Understanding the distribution, prevalence and risk factors of oral and maxillofacial lesions is essential to promote primary prevention, early diagnosis, promote treatment and the provision of appropriate health services.[1]
Biopsies are considered the golden standard for the definitive diagnosis of oral and perioral lesions, and are one of the diagnostic methods that routinely performed in the medical laboratories. By the histopathological reports we can assess the prevalence of OMLs in a specific population and determine the rate of utilization of biopsy diagnostic procedures and their challenges.[8]
Performing incisional and excisional biopsies is one of the responsibilities of general practitioners and specialists whenever indicated. The aim of the present study was to provide an important baseline data on the profile of OMLs in the capital of the republic, which will help the healthcare authorities in health planning, providing dental services, risk management, and prevention.
This study included 1376 biopsy reports from referral laboratories in the capital of the country; this increases the representativeness of the sample and generalizability of the results. Female patients predominance in this study were higher (50.3%) compared to their male counterparts. This also the finding of many other studies.[7, 9, 10] However, other studies reported higher prevalence rate among males.[11, 12]
The mean age of the patients with OMLs was 43.6; this in accordance with that of other study among neighbor Saudi population. [5] Most of the reports were of patients their age from 4th –6th decade of age. This finding is in consistent with previous prevalence studies.[7, 13, 14]This age group is labile to be affected by other health problems leading them to seek the health care while which the oral lesions might accidently found by health care providers.
The rate of malignant neoplastic lesions in this study (36.8%) was much higher than previously reported prevalence among other populations that represented 5.4%, 6.5%, 1.9%, 2.4% and 5.8% respectively. [7, 15–17] Surprisingly, studies from south western region of Saudi Arabia reported a higher incidence of malignant lesions (38.8%) and smokeless tobacco specifically shamma was held accountable for increased incidence of malignant lesions. [5, 18] This higher prevalence of oral cancers might be due to the commonly practiced habits among Yemeni population such as Qat chewing, smoking, and Shamma using, [19] which can contribute to oral cancers, and also could explains the relatively equal reported prevalence of malignant lesions among the presents study sample and that of Saudi study.
When compared to premalignant lesions, malignant neoplastic lesions was much higher (n = 90; 6.5% and 36.8%; respectively). This is an agreement with other authors, [5, 7, 13] and this suggests failure of early detection of suspicious oral lesions by oral health care providers, delay of case referral from general or specialized dental practitioners to biopsy the lesions or patients being unaware of oral malignant lesions and not seeking treatment in absence of the pain.
OSCC was the most predominant malignant (86.7%), this finding is nearly similar to that of the neighboring Saudi population study which reported prevalence of 93.1%. [5] Other studies in Arab region reported percentages in the same range such as Jordon (84%), [20] and UAE (77%). [21] OSSC also more prevalent among older age group of the present study sample; this is in the line with other previous studies.[11, 22] Higher incidence of OSCC in the present study might be due to that most of the patients came to the doctors at late stage of oral lesions when most of the premalignant lesions has undergone malignancy transformation. Furthermore, common bad habits mentioned before play an important role. On the other hand; studies from other populations reported much lower incidence of OSCC; Spain, 1.4%; [23] Brazil, 2.5%;[24] and Nigeria, 10.8%. [25]
Men to women ratio of OSCC patients in the current study was 1:1.5;comparable result was reported in previous study [5]which stated a ratio of 1:1.9. The ratio of benign to malignant lesions in this study was relatively equal 0.8: 1; this finding is greatly differ from that of other Saudi study which reported a ratio of 1:4.5, and British study that reported a value of 1: 5. This might be explained by the difference in the level of awareness among the patients in the different countries as well as the differences in the health care facilities and utilization of these services by the population.
Cystic lesions were the fifth most common oral and maxillofacial lesions in this study. Also, lesions related to immune-mediated diseases were observed in 13 specimens (1.9%) and more common in male patients (1.2%). These results are varied from that a recent study stated that cystic lesions were the second most common and lesions related to immune-mediated diseases were observed in 60 specimens (4.9%) with more predilection in female patients. [7] This might be owing to the different populations and consequently different social sociodemographic characteristics.
From the benign neoplastic lesions, fibroma was the most prevalent lesion in the present study sample (n = 98; 7.1%). This finding is in concordant with other studies. [7, 26] However, another study reported a lower percentage among its population 4.5%.[27] Fibromas are mostly non-painful lesions that caused by many etiologies, and since it is an exophytic lesions that commonly cause discomfort in the oral cavity for which the patients seek a treatment.
This study shows that squamous papilloma represented 3.2% of oral and maxillofacial lesions. This finding is higher than that of previous studies. [15, 28] Pyogenic granuloma was the second most common benign neoplastic lesion (n = 73, 5.3%) with higher prevalence among the younger age group of 40 years or less. This result is in agreement with other studies.[29, 30] Nevertheless, the relatively high prevalence of pyogenic granuloma suggests that difficulty in maintaining oral hygiene in children and adolescents is the main etiological factor involved in the development of pyogenic granuloma.
Among salivary gland lesions, adenoid cystic carcinoma was the most common lesion. Many other studies were reported the same finding. [7, 13, 31] However, another study was reported that mucocele was the most common lesion of salivary glands. [32] This difference might be related to varying in the study populations and their social habits.
In a recent study which performed among a sample of 409 Yemeni patients in Sana’a city, authors found premalignant lesions were not common in their study. [33] Contrarily, premalignant lesions represented the fourth most common category of oral and maxillofacial lesions in the present study (n = 90; 6.5%). This disagreement of the results in the same population is questionable and it might be due to differences in data collection methods and sampling technique. Moreover, the previous study sample was from the dental polyclinics of faculty of dentistry to which the patients came seeking specific dental treatment for usually milder compliances. Whereas the present study sample was more representative, including the main histopathological laboratories throughout the capital of the country.
In the current study, the tongue was the most affected site of oral neoplastic lesions (38.4%). A similar results had been reported in Yemen [19, 34] and most of the developed and developing countries. [21, 35, 36] So it is considered as one of the high risk area for development of oral neoplastic lesions. This also agreed that reported I the main textbooks of oral medicine.
The results of the present study show that most of OSCC were diagnosed at advanced stages. The same finding was reported in an earlier study in Yemen, [34] this finding might be related to lower oral health knowledge and behaviors among Yemeni patients. Moreover, other authors among different populations reported similar results. [37, 38] On the other hand, high proportion of OSCC cases in the developed countries were diagnosed at early stages. [39, 40]
In this study, well and moderately differentiated OSCC accounted for 86.1% of the reported cases. Comparable results were reported in other studies.[34, 35] Contrarily, Effiom et al reported a much higher proportion of poorly differentiated OSCC (47%) in Nigeria. [41]This difference may be due to the different prevalence of the risk factors worldwide and intensity of exposure to these factors or both. The role of genetic factors was suggested too. [42]
Tumor staging and histopathological grading systems are good predictors of the prognosis and survival. OSCC in Yemeni young patients might be a different sort of cancer with worse prognosis as tumor staging and histopathological grading are slightly worse compared to OSCC in Yemeni old patients, this finding supports that of Halboub’s study. Contrarily, previous studies reported that there are no specific clinical or histopathological features of OSCC in young adults. [38, 39]
Although the increased number of dental faculties and graduated dentists, there is a limited access and utilization of oral health services in Yemen, particularly in rural areas. Clearly, governorates with well-facilitated healthcare centers, acceptable socioeconomic status, highly educated community increases the patients access to health services. [43] These aspects apparently generate inequalities that modify the oral health profiles of rural populations. In addition, general medical and dental practitioners need better training in the diagnosis of oral conditions. The lack of skills in oral mucosal lesions detection and oral diagnostic process probably contributes to the underestimation of lesions prevalence. The data from this study highlight the importance of education in oral health promotion for health professionals and the general population. These activities should be included in oral premalignant and malignant lesions screening campaigns to improve their effectiveness.