Management of oral

submucous fibrosis
By
S.Roja prabha
 DEFINITION

• An insidious chronic disease affecting any part of

the oral cavity and sometimes pharynx although
occasionally preceded by and/or associated with
vesicle formation .it is always associated with
juxtaepithelia inflammatory reaction followed by
fibroelastic changes of lamina propria ,with epithelial
atrophy leading to stiffness of oral submucous and
causing trismus and inability to eat
(Pindborg and sirsat in1966)
 ETIOLOGY

• ARECANUT CHEWING
• BACTERIAL INFECTION
• NUTRITIONAL DEFECIENCY
• DEFECTIVE IRON METABOLISM
• COLLAGEN DISORDERS
• IMMUNOLOGICAL DISORDERS
• GENETIC SUSCEPTIBILITY
• ALTERED SALIVARY COMPOSITION
PATHOGENESIS
 Clinical features
• Onset is insidious
• Burning sensation
• Blanching of mucosa
• Difficulty in swallowing
• Trismus
• Dry mouth
• Inability to blow,whistle
• Change of gustatory sensation
• Shrunken uvula
• Nasal tonality of voice
 Staging osmf

Khanna and Andrade(Based on mean interincisal opening)

Stage 1. Early osmf without trismus (MIO>35mm ,burning
sensation,recurrent stomatitis,acute ulcer)

Stage 2 Mild to moderate disease (MIO :26-35mm mottled and marble

like appearance widespread sheets of fibrosis palpable
Satge 3. moderate to severe disease (MIO:15-25 trismus vertical fibrous
band palpable at soft palate
Stage 4a.severe disease (MIO<15 ,severe trismus.thickened faucial
pillars ,shrunken
uvula,restricted tongue movement )
Stage 4b extremely severe(premalignant/malignant,presence of
hyperkeratotic leukoplakia
 Lab investigation
• Decreased Hb level
• Decreased iron level
• Decreased protein level
• Decreased ESR
• Decreased vit b complex
 BIOPSY REPORT

• Atrophic oral epithelium

• loss of rete pegs
• Hyalinisation of collagen
• Epithelial atrophy
• Decreased fibroblast and blood vessel obliteration
 Malignant transformation

• oral submucous fibrosis to squamous cell carcinoma has

been estimted to between 2-8%
 Treatment
• Cessation of habits
• Medical
• Surgical
• Oral physiotherapy
• Diathermy
• Utrasound
• Stem cell theraphy
• CESSATION OF HABITS
cessation of habit of eating betel quid,areca nut and
other local irritants ,spicy and hot foods,alcohol and
smoking through education and motivation
 Medical

• 1. supportive
a)vitamin rich diet along with iron preparation
b) injection ranodine
each 2ml consists of
methyltrioxyethyl iodomine
vitamin B1-1.0mg
vitamin-B6-0.3mg
vitamin B2-0.6mg
nicotinamide-15.0mg
calcium pantothenate 1.0mg
c)injection arsenotyphoid
• 2.STERIODS
A)LOCAL
Hydrocortisone injection along with procaine
hydrochloride injection
Inhibits the proliferation of fibroblast
Inhibit the inflammatory response
b)SYSTEMIC
I)CORTISONE
Hydrocortisone 25mg tab in doses of 100mg/day
Triamcinalone or 90 mg of dexamethosone
• 3.PLACENTAL EXTRACT
It is a essential biogenic stimulator
It contains
nucleotides,enzymes,vitamins,steriods,fattyacids,trace
element
Dose –2ml of injetion is deposited at the interval of 3
days for 15 days
• LYCOPENE
It is an antioxidant useful in improving healing
lycopene oral capsule in combination with beta
carotene ,selenium are given on daily basis
most commonly used SM FIBRO-
• 4)HYALURODINASE
Hyalurodinase injection
Reduces the burning sensation and trismus
Acts by breaking down the hyaluronic acid ,lowers
the viscosity of
intracellular substances
Decreases collagen formation
• 5)Pentoxifylline
• It is a methylxanthine derivative
• Has vasodilating properties and increases mucosal
vascularity
• Pentoxiphylline theraphy: 400mg 3 times daily for 7
months
(conducted by Rajendran et
al )
• 5) VITAMIN E
Vit E along with dexamethasone and hyaluronidase
injection

• OTHER THERAPIES
Vitamin A ,collagenase
,chymotrypsin,interferon gamma,immune milk
 SURGICAL
• INDICATION
• Limitation of mouth opening
• Biopsy reveals neoplastic changes
• Dysphagia
• 1) CONVENTIONAL
Surgical excision of fibrous band followed by
Buccal fat pad
Nasolabial flap
Tongue flap
Split thickness skin graft
 Buccal pad fat reconstruction
• Buccal fat pad is a supple and lobulated mass which is easily accesible and mobilized
Advantage
Easily available
Has rich blood supply
No morbidity to the secondary donor site
Harvesting technique is simple
Epithelisation of BFP takes place by the 7th post op day and is completed at the end of 4 th
week
DISADVANTAGE
It would not be sufficient for big wound
 Buccal fat pad reconstruction
PROCEDURE
An incision was made in the buccal mucosa along the occlusal line and
fibrous band were sectioned
Buccal fat pad was removed by dissecting a tunnel along the ascending
ramus of the mandible and from lateral surface of buccinator muscle

The fat was interposed in the raw area and sutured to the mucosa using 3.0
vicryl

Tincture benzoin packs were placed for haemostasis

 NASOLABIAL FLAP
• Buccal mucosa was incised transversely from just behind the commissure of
the oral cavity ,fibrous bands were excised
• Maxillary and mandibualr third molar are extracted
Nasolabial flap from the tip of nasolabial fold to corner of the mouth were
marked and bilaterally raised in the plane of the superficial
musculoaponeurotic system
• The flap was transposed intraorally through a small transbuccal tunnel near
the commissure of the mouth with no tension
• The transposed flap were used to cover the intra oral defects
• after a latent period of 10 days ,physiotheraphy was started to prevent the
contractures and relapse
• 2)LASER
CO2 laser surgery offers advantage in alleviating the
functional restriction
Under general anesthesia CO2 laser is used to incise the
buccal mucosa and vapourise the sub mucosal
connective tissue
hemostasis is provided by the lased surface itself and
the mouth opening increases by itself
• 3) CRYOSURGERY
It is a method of local destruction of tissue by
freezing it in situ
Liquid nitrogen or argon gases are used preferrably
as s spray through cryoprobe guided by MRI/USG
 ORAL PHYSIOTHERAPHY

• Oral exercise are indicated in early and

moderately advanced cases
• This includes mouth opening and ballooning of
mouth
• Forceful mouth opening have been tried with
mouth gag and acrylic screw gauge
 DIATHERMY
• Microwave diathermy is useful in some early and
moderately advanced cases
• Low current is used (20watts x 2450 cycles)
• It acts by physiofibrolysis of bands
 ULTRASOUND
• Selectively rises the temperature in well circumscribed
area
• Efficient deep heating modality
• Ultrasound used for therapeutic purpose has frequency of
0.8-1MHz
• Intensity of 0.5-3w/cm2
 STEM CELL THERAPHY
• Intralesional injection of autologous bone marrow stem
cells
• It induces angiogenesis in the area of lesion which in turn
decreases the extent of fibrosis
 CONCLUSION
• Oralsubmucous fibrosis is an irreversible condition .and
has no effective treatment ,Early diagnosis,and treatment
and elimination of betel nut chewing habit may help in
resolving the condition