Oral sub mucous fibrosisOral sub mucous fibrosis

Dr V.RAMKUMAR

CONSULTANT DENTAL&FACIOMAXILLARY SURGEON

REG NO 4118 –TAMILNADU –INDIA-(ASIA)

Oral submucous fibrosisOral submucous fibrosis is a chronic insidious disease of is a chronic insidious disease of the oral mucosa characterized by loss of mucosal elasticity the oral mucosa characterized by loss of mucosal elasticity and excessive fibrosis leading to progressive difficulty in and excessive fibrosis leading to progressive difficulty in opening the mouth. opening the mouth.

OROR

“ “An insidious chronic disease affecting any part of the oral An insidious chronic disease affecting any part of the oral cavity and sometimes the pharynx. although occasionally cavity and sometimes the pharynx. although occasionally preceded by and or associated with vesicular formation ,it preceded by and or associated with vesicular formation ,it is always associated with a juxta epithelial inflammatory is always associated with a juxta epithelial inflammatory reaction followed by a fibro elastic change of the lamina reaction followed by a fibro elastic change of the lamina propria , with epithelial atrophy leading to stiffness of the propria , with epithelial atrophy leading to stiffness of the oral mucosa and causing trismus and inability to oral mucosa and causing trismus and inability to eat(PINDBORG-1952) eat(PINDBORG-1952)

PrevalencePrevalence

Indian Subcontinent, Asian countries.Indian Subcontinent, Asian countries. Asian immigrants in South Africa ,UK, Asian immigrants in South Africa ,UK,

other countries abroad.other countries abroad.

Pindborg (1980) Pindborg (1980) - 2,50,000 cases in India. - 2,50,000 cases in India.

..

Precancerous potentialPrecancerous potential

Paymaster(1956)- 1Paymaster(1956)- 1stst mentionof precancerous nature of mentionof precancerous nature of OSMF.OSMF.

Murti Murti et al., et al., (1985) Malignant transformation rate -7.6%(1985) Malignant transformation rate -7.6%

AETIOLOGYAETIOLOGY use of chillies-capsicum annum and capsicum use of chillies-capsicum annum and capsicum

grutescensgrutescens nutritional deficiencies- vitamin deficiency protein nutritional deficiencies- vitamin deficiency protein

deficiency iron deficiencydeficiency iron deficiency pan masala, pan, tobacco, arecanut chewingpan masala, pan, tobacco, arecanut chewing other etiological factorsother etiological factors

elevated IgG levels has been reported suggesting auto elevated IgG levels has been reported suggesting auto immunityimmunity

genetic predispositiongenetic predisposition according to a study by warna kula suriya(j oralmed according to a study by warna kula suriya(j oralmed

oral pathdec 2000) role of copper in osmf has been oral pathdec 2000) role of copper in osmf has been evaluated copper in arecanut can act as a mediator of evaluated copper in arecanut can act as a mediator of osmf it is assumed that copper upregulates collagen osmf it is assumed that copper upregulates collagen production in oral fibroblasts. production in oral fibroblasts.

chillieschillies osmf predominant in Indians who season their food osmf predominant in Indians who season their food

with chillieswith chillies frequent intolerance to spicy food by osmf patientsfrequent intolerance to spicy food by osmf patients

vesiculation following intake of food laced with vesiculation following intake of food laced with chillieschillies

no etiological role of chillies could be found in his no etiological role of chillies could be found in his studies between osmf and control patientsstudies between osmf and control patients

osmf occurred in people with arecanut chewing osmf occurred in people with arecanut chewing habithabit

nutritional deficienciesnutritional deficiencies iron vitamin b complex A ,C deficiency more in iron vitamin b complex A ,C deficiency more in

osmf patients than in controlsosmf patients than in controls

arecanut chewingarecanut chewing several epidemiological studies provide support several epidemiological studies provide support

linking arecanut chewing with oral sub mucous linking arecanut chewing with oral sub mucous fibrosisfibrosis

Areca nut consumption - the most important factor in the Areca nut consumption - the most important factor in the causation of OSMF .causation of OSMF .

the frequency of consumption was found to be more the frequency of consumption was found to be more important than duration.important than duration.

All cases of OSMF had areca chewing habits.All cases of OSMF had areca chewing habits. Pan masala chewing was found to have the highest risk for Pan masala chewing was found to have the highest risk for

developing OSMF.developing OSMF.

clinical featuresclinical features affects both sexes with a predominance of women affects both sexes with a predominance of women

(rao 1962 pindborg 1968 gupta 1980)(rao 1962 pindborg 1968 gupta 1980) age groups twenty to forty years.in India more age groups twenty to forty years.in India more

frequent among people over age of fortyfrequent among people over age of forty areas affected buccal mucosa retromolar areas also areas affected buccal mucosa retromolar areas also

affects soft palate palatal fauces uvula tongue and affects soft palate palatal fauces uvula tongue and labial mucosalabial mucosa

osmf originates in posterior most part of oral cavity osmf originates in posterior most part of oral cavity and progress anteriorly (can depend on whether the and progress anteriorly (can depend on whether the quid is swallowed or spit out)quid is swallowed or spit out)

onset is insidious over two to five yearsonset is insidious over two to five years

symptomssymptoms extraorally excess pigmentation or loss of extraorally excess pigmentation or loss of

pigmentation of vermilion border is one of the pigmentation of vermilion border is one of the symptomssymptoms

most common initial symptom is burning most common initial symptom is burning sensation of the oral mucosa aggravated by spicy sensation of the oral mucosa aggravated by spicy foodfood

vesiculation excessive salivation ulceration vesiculation excessive salivation ulceration pigmentation changes recurrent stomatitis pigmentation changes recurrent stomatitis defective gustatory sensation and dryness of defective gustatory sensation and dryness of mouthmouth

gradual stiffening of mouth after a few years of initial gradual stiffening of mouth after a few years of initial symptomssymptoms

inability to open mouth- trismus eventually occursinability to open mouth- trismus eventually occurs when fibrosis extends into pharynx and oesophagus when fibrosis extends into pharynx and oesophagus

patient may experience difficulty in swallowing the patient may experience difficulty in swallowing the foodfood

referral pain in the ears deafness and nasal voice also referral pain in the ears deafness and nasal voice also has been observed.has been observed.

hypogeusia or loss of taste sensationhypogeusia or loss of taste sensation regurgitation of foodregurgitation of food

SignsSigns earliest sign is the blanching which gives a marble like earliest sign is the blanching which gives a marble like

appearance to oral mucosaappearance to oral mucosa it can be localized diffuse or in the form of a lace like it can be localized diffuse or in the form of a lace like

networknetwork diagnosis is based on the palpation of the fibrous bandsdiagnosis is based on the palpation of the fibrous bands involvement of lips characterised by the presence of involvement of lips characterised by the presence of

circular fibrous bands around the lipcircular fibrous bands around the lip in severe labial involvement the lips are leathery and in severe labial involvement the lips are leathery and

may have difficulty in everting themmay have difficulty in everting them the faucial pillars become thick and short and tonsils the faucial pillars become thick and short and tonsils

may be compressed between the pillarsmay be compressed between the pillars

when the soft palate is affected its mobility is when the soft palate is affected its mobility is restricted restricted

the uvula when involved is shrunken and is bud the uvula when involved is shrunken and is bud likelike

tongue is devoid of papillae and is extremely tongue is devoid of papillae and is extremely stiff. Its protrusion may be impairedstiff. Its protrusion may be impaired

the floor of the mouth is blanched and leathery the floor of the mouth is blanched and leathery and the gingival is fibrotic depigmented and and the gingival is fibrotic depigmented and devoid of its normal stippled appearancedevoid of its normal stippled appearance

petechiae can be seenpetechiae can be seen depapillation of tonguedepapillation of tongue

Grade 1-only blanching of oral mucosa without Grade 1-only blanching of oral mucosa without symptomssymptoms

Grade 2-burning sensation dryness of mouth Grade 2-burning sensation dryness of mouth vesicles or ulcers in the mouth without tongue vesicles or ulcers in the mouth without tongue involvementinvolvement

Grade 3-in addition to grade 2 restriction of mouth Grade 3-in addition to grade 2 restriction of mouth opening will be thereopening will be there

Grade4- in addition to grade 3 palpable bands Grade4- in addition to grade 3 palpable bands present all over the mouth with out tongue present all over the mouth with out tongue involvementinvolvement

Grade5-grade4 and tongue also involvedGrade5-grade4 and tongue also involved

Grade6-osmf with histopathologically proven Grade6-osmf with histopathologically proven oral canceroral cancer

Microscopic featuresMicroscopic features

*atrophic epithelium with juxtaepithelial *atrophic epithelium with juxtaepithelial hyalinisation and collagen of various density. hyalinisation and collagen of various density. The epithelium is often keratinizedThe epithelium is often keratinized

*atrophic epithelium with out reteridges and in *atrophic epithelium with out reteridges and in advanced cases it will be ribbonlikeadvanced cases it will be ribbonlike

*presence of epithelial dysplasia and signet *presence of epithelial dysplasia and signet

cellscells

BIO CHEMICAL ANALYSISBIO CHEMICAL ANALYSIS

Copper hCopper higher in areca samples-302 nmol/gm.igher in areca samples-302 nmol/gm. About 11.3% copper soluble in vivo in human About 11.3% copper soluble in vivo in human

saliva. saliva. Chewing areca nut for 5.30mins significantly Chewing areca nut for 5.30mins significantly

increase soluble copper in whole mouth fluids. increase soluble copper in whole mouth fluids.

The role of copper should be assessed in OSMF The role of copper should be assessed in OSMF as it is involved in other fibrotic diseases.as it is involved in other fibrotic diseases.

Trace elementsTrace elements are inorganic molecules present in are inorganic molecules present in the human, animal and plant tissue in mg/kg the human, animal and plant tissue in mg/kg amounts with minimal requirement of less than amounts with minimal requirement of less than 100mg/day100mg/day..

Copper and Zinc- important trace elements.Copper and Zinc- important trace elements.

Copper is important in connective tissue formation.Copper is important in connective tissue formation.

Zinc influences mucosal absorption of copper Zinc influences mucosal absorption of copper

a cofactor of the collagen degrading enzyme a cofactor of the collagen degrading enzyme collagenase.collagenase.

Treatment modalities based on Treatment modalities based on gradinggrading

Gupta dinesh chandrs ind omfs 1992Gupta dinesh chandrs ind omfs 1992 Group I : removal of etiological factors Group I : removal of etiological factors Multivitamin and iron therapyMultivitamin and iron therapy Group II : topical therapy Group II : topical therapy Group III : injectable therapyGroup III : injectable therapy Group IV : micro wave diathermyGroup IV : micro wave diathermy GROUPV: surgical treatmentGROUPV: surgical treatment