1. Oral submucous fibrosis (OSF) is a chronic disease characterized by inflammation and fibrosis of the oral cavity that causes mouth opening restriction. It is associated with chewing betel nut and is considered a precancerous condition. 2. OSF has multiple treatment approaches including medication, physiotherapy, surgery, and lifestyle changes. Medications include steroids, hyaluronidase, and pentoxifylline to reduce inflammation. Surgeries such as fibrotomy and grafts help improve mouth opening. 3. While various treatments provide temporary relief, recurrence of fibrosis is common. The disease has no definitive cure, though early diagnosis and lifestyle changes may help prevent progression. Close monitoring is also

1. MANAGEMENT OF ORAL SUBMUCOUS
FIBROSIS
Presented by-
Maroti Wadewale
Postgraduate student
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

2. CONTENTS

3. • Diffuse firm whitish areas of submucosal scarring and
fibrosis usually associated with frequent and prolonged
contact with betel nut quid, tobacco, hot peppers.
• Lesions have a higher than normal risk of developing
squamous cell carcinoma.

4. DEFINANTION

5. HISTORY:
Sushruta ( 600 B.C) : described in his book
“ Sushruta Samhita” , a condition affecting the mouth with symptoms
and signs similar to those of OSMF. He labeled this condition as
“VIDARI”
“Schwartz” in 1952 was the first person to bring this condition
again into the lime light. He described this condition under the
heading “ Atropica Idiopathica Mucosa Oris “
“Joshi” ( 1953), who introduced the term “ OSMF of palate
and pillar” first time in India. He was the first who has thrown
light on etiology as well clinical picture of disease.

6. AUTHORS YEAR NOMENCLATURE GIVEN
Schwartz 1952 Atrophia Idiopathica mucosa oris
Joshi 1953 Oral submucous fibrosis
Lal 1953 Diffuse oral submucous fibrosis
Su 1954 Idiopathic scleroderma of mouth
Desa 1957 Submucous fibrosis of palate and check
George 1958 Submucous fibrosis of palate and mucosa
membrane
Goleria 1970 Sub-epithelial fibrosis
SamdariyaS,KumarD, KumarA, PorwalP,PareekP.Oralsubmucousfibrosis—ashortreview.InternationalJournalofMedicalScience andPublic Health.2014Nov1;3(11):1308-12.

7. GEOGRAPHIC
DISTRIBUTION :
overall prevalence rate in India is
believed to be about 0.2% to 0.5%

8. ETIOLOGY - UNKNOWN?
GuptaSC,Yadavyc. 'Misi'anetiologic
factorinoralsubmucousfibrosis.
IndianJOtolaryngoI1978;30:5-6.

9. INFECTIOUS AGENTS
• CANDIDA : only an association
• HSV1- high titers have been found in OSMF, isolation of virus specific proteins
have been unsuccessful.
AnilaK, HallikeriK,ShubhadaC,NaikmasurV,KulkarniR.Comparativestudyofcandida inoralsubmucousfibrosisandhealthyindividuals.Rev OdontoCiênc2011;26:71-6

10. ETIOPATHOGENESIS

13. CLASSIFICATION
More CB, Gupta S, Joshi J, Varma SN. Classification system for oral submucous fibrosis. Journal of Indian Academy of Oral Medicine and Radiology. 2012;24(1):24.

14. Group I -Very
early cases
•burning sensation
•acute ulceration
•recurrent stomatitis
Group II-
Early cases
•Buccal mucosa appears
mottled and marble
like
•fibrosis palpable
•interincisal distance of
26 to 35 mm.
Group III-
Moderately
advanced cases
-buccal mucosa
appeal's pale firmly
attached to underlying
tissues
•atrophy of vermilion
border, vertical fibrous
bands palpable
•interincisal distance of
15 to 25 mm
Group IV (a)-
Advanced
cases
•interincisal distance of
less than 15 mm,
• thickened faucial pillars,
• shrunken uvula,
• restricted tongue
movement,
•presence of circular band
around entire lip and
mouth.
Group IV (b)-
Advanced
cases
•presence of
hyperkeratotic
leukoplakia and/or
squamous cell
carcinoma.
Fine fibrillar collagen
network interspersed
with marked edema,
blood vessels dilated
and congested large
aggregate of plump
young fibroblasts
present
thickened edema,
constricted blood
vessels, mature
fibroblasts with scanty
cytoplasm and spindle-
shaped nuclei,
inflammatory exudates
which consists of
lymphocytes and
plasma cells, epithelium
markedly atrophic with
loss of rete pegs
Collagen hyalinized smooth sheet, extensive fibrosis,
obliterated the mucosal blood vessels, eliminated
melanocytes, absent fibroblasts total loss of epithelial
rete pegs, presence of mild to moderate atypia
Juxta-epithelial
hyalinizalion present,
collagen present as
thickened but separate
bundles, blood vessels
dilated and congested,
young fibroblasts seen
in moderate number,
flattening or shortening
of epithelial rete-pegs
C
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16. MALIGNANCY DEVELOPMENT:
• 7.6 % according to “Pindborg 1986 Int. J Dent Res. Is
submucous fibrosis is a precancerous condition”.
AroraR,Adwani D,NaphadeM,BhagatB,QureshiAQ.MalignantConversionofOralSubmucousFibrosisinSurgicallyTreatedCase.J ClinDiagnRes2014;8.

17. CLINICALPRESENTATION:

18. DIAGNOSIS
Patil S, Maheshwari S. Proposed new grading of oral submucous fibrosis based on cheek flexibility. Journal of clinical and experimental dentistry. 2014 Jul;6(3):e255.
CHEEK
FLEXIBILITY TEST

19. WORK UP
Complete blood evaluation
OPG
CT Contrast

20. Hegde K, Nair P, Gharate HP, Agarwal K, Bhat GR, Rajaram DK. Role of Hemoglobin and Serum Iron in Oral Submucous Fibrosis: A Clinical Study. The Scientific World Journal. 2012.
Vanjani MV, Phulari RG, Rathore R. Evaluation of relationship between serum homocysteine and Vitamin B12 levels in oral submucous fibrosis patients using chemiluminescence immunoassay.
Journal of Oral and Maxillofacial Pathology: JOMFP. 2019 Sep;23(3):363.

22. MANAGEMENT OF OSMF:

24. Restriction of habit /
Behavioral Therapy

25. COUNSELLING

27. Medicinal therapy

28. Kumar A, Sharma SC, Sharma P, Chandra O, Singhal KC, Nagar A. Beneficial effect of oral zinc in the treatment of oral submucous fibrosis. Indian J
Pharmac 1991;23:236-41.
NUTRITION

30. Sudarshan, Ramachandran, Rajeshwari G. Annigeri, and G. SreeVijayabala. "Aloe vera in the treatment for oral submucous
fibrosis–a preliminary study." Journal of Oral Pathology & Medicine 41.10 (2012): 755-761.
CounsellingCounselling
AURVEDIC

31. Pathak AG. Fibrin producing factor in OSMF. Indian J Otolaryngol. 1979;31(4):103-4.
Vijayavel T, Praveena NM, Ramani P. Corticosteroids in oral diseases. Indian Journal of Drugs and Diseases. 2012;1:168–70.
Ameer NT, Shukla RK. A cross sectional study of oral submucous fibrosis in central India and the effect of lo- cal triamcinolone
therapy. Indian J Otolaryngol Head Neck Surg. 2012;64:240-3.
Drug Dosage Mechanism Adverse reaction
Steroid-
hydrocortisone,
triamcinolone
(10mg/ml) ,
dexamethasone
(4mg/ml) and
betamethasone
intralesional injection of
dexamethasone1.5 ml,
hyaluronidase 1500 IU with
0.5 ml lignocaine HCL
injected intralesionally
biweekly for 4 weeks.
systemic prednisone (30–40
mg/day for 14–28 days and
then tapered) or
hydrocortisone (100 mg/day)
immunosuppressive
agents- decrease
inflammation and
collagen formation
always associated
with a high
incidence of
relapse.
STEROIDS

32. Drug Dosage Mechanism Adverse reaction
collagenase,
hyaluronidase
and
chymotrypsin
hyaluronidase 1500 IU with
0.5 ml lignocaine HCL injected
intralesionally biweekly for 4
weeks.
Collagenase is a lysosomal
enzyme, capable of degrading
phosphate esters, proteins,
polysaccharides, glycosides,
and sulfate esters.
Hyaluronidase by
breaking down
hyaluronic acid
always associated
with a high
incidence of
relapse.
ENZYMES

34. Drug Dosage Mechanism Adverse reaction
CARDIOVASCULAR DRUGS
Pentoxifylline
Buflomedil (vasoactive agent)
Nylidrin (sympathomimetic
agent)
400mg TDS for 6-7 months
improve circulation
suppressing leukocyte
function, altering fibroblast
physiology, and stimulating
fibrinolysis.
Nausea, vomiting
CARDIOVASCULAR DRUGS

35. Drug Dosage Mechanism Adverse reaction
Levamisole (Anthelminthic
drug)
150mg TDS in 3 consecutive
days a week for 3 alternate
weeks
Reduces Ig G, Ig A Muscle weakness, memory
loss
LEVAMISOLE

36. Drug Dosage Mechanism Adverse reaction
IFN-gamma Interferon γ (intralesional
injection) ACTIMMUNE (0.01-
10.0 U/mL) 3 times daily For 6
months or, (50 mg / 0.25 ml)
Twice a week 8 weeks
Upregulation of antifibrotic
cytokine and collagen
synthesis in the basal layer of
epithelium and lamina propria
Fever, chills, headache,
myalgia, arthralgia, injection
site reactions
IFN-GAMMA (IMMUNOREGULATORY CYTOKINE)

37. Drug Dosage Mechanism
Placental extract 2ml biweekly for 4
weeks
Anti-inflammatory,
2. Wound healing and
3. Immunotrophic.
PLACENTAL EXTRACT

41. Oral Physiotherapy

42. Vijayakumar M, Priya D. Physiotherapy for improving mouth opening & tongue protrution in patients with Oral
Submucous Fibrosis (OSMF) – Case Series. International Journal of Pharmaceutical Science and Health Care.
2013;2(3): 50-58.
JAW STRECHINGEXERCISE
Cox and Zoellner (2009) advocated five times
daily physiotherapy by interpositioning tongue
spatulas between teeth and adding a new spatula
every 5–10 days

43. PHYSIOTHERAPYWITH ULTRASOUND

44. OSTEOPATHICMANIPULATIVE TREATMENT

45. SPLINT

46. Surgical Therapy

47. FIBROTOMY

49. FIBROTOMYWITH GRAFTS

50. SPLIT THICKNESSGRAFT high reoccurrence rate
due to graft shrinkage

51. FULLTHICKNESSGRAFT

52. SUPERFICIAL TEMPORALIS presence and growth of hair in grafted
tissue and morbidity of temporal
hollowing are common problems

53. PLATYSM MYOCUTANEOUS FLAP

54. NASOLABIAL FLAP easy accessibility, the availability of a
healthy vascular pedicle based on the
inferior nasal vessels

56. TONGUE FLAP the possibility of the
donor area being afflicted
with the disease process.

57. PALATAL ISLAND FLAP restrictions imposed in harvesting the
flap, postoperative morbidity to the
donor site which heals by secondary
intention and the limited reach of the
flap.
need to extract the second maxillary
molars to allow the flap to reach the
host site.

59. BUCCAL PAD OF FAT easy access of the buccal fat tissue in close
proximity to the surgical site, its volume and
its non-involvement in the disease condition
make it an ideal choice as a donor site
relatively less morbidity associated with
procedure and the simplicity of the technique

61. MICROVASCULAR FREEFLAPS
RADIAL FOREARM FREE FLAP
econdary donor areas unaffected by the
local disease process, no encumberances of
anatomical restrictions
high expertise, high operating costs and
potential failure of anastomoses

62. ANTEROLATERAL THIGHFLAP
Mean flap size was 4.1 􏰀 7.5 cm, mean
pedicle length was 7.6 cm,
mean improvement in IID was 15.3 mm (range:
10-27 mm)

63. ARTIFICIAL DERMIS shortens the healing time of wound, decreases relapse of
fibrosis and improve the restricted mouth opening.

64. COLLAGEN MEMBRANE Six months after the surgery the average mouth opening
was 37.63 mm, at 1 year, 36.10 mm and at 2 years 34.87
mm. Collagen membrane which was used healed in 2
weeks with satisfactory results.

65. HUMAN PLACENTAL/AMNION GRAFTS
HAM has low immunogenicity, anti-inflammatory
properties and their cells can be isolated without the
sacrifice of human embryos.

66. ROLE OFCORONOIDOTOMY & TEMPORALIS MUSCLE MYOTOMY

67. DENTOALVEOLAR SURGERY IN ORALSUBMUCOUS FIBROSIS
Lubrication of Inflamed Mucosa
Modification of Local Anesthesia Technique- The
Vazirani-Akinosi closed-mouth mandibular block is
chosen
Modification of Surgical Technique- For extraction of
mandibular third molars using a transalveolar
technique, the flap design must be conservative
without overextension of distal releasing incision.
Tearing or shredding of flap, lingual gingiva,
pterygomandibular raphe must be avoided.

68. RECENT TRENDS

70. Sankaranarayanan S, Padmanaban J Ramachandran CR , Manjunath
S , Baskar S , Senthil Kumar R , Senthil Nagarajan R , Murugan P ,
Srinivasan V , Abraham S Autologous Bone Marrow stem cells for
treatment of Oral Sub-Mucous Fibrosis - a case report. Sixth Annual
Meeting of International Society for Stem Cell Research (ISSCR),
Philadelphia, PA USA, 11th - 14th June 2008.

73. FUTURE RESEARCH

75. PROPOSED
TREATMENT
PROTOCOL

76. • Numerous treatment modalities that have been implicated
• Most stable results was achieved by tongue flap.
• BFP grafting is suitable alternative to tongue flap
• “There are chancesof recurrence in the process of increasing fibrosis. Thus a close follow-up of these
patients should be done”.
• “In well established cases, allavailablemodalities of treatment fail to give lastingrelief. The
expectancy of life is not reduced unless the OSMF is associated with malignancy“ .
• A more extensive clinicaltrials involving a greater number of casesand including more parameters
are necessary
CONCLUSIONS

77. 1. Schwartz J. Atrophia Idiopathica Mucosae Oris. London: Demonstrated at the 11th Int Dent Congress; 1952.
2. Joshi SG. Submucous fibrosis of the palate and pillars. Ind J Otolaryng
1953;4:1-4.
3. Paissat DK. Oral submucous fibrosis. Int J Oral Surg 1981;10: 307-312.
4. Canniff JP, Harvey W, Harris M. Oral submucous fibrosis: its pathogenesis and management. Br Dent J
1986;160:429-34.
5. Shafer’s oral pathology
6. Management of oral submucous fibrosis an atlas by Madan Kapre
REFERENCES