Journal of Dr. NTR University of Health Sciences

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 7  |  Issue : 4  |  Page : 272--275

Is cashew nut shell liquid a causative factor for oral submucous fibrosis?. A study among cashew nut industrial workers


Vijayakumar Anu1, Parangimalai Diwakar Madan Kumar2, MahadevaShastry Shivakumar3,  
1 Department of Public Health Dentistry, Sathyabama Dental College and Hospital, Chennai, Tamil Nadu, India
2 Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
3 Department of Public Health Dentistry, Vivekanandha Dental College for Women, Namakkal, Thiruchengode, Tamil Nadu, India

Correspondence Address:
Dr. Vijayakumar Anu
Department of Public Health Dentistry, Sathyabama University Dental College and Hospital, Chennai, Tamil Nadu
India

Abstract

Background: Cashew nut shell liquid contains 90% anacardic acid and 10% cardol. This liquid when comes in contact topically is said to have deleterious effects both orally and systemically. Aim: The present cross-sectional study was conducted to assess the prevalence of oral submucous fibrosis (OSMF) among 600 cashew nut industrial workers in Kanyakumari district. Materials and Methods: Demographic data and tobacco habits were assessed using pretested questionnaire. Ranganathan K clinical grading system was used to examine OSMF. The data were assessed using SPSS version 11.5. Results: The overall prevalence of OSMF among the study population was 0.002%. Conclusion: The observation from this study clearly indicates that safe working environment prevents occupational hazards.



How to cite this article:
Anu V, Kumar PD, Shivakumar M. Is cashew nut shell liquid a causative factor for oral submucous fibrosis?. A study among cashew nut industrial workers.J NTR Univ Health Sci 2018;7:272-275


How to cite this URL:
Anu V, Kumar PD, Shivakumar M. Is cashew nut shell liquid a causative factor for oral submucous fibrosis?. A study among cashew nut industrial workers. J NTR Univ Health Sci [serial online] 2018 [cited 2019 Jun 17 ];7:272-275
Available from: http://www.jdrntruhs.org/text.asp?2018/7/4/272/249819


Full Text



 Introduction



Cashew processing is a small scale industry employing large number of workers. The unique feature of this industry is that the majority of workers are women belonging to the economically and socially disadvantaged strata of the south Indian society. The cashew nut industries in Kanyakumari district, Tamil Nadu is one such small scale industry, which has provided ample opportunity of employment for the women of low socio-economic status in that area.[1] There are various steps in processing cashew nut such as steam cooking, shelling, borma treatment, humidification, peeling, grading, conditioning, filling, and packing.[2] De-shelling is the mechanical cutter, soils the hands of an operator, causing corrosion due to cashew nut shell liquid (CNSL). This oil contains 90% anacardic acid and 10% cardol.[3] Pasricha JS et al.(1988)[4] has shown that topical contact with CNSL induces contact dermatitis. Hamilton et al. (1998)[5] reported a case of contact dermatitis due to raw cashew nuts. Rajendran R et al.(1988)[6] noted an increased risk of oral submucous fibrosis (OSMF) among the factory workers of Kerala, India exposed to cashew shell oil.

OSMF is an insidious, chronic disease affecting any part of the oral cavity and sometimes pharynx and esophagus. Occasionally preceded by and/or associated with vesicle formation, fibrous bands are always present, preferably in the buccal mucosa, pterygomandibular raphe, and the labial mucosa. In later stages, the oral mucosa becomes stiff causing trismus and thereby inability to eat. Pigment changes-either as loss of pigment or as hyperpigmentation are seen in most cases affecting the oral mucosa[7]. It is a potentially malignant disorder and crippling condition of the oral mucosa.[8],[9] Worldwide, estimates of OSMF shows a confinement to Indians and Southeast Asians, with the overall prevalence rate in India to be about 0.2% to 0.5%. Chronic exposure to betel nuts, chili, pepper, and prolonged deficiency of iron and zinc may lead to an alteration in oral mucosa, which causes hypersensitivity to these irritants. CNSL is acidic in nature and is said to cause allergic dermatitis.[4] When this comes in contact with buccal mucosa might cause hypersensitivity reaction in the buccal mucosa. The hypersensitivity reaction might results in juxta-epithelial inflammation that leads to increased fibroblastic activity and decreased breakdown of fibers. The fibroblasts which are phenotypically modified, produce thicker bundles that later become less elastic resulting in loss of flexibility and reduced opening of the mouth.

Very few studies have been conducted on the oral condition of the people exposed to cashew nut processing, and hence, this study was undertaken to test whether CNSL is a causative factor for OSMF among cashew nut industrial workers in Kanyakumari district.

 Materials and Method



Ethical clearance: Ethical clearance to conduct the study was obtained from the Institutional Review Board of Ragas Dental College and Hospital. Further, permission was also obtained from the Tamil Nadu Cashew nut industrial association and also from the proprietors of each cashew nut industry where the study was carried out. Informed consent was collected from individual subjects after explaining the purpose of the study.

Inclusion criteria: The workers who had at least 1 year of experience with no history of any systemic illness were included.

There are about 262 registered cashew nut processing industries in Kanyakumari district with approximately 75 workers working in each. The study samples were selected using the cluster random sampling method. Two hundred workers were screened in each division, i.e., shelling, peeling, and grading divisions. A pre-tested questionnaire (in local language, Tamil), which included demographic data and tobacco habits, was collected from the individuals prior to the clinical examination.

The examination was conducted in the cashew nut industries under bright natural light, by positioning the subject as to receive sufficient daylight. Six hundred workers were screened clinically for OSMF using Ranganathan K clinical grading system:[10],[11] Grade I: Only symptoms, with no demonstrable restriction in mouth opening; Grade II: Limited mouth opening. 20 mm and above; Grade III: Mouth opening less than 20 mm; and Grade IV: OSMF advanced with limited mouth opening.

The data recorded were transferred and tabulated to the computer - Windows Microsoft Excel (2007) - for the purpose of the data analysis. SPSS 11.5 (SPSS for Windows, Version 11.5. SPSS Inc., Chicago) was used for statistical analysis. The alpha error (Type I error) was assumed to be 0.01. Confidence limit 99% was set for the above analysis. Chi-square test was used for comparison between workers in shelling, peeling, and grading divisions.

 Results



The study population comprised of 600 workers working in shelling, peeling, and grading divisions. Approximately, 200 workers were selected from each division. [Table 1] shows that the majority of the population, i.e. 166 (27.7%) workers of the total population were in the age group ranging from 18 to24 years. Among 600 workers, majority 575 (95.8%) were females and 25 (4.2%) were males and were statistically significant. The modified Kuppuswamy scale was used to classify the socio-economic status of the workers. It was found that 597 (99.5%) workers were in upper lower scale, and 3 (0.5%) workers were in lower middle scale. There was no statistical difference between the socio-economic status and working division.{Table 1}

[Table 2] shows a statistical significant difference according to the work experience among the workers. Among 600 workers, 230 (38.3%) had 1–5 years of work experience, 158 workers had a work experience of 5–10 years, and 113 (18.8%) workers who had work experience of 10–20 years.{Table 2}

[Table 3] shows the distribution of study population based upon whether they have any habit of tobacco usage or alcohol consumption. Among the total study population, 17 (2.8%) workers had the habit of tobacco chewing alone, 4 (0.7%) workers had the habit of smoking and alcohol consumption, and 5 (0.8%) workers had the habit of smoking, tobacco chewing, and alcohol consumption. Statistical tests showed no significant difference between habits and working division (χ2 = 7.516; P = 0.276). [Table 4] shows that the prevalence of OSMF among study population is 1 (0.002%). The statistical analysis was not done because of minimal outcome.{Table 3}{Table 4}

 Discussion



According to WHO, over 1,000 million people worldwide are employed in small scale industries.[12] The cashew nut industries in Kanyakumari district are one such small scale industry, which has 77% of the total employment in the district.[1] This study showed majority 575 (95.8%) of the workers were females belonging to upper lower socio-economic status according to modified Kuppuswamy scale, as this job does not require any educational qualification and higher working skills. This is in accordance with the study done by Srinivasan MV, Ateeq N, and Jayanthi M (1999).[13] In total, 95% of the workforce in the cashew nut industry were women involved in four major production processes: (a) shelling, locally termed as thallu; (b) borma; (c) peeling; and (d) grading and packing. Roasting process was exclusively managed by men. Poverty and lack of alternative employment force women to pursue opportunities offered by cashew nut industry in this geographic area.

In a study conducted almost two decades back by Rajendran R, Anil S, and Vijayakumar T (1988)[6] among cashew nut industrial workers in Kerala, India 7.85% workers had OSMF. This was found in workers, especially in the shelling section, where the exposure to the cashew kernel oil is the maximum. However, our study showed that only one worker (0.002%) had Grade 1 symptoms of OSMF. Increase in awareness about the ill effects of cashew kernel oil and mechanization of industries preventing direct contact with cashew kernel oil might be the reason for the decrease prevalence of OSMF. In many industries where the study was carried out, de-shelling was done using mechanical devices, and in those industries where de-shelling was carried out manually, workers in shelling division used wood ash to prevent themselves from getting exposed to the cashew kernel oil.

Only 26(4.3%) workers had the habit of tobacco chewing and alcohol consumption. The decrease in the percentage of deleterious habits in the present study may be because of the fact that the majority of the workers in the cashew nut industries were females, and in India, it is a cultural/taboo to practice such habits by females. Tobacco is supposed to be a causative factor for OSMF. To test whether the OSMF in cashew nut workers is because of shell liquid or tobacco and alcohol they were included in the questionnaire. However, this analysis could not be done in this study as the prevalence of OSMF was very low.

 Conclusion



The results of the present study showed that the prevalence of OSMF among cashew nut industrial workers is low (0.002%). The observation from this study indicates that provision of a safe and attractive environment is important for the workers to prevent them from occupational hazards thereby maintain their dental and general health.

Acknowledgments

We would like to acknowledge the president Mr. Palavaarthangam and the secretary Mr. P.C.N. Vijayakumar of the Tamil Nadu Cashew nut Industrial Association for permitting us to carry out the study and also the proprietors of each cashew nut industries in Kanyakumari district where the study was carried out.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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