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oral submucous fibrosis

  1. Oral submucous fibrosis Dr Amitha Dept of oral and maxillofacial pathology
  2. 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)
  3. 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)
  4. 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.
  5. • 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.
  6.  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.
  7.  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
  8.  Fibrous band restricting mouth opening and causing difficulty in mastication, speech, swallowing and maintaining oral hygiene
  9.  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.
  10.  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.
  11.  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)
  12. 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.
  13.  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.
  14. 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
  15. 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.
  16. 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.
  17. 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.
  18. 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
  19. 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)
  20. 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)
  21. 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
  22. INVESTIGATION • Complete Hemogram • Toludine blue test • Biopsy :- Incisional biopsy • Immunofluorescent test: a) Direct b) Indirect

Editor's Notes

  1. COMMON SITES INVOLVED Buccal mucosa, faucial pillars ,soft palate, lips and hard palate. The fibrous bands in the buccal mucosa run in a vertical direction ,sometimes so marked that the cheeks are almost immovable. In the soft palate the fibrous bands radiate from the pterygomandibular raphe or the faucial pillars and have a sear like appearance
  2. The uvula is markedly involved , shrinks and appears as a small fibrous bud. The faucial pillars become thick , short, and extremely hard. The tonsils may be pressed between the fibrosed pillars The lips are often affected and upon palpation , a circular band can be felt around the entire rima oris When gingiva is affected , it is fibrotic, blanched and devoid of its normal stippled appearance.