cancer Study-a cluster-randomized controlled trial originally implemented to evaluate the efficacy of visual inspection on oral cancer, in Kerala State, South India-were followed up from 1995 to 2004. Weight and height were measured both at baseline and in 3.5-year follow-up surveys. Early years of follow-up were excluded from the analyses. Relative risks of overall death and cause-specific death were estimated according to the body mass index (BMI) category of the WHO Asian population definitions, and to weight changes between two surveys. RESULTS: Low BMI was a predictor of mortality, while high BMI was not. Mortality risks in men adjusted for age, smoking habits and other potential confounders, as compared with a BMI 18.5-22.9 kg/m(2), were 1.26 (95% CI 1.03-1.55) for BMI < 16 kg/m(2); 1.16 (1.03-1.32) for BMI = 16-18.4 kg/m(2); 0.95 (0.81-1.12) for BMI = 23-24.9 kg/m(2); 0.85 (0.69-1.05) for BMI = 25-27.4 kg/m(2); and 0.89 (0.65-1.21) for BMI >/= 27.5 kg/m(2). Similar findings were observed in women. BMI was not associated with deaths from cancer, cardiovascular and cerebrovascular diseases, and diabetes. A low BMI (<16 kg/m(2)) was associated with increased deaths from chronic respiratory diseases. Smoking and socio-economical status did modify the association. A moderate weight gain of 4-10% between the two surveys was associated with decreased risk of death, while moderate and severe weight loss were predictive factors of death. Similar results were observed in both men and women. CONCLUSIONS: Among this Indian rural population, mild to severe leanness (BMI < 16 kg/m(2)) and weight loss were important determinants of mortality, especially from chronic respiratory diseases, while overweight and above (BMI > 23 kg/m(2)) did not show any detrimental effect.

Role of tobacco smoking, chewing and alcohol drinking in the risk of oral cancer in Trivandrum, India: a nested case-control design using incident cancer cases.

Oral cancer is one of the most common cancers in the world, with two-thirds of the cases occurring in developing countries. While cohort and nested case-control study designs offer various methodological strengths, the role of tobacco and alcohol consumption in the etiology of oral cancer has been assessed mainly in case-control studies. The role of tobacco chewing, smoking and alcohol drinking patterns on the risk of cancer of the oral cavity was evaluated using a nested case-control design on data from a randomized control trial conducted between 1996 and 2004 in Trivandrum, India. Data from 282 incident oral cancer cases and 1410 matched controls were analyzed using multivariate conditional logistic regression models. Tobacco chewing was the strongest risk factor associated with oral cancer. The adjusted odds ratios (ORs) for chewers were 3.1 (95% confidence interval (CI)=2.1-4.6) for men and 11.0 (95%CI=5.8-20.7) for women. Effects of chewing pan with or without tobacco on oral cancer risk were elevated for both sexes. Bidi smoking increased the risk of oral cancer in men (OR=1.9, 95%CI=1.1-3.2). Dose-response relations were observed for the frequency and duration of chewing and alcohol drinking, as well as in duration of bidi smoking. Given the relatively poor survival rates of oral cancer patients, cessation of tobacco and moderation of alcohol use remain the key elements in oral cancer prevention and control.