Unveiling Mysteries of Quid-Induced Lichenoid Reactions: A Cross-Sectional Study

ABSTRACT

Lichenoid reactions occur exclusively in people who chew tobacco, areca nut, or both, in raw or any manufactured or processed form. The lesion is described as a lichen-planus–like lesion and is termed as quid-induced lichenoid reaction (QILR). In this cross-sectional study, amongst 935 quid consumers, 82 patients were diagnosed with QILR and it was seen that 65 patients used processed forms of tobacco and areca nut. Thereby, it could be concluded that QILR might occur because of flavors used in processing of tobacco and areca nut.

INTRODUCTION

Quid-induced lichenoid reactions (QILR) are often witnessed at sites of quid placement. They are commonly considered to be type IV contact hypersensitivity-type lesions with a clinical resemblance to oral lichen planus (OLP).[1] In 1980, Daftary et al.[2] described that QILR appeared to have white, linear, wavy, parallel, non-elevated streaks, or striae that could not be scraped off. The striae sometimes could radiate from a central erythematous area. These fine white lines did not overlap or crisscross as observed in classical OLP.[2,3,4] The mechanism of QILR has not been identified. Hence, this study had been conducted aiming to determine whether tobacco and areca nut in processed or unprocessed forms had been an etiological factor in the occurrence of QILR.

MATERIALS AND METHODS

All the subjects that had been reported to the Department of Oral Medicine Radiology and Diagnosis in a dental college, Jodhpur located in Western Rajasthan were screened for a period of 1 year after obtaining written consent from the patients. Amongst them, 935 quid users (using processed, unprocessed, and both processed and unprocessed forms of tobacco and areca nut was identified and included in the study). Subjects were categorized into three groups according to the contents of quid: Group I, quid with areca nut but without any tobacco products; Group II, quid with tobacco products but without areca nut; and Group III, quid with both areca nut and tobacco products. Subjects were further categorized into three subgroups according to the different forms of quid usage: Group A, unprocessed forms of quid; Group B, processed forms of quid; and Group C, both processed and unprocessed forms of quid. Patients who have discontinued the habit for 2 years or more, patients known to having other deleterious habits like smoking, alcohol, drug addiction, or other drugs, patients with amalgam or composite restoration, metallic crowns, any history of grafts placement, and treatment undertaken for any oral mucosal lesion had been excluded from the study. Clinical photograph of the lesion is shown in Figure 1.

Figure 1.

QILR and lichenoid dysplasia

RESULTS

In the present study, amongst 935 quid users, 82 subjects had developed QILR amongst which 69 males and 13 females were reported belonging to different age groups and had been using quid in different forms as shown in Figure 2.

Figure 2.

Chi-square test showing occurrence of QILR in subjects using different contents and forms of quid

Statistical analysis

Statistical analysis was carried out using the Pearson Chi-square Test to determine the association, if any, between quid usage and occurrence of the lesion.

DISCUSSION

Amongst 935 quid users, 82 subjects had developed QILR suggesting the prevalence of being 8.1%. Results of our study were found to be much higher than that observed by Daftary et al.,[2] Arya S[3] et al^., and Dang and Nagpal,[4] wherein prevalence was reported to be (0.7%.), (9.5)%, and (5.9%), respectively. This could be explained on the basis of regional variability in the availability, preparation, and usage of the quid. QILR developed mostly in subjects with Group III, wherein 14% used both areca nut and tobacco. In addition, 20% consumers belonged to Group B, thereby suggesting that usage of processed forms of quid caused more QILR as compared to subjects who consumed unprocessed and both processed and unprocessed forms of quid.

Out of 15 biopsies performed, in 3 cases lichenoid dysplasia has been reported as shown in Figure 1. Eisenberg and Krutchkoff described such lesions that showed lichenoid features along with dysplastic features.[5] Numerous studies have disclosed the fact that most of the previously reported cases of malignant transformation were either a Lichenoid Lesion or LD misdiagnosed as lichen planus.[6,7]

Possible mechanisms might be explained on the basis that quid usage containing both tobacco and areca nut could cause dehydration of oral mucosa, thereby accelerating the systemic absorption of metabolites of tobacco and areca nut and thereby triggering the occurrence of potentially malignant oral mucosal disorders. During processing and curing of tobacco and areca nut due to boiling as well as sun-drying, there would be an increase in concentration of tobacco and areca nut that could have been a variable in causing prolonged contact with mucosa, thereby leading to the development of QILR.[3] It has been evident in literature that after processing, moisture content of nicotine gets reduced up to 50% which is released more rapidly from the fine cut form due to the greater surface area or due to significant addition of flavoring agents like menthols, cinnamon, and preservatives like condiments and spices in processed packets could be a potential cause for the occurrence of QILR.[3,8,9] Betel nut ingredient such as arecoline content has been observed to be reduced variably following processing of the nut by different methods in different regions of the world. The alkaloids might be converted into various derivatives, each of which could potentially make even more diazohydroxide derivatives. Furthermore, areca nut has been reported to contain sodium, magnesium, chlorine calcium, vanadium, manganese, copper, and bromine. Sharan et al.[10] reported that the copper content of processed areca nut was found to be 2.5 times that of the raw, thereby suggesting the role of betel nut constituents causing type IV hypersensitivity reactions like that of QILR. Exact component associated and the mechanism involved in the occurrence of QILR is still not available in the literature and the research is going on regarding unveiling this mysterious lesion.

CONCLUSION

Thereby, the occurrence of QILR could be explained either on the basis of synergistic interaction of both tobacco and areca nut or the presence of flavoring agents or preservatives in them or due to the increase in concentration of carcinogens during processing. Further studies should be conducted with larger sample size comparing population residing in extreme climatic conditions such as coastal with hot and dry to inculcate more evidence in its occurrence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.