|Year : 2015 | Volume
| Issue : 1 | Page : 39-43
Prevalence of oro-mucosal lesions among rural population having tobacco habits: A cross-sectional study
Tarun Gupta1, KL Veeresha1, GM Sogi1, Ramandeep Singh Gambhir2, Ashu Loomba1, Harloveen Sabharwal3
1 Department of Public Health Dentistry, Maharishi Markandeshwar University, Ambala, Haryana, India
2 Department of Public Health Dentistry, Rayat and Bahra Dental College and Hospital, Mohali, Punjab, India
3 Department of Prosthodontics, Faculty of Dental Sciences, Varanasi, Uttar Pradesh, India
|Date of Web Publication||30-Jul-2015|
Dr. Ramandeep Singh Gambhir
Rayat and Bahra Dental College and Hospital, Mohali - 140 104, Punjab
Source of Support: None, Conflict of Interest: None
Background: Tobacco habit is one of the biggest curses that modern society has come across. It is not confined to any one country or region alone, but has widely afflicted the globe by addiction, ill-health, loss of man hours and premature death leading to various social problems. This study was conducted to assess the prevalence of oro-mucosal lesions among rural population having tobacco habits in Ambala district (Haryana).
Materials and Methods: This observational cross-sectional study was carried out among 680 subjects; a two-stage sampling technique was adopted for selection of villages in each block of Ambala and selection of subjects from individual villages. Oro-mucosal lesions were diagnosed using. Oral mucosal lesions were diagnosed using World Health Organization criteria and Pindborg's colored atlas. Type III clinical examination was done. Data were analyzed using SPSS version 16, P = 0.05 or less was considered significant.
Results: The prevalence of oro-mucosal lesions was found to be 34.8% among 680 subjects. Prevalence of smoker's palate/tobacco pouch was seen in 29.7%, in which 35.2% were males. Majority of the subjects (68.5%, 466) were bidi smokers and 72.3% of females were smoking bidi. The most common affected intra-oral site was hard palate on which 5.6% lesions were present. Prevalence of oro-mucosal lesions was significantly associated with age.
Conclusion: One-third of the subjects were having oro-mucosal lesions with high prevalence of smoker's palate and tobacco pouch and two-third of the lesions were on hard palate. There is an urgent need for awareness and mass health education programs.
Keywords: Oro-muscal lesions, prevalence, rural population, tobacco
|How to cite this article:|
Gupta T, Veeresha K L, Sogi G M, Gambhir RS, Loomba A, Sabharwal H. Prevalence of oro-mucosal lesions among rural population having tobacco habits: A cross-sectional study. Saint Int Dent J 2015;1:39-43
|How to cite this URL:|
Gupta T, Veeresha K L, Sogi G M, Gambhir RS, Loomba A, Sabharwal H. Prevalence of oro-mucosal lesions among rural population having tobacco habits: A cross-sectional study. Saint Int Dent J [serial online] 2015 [cited 2019 Jan 18];1:39-43. Available from: http://www.sidj.org/text.asp?2015/1/1/39/161801
A tobacco habit is one of the biggest curses that modern society has come across. It is not confined to any one country or region alone but has widely afflicted the globe.  Many social, economic and political factors have contributed to the global spread of tobacco consumption. The fast-changing social milieus, social sanctions, and other factors are mainly contributing to this proliferation and has posed a serious challenge to individuals, families, societies, and nations. 
The World Health Organization (WHO) predicts that tobacco deaths in India may exceed 15 lacs annually by 2020. Thus, with its 25 crore tobacco consumers, India is sitting on the verge of an unparalleled health crisis.  Every form of tobacco such as cigarettes, cigars, pipe tobacco, snuff, and chewing tobacco contain nicotine, which is highly addictive and is readily absorbed into the bloodstream when a tobacco product is chewed, inhaled, or smoked. 
The prevalence of smokeless tobacco use in India is the highest in the world. According to the Global Adult Tobacco Survey 2010 report, 60% of tobacco users in India currently use only smokeless tobacco and an additional 15% are mixed users.  There is a wide variety of smokeless tobacco in India, and these varieties vary considerably across different regions of the country, including chewing, holding in the mouth, or applying over teeth and gums. In India, using smokeless tobacco is not only common among males, but also among females and youth. 
The use of tobacco products has been widely implicated in the etiology of oral cancerous and precancerous lesions. The worldwide epidemiological studies conducted in diverse culture as Brazil, India, China, and France confirm the association. Some of the investigation has reported strong association of the smokeless tobacco use with the oral carcinomas,  but the more recent studies have reported low prevalence of oral lesion associated with smokeless tobacco use and majority of them being hyperkeratosis only. 
In Ambala, the low socioeconomic and educational status of people residing in rural areas has resulted in the practice of tobacco smoking and chewing by a majority of the population. No study has been conducted in this part of the country to study the prevalence of oro-mucosal lesions among the rural population. Hence, an attempt was made to assess the prevalence of oro-mucosal lesions among the rural population of Ambala having tobacco habits.
| Materials and Methods|| |
Ethical clearance and informed consent
This study was conducted after obtaining ethical clearance from the Ethics Committee of Maharishi Markandeshwar (MM) University, Mullana and prior permission from the head of the villages (Sarpanch) before the start of the study. The purpose of the study was explained to the subjects in the local language, and written consent was obtained before the start of the study.
Sampling procedure and study sample
The study was a cross-sectional questionnaire survey on the rural population residing in Ambala district. The entire Ambala district is divided into three tehsils Ambala, Nariangarh, Barara for administrative purpose, consisting of 198 villages. A two-stage sampling process was used which involved the sampling of villages within the district followed by sampling of subjects having tobacco habits in the selected villages with an aim to ensure generalization of the results. A total of 34 villages were selected based on the cluster random sampling. The sample size was calculated by taking the least prevalence of oral precancerous lesion (n = 4pq/d2 ). After doing all the calculations in the statistical software, a final sample size of 680 was obtained. Twenty subjects having tobacco habits were selected from individual villages based on the stratified random sampling method to reach a final sample size of 680.
Research instrument and clinical examination
The instrument used in the present study was a pretested self-structured format (questionnaire). Information regarding demographic details, socioeconomic status, history and duration of tobacco habits, history and duration of lesions, oral hygiene practices etc., were recorded on the format. A pilot study was conducted on among 40 patients in the department to test the feasibility of the study. After the pilot study, the questionnaire was translated into the local language (Hindi) using appropriate and simple words. Oral hygiene of the subjects was assessed using oral hygiene index-simplified (OHI-S) developed by Green and Vermillion.  Different oral mucosal lesions like leukoplakia, lichen planus, smoker's palate, ulceration, etc., were diagnosed using WHO criteria and Pindborg's colored Atlas More Details. , Socioeconomic status was evaluated using modified Kuppuswamy scale.  Type III clinical examination was carried out in village premises in natural light with two mouth mirrors and a straight probe. Each village visit was followed by free dental treatment camp and the villagers were imparted health education by one of the investigators. All the subjects were examined by a single trained examiner who was calibrated (kappa value was 0.7) in the department prior to the study.
Inclusion and exclusion criteria
The rural population of Ambala district having tobacco habits and those who gave consent to participate were included in the study. Subjects who refused to undergo clinical examination, who were consuming alcohol, denture wearers and having faulty dental restorations were excluded from the study.
Data were transferred to a personal computer and entered in the Microsoft Excel Worksheet, compiled, and analyzed using the Epi Info and SPSS software (SPSS software version 16, Chicago, IL, USA). The association between the categorical variables was tested by the Pearson's Chi-square test. Significance for all statistical tests was predetermined at a P ≤ 0.05.
| Results|| |
Various sociodemographic characteristics of the study population are depicted in [Table 1]. Males constituted 73.5% (500) of the study population. The mean age of the study subjects was 47.1 years, and maximum subjects (19.1%) were in the age group of 35-44 years. 31.5% (214) of the subjects were unemployed, and 27.4% (186) were farmers. The majority of the subjects (27.3%, 186) belonged to upper lower class.
Tobacco smoking and chewing habits
Gender-wise distribution of various tobacco habits is summarized in [Table 2]. The majority of the subjects (68.5%, 466) were bidi smokers and 72.3% of females were smoking bidi. 9.1% (62) of subjects were cigarette smokers, and 18.2% (124) of study subjects were tobacco chewers. The use of tobacco increased with increasing age, and the findings were statistically significant (P < 0.05).
|Table 2: Distribution of tobacco habits in the study population according to gender |
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Oral hygiene status of the subjects
[Figure 1] depicts gender-wise distribution of subjects, according to OHI-S. Among 680 subjects, more than half 63.2% (430) were having fair oral hygiene status in which 64% (320) were males and 61.1% (110) were females. 31.5% (214) had poor oral hygiene, and only 2.6% (9) of the subjects had good oral hygiene.
Prevalence of oro-mucosal lesions according to gender
Various oro-mucosal lesions (precancerous and noncancerous) were reported in 34.8% (236) of the subjects. The most common oro-mucosal lesion was smoker's palate which was reported in 29.1% (198) of the study subjects whereas leukoplakia was present in 0.9% (6) of the subjects. Moreover, there was a statistically significant relationship between the gender of the subjects and presence of oro-mucosal lesions (P < 0.05) [Table 3].
|Table 3: Gender wise distribution of subjects according of oro-mucosal lesions |
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Location of oro-mucosal lesions
The most frequently involved intra-oral site for the development of oro-mucosal lesion was hard palate (57.6%) and the least involved site was the floor of the mouth (0.8%). 22% of oro-mucosal lesions were located in the sulci region [Figure 2].
Prevalence of oro-mucosal lesions according to age
Approximately 40% of subjects (51) having oro-mucosal lesions were present in the age group of 55-64 years and 22.3% (44) of subjects having smoker's palate were also present in the same group. On the contrary, the majority of cases of leukoplakia (33.54%) were present in the age group of 65-74 years [Table 4]. The above results indicate that the prevalence of oro-mucosal lesions differed in subjects according to age, which was found to be statistically significant (c2 = 55.6, P = 0.002). However, results were insignificant in relation to the socioeconomic status of the population (P > 0.05).
| Discussion|| |
The present study was conducted on a rural population of Ambala district having tobacco habits. The number of male subjects was more as compared to females in the present study. This can be due to sociocultural characteristics of males regarding tobacco consumption in India. , More than one-third subjects were unemployed and maximum subjects belonged to lower socioeconomic status in this study. These findings are in accordance with some other study conducted elsewhere. 
The prevalence of smoking habit in the present study was more than chewing habit and among smoking habit, bidi was smoked by more than half of the subjects. About 19% of tobacco consumption in India is in the form of cigarettes while 53% is smoked as bidis, the rest is used mainly in the smokeless form. Bidis tend to be smoked by lower economic classes. Bidi smoking is may be one of the few affordable sources of immediate gratification in rural population.  Comparatively more males (81.2%) used a smoked form of tobacco. Percentage of females using smokeless or chewing tobacco was more as compared to males. This is in contrast to findings of some other study conducted on south Indian rural population. 
Oral hygiene of one-third of the subjects in the present study was poor, and very few had good oral hygiene as assessed on the basis of OHI-S. This is contrary to findings of some other study conducted on the rural population.  This may be because smokers accumulate markedly more dental calculus than nonsmokers, and the quantity of calculus is correlated with the frequency of smoking.  However, smokeless tobacco users have an incidence of gingivitis and gingival bleeding that is, similar to the incidence among nonusers. 
It was found in this study that tobacco use increased with increasing age. It is seen that in areas with a high prevalence of tobacco use, initiation may occur at an early age. Many factors contribute to the initiation, experimentation and regular use of tobacco among youth. Major determinants may be exposure to parental, sibling and peer group pressure, easy access to smoking and nonsmoking forms of tobacco, aggressive promotion and advertising, low cost, etc. 
Prevalence of oro-mucosal lesions was found to be 34.8% which was more as compared to some other study reports.  We have observed in our study the prevalence of oro-mucosal lesions increased with age which is in concurrence with the some other study reports  but contrary to other study findings.  The most common oro-mucosal lesion in this study was tobacco pouch whereas in other studies leukoplakia is the most common lesion.  There was less prevalence of leukoplakia in our study as compared to findings of a similar study conducted in Belgaum but the prevalence of lichen planus was almost same in both the studies.  The difference in prevalence of leukoplakia could be due to the difference in tobacco habits of Northern and Southern rural population of India. Prevalence of oro-mucosal lesions was insignificant in relation to socioeconomic status in the present study. On the contrary, a significant difference was observed in another study conducted in Nagpur.  Hard palate was the most common site, which was affected by the lesions in the present study and another study conducted elsewhere.  The difference in results of the present study with other studies could be due to the difference in study settings, study design and tobacco habits.
In the present study, data was gathered as a chairside procedure, which involved oral examination and format (questionnaire) administration. Since the information on the habits was collected through questionnaire, this could have resulted in some information bias, but this could only bias our results toward the mill. In this study, detailed information could not be gathered on other predictors of oral lesions such as nutritional status and body mass index; a more detailed and case-control study is required to understand better the oral lesions and habits association in this population.
| Conclusion|| |
In this study, one-third of the subjects were having oro-mucosal lesions with a high prevalence of smoker's palate and tobacco pouch keratosis and two-third of the lesions were on the hard palate. Prevalence of oro-mucosal lesions was significantly associated with age. There is an urgent need for awareness programs utilizing the community health workers, dentists and allied medical professionals. Mass health education regarding intake of proper nutrition and cessation of oral deleterious habits has to be taken in war footing by governmental and nongovernmental agencies using all communication media and man power. It is hoped that these results will form the basis for a state level, followed by a national level survey of oral lesions.
We would like to thank our honorable Chairman, Maharishi Markandeshwar University and the Sarpanchs of the villages and the volunteers for their support and cooperation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ramakrishna GS, Sankara Sarma P, Thankappan KR. Tobacco use among medical students in Orissa. Natl Med J India 2005;18:285-9.
Chaudhary K, Prabhakar AK, Prabhakaran PS, Prasad A, Singh K, Singh A. Prevalence of Tobacco Use in Karnataka and Uttar Pradesh in India. New Delhi: Indian Council of Medical Research and WHO; 2001.
Conrad KM, Flay BR, Hill D. Why children start smoking cigarettes: predictors of onset. Br J Addict 1992;87:1711-24.
Raute LJ, Sansone G, Pednekar MS, Fong GT, Gupta PC, Quah AC, et al.
Knowledge of health effects and intentions to quit among smokeless tobacco users in India: findings from the International Tobacco Control Policy Evaluation (ITC) India Pilot Survey. Asian Pac J Cancer Prev 2011;12:1233-8.
Winn DM, Blot WJ, Shy CM, Pickle LW, Toledo A, Fraumeni JF Jr. Snuff dipping and oral cancer among women in the Southern United States. N Engl J Med 1981;304:745-9.
Kaugars GE, Riley WT, Brandt RB, Burns JC, Svirsky JA. The prevalence of oral lesions in smokeless tobacco users and an evaluation of risk factors. Cancer 1992;70:2579-85.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.
Kramer IR, Pindborg JJ, Bezroukov V, Infirri JS. Guide to epidemiology and diagnosis of oral mucosal diseases and conditions. World Health Organization. Community Dent Oral Epidemiol 1980;8:1-26.
Pindborg JJ. Atlas of Diseases of Oral Mucosa. 4 th
ed. Copenhagen: Munksgaard: WB, Saunders Company; 1980.
Bairwa M, Rajput M, Sachdeva S. Modified Kuppuswamy′s Socioeconomic Scale: Social Researcher Should Include Updated Income Criteria, 2012. Indian J Community Med 2013;38:185-6.
Krishnan A, Shah B, Lal V, Shukla DK, Paul E, Kapoor SK. Prevalence of risk factors for non-communicable disease in a rural area of Faridabad district of Haryana. Indian J Public Health 2008;52:117-24.
Soni P, Raut DK. Prevalence and pattern of tobacco consumption in India. Int Res J Soc Sci 2012;1:36-43.
Gupta PC, Asma S, editors. Bidi smoking and public health. New Delhi: Ministry of Health and Family Welfare, Government of India; 2008.
Saraswathi TR, Ranganathan K, Shanmugam S, Sowmya R, Narasimhan PD, Gunaseelan R. Prevalence of oral lesions in relation to habits: Cross-sectional study in South India. Indian J Dent Res 2006;17:121-5.
Shenoy RP, Shetty MS, Shenai KP, Kotian MS. Evaluation of oral status and tobacco use in a rural population and testing a scale developed to rate oral status: A pilot study. J Res Pract Dent 2014;2014:8.
Sham AS, Cheung LK, Jin LJ, Corbet EF. The effects of tobacco use on oral health. Hong Kong Med J 2003;9:271-7.
Müller HP, Stadermann S, Heinecke A. Longitudinal association between plaque and gingival bleeding in smokers and non-smokers. J Clin Periodontol 2002;29:287-94.
Jahanbani J. Prevalence of oral leukoplakia and lichen planus in 1167 Iranian textile workers. Oral Dis 2003;9:302-4.
Patil PB, Bathi R, Chaudhari S. Prevalence of oral mucosal lesions in dental patients with tobacco smoking, chewing, and mixed habits: A cross-sectional study in South India. J Family Community Med 2013;20:130-5.
Narasannavar A, Wantamutte AS. Prevalence of oral precancerous lesions and conditions among tobacco consumers in rural population around Belgaum. A community based cross sectional study. IOSR J Dent Med Sci 2014;13:31-4.
Doifode VV, Ambadekar NN, Lanewar AG. Assessment of oral health status and its association with some epidemiological factors in population of Nagpur, India. Indian J Med Sci 2000;54:261-9.
García-Pola Vallejo MJ, Martínez Díaz-Canel AI, García Martín JM, González García M. Risk factors for oral soft tissue lesions in an adult Spanish population. Community Dent Oral Epidemiol 2002;30:277-85.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]