ORAL MEDICINE OMR PREMALIGNANT LESIONS OF ORAL CAVITY ORAL SUBMUCOUS FIBROSIS LIMITED MOUTH OPENING EASY LEARNING OSMF BURKETS ANIL GHOM

1. ORAL
SUBMUCOUS
FIBROSIS (OSMF)
By
JAyASHree.S
Iv yr BDS
DepT of oral medicine

2. CONTENTS
Introduction
History
Definition
Epidemiology
Etiopathogenesis
Clinical features
Classification
Histopathology
Differentialdiagnosis
Diagnostic Criteria
Investigations
Malignant Potential
Management

3. INTRODUCTION
The oral cavity is lined with an uninterrupted mucosa which is
continuous with the skin near vermillion border of the lips and
with the pharyngeal mucosa in the region of soft palate
OMM- Unique area - continuously exposed to various kinds of
stresses such as heat, cold, microorganisms, chemicals
andmechanical irritations.
Submucousa is a supporting layer of loose connective tissue
directly under a mucous membrane
In response to these stresses, both epithelium and connective
tissue layers of the oral mucosa exhibit acute and chronic
reactive changes
Oral submucous fibrosis (OSMF or OSF) is a chronic, complex,
premalignant condition of the oral cavity, characterized by juxta-
epithelial inflammatory reaction and progressive fibrosis of the
submucosal tissues

4. DEFINITION
Pindborg JJ,Sirsat S.M(1966) defined OSMF as, “an insidious, chronic disease
affecting any part of the oral cavity and sometimes the pharynx. Although
occasionally preceded by and/or associated with vesicle formation, it is
always associated with juxta-epithelial inflammatory reaction followed by
fibroelastic change of the lamina propria, with epithelial atrophy leading to
stiffness of the oral mucosa and causing trismus and inability to eat”.
Slowly progressive disease characterized by the fibrousbands in the oral
mucosa, ultimately leading to severe restriction of mouth movement
including the tongue.” - World Health Organization (1978)
“ Slowly progressive chronic fibrotic disease of the oral cavity and oropharynx,
characterized by fibro elastic change and inflammation of mucosa, leading to a
progressive inability to open the mouth swallow or speak.”( Burket's 10th edition )

5. HISTORY
First described among five
East African women of Indian
origin under the term
Atrophia idiopathica
(tropica) Mucosae Oris by
Schwartz 1952
Joshi in 1952 is credited
to be the first person
who described it and
gave the present term
“Oral sub-mucous fibrosis”
In the year 1954, Su. 1. P. from
Taiwan described similar
condition, which he called
"Idiopathic Scleroderma of
Mouth”

6. EPIDEMIOLOGY
OSMF is a crippling fibrotic disorder
prevalent in South East Asia.
Common in India, Indian subcontinents
 Prevalence rate : India, Burma and South
Africa : 0 to 1.2%
 In India, overall incidence : 0.5%
 sex predilection ratio shows 2.3: 1 =M:F
 High in southern parts of India, where the
incidence of oral cancer is also high
M:F
2.3: 1

7. ETIOPATHOGENESIS
Fibroelastic change of oral mucosa with epithelial atrophy leading to stiffness of oral mucosa
, causing trismus and inability to eat.
lime

8. Misi - black coloured powder has various
chemical substances like washing soda,
borax, powdered alum, charcoal of myrobalan
and fillers earth in varying proportions which
is used as cosmetic for the teeth and gums.
In eastern Uttar Pradesh, where villagers were
constantly using “Misi” as a cosmetic to keep
their teeth clean and shiny.
PAAN
Refers to the betel leaf itself – quid
Quid contains : arecanut, lime, aniseed,
cardamom, cinnamon, coconut, cloves, sugar,
tobacco wrapped in betel leaf.

11. Clinical features:
Sex : both sexes. Age : Majority - 20-40 yrs
Sites: buccal mucosa, retromolar areas. Soft
palate, palatal fauces, uvula, tongue,
labialmucosa, Floor of mouth and gingiva
Onset is insidious.
• Inability to whistle, blow
• Difficulty in swallowing
The fibrous bands in buccal mucosa run in
vertical direction ,so that cheeks are almost
immovable.

12. • burning sensation
• blanching oral mucosa
• fibrous band restricting
mouth opening
• dry mouth

13. Classification based on
clinical features of OSMF
JV Desa (1957)
Stage I:
Stomatitis and
vesiculation
Stage II:
Fibrosis
Stage III: As
its sequelae
Classification based on
mean interincisal opening
(MIO) Khanna & Andrade
stage I-
early
OSF
without
trismus
(MIO >35
mm)
stage II-
mild to
moderat
e
disease
(MIO 26–
35 mm)
stage III-
moderat
e to
severe
disease
(MIO 15–
25 mm)
stage
IVa-
severe
disease
(MIO
<15
mm)
stage IVb-
extremely
severe–
malignant/
premalign
ant
lesions
noted
intraorally.

14. Histopathology
- Atrophic Oral epithelium
- Loss of rete pegs
- Epithelial atypia may be observed.
- Hyalinization of collagen bundles.
- Fibroblasts decreased and blood
vessels obliterated

15. Differentialdiagnosis
ANEMIC
STOMATITIS:
patient will have
reduced diet and
hence nutritional
deficiency and
finally resulting
anemia
SCLERODERMA:
a connective
tissue disorder
resulting in
trismus and
stiffness of
mucosa
RADIATION
FIBROSIS: if the
patient gives
history of
radiation therapy
VERTICAL SCAR
BAND: if patient
gives history of
minor or major
surgical
procedures
Investigations
Hematological &
Biochemical
Serological
Cytogenetics
Histopathological
Immunohistochemical
Immunofluorescence
Tissue Culture

16. DIAGNOSIS
Assessment of tongue protrusion
Assessment of cheek flexibility
Males=1.3 cm
Females=1.08 cm
Assessment of mouth opening
MEAN INTERINCISAL DISTANCE
Male: 51.3 mm
(Range 39–65 mm)
Female: 44.3 mm
(Range 36–56 mm)
•Palpable fibrous bands
• Mucosal texture feels tough & leathery
•Blanching of mucosa together
• Decreased Hb, iron, protein and vitamin B complex levels
•Increased erythrocyte sedimentation rate

17. Malignant Potential
Pindborg JJ (1972) summarized a criteria to support
the precancerous nature of this disease as :
Higher prevalence of leukoplakia among submucous
fibrosis patients.
High frequency of epithelial dysplasia
Concurrent findings of submucous fibrosis in oral
cancer patients.
Histological diagnosis of oral cancer without clinical
suspicion, among submucous fibrosis cases.
Higher incidence of oral cancer among patients with
submucous fibrosis
Hyperkeratosis
intercellular edema in
prickle cell layers &
the basal cells
Hyperplasia
Excessive fibrosis
& Ischaemia
Carcinoma
vulnerability of
action of
Carcinogens
irritation by
Exogenous
factors
Atrophy of
epithelium

18. Management
Preventive
measures
Medical
treatment
Physical
therapy
Surgical
treatment
Laser
Muscle stretching exercises
Diathermy
Ultrasound
•Muscle stretching exercises
for the mouth includes
forceful mouth opening with
the help of sticks, ballooning
of mouth, hot water gargling.
•Forceful mouth opening
have been tried with mouth
gag & acrylic surgical screw.
•Physiotherapy can improve
oral opening but not affective
to reduce pain

19. Placental
extract
Proteolytic
enzymes
Collagenas
Hyaluronidas
e
Antioxidants : b-
carotene, vitamins A,
C and E, zinc
Promotion of
blood flow
Vitamin B-complex tablets-Orally in a dose of 200 mgtwice a day
Vitamin B complex with iodine(injection ranodine)
1. I.M -2ml daily
2. Contains
Methyl tri oxyethyl iodomine
Topical
•Triamcinalone acetonide 0.1%
(Kenacort)
•Betamethasone – 0.5%(Betnesol)
Intralesional
•Dexamethasone –4mg/ml (injDexona)
•Triamcinolone -40 mg/ml (inj Kenacort)
•Hydrocortisone – 25 mg/ml (injWycort)
Vitamin B1- 1mg
Vitamin B6-0.3 mg
Vitamin B2- 0.6mg
Nicotinamide- 15 mg
Calcium
pantothenate- 1mg
Placental extract
Available in 4 forms
•Aqueous solution of humanplacenta
•Lipoid extracts
•Immuno-gamma globulins
•Tissue coagulants
Placental extracts contains
1.Nucleotides –RNA , DNA, ATP
2. Enzymes –
a. Alkaline & acid phosphatase,
b. Glutammic Oxalo-acetic acid
c. Transaminase
d. Glutamic acid
e. Pyruvic acid transaminase
3. Vitamin – Vit E, B1, B6, B12, Pantothenic
acid , nicotinic acid, biotin, PABA, Folic acid
4. Steroids – 17 ketosteroids
5. Cholesterol , 6. Amino acids,
7. Fatty acids & 8. Trace elements. Zn,Sn, Mg

20. Surgical
striping
of fibrous
bands
Partial
thickness
skin or
mucosal
grafts
Buccal pad of
fat
interposition
Myotomy
Bilateral
temporalis
Tempora
lis
Nasolabial
flap
Palatal
island
flaps
Lasers-
diode and
KTP-532
laser