The Role of Selected Habits, Periodontal Disease and Oral Hygiene Status on the Occurrence and Prognosis of Oral Mucosal Lesions

Background & Aim: Patients presenting with an array of benign oral mucosal diseases to oral & maxillofacial (OMF) units practicing risk habits such as betel chewing could be at high risk of poor oral health and progressing into Oral Potentially Malignant Disorders (OPMD) or oral cancer. Against this backdrop, we investigated the possible role of selected habits, periodontal disease an oral hygiene in occurrence and prognosis of oral mucosal lesions, among a cohort of patients in Sri Lanka. Material & Methods: The study included newly diagnosed patients aged >18-years presented with benign oral mucosal diseases. The sample comprised of 134 patients. The data were collected by a pre-tested validated interviewer-administered questionnaire which comprised of socio-demographic information, information on risk habits and data on clinical oral examination for oral hygiene and periodontal disease status. Results: Descriptive statistics and Chi-Square test of statistical significance were used. The leading mucosal condition was fibro epithelial polyp (41.1%) followed by lichenoid reaction (31.3%). Majority attained General Certificate of EducationAdvanced level and ordinary levels education (33.6% and 30.6%) respectively. By occupational status, there was a variation ranging from skilled and unskilled laborer’s (35.1%) to 23.1% of professionals. Moreover, 26.9% of patients were chewing betel on a daily basis while another 14.2% at certain times. Frequency of betel chewing was significantly associated with male gender, moderate to poor oral hygiene, moderate to severe periodontal disease status (p=0.001). Whilst levels of education and occupational status were significantly associated with above conditions (p<0.05). Conclusions: Present findings provided new insights into the unharnessed potential of patients presented to OMF units with benign oral mucosal diseases for primordial and primary prevention and control of OPMD and oral cancer.


Introduction
Patients with an array of benign oral mucosal diseases comprising fibro-epithelial polyps, lipomas and lichen planus commonly present to Oral & Maxillofacial units. While managing their specific conditions, it is important to assess for their risk habits such as betel chewing which is associated with a high burden of periodontal disease as evident from research findings [1][2][3]. Moreover, recent research has found the association of periodontal disease with increased risk for an array of cancers [4][5][6]. In addition, several systematic reviews and some research articles as well have suggested periodontal disease as an independent emerging risk marker for oral cancer [7][8][9], however could be attenuated when adjusted for major confounding factors such as smoked and smokeless tobacco and alcohol use [7].
Betel chewing with or without tobacco is related to oropharyngeal cancers and its preceding condition, oral potentially malignant disorders (OPMD) as a dominant etiological and risk factor [10,11]. This relationship has garnered interest among many researchers across the globe from public health perspectives through to molecular perspectives [10]. Betel chewing is a lifestyle-related risk factor deeply ingrained into the sociocultural fabric of many Asia-Pacific countries since antiquity [11,12] thereby gaining recognition of betel quid as a socially endorsed masticatory product [8]. Recent research evidence demonstrates several mechanisms of carcinogenesis associated with betel quid and its ingredients such as tobacco, areca nut and slaked lime. For example, tobacco and areca nut specific carcinogens such as nitrosamine, polycyclic aromatic hydrocarbons, metals and metalloids, aldehydes and a consortium of co-carcinogens have been reported [13][14][15]. Furthermore, the prominent contribution of carcinogenic ingredients of betel quid on down regulation of antioxidant proteins and induction of reactive oxygen species influenced by oncogenes, epigenetics and immune modulation has been well appraised [16][17][18]. The dose-response relationship between betel chewing and increased risk for OPMD and oral cancer augmented by the duration of practice has also been established [19][20][21]. Moreover, this habit has been linked to an array of oral mucosal diseases ranging from chewer's mucosa to OPMD, high burden of periodontal disease and poor oral hygiene [22][23][24]. In addition, there is research evidence to suggest that the betel chewing was related to metabolic syndrome, the precursor condition for many non-communicable diseases [25,26].
The oral cavity harbors the second most diverse microbial community in the body with over 700 bacterial species [23]. Poor oral hygiene status is an established risk factor for periodontal disease, one of the most common oral diseases which demonstrate polymicrobial synergism [27]. Therefore, recent research evidence suggests the possibility of dysbiosis of oral microbiome induced by risk habits such as betel chewing and its possible association with initiation and progression of oral carcinogenesis [23]. Interestingly, recent molecular microbiological studies revealed that betel chewing contributed to significant alterations in the oral flora with increased proportions of periodontal pathogens such as Actinomyces, Tannerella, and Prevotella compared to non-chewers [25]. On the contrary, there is wealth of evidence for beneficial protective effects of daily fruit and vegetable consumption for an array of cancers including oral cancer [28][29][30]. However, there is research evidence to support low levels of daily fruit and vegetable consumption among high-risk groups for OPMD and oral cancer in developing countries [31,32].
Sri Lanka is a lower-middle-income-developing country with 21.67 million population and US$ 3,991 per capital income [33]. The most recently published Sri Lankan cancer incidence data reported 2,199 incidence oral cancer cases for the year 2014 [34]. Lip, tongue and mouth cancer was the leading cancer type among men, accounting for 15.7% of all cancers and ranked 8 th among women representing 4% of all cancer sites for women [34]. Therefore, any attempt to reduce the burden of oral cancer and OPMD should harness the potential of primordial and primary preventive strategies and opportunities.
Patients seeking health care with benign oral mucosal diseases could be at high risk of progressing into OPMD or oral cancer especially if they practice harmful risk habits such as betel chewing. Against this backdrop, present study aims to investigate the pattern of oral mucosal disease, selected habits and related factors among a cohort of patients in Sri Lanka. Additionally, we explore the possible role of selected habits, periodontal disease an oral hygiene in occurrence and prognosis of oral mucosal lesions, among a cohort of patients in Sri Lanka.

Materials and Methods
A cross-sectional descriptive study was conducted among patients aged >18-years presented with benign oral mucosal diseases. The newly diagnosed patients were included while those who were already on treatment were excluded from the study. The study setting was Oral & Maxillo-Facial Unit D, Dental Institute, Colombo currently upgraded to National Dental Hospital (Teaching) Sri Lanka, the premier, multispecialty public dental hospital in Sri Lanka. absolute precision of 5% and 90% prevalence of moderate to poor oral hygiene among patients with oral mucosal lesions based on a pilot study conducted elsewhere. The calculated sample size was 138, however, due to incomplete data 4 were excluded. The inclusion criteria were age ≥ 18-years diagnosed with oral mucosal lesions whilst those who had oral cancers and oral potentially malignant disorders were excluded. As recruitment of participants were done on outpatient clinic days there could have been possible selection bias and as the data on habits were collected based on self-reports of respondents there could be possible recall bias. However, measures were taken to control for biases and confounders by adherence to study protocol. The conditions were diagnosed clinically and histopathologically as needed. The data were collected by a pre-tested validated interviewer-administered questionnaire used for a previous study [36]  Data were entered and analyzed using SPSS-21 statistical software package. Descriptive statistics and chi-square test of statistical significance for group comparisons were employed for data analysis. Informed consent was obtained from participating patients. The ethics approval for the study was obtained from Sri Lanka Medical Association (ERC-15008).

Results
As shown in Figure 1, the leading type was fibro-epithelial polyps followed by lichen planus/lichenoid reactions.
As shown in Table 1, the majority 50.7% patients were aged 40-59 years while there were 61.2% of males. Majority of patients had attained an educational attainment of G.C.E. Advanced level and Ordinary levels (33.6% and 30.6% respectively). By occupational status, the majority were skilled and unskilled laborers (35.1%) and there was 23.1% of professionals. However, the sample comprised of 34.3% housewives who were females not in formal employment. Table 2, majority of patients reported betel chewing and daily consumption of vegetables.

As shown in
As illustrated in Figure 2A & B, the majority of patients had moderate to poor oral hygiene status and moderate to servere periodontitis.    Table 3 demonstrates the association of sociodemographic characteristics, plaque levels and periodontal disease status by the frequency of betel chewing habits among patients. Accordingly, higher proportions of one year back and daily betel chewers had moderate to poor oral hygiene status (80.0% and 66.7% respectively) compared to never betel chewers (27.0%). Furthermore, same pattern was evident with periodontal disease burden with more daily betel chewers (45.5%) having moderate to severe periodontal disease compared to never betel chewers (13.2%) and those differences were statistical highly significant (p=0.0001).
As shown Table 4, a higher proportion of patients with lower level of education significantly presented

Discussion
Patients presented with benign oral mucosal diseases to health care facilities provide a window of opportunity for improving their oral health status. Patients with oral mucosal lesions could be at elevated risk of getting OPMD and oral cancer especially if they practiced frequent betel chewing habit. This notion was further supported by the highly significant association of male gender with frequency of betel chewing. Moreover, as there was presentation of younger adults the findings indicated an opportunity to harness the potential to introduce primordial and primary preventive strategies in getting into the habit of betel chewing with or without tobacco.
The oral hygiene status and periodontal disease status of patients presented with benign oral mucosal diseases needs exploration for possible intervention. The literature on prevalence of oral mucosal diseases among different population groups with varying age and gender distribution as well as heterogenous mucosal conditions [39,40]. In the current sample the most prevalent oral mucosal condition was fibro epithelial polyp (41.1%), however, among Lebanese population it was hairy tongue (17.4%) [39] whereas Fordyce granules (3.8%) [40] among Saudi patients with wider age variation ranging from 15-73 years thus comparable to current study findings. The differences in life-style related risk habits, dietary habits and socio-cultural differences in population groups could influence varying oral mucosal lesions that occur in them. Furthermore, in the current sample 41.1% were betel chewers and 31.3% of patients presented with lichenoid lesions as studies have reported an association between betel chewing and lichenoid lesions which is a betelquid associated oral mucosal disease [22]. However, its prevalence was 10.4% among a cohort of Indian betel chewers which was much lower compared to present study [41]. Moreover, authors of a review that described the clinical and pathological aspects of oral lichenoid contact lesions caused by areca nut and betel quid, stated that this condition garnered limited attention in the published literature [42]. Therefore, it is timely to conduct more research on betel quid associated lichenoid reaction among different populations.
As frequent betel chewing contributes to poor oral health status and periodontal disease status, intervening on such risk habits contribute to beneficial effects. Improving oral hygiene of patients presenting to Oral & Maxillofacial (OMF) units had not garnered recognition as a priority despite voluminous evidence on its association with increased risk of oral cancer [27]. A previous study reported the poor oral hygiene status and high periodontal disease burden of male oral cancer patients in Sri Lanka and the significant association of frequent betel chewing with the above [36]. Hence, current findings on a cohort of Sri Lankan patients with benign oral mucosal diseases corroborated the findings of that study.
It has been recommended to include interventions to improve oral hygiene and periodontal disease of oral cancer patients as well as reducing their risk habits taken their levels of education into consideration in standard management protocols [36]. In contrast to findings among male oral cancer patients [36], age and educational attainment were not significantly associated with betel chewing habit among benign oral mucosal disease patients. This could be plausibly attributed to sociodemographic differences among two groups as oral cancer patients were dominated by older ages and low levels of educational attainment compared to oral mucosal disease patients. The latter group was dominated by younger age groups who had a higher level of educational attainment [36]. Therefore, such a demographic profile provided an opportunity to harness for interventions on risk habit reduction and enhancing healthy habits. In addition, improving the diets of those patients with a variety of fruits in addition to vegetables they consumed could have beneficial effects on them [43]. Despite the younger age groups, higher levels of education and occupational status, the fair proportion of oral mucosal disease patients demonstrated moderate to poor oral hygiene in the present study. Moreover, as little over quarter of patients had moderate to severe periodontitis the findings indicated the need for improving the periodontal health status of those patients. Not surprisingly lower level of education and occupational status were significantly associated with moderate to poor oral hygiene status and periodontal disease status among the current sample. Low levels of education and occupational status negatively impact on hygiene practices due to poor knowledge, attitudes and economic constraints [44]. Recent research evidence suggested the importance of oral hygiene for betel chewers to control bacterial pathogen related oral diseases such as periodontitis [45].
Findings of the present study should be interpreted cautiously due to small sample size and less vigorous statistical models used. Therefore, further research warranted with larger sample sizes and rigorous multivariate analyses.
In conclusion, present findings suggest the need for standard management protocols for patients with oral mucosal lesions embracing interventions to improve their oral hygiene and periodontal disease with risk habit intervention.