DOI 10.1007/s10006-014-0478-x
ORIGINAL ARTICLE
Received: 30 June 2014 / Accepted: 30 November 2014 / Published online: 17 December 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose Oral submucous fibrosis till date is a very poorly
understood and unsatisfactorily treated disease with variable
signs and symptoms. In this paper, we have classified the
disease in different groups according to the clinical signs,
radiological assessment, histopathological confirmation,
progress, and severity of disease and proposed a treatment
algorithm for effective treatment of the disease in 100 patients.
Material and method In our study, we randomly selected 100
patients of oral submucous fibrosis and classified them in to
five groups based on clinical symptoms and radiological and
histopathological parameters. We have given specific treatment for each group and followed them up for 2 years
regularly.
Results We found that almost all patients got symptomatic
relief from the disease. Patients interincisal mouth opening
increased significantly. All patients can take regular diet.
Progressive malignant transformation can be detected earlier
to avoid future morbidity and mortality.
Conclusion Oral submucous fibrosis (OSMF) scoring index
is very effective to decide the severity of disease and progress.
Based on this scoring and grouping we can give definite
prompt treatment to the patients with satisfactory results. Such
a way this proposed scoring and staging can play major role in
controlling and treating this widespread global disease.
Introduction
Oral submucous fibrosis (OSMF) may be defined as an insidious, chronic disease affecting any part of the oral cavity and
sometimes the pharynx. Although occasionally preceded by
and/or associated with vesicle formation, it is always associated with a juxta-epithelial inflammatory reaction followed by
a fibroelastic change of the lamina propria, with epithelial
atrophy leading to stiffness of the mucosa and causing trismus
and inability to eat [1]. A condition resembling OSMF was
described as early as 600 B.C. by Sushruta and it was named
as vidari [2]. The characteristic features of OSMF are loss of
pigmentation, blanching, and leathery texture of oral mucosa;
depapillation and reduced movement of the tongue, progressive reduction of mouth opening; and sometimes sunken
cheeks.
OSMF occurs at any age but is most commonly seen in
adolescents and adults especially between 16 and 35 years [2].
The prevalence rate in India is about 0.20.5 % [3] and the
prevalence by gender varies from 0.2 to 2.3 % in males and
1.2 to 4.57 % in females [4]. The malignant transformation
rate (730 %) [5] poses global problems for public health
where in our study was 14 %. The etiology of OSMF is
multifactorial but remains obscure. Although areca nut is
considered to be the most important causative agent [3, 6],
and responses observed in individuals using areca nut vary in
relation to quantity and duration. Once initiated, OSMF is not
amenable to reverse at any stage of the disease process even
after cessation of the causative factor of areca nut chewing [4].
Because of variable clinical presentation in different patients,
it is needful to understand the progress and severity. To
understand this, we propose the scoring index.
Four parameters like, mouth opening, involvement of site
in the oral cavity, severity and extent of fibrosis and presence
of any malignant change were denominated while determining the OSMF scoring index and patients were divided into
202
Grade
Mouth opening ()
Grade I
Grade II
Grade III
6050
4940
<40
4030
2920
<20
OSMF score
203
Groups
Mouth
opening (O)
Site (S)
Presence of
malignant feature
(clinical and
histopathological) (M)
Group I
O1
S1
Ma
F1
67
Group II
O2
S2a
Ma
F2
O3
S2b
S2b
Ma
F3
O3
S3
S3
Mp
F3
O3
S4
S4
Ms
F3
910
1112
13
Group III
Group IV
Group V
Group I: score 13
Group II: score 67
Group III: score 910
Group IV: score 1112
Group V: score 13
In our study of 100 patients, we classified our patients into
five different groups as mentioned above and implemented
treatment as follows (Table 5). Before the commencement of
treatment, all patients were advised for the cessation of habit,
balanced diet, and postoperative physiotherapy.
and nasolabial flap depending upon the extent and site of the
defect.
Group V with a score of 13 Five patients of oral submucous
fibrosis with advanced established malignant disease were
treated with definitive radical surgical treatment with neck
dissection and removal of lesion followed by radiotherapy.
All the patients were followed up for 2 years.
Results
Group I with a score of 13 Forty three patients with a score
of 3 were treated with topical triamcinolone ointment thrice a
day on the buccal mucosa and pterygomandibular raphe area,
and patients with ulcers were given topical anesthetic gel for
the relief of pain. Multivitamins tablet containing lycopene,
beta carotene, alpha carotene, lipoic acid, and minerals like
zinc and selenium were given BD for effective result.
Group II with a score of 67 Thirty patients with a score
of 67 were treated with injectable steroids and antioxidants with physiotherapy. The submucosal injections of
triamcinolone acetonide (40 mg) and hyaluronidase
(1500 IU) with 2 % xylocaine at 15-day interval for
34 months were injected into the faucial pillars,
retromolar area, and buccal mucosa.
Group III with a score of 910 Thirteen patients with a score
of 910 were treated by surgical intervention in which
fibrotomy was done to remove fibrous band, coronoidectomy,
all third molar extraction, and flaps used for covering of defect
by nasolabial flap and buccal pad of fat.
Group IV with a score of 1112 Nine patients with a score of
1112 were treated by elimination of etiological factor of
premalignant condition other than OSMF like prohibition of
habit and sharp and broken teeth and then treated with excision of lesion and defects were covered with buccal pad fat
204
Table 3 Illustration of
results for group I and
group II
No. of patients
Group I
43
Group II
30
1st month
2nd month
3rd months
1st month
2nd month
3rd month
Discussion
Oral submucous fibrosis is considered as a disease of the
Indian subcontinent [7] because of its high occurrence and
confinement of the disease within Southeast Asia. Because of
the popularity and easy availability of the betel nut and its
product, the disease has broken all the borders of the region
and the age of the occurrence. Though by initial appearance of
the sign and symptoms of the disease the condition seems to
be benign, it has high malignant potential. Its premalignant
nature was first described by Paymaster in 1956 [8]. Older
studies showed a variable malignant transformation rate from
3 to 7.8 % [9] while recent studies have shown very high
malignant transformation rate from 7 to 30 % [5]. Now, the
time has come when we have to think seriously and take a
prompt action with oral submucous fibrosis which is taking a
toll in millions of population.
As explained earlier, the oral submucous fibrosis is the
disease of fibrosis resulting from disturbed metabolism of
the collagen fibers secreted by the fibroblast of the
subepithelial connective tissue of the oral mucosa. The patient
affected with oral submucous fibrosis reported a wide range of
symptoms like burning sensation and stomatitis, stiffness of
the mucosa, reduced mouth, altered speech, and, in advanced
Burning sensation
Stomatitis
Trismus
88.37
93.02
97.67
80
86
100
83.72
95.34
100
70
83.33
100
72.09
83.72
100
63.33
80
100
23.33 %
60 %
3040
44.44 %
3040
46.15 %
>20 mm
100
100
100
60
80
100
80
80
100
05
Group V
1st month
2nd month
3rd month
>20 mm
100
100
100
88.88
100
100
66.66
77.77
88.88
09
Group IV
1st month
2nd month
3rd month
53.84
76.92
92.30
13
Group III
1st month
2nd month
3rd month
46.15
61.53
84.61
Trismus
Stomatitis
Burning
sensation
100
100
100
>20 mm
Mode of treatment
Mouth
opening
Improvements of symptoms (%)
No of
patients
205
Fibrotomy, coronoidectomy,
all 3rd molar extraction,
and covering defect with
various flaps
Excision of lesion, fibrotomy,
coronoidectomy, all 3rd molar
extraction, and covering defect
with various flaps
Excision of lesion with
effective safety margin
with neck dissection
3040
Intraoperative mouth
opening (mm)
206
Table 5 Demonstration
of different treatment
modalities used
Scoring index
Stages
03
Group I
No. of patients
Mode of treatment
43
Antioxidants, topical
steroids, physiotherapy
M=40
67
Group II
F=03
30
M=22
910
Group III
F=08
13
M=11
F=02
1112
Group IV
9
M=7
F=2
13
Group V
5
M=4
F=1
Conclusion
207
References
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3. Candramani Bhagvan More, Swati Gupta, Jigar Joshi, Saurabh N
Varma Classification system for oral submucous fibrosis review article
10.5005/jp-journals-10011-1254
4. Joseph AP, Rajendran R. Submucosa precedes lamina propria
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