What Is Oral Submucous Fibrosis

Overview

• Oral submucous fibrosis (OSF) is a potentially malignant disorder, which was first described by Schwartz in 1952 as “Atropica idiopathic mucosae oris”. Oral submucous fibrosis is associated with betel quid and areca nut chewing
• Mostly widespread in the population of the South East Asia and Indian Subcontinent. Approximately 2 to 8 % of the cases of oral submucous fibrosis (OSF) transform into squamous cell carcinoma (SCC) which is a malignant condition
• Traditionally, Oral submucous fibrosis (OSF) has been described as, “ a chronic, insidious, scarring disease of the oral cavity, often with the  involvement of the pharynx and the upper oesophagus”
• Millions of people in the world are affected by the oral submucous fibrosis in the world. Oral submucous fibrosis (OSF) has a high rate of malignant transformation and high morbidity, constant efforts have been made for effective development of the management of Oral submucous fibrosis (OSF)
• Oral submucous fibrosis (OSF) is also characterized by the depapillation of the tongue, reduced movement of the tongue, blanching and leathery texture of oral mucosa is also visible with continuous mouth opening reduction and shrunken uvula
• The Oral submucous fibrosis (OSF) is markedly seen in a wide age range from 11 to 60 years, predominantly affecting  females more compared to males
• Oral submucous fibrosis (OSF) is always associated with juxta epithelial inflammatory reaction followed by Fibroelastic change of the lamina propria and epithelial atrophy that leads to oral mucosa stiffness and causes inability to eat and trismus of the mouth

Causes of oral submucous fibrosis

The oral submucous fibrosis is  caused by many factors, some of which are as follows:

1. Chillies: the use of chillies has been thought to play an etiological role in oral submucous fibrosis
2. Tobacco : it is a known irritant and causative factor in oral malignancy. It may also act as a local irritant in oral submucous fibrosis
3. Lime: it is used along with betel nut for chewing. It causes local irritation and damage to the mucosa with vesicle and ulcer formation. It acts as a local irritant
4. Betel nut: The  term areca nut is used to denote the unhusked whole fruit of the areca nut tree and the term betel nut is used to refer exclusively to the inner kernel or seed which is obtained after removing the husk
5. Nutrition deficiency: The disease is characterized by repeated vesiculation and ulcer formation in the mouth. A subclinical deficiency of the Vitamin B complex has been suspected in many cases
6. Defective iron metabolism: Microcytic hypochromic anemia with high serum iron has  been reported in some of the cases of oral submucous fibrosis but as such, there is no definite proof available to support this cause-effect relation
7. Bacterial infection: Streptococcal toxicity is also a factor in causing oral submucous fibrosis, as in some other collagen disorders, such as rheumatic disease
8. Collagen disorders: Oral submucous fibrosis is thought to be localized collagen disease of the mouth. It is linked to scleroderma, rheumatoid arthritis, and intestinal fibrosis
9. Altered salivary composition: the study of saliva in cases of oral submucous fibrosis has shown increased pH, increase in salivary amylase, low level of calcium, increase in alkaline phosphatase and potassium and normal level of salivary immunoglobulins
10. Genetic susceptibility: The familial occurrence of oral submucous fibrosis has also been reported

Signs and symptoms of oral submucous fibrosis

Early symptoms:

• The onset of oral submucous fibrosis is deceptive and is often 2 to 5 years in duration. The most common initial symptom is a burning sensation which is usually aggravated by spicy food, followed by either hypersalivation or dryness of the mouth
• Vesiculation, ulceration, pigmentation, recurrent stomatitis and defective gustatory sensation have also been indicated as early symptoms of oral submucous fibrosis

Late symptoms:

• Trismus: gradual stiffening of the oral mucosa occurs in a few years after the initial symptoms appear. This leads to an inability to open the mouth completely
• Difficulty in tongue protrusion: Later on, patients experience difficulty in protruding the tongue.
• Difficulty in swallowing: When the fibrosis extends into the pharynx and esophagus, the patient may experience difficulty in swallowing the food
• Referred pain: referred pain in the ears and deafness, due to occlusion of Eustachian tube and typical nasal voice has been reported

Management and treatment for oral submucous fibrosis

The oral submucous fibrosis can be treated by five means depending upon its severity level:

1. Restriction of habit/ behavioral therapy: the preventive measure should be in the form of stoppage of habits, which can be encouraged through public education. Affected patients should be explained about the disease and its possible potential to become cancerous
2. Medical therapy: Supportive treatment
   • Vitamin-rich diet: A vitamin rich diet along with iron preparation is helpful to some extent but has little therapeutic value in relieving trismus
   • Iodine B- complex preparation: This is the combination of iodine preparation with synthetic vitamin B complex. Intramuscular injection starts with small doses and continues with larger doses. The injection contains Methoxyethyl iodomine which is active iodine,vitamin B1, vitamin B6, vitamin B2, Nicotinamide, Calcium pantothenate
   • Steroids: hydrocortisone injection along with procaine hydrochloride injection are given in the area of fibrosis. The early cases show good improvement with this therapy
   • Placental extract: The placental extract is an essential biogenic stimulator
   • Vitamin E: the use of vitamin E along with dexamethasone and hyaluronidase injection is thought to produce better results

3. Surgical therapies: 
   • Flap use as graft: excision of fibrous bands followed by use of tongue flap as a graft gives good results because the tongue flap is highly vascular and resists further fibrosis
   • Implantation of fresh human placenta: In some cases submucosal implantation of bits of fresh human placenta into the defect is done following the surgical excision of the fibrous band
   • Laser: The use of a laser for the treatment of submucous fibrosis is useful. CO₂  laser surgery offers advantage in alleviating the functional restriction, when compared to traditional surgical flap grafting technique
   • Cryosurgery: It is the method of local destruction of tissue by freezing the affected tissue. Open liquid sprays are better suited for the lesions like oral submucous fibrosis which are extensive and superficial and do not involve the deep tissue layer

4. Oral physiotherapy: Oral exercise is advised in early and moderately advanced cases. This includes mouth opening and ballooning of the mouth. This is thought to put pressure on fibrous bands. Forceful mouth opening has been tried with mouth gag and acrylic surgical screw
5. Diathermy: Microwave diathermy is useful in some early or moderately advanced stages of oral submucous fibrosis. Low current is used (20 watts☓ 2450 cycles. It acts by physio fibrinolysis of bands. Its value is increased if it is combined with other treatment modalities
6. Home remedies: Application of turmeric and aloe vera gel are very effective in treating the symptoms of oral submucous fibrosis. It helps to reduce the burning sensation

Diagnosis

oral submucous fibrosis can be diagnosed with the help of either clinical diagnosis or with help of laboratory diagnosis.

• Clinical diagnosis: in oral submucous fibrosis clinically there is reduced mouth opening with the palpable fibrous band is enough to make the diagnosis
• Laboratory diagnosis: oral epithelium is markedly atrophic which exhibits intracellular edema, signet cells, and epithelial atypia. The inflammatory cells are mostly mononuclear; eosinophils and occasional plasma cells may be seen 

FAQs

Can oral submucous fibrosis turn into cancer

oral submucous fibrosis is a precancerous disorder and approximately 1.5-15% of the cases transform into malignant tumor.

How can I prevent oral submucous fibrosis

One of the important steps in preventing oral submucous fibrosis is to decrease the area nut chewing habit by decreasing the easy availability of areca nuts in the market.

How common is oral submucous fibrosis

Millions of people are affected by oral submucous fibrosis in the world especially the population of South and South East Asian countries

Who are at risk of oral submucous fibrosis

 People with  the habit of chewing areca nuts are at high risk of developing oral submucous fibrosis.

When should I see a doctor

When one starts experiencing the pain and burning sensation of taking food and also when there is reduced mouth opening, then one should see a doctor. 

Summary

Oral submucous fibrosis is a precancerous condition prominently developed in the people who have the habit of areca nut chewing. People suffering from oral submucous fibrosis show classical signs of reduced mouth opening and other symptoms seen are pain and burning sensation usually on taking spicy food. The oral submucous fibrosis can be easily treated by using various means depending on the severity of the oral submucous fibrosis.