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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 32-36

Oral cancers among yemenis patient: A prospective hospital-based study


1 Department of Oral and Maxillo-facial Surgery, Al-Gomhory Teaching Hospital, Sana'a –, Republic of Yemen
2 Department of Oral and Maxillo-facial Surgery, Faculty of Dentistry, Al-Khartoum University, Republic of Sudan

Date of Web Publication21-Nov-2018

Correspondence Address:
Ali Ali Al-zamzami
Al-Gomhory Teaching Hospital, Sana'a
Republic of Yemen
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/dmr.dmr_2_18

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  Abstract 


Objective: The objective is to study oral cancer among Yemenis, determine the common types, common sites, and the pattern of the disease in relation to age and gender, and define the possible risk factors associated with its development. Materials and Methods: The present study is a prospective descriptive hospital-based study carried out at Al-Gomhori Teaching Hospital in Sana'a in the period 2009–2012. Data were collected from history (using a questionnaire form), clinical examination of patients, and from the histopathology results of the biopsies. Results: During the study period, 319 cases of oral cancers were seen. The majority of patients (92%) were over the age of 40 years, and the peak incidence is the seventh decade of life. Squamous cell carcinoma was the most common type of oral cancers accounting for 90.3%, followed by salivary gland tumors. The gingiva was the most frequent site accounting for 27.9%, followed by the tongue accounting 27.3%. Shammah (traditional name of smokeless tobacco in Yemen and Saudi Arabia) was the main risk factor and associated with development 65.2% of oral cancers. Conclusion: Oral cancer in Yemen as in all countries still remains the disease of the elderly and deprived patient. The majority of patient were over the age of 40 years. Males were affected more than females, male to female ratio was 1.2-1. Squamous cell carcinoma was the most common type of oral cancers. Gingiva was the most affected sites, followed by the tongue. Shammah (traditional-name of smokeless tobacco in Yemen and Saudia Arabia) was the main risk factor and play an important role to development of oral cancers.

Keywords: Cancer, oral cancers, oral cavity


How to cite this article:
Al-zamzami AA, Suleiman AM. Oral cancers among yemenis patient: A prospective hospital-based study. Dent Med Res 2018;6:32-6

How to cite this URL:
Al-zamzami AA, Suleiman AM. Oral cancers among yemenis patient: A prospective hospital-based study. Dent Med Res [serial online] 2018 [cited 2018 Dec 16];6:32-6. Available from: http://www.dmrjournal.org/text.asp?2018/6/2/32/245922




  Introduction Top


Of all factors believed to contribute to the etiology of oral cancers, tobacco is regarded as the most important risk factor. All forms of tobacco (smoking as well as smokeless tobacco) have been strongly linked to the causation of oral cancer.[1] Alcohol consumption plays an important role in the development of oral cancer. People who drink alcohol are more likely to develop oral cancer than people who do not drink.[2] There is good evidence that people who both drink and smoke have a much higher risk for oral cancer than those using only alcohol or tobacco.[3]

In most countries where data are available, the incidence of oral cancer is low. India and Sri lanka, are, however, exceptional and oral cancer account for approximately 40% or more of all body cancers.[4],[5] Worldwide, geographic variations in prevalence exist ranging from only a few percentage in most western countries to over 40% in South and Southeast Asia.[6]

In Yemen as in other countries (such as India, Southeast Asia, and Sudan), the habits of tobacco dipping or chewing are common. According to Sawair et al.,[7] oral cancer in Yemen was the most frequently body cancer. The mean age at diagnosis of oral cavity cancers was 56.3 years for both sexes. Basaleam et al.[8] reported that head and neck cancer was the fourth common type of cancer among Yemenis patient. Sawair et al.[7] as well as Nasr and Khatri[9] showed that the most common site of oral cancer was the tongue accounting for 70.5% and 42%, respectively, while Maki[10] found that the buccal mucosa was the most common site of involvement, accounting for 65%, followed by the tongue accounting for 30% of the series.


  Materials and Methods Top


The present study is a prospective descriptive hospital-based study carried out at Al-Gomhori Teaching Hospital in Sana'a in the period 2009–2012. A total of 319 cases of oral cancer were examined, patients biopsied, and specimens were sent for histopathology laboratory. The findings were recorded from the history (using a questionnaire form) as well as from the biopsy histopathology results.


  Results Top


A total of 319 cases of oral cancer were recorded, 173 of them (54.2%) were male and 146 cases (45.8%) were female. The majority of patients (92.1%) were over the age of 40 years. The peak of occurrence was in the seventh decade of life [Table 1].
Table 1: Age/gender distribution of oral cancers

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Squamous cell carcinoma was the most common type, accounting for 90.3%, followed by salivary gland neoplasms accounting for 4.7% and Burkitt's lymphoma, malignant melanoma, sarcoma, and malignant fibrous histiocytoma accounting for 2.2%, 1.3%, 1.3%, and 0.3%, respectively [Table 2].
Table 2: Type distribution of oral cancers

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Of the 288 cases of squamous cell carcinoma, 157 cases were male and 131 cases were female. The majority of patients (96.1) were over the age of 40 years. The peak age of occurrence was the seventh decade of the life [Table 3]. The majority of squamous cell carcinoma was on the gingiva, accounting for 30.6%, followed by the tongue (30.2%), the lip (12.8), the floor of the mouth (9.4), the buccal mucosa (9.0%), the major salivary glands (3.8%), the maxillary sinus (3.5%), and the palate (0.7%) [Table 4].
Table 3: Age/gender distribution of squamous cell carcinoma

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Table 4: Site distribution of squamous cell carcinoma

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The gingiva was the most frequent site accounting for 27.9%, followed in descending order by the tongue (27.3%), the lip (11.6%), the floor of the mouth (8.5%), the buccal mucosa (8.2%), the salivary glands (6.6%), the maxillary sinus (4.4%), jaw bones (3.1%), and the palate (2.5%) [Table 5].
Table 5: Site distribution of oral cavity cancers

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There were 89 cases of the gingiva, 54 cases (60.7%) were male, and 35 cases (39.3%) were female. Most patients (96.5%) were over the age of 40 years [Table 6]. Eighty-eight cases (98.8%) of gingival cancers were squamous cell carcinoma and the remaining one case (1.1%) was a malignant melanoma [Table 7]. Eighty-one cases (91%) of gingival cancers were on the lower gingiva and 8 cases (8.9%) were on the upper gingiva [Table 8].
Table 6: The relationship between the gingival cancers and age groups

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Table 7: Type distribution of gingival cancers

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Table 8: Site distribution of gingival cancers

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Tongue was the second commonly affected site, where 87 cases were recorded, 44 cases of theme (50.6%) were male and 43 cases (49.4%) were female. Most of the tongue cancer patients (94.4%) were over the age of 40 years, with a peak occurrence in the seventh decade of the life [Table 9]. All the tumors found on the tongue were squamous cell carcinoma. Seventy-two cases (82.8%) of the tongue cancers were located on the anterior two-thirds of the tongue and 15 cases (17.2%) were in the posterior one-third (base) of the tongue [Table 10]. Forty cases (46.0%) of tongue cancers were found on the right side, and 47 cases (54.0%) were found on the left side [Table 11].
Table 9: Age/gender distribution of tongue cancers

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Table 10: Site distribution of tongue cancers

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Table 11: Side distribution of tongue cancers

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Shammah use (is the traditional name of smokeless tobacco type of snuff dipping in the Arabian Peninsula particularly in Yemen and Saudi Arabia) was the main risk factor, and 65.2% of all oral cancer patients were shammah users, followed in descending order by qat chewing (traditional habits among Yemenis) (49.5%), mada'a (type of smokeless tobacco) (30.7%), and cigarette smoking (18.5%). The less common risk factors were outdoor work (long-standing exposure to sunlight) (10.0% for lip cancers), trauma (7.2%), chronic infection (3.4%), wood burn (2.8%), alcohol (2.5%), fair skin (1.9% for lip cancers), radiotherapy (1.3%), and hereditary disorders (0.3%) [Table 12].
Table 12: Risk factors distribution of oral cancers

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Shammah use was the main risk factor among this group of patients. Out of 319 cases of oral cancers, 208 cases were using shammah. Of these, 173 cases were male, and out of them, 119 cases (68.8%) were shammah users. There were 146 cases of female patients, 89 cases of them (61%) were shammah users [Table 13].
Table 13: Shammah use in relation to the gender of oral cancers

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The relationship between shammah use and the type of oral cancers was significant (P = 0.000). More than 70% (70.5%) of patients with squamous cell carcinoma and 27% of patients with salivary gland tumors were shammah users [Table 14].
Table 14: The relationship between shammah use an oral cancer*

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The relationship between shammah use and the anatomical site was significant (P = 0.000). The gingiva was the comments affected site (82.0%), followed by the tongue (81.0%), the floor of the mouth (77.8%), the buccal mucosa (65.4%), the salivary glands (57.1%), the lip (32.4%), and the maxillary sinus (14.3%) [Table 15].
Table 15: The relationship between Shammah use and the anatomical site of oral cancer*

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  Discussion Top


In the present study, 319 cases of oral cancer were examined during a 3-year period of study. The most common site of involvement was the gingiva accounting for 28% of the cases, followed by the tongue which accounted for 27% of the cases. These findings are similar to findings from Zimbabwe, India, and Sudan, where the habits of tobacco dipping or chewing are common. These studies showed that the most common site for oral cancer was the mandibular gingiva followed by the tongue.[11],[12],[13] In the present study, the high frequencies of the gingival and tongue cancers appeared to be strongly associated with the use of shammah. The habit was practiced by 82% of patients with gingival cancer and 81% of patients with carcinoma of the tongue.

In many previous studies, particularly those coming from the East of African and Australia. The lip was the most common site of involvement.[14],[15],[16] However, in this study, it was the third most common site of involvement accounting for 11.6% of the cases. The remaining other sites and subsites, including the floor of the mouth, the buccal mucosa, the salivary glands, the maxillary sinus, the jaw bones, and the palate, all were of a frequency <9%. It is well known worldwide that squamous cell carcinoma is the dominant type of oral cancer accounting for more than 90% of oral tumors.[11],[17],[18] In communities known for the excessive use of tobacco, like India, the incidence of squamous cell carcinoma was very high accounting for more than 95% of oral cancer.[19] Although the majority of patients in this study were tobacco users, the incidence of squamous cell carcinoma was not as high as in India and account for 90.3%, lying within the range found in Zimbabwe, Kenya, and England as mentioned above.[11],[17],[18]

In the present study, the salivary gland tumors were the second most common type of oral cancer, accounting for 4.7% of the series. Squamous cell carcinoma was the most common histological type, followed by mucoepidermoid carcinoma, carcinoma in ex-pleomorphic adenoma, and adenoid cystic carcinoma. These findings were different from findings of many of the previous studies particularly those coming from the west where the mucoepidermoid carcinoma and the adenoid cystic carcinoma were the most common types of cancer of the salivary glands.[20],[21],[22]

In the present study, the majority of patients (92.1%) were over the age of 40 years, and the peak incidence of oral cancer is the seventh decade of life. This is similar to many studies coming from the third world where there are many risk factors which play a role in the causation of oral cancer, such as tobacco use, dietary deficiencies, deficiency of the level of the health serves, and bad oral hygiene.[14],[23] In Brazil, Gervásio et al.[18] found that the average age of oral cancer patients at the time of diagnosis was 59 years, and most of the patients were in their sixties (32.5%), with the majority between 40 and 80 years of age (85.2%). The same observation to certain extent is applicable to oral cancer patients in the Sudan, where Idris et al.[13] reported that the seventh decade of life in both males and females was the most frequent decade for oral cancer patients. In the west, the peak incidence of oral cancer is usually in the seventh and eighth decade of life. The late presentation of oral cancer in the western communities is probably attributed to the improved health care, education, and the change in lifestyle associated with the socioeconomic development.[14] Some studies attributed the increase in the incidence of oral cancer among young individuals in the West and Eastern Europe to an increase in the exposure to the known risk factors, such as heavy use of tobacco and excessive consumption of alcohol, or possibly to other unknown factors.[24],[25],[26],[27],[28]

In the present study, although males outnumbered females, the difference between the two was not so big, with a male-to-female ratio of 1.2–1. This insignificant difference between the two sexes was possibly due to the equal exposure to tobacco use as both genders in Yemen use shammah and qat. In this study, the findings are in agreement with many previous studies from Sudan,[13] Kenya,[14] Brazil,[18] India,[19] England,[26] and Greece.[28] In Yemen, shammah (type of smokeless tobacco in Yemen an Saudi Arabia) is a main risk factor and plays an important role in development of oral cancer. Similar figures were reported from India, Southeast Asia, and Sudan where the habits of tobacco dipping or chewing are common. These studies also revealed a significant relationship between the habits of tobacco dipping or chewing and oral cancer, particularly at the place where it is kept.[13],[29],[30] This relationship is well known and documented to the International Agency for Research on Cancer which considers smokeless tobacco as a carcinogenic agent, and the risk of developing cancer varies according to the amount of smokeless tobacco used.[31]

In this study, qat chewing (traditional habits among Yemenis) was the second main risk factor that plays a role in the development of oral cancer among Yemenis patients. Qat chewing is a popular habit among Yemenis and is frequently associated with other habits such as shammah, mada'a, and cigarette smoking.

In the previous studies,[7],[32] the relationship between qat and oral cancer was observed. However, this is the only study which statistically confirmed the causal relationship between qat and oral cancer. Unfortunately, most of the patients using qat were using at the same time other habits like shammah and mada'a; therefore, it is important to study the direct effect of qat alone on the oral mucosa before labeling it as being carcinogenic.


  Conclusion Top


Oral cancer in Yemen as in all countries still remains the disease of the elderly and deprived patient. The majority of patient (90.1%) were over the age of 40 years, the peak incidence was the seventh decade of life. Males were affected more than females, without big difference between the two sexes, a male to female ratio was 1.2-1. This insignificant difference between the two sexes was possible due to the equal exposure to tobacco use in both genders in Yemen. Squamous cell carcinoma was the most common type of oral cancers, accounting for 90.3%, followed by salivary glands malignancies accounting for 4.7%. Gingiva was the most frequent sites accounting for 27.9%, followed by the tongue accounting 27.3%. Shammah (traditional-name of smokeless tobacco in Yemen and Saudia Arabia) was the main risk factor that play an important role to development of oral cancers among Yemenis and 65.2% of oral cancer patients were shammah users.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15]



 

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