 [Table 1] and [Figure 7].
Histological findings after 9 months use of Triphala mouth rinse revealed no changes in cells (normal) in 23 (85.2%), hyperkeratinization in 2 (7.4%). Hyperkeratinization and spongiosis was evident in 1 (3.7%), mild pleomorphism in 1 (3.7%) [Table 2] and [Figure 8].
Linear-by-Linear Association by Chi-square test showed high statistically significant correlation with value 8.098 (P < 0.01) [Table 2].
The subjects detected with the lesions gave a history of the placement of tobacco in the same area where the mucosa was found altered. In previous study researchers also reported that 80% of the patients with oral cavity carcinoma developed their cancers in areas where the wad of tobacco was held. [19] Alcohol and tobacco has site specificity in the etiology of oral cancer and found alcohol consumption to be more in patients with highest cancer incidence in floor of mouth, tongue and buccal mucosa. [17] Out of 127 smokeless tobacco users, 29 (22.8%) had an oral lesion at the time of examination. [20] Of these lesions, 23 (79.3%) were hyperkeratotic and 6 (20.7%) were epithelial dysplasia. Researcher studied prevalence of oral lichen planus and oral leukoplakia in 112 patients with oral squamous cell carcinoma. [21] The tongue and floor of the mouth were the most common locations and oral squamous cell carcinoma was seen to be strongly associated with these lesions.
Similar to presented study, a previous study evaluated the use of exfoliative cytology for the early diagnosis of oral cancers and its role for in education and private practice. [22] Exfoliative cytology may be used as an important aid in the early detection of oral cancers. Researcher studied the use of biopsy in the diagnosis and management of oral soft-tissue lesions. [23] Study stated that immediate biopsy should be done as a confirmatory diagnosis. An international seminar in 1983 agreed that leukoplakia is strongly associated with the use of tobacco. [12] In presented study, out of 34 acetowhite positive, 30 were consuming some form of tobacco and 26 out of 27 acetowhite positive lesions showed alarming changes on histological staging [Graph 1] [Additional file 1]. Unfortunately, a major impediment to treating oral cancer is that diagnosis is not usually established until 3 months after the onset of symptoms, which affects the treatments selected and the prognosis. [24] Late diagnosis of oral cancer is attributable to numerous factors, including insufficient oral cancer screening examinations performed in the elderly, patient procrastination and improper diagnosis of oral lesions. [24] The biochemical changes in cell-surface glycoproteins and glycolipids that take place during malignant transformation which has been found of clinical utility of total and lipid bound sialic acid in patients with oral pre-cancer and oral cancer. Mean values of serum sialic acid (total and lipid bound) in oral cancer were significantly higher than control and the pre-cancer group (P < 0.001). Serum sialic acid levels can differentiate between patients with oral pre-cancer and oral cancer. It could be used as an adjunct to diagnosis, monitor response to therapy and assess the staging of cancer. [25] The focus on young adult population has to be established to accomplish the objective of tumor down staging. Consequently, at the time of diagnosis, patients are twice as likely to have an advanced tumor compared to a localized lesion.
The results were quite evident and showed the reversal of the lesions with Triphala mouthwash. This can be attributed to its anti-oxidant property combined with various other beneficial properties like anti-bacterial properties, [28] exerts heart protective and cardiotonic effect, [29],[30] anti-mutagenic properties, [31],[32] anti-cancer properties. [33] Researchers in another study also proved that all three fruits have antioxidant property. [4] Each of the constituents of Triphala is equally efficient in scavenging superoxide and peroxide radicals, thus working synergistically to create a powerful antioxidant and detoxifier. [5],[6] Thus the direct application of herbal medicine, Triphala and rinsing with it can definitely be of great help in downstaging of pre-cancerous lesions. Although it was a small group of population screened the percentage of lesions detected was 3.1% of the total 1095 teenage population, figure that develops apprehension for the health professionals. The 25% of the teenage population involved in some or the other form of tobacco is also quiet astonishing. Thus with the results discussed above it shows that India needs a simple and low resource screening method for early detection and downstaging of pre-cancerous lesion and cancers and also to create awareness in the young adults who are the future of our society.
Triphala, the indigenous mouth rinse proved to be effective in reversal of the lesions and confirmed the promise of triphala as a potential chemopreventive and/or anticancer drug.
In the view of present findings in small population the increased percentage use of smokeless tobacco in young population is quite alarming. Thus, India being a developing country with limited funds needs such screening programs on a large scale to develop awareness, prevention and protection of this young population of India. The indigenous and cost-effective Triphala mouth rinse has proved to be a key tool in prevention and reversal of the pre-cancerous lesions, which is also another feather in the cap along with wide repertoire of treatment options available. However, the herbs need to be evaluated by long-term multicentric clinical trials.
The authors would like to thank Dr. Usha Arora, Senior Pathologist, Mariumpur Hospital, Kanpur, for her skillful assistance in preparing and diagnosing the histopathological slides.
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