Oral Submucous Fibrosis, Pre Malignant

ORAL SUBMUCOUS FIBROSIS Haris Mehmood BDS-III

DEFINITION OSF is chronic disease of oral cavity

characterized by  Inflammation 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

Tobacco Slaked lime Catechu

Nutritional Deficieny  Vitamin B complex deficiency  Iron 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 fibroblast  Cross linking of collagen peptide chains  Inhibition of collagen degradation  Inflammation  Cytokine and growth factor production  fibrosis

Areca nut contain copper that induces Lysyl

oxidase activity. upregulate collagen synthesis by fibroblasts Facilitate its cross linking Inhibit its degradation  (Ref: Research letters, The Lancet. www.hawaii.edu)

Eating chillies: Hypersenstivity reaction to

capsaicin

Typically affect Buccal mucosa Lips Retromolar area Soft palate Tongue Occasional Involvement Pharynx Esophagus Oral tissues are affected symmetrically

Burning sensation While chewing spicy foods Blanching of mucosa impairment 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  thick  rubbery  difficult to retract

 Cheeks  Thick and rigid  Absence of puffed out appearance when patient blows or

whistle

 Tongue  Restriction of movement  Blanching or Fibrosis of ventral mucosa  Depapillation

 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 ischemia Increased salivation Change of gustatory sensation Hearing loss due to stenosis of the eustachian tubes Dryness of the mouth Nasal tonality to the voice Dysphagia 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 levels Decreased iron levels Decreased protein levels Increased erythrocyte sedimentation rate Decreased vitamin B complex levels

Oral Biopsy

EPITHELIUM  Epithelial atrophy  Epithelial atypia  Epithelial dysplasia (10 to 15 % cases of biopsy)  Sub epithelial vesicles  Hyperkeratosis  Loss of rete pegs

Hyperkeratotic epithelium

Lamina Propria  Fibrosis  large fibroblasts  Avascular (blood vessels obliterated or

narrowed)  Chronic inflammatory infiltrate  Hyalinization (translucent)  Homogenization of collagen bundles  Fibroblasts are markedly diminished in number

Collagenization of sub epithelial tissue

Medical Care The treatment of patients with OSF depends

on the degree of clinical involvement  Early stage: Cessation of habit is suficient  Moderate-to-severe OSF is irreversible

Treatment includes the following:  Intra lesional steroid  Hylarunidase  IFN gamma

Surgical Care Indication:  Severe trismus  Biopsy reveal dysplastic or neoplastic change

 Simple excision of the fibrous bands  Split-thickness skin grafting

Consultation  ENT specialist  Plastic surgeon

DIET  Reduce exposure to risk factors such as betel

quid  Correct 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 lesion  Lesion undergoing red changes (erythroplakia)  A burning sensation in the mouth  An exophytic mass  A lump in the neck  Difficulty in chewing, swallowing, or speaking

GOOD PROGNOSIS