Oral submucous fibrosis: Recent
modalities of Treatment
Patel U1, Patel V2
1Dr Umesh Patel, L N Medical College, Bhopal,2Dr Vishnu Patel,
S S Medical College, Rewa, MP, India
Address for correspondence:
Dr Umesh Patel, Email: drumeshpatel@gmail.com
Abstract
Oral submucous fibrosis is chronic progressive condition of oral
cavity. It is characterized by progressive fibrosis of submucosal
tissue. The condition is well recognized for its malignant potential.
The pathogenesis of oral submucous fibrosis is not well understood. It
is one of the most poorly understood and unsatisfactorily treated
diseases. A wide range of treatment including drug management, surgical
therapy, and physiotherapy have been attempted till date, with varying
degrees of benefit, but none have been able to cure this disease
Key words:
Submucous fibrosis, precancerous, OSMF.
Introduction
In 1952, Schwartz coined the term atrophica
idiopathica mucosa oris to describe an oral fibrosing disease, he
discovered in 5 Indian women from Kenya [1]. In 1953, SG Joshi
subsequently coined the termed oral submucous fibrosis (OSMF) for the
condition [2]. Oral submucous fibrosis is a
chronic disease of the oral cavity, commonly found in patients in the
Asian subcontinent, usually in adults with areca nut chewing habit. It
is commonplace in various Indian states to use pan quid with tobacco
and lime. The pathogenesis of the disease is not well established, but
is believed to be multifactorial. There are multiple risk factors for
development of OSMF, including areca nut chewing, ingestion of spicy
red pepper, nutritional deficiency including vitamins (vitamin A and
B-complex) and trace elements (Cu, Zn, Iron and Selenium),
hypersensitivity to various dietary constituents, and genetic and
immunological susceptibility [3, 5,6]. Epidemiologic surveys in India
show the rate of prevalence to be about 0.5%. Persons between 20 and 40
years of age are most commonly affected, with a female: male ratio of
3:1. An estimated 2.5 million people suffer from this disease in India
[10]. Morbidity of OSMF among betal quid users is about 3.2% and it has
a malignant transformation rate in the range of 7-13% [4].
The hyalinization of the buccal mucosa forming band and decrease in
mouth opening is the first symptoms, followed by white band seen in
labial mucosa, palate and even spread to uvula. There is burning
sensation while taking food and difficulty in swallowing. There
are many treatment options. The treatment of patients with oral
submucous fibrosis depends on the degree of clinical involvement. Main
and first step in getting successful treated is asking the patient to
stop chewing areca nut completely. If the disease is detected at a very
early stage, cessation of the habit is sufficient, but most patients
with oral submucous fibrosis present with moderate-to-severe disease.
Moderate-to-severe oral submucous fibrosis is irreversible. Medical
treatment is symptomatic and predominantly aimed at improving mouth
movements. The different treatment strategies include local injections
of steroids (dexamethasone or betamethsone), placental extracts (both
work as a anti-infamatory, immunomodulator) and hyaluronidase
(breakdown hyaluronic acid and decrease hyaluronic bands), lycopene (an
antioxydents), pentoxyphylline, IFN-gamma, cholchicin, supplemented
with oral vitamins (Vitamin A) and other anti-oxidants. Various other
medications are in trial stage, eg- beta-carotin, selenium etc [8].
Colchicine has been reported to be beneficial in the treatment of
diseases associated with fibrosis in animals and human beings [9]. Most
of drugs are not approved by USFDA as the primary treatment of OSMF.
Surgical options are employed when mouth opening is severely limited.
Mostly surgical treatment is done on bands seen is buccal mucosa which
is the main reason of trismus and decreased mouth opening. It yields
good result, immediately giving relief from trismus. Surgical
modalities that have been used are simple excision of fibrous band,
Split thickness skin grafting, naso-labial flaps, and Lingual pedicle
flaps. Unfortunately, limited success has been seen with these
procedures.
One of the latest revolutions in the field of medicine and dentistry
has been the advent of laser. Erbium Chromium Yttrium Scandium Gallium
Garnet lasers (ErCr:YSGG laser), diode laser, CO2 laser, KTP-532 laser
etc, are different laser that are used to treat OSMF[13]. These lasers
provide an easy and comfortable option of keeping the procedures
efficacious as well as minimally invasive. The hyaline bands are
excised with the help of the laser, which is a very good alternative
for traditional surgical procedure. The quicker and uneventful healing
after laser therapy adds to patient satisfaction. The overall benefits
of laser surgery include a relatively bloodless operative field and
thus excellent visibility, reduced need for local anesthesia, less
chances of bacterial infection, reduced mechanical tissue trauma, fewer
sutures, quicker healing, and reduced post operative edema, scarring
and tissue shrinkage. At the same time, the possible complications in
laser surgery can be excessive or collateral tissue damage due to
misdirected usage. ErCr:YSGG laser has utility in both hard and soft
tissue procedures as the hydro-photonic process allows it to
out-perform other conventional modalities in many ways. All in all,
laser surgery is effective and safe. The laser therapy is a bit costly,
so affordability is main limiting factor for its general use.
Physiotherapy for OSMF is a very important part of treatment as it help
in increasing mouth opening. Muscle stretching for the mouth may be
helpful in preventing further limitation of mouth movement. If
physiotherapy is used along with micronutrients, results are more
favorable [12,13]. Novel mouth-exercising devices are also very helpful
to perform mouth exercise [14]. When a lot of remedies are suggested
for a disease, which means it can’t be cured, so patient
education, aimed at cessation of the chewing habit is most important
step to prevent OSMF.
To conclude, commercially available chewing products like gutka, paan
has strong association with OSMF. In the near future, younger ones may
be affected more and an active preventive approach is required to limit
the morbidity associated with the modern pouch culture.
Termination of these habits will reduce the incidence. The present drug
treatments are empirical and symptomatic in nature. A combination of
several drugs may play an important role in the treatment because it is
a multifactorial disease. While lasers are still in their infancy,
there is no doubt that the profession has started accepting them as an
alternative to traditional therapies. Steps should be taken to curb the
demand include increasing tax on all betel quid product, control
smuggling, closure of all advertising avenues and creation of
infrastructure for enforcement of law. Goswami
et al [15] in her study described that Intralesional injection of
triamcinolone combined with hyaluronidase with oral antioxidants is
more effective in treating the patients with OSMF than antioxidants
alone.
Funding:
Nil, Conflict of interest:
Nil
Permission
from IRB: Yes
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How to cite this article?
Patel U, Patel V. Oral submucous fibrosis: Recent modalities
of Treatment. Int J Med Res Rev 2014;2(2):79-80.doi:10.17511/ijmrr.2014.i02.001