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Year : 2013  |  Volume : 20  |  Issue : 1  |  Page : 41-48  

Prevalence study of oral mucosal lesions, mucosal variants, and treatment required for patients reporting to a dental school in North India: In accordance with WHO guidelines

1 Department of Oral Medicine & Radiology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar, Uttar Pradesh, India
2 Department of Microbiology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar, Uttar Pradesh, India
3 Department of Oral Medicine & Radiology, Dental College, JamiaMiliaIslamia, New Delhi, India

Date of Web Publication7-Mar-2013

Correspondence Address:
Puneet Bhatnagar
64-65, PremPrayag Colony, Garh Road, Meerut, Uttar Pradesh - 250 004
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2230-8229.108183

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The aim of the study was to evaluate the prevalence of oral mucosal lesions (OML) in adult patients reporting to the dental outpatient department at the Institute of Dental Studies and Technologies, Modinagar, Uttar Pradesh, India. The purpose was to determine the priorities in oral health education, preventive measures, and identify the group in urgent need of treatment. Materials and Methods: The study was conducted over a period of 6 months in 2010, when 8866 subjects were offered structured interviews and standardized extraoral and intraoral examinations according to the World Health Organization (WHO) guidelines . Result: Overall prevalence of OML was 1736 (16.8%), the most prevalent being smoker's palate (10.44%) followed by leukoplakia (2.83%), oral submucous fibrosis (1.97%), oral candidiasis (1.61%), recurrent aphthous stomatitis (1.53%), oral lichen planus (0.8%) and others (0.78%). The highest prevalence of the tobacco habit in both forms was recorded in the group aged 40-44 yearsand those aged between 60 and 64 years who wore dentures. Lesions were most prevalent in those aged 40-44 years with a significant predominance of males at 3:1 (M = 12.6% and F = 4.3%). Patients who consumed tobacco in any form or wore dentures had a significantly higher prevalence of OML (P < 0.001). The highest number of lesions were on the palate (59.7%) followed by buccal mucosa (19.9%). Various normal mucosal variants were recorded. Fordyce's granules (0.13%), fissured tongue (3.3%), leukoedema (1.47%), and lingual varices (2.73%) were also recorded. The tongue showed the highest number of variants (64.4%). Patients were grouped according to the treatment needed under the WHO criteria. One hundred and ninety-seven patients were given oral hygiene instructions only, whereas 1422 patients were advised on change of habit and a follow-up and 674 patients needed definitive treatment. Conclusion: This study thus highlights diagnostic criteria, multifactorial risk factors to make standard measurements of OML a basis for planning and evaluating oral health programs for data collection.

Keywords: Epidemiology, mucosal variants, oral mucosal lesions, prevalence, treatment, World Health Organization

How to cite this article:
Bhatnagar P, Rai S, Bhatnagar G, Kaur M, Goel S, Prabhat M. Prevalence study of oral mucosal lesions, mucosal variants, and treatment required for patients reporting to a dental school in North India: In accordance with WHO guidelines. J Fam Community Med 2013;20:41-8

How to cite this URL:
Bhatnagar P, Rai S, Bhatnagar G, Kaur M, Goel S, Prabhat M. Prevalence study of oral mucosal lesions, mucosal variants, and treatment required for patients reporting to a dental school in North India: In accordance with WHO guidelines. J Fam Community Med [serial online] 2013 [cited 2021 Dec 2];20:41-8. Available from:

   Introduction Top

In recent years, public and health professionals have become more aware of the importance of oral mucosal lesions (OML). Apart from evaluation of oral health for dental caries and periodontal diseases, the need for epidemiologic study of oral cancer and other oral mucosal conditions (especially related to human immunodeficiency virus (HIV) or hepatitis-B virus (HBV) infections) [1] is also being emphasized.

Epidemiologic studies provide important information for the understanding of the prevalence, incidence, and severity of oral disease in a specific population. It is important to understand the distribution, etiology, risk factors, and pathogenesis of OML. This presents an opportunity for a timely primary prevention, early diagnosis, and prompt treatment.

A broad range of OML has received interest for epidemiologic studies worldwide, but few studies have documented the entire range of possible lesions. Although in 1980, the World Health Organization (WHO)'s "Guide to epidemiology and diagnosis of oral mucosal disease and conditions" [2] provided a systemic approach of data collection, the epidemiologic literature on oral mucosal diseases is somewhat scanty in this country.

Cancer has always been a challenge to medical science with the continuing global increase of cases. Cases of oral cancer have increased considerably with almost 263,900 new cases and 128,000 deaths reported worldwide in 2006 [3]

Shankaranarayan et al. [4] revealed that India has one of the highest rates of oral cancer varying from over 20 per 100,000 people as compared with 10 per 100,000 in USA and less than 2 per 100,000 in the Middle East. Oral cancer accounts for almost 30% of all cancers in India.

Early diagnosis is the most important single factor in combating oral cancer and improving survival rate. Hence the need for this study to determine the prevalence of OML in the adult patients reporting to the dental outpatient department (OPD) at the Institute of Dental Studies and Technologies, Modinagar (Uttar Pradesh), India. The aim of the study was to provide a systemic standard approach, using the WHO guidelines [2] for the collection and report of data for OML and other conditions, and assign different codes of treatment.

   Materials and Methods Top

A total of 8866 patients were evaluated over a period of 6 months from May to October, 2010. The study was conducted of patients between 15 and 75+ years, attending the OPD of the Department of Oral Medicine and Radiology, Institute of Dental Studies and Technologies, Modinagar, Uttar Pradesh, India. The subjects were assigned groups according to gender, age (divided into 13 groups with 5 years interval), habit of tobacco use (cigarette/bidi smoking and smokeless tobacco), and the use of dental prosthesis.

A standardized extraoral and intraoral examination was performed by 3 trained examiners who were provided with pictorial manuals in accordance with the WHO guidelines. [5] The reliability of the examiners was calculated approximately 80%-85% (k = 0.82) using Kappa statistics, resulting in a high degree of agreement among the examiners beyond chance. Examinations were performed in a setting that had a fully reclining dental chair, diagnostic instruments, direct and indirect light, gauze, disposable gloves, mouth masks, drape, plane mouth mirrors, straight and curved probes, tweezers, containers (one for sterilized instruments and another for used ones), surgi-scrub, concentrated sterilizing solution (Dettol), hand towels, proforma, and consent form.

The diagnostic criteria for OML, such as leukoplakia, lichen planus, oral cancer, oral submucous fibrosis, smoker's palate, and candidiasis, were in accordance with WHO criteria of 1980. [2] For lesions such as angular cheilitis, denture stomatitis, median rhomboid glossitits, and other mucosal variants criteria described by Axell et al, [6] were used. For the mucosa of betel chewers, Riechert et al. [7] work was referred. A concise description of the main clinical features of each condition was given using the ICD-DA classification in the manual. [8] Standardized topography of the oral cavity with associated definitions of the boundaries and structures were adopted for the examination and recording. [9]

To arrive at a diagnostic criteria, the Kleinman et al. [10] guidelines on the methodology in epidemiologic studies and colored  Atlas More Details [11] were referred.

Excluded from the study were patients who could not open their mouths adequately for intraoral examination, were unconscious or sedated, had a recent history of maxillofacial trauma, were postsurgical cases, were undergoing orofacial radiation therapy, or intermaxillary fixation treatment, orrevisiting the OPD during this period.

The collected data were entered into the computer, and frequency tables were generated using Statistical Package for the Social Sciences (SPSS-16 version). Chi-square test was used to determine the association of age, gender, use of dentures, use of tobacco with oral mucosal disorders, various mucosal variants, and treatment required. The level of significance was set at (P<0.001) throughout the study. Kappa statistics (k) was determined using standard formulae to measure the correlation for degree of agreement among the examiners beyond chance.

   Results Top

The study population included 5187 males (58.5%) and 3679 females (41.5%) making a total of 8866 patients, divided into 13 age groups at 5-year intervals. The habit of tobacco smokingwas the least prevalent in age group 1 (15-19 years), that is, 3.34% (males = 15 and females = 9) and the most in group 6 (40-44 years), that is, 19.1% (males = 301 and females = 26). The habit of chewing tobacco was the most in group 6 (40-44years) with1704 (males = 1546 and females = 158) and the least in age group 13 (75 years onward) with 58 patients (males = 53 and females = 5) [Table 1].
Table 1: Cross - tabulation of gender, habits, and age groups

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A total of 939 (10.59%) males without dentures had a habit of smoking tobacco and 489 (5.51%) males had a habit of chewing tobacco, whereas 67 (0.75%) males had the habit of using tobacco in both forms. However, 126 (1.42%) males who wore dentures had the habit of bidi/cigarette smoking, 14 (0.16%) had a habit of chewing tobacco, whereas only 7 (0.07%) had both the habits (χ2 = 34.336, df = 2, P < 0.001). This was found to be highly significant. The prevalence of females who had no dentures was129 (1.45%) and 95 (1.07%), whereas only 24 (0.27%) and 10 (0.11%) who woredentures had the habit of smoking and chewing tobacco, respectively (χ2 = 2.637, df = 2; P < 0.05),, which was not significant [Table 2].
Table 2: Prevalence of habits in males and females

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Overall prevalence rate of OML was 16.8%. No lesions were seen in 7371 patients, OML were recorded for 1780 patients and normal mucosal variants were recorded in 834 patients [Figure 1]. The most prevalent oral lesion that was encountered in the course of this study was smoker's palate. A total of 926 cases (10.44%) were diagnosed in 787 males (8.87%) and 139 females (1.57%).
Figure 1: Graphic representation of the total number of patients with no lesions/oral mucosal lesions/normal variants in our study

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Leukoplakia was diagnosed in 251 patients (2.83%)-211 males (2.38%) and 40 (0.45%) females. There were 39 male (0.44%) and 32 (0.36%) female patients who suffered from oral lichen planus with a total of 71 (0.8%) reported cases. We did not encounter any case of oral carcinoma, cancrum oris, and acute necrotizing ulcerative gingivitis during this period. A total of 177 cases (1.97%) of oral submucous fibrosis were recorded, 146 of whom were male (1.66%) and 31 female (0.01%) Oral candidiasis was seen in 143 patients (1.61%), in 65 male (0.73%) and 78 female (0.88%) patients. A total of 136 patients (1.53%) reported to the OPD suffering from recurrent aphthous stomatitis, 62 of whom were male (0.69%) and 74 (0.83%) female. Other disease entities such as abscesses, sinus, epulis, herpes infection, and so on, were reported in 69 patients (0.78%)-38 of whom were male (0.43%) and 31 female (0.35%) [Figure 2].
Figure 2: Bar graph of the prevalence of different lesions in males and females

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The most prevalent site of lesions was the palate, which showed 1037 (59.7%), followed by 347 lesions on the buccal mucosa (19.9%), and 192 (11.1%) on the labial commissural region. On the lips were found 99 lesions (5.7%). Buccal sulcus region had 25 entities (1.44%) and the tongue had 26 (1.5%). Gingiva and other sites showed 7 (0.4%) and 3 (0.18%) lesions, respectively [Figure 3].
Figure 3: Prevalence of oral mucosal lesions according to site in the oral cavity

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Data were also evaluated according to the number of lesions found in males and females in relation to tobacco habits and dental prosthesis. The largest number of lesions was in male patients who had both forms of the tobacco habit and those who wore dentures (100%), (χ2 = 4.661, df = 2, P > 0.05), which was not significant. The next were the males with dentures who smokedbidis/cigarettes but did not chew tobacco (86.5%), (χ2 = 3.992, df = 2, P > 0.05). This was not significant.

On other hand, the largestnumber of lesions in females was recorded inthe group that had the habit of using tobacco in both the forms, but who wore nodentures (85.7%), (χ2 = 7.294, df = 2, P < 0.05), which was significant. The next were female patients who wore denturesand smoked tobaccoonly (70.8%), (χ2 = 3.992,df = 2, P > 0.05), which was not significant. The lowest prevalence was inpatients who did not wear dentures and had no tobacco habit ofany form, that is, males = 6.07% and females = 0.07%, respectively, (χ2 = 3.029, df = 2, P > 0.05), which was not significant [Table 3].
Table 3: Prevalence of lesions according to gender and habits

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A total of 834 normal mucosal variants were recorded in 8866 patients. Fordyce's spots were seen in 116 males (13.9%) and 50 females (5.99%), peaking in the 40-44 years age group in both the genders. Fissured tongue also peaked in the 40-44 years age group with 158 males (18.9%) and 137 females (16.4%). Lingual varices were seen in 158 (18.9%) males with the highest incidence in the 60-69 years age group and in 84 females (10.1%) with highest incidence in thegroup aged 60-64 years. Leukoedema was reported in 105 male (12.6%) patients with peak incidence in those aged 40-44 years, and 26 female (3.12%) patients with the most in those who are 35-39 and 60-64 years.

In the course of our study, the patients were grouped and assigned treatment codes for their needs according to WHO criteria, [2] as follows: (0) no treatment required, (1) oral hygiene instructions only, (2) change of habit recommended with follow-up, (3) definite treatment required, and (4) urgent treatment required with referral.

No treatment was required for 3387 male (38.2%) and 3186 female patients (35.9%) (χ2 = 1.660, df = 1, P > 0.05), which was not significant. Oral hygiene instructions were given to 111 male (1.2%) and 86 female patients (0.96%). In this study, 1225 male (13.8%) and 197 female (2.2%) patients were advised to change their habits and were to be given a follow-up (χ2 = 1.660, df = 1, P < 0.001). This difference was highly significant. Definitive treatment plans were set up for 448 male (5.05%) and 226 female (2.5%) patients. Antioxidants, antifungal medications, corticosteroids, immunomodulators, intralesional injection therapy, antiviral drugs were prescribed, physiotherapy for mouth opening and follow-up regimes were arranged (χ2 = 60.120,df = 1, P < 0.001). This was highly significant [Table 4].
Table 4: Treatment required according to gender and number of lesions

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   Discussion Top

The diagnosis of the wide variety of lesions that occur in the oral cavity is an essential part of dental practice. The prevalence of OML is an important parameter for the evaluation of the oral health of any population, and the prevalence data of these lesions is vital for planning oral health care services. In the present study conducted in IDST. Dental College, Modingar, India, 8866 outpatients comprising 5187 males (58.5%) and 3679 females (41.5%) were included. In previous studies, conducted on dental outpatients, a comparatively small group of patients were surveyed. For instance, 2017 outpatients (1287 males and 730 females) were included by Saraswathi et al., [12] 1190 (747 males and 443 females) were in the Mathew et al., study [13] 2552 outpatients were surveyed by Mobeeriek et al., [14] and 512 outpatients (292 males and 220 females) were included in the Shivakumar et al. study. [15]

All subjects were divided into subgroups according to age and gender, similar to studies conducted by Prasad et al., [16] Saraswathi et al., [12] Mathew et al., [13] and Shivakumar et al. [15]

The highest prevalence of OML was found in group 6 aged from 40 to 44 years. This finding is almost similar to a study by Ikeda et al. in Cambodia [17] and Mujica et al. [18] in Venezuela. The tobacco habit (whether chewed or smoked) was seen in group 6 (40-44 years), which may contribute to the fact that this group seemed to be at the most risk from exposure.

The overall prevalence of OML was 16.8%, similar to studies conducted by Shulman et al., [19] which showed the prevalence of OML as 10.26%, Splieth et al., [20] which had 11.83% prevalence, Cebeci et al. [21] at 15.5%, Mobeeriek et al. [14] at 15.0%, and Shivakumar et al. [15] at 11.33%.

Compared to our study, the prevalence of OML was found to be lower at 9.7% by Zain et al., [22] 4.9% by Ikeda et al., [17] 4.1% by Saraswathi et al., [12] and 8.4% by Mehrotra et al. [23] In the study done by Kovac et al., [24] there was a higher prevalence of OML at 61.2%, Lin et al. [25] had 66.2%, Espinoza et al. [26] had 53%, Mujica et al. [18] had 57% and Mathew et al. [13] had 41.2% prevalence.

In this study, males had more lesions (12.6%) than females (4.28%), which is in accordance with the studies done by Avcu et al., [27] Chung et al., [28] Castellanos et al. [29] and Mehrotra et al., [23] while in the study done by Mobeeriek et al. [14] the prevalence of oral lesions in females was higher than males, but in the Corbet et al. study in 1994 [30] there was no difference in the prevalence between men and women.

The high prevalence of lesions in males could be attributed to the higher number examined and the higher prevalence of tobacco use by males and the greater access they have to the outlets that sell tobacco and its products, whereas because of cultural constraints, women have to maintain a certain image and so are less likely to take up the unhealthy habit of smoking. Of the 8866 study population examined, 1139 male subjects had a habit of smoking bidi/cigarette while 162 females were recorded as smokers, (χ2 = 528.394,df = 1; P < 0.001). The difference was highly significant. Five hundred and seventy-seven males and 114 females chewed tobacco only (χ2 = 191.784, df = 1; P < 0.001), which was highly significant. This shows that incidence of tobacco chewing differs significantly between males and females. The habit of both chewing and smoking tobacco was seen in 67 males (0.75%) and 7 (0.08%) females. These findings were very similar to Mehta et al., [31] Avcu et al., [27] Mehrotra et al., [23] Shivakumar et al., [15] Mathew et al., [13] Mehrotra et al., [23] Zain et al., [22] Campisi et al., [32] Cebeci et al., [21] and Saraswathi et al. [12]

The prevalence of oral mucosal variants in our study was in accordance with the study conducted by Sudhakar et al. [33] in Eluru, Andhra Pradesh, India, which found a total of 1489 lesions in which 929 mucosal changes were either normal mucosal variants or developmental anomalies. In another study by Jahanbani et al., [34] oral developmental lesions were seen in 295 patients (49.3%), Fordyce granules only (27.9%), fissured tongue (12.9%), leukoedema (12.5%), and hairy tongue (8.9%). Another study conducted by Al-Mobeeriek et al. [14] King Saud University, Riyadh, Saudi Arabia, found that the most common lesion was Fordyce granules (3.8%; n = 98), followed by leukoedema (3.4%; n = 86).

In this study, treatment codes were assigned in accordance with WHO criteria [2] as follows: (0) no treatment required, (1) oral hygiene instructions only, (2) recommended change of habit and follow-up, (3) definite treatment required, and (4) urgent treatment required with referral. In the study population of 8866 patients, 6573 patients (M = 3387 and F = 3186) did not require any treatment, 197 patients (M = 111 and F = 86) were given oral hygiene instructions only. To 1422 patients (M = 1225 and F = 196) a change of habit with follow-up were recommended, but 674 patients (M = 448 and F = 226) needed treatment. The subjects were assigned the treatment code only on the basis of absence or presence of overt oral mucosa. Patients who were advised to change their habit with follow-up (code-2) and those for whom definitive treatment (code-3) was arranged, were found to be statistically highly significant (P < 0.001). No study of this nature has been carried out on treatment coding for patients with OML in accordance with WHO guidelines prior to this study.

   Conclusion Top

The diagnosis of the wide variety of lesions that occur in the oral cavity is an essential part of the dental practice. An important parameter for evaluating the oral health of any population is the prevalence data of OML , which is also vital for planning the oral health care services.

Many studies are conducted worldwide on the epidemiology and prevalence of OML and normal physiologic variants, but there have been very few in which subjects are assigned groups according to the required treatment. This study not only recognizes groups in urgent need of treatment, but also emphasizes the current trends of treatment given to the groups by the oral health care providers. This particular variable in the study calls for an urgent need for awareness programs involving the community health workers, dentists, and allied medical professionals. Dental professionals should advise and encourage patients to quit the use of tobacco. It is important to counsel patients who use tobacco in any form that no form of tobacco use is safe.

This study was undertaken to encourage oral health administrators to follow standard methods for evaluating the prevalence of oral lesions according to WHO guidelines in order to maintain uniformity in epidemiologic studies.

   Acknowledgment Top

The authors are indebted to Dr. Hemant Kumar, Associate Professor, Department of Statistics, Saraswati Institute of Medical Sciences, Ghaziabad (U.P.), India, for his valuable and collaborative support as a statistician for the entire study.

   References Top

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5 Tobacco use and oral mucosal changes in Baiga tribals of Madhya Pradesh
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6 Dermographic Properties And Correlation of Oral Mucosa Lesions with Dermatological Preliminary Diagnosis
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7 Reporting frequency of potentially malignant oral disorders and oral cancer: A 10-year retrospective data analysis in a teaching dental institution
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Journal of Dr. NTR University of Health Sciences. 2020; 9(2): 124
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8 Prevalence and risk indicators of oral mucosal lesions in adult population visiting primary health centers and community health centers in Kodagu district
Sendhil Kumar,VeenaS Narayanan,SR Ananda,AP Kavitha,R Krupashankar
Journal of Family Medicine and Primary Care. 2019; 8(7): 2337
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9 Evaluation and Comparison of Total Antioxidant Capacity of Saliva Between Patients with Recurrent Aphthous Stomatitis and Healthy Subjects
Fatemeh Rezaei,Taher Soltani
The Open Dentistry Journal. 2018; 12(1): 303
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10 Prevalence of oral mucosal lesions among smokeless tobacco usage: A cross-sectional study
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11 A Clinicopathologic and Epidemiologic Study of Chronic White Lesions in the Oral Mucosa
Sampurna Ghosh,Sudipta Pal,Soumya Ghatak,Somnath Saha,Surajit Biswas,Prabha Srivastava
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Herman Guild Manayil John,Rani Mathew
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Santanu Chaudhuri,Somnath Dey,Ashish Awasthi,Ram Chandra Bajpai
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Zohaib Khan,Sheraz Khan,Lara Christianson,Sara Rehman,Obinna Ekwunife,Florence Samkange-Zeeb
Nicotine & Tobacco Research. 2016; : ntw310
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15 Oral Mucosal Lesions and Adverse Habits Among Hospitalized Tuberculosis Patients of Udaipur, Rajasthan, India
Mridula Tak,Kushal Shinde,Nagesh Bhat,Kailash Asawa,Anukriti Singh,Sandeep Jain
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16 High Prevalence of Tobacco Use and Associated Oral Mucosal Lesion Among Interstate Male Migrant Workers in Urban Kerala, India
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19 Oral Mucosal Lesions in Indians From Northeast Brazil
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20 Oral Mucosal Disorders in Pregnant versus Non-Pregnant Women
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21 A Study to evaluate the Frequency and Association of Various Mucosal Conditions among Geriatric Patients
RGK Shet,Shobith R Shetty,M Kalavathi,M Naveen Kumar,Rishi Dev Yadav,S Soumya
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