Oral submucous fibrosis (OSMF or OSF) is a chronic, complex, premalignant (1% transformation risk) condition of the oral cavity, characterized by juxta-epithelial inflammatory reaction and progressive fibrosis of the submucosal tissues (the lamina propria and deeper connective tissues). As the disease progresses, the jaws become rigid to the point that the person is unable to open the mouth. The condition is remotely linked to oral cancers and is associated with areca nut or betel quid chewing, a habit similar to tobacco chewing, is practiced predominantly in Southeast Asia and India, dating back thousands of years.

1. Dr Ajins

2. INTRODUCTION:
Oral precancerous condition is a generalized pathological
state associated with a significantly increased risk of cancer
according to World Health Organization (WHO) in 1978.
Oral submucous fibrosis is a premalignant condition affecting
any part of oral cavity & sometimes the pharynx.
Oral submucous fibrosis is a chronic progressive scarring
disease that predominantly affects the people of South East Asian
origin.
This condition was described by Schwartz in 1952 designated
the condition as “oral Submucous fibrosis”.

3. SYNONYMS:
• Atrophia Idiopathica
• Tropica mucosae orali
• Idiopathic scleroderma of the mouth
• Idiopathic palatal fibrosis
• Sclerosing stomatitis
• Juxta-Epithelial fibrosis (Juxta means near)

4. DEFINITION
Oral submucous fibrosis is a slowly progressive chronic fibrotic disease of
the oral cavity and oropharynx; characterized by fibro elastic change and inflammation
mucosa, leading to a progressive inability to open the mouth, swallow or speak.
ETIOLOGY
PRIMARY FACTORS: Habitual use of betel and its constituents, which include areca
nut (areca catechu), leaf to betel pepper (piper betel), and lime (CaOH2).
OTHER FACTORS :
Nutritional & Vitamin deficiencies.
Hypersensitivity of chili pepper, chewing tobacco etc.
Tobacco, Lime & Betel Quid
Chronic Candidiasis (In fungal infection → Yeasts → produce carcinogen mainly
nitrosamine → malignant transformation.)
Genetic Abnormalities
HSV/HPV
Autoimmunity( In HLA-DR3 antigen (+) ce of serum immunoglobulins and
autoantibodies )

5. PATHOGENESIS OF OSMF
Areca products contain high level of copper
(mean 302 nml/g)(Daily intake → 0.6-1.6 mg)
Copper intake → Increased Lysyl oxidase activity →Increase in collagen cross-
linkage- Fibrotic disorder like OSMF, Hepatic &pulmonary fibrosis, Scleroderma.
Areca nut chewing → Copper > 5mg/ day.
Arecoline, an active alkaloid found in betel nuts, simulates fibroblasts to increase
production of collagen.
Arecanut decreases the secretion of collagenase.
Deficiency in collagen phagocytosis by OSF fibroblasts.
Stabilization of collagen structure by catechin and tannins from the arecanut.
Ingestion of chilies ( capsaicin, active ingredient of chilies, stimulates widespread
palatal fibrosis in rats)

6. CLINICAL FEATURES:
The onset is insidious over 2-5 years period
Prodromal symptoms include;
Burning sensation in the mouth when consuming spicy food
Appearance of blister especially in the palate; ulceration or generalized
inflammation of the oral mucosa
Excessive salivation; defective gustatory sensation & dryness of the mouth
Early stage → Focal vascular dilatations clinically manifests as petechiae (may
be vascular response due to hypersensitivity of oral mucosa to some irritants like
chilly)
Petechiae were observed mostly in the tongue followed by labial and buccal
mucosa with no sign of blood dyscrasia or systemic disorders
There is pain on palpation on the areas where the submucosal fibrotic bands are
developing.

7. Advanced OSMF:
As the disease progresses, oral mucosa become blanched and slightly opaque
and white thick fibrous band appear
Oral mucosa is symmetrically involved & fibrous band in the oral mucosa run
in vertical direction.
It is preceded by and/or associated with vesicle formation and is
always associated with juxta epithelial inflammatory reaction followed by
progressive hyalinization of lamina propria.
Later → Sub epithelial and sub mucosal myofibrosis leads to
stiffness of oral mucosa and deeper connective tissue with
progressive limitation in opening of the mouth and protrusion of tongue
leading to difficult in eating, swallowing and phonation.

8. Severe cases →Deviation of uvula
Inability to whistle or blow a candle.
Pterygomandibular raphe involvement → Limitation of mouth opening
Most of the patient experience a protracted period of stomatitis and/or glossitis
with remission and exacerbation.
If fibrosis involves pharynx→ patient experience referred pain in ear.
Nasal voice as one of the later signs in some patients.

13. • Atrophic oral epithelim that may show atypia and
dysplasia
• Diffuse hyalinization of the subepithelial stroma with
pigment incontinence from the ovelying epithelial melanin
• Intercellular edema with or withot
hyperkeratosis,parakeratosis or orthokeratosis.
• EARLY STAGE:
• Epithelial hyperplasia,marked oedema,thickened
collagen bundles,moderate numbers of large
fibroblasts,dilated and congested blood vessels and
inflammatory cell infiltration containing a number of
polymorphonuclear leukocytes.

14. • ADVANCED STAGE:
• Epithelial atropy
• Dense bundles and sheets of collagen
• Thick bands of subepithelial hyalinization extending into
the submucosal tissues
• Decreased vascularity
• No oedema
• Decreased inflamatory cells are found

15. • Buccal mucosa
• Facial pillars
• Soft palate
• Lips and
• Hard palate
• The fibrous bands in the buccal mucosa run in the
vertical direction , sometimes so marked that the cheeks
are almost immovable.

16. • Decreased hemoglobin level
• Decreased iron level
• Decreased protein level
• Increased erythrocyte sedimentation rate
• Decreased vitamin B levels.

17. MANAGEMENT:
• Reduction or even elimination of the habit of arecanut chewing.
• Nutritional support: Mainly for high proteins and calories and for vitamin B complex
and other vitamins and minerals. Vitamin A supplements are excellent sources of
anti-oxidants.
• Immunomodulatory drugs: Local and systemic application of glucocorticoids and
placental extracts.
• Physiotherapy: Forceful mouth opening and heat therapy.
• Ask the patient to stand in front of the mirror and cause mouth opening by holding
hands over the two arches and stretching.
• Ask the patient to blow the balloon atleast three times a day.
• Patient can place bundles of ice-cream stick in the posterior part of the mouth and
ask them to increase the sticks day by day.

18. • Local drug delivery: Local injection of corticosteroids,
Placental extracts and hyaluronidase.
Oral iron preparations.
• Combined therapy:
With peripheral vasodilators, vitamins D, E, A and B complex, iodine, placental
extract, local and systemic corticosteroids and physiotherapy claim a high success
rate in management of OSMF.
• Surgical management:
Submucosal resection of the fibrotic bands and replacement with a partial thickness
skin or mucosal graft.
Bilateral temporalis myotomy.
Surgery seems to be a poor option in the treatment of oral submucous fibrosis since
the more fibrosis and disability on resecting the bands.
PROGNOSIS :
It is a premalignant condition.
Malignant transformation rate is 4 – 13%

19. • THANKYOU !