Oral submucous fibrosis remains a public health concern because of its malignant transformation potential over some time [13]. The pathogenesis of OSMF is still not completely understood, but it is presumed to be multifactorial based on available research. The primary causative agent is areca nut chewing in the form of betel quid [14] along with precipitating factors like nutrient deficiencies of zinc, vitamin, and Iron and increased capsaicin intake from chilies [3]. The prevalence of OSMF in India varies among zones with 0.6% in the south, 30–42% in the north, 2.7% in the east, and 0.03–0.2% in the west [15] because of the exponential increase in younger generations among migrant workers. In the olden days, among the countries of the Pacific belt and of south-eastern Asia, areca nut chewing was a part of traditional, cultural, and religious ceremonies as part of socialization and harmony.

During colonial rule, areca nut was exported and introduced into the western world for its therapeutic potential in curing indigestion, halitosis, and deworming [16]. Over the ages, these customary offerings of areca nut faded from household practices and commercialization increased. The areca nut was milled into different forms at various concentrations with the addition of sweeteners and mouth fresheners. It was vigorously promoted to the general public with ease of availability even in petty shops. Of late, Chronic chewers had increased among the younger populations of the psychoactive nature of areca nut products. The acute effects are neuroexcitatory and pleasure inducer with a sense of euphoria, heightened alertness, a sense of well-being, and warmness over the body surface with improved work capacity [17].

In most situations, the diagnosis of OSMF has become an additional finding in public dental screening camps or among those who report to clinics for tooth-related complaints [18]. It has therefore become important to understand those non-specific complaints observed in OSMF patients which motivate them to approach dental settings for treatment care. Hence this study was designed to assess the non-specific chief complaint among those who reported to our dental institution for one year. The data was collected retrospectively and statistical analyses were performed.

Among the 155 OSMF cases, 93.55% were males, and 6.452% were females with a mean age of 42.5 ± 11.8 and 52.4 ± 9.4 years respectively. The gender prevalence is similar to previous studies where OSMF males were more predominant chronic tobacco chewers than females [19, 20]. In OSMF grading using Kerr et al. classification [12], 76% were Grade-1, 7.74 % were Grade-2, 12.9% were Grade-3, and 3.2% were Grade-4. Interestingly, the patients with non-specific chief complaints unrelated to OSMF clinical presentation were the majority of 76.13 % comprising both males [94.07%] and females [5.93%]. Toothache [63%] was the most common non-specific complaint followed by stains on teeth [24%], missing teeth [11%], and mobility [2%]. This signifies that the patients are completely unaware of their existing precancerous lesion in the oral cavity and are focused more on dental complaints in the early stages of oral submucous fibrosis.

The association between gender and non-specificity of chief complaints was interpreted as statistically not significant [P-Value 0.63] implying that gender does not influence the patients to report chief complaint nature. But there was a statistically significant association between non-specific OSMF complaints and grading [P-Value of 0.0001]. This signifies the fact that asymptomatic cases reported in the early stages of OSMF for toothache are made aware of the lesion only after counseling and while presenting the formulated comprehensive treatment plan. Had they reported later, the progression of OSMF would complicate treatment further with an extended period of pharmacotherapy and follow-up care posing as a burden to the patient financially and emotionally [21]. Also, the quality of life [QoL] gets affected when reported at later stages of OSMF involving inferiority complex, weight loss, loss of appetite, sleep disturbances, nutritional deficiencies, and social isolation [22].

Very few studies have been done in assessing non-specific chief complaints in OSMF and ours is one among them. The result of our study was similar to the previous study done by Sachdev et al. [23] where 72.41% of stage 1 OSMF patients had non-specific dental complaints, and tooth pain in the third molar region [33.15%] was the most common complaint followed by stains on teeth [10.32%] and mobility of teeth [3.804%]. Another notable study was done by Gadbail et al. [24] in which 73.41% of OSMF cases reported to the dental hospital had non-specific chief complaints in the early stages [stage I comprising 47.05% and stage II comprising 22.5%] and 30.37% of the complaint was toothache in the third molar region. The reason attributed was negligence in maintaining adequate oral hygiene that had precipitated dental caries.

Our study had a few limitations that need to be taken into account while viewing this result. As it was a retrospective data collection study, the clinical cases included only those who reported to our dental institution. The possibility that a vast population has yet not been accounted for persists in our society who are beyond the accessibility of this institution spanning across rural areas and also among migrant workers with shifting demographics. To overcome this, larger-scale multicentric studies have to be devised engulfing diverse populations of various ethnicities to appreciate the malignant nature of the lesion and its variable clinical presentation. The predominant gender prevalence in OSMF was inclined towards males as per our analyses, which also has to be viewed in a broader aspect. This also could be understood as the significant number of the female population might have not reported to the dental hospitals due to barriers in health care such as social stigma, lack of financial independence, lack of accessibility to hospitals, and negligence towards self-care leading to procrastination in diagnosis.

A comprehensive clinical examination and correlation are vital for the early detection of oral submucous fibrosis which leads to designing the required treatment plan. Long-term multicentre studies with samples spanning major regions and provinces will be a better study design to understand OSMF patients who continue or discontinue treatment care. Routine screening and follow-up are still recommended, and OSMF patients should be regularly monitored with scheduled visits. This is crucial for health promotion among the public where health policies are drafted based on community needs and financial burdens thereby reducing comorbidities among people.

Conclusion

The findings of this study suggest that most OSMF diagnoses are incidental, especially in the early stages which brings into focus the abundant negligence by chronic tobacco chewers. Unless and until there is gravitated incapacitation of masticatory or speech functions, OSMF individuals do not visit dentists. Grade 1 OSMF patients have a predominant non-specific dental complaint of toothache only, as OSMF are asymptomatic in that stage. This study highlights that even if OSMF had been diagnosed as an ancillary finding, histopathological grading followed by therapeutic interventions is needed irrespective of the chief complaint reported by the patient.

Acknowledgments: None

Conflict of interest: None

Financial support: The authors of this article would like to thank Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai for their support in conducting this study.

Ethics statement: This study was approved in its ethical and methodological aspects by the Institutional ethical clearance committee under the protocol number: IHEC/SDC/OMED‑2002/22/428