Systematic review

(Oral cancer risk for diabetic patients)

Abstract

Introduction: The research would contribute to finding the reasons for the increased risk

of oral cancer among the patients of diabetes along with the socio-demographic

determinants of higher risk of cancer among patients specifically.The most affected areas

of oral part of a human that face cancer situation involve buccal mucosa, hard palate, the

gingival floor of mouth, lips and oropharynx as well as the tongue. The diabetes mellitus

causes many immunologic and metabolic changes in the oral mucosa.

Methods: The search strategy has focused on expert’s knowledge and past researches

that are based on the selected topic of research. Moreover, the analysis of internet search

strategy has also helped to maintain an appropriate process for managing the research.

The researcher has focused on key factors that are causing oral cancer to the diabetic

patients. The process that used for managing information regarding oral cancer in

diabetic people from different age and gender were helpful for meeting the outcome of

the study.

Results: The study focuses on different factors related to the risk of both cancer and

diabetes and its influences over the health of common people. The data and findings

have been evaluated on the basis of available cases and real-life events in the diseases.

The major population of the studies was the patients suffering from a disease or the

people diagnosed with the issues initially in real time.

Conclusion: It has been found that there are higher risks of occurring oral cancer among

the people suffering from diabetes and could impact their health to a greater extent. The

review also revealed that there are various factors which could lead towards the risk of

cancer among diabetic people like age, obesity, diet, physical inactivity, etc.

TABLE OF CONTENTS

1. Introduction ................................................................................................................................. 1

1.1 Introduction ........................................................................................................................... 1

1.2 Background ........................................................................................................................... 1

1.2.1 Oral cancer and diabetic patients ................................................................................... 1

1.2.2 Impact of diabetics on the health of people ................................................................... 3

1.2.3 Oral risk factors in diabetic patients .............................................................................. 4

1.3 Aims and objectives .............................................................................................................. 6

1.4 Research questions ................................................................................................................ 6

1.5 Rationale ............................................................................................................................... 6

2. Methodology and protocol .......................................................................................................... 7

2.1 Introduction ........................................................................................................................... 7

2.2 Design ................................................................................................................................... 7

2.3 Literature search strategy ...................................................................................................... 7

2.3.1 Database searches .......................................................................................................... 7

2.3.2 Search items ................................................................................................................... 8

2.3.3 Restrictions on the search .............................................................................................. 8

2.3.4 Journal hand searched .................................................................................................... 8

2.3.5 Organization and topic experts contacted ...................................................................... 9

2.3.6 Internet search strategy .................................................................................................. 9

2.3.7 Outcome of search process ............................................................................................ 9

2.3.8 Justification .................................................................................................................... 9

2.4 Study selection .................................................................................................................... 10

2.4.1 Inclusion criteria .......................................................................................................... 10

2.4.2 Exclusion criteria ......................................................................................................... 10

2.4.3 How the criteria used ................................................................................................... 10

2.4.4 Outcome of selection process ...................................................................................... 10

2.4.5 Justification .................................................................................................................. 11

2.5 Critical appraisal ................................................................................................................. 11

2.6 Ethical appraisal .................................................................................................................. 12

2.6.1 Process for ethical review ............................................................................................ 12

2.6.2 Principles used in study ............................................................................................... 12

2.6.3 Outcome of ethical appraisal ....................................................................................... 12

2.6.4 Justification .................................................................................................................. 13

2.7 Data abstraction .................................................................................................................. 13

2.7.1 List of variables............................................................................................................ 13

2.7.2 Strategies used for manage missing data ..................................................................... 17

2.8 Analysis............................................................................................................................... 17

2.9 Boolean operating for research ........................................................................................... 19

3. Result and discussion ................................................................................................................ 19

3.1 Results ................................................................................................................................. 19

3.2 Discussion ........................................................................................................................... 19

4. Conclusion and recommendation .............................................................................................. 20

4.1 Conclusion .......................................................................................................................... 20

4.2 Recommendation ................................................................................................................ 21

References ..................................................................................................................................... 22

Appendix ....................................................................................................................................... 27

1

1. Introduction

1.1 Introduction

With the change in lifestyles, there had been a drastic increase in various diseases like

diabetes and cancer which laid a severe impact on the health of people nowadays. The current

study has been carried out with the intention to explore knowledge and facts about the risk of

Oral Cancer in Diabetes patient in an elegant manner. It would help in determining the

relationship between oral cancer and Diabetes among the people of society (D'Aiuto and et al,

2017). The research would contribute to finding the reasons for the increased risk of oral cancer

among the patients of diabetes along with the socio-demographic determinants of higher risk of

cancer among patients specifically. In addition to this, it would help in collecting the facts and

information related to disease and resolves the issues effectively.

1.2 Background (Systematic Review of Literature)

Around 150 million people are affected by diabetic issues that lead them to further

disease. Apart from that, cancer is the most common cause of death and oral cancer plays a

critical role in the current scenario of lifestyle. Oral cancer accounts for approximately 4-5 % of

all cancer patients in the world. The major symptoms and signs of oral cancer include sore that

does not heal, sore that bleeds a growth lump or thickening of the skin or lining of the mouth. In

addition to this, the loose teeth, tongue pain and jaw panning are leading to oral cancer for

diabetic and other people. For diabetic people, the issues like heavy alcohol use, a broken

immune system and excessive sun exposure to the lips are having an important impact on cancer

issues.

1.2.1 Oral cancer and diabetic patients

Marni Stott-Miller and et al, (2011) in their studies had discussed diabetes and risk of

head and neck cancer in an elegant manner. Its major aim of this study was to identify the

aspects related to the statement that whether diabetes is a risk factor for head and neck cancer

(HNC). It has been identified that head and neck cancer is considered among the most common

all over the world. The study revealed that nearly about 400,000 cases and more than 200,000

deaths from cancer were recorded in past decades around the world (Marni Stott-Miller and et al,

2011). The pooled analysis of case-control studies was carried out by the researcher so that to

pool the data and information required for the study and reach towards the findings effectively.

The data has been polled from nearly about 12 case-control studies focusing upon the subject

2

matter. The authors, however, found that there is a weaker relationship between the head and

neck cancer and diabetes incidences (Maisonneuve and et al, 2017).

With respect to the current research, the above study is helpful in establishing the fact

about the association of HNC and diabetes. Its data and information would help in identifying the

factors and relating the variables in a more proficient manner. Along with this, it would even

provide with the idea of target population and methods of evaluating the current study

specifically. It has been found that the research carried on a similar topic would also help in

making effectual conclusions out of it.

The article by Marni Stott-Miller and et al, (2011) have stated that Diabetes mellitus has

become a serious and leading health problem for common people. The study carried out by the

authors discusses the connection between oral cancer and diabetes mellitus with the aim of

identifying the relationship between oral cancer and impaired glucose tolerance specifically. It

had even found the occurrence of other risk factors related to oral cancer. The study includes

more than 45 cases and 45 controls related to the topic which helped in assessing the facts more

specifically (Marni Stott-Miller and et al, 2011). The data and information have been evaluated

with the help of MS- Excel and SPSS. The article concluded that Diabetes mellitus is positively

related to the incidence of oral cancer.

Moreover, the present study would evaluate the factor and variables related to oral cancer

and its risk due to diabetes. The above article would help in establishing the determinants of

finding the actual outcome and assessing the latest data collected out of the population. The

researcher would require implementing sufficient techniques to evaluate the facts and reach the

findings effectively. The study would reveal the relationship between oral cancer and diabetic

patients stating the figures out of the evaluation.

In accordance with Edward Giovannucci and et al (2010), cancer and diabetes are two

common diseases which lay tremendous impacts on health all over the world. The studies carried

out by the authors mainly aims to revise the questions like what are the risk factors which are

common to both cancer and diabetes, do treatments of diabetes influences the risk of cancer,

possible biological links among cancer risk and diabetes and the association between both the

diseases. The study focuses on different factors related to the risk of both cancer and diabetes

and its influences over the health of common people (Edward Giovannucci and et al 2010). The

data and findings have been evaluated on the basis of available cases and real-life events in the

3

diseases (Pettit and et al, 2017). The basic reason found for the association might be due to the

risk factors like aging, diet, obesity and physical inactivity specifically.

With reference to the current study, the researcher would focus on the identification of

factors related to the diseases and their risks. It could include the data which depicts the

association of both cancer and diabetes and their risks upon each other. The present study would

elaborate the factors provided in the above article and evaluate the information so that to gain the

higher authentic outcome.

1.2.2 Impact of diabetics on the health of people

The article titled “Diabetes and Oral Oncogenesis”, aims to study the risk factors of Oral

Squamous cell carcinoma cancer developed due to diabetes. As per Eleftherios vairaktaris and et

al (2007), stated the association between the risk factors of disease with each other and

influenced the health of people extensively. It has been identified that the authors had utilized the

animal model to study the aspects and understand the significant mechanism of oral cancer

effectively. It is even observed that the study include the cases or patients as the target

population of the disease (Eleftherios vairaktaris and et al., 2007). The study includes the

information and mechanism of the issues faced out of the risks specifically.

The current research is based upon the identification of reasons of risks of cancer in

diabetes patients and the factors influencing the same (Haukka and et al, 2017). The above article

would be helpful in collecting sufficient knowledge and understanding about the different

mechanism and the tool which could justify the topic in an enhanced manner. The investigator

has collected useful information out of the article and makes use of the same in the study. It

would even describe the levels of risks and different parameters set in various types of diabetes

and cancer in an expanded manner (Decuseara and et al, 2018).

The article by Cassius Torres-Pereira, (2010) discussed the information regarding public

policies for oral cancer that could contribute in controlling the impacts specifically. The

researcher aimed to study the literature relevant to public policies of oral cancer and collect the

evidence of the execution of oral health policies all over the world. The researcher had identified

various relevant aspects of oral cancer and its related policies over health issues (Cassius Torres-

Pereira, 2010). It has been identified that there are different risk factors out of oral cancer that

could hamper the health of common public (Bányai and et al, 2018) It has been discovered that

4

the oral health issues must not be overlooked and acquire proper observation for better

treatments.

Gong Y and et al, (2015) had investigated the relevant aspects of the relationship between

the type 2 diabetes and the risk of oral cancer and precancerous lesions effectively. It has been

found that there is a higher risk of oral cancer in the type 2 diabetes mellitus patients as

compared to the non-diabetic people. The researcher applied meta-analysis method to extract the

exact results out of the study and authenticate the outcome effectively (Gong Y and et al, 2015).

The researcher in the present study had made use of the information to strengthen the fact and

information and make sure about the results out of it (D'Aiuto and et al, 2017). It has been found

that the information proved to be useful for the author in this study and contributed to enhancing

the outcome as well.

1.2.3 Oral risk factors in diabetic patients

The article by L.Goutzanis and et al (2007), states that the diabetic patients might face

higher risks of oral cancer due to the focal adhesion kinase and insulin receptor substrate-1

comparatively to others. The studies had described the consequences of insulin to the patients of

diabetes and increase the probabilities of incurring oral cancer as well. (L.Goutzanis and et al.,

2007). The investigator had made use of the information from the past literature and presented

with the facts in recent times specifically to analyze oral cancer risk (Gupta and et al, 2017).

As per Rajesh P. Dikshit and et al, (2005) described the role of diabetes mellitus in

developing the oral inflammatory and neoplastic lesions. The researcher mainly aimed to identify

and evaluate the association between premalignant oral disease and diabetes mellitus

specifically. The author utilized cluster random sampling method to identify the actual targets

and conducted a controlled oral cancer screening among the patients. It has been found that there

is a positive association among the two diseases and lays severe impacts over the patients of

diabetes (Rajesh P. Dikshit and et al, 2005). The present research reveals the facts of oral cancer

and diabetes mellitus along with the relevant impact on patients.

Edward Giovannucci and et al (2010) in their studies had described the link between the

impacts of diabetes and cancer over each other. It has been stated that these are the two most

common diseases that impact the health of people around the world tremendously. The aim

behind this study was to identify the risk factors that are common to cancer and diabetes,

possible biological links among cancer risk, influences of treatment of diabetes over the risk of

5

cancer and the relationship among both (Edward Giovannucci and et al 2010). The authors had

considered real-life events and an available case of the diseases to study the facts in detail and

extract effective results out it. In the context of the present research, the investigators had

focused over the risks of cancer and its related factors specifically (Kumar and et al, 2017). It has

been identified that the basic reasons for the association might be the risk factors like aging, diet,

obesity and physical inactivity specifically.

Dániel végh and et al, (2017) had considered diabetes as the most common medical

condition having an increasing occurrence all over the world. It focused the population of

Hungary and its global statistics of oral cancer and the higher incidences of type 2 diabetes

specifically. The article reveals that diabetes is a major factor in the development of malignant

tumours at different places and lays negative impacts on the progression of a tumour and patient

survivals (Dániel végh and et al, 2017). It is very important for the researcher to display

authentic and rationale information out of the study. It has been described that the disease

includes higher risks among patients and might impact them to a great extent.

Nandita Shenoy and et al, (2014) in their article aimed to identify the link between oral

cancer and impaired glucose tolerance along with common risk factors of the diseases. The

research found that patients with diabetes are at greater risk of cancer and possibly influenced

with the same. The study revealed that glucose intolerance was linked with the greater risks of

deaths due to oral cancer initially at the prediabetic range (Nandita Shenoy and et al, 2014). The

researcher had evaluated the facts and information with the help of MS Excel and SPSS. It has

been found that abnormal glucose was detected among almost half of the cases of oral cancer out

of the population (Heikkilä and et al, 2018). The researcher in the present study had focused over

the relevant facts of oral cancer and diabetes that helped in making an adequate justification for

the objectives. The study had includes the information of patients of oral cancer and diabetes in

their target controls so that to avail positive out of extensively.

The article by Siddharth Pandit and et al, (2015) stated that diabetes mellitus mainly

involves a group metabolic disorders which have been specified by hyperglycemias caused due

to the lack of insulin secretion among people. The researchers had also explored the association

between oral cancer and diabetes with a possible mechanism of both. The authors had studied

various real life events and real cases of cancer among people so that to gain realistic information

about the risk factors (Siddharth Pandit and et al, 2015). The present study depicts the facts of

6

risks over patients having diabetes and the influences of cancer specifically. The research

revealed a sufficient amount of information and sources related to diabetes and oral cancer

among people (Tseng, 2017). The above article found to be useful for the investigator in

understanding the mechanism and collecting data related to the diseases effectively.

1.3 Aims and objectives

Aims

The major aim of this study is to evaluate the risk of oral cancer among diabetes patients.

It is aimed to assess the factors or determinants related to the diseases and analyse the facts in an

effective manner.

Objectives

To identify the reasons for the increment of the risk of oral cancer among diabetes

patients

To assess the socio-demographic determinants of higher oral cancer risk

To determine the influences of the issue over the health of society

To evaluate the relationship between oral cancer and diabetes among people

To evaluate the socio-demographic factors associated with a higher risk of oral cancer in

diabetic patients

1.4 Research questions

1. What are the reasons for increased oral cancer risk among diabetic patients?

2. What are the socio-demographic determinants of higher oral cancer risk among diabetic

patients?

1.5 Rationale

Oral cancer is the rising concern of health specialists and has influenced immense

numbers of people in the society. The current study would prove to be highly beneficial to the

concerning experts and the society to a great extent. It would help in measuring the levels of risk

of oral cancer to diabetic patients and would help in mitigating the issues as well (Végh and et

al., 2017). The research would determine the reasons behind the increased risk and determine the

socio-demographic factors related to the risk. The investigation would highly contribute to

finding out the relationship between oral cancer and diabetes among the common people. It

would prove to be useful for many scholars and researcher carrying out their studies on similar

topics. It would even help many health or medical professionals to understand the risk and

7

resolve the issues effectively. The major rationale of this study is to identify the risk levels and

relationships between oral cancer and diabetes among patients so that to reduce the death rates of

people.

2. Methodology and protocol

2.1 Introduction

According to Gào and Schöttker (2017), a systematic review of literature is basically the

whole and methodological mixture mainly concerned with the well formulates research

questions. The review is mainly focused with the aim of identifying and combining both the

unpublished and published studies of different scholars on the similar topic. It is a reproductive

and unbiased manner of identifying the evidence related to the subjects and identifying the gap in

research specifically. It could even include a clinical analysis, which is basically a secondary

analysis that blends the outcome of different studies. The current systematic review of literature

is highly focused on the identification and review of facts related to the risk of oral cancer among

diabetic patients specifically.

2.2 Design

For the research, the qualitative approach will be used that will help to manage the

research outcome according to expected manner. The design of the current study is quantitative

and follows the descriptive approach. The descriptive design of the study will be helpful for

describing the current state of a variable or phenomena considering the hypothesis that typically

developed by using the collected data for the study. The descriptive analysis is used for

collecting the data and planning of the activities related to research. For the current study, the

data will be collected for identifying the factors that causing oral cancer for diabetic patients and

affecting their lifestyle. The descriptive analysis design of the study will be used for the

comparative and descriptive design of the study. The description of causes for oral cancer in

diabetic patients will provide information about major issues and factors that are affecting the

health of these people (Lewis, 2015). The consideration of quantitative design for the study has

supported to maintain the ethical process and meet the proposed outcomes.

2.3 Literature search strategy

2.3.1 Database searches

For the current research, the researcher has used the keywords like oral cancer risk,

diabetic’s patient, oral issues according to age, gender and process. These keywords are used for

8

searching the articles for collecting the data and gaining the understanding of the topic of study.

These keywords have helped to find out related articles for analyzing research and develop a

strong background for current systematic review for oral cancer risk in diabetic patients. The

major database considered for research includes emerald-inside, academic search, Google

Scholar, Scopus and web of science (Layton and Clarke, 2016). The researcher has collected data

from these databases for collecting the data about oral cancer in diabetic people.

2.3.2 Search items

The researcher has used keywords like potential factors for oral cancer in diabetic

patients and prevention activities that used to overcome the impact of it. Moreover, the search

strategy of data is involving a search of books and journals that are providing information related

to oral cancer and diabetic people. The search strategy has focused on expert’s knowledge and

past researches that are based on the selected topic of research. The major search items are oral

cancer and diabetic people who are affected and having the possibilities of oral cancer. The

research terms are used to define the research objectives and collect the data about the relevant

outcome (Aromataris and Riitano, 2014). The terms that majorly used for collecting and

analyzing data are involving detail information about oral cancer, risk factors involve that causes

cancer for diabetic people.

2.3.3 Restrictions on the search

The major restrictions in systematic review for oral cancer in diabetic people were time

and cost of searching the data and analysis of key information which is important for study. The

researcher has spent a lot of time for searching the data for developing a strong theoretical

background for the study. Moreover, the cost of accessing the database and international libraries

was also high that has affected the fund planning and investment in the research. The restrictions

involve password protection and registration on the international library sites that have also

affected the time and cost for this particular research (Domecq and et al., 2014).

2.3.4 Journal hand searched

The journal hand searching refers to planned searching of journals pages by pages that

include editorial, letters, and research papers for collecting data related to the research topic and

meeting the objectives. The researcher has used hand searching process that involves manual

research options for searching the journals. The hand search process of journals involves page-

for-page, for articles and citations relevant to the systematic review (Gargon and et al., 2014).

9

Hand searching is an extended search technique used for finding the appropriate studies that may

have used for further studied about oral cancer in diabetic patients.

2.3.5 Organization and topic experts contacted

The systematic review of oral cancer in diabetic patients has required in-depth research

for managing data as well as gain the understanding regarding the topic of review. The major

focus of researcher was on past research and expert's content to improve the effectiveness of

research and to encourage the effectiveness related to the topic (Stone and et al., 2017). The topic

experts that are considered for study involve most viewed studies that are used for academic

research and meet the objectives of the research.

2.3.6 Internet search strategy

The internet search strategy that has been used by the researcher for systematic review

involves the use of search keywords that are determined by an investigator for further research

regarding the topic. The search strategy over the internet is used for managing data and use of

books, journals, online articles and research papers. This kind of study was helpful for analyzing

the current and more effective data to support the study (Civitello and et al., 2015). Moreover,

the internet search strategy has helped to overcome the time and cost of data research and

utilization of information.

2.3.7 Outcome of the search process

The major outcome of search process involves proper consideration of required

information and planning of functions that were used for conducting the research. The research

strategy has helped to cover all relevant topics and issues that were essential for systematic

review of oral cancer risk in diabetic people. The major outcome of research strategy involves

improvement in the numbers of cancer patients in the recent times (Weiss, and et al., 2017).

Moreover, the analysis of internet search strategy has also helped to maintain an appropriate

process for managing the research.

2.3.8 Justification

These keywords are used for searching the articles for collecting the data and gaining

the understanding of the topic of study. The major database considered for research includes

emerald-inside, academic search, Google Scholar, Scopus and web of science. The search

strategy has focused on expert’s knowledge and past researches that are based on the selected

topic of research. The major restrictions in systematic review for oral cancer in diabetic people

10

were time and cost of searching the data and analysis of key information which is important for

study. The hand search process of journals involves page-for-page, for articles and citations

relevant to the systematic review. The topic experts that are considered for study involve most

viewed studies that are used for academic research and meet the objectives of the research. The

search strategy over the internet is used for managing data and use of books, journals, online

articles and research papers. The major outcome of research strategy involves improvement in

the numbers of cancer patients in the recent times.

2.4 Study selection

2.4.1 Inclusion criteria

For the particular study, the inclusion criteria were used for analyzing the characteristics

that were used in the study. The major criteria that used for the current study involve oral cancer

risk, diabetic patients and their impact on the health of people who are suffering from this

disease (Vedovati and et al., 2015). The researcher has focused on key factors that are causing

oral cancer to the diabetic patients. The key features that were majorly considered for study

involve age, gender and ethnicity at the time of disease.

2.4.2 Exclusion criteria

The exclusion criteria refer in the study for avoiding the poor studies and activities that

are not relevant to the current systematic review. The researcher has analyzed specific studies

regarding oral cancer risk in diabetic people. The strongly justified reasons for exclusion involve

the poor content of researches and lack of equipoise as well as the difficulty in the intervention

of study and purpose of current study (Warnakulasuriya, and Ariyawardana, 2016). Moreover,

the researcher may not adhere to the rules and regulation for study lead to exclusion.

2.4.3 How the criteria used

The researcher has used criteria for systematic research to maintain the effectiveness and

justified the objectives for analyzing the factors for oral cancer in diabetic people. The selection

criteria for past studied involve outcome of the studies which are relevant to the current research

and approach. The major characteristics were considered regarding the chosen subject of study

and included in the study.

2.4.4 Outcome of the selection process

The outcome of the selection process involves inclusion and exclusion criteria for

investigating the information and using them for current research. The focus of the selection

11

process involves oral cancer risk factors and realistic outcome of research for taking the note for

the current research to meet the determined objectives (Geels and et al., 2015).

2.4.5 Justification

The major criteria that used for the current study involve oral cancer risk, diabetic

patients and their impact on the health of people who are suffering from this disease. The

researcher has analyzed specific studies regarding oral cancer risk in diabetic people. The major

characteristics were considered regarding the chosen subject of study and included in the study.

The chosen criteria have helped to maintain the flow of study and meet the desired outcome.

2.5 Critical appraisal

Critical appraisal is a systematic process for identifying the strength and weakness of

research articles selected for the systematic study. The critical appraisal of articles is useful for

maintaining usefulness and validity of research finding. The researcher has used reputed sources

for collecting the data as well as maintains the effectiveness that helps to increase the

understanding regarding topics. The process that used for critical appraisal of research involves

how the outcome was measured in the study, what was the effective size, what are the major

implications and applications of results in the study. The clinical process is important for

managing outcome as well as maintaining the effectiveness for oral cancer risk and diabetic

patients. The research would determine the reasons behind the increased risk and determine the

socio-demographic factors related to the risk (LoBiondo-Wood and Haber, 2014). The

investigation would highly contribute to finding out the relationship between oral cancer and

diabetes among the common people. The process that used for managing information regarding

oral cancer in diabetic people from different age and gender were helpful for meeting the

outcome of the study. The major criteria for maintaining the quality of the research for selection

of articles was studied on oral cancer and diabetic people.

The major outcome of the critical appraisal process involves different factors related to

the risk of both cancer and diabetes and its influences over the health of common people. The

data and findings have been evaluated on the basis of available cases and real-life events in the

diseases. The study reveals various facts related to both cancer and diabetes which could prove to

be helpful in the present research (Phillips and Swartz, 2014). The researcher has tried to

maintain quality and used the full research articles for developing a strong background for

systematic review and meeting the key objectives.

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2.6 Ethical appraisal

2.6.1 Process for ethical review

The ethical appraisal framework is used for carrying out the study for maintaining high

standards for research and collecting the data about the selected topic. The researcher has used

the ethical process of selecting articles and information for developing the strong theoretical

background of the systematic study. In order to produce ethically sound research across social

sciences setting the consideration of ethical framework is essential. The process that researcher

has used for the current study to maintain the ethical approach involve consequential ethical

thinking external and ecological approach for selecting data and relational ethical thinking to

produce the study (Lehnert and et al., 2015). The ethical framework helped to decide the

approach for managing the participants and keeping them engage in aims and objectives of the

research. The use of relational thinking for collecting data for oral cancer in diabetic people has

helped to develop relationships in both variables. The keywords that are used for researching the

articles have helped in designing the sensitive issues for study.

2.6.2 Principles used in the study

For ethical framework and maintaining the fair process in the study, the researcher has

used the ethical principles like consideration of moral problems in medical research, sources, and

evaluation of clinical trials. The specified articles are used in the study for developing the ethical

background and arguments that have supported for meeting the objectives of the systematic

review of oral cancer in diabetic people (Huang and et al., 2016). The human researches have

errors for the considerations of numerical data, but the researcher has tried to maintain the

research outcome according to the specified ethical principles.

2.6.3 Outcome of ethical appraisal

The major outcome of ethical appraisal involves the use of fair and reliable data for

managing information for offering the valid information for systematic review of selected

articles. The major outcomes of ethical appraisal involve collecting the sufficient knowledge and

understanding about the different mechanism and the tool which could justify the topic in an

enhanced manner (Smith, 2015). The investigator has collected useful information out of the

article and makes use of the same in the study. It would even describe the levels of risks and

different parameters set in various types of diabetes and cancer in an expanded manner.

13

2.6.4 Justification

The chosen ethical framework and principle has supported in the development of strong

and reliable background for systematic study. The consideration of moral problems in medical

research, sources and evaluation of clinical trials has helped to maintain a valid approach in the

planning of systemic review as well as proper analysis of information from the selected articles.

2.7 Data abstraction

The term data abstraction refers to data vitalization that recognized as popular articles

that have been selected for study to conduct the symmetric review. This has helped to maintain

consistency and security of information that has been used for further analysis of oral cancer risk

factors in diabetic people in different age and gender groups. For database administration, the

term data abstraction is good for managing the information. The researcher has used the

conceptual level of data for conducting a systematic review and providing information related to

the topic of the study (LoBiondo-Wood and Haber, 2014). The researcher has used the

verification process of extracting data by two reviewers for meeting the defined outcomes.

2.7.1 List of variables

Table 1: Data abstraction

Authors Citation Role Objecti

ves

Methods Results

EDWARD

GIOVANN

UCCI, MD,

SCD1

DAVID M.

HARLAN,

MD

MICHAEL

C.

ARCHER

Edward

Giovannuc

ci and et al

(2010)

The study was to

identify the aspects

related to the statement

that whether diabetes is

a risk factor for head

and neck cancer.

To

identify

oral risk

factors

in

diabetic

people

Primary Found that basic

reasons for the

association might

be the risk factors

like aging, diet,

obesity and

physical inactivity

specifically.

Eleftherios

vairaktaris

Eleftherios

vairaktaris

and et al.,

The study would reveal

the relationship between

oral cancer and diabetic

Identify

the

relations

Primary The researcher

had used a case-

control study

14

2008 patients stating the

figures out of the

evaluation.

hip

between

oral

cancer

and

diabetic

people

design so that to

evaluate the role

of diabetes in

developing

premalignant oral

lesions and

hamper the

patients

specifically.

Manu

Prasad

Sen1,

Nandita

Shenoy

Manu

Prasad and

et al.,

2017

The risk factors which

are common to both

cancer and diabetes, do

treatments of diabetes

influences the risk of

cancer, possible

biological links between

cancer risk and diabetes

and the association

between both the

diseases.

Analysis

of risk

factors

for oral

cancer in

diabetic

people

Secondary It has been

discovered that

oral cancer and

diabetes are

higher

interconnected

and involves

greater risks over

each other.

Marni

Stott-

Miller, Chu

Chen, Shu-

Chun

Chuang

(Marni

Stott-

Miller and

et al,

2011)

It has described that

diabetes is found to

promote the activation

of various cell receptors

which could influence

the factors of higher

risks towards cancer.

Risk of

oral

cancer in

diabetic

people

Primary The researcher

had identified

various relevant

aspects of oral

cancer and its

related policies

over health issues

Av.

Lothário

Meissner

(Lothario

and et al.,

2010)

Investigation of oral

cancer comprises many

different fields such as

epidemiology, risk

The

evaluati

on of

oral

Primary There are various

reasons behind

the issues such as

smoking, alcohol

15

factors, biological

markers, diagnostic

testing, screening,

treatment and prognosis.

cancer

risk

factors

in

diabetic

patients

consumption,

tobacco

consumption and

higher glucose

levels in people

Gong Y,

Wei B, Yu

L, Pan W

(Gong and

et al.,

2014)

The findings of this

meta-analysis indicate

that compared with non-

diabetic individuals,

individuals with type 2

DM have an elevated

risk of oral cancer and

precancerous lesions

development.

The

analysis

of oral

cancer

consider

ing type

2

diabetic

Secondary There is a higher

risk of oral cancer

in the type 2

diabetes mellitus

patients as

compared to the

non diabetic

people

Yuhua

Gong,

Benjuan

Wei, Li Yu,

Weijuan

Pan

(Yuhua

and et al.,

2015)

Type 2 DM was

associated with

increased oral cancer

mortality (SRR = 1.41,

95% CI: 1.16–1.72; 4

studies). Meta-analysis

of the four case-control

studies showed a

positive association

between type 2 DM and

risk of oral

precancerous lesions.

Associat

ion of

oral

cancer

risk with

diabetic

people

Secondary It concludes that

the issue of oral

cancer had

become a major

problem with the

late diagnosis and

critical impacts

on public health

L.Goutzani

sa E.

Vairaktaris

a

L.Goutzan

is and et al

(2007)

In light of recent

epidemiological studies

that associate diabetes

mellitus with increased

To

analyze

the risk

of oral

Primary It found that the

diabetic patients

might face higher

risks of oral

16

C.Yapijakis

a

risk for oral cancer.

Additionally, expression

was significantly higher

in rats with cancer in

comparison to the ones

without it, regardless of

the diabetes status.

cancer in

diabetic

people

and the

major

factors

cancer due to the

focal adhesion

kinase and insulin

receptor subtrate-

1 comparatively

to others

Dániel

Végh

Dániel

végh and

et al,

(2017)

Among diabetic

patients, the labial

tumor location showed

long-term dominance.

The smoking rate of

diabetes patients with

oral cancer was higher

in the present than in the

study.

Identific

ation of

key

factors

of oral

cancer in

diabetic

people

Primary Diabetes is a

major factor in

the development

of malignant

tumors at

different places

and lays negative

impacts on the

progression of

tumor and patient

survivals

Nandita

Shenoy

Nandita

Shenoy

and et al,

(2014)

Diabetes mellitus is a

serious and leading

health problem

worldwide and is

associated with severe

acute and chronic

complications that

negatively influence

both the quality of life

and survival of affected

persons.

Health

problem

s in

diabetic

people

regardin

g oral

cancer

Primary Patients with

diabetes are at

greater risk of

cancer and

possibly

influenced with

the same.

Siddharth

Pandit

Siddharth

Pandit and

The studies disclose that

the patients with

Analysis

of risk

Primary Results in

positive

17

et al,

(2015)

diabetes are at higher

risks of common

cancers like oral, breast,

pancreatic, urinary,

liver, etc. The

researchers had also

explored the association

between oral cancer and

diabetes with a possible

mechanism of both.

factors

in

diabetic

people

regardin

g oral

and

other

cancer

association

between the two

diseases and

severe lay

impacts on the

patients with

diabetes.

2.7.2 Strategies used for manage missing data

In order to manage the missing data the strategies that used by researcher involve

consideration of articles and abstracts of the studies using the keywords like oral cancer and

diabetic people. This strategy has helped the researcher to manage data and provide some

specific information related to study for oral cancer. The research strategy has helped to cover all

relevant topics and issues that were essential for systematic review of oral cancer risk in diabetic

people. The major outcome of research strategy involves improvement in the numbers of cancer

patients in the recent times (Mao and et al., 2015). Moreover, the researcher has used hand

searching process that involves manual research options for searching the journals. The

investigation would highly contribute to finding out the relationship between oral cancer and

diabetes among the common people. It would prove to be useful for many scholars and

researcher carrying out their studies on similar topics.

2.8 Analysis

For the analysis of articles and information collected from the secondary sources, the

researcher has used the clinical method. The clinical method of analysis is useful for managing

the information and clear distinction between preliminary evidence and confirmation data

analysis. According to this approach of data analysis, the sample population is small and

important for collecting the considerable preliminary data for the selected topic (Kraemer and

Blasey, 2015). The researcher has defined the size of data that needed for critical analysis and

effect of oral cancer in diabetic people from different age and gender.

18

Theme 1: Reasons for increasing oral cancer in diabetic people

The diabetic people are facing several issues that are affecting their life in many ways. To

protect these people from disease and other side effects the consideration of potential issues is

essential. In addition to this, the clinical data analysis method has helped to understand that, the

adult males are majorly affected by oral cancers who are engaged in heavy smoking and alcohol

drinking for long years. The major symptoms and signs of oral cancer include sore that does not

heal, sore that bleeds a growth lump or thickening of the skin or lining of the mouth. In addition

to this, the loose teeth, tongue pain, and jaw panning are leading to oral cancer for diabetic and

other people (Li and et al., 2015).

Theme 2: To assess the demographic determinants of higher oral cancer risk

The adult males are majorly affected by oral cancers who are engaged in heavy smoking

and alcohol drinking for long years. The most affected areas of oral part of a human that face

cancer situation involve buccal mucosa, hard palate, the gingival floor of mouth, lips and

oropharynx as well as the tongue. The study has analyzed and critically evaluated the potential

causes of oral cancer factors that are having the significant impact on the daily life functions of

these people. The diabetic people include a group of metabolic disorder that is characterized by

hyperglycemia caused due to complete or an incomplete lack of insulin secretion and insulin

resistance or both. The diabetes mellitus causes many immunologic and metabolic changes in the

oral mucosa. The impact of changes in the oral section has a significant impact on mouth

functions.

Theme 3: Determine the influences of the issue over the health of society

With the change in lifestyles, there had been a drastic increase in various diseases like

diabetes and cancer which laid a severe impact on the health of people nowadays. The current

study has been carried out with the intention to explore knowledge and facts about the risk of

Oral Cancer in Diabetes patient in an elegant manner. The basic reason found for the association

might be due to the risk factors like aging, diet, obesity and physical inactivity specifically. It has

been identified that the occurrence of type-2 diabetes and impaired fasting glucose had

significantly increased among the patients of oral cancer in the past few decades. The current

research includes the facts presented in the past studies so that to develop a strong theoretical

background and add more authentication to the same.

Theme 4: The relationship between oral cancer and diabetes among people

19

It has been identified that the issue of oral cancer had become a major problem with the

late diagnosis and critical impacts on public health. The study includes different risk factors

leading towards the critical disease. The researcher had identified various relevant aspects of oral

cancer and its related policies over health issues. The study has analyzed that both the diabetic

and non-diabetic individuals so that to get an efficient result out of the analysis. The researcher

in the present study had made use of the information to strengthen the fact and information and

make sure about the results out of it. Moreover, it has also identified that the risk factors that are

common to cancer and diabetes, possible biological links among cancer risk, influences of

treatment of diabetes over the risk of cancer and the relationship among both.

2.9 Boolean operating for research

The Boolean operations are used for research to find out the relevant data by merging and

separating two or more keywords. The major Boolean operations are used for the current study

are AND, OR and NOT. AND is used to narrow the results. The use of AND will retrieve search

results containing both keywords like oral cancer and diabetic patients. The OR Boolean is used

to broaden the search results (Zhang and et al, 2017). This Boolean is used to retrieve search

results containing either the keyword oral cancer or diabetic patients. Moreover, NOT Boolean is

used for narrow the search that containing oral cancer but will not retrieve search for diabetic

patients.

3. Result and discussion

3.1 Results

The result of the systematic review displays numerous useful facts and information

related to diabetes and oral cancer diseases. Different articles had focused on different

characteristics like gender, age, real-life events, case, etc. The studies mainly focused on the

influences and risks among the patients of diabetes and the consequences of oral cancer out of

the same. The major aim was to study and identify the factors that lead to oral cancer among

diabetic patients resulting in life-threatening or death events extensively (Yap, 2017). The

articles included in the study were majorly focused on the findings of risk factors and related

aspects of cancer and diabetes specifically.

3.2 Discussion

The major finding of the study depicts the fact of higher risks of diabetic patients having

oral cancer and might be influenced with the same extensively. The study identified that there is

20

a remarkable relationship between oral cancer and diabetes. The major reasons for the higher

risks of oral cancer found in the studies are a .late diagnosis of the issues, higher levels of

impaired glucose tolerance among people. The demographic profile of the patients could vary

from gender, obesity, diet, etc. While carrying out the systematic review, the major limitation

faced was a limited amount of time and budget which restricted in exploring wider sources

related to the subject matter (Dąbrowski and Grondecka, 2017). There were numerous useful

sources which were charged and could not be accessed due to a limited budget. However, the

researcher managed to overcome the limitation by accessing online libraries, published journals

and books available for free or low charges.

4. Conclusion and recommendation

4.1 Conclusion

The above review concludes with the findings of information and facts about the

association of diabetes and oral cancer among people. It has been found that there are higher

risks of occurring oral cancer among the people suffering from diabetes and could impact their

health to a greater extent. The review also revealed that there are various factors which could

lead towards the risk of cancer among diabetic people like age, obesity, diet, physical inactivity,

etc. The patients might incur the risk of oral, breast, pancreas, and urinary cancer due to diabetes

mellitus. It is even concluded that the studies focused on the issues of oral cancer and diabetes

had discovered immense numbers of real-life cases and events faced by the patients eventually.

However, the study reveals that higher diabetic rate is associated with the increased risk of oral

cancer among people. There are various reasons behind the issues such as smoking, alcohol

consumption, tobacco consumption and higher glucose levels in people. The researcher had used

a case-control study design so that to evaluate the role of diabetes in developing premalignant

oral lesions and hamper the patients specifically. The facts and information about different

articles in the current study played an important role in acquiring practical understanding and

data for the study.

In the study carried currently, the investigator had related the facts and information from

the present material and had made the best use of the same. It has been discovered that oral

cancer and diabetes are higher interconnected and involves greater risks over each other. The

study reveals the importance of identifying the risks and treating the same effect so that to

eradicate the issues out of the diseases. It has described that diabetes is found to promote the

21

activation of various cell receptors which could influence the factors of higher risks towards

cancer. It has been discussed that diabetes is considered as one of the factors which contribute to

the initiation and development of certain cancer issues specifically. The studies disclose that the

patients with diabetes are at higher risks of common cancers like oral and breast. It has been

identified that the occurrence of type-2 diabetes and impaired fasting glucose had significantly

increased among the patients of oral cancer in the past few decades.

The current research includes the facts presented in the past studies so that to develop a

strong theoretical background and add more authentication to the same. The research has helped

to understand in the impact of specific medication to the patients and risks of the same. It has

been identified that the insulin receptor substrate-1 (IRS-1) and focal adhesion kinase pathway

(FAK) are distorted by diabetes which leads towards the reduction in cell adhesive and might

enhance the risks of oral cancer eventually. In the context of the current research, the investigator

had extracted useful information about oral cancer and its impacts on the public. The study

focused on both the diabetic and non-diabetic individuals so that to get an efficient result out of

the analysis. It has been identified that the issue of oral cancer had become a major problem with

the late diagnosis and critical impacts on public health. The study includes different risk factors

leading towards the critical disease.

4.2 Recommendation

In the context of the research, it is recommended that the investigation must be carried

out with authentic facts so that to validate the findings of the same. The findings are found to be

highly useful for the purpose of education as well as the management of hospitals for their future

case studies. It is very important to make realistic investigations and outcomes so that the facts

could be practiced and studies by the other scholars and researchers in their studies relevant to

the subject matter. The study suggested various facts related to both cancer and diabetes which

could prove to be helpful in the present research. It concludes that there is an association

between cancer and diabetes and includes higher risks among the patients.

22

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Appendix

Figure 1: Oral cancer facts

(Source: https://todaysorthodontist.com/oral-cancer-everything-you-need-to-know/)

Figure 2: Oral cancer risk factors

(Source:

http://www.ijnpnd.com/viewimage.asp?img=IntJNutrPharmacolNeurolDis_2016_6_2_51_17996

4_u1.jpg)