|Year : 2021 | Volume
| Issue : 1 | Page : 115-119
|Incidence of grinspan syndrome among tribal and suburban population of Maharashtra – A cross sectional study
Lalitkumar P Gade1, Snehal D Lunawat2, Kiran S Jagtap2, Sneha H Choudhary3, Monica Mahajani4, Vishwas D Kadam5
1 Department of Oral Pathology, S.M.B.T. Dental College & Hospital and Post Graduate Institute, Sangamner, Maharashtra, India
2 Department of Oral Pathology, SMBT Institute of Dental Sciences and Research, Dhamangaon, Nashik, Maharashtra, India
3 Department of Oral Medicine and Radiology, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India
4 Department of Periodontics, Dr HSRSM Dental College and Hospital, Hingoli, Maharashtra, India
5 Department of Oral Medicine and Radiology, C.S.M.S.S. Dental College and Hospital, Aurangabad, Maharashtra, India
Click here for correspondence address and email
|Date of Submission||22-Aug-2019|
|Date of Decision||30-Dec-2019|
|Date of Acceptance||22-Nov-2020|
|Date of Web Publication||13-Jul-2021|
| Abstract|| |
Background: Grinspan syndrome is characterised by presence of the triad: hypertension, diabetes mellitus (DM) and oral lichen planus (OLP). OLP, seen in hypertension and diabetes mellitus, is caused by drugs used to treat these diseases according to literature, however the incidence of this syndrome in India has not yet been reported anywhere. Hence the present study was conducted with the following objectives: (i) To determine the incidence of Grinspan syndrome amongst tribal and suburban study population of Maharashtra in different gender and age groups (ii) To correlate occurrence of OLP with DM type 2 and hypertension (iii) To find out the number of patients with OLP, DM type 2 and hypertension either alone or in combination. Methods and Material: The present study was conducted on 4681 new patients attending the routine outpatient department (O.P.D.) of the dental hospital between January 2017 and December 2018. Patients with OLP or DM (type-2) or hypertension or any combination of these diseases were included in the present study. Brief case history of each patient was recorded. Data thus collected were analysed using SPSS version 20 for Chi-square test. Results: Grinspan syndrome was found in 1.62% of the study population. Syndrome was seen in 1.02% of female and 0.59% of male. Maximum patient affected by syndrome were in 35-50 years of age group. Conclusions: Incidence of Grinspan syndrome was 1.62%, mainly seen in sub-urban females of 35-50 years and OLP seen in hypertension and diabetes mellitus has different etiology and is not caused by drugs used to treat these diseases.
Keywords: Diabetes mellitus, Grinspan syndrome, hypertension, oral lichen planus
|How to cite this article:|
Gade LP, Lunawat SD, Jagtap KS, Choudhary SH, Mahajani M, Kadam VD. Incidence of grinspan syndrome among tribal and suburban population of Maharashtra – A cross sectional study. Indian J Dent Res 2021;32:115-9
|How to cite this URL:|
Gade LP, Lunawat SD, Jagtap KS, Choudhary SH, Mahajani M, Kadam VD. Incidence of grinspan syndrome among tribal and suburban population of Maharashtra – A cross sectional study. Indian J Dent Res [serial online] 2021 [cited 2021 Oct 17];32:115-9. Available from: https://www.ijdr.in/text.asp?2021/32/1/115/321380
| Introduction|| |
Grinspan syndrome comprises of hypertension, diabetes mellitus (DM) and oral lichen planus (OLP). In the oral cavity many premalignant lesions and conditions can occur and OLP is one of them. It is a chronic inflammatory disease which clinically has six variants, i.e., papular, bullous, plaque-like, reticular, atrophic, erosive or ulcerative. OLP is a T- cell mediated inflammatory disease of the oral mucosa with unknown etiology having a prevalence of 0.5%–1.9%. When OLP is associated with hypertension and DM, this triad is known as 'Grinspan syndrome'. DM is a metabolic disease in which there is defect in insulin secretion, insulin action, or both, and is characterised by hyperglycemia. There is a known association between DM and OLP with a prevalence rate of 1.6%–85%. The presence of chronic inflammation in OLP may explain its association with dyslipidemia and cardiovascular (CV) risk. The association between OLP and DM has been proven in many studies reported in literature and the association between high lipid levels and lichen palnus is also a well-known fact. There have been many queries regarding the nature and cause of oral lichen planus in this syndrome, amongst which one was if lichen planus is caused due to the drugs used in the treatment of DM and hypertension or it has a separate etiology. This hospital-based cross sectional study was thus carried out in an attempt to find out the incidence of Grinspan syndrome in India and to know whether the OLP in such patients is a drug induced lichenoid reaction caused due to medication used for hypertension and DM or it has a separate etiology.
| Subjects and Methods|| |
The present hospital-based cross-sectional study was conducted on 4681 new patients attending the routine outpatient department of the dental hospital between January 2017 and December 2018. A total of 1325 patients with OLP and those with history of DM type 2 and hypertension or any of the these or combination of two were included in the study. Amongst 1325 patients, 785 patients were from suburban area, in which there were 370 males and 415 females and 540 patients were from Tribal area, in which there were 275 males and 265 females. To co-relate the occurrence of OLP with DM type 2 and hypertension, the study population was divided into two groups, Group 1 having hypertension, DM type 2 or both and Group 2 having OLP, or OLP in combination with DM type 2 or hypertension or both. For age related co-relation the study population was divided into three age groups; 35-50 years, 50-70 years, and >70 years. Study protocol was approved by the institutional review board and ethical committee clearance was obtained. All the new patients visiting the dental OPD during the study period with the presence of any of the above mentioned disease or in combination with previous history were included in the study. The patients having type 1 DM or any other systemic disease along with type 2 DM or hypertension were excluded from the study. Also the patients who were not willing to participate in the study or those who have not reported again with the confirmatory reports were excluded. A brief case history was recorded followed by the written informed consent from all the patients participating in the study. All patients were examined clinically for the presence of OLP. Those patients who met the clinical criteria for the diagnosis of OLP were referred to the department of oral surgery for biopsy followed by the histopathological confirmation of OLP from the department of oral pathology. Patients with clinically and histopathologically diagnosed OLP – as per the modified WHO criteria 2003 were included in the present study. Patients diagnosed with OLP were evaluated for the presence of hypertension and DM type 2. Those patients who have positive history for hypertension and DM type 2 and on medication were also included in the study. The diagnosis of diabetes mellitus was done according to the recommendations given by the ADA in 2010, i.e., an A1c value of ≥6.5%, fasting glucose level of ≥126 mg/dL, 2-h glucose of ≥200 mg/dL, or a random glucose in patients with classic symptoms of diabetes mellitus of ≥200 mg/dL are diagnostic for diabetes mellitus.
Hypertension was measured according to the American Heart Association/American cardiology college (AHA/ACC) guidelines given in 2017. According to AHA/ACC normal blood pressure was defined as having a clinical measurement of systolic BP (SBP) <120 mmHg and diastolic BP (DBP) <80 mmHg, while elevated blood pressure (pre-hypertensive) values are SBP 120-129 mmHg and DBP <80 mmHg and above these values they called hypertension. The SBP of 130-139 mmHg and DBP of 80-89 mmHg is considered as Stage 1 Hypertension and the SBP of ≥140 mmHg and DBP of ≥90 mmHg is considered as Stage 2 Hypertension. Data thus collected were analysed using SPSS version 20 by Chi-square test. Incidences were calculated by using the following formula for incidence:
| Results|| |
A total of 1325 patients were found to have clinically evident OLP, DM type 2, hypertension or any of these or combination of two diseases. It was found that more number of patients were in the Group 1 (772) as compared to Group 2 (553), which was statically significant (X2 = 72.39 and P = 0.000) [Table 1]. Incidence of Grinspan syndrome was found in 1.62% of the study population, amongst which 0.49% of population was from tribal group and 1.13% from sub-urban group. However, the difference between these two population was not statistically significant (X2 = 3.68 and P = 0.055). Grinspan syndrome was found in 1.02% of females and 0.59% of males which was statically significant (X2 = 4.52 and P = 0.033). Also, maximum patients with Grinspan syndrome were in 35-50 years of age group while only a few patients were above 70 years, which was statistically very significant (X2 = 26.24 and P = 0.000) [Table 2]. The demographic distribution of various diseases is shown in [Table 3]. It was observed that there was no difference in the percentile distribution of various diseases according to the locality [Figure 1] and [Figure 2]. In both the localities there was less number of patients with lichen planus (12-13%) observed as compared to either DM (16-18%) or hypertension (18-20%). While observing these three diseases in combination, there were more patients having DM with hypertension (22-23%) as compared to lichen planus with diabetes (11-12%) or lichen planus with hypertension (12%).
|Figure 1: Demographic distribution of various diseases among tribal population|
Click here to view
|Figure 2: Demographic distribution of various diseases among sub-urban population|
Click here to view
|Table 2: Incidence of Grinspans syndrome according to locality, gender and age|
Click here to view
|Table 3: Demographic distribution of various diseases among study population|
Click here to view
| Discussion|| |
Triad of hypertension, DM and OLP is known as Grinspan syndrome. In the present study a total incidence of 1.62% of Grinspan syndrome was found, in which 0.49% of the population was from tribal area and 1.13% from sub-urban area. There was no significant difference in the incidence in terms of locality among tribal and sub-urban population but it can be said that, it is mainly seen in suburban as compared to tribal population. The difference in incidence can be due to the difference in the hectic and more stressful lifestyle, intake of junk food, inactive routine and high socio-economic status of people from the suburban group.
In the present study, OLP has an incidence of 2.07% which is in accordance with the results of previous studies reported in literature which stated that OLP has a prevalence of 0.5‒2% in general population. However, geographically no significant result was obtained. The present study results showed that females are more commonly affected than males; reason attributed to this can be the higher level of psychological stress which further causes OLP. This is in accordance with the results of previous studies which stated that it is more common in females than males at a ratio of 3:2, and most of the cases are diagnosed between the age of 30 and 60 years, but it can occur at any age. Multivariate analysis done by Moreira APL et al. showed that women above 65 years of age who are overweight and self-assessed poor health have higher prevalence of hypertension. Similarly women of 55-64 years of age with less than 4 years of education have higher prevalence of DM.
In the present study more number of patients was observed in the 35–50 years of age group. The meta-analysis study done by Hamid RM showed that the patients with DM and OLP were in the age range of 33–55 years with the average age of 51 years, which is in accordance with the present study. Aniyan KY in his case control study had divided population into six different age groups and he found that amongst the cases who had dyslipidemia, 37% of patients were in the middle age group, i.e., 31–40 years and 41–50 years. This was in support with the fact that OLP is mainly seen in middle age group.
In order to verify whether the occurrence of OLP in Grinspan syndrome has a separate etiology or it is caused by the drugs used to treat hypertension and DM, the present study population was divided into two groups, Group 1 having hypertension, diabetes or both and Group 2 having combination of these along with OLP. More number of patients was found in Group 1 as compared to group 2 [Table 2]. This was statistically significant (X2 = 72.39 and P = 0.000) which suggests that OLP in Grinspan syndrome has separate etiology and is not caused by the drugs used to treat hypertension and DM.
Naheed et al. in 2002 reported that 4.4% of patients with OLP had DM in Iranian patients. The study done by Syeda Arshiya et al. in 2011 in India observed DM in 10% of their patients with OLP. However, Munde et al. in 2013 found only 1.6% of DM patients having OLP. In the present study, 3.20% cases of lichen planus were associated with DM, which is in accordance with the previous studies. In both these conditions IL-8 is the important inflammatory mediator involved. Patients who are suffering from type 2 DM have higher levels of triglycerides while low-density lipoprotein cholesterol (LDL-C) may be elevated, borderline, or normal. In some studies it has been found that there is increase in the levels of total cholesterol (TC), LDL-C and decrease in the levels of high-density lipoprotein cholesterol (HDL-C) in patients with OLP as compared to the control group. According to some investigators there is no correlation between OLP and DM. Some researchers postulated that the drugs used to treat DM can cause lichenoid reactions which is unable be differentiate it from classic LP disease clinically. Mozaffari HR et al. in his meta-analysis study concluded that the risk of OLP in DM was more with prevalence of 9.3% compared with control subjects (1.8%) and very important factor for this difference is type of medications used to treat diabetes and reducing the immune system in DM patients. If this would have been the cause then we could have got more number of patients with DM having OLP, but we found significantly more number of patient with DM alone than the patients with DM having OLP (X2 = 159.33 and P = 0.000). Thus this contradicts the statement which says that the drugs used to treat DM cause lichenoid reactions which appears clinically similar to the classic OLP disease.
In the present study we found 3.43% incidence of lichen planus with hypertension. Shahnam M et al. in his study found individuals high-stress levels in patients with high TC, high LDL-C, and low HDL-C compared to person with normal lipid profile. Also, dyslipidemia and stress levels can be positively co-related with the occurrence of OLP. However, gender distribution and geographic distribution of this lesion was not statistically significant.
Shah A, Afzal M in his article stated that the prevalence of DM and hypertension in Maharashtra was 39.8% and 56.4%, respectively and there is 13.8% co-prevalence of DM with hypertension. However, in the present study, prevalence of DM and hypertension was found to be 4.78% and 5.42% respectively and 6.28% of individuals has the prevalence of DM with hypertension. When the overall distribution of diseases was observed in the present study population [Figure 3], 17% patients has DM, 19% has hypertension and 22% patients suffered from DM with hypertension. For DM there is female predominance (X2 = 7.79 and P = 0.005) which is statistically significant, but area wise there is no significant results. Results of the present study is similar to the results of the study conducted in Turkey which stated that type-2 DM has high prevalence among women. For hypertension, geographically and gender wise no statistically significant result was obtained. Incidence of DM with hypertension is not significant geographically but gender wise there is more male predominance for diabetes with hypertension (X2 = 41.81 and P = 0.000) which is highly significant. Reason for this could be that the males in India have alcohol and tobacco habits which are main cause for hypertension. Studies have also suggested that hypertensive person has higher risk for development of DM than are normotensive person.
This is hospital based study, so only limited population who attended the hospital were included, random sampling with large population from different area with more time period is required for better and accurate results. Also, the fixed time period for the residential area was not strictly considered, hence there are chances of errors due to migration of people from one place to another.
I acknowledge the participation of all the patients for this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ingafou M, Leao JC, Porter SR, Scully C. Oral lichen planus: A retrospective study of 690 British patients. Oral Dis 2006;12:463-8.
Porter SR, Kirby A, Olsen I, Barrett W. Immunologic aspects of dermal and oral lichen planus: A review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;8:358-66.
Grinspan D, Diaz J, Abulafia J, Villapol L, Schneiderman J, Palese D, et al
. Our experience with lichen ruber planus of oral mucosa. Ann Dermatol Syphiligr (Paris) 1966;93:531-42.
Desir GV. Kv1.3 potassium channel blockade as an approach to insulin resistance. Expert Opin Ther Targets 2005;9:571-9.
Atefeh T, Faezeh K, Fereshtehossadat G, Mahsa A. Serum level of Interleukin-8 in subjects with diabetes, diabetes plus oral lichen planus, and oral lichen planus: A biochemical study. Dent Res J (Isfahan) 2016;13:413-8.
Arias-Santiago S, Buendía-Eisman A, Aneiros-Fernández J, Girón-Prieto MS, Gutiérrez-Salmerón MT, García-Mellado V, et al
. Cardiovascular risk factors in patients with lichen planus. J Eur Acad Dermatol Venereol 2011;25:1398-401.
Patil S, Rao RS, Sanketh DS, Sarode SC, Sarode GS. A universal diagnostic criteria for oral lichen planus: An exidency. Int J Contemp Dent Med Rev. 041214, 2014.
Fox CS, Golden SH, Anderson C, Bray GA, Burke LE, de Boer IH, et al
. Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: A scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care 2015;38:1777-803.
Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al
. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Hypertension 2018;71:1269-324.
John JB, Asokan S, Aswanth KP, Priya PR, Shanmugaavel AK. Dental caries and the associated factors influencing it in tribal, suburban and urban school children of Tamil Nadu, India: A cross sectional study. J Public Health Res 2015;4:361.
Sawant NS, Vanjari NA, Khopkar U, Adulkar S. A study of depression and quality of life in patients of lichen planus. Sci. World J. 2015;2015;817481. doi: 10.1155/2015/817481.
Gupta S, Jawanda MK. Oral lichen planus: An update on etiology, pathogenesis, clinical presentation, diagnosis and management. Indian J Dermatol 2015;60:222-9.
] [Full text]
Moreira APL, Malta DC, Vianna RPT, Moreira PVL, Carvalho AT. Risk and protection factors for self-reported hypertension and diabetes in João Pessoa, Brazil. The VIGITEL survey 2014. A cross-sectional study. Sao Paulo Med J 2017;135:450-61.
Hamid RM, Roohollah S, Masoud S. Prevalence of oral lichen planus in diabetes mellitus: A meta-analysis study. Acta Inform Med 2016;24:390-3.
Aniyan KY, Guledgud MV, Patil K. Alterations of serum lipid profile patterns in oral lichen planus patients: A case-control study. Contemp Clin Dent 2018;9(Suppl 1):S112-21.
Goyal L, Narinde, Gupta D, Gupta N. Grinspan syndrome with periodontitis: Coincidence or correlation? J Indian Soc Periodontol 2018;22:263-5.
] [Full text]
Naheed T, Akbar N, Akbar N, Shehzad M, Jamil S, Ali T. Skin manifestations amongst diabetic patients admitted in general medical ward for various other medical problems. Pak J Med Sci 2002;18:291-6.
Arshiya Ara S, Mamatha GP, Balaji Rao B. Incidence of diabetes mellitus in patients with lichen planus. Int J Dent Clin 2011;3:29-33.
Munde AD, Karle RR, Wankhede PK, Shaikh SS, Kulkurni M. Demographic and clinical profile of oral lichen planus: A retrospective study. Contemp Clin Dent 2013;4:181-5.
] [Full text]
Cassol-Spanemberg J, Rodríguez-de Rivera-Campillo ME, Otero-Rey EM, Estrugo-Devesa A, Jané-Salas E, López-López J. Oral lichen planus and its relationship with systemic diseases. A review of evidence. J Clin Exp Dent 2018;10:e938-44.
Tavangar A, Khozeimeh F, Ghoreishian F, Boroujeni MA. Serum level of Interleukin-8 in subjects with diabetes, diabetes plus oral lichen planus, and oral lichen planus: A biochemical study. Dent Res J 2016;13:413-8.
] [Full text]
Falguni HP, Somshukla R, Renuka PM, Supriya SB, Chitra SN. Alterations in lipid metabolism and antioxidant status in lichen planus. Indian J Dermatol 2015;60:439-44.
Atefi N, Majedi M, Peyghambari S, Ghourchian S. Prevalence of diabetes mellitus and impaired fasting blood glucose in patients with Lichen Planus. Med J Islam Repub Iran 2012;26:22-6.
Mozaffari HR, Sharifi R, Sadeghi M. Prevalence of oral lichen planus in diabetes mellitus: A meta-analysis study. Acta Inform Med 2016;24:390-3.
Shahnam M, Roohafza HR, Sadeghi M, Bahona A, Sarafzadegan N. The correlation between lipid profile and stress levels in central Iran: Isfahan healthy heart program. ARYA Atheroscler J 2010;6:102-6.
Shah A, Afzal M.Prevalence of diabetes and hypertension and association with various risk factors among different Muslim populations of Manipur, India. J Diabetes Metab Disord. 2013;12:52.
McKeigue PM, Bela S, Marmot MG. Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians. Lancet 1991;337:382-6.
Sowers JR, Epstein M, Frohlich ED. Diabetes, hypertension, and cardiovascular disease: An update. Hypertension 2001;37:1053-9.
Dr. Sneha H Choudhary
Department of Oral Medicine and Radiology, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]
| Article Access Statistics|
| Viewed||664 |
| Printed||38 |
| Emailed||0 |
| PDF Downloaded||25 |
| Comments ||[Add] |