Year : 2009 | Volume
: 20 | Issue : 1 | Page : 41--46
The prevalence of oral mucosal lesions in alcohol misusers in Chennai, south India
T Rooban1, Anita Rao2, Elizabeth Joshua1, K Ranganathan1,
1 Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Chennai, India
2 Director, Medical Services, TTK Hospital, TT Ranganathan Clinical Research Foundation, Chennai, India
Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Chennai
Aims and Objectives: This study was conducted to assess the prevalence of various oral mucosal lesions (OML) among alcohol misusers attending a rehabilitation center in Chennai, south India.
Materials and Methods: Qualified dental surgeons examined 500 consecutive alcohol misusers at Ragas Dental College and Hospital and TTK Hospital, India. Thorough history and oral findings were recorded in a pre-determined format. Data entry and statistical analysis were done using SPSS 10.0.5β.
The variables for this study were OML, Oral Hygiene Index (OHI), age, smoking, and alcohol misuse (type and units consumed and duration of misuse).
Results: Of the 500 patients, 77% were in the 25-44 years old age group and 84% were married. The mean age of initiation of alcohol misuse was 34 years. In addition to alcohol, 72% smoked tobacco and 96% used other psychoactive substances. The mean alcohol use duration was 12.6 years. A total of 25% of the study group had at least one OML. The common oral lesions were smoker«SQ»s melanosis (10.2%), oral submucous fibrosis (8%), and leukoplakia (7.4%). Those who misused spirits had a higher incidence of OML than those who misused beer or both. Patients with fair oral hygiene had an odds ratio (OR) of 2.96 for OML compared with an OR of 2.08 for those who had OML with good oral hygiene.
Conclusion : This study indicates that subjects who misuse alcohol have poor oral hygiene and are at risk for the development of periodontal disease and OML. This survey indicates that oral examination and treatment should be a part of the standard care for alcohol misusers at rehabilitation centers.
|How to cite this article:|
Rooban T, Rao A, Joshua E, Ranganathan K. The prevalence of oral mucosal lesions in alcohol misusers in Chennai, south India.Indian J Dent Res 2009;20:41-46
|How to cite this URL:|
Rooban T, Rao A, Joshua E, Ranganathan K. The prevalence of oral mucosal lesions in alcohol misusers in Chennai, south India. Indian J Dent Res [serial online] 2009 [cited 2021 Mar 9 ];20:41-46
Available from: https://www.ijdr.in/text.asp?2009/20/1/41/49064
Alcohol misuse is described as an unsanctioned, maladaptive, repeated pattern of alcohol ingestion, irrespective of its adverse physical, psychological, and social consequences.  A male subject is considered an alcohol misuser if he consumes a minimum of 21 units of alcohol per week while for females it is 14 units per week. An international unit of alcohol is either 350 ml of beer, 175 ml of wine, or 30 ml of spirit.  Globally, 2 billion people are alcohol misusers and it is the single most commonly misused substance.  In India, 4.5% of the population use alcohol regularly.  Alcoholic beverages used in India include wine, beer, toddy, whisky, gin, rum, brandy, arrack, and liqueurs.
Alcohol use often coexists with tobacco consumption. Epidemiological studies associate alcohol along with tobacco as a significant risk factor for oral precancer and cancer lesions. ,, Ethanol by itself is not a mutagenic, clastogenic, or carcinogenic material. Alcoholic beverages contain volatile and non volatile flavor compounds and other additives that could cause these effects. Alcohol also causes a change in the rate of penetration of substances from the oral environment across the mucosa and this alteration of mucosal permeability may have a role to play in carcinogenesis.  It has been shown that chronic alcohol exposure in rats causes oral mucosal atrophy, dysplastic changes, an increase in the size of the basal cell nuclei, and an increase in basal cell layer thickness.  Fat accumulation in acinar cells and reduction in salivary flow are some of the effects of alcohol on the salivary glands in rats  and a similar effect could be expected in humans. Systemic effects in humans including altered liver functions, protein depletion, immunosuppression, and portal hypertension also influence the course of oral lesions and conditions in chronic alcoholic misusers. Thus, altered morphology of oral mucosa coupled with other local and systemic factors like poor oral hygiene, altered liver function, associated systemic diseases, and psychological problems may cause and alter the course and progression of oral lesions and diseases. , It is reported that 1 in 5 male dental patients and 1 in 10 female dental patients habitually consume alcohol in the United States of America.  In India, it has been reported that around 13.4% of male patients and 0.6% of female patients seeking dental treatment habitually consume alcohol. 
India, with a population of more than 1 billion people with varying cultural and dietary patterns, has varied types of alcohol consumption and misuse. Given the paucity of published reports on the relation of alcoholism to oral health status in this part of the world, this study was undertaken to record the prevalence of oral mucosal lesions and conditions among alcohol misusers attending a rehabilitation center in Chennai, south India.
Materials and Methods
The study group consisted of 500 consecutive first visit alcohol misusers examined over a period of 2 years (June 2002-May 2004) attending Ragas Dental College and Hospital, Chennai, referred from TTK Hospital, Chennai, India. TTK Hospital is a Non Governmental Organization (NGO) run by T.T. Ranganathan Clinical Research Foundation, Chennai and is involved in the rehabilitation of alcohol and drug misusers. This hospital serves the local district population and those from adjoining districts and states including Karnataka, Kerala, and Andhra Pradesh and is recognized by the United Nations Office of Drug and Crime, Regional Office of South Asia as a training institute for NGOs in the prevention and treatment of alcohol and drug misuse. Ragas Dental College and Hospital, Chennai caters to the oral hygiene and dental treatment needs of the patients enrolled at the center.
A standard dental examination was performed. The findings from the examination were recorded in a pre-determined format that included a detailed record of the type of alcohol consumed, the frequency, and the duration of misuse. Smoking habits, use of areca nut, misuse of drugs, and standard demographic data were also recorded. All examinations were performed under illuminated light with sterilized instruments. Trained physician and dental surgeons examined the patients. The period of interview and examination lasted for 30 minutes.
The study population was broadly categorized into 5 major groups based on the psychoactive substance misuse without any overlap. They were as follows:
Group A: Alcohol only (includes beer and spirits; spirits include wine, whisky, brandy, rum, gin, vodka, and illicit brewed alcohol)
Group AS: Alcohol and smoking tobacco (cigarettes/ beedis)
Group AC: Alcohol and chewing areca nut with or without tobacco
Group ASC: Alcohol, smoking tobacco, and chewing areca nut with or without tobacco
Group ALL: Alcohol, smoking tobacco, chewing areca nut with or without tobacco, and misuse of drugs (including narcotics [opioids, heroin, pentazocine, bupenorphine, brown sugar] benzodiazepines [diazepam, flurazepam, alprozolam], and miscellaneous drugs [cough syrups and antihistaminics])
The study group was further stratified by age into 5 groups: ≤ 25 years old, 26-34 years old, 35-44 years old, 45-54 years old, and ≥ 55 years old. The quantity of alcohol consumed per month was categorized into 8 groups: ≤ 50 units, 51-100 units, 101-150 units, 151-200 units, 201-250 units, 251-300 units, 301-350 units, and ≥ 350 units of alcohol.  Duration of alcohol misuse was stratified as those who misused alcohol for ≤ 5 years, 6-10 years, 11-15 years, 16-20 years, 21-25 years, and ≥ 26 years. Lesions were diagnosed as per the clinical features  and a biopsy was done if needed. The Oral Hygiene Index - Simplified  was employed to assess the oral hygiene status of the study population.
Data were entered and analyzed using the Statistical Package for Social Servicesβ, version 10.0.5. Descriptive statistics were presented for all variables. Pearson's Chi square test was done to find the association between age, duration, alcohol units, and lesions with habits. A univariate logistic regression was presented for significant associations with any OML. A p-value of ≤ 0.05 was considered to be statistically significant.
[Table 1] shows the demographic details of the study population and [Figure 1] shows the habits in the study population in which there were 18 patients (3.6%) in Group A, 164 patients (32.8%) in Group AS, 121 patients (24.2%) in Group AC, 160 patients (32%) in Group ASC, and 37 patients (7.4%) in Group ALL.
The mean duration of alcohol misuse in the study population was 12.6 years, with a minimum of 6 months and a maximum of 39 years. The duration of alcohol misuse until reporting for treatment was 13.3 years, 14.1 years, 12.1 years, 12.1 years, and 9 years for Groups A, AS, AC, ASC, and ALL, respectively. The mean age at which alcohol consumption was initiated was 34.4 years ranging from 16 years to 59 years.
The mean amount of alcohol consumed by the study population was 113.2 units of alcohol per week. The amount of alcohol consumed had no statistically significant difference with respect to duration, age, marital status, religion, or education. Duration of alcohol misuse had a statistically significant pattern in relation to age (P = 0.000) and marital status (P = 0.000) and no statistically significant relationship to religion or education. [Figure 2] and [Figure 3] show the type and quantity of alcohol consumed by the different groups in the study. Tobacco in any form was used by 482 patients (98.4%) and in the smoking form it was used by 361 patients (72.2%).
Medical examinations revealed that 42 patients (8.4%) were diagnosed with hypertensives, 35 patients (7%) were diabetics, 4 patients (1%) were infected with Human Immunodeficiency Virus (HIV), 3 patients (0.6%) had peptic ulcers, 3 patients (0.6%) had pulmonary tuberculosis infection, 2 patients (0.4%) had jaundice, 3 patients (0.6%) were epileptics, 2 patients (0.4%) had wheezing, and 1 patient each (0.2%) had hypothyroidism and alcoholic hepatitis. Nine patients (1.8%) had evident scars as a result of earlier trauma.
A total of 25% of the study population had at least one oral mucosal lesion (OML). The distribution of OMLs in the study population is shown in [Table 2]. The prevalence of OML was 5.6%, 26.8%, 33.9%, 46.3%, and 37.8% in Groups A, AS, AC, ACS, and ALL, respectively. This difference of OML prevalence between the habit subgroups was statistically significant (P =0.00). The common lesions were smoker's melanosis, oral submucous fibrosis (OSF), and leukoplakia (10.2%, 8%, and 7.4%, respectively).
It was observed that those who misused spirits had a higher number of OMLs than those who misused beer or beer with spirits. This difference in occurrence of OML was statistically significant (P =0.04) [Table 3]. The influence of tobacco on the prevalence of OMLs in the study group is shown in [Table 4]. Alcohol misusers who chewed areca nut with or without tobacco and smoked tobacco were more likely to have OMLs than those who smoked tobacco alone.
The units of alcohol consumed by the study population were dependent on the other substances misused along with alcohol (P =0.00; [Table 5]). Interestingly, the quantity of alcohol consumed had no statistically significant relationship with the occurrence of OML.
[Figure 4] and [Table 5] summarize the OHI of the study population. The overall OHI score of the study population was 1.71 (Fair). The OHI of the study population when compared across the groups was found to be significantly reduced (P = 0.043) with 5.6% of Group A, 4.3% of Group AS, 9.9% of Group AC, 6.9% of Group ACS, and 5.4% of Group ALL having poor OHI. Logistic regression analysis revealed that patients with fair oral hygiene had an OR of 2.96 (95% CI 1.3-6.72, P = 0.009) for OML as compared with good OHI while those who had poor OHI had an OR of 2.08 (95% CI; 1.29 to 3.37; P = 0.003).
Oral mucosal conditions and lesions could be due to infection (bacterial, viral, fungal), local trauma and or irritation (traumatic keratoses, fibroma, burns), systemic disease (metabolic or immunological), or relate to lifestyle factors such as the usage of tobacco, areca nut, betel quid, or alcohol. There are only a few reports about the effect of alcohol on OMLs ,, and dental conditions.  The study population was at a high risk for OML as they were long-term alcohol and tobacco misusers seen in the detoxification unit.
Harris, et al. studied OMLs among 693 alcohol misusers in London (77.5% were males and 22.5% were females). A total of 56% were solely alcohol misusers, 44% misused other substances along with alcohol, 89.5% smoked tobacco, 28.1% had at least one OML with frictional keratosis (8.8%) being the most common lesion while candidiasis (3.9%), smokers palate (2.0%), and leukoplakia (0.4%) were also observed. In contrast, in our study, 99.8% were males and 0.2% were females. A total of 3.6% were solely alcohol users, 72.2% smoked tobacco, 96.4% used tobacco, areca nut, or drugs along with alcohol. A total of 25% of the study population had at least one OML with smokers melanosis (10.2%), OSF (8%), leukoplakia (7.4%), erythroplakia (0.6%), candidiasis (0.2%), frictional keratosis (3.6%), smoker's palate (2.4%), and traumatic keratosis (0.4%). The low female percentage in our study group is due to the difference in social, cultural, and ethnical differences between the study populations due to which women are less likely to accept their habit and present for rehabilitation. Harris, et al.  did not delineate tobacco as an abused substance. The higher incidence of potentially malignant states (18% of our study as compared with 0.4% in the study conducted by Harris, et al.) in our study group is probably due to the high prevalence of smoking tobacco, beedi, and the consumption of areca nut (96.4% as compared with 86.5% in the study conducted by Harris, et al.)
On studying the quantity and type of alcohol consumed by the study group, 30.7% of them consumed 151 to 200 units of alcohol per week. A total of 2.6% of the study population preferred beer, 68.2% preferred spirits, and 29.2% preferred both spirits and beer. In comparison, Harris, et al.  reported 50.1% of their study population consumed 251 to 300 units of alcohol per week, 27.85% preferred beer and 47.05% preferred spirits. The reason could be the difference in lifestyle and alcohol consumption pattern between the two study populations.
Our earlier dental-hospital-based, cross-sectional survey among the general population found that 15% smoked tobacco and 8.8% used alcohol. Only 4.1% of them had an oral mucosal lesion.  Of all the males in the earlier study group, the prevalence of smoker's melanosis was 1.63%. The other common mucosal lesions were stomatitis nicotina palatini (1.2%), leukoplakia (0.7%), and OSF (0.6%). In contrast, in this study group, 72.2% used tobacco in any form and 25% of them had at least one OML. The common OML in the present study group was smoker's melanosis (10.2%), OSF (8%), and leukoplakia (7.4%). The higher prevalence of potentially malignant states in our study group underlines the fact that alcohol misusers are at a higher risk for these lesions.
The percentage of subjects and the prevalence of OML increased with an increase in the number of psychoactive substances misused. This difference was statistically significant ([Table 2], P= 0.00). This is probably the result of additive effects of substances misused.
The prevalence of OML was analyzed across the type of alcoholic beverages misused, it was observed that those misusing beer had fewer lesions (n =1; 7.7%) when compared with those misusing spirits (n=108; 31.7%). When misused together, they caused more lesions (n = 55; 37.67%) indicating the need for further study of the combined effects.
On comparing the effect of tobacco smoking in the study population, it was observed that those who smoked ≥10 sticks per day for ≥ 20 years had more lesions [Table 4]. Group ACS had a higher number of OMLs (35%), pointing to the fact that tobacco is a significant risk factor for OML. In the ALL group, subjects who smoked ≥ 10 sticks per day for ≥ 10 years had more OMLs than others underlining the role of other substances as a risk factor for OMLs. A total of 76% of all those who had OMLs were smokers and the chance of having OML increases with the intensity and frequency of tobacco usage along with alcohol misuse.
When the unit of alcohol consumed was studied among different habit groups, the difference was statistically significant (P = 0.002), indicating that the other substances that were misused along with alcohol influences the unit of alcohol consumed by the study population. This could be due to the fact that alcohol has a synergistic effect with other mood altering substances. The effect of these combinations needs further investigations.
On analyzing the OHI, a predictor of oral hygiene status, it was observed that the lower the number of substances misused, the better the oral health as well as the fact that smoking tobacco was the single most important cause for poor oral hygiene. Logistic regression analysis of the OHI when employed for OMLs revealed that a fair OHI had an OR of 2.96 as compared with a good OHI having an OML while those who had poor OHI had an OR of 2.08. Thus, OHI could be a predictor of OMLs in substance misusers.
The interrelationships between oral mucosal health and alcohol usage have implications for preventive counseling in this patient group. This study highlights poor oral hygiene status and the higher prevalence of OMLs, including potentially malignant states in this high-risk population. Regular inquiry into psychoactive substance misuse and the details of alcohol consumption in a dental clinic will be helpful for better patient rehabilitation. This survey also underlines the need for a routine dental examination and treatment as a part of the long-term standard care for alcohol misusers at rehabilitation centers.
We acknowledge the support extended to us for this study by Dr. S. Ramachandran MDS, Principal, Ragas Dental College and Hospital, Chennai and Mrs. Jothi, Nursing Superintendent, T.T. Ranganathan Clinical Research Foundation, Chennai. We thank Mrs. R. Hemalatha M Sc, Biostatistician, Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Chennai, for her valuable contribution in analyzing the data.
|1||Christopher Haslett. In: Chilvers ER, Hunter JAA, Boon NA, editors. Davidson's Principles and practice of medicine. 18 th ed. New York: Churchill Livingstone publishers; 1999. p. 1083.|
|2||Thavarajah R, Rao A, Raman U, Rajasekaran ST, Joshua E, Hemalatha R, et al. Oral lesions of 500 habitual psychoactive substance users in Chennai, India. Arch Oral Biol 2006;51:512-9. |
|3||Neufeld KJ, Peters DH, Rani M, Bonu S, Brooner RK. Regular use of alcohol and tobacco in India and its association with age, gender, and poverty. Drug Alcohol Depend 2005;77:283-91.|
|4||Harris CK, Warnakulasuriya KA, Cooper DJ, Peters TJ, Gelbier S. Prevalence of oral mucosal lesions in alcohol misusers in south London. J Oral Pathol Med 2004;33: 253-9.|
|5||Wickholm S, Galanti MR, Soder B, Gilljam H. Cigarette smoking, snuff use and alcohol drinking: Coexisting risks behaviors for oral health in young males. Community Dent Oral Epidemiol 2003;3:269-74.|
|6||Zain RB. Cultural and dietary risk factors of oral cancer and precancer: A brief overview. Oral Oncol 2001;37:205-10.|
|7||Hindle I, Downer MC, Moles DR, Speight PM. Is alcohol responsible for more intra-oral cancer? Oral Oncol 2000;36:328-33.|
|8||Wright AJ, Ogden GR. Possible mechanism by which alcohol may influence the development of oral cancer: A review. Oral Oncol 1998;34:441-7.|
|9||Little JW, Falace DA, Miller CS, Rhodus NL, editors. Dental management of the medically compromised patient. 6 th ed. St. Louis: Mosby; 2002. p. 448-52. |
|10||Saraswathi TR, Ranganathan K, Shanmugam S, Ramesh S, Narasimhan PD, Gunaseelan R. Prevalence of oral lesions in relation to habits: Cross sectional study in south India. Indian J Dent Res 2006;17:121-5.|
|11||Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.|
|12||Hornecker E, Muub T, Ehrerreich H, Mausberg RF. A pilot study on the oral conditions of severely alcohol addicted persons. J Contemp Dent Pract 2003;4:51-9.|