Oral Submucous Fibrosis

• Clinical Definition: An aggressive progressive scar forming disease of the inner lining of the mouth that has been found to be most commonly linked to the use of areca nuts. 

• Urgent Clinical Indicators: Interincisal mouth opening of less than 3 fingers, failure of oral ulcers to heal, pain on consuming foods/warm/mild spiced items and bands formed by fibrous tissue within the buccal space.  

• Treatment Options: Ceasing all exposure to OSMF causing agents, pharmacological treatments using steroids/hyaluronidases administered directly into the lesions along with physical rehabilitation of the jaw via devices designed to stretch/jointly move the jaw, and surgical interventions including removal of fibrotic tissue with application of vascularized tissue grafts.

Early symptoms develop gradually over time, until they have significantly impaired your ability to function structurally:

• Stomatopyrosis: A burning sensation in the mucous membranes occurs when eating mildly spicy food, acidic foods/drinks or extremely hot liquid.

• Blanching Mucosa: The buccal mucosa (the inside of the cheeks), palatal area and labial mucosa all lose their normal pink color and appear white, marbled or chalky.

• Band-like Fibers: Fibrous band-like structures can be felt in the buccal mucosa (the inside of the cheeks), retromolar pad and the soft palate.

• Trismus: Your mouth will slowly start to close; limiting mastication (chewing), talking and proper oral care.

• Loss of Oral Mucosa Elasticity: When you touch your oral mucosa it will feel stiff and rigid like leather rather than elastic.

• Changes in Tongue and Uvula: Loss of papillae on your tongue surface results in a reduced sense of taste; also causes your uvula to shrink into a bud-like shape.

If you experience any of the above symptoms immediately seek out an evaluation from an Oral Medicine Specialist or Maxillofacial Surgeon. These are serious signs that indicate possible OSMF and need immediate medical attention:

• A rapid decrease in mouth closure (your inter-incisal space is less than 15mm [less than 1.5 fingers]).

• Any red and white patches (erythroleukoplakia) or ulcers lasting >14d that are indurated (hard) or bleed with pressure.

• Speech altered by painful swallowing due to soft palate fixation and/or inability to move your tongue.

• Cervical lymph node enlargement (firm/non tender masses in the lymph nodes located under the jaw/along the neck); this could potentially indicate malignancy.

• Alkaloids from betelnut stimulate fibroblast overproduction of collagen, while tannins inhibit enzymatic degradation by directly cross-linking collagen fibers; alkaloids are stabilized for a longer time. 

• Combination of slaked lime with betelnut creates an alkaline environment that enhances absorption of toxic alkaloids into local epithelial micro-vessel tissue. 

• Continued irritation by coarsely ground tobacco particles causes continuous damage to the delicate lining of the oral cavity.

• Increased systemic absorption of copper from packaged chewable betel products increases the activity of lysyl oxidase enzymes, compounding the cross-linking of collagen.

• Habitual practices of chewing pan masala, or betel quid blends among communities across Kerala.

• Impaired mucosal epithelial repair due to iron-deficiency anemia and vitamin B-complex deficits impairs the ability to protect against chemical toxins.

• Specific HLA antigen profiles (such as HLA-A10, B7, and DR3) alter responses to tissue remodeling.

• Dietary habits with increased consumption of spicy curries (high in capsaicin) continue to irritate the submucosa in already damaged areas.

Complete this non-invasive self-check with a mirror, proper lighting, and clean hands:

• Three-Finger Test: Try to vertically place your three fingers (index, middle and ring) between your top front tooth and bottom front tooth. If you are unable to fit all three of your fingers between these two teeth, it is an indicator that there has been some degree of restriction.

• Visual Inspection: Place your lips back from your teeth and look into the crevice formed by them. Compare what you see with healthy cheek tissues which appear as a vibrant coral pink color. The presence of pale or marble white patches may indicate OSMF.

• Palpation: Use the pad on your index finger to run down the interior of your cheek toward the posterior molars. When checking for OSMF, when you feel something hard beneath the surface, running vertically from top-to-bottom, and can be described as rope-like, you have found evidence of disease.

• Clinical Mapping & Staging: Using measurement of inter-incisal space with digital calipers, while simultaneously performing palpation of buccal, labial and palatal fibrous bands to determine extent of disease. 

• Biopsy: Performing incisional punch biopsy of suspicious lesions in order to assess histologically for signs of epithelial atrophy, juxta-epithelial hyalinization, dense collagen bundling and/or dysplasia.

• Imaging: CT and MRI imaging used for evaluation of deep muscle fascial planes in advance stages of the disease process before surgical reconstruction.

The treatments below involve medical and surgical therapies that are aimed at reducing the progression of OSMF disease, eliminating symptoms of OSMF and restoration of some degree of jaw movement:

• Complete cessation of all use of betel quid, areca nut and tobacco products in conjunction with Behavioral Counseling for Habit Elimination Protocols.

• Weekly bilateral intra-lesional injection therapy utilizing a combination of Triamcinolone Acetonide (40 mg/mL) and Hyaluronidase (1500 IU) to dissolve fibrous strands within the connective tissue and reduce chronic inflammation.

• Oral supplementation with antioxidants such as Lycopene (16-24 mg per day), Pentoxifylline (400 mg three times per day to increase microcirculatory blood flow) and zinc curcumin.

• Physical stretching of collagen fibers through the use of physiotherapy techniques such as mouth prop devices, wooden spatula's and/or dynamic jaw exercising devices on an almost daily basis.

• For Stages III and IV Trismus Surgical Release of Fibrotic Bands and Interpositional Grafting via Buccal Fat Pads, Nasolabial Flaps or Microvascular Radial Forearm Free Flaps.

Kerala Treatment Costs are based on the level of disease severity; whether treatment is provided in a Private Dental Clinic or Tertiary Hospital setting; and Reconstructive Procedures utilized:

• Consultation/ Initial Biopsy Cost: ₹1,500 - ₹4,500.

• Total Intra-lesional Injection series cost (6-10 Sessions): ₹6,000 - ₹18,000.

• Cost associated with Physiotherapy/Jaw Exercise Devices: ₹2,000 - ₹5,000.

• Costs associated with Surgical Fibrotomy and Flap reconstruction: ₹60,000 - ₹1,80,000+

Government Healthcare Frameworks  and Private Health Insurance Schemes across Kerala will cover advanced surgical hospital admissions for patients diagnosed with biopsy confirmed OSMF related dysplasia.

• An oral medicine/radiology specialist will help manage your non-surgical evaluation of your condition, provide you with recommendations for systemic antioxidant therapy, evaluate your biopsy results, as well as develop an intra-lesionally injected treatment regimen. 

• An oral/maxillofacial surgeon can assist with the development of the surgical plan for managing your severe trismus by developing a surgical plan for fibrotomy, coronoidectomy, laser excision, and/or soft-tissue reconstruction using flaps.

• A physical therapist/rehabilitation specialist will be able to assist you in developing a rehabilitation program to educate you on how to restore function to your jaw after surgery.

• Oral pathologists will evaluate tissue samples under the microscope to look at them for evidence of dysplasia (abnormal cellular growth) and/or early stage squamous cell carcinoma.

• Evaluation within 24 – 48 hrs: If you experience a rapid loss of mouth opening; you have pain from non-healing mucous membrane ulcerations; you experience swelling of the lymph nodes in your neck.

• Consultation with a specialist scheduled within 1 – 2 weeks: If you continue to have a burning sensation while consuming warm foods/liquids; you are experiencing gradual blanching of tissues.

• Daily post-surgical rehabilitation protocol: The sooner you start doing your jaw-stretching exercises (within 48 to 72 hrs), the better your chances of maintaining the original length of the stretched tissues and preventing the formation of new fibers.

1. Does oral submucous fibrosis ever completely heal?

Though fibrotic collagen bands cannot convert back into their original elastic form without surgical intervention; individuals with Stages i and ii OSMF can manage and halt progression of the condition through cessation of use of areca nuts, anti-oxidative treatments, intra-lesional injections, and jaw exercises.

2. Is oral submucous fibrosis a cancer?

Although OSMF is not an oral cancer itself, it is categorized under oral potentially malignant disorders (OPMD). The risk for a patient to develop OSCC (Oral Squamous Cell Carcinoma) as a result of malignant transformation is about 7-13 percent over a ten year span. Therefore, patients should have regular examinations by an oral medical specialist to monitor the disease.
 

3. When do I notice improvement in my mouth opening after starting treatment?

Adhering to both habit cessation and the cycle of intra-lesional injections along with performing daily physical therapy on the affected area, patients generally will notice improvements in tissue elasticity and an increase in interincisal mouth opening of 3 millimeters to 7 millimeters within 8 to 12 weeks.

• Erythroplakia & Leukoplakia: White or red pre-malignant patches which appear on the mucosa surface as a direct result of erythema and/or leukocyte infiltration. These lesions frequently occur adjacent to the scarring of fibrotic tissue.

• Oral Squamous Cell Carcinoma (OSCC): A result of continued chemical irritation combined with chronic atrophy of epithelium. As such, this represents the potential malignant transformation of OSMF.

• Dental Decay/Periodontitis: Advanced dental caries and gum disease secondary to being unable to practice normal tooth brushing secondary to severe limitation of opening of the jaws

The treatments listed below may be related to the treatment options for Oral Submucous Fibrosis:

• Laser-Assisted Fibrotomy: The use of laser photothermal therapy for ablating superficial fibrotic tissue using CO2 or diode lasers is employed to reduce intra-operative bleeding during reconstruction.

• Hyperbaric Oxygen Therapy (HBOT): HBOT is an adjunctive therapy that can help provide tissue oxygenation and assist with micro-vessel healing of compromised mucosa post-reconstruction.

• Prosthetic Rehabilitation: Flexible or modified dentures for rehabilitation of patients who have limited mouth opening as a result of jaw release surgery.

Oral Submucous Fibrosis requires both a reduction of exposure to chemicals involved in causing the condition, as well as breaking down the established sub-mucosal scarring. Primary treatment success is heavily dependent upon ceasing all chemical exposures, i.e., betel quid, areca nut, and tobacco products. Unless there is total cessation of these habits, other medical and/or surgical interventions will likely only temporarily alleviate symptoms prior to the fibrosis recurring.