Oral Submucous Fibrosis

Definition of Oral Precancerous Condition: A generalised pathological state of the oral mucosa associated with a significantly increased risk of cancer.

Oral Submucous Fibrosis: a chronic debilitating disease of the oral cavity characterized by inflammation and progressive fibrosis of the sub mucosal tissues.

Clinical Features:

Early OSF-Prodromal symptoms:

Burning sensation in the mouth on consuming spicy food,

Blisters on the palate

Ulcerations or recurrent generalized inflammation of the oral mucosa,

excessive salivation,

defective gustatory sensation,

dryness of the mouth

Periods of exacerbations with appearance of small vesicles in the cheek and palate.

Petichiae are observed on tongue followed by labial and buccal mucosa.

Pain in area with submucosal fibrotic bands on palpation is a useful clinical test.

Histologically-

Hyperplastic epithelium

Numerous dilated and blood filled capillaries juxtaepithelially.

Inflammatory cells: lymphocytes, plasma cells.

Large number of Lymphocytes, fibroblasts and plasma cells suggest  tissue reaction leading to  OSF

Advanced OSF:

Oral mucosa  becomes blanched and slightly opaque and white fibrous bands appear

Buccal mucosa, lips, palate and faucial pillars are affected

Oral mucosa is involved symmetrically and fibrous bands in the buccal mucosa run in vertical direction

Soft Palate:

initially: fibrous depostis varies from slight whitish areas on soft palate, with no symptoms

later: dense fibrosis, causing fixation and shortening or even deviation of uvula and soft palate.

Faucial Pillars: ranges from slight sub mucosal accumulation in both pillars to a dense fibrosis extending deep into the pillars with strangulation of tonsils.

Difficulty in mouth opening is due to Dense Fibrosis involving the tissues around the pterygomandibular raphae.

In severe cases the Fibrosis may spread to Pharynx and down the piriform fossae

Circular bands are felt around the entire Rima Oris(mouth orifice) and seen more around the lower lip.

Tongue: Decreased movement and atrophy of tongue papillae.

With Progressive fibrosis the following changes can be seen :

• Difficulty in mouth opening
• Inability to whistle
• Difficulty to blow out a candle
• Difficulty in swallowing

Fibrosis involving Nasopharynx:  Referred pain to the ear, nasal voice

Epidimiology:

Sex- F>M

Etiology:

• Habitual areca Nut chewing is the main cause which leads to
• Stimulation of Fibroblast proliferation leading to excessive collagen synthesis.
• Decreased secretion of collagenase

Pathology:

Structural and Microstructural changes:

Epithelial changes in different  stages of OSF

Early stage – Hyperplasia

Advanced stage – Atrophy

Lesions of Palate – Orthokeratosis

Lesions of the buccal mucosa – Parakeratosis

Sub Epithelial changes:

On the basis of histopathological appearances OSF can be divided into 4 stages:

• Very early
• Early
• Moderately advanced
• Advanced

Criteria for classification:

• Subepithelial collagen
• Presence or absence of edema
• Physical state of mucosal collagen
• State of blood vessels

Predominant inflammatory cell types are mainly lymphocytes and plasma cells

Management:

The reduction or even elimination of the habit of arecanut chewing is an important preventive measure.

Nutritional Support

Immunomodulatory drugs

Physiotherapy – Which includes regular excercise by patient at home, which comprises of Forceful opening of mouth against pressure and regular opening and closing of mouth.

Local Drug delivery – Local injections of Corticosteroids and Placental Extracts

Combined Therapy – All the above techniques are used together

Surgical Management- Forcing the mouth open and cutting the fibrotic bands