ISSN: 2456-8090 (online)

DOI: 10.26440/IHRJ/0412.03391

 

Distribution of Oral Submucous Fibrosis Cases and Malignant Transformation Rate among Bhutanese Patients Treated at Jigme Dorji Wangchuck National Referral Hospital, Bhutan

PRATAP SINGH TAMANG1, GYAN PRASAD BAJGAI1, HARI PRASAD POKHREL*2

 

Cite this article as: Tamang PS, Bajgai GP, Pokhrel HP. Distribution of Oral Submucous Fibrosis Cases and Malignant Transformation Rate among Bhutanese Patients Treated at Jigme Dorji Wangchuck National Referral Hospital, Bhutan. Int Healthc Res J. 2021;4(12):OR7-OR10. https://doi.org/10.26440/IHRJ/0412.03391

 

Author Affiliations:

  1. Department of Dentistry, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan.
  2. Gidakom Hospital, Ministry of Health, Thimphu, Bhutan (https://orcid.org/0000-0003-4421-7378).

 

Contact Corresponding Author at: hari88pokhrel[at]gmail[dot]com

 

ABSTRACT

BACKGROUND: Oral Submucous Fibrosis (OSMF) is a chronic, insidious, scarring disease of the mouth often involving the palate, oro-pharynx, pharynx, esophagus, tongue and the buccal mucosa which leads to ulceration, blanching and ultimately limited mouth opening. The aim of the study is to describe the age, gender and district-wise distribution of oral submucous fibrosis cases and to assess the malignant transformation rate among the patients with oral submucous fibrosis who were treated at Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan.

MATERIALS AND METHOD: This is a descriptive retrospective study. The patients were clinically diagnosed by examining their mouth and by measuring their mouth opening (Inter-incisal height). Patients who had less than 3 fingers mouth opening and diagnosed as Oral submucous fibrosis (OSMF) during these three-year period from 2018 to 2020 were considered for the study.

RESULTS: There were 278 cases in total. Thimphu district had the maximum number of cases followed by Wangduephodrang and Samtse. Gasa and Haa districts had the minimum cases. More males were affected than females. The malignant transformation rate among these patients was 4.3%.

CONCLUSION: Thimphu district had the highest proportion of OSMF cases and was almost equally distributed among genders. Over 90% of the patients reported improvement without surgery while the malignancy transformation rate was 4.3%. The study recommends conducting screening in districts with high burden of OSMF cases for early diagnosis and treatment.

 

KEYWORDS: Oral Submucous Fibrosis, Distribution, District, Bhutan

 

INTRODUCTION

Oral Submucous Fibrosis (OSMF) is a chronic, insidious, scarring disease of the mouth often involving the palate, oro-pharynx, pharynx, esophagus, tongue and the buccal mucosa which leads to ulceration, blanching and ultimately limited mouth opening. Epidemiological data and intervention studies suggest that betel nut and its products are the main etiological factors for development of OSMF.1 Other factors are chillies, lime, tobacco, nutritional deficiencies such as iron and zinc, immunological disorders, collagen disorders, GERD, smoking or chewing tobacco, alcohol and certain syndromic diseases.1-4 OSMF is a pre-cancerous condition which has the potential to turn into cancer.  It has one of the highest rates of malignant transformation among potentially malignant oral lesions and conditions.5 

Mouth opening is restricted in this disease along with pain and burning sensation in the mouth. In most of the cases, these are the only reasons patients visit hospital for care and support. The primary aim of the treatment is to increase mouth opening and rendering them asymptomatic while eating.6 The normal range of mouth opening differs from person to person, varying between 40 – 60 mm with an average between 35 – 55 mm which is equal to the width of three fingers.7,8 In general, males display greater mouth opening than females. 7,8 There are numerous classifications used for classifying the severity of mouth opening. Passi D et al., classified the mouth opening as; Grade I- mouth opening up to 35 mm, Grade II- mouth opening between 25-35 mm, Grade III- mouth opening between 15-25 mm and Grade IV where mouth opening is less than 15 mm to nil.9 

The South East Asian region has a higher prevalence of OSMF compared any other part of the world which can be attributed to habit of chewing betel and betel products.1,2 Betel wrapped in betel leaf along with different spices is consumed in parts of India, Bangladesh, Nepal, Pakistan and Thailand. In Bhutan, it is customary to offer betel during functions and festivals, which is chewed by wrapping it in a betel leaf along with lime. However, there is limited data about the topic in Bhutan. Thus, this study describes the age, gender and district wise distribution of oral submucous fibrosis cases and malignant transformation rate among   the   patients   with   oral   submucous  fibrosis who were treated at the dental department of JDWNRH from 2018 to 2020. 

MATERIALS AND METHOD

This is a retrospective study conducted at Jigme Dorji Wangchuck National Referral Hospital, Bhutan. Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) is the apex hospital in the country and caters to all complex medical, surgical and dental cases referred in from district hospitals. Patients were clinically diagnosed by examining their mouth and by measuring their mouth opening (Inter-incisal height). Patients who had less than 3 fingers mouth opening and diagnosed as Oral submucous fibrosis (OSMF) during the three-year period from 2018 to 2020 were considered for the study. Malignant transformations were confirmed by biopsy and histopathological examinations. Radiographic examination including X-Rays and CT, MRI were also done in confirmed cancer cases to assess the involvement of other structures like the jaw, brain, neck and cervical lymph nodes. Ethical approval for the study was obtained from the Research Ethics Board of Health (REBH), Ministry of Health, Bhutan. 

Data analysis: Data collected was double entered and validated using Epi-Data version 3.1 and analyzed using Microsoft Excel. The findings are presented as frequencies and percentages.

RESULT

There were a total of 278 OSMF cases recorded in the past three years. Over half (54.7%) of the participants were male and a majority (77%) of them in the age group 19-59 years (table 1). 

Case distribution is presented in table 2. OSMF cases were present in all the twenty districts of Bhutan. Thimphu district had the highest proportion of cases (14%) while Gasa had the lowest proportion (2.2%).

Prognosis / Outcome of the patients is being presented in table 3. Majority (90.6%) of the participants reported improvement without surgery while 4.3 % had transformation to cancer. 

Alternate link to Tables/Figures (Copy and paste link in new browser window): https://drive.google.com/file/d/1FbYbcEM60DkhLNgbcwXSFtU552GCce_4/view?usp=sharing

DISCUSSION

Thimphu had the highest proportion of OSMF cases which can be attributed to larger population as Thimphu is also the capital of Bhutan. The malignancy transformation rate to cancer was 4.3%. There are different studies suggesting malignant transformation rates of OSMF. According to one of the recent studies, it is seen that it has increased from 0.03% to 6.42% in India.1 According to Chourasia et al. the incidence of malignant transformation to oral squamous cell carcinoma in patients of untreated oral submucous fibrosis is 4.2%.10 The incidence of oral cancer concomitant with oral submucous fibrosis is found to be 25.77 % by the same study.10  It was observed that OSMF developed on one side of the buccal vestibule where they kept and chewed betel and tobacco products while the other side was normal.4 There is no effective treatment for OSMF.3 In OSMF, the incidence of oral cancer is 7.6 per cent for a median 10-year follow‐up period. Risk markers for malignant transformation in OSMF include epithelial dysplasia, and p53 tumor suppressor gene mutations.11 In normal patients mouth opening is more in males than females.7  However, there was no difference in mouth opening between males and females in diseased condition (OSMF). Early and timely diagnosis and treatment is important for good prognosis of the disease. 

CONCLUSION

Thimphu district had the highest proportion of OSMF cases and was almost equally distributed among genders. Over 90% of the patients reported improvement without surgery while the malignancy transformation rate was 4.3%. The study recommends conducting screening in districts with high burden of OSMF cases for early diagnosis and treatment. 

Acknowledgement: The authors would like to thank all staffs of dental department for their help and management of the hospital for permitting us to conduct this study. 

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©  Pratap Singh Tamang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY-NC 4.0, which permits unrestricted use, distribution and reproduction in any medium, provided the use is not commercial and the original author(s) and source are cited.