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Comparative Severity of Oral Submucous Fibrosis among gutkha and other areca nut products chewers.

Mohammad Sami Ahmad, B.D.S., M.Sc.
Sharique Ather Ali, PhD
Ayesha Sharique Ali, PhD
Krishna Kumar Chaubey, B.D.S., M.D.S.

Corresponding Author

Dr Mohammad Sami Ahmad

Senior Lecturer in Dental Public Health

Health Science College

PO. Box 3761

Dammam 31481, Saudi Arabia

ABSTRACT

A case control study was conducted in some selected dental clinics of Bhopal, India. The total 132 cases of Oral Submucous Fibrosis (OSMF) were selected for study in the period of 2002 – 2005. The cases were diagnosed by oral examination and it was confirmed by biopsy. Biopsy of all the patients was not taken because of refusal from the patients. The cases were devided into three groups, grade I (mild), grade II (moderate) and grade III (severe) according to the presence of clinical symptoms. Statistical analysis were performed to find out the significance relation of severity with socioeconomic status, gutkha and other areca nut products along with its duration, frequency, time of keeping in the mouth and style of chewing. Lower and middle socioeconomic class suffered more from OSMF but mostly with grade I where as Upper middle and Upper socioeconomic class suffered less but mostly present grade III. There were only two cases that did not chew gutkha and other areca nut products and suffered from grade II of OSMF. About 63 percent of cases chewed gutkha and other areca nut products for less than two years suffered from grade I and 24 percent who chewed for 2 < 4 years developed grade III. The patient who were taking less tan 2 pouch per day and keeping for less than 2 minutes mostly developed grade I where as patients who were taking more than ten pouches per day and keeping 5 < 10 minutes in the mouth developed grade III. About 60 percent who chewed gutkha and other product and spitted out after keeping few minuts developed grade I and who chewed and swallowed it after keeping in the mouth or kept longer period in buccal vestibules developed grade III OSMF.

Key words: Oral Submucous fibrosis, Gutkha, Areca nut, Biopsy, Pan

INTRODUCTION

Oral sub mucous fibrosis (OSMF) is an insidious, chronic fibrotic change affecting any part of oral mucosa and has been considered as an oral precancerous condition.1,2 Technically speaking OSMF is a chronic disease of oral mucosa characterized by inflammation and progressive fibrosis of the lamina propria and deeper connective tissues, followed by stiffening of mucosa resulting in difficulty in opening the mouth. Symptoms of OSMF include localized burning sensation and intolerance to spicy food, followed by ulceration and blanching of the mucosa and the formation of characteristic fibrous band.3 These bands form bilaterally, initially in the fauces and then in the buccal mucosa and labial areas: as the disease progress the band on either side meet on the floor and roof of the mouth, forming a fibrous ring. The diagnosis of OSMF is made on clinical grounds.

Habitual chewing of gutkha (mixture of dry areca nut, tobacco and other chemical in trace for flavoring) and other areca nut quid plays a major role in the etiology of the disease.4,5 During the recent past the new menace of gutkha has sprung up in a monstrous proportion, which is taking more dangerous dimension in causing OSMF and oral cancer across the country. Gutkha is very commonly used by youth and has become extremely popular, this is the main cause of epedimic of OSMF.6 Surveys and studies in India have shown that the over all prevalence of OSMF is 0.5 percent with range of 0.2 to 1.2 percent in different regions of the country and there may be more than 2.5 million cases of the OSMF.7,8 Recently Nair 9 has estimated that as many as 5 million young Indians are suffering from this precancerous condition as a result of the increased popularity of the habit of chewing gutkha and panmasala. It is generally accepted today that areca nut quid plays a major role in the etiology of the disease.10 While many contributing factors have been discussed in the literature,3 the condition almost never develops in people who do not chew areca nut.4,5 Studies also associate getting OSMF with the frequency and duration of the habit of chewing areca nut.4,5 The disease occurs mostly in India and in South East Asia but the cases have been reported world wide like Kenya, China, UK, Saudi Arabia and other parts of the world where Asian are migrating.11,12 In recent years marked increase in occurance of OSMF was observed in many parts of India like Bihar, MP, Gujrat and Maharashtra. The younger generations is suffering more due to incoming of areca nut products in different multicoloured attractive pouches with heavily advertised by electronic and mass media and sell every corner of the road.

Comparatively clinicopathological studies of the OSMF in habitual chewers of gutkha, panmasala and betel quid have revealed very interesting data, that the increasing use of gutkha is associated with an earlier onset of OSMF. It was found that the dry weight of gutkha was responsible for early onset of the disease.10

In view of such a situation when there is a tremendous increase of OSMF cases and its early onset, so there is an urgent need to conduct extensive comparative studies to evaluate the effect of gutkha in young adults of the area where it is highly prevalent. It becomes imperative to investigate the extent of damage done by the massive consumption of gutkha along with areca nut and lime with reference to the onset of OSMF and its histopathological changes, so that a comparative assessment can be made for the better understanding of its etiology, diagnosis and prognosis. There is a scarcity of reports on staging it by severity with socioeconomic status, and habitual eating of gutkha and other quids. The main purpose of this study was to investigate the relationship of gutkha and other areca nut quid with severity of OSMF along with socioeconomic status of the patient.

MATERIAL AND METHODS

The present study was conducted at some selected dental clinics in the city of Bhopal, Madhya Pradesh, India. Patients attending the Clinics of Bhopal for oral diseases (disorders) were screened for Oral Submucous Fibrosis. The total 132 patients of Oral Submucous Fibrosis were selected for study in the period of 2002 – 2005. The OSMF cases were diagnosed by presence of certain clinical criteria and some of them were confirmed by histopathological examination. Histopathology of all the patients was not done because many of them refused to undergo biopsy.

An appropriate format was designed after pre testing, to collect detailed information of all the subjects such as age, sex, socioeconomic status, residential status, religion, oral hygiene condition, any chewing habits, brand of quid, frequency of taking quid, style of chewing, duration of chewing habits, nutritional value of diet, amount of spices and chilies use were recorded. Socioeconomic status was classified according to the income and education of the patient.

Clinical examination of the subjects was performed examining the factors such as burning sensation of mouth and tongue, irritation of mouth with chilies and spicy food, dryness of mouth or hyper salivation, difficulty or inability in opening mouth, blanched or opaque appearance of mucosa, loss of tongue papillae, atrophy of the tongue, soft palate movement restriction, inability to protrude tongue, presence of palpable fibrous band.

The cases were divided into three grades according to the severity of the disease; grade I (mild), grade II (moderate) and grade III (Severe). Grade I (mild) subjects had burning sensation and dryness of the mouth, irritation on eating hot and spicy food, Oral mucosa was blanched and had lost elasticity with slight restriction of mouth. Grade II (moderate) when all the clinical finding present in grade I and blanched, opaque leather like mucosa, vertical fibrotic bands or buccal mucosa making it stiff, considerable restriction of mouth opening, tongue protrusion is little restricted, difficulty in speaking and eating and oral hygiene poor. In grade III (severe) all the clinical features were like grade I and grade II including thick fibrous bands occurring on both buccal mucosa of cheek, very little mouth opening, restricted tongue protrusion, speech and eating very much impaired and oral hygiene very poor. Biopsies were taken from the site of lesion of oral submucous fibrosis mainly from buccal mucosa. Biopsies were done under local anesthesia. Relation of different grade of OSMF was corelated with the data gathered from the format. The data were analysed by SPSS (Statistical Package for Social Services, version 10) and inferential statistics such as Chi – Square test was used following the method of Rao and Richard.13

RESULTS

Severity of the disease was correlated with the use of gutkha and other areca nut products along with its duration of use, time of keeping in the mouth, frequency and style of chewing. The socioeconomic status of the patients was also correlated with the severity. Out of total 132 OSMF patients, 21 cases belonged to grade III followed by 49 grade II and 62 grade I.

It was observed that in lower socioeconomic class maximum number of cases 56.5 percent belonged to grade I followed by grade II 30.5 percent and grade III 13 percent. In middle socioeconomic class pattern was same as of the lower class being 57.5 percent of grade I, 42 percent grade II and 1.5 percent grade III. In the upper middle class severity of cases in the grades was grade III 56.5 percent followed by grade II 30.5 percent and grade I 13 percent where as OSMF cases belonging to the upper class equally suffered from grade II and grade III, being 36 percent and grade I, 28 percent respectively (Table No.1). P < 0.001.

All the OSMF cases were having some chewing habits only 2 cases were found to be without chewing habits and they suffered from grade II. It was observed from the data that most of the cases were gutkha chewers and among them 40 percent developed grade I followed by grade II 38 percent and grade III 22 percent. Pan chewers were also having same pattern, maximum number of cases 61.5 percent were suffering from grade I which is quite higher than those who used gutkha (Table No. 2). P = 0.18

The data show that 63.5 percent patients who were chewing gutkha and other products for less than 2 years suffered from grade I, followed by 27.5 percent grade II and only 9 percent grade III. Where as the patients who chewed gutkha and other products between 2 < 4 years suffered more about 38 percent grade II and 24 percent grade III (Table No.3). P = 0.45

It has been also observed from the data that the patients who were keeping gutkha and other products for less than 2 minutes in the mouth developed 72.5 percent grade I, 27.5 percent grade II and not a single case from grade III. The OSMF cases who kept it between 5 < 10 minutes suffered 29.5 percent grade III, followed by 37 percent grade II and 33 percent grade I (Table No.4). P< 0.001

Table 5 shows the distributions of severity of OSMF in relation to the frequency of using gutkha and other related products per day. The data show that the patients who used gutkha and other products less than 2 pouches per day developed 77.5 percent grade I followed by 22.5 percent grade II and not a single developed grade III. On the other hand the OSMF cases used gutkha and other related products more than 10 pouches per day developed 59 percent grade III, 33 percent grade II and 8 percent grade I (P< 0.001) highly significant.

About 60 percent of the patients who chewed gutkha and other products and spitted it out after keeping for few minutes developed grade I OSMF followed by 33.5 percent grade II and 6.5 percent suffered from grade III. On the other hand those who chewed and swallowed the gutkha and other products or kept it in the buccal vestibules for longer periods suffered from grade III 34.5 percent and 47 percent respectively. (Table 6) P < 0.001, Highly Significant

DISCUSSION

The present epidemiological findings along with histopathological observations of the OSMF cases due to habitual gutkha chewing have been comparatively analysed for assessment of severity and related risk factors. Confirmed cases of OSMF by clinical examination, and patient’s history along with histopathological evaluation have been devided into three grades: grade I (mild), grade II (moderate) and grade III (severe) depending upon the extent of the severity of the disorder. The salient features of such grading on the basis of symptoms and histopathological findings are discussed here in order to have a comparative idea of the OSMF subjects.

It has been observed that the maximum number of cases of grade I OSMF belonged to low socioeconomic and middle class people; i.e. 56.5 percent and 57.5 percent respectively, where as maximum number of grade III OSMF belonged to upper middle class and upper class; i.e. 56.5 percent and 36 percent respectively. It might be due to low socioeconomic class can not afford to buy more gutkha and other areca nut products.

Only few workers have correlated severity of OSMF with socioeconomic status. As previously reported by Sirsat and Khanolkar 14 who found more grade III OSMF cases in low socioeconomic status of patients who were using more chillies, where as Hashibe et al. 15 has reported higher education level as a reducing factor in the relative risk of OSMF as well as severity of the disease.

It is very interesting to note that pan chewers mostly developed grade I OSMF. 61.5 percent where as maximum number of gutkha chewers developed grade III of OSMF. The data further show that pan chewing does produce OSMF but does not increase the severity of the disease. It might be due to the presence of betacarotene in pan, which probably delays the onset of OSMF. Betel leaf (pan) is known to be rich in betacarotene, which has the capacity to quench free radicals that are mutagenic.16,17,18

As in the present study, gutkha chewers developed more severe OSMF probably due to use of more dry weight of areca nut and tobacco as compared to other chewing products. Many workers like Wahi et al. 19 have found grade III OSMF mostly in areca nut tobacco chewers than non-tobacco chewers. Chin and Lee 20 also found more mucosal changes in tobacco containing quids in their study in Malaysia. Many workers described that the degree of histological changes mostly depend upon amount of areca nut and tobacco used.21,22,23 Further relation of severity of OSMF with areca nut and tobacco was stressed by Reichart et al.24 Similarly Babu et al. 10 and Gupta & Ray 25 have described that gutkha chewers develop OSMF earlier and in a more severe condition than chewers, using other products.

In the present study it was also found that most of the OSMF cases, who were using gutkha and other products since less than 2 years developed grade I of OSMF where as the patients who were taking the gutkha and other products more than 4 years developed mostly grade II and grade III of OSMF. The OSMF patients who were chewing gutkha and other products for less than 5 minutes in duration and less than 5 pouches (1 pouch = about 3.5 gram) per day in quantity mostly developed grade I of OSMF. On the other hand OSMF cases who were chewing gutkha and other products at a rate of 10 pouches per day with a chewing period of more than 5 minutes developed more severe OSMF.

From the present study it becomes clear that frequency of addiction, duration of chewing with style of keeping in minutes the gutkha and other products have direct significant relation with the severity of the disorder, as some workers, like Sinor et al. 4 have reported that frequency and duration of chewing gutkha is directly related to the severity of the disease. Rajendran et al. 26 also agreed that frequency of taking gutkha is directly related to the severity of OSMF but duration of using has no effect. Maher et al. 5 in their study from Pakistan also reported that frequency of taking areca nut and tobacco quid has a significant relation with the severity of OSMF but duration has no relation even if the patient takes gutkha through out his life.

Style of chewing gutkha and other products have very significant relation with the severity of OSMF. From Table 6 it becomes evident that most of the patients who chewed the gutkha and other products and spitted it out after keeping for few minutes, developed mostly grade I of OSMF compared to the OSMF cases that chewed and swallowed it or kept it in the buccal vestibules for a longer period. Sixty per cent of OSMF cases developed grade I of OSMF who chewed and spitted the gutkha and other products where as only 6.5 percent developed grade III.

Some workers have mentioned that these exists a strong relation of OSMF with the location of the quid in different regions of mouth, which are affected by different styles of chewing. 27,28 Some literature could be found which describes the severity of the disease is associated with keeping longer duration of areca nut and tobacco quid in the buccal vestibule. 29,30 But in the data of the present histopathological and epidemiological study, severity of OSMF has been found in mostly the cases, which chewed the gutkha and other products and swallowed it or kept in the buccal vestibules for longer period. It is possible that as areca nut has high alkaloid arecoline and tobacco ingredients like nitrosoamine, which are, absorbed more in the patients who keep it for longer periods in their buccal vestibules or swallow it, have more severity of the disorder.

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Table: (1) Showing socioeconomic statuses of OSMF cases in relation to the severity of

disease.

Socioeconomic status	Grade I (Mild) N %	Grade II (Moderate) N %	Grade III (Severe) N %	Total N %
Lower Class	13 56.5	7 30.5	3 13	23 100
Middle Class	43 57.5	31 42.0	1 1.5	75 100
Upper Middle Class	3 13.0	7 30.5	13 56.5	23 100
Upper Class	3 28.0	4 36.0	4 36.0	11 100
Total	62 47.0	49 37.0	21 16.0	132 100

χ2 = 46.49, P < 0.001 (Highly Significant)

Table: (2) Showing severities of OSMF cases using gutkha and other products.

Ggutkha and other products	Grade I (Mild) N %	Grade II (Moderate) N %	Grade III (Severe) N %	Total N %
No habit	0 0.0	2 100	0 0.0	2 100
Gutkha	20 40.0	19 38.0	11 22.0	50 100
Pan	27 61.5	11 25.0	6 13.5	44 100
Panmasala	9 37.5	11 46.0	4 16.5	24 100
Areca nut	6 50.0	6 50.0	0 0.0	12 100
Total	62 47.0	49 37.0	21 16.0	132 100

χ2 = 8.87, P = 0.181 (Not Significant)

Table: (3) Showing duration of using gutkha and other products related to the severity of

OSMF cases.

Duration of using gutkha and other products	Grade I (Mild) N %	Grade II (Moderate) N %	Grade III (Severe) N %	Total N %
< 1 yr	7 63.5	3 27.5	1 9.0	11 100
1 < 2 yrs	11 52.0	8 38.0	2 10.0	21 100
2 < 4 yrs	21 38.0	21 38.0	13 24.0	55 100
≥ 5 yrs	23 53.5	15 35.0	5 11.5	43 100
Total	62 47.5	47 36.0	21 16.5	130 100

χ2 = 5.74, P = 0.45 (Not Significant)

Table: (4) Showing duration of keeping gutkha and other products in the mouth related to

the severity of OSMF cases.

Duration of keeping gutkha and other products	Grade I (Mild) N %	Grade II (Moderate) N %	Grade III (Severe) N %	Total N %
< 2 minutes	8 72.5	3 27.5	0 0.0	11 100
2 < 5 minutes	28 68.0	11 27.0	2 5.0	41 100
5 < 10 minutes	16 33.0	18 37.5	14 29.5	48 100
≥10 minutes	10 33.5	15 50.0	5 16.5	30 100
Total	62 47.5	47 36.0	21 16.5	130 100

χ2 = 21.35, P < 0.001 (Highly Significant)

Table: (5) Showing frequency of using gutkha and other products related to the severity of

OSMF cases.

Using gutkha and other products per day	Grade I (Mild) N %	Grade II (Moderate) N %	Grade III (Severe) N %	Total N %
< 2 pouches/day	21 77.5	6 22.5	0 0.0	27 100
2 < 5 pouches/day	20 60.5	11 33.0	2 60.5	33 100
5 < 10 pouches/day	20 34.5	26 35.0	12 21.0	58 100
≥ 10 pouches/day	1 8.0	4 33.0	7 59.0	12 100
Total	62 47.5	47 36.0	21 16.5	130 100

χ2 = 35.45, P < 0.001 (Highly Significant)

Table: (6) Showing style of chewing gutkha and other products related to the severity of

OSMF cases.

Style of chewing gutkha and other products	Grade I (Mild) N %	Grade II (Moderate) N %	Grade III (Severe) N %	Total N %
Keeping in the cheek	2 13.0	6 40.0	7 47.0	15 100
Chewing and spitting	55 60.0	31 33.5	6 6.5	92 100
Chewing and swallowing	5 22.0	10 43.5	8 34.5	23 100
Total	62 47.5	47 36.0	29 16.5	130 100