Keywords
oral submucous fibrosis, self-examination, follow-up, smartphone applications, public awareness
This article is included in the Datta Meghe Institute of Higher Education and Research collection.
oral submucous fibrosis, self-examination, follow-up, smartphone applications, public awareness
The World Health Organization (WHO) described this condition as “a slowly progressing disease in which fibrous bands form in the oral mucosa, ultimately leading to the severe restriction of movement of the mouth including tongue” in 1978.1 In 2019, More and Rao described it as “a debilitating, progressive, irreversible collagen metabolic disorder induced by chronic chewing of areca nut and its commercial preparations; affecting the oral mucosa and occasionally the pharynx and esophagus; leading to mucosal stiffness and functional morbidity, and has a potential risk of malignant transformation”.2,3
According to estimates, 7–30% of oral submucous fibrosis (OSMF) cases will develop into oral squamous cell carcinoma (OSCC).4 Due to the high malignant transformation rate of this illness (1.5–15%), death rates are high. OSMF incidence varies by area and ethnicity and is strongly correlated with culture, habits, and diet.5 Patients with OSMF are most predominant in South and South-East Asia. The high percentage of Indian immigrants in South Africa also contributes to the high prevalence of patients with OSMF there.6 Different South-East Asian nations have different oral submucous fibrosis (OSMF) prevalence rates. According to statistics, the prevalence is 0.9–4.7% in China, 0.6–6.42% in India, 0.15–14.6% in Vietnam, and 0.086–17.6% in Taiwan. According to statistics from WHO, more than five million individuals are living with OSMF worldwide.7 Patients with OMSF can range from 8 to 80 years old, and the mean age varies between studies.
OSMF is closely linked with the use of betel nut/areca nut, which is classified as grade I hazard by WHO. The use of betelnut is very common in the Indian population being part of cultural events. The betelnut and its products are easily accessible.8 Various preparations of betel nut including smokeless tobacco, e.g., kharra, gutkha, and processed packed supari, are very common in this region, giving rise to the number of patients with OSMF.
The oral mucosa of patients with the condition has a leathery feel and perceptible vertical fibrous bands, which finally restricts mouth opening and makes the tongue hard. Early signs of the condition include a burning feeling when eating spicy food, losing normal pigmentation, and blanching of the mucosa. Ulcers, dry mouth, burning in the mouth, and restricted mouth opening are some of the clinical symptoms of OSMF.9 As the condition worsens, it could cause distress to the throat and esophagus, causing fibrosis of the upper digestive tract, while mouth-opening limitation is triggered by fibrosis of oral mucosa in the late phases of OSMF. Oral mucosa blanching is a significant clinical characteristic in the initial phases.7 Life quality is directly impacted by the characteristic manifestations and signs of OSMF patients who exhibit a constrained mouth opening.5 It should be noted that many patients with OSMF exhibit symptoms of anxiety, sadness, stress, and poor social interaction, and the incidence of these symptoms is contrarywise linked with the ailment’s severity.2
A mobile application containing material that is specifically designed for end users, such as the general public, may increase the intervention’s acceptability and effectiveness. The creation of mobile applications that incorporate theory may emphasize and support behavior modification for health promotion in patients with OSMF.10 Public health promotion will be practiced by the built mobile application. Therefore, enhancing the mobile application’s visual appeal, usability, acceptance, and effectiveness is necessary.11
Phase 1: Development of an evidence based self-assessment smartphone application:
a. To develop evidence based relevant content for the development of a user-friendly self-assessment smartphone application for patients with OSMF.
Phase 2: Distribution of the smartphone application:
a. To train and counsel patients regarding the utilization of the smartphone application.
b. To modify the application as per the requirement and suggestions of the user.
Phase 3: To assess the outcome of the smartphone-based application on patient follow-up:
Ethical approval has been received from Datta Meghe Institute of Higher Education and Research, Sawangi, Wardha IEC reference number DMIHER (DU)/2023/568. Consent from the intervention group will be taken using electronic consent forms. For the routine outpatient department (OPD)-based follow-up, written consent form will be taken manually. This clinical trial study protocol adhered to the SPIRIT checklist.16
After getting ethical approval from “The Institutional Ethics Committee (IEC)” of Datta Meghe Institute of Higher Education and Research, Sawangi (Meghe), Wardha, for this study, the patients will be selected as per the inclusions and exclusions given in the criteria. The study will be conducted at Sharad Pawar Dental College, Sawangi (Meghe), Wardha in the Dept. of Oral Medicine and Radiology.
The investigator will perform the intervention with the following inclusion and exclusion criteria.
Inclusion criteria
1. Patients habitual to betelnut chewing (more than six months duration).
2. Patients clinically diagnosed with OSMF.
3. Patients having an acceptable literacy level (e.g., are able to read and write Hindi, Marathi, and English).
4. Patients having access to smartphones.
5. Patients who are able to provide electronic informed consent.
Exclusion criteria
The participants of the intervention group will be given access to smartphone application for the follow-up of the OSMF. Whereas the control group will not be given access to the application. The participants in the control group will be referred to the OPD for the follow-up of OSMF.
The intervention will be accustomed for seven months. The initial two months will be the training period for the participants for the usage and various features of the smartphone application. The smartphone application will also be surveyed for any modifications in the smartphone application.
The smartphone application will contain monthly and weekly follow-ups for the users and information regarding the disease and ill-effects of the use of betelnut and its products. After downloading the application, the user will have to fill the demographic details for the sign-in of the application. After the sign-in, the user will have access to follow-up section and the information available on the smartphone application. The user can follow the steps and answer the questions of the follow-up for the monthly and weekly follow-up.
To improve the adherence of the participants in the intervention group, the smartphone application will have a feature of notification reminder to adhere to the follow-up of OSMF on weekly and monthly basis.
The outcomes of the study will be regular follow-up of the patients who have OSMF or have the habit of betel-nut chewing. The participants can adhere to the follow-up more efficiently using the smartphone application for the follow-up and inspect for the improvement of the signs of OSMF on their own.
After introducing the participants of the intervention group to the smartphone application, they will perform the weekly and monthly follow-ups for the period of 6 months.
• Significance level Type I error rate, α = 0.05
• Power (1-beta) = 0.8
• Z alpha value = at 90% 1.645
• Z beta value = at 80% 0.842
• Ratio of sample size, Treatment/control =1
• Allowable difference, d = μT− μC = 0.7
• Expected population standard deviation, SD = 1.5
• δ(>0), Margin = 1.1
• Drop rate (%) = 10
G power software analysis
Ratio var1/var0 = 1.5
α err prob = 0.05
Power (1-β err prob) = 0.95
Lower critical χ2 = 49.10
Upper critical χ2 = 120.32
Df = 80
Total sample size = 110
Actual power = 0.90
The total sample size will be 110 participants. Sample size depends on the true mean difference, d, standard deviations for the two groups, and a level of significance α (type|error), and the power. The total sample size n = n1 + n0 is minimized when r = σ1/σ0. With the aforementioned calculation, sample size determination with a 90% of confidence interval is 110, considering drop outs.
All the patients visiting the out-patient department (OPD) will be thoroughly inspected for the habit of betelnut chewing and will be introduced to the smartphone application which will be developed. They will be explained about the efficacy of the use of the application for the follow-up of the habit and OSMF which will also help the to cease the habit.
Sequence generation for both the groups will be done using simple randomization.
Allocation concealment mechanism
The mechanism of implementing the allocation sequence is by sequential numbering.
Implementation
The investigator will generate the allocation sequence, enroll the participants, and will assign the participants to intervention and the control group.
Phase 1: Development of the self-assessment smartphone application
The evidence-based informational materials on OSMF, cancer prevention, and self-examination will be taken from reliable sources such as articles published in indexed journal i.e scopus, pubmed and web of sciences.12 Following which, the contents will be modified, and animated educational videos will be created. Then, with the assistance of professionals in the creation of electronic content, the materials will be created with modifying rules and converting lessons to electronic formats, images, animations, also audio and video clips will be included.11
The resources will then be created using Android Studio, a software development environment for the Android platform, in the form of installable applications for mobile devices.
The application will be multilingual.
The OSMF application will consist of two components: the OSMF self-assessment and the OSMF educational resources.11
The participants’ smart electronic devices will have the application downloaded, and it can be utilized online. Patients will also be trained by the researcher for the handling of the application. It should be noted that an internet connection will be necessary for the application’s installation.
Phase 2: Distribution of the application
The created application will be put on the smartphones of the participants in the following phase, and its functionality will be inspected. The patients will be trained to use the application along with motivation and counselling. After a month of testing, participants will be requested to get in touch with the researcher if they encounter any issues or have any concerns about using the application.11
Phase 3: To assess the outcome of the smartphone-based application on patient follow-up
The data generated from application will be used to assess: i) Patient compliance; ii) modifications in symptoms; and iii) analysis of patient feedback will be done.
The study will be conducted in two groups: i) Group I: the control group, routine OPD-based follow-up (55) and ii) Group II: the smartphone application using group (55). The control group will be monitored by the conventional follow-up method of assessment in patients with OSMF and the latter group will be monitored through the self-assessment smartphone application. Depending on the findings of the two comparative groups, the efficacy of the application will be tested in maintaining the follow-up in the patients with OSMF.
The data will be collected from the patients for follow-up of OSMF visiting OPD for the control group. The data of the participants using the self-assessment smartphone application for OSMF follow-up who belongs to the intervention group will be stored in the application which can be accessed by the investigator. The data collected include demographic details such as age, address, contact details. Data will also be collected from the questionnaire of the self-assessment application for OSMF follow-up.
Retention
The participants will get regular reminder notifications on their smartphone application which they will be using for the follow-up of OSMF which will improve participant retention. This will also ensure complete follow-up of the participants of the intervention group.
For the maintenance of the data quality, once the data is collected from the participants of the control and intervention group it will be cross-checked by all the investigators.
The follow-up of the OSMF patients is expected to be better using a smartphone application as compared to the regular OPD-based follow-up. Numerous studies on these applications have been carried out, and more than 40,000 mobile health applications are already accessible on several platforms. However, there isn’t enough research to prove that these mobile apps integrate theory and were created using a qualitative design process. However, as mobile health technologies advance, there is growing concerned about how mobile application performance is constrained by their usability, accuracy, and data privacy.11,13
Rêgo et al., 2022, undertook a study with the goal of creating and validating a tool for identifying oral cancer risk factors. To evaluate the probability of developing oral cancer, an application was created that included predictors of the disease.14 For 40 experts in oral diagnostics to evaluate the algorithm and test its usability and accessibility, simulated clinical scenarios were created. The oral cancer screening was efficient, had good sensitivity and usability, and may even help find early oral lesions.14
Chang et al., 2019 conducted a study to show the methodical development course and content of the oral self-care application. Behavioral diagnosis, intervention design, and oral self-care assessment are the three phases of the systematic development process for oral self-care assessment.15 Through skilled assessment of the beta and final versions of the application and serviceability testing of the final version by patients with periodontal disease, the produced oral self-care app was evaluated and found to have good usability. This study described a meticulous design procedure for creating a customized, evidence-based mobile application for oral self-care, which makes it a personalized application for enhancing oral health in individuals with periodontal disease.15
The OSMF self-examination awareness approach involves inspecting and palpating one’s oral mucosa or oral cavity periodically in order to become familiar with it and spot anomalies. The goal of OSMF examination awareness facilitation and intervention is to raise public knowledge. Educational activities significantly contribute to the advancement of information, convictions, and OSMF screening practice.13
The population that consumes betel nut and tobacco products is the main focus of the study. The consumption of betel nut and tobacco products is done by a vast number of the Indian population. It is not always feasible for the patients to visit a dental setup for maintaining the follow-up. The study will be helpful in the follow-up of OSMF patients more promptly.
Zenodo: SPIRIT checklist for ‘Comparative evaluation of efficacy of a smartphone application for oral submucous fibrosis (OSMF) self-examination in follow-up of the patients compared to routine Outpatient Department-based follow-up’. https://doi.org/10.5281/zenodo.7965059. 16
Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).
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Is the rationale for, and objectives of, the study clearly described?
No
Is the study design appropriate for the research question?
No
Are sufficient details of the methods provided to allow replication by others?
No
Are the datasets clearly presented in a useable and accessible format?
No
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: smart phone technologies. digital dentistry applications
Is the rationale for, and objectives of, the study clearly described?
Yes
Is the study design appropriate for the research question?
Yes
Are sufficient details of the methods provided to allow replication by others?
Yes
Are the datasets clearly presented in a useable and accessible format?
Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: As an Oral Physician I understand the epidemiology, clinical presentation and molecular pathogenesis of the disease studied in the present article.
Alongside their report, reviewers assign a status to the article:
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