Table of Contents      
ORIGINAL RESEARCH
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 62-66

Use of colposcopy in diagnosing early dysplastic changes in oral premalignant condition


1 Department of Periodontics and Implantology, VSPM Dental College and Research Centre, NKPSIMS, Nagpur, Maharashtra, India
2 Department of Gynaecology and Obstetrics, NKP Salve Institute of Medical Sciences, Nagpur, Maharashtra, India
3 Department of Ear, Nose and Throat, NKP Salve Institute of Medical Sciences, Nagpur, Maharashtra, India

Date of Web Publication21-Dec-2017

Correspondence Address:
Dr. Ishita Wanikar
104, Department of Periodontology and Implantology, VSPM Dental College and Research Centre, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_17_17

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   Abstract 


Purpose: Areca nut, a suspected human carcinogen, is responsible for oral submucous fibrosis (OSMF). Micro colposcopy, a noninvasive technique, can be used for early detection of dysplastic changes in the oral tissues. The aim of this study was to evaluate and compare the effect of areca nut on oral mucosa in healthy controls and those with OSMF using a colposcope. Materials and Methods: The study was conducted on participants with a habit of chewing areca nut and suffering from OSMF. 2% acetic acid was applied on the parts of the gingiva and oral mucosa kept for 2 min and viewed under the colposcope. After a few minutes, Lugol's iodine solution was applied and reviewed under the colposcope. Results: All clinical parameters were higher in Group III (areca nut chewers with OSMF) and Group II (areca nut chewers without OSMF) as compared to Group I (healthy controls) (P < 0.05). Conclusion: Colposcope could aid in the visualization of the changes developed in oral mucosa as an effect in the vasculature of the gingiva.

Keywords: Changes in blood vasculature patterns, early diagnosis, noninvasive approach


How to cite this article:
Rathod S, Wanikar I, Kolte AP, Maske S, Joshi S, Harkare V. Use of colposcopy in diagnosing early dysplastic changes in oral premalignant condition. J Int Clin Dent Res Organ 2017;9:62-6

How to cite this URL:
Rathod S, Wanikar I, Kolte AP, Maske S, Joshi S, Harkare V. Use of colposcopy in diagnosing early dysplastic changes in oral premalignant condition. J Int Clin Dent Res Organ [serial online] 2017 [cited 2018 Sep 20];9:62-6. Available from: http://www.jicdro.org/text.asp?2017/9/2/62/221390




   Introduction Top


The habit of chewing areca nut quid has been perceived as enslavement, very common to 20% of the Indian and Southeast Asian population.[1] Epidemiological and experimental investigations have exposed the bare gruesome correlation of its genotoxic, carcinogenic, embryotoxic, and immunotoxic potencies.[2] Arecoline, a natural alkaloid in Areca nut, inhibits protein synthesis, interferes with the microbial mechanism of neutrophils and attachment of fibroblasts. It promotes bacterial colonization, disrupts the harmony between various periodontal structures, induces periodontal infection.[3] It generates reactive oxygen species leading to lipid peroxidation and thus causes oral submucous fibrosis (OSMF). In OSMF, there is an excessive production of collagen leading to inelasticity of the oral mucosa as well as atrophic changes of the epithelium reflected clinically as mucosal rigidity which makes it a chronic, insidious, disabling potentially malignant condition of the oral cavity.[4]

Colposcopy optically examines the illuminated cervix and lower genital tract in higher magnification and qualifies evaluation of changes in surface features and vascular arrangements of the lining mucosa. Thus, aids in selecting the most appropriate site for biopsy.[5] The similarity between the oral and the cervical mucosa has also been recognized by various authors.[4],[6]

Currently, the downstaging of oral precancerous condition at diagnosis from advanced to earlier disease is the primary focus. If a premalignant lesion or condition is timely detected and treated, the lesion may not progress to cancer.

There are various techniques such as comet assay test, micronucleus, and nick test that investigate the changes in the oral tissues in OSMF but these are invasive, inaccurate or expensive. Intraoral application of colposcopy could compliment the detailing of the oral tissues and changes in its color and vascularity and prove as a useful aid for the early enough diagnosis of oral precancerous and cancerous conditions and lesions.

There is paucity of information on the use of intraoral noninvasive colposcopy in oral premalignant condition. Therefore, the aim of this study was to evaluate and compare the use of colposcope on oral tissues in healthy controls and those with OSMF with the objectives of assessing the practicability of using colposcope for examination of OSMF; and comparing colposcopic and clinical findings for selection of biopsy site in OSMF.


   Materials and Methods Top


The study abided by the Declaration of Helsinki of 1973 (revised 2000) and was approved by Institutional Ethics Committee. The study was conducted on 45 subjects (age-25–60 years) visiting the Department of Periodontology and Implantology between February and June 2016. Split into three groups with 15 individuals each as follows: Group I-healthy controls without OSMF and no habit of areca nut consumption. Group II-individuals with a habit of chewing areca nut but not suffering from OSMF. Group III-individuals with a habit of chewing areca nut and suffering from OSMF. A special pro forma was designed to facilitate data recording of the individuals that included a detailed case history, clinical and colposcopic examination. The subjects were sensitized about the purpose and design of the study, and a written informed consent was obtained from them. The inclusion criteria for the test groups were a habit of chewing areca nut for at least more than 5 years, five times per day with and without OSMF. Participants with any other premalignant condition and systemic disease, allergies or drug usage, smokers and tobacco chewers, history of periodontal treatment in the past 6 months or pregnant and lactating women were excluded from the study.

Methodology

Clinical parameters

OSMF was graded based on inspectory and palpatory findings adhering to the clinical classification by Ranganathan and Gauri.[7]

Colposcopic parameters

All the participants endured the colposcopic examination performed by Colposcope (COLpro777, Australia) were graded on the basis of the Reid's and Scalzi classification [8] of genital epithelium which included the color tone and vascular pattern. The oral buccal mucosa and gingiva were divided into 6 sextants being Maxillary and Mandibular Right, Anterior and Left regions. 2% acetic acid was applied on the parts of the gingiva [Figure 1], left for 2 min and viewed under the colposcope followed by reviewing after a few minutes of Lugol's iodine solution application [Figure 2]. The hairpin capillaries and network capillaries were considered as normal capillary networks seen under colposcopy were. The abnormal patterns visible were mosaic, punctation, and atypical [Figure 3]. When it was difficult to describe the pattern of the vessels, the term atypical vessel was used. Depending on the severity of the tissues involved in OSMF after clinical and colposcopic examination, a biopsy confirmed the stage of OSMF.
Figure 1: colposcopic view of the mandibular anterior region with the labial vestibule showing a network vascular pattern after application of 2% acetic acid with acetowhite region

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Figure 2: colposcopic view of the mandibular anterior region with the labial vestibule showing a network vascular pattern after application of Lugol's iodine. Non uniform iodine uptake can be seen at 6 o' clock position

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Figure 3: colposcopic view of the left mandibular posterior region with the buccal vestibule showing atypical pattern after application of Lugol's iodine

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Statistical analysis

Statistical analysis was performed using the SPSS software. The two groups were compared using the unpaired t-test while a comparison among the three groups was drawn using the ANOVA. Differences in the clinical parameters among the three groups were analyzed using one-way analysis of variance with the Tukey test. The level of statistical significance was set at P < 0.05.


   Results Top


Clinical findings

This cross-sectional study compared the clinical and colposcopic parameters in a total of 45 subjects (mean age of 35 years) split into Group I-Periodontally healthy controls (n = 15), Group II-Areca nut chewers without OSMF (n = 15), and Group III-Areca nut chewers with OSMF (n = 15). All clinical parameters were significantly higher in Group III as compared to Group II as well as Group I (P < 0.05). Pairwise analysis using Tukey's post hoc test revealed statistically significant difference between Group II and Group I and Group III and Group I.

Colposcopic findings

The colposcopic examination unveiled that 26.7% subjects of Group III were diagnosed with from Stage III OSMF which coincided with the clinical diagnosis and classification of OSMF by Ranganathan and Gauri. 100% subjects in Group III showed atypical capillary arrangement while Group I and II showed network or tree-like capillary arrangement. 74% subjects in Group III took faint acetowhite stains and concurrent with stage I OSMF condition [Table 1] and [Table 2].
Table 1: Colposcopic evaluation for changes in color and vascularity

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Table 2: Correlation of stages of oral submucous fibrosis and colposcopic evaluation for color tone

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   Discussion Top


The soaring incidence of oral cancer in India amounts to about 40% of all malignancies. The consumption of areca nut, the fourth most psychoactive agent, leads to increased deposition of extracellular matrix that unsettles the equilibrium between the matrix metalloproteinases and tissue inhibitors of matrix metalloproteinase leading to inevitable periodontal destruction. The oral mucosa, although normal in color, loses its normal resiliency, the condition known to be OSMF. As the disease progresses, stiffness is characterised by the formation of fine fibrillar dispersed collagen with marked edema in the initial stages and juxta-epithelial hyalinization.[9] The intention of the present study was to predict early changes in oral mucosa suggestive of malignant transformation.

Various adjunctive techniques have evolved to aid differentiation between benign changes of the mucosa from dysplastic/malignant changes as well as to identify areas of dysplasia/early oral squamous cell carcinoma that are not visible to the naked eye. The early recognition of precancerous conditions and lesions done by oral brush biopsy, autofluorescence, exfoliative cytology, chemiluminescence, veloscope, etc., fail to deduce a final diagnosis.[10]

Hans Hinselmann from Germany in 1925 invented a colposcope to diagnose the microcarcinomas of the uterine cervix on realisation that its obvious early clinical features were undetected by the naked eye. Of late, colposcopy has worked as an aid to cytologic testing in the investigation of genital tract epithelium. A study by Ellen H Hopman conducted to diagnose cervical intraepithelial neoplasia colposcopically showed that the mosaic, punctation and acetowhite epithelium with a thick white epithelium, clear-elevated margin, irregular surface contour, and raised capillaries was suggestive of micro-invasive carcinoma.[11] This noninvasive technique has thus been employed in the orofacial region due to the striking resemblance between the oral and cervical mucosa.[1]

Shetty et al. in his study, the most reliable criterion for a correct diagnosis in cases of epithelial dysplasia is histopathological assessment of a biopsy specimen which must be taken from the most representative area of a lesion for an accurate diagnosis.[12]

Of the 45 individuals, 15 cases of OSMF clinically diagnosed on the basis of classification by Ranganathan and Gauri were included.[7]

On application of 2% acetic acid, the mucosa appeared faint to dense acetowhite in color which reduced in intensity over the period of time. About 73% individuals OSMF in Stage 1 reported faint acetowhite staining and 27% individuals with clinically Stage II and III OSMF attained a dense acetowhite stain, signifying the deleterious effects of the advanced condition. This reversible osmolar change depends on the nuclear-cytoplasmic ratio and number of cells redirected as cytoplasmic dehydration and membrane collapse. The acetic acid coagulates mucus (nuclear-proteins and cytokeratins) which upon removal expedites visibility to the underlying mucosa. The Lugol's iodine application did not show uniform uptake whereas the normal epithelium, enriched with glycogen, took up Lugol's iodine and stained brown uniformly.[13],[14]

Areca nut chewers with OSMF presented an atypical vasculature whereas the areca nut chewers without OSMF displayed network capillaries similar to the healthy group. The epithelium acts as a filter that allows both the incident and the reflected light to pass through. The ratio of reflected and absorbed light with respect to the thickness of the epithelium; its optical density; vascularity and nature of the underlying stroma; volume of hemoglobin; and concentration of the tissue chromospheres determine the color tone of the mucosa.[15]

In the normal oral or genital mucosa, two basic vascular patterns that can be seen are network capillaries and hairpin capillaries. Some principal abnormal findings include:

Punctation – Wherein the tips of the terminal vessels reach the surface of the epithelium through stromal papillae and appear as red dots.

Mosaic – Wherein the vessels extend only partially into the epithelium appearing as red lines surrounding blocks of epithelium and fail to reach the epithelial surface.

Atypical vessels – Wherein these vessels, of irregular caliber, seem to be running on or parallel to the surface of the epithelium and its branching appearing as coarse wide hairpins and commas, corkscrews, waste paper, coarse and caliber tree-like and root-like forms or spaghetti-like forms. The findings were consistent with findings of Rene Cartier et al. who reported that alterations in the vascular network reflect biochemical and metabolic changes in cervical tissue.[15] Malcolm Coppleson had stated that atypical vessels appeared corkscrew or comma-shaped indicating greatly increased vascularity to keep pace with the growth of atypical epithelium.[16] In few subjects due to extensive pigmentation of the gingiva, discolored oral mucosa and increased keratinization the capillary arrangement was not clearly discernible.

Since the anatomy of the oral mucosa and the marginal, papillary and attached gingiva was different on the basis of thickness and keratinization of the epithelium, colposcope could not be used to its full potential to examine the changes in the gingiva as an effect of areca nut.

The signs and symptoms vary with the affected sites and stage of disease. Thick inelastic ropelike fibrous bands extending from the lamina propria through entire submucosa to the muscle layer appear vertically in the buccal mucosa, along the contours of the faucial pillars and around the entire circle of lips narrowing the rima oris and reducing the mouth opening and thereby compromising oral hygiene and food intake.[17] The hardness of areca nut as well as its interaction with the ingredient, in turn, depresses the hosts resistance to local factors and causes greater calculus formation accounting for the more periodontal destruction in its consumers.[18],[19]

In the present study, oral mucosa colposcopically visualized as dense acetowhite staining of the oral mucosa and development of atypical vasculature. Therefore, early diagnosis is of prime importance in arriving at a correct conclusion where the prognosis can be improved.

Limitations

The major shortcomings of this study have been enlisted below:

A small sample size and unequal number of subjects in different stages of OSMF restricted a direct correlation to be drawn between colposcopic findings and severity of disease. With the increasing severity of OSMF, the keratinization of the epithelium increased, restricting light from the underlying connective tissue stroma from being reflected. Therefore, visualization of the oral buccal mucosa in stage III OSMF was not possible.

Since the purpose of this study was to test the sensitivity of colposcopy in detecting premalignant condition as a noninvasive tool, the histopathological comparative evaluation of the OSMF individuals was not performed.


   Conclusion Top


With the help of colposcope, it is possible to visualize dyspastic changes in the oral tissues. Intraoral application of oral colposcope has a promising future. The colposcope is a not an economically feasible device to be brought to use by every dentist. Further long-term studies with a larger population in detecting early changes in premalignant conditions should be carried out.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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