Introduction
The oral mucosa is subjected to numerous local irritants throughout the life. This makes the oral cavity one of the most common sites for various benign, premalignant and malignant lesions. These lesions can cause variety of symptoms such as pain, bleeding, halitosis, difficulty in chewing, swallowing and speech, leading to severe discomfort in daily life. Oral lesions generally present in the form of ulcer, swelling, discolouration or restricted mouth opening. Hence the knowledge of all these pathological lesions of oral cavity becomes important in their early diagnosis and effective management.
Materials and Methods
Duration of study Months, Sample size: 80
Exclusion criteria
Biopsy proven cases
Post op Head and Neck malignancy
Post chemotherapy and/or radiotherapy
Recurrence
Associated with systemic disorders and infections
All subjects who met above criteria underwent a detailed study. A written and valid informed consent was obtained from each subject. A given pro-forma was filled to elicit detailed history. Patients underwent general physical examination and intra-oral examination. Under all aseptic precautions biopsy was collected from the lesion in the outpatient-setting and was sent for histopathology. Patients were followed up with histopathology reports. After going through the history, clinical profile and histopathology reports a definitive diagnosis was made and various diagnosed lesions were studied in relation to age, sex and habits. Patients were also counselled regarding their prognosis and outcomes of various treatment modalities available and were encouraged to quit addictions.
Results
In this study, the age group of 46-60 years had 34 (43%) patients which accounted to be the maximum number. Minimum number of patients belonged to the age group of 18-30 years. On plotting the age against type of lesion i.e. premalignant, benign and malignant; we found a moderate positive correlation between age and chances of malignant transformation, with coefficient of correlation 0.5004 and p value 0.01276 which was statistically significant. Benign lesions were more often found in age less than 45 years while malignant lesions were found more frequently in age more than 45 years. Premalignant lesions were found in all age groups with a trend towards increasing age. This study consisted of 51 (64%) males and 29 (36%) females.
Out of 80 subjects, 19 (24%) consumed vegetarian diet while 61 (76%) consumed mixed type of diet. Occurrence of Aphthous stomatitis (recurrent aphthous ulcers) showed positive correlation with consumption of pure vegetation diet. In India, people are seen to clean oral cavity with products like toothpaste, bamboo stick and mishri etc. In this study, maximum number of individuals used toothpaste to clean oral cavity.
Table 1
Diet and oral hygiene practices amongst subjects
|
Various practices amongst subjects |
No. of subjects |
Percentage of subjects |
|
|
Diet |
Veg |
19 |
24% |
|
Mixed |
61 |
76% |
|
|
Oral hygiene habits |
Toothpaste |
53 |
66% |
|
Bamboo stick |
9 |
11% |
|
|
Mishri |
18 |
23% |
|
Most of the patients (43%) presented within 1-6 months of symptom onset. The most common chief complaint was pain (78%), followed by burning at the site of lesion (64%). Forty three subjects (54%) had oral ulcer as their primary complaint. Six (8%) individuals had prior history of Aphthous stomatitis. Fourteen (18%) and twenty five (31%) subjects presented with swelling and bleeding, respectively. Hyperpigmentation and hypopigmentation accounted for 26% and 16% of subjects respectively. Fifteen (19%) individuals had restricted mouth opening and six (8%) individuals had loose teeth. One patient had difficulty in swallowing and speaking because of large oral lesion. The most common site of oral lesion in this study was buccal mucosa (52%).
Table 2
Distribution of chief complaints of patients
Table 3
Distribution of site of lesion
|
Distribution of site |
No. of subjects |
Percentage of subjects |
|
Tongue |
26 |
33% |
|
Buccal mucosa |
42 |
52% |
|
Lip |
5 |
6% |
|
Hard palate |
5 |
6% |
|
Tonsil |
2 |
3% |
The study had 60 tobacco chewers, and majority of them (68%) had habit of daily tobacco chewing with frequency of more than 10 times a day and total duration of more than 15 years (93%). We encountered 35 smokers in our study and 24 subjects (69% of total smokers) had smoked more than 20 pack-year (py). The study also had 29 alcohol users and majority of them (65%) consumed 20-40 grams of alcohol per day.
Table 4
Daily frequency of tobacco chewing
|
Daily frequency of tobacco chewing |
No. of subjects |
Percentage of subjects |
|
1-3 times |
0 |
0% |
|
4-10 times |
19 |
32% |
|
>10 times |
41 |
68% |
|
Total tobacco chewers |
60 |
100% |
Table 5
Duration of tobacco chewing
|
Duration of tobacco chewing |
No. of subjects |
Percentage of subjects |
|
< 5 years |
0 |
0% |
|
5-15 years |
4 |
7% |
|
>15 years |
56 |
93% |
|
Total tobacco chewers |
60 |
100% |
Table 6
Amount of smoking in pack- year (py)
|
Amount of smoking in py |
No. of subjects |
Percentage of subjects |
|
<10 py |
3 |
8% |
|
10-20 py |
8 |
23% |
|
>20 py |
24 |
69% |
|
Total smokers |
35 |
100% |
Table 7
Amount of alcohol consumption in average gram/day
|
Alcohol consumed (gram/day) |
No. of subjects |
Percentage of subjects |
|
<20 |
6 |
21% |
|
20- 40 |
19 |
65% |
|
>40 |
4 |
14% |
|
Total drinkers |
29 |
100% |
Table 8
Distribution of past history and co-morbidities
|
Past history |
No. of subjects |
Percentage of subjects |
|
Similar lesion in oral cavity in past |
9 |
11% |
|
Diabetes |
7 |
9% |
|
Hypertension |
7 |
9% |
|
Tuberculosis |
3 |
4% |
|
Dental prosthesis |
1 |
1.25% |
After obtaining the histopathology reports, we came across 13 benign, 32 benign and 35 malignant cases. The sites showing malignancy were tongue, buccal mucosa, lip, hard palate and tonsil. Aphthous stomatitis of buccal mucosa was the most common benign lesion noted in our study. The most common premalignant and malignant lesions noted were Oral submucous fibrosis and Squamous cell carcinoma of tongue.
We found statistically significant and a very strong positive correlation between duration of tobacco chewing & premalignant and malignant lesions, with coefficient of correlation of 0.9995 (p value 0.000013) and 0.9997 (p value 0.00001), respectively. Hence the incidence of malignant transformation were seen to increase with increase in duration of tobacco chewing.
There was no correlation between smoking and benign oral lesions (coefficient of correlation -0.3278). However a strong positive correlation was found between smoking and premalignant lesions with coefficient of correlation 0.9548 and p value 0.01146. Similarly, the correlation between smoking and malignant lesions was found to be very strong with coefficient of correlation 0.9585 and p value 0.010085.
There was no positive correlation found between alcohol consumption and benign as well as premalignant lesions. A weak positive correlation was found between alcohol consumption and malignant lesions with coefficient of correlation 0.3352 and p value 0.5813 with no statistical significance. Subjects consuming more than 40 gram of alcohol per day only showed malignant lesions.
Histopathologic examination classified squamous cell carcinoma into three categories:
Well differentiated squamous cell carcinoma
Moderately differentiated squamous cell carcinoma
Poorly differentiated squamous cell carcinoma
We studied the correlation between various addictions with histopathologic differentiation of squamous cell carcinoma. A very strong correlation was found between duration of tobacco chewing and histopathologic differentiation. With more number of years of tobacco consumption there were increased chances of lesion becoming poorly differentiated. The coefficient of correlation for moderately differentiated squamous cell carcinoma was 0.9918 (p value 0.00089), and that for poorly differentiated one was 0.9944 (p value 0.000503). These results were statistically significant.
There was strong statistically significant association between smoking and histopathologic differentiation. The coefficient of correlation for well, moderately and poorly differentiated squamous cell carcinoma were 0.8839, 0.9667 and 0.9848, respectively. There was no association found between alcohol and histopathologic differentiation of squamous cell carcinoma.
Table 9
Distribution of type of oral lesion at various sites
|
Site of lesion |
Benign |
Premalignant |
Malignant |
|
Tongue |
1 |
6 |
19 |
|
Buccal mucosa |
7 |
26 |
9 |
|
Lip |
3 |
0 |
2 |
|
Hard palate |
2 |
0 |
3 |
|
Tonsil |
0 |
0 |
2 |
|
Total |
13 |
32 |
35 |
Table 10
List of benign, premalignant and malignant lesions found at various site
Various addictive habits and type of lesion habits and type of lesion:
Graph 1
Correlation between different types of oral lesion cases and daily frequency of tobacco chewing
Discussion
In our study, oral lesions were found in all age groups with maximum number of cases distributed between the age of 46 and 60 years (43%). In Gupta et al. study, maximum incidence of oral lesions was found from 51 to 60 years of age.1 In Mathew AL et al. and Pai KM et al. studies, maximum incidence of oral lesions was found in the age group of 21-40 years.2 TR Saraswathi in his cross sectional study, conducted in Chennai, in 2006, had maximum subjects belonging to the age group of 21-30 years.3
In our study, male to female ratio was found to be 1.78, while in Gupta et al. study it was 2.28.1 It was found 1.68 and 1.76 in Mathew AL et al.2 and TR Saraswathi et al. 4 studies respectively.
We found 16.25% benign, 40% premalignant and 43.75% malignant lesions, in our study. In Gupta and Choudhary study, there were 11% of benign, 7% of premalignant and 82% of malignant conditions observed.1 Goyal and Jadia study had 57% of benign, 28% of premalignant and 15% of malignant lesions.3
In studies carried out by Gupta et al., Mathew et al., Goyal et al. and TR Saraswathi et al., it was concluded that tobacco chewing and smoking had a very strong association with oral mucosal lesions, especially with premalignant and malignant lesions. Alcohol consumption failed to show direct correlation with oral lesion, in these studies.[1,86,87,93]1 These results were comparable with those of our study. In Gupta et al. study, alcohol consumption was seen to be associated with premalignant lesions.
In this study, most common lesions associated with tobacco chewing were Oral Submucous Fibrosis (OSMF), Leukoplakia and Carcinoma. Lesions found to be highly associated with smoking were Stomatitis nicotina, Ulcerative leukoplakia, Erythroplakia and Carcinoma. Apart from duration of smoking, number of cigarettes smoked per day was found to be significant, in all these studies. Alcohol consumption showed weak positive correlation with occurrence of malignant lesions. We had two rare cases in our study, i.e. Mucoepidermoid carcinoma of right palatine tonsil in a 47 year old female with no any history of addictions, and Sarcomatoid carcinoma of tongue in a 48 year old male in a chronic tobacco chewer.
Conclusion
It is important to study oral mucosal lesions in more detail with respect to demographic details of the patient. History and clinical examination are always needed to know the type and extent of the lesion, including clinical TNM stage in case of malignant lesions. However final diagnosis is made only after histopathology report, which also have prognostic significance.
