Epidemiology, Etiology and Prevention of Oral Cancer

2. EPIDEMIOLOGY OF
ORAL CANCER
Dr. Nabeela Basha
Seminar 11
2

3. Contents
• Introduction
• Global Scenario of Oral Cancer
• Spectrum of Oral Cancer in India
• Epidemiological studies
• Aetiology and Risk Factors
• Staging of Oral Cancer
• Prevention of Oral Cancer
• Cancer Registration in India
• Conclusion
• Previous year questions
• References
3

4. Introduction
Cancer: WHO defines it as the uncontrolled growth and
spread of cells.
• Growths often invade surrounding tissue and can
metastasize to distant sites.
• Can be prevented by avoiding exposure to common risk
factors, such as tobacco smoke.
• Significant proportion of cancers can be cured, by surgery,
radiotherapy or chemotherapy.
4

5. Oral Cancer
• The term oral cancer is used to describe any malignancy
that arises from oral tissues.
• One of the most common sites of oral cancer is on lateral
aspect of the tongue.
• In the International Classification Of Diseases, oral cancer
is classified under the rubrics 140 (lip), 141 (tongue), 143
(gingiva), 144 (floor of the mouth) and 145 (other parts of
the mouth).
Oral Cancer Foundation 2016
5

6. 6

7. Global Scenario of Oral Cancer
• World Health Report 2004 describes cancer as accounting
for 7.1 million deaths in 2003, and it was estimated that the
overall number of new cases will rise by 50% in the next 20
years.
• Oral Cancer is the 8th most common cancer worldwide, the
prevalence of which is particularly high among men.
• In South-central Asia – Oral Cancer ranks the 3rd most
common type of cancer.
7

8. • Between the 1960s and the present, male patients aged 30-39
years have presented a nearly fourfold increase in oral cancer
incidence.
• Prevalence of tongue cancer is noted in parts of Europe
showing male incidence rates up to 8.0 per 100,000 per
annum.
• High male lip cancer rates are reported for regions of North
America (12.7 per 100,000 per annum), Europe (12.0 per
100,000 per annum) and Oceania (13.5 per 100,000 per
annum).
8

9. Spectrum of Oral Cancer in India
• The Indian subcontinent, especially India itself because of its
large population, has long been regarded as the global
epicenter of oral cancer.
• With an annual incidence rate of 64,460 in India, it is
estimated that among the 400 million individuals aged 15
years and over, 47% use tobacco in one form or the other.
• As cancer registration is not Compulsory in India, it is
probable that the true incidence and mortality are much
higher: many cases go unrecorded and/or are lost to follow-
up. 9

10. Epidemiological Studies
• Gupta et al conducted a systematic review of oral cancer
registries in India in 2013 to enumerate the present
epidemiological picture of oral cancer in India.
• According to the review, Oral cancer with ICD-10 codes
ranging C01-C06, ranks amongst the 3 most common
cancers in India.
• This systematic review shows, in India, approximately
70,000 new cases and more than 48,000 oral cancer-related
deaths occur yearly.
10

11. • The overall incidence as high as 19 per 100,000 per annum
has been derived from Indian databases.
11

12. • Byakodi R et al conducted a study in 2012 in Sangli,
Maharashtra and found that the prevalence of oral cancer
was 1.12%.
• The findings in the study revealed a high prevalence of oral
cancer and a rampant misuse of variety of addictive
substances in the community.
12

13. • Coelho K. R conducted a systematic review in 2012 on oral
cancer prevalence in India.
• The study found out that oral cancer was a major problem in
the Indian subcontinent where it ranks among the top 3 types
of cancer in the country.
• Age-adjusted rates of oral cancer was high, i.e., 20 per
100,000 population which accounts for over 30% of all
cancers in the country.
13

14.  Oral cancer is an important public health issue.
 During Social engineering phase (1960-1980)- pattern of
disease changed in developed world, new health problems
in form of chronic diseases began to emerge, e.g., cancer,
diabetes, cardiovascular diseases, alcoholism and drug
addiction etc. A new concept, the concept of "risk factors" as
determinants of these diseases came into existence.
Epidemiology of Oral Cancer
14

15. • Non-communicable diseases (NCDs) are a major threat to
development, economic growth and human health.
• There is variation in incidence and pattern of the disease
which can be attributed to the combined effect of ageing of
the population, as well as regional differences in the
prevalence of disease-specific risk factors.
• The major risk factor leading to oral cancer is tobacco.
World Economic Forum and the Harvard School of Public Health(November 2014)
15

16. Incidence and Prevalence of Oral Cancer
• The high incidence of oral cancer in India has long been
linked with the habit of betel quid chewing, tobacco
consumption, smoking and indigenous methods of oral
habits.
16

17. Global Youth Tobacco Survey (GYTS)
India (Ages 13-15)
• The India GYTS includes data on prevalence of
cigarette and other tobacco use as well as information
on five determinants of tobacco use: access/availability
and price, exposure to secondhand smoke (SHS),
cessation, media and advertising, and school
curriculum.
• The India GYTS was a school-based survey of students
in grades 8, 9 and 10 conducted in 2009. A total of
10,112 students aged 13-15 years had participated. 17

18. • 14.6% of students used any one form of tobacco; 4.4%
smoked cigarettes; 12.5% used some other form of
tobacco.
• SHS exposure was moderate – one in five students lived in
homes where others smoked, and more than one-third of the
students were exposed to smoke around others outside of the
home; one-quarter of the students had at least one parent who
smoked.
• Two-thirds of the students thought smoke from others was
harmful to them.
18

19. • Over 6 in 10 students thought smoking in public places
should be banned.
• Two-thirds of the current smokers wanted to stop
smoking.
• Three-quarters of the students had seen anti-smoking
media messages in the past 30 days.
19

20. Global Adult Tobacco Survey (GATS-2)
India (2016-17)
• GATS 2016-17 was conducted by the Union health ministry
with technical assistance from the World Health
Organisation (WHO) and Centres for Disease Control and
Prevention (CDC), US. A nationally representative
household survey of persons aged 15 and above, it was
conducted in all 30 states of India and two union territories. A
total of 74,037 individuals were interviewed between August
2016 and February 2017.
20

21. • India has witnessed an overall decline in the number of
tobacco users in past seven years, especially among the age
group of 15 to 24.
• As per the report, over 61.9 per cent adults thought of
quitting cigarettes, 53.8 per cent thought of quitting bidi and
46.2 per cent adults thought of quitting smokeless tobacco
because of the warnings on tobacco products.
21

22. • While the number of tobacco users has reduced by about 81
lakh in last seven year, tobacco products have also gradually
become unaffordable. The average expenditure incurred on
last purchase of cigarette, bidi and smokeless tobacco is Rs
30, Rs 12.5 and Rs 12.8 respectively. The expenditure on
cigarette has tripled and that on bidi and smokeless tobacco
has doubled since GATS 1, the survey found.
22

23. EPIDEMIOLOGICAL TRIAD
23

24. Host Factors
Human host- “soil” and Disease agent- “seed”
• Classified as:
Demographic characteristics-
 Gender : Oral cancer and oropharyngeal cancer are
twice as common in men as in women. This
difference may be related to the use of alcohol and
tobacco, a major oral cancer risk factor that is seen
more commonly in men than women.
24

25. Mishra et al (2014)
25

26.  Age: Disease that occurs mainly in the elderly.
• Most of the cases of OC occur between 50 and 70
years of age, it still could occur in children as early
as 10 years of age in the absence of any known risk
factors.
• Mean age of occurrence of cancer in different parts
of oral cavity is usually between 51-55 years in most
of the countries but higher around 64 years.
26

27.  Race: An elevated incidence of cancers of the nasopharynx
has been reported in persons of Chinese ancestry in the
United States and elsewhere; decreased incidence of oral
cancers has been observed in American Native populations
compared with American whites.
http://www.oralcancerfoundation.org/cdc/cdc_chapter1
27

28. • Biological characteristics
• Genetic: Increased risk of oral cancer associated with
exposure to genetic mutagens in tobacco, alcohol and
betel quid.
• Gene mutations- 3p, 4q, 6p, 8p, 9p, 11q, 13q
(retinoblastoma [Rb] tumor suppressor gene), 14q, 17p
(p53 tumor suppressor gene), 18q (deleted in colon
cancer [DCC] tumor suppressor gene) and 21q.1113
28

29.  Social and economic characteristics
• Socio economic status: oral cancer affects those from
the lower socioeconomic groups of society due to a
higher exposure to risk factors such as the use of
tobacco.
Ken Russell Coelho (2012) 29

30. • Education: Illiterates those who never attended
school and with low educational attainment have
greater risk. In the Indian population OR for OC related
to education is greater for illiterates (6.4) compared to
low education level (5.3).
Krishna Rao et al (2014) 30

31.  Occupation:
• Certain occupations where exposure to
carcinogens is common like tar manufacturing.
• Certain oils, textile industries etc – are
susceptible to cancer.
• Leather workers are shown to have a higher
rate of cancer of buccal cavity.
• Other workers at increased risk for cancer:
Coal mine and tar workers, Oil factory
workers, Uranium miners and X-ray
technicians.
31

32.  BLOOD GROUPS:
• Association of blood groups with oral cancer has also
been observed.
• It has been reported that Group O showed the least
susceptibility, Group B and AB showed doubtful
susceptibility and Blood Group A showed higher
susceptibility.
32

33.  Lifestyle factors
• Living habits and Nutrition: It has been observed that
vitamin deficiencies (A, C, E)- contribute to high
prevalence of oral cancers in India.
• In rural India- oral pre-cancerous lesions associated with
low plasma levels of vitamin E and beta-carotene.
• Body mass index (BMI) has been inversely associated
with oral cancer, and paan chewers with low BMI has a
very high risk of oral cancer.

34. LINKS BETWEEN CANCER AND DIETARY FACTORS
34

35.  Site distribution
• Lip cancer is most common in fair skinned races,
particularly in rural areas and in men who work out
doors.
• Intra oral cancer in western countries most commonly
affects the lateral borders of the tongue.
• Buccal mucosa (65%), lower alveolus (30%) and
retromolar trigone (5%) : these constitute more than
60% of all cancers.

36. Agent factors
The disease "agent" is defined as a substance living or non-
living, or a force, tangible or intangible, the excessive presence
or relative lack of which may initiate or perpetuate a disease
process.
• Biological factors: Human papilloma viruses, or HPV,
is a risk factor for oral and oropharyngeal cancers. In
particular, there is a strong link between HPV-16 and
oropharyngeal cancer.
36

37. • Chemical: Habit of applying dry lime and ‘kaththa’
(Acacia katechu) on superficial mucosal lesion/ abrasion
for healing is a common practice in north central India.
• In 1984 Bhopal Gas Tragedy, the local population exposed
to high levels of methyl isocynate showed a marginally
increased risk for cancer of oropharynx suggesting it to be a
potential established risk factor.
37

38. • Mechanical- An association between oral carcinoma and
chronic irritation of the mucosa by the dentures. Case
reports have detailed the development of oral carcinomas
in patients who wear ill fitting dentures.
Shafers (2012)
38

39. Environment factors (extrinsic)
• Ultraviolet (UV) radiation, and in particular solar radiation,
is carcinogenic to humans, causing all major types of skin
cancer, such as basal cell carcinoma (BCC), squamous cell
carcinoma (SCC) and melanoma.
• The lower lip receives considerable sunlight exposure than
upper lip that is comparatively shaded accounting for a higher
occurrence than later.
http://www.who.int/cancer/prevention/en/
39

40. • Indian race with a tanning skin and a higher melanin
content naturally protects against the ultraviolet induced
actinic skin changes, hence majority of the population
(farmers and labourers) working outdoor in the scorching
sunlight is less effected
40

41. Major risk factors for Oral cancer
Tobacco
Alcohol
41

42. TOBACCO
42

43. SMOKING TOBACCO
a)Bidi : most popular form- tobacco in
India. total production of tobacco in India-
34% is used for manufacturing of Bidi.
b) Chillum : Straight 10-14cm long
conical clay pipe used for smoking
tobacco.
c) Chutta : Cylindrical coarsely prepared
cheroot. Cured tobacco is wrapped in a
dried tobacco leaf. 43

44. d) Cigarettes : About 1gram of tobacco
cured in the sun or artificial heat is covered
with paper
e) Dhumti : Rolled leaf tobacco is used
inside a leaf of fruit tree. Sometimes dried
leaf of the banana plant is used.
f) Hookli : Clay pipe- short stem varying
from about 7 to 10 cms with a mouth piece
and a bowl. Commonly used in Bhavnagar
district of Gujarat.
44

45. g) Hookah : Water pipe or Hubble-bubble-
used in places with strong Mughal cultural
influence.
a) Gudakhu : Paste of powdered tobacco,
molasses (brown sugar) and other ingredients
primarily used to clean tooth. Used- women
in Bihar.
b) Khaini : Powdered sun-dried tobacco,
slaked lime (calcium hydroxide)-paste
mixture occasionally used with arecanut.
Widespread in use in Maharastra.
45
SMOKELESS TOBACCO

46. c) Mainpuri Tobacco : Ingredients are
tobacco, slaked lime, finely cut arecanut,
camphor and cloves.
d) Mishri/Masheri : Prepared by roasting
tobacco on a hot metal plate until it is
uniformly black. It is then powdered. Used
with or without catechu.
e) Mava : Preparation of thin shavings of
arecanut with addition tobacco and slaked
lime-wrapped in cellophane papers. Mixture
is chewed until becomes softer and
transferred to mandibular groove. 46

47. e) Paan : Most common habit of smokeless
tobacco usage in India. Paan refers betel leaf
(from piper betel wine) itself and often to the
quid.
f) Snuff : Finely powdered air-cured and
fire-cured tobacco leaves. It may be dry or
moist, used plain or with other ingredients.
Used orally or nasally.
g) Zarda : Tobacco leaf is boiled in water
along with lime and spices until evaporation.
The residual tobacco is then dried and
coloured with dyes. It is chewed.
47

48. CONSTITUENTS IN TOBACCO
CONSTITUENTS ADVERSE EFFECTS
Polycyclic aromatic
hydrocarbon
Carcinogenesis
Nicotine Carcinogenic
Phenol Ganglionic stimulation and
depression & tumour promotion
Benzopyrene Tumour promotion & irritation
CO Impaired O2 transport and
repair
Formaldehyde and oxides of N2 Toxicity to cilia and irritation
Nitrosamine Carcinogenic
48

49. • Reverse smoking : The habit of tobacco smoking with the
lighted end inside the mouth (reverse smoking) is found in
people of the lower socio-economic states in Colombia,
Panama.
• Pipe Smoking : A high incidence of lip cancer has been
observed in those who smoke with short-stemmed pipes.
49

50. Major risk factors for Oral cancer
Tobacco
Alcohol
50

51. • A synergistic effect of tobacco and alcohol has been
observed.
• Account for 75% of all oral and pharyngeal cancers and
have been implicated in the formation of multiple primary
cancer sites found in oropharyngeal patients.
http://www.who.int/cancer/prevention/en/
51

52. • Alcohol may promote carcinogenesis by include
dehydrating effects of alcohol on the mucosa increasing
mucosal permeability and effects of carcinogen in tobacco,
nutritional deficiency and solubilizing tobacco.
• Attributable fractions vary between men and women for
certain types of alcohol-related cancer, mainly because of
differences in average levels of consumption.
52

53. • For example, 22% of mouth and oropharynx cancers in
men are attributable to alcohol whereas in women the
attributable burden drops to 9%.
http://www.who.int/cancer/prevention/en/
53

54. Histological Classification of Cancer and
Precancer of the Oral Mucosa
1. Carcinomas
• Squamous cell
• Verrucous
• Basaloid squamous cell
• Adenoid squamous cell
• Spindle cell
54

55. 2. Benign lesions capable of microscopically resembling oral
squamous cell carcinoma and oral verrucous carcinoma
• Papillary hyperplasia
• Granular cell tumour
• Discoid lupus erythematosus
• Median rhomboid glossitis
• Keratoacanthoma
• Necrotizing sialometaplasia
• Chronic hyperplastic candidiasis
• Verruca vulgaris
55

56. 3. Precancerous lesions (clinical classification)
• Leukoplakia
• Erythroplakia
• Palatal keratosis associated with reverse smoking
56

57. 4. Benign lesions capable of resembling oral precancerous
lesions
• White lesions resembling leukoplakia
• Red lesions resembling erythroplakia
• Focal epithelial hyperplasia
• Reactive and regenerative atypia
57

58. 5. Precancerous conditions
• Sideropenic dysphagia
• Lichen planus
• Oral submucous fibrosis
• Syphilis
• Discoid lupus erythematosus
• Xeroderma pigmentosum
• Epidermolysis bullosa
58

59. Precancerous oral lesions
• India accounts for one third of the world’s oral cancer and
has a high rate of pre-malignant lesions.
• The World Health Organization classifies oral precancerous/
potentially malignant disorders into 2 general groups, as
follows.
59

60. • A precancerous lesion is “a morphologically altered tissue in
which oral cancer is more likely to occur than its apparently
normal counterpart.” The precancerous lesions include
leukoplakia, erythroplakia, and the palatal lesions of reverse
smokers.
• A precancerous condition is “a generalized state associated
with significantly increased risk of cancer.” The precancerous
conditions include submucous fibrosis, lichen planus,
epidermolysis bullosa, and discoid lupus erythematosus.
60

61. • Leukoplakia is the most common premalignant oral lesion.
• Leukoplakia is described as a white patch which cannot be
rubbed off and cannot be diagnosed as another specific
disease entity.
• It is commonly seen on buccal mucosa, gingiva and tongue.
• Leukoplakia prevalence in India varies from 0.2%-5.2%, the
overall prevalence of precancerous lesion among patients
attending hospital in certain places of India range between
2.5% to 8.4%
61

62. • Oral premalignant lesions have shown a rate of progression
to cancer up to 17% within a mean period of 7 years after
diagnosis.
• In India a cohort study conducted in Ernakulum district of
Kerala showed 79% of cancers arose from preexisting
precancerous lesions and conditions.
62

63. Prevalence of Oral precancerous lesions/conditions
Lesion/Condition % Studies conducted by
Oral Leukoplakia 0.3 – 11.7 Yardimci G et al, Shulman
et al, Kumar A et al
Oral Erythroplakia 0.02 – 3.84 Yardimci G et al, Gaphor
SM et al, Narasannavar A
et al
Oral Lichen Planus 0.5 - 3.0 Yardimci G et al,
Narasannavar A et al
Oral Submucous Fibrosis 0.2 – 1.2 de Souza et al
63

64. Clinical Presentations of Cancer of Oral
Mucosa
• More than 90% of oral cancers are Squamous cell
carcinomas. The other 10% are salivary gland tumours,
lymphoma, sarcoma and others.
• A considerable amount of clinical uncertainty is involved in
the early detection of malignancy as many of the lesions may
not always remain benign.
• However, following clinical signs should be regarded with
great suspicion.
64

65. • ULCER
• INDURATION
• FUNGATION/GROWTH
• FIXATION
• FAILURE TO HEAL OF A TOOTH SOCKET OR ANY
OTHER WOUND
• TOOTH MOBILITY, PAIN/PARESTHESIA, DYSPHAGIA
• WHITE/RED PATCHES
• LYMPHADENOPATHY
65

66. 66
TNM STAGING AND GRADING
• Devoloped by PIERRE DENOIX in France between
1943 and 1952.
• Staging: extend of spread of tumor with in the patient
• Grading: microscopic and macroscopic degree of
differentiation of the tumor.

67. 67
• Grading and staging are two systems to determine the
prognosis and choice of treatment after malignant tumor
detected.
• “Tumor – Node – Metastasis” Or “TNM” staging system”
• T = Size of primary tumor in centimeters
N = Involvement of local lymph nodes
M = Distant metastasis.

68. TNM staging
AMERICAN JOINT COMMITTEE ON CANCER 1997
68

69. 69
CANCER REGISTRATION IN INDIA
• Until 1964, no information on cancer occurrence in India
was available from surveys.
• However, the boost for cancer registration in India was in
1982, through initiation of National Cancer Registry
Program (NCRP) by Indian Council of Medical Research.

70. 70
PREVENTION OF ORAL CANCER
• Mainly focuses on modifying habits associated with the
use of tobacco.
• India- 4th largest consumer and 3rd largest producer of
tobacco.
• 3 well-known approaches:
1. Regulatory Approach
2. Service Approach
3. Educational Approach

71. 71
REGULATORY OR LEGAL APPROACH
• As early as 1590, The Government in Japan, edict against
tobacco use, where users were penalized by having their
property confiscated or were jailed.
• Similar edicts have been reported in Turkey, Russia and
China. Religious groups have also banned the use of
tobacco.

72. 72
• In India, Cigarette Act 1975 has made it necessary to print
warning on cigarette packets. Bidi, not being included for
printing statutory warnings.
• In some countries like Italy, Norway, Portugal Singapore
and Thailand there has been a ban on advertising tobacco
products.

73. 73
• The cigarette packs are now required to carry graphical
health warnings. After years of wrangling, graphic health
warnings (GHW) are now mandatory on tobacco products
sold in India.
• The Cigarette and Other Tobacco Products (Packaging and
Labelling) Rules 2009 requiring GHW came into force on
31 May.

74. 74
Cigarettes And Other Tobacco Products
(prohibition Of Advertisement And Regulation Of
Trade And Commerce, production, Supply
Distribution)Act (COTPA), in 2003:
• The Indian Parliament passed the bill in April 2003. This
bill became an act on 18 May 2003.
• The key provisions of COTPA-2003 are as follows:

75. 75
a. Prohibition Of Smoking In Public Places Implemented
From 2nd October 2008.
b. Prohibition Of Advertisement-direct Or Indirect And
Promotion Of Tobacco Products.
c. Prohibition of sales to minors(tobacco products cannot be
sold to children less than 18yrs of age and cannot be sold
within a radius of 100 yards of any educational institutions.

76. 76
d. Regulation of health warning in tobacco products pack .
English and one more Indian language to be used for health
warnings on tobacco packs . Pictorial health warnings also to
be included.
e. Regulations and testing of tar and nicotine content of
tobacco products and declaring on tobacco product packages.
f. Law pertaining to pictorial health warnings on tobacco
product packages: Implemented with effect from 31st May
2009.

77. 77
SERVICE APPROACH
• Primary goal is a fundamental of prevention. This can be
achieved through screening and early detection.
• It also provides an opportunity to identify and council the
patients about habits that increase the risk of cancer. Other
than professional, primary health care workers can also be
used for screening.
• Diagnostic methods such as Biopsy Technique,
Exfoliative Cytology, Toluidine Blue Vital Staining can be
used under this approach.

78. 78
EDUCATIONAL APPROACH
 The process of becoming a smoker, for example,
essentially involves four stages :
• Awareness
• Initiation / Experimentation
• Habituation
• Maintenance / Dependence
 So education has an important part to play in discouraging
people from starting its use and from helping people to
stop the habit.

79. 79

80. 80
Guide to Counseling for tobacco
cessation (5A’s):
Ask –use oftobacco
Advise –non userstoneveruse andusers toquit
Assess- thepatientreadiness toquit
Assist-withquitting
Arrange-for followups

81. 81
Counseling those unwilling to quit
(5Rs):

82. 82
USE OF PHARMACOTHERAPY
• There are 2 main types of pharmacotherapy for tobacco
use cessation:
• Nicotine Replacement therapies (NRT): These lessen the
cravings and other withdrawal symptoms and the
individual learns to stop the behaviours connected with
tobacco use. Eventually, patients need to give up using
nicotine replacement.
• Antidepressants: They also serve as anticraving
medications and can be used with NRTs.

83. Conclusion
• India is a heterogeneous country, and solutions to the challenge
of oral cancer must be tailored. A comprehensive set of
solutions must be deployed by multiple stakeholders to put
India on the path to further preventing and controlling this
disease.
83

84. • Affordable and accessible diagnostic, therapeutic and
palliative care services should be made available in India.
• Tobacco control has to be strengthened and the present
status of women and children as non-users of tobacco
should be sustained at any cost.
84

85. Previous Year Questions
• Smokeless tobacco and oral cancer [RGUHS M.D.S. Degree
Examination – April/May 2007; 10 marks].
• Diet and oral cancer [RGUHS M.D.S. Degree Examination –
April/May 2007; 10 marks].
• Prevention of oral cancer. [RGUHS M.D.S. Degree
Examination – May 2011; 10 marks].
• Discuss the role of tobacco in oral health [RGUHS M.D.S.
Degree Examination – May 2013; 20 marks].
• Tobacco control [RGUHS M.D.S. Degree Examination –
May 2014; 10 marks].
85

86. References
• K. Park. Park’s Textbook of Preventive and Social medicine.
23th ed. Jabalpur: M/s Banarsidas bhanot; 2015.
• MC Gupta and BK Mahajan. Textbook of Preventive and
Social Medicine. 3rd Edition 2003. Jaypee Brothers Medical
Publishers Ltd, New Delhi.
• P. Soben. Essentials of preventive and social medicine. 5th ed.
Arya publishing house, New Delhi; 2013.
• Hiremath SS. Textbook of Preventive and Community
Dentistry. 3rd edition. Elsevier Publishers, New Delhi; 2016.
86

87. • CM Marya. A Textbook of Public Health Dentistry. 1st
Edition 2011. Jaypee Brothers Medical Publishers, New
Delhi.
• Byakodi R,Byakodi S,Hiremath S,Byakodi J,Adaki
S,Mara.the K et al.Oral Cancer in India:An Epidemiological
and Clinical Review.J Community Health 2012;37:316-319.
• Centre for Disease Control.Improving Diagnoses of Oral
Cancer. http://www.cdc.gov/OralHealth/pdfs/oral_cancer.pdf
• CoelhoKR. Challenges of the Oral Cancer Burden in India.
Journal of Cancer Epidemiology: 2012, June :1-17.
87

88. • American joint committee on cancer 1997.
• Cancer: Current scenario, intervention strategies and
projections for 2015 M. Krishnan Nair, Cherian Varghese, R.
Swaminathan NCMH Background Papers Burden of Disease
in India, WHO India.
• Ken Russell Coelho, Review Article Challenges of the Oral
Cancer Burden in India Journal of Cancer Epidemiology
Volume 2012, 17 pages
• Krishna Rao et.al Epidemiology of Oral Cancer in Asia in
the Past Decade- An Update (2000-2012) Asian Pac J Cancer
Prev, 14 (10), 5567-5577
88

89. • Shafer’s Textbook of Oral Pathology,2012 Seventh Edition
• NCRP ANNUAL REPORT of hospital based cancer
registries 2007- 2011.
• Petti S Lifestyle risk factors for oral cancer,Oral
Oncology. 2009 Apr-May;45(4-5):340-50.
• WHO (ONLINE)http://www.who.int/cancer/prevention/en/
• WHO Report on the Global Tobacco Epidemic, 2015.
• http://www.icd10data.com/ICD10CM/Codes/C00-D49/C00-
C14
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