ABSTRACT
Introduction:
In developing countries, oral cancer (OC) is estimated to be the third most common malignancy after cancer of the cervix and stomach. The aim of this study was to report the prevalence of OC for 3 years and its association with age, gender, type, and duration of habits along with the site of OC.
Materials and Methods:
This study was conducted in the Department of Oral Medicine and Radiology from January 2019 to December 2021. All the patients were examined after recording their demographic data using a mouth mirror and probe. The diagnosis of OC was arrived based on the clinical features of the lesions. The type and duration of habits and site were recorded in clinical pro forma. The Statistical Package for the Social Sciences (SPSS) software version 21.0 was used for the statistical analysis, the Chi-square test was applied, and the significance level was set at P < 0.05.
Results:
The prevalence of OC was 0.22% in our study. Of 317 cases, the majority of the patients were males (n = 204), and females (n = 113) accounted for a male: female ratio of 2:1. The most common age affected was 51–70 years with a history of tobacco chewing, followed by patients with multiple habits (smokers, tobacco chewers, and alcoholic). The buccal mucosa was the most common site followed by malignancies of multiple sites.
Conclusion:
Regular camps regarding tobacco cessation and counseling should be taken care of by dentists. Male patients aged above 40 years are routinely recommended for dental visits.
KEYWORDS: Alveolus, buccal mucosa, floor of the mouth, oral cancer, tobacco, tongue
INTRODUCTION
In developing nations such as southeast Asia, head-and-neck cancers are common. Oral cancer (OC) is the most common of all head-and-neck malignancies. It is a major public health problem in the Indian subcontinent. OC is a broad term that includes various malignant diseases that are present in oral tissues involving the lip, floor of the mouth, buccal mucosa, gingiva, palate, or tongue. The majority (84%–97%) of OCs are squamous cell carcinoma which arises from preexisting “potentially malignant disorders.”[1]
Numerous predisposing factors such as tobacco (smoking and smokeless form), alcohol such as rum, beer, and wine, viruses such as Epstein–Bar virus, Human papillomavirus, dietary factors such as deficiency of Vitamin A, C, and E, spicy food, sharp teeth, and genetic factors contribute to the development of OC. These patients usually present with a history of pain, swelling, reduced mouth opening, and difficulty in eating or drinking. Clinically, the lesion appears as proliferative, infiltrative, or ulcerative growth. The most common sites involved are buccal mucosa, alveolus, lip, and palate.[2]
There is a high prevalence of OC in Asian countries, especially in South and Southeast Asia since these people use varying patterns of tobacco chewing, alcohol, and consumption of spicy foods. Hence, epidemiological studies across India regarding the prevalence of OC with its association with etiological factors are beneficial for the early treatment of patients.
Aim and objectives of the study
The aim and objectives of the study were to assess the prevalence of OC and its association with age, gender, type, and duration of habits along with the site of OC.
MATERIALS AND METHODS
A prospective cross-sectional study was conducted in the Western Maharashtra Population of India. A study was carried out for 3 years from January 2019 to December 2021 in the Department of Oral Medicine and Radiology, School of Dental Sciences, Karad, Maharashtra, India. The ethical clearance was obtained from the ethical committee of Krishna Institute of Medical Sciences, Deemed to be university, Karad (KIMSDU/IEC/03/2019) before commencing the study. The rationale of the study was explained to all the patients in their local language (Marathi), and informed consent was obtained before enrolling the patients in the study.
All the patients reported to the department of oral medicine and radiology were enrolled in the study. The demographic data were recorded in clinical pro forma, and a clinical examination was conducted using a mouth mirror and probe. The diagnosis of OC was made based on the clinical presentation of the lesions. The patients diagnosed with OC were recorded with a detailed history of type and duration of habits such as tobacco chewing, smoking, and alcohol and consumption of spicy food along with their duration in clinical pro forma. The prevalence of OC was assessed by determining the percentage of the study population affected.
Statistical analysis
The data recorded were entered into a Microsoft Excel sheet and subjected to statistical analysis. The analysis was done to find out the prevalence of OC and its association with different types of habits. The Statistical Package for the Social Sciences (SPSS) software version 21.0 (version 21.0, Inc., and Chicago, IL, USA) was used for the statistical analysis, the Chi-square test was applied, and the significance level was set at P < 0.05.
RESULTS
A total of 141,752 patients were reported for 3 years, of which only 317 patients were diagnosed with OC with a prevalence rate of 0.22%.
Table 1 shows the age- and gender-wise distribution of OC patients. There were 204 males (64.3%) and 113 females (35.7%), with a male-to-female ratio of 2:1. The patients were divided into a total of five groups according to their age. There were more patients in the age group of 51–60 years (n = 106) and 61–70 years (n = 105), followed by 41–50 years and 31–40 years. The least common age group affected was patients aged above 71 years (n = 18). Age-wise distribution does not show any statistically significant differences (P > 0.731).
Table 1.
Age- and gender-wise distribution of oral cancer patients
| Age (years) | Number of male patients (%) | Number of female patients (%) | Total | χ2, P |
|---|---|---|---|---|
| 31–40 | 17 (68) | 8 (32) | 25 | 2.024, >0.731 |
| 41–50 | 43 (68.3) | 20 (31.7) | 63 | |
| 51–60 | 70 (66) | 36 (34) | 106 | |
| 61–70 | 62 (59) | 43 (41) | 105 | |
| 71 and above | 12 (66.7) | 6 (33.3) | 18 | |
| Total | 204 | 113 | 317 |
Table 2 shows the association of different habits with OC patients. The majority of patients in our study were chewing different forms of tobacco in our study which accounted for 132 cases totally, of which 53% were male and 47% were female. The second most common group associated with OC was the patients with multiple habits such as tobacco chewers, alcohol, and smoking which accounted for a total of 85 cases, of which 71.8% were males and 28.2% were females. The least common group affected in our study was patients with no habits (n = 5). The association of tobacco chewing in OC was statistically significant in our study (P < 0.001).
Table 2.
Gender-wise distribution of oral cancer patients with habits
| Habits | Number of males (%) | Number of females (%) | Total number of patients | χ2, P |
|---|---|---|---|---|
| Tobacco chewing products only | 70 (53) | 62 (47) | 132 | 24.535, <0.001 |
| Smoking | 35 (85.4) | 6 (14.6) | 41 | |
| Alcoholic | 28 (77.8) | 8 (22.2) | 36 | |
| Combination of tobacco chewing, smoking, and alcoholic | 61 (71.8) | 24 (28.2) | 85 | |
| Consumption of spicy food | 8 (44.4) | 10 (55.6) | 18 | |
| No habits of smoking, tobacco chewing/alcohol | 2 (40) | 3 (60) | 5 | |
| Total | 204 | 113 | 317 |
Table 3 shows the distribution of OC patients according to the duration of their habits. A comparison of the duration of habits in OC patients showed patients with the duration of habits between 15 and 20 years were more affected, followed by patients with the duration of habits more than 20 years and more than 10–15 years with no statistically significant differences. The least common group affected was patients with the duration of habits < 5 years.
Table 3.
Association of the duration of habits with oral cancer
| Duration of habits (years) | Number of males (%) | Number of females (%) | Total |
|---|---|---|---|
| <5 | 8 (58.3) | 5 (41.7) | 13 |
| 5–10 | 20 (71.4) | 8 (28.6) | 28 |
| 10–15 | 34 (67.3) | 17 (32.7) | 51 |
| 15–20 | 92 (63.9) | 52 (36.1) | 144 |
| >20 | 50 (61.7) | 31 (38.3) | 81 |
| Total | 204 | 113 | 317 |
Table 4 depicts the site-wise distribution of patients with OC. Figures 1 and 2 show buccal mucosa as the most common site which accounted for a total of 108 cases. In males, buccal mucosa site accounted for 61.9%, and in females, it accounted for 38.1%. The second most common site for OC was patients with multiple sites of malignancy accounted for 73 cases, followed by alveolar mucosa, tongue, labial mucosa, and floor of the mouth. The least common site affected was the retro commisure area (n = 3). The site-wise distribution of OC was not statistically significant (P > 0.783).
Table 4.
Site-wise distribution of patients with oral cancer
| Site of malignancy | Number of males (%) | Number of females (%) | Total | χ2, P |
|---|---|---|---|---|
| Buccal mucosa | 65 (61.9) | 40 (38.1) | 108 | 3.969, >0.783 |
| Labial mucosa | 20 (58.8) | 14 (41.2) | 29 | |
| Alveolar mucosa | 33 (71.7) | 13 (28.3) | 51 | |
| Tongue | 15 (75) | 5 (25) | 50 | |
| Floor of mouth | 20 (71.4) | 8 (28.6) | 28 | |
| Palate | 5 (62.5) | 3 (37.5) | 8 | |
| Retrocommisure area | 2 (66.7) | 1 (33.3) | 3 | |
| Malignancy involving multiple sites (buccal mucosa, alveolar mucosa, tongue, and floor of mouth) | 44 (60.3) | 29 (39.7) | 73 | |
| Total | 204 | 113 | 317 |
Figure 1.
Intraoral photograph showing oral cancer of left buccal mucosa and retrocommisural area
Figure 2.
Intraoral photograph showing oral cancer of lower right alveolus
Clinical features of oral cancer
In our study group of patients, there were more patients with proliferative lesions accounting for 147, ulcerative lesions accounted for 90, and infiltrative types of lesions accounted for 80.
DISCUSSION
OC is an important health issue in India as it is one of the most common types of cancer affecting a large population. The low-income population is at the highest risk due to extensive exposure to various risk factors.[3] Tobacco consumption has been the predominant factor in causing OC. The various forms of tobacco such as gutka, zarda, mawa, kharra, khaini, cigarettes, beedi, and hookah are major causes of OC.[4]
The prevalence of OC was 0.22% in the present study. The results were in accordance with our previous retrospective study conducted in the Western population of Maharashtra,[2] whereas higher prevalence was seen in a previous study.[5] Other studies conducted in Kerala reported the lowest incidence and West Bengal reported the highest incidence of OC.[6,7]
Worldwide, the majority of the studies showed male predominance for OC when compared to females. In our study, the male-to-female ratio was 2:1. The results of our study were in accordance with previous studies.[8-10]
Age is considered an important predictive factor in cancers. In the present study, most of our patients were in an age group between 51 and 70 years which accounted for 66.5%. The results were slightly higher than the Sahu and Kumar study conducted in the north Indian population which showed 51.5% of patients in the age group between 51 and 70 years.[11] The other previous studies conducted showed that the most common age affected by OC was 41–50 years.[12,13]
The International Agency for Research on Cancer has classified Tobacco as a Group I carcinogen. In India, there are different types of tobacco products available which are classified according to the constituents, method of processing, and mode of use. The two main forms include smoking tobacco (combustible) and smokeless tobacco (noncombustible). In India, smoked tobacco products are made from Nicotiana tabacum, and smokeless tobacco products are made from Nicotiana rustica with or without N. tabacum.[14] Both of these types are responsible for causing OC.
The association of different habits with OC showed tobacco chewing as a prime factor involved in the pathogenesis of OC. In our study, the majority of patients were using a smokeless form of tobacco products (n = 132), which accounted for 53% in males and 47% in females. The previous studies conducted also showed chewing tobacco as the main etiological factor in the development of OC.[11] The study conducted by Muwonge et al. also showed tobacco chewing as a prime factor in the pathogenesis of OC.[15] The second most common habit associated with OC was patients with multiple habits such as tobacco chewing, smoking, and the use of alcohol. The results were in accordance with previous studies.[15] The habit of tobacco smoking and the use of smokeless forms of tobacco such as mishri, gutka, and pan have been identified as the main risk factors for OC in the Southeast Asian population.[16,17]
The duration of habits plays an important role in the development of OC since it is the result of a multistage process from normal to dysplastic lesions and ultimately to OC. In the present study, patients with the duration of habits more than 15–20 years were more affected followed by habits with the duration of more than 20 years and more than 10–15 years. These findings suggest that patients with more duration of habits constitute a major role in the development of OC.
The site of OC depends on the type of habits; in the case of patients using the smokeless form of tobacco products usually keep the quid in the vestibular region of the anterior or posterior maxilla or mandible. The carcinogens enter and affect vestibule, alveolar mucosa, and buccal mucosa most commonly. In the case of patients with a history of smoking habits, tongue is the most common site affected. The buccal mucosa was the most common site affected by OC in our study constituting 61.9% in males and 38.1% in females. The results were in accordance with other studies conducted on the north and south Indian populations.[11,18,19] A retrospective study conducted regarding trends of OC with age, gender, and subside over 16 years at a tertiary cancer center in India showed buccal mucosa and tongue cancer more than 4 yearly for 16 years from 1996 to 2004.[20] The other studies conducted in India showed the tongue as the most common site followed by buccal mucosa.[21]
CONCLUSION
The understanding of various epidemiological characteristics and awareness of various risk factors of OC is essential for society in controlling OC. All the patients reporting to medical hospitals should be enlightened on the effects of tobacco and alcohol by showing charts or photographs or available online videos. Based on the results of our study, there was an increase in buccal mucosa cancers than that palatal and retrocommissural cancer. The proportion of males with respect to females presenting with these cancers has increased with the habit of tobacco chewing in an age group between 51 and 70 years.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We would like to thank all the patients for their participation in the study. Furthermore, we would like to thank the school of dental sciences and Krishna Institute of Medical Sciences for their immense support.
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