Oral submucous fibrosis
Dr Amitha
Dept of oral and maxillofacial pathology

Oral Submucous Fibrosis (OSMF)
“OSMF is an insidious chronic disease affecting any part of the
oral cavity and sometimes the pharynx. Although, occasionally
preceeded by and/or associated with vesicle formation, it is
always associated with juxta epithelial inflammatory reaction,
followed by a fibroelastic change of the lamina propria, with
epithelial atrophy leading to stiffness of the oral mucosa and
causing trismus and inability to eat”.
(J.J Pindborg and Sirsat 1966)

CLINICAL FINDINGS
 The disease occurs mainly in Indians between 0.2%and 1.2%.
 The total number of cases in India is around 2 million
 Shear et al (1967) reported a prevalence of OSF is 0.5% in women.
 But at present ,study ratio shows 2.3: 1 = M:F
 Age group common is 2 to 3rd decade of life ( mean age group is 43yrs)

INITIAL SIGNS AND SYMPTOMS
Onset is insidious.
The most common initial symptoms are:
 Burning sensation on eating spicy food
 Blisters on the palate
 Ulceration or recurrent stomatitis
 Defective gustatory sensation
 Dryness of mouth.

• Blanching of the oral mucosa is caused by impairment of local
vascularity because of increasing fibrosis and results in a marble-like
appearance.
• Blanching may be localized, diffuse or reticular.

 In some cases, blanching may be associated with small vesicles that rupture to form erosions.
 Patients complain that these vesicles form after they eat spicy food, suggesting the possibility of an
allergic reaction to capsaicin.

 Difficulty in opening mouth
 Inability to whistle, blow
 Difficulty in swallowing
 When fibrosis involves pharynx-
referred pain to the ear.
 Changes in tone of the voice due to
vocal cord involvement
 Some times deafness due to
occlusion of eustachian tubes
ADVANCED STAGE

 Fibrous band restricting mouth opening and causing difficulty in mastication, speech, swallowing and
maintaining oral hygiene

 Development of fibrous bands in the lip makes the lip thick, rubbery
and difficult to retract or evert.
 A band around the lips gives the mouth opening an elliptical shape.
 Fibrosis makes cheeks thick and rigid.
Upon palpation:
 A circular band can be felt around the entire orifice, this changes are
marked in lower lip
 When a patient blows a whistle or tries to inflate a balloon, the usual
puffed-out appearance of the cheeks is missing.

 Impairment of tongue movements in patients
with advanced osf with significant atropy of
tongue papillae
 In the tongue, depapillation of mucosa around the
tip and lateral margins may occur with blanching
or fibrosis of the ventral mucosa.
 Fibrosis of the tongue and the floor of the mouth
interfere with tongue movement.

 Hard palate involvement includes extensively blanched mucosa.
 Fibrosis may extend posteriorly to involve the soft palate and uvula.
 Uvula may appear shrunken and, in extreme cases, budlike. ( hockey stick apperance)

Malignent potential:
Atropic epithelium first becomes hyperkeratotic and later, intercellular edema and
basal cell hyperplasia develop eventually, fallowing atypia with moderate epithelial
hyperplasia and then, carcinoma can develop at any time.

 Gingival involvement is relatively uncommon and is characterized by:
Fibrosis, blanching and loss of normal stippling
 In rare cases of extensive involvement, there may be loss of hearing due to blockage of Eustachian
tubes and difficulty in swallowing because of esophageal fibrosis.

Classifications
 In 1989 Pindborg OSF is clinically divided into 3 stages
 In 1995 Khanna developed a group classification system for the surgical
management of trismus.
 In 2011 Chandramani More et al classified based on clinical and functional
staging
 In 2000 Haider et al classified based on Clinical and functional staging

According to Pindborg in 1989
OSF is clinically divided into 3 stages ,
Stage 1: stomatitis includes erythematous mucosa, vesicles, mucosal ulcers, melanotic mucosal pigmentation, and
mucosal petechia.
Stage 2: fibrosis occurs in ruptured vesicles and ulcers when they heal, which is the hallmark of this stage.
 Early lesions demonstrate blanching of the oral mucosa.
 Older lesions include vertical and circular palpable fibrous bands in the buccal mucosa and around the mouth
opening or lips, resulting in a mottled, marble like appearance of the mucosa because of the vertical, thick,
fibrous bands running in a blanching mucosa.

Specific findings include the following:
1. Reduction of the mouth opening (trismus)
2. Stiff and small tongue
3. Blanched and leathery floor of the mouth
4. Fibrotic and depigmented gingiva
5. Rubbery soft palate with mobility decreased
6. Blanched and atrophic tonsils
7. Shrunken budlike uvula
8. Sinking of the cheeks, not commensurate with age or nutritional status
Stage 3:
Squeal of OSF are as follows:
• Leukoplakia is precancerous and is found in more than 25% of individuals with OSF.
• Speech and hearing deficits may occur because of involvement of the tongue and the
eustachian tubes.

In addition to the above staging, in 1995 Khanna developed a group
classification system for the surgical management of trismus.
Group I: This is the earliest stage and is not associated with mouth
opening limitations. It refers to patients with an interincisal distance
of greater than 35 mm.
Group II: This refers to patients with an interincisal distance of 26-35
mm.
Group III: These are moderately advanced cases. This stage refers to
patients with an interincisal distance of 15-26 mm. Fibrotic bands are
visible at the soft palate, and pterygomandibular raphe and anterior
pillars of faucets are present.

Group IVA: Trismus is severe, with an interincisal distance of less than
15 mm and extensive fibrosis of all the oral mucosa.
Group IVB: Disease is most advanced, with premalignant and malignant
changes throughout the mucosa

CLINICAL STAGING
 Stage 1.(S1) – Stomatitis and/or blanching of oral mucosa.
 Stage 2.(S2) – Presence of palpable fibrous bands in buccal mucosa and/or
oropharynx, with/without stomatitis.
 Stage 3.(S3) – Presence of palpable fibrous bands in buccal mucosa and/or
oropharynx, and in any other parts of oral cavity, with/without stomatitis.
 Stage 4.(S4)
A. Any one of the above stage along with other potentially malignant disorders
e.g. oral leukoplakia, oral erythroplakia, etc.
B. Any one of the above stage along with oral carcinoma.
Chandramani More et al (2011)

FUNCTIONAL STAGING
M1. Inter-incisal mouth opening up to or >35 mm.
M2. Inter-incisal mouth opening between 25 mm and 35 mm.
M3. Inter-incisal mouth opening between 15 mm and 25 mm.
M4. Inter-incisal mouth opening <15 mm.
Chandramani More et al (2011)

Haider et al. (2000)
Clinical staging: -
Stage 1: Faucial bands only
Stage 2: Faucial & buccal bands
Stage 3: Faucial, buccal & labial bands
Functional staging: -
Stage 1: Mouth opening >20 mm
Stage 2: Mouth opening 11-19 mm
Stage 3: Mouth opening <10 mm

INVESTIGATION
• Complete Hemogram
• Toludine blue test
• Biopsy :- Incisional biopsy
• Immunofluorescent test:
a) Direct b) Indirect