Oral Sub mucous Fibrosis by Dr. Bhavik Patel

Introduction

Oral Sub mucous Fibrosis is considered to be a potentially malignant condition of the oral cavity which affects lamina propria, sub mucosa and deeper tissues with increased production of collagen fibers and loss of fibro elasticity.
Commonly seen in Asia pacific region, this disease mostly targets buccal tissues, palate, retromolar pad region and upper part of pharynx and associated with the following clinical features –
  • Trismus
  • Burning sensation
  • Stiffness of mucosa
  • Loss of mobility of tongue

etiology

There are various authors with different beliefs and evidences, hence it is considered as a multifactorial pathological condition with the following commonly associated etiological factors:
  • Capsasin
  • Betel nut alkaloids
  • Hypersensitivity reaction
  • Genetics
  • Tobacco
  • Vitamin B complex deficiency

OSmF and Oral Cancer

 

 

 

Oral sub mucous fibrosis is a potentially malignant condition; many authors have conducted researches which indicate 2-10% of development of OSF into oral cancer. This is indeed a very serious number which indicates that any such condition must not be allowed to develop further and treated as well as prevented at every possible level.

 

 

Prevention of osmf

 

 

The disease can be prevented if the collagen formation has not started yet and it is in its initial stages of development, once it develops there can be only symptomatic management done for it.
Best way to prevent is by cessation of any consumption of beetle nut and chillies, along with taking a healthy and nutritious diet.

 

 

Can consumption of too much chillies cause osmf?

 

 

 

Yes, there are many studies which indicate there is involvement of high consumption of chillies in development and progression of this condition, therefore as a precautionary measure avoiding chilli in any way is a part of many treatment regimes , this not only helps to decrease the progression but also provide symptomatic relief from burning sensation.

Habits associated with osmf

 

 

 

It is commonly seen that patients suffering from osmf are having some bizarre chewing habits, these are basically various compounds chewed as recreational activity which contains some chemicals to provide pleasure to the consumer.
These habits are considered a major cause of development of osmf by many authors; some patients may have more than one habit. These habits are often associated with religious rituals performed by their community hence sometimes it is very difficult for the doctor to convince the patient to stop the habit.
Some of the most commonly associated habits with osmf are
  • Areca nut chewing
  • Tobacco chewing
  • Tobacco smoking
  • Kharra chewing
  • Gutkha chewing
  • Snuffing
  • Betal quid chewing

 

 

Clinical Classification

 

  • Stage I – Early OSMF without trismus & mean interincisal opening(MIO)  >35mm.
  • Stage II – Mild to moderate OSMF. MIO (26-35mm)
  • Stage III – Moderate to severe, MIO  15 – 25mm
  • Stage IV a – Severe, MIO – <15mm
  • Stage IV b – Malignant/pre malignant lesion seen intraorally.

 

 

Histologic Grading

Depending upon the microscopic features of the lesion, it can be divided into four categories.

  • Grade I –  A finely fibrillar collagen, dispersed with marked edema.

Inflammatory cells, polymorpho-nuclear leukocytes with an occasional eosinophil are present.

  • Grade II – The juxta-epithelial area shows early hyalinization.

The inflammatory cells are mostly mononuclear lymphocytes, eosinophils and an occasional plasma cell

  • Grade III – The collagen is moderately hyalinized. 

The inflammatory exudates consist of lymphocytes and plasma cells, although an occasional eosinophil is seen

  • Grade IV – The collagen is completely hyalinized. 

The inflammatory cells are lymphocytes and plasma cells.

 

 

Treatment/Management

 There are various conventional and new management methods available to manage the progression of this disease, there is no definitive treatment protocol to treat this disease but it can be effectively managed with help of proper medication and surgery if needed.
The most common approach is medicinal/medical approach; surgical treatment is not popularly followed because of high incidence of relapse after the surgery and many times the condition worsen post operatively.
Some of the treatment/management modalities are –
  • Steroids

  • Enzymes

  • Vitamin Supplements

  • Peripheral vasodilators

  • Ayurveda therapy

Steroids – They are very popularly used as first line of treatment by either injecting the drug into and around the lesion or via topical application of the drug, it’s very effectively suppress the inflammatory response which helps in reducing the progression of this disease. E.g. Hydrocortisone, dexamethasone.
Enzymes- Compounds like hyaluronidase, collagenase, chymotrypsin etc. are also used for management of osmf.
These enzymes work by reducing the formation of collagen fibers and reducing the burning sensation, however due to short half-life of those enzymes their effect is short termed, but studies have shown a prolonged effect when administered with steroids, which possibly decreases the breakdown of the enzymes by body and prolongs the effects of the enzymes.
Vitamin supplements – The believed mechanism of action of beetle nut alkaloid is because of release of reactive oxygen which damages the various cellular structures. Antioxidants reduce this damage by reducing the action of free radicals before they attack the structures, hence limiting the damage and further collagen production.  E.g. Vit A, Vit B complex, Vit C etc. are given for this purpose.
Peripheral vasodilators- Certain peripheral vasodilators like pentoxifylline are used to alter the fibroblast cells and increase the fibrolysis of collagen fibers.
Ayurveda Therapy – Medicinal herbs like turmeric and Tulsi (Basil) have been used for their medicinal properties since a long time. Various ancient scriptures and scrolls have explained their use. Turmeric protects against the free radical damage, and reduces the histamines & decreases the inflammation.

 

Various studies have been done in which turmeric extracts or a turmeric paste is applied over the oral mucosa 4-5 times a day and patient was asked not to eat or drink 30 min after the application, after that various tests were done to assess the efficiency of the effects of turmeric and it showed statistically significant results by reducing the burning sensation and increasing the mouth opening of the individual, hence making patient comfortable.

Conclusion

Oral sub mucous fibrosis is a potentially malignant disease, and it should be controlled and reduced at an initial stage because it is not a completely curable disease but it can be managed with multi drug treatment. Areca nut is known as the main cause of the disease and its use should be limited to control the spread of the disease.

 

 

 

 

Dr. Bhavik Patel
B.D.S,
ALABAMA, USA.

About the author: Dr Patel did his BDS from India and with aim towards providing better healthcare to the community is currently volunteering in Alabama, USA.

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