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Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 1-3

A cytological study of leukoplakia in oral cavity at Patliputra Medical College and Hospital, Dhanbad

1 Department of Dentistry, Patliputra Medical College and Hospital, Dhanbad, Jharkhand, India
2 Department of Dentistry, Government Medical College, Kathua, Jammu, India

Date of Web Publication26-Jun-2019

Correspondence Address:
Dr. Animesh K Shivam
Department of Dentistry, Patliputra Medical College and Hospital, Dhanbad 828127, Jharkhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INJO.INJO_16_19

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Objectives: To assess the role of cytology in leukoplakia and its etiology in patients attending outpatient department at Patliputra Medical College and Hospital (PMCH), Dhanbad, Jharkhand, India. Materials and Methods: The diagnosis of leukoplakia was based on clinical examination and cytological smear. Results: The total number of patients affected by leukoplakia in this time duration was 268. Of these, 238 (86%) were male, whereas 30 were female (14%). Greatest proportion of patients with leukoplakia had a habit of consuming khaini and tobacco in other forms. Mild form of leukoplakia was commonly seen. Conclusion: This study reveals that the incidence rate of leukoplakia in patients visiting PMCH, Dhanbad, was 1%. Males were more affected than females. Use of cytology in mass screening programs helped in identifying leukoplakias with parakeratotic patterns and leading to those cases, which need careful long-term follow-up.

Keywords: Cytology, leukoplastic lesion, oral cavity

How to cite this article:
Shivam AK, Azam F, Sadiq H. A cytological study of leukoplakia in oral cavity at Patliputra Medical College and Hospital, Dhanbad. Int J Oral Care Res 2019;7:1-3

How to cite this URL:
Shivam AK, Azam F, Sadiq H. A cytological study of leukoplakia in oral cavity at Patliputra Medical College and Hospital, Dhanbad. Int J Oral Care Res [serial online] 2019 [cited 2023 Mar 25];7:1-3. Available from: https://www.ijocr.org/text.asp?2019/7/1/1/259901

  Introduction Top

Leukoplakia literally means white patch, “Leukos” means “white,” and “Plakia” means “patch.” This term was proposed by the Hungarian dermatologist, Erno Schwimmer in 1877. In 1978, a World Health Organization group defined oral leukoplakia as: “A white patch or plaque that cannot be characterized clinically or pathologically as any other disease.”[1] It is therefore a diagnosis of exclusion from other oral white lesions such as leukokeratosis, infective lesions (candidiasis, syphilitic oral lesion, and oral hairy leukoplakia caused by Epstein–Barr virus), lichen planus, lupus erythematosus, dyskeratosis congenita, white sponge nevus, submucosal fibrosis, and frank carcinomas.[1],[2],[3] It is common in adults beyond 40 years of age and affects 1% of the total population.[4] A very strong association has been found between smoking, chewing tobacco, betel nut, consumption of alcohol, or combination with leukoplakia. Cytology is now recognized as an adjunct to biopsy in the diagnosis of carcinoma. Biopsy for premalignant lesions is not always possible, especially during mass screening, so cytologic screening is carried out for the evaluation of premalignant lesions such as leukoplakia.

This study aimed to explore the possible etiological factors responsible for oral leukoplakia and to assess the utility of exfoliative cytology in the detection of malignant changes in the patients visiting Patliputra Medical College and Hospital, Dhanbad, Jharkhand, India.

  Materials and Methods Top

This prospective study was carried out from January 2015 to December 2015. During this period, all cases presenting to the department of dentistry with white lesions in the oral cavity were made part of the study. A pretested, semi-structured pro forma was used for collecting information from the patients. Written consent from each patient was obtained after explaining the purpose of the study. Pro forma consisted of two components: sociodemographic status and clinical features of the patients. Cases of oral white lesions found to be of any infective etiology or a part of any other systemic disease were excluded from the study. The rest of the cases with no demonstrable cause, except tobacco use, were subjected to cytological examination. The cytological smear was prepared, the patients were asked to rinse their mouth with normal saline three times. Dry lesions were moistened with saline. Sterile wooden spatula was used for cytology. The lesions were scraped gently with the spatula and the material obtained was smeared on glass slides. Precaution was taken to avoid smudging of smear. The slides were kept in fixative (mixture of ethanol [80%] and ether [20%]) immediately after spreading for approximately 30min.

The fixed smears were stained by the method of Papanicolaou. The stained smears were screened for various pathological lesions and classified as (1) orthokeratotic, (2) parakeratotic, and (3) combined, as per the criteria laid down by Sahiar et al.[5] Similarly, smears with atypia were again divided into mild, moderate, and severe. At the end of the study period, the results were compiled, tabulated, and analyzed using suitable statistical tools such as percentages and Student’s t-test.

  Results Top

During the time span of the study, 268 cases were diagnosed to have oral leukoplakia, this constituted 0.78% of all new cases attending the outpatient department of dentistry. Of these 268 cases, 230 (85.82%) were male and 38 (14.18%) female [Table 1]. Their ages ranged from 9 to 80 years with a mean of 40.8 years. The maximum percentage of patients (55.47%) were seen in the 21–30 years age group (third decade) followed by the fourth and fifth decades.
Table 1: Site of lesion

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The sites involved included the lips, tongue, palate buccal mucosa, and vestibule [Table 1]. In both sexes, the most common site involved was the buccal mucosa (52.26%, P < 0.05) followed by the tongue (31.23%). The lips and palate showed lesions in 11.7% and 2.22% cases, respectively.

Snuff (khaini) was found to be the most common associated addiction, seen in 50.2% patients, and the use of betel leaf (paan) was observed in 16.26% patients, and 11.7% cases reported cigarette smoking. Tobacco in some form or the other was observed as the most common associated factor in the development of leukoplakia [Table 2].
Table 2: Incriminating factor for leukoplakia

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Grading of the cytological atypia showed the number of cases with mild atypia were 202 (75%) and moderate atypia were 41 (24.9%). No case showed severe atypia or malignant cells (1, 0.1%) [Table 3].
Table 3: Cytological atypia in oral leukoplakia

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  Discussion Top

Idiopathic leukoplakias are mostly benign lesions occurring in response to chronic irritation. Tobacco in different forms has been described as the most common incriminating factor for such lesions.[6],[7],[8] However, other factors, depending on the sociocultural habits of the patients that lead to chronic irritation of oral and buccal mucosa may also be contributory. It starts as a thin homogeneous grayish white plaque either well defined or blending with the surrounding tissue. The lesion enlarges to leathery appearance with surface fissures (thick homogeneous leukoplakia). Some lesions develop surface irregularities (granular or nodular leukoplakia), warty papillary surface projections (verrucous leukoplakia), or mixed red and white lesions (speckled leukoplakia or erythroplakia). The uncommon variant, namely proliferative verrucous leukoplakia is characterized by widespread multifocal sites of involvement, often in patients with known risk factors Patients with idiopathic leukoplakia have the highest risk of developing cancer.[9]

In this study, the adult population was taken into consideration with a definite history of betel nut, tobacco and lime chewing, and smoking. Of the total 15,000 patients, 268 cases had leukoplakia and used tobacco in the form of khaini followed by other tobacco products. In India, highest prevalence (3.5%) of leukoplakia was reported by Mehta et al.[10] from Bombay in persons with smoking and chewing habits. Highest prevalence (8.1%) was reported by Atkinson et al.[11] from New Guinea.

The age range was wide showing that no age was exempted, whereas several other studies worldwide have shown preponderance of leukoplakia in a later age group beyond 40 years. The discrepancy could be due to the use of tobacco, lime, and betel, which is quite prevalent among the younger population in our country. The male were more affected when compared to female. The leukoplakia cases were highest in the third decade followed by fourth and fifth decades. This is in accordance with the findings by Mehta FS et al. although it was higher in comparison to other studies by Mehta et al.[10]

There has been a conflicting evidence as to the efficacy of the cytological examination when it was used to diagnose the malignant potentialities of the oral precancerous condition, mainly leukoplakia. In such lesions, the presence of thick keratinized layer may lead to a scant exfoliation of atypical cells on the surface, and viable cells may be sparse in the smear. The keratinization pattern of 229 smears was studied as 21 of the smears were unsatisfactory. The smears were categorized into parakeratotic, orthokeratotic, or combination. It was assessed quantitatively if organophilic, yellowish, or eosinophilic nucleated squames were present predominantly. This involved at least 60% of the cells in the smear and very often they were the only cells present. Similarly, parakeratotic smears were judged by the predominant presence of eosinophilic cells with pyknotic nuclei. The determination of the type of keratinization assumes importance because with parakeratosis, the mitotic index rises, indicating proliferative tendency, which often leads to epithelial hyperplasia, dysplasia, carcinoma in situ, and even carcinoma. Our study showed maximum cases with parakeratosis, indicating proliferative tendency in these cases. It was observed that with an increase in the frequency of habits, an increase in the percentage of combination smears was also observed. Oral cytology is useful in diagnosing oral leukoplakias with parakeratosis patterns and leading to those cases, which need careful long-term follow-up.

  Conclusion Top

Leukoplakia is the most common potentially malignant lesion of the oral cavity, and its clinical association with the habit of tobacco and betel nut chewing along with smoking, of which smoking is the most important etiological factor for oral leukoplakias in Dhanbad District. The determination of the type of keratinization on cytology assumes significance because it helps in identifying parakeratosis, orthokeratosis, and also indicates the proliferative tendency. This study justifies the use of cytology in mass screening programs in identifying leukoplakias with parakeratotic patterns and leading to those cases, which need careful long-term follow-up.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kramer IR, Lucas RB, Pindborg JJ, Sobin LH. Definition of leukoplakia and related lesions: An aid to studies on oral precancer. Oral Surg Oral Med Oral Pathol 1978;46:518-39.  Back to cited text no. 1
Shafer WB, Waldron CA. A clinical and histopathologic study of oral leukoplakia. Surg Gynecol Obstet 1961;112:411-20.  Back to cited text no. 2
Scully C. The oral cavity. In: Champion RH, Burton JL, Burns DA, Breathnach SM, editors. Rook/Wilkins/Ebling Textbook of Dermatology, 6th ed. London, UK: Blackwell Science; 1998. p. 3097-9.  Back to cited text no. 3
Petit S. Pooled estimate of world leukoplakia prevalence: A systemic review. Oral Oncol 2003;39:770-80.  Back to cited text no. 4
Sahiar BE, Daftary DK, Mehta FS. Cytological and histological keratinization studies in leukoplakias of the mouth. J Oral Pathol 1975 Jul;4:19-26.  Back to cited text no. 5
Axell T, Pindborg JJ, Smith CJ, van der Waal I. Oral white lesions with special reference to precancerous and tobacco-related lesions: Conclusions of an international symposium held in Uppsala, Sweden. J Oral Pathol Med. 1994.  Back to cited text no. 6
Axell T, Pindborg JJ, Smith CJ, van der Waal I. Oral white lesions with special reference to precancerous and tobacco- related lesions: conclusions of an international symposium held in Uppsala. Sweden. J Oral Pathol Med. 1996 Feb;25:49-54.  Back to cited text no. 7
Bouquot JE, Gorlin RJ. Leukoplakia, lichen planus, and other oral keratoses in 23,616 white Americans over the age of 35 years. Oral Surg Oral Med Oral Pathol 1986;61:373-81.  Back to cited text no. 8
Mishra M, Mohanty J, Sengupta S, Tripathy S. Epidemiological and clinicopathological study of oral leukoplakia. Indian J Dermatol Venereol Leprol 2005;71:161-5.  Back to cited text no. 9
[PUBMED]  [Full text]  
Mehta FS, Sanjana MK, Shroff BC, Doctor RH. Incidence of leukoplakia among ‘pan (betel leaf) chewers’ and ‘bidi smokers’ a study of sample survey. IJM R 1961;49:393-9.  Back to cited text no. 10
Atkinson L, Chester IC, Smyth FG, Ten Seldamr. Oral cancer in New Guinea. A study in demography and etiology. Cancer 1964;17:1289-98.  Back to cited text no. 11


  [Table 1], [Table 2], [Table 3]


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