|Year : 2021 | Volume
| Issue : 1 | Page : 40-45
Oral potentially malignant disorders among dental patients
Eva Shamlee, Sreedhar Reddy
Department of Public Health Dentistry, CSI College of Dental Science and Research, Madurai, Tamil Nadu, India
|Date of Submission||06-Oct-2021|
|Date of Acceptance||06-Oct-2021|
|Date of Web Publication||29-Nov-2021|
Dr. Sreedhar Reddy
Departments of Public Health Dentistry, CSI College of Dental Science and Research, Madurai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: Most potentially malignant disorders (PMDs) are asymptomatic, and the main aim of treatment is to prevent and/or to detect cancer development early. Etiological factors can be identified and patients can be warned of the potential of malignancy. Abstinence from tobacco and alcohol, even after many years of use, significantly reduces the risk of developing cancer. The knowledge of susceptibility to cancer among the general population must be imparted by awareness programs and publications in media. Oral PMDs may be considered a blessing in disguise as they can help in early diagnosis and prevention of oral malignancies which can decrease the burden of cancer prevalence, especially in the youth and working class of the society. Results: According to this survey, awareness of oral PMDs was low among patients. It was found that television and Internet had played a significant role in patients who were aware of oral precancerous conditions. The aim of this survey is to assess the awareness about oral PMDs among dental patients. Materials and Methods: To assess the awareness about oral PMDs, a self-interviewed questionnaire was used to collect information from 100 patients of different age groups attending the dental hospital, Chennai. The questionnaire was designed and included relevant questions to ascertain information on awareness, and sources of information about oral precancerous conditions. Results: A total of 100 questionnaires were distributed. The study population consisted of 41 female and 59 male patients of different age groups. Forty-two percent of the individuals out of 100 were aware of PMDs whereas, 58% did not know about it. Conclusion: According to this survey, awareness of oral PMDs was low among patients.
Keywords: Awareness, lesions, mucosa, patients, precancer
|How to cite this article:|
Shamlee E, Reddy S. Oral potentially malignant disorders among dental patients. Int J Soc Rehabil 2021;6:40-5
| Introduction|| |
Potentially malignant disorders (PMDs) of oral cavity were classified as “lesions” and “conditions” by the WHO in 1978. A precancerous lesion is a morphologically altered tissue in which oral cancer is more likely to occur than its apparently normal counterpart, whereas a precancerous condition is a generalized state associated with a significantly increased risk of cancer. However, World Health Organization decided to use the term “potentially malignant disorders (PMD)” to convey that not all disorders described under this term may transform into cancer rather this is a family of morphological alterations among which some may have an increased potential for malignant transformation. These lesions are not only site-specific predictors of malignancy but also indicate an increased risk of future malignancies elsewhere in oral mucosa.
In the past decades, little progress has been made in defining oral leukoplakia. In 1978, the World Health Organization defined leukoplakia as “a white patch or plaque that cannot be characterized clinically or pathologically as any other disease.” In that communication, it was noted that the term leukoplakia was unrelated to the absence or presence of epithelial dysplasia. In 2005, the World Health Organization defined leukoplakia as “a white plaque of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer”. Both the 1978 and the 2005 definitions are worded in a somewhat negative way. Besides, when accepting the view that lichen planus is a PMD, then this disease actually falls within the 2005 WHO definition of leukoplakia.
The prevalence of leukoplakia for all ages is approximately 1%, with an increasing prevalence in adults. The male-to-female ratio varies in different parts of the world. Smoking is the most common etiologic factor. Nevertheless, leukoplakia may occur in nonsmokers as well. Cessation of smoking habits may result in regression or even disappearance of the leukoplakia in a matter of a few months. The prevalence of oral lichen planus is in general accepted to be approximately 1%. This chronic disorder mainly affects middle-aged people. The etiopathogenesis is still poorly understood. There is no effective treatment and there are no preventive measures either.
When the incidence of oral cancer is set at 5/100.000 population per year, then an annual risk of malignant transformation in oral leukoplakia patients of 2% is a four hundred times increased risk. Prevalence of erythroplakia is only available from studies done in South and South East Asia and is as low as 0.02%. The annual malignant transformation rate is actually unknown but is much higher than in leukoplakia. There are numerous reported parameters that allegedly predict future malignant transformation of oral leukoplakia. These parameters include previously diagnosed cancer in the head-and-neck region, older age, female gender, absence of smoking habits, duration of the leukoplakia, clinical subtype (homogeneous versus nonhomogeneous), large, and oral subsite such as borders of the tongue and floor of the mouth. The use of toluidine blue staining may help to identify high-risk leukoplakias with poor outcomes. Other predicting factors include the presence of Candida albicans, the presence and severity of epithelial dysplasia, and, in addition, numerous molecular markers, such as aberrant expression of p16INK4a and Ki-67, chromosome instability, and loss of heterozygosity at 9p and mutated TP53. Some of the predicting factors mentioned above carry a certain degree of subjectivity. Some clinicians use this adjective only in case of thin, smooth, and homogeneously white lesions, while others may apply this adjective also in homogeneously white and homogeneously verrucous lesions. The histopathological assessment of the presence of epithelial dysplasia and the degree of dysplasia is another source of substantial subjectivity.
| Materials and Methods|| |
To assess the awareness about oral PMDs, a self-interviewed questionnaire was used to collect information from 100 patients of different age groups (convenience sampling) attending the dental hospital, in Private Dental College, Chennai. The questionnaire was designed and included relevant questions to ascertain information on awareness, and sources of information about oral precancerous condition.
| Results|| |
A total of 100 questionnaires were distributed. The study population consisted of 41 female and 59 male patients of different age groups [Table 1]. In terms of education, most of the respondents are undergraduate (38%), 29% are postgraduate individuals [Table 2], although almost all the individuals had some form of education.
The participants were asked if they had any adverse habits, 43% of the individuals agreed that they have adverse habits which include smoking, tobacco, and pan chewing and 57% of the respondents did not have any adverse habits. About 42% of the individuals out of 100 were aware of PMDs whereas, 58% did not know about it. The participants were asked if they had any white or red patches in oral cavity and 21% of them had patches in their oral cavity. More than 66% of the respondents said that PMD is preventable; however, 34% felt it is not preventable [Table 3].
Participants were aware of PMDs through television, newspaper, Internet (37%) and through parents (20%), dentist (22%) and other ways (21%) [Table 4].
The participants were asked about the factors which cause PMDs, out of which 23% of the individuals said that both adverse habits and sun exposure can be the main causative factors and 46% of the respondents admitted that they do not know about the cause [Table 5].
Out of 100 participants, 59% of the individuals said that PMDs are more common in male than female (41%) [Table 6].
The participants were asked about the mode of prevention, 17% of the individuals said that quitting habit and regular screening for PMDs can help to prevent the PMDs [Table 7].
| Discussion|| |
Precancerous condition can be defined as a disease or patient habit which does not necessarily alter the clinical appearance of local tissue but is known to have a greater than normal risk of precancerous lesion or cancer development. A precancerous lesion is a morphologically altered tissue in which oral cancer is more likely to occur than its apparently normal counterpart, whereas a precancerous condition is a generalized state associated with a significantly increased risk of cancer. PMD is defined by WHO 2005 as the risk of malignancy being present in a lesion or condition either at time of initial diagnosis or at a future date. Oral cancer is a carcinoma that occurs in the oral cavity and belongs to the group of head-and-neck tumors. Malignant oral cavity tumors account for about 3%–5% of all tumors. According to epidemiological data, oral cavity cancer is the sixth most frequent among all types of cancer, and one of the ten most common causes of death, with an incidence of 10 in 100,000 people. The most common type is squamous cell carcinoma that makes up 90% of all malignant tumors. Oral cancer accounts for about 4% of all malignant tumors in men, and 2% in women, of an average age of about 60, although an increase in incidence has been recorded recently in people of younger age. The main etiologic factors for the development of oral cavities cancers are smoking, alcohol consumption, sun exposure, liver cirrhosis, dietary deficiencies, viruses, chronic tooth injuries, etc. Oropharyngeal carcinoma belongs to the group of the most malignant tumors, given the fact that the survival rate is about 50%. Although the oral cavity is accessible for visual examination, oral cancers are generally diagnosed late. Lack of awareness in patients and the phase of negation and ignoring the symptoms are the reasons for not seeing a doctor right away, which is considered the “first loss of time”. The “second loss of time” occurs due to a lack of awareness of medical and dental professionals and a lack of a timely diagnosis. The “third loss of time” is the period that passes from the diagnosis to the commencement of treatment. It is important to reduce the “first loss of time” by increasing awareness of the importance of self-examination and to shorten the “second loss of time” through education of medical and dental staff.
Oral cancers mostly develop from potentially malignant lesions (PMLs) (precancerouses). PMLs are lesions of the oral mucosa which are at an increased risk for malignant transformation compared to healthy mucosa. At the congress of the World Health Organization in 2005, “potentially malignant diseases” was suggested as a term for malignant and precancerous conditions. The most common precancerous lesions are leukoplakia, erythroplakia, oral lichen planus, and actinic cheilitis. Leukoplakia is a white spot or plaque which cannot be clinically nor histologically characterized as any other lesion, and is not associated with any physical or chemical causal factor, aside from the use of tobacco. According to epidemiological data, general prevalence of leukoplakia ranges from 0.6% to 4.6%. It is most common in men of middle and older age. Cancer will develop from leukoplakia in 1%–20% of cases. The main activators of cancerization are exogenous factors such as smoking, alcohol, human papillomavirus, or chewing betel. According to clinical studies, the most common site of malignant transformation of leukoplakia is the oral cavity floor.
Oral lichen planus is immune-mediated inflammatory mucocutaneous disease which occurs in adults, more frequently in females. It occurs in three basic forms (lichen ruber planus, erosivus, and bulosus), and it is classified by its appearance as either reticular, annular, nodular, atrophic, or sclerosus. Premalignant potential of this disease is from 0.4% to 3.3%, particularly for erosive lichen.
Actinic cheilitis is a PML caused by exposure to sunlight. It affects males more often than females, and the most common localization is the lower lip. Off-white or red changes may be ulcerated. It is estimated that the rate of malignant alteration ranges from 1.4% to 36%.
From the above, it was concluded that there may be PMLs in the oral mucosa that can turn malignant, and early diagnosis of PML is of great importance in cancer prevention and early-stage cancer detection. If cancer is detected in the initial stage, the potential for remission is 80%.
In a study done by Arpita et al., it has brought to light a disturbing aspect that though all the study subjects in this study had high-risk behavior, only a handful recognized that their adverse habit could lead to OPMD. Tobacco use and alcohol consumption were appreciated as risk factors for oral cancer by 77% and 60% of the subjects, which was an encouraging finding, but only 14% and 8.6% were aware of these as high-risk behaviors for OPMD. Among those who were aware of OPMD, not even half appreciated their lifestyle could lead to the development of OPMD. The awareness of other risk factors such as poor oral hygiene, actinic radiation, viral infections, and micronutrient deficiency was very low. Formosa et al. have reported that 92% of their study respondents agreed or strongly agreed that smoking is a strong risk factor for oral cancer, followed by tobacco chewing (84%), tobacco chewing with areca nut (68%), chewing areca nut alone (51%), and exposure to actinic radiation (71%) as risk factors. However, the results for alcohol intake, age, and HPV infection were found to be relatively poor with proportions 33%, 34%, and 23%, respectively. In the study by Elango et al., 77% of the subjects identified smoking, 64% alcohol, and 79% pan chewing as a cause of oral cancer. Ariyawardana et al. reported that 80.7%, 47%, and 17% were aware of links with tobacco smoking and alcohol consumption, respectively. Results similar to our study were reported by Amarasinghe et al. where majority of alcohol consumers and smokers and about half of the betel quid chewers surveyed were unaware of the risks conferred by their lifestyles. Pai et al. reported that smokers and past users of tobacco were found to be more aware of effects of tobacco on oral and general health as compared to smokeless and current users, but awareness about OPMD remained low in their study as well. This situation calls for specific intervention. There is a need for not only increasing awareness regarding OPMD and its presentation in the oral cavity, but the association between adverse lifestyle and increased risk of developing OPMD needs to be stressed. In addition, information needs to be focused on making the tobacco and alcohol users aware of the synergistic potential of these high-risk behaviors leading to the development of oral cancer and OPMD. For the small number of tobacco and alcohol users who were aware of OPMD as well as its causal relationship with their adverse lifestyle, it is understood that other factors must be reinforcing continued use. Further investigations have to be carried out to find out the reasons behind the continued practice of high-risk habits, despite knowledge. For this subset, specific counseling is necessary.
In a survey done among dental patients in Queensland, Australia, almost all of the participants were with secondary school education (44.7%). However, in this study, majority of the participants are undergraduate individuals (38%). In the present study, we did not observe any significant differences in the level of knowledge between genders and age groups. This suggests that the education level is the most important variable influencing level of knowledge. Therefore, improving the knowledge of people, especially those with low education, is particularly important.
In a study done by Jayasinghe et al., identification of alcohol as a potential risk for oral carcinogenesis was low (47.8%). In contrast to the published literature, where the identification of alcohol as a risk factor is high among dental students in this study, only 43.4% of dental students in this study identified it correctly, whereas among medical students, it was higher (49.3%). This shows the importance of emphasizing the role of alcohol in causation of oral cancer in teaching curricula. Even though they had a good knowledge of some OPMDs, oral erythroplakia as an OPMD was identified correctly only by 18.3% of the respondents. Low awareness of erythroplakia as an OPMD has been reported by others as well. Only 11% knew the overall 5-year survival rate of oral cancer. Knowledge of OPMD and oral cancer among the participants was not satisfactory, and only 10.7% of the respondents had good knowledge of OPMD and oral cancer, and in 12.5%, it was very poor. Similar to the literature from other countries, dental students, especially students in the final year, had a significantly better knowledge (P < 0.05). About 80% of the medical students had not examined an OPMD or a single oral cancer. A significant number of medical and dental students who have completed clinical training believe that they do not have sufficient knowledge on prevention and detection of OPMD and oral cancer. In a country where OPMD and oral cancers are common, this emphasizes the need for a change in the medical curriculum to incorporate this important area.
Ariyawardana and Vithanaarachchi reported in their hospital-based study that over 90% were aware of oral cancer and the figure for PMD was 45%. Higher prevalence of oral cancer in that population and the displayed oral cancer education material, such as posters and pamphlets in public hospitals, into which the general public has free access, may be contributory for this high level of awareness.
Amarainghe et al. reported comparable results for awareness of oral and pharyngeal cancer in their community-based study in rural Sri Lanka. However, this study reported a significantly low level (23.0%) of public awareness of oral cancer in the U. K. The study reported in comparison to lung cancer of which the awareness was 97%, whereas only 56% of the participants of the survey were aware of oral cancer. Relatively low prevalence of oral cancer may have contributed to the result. Knowledge of the risk factors among the general public is one of the most important parameters for efficacious prevention of OC in the community. In the study, it was found that 48.2% of the respondents were able to identify pan chewing as a strong risk factor, while 46.8% identified cigarette smoking as a risk factor. Contrary to this, Park et al. in their study based in Western Australia found that only 42 and 5% of patients were able to identify tobacco and alcohol, respectively, as risk factors for OC. The present study found the level of education, the most significant sociodemographic factor affecting patients' risk factor knowledge; participants educated till undergraduate level or higher displayed an overall lesser level of awareness of OC and OPMDs (42%) through television, newspaper (37%), dentist (22%), and others (21%).
According to the statistics, in 2012, the incidence of oral cancer in India is 53,842 in males and 23,161 in females. Considering the gender in all the age groups, men are more affected than women. In India, men are two to four times more affected than women due to the changes in the behavior and lifestyle patterns and a study shows that the participants were aware that men (59%) are commonly affected by PMD than women (41%). Detection of oral PMDs at an early stage, especially in high-risk groups, is of utmost importance to prevent further morbidity as they have shown a rate of progression and cancer transformation of up to 17% within a mean period of 7 years after diagnosis. The highest transformation rate is seen in heterogenous erythroplakia and erythroleukoplakia with dysplastic changes. In this study, the participants felt that quitting habits (39%) and regular screening of oral cavity for PMDs (15%) can help us to prevent PMDs.
| Conclusion|| |
According to this survey, awareness of oral PMDs was low among patients. It was found that television and Internet had played a significant role in patients who were aware of oral precancerous conditions. PMD is asymptomatic at early stages, and hence, the affected individuals do not seek treatment. Therefore, knowledge of the clinical signs and symptoms of OC is of utmost importance.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]