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 Table of Contents  
ORIGINAL ARTICLES
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 109-112

Correlation of areca habit, clinical grading, anorexia, and fatique in oral submucous fibrosis


1 Department of Oral Medicine and Radiology, People's College of Dental Science and Research Centre, Bhopal, Madhya Pradesh, India
2 Department of OMR, People's College of Dental Science and Research Centre, Bhopal, Madhya Pradesh, India

Date of Web Publication19-Nov-2015

Correspondence Address:
Rashmi S Sathe
Department of Oral Medicine and Radiology, People's College of Dental Science and Research Centre, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-2915.167874

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  Abstract 

Aim: The aim was to correlate the habit index (HI), clinical grading with anorexia, and fatigue in oral submucous fibrosis (OSMF). Settings and Design: Hospital-based study including a total of 60 individuals, out of which 30 patients were with OSMF, (27 males and 3 females). A group of 30 individuals, with areca chewing habit but without any oral lesions were selected as a control group. Subjects and Methods: Detailed case history was recorded. Height and weight measurements were made to assess body mass index (BMI). Fatigue and anorexia scores were calculated using structured questionnaires. Clinical staging of OSMF was done according to Khanna JN and Andrade NN (1995) classification. The information related to the type of habit, site of placement of areca nut, and duration was recorded using HI. Statistical Analysis Used: Statistical analysis was done using Pearson's correlation and Student's t-test. Results: A statistically significant difference was found between anorexia in both the groups (P = 0.01) and a highly significant difference was seen in HI (P = 0.001). However, the comparison between other parameters was found to be statistically not significant. The correlation of HI, anorexia, and fatigue score in Grade I, Grade II, Grade III, and Grade IV OSMF within each group was not significant statistically. However, in Grade IV a strong correlation was found between BMI and anorexia score (P = 0.0188). Conclusion: The merits of this study include a positive correlation between anorexia and fatigue with disease progression and a congruent relation of HI with the grades of OSMF.

Keywords: Anorexia, areca nut, fatigue


How to cite this article:
Sathe RS, Gharote HP, Nair PP, Hegde KJ, Sood MS, Gangwal PA. Correlation of areca habit, clinical grading, anorexia, and fatique in oral submucous fibrosis. J Dent Res Rev 2015;2:109-12

How to cite this URL:
Sathe RS, Gharote HP, Nair PP, Hegde KJ, Sood MS, Gangwal PA. Correlation of areca habit, clinical grading, anorexia, and fatique in oral submucous fibrosis. J Dent Res Rev [serial online] 2015 [cited 2019 Oct 23];2:109-12. Available from: http://www.jdrr.org/text.asp?2015/2/3/109/167874


  Introduction Top


Modernization has brought about an immense progress in human beings. Along with this progress, stressful lifestyle has become a part and parcel of today's modern life. To relieve this stress humans consume stress-relieving substances like tobacco, alcohol, and betel nut. These are harmful as well as addictive to the human body. There are a wide variety of mucosal changes seen in day-to-day clinical practice by dental surgeons. One such pathological condition is oral submucous fibrosis (OSMF). OSMF is a chronic progressive, insidious, irreparable, and debilitating condition of the oral cavity characterized by fibrotic change and severe burning sensation along with trismus and difficulty in eating.[1],[2]

The age of occurrence for OSMF is ranging between 20 and 40 years of age.[3] The etiology of OSMF is multifactorial. It has been suggested that areca nut chewing, ingestion of chillies, genetic susceptibility, nutritional deficiencies, altered salivary constituents, autoimmunity, and collagen disorders may be involved in the pathogenesis of this condition.[4],[5] As per the recent epidemiological data, the chewing of betel quid and pan masala has been recognized as the one of the most important risk factors for OSMF.[5]

The chewing of gutkha often starts at a very young age either due to peer pressure or as a fashion statement. A large amount of sweeteners may be added to conceal the bitterness of tobacco. Children often get tempted to eat them because of its flavor. Many people think gutkha to be harmless and consider it to be a mere “mouth freshener.”[6] It has been noted that ingredients present in areca nut can modulate metabolic signals that regulate appetite in man. Previous unscientific evidence suggests that use of areca nut may moderate appetite and can affect factors like body weight and fatness. The use of areca nut to alleviate hunger by people exposed to the periodic scarcity of food has been found in older literature and studies.[7] The betel nut has psychotropic and anti-helminthic property due to the presence of areca alkaloids. These alkaloids have powerful parasympathetic properties which produce euphoria and counteract fatigue.[8]

This study is an attempt to correlate various parameters such as, anorexia, fatigue in OSMF individuals, and body mass index (BMI) with clinical grades and habit index (HI).


  Subjects and Methods Top


This study was conducted in Department of Oral Medicine and Radiology, Peoples College of Dental Sciences and Research Center, Bhanpur, Bhopal. The ethical clearance was obtained for the study and a written informed consent was signed by the patients.

A total sample of 60 patients were selected, out of which 30 individuals with clinically diagnosed OSMF were selected (27 males and 3 females). A control group comprised of 30 individuals with the history of areca habit, but without any oral lesions was selected for comparison. Detailed case history was recorded as per the standard proforma. Height and weight measurements were made to assess BMI.

Fatigue and anorexia scores were calculated using structured questionnaires. Simplified Nutritional Assessment Questionnaire was used for evaluation of anorexia.[9] The fatigue questionnaire was formulated using guidelines given for evaluation of fatigue by Portenory and Loretta.[10] Clinical staging of OSMF was done according to Khanna JN and Andrade NN (1995) classification.[11] The information related to type of habit, site of placement of areca nut/product, and duration of habit was recorded using HI.[12]


  Results Top


Mean and standard deviation were calculated for all the parameters viz. BMI, fatigue score, anorexia scores, and HI in both the groups. They were compared with control group using Student's t-test. Pearson's correlation was used to evaluate the association between the various parameters within various OSMF grades.

The study comprised of 30 OSMF individuals and 30 controls. The comparison of their ages was statistically nonsignificant [Table 1].
Table 1: Gender distribution between OSMF and Control group

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A statistically significant difference was found between anorexia score of both the groups (P = 0.01) and a highly significant difference was seen in HI (P = 0.001). However, comparison between other parameters was found to be statistically not significant [Table 2].
Table 2: Group statistics

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The [Table 3],[Table 4],[Table 5],[Table 6] showing correlation of HI, anorexia, and fatigue score in Grade I, Grade II, Grade III, and Grade IV OSMF.
Table 3: Correlation table for Grade I OSMF

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Table 4: Correlation table for Grade II OSMF

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Table 5: Correlation table for Grade III OSMF

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Table 6: Correlation table for Grade IV OSMF

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The correlation between various parameters within each grade was not significant statistically, however, in Grade IV a strong correlation was found between BMI and anorexia score (P = 0.0188).


  Discussion Top


OSMF has an ancient history with Sushruta, who mentioned about a condition “Vidari,” the features of which simulate OSMF.[1] Later it was described in 1952 by Schwartz, as “atrophia idiopathica (tropica) mucosae oris” and by Joshi (1953) as OSMF taking into account its histological nature.[2]

The history regarding the use of areca nut as a chewing object by humans has been mentioned by Theophrastus in scripts dating around 430 BC, which described it as a component of the betel morsel.[3] Nut of areca catechu is mainly composed of four compounds alkaloids, polyphenols, tannins, and trace elements. Four alkaloids have been identified as arecoline, arecaidine, guvacine, and guvacoline, of which arecoline is the main agent. These alkaloids have powerful parasympathetic properties which produce euphoria and counteract fatigue. Recent studies regarding pathogenesis of OSMF has suggested the dual action of areca nut. It is suggested that arecoline not only stimulates fibroblastic proliferation and collagen synthesis but also decreases its breakdown.[4],[5]

In India, there is a practice of adding tobacco to betel nut, which increases its addictive properties. Areca nut is the fourth most addictive substance in the world and is associated with a dependency syndrome.[6]

It is also well-established fact that tobacco and areca nut consumption may contribute to body weight regulation through effects on appetite and energy expenditure.[6],[9]

Pharmacological properties of areca nut influence body composition, perhaps through 5-hydroxytriptamine (5-HT) - mediated effects on energy metabolism and appetite.[5] Further, it has been found that areca nut chewing practices result in energizing, comforting and calming effect and help to reduce fatigue.[6]

In a study conducted by Singh et al.,[7] regarding the evaluation of cachexia in OSMF individuals stated the strong correlation between loss of appetite and body weight in OSMF individuals. Similar results were found in the present study. Although other parameters in the present study did not reveal positive correlation, these can possibly be evaluated in OSMF individuals with potential malignant transformation.

The three principal alkaloids known to be neuroactive in areca nut are arecoline and its metabolite arecaidine which activate muscarinic receptors. Arecoline is also a nicotinic receptor agonist. Their effects are thus mainly parasympathomimetic and resemble those of acetylcholine. Arecaidine and guvacine inhibit uptake of the central inhibitory neurotransmitter g-amino-butyric acid. Both neurotransmitters are known to play a role in hypothalamic monoaminergic systems of human thermoregulation. These pathways have been implicated in modulating the intake and metabolism of macronutrients. These pathways have also been investigated in relation with the nutritional status of an individual consuming areca nut. Further, the potent anorectic agent dexfenfluramine is a 5-HT-ergic compound related with appetite modulation in OSMF individuals is also studied in this respect.[13]

In our study, as the duration of consuming habit increased above 10 years, the severity of the disease also increased with maximum number of cases observed in Grade II and Grade III OSMF. The frequency of habit of consuming areca nut for more than 10 times per day resulted in increased severity of OSMF. Subjects, who consumed, <10 times per day had Grade I and Grade II OSMF. This was in accordance with results of the study conducted by Reddy et al.[14]

In our study, the correlations of HI, anorexia, and fatigue score in Grade I, Grade II, and Grade III were found to be statistically insignificant [Table 3],[Table 4],[Table 5]. Further, a strong correlation was found between BMI and anorexia score in Grade IV OSMF, which signifies that as the disease progresses, the level of anorexia increases further causing loss of weight in OSMF individual. Nevertheless, food intake is compromised due to the increased burning of oral mucosa, ulcers, and reduced mouth opening. This affects the overall health and nutritional status of the individual. Similar findings were also observed in a study conducted by Yallamraju et al.[15]

The pathogenesis of OSMF involves the mechanical as well as chemical trauma to the oral mucosa. Because of constant micro-trauma caused by dry areca nut pieces to the oral mucosa, a chronic inflammatory reaction is induced. This results in increase in oxidative stress and cytokines production. The alkaloid like arecoline, arecaidine, guvacine, tannins, catechins, leaches out in saliva from areca nut, and acts on the chronically inflamed mucosa. It has been accepted that dense fibrosis and less vascularity of the corium, in the presence of an altered cytokine activity creates a unique environment for carcinogens to act on the epithelium. There is an increased amount of cytokines produced in oral mucosa which are fibroblast growth factor, transforming growth factor, and platelet-derived growth factors which results in increased production of collagen in the submucosal region. There is a reduced degradation of collagen due to inhibition of cytokine in collagen production.[1],[5] Thus, it can be stated that the pathophysiology of potential malignant transformation in OSMF begins during its progression. Therefore, early intervention can be helpful in reverting the progression of disease in OSMF.[7]

The loss of appetite and decreased nutritional status can be found in progressive cases of OSMF and may further contribute to the malignant transformation of this entity. Many OSMF patients present with anemia and nutritional deficiencies. The relationship between these factor and disease progression is still not clear.[7]


  Conclusion Top


The merits of this study include a positive correlation of anorexia and fatigue with disease progression and a congruent relation of HI with the grades of OSMF. Thus, beginning of the early process of anorexia and alterations in the nutritional status during the progression of OSMF can be assessed in a larger sample using these parameters. Further, evaluations of these parameters in treated OSMF individuals can be helpful in assessing the treatment outcomes. Nevertheless, the biochemical analysis of OSMF individuals in relation to physical parameters evaluated in the present study needs to be correlated.

 
  References Top

1.
Ali FM, Aher V, Prasant MC, Bhushan P, Mudhol A, Suryavanshi H. Oral submucous fibrosis: Comparing clinical grading with duration and frequency of habit among areca nut and its products chewers. J Cancer Res Ther 2013;9:471-6.  Back to cited text no. 1
    
2.
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. 2
    
3.
Pindborg JJ. Oral submucous fibrosis as a precancerous condition. J Dent Res 1966;45 Suppl 3:546-53.  Back to cited text no. 3
    
4.
Rajendran R. Oral submucous fibrosis: Etiology, pathogenesis, and future research. Bull World Health Organ 1994;72:985-96.  Back to cited text no. 4
    
5.
Rajalalitha P, Vali S. Molecular pathogenesis of oral submucous fibrosis – A collagen metabolic disorder. J Oral Pathol Med 2005;34:321-8.  Back to cited text no. 5
    
6.
Sharan RN, Mehrotra R, Choudhury Y, Asotra K. Association of betel nut with carcinogenesis: Revisit with a clinical perspective. PLoS One 2012;7:e42759.  Back to cited text no. 6
    
7.
Singh P, Gharote H, Nair P, Hegde K, Saawarn N, Guruprasad R, et al. Evaluation of cachexia in OSMF. J Indian Acad Oral Med Radiol 2012;24:130-2.  Back to cited text no. 7
  Medknow Journal  
8.
Gupta MK, Mhaske S, Ragavendra R. Oral submucous fibrosis – Current concepts in etiopathogenesis. Peoples J Sci Res 2008;1:39.  Back to cited text no. 8
    
9.
Wilson MM, Thomas DR, Rubenstein LZ, Chibnall JT, Anderson S, Baxi A, et al. Appetite assessment: Simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr 2005;82:1074-81.  Back to cited text no. 9
    
10.
Portenory R, Loretta M. Cancer related fatigue: Guidelines for evaluation and management. Oncologist 1999;4:1-10.  Back to cited text no. 10
    
11.
More BC, Gupta S, Joshi J, Varma SN. Classification systems for oral submucous fibrosis. J Indian Acad Oral Med Radiol 2012;24:24-9.  Back to cited text no. 11
  Medknow Journal  
12.
Bailoor N, Nagesh KS. Fundamentals of Oral Medicine and Radiology. Dariyaganj, New Delhi, India: Jaypee Brothers; 2005.  Back to cited text no. 12
    
13.
Strickland SS, Duffield AE. Nutrition and ecosystems in Sarawak: The role of the areca nut. Asia Pac J Clin Nutr 1998;7:300-6.  Back to cited text no. 13
    
14.
Reddy V, Wanjari PV, Banda NR, Reddy P. Oral Submucous Fibrosis: Correlation of Clinical Grading to various habit factors. Int J Dent Clin 2011;3:21-4.  Back to cited text no. 14
    
15.
Yallamraju SR, Mehrotra R, Sinha A, Gattumeedhi SR, Gupta A, Khadse SV. Use of mid upper arm circumference for evaluation of nutritional status of OSMF patients. J Int Soc Prev Community Dent 2014;4 Suppl 2:S122-5.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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Abstract
Introduction
Subjects and Methods
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