Oral Mucosal Lesions and Oral Health-Related Quality of Life in Persons Attending a Dermatology Clinic in Khartoum, Sudan

Abstract

Background: The mucous membrane of the oral cavity is the site of many neoplasms, reactive processes, infections and manifestation of systemic diseases. Lesions in the oral mucosa may be the primary clinical feature or the only sign of muco-cutaneous diseases. Some conditions can result in considerable morbidity and mortality if not properly treated. Patients with such conditions may often consult a dermatology clinic. Information on the diversity, magnitude and burden of these conditions in general is rare in Africa and specifically in Sudan. To plan for effective oral health services, correct diagnosis based on proper investigations and epidemiological studies are essential. Objective: This study aimed to explore the diversity of pathological and nonpathological conditions of the oral mucous membrane in patients with skin lesions attending the outpatient facility of Khartoum Teaching Hospital (KTH) - Dermatology Clinic, Sudan. The study also had the following specific objectives: to estimate the frequency and socio-behavioural distribution of oral mucosal lesions (OML) in patients with skin diseases; to assess the impact of these conditions on patients’ daily life activities using the Arabic version of the Oral Impact on Daily Performances (OIDP) inventory in patients with and without OML; and, to describe clinical features of oral pemphigus in persons attending the outpatient clinic. Methods: From October 2008 to January 2009, all outpatients aged above 18 years attending the dermatology clinic of KTH were invited to participate in a crosssectional hospital-based study. Data were collected by face-to-face interviews using structured questionnaires followed by clinical examinations of the skin and the oral cavity. Oral cavity clinical examinations, diagnosis of OML and decayed, missing and filled teeth (DMFT) registration were performed following the World Health Organization (WHO) criteria. Biopsies, smears and immunohistochemistry (IHC) were used as adjuvant techniques for confirmation. An Arabic version of the OIDP inventory was used to assess oral health related quality of life. Results: In Paper 1, OML were registered in 315 out of 544 (57.9%) patients with confirmed skin diseases. Tongue lesions were the most frequently diagnosed OML (23.3%), followed in descending order by white lesions (19.1%), red and blue lesions (11%) and vesiculobullous diseases (6%). Presence of OML in patients with skin disease was most common in older age groups (p<0.05), in males (p<0.05), patients who reported systemic disease (p<0.05) and among current users of smokeless tobacco (toombak) (p<0.00). In Paper II, at least one oral impact (OIDP > 0) was reported by 190 patients (35.6%). The prevalence of any oral impact was 30.5%, 36.7% and 44.1 % in patients with no OML, one type of OML and more than one type of OML, respectively. The number of types of OML and the number and types of oral symptoms were consistently associated with the OIDP scores. Patients who reported bad oral health, ≥ 1 dental attendance, > 1 type of OML, or ≥ 1 type of oral symptom were more likely than their counterparts in the opposite groups to report any OIDP. The odds ratios (OR) were respectively; 2.9 (95% CI 1.9-4.5), 2.3 (95% CI 1.5-3.5), 1.8 (95% CI 1.1-3.2) and 6.7 (95% CI 2.6-17.5). Vesiculobullous and ulcerative lesions of OML disease groups were statistically significantly associated with OIDP. In Paper III, nineteen of 21 patients with PV had oral lesions (mean age 43.0, range 20 – 72 yrs.). Of 18 patients who had experienced both skin and oral lesion during their lifetime, 50% reported that oral lesions preceded skin lesions. More than 68% (13/19) of these patients were < 50 years of age, with female: male ratio of 1.1:1. The palatal and buccal mucosae were the most common locations followed by tongue and lower lip. The Oral Lesion Activity Score (OLAS) was higher in those who reported living outside of Khartoum, were outdoor workers, had lower education and belonged to central and Western tribes, compared with their counterparts. The histopathological pictures of all specimens were in agreement with the IHC findings. Conclusions: OML were frequently diagnosed in patients with skin disease and varied with age, gender, systemic condition and use of toombak. OIDP occurred more frequently among patients with skin disease with OML, compared with patients with skin disease without OML. The Arabic version of the OIDP inventory used in this study showed acceptable and reliable psychometric properties. The majority of PV patients had oral lesions. The socio-demographic, clinical and histological pictures of oral PV are in accordance with the literature. The IHC on formalin-fixed tissue samples may be an alternative test to confirm the diagnosis of PV. The results of this study shed light on the higher prevalence of OML in patients with dermatologic diseases and thus emphasize the importance of routine examination of the oral mucosa in these patients. Collaboration efforts between dermatologists and dentists would provide better treatment and avoid serious morbidity and mortality.