|Year : 2006 | Volume
| Issue : 2 | Page : 84-89
Epidemiological and etiological study of oral submucous fibrosis among gutkha chewers of Patna, Bihar, India
Mohammad Sami Ahmad1, SA Ali2, AS Ali3, KK Chaubey4
1 Dental Public Health Science College, Dammam, Saudi Arabia,
2 Dept. of Biotechnology, Safia Postgraduate College of Science and Education, Bhopal - 462 001, MP, India,
3 Prof. of Bioscience, Saifia Postgraduate College of Science and Education, Bhopal - 462 001, MP, India,
4 Department of Periodontology Patna Dental College and Hospital, Patna, Bihar, India,
Mohammad Sami Ahmad
Dental Public Health Health Science College, P.O. Box 3761, Dammam 31481, Saudi Arabia
An etiological and epidemiological study of oral submucous fibrosis (OSMF) has been done in Patna, Bihar. Total 157 cases of OSMF and 135 control subjects were selected for study in the period of 2002-2004. It was observed that Male: Female ratio was 2.7: 1. The youngest case of OSMF was 11 year old and the oldest one was 54 years of age. Maximum number of cases were belonging to 21-40 years of age and they were belonging to low or middle socioeconomic class. Most of the OSMF cases used heavy spices and chillies, where as control mild spices and chillies. Gutkha was the most commonly used by the OSMF cases only 3 per cent did not use any gutkha or other areca nut product where as 80 per cent control did not have any chewing habit. The OSMF cases used gutkha and other products 2-10 pouches per day and kept in the mouth for 2-10 minutes and they were using since 2-4 years. Most of the OSMF cases kept gutkha in the buccal vestibule or they chewed and swallowed it, only a small number of patients chewed and spitted it out. It was also observed that OSMF developed on one side of the buccal vestibule where they kept the chew and other side was normal.
Keywords: Areca nut, chillies, gutkha, oral submucous fibrosis, panmasala
|How to cite this article:|
Ahmad MS, Ali S A, Ali A S, Chaubey K K. Epidemiological and etiological study of oral submucous fibrosis among gutkha chewers of Patna, Bihar, India. J Indian Soc Pedod Prev Dent 2006;24:84-9
|How to cite this URL:|
Ahmad MS, Ali S A, Ali A S, Chaubey K K. Epidemiological and etiological study of oral submucous fibrosis among gutkha chewers of Patna, Bihar, India. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2013 May 21];24:84-9. Available from: http://www.jisppd.com/text.asp?2006/24/2/84/26022
Oral submucous fibrosis (OSMF) is a chronic disease of oral mucosa characterized by inflammation and progressive fibrosis of lamina propria and deeper connective tissues, followed by stiffening of an other wise yielding mucosa resulting in difficulty in opening the mouth. (Pindborg et al ; WHO).
In 1952, Schwartz described five Indian women from Kenya with a condition of the oral mucosa including the palate and the pillars of the fauces, which he called "atrophica idiopathica mucosa oris". Later on it was termed OSMF by Joshi in 1953.
It is generally accepted today that areca nut quid plays a major role in the etiology of the disease (Babu et al ). The disease occurs mostly in India and in South East Asia but the cases have been reported world wide like Kenya, China, UK, Saudi Arabia and other part of the world where Asians are migrating (Tang et al , Shah et al ).
In recent years marked increase in the occurance of OSMF was observed in many parts of India like Bihar, MP, Gujarat and Maharashtra and the younger generation are suffering more due to incoming of areca nut products in different multicolored attractive pouches. In Bihar areca nut with flavoring agent and tobacco like gutkha are available in each and every corner of the road. The younger generation is very much addicted to these products especially gutkha and panmasala.
No study on OSMF has been done in Bihar where selling of gutkha is very common and even sold on the gate of schools and colleges. The study has been conducted to find out the etiological and socioeconomic aspect of the disease so in future proper preventive measure can be taken to reduce this monstrous disease which is affecting our whole population along with the younger generation.
| Materials and Methods|| |
The study was conducted at Patna Dental College, Patna, Bihar. Patients attending the out patient clinic of Patna Dental College for oral diseases (disorders) were screened for OSMF. The total 157 patients of Oral Submucous Fibrosis and 135 controls were selected for study in the period of 2002-2004. The OSMF cases were diagnosed by presence of certain clinical criteria and some of them were confirmed by histopathological examination. Histopathology of all the patients was not done, because both controls and OSMF cases, many of them refused to undergo biopsy. Controls were selected from the patients who did not exhibit any oral mucosal lesions or conditions. Controls were matched for age (+ or - 2 years), sex, religion and socioeconomic status by their income and education. An appropriate format was designed after pre testing, to collect detailed information of all the subjects such as sex, age, socioeconomic status, residential status, oral hygiene condition, amount of spices and chilies use, nutritional value of diet, any chewing habits of gutkha and other areca nut product, duration of chewing, duration of keeping in the mouth, frequency of chewing and style of chewing were recorded.
Clinical examination of the subjects along with well matched control was performed examining the factors such as burning sensation of mouth and tongue, irritation of mouth with chillies and spicy food, dryness of mouth or hyper salivation, difficulty or inability in opening mouth, blanched or opaque appearance of mucosa, loss of tongue papillae, atrophy of the tongue, soft palate movement restriction, inability to protrude tongue, presence of palpable fibrous band.
The data were analyzed by SPSS (Statistical Package for Social Services version 10). Descriptive statistics such as frequency, percentage and mean values were used. The inferential statistics such as Chi-square test (χ 2- test) and Odds Ratio were used following the method of Rao and Richard (2004).
| Results and Discussion|| |
In the present study males were dominating, 115 (73%) OSMF out of 157 were male. The male to female ratio was 2.7:1. In an earlier study conducted in Indian city of Mumbai by Sirsat and Khanolkar it was found that the male:female ratio was 1:1. Similarly Wahi et al reported a male to female ratio of 2:1. Later on Shah and Sharma in their study in All India Institute of Medical Sciences, New Delhi reported a male to female ratio of 1.8:1, which is quite similar to that found in the present study.
However, in the present study, males were found to be dominating, as they were using gutkha and other related products more because of easy availability in all the places where as females being more conscious about their health and esthetic value, probably felt uncomfortable to ask the vendors in getting the gutkha products. This is one of the reasons, which may be responsible for a high male to female ratio [Table - 1].
In our study youngest patient was 11 years of age where as the oldest patient was 54 years. Majority of the OSMF cases belonged to 21-40 years of age group [Table - 2]. Earlier Sirsat and Khanolkar reported majority of OSMF cases belonged to the age group of 20-40 years of age. Sinor et al reported 79 per cent of the OSMF cases were under the age of 35 years and maximum numbers of cases were in 25-44 years of age group. Shah and Sharma in their study from Delhi also reported the majority of cases from 21-40 years of age group. Present study indicated that most of the younger people were suffering from OSMF. Traditionally in India, only married adults have been consumers of areca nut. However, during the recent years, with the advent of attractive, conveniently packed sachets and mass and media advertisements, consuming of gutkha and panmasala by younger people has increased. The other reason might be easy availability of gutkha and panmasala in every corner as well as a social status evil.
Most of the OSMF patients belonged to middle class and 30 per cent of OSMF cases belonged to low socioeconomic group [Table - 3]. Shiau and Kwan observed OSMF mostly in farmers belonged to low socioeconomic class. Ramanathan also found most of the OSMF cases from India were also of low socioeconomic group. McGurk and Crag studied Asian community settled in United Kingdom and they found that most of the OSMF patients were from low or middle-income group. The reason for OSMF cases coming from low socioeconomic group might be due to poor quality of food, low vitamins particularly in iron deficiency and use of more spices and chillies to make the food tasty, coupled with lack of health consciousness.
Chillies and spices were observed as one of the predisposing factors of OSMF. Several workers like Sirsat and Khanolkar, Shiau and Kwan, McGurk and Crag, Rajendran et al , Pillai et al and Van Wyk have reported that use of spices and chillies as one of the predisposing factors of OSMF. It may be mentioned that chillies can damage the cells of the mucosa and if this is continuous, it probably causes chronic inflammation, which leads to the formation of excessive fibrosis. So chillies have indirect effect on the pathogenesis of OSMF as hypersensitivity to chillies is often explained as a common factor in the development of OSMF. These findings are similar to that observed in the present study. By excessive use of chillies and spices, as in the case of OSMF subjects, along with low nutritional value food, common in lower middle class, it appears that such factors have a cumulative effect on the incidence, nature and severity of the disorder.
Out of 157 cases 47 (30%) of the OSMF patients were having poor nutritional food values. People having poor nutritional value in their food probably suffered more from OSMF. Rajendran et al who reported that vitamin and iron deficiency together with malnourished state of the host leads to derangement in the inflammatory reparative response of the lamina propria with resultant defective healing and scarification which ultimately leads to OSMF. Rajendran, Aziz and Beena and Gupta et al and Zain have also reported that females, who were having deficiency of iron and vitamin B complex, had more OSMF. Similarly, recently Thomas et al have reported that high intake of fruits and vegetables can act as protective shield for OSMF, which again upholds the theory that poor nutrition is one of the causative factors of OSMF.
It is very interesting to know that 152 out of 157 OSMF cases used gutkha and other areca nut products, the relative number of cases who used only gutkha were more. About 55 per cent of subjects consumed only gutkha. It was also observed that after the preference of gutkha about 16 per cent of the fibrosed cases were addicted to pan chewing habit [Table - 7]. From these data, it becomes evident that, it is the gutkha, containing areca nut, tobacco as main ingredients along with lime, catechu, pan extracts and other flavouring agents in almost all the brands available in the market may be regarded as possible prime etiological factors for inducing OSMF. Moreover the habit-forming process of gutkha chewers is due to tobacco and areca nut, which if consumed for longer duration and frequencies is responsible for causing addiction, leading to OSMF.
It was found that average betel quid (areca nut, tobacco, catechu and lime wrapped in betel leaf) approximately weighing 3.5-4 grams has 70 per cent moisture and dry weight of areca nut and tobacco is only 1.14 grams where as the gutkha sachet weighing 3.5 gram has only 7 per cent moisture and dry weight 3.26 grams (Babu et al ). Since habitual chewers tend to consume more dry weight of areca nut and tobacco when they use gutkha so they probably develop more fibrosis of the oral mucosa, particularly the disorder afflicting quite earlier as well. It was also observed that most of the patients of OSMF were using gutkha and other related products till the diagnosis of the disease i.e., they were not aware of the symptoms till the severity got developed. It was also found that the some of the patients left the habit after knowing about the harmful effects of gutkha i.e., areca nut and tobacco in combination. Such cases on several post treatment check ups continued with the OSMF, as there was no cessation of the disease. The extent of the disease was as it was before but it did not increase any further, as the follow up of cases revealed.
Seedat and Van Wyk, Murti et al and Jayanthi et al who had reported that once areca nut chewing induced OSMF, there is no or little reversal of the disease even after cessation of the gutkha chewing habit. But Anil and Beena had reported little improvement when areca nut and tobacco chewing habit was discontinued in early stage of disease. Avon had also reported improvement in mucosal lesion as well as clinical symptoms after the cession of the areca nut tobacco chewing habit.
In the above quoted study it was also observed that OSMF patients were taking different kinds of areca nut products like pan, panmasala, raw areca nut along with the gutkha, however most of the patients who had OSMF were using gutkha maximally and consequently suffered more. This condition might be due to dry contents of gutkha, which has comparatively more areca nut and tobacco. Dry tobacco absorbed by the mucosa in more amounts produces addiction to the patients.
The findings of Babu et al on OSMF cases of Hyderabad showed that people were more addicted to gutkha than any other related areca nut and tobacco products such as pan, panmasala, raw areca nut etc. They found strong association between gutkha chewing and OSMF and they also pointed that gutkha produced OSMF earlier than raw areca nut. Similar work was shown by Shah and Sharma in Delhi, who observed that gutkha chewing produced OSMF earlier as compared to raw areca nut and other product. Gupta and Ray observed that areca nut with smokeless tobacco cause earlier onset of the disease as compared to areca nut only. The protective effects of pan to the oral mucosa against the harmful alkaloids present in the areca nut is one of the considerable factor for less OSMF cases in pan chewers, because pan (betel leaf) is known to be rich in beta-carotene and hydroxychavicol, which have the capacity to quench free radicals that are toxic. Van Wyk who studied South Africans of Indian origin and found that most of the women preferred to take pan which caused lesser OSMF in severity as well as immense as compared to the males who took only areca nut and tobacco products.
Association of OSMF as well as well matched controls with duration of addiction of the chewing habit and period of keeping gutkha and other products in minutes in the mouth was observed and, it has been found that 44 percent of the subjects from the total cases developed OSMF with the chewing habit duration 2-4 years. With regard to period of keeping gutkha and other products in minutes in the mouth it was found that out of total 74.5 percent of OSMF cases kept the gutkha and related products for 2-10 minutes in the mouth. At the same time it is clear from [Table - 10], that 69 percent of OSMF cases were using gutkha and other products 2-10 pouches per day [Table - 8][Table - 9]. It has been observed from the above study that maximum number of cases developed the symptoms of OSMF quite earlier. It was found by Me Gurk and Crag that most of the patients of Indian origin living in UK developed OSMF within the period of 5 years of chewing areca nut and tobacco. Other workers who have reported the onset of OSMF as early as 4 years after chewing habits of areca nut and tobacco are: Canniff et al. Pindborg, Babu et al, Merchant et al, Shah and Sharma, and Gupta et al .
With regard to the style of chewing gutkha and other products, it was observed that 21 percent of OSMF cases chewed gutkha and other products and spitted out it after keeping it for 2-10 minutes in the mouth. Rest 40 percent chewed and swallowed after keeping for 2-10 minutes in the mouth and 39 percent kept it for longer period in the buccal vestibules [Table - 11]. Majority of the subjects suffering from OSMF kept gutkha and other products in the buccal vestibules and swallowed the gutkha contents after chewing it for some time. Therefore it appears that more amount of gutkha contents are absorbed by buccal mucosa or posterior region of the mouth like soft palate and uvula in such type of style of chewing and swallowing.
These findings further demonstrate that due to this style of keeping the gutkha in the vestibular area of the mouth fibrosis was more in this region followed by soft palate and uvula as absorbed in OSMF. On the other hand, it was observed that OSMF subjects chewed gutkha and other products for longer time and spitted it out, for this reason fibrosis mostly got developed in the whole of buccal mucosa, parts of labial mucosa and also floor of the mouth. Some workers like Van Wyk, Gupta et al and Chiu et al have also reported fibrosis in OSMF patients according to the style of chewing the areca nut and tobacco. They have reported that fibrosis occurs in the region of buccal mucosa, soft palate and uvula of OSMF subjects who chewed and swallowed areca nut and tobacco after keeping for few minutes in the mouth as observed in the present study. In the present study most of the OSMF cases also kept areca nut and tobacco in the buccal vestibules for which they developed fibrosis in the buccal mucosa. Trivedy et al , Shieh et al and Tsai et al who reported fibrosis of buccal mucosa due to exposure of high concentration of areca nut and tobacco in that region, suggesting localized irritating reactions.
Interestingly in the present study some OSMF subjects showed unilateral fibrosis in the mouth. On examination one side of the buccal mucosa was fibrosed where as other side was completely normal. The patients used to keep the gutkha on the fibrosed side for few minutes and after that partially swallowed and partially spitted out. Most of the workers like Mukherji and Biswas, Ramanathan, Canniff and have reported OSMF in which fibrosis was in both sides of buccal mucosa or it was extended into soft palate, uvula, pharynx and root of the tongue. But no one has reported fibrosis on very localized on one side of buccal mucosa and other side completely normal.
The data of the present study with regard to etiological factors suggest that from many ingredients of the gutkha, it is the areca nut with tobacco, which is responsible for a "habitual" chewing response in almost all the gutkha users, irrespective of age, community and socioeconomic status. The data of the epidemiological survey presented in [Table - 7][Table - 8][Table - 9][Table - 10][Table - 11]; prove beyond doubt that the chewing habit is caused by tobacco, which initially triggers histophysiological and histopathological changes leading to OSMF in susceptible individuals. It was also observed that gutkha chewing was preferred by people in the younger age group (i.e., 11-30 years). As the onset of OSMF changes had occurred earlier with gutkha chewing compared to only areca nut chewing. These findings clearly document the hazard of gutkha chewing. Since people take to gutkha chewing at a comparatively younger age and as it requires a shorter duration of chewing to precipitate OSMF, there may be an increased risk of their developing malignant changes, in such OSMF cases. It is also observed that poor quality of di et al ong with heavy spices and chillies play cumulative effect in producing OSMF. A small attempt has been taken to know the epidemiology and etiology of the disease in Bihar where gutkha selling is very commonly seen in every corner of the street. But there is a need of extensive study on gutkha and other areca nut product and its effect on oral mucosa.
| References|| |
|1.||Pindborg JJ, Barmes D, Roed-Peterson B. Epidemiology and histology of oral leukoplakia and leukoedema among Papuans and New Guineans. Cancer 1968;22:379-84. |
|2.||WHO. Meeting report. Control of oral cancer in developing countries. WHO Bull 1984;62:617. |
|3.||Schwartz J. Atrophia Idiopathica Mucosae Oris. Demonstrated at the 11th Int Dent Congress: London; 1952. |
|4.||Joshi SG. Fibrosis of the palate and pillars. Indian J Otolaryngol 1953;4:1. |
|5.||Babu S, Bhat RV, Kumar PU, Sesikaran B, Rao KV, Aruna P, et al . A comparative clinico-pathological study of oral submucous fibrosis in habitual chewers of panmasala and betel quid. Clin Toxicol 1996;34:317-22. |
|6.||Tang JG, Jian XF, Gao ML, Ling TY, Zhang KH. Epidemiological survey of oral submucous fibrosis in Xiangtan city, Hunan Province, China. Commun Dentist Oral Epidemiol 1997;25:177-80. [PUBMED] |
|7.||Shah B, Lewis MA, Bedi R. Oral submucous fibrosis 11 year-old Bangladeshi girl living in United Kingdom. Br Dent J 2001;191:130-2. [PUBMED] [FULLTEXT]|
|8.||Sirsat SM, Khanolkar VR. Submucous Fibrosis of the Palate and Pillars of the Fauces. Indian J Med Sci 1962;16:188-97. |
|9.||Wahi PN, Kapoor VL, Luthra UK, Srivastava MC. Submucous Fibrosis of the oral cavity: 2. Studies on Epidemiology. Bull WHO 1966;35:793-9. |
|10.||Shah N, Sharma PP. Role of chewing and smoking habits in the etiology of oral submucous fibrosis: A case control study. J Oral Pathol Med 1998;27:475-9. [PUBMED] |
|11.||Sirsat SM, Khanolkar VR. Sub mucous fibrosis of the palate in diet. Pre conditioned Wister rats: Induction by local painting of capsaicin-an optical and electron microscopic study. Arch Pathol 1960;70:171-9. [PUBMED] |
|12.||Sinor PN, Gupta PC, Murti PR, et al . A case control study of oral submucous fibrosis with special reference to the etiologic role of areca nut. J Oral Pathol Med 1990;19:94-8. |
|13.||Shiau YY, Kwan HW. Submucous Fibrosis in Taiwan. Oral Surg 1979;47:453-7. [PUBMED] |
|14.||Ramanathan K. OSMF-An alternative hypothesis as to its causes. Med J Malaysia 1981;36:243-5. [PUBMED] |
|15.||McGurg M, Craig GT. OSMF: Two Cases of Malignant Transformation in Asian Immigrants to the United Kingdom. Br J Oral Maxilofac Surg 1984;22:56-64. |
|16.||Rajendran R. Oral submucous fibrosis: Etiology, pathogenesis and future research. Bull WHO 1994;72:985-96. [PUBMED] |
|17.||Pillai R, Balram P, Reddiar KS. Pathogenesis of oral submucous fibrosis. Relationship to risk factors associated with oral cancer. Cancer 1992;69:2011-20. |
|18.||Van Wyk CW. Oral Submucous Fibrosis. The South African experience. Indian J Dent Restorat 1997;8:39-45. |
|19.||Aziz S, Beena VT. Oral sub mucous fibrosis: An unusual disease. JNJ Dent Assoc 1997;68:17-9. |
|20.||Gupta PC, Sinor PN, Bhonsle RB, Pawar VS, Mehta BC. Oral submucous fibrosis in India: A new epidemic? Nat Med J India 1998;11:113-6. International classification of disease for oncology. 2nd ed. Percy C, Holton VV, Muir CS, editors. World Health Organisation: Geneva; 1990. |
|21.||Zain RB. Cultured and dietary risk factors of oral cancer and precancer and a brief overview. Oral Oncol 2001;37:205-10. [PUBMED] [FULLTEXT]|
|22.||Thomas G, Hashibe M, Jacob BJ, Ramdas K, Mathew B, Sankaranarayan R, et al . Risk factors for multiple oral premalignant lesions. Int J Cancer 2003;107:285-91. |
|23.||Seedat HA, van Wyk CW. Oral submucous fibrosis in ex-betel nut chewers: A report of 14 cases. J Oral Pathol 1988;17:226-9. [PUBMED] |
|24.||Murti PR, Gupta PC, Bhonsle RB, Daftary DK, Mehta FS, Pindborg JJ. Effect of oral submucous fibrosis of intervention in the areca nut chewing habit. J Oral Pathol Med 1990;19:99-100. [PUBMED] |
|25.||Jayanthi V, Probert CS, Sher KS, Mayberry JF. Oral sub mucous fibrosis-a preventable disease. Gut 1992;33:4-6. [PUBMED] |
|26.||Anil S, Beena VT. Oral sub mucous fibrosis in a 12 year old girl: Case report. Pediat Dentist 1993;15:120-2. [PUBMED] |
|27.||Avon SL. Oral mucosal lesions associated with use of quid. J Can Dent Assoc 2004;70:244-8. [PUBMED] [FULLTEXT]|
|28.||Gupta PC, Ray CS. Smokeless tobacco and health in Indian and South Asia. Respirology 2003;8:419-31. [PUBMED] [FULLTEXT]|
|29.||Canniff JP, Harvey W, Harris M. Oral submucous fibrosis: Its pathogenesis and management. Br Dent J 1986;160:429-34. [PUBMED] |
|30.||Merchant AT, Haider SM, Fikree FF. Increased severity of oral submucous fibrosis in young Pakistani man. Br J Oral Maxilofac Surg 1997;35:284-7. [PUBMED] |
|31.||Chiu CJ, Lee WC, Chiang CP, Hahen U, Kuo YS, Chen CJ. A scoring system for the early detection of oral sub mucous fibrosis based on a self administered questionnaires. J Pub Health Dentist 2002;62:28-31. |
|32.||Trivedy C, Craig G, Warnakulasuriya S. The oral health consequences of chewing areca nut. Addict Biology 2002;7:115-25. |
|33.||Shieh DH, Chiang LC, Lee CH, Yang YH, Shieh TY. Effect of arecoline, safrole, nicotine on collagen phagocytosis by human buccal mucosal fibroblasts as possible mechanism for oral sub mucous fibrosis. J Oral Pathol Med 2004;33:581-7. [PUBMED] [FULLTEXT]|
|34.||Tsai CH, Yang SF, Chen YJ, Chou MY, Chang YC. Raised keratinocyte growth factor-I expression in oral submucous fibrosis in vivo and upregulated by arecoline in human buccal mucosal fibroblasts in vitro. J Oral Pathol Med 2005;34:100-5. [PUBMED] [FULLTEXT]|
|35.||Mukherji Al, Biswas SK. Oral submucous fibrosis- A search for etiology. Indian J Otolaryngol 1972;24:11. |
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9], [Table - 10], [Table - 11]
|This article has been cited by|
||Proposed clinical classification for oral submucous fibrosis
| ||Chandramani B. More, Sunanda Das, Hetul Patel, Chhaya Adalja, Vaishnavee Kamatchi, Rashmi Venkatesh |
| ||Oral Oncology. 2011; |
||Correlation of addictive factors, human papilloma virus infection and histopathology of oral submucous fibrosis : HPV infection addiction histopathology OSMF
| ||Ravi Mehrotra, Ajay Kumar Chaudhary, Shruti Pandya, Sharmistha Debnath, Mangal Singh, Mamta Singh |
| ||Journal of Oral Pathology and Medicine. 2010; 39(6): 460 |
||Oral submucosal fibrosis in Iran: a case review : Oral submucosal fibrosis in Iran
| ||Parvin Mansouri, Shideh Yazdanian, Farid Safar, Ramin Espandar, Samad Rezaii, Zahra Safaie-Naraghi, Reza Chalangari |
| ||International Journal of Dermatology. 2010; 49(12): 1424 |
||Oral mucosal disorders associated with habitual gutka usage: A review
| ||Javed, F., Chotai, M., Mehmood, A., Almas, K. |
| ||Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology. 2010; 109(6): 857-864 |
||Tobacco use by Indian medical students and the need for comprehensive intervention strategies
| ||Mehrotra, R., Chaudhary, A.K., Pandya, S., Mehrotra, K.A., Singh, M. |
| ||Asian Pacific Journal of Cancer Prevention. 2010; 11(2): 349-352 |