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Oral Submucous Fibrosis: the Soft Tissue Marble of Asia

Article · January 2018

DOI: 10.26717/BJSTR.2017.01.000629

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 Volume 2- Issue 1 : 2018
DOI: 10.26717/BJSTR.2018.02.000629
Karthik D Yadav. Biomed J Sci & Tech Res

ISSN: 2574-1241

Mini Review Open Access

Oral Submucous Fibrosis: the Soft Tissue Marble of Asia

Karthik D Yadav1*and PaiAnuradha2
1
Post Graduate student, Department of oral medicine and radiology, The oxford dental college and research center, India
2
HOD &Professor, Department of oral medicine and radiology, The oxford dental college and research center, India
Received: December 20, 2017; Published: January 04, 2018
*Corresponding author: Karthik D Yadav, Post Graduate student, Department of oral medicine and radiology, The oxford dental college and research
center, 10th Milestone, Bommanahalli, Bangalore-560102, India; Tel: , Email:

Introduction
effects, which modulate matrix metalloproteinases, lysyl oxidases
Oral squamous cell carcinoma is the sixth most common
and collagenases, which affect the collagen metabolism leading
malignant neoplasm worldwide. Each year it accounts for more than
to fibrosis [7]. Concomitantly, a decrease in the water-retaining
300,000 cases worldwide. The 5-year survival rate for OSCC has
proteoglycans will occur which favors an increase in type I collagen
remained at approximately 50% for the past several decades [1].
production and the flavonoids catechin and tannin in the betel
The impact of oral cancer is such that the disease and its treatment
nut stabilizes the collagen fibers and makes them resistant to
bring a heavy financial burden to both the social resources and the
degradation by collagenase [6]. Genetically, polymorphism of the
patient’s family with psychological stress affecting the quality of life
gene coding for tumor necrosis factor α (TNF-α) leads to stimulation
[2]. It develops through a multistep process of genetic, epigenetic
of fibroblasts and aberrations of other cytokines which include
and metabolic changes resulting from exposure to carcinogens,
transforming growth factor β and interferon-γ, lead to increased
with initially the presence of a precursor/pre-cancer such as oral
production and decreased degradation of collagen. Concomitant to
leukoplakia, oral erythroplakia oral submucous fibrosis. The most
tobacco chewing, smoking and consumption of alcohol increases
frequently reported etiological agents being tobacco, alcohol,
the risk of oropharyngeal malignancies. 7% to 13% lesions of OSMF
chewing of betel quid containing areca nut [3]. The global incidence
can transform into oral cancer, especially squamous-cell carcinoma
of oral submucous fibrosis is estimated at 2.5 million individuals.
over a period of 10 years [6-8].
It is one of the most predominant potentially malignant conditions
in South Asia with a high rate of prevalence in India, but is now
also being acknowledged in Europe and North America [4-6]. The
prevalence in Indian populations is 5% for women and 2% for men,
which is reflected by the fact that the habit is more common among
women in some geographic areas [7].

Aetiopathogenesis
Oral submucous fibrosis (OSMF) is a chronic inflammatory
disease of the oral soft tissues with progressive juxta-epithelial
fibrosis resulting in increasing difficulty in chewing, swallowing,
speaking and mouth opening, often associated with burning
sensation inside oral cavity that is aggravated on exposure to spicy
food [8]. The habit of chewing betel nut (Areca catechu) is considered
to be the main etiological agent, with others factors being genetic
predisposition, infections and viral agents, carcinogens, nutritional
and immunologic factors [8]. The role of chilliin the pathogenesis of Figure 1.
OSMF remains controversial and is postulated as an hypersensitivity
Clinical Features
reaction to capsaicin due to allergen induced eosinophilia [6]. The
mixture of areca nut and tobacco has led to a sharp increase in the The buccal mucosa and retromolar area are the primary sites
frequency of OSMF [5]. A relationship has been observed between affected, followed by soft palate, palatal fauces, uvula, tongue and
the areca quid consumption and development of OSMF. labial mucosa [6]. It occurs in the age group of 12–62 years with
the mean age being 40 years. A definite female predilection, with
Areca nut (Figure 1) contains alkaloids notably arecoline the male: female ratio being 3:2 [6]. A difficulty in opening mouth
and guavacoline, with a wide range of parasympatheticomimetic

Cite this article: Karthik D Y, Pai A. Oral Submucous Fibrosis: the Soft Tissue Marble of Asia. Biomed J Sci & Tech Res 2(1)- 2018. BJSTR.
MS.ID.000629. DOI : 10.26717/BJSTR.2018.02.000629 2092
Karthik D Yadav. Biomed J Sci & Tech Res Volume 2- Issue 1 : 2018

accompanied with burning sensation is usually the reason for the rubbery soft palate with decreased mobility and blanched and
patient’s initial visit. On examination, blanching of the oral mucosa atrophic tonsils, and shrunken bud like uvula with impairment
is noted which imparts a marble-like appearance, attributed to of activities such as eating, whistling, blowing, sucking [6]. Other
inflammation, trailed by hypovascularity and fibrosis that may be symptoms are increased salivation, change of gustatory sensation,
associated with small vesicles and mucosal erosions [8]. As the hearing loss due to stenosis of the Eustachian tubes, dryness of the
disease progresses, there may be stiffness of the tongue, blanched mouth, nasal tonality to the voice anddysphagia to solids. Pindborg
and leathery floor of the mouth, fibrotic, depigmentation of gingiva, has classified OSMF into 3 stages as shown in Table 1.
Table 1: Pindborg has classified OSMF into 3 stages.

Pindborg’s Clinical Staging [9]

Stage 1: Early OSMF Stage 2: Moderate OSMF Stage 3: Severe OSMF
1. Moderate to severe blanching 1. Burning sensation very severe
2. Mouth opening reduced by 33%, tongue 2. More than 66% reduction in the mouth
1. Mild blanching
protrusion reduced by 33% and reduced opening, cheek flexibility and tongue protrusion.
2. No restriction in mouth opening flexibility In much tongue may appear fixed
3. No restriction in tongue protrusion up to 3. Burning sensation even in the absence of 3. Ulcers over the buccal mucosa
mesioincisalangle of upper central incisor when stimuli
maximally extended with mouth wide open. 4. Thick palpable bands
4. Presence of palpable bands
4. Burning sensation only on taking spicy food or 5. Bilateral lymphadenopathy, definite
5.Lymphadenopathy eitherunilateral or bilateral nutritional compromise Can be established in B
hot liquids.
6. Demonstrable anemia on hematological complex (angular cheilitis) and iron deficiency
examination. group.

Diagnosis & Investigations References

Diagnosis of the disease is mainly by clinical findings and can 1. S Gokul (2010) Oxidant-antioxidant status in oral squamous cell
be confirmed by incisional biopsy. Other investigations include carcinoma patients. Oral Diseases 16(1): 29-33.

hematological, serological, immunological and biochemical factors 2. Han (2010) BMC Public Health 10:196
which may reflect findings such as a raised ESR, slight eosinophilia, 3. Gurkan Yardimci, ZekayiKutlubay, Burhan Engin, YalcinTuzun (2014)
microcytosis and hyperchromic indicative of anemia. The Precancerous lesions of oral mucosa. World J Clin Cases 2(12): 866-872.
differential diagnosis includes anemia and scleroderma which can 4. Kumar S, Mohan C, Pagrani M, Srivastava A (2014) Oral submucous
be distinguished by other cutaneous, systemic and characteristic fibrosis - revisited. Annals of Dental Specialty 2(2): 43:46.
radiographic and laboratory findings [6]. 5. Wollina U, Verma SB, Ali FM, Patil K (2015) Oral submucous fibrosis: an
update. Clinical, Cosmetic and Investigational Dermatology 8: 193-204.
Management
6. Ongole RK, Praveen BN (2014) Textbook of Oral Medicine and Oral
Management of OSMF includes use of hyaluronidase and corti- Diagnosis and Oral Radiology, 2nd ed. Elsevier Inc: 283-289.
costeroids or a combination of both. Other treatment modalities in-
7. Burket L, Greenberg M, Glick M, Ship J (2015) Burket’s oral medicine.
clude antioxidants, Immunomodulators, Physiotherapy, Intereferon Hamilton, Ont. BC Decker 84: 98-117.
-γ, Hyper Baric Oxygen (HBO) therapy, Curcumin, Oxitard, Aloevera,
8. Jena AJ, Das SR (2016) A Review of Treatment Modalities in Oral
Surgery [6,8,10]. Even though it is easy to diagnose but the irre- Submucous Fibrosis. Int. J. Pharm. Sci. Rev. Res 36(2): 128-130.
versible condition reflects the failure of the present treatment mo-
9. Patil S, Maheshwari S (2014) Proposed new grading of Oral Submucous
dalities. The lack of knowledge and the delay in seeking treatment Fibrosis based on cheek flexibility. J Clin Exp Dent 6(3): 255-258.
leads to the progression of the disease. Hence, more focus should be
10. M Ashwini Kumar (2015) Hyperbaric Oxygen Therapy in the Treatment
emphasized in detecting newer treatment modalities which is the of Oral Submucous Fibrosis. Journal of Clinical and Diagnostic Research
need of the hour and the future. 9(5): ZE01-ZE04.

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