|Year : 2019 | Volume
| Issue : 2 | Page : 89-92
Targeted Screening Programme For Early Detection Of Oral Malignant And Potentially Malignant Lesions Using The Oral Rub And Rinse Technique Among Truck Drivers in Dakshina Kannada District − A Cross-Sectional Study
Audrey Madonna D'Cruz, Pushparaja Shetty MDS , Urvashi Ashwin Shetty
A. B. Shetty Memorial Institute of Dental Sciences, Nitte (Deemed to be University), Mangalore, India
|Date of Submission||24-Jun-2019|
|Date of Acceptance||24-Oct-2019|
|Date of Web Publication||29-Jan-2020|
Professor and Head, Department of Oral Pathology and Microbiology, A. B. Shetty Memorial Institute of Dental Sciences, Nitte (Deemed to be University), Mangalore
Source of Support: None, Conflict of Interest: None
Introduction: Early detection of oral malignant and potentially malignant disorders is very important in reducing morbidity and mortality. Truck drivers are transport workers who transport goods over long distances in trucks are at a very “high risk” due to various factors. The aim of this study was to detect potentially malignant and malignant oral lesions using the oral rub and rinse technique among truck drivers in Dakshina Kannada. Materials and Methods: An oral cancer screening program among truck drivers was conducted in Dakshina Kannada district, Karnataka. Data regarding socio-demographic details, history of tobacco use were collected. Oral cancer screening was carried out. Exfoliative cytology was done using the oral rub and rinse technique if red/white lesions were present and biopsies were taken in case of ulcerated lesions. Descriptive statistics was used in this study in the form of number and percentage. Results: A total of 964 subjects were screened for potentially malignant and malignant oral lesions. Most of the patients (83%) were current tobacco users. Of the 964 subjects, 148 had red/white lesions. Results of exfoliative cytology showed that 23% smears were Class I, 24% were Class II, 31% were Class III, and 16% were Class IV smears; 6% smears were unsatisfactory. Tissue biopsy was taken for 23 patients with ulcerated lesions − 2 were confirmed for oral squamous cell carcinoma and 21 had dysplasia. Conclusion: High-risk targeted screening for oral cancer can help identify oral precancerous lesions at an early stage.
Keywords: Early diagnosis, mouth neoplasm, oral cancer
|How to cite this article:|
D'Cruz AM, Shetty P, Shetty UA. Targeted Screening Programme For Early Detection Of Oral Malignant And Potentially Malignant Lesions Using The Oral Rub And Rinse Technique Among Truck Drivers in Dakshina Kannada District − A Cross-Sectional Study. J Orofac Sci 2019;11:89-92
|How to cite this URL:|
D'Cruz AM, Shetty P, Shetty UA. Targeted Screening Programme For Early Detection Of Oral Malignant And Potentially Malignant Lesions Using The Oral Rub And Rinse Technique Among Truck Drivers in Dakshina Kannada District − A Cross-Sectional Study. J Orofac Sci [serial online] 2019 [cited 2020 Oct 20];11:89-92. Available from: https://www.jofs.in/text.asp?2019/11/2/89/276719
| Introduction|| |
Oral cancer or squamous cell carcinoma of the oral cavity accounts for approximately 3% of all cancers worldwide with increased incidence in developing countries. Tobacco (smoke and smokeless) and alcohol are risk factors for occurrence of oral cancer. Human Papilloma virus has also been associated especially in young population. Early detection of a premalignant or malignant oral lesion reduces morbidity and improves the patient survival. Conventional oral examination is widely used to screen the population. Various aids and adjuncts along with conventional oral examination are the most economical method for screening of large population. Adjunctive techniques such as toluidine blue, chemiluminescence, tissue autofluoroscence, and brush biopsies are used with varied results for screening of oral cancer. “Targeted screening” is when screening is done for “high-risk” individuals. ,
Truck drivers (also called as Truckers) are transport workers who transport goods over long distances in trucks. Their long and irregular working hours, lack of job security, and income are a few reasons for stress in this group of people. Hence, they get addicted to various substances such as tobacco, alcohol, drugs etc. Several reasons have been reported in literature such as “to boost morale”, to “cope with frustration”, “for energy”, “for relaxation”, “to get rid of hunger” etc., Hence this group of population is at a very “high risk” for oral cancer. Most of the drivers have a low level of education.
Exfoliative cytology is used as a tool for screening of oral potentially malignant disorders like leukoplakia and oral squamous cell carcinoma. Although it is popular because of its low cost and non-invasiveness, it lacks sensitivity in screening of oral cancers. A study reported that oral rub and rinse technique showed an overall improvement in sample adequacy and cellular clarity than the conventional exfoliative cytology. However, to our knowledge this technique has not been used as a tool in population-based oral cancer screening program. Hence, the objective of this study was to detect potentially malignant and malignant oral lesions using the oral rub and rinse technique among the truck drivers in Dakshina Kannada district.
| Materials and Methods|| |
A high-risk targeted oral cancer screening program among truck drivers was conducted in Dakshina Kannada district, Karnataka, South India. Ethical clearance for the study was obtained from the Central Ethics Committee of the Nitte (Deemed to be University) (Ethical Committee number NU/CEC/2016-2017/052) on 20 April 2016. The participants were informed about the procedure of the study, and informed consent was obtained.
Participants were then screened for presence of oral premalignant/malignant lesions or conditions. Exfoliative cytology using the oral rub and rinse technique was done if red/white lesions were present. After patient had rinsed his mouth with water, the clinician rubbed the suspected red/white lesion firmly using finger for 30 seconds. The patient was then asked to swish phosphate buffered saline (pH‑7.2) and expectorate into a sterile container. The sample was labeled and centrifuged at 1000 rpm for 5 minutes. The cells settle down forming the cell plug and the supernatant fluid will be present on the top which was discarded. Using a micro-pipette, the cells from the cell plug were collected and smeared on glass slides. The slides were immediately fixed in absolute alcohol and stained with a Papnicolaou stain. Biopsies were also taken in case of ulcerated lesions. Data were tabulated in MS Excel for Windows and presented as numbers and percentage.
| Results|| |
A total of 964 subjects were screened for potentially malignant and malignant oral lesions. [Table 1] shows the socio-demographic distribution of the study participants. All participants were male (100%). About 26.6% of the participants were current tobacco users, of which a 42.5% were smokers, 52.9% used smokeless tobacco, and 4.6% used both smoke and smokeless tobacco. About 28% smoked cigarettes and hans was the most used (19.8%) smokeless tobacco. About 65.6% of the tobacco users started using tobacco at a young age (30 years and below).
Of the 964 subjects, 148 had red/white lesions. [Table 2] shows the type and site of the lesions and the category based on the results of exfoliative cytology. About 39.2% of the lesions were on the buccal mucosa followed by labial mucosa, gingiva, and tongue. Results of exfoliative cytology showed that 23% smears were Class I, 23.6% were Class II, 31.1% were Class III, and 16.2% were Class IV smears; 6% smears were unsatisfactory ([Table 2]). Tissue biopsy was taken for 23 patients with ulcerated lesions − 2 were confirmed for oral squamous cell carcinoma and 21 had dysplasia.
| Discussion|| |
Oral cancer is a major public health problem especially in India as it is associated with high morbidity and mortality rates.  Risk factors for oral cancer include use of tobacco (smoking and smokeless), areca nut chewing, alcohol use, and poor nutrition. The risk of oral cancer is increased with age, alcohol, and tobacco use. Smokeless tobacco is prevalent among rural disadvantaged population in Southeast Asia.  Most of the drivers used tobacco or alcohol or both.
This study was conducted to detect potentially malignant and malignant oral lesions among truck drivers using a high-risk targeted approach. Homogenous leukoplakia was the most common lesion among the study participants followed by speckled leukoplakia. This finding is in contrast to the findings of Gupta et al. where oral submucous fibrosis (OSMF) followed by tobacco pouch lesion was the most common lesion. There is high reported use of smokeless form of tobacco in Indian subcontinent.  Most of the lesions were present in the buccal mucosa (39.2%) followed by the labial mucosa. This is because of the increased use of smokeless tobacco and placement of the quid in the buccal or labial mucosa. A similar pattern was found in the study by Gupta et al.  Studies conducted in Western countries have reported an increased prevalence of lesions on the tongue and floor of the mouth. The difference in presentation maybe due to the differences in the form of tobacco used. Smoked tobacco use is more prevalent in West, whereas in India smokeless form of tobacco is predominantly used.
In this study, of the 964 subjects screened, 148 had red/white lesions of which 23 lesions were ulcerated and had indurated borders. Tissue biopsy was performed for these 23 suspicious ulcerated lesions of which 2 were confirmed for oral squamous cell carcinoma and 21 had dysplasia. A population-based oral cancer screening program in Kannur, Kerala, detected 13 cancer cases and 173 precancer cases among 2507 patients of which majority were males with low socioeconomic status. About 7 patients were diagnosed histopathologically as oral squamous cell carcinoma out of 72 clinically suspected lesions in a study conducted by Gupta et al.  It is therefore important for high-risk individuals to undergo an oral cancer screening by a thorough clinical examination. Huang et al.  in their retrospective analysis of 22,024 pathologically verified cases of oral cancer in Taiwan concluded that early diagnosis and intervention before stage II can significantly improve life expectancy and decrease expected years of life lost to oral cancer. The Cochrane collaboration and several other studies reported in literature have recommended opportunistic screening using a visual and tactile examination for high-risk targeted groups such as tobacco users and alcohol consumers who are above 40 years of age in the primary care setting. ,,,,,,Exfoliative cytology using the oral rub and rinse technique was used in this study for screening of the truck drivers. The conventional exfoliative cytology method has a high proportion of false negatives, that is, low sensitivity, inadequate sampling, procedural errors, and the need for a subjective interpretation of findings. 
A study compared specimen adequacy and diagnostic agreement between oral rinse-based smears and conventional exfoliative cytology smears in oral cancer, oral leukoplakia, and normal controls. The authors concluded that although both smears were diagnostically reliable, the oral rinse-based method had better adequacy and cellular clarity. Since this method was not tried in community settings, this study used the oral rub and rinse method for oral cancer screening of truck drivers. 
High-risk targeted screening for oral cancer can help identify oral precancerous lesions at an early stage. Successful intervention in the early stages can lead to improvement in symptoms and hence reduce the morbidity and mortality associated with oral cancer. Exfoliative cytology using oral rub and rinse technique is a non-invasive, painless procedure which can be easily carried out during population-based screening programs and during routine treatment planning and follow‑up of patients with oral precancerous lesions.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Ford PJ, Farah CS. Early detection and diagnosis of oral cancer: strategies for improvement. J Cancer Policy 2013;1(1):2-7.
Brocklehurst P, Kujan O, O’Malley LA, Ogden G, Shepherd S, Glenny AM. Screening programmes for the early detection and prevention of oral cancer. Cochrane Database Syst Rev 2013; CD004150. doi: 10.1002/14651858. CD004150. pub4
Kartikeyan S, Gurav RB, Joshi SD, Reshma W. Health and socio-demographic profile of transport workers. Indian J of Occ and Environ Med 2004;8:8-10.
Okpataku CI. Pattern and reasons for substance use among longdistance commercial drivers in a Nigerian city. Indian J Public Health 2015;59:25963.
] [Full text]
Rose S, Wojcik J. The health habits and physical activity of student truck drivers. The Winthrop McNair Research Bulletin 2015;1:68-76.
Joseph I, Rooban T, Ranganathan K. Tobacco use, oral cancer screening and oral disease burden in Indian women. Indian J Dent Res 2017;28:706-10.
] [Full text]
McCullough MJ, Prasad G, Farah CS. Oral mucosal malignancy and potentially malignant lesions: an update on the epidemiology, risk factors, diagnosis and management. Aust Dent J 2010;55:61-5.
Philip PM, Nayak P, Philip S, Parambil NA, Duraisamy K, Balasubramanian S. Population-based cancer screening through community participation: outcome of a district wide oral cancer screening program from rural Kannur, Kerala, India. South Asian J Cancer 2018;7:244-8.
] [Full text]
Gupta S, Shah JS, Parikh S, Limbdiwala P, Goel S. Clinical correlative study on early detection of oral cancer and precancerous lesions by modified oral brush biopsy and cytology followed by histopathology. J Can Res Ther 2014;10:232-8.
] [Full text]
Early detection of oral cancer in Portugal: the experience of UMEMD. Journal of Clinical Oncology 2017;35. doi: 10.1200/JCO. 2017.35.15_suppl.e13039.
Huang CC, Ou CY, Lee WT, Hsiao JR, Tsai ST, Wang J. Life expectancy and expected years of life lost to oral cancer in Taiwan: a nation-wide analysis of 22,024 cases followed for 10 years. Oral Oncol 2015;51:349-54.
van der Waal I, de Bree R, Brakenhoff R, Coebergh JW. Early diagnosis in primary oral cancer: is it possible? Med Oral Patol Oral Cir Bucal 2011;16:e300-5.
Warnakulasuriya S, Fennell N, Diz P, Seoane J, Rapidis A. An appraisal of oral cancer and pre-cancer screening programmes in Europe: a systematic review. J Oral Pathol Med 2015;44:559-70. doi: 10.1111/jop.12267. Epub 2014 Oct 25
Kujan O, Glenny AM, Oliver RJ, Thakker N, Sloan P. Screening programmes for the early detection and prevention of oral cancer. Cochrane Database Syst Rev 2006;(3):CD004150.
Chuang SL, Su WW, Chen SL, Yen AM, Wang CP, Fann JC, Chiu SY, Lee YC, Chiu HM, Chang DC, Jou YY, Wu CY, Chen HH, Chen MK, Chiou ST. Population-based screening program for reducing oral cancer mortality in 2,334,299 Taiwanese cigarette smokers and/ or betel quid chewers. Cancer 2017;123:1597-1609.
Brocklehurst P, Kujan O, Glenny AM, Oliver R, Sloan P, Ogden G et al.
Screening programmes for the early detection and prevention of oral cancer. Cochrane Database Syst Rev 2010;CD004150. doi: 10.1002/14651858. CD004150. pub3
Rethman MP, Carpenter W, Cohen EE, Epstein J, Evans CA, Flaitz CM et al.
Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc 2010;141:509-20.
Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara S, Mathew B, Rajan B, Trivandrum Oral Cancer Screening Study Group: effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. Lancet 2005;365:1927-33.
Diniz Freitas M, García García A, Crespo Abelleira A, Martins Carneiro J, Gándara Rey JM. Applications of exfoliative cytology in the diagnosis of oral cancer. Med Oral 2004; 9:355-61.
Mulki S, Shetty P, Pai P. Oral rinse-based cytology and conventional exfoliative cytology: a comparative study. J Can Res Ther 2015;11:129-35.
] [Full text]
[Table 1], [Table 2]