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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 30-33

Prevalence of oral submucous fibrosis among habitual gutkha and areca nut chewer in Bihar population: A community-based research

1 Department of Orthodontic, Buddha Institute of Dental Science, Patna, Bihar, India
2 Department of Oral Medicine and Radiology, Buddha Institute of Dental Science, Patna, Bihar, India

Date of Submission12-Mar-2020
Date of Decision18-May-2020
Date of Acceptance23-Sep-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Kriti Singh
Department of Oral Medicine and Radiology, Buddha Institute of Dental Science, Patna, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_39_20

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Background: The aim of the study was to determine the prevalence and severity of oral submucous fibrosis (OSMF) among habitual gutkha, areca nut, and pan chewers of Bihar population. Materials and Methods: The study was conducted of 3000 adult patients aged over 15 years who visited the Department of Oral Medicine and Radiology, Buddha Institute of Dental Sciences and Hospital. They were subjected to a thorough oral examination, and the bindings were recorded in the prescribed WHO Pro forma. Results: Our study revealed that the prevalence of OSMF was 1.6%. The prevalence among males was 2.60% and among females was 0.16%. All the 243 cases (100%) were associated with areca nut habits. Conclusion: Educating the population about the deleterious effects of the practice of tobacco and related habits on the body in general and the oral cavity. It is hoped that this study would serve as a reference for further epidemiological studies on the abovementioned lesion in this region.

Keywords: Areca nut, gutkha, oral submucous fibrosis

How to cite this article:
Chauhan R, Singh AK, Singh K, Rani K, Anand K, Tiwari A. Prevalence of oral submucous fibrosis among habitual gutkha and areca nut chewer in Bihar population: A community-based research. Indian J Dent Sci 2021;13:30-3

How to cite this URL:
Chauhan R, Singh AK, Singh K, Rani K, Anand K, Tiwari A. Prevalence of oral submucous fibrosis among habitual gutkha and areca nut chewer in Bihar population: A community-based research. Indian J Dent Sci [serial online] 2021 [cited 2021 Jan 16];13:30-3. Available from: http://www.ijds.in/text.asp?2021/13/1/30/305974

  Introduction Top

In the era of the fast growth of industrialization and urbanization, the result of this growth and progress, human beings are subjected to more physical and mental stress. Humans react to this stress by adopting stress-relieving habits such as smoking, alcohol, betel nut chewing, and pan chewing etc.[1]

These adverse habits do much harm than good to a human being. This habit has many detrimental effects on the human body, apart from being addictive[2]. Due to these habits and cultural practices, human has been abusing the oral cavity. In day-to-day clinical practice, medical practitioners and dental surgeons often encounter a wide spectrum of oral mucosal lesions.

One such pathological condition is oral submucous fibrosis (OSMF). It is a peculiar, chronic progressive, insidious, irreversible, crippling disease of the oral cavity characterized by fibrotic change and severe burning sensation[3],[4],[5] with restricted mouth opening.[3]

The disease affects the most part of oral cavity as well as the upper third of the esophagus. The disease is characterized by blanching and stiffness of oral mucosa, followed by trismus and burning sensation in the mouth. It also produces hypomobility of the soft palate and tongue and loss of gustatory sensation. [4] There can be mild hearing impairment due to blockade of the  Eustachian tube More Details.

Malignant transformation rate of OSMF was found to be in the range of 7%–13%.

The disease is predominantly seen in India, Bangladesh, Sri Lanka, Pakistan, Taiwan, and China, with a reported prevalence ranging up to 0.4% in the Indian rural population.[5]

  Materials and Methods Top

This prospective study has been conducted in the Department of Oral Medicine, Diagnosis and Radiology and Oral and Medicine and Radiology of a Buddha Institute of Dental Sciences and Hospital. The study was conducted in September 2019–December 2019. A total of 3000 patients were examined, in which 243 patients were diagnosed as OSMF.

Patients who reported with the limited mouth opening and associated blanched oral mucosa with palpable fibrous bands were screened and those patients who were diagnosed clinically having OSMF were included in the present study. Pro forma was provided to the patient to fill up the information regarding the type of habit, type of placement of areca nut, and its product.

Criteria for the diagnosis of OSMF were followed according to the workshop held in Kuala Lumpur, Malaysia, in 1996.

OSMF can be diagnosed on the basis of the presence of one or more of the following characteristics:

  1. Presence of palpable fibrous bands
  2. The mucosal texture feels tough and leathery
  3. Blanching of the mucosa together with the histopathological features characteristic of OSMF.

Patients were divided into four groups according to severity, according to the criteria from a study done by Ranganathan et al.

The criteria taken were mouth opening as follows.

  • Grade I: Only symptoms with no demonstrable restriction in mouth opening
  • Grade II: Limited mouth opening. 20 mm and above
  • Grade III: Mouth opening < 20 mm
  • Grade IV: OSMF advanced with limited mouth opening. Precancerous or cancerous changes are seen throughout the mucosa.

Study design

After obtaining ethical clearance from the institutional review board, a cross-sectional study of stratified random technique 243 habitual chewers were selected. The study was conducted in the time period of 1 year from July 2018 to June 2019. The study population comprised rural and urban areas in close proximity.

Sample size and technique

Two hundred and forty-three individuals of the age range of 16–60 years were selected using a stratified random sampling technique from the rural and urban population.

Inclusion criteria

  • Patients with habit of chewing areca nut, pan, and gutkha.
  • Patients who were diagnosed clinically having OSMF were included in the present study.

Exclusion criteria

Patients with limitation of mouth opening due to other causes such as odontogenic infections and joint disorders were excluded from the study.

Informed consent for each patient and biopsies were included in the study. The tissue samples were taken from the affected areas and then studied histopathologically. The data were analyzed statistically using t-test.

  Results Top

A total of 243 adults over the age range of 11–60 years were examined. Among them, 213 were males and 30 were females. Among 243 adults, 90.32% had chewing habits and 9.68% had smoking habits.

All the cases of OSMF were associated with tobacco and related habits. It was observed that the prevalence of OSMF among males was 2.6% and among females was 1.16%. The combined prevalence for both males and females was 1.96%. The difference in the prevalence among males and females was statistically significant

Maximum number of patient were of Grade 2 OSMF and minimum number of patient were of Grade 4 OSMF. [Figure 1] showing prevalence of various grades of OSMF.
Figure 1: Prevalence of various grades of oral submucous fibrosis

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Maximum number of patient were seen in 20-30 year age range and minimum number of patient were seen in 50- 60 years of life. [Figure no 2] showing distribution of various Grades of OSMF according to the age of the patient.
Figure 2: Distribution of various grades according to the age of the patient

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[Table 1] shows the distribution of study participants according to the type of habit.A maximum number of patients were seen with an adverse habit of tobacco chewing 1–5 packets per day in duration of more than 10 min.[Table no 2] showingduration frequency number of subjects and Grades of OSMF.
Table 1: Duration Frequency Number of subjects and Grades of OSMF

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Table 2: Corelation of various grades of oral submucous fibrosis and areca nut chewing

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Among all the patients, a maximum number of male and female patients were seen in Grade 2 OSMF patients that 91 male and 15 female patients. [Figure 3] showing prevalence in male and female population in various grades of OSMF.
Figure 3: Prevalence in male and female population in various grades of oral submucous fibrosis

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  Discussion Top

Chewing areca nut in a betel quid has a long history, which is deeply ingrained in many sociocultural and religious activities[7],[8],[9],[10],[11]. In ancient Sanskrit literature, as early as the 1st century BC references to betel nut appear. Areca nut with the ancient history of chewing in the Indian subcontinent, OSMF is commonly seen[11],[12],[13],[14],[15].

Areca nut incorporated in betel quid is the fourth most common psychoactive substance in the world. Its use is extending to several hundred million people. It has been reported that that betel quid is used by about 10%–20% of the world's population and that globally up to 600 million users chew areca nut.[3]

In this present prospective study, there were 243 patients (213 males and 30 females) who were identified and diagnosed clinically for having OSMF. Although OSMF affects both genders, male predominance for this condition has been noted in many studies.

In our present study, 213 (87.6%) males were dominating. The male-to-female ratio was 7.1:1, which was quite high when compared to earlier studies. Thakur et al, in their studies, reported a male to female ratio of 2.7:1.[3] However, a male predominance for this condition has been noted in several studies.[7] The reason for male predominance is because of the availability of gutkha and other related products among young people. Males are the working gender and money earner among the Indian subcontinent. Areca nut/ betel quid, gutkha is chewed for various reasons as it act as stress reliever, mouth freshener.Females are more conscious about their esthetic values and it is considered socially unacceptable for a female. All the female patients in present study with OSMF were addicted to areca nut or betel quid, none of the showed addiction to gutkha.

In contrast to the present study, female predominance also has been noted in many studies. As these studies were done in the 70s and 80s, it was common a few decades earlier for females to chew areca nut for digestion after having food.[10]

In the present study, the age of subjects was ranging from 20 years minimum to 61 years maximum with a mean of 38.6 years. It is similar to another hospital-based study by Ahmed where they reported the majority of the OSMF cases belonged to 21–40 years of age group. Sirsat reported OSMF cases from 20 to 40 years of age.[11] According to a population-based relation studies in India conducted by Bhosle et al. (1987) the mean age of the 27 patients was 37 years which was significantly lower compared to the mean age of 64 patients in Ernakulum which was 52 years.[16],[17],[18],[19],[20],[21],[22],[23],[24],[25]

In the present study, gutkha chewers showed more predominance of Grade II and Grade I stages of OSMF, and the mean duration was much less when compared to those having betel quid and mawa.

The abrasive nature of areca nut causes continuous local trauma and irritation to the oral mucosa, leading to morphological changes in the oral mucosa.[25]

The reason for increased severity and risk of developing OSMF in gutkha chewers is due to more dry weight of areca nut releasing high amount of arecoline. The dry weight of areca nut in gutkha sachets is 3.26 g, whereas that in betel quid is 1.14 g; therefore, the betel quid chewers show less amount of severity, as the betel leaf contains beta-carotene, which has the capacity to neutralize the free radicals that are released from the areca nut.

  Conclusion Top

OSMF is a commonly occurring premalignant condition increasingly affecting the youth. The occurrence of OSMF in gutkha chewers is more faster and more severe as compared in other forms of areca nut product chewers. The easy availability and promotions of these areca nut products, specially gutkha and pan masala outside the schools, colleges, and social places, have impacted young population in India, due to which has led to the increased occurrence of OSMF, a premalignant condition and malignancies such as squamous cell cancer. Control on the use of areca nut and its products in various forms, specially gutkha and pan masala, is essential.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rao PK. Efficacy of alpha lipoic acid in adjunct with intralesional steroids and hyaluronidase in the management of oral submucous fibrosis. J Cancer Res Ther 2010;6:508-10.  Back to cited text no. 1
Misra SP, Misra V, Dwivedi M, Gupta SC. Oesophageal subepithelial fibrosis: An extension of oral submucosal fibrosis. Postgrad Med J 1998;74:733-6.  Back to cited text no. 2
Thakur N, Keluskar V, Bagewadi A, Shetti A. Effectiveness of micronutrients and physiotherapy in the management of oral submucous fibrosis. Int J Contemp Dent 2011;2:101-5.  Back to cited text no. 3
Aziz SR. Lack of reliable evidence for oral submucous fibrosis treatments. Evid Based Dent 2009;10:8-9.  Back to cited text no. 4
Pindborg JJ. Oral submucous fibrosis: A review. Ann Acad Med Singapore 1989;18:603-7.  Back to cited text no. 5
Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya S. Oral submucous fibrosis: Review on etiology and pathogenesis. Oral Oncol 2006;42:561-8.  Back to cited text no. 6
Murti PR, Bhonsle RB, Pindborg JJ, Daftary DK, Gupta PC, Mehta FS. Malignant transformation rates in oral submucous fibrosis over a 17 year period. Community Dent Oral Epidemiol 1985;13:340-1.  Back to cited text no. 7
Murti PR, Bhonsle RB, Gupta PC, Daftary DK, Pindborg JJ. Etiology of oral submucous fibrosis with special reference to the role of areca nut chewing. J Oral Pathol Med 1995;24:145-52.  Back to cited text no. 8
Reichart PA, Philipsen HP. Oral submucous fibrosis in a 31-yearold Indian women: First case report from Germany. Mund Kiefer Gesichtschir 2006;10:192-6.  Back to cited text no. 9
Hayes PA. Oral submucous fibrosis in a 4-year-old girl. Oral Surg Oral Med Oral Pathol 1985;59:475-8.  Back to cited text no. 10
Gupta PC, Mehta FS, Daftary DK, Pindborg JJ, Bhonsle RB, Jalnawalla PN, et al. Incidence rates of oral cancer and natural history of oral precancerous lesions in a 10 year follow up study of Indian villages. Community Dent Oral Epidemiol 1980;8:287-333.  Back to cited text no. 11
Ahmad MS, Ali SA, Ali AS, Chaubey KK. Epidemiological and etiological study of oral submucous fibrosis among gutkha chewers of Patna, Bihar, India. J Indian Soc Pedod Prev Dent 2006;24:84-9.  Back to cited text no. 12
[PUBMED]  [Full text]  
Khanolkar VR. Sub mucous fibrosis of the palate in diet. Pre conditioned Wister rats: Induction by local painting of capsaicin-an optical and electron microscopic study. Arch Pathol 1960;70:171-9.  Back to cited text no. 13
Bhonsle RB, Murti PR, Daftary DK, Gupta PC, Mehta FS, Sinor PN. Regional variations in oral submucous fibrosis in India. Community Dent Oral Epidemiol 1987;15:225-9.  Back to cited text no. 14
Reichart P, Boning W, Srisuwan S, Theetranout C, Mohr U. Ultrastructural finding in the oral mucosa of betel chewers. J Oral Pathol 1984;13:166-77.  Back to cited text no. 15
Gupta PC, Ray CS. Smokeless tobacco and health in Indian and South Asia. Respirology 2003;8:419-31.  Back to cited text no. 16
Lee CH, Ko YC, Huang HL, Chao YY, Tsai CC, Shieh TY, et al. The precancer risk of betel quid chewing, tobacco use and alcohol consumption in oral leukoplakia and oral submucous fibrosis in southern Taiwan. Br J Cancer 2003;88:366-72.  Back to cited text no. 17
Maher R, Lee AJ, Warnakulasuriya KA, Lewis JA, Johnson NW. Role of areca nut in the causation of oral submucous fibrosis: A case control study in Pakistan. J Oral Pathol Med 1994;23:65-9.  Back to cited text no. 18
Yang YH, Lee HY, Tung S, Shieh TY. Epidemiological survey of oral submucous fibrosis and leukoplakia in aborigines of Taiwan. J Oral Pathol Med 2001;30:213-9.  Back to cited text no. 19
Nair U, Bartsch H, Nair J. Alert for an epidemic of oral cancer due to use of the betel quid substitutes gutkha and pan masala: A review of agents and causative mechanisms. Mutagenesis 2004;19:251-62.  Back to cited text no. 20
Macfarlane GJ, Zheng T, Marshall JR, Boffetta P, Niu S, Brasure J. Alcohol, tobacco, diet and the risk of oral cancer: A pooled analysis of three case-control studies. Eur J Cancer 1995;31:181-7.  Back to cited text no. 21
Stich H, Mathew B, Sankaranarayanan R, Nair MK. Remission of oral precancerous lesions of tobacco/areca nut chewers following administration ob beta-carotene or vitamin A, and maintenance of the protective effect. Cancer Detect Prev 1991;15:93-8.  Back to cited text no. 22
Howell RE, Wong FS, Fenwick RG. A transforming Kirsten ras oncogene in an oral squamous carcinoma. J Oral Pathol Med. 1990 Aug;19:301–5.  Back to cited text no. 23
Smita, Afjal M, Siddiqui YH. Genotoxic effects of pan masala and gutkha: A review. World J Zool 2011;6:301-6.  Back to cited text no. 24
Tsai CC, Ma RH, Shieh TY. Deficiency in collagen and fibronectin phagocytosis by human buccal mucosa fibroblasts in vitro as a possible mechanism for oral submucous fibrosis. J Oral Pathol Med 1999;28:59-63.  Back to cited text no. 25


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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