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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 2  |  Issue : 3  |  Page : 66-71

Prevalence of oral submucous fibrosis in relation to habits among high school children of Kanpur City: A cross-sectional study


1 Department of Oral Medicine and Radiology, Rama Dental College Hospital and Research Centre, Kanpur, Uttar Pradesh, India
2 Department of Oral Medicine and Radiology, M.B Kedia Dental College and Teaching Hospital, Birgunj, Nepal
3 Department of Public Health Dentistry, Rama Dental College Hospital and Research Centre, Kanpur, Uttar Pradesh, India
4 Department of Public Health Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
5 Department of Conservative Dentistry and Endodontics, Rama Dental College Hospital and Research Centre, Kanpur, Uttar Pradesh, India
6 Department of Prosthodontics, Crown and Bridge, Rama Dental College Hospital and Research Centre, Kanpur, Uttar Pradesh, India

Date of Submission21-May-2021
Date of Decision16-Jun-2021
Date of Acceptance29-Jun-2021
Date of Web Publication25-Aug-2021

Correspondence Address:
Rahul Srivastava
Department of Oral Medicine and Radiology, Rama Dental College, Hospital and Research Centre Kanpur, Kanpur, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcdoh.jpcdoh_18_21

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  Abstract 


Background: Oral submucous fibrosis (OSMF) is a chronic insidious disease that affects oral cavity, may also involve pharynx or esophagus, and may be associated with vesicle formation. The present study aimed to determine prevalence of oral submucous fibrosis among school children in Kanpur city through cross-sectional study and its association with various type of quid and areca nut chewing habit. Materials and Methods: In different urban and rural educational areas of the Kanpur district of Uttar Pradesh, a school-based cross-sectional study was carried out. Data on consumption of areca nut were obtained by a self-administered questionnaire based on demographic characteristics, areca nut use, daily frequency of areca nut chewing, other ingredients mixed with nut, tobacco use (smoking and/or chewing), age of initiation of nut chewing, reasons for use, social influence factors, and risk perceptions. All oral examinations were done by specialist examiners who were familiar with oral mucosal lesions in the local population. Results: The results from this study shows that the areca nut chewing habit is significant among school children of rural areas as compare to urban areas in Kanpur district. No female subject was found to be suffering from OSMF in both the urban as well as rural areas however 27 (3.41%) male subjects were found to be suffering from OSMF. Conclusion: In order to spread awareness through educational programs, newspapers, and mass media in neighborhoods and classrooms, steps should be taken at the public health level.

Keywords: Children, habits, oral submucous fibrosis


How to cite this article:
Srivastava R, Wazir SS, Pradhan D, Sharma L, Kumar R, Kumari P. Prevalence of oral submucous fibrosis in relation to habits among high school children of Kanpur City: A cross-sectional study. J Prim Care Dent Oral Health 2021;2:66-71

How to cite this URL:
Srivastava R, Wazir SS, Pradhan D, Sharma L, Kumar R, Kumari P. Prevalence of oral submucous fibrosis in relation to habits among high school children of Kanpur City: A cross-sectional study. J Prim Care Dent Oral Health [serial online] 2021 [cited 2021 Dec 3];2:66-71. Available from: http://www.jpcdoh.org/text.asp?2021/2/3/66/324537




  Introduction Top


Oral submucous fibrosis (OSMF) is a chronic insidious disease that affects oral cavity.[1],[2] This condition was first reported by Schwartz in 1952 and by Joshi in 1953 in India.[3] Its premalignant nature was described by Paymaster. An incidence of carcinoma occurring from OSMF varies from 2% to 30%.[4] Despite multifactorial etiopathogenesis, areca nut chewing in any formulation is considered as the principal causative agent of OSMF. After tobacco, alcohol and caffeine areca nut is the fourth most common substance of abuse in the world.[5]

Experimental epidemiological and in vitro studies have shown that chewing areca nut (Areca catechu) is the main etiological cause for OSF. Although the form of areca nut products used in India has regional variations, the betel quid (BQ) was the most common and prevalent habit in ancient Indian culture. However, both areca quid products such as Pan masala (Areca quid) and Gutkha (AQ + tobacco) were launched as commercial preparations in the Indian market in 1980.[6] The key reasons for using areca nut are to achieve euphoria, satiation, hence making the habit addictive.[7]

Quid is a substance or mixture of substance (in either manufactured or processed form) that typically contains one or both of two essential ingredients, tobacco, and areca nut. The composition of BQ, also known as paan. Tobacco may also be used as a component of paan. Variants of pan include use of sliced areca nut alone and addition of sweeteners to make the product particularly attractive to younger children, to whom it is sold under the names sweet Supari, Gua, Mawa or Mistee pan.[8]

Maharashtra has recently decided to ban the manufacture, storage, distribution and selling of gutka and pan masala from another Indian State. In other Indian states, such as Kerala, Madhya Pradesh, Bihar and Uttar Pradesh, a ban on Gutka already exists but Maharashtra will be the first state to ban both gutka and pan masala.[9] With over 600 million people following the habit of chewing areca nut, OSMF cases are rising at an alarming pace. More and more OSMF cases among children are being recorded recently due to easy availability, low cost, attractive packaging, aggressive marketing, and a sweet taste of areca nut.[10] In children from the lower socioeconomic strata or marginalized communities of India, areca nut and its product use is rampant. Alarmingly or a great concern, it has been observed that the highest period of risk for engaging in areca nut alone is between the ages of 5 and 12, therefore present study aimed to determine prevalence of oral submucous fibrosis among school children in Kanpur city through cross-sectional study and its association with various type of quid and areca nut chewing habit.


  Materials and Methods Top


In different urban and rural educational areas of the Kanpur district of Uttar Pradesh, a school-based cross-sectional study was carried out. Sample size was calculated by the following formula

Where,

N = is the sample size

p = Prevalence

q = (1 − p)

L = is the permissible error in the estimation of P = 0.02

N = 4 × 0.58 × 0.42/0.02 × 0.02

N = 2436

Sample size calculated was 2436 which was rounded off to 3000. So, N (Sample size) = 3000.

Study samples were taken from high schools and inter colleges by random selection, which are affiliated to the Government. Ethical Approval was obtained from the Ethical Committee of the institution. Permission was obtained from the principal of the institute to conduct screening camps. The parents of the students regarding the examination were informed through the concerned class teachers. Free dental screening camps were organized in 16 schools during a period of 5 months (1 October 2019 to 29 February 2020) at different regions of Kanpur city and 3000 students were included in the study.

The students aged between 14 and 18 years (both boys and girls) and having history of taking any type of areca nut products, tobacco or non tobacco products included in this study. Students more than age of 18 years, who have already been treated for OSMF and having any systemic disease were excluded from the study. Data on consumption of areca nut were obtained by a self-administered questionnaire.

All oral examinations were done by specialist examiners who were familiar with oral mucosal lesions in the local population. Clinical diagnosis of OSMF was based on the following criteria:

  • Fibrotic bands making the mucosa stiff
  • Restricted mouth opening
  • Blanched, opaque, leather like mucosa.


Mouth opening (inter-incisal distance) was measured in millimeters using a sterile metal scale and divider to establish any limitation of opening to confirm OSMF. The data were compiled and Chi-square test was used for comparing the categorical data. All values were considered statistically significant for a value of P < 0.05.


  Results Top


[Graph 1] shows the number of the schools included in this study in which 8 schools were selected from urban areas and 8 from the rural areas.



[Table 1] shows the distribution of the study subjects according to gender and habit, out of 3000 subjects, 1866 (62.2%) were males out of which 338 (18.11%) males were in the age group of 14–15 years, 423 (22.66%) were in the age group of 15–16 years, 493 (26.42%) were in the age group of 16–17 years and 612 (32.79%) were in the age group of 17–18 years. Out of 3000 subjects 1134 (37.8%) were females out of which 186 (16.4%) females were in the age group of 14–15 years, 281 (24.77%) were in the age group of 15–16 years, 280 (24.69%) were in the age group of 16–17 years and 387 (34.12%) were in the age group of 17–18 years.
Table 1: Distribution of subjects according to gender

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[Table 2] shows the association of chewing habit according to sex in rural areas. In the age group of 14–15 years, total number of subjects were 306 out of which 35 were habituated and 271 were non habituated with X2 = 3.52 with P < 0.001 which was found to be highly significant. In the age group of 15–16 years, total number of subjects were 452 out of which 86 were habituated and 366 were non habituated with X2 = 8.64 with P value 0.008 which was found to be nonsignificant. In the age group of 16–17 years, total number of subjects were 495 out of which 169 were habituated and 326 were non habituated with X2 = 5.4 with P value 0.072 which was found to be nonsignificant. In the age group of 17–18 years, total number of subjects were 631 out of which 225 were habituated and 406 were non habituated with X2 = 10.81 with P < 0.001 which was found to be highly significant.
Table 2: Association of chewing habit according to sex in rural areas

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[Table 3] shows the association of chewing habit according to sex in urban areas. In the age group of 14–15 years, total number of subjects were 218 out of which 30 were habituated and 188 were non habituated with X2 = 5.57 with P value 0.006 which was found to be nonsignificant. In the age group of 15–16 years, total number of subjects were 252 out of which 53 were habituated and 199 were non habituated with X2 = 6.43 with P < 0.001 which was found to be highly significant. In the age group of 16–17 years, total number of subjects were 278 out of which 127 were habituated and 151 were non habituated with X2 = 4.23 with P < 0.001 which was found to be highly significant. In the age group of 17–18 years, total number of subjects were 368 out of which 67 were habituated and 301 were non habituated with X2 = 9.78 with P < 0.001 which was found to be highly significant.
Table 3: Association of chewing habit according to sex in urban areas

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[Table 4] shows the habit details of the males in the rural areas. Out of 335 habituated males 125 (37.31%) were in the habit of taking sweet supari, 81 (24.17%) were in the habit of taking pan masala and 129 (38.51%) were in the habit of taking pan masala with tobacco with X2 = 12.86, P < 0.001.
Table 4: Habit details of males in rural area

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[Table 5] shows the habit details of the males in the urban areas. Out of 199 habituated males 91 (45.73%) were in the habit of taking sweet supari, 36 (18.09%) were in the habit of taking pan masala and 72 (36.18%) were in the habit of taking pan masala with tobacco with X2 = 9.74, P = 0.004.
Table 5: Habit details of males in urban area

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[Table 6] shows the habit details of the females in the rural areas. Out of 180 habituated females 146 (81.11%) were in the habit of taking sweet supari and 34 (18.89%) were in the habit of taking pan masala with X2 = 6.79, P = 0.081.
Table 6: Habit details of females in rural area

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[Table 7] shows the habit details of the females in the urban areas. Out of 78 habituated females 72 (92.31%) were in the habit of taking sweet supari and 06 (7.69%) were in the habit of taking pan masala with X2 = 5.98, P < 0.001.
Table 7: Habit details of females in urban area

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[Table 8] shows duration of habits in the both the habituated males and females of different age groups.
Table 8: Duration of habits in the both the habituated males and females of different age groups

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[Table 9] shows the frequency rates of different habituated subjects. In rural areas, most of the males (29.85%) were in the habit of taking areca nut 1–5 pouch/day. Regarding, females, most of them (40%) were in the habit of 1 pouch/day. In urban areas, most of the males (26.63%) were in the habit of taking-5 pouch/day. Regarding, females, most of them (43.59%) were in the habit of 1 pouch/day.
Table 9: Frequency rates of different habituated subjects

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[Graph 2] shows the list of reasons for chewing areca nut, taste (24.84%) was the most prevalent reason for chewing areca nut followed by craving (23.04%), do something with mouth, custom (14.73%) and refresh breath (10.32%).



No female subject was found to be suffering from OSMF in both the urban as well as rural areas however 27 male subjects were found to be suffering from OSMF, 9 (42.86%) subjects were suffering from Grade I and 18 (66.67%) subjects were suffering from Grade II OSMF. Out of 9 Grade I OSMF subjects 3 subjects (2 from urban area and 1 from rural area) were from age group 14–15 years, 2 subjects (1 from urban area and 1 from rural area) were from age group 15–16 years, 3 subjects (1 from urban area and 2 from rural area) were from age group 16–17 years and 1 subject (rural) from age group 17–18 years.

Out of 18 Grade II OSMF subjects 9 subjects (5 from urban area and 6 from rural area) were from age group 16–17 years, 9 subjects (3 from urban area and 6 from rural area) were from age group 17–18 years. This is depicted in [Table 10].
Table 10: Details of diseased (oral submucous fibrosis)

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  Discussion Top


Worldwide, the number of OSMF cases in 1996 was estimated at 2.5 million. In India, the prevalence of OSMF has been estimated to range from 0.2% to 2.3% in men and 1.2% to 4.6% in women, with a large age range from 11 to 60 years. After widespread marketing of commercial tobacco and areca nut products, commonly known as Gutkha, sold in single-use packages, a marked rise in incidence of OSMF has been observed.[11]

In the past few years, the production and consumption of areca nut have increased in the country. Its sale is commercially aimed at children and accessibility around and near school premises makes young generations addicted to it.[10] Therefore the present study was conducted to assess the prevalence of oral submucous fibrosis among school children in Kanpur city and its association with various type of areca nut chewing habit. Shah et al. in his study reported high frequency of areca nut use particularly among children of lower socioeconomic strata, raising the chances of development of OSMF.[12] In the present study, the habit of areca nut chewing was seen to be more prevalent in rural areas than the urban areas.

The findings of Shah et al., Oakley et al., Khandelwal et al., Sarfaraz et al., Dere et al., and Leghari et al. showed that areca nut chewing was more prevalent in males than females.[13],[14],[15],[16],[17],[18] In the present study, male predominance was seen that may be due to more social acceptance of use of areca nut and its associated products in males.

Khandelwal in his study assessed the prevalence of areca nut chewing in the middle school-going children of Indore, India and he found that 45.42% of school going children of rural area pander to areca nut chewing habit, whereas in urban area 20.09% children were indulged.[15] Similarly, in the present study, gutkha chewing habit was more prevalent in rural area as compare to urban area. Chewing areca nut alone was the most common of the habits currently being used in the form of sweet supari, followed by pan masala and pan masala with tobacco. The highest period of risk for taking up the habit of taking sweet supari and areca nut alone for both the boys and the girls was between the ages of 14 and 15, while pan masala with tobacco was also more likely to be taken up after the age of 14 years. Additionally, the frequency of chewing areca nut products was reported to increase with the age.

Dere et al. assessed the prevalence and characteristic patterns of areca nut, gutka, and tobacco chewing habits among school children. Craving was the major reason of consumption in both boys and girls. Oakley et al., 2005 stated that the users felt that areca nut gives relief from boredom (75%), aids in concentration (53%), elates the mood (51%), and postpones hunger (46%). The most prevalent reasons for chewing the areca nut in this study was taste (24.84%) followed by craving (23.04%), do something with mouth (17.38%) and refresh breath (10.32%). Jain and Taneja conducted a systematic review evaluating the cases of OSMF in pediatric patients and it was found that pediatric patients affected by OSMF range from 2.5 to 10 years old.[10]

Dere et al. reported 12% of OSMF cases among school children of rural areas in and around Gandhinagar district, Gujarat.[17] Singh et al. assessed the prevalence of OSMF in children of rural areas of Nagpur, Maharashtra (India), the prevalence of OSMF in that study was 2.86% whereas Agrawal et al. reported prevalence of OSMF as 5.4% in the age group of 13–19 years.[19],[20]

In the present study, prevalence of OSMF was assessed with clinical staging. It was found that maximum subjects were seen in Stage II followed by Stage I OSMF. Most of the subjects suffering from OSMF were from age group of 16–18 years.

A recent study from India has reported that 25.77% OSF cases converted to oral squamous cell carcinoma which indicates the alarming malignant potential of OSMF. It is strongly suggested that other approaches such as the use of health promotion strategies specifically directed toward reducing the number of children being engaged in any areca nut habits may be required. However, there is an urgent need to educate the parents as well about the adverse effects of the habit and government has to ban these products.[21]

Primary health-care professionals and dentists should also help the public in quitting these habits by participating in the programs.[22]


  Conclusion Top


The current study provides information on OSMF disease in school-going children and their early attraction to areca nut products due to the ease of availability near schools. The need of the hour is to create awareness and management of these lesions among the general population as well. There is an urgent need to create awareness among the public about the adverse effects of such products. However, the Supreme Court, Government of India, and other state governments must put forward specific strategies to ban such commercial products.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Pindborg JJ, Sirsat SM. Oral submucous fibrosis. Oral Surg Oral Med Oral Pathol 1966;22:764-79.  Back to cited text no. 1
    
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Oakley E, Demaine L, Warnakulasuriya S. Areca (betel) nut chewing habit among high-school children in the Commonwealth of the Northern Mariana Islands (Micronesia). Bull World Health Organ 2005;83:656-60.  Back to cited text no. 14
    
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Dere K, Choudhary P, Bhaskar V, Ganesh M, Venkataraghavan K, Shah S. Prevalence and characteristics of chewing habits of areca nut, gutka and tobacco among school children of rural areas in and around Gandhinagar District, Gujarat. J Adv Oral Res 2014;5:20-6.  Back to cited text no. 17
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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