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| Oral Sub-Mucous Fibrosis |
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Definition
Oral Sub-mucous Fibrosis (OSF) is a well-recognised oral
pre-cancerous condition, observed predominantly in
populations of South Asian ethnic origin. It predominantly
occurs in the Indian sub-continent and people of South
Asian ethnicity living in other countries such as the UK,
Singapore and Malaysia, among others.
It is characterised by a unique generalised fibrosis
(scarring) of the sub-mucosal oral soft tissues, resulting in
marked rigidity of the oral mucosa leading to progressive
trismus (inability to open the mouth), rigidity of lips and
difficulty in protruding the tongue.
Ætio-Pathogenesis:
Risk Factors:
An increase in the frequency of this disease, especially
among the young, has been reported in India due to the
increase in the use of commercially prepared areca nut
preparations without betel leaf (pan masala).
A genetic predisposition for the development of this
disease has also been reported.
The areca nut, which contains alkaloids such as arecoline,
and other chemicals, such as catechin and tannin, plays a
major role by stimulating production of collagen fibres and
making them less susceptible to the action of collagenase
(an enzyme that breaks down collagen).
It is suggested that components of the areca nut also
affect gene expression in the fibroblasts leading to the
production of greater amounts of normal collagen. Areca
nut has been shown to have a high copper content, and
chewing areca nuts for 5 – 30 minutes significantly
increases soluble copper levels in oral fluids. This
increased level of soluble copper supports the hypothesis
that copper acts as an initiating factor in OSF by
stimulating fibrogenesis.
It is not clear if a hypersensitivity reaction to chillies plays
any role in the development of OSF.
Iron deficiency anæmia, vitamin B complex deficiency
and malnutrition are implicated in the development of OSF
leading to deranged repair processes of the inflamed oral
mucosa, contributing to defective healing and scarring.
The resulting atrophic oral mucosa is more susceptible to
the effects of areca nut and alcohol. An immunological
process and a genetic component are assumed to be
involved because of reported cases in non–areca nut
chewers. Increased levels of pro-inflammatory cytokines
and reduced anti-fibrotic interferon have also been
demonstrated in patients with OSF.
Clinical Features:
Clinically, patients present with a lustre-less, marble-like
blanching of the oral mucosa.
In the early stages, features of stomatitis such as
erythematous (reddened) mucosa, vesicles (blisters),
mucosal ulcers, blotchy melanotic mucosal pigmentation
(like freckles) and mucosal petechiæ (bruising) may be
observed.
Oral Sub-mucous Fibrosis (OSF) is a well-recognised oral
pre-cancerous condition, observed predominantly in
populations of South Asian ethnic origin. It predominantly
occurs in the Indian sub-continent and people of South
Asian ethnicity living in other countries such as the UK,
Singapore and Malaysia, among others.
It is characterised by a unique generalised fibrosis
(scarring) of the sub-mucosal oral soft tissues, resulting in
marked rigidity of the oral mucosa leading to progressive
trismus (inability to open the mouth), rigidity of lips and
difficulty in protruding the tongue.
Ætio-Pathogenesis:
Risk Factors:
- areca nut chewing ± tobacco
- capsaicin in chilies and
- micro-nutrient deficiencies of iron, zinc and essential
vitamins.
An increase in the frequency of this disease, especially
among the young, has been reported in India due to the
increase in the use of commercially prepared areca nut
preparations without betel leaf (pan masala).
A genetic predisposition for the development of this
disease has also been reported.
The areca nut, which contains alkaloids such as arecoline,
and other chemicals, such as catechin and tannin, plays a
major role by stimulating production of collagen fibres and
making them less susceptible to the action of collagenase
(an enzyme that breaks down collagen).
It is suggested that components of the areca nut also
affect gene expression in the fibroblasts leading to the
production of greater amounts of normal collagen. Areca
nut has been shown to have a high copper content, and
chewing areca nuts for 5 – 30 minutes significantly
increases soluble copper levels in oral fluids. This
increased level of soluble copper supports the hypothesis
that copper acts as an initiating factor in OSF by
stimulating fibrogenesis.
It is not clear if a hypersensitivity reaction to chillies plays
any role in the development of OSF.
Iron deficiency anæmia, vitamin B complex deficiency
and malnutrition are implicated in the development of OSF
leading to deranged repair processes of the inflamed oral
mucosa, contributing to defective healing and scarring.
The resulting atrophic oral mucosa is more susceptible to
the effects of areca nut and alcohol. An immunological
process and a genetic component are assumed to be
involved because of reported cases in non–areca nut
chewers. Increased levels of pro-inflammatory cytokines
and reduced anti-fibrotic interferon have also been
demonstrated in patients with OSF.
Clinical Features:
Clinically, patients present with a lustre-less, marble-like
blanching of the oral mucosa.
In the early stages, features of stomatitis such as
erythematous (reddened) mucosa, vesicles (blisters),
mucosal ulcers, blotchy melanotic mucosal pigmentation
(like freckles) and mucosal petechiæ (bruising) may be
observed.
| Photo of palate showing the development of OSF with the lustre-less, marble-like blanching of the oral mucosa. |
peri-commissural area. A mottled, marble-like
appearance may be evident due to the bands running in the
blanched mucosa.
In advanced disease, there is trismus, sinking of the
cheeks out of proportion to age, stiff and small
depapillated tongue, blanched floor of mouth, fibrotic
(scarred) gingival tissues, stiff soft palate with reduced
mobility and shrunken bud-like uvula and blanched and
atrophic tonsils.
> 25% of affected persons may have co-existing
leukoplakia. The buccal mucosa is the most commonly
involved site, followed by the lip and tongue but OSF can
occur in any intra-oral site.
The frequency of malignant transformation in OSF has
been reported to be in the range of 7 – 13%. Whether the
malignant transformation is more common in leukoplakic
areas than non-leukoplakic areas in patients with OSF is
not clear.
Diagnosis
A clinical diagnosis of OSF is made based on the
symptoms and clinical features described above. A biopsy
should be taken to confirm the diagnosis and to rule out
dysplasia and malignancy.
Management
The treatment of patients with OSF depends on the degree
of clinical involvement.
If the disease is detected at a very early stage, cessation
of the habit is effective. However, it is often irreversible in
OSF patients who present with severe disease.
The focus of treatment should be on reducing exposure to
the risk factors, especially the use of betel quid and
correcting any nutritional deficiencies, such as iron and
vitamin B complex and on regular mouth opening exercises.
Muscle stretching exercises for the mouth may be helpful
to prevent further limitation of the mouth opening.
Sub-mucosal injections of agents such as
dexamethasone, hyaluronidase, placentral extracts and
collagenase have been tried with some benefit in
symptomatic improvement.
Excision of the fibrous tissues, with correction of the defect
using various grafts especially with buccal fat pad graft,
has been tried in patients with severe OSF.
Lycopene has been shown to be of some benefit.
In general, there is no effective treatment for OSF and the
condition is irreversible once fibrosis sets in. Even though
several treatment regimens have been tried with varying
success, so far no effective treatment is available for OSF.
Useful Websites:
New Zealand Dermatological Society (DermNZ)
Emedicine
Wikipedia
International Agency for Research on Cancer / World
Health Organisation
Bond's Book of Oral Diseases, 4th Edition
Useful Articles:
Cochrane Review 2008. Interventions for the Management
of Oral Sub-Mucous Fibrosis
J Oral Maxillofac Surg 2009. Drug Treatment of Oral Sub-
Mucous Fibrosis - A Review of the Literature
BJOMS 2009. Extended Naso-Labial Flaps in the
Management of Oral Sub-Mucous Fibrosis
Evidence-Based Dentistry 2009. Lack of Reliable
Evidence for Oral Submucous Fibrosis Treatments
Evidence-Based Dentistry 2010. Drug Treatment for Oral
Submucous Fibrosis
JOMS 2011. Use of Buccal Fat Pad for Treatment of Oral
Submucous Fibrosis
appearance may be evident due to the bands running in the
blanched mucosa.
In advanced disease, there is trismus, sinking of the
cheeks out of proportion to age, stiff and small
depapillated tongue, blanched floor of mouth, fibrotic
(scarred) gingival tissues, stiff soft palate with reduced
mobility and shrunken bud-like uvula and blanched and
atrophic tonsils.
> 25% of affected persons may have co-existing
leukoplakia. The buccal mucosa is the most commonly
involved site, followed by the lip and tongue but OSF can
occur in any intra-oral site.
The frequency of malignant transformation in OSF has
been reported to be in the range of 7 – 13%. Whether the
malignant transformation is more common in leukoplakic
areas than non-leukoplakic areas in patients with OSF is
not clear.
Diagnosis
A clinical diagnosis of OSF is made based on the
symptoms and clinical features described above. A biopsy
should be taken to confirm the diagnosis and to rule out
dysplasia and malignancy.
Management
- Cessation of habits
- Correction of nutritional deficiency
- Mouth opening exercise
- Oral lycopene (anti-oxidant found in tomatoes)
- Sub-mucosal injections of steroids, hyaluronidase,
collagenase & placental extract - Surgical removal of fibrous tissues & use of tissue
grafts
The treatment of patients with OSF depends on the degree
of clinical involvement.
If the disease is detected at a very early stage, cessation
of the habit is effective. However, it is often irreversible in
OSF patients who present with severe disease.
The focus of treatment should be on reducing exposure to
the risk factors, especially the use of betel quid and
correcting any nutritional deficiencies, such as iron and
vitamin B complex and on regular mouth opening exercises.
Muscle stretching exercises for the mouth may be helpful
to prevent further limitation of the mouth opening.
Sub-mucosal injections of agents such as
dexamethasone, hyaluronidase, placentral extracts and
collagenase have been tried with some benefit in
symptomatic improvement.
Excision of the fibrous tissues, with correction of the defect
using various grafts especially with buccal fat pad graft,
has been tried in patients with severe OSF.
Lycopene has been shown to be of some benefit.
In general, there is no effective treatment for OSF and the
condition is irreversible once fibrosis sets in. Even though
several treatment regimens have been tried with varying
success, so far no effective treatment is available for OSF.
Useful Websites:
New Zealand Dermatological Society (DermNZ)
Emedicine
Wikipedia
International Agency for Research on Cancer / World
Health Organisation
Bond's Book of Oral Diseases, 4th Edition
Useful Articles:
Cochrane Review 2008. Interventions for the Management
of Oral Sub-Mucous Fibrosis
J Oral Maxillofac Surg 2009. Drug Treatment of Oral Sub-
Mucous Fibrosis - A Review of the Literature
BJOMS 2009. Extended Naso-Labial Flaps in the
Management of Oral Sub-Mucous Fibrosis
Evidence-Based Dentistry 2009. Lack of Reliable
Evidence for Oral Submucous Fibrosis Treatments
Evidence-Based Dentistry 2010. Drug Treatment for Oral
Submucous Fibrosis
JOMS 2011. Use of Buccal Fat Pad for Treatment of Oral
Submucous Fibrosis
| Last Updated 10th February 2012 |