oral submucous fibrosis, pre malignant

ORAL SUBMUCOUS FIBROSIS

Haris MehmoodBDS-III

DEFINITIONOSF is chronic disease of oral cavity

characterized byInflammation and progressive fibrosis of

submucosal tissues

Resulting in inability to open the mouth (Trismus)

It is a pre malignant condition

Obscure (unclear)

Betel Quid or pan

Diet (Spice or Chillies)

Components of Betel Quid

Areca nut Biologically active alkaloids

Arecholine, Arecaidine, arecolidine, guvacoline, guvacine, flavonoids, tannins, catechins.

Copper

TobaccoSlaked limeCatechu

Nutritional DeficienyVitamin B complex deficiencyIron deficiency

derange the repair of the inflamed oral mucosa, leading to defective healing and resultant scarring.

Genetic predisposition

Arecoline, a substance found in betel nuts, stimulates the production of collagen by fibroblasts, producing a pale, marble-like appearance in the tissues

Tannins from areca nut causes:Activation of fibroblastCross linking of collagen peptide chainsInhibition of collagen degradationInflammation

Cytokine and growth factor production fibrosis

Areca nut contain copper that induces Lysyl oxidase activity.

upregulate collagen synthesis by fibroblastsFacilitate its cross linkingInhibit its degradation

(Ref: Research letters, The Lancet. www.hawaii.edu)

Eating chillies: Hypersenstivity reaction to capsaicin

Typically affect Buccal mucosaLipsRetromolar areaSoft palateTongue

Occasional InvolvementPharynxEsophagus

Oral tissues are affected symmetrically

Burning sensationWhile chewing spicy foods

Blanching of mucosaimpairment of local vascularity because of

increasing fibrosis and results in a marble-like appearance.

small vesicles form after they eat spicy food:an allergic reaction to capsaicin.

Vesicles rupture to form ulcers

Fibrous band Lips

thickrubbery difficult to retract

CheeksThick and rigidAbsence of puffed out appearance when patient blows or

whistle Tongue

Restriction of movementBlanching or Fibrosis of ventral mucosaDepapillation

Soft palate Uvula

Shruken

Tight vertical bands in buccal mucosa , labial mucosa and soft palate are palpable

Restricted mouth opening (TRISMUS)Less than 20mm is considered severe.

Areas appear white (smooth, thin and atrophic)Marble like Pallor is due to underlying fibrosis

and ischemiaIncreased salivationChange of gustatory sensationHearing loss due to stenosis of the eustachian

tubesDryness of the mouthNasal tonality to the voiceDysphagia to solids (if the esophagus is involved)

Lab Studies

No specific laboratory tests are available for OSF. Some OSF studies report the following laboratory findings:

Decreased hemoglobin levelsDecreased iron levelsDecreased protein levelsIncreased erythrocyte sedimentation rateDecreased vitamin B complex levels

Oral Biopsy

EPITHELIUMEpithelial atrophy Epithelial atypiaEpithelial dysplasia (10 to 15 % cases of

biopsy)Sub epithelial vesiclesHyperkeratosisLoss of rete pegs

Hyperkeratotic epithelium

Lamina PropriaFibrosislarge fibroblastsAvascular (blood vessels obliterated or

narrowed)Chronic inflammatory infiltrateHyalinization (translucent)Homogenization of collagen bundlesFibroblasts are markedly diminished in number

Collagenization of sub epithelial tissue

Medical Care

The treatment of patients with OSF depends on the degree of clinical involvementEarly stage: Cessation of habit is suficientModerate-to-severe OSF is irreversible

Treatment includes the following:Intra lesional steroid HylarunidaseIFN gamma

Surgical CareIndication:

Severe trismusBiopsy reveal dysplastic or neoplastic change

Simple excision of the fibrous bandsSplit-thickness skin grafting

ConsultationENT specialistPlastic surgeon

DIETReduce exposure to risk factors such as betel

quidCorrect nutritional deficiencies, such as iron

and vitamin B complex deficiencies

ACTIVITY:

Muscle stretching exercises for the mouth may be helpful to prevent further limitation of mouth movements

Prognosis depends upon the stage of tissue damage.

Fibrosis often recurs.Regular follow up is important.Malignant change is reported to be about 5-8

percent.

Special Concerns

Watch for signs that indicate malignant change, which include the following:An unhealing ulcer in the lesionLesion undergoing red changes (erythroplakia)A burning sensation in the mouthAn exophytic massA lump in the neckDifficulty in chewing, swallowing, or speaking

GOOD PROGNOSIS