Table 1 Classification of oral biopsied lesions

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1 Original Article A Review of Biopsied Oral Lesions in Department of Oral Medicine, University of Dental Medicine, Mandalay Mu Mu Win**, Thiri Su Myat Chel*, Su Mon Than*, Aye Mya Mya*, Aye Aye Thet*, Nandar Aung*, Khin Soe*, Moe Thida Htwe*, Myint Shwe* * Department of Oral Medicine, University of Dental Medicine, Mandalay Abstract Frequency of oral lesions is varied in different population and knowledge of diseases prevalence in a geographic location will improve preventive measures. Two hundreds and fifty-nine (259) cases of oral biopsies obtained from 1st October 2014 to 31st October 2015 at Department of Oral Medicine, University of Dental Medicine, Mandalay were retrospectively reviewed. Clinical data regarding age, gender, characteristics (site, color, size, surface, consistency and base) of lesions were obtained for each case. The lesions were classified into oral malignancies, oral potentially malignant disorders (OPMD), odontogenic cysts and tumors, salivary gland disorders, fibro-osseus lesions and benign soft tissue lesions. Among these oral lesions, oral squamous cell carcinoma was the most frequent (38.22%) and majority of these oral lesions were located in the buccal mucosa (32.8% ).The gender frequently affected were male (62.9%) and the common age group was between 41 to 60 years old (48.6%). From this review, frequency and distribution of various oral lesions regarding to different gender, age and location can point out the needful management of public education, oral screening and early referral for prompt treatment to improve quality of life. Introduction Patients often present with intraoral pathology in the general dental practice setting. Therefore, it is crucial that oral health professionals look for abnormal changes in the oral cavity that are called oral lesions in making a diagnosis. Many oral lesions are innocuous and can be readily diagnosed based upon the appearance with their respective history. However, some lesions are not as easy to identify and require additional diagnostic step, such as a biopsy which is a definitive procedure that provides tissue for microscopic analysis. The American Academy of Oral and Maxillofacial Pathology recommends that all abnormal tissue be submitted promptly for microscopic evaluation and analysis. Microscopic or histopathological examination of tissue is the gold standard for the diagnosis of many lesions that present in the oral cavity and surrounding regions (Melrose, 2007). The purpose of this review was to investigate the relative prevalence of different types of oral and maxillofacial biopsied lesions in accordance with their demographic variation received by the Oral Medicine Department of University of Dental Medicine, Mandalay within a period of about one year. Material and methods: A retrospective study was done on data obtained from the archive of Oral Medicine department of University of dental Medicine Mandalay, from 1st October 2014 to 31st October 2015 and following variables were analyzed: age, gender, anatomic location, and the histological results. Lesions were classified in 6 different categories, as detailed in table 1. 21

2 Table 1 Classification of oral biopsied lesions Results The number of patients studied was 259. Malignant lesions were the most frequent lesions and constituted (42.46%) of which oral squamous cell carcinoma (OSCC)was the most common oral malignancy (38.22 %) (Fig 1).The age range of the patients was years and most of the lesions (49%) were found in the age group of 41 to 60 years (Table 2). Females constituted % (n = 96) of the cases and % (n = 163) of the lesions found in males (Figure 2). The distribution of lesions according to location is shown in Figure 3.The most affected anatomic location was the buccal mucosa (32.8 %). Figure 1.Frequency distribution of Biopsied Oral Lesions Table 2. Age distributions of Biopsied Oral Lesions 22

3 Figure 2. Frequency distributions of Biopsied Oral Lesions as per gender Figure 3. Site distribution of Biopsied Oral lesions 23

4 Discussion In this study, we analyzed the prevalence of oral lesions, biopsied during a period of 1st October 2014 to 31st October 2015 at Department of Oral Medicine, University of Dental Medicine, and Mandalay and found 259 cases. The mean age of the patients was 47.5 years and 49 % of the lesions were discovered during the fourth to sixth decades of life. The most prevalent pathologies were oral malignancy (42.46%) and mainly seen in this age group. The mean age reported by Fierro-Garibay et al. (2011) and Sixto-Requeijo et al.(2012) were 54 and 51.8 years respectively. The mean age of occurrence of cancer in different parts of oral cavity is usually between years in most of the countries but higher around 64 years in Thailand (Bhurgri et al., 2006). According to the WHO data published in 2015 life expectancy in Myanmar is: Male 64.6, female 68.5 and total life expectancy is 66.6 which give Myanmar a World Life Expectancy ranking of 126. Thus, the age group commonly affected by oral diseases in this study was younger than those of some studies. Regarding the incidence of biopsied lesions according to patient gender, men were more affected than women in most of the lesions except benign soft tissue lesions where a slight reverse gender distribution was evident because pregnancy tumor (pyogenic granuloma) was found to be the most frequent in this category. Being the highest pathologies in this review, OSCC was mostly detected in men and this may be due to the more frequent use of tobacco in males than females in Myanmar. Similar with the present study, in most regions of India, oral cancer is the most common cancer in men and the third most common cancer in women (Sturgis EM,.2004). Information emerging from Taiwan and China indicates that the incidence of oral cancer in men has tripled since the 1980s due to the chewing of betel quid (WHO, 2008). Concerning the anatomical location, (32.8 %) of lesions in our study was located in the buccal mucosa which was mostly affected by oral cancer, oral potentially malignant disorders and 24

5 benign soft tissue lesions. It also reflected the culprit of betel quid or tobacco snuff placement habits of patients with OSCC, a highest lesion in the study group. This finding was not in line with other study where the tongue is the leading site not only among oral cancers but also among head and neck cancers in India (Addala et al, 2012). For benign neoplasm, the gingival was the most common location followed by buccal mucosa,tongue and palate. Oral malignant lesions constituted % of the lesions in the present study which were composed of 99 cases (38.22%) of OSCC (Fig.2) and 11 cases (4.24%) of other oral malignancies. On the other hand, the total frequency of OSCC in the reports of Fierro-Garibay et al. (2011) and Franklin and Jones (2006) were 0.4% and 0.1%, which are much lower than our assessment. In 2013, an epidemiological study of oral cancer in Asian countries revealed that an increasing trend of OSCC has been observed in Pakistan, Taiwan and Khonkaen province of Thailand, an opposite decreasing trend is seen in Philippines, Sri Lanka and Chiangmai province of Thailand ( Rao et al, 2013). Even though it has been proved that chewing betel quid causes oral cancer, there are very few education or intervention programs in our country. Of the adult males who chew paan in Myanmar, also smoke tobacco. There are no laws in Myanmar that prohibit the sale of smoking and smokeless tobacco within 100 yards of schools. Thus, Myanmar is still far from banning the practice of chewing betel quid and or tobacco smoking. Out of a total of 259 study subjects, 5.79 % (15cases) of the subjects were diagnosed of having potentially malignant disorders like leukoplakia,oral submucous fibrosis and epithelial dysplasia. Most frequently encountered OPMD was leukoplakia which was generally seen at ages between 4th and 6th decade with a male predominance. On the other hand, in the hospital based retrospective study conducted in India from 2012 to 2015, 32% of oral submucous fibrosis was observed. Majority of the oral lichen planus cases were clinically evident for diagnosis and histological confirmation was not done routinely in our institution. Thus this content could not be attributable to OPMD of the review. In our study a few cases of OPMD were evaluated because people in this study area did not recognize them as precursors of oral squamous cell carcinoma/oral cancer. Thus, they only attend to the treatment centre once the lesions became aggressive. In addition to the lesions discussed earlier, 13.89% of odontogenic cyst and tumor, 3.08% of salivary gland disorders and 3.08% of fibro-osseous lesions were explored respectively in this study. Our review was carried out within a period of one year and one month duration and hence further studies are required to investigate an association between these lesions and the various parameters in detail. Conclusion In this review, it was found that Oral Squamous Cell Carcinoma (OSCC) had the highest frequency (38.22%) among all the biopsied oral lesions. Male patients were mostly affected (62.9%) by OSCC and the commonest age group was (41-60 years) (48.6%). Almost all of the male patients with OSCC had histories of habitual betel quid chewing and or tobacco smoking. A small number of OPMD were detected in this review. Being the silent nature of most of the OPMD, public has lack of chance to know malignant transformation and failed to seek early detection for prompt treatment. In Myanmar, oral cancer is the fourth most common cancer among males and sixth most common among females (Kim- 25

6 man, 2012). According to the data obtained from this review, it can clear be seen that oral squamous cell carcinoma is still as high as before. Furthermore, it reveals that people from middle and upper part of Myanmar who attended mostly to University of Dental Medicine Mandalay were still far from banning the practice of tobacco consumption. From this review, it was highlighted that public education and intervention programs should be implemented to encourage for primary prevention and early detection of oral lesions especially oral cancer and potentially malignant disorders to achieve sustainable improvement of oral health in Myanmar. References Addala L, Pentapati CK, Thavanati PKR, Anjaneyulu V, Sadhnani MD, Risk factor profiles of head, neck cancer patients of Andhra Pradesh, India. Indian J Cancer, 2012; 49, Bhurgri Y, Bhurgri A, Usman A,Pervez S. Kayani N, Bashir L, Ahmed R,Hasan SH, Epidemiological review of head, neck cancers in Karachi. Asian Pac J Cancer Prev, 2006; 7, Fierro-Garibay C, Almendros-Marqués N, Berini-Aytés L, Gay-Escoda C. Prevalence of biopsied oral lesions in a Department of Oral Surgery. J Clin Exp Dent. 2011;3(2):e73-7. Franklin CD, Jones AV. A survey of oral and maxillofacial pathology specimens submitted by general dental practitioners over a 30-year period. Brit Dent J. 2006; 200(8): Kimman M, Norman R, Jan S, Kingston D, Woodward M. The burden of cancer in member countries of the Association of Southeast Asian Nations (ASEAN) Asian Pac J Cancer Prev.; 2012; 13: Melrose RJ, Handlers JP, Kerpel S, Summerlin D-J, Tomich CJ. The use of biopsy in dental practice: the position of the American Academy of Oral and Maxillofacial Pathology. Gen Dent; 2007; 55: Owais Gowhar, Tasneem S. Ain, Narendra Nath Singh, Saima Sultan; Prevalence of Oral Premalignant and Malignant Lesions in Moradabad, India - A Retrospective Study ; International Journal of Contemporary Medical Research;2016 Volume 3 Issue 7; Rao SVK, Gloria Mejia, Kaye Roberts-Thomson, Richard Logan, Epidemiology of Oral Cancer in Asia in the Past Decade- An Update ( ); Asian Pacific Journal of Cancer Prevention, 2013; Vol 14, Sixto-Requeijo R, Diniz-Freitas M, Torreira-Lorenzo JC, Garcia-Garcia A, Gandara-Rey JM. An analysis of oral biopsies extracted from 1995 to 2009, in an oral medicine and surgery unit in Galicia (Spain). Med Oral Patol Oral Cir Bucal. 2012; 17(1):e Sturgis EM. A review of social and behavioral efforts at oral cancer preventions in India. Head Neck. 2004; 26(11): World Health Organization. Oral Health. WHO 2001 July 18 (cited 2008 Jun 27). Available from: World Health Organization. Myanmar Life Expectancy, (cited in 2016 Nov 16) Available from 26

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