Oral Submucous Fibrosis and its Management.
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Oral Submucous Fibrosis and its various treatment modalities inclusive of both non-surgical and surgical management. Mentor: Dr Saikat Saha MDS, OMFS, SIliguri, West Bengal, India Address: MAXFAC Center for Oral and Maxillofacial and Head & Neck Surgery, Siliguri Email : maxfacmail@gmail.com
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Oral Submucous Fibrosis and its Management.
- 1. ORAL SUBMUCOUS FIBROSIS AND ITS MANAGEMENT Maxfac Center for Cranio - Maxillofacial & Head and Neck Surgery, Siliguri Contact us at : maxfacmail@gmail.com Mentor & Guide : Dr Saikat Saha MDS OMFS Presenter : Dr Mukesh Chhetri BDS Fellow Trainee at Maxfac
- 2. CONTENTS • Introduction • Definition • WHO definition of precancerous condition • Epidemiology • Etiology/Predisposing factors • Common products • Symptoms • Signs • Diagnostic measurements • Constituents of arecanut • Pathogenesis • Histopathology • Staging • Blood chemistry & hematological variations • Management • Surgical management • An overview • Conclusion • Reference
- 3. INTRODUCTION • Oral Submucous Fibrosis is a chronic debilitating disease characterized by gradually increasing fibrosis of the oral cavity and pharynx, mainly the buccal mucosa, resulting in trismus. • Most treatment modalities in OSMF have centered on release of the fibrotic bands to assist oral opening and some to provide symptomatic relief to the patient.
- 4. DEFINITION "An insidious chronic disease affecting any part of the oral cavity and sometime the pharynx. Although occasionally preceeded by and/or associated with vesicle formation, it is always associated with juxta-epthelial inflammatory reaction followed by fibro- elastic change of lamina propria, with epithelial atrophy leading to stiffness of the oral mucosa and causing trismus and inability to eat" -Pindborg (1966)
- 5. Diffuse oral submucous fibrosis Idiopathic scleroderma of mouth Idiopathic palatal fibrosis Sclerosing stomatitis Juxtaepithelial fibrosis Also called:
- 6. Upper Digestive Tract Submucous fibrosis Pharynx
- 7. WHO Definition of ‘Oral Precancerous Condition’ “A generalized pathological state of the oral mucosa associated with a significantly increased rick of cancer”– accords well with the characteristics of OSF
- 8. • VIDARI ~ 600AD (Sushruta) • Atrophia Idiopathica (tropica) Mucosae Oris ~ Schwartz(1952) • Oral Submucous Fibrosis ~ Joshi(1953)
- 9. EPIDEMIOLOGY • Adolescents and adults (16 – 35 years) • 0.2 – 0.5 % prevalence rate in India.
- 10. ETIOLOGY / PREDISPOSING FACTORS (multifactorial) ARECANUT & PRODUCTS TOBACCO CHILIES(CAPSAICIN) GENETIC & IMMUNOLOGICAL PROCESSES NUTRITIONAL DEFICIENCIES SMOKING ALCOHOL MISI (BLACK POWDER USED BY WOMEN IN U.P.)
- 11. COMMON PRODUCTS BETEL QUID (areca nut, tobacco, slaked lime and other species)
- 12. TOBACCO PREPARATIONS Gutkha, Pan Masala, Mawa, Flavoured Supari, Khaini etc.
- 13. MISI (sodium bicarbonate, alum, myrobalan charcoal and filler earth)
- 14. Symptoms • Burning sensation • Difficulty in mouth opening • Difficulty in swallowing • Taste changes • Dryness of mouth • Excessive salivation • Difficulty in speaking • Vesicles & Ulcers • Hearing difficulty • Hoarseness of voice • Nasal twang
- 15. Signs • Blanching of oral mucosa • Presence of fibrous bands • Leathery texture of oral mucosa • Trismus • Restriction of Tongue Movements • Blisters/Erythematous areas/ Ulcers/Vesicles/Erosions • Depapillation of Tongue • Shrunken/Deviated/Bud like Uvula • Atrophic tongue • Bilateral pouching-in while opening mouth/Sunken cheeks • Lymphadenopathy • Anaemia • Secondary/Malignant changes
- 16. Presence of fibrous bands Blanching of oral mucosa
- 17. Leathery texture of oral mucosa
- 18. Trismus Restriction of Tongue Movements
- 20. Depapillation of Tongue Atrophic tongue
- 21. Bud like Uvula Shrunken Uvula Deviated Uvula
- 22. Bilateral pouching-in while opening mouth / Sunken cheeks Angular cheilitis
- 24. DIAGNOSTIC MEASUREMENTS INTERINCISAL DISTANCE (MAXIMUM MOUTH OPENING) Normal distance between Central Incisor Tips: Males: 35 to 45 mm Females: 30 to 42 mm
- 25. TONGUE PROTRUSION Normal Mesio-Incisal Angle of the Upper Central Incisor to the Tip of the Tongue when maximally extended with the mouth wide open: Males: 5 to 6 cm Females: 4.5 to 5.5 cm
- 26. CHEEK FLEXIBILITY: CF= V1-V2 . V2- Point measured between at one-third the distance from the angle of the mouth on a line joining the tragus of the ear to the angle of the mouth The patient is then asked to blow his cheeks fully and the distance between the two points is marked on the cheek as V1 Mean values for cheek flexibility: Males 35 to 45 mm Females 30 to 40 mm [Patil S. and Maheshwari S.(2014)]
- 27. 1/3 V2 V1 1/3 When normally When cheeks fully blown
- 29. QUID “A substance or mixture of substances, placed in the mouth or chewed or remaining in contact with the mucosa, usually containing one or both of the two basic ingredients tobacco and/or arecanut, in raw or any manufactured or processed form”
- 30. ARECA NUT ALKALOIDS FLAVANOIDS ARECOLINE ARECAIDINE ARECOLIDINE GUYACOLINE GUACINE TANNINS CATECHINS
- 33. PATHOGENESIS [P.Rajlalitha, S.Vali (2005)] COLLAGEN PRODUCTION PATHWAY COLLAGEN DEGRADATION PATHWAY
- 34. Initial events of the disease Oral mucosa Betel quid habit Chronic inflammation Activated T cell & Macrophage at the site Constant irritation ↑Cytokines & Growth factors Duration & Frequency of habit Deficiency of Iron &Vit. B12 mechanical chemical 15 MINS - HOUR X 5-6 TIMES A DAY
- 35. COLLAGEN PRODUCTION PATHWAY ACTIVATION OF PRO-COLLAGEN GENES ELEVATION OF PROCOLLAGEN PROTEINASES LEVELS PNP PCP UPREGULATION OF LYSYL OXIDASE(LOX) ACTIVITY
- 36. COLLAGEN DEGRADATION PATHWAY ACTIVATION OF TISSUE INHIBITOR OF MATRIX METALLOPROTEINASE GENE(TIMPs) ACTIVATION OF PLASMINOGEN ACTIVATOR INHIBITOR GENE(PAI)
- 37. OVER ALL EFFECT INCREASE IN COLLAGEN PRODUCTION DECREASE IN COLLAGEN DEGRADATION INCREASED COLLAGEN (INSOLUBLE FORM— CROSS-LINKING OF INSOLUBLE COLLAGEN) FIBROSIS ORAL SUBMUCOUS FIBROSIS
- 38. HISTOPATHOLOGY EARLY STAGE ADVANCED STAGE
- 39. STAGING Chandramani B. More et al (2011) CLINICAL STAGING
- 40. Stage 4 (S4) • Any one of the above stage with other PMDs (oral leukoplakia, oral erythroplakia, etc) • Any one of the above stage along with oral carcinoma.
- 41. FUNCTIONAL STAGING Interincisal mouth opening: ≥ 35 mm. Interincisal mouth opening: 15 — 25 mm. Interincisal mouth opening: < 15 mm Interincisal mouth opening: 25 – 35 mm. M 1 M 4 M 2 M 3
- 42. BLOOD CHEMISTRY & HEMATOLOGICAL VARIATIONS ↓ Vit. B12 ↓ Serum Albumin ↓Fe ↓ Folate Slight Eosinophilia ↑ Gammaglobulin ↑ TIBC Microcytic Hypochromic Anaemia↑ESR Macrocytic Normochromic Anaemia
- 43. MANAGEMENT
- 44. ELIMINATION OF HABITS NUTRITIONAL SUPPORT IMMUNO-MODULATORY DRUGS LOCAL DRUG DELIVERY INTRALESIONAL INJECTIONS PHYSIOTHERAPY INTERFERON GAMMA-1 D (IMMUNOKINE OF BOEHRINGER) COMBINED THERAPY MOUTH RINSES SURGICAL MANAGEMENT
- 45. BETEL QUID CHEWING HABIT CHRONIC INFLAMMATORY PROCESS TGF-β COLLAGEN PRODUCTION COLLAGEN DEGRADATION TIMPPCPPNP PLASMINOGEN ACTIVATOR SYSTEM COLLAGENASE - - - - 1. Anti-inflammatory/ Immune-modulatory drugs 2. Anti- TGF-β 3. Cu Chelators 4. Anti-LOX drugs 5. Collagenase activators + LOX (Lysyl Oxidase)
- 46. Type Drug ANTI-INFLAMMATORY / IMMUNE-MODULATORY DRUGS Pirfenidone (ESBRIET, INTERMUNE) (immunosuppressant) IFN-gamma (immunoregulatory cytokine) Still in research 200 µg/ml have been tried ANTI- TGF-Β Mouse monoclonal antibodies: Anti-TGF-β1 (8A11) (NovusBio®, USA) (Cat No: NB110- 59988) Anti-TGF-β2 (TB21) (NovusBio®, USA) (Cat No: NBP1- 51749) Dilution: 4 μl/100 μl (for anti-TGF-β1) 1 μl/100 μl (for anti-TGF-β2) CU CHELATORS Penicillamine Still in research ANTI-LOX DRUGS β-aminopropionitrile (BAPN, 100 µM) an irreversible LOX inhibitor Still in research COLLAGENASE ACTIVATORS Colchicine 0.5 mg orally twice a day
- 48. As gum, skin patch, nasal spray, or inhaler. Chewing gums Skin Patch
- 50. Bupropion Hydrochloride (ZYBAN) Varenicline (CHANTIX) ZYBAN prescribed under another name“WELLBUTRIN” to treat depression. As tablets
- 52. HIGH PROTEINS & HIGH- CALORIE DIET VITAMIN B COMPLEX & OTHER VITAMINS MINERALS Intake of red tomatoes, fresh foods, green leafy vegetables Green tea Routine Hb % levels followed by Iron supplementation LYCOPENE
- 54. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Lycopene LYCOPENE (NOW) (lycopene ~10mg) SM FIBRO (lycopene ~5mg) LYCOSTAR (Lycopene~5000mcg) 8 – 10 mg Twice daily For 2 months (16mg in 2 divided doses) Powerful antioxidant obtained from tomatoes Manufactured by the Lyc-O-Mato™ process
- 55. MECHANISM OF ACTION ADVERSE EFFECTS Reducing the free radical reaction That can cause DNA mutations and changes in lipid peroxidation of cellular membranes and changes in enzymatic activities Generally well tolerated. The scientific literature documents some GI complaints
- 58. Topical Application: TRIAMCINOLONE GEL 0.1% (Kenacort) / TRIAMCINOLONE IN ORA-BASE BETAMETASONE 0.5% (Betnesol) KENALOG S EYE OINTMENT (triamcinolone acetonide 1 mg, gramicidin 0.25 mg, neomycin sulphate 2.5 mg/1 g) IN EARLY STAGES 3-4 TIMES A DAY
- 61. GLUCOCORTICOIDS & PLACENTAL EXTRACTS (LOCAL & SYSTEMIC APPLICATION) SUPPRESS INFLAMMATORY RECATION PREVENT FIBROSIS Placentrix injection intralesionally (Aqueous extract) Levamisole (Dewormis) Pentoxifylline (Trental)
- 62. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Levamisole DEWORMIS BIOVAM LEVOMOL 150 mg Three times daily Three consecutive days in a week Three alternate weeks Or, In combination with Two capsules of Antaoxid daily For Six weeks. Anthelminthic drugs
- 63. MECHANISM OF ACTION ADVERSE EFFECTS CONTRAINDICATIONS Immunomodulator (modifies both cellular and humoral immunity) In OSF it reduces the level of IgG, IgA and IgM thus slow down the chronic inflammatory process CENTRAL NERVOUS SYSTEM Memory loss, loss of consciousness MISCELLANEOUS Muscle weakness Pre-existing blood disorders Pregnancy and lactation Inflammation of joints Severe kidney problems
- 65. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Pentoxyfylline TRENTAL-400 FLEXITAL 400mg SR tabs 400 mg TDS For 6-7 months Peripheral Vasodilators (Methylxanthine derivative)
- 66. MECHANISM OF ACTION ADVERSE EFFECTS CONTRAINDICATIONS It increases mucosal vascularity. Anti inflammatory properties Immuno-modulating actions Nausea, Vomiting, Dyspepsia, Bloating Severe allergic reactions Allergic to any ingredient in Pentoxifylline / Methylxanthines (eg, theophylline, caffeine, theobromine) Recent bleeding in the brain or eye
- 68. INTERFERON GAMMA-1 D (IMMUNOKINE OF BOEHRINGER)
- 69. 200 µg/ml have been tried (Anti-fibrotic cytokine) Adverse effects: Fever, chills, headache, myalgia, arthralgia, injection site reactions Contraindication: Severe hepatitis, renal impairment & cardiac disease.
- 70. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION 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 Anti-fibrotic cytokine
- 71. MECHANISM OF ACTION ADVERSE EFFECTS CONTRAINDICATIONS Regulation of fibroblast proliferation & collagen synthesis Upregulation of antifibrotic cytokine and collagen synthesis in the basal layer of epithelium and lamina propria Fever Chills Headache myalgia Arthralgia injection site reactions Severe hepatitis Renal impairment Cardiac disease
- 72. MOUTH RINSES
- 73. Listerine Mouthwash Essential Oils : Menthol (mint) 0.042% Thymol(thyme) 0.064% Methyl Salicylate (wintergreen) 0.06% Eucalyptol (eucalyptus) 0.092% With Powdered Dexamethasone tablet (2mg in 5mL) 3 – 4 times a day
- 76. INTRALESIONAL INJECTIONS (IN MODERATE PHASE) ENZYMES GLUCOCORTICOIDS AQEOUS EXTRACT HYALURONIDASE CHYMOTRIPSIN COLLAGENASE SHORT ACTING HYDROCORTISONE INTERMEDIATE ACTING TRIAMCINOLONE ACETONIDE LONG ACTING DEXAMETHASONE SODIUM PHOSPHATE BETHAMETHASONE SODIUM PHOSPHATE PLACENTAL EXTRACT
- 79. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Hyaluronidase (intralesional injection) HYNIDASE HYA 1500 IU (0.5-2 ml) With 2% lignocaine Twice daily For 10 weeks Hydrolytic enzyme
- 80. MECHANISM OF ACTION ADVERSE EFFECTS CONTRAINDICATIONS Breaks down Hyaluronic acid (Depolymerizing) Lowers the viscosity of intracellular substances Decreases collagen formation Local Injection site reactions such as Pain Itching Redness Swelling Urticaria, Angioedema (in less than 0.1% ) Hypersensitivity to Hyaluronidase
- 83. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Chymotripsin (intralesional injection) TRYPSIN CHOMISIN CHYMASE CHYMOTRIP 5000 IU Twice a week For 10 weeks Proteolytic enzyme Anti-inflammatory agent
- 84. MECHANISM OF ACTION ADVERSE EFFECTS Endopeptidase Hydrolyses peptide bonds and esters Local: Injection site reaction Allergic reactions rare
- 87. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Collagenase (intralesional injection) XIAFLEX SANTYL COLLAGENASE SANTYL 2mg of collagenase materials dissolved in 1ml of distilled water Lysosomal enzyme
- 88. MECHANISM OF ACTION ADVERSE EFFECTS Degrading, Phosphate esters Proteins Polysaccharides Glycosides Sulphate Esters Pain Swelling Trismus
- 89. INTRALESIONAL INJECTIONS (IN MODERATE PHASE) ENZYMES GLUCOCORTICOIDS AQEOUS EXTRACT HYALURONIDASE CHYMOTRIPSIN COLLAGENASE SHORT ACTING HYDROCORTISONE INTERMEDIATE ACTING TRIAMCINOLONE ACETONIDE LONG ACTING DEXAMETHASONE SODIUM PHOSPHATE BETHAMETHASONE SODIUM PHOSPHATE PLACENTAL EXTRACT
- 92. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Hydrocortisone (intralesional injection) WYCORT EFCORLIN CORT-S MOSACORT 25 mg/ml (1.5cc) Once a week For a duration of 12 weeks Short acting Glucocorticoid (t½ < 12 hours)
- 96. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Triamcinolone acetonide (intralesional injection) KENACORT TRICORT P-CORT-40 KENALOG-40 40 mg/ml (1.5cc) Once a week For a duration of 12 weeks Intermediate acting Glucocorticoid (t½ > 12-36 hours)
- 100. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Dexamethasone sodium phosphate (intralesional injection) DECADRON PHOSPHATE DEXONA WYMESONE DECDAN DEXASONE 4 mg/ml (0.5-1 ml bilaterally) At multiple sites Once a week For 6 weeks Long acting Glucocorticoid (t½ > 36 hours)
- 101. MECHANISM OF ACTION ADVERSE EFFECTS CONTRAINDICATIONS Anti inflammatory action Inhibits the proliferation of fibroblasts Immunosuppressive action Cushing habitus Suppression of Hypothalamo- Pituitary- Adrenal(HPA) axis Hyperglycemia Recent myocardial infarction Osteoporosis (post-menopausal females are particularly at risk) Peptic ulcer HTN/CHF Renal failure
- 104. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Betamethasone sodium phosphate (intralesional injection) BETNESOL BETACORTRIL CELESTONE BETAGIN 4 mg/ml (0.5-1 ml bilaterally) At multiple sites Once a week For 6 weeks Long acting Glucocorticoid (t½ > 36 hours)
- 105. MECHANISM OF ACTION Anti inflammatory action Inhibits the proliferation of fibroblasts Immunosuppressive action
- 106. INTRALESIONAL INJECTIONS (IN MODERATE PHASE) ENZYMES GLUCOCORTICOIDS AQEOUS EXTRACT HYALURONIDASE CHYMOTRIPSIN COLLAGENASE SHORT ACTING HYDROCORTISONE INTERMEDIATE ACTING TRIAMCINOLONE ACETONIDE LONG ACTING DEXAMETHASONE SODIUM PHOSPHATE BETHAMETHASONE SODIUM PHOSPHATE PLACENTAL EXTRACT
- 107. PLACENTAL EXTRACT AQEOUS EXTRACTINTRALESIONAL INJECTIONS
- 109. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Placental extract (intralesional injection) PLACENTREX 2 ml Once a week For 10 weeks Biogenic stimulants Aqueous extract of human placenta
- 110. MECHANISM OF ACTION ADVERSE EFFECTS CONTRAINDICATIONS Anti-inflammatory and significant analgesic effect Increase in blood circulation and tissue vascularity Arrest of tissue growth stagnation Lower immune response factor Local: Injection site reaction Hypersensitivity to placental extract
- 111. BETEL QUID CHEWING HABIT CHRONIC INFLAMMATORY PROCESS TGF-β COLLAGEN PRODUCTION COLLAGEN DEGRADATION TIMP LOX (Lysyl Oxidase) PCPPNP PLASMINOGEN ACTIVATOR SYSTEM COLLAGENASE 5. Collagenase activators +
- 113. DRUG NAME BRAND NAME DOSAGE CLASSIFICATION Colchicine COLCHINDON GOUTNIL ZYCOLCHIN 0.5 mg orally Twice a day Antigout agent Collagenase activators
- 114. MECHANISM OF ACTION ADVERSE EFFECTS DRUG INTERACTIONS Disruption of the microtubule formation and Depolymerizes microtubules which prevent the Extrusion of collagen fibers from the fibroblast and increases Collagenolytic activity Dose related Overdose: Kidney damage CNS Depression Chronic Therapy: Aplastic anaemia Azole antifungals (Itraconazole, Ketoconazole) Macrolide antibiotics (Clarithromycin, Erythromycin) Can affect the removal of colchicine from your body
- 115. SURGICAL MANAGEMENT
- 116. SEVERE PHASE SUBMUCOSAL RESECTION OF FIBROUS BANDS (FIBROTOMY) BILATERAL TEMPORALIS MYOTOMY or CORONOIDECTOMY NASOLABIAL FLAP OR LINGUAL PEDICAL FLAP SPLIT SKIN GRAFT / MUCOSAL GRAFT BUCCAL PAD OF FAT COLLAGEN
- 118. PHYSIOTHERAPY
- 119. MOUTH OPENING EXCERCISES USE OF APPLIANCE (HEISTER’S JAW OPENER) STICK BALLOONING HEAT THERAPY MOUTH OPENING EXERCEISES USING WOODEN SPATULA / ICE CREAM STICKS MOUTH GAG/ ACRYLIC SURGICAL SCREW
- 121. COMBINED THERAPY
- 122. VASODILATORS PENTOXYFYLLINE NYLIDRIN HYDROCHLORIDE VITAMIN D, E, B-COMPLEX IODINE PLACENTAL EXTRACT LOCAL & SYSTEMIC CORTICOSTEROIDS PHYSIOTHERAPY
- 123. OTHER THERAPIES
- 124. IMMUNISED COW MILK SKIMMED MILK FORM COW IMMUNISED WITH MULTIPLE HUMAN INTESTINAL BACTERIA VIT A, C , B1, B2 , B6, B12, NICOTINIC ACID, PANTHOTENIC ACID, FOLIC ACID, IRON, COPPER, ZINC 20-30% HIGHER IgG ANTIBODY 2L DAILY / 45g MILK POWDER TWICE DAILY FOR 3 MONTHS
- 125. TURMERIC (Curcuminoids) TURMERIC OIL & OLEORESIN IN VITRO FREE RADICAL SCAVENGER
- 126. INJ OF GOLD, VITAMIN A & COLLAGENASE CHEMOTHERAPEUTIC AGENTYS LIKE TOPICAL BLEOMYCIN
- 127. DIATHERMY Microwave diathermy Low current (20 Watts x 2450 cycles) Early – Moderate stage
- 128. ULTRASOUND Efficient deep heating modality (Frequency 0.8-1 MHz Intensity 0.5-3 w/sq.cm)
- 130. AN OVERVIEW J Maxillofac Oral Surg. 2015 Sep; 14(3): 521–531.
- 131. TONGUE FLAP
- 132. PALATAL FLAP
- 133. Palatal island flap based on greater palatine artery (contd.) J N Khanna, N N Andrade
- 134. BUCCAL PAD OF FAT
- 135. NASO-LABIAL FLAP
- 136. RADIAL FOREARM FREE FLAP
- 137. ANTERO-LATERAL THIGH (ALT) FLAP (Huang et al)
- 138. SPLIT SKIN GRAFT
- 139. COLLAGEN MEMBRANE
- 140. ARTIFICIAL DERMIS
- 141. HUMAN PLACENTA / AMNION GRAFT
- 142. CORONOIDECTOMY
- 143. MUSCLE MYOTOMY
- 144. ORAL STENTS
- 145. CONCLUSION • OSF is one of the most poorly understood and unsatisfactorily treated diseases. • Among the above mentioned modalities for treatment of OSF none of them can be considered to be completely effective. • All available treatments provide symptomatic relief, which is short lived. • This is mainly due to the fact that the etiology of the disease is not fully understood and the disease is progressive in nature. • The wide range of treatment modalities currently used for OSF is ample evidence that there is no simple answer to how it should be managed. • Therefore, an evidence based practice will help to provide the best possible treatment for the disease.
- 146. References • Shafer’s Textbook of Oral Pathology(seventh edition)~ Shafer, Hine, Levy. Editors- R Rajendran, B Sivapathasundharam. • DIAGNOSTIC ORAL MEDICINE (first edition, 2013)- B K Venkataraman (Chief Editor); Asha R Iyengar, K S Ganapathy, C V Mohan, K S Nagesh (Associate Editors). • Venkatesh V. Kamath. Surgical Interventions in Oral Submucous Fibrosis: A Systematic Analysis of the Literature. J Maxillofac Oral Surg. 2015 Sep; 14(3): 521–531.Published online 2014 Dec 25. doi: 10.1007/s12663-014-0639-3.Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4510093/ • Kumar L. K. Surej, Nikhil M. Kurien, and Nasil Sakkir. Buccal fat pad reconstruction for oral submucous fibrosis. Natl J Maxillofac Surg. 2010 Jul-Dec; 1(2): 164–167. doi: 10.4103/0975-5950.79222. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3304196/. • P. Rajalalitha, S. Vali. Molecular pathogenesis of oral submucous fibrosis- a collagen metabolic disorder(Review article). J Oral Pathol Med. 2005 Jul;34(6):321-8. • More C B, Gupta S, Joshi J, Varma S N. Classification system of Oral Submucous Fibrosis(Review article). J Indian Aca Oral Med Radiol 2012;24(1):24-29. • Vikas Berwal, Monika Khangwal, Ravinder Solanki, Rakshit Khandeparker, Kiran Savant, Omkar Shetye. CLASSIFICATION SYSTEMS FOR ORAL SUBMUCOUS FIBROSIS- FROM PAST TO PRESENT: A REVIEW. Berwal V. et al., Int J Dent ealth Sci 2014; 1(6):900-913. • Harsha Pradhan, Hemant Gupta, VP Sinha, Sumit Gupta, MC Shashikanth. Two wound-covering materials in the surgical treatment of oral submucous fibrosis: a clinical comparison. Journal of Oral Biology and Craniofacial Research 2012 April Original Article Volume 2, Number 1; pp. 10–14. doi: 10.1016/S2212-4268(12)60004-9. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3941626/pdf/main.pdf • Shobha Nataraj, Yadavalli Guruprasad, Jayaprasad N.Shetty. A Comparative Clinical Evaluation of Buccal Fat Pad and Collagen in Surgical Management of Oral Submucous Fibrosis. Archives of Dental Sciences, Vol.2, Issue 4, 17-24 (http:www.archdent.org). Available at https://www.researchgate.net/publication/232702355_A_Comparative_Clinical_Evaluation_of_Buccal_Fat_Pad_and_Collagen_in_Surg ical_Management_of_Oral_Submucous_Fibrosis
- 147. • Venkatesh Viswanath Kamath, Shruti Krishnamurthy, Krishnanand P. Satelur, and Komali Rajkumar. Transforming growth factor-β1 and TGF-β2 act synergistically in the fibrotic pathway in oral submucous fibrosis: An immunohistochemical observation. Indian J Med Paediatr Oncol. 2015 Apr-Jun; 36(2): 111–116. doi: 10.4103/0971-5851.158842. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477373/ • L. Ashok, G. P. Sujatha. Targeted therapy for oral submucous fibrosis - Future strategies. Journal of Medicine, Radiology, Pathology & Surgery ● Vol. 1:6 ● Nov-Dec 2015. • Usha Dayanarayana, Nagabhushana Doggalli,Karthikeya Patil, Jai Shankar, Mahesh K.P, Sanjay. Non surgical approaches in treatment of OSF. IOSR Journal of Dental and Medical Sciences (IOSR- JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 11 Ver. III (Nov. 2014), PP 63-69 www.iosrjournals.org. • Manas Gupta, Pankaj Mishra ,Kirti Shrivastava ,Neha Singh ,Pushpraj Singh. Oral Submucous Fibrosis- Current Concepts of Aetiology & its Management(Review article). Journal Of Applied Dental and Medical Sciences 1(1);2015 28-39. Available online at www.joadms.org
- 148. Thank You Maxfac Center for Cranio - Maxillofacial & Head and Neck Surgery, Siliguri Contact us at : maxfacmail@gmail.com Mentor & Guide : Dr Saikat Saha MDS OMFS Presenter : Dr Mukesh Chhetri BDS Fellow Trainee at Maxfac