Year : 2008 | Volume
: 19 | Issue : 4 | Page : 349--353
Utilizing dental colleges for the eradication of oral cancer in India
Department of Community Dentistry, Mar Baselios Dental College, Kothamangalam, Ernakulam District, Kerala, India
Department of Community Dentistry, Mar Baselios Dental College, Kothamangalam, Ernakulam District, Kerala
Dental education in India has grown in such a way that it ranks first in the world in having the highest number of dental schools. There are 240 dental schools all over the country. Paradoxically, even with this large number of dentists and dental institutions, India contributes to the highest number of incident cases of oral cancer. In India, oral cancer burden approximates to 20-30% of all cancers. The plausible reason for this high incidence of oral cancer could be expounded on the fact that there exists a high usage of tobacco within the country. The evidence for the high prevalence of using chewable tobacco products, especially in the youth, was recently reported in the Global Youth Tobacco Survey. This increasing usage of chewing tobacco and related products will further accrue to the mortality and morbidity figures in the near future. To effectuate a breakthrough in the existing situation, the work force of dental schools could be capitalized on. The aim of this article is to present the burden of oral cancer in the country and identify trends in the prevalence of tobacco usage, which if continues could alert an epidemic of oral cancer in the near future; and how dental schools in the country can be utilized for preventing this upcoming epidemic.
|How to cite this article:|
Kuruvilla J. Utilizing dental colleges for the eradication of oral cancer in India.Indian J Dent Res 2008;19:349-353
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Kuruvilla J. Utilizing dental colleges for the eradication of oral cancer in India. Indian J Dent Res [serial online] 2008 [cited 2020 Feb 21 ];19:349-353
Available from: http://www.ijdr.in/text.asp?2008/19/4/349/44541
According to the international classification of diseases (ICD) classification and codes oral cancer is a malignancy of the lips and intraoral sites. Approximately 90% of oral cancers are primary squamous cell carcinomas arising from the lining mucosa of the mouth, most commonly the tongue and the floor of the mouth.  Although it is largely preventable,  if diagnosed late, the prognosis is poor and severe functional and cosmetic defects may accompany its treatment. In developed countries, for 80% of oral cancers, tobacco smoking and alcohol consumption are the commonest etiological risk factors, where as in India in addition to tobacco smoking and alcohol consumption, there also exists high usage of chewing tobacco. This is evident from the surveys carried out by National Family Health Survey (NFHS) and Global Youth Tobacco Survey (GYTS).
As an early sign of damage to the oral mucosa, chewers of betel quid (BQ) with or without tobacco often develop clinically visible whitish (leukoplakia) or reddish (erythroplakia) lesions, and/or stiffening of the oral mucosa and oral submucous fibrosis (OSF). All these well-established precancerous lesions are easily diagnosed and present an important indicator of oral cancer risk.
Global comparison shows that India has high incidence rates of cancers of oral cavity, pharynx, and cervix.  Age-standardized incidence rates per 100,000 population in India were estimated to be 12.8 in men and 7.5 in women.  The age-adjusted rates for tongue cancer are highest in Bhopal followed by Ahmedabad - both in India. Other cities in India like Chennai, Delhi, and Mumbai also closely follow in their tongue cancer rates. This burden considerably rises when the tongue and mouth cancers are computed together [Figure 1] and [Figure 2].
Tobacco smoking and heavy alcohol consumption are the main risk factors for oral cancer in developed countries,  where over 80% of the cases are attributable to these causes.  In India, in addition to tobacco smoking and alcohol consumption, there is also a high prevalence of chewing pattern. This is evident from the following reports.
Tobacco usage in India
India is the second largest producer of tobacco and also the second leading seller in the world. By present estimates, there are 185 million tobacco consumers in India. The prevalence of tobacco use varies widely by region; from 33-80% among men and 7-67% among women. Most of the tobacco produced in India is used within the country. The variety of forms in which tobacco is used is unique to India. Apart from the smoking forms that include cigarettes, bidis, and cigars, a plethora of smokeless forms too exist, which accounts to about 35% of the total tobacco consumption. Presently, there are around 60 cigarette-production units and about 1000 gutka- and pan masala-production units. In India patterns of tobacco use differ by gender, age, and class as well as region, but are marked by important emerging trends - in particular, shifting patterns of use among youth. However, little is known about such patterns of use or other important factors such as age of initiation.
The NFHS-2 conducted in 1998-1999, reported a prevalence rate of 28.3% for chewing tobacco and 29.4% for smoking tobacco in men aged 15 years and above. For women, the corresponding prevalence rates were 12.4 and 2.5 percents, respectively. This shows that adults in India use smokeless forms of tobacco products than smoking forms. This is a major contrasting feature of tobacco usage in India compared to other countries. This may be one of the major reasons for the high incidence of oral cancers in India.
Products used for chewing in India
From the early days itself, BQ is mainly used for chewing. It usually consists of four main ingredients: betel leaf (Piper betel), areca nut (Areca catechu), slaked lime [Ca (OH)2] , and catechu (Acacia catechu). Since the introduction of pan, tobacco has become an important ingredient of it and most of the habitual pan-chewers include tobacco along with pan. Here, the user himself prepares the pan suiting to his /her need. This is the conventional type of chewing.
Betel pan chewing and oral cancer
The relative risk for the development of oral cancer due to pan chewing is estimated as 25.3%. Population attributable risk percentage was observed to be 66.1 for tobacco chewers for the development of oral cavity cancer.  Studies have shown that BQ chewing without tobacco can also cause precancerous conditions in the oral cavity in the form of erythroplakia and OSF. 
Commercial betel quid substitutes: Pan masala and gutka
Betel leaf is perishable and preparation of BQ is somewhat complex or requires visits to shops selling pan/BQ. With the emergence of commercial pan masala and gutka about three decades ago, not only did the Indian market witness a massive growth in the sales of smokeless tobacco and areca nut products, but also a huge worldwide export market developed.
Pan masala is basically a preparation of areca nut, catechu, cardamom, lime, and a number of natural and artificial perfuming and flavoring materials. Gutka is a variant of pan masala, which in addition to these ingredients contain flavored chewing tobacco. Both products are often sweetened to enhance the taste.
The packaging revolution has made these products portable, cheap, and convenient, with the added advantage of a long shelf-life. Tobacco products which were usually consumed by a small section of the population are today part of the modern urban and rural lifestyle. Promoted by slick, high-profile advertising campaigns and aggressive marketing, pan masala and gutka have become very popular with all the sections of Indian society, including school children. For most children, teenagers, and women, cigarette smoking still remains a taboo in India. These alternative tobacco products are often advertised as being safer than conventional cigarettes, leading to a much higher frequency of use. This is found to be true as the recent GYTS reports.
Usage of chewing tobacco among the youths in India
The World Health Organization and Center for Disease Control and Prevention developed the GYTS to track tobacco use among young people across countries. The results from GYTS conducted in 18 states in India have shown us an alarmingly high prevalence of chewable products among the younger generation of this country [Figure 3] and [Table 1].
This figure of 28% of usage among the younger generation of India is very high and it has to be brought under control immediately. The main reasons for this usage may be lack of awareness regarding the ill effects of smokeless tobacco usage, availability of various colored chewing tobacco sachets at cheaper costs, ban of smoking in public places under the existing tobacco control laws, and the smokeless forms offering the convenience of usage without drawing much public attention.
As with tobacco and areca nut, the addictive nature of pan masala and gutka results in a high frequency of chewing. A relative risk of 489 has been reported for OSF in pan masala chewers compared with nonusers.  In a survey of 236 consecutive cases of OSF and 221 matched control subjects, chewing of areca nut, BQ, or pan masala were directly related to OSF. Comparitively, pan masala usage was more in younger age groups and was associated with OSF changes earlier than areca nut or BQ chewing. Moreover, the frequency of chewing rather than the total duration of the habit was directly correlated with OSF.  In a clinicopathological study in current chewers, chewers of pan masala or gutka presented with OSF within in a shorter duration of initiation of the habit (2.7 ± 0.6 years) than BQ chewers (8.6 ± 2.3 years).  Symptoms of cancer appeared at an early age in youngsters. 
If the present trend continues, the condition will further worsen with more and more cases of oral cancers in the near future - the signs of which are already evident. An evolving epidemic of OSF attributed to gutka usage has been documented among youth, with a resultant increase in oral cancer in lower age groups. This prediction is based upon the observation of an increasing prevalence of OSF, especially in younger individuals, caused by gutka. A comparison of the age distribution of recently reported OSF cases and incident cases reported in the past clearly establishes that the disease is now occurring at much younger ages. A comparison of the age specific incidence rates of mouth cancer (ICD 143-5) during 1983-1987 and 1995 in the city of Ahmedabad shows that the incidence has significantly increased in the younger population (  A study conducted in Mumbai to estimate the trends in the incidence of oral cancer in Mumbai using the Population Based Cancer Registry (PBCR) found that a statistically significant decreasing trend in the overall age-adjusted incidence rates during the period 1986-2000, with a yearly decrease of 1.70%. This decrease was significant for men above the age of 40, but for young adult men below the age of 40 there was no significant decrease, the level being stable. The high prevalence in the usage of smokeless tobacco among the youth may explain the stable trend in oral cancer incidences in this age group. 
In the present situation, we have to think about how we can prevent this future epidemic of oral cancers. The main modalities of treatment of oral cancer are surgery, radiotherapy, and rehabilitation. The expertise for these treatment modalities lies in oral surgeons, oral radiotherapists, and prosthodontists. When the etiology of oral cancer is the tobacco chewing habit among the population, the dentists in the country are bound to take the responsibility of reducing this growing menace. There should be a programmed approach whose primary aim should be to 'treat oral cancers and control the usage of chewing tobacco'. This program should cover all aspects concerned with oral cancer prevention and treatment [Figure 4].
This program should have all the modalities of healthcare starting from promotion to rehabilitation. Apart from this, emphasis should also be given to surveillance and research in this field. The success of this program largely depends on having all the segments of the chain functioning. At present the chain is scattered apart. Dental schools can undertake this program under one roof without breaking any component of the chain.
Dental education in India has grown enormously from one college in the early 1950s to 240 colleges, the highest number in the world.
This enormous growth has occurred post early eighties. From 17 colleges in the year 1979, it reached to 117 within 20 years. In the last seven years, 123 new colleges also added to the rest reaching a total of 240 to date  [Figure 5].
The major thrust area for the dental colleges at the moment is curative services than preventive and primitive dental care. This can be seen from the distribution of specialty seats in dentistry.
This should be utilized as an opportunity for implementing these programs. With 240 dental colleges scattered all over the country, programs conducted through these colleges will reach almost all corners of the nation. Each of these colleges should implement such a program and work on it.
The functional strategies should be in such a way that:
Initially, all the dental students should be sensitized regarding the situation through epidemiological surveys; this would motivate them to take part in such programs. Detailed case history regarding the habits of the patients should be taken and all the patients should be thoroughly screened.
Community dentistry departments in the colleges should select few outreach areas after consensus with the nearby colleges. These areas should be mapped and the department should carry out periodic routine oral screening programs in their assigned areas and conduct health promotion education for the community.
Utilizing dental colleges has the following advantages:
As the colleges transcend wide geographical areas including rural areas, collectively they will be able to cover a large number of populations.Community dentistry departments being already functional in the colleges, the need for further infrastructure supply will be negligible. Thus, the whole program can be made cost-effective.As dentists constitute the main manpower in conducting the screening programs, the validity of the cases identified will be high, thus reducing the number of false positive cases.Treatment can be initiated without undue delay following detection.Dental colleges can provide all modalities for oral cancer care like prevention, treatment, and rehabilitation as they are bound to have all the departments.Through dental colleges, both community-based and hospital-based oral screening can be carried out effectively.If all colleges follow a standardized approach, this can act as a surveillance tool of oral cancer to estimate the frequency with type, location, study of etiology, age distribution, and prognosis of the condition.Community dentistry posting is mandatory in the undergraduate course curriculum. Therefore, the manpower of students and interns in the department can be used for cancer screening and tobacco control in the outreach areas of the dental college.
For this, each dental college should be directed to include oral screening in their routine work. Within the hospital, the oral medicine and diagnosis department should take measures to screen all the patients presenting for outpatient care by eliciting information regarding all forms of habits.
When dental students are consistently trained in oral screening during their undergraduate period, they will have a tendency to incorporate the same in their future practice.
The link of oral cancer with tobacco usage is proved beyond doubt. Utilizing the present strength of dental colleges in the country is one among the many ongoing strategies in the control of this menace in our society. Having said and done these, no such programs can be successful without bold government initiatives in regulation of tobacco manufacture and usage, as well as administrative and economic support in carrying out screening programs, developing preventive strategies, and promoting research activities
I would like extend my deep gratitude to Dr. Jayan Jacob Mathew, MDS, periodontist for reviewing this literature.
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