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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 177-181

Evaluation of tobacco-associated oral lesions in the police personnel from Greater Mumbai: A survey with review of literature


Department of Oral Medicine and Radiology, Saraswati-Dhanwantari Dental College and Hospital, Post-Graduate Research Institute, Parbhani, Maharashtra, India

Date of Web Publication15-Dec-2017

Correspondence Address:
Abhishek Singh Nayyar
44, Behind Singla Nursing Home, New Friends' Colony, Model Town, Panipat - 132 103, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_55_17

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  Abstract 

Context: The police personnel resort to tobacco-associated habits often as a stress buster and consider the nicotine rush will settle their nerves so that they can focus better on their work. Recently, some nongovernmental organizations have taken a note of this and carried out health checkup camps for the police personnel in the city of Mumbai, but similar awareness for oral and dental health is still largely missing. Aim: The present study was carried out with the primary aim to determine the prevalence of tobacco-associated habits and oral lesions in the police personnel from Greater Mumbai. Materials and Methods: All the police personnel included in the study were subjected to a detailed case history elicitation and examination procedure after obtaining their informed written consent. Special stress was given in eliciting history of tobacco-associated habits while care was taken to diagnose tobacco-associated oral lesions such as tobacco pouch keratosis, preleukoplakia, leukoplakia, oral submucous fibrosis, carcinomatous, and other lesions. The data so collected were tabulated and sent for statistical analysis, and objective conclusions were drawn. Results: Use of tobacco with lime was found to be the most common habit present in the police personnel (34.0%), whereas the least common habit found was betel nut chewing (3.9%). In a sample size of 2388 police personnel included in the study, the overall prevalence of leukoplakia was found to be 11.12% with homogenous leukoplakia being the most common sub-type encountered (96.24%) with the second most common subtype encountered being speckled leukoplakia accounting for 2.26% of the cases reported. Conclusion: The results of the present study indicated tobacco-associated habits to be very common in the police personnel from Greater Mumbai which emphasized specific efforts to be made to reduce tobacco usage by police personnel on active duty.

Keywords: Greater Mumbai, police personnel, tobacco-associated oral lesions


How to cite this article:
Puri H, Nayyar AS. Evaluation of tobacco-associated oral lesions in the police personnel from Greater Mumbai: A survey with review of literature. Arch Med Health Sci 2017;5:177-81

How to cite this URL:
Puri H, Nayyar AS. Evaluation of tobacco-associated oral lesions in the police personnel from Greater Mumbai: A survey with review of literature. Arch Med Health Sci [serial online] 2017 [cited 2018 May 25];5:177-81. Available from: http://www.amhsjournal.org/text.asp?2017/5/2/177/220827




  Introduction Top


The occupation of police officers is generally perceived as highly stressful. Cadets of other armed forces have a more or, less structured lifestyle which is mostly lived away from the main communal settlements. Police personnel perform their duties by being a part of civilian life. Furthermore, unlike the army personnel, this group of the uniformed force has a distinction of having a highly unstructured duty schedule. Their working hours are unrealistic requiring long and tiresome shifts and often, such long working hours are spent in live wire situations, wherein the levels of stress and tension are certainly high. Such unhealthy lifestyles and paramount load of stress often lead police personnel toward different types of addiction, especially the tobacco-related habits. The police personnel resort to tobacco-associated habits often as a stress buster and consider the nicotine rush will settle their nerves so that they can focus better on their work.[1] Repetitive effect of tobacco products (nicotine, nitrosamines etc.,) directly cause hyperkeratotic, and dyskeratotic changes in the oral mucosa, of which homogenous type of leukoplakia which presents as a nonscrapable hyperkeratotic patch with superficial cracks (cracked mud appearance) is the one most commonly encountered clinically.[2],[3] Speckled leukoplakia, that is considered to be an advanced form of dysplastic change, is believed to affect the proliferative capacity of the basal cell layer, in addition, to the keratinizing capacity of the superficial layer as a result of which red areas (wherein keratinization as well as epithelial coverage is missing) are seen within the leukoplakic patch.[3] As the red areas represent areas of the atrophic mucosa, such areas are open to the impact of carcinogens without protection from the keratinized layer of epithelia. Speckled leukoplakia is considered to be more dangerous than the homogenous variant of leukoplakia since it is believed that the basal cell layer which consists of rapidly multiplying cells has a greater proximity to carcinogens in such situations, and hence, such lesions are more likely to turn into frank malignant transformations. It is also believed that secondary candidiasis might have a role to play in the pathogenesis of speckled leukoplakia and this might, also, suggest an immunological basis for greater chances of malignant transformation seen in case of speckled leukoplakia.[3] Recently, some non-governmental organizations have taken a note of this and carried out health checkup camps for the police personnel in the city of Mumbai, but similar awareness for oral and dental health is still largely missing. Keeping this in mind, the present study was carried out with the primary aim to determine the prevalence of tobacco-associated habits and oral lesions in the police personnel from Greater Mumbai.


  Materials and Methods Top


The present study was carried out with the primary aim of evaluating tobacco-associated oral lesions in the police personnel from Greater Mumbai after obtaining ethical clearance from the Institutional Ethics Board. Two thousand three hundred and eighty-eight police personnel working in various police stations across the city of Greater Mumbai were examined. All the police personnel included in the study were subjected to a detailed case history elicitation and examination procedure after obtaining their informed written consent. Special stress was emphasized in eliciting history of tobacco-associated habits. Extra-oral and intra-oral examinations were carried out using daylight as well as an artificial white light. Aseptic measures were taken during the examination process. Abnormalities such as masseteric hypertrophy, jaw deviation during opening and closing, and lateral excursive movements of the mandible, tenderness of the muscles of the temporomandibular joint area, and the joint per SE noticed during the extra-oral examination were recorded in the pro forma. The detailed intra-oral examination was carried out using artificial white light. Special care was taken to diagnose tobacco-associated oral lesions such as tobacco pouch keratosis, preleukoplakia, leukoplakia, oral submucous fibrosis, carcinomatous, and other lesions. Clinical diagnosis of various lesions was determined after following the set guidelines, and the findings were recorded. Complaints and other findings of the patients were observed, recorded and were attended. Police personnel requiring dental treatment/biopsy and any other detailed investigation were referred to the Institution.


  Statistical Analysis Used Top


The data so collected were tabulated and sent for statistical analysis, and objective conclusions were drawn.


  Results Top


Use of tobacco with lime was found to be the most common habit present in the police personnel (34.0%) followed by alcohol (19.3%), whereas the least common habit found was betel nut chewing (3.9%). Smoking habit was found to be comparatively less common in the present study (12.3%). The habit of gutkha chewing was also found to be less commonly seen in the police personnel from Greater Mumbai (4.8%) [Table 1]. In a sample size of 2388 police personnel included in the study, the overall prevalence of leukoplakia was found to be 11.12% with homogenous leukoplakia being the most common subtype encountered (96.24%) with the second most common sub-type encountered being speckled leukoplakia accounting for 2.26% of the cases reported. Verrucous leukoplakia accounted for 0.75% of the total cases reported while homogenous and speckled combined had an equal prevalence in the study population accounting for 0.75% of the total cases reported [Table 2] and [Graph 1].
Table 1: Percentage-wise distribution of type of habits (tobacco and alcohol)

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Table 2: Distribution of leukoplakia with its subtypes

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  Discussion Top


The present study was carried out on police personnel working in the city of Greater Mumbai and as such these groups of individuals are subjected to unusual levels of stress and were supposed to be relatively more vulnerable to the tobacco-associated habits. Detailed perusal of voluminous literature available on this subject failed to show much work done in this regard, however, little work that came to fore was done by Mehta et al.[2],[3],[4],[5] and had some similarities with the present study including the aim and the study participants, the population group used, police personnel working in the city of Mumbai as was in the present study, police personnel working in the city of Greater Mumbai. The aim of their study was to find the incidence of leukoplakia in relation to tobacco-associated habits in a 10 year follow-up period. As the population group was same, we could compare data of the present study with theirs. [Table 1] shows percentage-wise distribution of type of habits (tobacco and alcohol) in the study population. As seen in the table, tobacco with lime was found to be the most common habit present in the police personnel (34.0%) followed by alcohol (19.3%) while the least common habit was betel nut chewing (3.9%). Smoking habit was found to be comparatively less common in the present study (12.3%). The habit of gutkha chewing was also found to be less commonly seen in the police personnel from Greater Mumbai (4.8%). Surprisingly, 16.1% of the study group was having habit of mishri usage.

The findings of the present study were found to be comparable with the results of the study conducted by Mehta et al. in 1972,[5] wherein they found 44.89% of the police personnel with chewing habit, 23.20% with smoking habit and 14.05% of the police personnel with mixed habits. In the present study, however, the chewing habits (tobacco with lime, betel nut, mishri, mawa, pan, and gutkha) were not grouped together as was the case in their study. Smoking habit was found to be comparatively less common in the present study (12.3%) as against their study (23.20%) which might be due to the recent ban on smoking in public places in Mumbai. Even if the findings of the present study had a target population of police personnel, the results of the present study could not ideally be compared with the findings of the other similar studies because of variability in so many factors apart from the ones conducted by Mehta et al.,[2],[3],[4],[5] especially the one conducted with the similar population group used, police personnel working in the city of Mumbai in 1972.[5]

Mehta et al. in 1969,[4] also conducted an epidemiological survey on oral cancer and leukoplakia among 4 different states of India and found the prevalence of chewing habit in a range of 1.9% in the state of Andhra Pradesh to 12.9% in Darbhanga district of Bihar. The prevalence of smoking habit was, on the contrary, found to be 11.4% in Darbhanga district of Bihar to 28.9% in the state of Gujarat. Mixed habit ranged from 3.2% in the state of Gujarat to 12.3% in the Darbhanga district of Bihar. Compared to the findings of their study, the results of the present study showed greater percentage of chewing habit as against smoking. Malaovalla et al. in 1976[6] showed that smoking habit was more prevalent (42%) in their study group in Gujarat, India. Furthermore, smoking and pan/supari chewing habit was present in 26%, whereas all other habits together constituted 32% of the study population. The results of the present study, however, showed tobacco and lime chewing to be most common habit (34%). The reason behind this might be because this habit was relatively less conspicuous than smoking. According to Saraswathi et al. in 2006,[7] smoking habit was more prevalent (15.2%) than chewing (6.99%) and use of alcoholic beverages was found in 8.78% of the study population in south India. The prevalence of smoking habit in their study was comparable to the results of the present study; however, chewing habit in the present study was found to be more prevalent. Alcohol consumption, in the present study, was found to be two times more common than the results obtained in their study.

According to the National Sample Survey Organization report in 1993-94,[8] the prevalence of tobacco usage, in any form, was found to range from 45.3% in the rural areas to around 29.9% in the urban areas in India. In the state of Maharashtra, the prevalence the prevalence of tobacco usage was found to be 45.4% in rural and 25.4% in urban areas. The findings of the said report were found comparable to the findings of the present study. [Table 2] and [Graph 1] show the distribution of leukoplakia with its subtypes. In a sample size of 2388 police personnel included in the study, the overall prevalence of leukoplakia was found to be 11.12% with homogenous leukoplakia [Figure 1] being the most common subtype encountered (96.24%) with the second most common subtype encountered being speckled leukoplakia [Figure 2] accounting for 2.26% of the cases reported. In leukoplakia with red elements, special attention was given during examination not to confuse the lesions with the other lesions with similar clinical appearance including chemical burns, candidiasis, and numerous other similarly appearing lesions. Only two cases of verrucous subtype of leukoplakia were found while an equal number of police personnel presented with both homogeneous and speckled types together although at different locations. The clinically diagnosed speckled and verrucous subtypes of leukoplakia were immediately referred to the Institution for further investigation and treatment.
Figure 1: Homogenous leukoplakia in a study participant in right lower labial mucosa

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Figure 2: Speckled leukoplakia in a study participant in left retrocommissural area

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All 266 participants who reported with leukoplakia in the study had a definite history of tobacco consumption in one form or the other. Mehta et al. in 1969[4] carried out epidemiological survey in 4 different states of India and found that the prevalence of leukoplakia ranged from 0.2% to 4.9%. Among the cases reported, homogenous variant of leukoplakia was found to be the most common subtype (83.8%) while speckled leukoplakia constituted 16.18% of the cases reported. None of the cases presented with verrucous leukoplakia in their study. An increase in the prevalence of leukoplakia (11.2%) in the present study might be due to more tobacco consumption rate in police personnel. Among the subtypes of leukoplakia, the prevalence of homogenous variant was comparable with the results of the present study although speckled leukoplakia cases reported in their study were found to be far more than those observed in the present study. Dagli et al. in 2008,[9] reported a high prevalence of leukoplakia (33.3%) among green marble mine labors. The results of the present study revealed a comparatively lower prevalence of leukoplakia than the results obtained in their study which might be explained on the basis of high occupational stress, poor nutrition, and illiteracy among the mine workers than in the study group used in the present study. The results of their study also significantly indicated stress to be an important factor that increased the chance of an individual to indulge in the tobacco-associated habits.

In the present study, there were two cases of clinically suspected verrucous leukoplakia out of which one patient refused to undergo biopsy while the other case turned out to be verruciform xanthoma. Furthermore, one case had a history of pain in lower left posterior mucosal region and associated jawbone for >5 months. On examination, it revealed a granular lesion [Figure 3] which took the toluidine stain positively [Figure 4] when tested. Biopsy of the region revealed well-differentiated oral squamous cell carcinoma while radiology, intra-oral (intra-oral peri-apical radiograph-IOPAR [Figure 5] as well extra-oral (orthopantomograph) [Figure 6] revealed extensive bone loss in the area.
Figure 3: Granular lesion in a study participant in left retromolar area

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Figure 4: Toluidine stain positivity in the same area

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Figure 5: Intra-oral periapical radiograph in the same area revealing extensive bone loss

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Figure 6: Orthopantomograph of the same patient revealing extensive bone loss in the same area

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Very few studies have been conducted to date to trace tobacco usage in police and army with related implications of stress behind them. Chisick et al. in 1998[10] conducted a cross-sectional survey in the United States Armed Forces to compare the tobacco use profile of recruits with that of military personnel on active duty to determine whether the military environment in some way induces service members to initiate tobacco use. They included 2711 military recruits and 4603 military personnel on active duty. The results of their study found that there was increase in tobacco use among American military personnel, more so, exclusively, in men while they concluded that efforts were required to be made to reduce tobacco usage by American military personnel on active duty and that they should focus more on discouraging the initiation of tobacco use.

Peterson et al. in 2007,[11] conducted a study to evaluate the characteristics of smokeless tobacco usage in 785 active duty military personnel and found that there were significant differences in smokeless tobacco usage patterns in military personnel and cessation programs should be tailored to meet these differences. Nelson et al. in 2009,[12] also conducted a similar kind of study to describe patterns, practices, and experiences of active duty army soldiers who used tobacco, had quit using tobacco and had relapsed after a period of tobacco abstinence and concluded that the army culture supported soldier's tobacco usage.


  Conclusion Top


The results of the present study indicated tobacco-associated habits to be very common in the police personnel from Greater Mumbai which emphasized specific efforts to be made to reduce tobacco usage by police personnel on active duty and to focus more on discouraging the initiation of tobacco use.


  Future Research Directions Top


As police personnel's job is associated with high levels of stress and anxiety, a detailed study of stress-associated habits with a greater sample size should be carried out with a psychological evaluation. The frequently employed method of stress analysis in survey-based studies is by utilizing questionnaires; however, there is no objectification of their criteria. Further studies can also focus on the systemic conditions associated with stress including hypertension and coronary artery disease along with the tobacco-associated oral lesions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Collins PA, Gibbs AC. Stress in police officers: A study of the origins, prevalence and severity of stress-related symptoms within a county police force. Occup Med (Lond) 2003;53:256-64.  Back to cited text no. 1
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2.
Mehta FS, Sanjana MK, Shroff BC, Doctor RH. Incidence of leukoplakia among 'pan' (betel leaf) chewers and 'bidi' smokers: A study of a sample survey. Indian J Med Res 1961;49:393-9.  Back to cited text no. 2
    
3.
Mehta FS, Daftary DK, Shroff BC, Sanghvi LD. Clinical and histologic study of oral leukoplakia in relation to habits. A five-year follow-up. Oral Surg Oral Med Oral Pathol 1969;28:372-88.  Back to cited text no. 3
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Mehta FS, Pindborg JJ, Gupta PC, Daftary DK. Epidemiologic and histologic study of oral cancer and leukoplakia among 50,915 villagers in India. Cancer 1969;24:832-49.  Back to cited text no. 4
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Mehta FS, Shroff BC, Gupta PC, Daftary DK. Oral leukoplakia in relation to tobacco habits. A ten-year follow-up study of Bombay policemen. Oral Surg Oral Med Oral Pathol 1972;34:426-33.  Back to cited text no. 5
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Malaovalla AM, Silverman S, Mani NJ, Bilimoria KF, Smith LW. Oral cancer in 57,518 industrial workers of Gujarat, India: A prevalence and followup study. Cancer 1976;37:1882-6.  Back to cited text no. 6
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Saraswathi TR, Ranganathan K, Shanmugam S, Sowmya R, Narasimhan PD, Gunaseelan R, et al. Prevalence of oral lesions in relation to habits: Cross-sectional study in South India. Indian J Dent Res 2006;17:121-5.  Back to cited text no. 7
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8.
Report of the National Sample Survey Office, 1998-1999. Key Selected Studies and Estimation of the Number of Tobacco Users: Sarvekshana 1998. Ch. 3.5. New Delhi: Ministry of Statistics and Programme Implementation (MOSPI), Government of India (GOI); 1998. p. 68-81.  Back to cited text no. 8
    
9.
Dagli RJ, Kumar S, Mathur A, Balasubrimanyam G, Duraiswamy P, Kulkarni S, et al. Prevalence of leukoplakia, oral submucous fibrosis, papilloma and its relation with stress among green marbles mine laborers, India. Med Oral Patol Oral Cir Bucal 2008;13:E687-92.  Back to cited text no. 9
    
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Chisick MC, Poindexter FR, York AK. Comparing tobacco use among incoming recruits and military personnel on active duty in the United States. Tob Control 1998;7:236-40.  Back to cited text no. 10
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Peterson AL, Severson HH, Andrews JA, Gott SP, Cigrang JA, Gordon JS, et al. Smokeless tobacco use in military personnel. Mil Med 2007;172:1300-5.  Back to cited text no. 11
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Nelson JP, Pederson LL, Lewis J. Tobacco use in the army: Illuminating patterns, practices, and options for treatment. Mil Med 2009;174:162-9.  Back to cited text no. 12
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