review article

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Copyright ©2013
Review Article
J Res Adv Dent 2014; 3:2:72-75.
An outline of existing clinical classification system for oral sub
mucous fibrosis
Nidhi Thakur1* Vishal Kumar2
1Senior Lecturer, Department of Oral Medicine and Radiology, Dr. B R Ambedkar Institute of Dental Sciences and Hospital, Patna, Bihar, India.
2Reader, Department of Orthodontics, Dr. B R Ambedkar Institute of Dental Sciences and Hospital, Patna, Bihar, India.
ABSTRACT
Objectives: Oral submucous fibrosis remains an enigma, with a poorly defined classification system and elusive
pathogenesis. Many attempts have been made to classify OSMF, some based on clinical criteria and some on
histopathological criteria. Some authors have classified it based on the functional aspects. But none of these
classification systems have a universal acceptance. Here is an attempt to compile the different systems of OSMF
classification for the ease and better understanding of the clinicians.
Keywords: Oral submucous fibrosis, potentially malignant disorder.
INTRODUCTION
Oral submucous fibrosis is a potentially
malignant disorder that is characterized by
blanching and stiffness of oral mucosa, trismus, and
burning sensation in the mouth. It also produces
hypomobility of the soft palate and tongue, and loss
of gustatory sensation. Occasionally there can be
mild hearing impairment due to blockade of the
eustachian tube. Although the etiology is not very
clear but a definitive association of the same with
areca nut (Areca catechu) consumption in variable
forms has been established by many studies1-5.
Some cases of oral submucous fibrosis have been
reported in patients without any habit of areca nut
consumption6. It affects people of all age groups and
both the sex but is more prevalent in males in
second and third decade. The malignant potential
for oral submucous fibrosis is considered high7.
Extensive studies done on the
etiopathogenesis of the disease have observed an
evidence of OSMF being a mucosal change
secondary to chronic iron and /or vitamin B
complex deficiency5.It has been suggested that the
disease is an Asian analogue of sideropenic
dysphagia. The biological basis for OSMF remains
unclear but cytotoxic, apoptotic and proliferative
effects from areca nut agents have been proposed
for it 8-11. Active oxygen species and reactive free
radicals mediate alterations that lead to mutations
and produce the genotypic and phenotypic
manifestations of the disease.
Both surgical and pharmacological
treatments have been tried in the management of
OSMF. Surgical treatment by excision of fibrous
tissues is effective but is often followed by relapse.
They are also inaccessible in certain backward
communities where OSMF is a common entity.
Conservative management has shown significant
improvement in mouth opening and providing
symptomatic relief to the patients14 to 16.
Physiotherapy along with micronutrients
supplements has also been reported to show
significant improvement in mouth opening in these
patients17, 18, 19.
Outline of the clinical classification systems:

2. 73
Though oral submucus fibrosis has been classified
based on its clinical symptoms as well as
histopathological features but clinical staging is
gaining significance. This is because biopsy per se
for diagnosis has been largely abandoned as it is
seen to cause further fibrosis and scarring. The
existing clinical classification system has been
placed here arbitrarily in two groups (Table 1).
Classifications given before
year 2000
Classifications given
after year 2000
1. J V Desa(1957) 1. Rangnathan K et al
(2001)
2. Pindborg JJ(1989) 2. Rajendran et
al(2003)
3. S K Katharia(1992) 3. Nagesh and
Bailoor(2005)
4. Lai DR et al(1995) 4. Tinky Bose & Anita
Balan
5. R Maher(1996) 5. Kiran kumar et al
(2007)
6. Chandramani more
et al (2011)
Classification by J V Desa (1957)
 Stage I- stomatitis & vesiculations
 Stage II- Fibrosis
 Stage III- As its sequelae
Classification by Pindborg JJ (1989)
Stage I- Stomatitis includes erythematous mucosa,
vesicles, mucosal ulcers, melanotic mucosal
pigmentations and mucosal petechiae.
Stage II-Fibrosis occurring in the healing vesicles
and ulcers, 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. This results in a mottled marble like
appearance of the mucosa because of the
vertical thick fibrous bands in association
with a blanched mucosa.
Stage III- Sequelae of OSMF are as follows
 Leukoplakia as found in more than 25% of
individuals with OSMF
 Speech and hearing defects may occur
because of involvement of the tongue and
the Eustachian tubes.
SK Katharia classification et al (1992)
 Score 0- mouth opening is greater than 41 mm
 Score 1- mouth opening between 37 to 40 mm
 Score 2- mouth opening between 33 to 36 mm
 Score 3- mouth opening between 29 to 32 mm
 Score 4- mouth opening between 25 to 28 mm
 Score 5- mouth opening between 21 to 24 mm
 Score 6- mouth opening between17 to 20 mm
 Score 7- mouth opening between13 to 16 mm
 Score 8- mouth opening between 9 to 12 mm
 Score 9- mouth opening between 5 to 8 mm
 Score 10- mouth opening between 0 to 4mm
Lai DR conducted a study and dvided the patients
based on the interincisal distance as
 Group A- Mouth opening greater than 35mm
 Group B- Mouth opening between 30 to 35mm
 Group C – Mouth opening between 20 to 25mm
 Group D – Mouth opening less than 20mm
R Maher has given a classification based on area of
involvement of the oral cavity
 Involvement of 1/3rd or less of the oral cavity

3. 74
 Involvement of 1/3rd to 2/3rd of the oral
cavity(if 4 to 6 intra oral sites are involved)
 Involvement of greater than 2/3rd of the oral
cavity.
Ranganathan K et al used a baseline study on the
mouth opening parameters of normal patients and
divided the OSMF patients as
 Group I- Only symptoms with no restriction of
mouth opening
 Group II- Limited mouth opening 2o mm and
above
 Group III- Mouth opening less than 20 mm
 Group IV – OSMF advanced with limited mouth
opening along with precancerous or cancerous
changes seen throughout the mucosa.
Rajendran R classification reported the clinical
features of OSMF as:
 Early OSMF- Burning sensation in the mouth.
Blisters especially on the palate, ulceration or
recurrent generalised inflammation of the oral
mucosa, excessive salivation, defective
gustatory sensation and dryness of mouth
present.
 Advanced OSMF- Blanched and slightly opaque
mucosa, fibrous bands in buccal mucosa
running in vertical direction. Palate and the
faucial pillars are the areas involved. Gradual
impairment of tongue movement and difficulty
in mouth opening.
Tinky Bose and Anita Balan classification of OSMF
 Group A – mild cases
 Group B – moderate cases
 Group C – severe cases
Kiran Kumar et al
 Stage I (Mouth opening greater than 45mm)
 Stage II (Restricted mouth opening 20 to
40mm)
 Stage III (Mouth opening less than 20mm)
Chandramani More et al classification20 (2011)
A. Clinical Staging:
Stage I (S1) –stomatitis and blanching
Stage II (S2) - Presence of palpable fibrous bands in
buccal mucosa and or oropharynx with or
without stomatitis.
Stage III- Involvement of other part.
Stage IV (S4)-
 Any of the above stage along with presence of
potentially malignant disorder.
 Presence of oral carcinomas.
Functional classification (Based on interincisal
distance)
M1- Interincisal mouth opening up to or > 35mm
M2- Interincisal distance between 25 to 35mm
M3- Interincisal distance between 15 to 25mm
M4- Interincisal distance of less than 15mm
CONCLUSION
The purpose of the present article is to outline the
existing clinical classification for the ease of
diagnosis and treatment of oral submucous fibrosis.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this
article was reported.
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