187th publication jmos- 5th name

187th publication jmos- 5th name

1. 123 Journal of Maxillofacial and Oral
Surgery

ISSN 0972-8279

J. Maxillofac. Oral Surg.
DOI 10.1007/s12663-020-01399-8
Evaluation of Digital Palmar
Dermatoglyphics in Oral Submucous
Fibrosis and Leukoplakia: A Prospective
Comparative Clinical Study
Ratna Samudrawar, Heena Mazhar,
Rashmi Wasekar, Prashant Tamgadge,
Rahul Vinay Chandra Tiwari &
Siddhartha Bhowmick

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3. ORIGINAL ARTICLE
Evaluation of Digital Palmar Dermatoglyphics in Oral Submucous
Fibrosis and Leukoplakia: A Prospective Comparative Clinical
Study
Ratna Samudrawar
1
•Heena Mazhar
2
•Rashmi Wasekar
3
•Prashant Tamgadge
4
•
Rahul Vinay Chandra Tiwari
5
•Siddhartha Bhowmick
6
Received: 16 August 2019 / Accepted: 19 June 2020
The Association of Oral and Maxillofacial Surgeons of India 2020
Abstract
AimTo analyze and compare digital dermatoglyphic pat-
terns in patients with oral leukoplakia and oral submucous
fibrosis and their role as noninvasive diagnostic tool.
Materials and MethodsTwo hundred patients were seg-
regated into four groups of 50 patients each with oral
leukoplakia, oral submucous fibrosis, and patients with
habits but no lesions were included. They were compared
with 50 subjects without habits and without lesions. The
study was undertaken to investigate the association of
palmar dermatoglyphics with leukoplakia and oral sub-
mucous fibrosis. Palm and fingerprints were taken using
digital method which were analyzed qualitatively and
quantitatively.
ResultsThe present study found increase in frequency of
whorls, palmar patterns in I
2–I3area, total finger ridge
count, total triradius count and decrease in atd angle with
the absence a–b ridge count in patients with oral leuko-
plakia and OSMF.
ConclusionThus, with the study of peculiar changes in
digital dermatoglyphic patterns in patients with oral
leukoplakia and oral submucous fibrosis, early detection
and preventive measures can be instituted in normal indi-
viduals having habit history without lesions to prevent the
occurrence and progression of these potentially malignant
disorders.
KeywordsDermatoglyphicsOral submucous fibrosis
Oral leukoplakia
Introduction
The word ‘‘Dermatoglyphics’’ is originated from Greek
words ‘‘Dermato’’ meaning skin and ‘‘Glyphics’’ meaning
carving [1]. The term was coined by Cummins and Midlo
[2]. Dermatoglyphics is the scientific study of fingerprints
from palms, fingers, soles and toes of humans and animals.
Since it is unique for each person and is not same even in
monozygotic twins, dermatoglyphics could turn out to be
an adjunctive diagnostic tool. In addition to this, since it is
noninvasive, it can be used as a diagnostic tool in assessing
individuals with suspected genetic disorders and also in
forensics [3–5]. Presently, many researches claim that the
study of dermatoglyphics is an important diagnostic tool
for diseases with uncertain etiology and obscure patho-
genesis such as trisomy 18, Down’s syndrome, Klinefelter
syndrome, congenital heart disease, leukemia, cat’s cry
syndrome, Turner’s syndrome [3,6,7].
In dentistry, dermatoglyphics has been studied to help
predict disorders like cleft lip and cleft palate, dental car-
ies, gingival fibromatosis, periodontitis, bruxism,
&Ratna Samudrawar
[email protected]
1
Consultant Oral Medicine and Radiology, EJHS Wellness
Center, Adilabad, Telangana, India
2
Department of Oral and Maxillofacial Surgery, Chhattisgarh
Dental College and Research Institute, Rajnandgaon,
Chhattisgarh, India
3
Department of Oral Medicine and Radiology, Swargiya
Dadasaheb Kalmegh Smruti Dental College and Hospital,
Wadhamna Road, Hingna, Nagpur, Maharashtra, India
4
Department Oral and Maxillofacial Surgery Department,
Chhattisgarh Dental Collage and Research Centre,
Rajnandgaon, Chhattisgarh, India
5
Department of Oral and Maxillofacial Surgery, Sri Sai
College of Dental Surgery, Vikarabad, India
6
Department of Conservative and Endodontics, Awadh Dental
College and Hospital, Jamshedpur, India
123
J. Maxillofac. Oral Surg.
https://doi.org/10.1007/s12663-020-01399-8Author's personal copy

4. malocclusion, congenital anomalies like ectodermal dys-
plasia, etc. Smoking, drinking and tobacco chewing have
been positively associated with oral lesions such as oral
lichen planus, oral leukoplakia, oral submucous fibrosis
and have strong potential for malignant transformation
[6–9].
Activation of oncogenes or deletion and injuries to
suppressor genes and genes responsible for DNA repair
will all contribute to a defective functioning of the genome
that governs cell division. A genetic predisposition is also
supported by association-specific human leukocyte antigen
(HLA) molecules, such as HLA-A10, -B7 and -DR3
[8,10]. So to rule out the factor of genetic susceptibility,
dermatoglyphics can be used as noninvasive tool as fin-
gerprints are genetically determined. The present study was
carried out to analyze the dermatoglyphic patterns digitally
in oral leukoplakia, oral submucous fibrosis, subjects with
habits and without lesions and to compare with the control
group.
Materials and methods
This case–control prospective clinical study is a multi-
centric, multidisciplinary study conducted on 200 patients
from October 2014 to September 2017. All patients were
segregated into four groups with each group consisting of
50 patients. All patients belonged to an age-group of
20–70 years of age. Group I included 50 patients who were
diagnosed clinically with oral leukoplakia. Group II
included 50 patients who were diagnosed clinically with
oral submucous fibrosis. Group III included 50 patients
who were healthy individuals with habits of tobacco
chewing but did not present any clinical oral lesions. Group
IV included 50 patients who are healthy individuals with-
out habits and without any clinical oral lesions. The con-
firmation of leukoplakia/OSMF was arrived at with the aid
of biopsy. Patients with any systemic disease or skin dis-
eases, patients with any congenital or acquired deformities
of palms and fingers or having any scar or wound on the
palms and fingers were excluded. Institutional ethical
clearance was obtained. Written informed consent from the
patients was taken.
Procedure for obtaining finger and palm prints
After informing the patients in detail about the procedure,
sweat, oil and dirt are removed from the skin by washing
the ridged areas with soap and water followed by drying.
The digital green bit 84c dactyscan device was used for
finger- and palm prints. Alcohol swab was used to clean the
machine after every patient use. Dermatoglyphics was done
by the clinicians themselves. Prints of the fingers were
taken in three steps with the digital green bit 84c dactyscan
device: (1) first four left fingers, (2) right four fingers and
(3) thumbs of left and right hands. The prints were taken by
pressing firmly against the screen of the machine. The
acquisition was viewed on screen of laptop using the
bioscan 10 software as shown in Fig.1. Data were stored
digitally as shown in Fig.2. An image indicating the
markings of the parameters studied is shown in Fig.3. All
the digital data are analyzed and assessed by a single
operator, and patient selection on the basis of clinical
findings is done by another operator.
The following dermatoglyphic parameters were ana-
lyzed both qualitatively and quantitatively.
Qualitative Analysis
1. Fingertip patterns and palmar patterns were studied
under qualitative analysis.
2. Fingertip patterns were studied as: (a) arches (A),
(b) loops (L) and (c) whorls (W)
3. Palmar patterns were studied as: (a) hypothenar area,
(b) thenar/first interdigital area and (c) I
2,I3and I4
interdigital area.
Quantitative Analysis
Quantitative analysis was done under the following
headings.
1. a–b ridge count,
2. Finger ridge count
3. Total finger ridge count (TFRC).
4. atd angle.
5. Tri—radius.
Fig. 1Acquisition of left-hand fingerprints
J. Maxillofac. Oral Surg.
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5. Statistical Analysis
Groups were compared among by one-way analysis of
variance (ANOVA), the significance of difference in mean
between the groups was calculated by Tukey’s post hoc test
after ascertaining normality by Shapiro–Wilk’s test and
homogeneity of variance between groups was calculated by
Levene’s test. Discrete (categorical) groups were compared
by Chi-square (v
2
) test. Analyses were performed on SPSS
(Window version 17.0) software.
Fig. 2Screen shot of palm
print
Fig. 3An image indicating the
markings of the parameters
studied
J. Maxillofac. Oral Surg.
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6. Results
Qualitative Analysis Results
Fingerprint Patterns
Comparison of fingerprint Patterns in Both HandsIn
Study groups, OSMF showed higher frequency (69.2%) in
loops followed by leukoplakia (54.4%), with habits and
without lesions (46%) and control group (47.2%). The loop
pattern was predominantly observed in all the four groups:
group I (58%), group II (67.6%), group III (45.2%) and
group IV (45.8%). The whorl pattern and arch pattern were
predominantly observed in group III and control group
(Table1).
Comparison of Fingerprint Patterns in DigitLoop pat-
tern was predominantly seen in group II as compared to
other groups in all the digits except D4, which showed
higher frequency of whorls than loops. The second com-
mon pattern observed in all the groups except D5 was
whorl pattern, and a least number of arch patterns were
seen in all the groups (Table1).
Comparison of Palmar Patterns of Both HandsOn
comparing the distribution of palm patterns on the right and
left palm among the four groups, the highest pattern was
observed in I
3–I4area followed by I2–I3area, hypothenar
area I
1–I
2and the least patterns were found on thenar area.
The distribution of palm patterns showed high frequency in
group II as compared to other groups. The palm patterns in
I
2–I
3area were found predominantly in group II (31),
followed by group III (24), control group (17) and least in
group I (6). The palm pattern in hypothenar area showed
high distribution in group II (23) and group III (23) fol-
lowed by control group (22) and least in group I (16)
(Table2).
Total Finger Ridge Count of Right and Left Hand
The mean ridge count in group I cases was insignificant
on comparison with group II and control group but found
moderately significant with group III (P\0.01**)
(Fig.4).
Triradius Count of Right- and Left-Hand Fingers
The mean triradius count of right- and left-hand fingers
in group II was 5.48 with a SD±3.14; in control group,
5.02 with a SD±2.97; in group I, 4.16 with a SD±2.66;
and in group III, 3.34 with a SD±2.84. Testing with one-
way ANOVA gave highly significant difference in mean
(F—5.31,P—0.0015) (Fig.5).
Total Triradius Count
The mean total triradius count of both hands was pre-
dominantly high in control group as compared to other
groups. The mean total triradius count of both hands in
control group was 7.84 with a SD±3.48; in group III,
7.34 with a SD±3.66; group II, 7.26 with a SD±3.53;
and group I, 5.42 with a SD±2.89. Testing with one-way
ANOVA gave highly significant difference in mean (F—
4.21,P—0.0075) (Fig.6).
Atd ANGLE: The mean atd angle of right and left palm
was predominantly high in control group as compared to
other groups. Testing with one-way ANOVA gave highly
significant difference in mean (F—4.36,P—0.0093—right
palm; (F—7.22,P—0.0006—left palm) (Tables3,4).
Total a–b ridge count: The a–b ridge count was not
prevalent in any of the groups.
Discussion
Dermatoglyphics is considered a window of congenital and
intrauterine abnormalities. The importance of dermato-
glyphic studies in clinical medicine is that, during devel-
opment, maternal environment, gene deviants, and
chromosomal aberrations affect ridge formation. Literature
suggested that the study of dermatoglyphics is an important
diagnostic tool in potentially malignant disorders for sus-
pecting the genetic etiology [11–14]. Hence, preventive
measures can be instituted to minimize premalignant
lesions.
Millions of the people in India chew gutkha, tobacco,
which initiates oral premalignant lesions like oral submu-
cous fibrosis and leukoplakia [9]. As a biomarker to assess
genetic susceptibility of such lesions, the present study was
conducted to evaluate any association between oral sub-
mucous fibrosis and oral leukoplakia with palmar der-
matoglyphics [1,8,15–18]. We found increase in
frequency of whorls, palmar patterns in I
2–I
3area, total
Table 1Comparison of fingerprint pattern of both hands
Fingerprint pattern Group I (N= 50) Group II (N= 50) Group III (N= 50) Group IV (N= 50)v
2
valuePvalue
Arches 43 (8.6%) 28 (5.6%) 71 (14.2%) 69 (13.8%) 27.65 \0.0001*
Loops 290 (58%) 338 (67. (5%) 226 (45.2%) 229 (45.8%) 69.59 \0.0001*
Whorls 167 (33.4%) 134 (26.8%) 203 (40.6%) 202 (40.4%) 28.45 \0.0001*
* denotes statistical significance
J. Maxillofac. Oral Surg.
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7. finger ridge count, total triradius count and decrease in atd
angle with the absence a–b ridge count in patients with oral
leukoplakia and OSMF.
On comparison of fingerprint patterns in both right and
left hands, the frequency of loop pattern was highly sig-
nificant in all the four groups: group I (58%), group II
(67.6%), group III (45.2%) and group IV (45.8%). Patients
with OSMF showed the highest frequency of loop pattern
compared to other three groups. The whorl pattern and arch
pattern were predominantly observed in group III and
control group.
Previous studies revealed that in patients with oral
leukoplakia and OSCC, there was a highly significant
increased frequency of loops [2,19,20]. This is in accor-
dance with the findings of our study in which OSMF
showed the highest frequency of loop pattern compared to
Table 2Comparison of palmar pattern of both the hands
Palmar pattern Group I (N= 50) Group II (N= 50) Group m (N= 50) Group IV (N= 50)v
2
valuePvalue
Thenar/I
1 1 7 2 6 6.77 O.079 NS
I
1–I
2 7 3 7 6 1.98 0 58 NS
I
2–I
3 16 31 24 17 8.51 0.036* significant
I
3–I
4 27 43 43 39 7.30 0.062 NS
Hypothenar area 16 22 23 23 2.05 0 56 NS
* denotes statistical significance
Fig. 4Graph 1 showing the
comparison of total mean finger
ridge count in both the hands
Fig. 5Graph 2 showing the
comparison of triradius count of
right- and left-hand fingers
J. Maxillofac. Oral Surg.
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8. other three groups. Previous studies on qualitative analysis
found finger ridge patterns among the four study groups to
be statistically significant for arches which are in accor-
dance with our study. Previous studies showed that arch
pattern (60.7%) was predominant with a decrease in whorl
pattern (29.3%) in study group when compared with the
controls group [21]. However, their results were contra-
dictory to our study.
Few studies observed predominant fingerprint pattern of
whorls in OSCC and OSMF, whereas loops were pre-
dominant in control-group individuals, the results of which
are not in accordance with our study where loop pattern
was predominant in OSMF [22]. A recent study showed the
percentage of loops was 30% in right and 38% in the left
hand of subjects with OSMF. The whorl pattern among
subjects having OSMF was 24% and 20% in right and left
hands, and in the controls, it was 7% and 5%, respectively
[23]. However, our study found the frequency of loop
pattern of the right hand in OSMF group was higher when
compared to the frequency on the left hand. Next, common
pattern seen in our study was whorl pattern, which is in
accordance with previous studies [24–26].
A recent study revealed that the ring fingers (D4) of both
right and left hands had the highest percentage of whorl
pattern at 35% and 30% respectively. This was followed by
the right thumb (D1) and right index finger (D2), which had
25% of whorl pattern each. In control group, the highest
percentage of whorl pattern was seen in the right ring finger
(D4) with 15% and the arch pattern was highest in the left
thumb (D1) with 15% [23]. These observations matched
the findings of our results except for the OSMF group
where loops were predominant in D4.
Another study found significant increase in pattern fre-
quency in thenar/hypothenar area in both the hands in
OSMF group as compared to other groups [24]. This
contradicted our result where we found significance only in
I
2–I3region.
A recent study compared total finger ridge counts in
OSMF, OL, OSCC, and it was observed that there was an
increase in the total finger ridge count (64.7%) in patients
with OL, OSMF and OSCC (group A) [21]. Our results
also showed significant increase in total finger ridge count
in OSMF group compared to other groups. Venkatesh et al.
compared total finger ridge count (TFRC) in all three study
groups and observed that there was no significant differ-
ence in the mean TFRC among the three groups [2]. Our
results revealed that mean total finger ridge count of OSMF
group and leukoplakia group showed moderate significance
with group III.
Fig. 6Graph 3 showing total
triradius count
Table 3Showing atd angle of right palm
Groups Atd angle of right palm ‘ F’ ratioPvalue
Mean±SD
Group I 39.86 ±6.67 4.36 P= 0 0093
Group II 40.29±6.97
Group EH 45.53±3.38
Group IV 47.63±6.75
Table 4Showing mean atd angle of left palm
Groups Atd angle of left palm ‘ Fratio’Pvalue
Mean±SD
Group I 38.43 ±6.21 7.22 P= 0.0006
Group II 41.38±6.82
Group IE 45.53±3.38
Group IV 48.3 ±3.33
J. Maxillofac. Oral Surg.
123Author's personal copy

9. Gupta and Karjodkar analyzed frequency of total finger
ridge counts (TFRC) and revealed that the mean value of
TFRC in OSF group was lower than the other groups. But,
the values were not found to be significant [19]. Con-
versely, our study showed higher mean value of TFRC in
OSMF group compared to other groups and total finger
ridge count of OSMF group and leukoplakia group showed
moderate significance with group III. Our results showed
that the mean atd angle of right palm and left palm was
predominantly high in control group as compared to other
groups. Previous studies show no significant difference in
frequency of mean atd angles of both right and left hands in
all three study groups.
Gupta and Karjodkar analyzed the number of accessory
palmar triradii on right and left hands of the samples in
each group and found statistically significant difference in
frequency of palmar triradii [20]. Our study also showed
high frequency of triradii count in both right and left palms
among the study groups, highest in group III followed by
control group, OSMF group and leukoplakia group. Our
study also showed statistically significant difference in
frequency of palmar triradii as per the literature
[20,25–27].
Conclusion
The results of the present study suggest peculiar changes in
digital dermatoglyphic patterns in patients with oral
leukoplakia and oral submucous fibrosis. Hence, dermato-
glyphics can be used as a diagnostic tool for early detec-
tion. This helps in institution of preventive measures in
normal individuals having habit history but without clinical
lesions to prevent the occurrence and progression of these
potentially malignant conditions.
Authors’ ContributionRS was the operating surgeon and involved
in design of the study, data acquisition, data analysis and drafting of
the article. HM contributed to data acquisition and data analysis. RW
designed the study and analyzed the data. PT was the operating sur-
geon and designed the study. RVCT was involved in data acquisition,
data analysis and drafting of the article. SB contributed to data
acquisition and data analysis.
FundingThis study is self-funded.
Compliance with Ethical Standards
Conflict of interestThe authors declare that they have no conflict of
interest.
Informed ConsentWritten informed consent from the patients was
taken.
Ethical StandardInstitutional ethical clearance was taken.
References
1. Sengupta AB et al (2013) A cross-sectional study of dermato-
glyphics and dental caries in Bengalee children. J Indian Soc
Pedod Prevent Dent 31(4):245–248
2. Venkatesh E, Bagewadi A, Vaishali K, Palmar Arvind S (2008)
Dermatoglyphics in oral leukoplakia and oral squamous cell
carcinoma patients. J Indian Acad Oral Med Radiol 20:94–99
3. Lakshmi Prabha J, Thenmozhi R (2014) A short review on der-
matoglypics. J Pharm Sci Res 6(4):200–202
4. Priya NS, Sharada P, Chaitanya Babu N, Girish HC (2013)
Dermatoglyphics in dentistry: an insight. World J Dent
4(2):144–147
5. Ceena Denny E, Junaid A, Nandita S, Almas B (2013) Der-
matoglyphics in dentistry—a review. Int J Curr Res 5(21):30–33
6. Cummins H, Midlo C (1961) Fingerprints palms and soles—an
introduction to dermatoglyphics. The Blakistan Co., Inc, New
York
7. Vijayaraghavan A, Aswath N (2015) Qualitative and quantitative
analysis of palmar dermatoglyphics among smokeless tobacco
users. Indian J Dental Res 26(5):484–487
8. Liao HP, Yang WH, Huang YF (2013) Genetic expression sig-
nature of oral submucous fibrosis and oral cancer—a preliminary
microarray report. J Dent Sci 20:1–6
9. Tilakaratne WM, Klinikowski MF, Saku T, Peter TJ, Warnaku-
lasuriya S (2006) Oral submucous fibrosis: review on aetiology
and pathogenesis. J Oral Oncol 42:561–568
10. Kumar K, Sarasvvathi TR, Rangnathan K, Devi M, Elizabeth J
(2007) Oral submucous fibrosis: a clinico-histopathological study
in Chennai. Indian J Denial Res 18(3):106–111
11. Pundir S, Saxena S, Aggrawal P (2010) Oral submucous fibrosis a
disease with malignant potential—report of two cases. J Clin Exp
Dent 2(4):215–218
12. Nelson BS, Heischober B (1999) Betel nut: a common drug used
by naturalized citizens from India, Far East Asia, and the South
Pacific Islands. Ann Emerg Med 34(2):238–243
13. Wollina U, Shyam BV, Fareedi MA, Kishor P (2015) Oral sub-
mucous fibrosis: an update. Clin Cosmet Investig Dermatol
8:193–204
14. Gupta M, Mishra P, Shrivastava K, Singh N, Singh P (2015) Oral
submucous fibrosis—current concepts of aetiology & its man-
agement. J Appl Dent Med Sci 1(1):29–39
15. Chaturvedi P, Nair DR, Pawar U (2012) Oral cancer: premalig-
nant conditions and screening—an update. J Cancer Res Ther
8(6):57–66
16. Parlatescua I, Carmen G, Elena C, Serban T (2014) Oral leuko-
plakia—an update. Maedica A J Clin Med 9(1):88–93
17. Mithani SK, Mydlarz WK, Grumbine Fl, Smith IM, Califano Ja
(2007) Molecular genetics of premalignant oral lesions. Oral Dis
13:126–133
18. Sikdar N, Paul RR, Roy B (2014) Glutathione S-transferase M3
(A/A) genotype as a risk factor for oral cancer and leukoplakia
among Indian tobacco smokers. Int J Cancer 109:95–101
19. Gupta A, Karjodkar FR (2013) Role of dermatoglyphics as an
indicator of precancerous and cancerous lesions of the oral cavity.
Contemp Clin Dent 4(4):448–453
20. David MP, Sinha P (2015) Dermatoglyphic patterns in subjects
with potentially malignant disorders and oral carcinoma. J Adv
Clin Res Insights 2:7–11
21. Jatti D, Kantraj YDB, Nagaraju R (2014) Role of dermato-
glyphics in malignant and potentially malignant disorders of the
oral cavity: a cross-sectional study. J Indian Acad Oral Med
Radiol 26(4):370–384
22. Ganvir SM, Gajbhiye NY (2014) Detection of genetic predispo-
sition in oral squamous cell carcinoma (OSCC) and oral
J. Maxillofac. Oral Surg.
123Author's personal copy

10. submucous fibrosis patients by qualitative analysis of finger and
palm-print patterns: a dermatoglyphic study. Clin Cancer Investig
J 3(5):377–380
23. Shetty P, Shamala R Murali, Yalamalli M, Kumar VA (2016)
Dermatoglyphics as a genetic marker for oral submucous fibrosis:
a cross-sectional study. J Indian Assoc Public Health Dent
14:41–45
24. Kulkarni V (2014) Palmar dermatoglyphics among gutkha
chewers with and without oral submucous fibrosis. Med Innov
3(1):15–21
25. Munishwar PD et al (2015) Qualitative analysis of dermato-
glyphics in oral submucous fibrosis. J Indian Acad Oral Med
Radiol 27(2):207–212
26. Dutta N, Shetty R, Pandey V, Kumar S, Rathore N (2016)
Comparison of finger print patterns in patients with and without
oral submucosis fibrosis—a dermatoglyphics study. Int J Con-
temp Med Res 3(4):1172–1173
27. Kumar S, Kandakurti S, Saxena VS, Sachdev AS, Gupta J (2014)
A dermatoglyphic study in oral submucous fibrosis patients.
J Indian Acad Oral Med Radiol 26(3):269–273
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