A GUIDE TO ORAL SUBMUCOUS FIBROSIS

6 min


Oral submucous fibrosis is a long-standing or chronic condition of the mouth. Inflammation and fibrosis are the main presentations. Meanwhile, restricted mouth opening or difficulty in mouth opening is the main symptom.

The world health organisation describes this condition as an oral pre-cancerous condition as a generalised pathological state of the oral mucosa associated with an increased risk of cancer.

EPIDEMIOLOGY OF OSMF:

Firstly, this condition is commonly prevalent in and around areas of South Asia and the Western Pacific basin. Areca has been in use for hundreds of years in many Southern parts of Asia. Once a very common practice in Southern Asia, it has now started to spread to parts of Europe and America.

The global incidence of oral submucous fibrosis is estimated at 2.5 million individuals. People less than 20 years are more commonly affected than other age groups. This might be due to the advertisement directed towards these age groups.

This condition was first described by Schwartz in 1952. He noticed this condition in 5 Indian women in Kenya. It was a chronic progressive scarring disease. On the other hand, the habit not only includes areca, chewing betel quid, containing fresh, dried, or cured areca nut and other flavouring agents.

Genetics plays an important role in the development of OSMF. Moreover, this condition has a great female predilection. The other names are idiopathic scleroderma of the mouth, sclerosing stomatitis, and juxta epithelial fibrosis.

TYPES:

There are 2 types of sub mucous fibrosis, namely

  • Insidious
  • Chronic

MECHANISM OF ORAL SUBMUCOUS FIBROSIS:

OSMF is a chronic disease. Further, it not only affects the oral cavity, but also the pharynx and the upper two-thirds of the oesophagus.

The main reasons cited for the occurance of OSMF are,

  • Clonal selection of the fibroblast (it is a type of cell that synthesizes collagen and forms the framework of an animal cell, it is very important for wound healing)
  • Stimulation of the fibroblast by areca alkaloids. The alkaloids especially coline plays a primary etiological factor.
  • In addition, the increased fibrosis is due to the arecolines capacity to modulate matrix metalloproteinases, lysyl oxidase, and collagenases.
  • The production of type I collagen production is favoured in OSMF.
  • Genetically, polymorphism of the gene occurs that codes for tumour necrosis factor-alpha (TNF Alpha). Meanwhile, this promotes the development of the disorder.
  • The collagenase is affected and reduced
  • Further, there might be a deficiency in collagen phagocytosis
  • The stable collagen structure formed by catechins and tannins are affected by areca
  • The release of lysyl oxidase is also seen as a reason.

SYMPTOMS OF ORAL SUB MUCOUS FIBROSIS:

The commonly observed symptoms are,

  • Restricted mouth opening
  • The elasticity of the lips and the cheek muscles might slowly decrease
  • Small bleeding spots might be observed
  • An inability to take hot or spicy food is very common

RISK FACTORS FOR OSMF:

The major reason for OSMF is betel nut chewing. Further, betel is the fourth most commonly consumed substance after nicotine, ethanol, and caffeine. Apart from that tobacco chewing, tobacco smoking, and alcohol.

Chewing substances like paan, gutka also adds up and contributes to OSMF. Apart from these, high intake of chillies in the diet, harmful traces of copper in the food products we take and certain micronutrient deficiencies.

With the inability to take food orally and the progressive scarring of the mouth, oesophagus and the restriction of the tongue and mouth opening, it becomes difficult to take food. This may lead to conditions like anaemia and malnutrition.

DIAGNOSING ORAL SUBMUCOUS FIBROSIS:

OSMF can be diagnosed easily by your dentist. These can be diagnosed easily through clinical examination and some tests. In some cases, a biopsy might be needed and the histo-pathological component has to be studied to arrive at a diagnosis. The diagnosis can be accurate if the clinical findings can be backed up with the personal history of the patient. The family history and the information about genetics can play a good role in diagnosis.

Clinically some of the following symptoms are present,

  • Palpable (something that can be felt through touch), pale or whitish, fibrous bands are seen.
  • Small erythematous lesions along with petechiae (small pinpoint bleeding spots), pigmentations, and vesicles.
  • A white-marbled appearance is common
  • Fibrotic bands may be located beneath the atrophic epithelium.
  • This increased fibrosis may eventually lead to a loss of resilience.
  • The decreased resilience might sometimes lead to interferences with speech, movement of the tongue, and decreased ability to open the mouth.
  • The mucosa can be leathery, and tough in texture
  • On the other hand, blanching might be present, marble-like texture with a localized, diffuse, or reticular pattern.
  • Often, trismus is present.
  • In addition, inflammation and oedema are very common.
  • The lips, buccal mucosa, and even the palatal mucosa are common regions of the complaint.
  • In more than 25% of the cases, oral leukoplakias can be seen.

COMPLICATIONS OF OSMF:

Submucous fibrosis can lead to oral squamous cell carcinoma. In other words, it is one of the most common malignancies of the oral cavity. The consumption of tobacco increases the occurrence of oral squamous cell carcinoma (also known as oral cancer).

The chances of malignant transformation of OSMF ranges between 7% to 13%. The incidence over a 10 year period is approximately 8%.

MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS:

The management of OSMF, consist of the following,

  • Cessation of chewing habits is the first step towards managing OSMF.
  • The products derived from areca nut are carcinogenic, regardless of concomitant use of tobacco products.
  • If the person stops the habit, there are very good chances that the early lesion may regress and the chances of prognosis may improve.

Medical management:

Trials for coming up with other management strategies are taking place. The medical management includes the following,

MANAGING THROUGH DRUGS AND SURGERY:

  • Usage of topical and systemic steroids. Intra-lesional injections given for the patients contain steroids.
  • Repeated dilation with physical devices and surgery in case of extreme restriction in mouth opening.
  • Follow mouth opening exercises as instructed by your doctor. It is important to improve and maintain the mouth opening.
  • Vitamin and nutrient supplements are very essential parts of management. Do a thorough blood test and vitamin levels check. Based on the levels, modulation of vitamins takes place. Nutritional supplements with Vitamin A, B, C, and E on the other hand minerals like iron, magnesium, and selenium improved epithelial atrophy. Further tongue depapillation and ulcerations as a result of OSMF also improved significantly. Besides, zinc along with copper regulates the disproportionate deposition of excess copper. This is one of the causative agents of OSMF. This proves that a proper supplement of micro-nutrients and macro-nutrients is essential for resolving this condition.
  • IRON SUPPLEMENTS: Studies show decreased levels of serum ferritin and haemoglobin in OSMF. Since the synthesis of collagen uses iron. Therefore, iron supplements can improve nutritional status and reduce atrophy and fibrosis.

MANAGING THROUGH HERBAL MEDICATIONS:

  • Herbally, triple therapy has proved to be very beneficial
  • TRIPLE THERAPY: This uses naturally occurring herbal medicines such as Curcumin, Aloe vera and Tulsi. Immense potential in managing pre-cancerous OSMF is possible with Tulsi.
  • Herbal therapy doesn’t give off any side effects (even on long term use)
Aloevera

RECENT ADVANCES IN MANAGING OSMF:

  • Recent advances include the use of personalized precision medicine (PPM). This is a form of immunotherapy.
  • For managing OSMF, Hyperbaric oxygen therapy (HBO) has been tried. Studies have shown, hyperbaric oxygen therapy can reduce the proliferation of fibroblast and collagenase synthesis and improve vascularity by means of angiogenesis. This combination can significantly reduce OSMF and improve wound healing. It is a promising therapy in the management of OSMF.
  • TEA PIGMENTS: The tea pigments contain a substance called flavins, which possess anti-oxidants, anti-neoplastic and anti-inflammatory properties. This also reduces the viscosity of blood and improves micro-circulation. The pro-inflammatory activities are a great advantage of tea. All these properties are good at improving OSMF. Studies show improvement in mouth opening after regular use (in patients with a haematinic deficiency)
  • IMMUNOMODULATORS: Certain drugs with immuno-modulator properties boost cellular and humoral immunity. Treating OSMF is based on this therapy. These drugs also showed improvement in mouth opening and the burning sensation also greatly reduced. Further, the healing process also reduced greatly and the risk of malignant transformation reduced greatly.

CONCLUSION:

To sum up, like many other conditions of the oral cavity, oral submucous fibrosis also develops as a compulsion of habit. It is very important to know what types of substances can harm your health in general. It’s good to avoid all the above-mentioned food that may lead to OSMF. It is also equally important to keep a check on the symptoms. Report to the dentist immediately and take the needed measures. In addition, create awareness and explain to people about the ill effects of the substances.

Always keep an eye on children to check for any harmful habits in the adolescent years. It’s good to educate and enlighten them on the harm that substances like this can cause. Awareness programs conducted for children might do a great deal of good.


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Dr Kavitha M

I am an undergraduate degree holder in dentistry. I have a great interest in music and reading. I am a linguaphile. My areas of interest lie in psychology, medical imaging, diagnostics, and oncology. I am a person who focuses more on the emerging areas of forensics.

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