Oral premalignant lesions are morphologically altered oral mucosal tissues or conditions associated with an increased risk of developing oral cancer compared with normal mucosa ^[1,2]. Common potentially malignant lesions and disorders include leukoplakia, erythroplakia, oral lichen planus, and other chronic mucosal abnormalities. These conditions are clinically important because some may undergo dysplastic changes and progress to oral squamous cell carcinoma if not recognized and appropriately managed ^[2,3].

Oral mucosal lesions are common in older adults and may present with considerable clinical variation. They can occur as white, red, ulcerative, pigmented, or other mucosal abnormalities and may be associated with pain, discomfort, altered sensation, or functional difficulties ^[1,4]. Studies among elderly dental patients have demonstrated a wide range of oral mucosal conditions, with variations in their frequency and distribution according to age, population characteristics, and associated risk factors ^[4,5-8].

The natural history of potentially malignant oral lesions is variable, and the likelihood of malignant transformation differs according to the type, clinical characteristics, anatomical site, and duration of the lesion ^[2]. Leukoplakia and erythroplakia are particularly important because of their recognized malignant potential, while the premalignant nature of oral lichen planus remains an area of clinical and pathological interest ^[9-11]. Tobacco and alcohol exposure, chronic mucosal irritation, poor oral health, and other environmental and individual factors may further contribute to the development and progression of oral potentially malignant disorders ^[2,9].

The elderly population is particularly vulnerable to oral mucosal abnormalities because aging is accompanied by structural and functional changes in the oral tissues. Age-related thinning and increased fragility of the mucosa may reduce its resistance to trauma and environmental insults ^[1,6]. Older adults also frequently have multiple systemic diseases, use several medications, and may experience xerostomia, nutritional deficiencies, or other conditions that influence oral mucosal health ^[4,10]. Consequently, distinguishing age-related benign changes from potentially malignant lesions can present a significant clinical challenge.

Clinical examination is fundamental for detecting suspicious oral lesions in older adults. Persistent, unexplained, or clinically atypical lesions require careful evaluation, and biopsy with histopathological examination remains essential when dysplasia or malignancy is suspected ^[9]. Management generally involves elimination of relevant risk factors, appropriate treatment of identified lesions, and continued clinical surveillance because potentially malignant lesions may recur or progress despite intervention ^[9]. Early diagnosis and regular follow-up are therefore essential to reduce the risk of malignant transformation and improve outcomes.

Given the high frequency of oral mucosal abnormalities among older adults and the potential for some lesions to progress to oral cancer, oral premalignant lesions represent an important clinical challenge in this population. The present study aimed to characterize the clinical and histopathological profile of oral potentially malignant disorders in elderly patients, focusing on lesion type, clinical presentation, anatomical site, associated oral habits, comorbidities, and histopathological findings to facilitate early diagnosis and appropriate management.

Study Design and Setting This hospital-based cross-sectional study was conducted in the Department of Oral and Maxillofacial Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, from January to December 2008. The study was designed to assess the clinical pattern of oral premalignant lesions among elderly patients and to evaluate their association with selected sociodemographic characteristics, oral habits, clinical features, and histopathological findings. Study Population and Sample Size The study included elderly patients aged 60 years or above who attended the study department during the study period and were clinically diagnosed with suspected oral premalignant lesions. A total of 122 patients fulfilling the eligibility criteria were included in the study. Inclusion and Exclusion Criteria Patients aged ≥60 years with clinically suspected oral premalignant lesions, including leukoplakia, oral submucous fibrosis, oral lichen planus, erythroplakia, erythroleukoplakia, actinic cheilitis, smokeless tobacco-associated keratosis, and proliferative verrucous leukoplakia, were included. Patients with previously diagnosed oral malignancy, recurrent oral cancer, or inadequate clinical information were excluded. Data Collection Data were collected using a structured data collection form through face-to-face interviews and clinical examination. Sociodemographic information included age, sex, residence, and educational status. Detailed information regarding potentially harmful oral habits, including betel quid/areca nut chewing, cigarette or bidi smoking, smokeless tobacco use, and alcohol consumption, was recorded. A thorough oral examination was performed to determine the type, anatomical site, duration, size, and clinical characteristics of the lesions. Symptoms such as pain or discomfort, burning sensation, ulceration, induration, and restricted mouth opening were documented. Patients were also classified according to whether the lesion was symptomatic or asymptomatic. Histopathological Examination Where clinically indicated, an incisional or excisional biopsy was performed after obtaining appropriate consent. Tissue specimens were processed and examined histopathologically. The epithelial changes were categorized as no dysplasia, mild dysplasia, moderate dysplasia, severe dysplasia, or carcinoma in situ according to established histopathological criteria. Histopathological assessment was available for 94 of the 122 participants. Statistical Analysis Data were checked for completeness and consistency before analysis. Statistical analysis was performed using IBM SPSS Statistics version 16.0. Categorical variables were presented as frequencies and percentages. Associations between categorical variables were assessed using the Chi-square test or Fisher's exact test, as appropriate. The relationship between oral habits and major types of oral premalignant lesions was assessed, and selected risk factors were compared between participants with and without epithelial dysplasia among those who underwent biopsy. A p-value <0.05 was considered statistically significant. Ethical Considerations Ethical approval was obtained from the appropriate institutional ethical review authority of Bangabandhu Sheikh Mujib Medical University before commencement of the study. Written informed consent was obtained from each participant before interview, clinical examination, and biopsy where indicated. Participant confidentiality was maintained throughout data collection, analysis, and reporting.

A total of 122 elderly patients with clinically suspected oral premalignant lesions were included in the study. The mean age of the participants was 68.1 ± 6.2 years, with an age range of 60–84 years. The majority of participants were male (78, 63.9%), while 44 (36.1%) were female. The largest proportion belonged to the 65–69-year age group (43, 35.2%).

Table 1 shows the majority of participants were aged 65–69 years (35.2%), followed by those aged 60–64 years (28.7%). Males constituted 63.9% of the study population, and 59.8% of participants were from rural areas. Regarding education, 37.7% had no formal education, while only 10.7% had completed higher secondary education or above.

Table 1. Sociodemographic characteristics of the study participants (n=122)

Table 2 shows the distribution of different oral premalignant lesions. Leukoplakia was the most common lesion, accounting for 47 (38.5%) cases, followed by oral submucous fibrosis in 25 (20.5%) cases and oral lichen planus in 19 (15.6%) cases. Erythroplakia was identified in 9 (7.4%) participants, while proliferative verrucous leukoplakia was the least common lesion (4, 3.3%).

Table 2. Distribution of oral premalignant lesions among the study participants (n=122)

Table 3 presents 89 (73.0%) participants reported at least one potentially harmful oral habit, whereas 33 (27.0%) reported no harmful oral habit. Betel quid/areca nut chewing was the most frequently reported habit (44.3%), followed by cigarette/bidi smoking (32.0%) and smokeless tobacco use (23.8%). Alcohol consumption was reported by 11 (9.0%) participants.

Table 3. Oral habits among the study participants (n=122)

Multiple responses were possible.

Table 4 shows 52 (42.6%) participants had lesions persisting for more than 12 months. Nearly half of the participants (59, 48.4%) were asymptomatic at presentation. Pain or discomfort was reported by 39 (32.0%) participants, while 29 (23.8%) reported a burning sensation. Restricted mouth opening was documented in 25 (20.5%) cases, predominantly among patients with oral submucous fibrosis.

Table 4. Clinical characteristics of the oral lesions (n=122)

Multiple clinical features could be present in the same participant.

Table 5 shows the buccal mucosa was the most frequently affected anatomical site (44, 36.1%), followed by the tongue/lateral border (23, 18.9%) and gingiva/alveolar mucosa (17, 13.9%). Lesions involving the floor of the mouth were found in 11 (9.0%) participants.

Table 5. Anatomical distribution of oral premalignant lesions (n=122)

Table 6 demonstrates a significant association between oral habits and the distribution of major oral premalignant lesions. Betel quid/areca nut chewing was particularly frequent among participants with oral submucous fibrosis (84.0%), and the overall association was statistically significant (p<0.001). Cigarette/bidi smoking was also significantly associated with lesion type (p=0.032).

Table 6. Association between oral habits and major oral premalignant lesions

Percentages are calculated within each lesion group; multiple habits were possible.

Table 7 shows 45 (47.9%) biopsied lesions showed no epithelial dysplasia, whereas 49 (52.1%) demonstrated epithelial dysplasia of varying grades. Mild dysplasia was the most frequent dysplastic finding (28, 29.8%), followed by moderate dysplasia (15, 16.0%). Severe dysplasia was identified in 5 (5.3%) cases, while carcinoma in situ was detected in 1 (1.1%) case.

Table 7. Histopathological findings among biopsied lesions (n=94)

Table 8 shows epithelial dysplasia was identified in 49 of 94 biopsied lesions (52.1%). Dysplasia was significantly associated with betel quid/areca nut chewing (p=0.005), smoking (p=0.006), lesion duration >12 months (p=0.007), and lesion size ≥2 cm (p=0.004). Although dysplasia was more frequent among participants aged ≥70 years, the association with age did not reach statistical significance (p=0.079). Similarly, sex was not significantly associated with the presence of epithelial dysplasia (p=0.235).

Table 8. Association between selected risk factors and epithelial dysplasia among biopsied lesions (n=94)

Overall, the findings indicated that leukoplakia was the predominant oral premalignant lesion among elderly patients, with the buccal mucosa being the most frequently involved site. A substantial proportion of participants reported potentially harmful oral habits, particularly betel quid/areca nut chewing and tobacco use. Histopathological examination demonstrated epithelial dysplasia in more than half of the biopsied lesions, with significant associations observed between dysplasia and betel quid/areca nut chewing, smoking, longer lesion duration, and larger lesion size.

In the present study, the mean age was 68.1 ± 6.2 years, with most participants aged 65–69 years. Males predominated, while 59.8% were from rural areas and 37.7% had no formal education. Similar studies have reported a high burden of oral mucosal lesions among older adults, with age-related changes, systemic diseases, medications, and limited access to dental care contributing to oral vulnerability [12,13]. Leukoplakia was the most common lesion, followed by OSMF and oral lichen planus. These findings are consistent with previous literature identifying leukoplakia and erythroplakia as important potentially malignant disorders requiring careful assessment and management [14,15]. In the present study, 73.0% reported harmful oral habits, with betel quid/areca nut chewing being most common, followed by smoking and smokeless tobacco use. Previous studies have demonstrated strong associations between tobacco, smokeless tobacco, areca nut, and oral mucosal abnormalities [16,17]. The strong relationship between areca nut chewing and OSMF is consistent with its recognized role in progressive oral fibrosis. Overall, 42.6% of lesions persisted for >12 months, while 48.4% were asymptomatic. Pain/discomfort and burning were the commonest symptoms, and restricted mouth opening was mainly observed in OSMF. Previous studies emphasize that oral lesions in older adults may remain asymptomatic and therefore require routine examination for early detection [12,18]. The buccal mucosa was the most commonly affected site, followed by the tongue/lateral border and gingiva/alveolar mucosa. Similar biopsy-based studies have reported diverse anatomical distributions of oral lesions among elderly patients [13,15]. The predominance of buccal lesions may reflect prolonged local exposure to tobacco, betel quid, and areca nut. Betel quid/areca nut chewing was significantly associated with lesion type, particularly OSMF, while smoking was also significantly associated with lesion type. These findings support previous evidence linking tobacco and areca nut exposure with oral potentially malignant disorders [16,17]. Among biopsied lesions, 52.1% demonstrated epithelial dysplasia, with mild dysplasia being most common. This finding emphasizes the importance of histopathological assessment in clinically suspicious lesions. Previous studies have similarly highlighted biopsy and histopathology as essential for evaluating potentially malignant disorders [14,17]. Epithelial dysplasia was significantly associated with betel quid/areca nut chewing, smoking, lesion duration >12 months, and lesion size ≥2 cm. These findings are consistent with evidence that chronic exposure to tobacco and areca nut can induce epithelial and molecular alterations associated with carcinogenesis [17]. Persistent and larger lesions may therefore warrant particularly careful evaluation and surveillance. Overall, oral potentially malignant disorders were common among elderly patients, with leukoplakia predominating. Harmful oral habits and persistent, larger lesions were significantly associated with epithelial dysplasia, highlighting the importance of early detection, risk-factor modification, biopsy, and regular surveillance in older adults.

This hospital-based study highlights a substantial burden of clinically important oral potentially malignant disorders among older adults, with leukoplakia being the most common lesion. The high frequency of harmful oral habits, particularly betel quid/areca nut chewing and tobacco use, and the significant association of these exposures with epithelial dysplasia underscore the importance of risk-factor modification. Persistent and larger lesions were also associated with dysplasia, emphasizing the need for careful clinical assessment and timely histopathological evaluation. Systematic oral examination, habit cessation counselling, and risk-based surveillance may facilitate earlier recognition and management of OPMDs in older adults. Further prospective, population-based studies are needed to establish the long-term risk of malignant transformation and independent predictors of dysplasia.