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ORIGINAL RESEARCH

The of oral mucosal in patients visiting a dental school in Southern India

Anuna Laila Mathew, Keerthilatha M Pai, Amar A Sholapurkar, Manoj Vengal

Department of Oral Medicine AABSTRACTBSTRACT and Radiology, Manipal College of Dental Sciences, Manipal, The purpose of the present study was to evaluate the prevalence of oral mucosal lesions in Karnataka - 576 104, India Manipal, Karnataka State, India. A total of 1190 subjects who visited the department of oral medicine and radiology for diagnosis of various oral complaints over a period of 3 months were interviewed and clinically examined for oral mucosal lesions. The result showed the presence of one or more mucosal lesions in (41.2%) of the population. Fordyce’s condition was observed most frequently (6.55%) followed by frictional keratosis (5.79%), (5.71%), (3.78%), smoker’s (2.77%), recurrent aphthae, (2.01%), oral malignancies (1.76%), (1.59%), median rhomboid (1.50%), (1.3%), (1.20%), varices (1.17%), traumatic and oral (1.008%), denture , , betel chewer’s mucosa and irritational (0.84%), , angular (0.58%), and mucocele (0.16%). Mucosal lesions like tobacco-related lesions (leukoplakia, smoker’s palate, oral submucous fibrosis, and oral Received : 21-07-07 malignancies) were more prevalent among men than among women. Denture stomatitis, herpes Review completed : 02-09-07 labialis, and occurred more frequently in the female population. Accepted : 21-11-07 PubMed ID : ???????? Key words: Abnormalities, mucosal lesions, prevalence

Although the terms dental health and oral health are used 2005 to 1st June 2005 were included in the study. The patients almost synonymously when stating the goals for oral health, were divided into four groups based on age: 2-20 years, such statements are usually valid only for dental health. This 21-40 years, 41-60 years, and 61-80 years old. All the subjects may lead to severe underestimation of the need for total oral were examined clinically and questioned regarding any health care.[1] When planning measures for improving oral habits like , pan chewing, and alcohol intake, and health, the lack of data may lead to a risk of overlooking the frequency and duration of the habit. Patients in whom of the soft tissues in, and adjacent to, the oral cavity. an intraoral examination was not possible due to inadequate Prevalence data of oral mucosal lesions are available from opening were excluded from the study. History many countries, but the information is usually restricted to was obtained from parents or relatives for patients who very few lesions in each survey. Only two studies,[2,3] with were not able to communicate either due to age or . sufÞ ciently large number of individuals, have presented data The patients were examined clinically by two trained on a broad spectrum of oral mucosal lesions in a general examiners using artiÞ cial light, mouth mirror, gauze, etc.; population. the diagnosis was made based on history, clinical features, and investigations, according to the WHO guidelines and Hence, the aim of the present study was to evaluate the color atlas. Biopsies were advised for suspicious lesions. prevalence of oral mucosal lesions in patients who visited the Department of Oral Medicine and Radiology, Manipal RESULTS AND DISCUSSION College of Dental Sciences, Manipal, India. A total of 1190 patients (747 men and 443 women) in the age MATERIALS AND METHODS range 2-80 years represented the population in this 3-month study conducted in our department. The different age- A total of 1190 outpatients seeking dental treatment at groups and the number of subjects in each was as follows: the Department of Oral Medicine and Radiology, Manipal 2-20 years old (n = 243, 21-40 years old (n = 527), 41-60 years st College of Dental Sciences, Manipal, India, from 1 March old (n = 325), 61-80 years old (n = 95). Reference to the color Correspondence: atlas while making the clinical examination and diagnosis Dr. Amar A Sholapurkar, resulted in a high proportion of both intra-examiner and E-mail: [email protected] inter-examiner agreement for the presence of lesions

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Prevalence of oral mucosal lesions Mathew, et al.

and their categorization. Out of 1190 subjects, 1167 were Fordyce’s condition dentulous and 13 were totally edentulous (1.1%). Forty-Þ ve Fordyce’s condition was observed in 6.5% of our population subjects were denture wearers. One hundred and Þ fteen and was more frequently observed on the buccal and (9.7%) were presently smokers, 22 (1.9%) were ex-smokers, mucosa. It was more prevalent in men (8.9%) than in women and 1053 (88.4%) were nonsmokers. Among the current (2.48%). Corbet,[4] however, had reported a prevalence of smokers, there was a high proportion of heavy smokers 0.6%, which was very different from our Þ nding. (21 or more cigarettes/day). The habit of tobacco chewing was present in 123 subjects. The frequency of tobacco Fissured tongue chewing was more prevalent in males than in females (98 Fissured tongue was seen in 5.7% of our population. This males and 25 females) and was more prevalent in the 21-40 included all subjects with Þ ssures of at least 2-mm depth age-group. Ex-pan chewers were 21 in number. on the dorsal aspect of the tongue. This prevalence is lower than that found by Darwazeh and Pillai (11.4%)[5] and also Table 1 shows the demographic data. Tables 2 and 3 shows by Marij a in Slovenia[6] (21.1%). In our population, the the prevalence of oral mucosal variants and abnormalities presence of Þ ssured tongue increased with age and was more according to age and gender. No mucosal abnormalities prevalent among men than in women which is in accordance were detected in 58.8% of subjects. The most prevalent with the Þ ndings of Aboyons and Ghaemma Ghami in Iran[6] normal variant was Fordyce’s granules (6.55%), followed and Darwazeh and Pillai in Jordan.[5] by Þ ssured tongue (5.71%), Leukoedema (3.78%), and varices (1.17%).The most prevalent was frictional Leukoedema keratosis (5.79%), followed by smoker’s palate (2.77%), In our study population, the prevalence of leukoedema (2.1%), oral submucous fibrosis was 3.7%. Males were more affected than females. It was (2.01%), oral malignancies (1.76%), leukoplakia (1.59%), especially prevalent in the 41-60 years age-group (5.35% and median rhomboid glossitis (1.5%), (1.3%), 1.1%, respectively, in males and females). The prevalence lichen planus (1.26%), traumatic ulcer (1.01%), denture was more among smokers than nonsmokers, with an increase stomatitis (0.84%), geographic tongue (0.84%), betel in age. A correlation between leukoedema and smoking, chewers mucosa (0.84%), irritational Þ broma (0.84%), tobacco chewing, and could be demonstrated in angular cheilitis (0.58%), herpes labialis (0.58%), and our study as was seen in some groups of people in the study mucocele (0.16%). by Karen in Thailand.[7]

Table 1: Demographic data of 1190 patients (2-80 years old) Patients no. according to 2-20 21-40 41-60 61-80 Total Total age and gender M - 135; F - 108 M - 332; F - 195 M - 210; F - 114 M - 70; F - 26 M - 747; F - 443 1190 Dentate patients M - 135 M - 332 M - 206 M - 63 M - 736 1177 F - 108 F - 195 F - 113 F - 25 F - 441 Totally edentulous M - 0 M - 0 M - 4 M - 7 M - 11 13 F - 0 F - 0 F - 1 F - 1 F - 2 Denture wearers M - 1 M - 4 M - 8 M - 10 M - 23 45 F - 0 F - 2 F - 15 F - 5 F - 22 Present smokers M - 5 M - 50 M - 55 M - 5 M - 115 115 F - 0 F - 0 F - 0 F - 0 F - 0 Ex- smokers M - 0 M - 5 M - 10 M - 7 M - 22 22 F - 0 F - 0 F - 0 F - 0 F - 0 Tobacco chewers M - 5 M - 46 M - 39 M - 8 M - 98 123 F - 0 F - 5 F - 15 F - 5 F - 25 Ex-pan chewers M - 0 M - 7 M - 6 M - 4 M - 17 21 F - 0 F - 0 F - 1 F - 3 F - 4 Alcoholics M - 1 M - 10 M - 9 M - 0 M - 20 20 F - 0 F - 0 F - 0 F - 0 F - 0

Table 2: Prevalence of oral mucosal variants in 1190 patients (2-80 years old) Mucosal fi ndings Gender 2-20, n (%) 21-40, n (%) 41-60, n (%) 61-80, n (%) Total, n (%) Total, n (%) Fordyce’s granules M 3 (2.2) 30 (9.03) 28 (13.3) 6 (8.5) 67 (8.9) 78 (6.55) F 3 (2.77) 6 (3.07) 2 (1.73) 0 11 (2.48) Fissured tongue M 1 (0.74) 11(3.37) 18 (8.57) 14 (20) 44 (57.14) 68 (5.71) F 3 (2.77) 7 (3.58) 10 (8.69) 4 (16) 24 (5.41) Leukoedema M 0 7 (2.10) 29 (13.3) 4 (5.7) 40 (5.35) 45 (3.78) F 1 (0.9) 2 (1.02) 1 (0.86) 1 (4) 5 (1.12) Varices M 0 1 (0.30) 3 (1.42) 10 (14.2) 14 (1.87) 14 (1.17) F 0 0 0 0 0

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Prevalence of oral mucosal lesions Mathew, et al.

Table 3: Prevalence of oral mucosal abnormalities in 1190 patients (2-80 years old) Abnormal Mucosal Finding Sex 2-20, n (%) 21-40, n (%) 41-60, n (%) 61-80, n (%) Total, n (%) Total, n (%) Frictional keratosis M 4 (2.96) 30 (9.03) 20 (9.5) 6 (8.5) 60 (8.03) 69 (5.79) F 1 (0.92) 5 (2.5) 2 (1.73) 1 (4) 9 (2.03) Smoker’s palate M 1 (0.74) 6 (1.80) 22 (10.4) 4 (5.7) 33 (4.4) 33 (2.77) F 0 0 0 0 0 Aphthous stomatitis M 3 (2.2) 9 (2.71) 4 (1.9) 1 (0.42) 17 (2.27) 25 (2.1) F 1(0.9) 5 (2.56) 2 (1.73) 0 8 (1.8) Oral submucous Þ brosis M 1 (0.74) 13 (3.9) 9 (4.2) 0 23 (3.07) 24 (2.01) F 0 0 1 (0.86) 0 1 (0.22) Oral malignancies M 0 1 (0.30) 9 (4.2) 6 (8.5) 16 (2.14) 21 (1.76) F 0 0 4 (3.47) 1 (4) 5 (1.12) Leukoplakia M 0 6 (1.8) 10 (4.76) 1 (1.42) 17 (2.27) 19 (1.59) F 0 1 (0.51) 1 (0.86) 0 2 (0.45) Median Rhomboid glossitis M 0 5 (1.5) 5 (2.38) 3 (4.2) 13 (1.7) 18 (1.5) F 0 4 (2.05) 1 (0.86) 0 5 (1.12) Candidiasis M 1 (0.74) 2 (0.6) 6 (2.85) 4 (5.71) 13 (1.7) 16 (1.3) F 0 1 (0.51) 0 2 (8) 3 (0.97) Lichen planus M 0 4 (1.2) 4 (1.9) 1 (1.42) 9 (1.2) 15 (1.26) F 0 2 (1.02) 4 (3.47) 0 6 (1.3) Traumatic ulcer M 4 (2.96) 4 (1.2) 2 (0.96) 1 (1.42) 11 (1.47) 12 (1.008) F 0 1 (0.51) 0 0 1 (0.22) Denture stomatitis M 0 2 (0.6) 2 (0.95) 0 4 (0.53) 10 (0.84) F 0 1 (0.51) 5 (4.34) 0 6 (1.35) Geographic tongue M 0 5 (1.5) 2 (0.95) 0 7 (0.93) 10 (0.84) F 1 (0.9) 1 (0.51) 0 1 (4) 3 (0.67) Betel chewers mucosa M 0 7 (2.10) 1 (0.47) 2 (2.85) 10 (1.33) 10 F 0 0 0 0 0 (0.84) Irritational Þ broma M 0 2 (0.6) 2 (0.95) 2 (2.85) 6 (0.8) 10 (0.84) F 0 1 (0.51) 3 (2.6) 0 4 (0.9) Angular cheilitis M 1 (0.74) 0 1 (0.47) 1 (1.42) 3 (0.4) 7 (0.58) F 0 0 4 (3.47) 0 4 (0.9) Herpes labialis M 1 (0.74) 2 (0.6) 0 0 3 (0.4) 7 (0.58) F 0 3 (1.53) 1(0.86) 0 4 (0.9) Mucocele M 0 1 (0.30) 1 (0.47) 0 2 (0.26) 2 (0.16) F 0 0 0 0 0 No lesion M 112 (82.9) 195 (58.7) 71 (33.8) 21 (38) 399 (53.4) 700 (58.8) F 90 (83.3) 130 (66.6) 66 (57.3) 15 (60) 301 (67.9)

Sublingual varices study population were more prevalent in men than in The prevalence of sublingual varices was 1.17% in our women (3.3% and 0.22%, respectively). This difference was population. It occurred more frequently in the 61-80 years attributable to the high tobacco consumption in men. age-group; however, the prevalence of 14.2% that we found in this age-group is considerably lower than the prevalence Aphthous stomatitis of 68.2% found by Ettinger and Mandersan in Edinbourgh.[6] The presence of recurrent aphthae was 2.1%. It was most Our observation was 7.1% more than that found Corbet.[4] prevalent (2.6%) in the 21-40 years age-group and more frequent in men (2.27%) than in women (1.8%). However, Frictional keratosis the prevalence in a Swedish population as reported by White lesions near rough dental restorations, a sharp tooth, or Axell and Henricsson[8] and in Slovenia by Marij a[6] was due to biting because of unsuitable prosthesis were registered 17.7% and 9.7%, respectively. Irwin[9] conducted a study as frictional keratosis.[6] The occurrence of frictional keratosis in Pennsylvania and concluded that the prevalence of was in 5.79% of all subjects. The highest prevalence of this recurrent aphthous stomatitis was higher in students. lesion in men was in the 21-60 years age-group (8.03%) and in women in the 21-40 years age-group (2.03%). This result Oral submucous fibrosis is comparable to that of Corbet et al. (6%).[4] The prevalence of oral submucous Þ brosis in our population was (2.01%); it was more among men (3.07%) than women Smoker’s palate (0.22%) and more often seen in the 41-60 years age-group. In our population, smoker’s palate was observed only in This is comparable to the prevalence found in a Cambodian men. The prevalence of 4.4% that we found was more population[10] (0.2%). There was generalized blanching, than that observed in Ljubljana, Slovenia, by Marij a (0.5%) Þ brotic bands on the buccal mucosa and hard and soft and in Swedish men by Axell (2.1%).[2] Tobacco-related palate, limited mouth opening, and complaints of a burning white lesions (leukoplakia and smoker’s palate) in our sensation.

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Prevalence of oral mucosal lesions Mathew, et al.

Oral malignancies than men (1.3 and 1.2%, respectively). This is in accordance The prevalence of oral malignancies in our study was 1.7%. with the results obtained by Axell and Rundquist,[14] Ikeda Males (2.14%) had a higher predilection for this lesion than et al.,[10] and Marij a Kovac Kavcic (in Slovenia).[6] The most females (1.12%); it was observed more often in the age- prevalent type was the reticular type. It was located most group of 41-60 years. In clinically suspicious lesions, biopsy frequently on the buccal mucosa followed by the tongue was done; some cases had already been histopathologically and the alveolar ridge. proven to be malignancies. The main site of involvement was the buccal mucosa and the lateral border of the tongue. Denture stomatitis It was more prevalent in patients who were chronic smokers Denture stomatitis was observed in ten subjects (out of 45 and tobacco chewers, with or without alcohol consumption. denture wearers). The prevalence in our study was 0.84%. This prevalence is more than that found by Ikeda (0.1%) The majority of denture stomatitis was observed in the 41-60 in a Cambodian population[10] and by Axell (<0.1%) in years age-group. The frequency was observed to be more in Sweden.[2] females (1.35%) than in men (.53%). The higher prevalence of denture stomatitis among women is in accordance with Leukoplakia the Þ ndings of Axell.[2] This is lower than that observed by The prevalence of leukoplakia in our population was Corbet et al. in a Chinese population in Hong Kong[15] (10%) 1.59%. All the subjects with leukoplakia in our population and by Marij a in Slovenia[6] (14.7%). were smokers and tobacco chewers. It was more prevalent in men than in women (2.27% and 0.45%, respectively). Geographic tongue This prevalence is in agreement with the results obtained Geographic tongue was present in 0.84% of our population, in Thailand by Reichart et al.[7] (1.1%) and in Hungary by which is less than the prevalence found by Axell in a Swedish Banoczy (1.3%)[11] but low when compared with the studies population (8.5%) and by Marij a in Slovenia (2.2%)[6] and by Ikeda in Japan (25%),[12] Bouquot in USA (2.96%), and more than that found by Bouquot (0.3%) and by Ikeda in Axell in Sweden (3.6%).[13] Axell found more tobacco- 18-63 years old Japanese subjects (<0.1%). associated leukoplakia as compared to our study. The highest prevalence of leukoplakia in our male population was in Betel chewer’s mucosa the 41-60 years age-group (4.76%). The most frequent The prevalence of betel chewer’s mucosa in our study was site of involvement was the buccal mucosa, including 0.84%. It was only observed in men, probably because of the commissures, followed by the alveolar ridge and the the chronic and high usage of tobacco in men. Our study retromolar region. No leukoplakia was seen in the ß oor of Þ ndings were in agreement with the study by Chiag Mai in the mouth. All the leukoplakias were of the homogenous Thailand (1%). Older subjects had higher prevalence (2.85%) type. Toluidine blue staining was done and biopsy advised than the younger ones. if there was stain uptake. Irritational fibroma Median rhomboid glossitis The prevalence of irritational Þ broma in our study was The prevalence of median rhomboid glossitis was 1.5% and 0.84%. It was more prevalent in males than in females was observed more in males (1.7%) compared to females and in older subjects (2.85%). This is in accordance with (1.12%). This prevalence is comparable to that in the studies the study done by Corbet et al., where the prevalence was conducted in Thailand, Kuala Lumpur, and Sweden (1.3%, found to be 1%. 1.3%, and 1.4%, respectively). Angular cheilitis Oral candidiasis Angular cheilitis was found in 0.58% of our population, The prevalence of oral candidiasis in our population was which is comparable to the Þ nding recorded by Corbet 3.07%. Pseudomembranous candidiasis was present in 1.3% et al. (1%)[4] and Marij a in Slovenia[6] (1%). It was more and was more frequently observed in males (1.7%) than in frequently found in the 41-60 years age-group and had more females (.67%) and in the older age-group (61-80 years). This predilection for females. is comparable to the Þ nding by Ikeda[10] (1.4%) and more than that found by Axell in Kuala Lumpur (0.4%).[1] Herpes labialis The prevalence of a positive history of recurrent herpes Lichen planus labialis was 0.58%. In our study population it decreased with Lichen planus was found in 1.26% of our population, which is age and was more prevalent in the 21-40 year age-group and comparable to that in Swedish[14] and Japanese populations[10] was more common in females than in males (0.9% and 0.4%, (1.9% and 1.8%, respectively). In our population, lichen respectively). This is comparable to the Þ nding by Chiang Mai planus was most prevalent in the 41-60 year age-group in Thailand (0.9%).[1] According to Bouquot[3] and Axell[2] it (2.4%). It was more frequently observed among women was 2.5% and 14.3%, respectively, in males and females.

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Prevalence of oral mucosal lesions Mathew, et al.

Mucocele examination. J Am Dent Assoc 1986;112:50-7. 4. Corbet EF, Holmgren CJ, Philipsen HP. Oral mucosal lesions in The prevalence of mucocele in our population was 65-74 year old Hong Kong Chinese. Community Dent Oral Epidemiol 0.16%, and it was found only in males. This prevalence is 1994;22:392-5. comparable with that in the study by Axell[2] (0.1%) and by 5. Darwazeh AM, Pillai K. Prevalence of tongue lesions in 1013: Jordanian Bouquot[3] (0.2%) and less than in the population studied in dental out patients. Community Dent Oral Epidemiol 1993;21:323-4. [6] 6. Kovac-Kovacic M, Skaleric U. The prevalence of oral mucosal lesions in a Slovenia (0.9%). population in Ljubljana, Slovenia. J Oral Pathol Med 2000;29:331-5. 7. Reichart PA, Mohr U, Srisuwan S, Geerlings H, Theetranont C, No lesions were found in 58.8% of the population; 67.9% of Kangwanpong T. Pre cancerous and other Oral mucosal lesions related them were females and 53.4% were males. The maximum to chewing, smoking and drinking habits in Thailand. Community Dent number of lesion-free patients were in the 0-20 years old Oral Epidemiol 1987;15:152-60. 8. Axell T, Henricsson V. The occurrence of recurrent apthous ulcer in an female population. adult Swedish population. Acta Odontol Scand 1985;43:121-5. 9. Ship II, Brightman VJ, Laster LL. The patient with recurrent aphthous CONCLUSION ulcers and the patient with recurrent herpes labialis: A study of two population samples. J Am Dent Assoc 1967;75:645-54. 10. Ikeda N, Handa Y, Khim SP, Darward C, Axell T, Mizuno T, et al. Prevalence The result of the present study provides some information study of oral mucosal lesions in a selected Cambodian population. on the prevalence of oral mucosal Þ ndings in Manipal, Community Dent Oral Epidemiol 1995;23:49-54. India. The results showed that tobacco-associated lesions 11. Banoczy J, Rigo O. Prevalence study of oral precancerous lesions with a complex screening system in Hungary. Community Dent Oral Epidemiol were observed more in males than in females. Habituated 1991;19:265-7. patients were advised to give up smoking and other harmful 12. Ikeda B, Ishii T, Iida S, Kawai T. Epidemiological study of oral leukoplakia habits. All patients underwent scaling and were advised based on mass screening for oral mucosal diseases in a selected Japanese about individual oral and dental needs. Although some population. Community Dent Oral Epidemiol 1991;19:160-3. 13. Axell T. Occurrence of leukoplakia and some other oral white lesions recent curbs have been put on the manufacture and sale among 20333 adult Swedish people. Community Dent Oral Epidemiol of gutkha, pan masala, and other established - 1987;15:46-51. causing tobacco products,[15] further education is necessary 14. Axell T, Rundquist L. Oral Lichen planus a demographic study. to reduce or eliminate the use of these preparations. Community Dent Oral Epidemiol 1987;15:52-6. 15. Nai U, Bartsch H, Nair J. Alert for an epidemic of oral cancer due to use of the betel quid substitutes gutkha and pan masala review of agents REFERENCES and Causative mechanisms. Mutagenesis 2004;19:251-62.

1. Axell T, Zain RB, Siwamogsthom P, Tantiniran D, Thampipit J. Prevalence of oral soft tissue lesions in out patients at two Malaysian and Thai How to cite this article: Mathew AL, Pai KM, Sholapurkar AA, Dental School Community Dent. Oral Epidemiol 1990;18:95-9. Vengal M. The prevalence of oral mucosal lesions in patients visiting a dental school in Southern India. Indian J Dent Res 2008;19: 2. Axell T. A prevalence study of oral mucosal lesions in an adult Swedish 99-103 population. Thesis Odontol Revy 1976;27:1-103. 3. Bouquot JE. Common oral lesions found during a mass screening Source of Support: Nil, Confl ict of Interest: None declared.

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