Original article
Diagnoses of 964 oral biopsies from people aged over 50 years in Karnataka State, India Bhavna C. Mohan, Punnya V. Angadi, Seema Hallikerimath and Alka D. Kale Department of Oral Pathology and Microbiology, KLEVK Institute of Dental Sciences and Hospital, Belgaum, India
doi: 10.1111/ger.12143 Diagnoses of 964 oral biopsies from people aged over 50 years in Karnataka State, India Introduction: The drastic epidemiological transition has created a huge void in evidence with regard to the health statistics of elderly population. Data are sparse on the oral mucosal conditions prevalent among the elderly Indian population. This study aimed to review the oral biopsies reported in the institute over the last 21 years and to examine the trends in geriatric oral pathologies. Methodology: A total of 964 histologically confirmed geriatric (age ranging 50–97 years) oral lesions among 4000 cases reported were retrieved from the files of Department of Oral Pathology and Microbiology of KLE VK institute, Belgaum, Karnataka commencing since 1992 till 2012. These cases were retrospectively evaluated for various parameters such as age, gender, duration, location and type of lesions. Results: The geriatric oral lesions were seen to occur predominantly in men (65%), especially the sixth decade of life (47%). The most common location was the buccal mucosa (29%). The malignant neoplastic lesions accounted for the majority of the geriatric lesions (36%) followed by non-neoplastic lesions (27%), potentially malignant disorders (26%) and benign neoplasms, which formed a minor proportion of (11%). The oral squamous cell carcinoma was the single most common geriatric lesion accounted. Gender and age-wise correlation analyses among the various lesion categories showed statistical significance. Conclusion: The study provides valuable information about major oral pathologies in our scenario that contribute to significant morbidity and mortality among the geriatric population. It also sheds light about the diseases that need to be targeted in future Indian public health policies and initiatives for geriatric care. Keywords: geriatric, ageing, oral mucosal lesion, oral biopsy, oral cancer. Accepted 4 July 2014
Introduction A rise in the geriatric population is an inevitable trend that has been observed in the developed countries with an enormous amount of resources being directed to target the well-being of this group of people1. This demographic transformation over the recent decades is not restrained to the developed world and has gradually evolved into a global trend. Based on various statistics and demographic information; the era between 1975 and 2025 has been projected as the ageing era by the United Nations Organization (UNO)1,2. India is one of the key nations which faces this drastic rise in ageing population and the projected demographics demonstrate that by 2050; more than 323 million people (equalling US population in 2011)
will be above the age of 603. In the developing countries, this transition poses significant challenges on health care as there is a huge void in the data and resources required to deal with this imminent boom in senescent population. The oral cavity frequently gives an insight into the general health of a person, and examination of the oral cavity is considered a mandatory diagnostic step in every clinician’s routine. Further, the oral cavity often exhibits the early signs associated with most diseases, making it an ideal and easy location to examine in epidemiological surveys. Oral mucosal changes including atrophy, decreased cellularity and turnover leading to dryness of mouth, burning sensation, salivary gland changes such as fatty degeneration, fibrosis predisposing to decreased salivation, increased
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd, Gerodontology 2016; 33: 217–224
217
218
B. C. Mohan et al.
caries, periodontitis and edentulousness are some of the common changes reported in the older indivduals4,5. Increased incidences of various oral pathologies are also known to occur in old age6–8; however, limited studies regarding their incidences have been performed in India. Many studies throughout the world have assessed oral pathologies based on clinical presentation and denture association6–9; however, studies with histological confirmation are extremely rare10–12. Although these clinical reviews provide valuable information about the oral pathologies seen in geriatric population, they have disadvantages because the diagnosis is not precise and the stage of the pathology is not recognised. This is of serious consequence especially in the Indian scenario where oral cancer and pre-cancers are widespread and early identification and confirmation with histopathology has a pivotal role in implementation of the treatment strategies. Thus, both clinical and histological data complement one another and give valuable information for identification of major challenges associated with geriatric population. Further, clinical and histological oral pathology surveys in various parts of the world have identified that the oral lesions and intervention strategies vary greatly among the various countries, regions and hospitals6–12. Few studies across the world have documented histological presentations10–12, but in India, it is nonetheless, shocking to note that till date, there is no review about geriatric oral pathology trends. The differences in socioeconomic status, the presence of tobacco and quid chewing habits predict that the oral lesional profile of this ageing population may be diverse. The World Health Organization in 1963 proposed middle age group as 45–59 years, elderly age group as 60–74 years and aged as more than 75 years13. The exact age for ageing is, however, not precise as it is noted that in many countries, the biological ageing process is faster due to varying economic condition, increased lifestyle disorders, infectious diseases and other factors13–15. The low income nations such as India are faced with what has been termed as the ‘double burden of disease’, where the nation has to combat the difficulties posed by both infectious diseases such as HIV, tuberculosis and malaria and the lifestyle diseases such as malnutrition, hypertension, diabetes mellitus, obesity, cancer, leading to a significant decrease in the health of an individual above the age of 5013,15,16. In several recent projects such as MDS project in Africa and the recent multicentric study performed by WHO-SAGE collaboration, an age group of above 50 was taken as the
working definition of old age14,15. Similarly, in this study, we have categorised above 50 years as the working age group in understanding geriatric oral pathologies. We believe that this expansion of the target age group helps in an early initiation of diagnostic, counselling and preventive services for the geriatric patients with oral lesions. Further, the biopsy survey presents with reliable and accurate diagnosis of geriatric oral health data. Some of these pathologies often result in serious outcomes, and thus, early recognition and treatment of these conditions can aid in significant reduction in the mortality and morbidity in geriatric patients. This study aimed to review the oral biopsies reported in patients aged more than 50 years who have reported to the institution over the last 21 years to examine the patterns in geriatric oral pathologies.
Materials and method After obtaining institutional ethical clearance, an analysis was made of the clinical data and histopathological diagnosis between 1992 and August 2012 of elderly patients (above the age of 50) retrieved from the files of the Department of Oral Pathology and Microbiology of KLE VK Institute of Dental Sciences located in Belgaum district of Karnataka State, India. The biopsies were performed on patients attending the hospital in Belgaum City, Karnataka State, for a routine dental check-up or with specific complaints. The patients were screened in the Oral Medicine Department and referred to the Department of Oral Pathology for the biopsy of the oral lesions. The population attending the hospital lives mostly in Belgaum City and surrounding villages such as Gokak, Hukkeri, Koppa, Vakkund and Kakti. A total of 964 histologically confirmed geriatric oral lesions among 4000 cases (both soft tissue and intraosseus lesions) reported by the Department of Oral Pathology, KLE VK Institute of Dental Sciences were retrieved, and data related to the patients’ age, sex, location of the lesion, clinical diagnosis and histopathological diagnosis were tabulated. The lesions were categorised into malignant neoplastic lesions, non-neoplastic lesions, potentially malignant disorders and benign neoplastic lesions17,18. These categories were further subdivided into the various categories as depicted in Table 2. The number of malignant neoplasms being biopsied would certainly be more due to their serious nature as compared to benign fibrous hyperplasia or reactive lesions, which even though surgically excised are often
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd, Gerodontology 2016; 33: 217–224
Geriatric Oral Pathology
not sent for histopathological examination due to their obvious benign nature unless there is a suspicion of malignancy. The various clinical and histological groups were studied using frequency and percentage parameters. The gender and agewise association between the various lesion groups were discerned using the chi-squared test. Further, adjusted residual analysis was also performed, which demonstrates the direction and the strength of association between the variables. A larger AR(>2) provides evidence of association in that cell.
Results The data retrieved were arranged year-wise, and a progressive increase in the geriatric pathologies was observed with only around 15 cases reported in 1991, while 119 geriatric cases were reported in 2011. The sample of 964 elderly individuals consisted of 629 (65%) men and 335 (35%) women. The ages analysed ranged from 50 to 97 years with an average of 59.96 (8.29) years. It was noted that the oral lesions were more prevalent in patients of sixth decade (Table 1). The location of the lesions was studied, and the buccal mucosa was the most common site (29.2%) with other predominant sites being intraosseous lesions (27.7%), tongue (9.4%) and vestibule (8.8%). Mandible (19%) was more frequently affected as compared to the maxilla (9%) in the intraosseous sites. Histopathologically, the lesions were classified into four main groups in which malignant neoplastic lesions(MN) formed the major contributor to the geriatric lesions (36%) followed by nonneoplastic (NN)(27%), potentially malignant disorders (PMD) (26%) and benign neoplasms (BN), which formed a minor proportion of (11%). The subclassifications within these main lesion groups were also attempted and are described in Table 2. Among the malignant neoplasms, the malignant Table 1 Distribution of lesions by age group in 964 oral biopsies from people aged more than 50 in Karnataka State, India. Distribution Age range (Years)
Number
Percentage
50–59 60–69 70–79 80–89 90–99
453 368 109 27 7
47 38 109 27 7
219
Table 2 Distribution of diagnosis by general categories among 964 oral biopsies lesions from people aged more than 50 in Karnataka State, India. Percentage Lesion categories
Number
Group
Total
Malignant neoplasms Oral epithelial Odontogenic carcinomas Mesenchymal sarcomas Salivary gland carcinomas Potentially Malignant Disorders Hyperkeratosis Dysplasia Oral submucous fibrosis Lichen planus Lichenoid reaction Carcinoma in situ Verrucous hyperplasia Non-neoplastic conditions Odontogenic cysts Non-odontogenic cysts Mucocutaneous lesions Reactive lesions Infective lesions Normal Benign neoplasms Benign epithelial Benign odontogenic Benign salivary gland Benign mesenchymal
350 328 4 9 9 246 48 110 14 44 8 15 7 250 46 7 10 118 69 10 108 0 37 4 67
100 94 1 2.5 2.5 100 19 45 6 18 3 6 3 100 18 3 4 45 26 4 100 0 34 4 62
36 34 0.4 0.9 0.9 26 4.9 11.4 1.5 4.5 0.8 1.6 0.8 26 4.8 0.7 1 12.3 7.2 1 11 0 3.7 0.4 6.7
oral epithelial neoplasms (94%) demonstrated the highest frequency, while no benign epithelial tumours were encountered in the present geriatric sample studied. Reactive lesions were the most common non-neoplastic lesions in this study (46%). In benign neoplasms, the mesenchymal tumours showed the highest prevalence (62%) and in potentially malignant group, epithelial dysplasia was the most common diagnosis. All the lesions were finally assessed together, and the top 5 predominant lesions to occur in the oral cavity of a geriatric adult were squamous cell carcinoma (30%), epithelial dysplasia (11%), fibrous hyperplasia (7%), hyperkeratosis (4%) and non-specific inflammations (4%) (Table 4) However, the possibility of fibrous hyperplasia not being biopsied or not being subjected to histopathological examination due to their benign nature in comparison with the malignancies could be an important limitation for the observed result. Chi-squared test revealed a statistically significant difference between the main lesion groups and age ranges and gender distribution (Table 3). Gender-wise
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd, Gerodontology 2016; 33: 217–224
220
B. C. Mohan et al.
Table 3 Associations between diagnoses of 964 oral lesions and the age and sex of the patients in Karnataka State, India. Number (% and AR)
Age* 50–59 60–69 70–79 80–100 Sex** Male Female
Non-neoplastic lesions
Benign Neoplasms
Potentially Malignant Disorders
Malignant Neoplasms
118 89 41 12
61 33 10 4
126 98 19 3
148 148 40 14
(12.2; 0.62) (9.2; 1.52 (4.2;2.57*) (1.2;1.23)
147 (15.2; 3.43**) 113 (11.7;3.43**)
(6.3;2.12*) (3.4; 1.72) (1; 0.74) (0.4;0.11)
47 (4.9; 5.01**) 61 (6.3;5.01**)
(13;1.56) (10;0.62) (2; 2.11*) (0.3; 2.20*)
185 (19.1;3.80**) 61 (6.3; 3.80**)
(15.4; 2.23*) (15.4;1.96) (4; 0.02) (1.5;0.77)
250 (26;3.02**) 100 (10.3; 3.02)
AR – adjusted residuals. Age – chi-squared test = 21.92, degree of freedom = 9, p = 0.009 (significant). ** Sex – chi-squared test = 47.836, degree of freedom = 3, p =
Diagnoses of 964 oral biopsies from people aged over 50 years in Karnataka State, India Bhavna C. Mohan, Punnya V. Angadi, Seema Hallikerimath and Alka D. Kale Department of Oral Pathology and Microbiology, KLEVK Institute of Dental Sciences and Hospital, Belgaum, India
doi: 10.1111/ger.12143 Diagnoses of 964 oral biopsies from people aged over 50 years in Karnataka State, India Introduction: The drastic epidemiological transition has created a huge void in evidence with regard to the health statistics of elderly population. Data are sparse on the oral mucosal conditions prevalent among the elderly Indian population. This study aimed to review the oral biopsies reported in the institute over the last 21 years and to examine the trends in geriatric oral pathologies. Methodology: A total of 964 histologically confirmed geriatric (age ranging 50–97 years) oral lesions among 4000 cases reported were retrieved from the files of Department of Oral Pathology and Microbiology of KLE VK institute, Belgaum, Karnataka commencing since 1992 till 2012. These cases were retrospectively evaluated for various parameters such as age, gender, duration, location and type of lesions. Results: The geriatric oral lesions were seen to occur predominantly in men (65%), especially the sixth decade of life (47%). The most common location was the buccal mucosa (29%). The malignant neoplastic lesions accounted for the majority of the geriatric lesions (36%) followed by non-neoplastic lesions (27%), potentially malignant disorders (26%) and benign neoplasms, which formed a minor proportion of (11%). The oral squamous cell carcinoma was the single most common geriatric lesion accounted. Gender and age-wise correlation analyses among the various lesion categories showed statistical significance. Conclusion: The study provides valuable information about major oral pathologies in our scenario that contribute to significant morbidity and mortality among the geriatric population. It also sheds light about the diseases that need to be targeted in future Indian public health policies and initiatives for geriatric care. Keywords: geriatric, ageing, oral mucosal lesion, oral biopsy, oral cancer. Accepted 4 July 2014
Introduction A rise in the geriatric population is an inevitable trend that has been observed in the developed countries with an enormous amount of resources being directed to target the well-being of this group of people1. This demographic transformation over the recent decades is not restrained to the developed world and has gradually evolved into a global trend. Based on various statistics and demographic information; the era between 1975 and 2025 has been projected as the ageing era by the United Nations Organization (UNO)1,2. India is one of the key nations which faces this drastic rise in ageing population and the projected demographics demonstrate that by 2050; more than 323 million people (equalling US population in 2011)
will be above the age of 603. In the developing countries, this transition poses significant challenges on health care as there is a huge void in the data and resources required to deal with this imminent boom in senescent population. The oral cavity frequently gives an insight into the general health of a person, and examination of the oral cavity is considered a mandatory diagnostic step in every clinician’s routine. Further, the oral cavity often exhibits the early signs associated with most diseases, making it an ideal and easy location to examine in epidemiological surveys. Oral mucosal changes including atrophy, decreased cellularity and turnover leading to dryness of mouth, burning sensation, salivary gland changes such as fatty degeneration, fibrosis predisposing to decreased salivation, increased
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd, Gerodontology 2016; 33: 217–224
217
218
B. C. Mohan et al.
caries, periodontitis and edentulousness are some of the common changes reported in the older indivduals4,5. Increased incidences of various oral pathologies are also known to occur in old age6–8; however, limited studies regarding their incidences have been performed in India. Many studies throughout the world have assessed oral pathologies based on clinical presentation and denture association6–9; however, studies with histological confirmation are extremely rare10–12. Although these clinical reviews provide valuable information about the oral pathologies seen in geriatric population, they have disadvantages because the diagnosis is not precise and the stage of the pathology is not recognised. This is of serious consequence especially in the Indian scenario where oral cancer and pre-cancers are widespread and early identification and confirmation with histopathology has a pivotal role in implementation of the treatment strategies. Thus, both clinical and histological data complement one another and give valuable information for identification of major challenges associated with geriatric population. Further, clinical and histological oral pathology surveys in various parts of the world have identified that the oral lesions and intervention strategies vary greatly among the various countries, regions and hospitals6–12. Few studies across the world have documented histological presentations10–12, but in India, it is nonetheless, shocking to note that till date, there is no review about geriatric oral pathology trends. The differences in socioeconomic status, the presence of tobacco and quid chewing habits predict that the oral lesional profile of this ageing population may be diverse. The World Health Organization in 1963 proposed middle age group as 45–59 years, elderly age group as 60–74 years and aged as more than 75 years13. The exact age for ageing is, however, not precise as it is noted that in many countries, the biological ageing process is faster due to varying economic condition, increased lifestyle disorders, infectious diseases and other factors13–15. The low income nations such as India are faced with what has been termed as the ‘double burden of disease’, where the nation has to combat the difficulties posed by both infectious diseases such as HIV, tuberculosis and malaria and the lifestyle diseases such as malnutrition, hypertension, diabetes mellitus, obesity, cancer, leading to a significant decrease in the health of an individual above the age of 5013,15,16. In several recent projects such as MDS project in Africa and the recent multicentric study performed by WHO-SAGE collaboration, an age group of above 50 was taken as the
working definition of old age14,15. Similarly, in this study, we have categorised above 50 years as the working age group in understanding geriatric oral pathologies. We believe that this expansion of the target age group helps in an early initiation of diagnostic, counselling and preventive services for the geriatric patients with oral lesions. Further, the biopsy survey presents with reliable and accurate diagnosis of geriatric oral health data. Some of these pathologies often result in serious outcomes, and thus, early recognition and treatment of these conditions can aid in significant reduction in the mortality and morbidity in geriatric patients. This study aimed to review the oral biopsies reported in patients aged more than 50 years who have reported to the institution over the last 21 years to examine the patterns in geriatric oral pathologies.
Materials and method After obtaining institutional ethical clearance, an analysis was made of the clinical data and histopathological diagnosis between 1992 and August 2012 of elderly patients (above the age of 50) retrieved from the files of the Department of Oral Pathology and Microbiology of KLE VK Institute of Dental Sciences located in Belgaum district of Karnataka State, India. The biopsies were performed on patients attending the hospital in Belgaum City, Karnataka State, for a routine dental check-up or with specific complaints. The patients were screened in the Oral Medicine Department and referred to the Department of Oral Pathology for the biopsy of the oral lesions. The population attending the hospital lives mostly in Belgaum City and surrounding villages such as Gokak, Hukkeri, Koppa, Vakkund and Kakti. A total of 964 histologically confirmed geriatric oral lesions among 4000 cases (both soft tissue and intraosseus lesions) reported by the Department of Oral Pathology, KLE VK Institute of Dental Sciences were retrieved, and data related to the patients’ age, sex, location of the lesion, clinical diagnosis and histopathological diagnosis were tabulated. The lesions were categorised into malignant neoplastic lesions, non-neoplastic lesions, potentially malignant disorders and benign neoplastic lesions17,18. These categories were further subdivided into the various categories as depicted in Table 2. The number of malignant neoplasms being biopsied would certainly be more due to their serious nature as compared to benign fibrous hyperplasia or reactive lesions, which even though surgically excised are often
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd, Gerodontology 2016; 33: 217–224
Geriatric Oral Pathology
not sent for histopathological examination due to their obvious benign nature unless there is a suspicion of malignancy. The various clinical and histological groups were studied using frequency and percentage parameters. The gender and agewise association between the various lesion groups were discerned using the chi-squared test. Further, adjusted residual analysis was also performed, which demonstrates the direction and the strength of association between the variables. A larger AR(>2) provides evidence of association in that cell.
Results The data retrieved were arranged year-wise, and a progressive increase in the geriatric pathologies was observed with only around 15 cases reported in 1991, while 119 geriatric cases were reported in 2011. The sample of 964 elderly individuals consisted of 629 (65%) men and 335 (35%) women. The ages analysed ranged from 50 to 97 years with an average of 59.96 (8.29) years. It was noted that the oral lesions were more prevalent in patients of sixth decade (Table 1). The location of the lesions was studied, and the buccal mucosa was the most common site (29.2%) with other predominant sites being intraosseous lesions (27.7%), tongue (9.4%) and vestibule (8.8%). Mandible (19%) was more frequently affected as compared to the maxilla (9%) in the intraosseous sites. Histopathologically, the lesions were classified into four main groups in which malignant neoplastic lesions(MN) formed the major contributor to the geriatric lesions (36%) followed by nonneoplastic (NN)(27%), potentially malignant disorders (PMD) (26%) and benign neoplasms (BN), which formed a minor proportion of (11%). The subclassifications within these main lesion groups were also attempted and are described in Table 2. Among the malignant neoplasms, the malignant Table 1 Distribution of lesions by age group in 964 oral biopsies from people aged more than 50 in Karnataka State, India. Distribution Age range (Years)
Number
Percentage
50–59 60–69 70–79 80–89 90–99
453 368 109 27 7
47 38 109 27 7
219
Table 2 Distribution of diagnosis by general categories among 964 oral biopsies lesions from people aged more than 50 in Karnataka State, India. Percentage Lesion categories
Number
Group
Total
Malignant neoplasms Oral epithelial Odontogenic carcinomas Mesenchymal sarcomas Salivary gland carcinomas Potentially Malignant Disorders Hyperkeratosis Dysplasia Oral submucous fibrosis Lichen planus Lichenoid reaction Carcinoma in situ Verrucous hyperplasia Non-neoplastic conditions Odontogenic cysts Non-odontogenic cysts Mucocutaneous lesions Reactive lesions Infective lesions Normal Benign neoplasms Benign epithelial Benign odontogenic Benign salivary gland Benign mesenchymal
350 328 4 9 9 246 48 110 14 44 8 15 7 250 46 7 10 118 69 10 108 0 37 4 67
100 94 1 2.5 2.5 100 19 45 6 18 3 6 3 100 18 3 4 45 26 4 100 0 34 4 62
36 34 0.4 0.9 0.9 26 4.9 11.4 1.5 4.5 0.8 1.6 0.8 26 4.8 0.7 1 12.3 7.2 1 11 0 3.7 0.4 6.7
oral epithelial neoplasms (94%) demonstrated the highest frequency, while no benign epithelial tumours were encountered in the present geriatric sample studied. Reactive lesions were the most common non-neoplastic lesions in this study (46%). In benign neoplasms, the mesenchymal tumours showed the highest prevalence (62%) and in potentially malignant group, epithelial dysplasia was the most common diagnosis. All the lesions were finally assessed together, and the top 5 predominant lesions to occur in the oral cavity of a geriatric adult were squamous cell carcinoma (30%), epithelial dysplasia (11%), fibrous hyperplasia (7%), hyperkeratosis (4%) and non-specific inflammations (4%) (Table 4) However, the possibility of fibrous hyperplasia not being biopsied or not being subjected to histopathological examination due to their benign nature in comparison with the malignancies could be an important limitation for the observed result. Chi-squared test revealed a statistically significant difference between the main lesion groups and age ranges and gender distribution (Table 3). Gender-wise
© 2014 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd, Gerodontology 2016; 33: 217–224
220
B. C. Mohan et al.
Table 3 Associations between diagnoses of 964 oral lesions and the age and sex of the patients in Karnataka State, India. Number (% and AR)
Age* 50–59 60–69 70–79 80–100 Sex** Male Female
Non-neoplastic lesions
Benign Neoplasms
Potentially Malignant Disorders
Malignant Neoplasms
118 89 41 12
61 33 10 4
126 98 19 3
148 148 40 14
(12.2; 0.62) (9.2; 1.52 (4.2;2.57*) (1.2;1.23)
147 (15.2; 3.43**) 113 (11.7;3.43**)
(6.3;2.12*) (3.4; 1.72) (1; 0.74) (0.4;0.11)
47 (4.9; 5.01**) 61 (6.3;5.01**)
(13;1.56) (10;0.62) (2; 2.11*) (0.3; 2.20*)
185 (19.1;3.80**) 61 (6.3; 3.80**)
(15.4; 2.23*) (15.4;1.96) (4; 0.02) (1.5;0.77)
250 (26;3.02**) 100 (10.3; 3.02)
AR – adjusted residuals. Age – chi-squared test = 21.92, degree of freedom = 9, p = 0.009 (significant). ** Sex – chi-squared test = 47.836, degree of freedom = 3, p =
