|Year : 2014 | Volume
| Issue : 1 | Page : 23-27
Prevalence of precancerous lesions and conditions in Telangana region, Andhra Pradesh, India
B Hari Vinay1, P Venkat Baghirath1, J Vijay Kumar1, Arvind2
1 Department of Oral and Maxillofacial Pathology, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
2 Department of Oral and Maxillofacial Surgery, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
|Date of Web Publication||18-Aug-2014|
B Hari Vinay
46/19 7, Sattar Colony, Kadapa 516 003, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Aim: To assess the prevalence of oral precancerous lesions and conditions and to determine the potential risk factors associated among general population aged 20-70 years of Telangana region, Andhra Pradesh. Materials and Methods: An oral screening campaign was organized with the help of local general dental practitioners in each district. All the relevant information regarding the subject was documented and clinical examination of the oral soft tissues was carried out. Clinically diagnosed as precancerous lesion or condition were subjected to punch (incisional biopsy) biopsy and evaluated histopathologically to confirm the diagnosis. Results: Among 1200 screened, 150 subjects were chewers and 136 subjects were smokers with 29 chewers and 16 smokers had precancerous lesions and conditions. An overall prevalence of oral precancerous lesions and conditions were found to be 4.2% (males 5.5%; females 2.5%). Leukoplakia was seen in 0.8%, Oral submucous fibrosis in 1.3% and lichen planus in 2% of the study population. Conclusions: The prevalence of precancerous lesions and conditions in our study is higher when compared with the reports from different parts of the country and in South East Asia. These lesions can be prevented from malignant transformation by mass screening, close monitoring, early detection, appropriate treatment plan and prognosis.
Keywords: Leukoplakia, lichen planus, oral submucous fibrosis
|How to cite this article:|
Vinay B H, Baghirath P V, Kumar J V, Arvind. Prevalence of precancerous lesions and conditions in Telangana region, Andhra Pradesh, India. J Indian Assoc Public Health Dent 2014;12:23-7
| Introduction|| |
Oral cancer is the sixth most common cancer worldwide. According to the International Agency for Research on Cancer, in the year 2000 there were 266,000 intraoral cancers reported and majority occurring in males (64%). The estimated numbers of deaths from oral cancer in the same year were nearly 128,000.  In the Indian subcontinents, the prevalence of oral cancer is the second highest among all cancers in men and is estimated that 100,000 more new cases are being detected annually and 90% of all oral malignancies are oral squamous cell carcinomas. 
In addition to increasing incidence, the mortality remains high with over 50% of patients dying of this disease every year. The simple fact is that over 60% of all patients present with late lesions when already the prognosis is proved very poor and metastatic spread has already occurred. It is estimated that around 43% of cancer deaths are due to tobacco use, alcohol consumption, unhealthy diets, inactive lifestyles and infections. Of these, tobacco is the world's most avoidable cause of cancer. 
To decrease the high mortality and morbidity associated with this cancer, one way forward is to improve early detection of oral cancer either by case finding or by organized screening programs.  It has been well established by researchers that virtually all oral cancers are preceded by visible changes in the oral mucosa, usually in the form of white, red, or red and white patches. Lack of public awareness about these signs, symptoms and risk factors are believed to be responsible for the diagnostic delay in identifying these potentially malignant disorders. The risk factors including tobacco smoking and chewing, the common social habits in India, have been positively associated with oral lesions such as oral erythroplakia, oral submucous fibrosis (OSMF), oral leukoplakia, and oral lichen planus (OLP), which have potential for malignant transformation. 
Clinically for a precancerous lesion or condition to be considered, World Health Organization (WHO) suggested a definition for a precancerous lesion as "a morphologically altered tissue in which oral cancer is more likely to occur than its apparently normal counterpart" and the precancerous condition as "a generalized state associated with significantly increased risk of cancer."  Later in 2005, to avoid the confusion between the terminologies WHO workshop recommended to abandon the distinction between the precancerous lesions and conditions and to use instead the term "potentially malignant disorders." 
There are already indications in India of an increased occurrence of oral precancerous lesions and conditions due to change in life style. There is a steep rise in smoking and chewing habits and this is likely to reach an alarming proportion in the near future. This implies that oral cancer occurrence would also increase simultaneously.  The malignant transformation rate of most of the precancerous lesions and conditions are high. Through mass screening, close monitoring, early detection, appropriate treatment plan and prognosis these lesions can be prevented from malignant transformation. Hence, the present study was undertaken to assess the prevalence of oral precancerous lesions and conditions and also determine the potential risk factors among general population aged 20-70 years of Telangana region, Andhra Pradesh.
| Materials and Methods|| |
Study design and setting
A cross-sectional descriptive epidemiological study on prevalence of precancerous lesions and conditions was carried out among the general population residing in Telangana region. Telangana has a total population of 35,286,757 (2011 census), which is 41.6% of Andhra Pradesh state population.  Permanent residents, aged 20-70 years with no gender discrimination and without any previous history of treatment for any type of oral diseases and having the habit for at least a year or more were selected for screening. Subjects with previous history of hospitalization for any systemic illness, immuno-compromised patients, and patients with recurrence of the primary lesions and multiple oral and/or head and neck lesions were excluded.
Our research was conducted in full accordance with the world medical association declaration of Helsinki. The study protocol was reviewed and approved by the Institutional Ethical Committee. Written informed consent was obtained from all the study participants after explaining the nature and purpose of research.
Sampling design and study population
Based on the prevalence obtained in the earlier studies, 95% confidence level and 10% allowable error, the sample size was determined as 1171 which was rounded off to 1200. The study was conducted during August to October 2012 and the sample were selected by a multistage stratified random sampling procedure. Telangana region consisting of 10 districts was divided geographically into five areas; North-East, North-West, South-East, South-West and Central. In the first stage, 2 districts were randomly selected from each geographic area. List of all the blocks from the 2 selected districts was obtained from Census Enumeration Areas Data. In the second stage, 3 blocks were selected randomly from each ward. In the third stage, door to door survey was conducted and around 120 individuals, aged 20-70 years were interviewed and examined from each block. A total of 1293 subjects were approached to participate in the study, but 93 declined citing a variety of reasons (response rate 92.8%).
On an average 15-20 subjects were interviewed and examined per day. Single investigator who was trained and calibrated performed all oral examinations (k = 0.90). Smokers/tobacco chewers included the current smokers/chewers. Persons chewing at least one pouch of tobacco a day since at least 1-year were defined as tobacco chewers.  Individuals smoking at least one cigarette a day since at least the past 12-months were defined as smokers. 
The clinical diagnosis of the precancerous lesions and conditions were done as per the WHO (1997) criteria.  All the relevant information regarding the subject was documented in a standard format and clinical examination of the oral soft tissues was carried out. Punch (incisional) biopsy was performed for confirmation among the subjects who were clinically diagnosed of precancerous lesion or conditions. The tissue specimen was stored in 10% formalin and routine tissue processing was done in the histopathology laboratory, Department of Oral and Maxillofacial Pathology, Panineeya Mahavidyalaya Institute of Dental Sciences, Hyderabad and stained with hematoxylin and eosin. The stained soft tissue section was then observed under binocular light microscope (OLYMPUS CH 20i olympus India pvt. Ltd, New delhi) and a thorough histopathological evaluation of the stained sections were done. Cases confirmed through histological examination were only considered as positive and included in the analysis.
The recorded data were compiled and entered in a spreadsheet computer program (Microsoft Excel 2007) and then exported to data editor of SPSS version 15.0 (SPSS Inc., Chicago, Illinois, USA). The variables were assessed for normality using the Kolmogorov-Smirnov test. Descriptive statistics included computation of percentages, means and standard deviations. Chi-square test and logistic regression analysis were used for comparisons. Multivariate analysis was used to assess the relative importance of independent variables and to identify the main variables influencing precancerous lesions and conditions. Statistical significance was set at P ≤ 0.05.
| Results|| |
The study group consisted of 1200 subjects, 674 (56.2) males and 526 (43.8) females and were divided into 10 year interval age groups 20-29, 30-39, 40-49, 50-59, 60 years and above. The maximum subjects (33.9%) were under 30-39 years and the minimum number of subjects (4%) was in 60 years and above age group [Table 1]. An overall prevalence of precancerous lesions and conditions was 4.2%, which was significantly higher among males (5.5%) when compared to females (2.5%) (P = 0.00943). Prevalence according to gender was leukoplakia 0.8%, OSMF 1.3% and lichen planus 2%. The OSMF was not found in females and lichen planus showed equal distribution [Table 2].
|Table 2: Prevalence of oral precancerous lesion and condition in relation to gender |
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The total number of chewers and smokers were 150 and 136 respectively out of 1200 subjects. Out of 150 tobacco chewers, 29 (12.5%) subjects had precancerous lesions and conditions and OSMF was the most prevalent precancerous condition (P = 0.000). Out of 136 smokers, 16 (11.3%) subjects had precancerous lesions and conditions and leukoplakia was the most commonly found precancerous lesion (P = 0.000) [Table 3].
Logistic regression was performed in order to assess whether chewing and smoking tobacco was associated with oral precancerous lesions and conditions [[Table 4] and [Table 5]]. Based on the analysis a statistically significant association with oral precancerous lesions and conditions with the duration of both chewing and smoking tobacco (P < 0.05) was observed.
|Table 3: Prevalence of oral precancerous lesions and conditions in relation to chewing and smoking habit |
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|Table 4: Effects of chewing and smoking on oral precancerous lesions and conditions by logistic regression analysis |
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|Table 5: Effects of duration of chewing and smoking on oral precancerous lesions and conditions by logistic regression analysis |
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| Discussion|| |
It is widely understood that neither do all precancerous lesions progress to cancer nor all cancers necessarily originate from such lesions, but it has been proved that the majority of these lesions and conditions progress to cancer unless diagnosed early and treated. In our study the overall prevalence of precancerous lesions and conditions were 4.2% which is almost similar to the studies done by Warnakulasuriya et al., in the year 1984 (4.2%),  Rao et al., in 1998  (3.98%), and Lim et al., in 2003  (4.2%). In contrast, our prevalence of lesions and conditions were much higher when compared with the study done by Bhonsle et al., in 1976  (1.78%), suggesting that there is a slight regional variation in occurrence of the disease.
Few research workers in the past have included different age groups ranging from 35 years and above by Lim et al., in 2003  followed by 13 years and above by Saraswathi et al. in 2006.  However, our study included the population with a mean age group of the previously mentioned authors by selecting 20 years and above age group which was similar to Pindborg. 
The general agreement has been that OSMF occur usually between third and fifth decade of life.  In a study by Murti et al.  maximum numbers of subjects were from 35 to 44 years and 45-54 years age group, but in our study the maximum number were in third decade, which is similar to the study by Hazarey et al.  This may imply that apart from habits, stress also plays a major role in occurrence of OLP.
Considering the individual lesions in our study, first, leukoplakia showed an overall 0.8% prevalence, which was almost similar to the studies done by Saraswathi et al., in 2006  (0.6%), but in contrast to a study by Bhonsle et al., at Goa in 1976  (1.6%), which could be due to a variation of habits between the study groups. Second, prevalence of OSMF in our study is significantly higher than the other studies, done by Pindborg et al., at Lucknow (0.5%), and Trivandrum in 1965  (0.9%),  and Saraswathi et al., at Chennai in 2006  (0.55%). This could be due to an increase in the popularity of commercially available tobacco products over a period of time. Finally, the prevalence of lichen planus is 2% in our study, which is higher in contrast to the studies done by Lay et al., at Bilugyum in 1982  (0.4%), Saraswathi et al., at Chennai in 2006  (0.15%), which could be due to the change in life style and increased stress level of the individuals.
An assessment of lesions and conditions gender-wise was done in our study and we found leukoplakia in 10 subjects (0.83%) out of which 9 were males and 1 was female showing overwhelming predominance in men, which is similar to several studies. , The prevalence of OSMF in our study was 16 subjects (1.33%) and it was exclusively seen in males which was similar to some of the studies done by Shah and Sharma in 1998  and Hazarey et al., in 2007  and in contrast to the study by Bhonsle in 1976  who had seen only in females. Perhaps this difference is due to the habit of chewing, is increasing day by day in both the genders where males have the habit of chewing commercial products, which are mixed with both tobacco and arecanut, and females have the habit of chewing only arecanut. Lichen planus in our study was seen in 24 subjects (2%) with an equal distribution of 12 each in both the sexes, which is similar to the study by Bhonsle et al., in 1976  and Murti et al., in 1986. 
The observations in the present study clearly indicate that both chewing and smoking habit has a predominant role in the occurrence of precancerous lesions and conditions. Several studies have emphasized that tobacco in various forms such as chewing, smoking cigarettes and beedis as an important etiologic factor in the development of leukoplakia. ,, In our study, all the leukoplakia cases had tobacco chewing, smoking, or both the habit in one or the other form. In our study, all the OSMF cases had chewing habit, and this clearly indicates that commercial product gutkha played a major role in OSMF, and our result is similar to Hazarey et al., in 2007  and Bathi et al., in 2009.  Half of the cases with lichen planus reported with habits, while the other half were without any habit, which suggests that habits does not necessarily play a role in the etiopathogenesis of lichen planus, which is in line with the studies done by Murti et al., in 1986,  Lim et al., in 2003  and Saraswathi et al., in 2006. 
Ideally substantiation of the etiological role of tobacco should be sought from population-based cross-sectional, prospective, and intervention studies. Cross-sectional studies provide evidence in the form of prevalence rates of leukoplakia among people with and without tobacco habits as well as the influence of different kinds of habits. New concepts and better understanding of this precancerous lesions and conditions would be a gain for the successive studies and we consider our study one among those genuine efforts in this direction.
The widely prevalent arecanut chewing habit in various forms is a matter of concern for many health professionals involved in the work on oral cancer. The pattern of chewing habits among the study groups gave us an insight into the lifestyle of the population and the statistics thus obtained in this study can serve as a valuable source of data to plan and implement various health programs for the community. The preventive approach is therefore clear for oral cancer and precancers and all health care professionals have an obligation and an excellent opportunity to contribute. As India aspires to become a developed country in the near future its achievement in the social arena will be seen with equal interest as its economic and scientific advancement. Hence, the young health professionals have a major responsibility in ensuring a healthy nation.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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