ORIGINAL�ARTICLE ABSTRACT Objective: To find out the pattern of tobacco use practices and the effects of chewable tobacco and other forms of tobacco use on oral mucosa. Study Design: Retrospective observational study. st st Place and Duration of Study: Study was started from 1 July 2018 to 31 December 2018 and was conducted at Maxillofacial surgery OPD, Isra Dental Hospital. Materials and Methods: Samples of leukoplakia, erythroplakia or growth in oral cavity were collected from Maxillofacial surgery OPD. After taking detailed history including chewable tobacco habits, biopsy was taken and then results were analyzed by using SPSS version 22.0.The categorical data were expressed in terms of frequencies and percentages. The Chi square test was used to determine the association of different variables. Results: Majority of the patients were found to have naswaar addiction followed by gutka, smoking, areca nut, mainpuri and paan. Most of the patients i.e., 59% with oral lesions were having basic education at primary level and belonged to middle class monthly income category 35(39.77%) followed by low monthly income 28(31.8%).We noted significant association between various oral habits of tobacco use and biopsy reports and oral squamous cell carcinoma was observed as the common findings among study population. Conclusion: We have reached to the conclusion that in our region chewable tobacco is most common and significantly associated with risk of development of oral lesions and subsequent oral squamous cell carcinoma. Key Words: ChewableTobacco, Gutka, Mainpuri, Naswar, Oral Lesions, Squamous Cell Carcinoma. demographic variations are responsible for 2 differences in the incidence of oral lesions. Tobacco use is directly linked with higher incidence of oral cancer as large proportion of our population is consuming the various forms of tobacco. Tobacco is used in the form of cigarettes, pipe, bidi or chewable 3 form such as naswar, ghutka and paan. Various studies have reported the presence of nearly 28 or more carcinogenic agents in chewable tobacco such as tobacco-specific nitrosamines (TSNAs), polonium, formaldehyde, cadmium, lead and benzopyrene.The various forms of chewable tobacco have been reported to be linked with malignant tumors of head 4,5 and neck. Most of the cases of oral lesionsinvolve prolonged usage of tobacco. Such lesions also have chances of 6 malignant transformation at the rate of 3-5%. The type of oral lesionboth malignant and nonmalignant varies with the type of tobacco being consumed and 7 the way it is used. Oral cancer is gaining attention as one of the most challenging dilemma for the world which is thought to be directly associated with 8 prolong tobacco usage. Despite of modern therapeutic modalities, Pakistan is still ultra- receptive to oral cancer. This can possibly be credited Introduction In Southeast Asian countries including Pakistan tobacco is easily available in open market and our 1 cultural norms are adding support to these habbits. The habits of chewing tobacco are also popular in younger age groups and females due to attractive appearance and easy availability of these products at cheaper rates. Such habits are also supported by illiteracy and deficiency of knowledge about their devastating effects. The cultural norms and regional Types of Various Oral Mucosal Lesions with Respect to Trends of Chewable Tobacco and Their Subsequent Histopathological Findings 1 2 3 4 5 6 Abdul Majid , Shankar Lal Rathi , Amin Fahim , Sarwat Batool , Waqas Iqbal , Bhawani Shankar Correspondence: Prof. Dr. Amin Fahim Department of Pathology PUMHSw Shaheed Benazirabad E-mail:draminfahim@gmail.com 1,2 5 Department of Pathology/Department of oral pathology Isra University, Hyderabad 3 Department of Pathology PUMHSw Shaheed Benazirabad 4 Department of Pathology Al-Tibri Medical College, Isra University,Karachi 6 Department of Pathology Muhammad Medical College, Mirpurkhas Received: July 16, 2021; Revised: November 10, 2022 Accepted: November 14, 2022 Histopathology of Oral Mucosal LesionsJIIMC 2022 Vol. 17, No.4 245 DOI: https://doi.org/10.57234/652 to the exposure to lower socioeconomic status, 9 illiteracy, and various environmental factors. Looking at the co-morbidities associated with use of tobacco and its consequences, it is very sad to write here that at the country level no definitive measures are being taken. Thereforeit is a real need for public awareness to curtail such tobacco addiction to reduce the incidence of different oral lesions as well 2 as oral squamouscell carcinoma. Although we know that tobacco is linked with oral cancer but it is not clear in literature that which form of tobacco and tobacco chewing habits are more prone to cause which type of oral lesion; therefore the present study was designed with the objective to find out the patterns of tobacco use practices and the effects of chewable tobacco and other forms of tobacco use on oral mucosa. Materials and Methods This was a retrospective observational study done st st from 1 July 2018 to 31 December 2018.The study was approved by Ethics Review Committee (ERC), Board of Advanced studies and Research (BASR)Isra university Hyderabad. A total of 88 samples were collected from Maxillofacial surgery OPD, Isra Dental Hospital by non-probability purposive sampling technique. Samples from patients with leukoplakia, erythroplakia or growth in oral cavity were included in the study.Both the male and female patients, belonging to all age groups and ethnic groups without socioeconomic discrimination were included in this study. Medical records were studied for demographical data of the participants. Samples with inadequate oral biopsy material were excluded from the study. Informed consent was taken from all the participantsand biopsy was performed by standard protocols by dental surgeon. Paraffin embedded blocks were prepared from all the biopsy samples and were cut into 5µ thin sections by microtome. Thin sections were processed further by using Haematoxylin and Eosin stains and were focused under light microscope by experienced pathologists for the histopathological diagnosis. The data was analyzed through SPSS version 22.0. The categorical data were expressed in terms of frequencies and percentages. The Chi square test was used to determine the association of different variables. Results In present study 88 patients with leukoplakia, erythroplakia or growth in oral cavity were studied. In our study most of the patients i.e., 59% with oral lesions fall under the category of basic education level according to proforma designed (Table-I). According to socioeconomic status patients were divided into four categories with respect to their monthly income as shown in table-I. Most of the patients with oral lesions belonged to middle class monthly income category 35(39.77%) followed by low monthly income 28(31.8%). The biopsy findings based on histopathological diagnosis revealed; oral squamous cell carcinoma (OSCC) being most common finding with 64(72.7%) cases (Table- II).According to the various addiction trends majority of the patients were found to have naswar addiction 21(23.9%) followed by gutka 15(17%), smoking 15(17%), areca nut 13(14.8%), mainpuri 6(6.8%) and paan6(6.8%). However about 12(13.6%) patients were found with no use of chewable tobacco. This shows that most patients with oral lesions 61(69.3%) were addicted to smokeless tobacco use (Table- III).The association between various oral habits of tobacco use and biopsy findings were found statistically significant with p-value=0.01, as is shown in table-III. TableI: The Distribution of Patients according to Literacy Level and Economy Status Histopathology of Oral Mucosal LesionsJIIMC 2022 Vol. 17, No.4 246 DOI: https://doi.org/10.57234/652 Discussion Tobacco induced oral mucosal lesions are result of damage to oral protective mechanism or presence of 10 carcinogen in tobacco products. In our study the most prevalent habit was naswaar chewing. Similar results with little variations were given by Saira et al 11 in 2019. Inpresent study the second most common habit was smoking and gutka chewing which is in 12 consistent with the results of Behura SS in 2015. However another study conducted in India by Rooban has reported alcohol as most seen habit for 13 oral mucosal lesions. These differences might be due to cultural variations and increase alcohol misuse among individuals in their population. In another study, the second mostly reported chewing habits was betel quid which is in similarity with our study showing 17% cases with gutka or quid 14 chewers. According to our study most encountered oral lesions were oral squamous cell carcinoma which was in contrast with the results found by Mohiuddin S in 2016 and Priya MK in 2018 who found oral submucus fibrosis as most common tobacco induced 15,16 oral lesions. In present study majority of the patients i.e., 59% with oral lesions had primary education level. This finding is consistent with an Egyptian cohort study in which they classified patients according to education level in three groups i.e. No education, basic education, and high education and their most of the patients were of 17 basic education (55.2%). In another study in Iran has divided population in two groups i.e., illiterate and literate having 78.9% oral lesions in illiterate people. However, they did not define the term illiterate. As many people doesn't consider primary education as criteria of literacy; if it is that so then our 18 study is also consistent with this study. In present study majority of the patients with oral lesions belonged to middle class monthly income category 35(39.77%) followed by low monthly income 28(31.8%).It may be also because most of the population in our country is comprised of middle class that is low monthly income and middle monthly income. It may also be due to their working environment and easy availability or affordability of chewing tobacco to these proportions of population. The comparable findings by some other studies have reported the low socioeconomic status in majority of 19 the patients in other parts of the country. Another national study conducted in Karachi reported higher 45% of the cases with OSCC with very low socioeconomic status which contrasts with the 20 findings of present study. Our study revealed that most of the OSCC cases were smokeless tobacco addicts;in the form of naswaar and ghutka which was in similarity with the results of studies done by Younis S et al in 2016 and Muange P 21,22 in 2014. However Wang X has revealed that joint effect of tobacco and alcohol had a significant effect 23 on occurrenceof OSCC. Our study showed that second mostly seen risk factor for oral squamous cell carcinoma was smoking and areca nut which was in similarity with the results by Khan et alwho have reported both smoking and betel nut chewing as most common related factors for oral submucus TableII: TheDistribution of Patients According to Biopsy Findings (n=88) Table III: Association of Biopsy Findings with Various Chewable Tobacco Habits P value significant at < 0.05 Histopathology of Oral Mucosal LesionsJIIMC 2022 Vol. 17, No.4 247 DOI: https://doi.org/10.57234/652 24 fibrosis. According to present study tobacco induced reactive inflammatory lesions were about 7% which is also supported by Kamble KA study, 25 conducted in india. But in contrast Cebeci AR in 2009 reported that mostly oral mucosal lesions are 26 reactive in nature. This difference might be due to less frequent usage of tobacco among study groups and some cultural variations. Our study proved the indication that unfortunately prevalence of tobacco induced OSCC in our community is 17%. However other authors believed that tobacco induced OSCC is only 1% in their 27 society. This variation might be due to adequate screening programs of oral precancerous lesions by timely biopsies done by oral practitioners in their society. But in our society oral soft tissue biopsies are 28 advised at very late stage. Conclusion We reached to the conclusion that in our region chewable tobacco is most common and significant risk factor for development of oral lesions and subsequent oral squamous cell carcinoma. 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