Oral submucous fibrosis / Osmf


Definition
 An insidious, chronic disease affecting any part of the oral cavity and sometimes pharynx. Although occasionally preceded by and/or associated with vesicle formation, it is always associated with juxtaepithelial inflammatory reaction followed by fibroelastic changes of lamina propria, with epithelial atrophy leading to stiffness of oral mucosa and causing trismus and inability to eat.

Epidemiology:-

 The disease is very common in India, The prevalence rate of oral submucous fibrosis in India, Burma and South Africa ranges from 0 to 1.2%.

Etiopathological factors:

Chillies 
Betel nut 
Tobacco
Lime
Nutritional deficiency
defective iron metabolism
Collagen disorder
Immunological disorder
altered salivary composition

Etiopathogenesis:


Main factor for osmf is betel nut.
• Areca (betel nut ) chewing :
1. arecaidine - this stimulates fibroblast production and inhibits action of collagenase 
2. flavonoids catechin and tannis - stabilizes the collagen fibers and makes resistance to degeneration by collagenase.

 • Role of copper : 
increase in collagen cross-linkage as caused by upregulation of lysyl oxidase enzyme by OSF  fibroblasts.
 • by decreased secretion of collagenase.
 • deficiency in collagen phagocytosis by OSF fibroblasts.
 • by production of collagen with more stable structure ( collagen type 1) by OSF fibroblasts.
 •  by fibrogenic cytokines secreted by activated macrophages and T-lymphocytes.

Clinical features:-

• Age:  between 20 to 40 years of age.
• Sex: It affects both sexs.
• Site distribution: mostly buccal mucosa and retro-molar areas. It also involves soft palate, palate, uvula, tongue and labial mucosa.
• Prodromal symptoms: most common symptoms is burning sensation of oral mucosa, aggravated by spicy food followed by hypersalivation or dryness of mouth.
• Late symptoms: Trismus, difficulty in tongue protrusion, difficulty in swallowing and referred pain.
• Blanching of mucosa: this is the most common and earliest sign in osmf. The blanched mucosa becomes slightly opaque and white.
• Betel chewer mucosa: It is brownish red discoloration of mucosa with irregular surface thant tent to desquamate.
• Fibrous band: Vertical band can be appears. These band can be palpated easily and feel rough on palpation
• Soft palate and uvula: The mobility of the soft palate is restricted. Uvula when involved, is shrunken and in extreme cases it becomes bud like or hockey stick appearance.

Clinical stages:-

1.) Stage of stomatitis and vesiculation
2.) Stage of fibrosis
3.) stage of sequel and complication

classification based on clinical features:

1.) Group-1 : very very early cases
• Common symptom is burning sensation
•  Acute ulceration
• Not association with mouth opening

2.) Group-2 : early cases
• Buccal mucosa appears mottled and marble like
• Wide spread sheets of fibrosis palpable.
• Patients with mouth opening 26-35mm (interincisal distance)

3.) Group-3 : moderately advanced cases
•  Trismus evident, with an interincisal distance of 15-25 mm
• Buccal mucosa appears pale and firmly attached to underlying tissue
• Atrophy of vermillion border
• Vertical fibrous bands palpated

4.) Group-4 : advanced cases
• Trismus is severe and interincisal distance is less than 15mm.
• Uvula is shrunken and appears small.
• Tongue movements limited

5.) Group-5 : advanced cases with pre-malignant or malignant changes
• Hyperkeratosis, leukoplakia, or sqamous cell carcinoma can be seen.

Diagnosis:

Clinical diagnosis: clinically reduced mouth opening with palpable fibrous band.
Laboratory diagnosis: intercellular edema, signet cells, epithelial atypia and inflammatory cells may be seeen.

Management:-

• Restriction of the habit
• Oral physiotherapy
  Ice cream stick therapy
  Ballooning of mouth 
  Warm water gargling

• Medicinal therapy
  Triamcinolone acetonide n
  Vitamin rich diet
  Iodine B-complex
  Steroids (intralesion injection of hydrocortisone along with procaine hydrochloride )
  Hyaluronidase
  Lycopene
  Vitamin E

• Surgical treatment
  Flap used as graft
  nasolabial flap
  bilateral flap
  oral stents

• Cryo-surgery
• LASER

    You can also see my video on osmf:-









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