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Dr. Vibhuti Kaul
INDEX
Definition
 History
 Keywords
 Pathogenesis
 Clinical Features
 Laboratory Findings
 Classification
 Treatmen...
DEFINITION
It is an insidious chronic disease affecting any part of
the oral cavity and sometimes the pharynx. Although
oc...
HISTORY


The condition of oro -pharyngeal OSMF of oral cavity
was prevalent even in the days of Shushrutha (600
B.C).

...


First described among five East African women of
Indian origin under the term Atrophia idiopathica
(tropica) Mucosae Or...
KEY WORDS
Quid has been defined as a substance or mixture of
substances placed in the mouth or chewed and
remaining in con...
PATHOGENESIS
Dyavanagoudar SN. Oral Submucous Fibrosis: Review on
Etiopathogenesis. J Cancer Sci Ther 2009; 1: 072-077.
The major areca nut alkaloids are arecoline, arecadine,
arecolidine, guyacoline and guacine.
 The important flavonoid com...
Oral mucosa

Betel quid

Constant irritation

Chronic inflammation

Activated T cell and macrophages at the site

Increase...
Increase in
collagen
production

Decrease in
collagen
degradation

Increased collagen (insoluble crosslinking of insoluble...
COLLAGEN PRODUCTION PATHWAY
3 main events in this pathway activation of
procollagen, elevation of procollagen proteinase l...
UP-REGULATION OF LOX
The Cu content of areca nut is high & levels of
soluble Cu in saliva may rise in volunteers who
chew ...
“The Evaluation of serum copper & iron levels among
oral submucous fibrosis patients.”
50 cases and controls each were eac...
COLLAGEN DEGRADATION PATHWAY
2 main events modulated by TGF which decreases
the collagen degradation are:
 Activation of ...
PRECANCEROUS NATURE & MALIGNANT
TRANSFORMATION
First described by Paymaster in 1956.
 Pindborg et al., 1984, put forward ...
Areca nut/Betel nut

Mechanical trauma
to epithelium

Carcinogen acts as antigen
to keratinocytes

Carcinogen reaches
basa...
“Estimation of serum beta carotene levels in patients
with oral submucous fibrosis in India.”
45 cases & controls each wer...
CLINICAL FEATURES
Dyavanagoudar SN. Oral Submucous Fibrosis: Review on
Etiopathogenesis. J Cancer Sci Ther 2009; 1: 072-07...
Progressive inability to open the mouth(trismus)
due to oral fibrosis & scarring.
 Oral pain & a burning sensation upon c...
Intra-oral view showing: A. Marble-like appearance of soft palate, faucial pillars &
upper pharyngeal mucosa B. shrunken u...
LABORATORY FINDINGS
Dyavanagoudar SN. Oral Submucous Fibrosis: Review on
Etiopathogenesis. J Cancer Sci Ther 2009; 1: 072-...
Decreased hemoglobin levels
 Decreased iron levels
 Decreased protein levels
 Increased erythrocyte sedimentation rate
...
“Lipid profile in oral submucous fibrosis”
65 clinically diagnosed and histopathologically proven patients of
OSMF and 42 ...
STAGING
More CB et al. Classification system for Oral
submucous fibrosis. JIAOMR. 2012; 24(1): 24-29.
Pindborg JJ, 1989
Stage I: Stomatitis includes erythematous mucosa, vesicles, mucosal
ulcers, melanotic mucosal pigmentati...
Nagesh & Bailoor (1993)
Stage I early OSMF: Mild blanching, no restriction in mouth
opening (normal distance between centr...
Khanna JN & Andrade NN (1995)
Group I:
- Very early cases: burning sensation in the mouth, acute
ulceration & recurrent st...
Khanna JN & Andrade NN (1995)
Group II:
- Early cases: Buccal mucosa appears mottled & marble
like, widespread sheets of f...
Khanna JN & Andrade NN (1995)
Group III:
- Early cases: Moderately advanced cases- Trismus,
interincisal distance of 15-25...
Khanna JN & Andrade NN (1995)
Group IVA:
- Advanced cases- severe trismus, interincisal distance of
less than 15 mm, thick...
Haider et al. (2000)
Clinical staging:
- Stage 1: Faucial bands only
- Stage 2: Faucial & buccal bands
- Stage 3: Faucial,...
TREATMENT
Taneja L, Nagpal A, Vohra P, Arya V. Oral submucous
Fibrosis: An oral physician approach. J Innov Dent
2011; 1(3...
DISCONTINUATION OF HABIT & COUNSELING
Encouraged through education & advocacy.
 Patient should be explained about the dis...
SUPPORTIVE CARE
Vitamins, iron & mineral rich diet should be advised
to patients with OSMF.
 Intake of red tomatoes, fres...
“The Response of Oral Submucous Fibrosis to
Lycopene – A Carotenoid Antioxidant: A
Clinicopathological Study”
2000µg of Ly...
MEDICAL MANAGEMENT
STEROIDS:
 Inhibit proliferation of fibroblasts.
 Release cellular proteases in the connective tissue...
HYALURONIDASE
Reduces burning sensation & trismus.
 Acts by breaking down hyaluronic acid, lowers the
viscosity of intrac...
“Efficacy of hydrocortisone acetate/hylauronidase vs
triamcinolone acetonide/hyaluronidase in the
treatment of oral submuc...
PLACENTAL EXTRACTS
It is an aqueous extract of human placenta that
contains nucleotides, enzymes, vitamins,
aminoacids & s...
CHYMOTRYPSIN


An endopeptidase, hydrolyses ester & peptide
bonds, thus acting as a proteolytic & antiinflammatory agent.
INTERFERON-GAMMA
Has immuno-regulatory effect, is a known antifibrotic cytokine.
 Patients treated with IFN-γ experienced...
IMMUNE MILK
Immune milk is a kind of skimmed milk produced
from cows immunised with multiple human
intestinal bacteria.
 ...
TURMERIC
Administration of turmeric powder offers protection
against benzopyrene induced increase in
micronuclei in circul...
“Comparative study of the efficacy of curcumin & turmeric
oil as chemopreventive agents in oral submucous
fibrosis: a clin...
OTHER THERAPIES
Injection of Gold, Vitamin A & Collagenase.
 Vasodilator injection can be used.
 Chemotherapeutic agents...
“Pentoxifylline therapy : A new adjunct in the
treatment of oral submucous fibrosis”
14 cases and 15 controls were include...
ORAL PHYSIOTHERAPY
Muscle stretching exercises:
 Includes forceful mouth opening with the help of
sticks ballooning of mo...
DIATHERMY
Microwave diathermy (Low current is used 20 Watts
x 2450 cycles) is useful in some early or moderately
advanced ...
ULTRASOUND
It selectively raises the temperature in some well
circumscribed areas.
 It is an efficient deep heating modal...
“Physiotherapy for improving mouth opening & tongue
protrusion in patients with Oral Submucous Fibrosis
(OSMF) – Case Seri...
TREATMENT
Micronutrients and
minerals

TREATMENT DETAILS

Milk from immunized
cows

Vitamin A, B complex, C, D
and E, Fe, ...
TREATMENT

TREATMENT DETAILS

Hyalase +
dexamethasone
Placental extracts
Turmeric

Chymotrypsin,
hyaluronidase and
dexamet...
SURGICAL TREATMENT
Simple excision of the fibrous bands.
 Split-thickness skin grafting following bilateral temporalis
my...
“The only way to keep
your health is to eat what you
don’t want, drink what you
don’t like and do what you’d
rather not.”
Oral Submucous Fibrosis
Oral Submucous Fibrosis
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Oral Submucous Fibrosis

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Oral Submucous Fibrosis

  1. 1. Dr. Vibhuti Kaul
  2. 2. INDEX Definition  History  Keywords  Pathogenesis  Clinical Features  Laboratory Findings  Classification  Treatment 
  3. 3. DEFINITION It is 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 juxtaepithelial inflammatory reaction followed by a fibroelastic changes 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)
  4. 4. HISTORY  The condition of oro -pharyngeal OSMF of oral cavity was prevalent even in the days of Shushrutha (600 B.C).  Shushrutha, the greatest practitioner of ancient medicine stated in his book "Shushrutha Samhita' a condition called 'VIDARI' in his classification of diseases of mouth and throat.  The features of which suit the symptomatology of OSMF.
  5. 5.  First described among five East African women of Indian origin under the term Atrophia idiopathica (tropica) Mucosae Oris by Schwartz 1952  Joshi in 1953 is credited to be the first person who described it and gave the present term “Oral submucous fibrosis”.  In the year 1954, Su. P. from Taiwan described similar condition, which he called "Idiopathic Scleroderma of mouth"
  6. 6. KEY WORDS Quid has been defined as a substance or mixture of substances placed in the mouth or chewed and remaining in contact with the mucosa usually containing one or both of the two basic ingredients tobacco and/or areca nut in raw or any manufactured or processed form (Zain et al., 1999).  A precancerous lesion is a morphologically altered tissue in which oral cancer is more likely to occur than in its apparently normal counterpart‟;  A precancerous condition is a generalized state associated with a significantly increased risk of cancer‟.  J Cancer Science & Therapy - Volume 1(2) : 072-077 (2009) - 075
  7. 7. PATHOGENESIS Dyavanagoudar SN. Oral Submucous Fibrosis: Review on Etiopathogenesis. J Cancer Sci Ther 2009; 1: 072-077.
  8. 8. The major areca nut alkaloids are arecoline, arecadine, arecolidine, guyacoline and guacine.  The important flavonoid components in areca nut are tannins and catechins.  These alkaloids undergo nitrosation and give rise to Nnitrosamine which may have cytotoxic effect on cells. (Hoffmann et al., 1994)  Betel quid is placed in the buccal vestibule for ~15 min to 1 hr & repeated 5-6 times a day which leads to constant contact between mixture & mucosa.  The alkaloids from the quid are absorbed into the mucosa and undergoes metabolism.  Microtrauma produced by the friction of coarse fibers of areca nut also facilitates diffusion of the alkaloids into the subepithelial connective tissue resulting in juxtaepithelial inflammatory cell infiltration. (Chiang et al., 2002). 
  9. 9. Oral mucosa Betel quid Constant irritation Chronic inflammation Activated T cell and macrophages at the site Increase in cytokines IL 6, TNF, Ifa, increase in growth factor TGFβ
  10. 10. Increase in collagen production Decrease in collagen degradation Increased collagen (insoluble crosslinking of insoluble form of collagen) Fibrosis Oral Submucous Fibrosis
  11. 11. COLLAGEN PRODUCTION PATHWAY 3 main events in this pathway activation of procollagen, elevation of procollagen proteinase levels, and upregulation of lysyl oxidase (LOX activity).  The genes COL1A2, COL3A1, COL6A1, COL6A3, COL7A1 have been identified as definitive TGF-β targets. (Rajalalitha & Vali, 2005).  Yi-Ting et al., 2009, found arecoline stimulated CTGF production in buccal mucosal fibroblasts (BMFs) 
  12. 12. UP-REGULATION OF LOX The Cu content of areca nut is high & levels of soluble Cu in saliva may rise in volunteers who chew areca quid (Trivedy et al, 1997).  The enzyme Lysyl oxidase (LOX) is found to be upregulated in OSMF.  The fibroblast in OSMF have not only increased LOX activity but also specific growth characteristics. This was evident with the reported cell doubling time of 3.2 days for OSMF & 3.6 days for normal fibroblasts (Ma et al., 1995). 
  13. 13. “The Evaluation of serum copper & iron levels among oral submucous fibrosis patients.” 50 cases and controls each were each tested for serum copper & iron levels. Conclusion: Copper levels increased & iron levels decreased in study group in comparison to healthy controls. Copper levels increased as clinical stage of oral submucous fibrosis increased. Tadakamadla J, Kumar S, Mamatha GP. Med Oral Patol Oral Cir Bucal. 2011: 1; 16(7); e870-3.
  14. 14. COLLAGEN DEGRADATION PATHWAY 2 main events modulated by TGF which decreases the collagen degradation are:  Activation of inhibitor of matrix metalloproteinase gene TIMPs  Activation of plasminogen activator inhibitor PAI gene.
  15. 15. PRECANCEROUS NATURE & MALIGNANT TRANSFORMATION First described by Paymaster in 1956.  Pindborg et al., 1984, put forward 5 criteria to prove disease to be precancerous. These include, high occurrence of OSMF in oral cancer patients, higher incidence of SCC in patients with OSMF, histological diagnosis of cancer without any clinical suspicion in OSMF, high frequency of epithelial dysplasia and higher prevalence of leukoplakia among OSMF.  Malignant transformation rate of OSMF was found to be the range of 7-13%. 
  16. 16. Areca nut/Betel nut Mechanical trauma to epithelium Carcinogen acts as antigen to keratinocytes Carcinogen reaches basal zone & affects stem cells Stem cells produce iNOS DNA DAMAGE TGF-β FGF Stem cell hypoproliferation (Epithelial hypoplasia) Sustained DNA DAMAGE Loss of rete ridges Dysplasia Subepithelial hyalinization
  17. 17. “Estimation of serum beta carotene levels in patients with oral submucous fibrosis in India.” 45 cases & controls each were evaluated for their serum beta carotene levels. Results: Mean serum beta carotene levels were found to be lower for cases than controls. They concluded that beta carotene plays an important role in the pathogenesis of OSMF, and that its level decreases with disease progression. Aggarwal A, Shetti A, Keluskar V, Bagewadi A. J Oral Sci. 2011: 53(4); 427-431.
  18. 18. CLINICAL FEATURES Dyavanagoudar SN. Oral Submucous Fibrosis: Review on Etiopathogenesis. J Cancer Sci Ther 2009; 1: 072-077.
  19. 19. Progressive inability to open the mouth(trismus) due to oral fibrosis & scarring.  Oral pain & a burning sensation upon consumption of spicy foodstuffs.  Increased salivation  Change of gustatory sensation  Hearing loss due to stenosis of the eustachian tubes  Dryness of the mouth  Nasal tonality to the voice  Dysphagia to solids (if esophagus is involved)  Impaired mouth movements 
  20. 20. Intra-oral view showing: A. Marble-like appearance of soft palate, faucial pillars & upper pharyngeal mucosa B. shrunken uvula, blanching of left buccal mucosa & retromolar region, C. Fibrosis & depapillation of tongue, D. Blanching of right buccal mucosa, E. Fibrosis & pigmentation of lower lip
  21. 21. LABORATORY FINDINGS Dyavanagoudar SN. Oral Submucous Fibrosis: Review on Etiopathogenesis. J Cancer Sci Ther 2009; 1: 072-077.
  22. 22. Decreased hemoglobin levels  Decreased iron levels  Decreased protein levels  Increased erythrocyte sedimentation rate  Decreased Vitamin B complex levels 
  23. 23. “Lipid profile in oral submucous fibrosis” 65 clinically diagnosed and histopathologically proven patients of OSMF and 42 age and sex matched controls were studied. In these samples serum lipids including: (i) Total cholesterol, (ii) LDL cholesterol (LDLC), (iii) HDL cholesterol (HDLC) (iv) VLDL cholesterol (VLDLC) (v) triglycerides (vi) Apo-A1 (viii) Apo-B and (viii) LPa were analyzed. A significant decrease in plasma total cholesterol, HDLC and ApoA1 was observed in patients with OSMF as compared to the controls. Thus an inverse relationship between plasma lipid levels and patients was found in OSMF. Mehrotra R et al. Lipids in Health and Disease. 2009; 8: 29
  24. 24. STAGING More CB et al. Classification system for Oral submucous fibrosis. JIAOMR. 2012; 24(1): 24-29.
  25. 25. Pindborg JJ, 1989 Stage I: Stomatitis includes erythematous mucosa, vesicles, mucosal ulcers, melanotic mucosal pigmentation & mucosal petechiae. Stage II: Fibrosis occurs in healing vesicles & ulcers, which is the hallmark of this stage. - Early lesions show blanching of the oral mucosa. - Older lesions include vertical & circular palpable fibrous bands in the buccal mucosa & around the mouth opening or lips. - This results in a mottled marble like appearance. - Specific findings include reduction of mouth opening, stiff & small tongue, blanched & leathery floor of the mouth, fibrotic & depigmented gingiva, rubbery soft palate with decreased mobility, blanched & atrophic tonsils, shrunken bud-like uvula & sunken cheeks not commensurate with age or nutritional status. Stage III: Sequelae of OSMF are as follows: - Leukoplakia is found in more than 25% of individuals with OSMF. - Speech & hearing deficit may occur because of involvement of tongue & eustachian tube.
  26. 26. Nagesh & Bailoor (1993) Stage I early OSMF: Mild blanching, no restriction in mouth opening (normal distance between central incisor tips: Males 35-45 mm, females 30-42 mm), no restriction in tongue protrusion, cheek flexibility. Burning sensation on taking spicy food or hot beverages. Stage II moderate OSMF: Moderate to severe blanching, mouth opening reduced by 33%, cheek flexibility also demonstrably reduced, burning sensation also in absence of stimuli, palpable bands felt. Lymphadenopathy either U/L or B/L, anemia on hematological examination.
  27. 27. Khanna JN & Andrade NN (1995) Group I: - Very early cases: burning sensation in the mouth, acute ulceration & recurrent stomatitis & not associated with mouth opening limitation. - Histology: Fine fibrillar collagen network interspersed with marked edema, blood vessels dilated & congested, large aggregate if plump young fibroblasts present with abundant cytoplasm, inflammatory cells mainly consist of PMNs with few eosinophils. The epithelium is normal.
  28. 28. Khanna JN & Andrade NN (1995) Group II: - Early cases: Buccal mucosa appears mottled & marble like, widespread sheets of fibrosis palpable, interincisal distance of 26 to 35 mm. - Histology: Juxta-epithelial hyalinization present, collagen present as thickened but separate bundles, blood vessels dilated & congested, young fibroblasts seen in moderate number, inflammatory cells mainly consist of PMNs with few eosinophils & occasional plasma cells, flattening or shortening of epithelial rete-pegs evident with varying degree of keratinization.
  29. 29. Khanna JN & Andrade NN (1995) Group III: - Early cases: Moderately advanced cases- Trismus, interincisal distance of 15-25 mm, buccal mucosa appears pale firmly attached to underlying tissues, atrophy of vermilion border, vertical fibrous bands palpable at the soft palate, pterygomandibular raphe & anterior faucial pillars. - Histology: Juxta-epithelial hyalinization present, thickened collagen bundles, residual edema, constricted blood vessels, mature fibroblasts with scanty cytoplasm & spindle-shaped nuclei, inflammatory exudate which consists of lymphocytes & plasma cells, epithelium markedly atrophic with loss of rete pegs, muscle fibers seen with thickened dense collagen fibers.
  30. 30. Khanna JN & Andrade NN (1995) Group IVA: - Advanced cases- severe trismus, interincisal distance of less than 15 mm, thickened faucial pillars, shrunken uvula, restricted tongue movement, presence of circular band around entire lip & mouth. Group IVB: - Advanced cases- presence of hyperkeratotic leukoplakia &/or squamous cell carcinoma. - Histology: Collagen hyalinized smooth sheet, extensive fibrosis, obliterated the mucosal blood vessels, eliminated melanocytes, absent fibroblasts within the hyalinized zones, total loss of epithelial rete pegs, presence of mild to moderate atypia & extensive degeneration of muscle fibers.
  31. 31. 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
  32. 32. TREATMENT Taneja L, Nagpal A, Vohra P, Arya V. Oral submucous Fibrosis: An oral physician approach. J Innov Dent 2011; 1(3)
  33. 33. DISCONTINUATION OF HABIT & COUNSELING Encouraged through education & advocacy.  Patient should be explained about the disease & its possible malignant potential.  Thorough counseling should be given for deaddiction. 
  34. 34. SUPPORTIVE CARE Vitamins, iron & mineral rich diet should be advised to patients with OSMF.  Intake of red tomatoes, fresh fruits & green leafy vegetables should be included in the regular diet.  Green tea should be included in the diet chart.  Routine Hb levels followed by iron supplements should be included in treatment plan. 
  35. 35. “The Response of Oral Submucous Fibrosis to Lycopene – A Carotenoid Antioxidant: A Clinicopathological Study” 2000µg of Lycopene capsule was given orally twice daily for 3 months to 12 patients. Clinical and histological improvement was seen in various parameters used in the study. Gowda BBK et al. JCDR. 2011
  36. 36. MEDICAL MANAGEMENT STEROIDS:  Inhibit proliferation of fibroblasts.  Release cellular proteases in the connective tissue extracellular compartment.  Inhibit the inflammatory response.
  37. 37. HYALURONIDASE Reduces burning sensation & trismus.  Acts by breaking down hyaluronic acid, lowers the viscosity of intracellular substances.  Decreases collagen formation.  “The combination of steroids & hyaluronidase shows better long-term results than either agent used alone.” (Kakar, 1985). 
  38. 38. “Efficacy of hydrocortisone acetate/hylauronidase vs triamcinolone acetonide/hyaluronidase in the treatment of oral submucous fibrosis” was evaluated.  1 group received hydrocortisone acetate (1.5 ml)/ hyaluronidase (1500 IU) weekly while other received triamcinolone acetonide (10 mg/ml)/hyaluronidase (1500 IU) at 15 days interval for 22 weeks.  No statistically significant difference was seen in both groups.  Treatment regimen B was more convenient because of lesser visits & less cost.  Indian J Med Res 2010:131;6655-669.
  39. 39. PLACENTAL EXTRACTS It is an aqueous extract of human placenta that contains nucleotides, enzymes, vitamins, aminoacids & steroids.  It acts by “Biogenic stimulation”.  Its use is based on the method of “tissue therapy” introduced by Filatov in 1933.  No contraindications & the results are found to be lasting. 
  40. 40. CHYMOTRYPSIN  An endopeptidase, hydrolyses ester & peptide bonds, thus acting as a proteolytic & antiinflammatory agent.
  41. 41. INTERFERON-GAMMA Has immuno-regulatory effect, is a known antifibrotic cytokine.  Patients treated with IFN-γ experienced improvement of symptoms.  “IFN-γ, through its effect of altering collagen synthesis, appears to be a key factor to the treatment of patients with OSMF, & intra-lesional injections of the cytokine may have a significant therapeutic effect on OSMF.” (Haque, 2001). 
  42. 42. IMMUNE MILK Immune milk is a kind of skimmed milk produced from cows immunised with multiple human intestinal bacteria.  It has good anti-inflammatory effect & contains moderate amounts of Vit. A, C, B1, B2, B6, B12, nicotinic acid, pantothenic acid, folic acid, iron, copper & zinc.  Though chemically its identical to commercial milk but it contains 20-30% higher concentration of IgG type 1 antibody. 
  43. 43. TURMERIC Administration of turmeric powder offers protection against benzopyrene induced increase in micronuclei in circulating lymphocytes & it is an excellent scavenger of free radical in vitro.  Turmeric oil & turmeric oleoresin both act synergistically in vivo to offer protection against DNA damage. (Hastak et al., 1997) 
  44. 44. “Comparative study of the efficacy of curcumin & turmeric oil as chemopreventive agents in oral submucous fibrosis: a clinical and histopathological evaluation” 48 cases divided into 3 groups were given curcumin capsules, turmeric oil & multinal capsules respectively. Statistically significant improvement was seen clinical signs & symptoms of cases treated with curcumin & turmeric oil. Positive changes were also observed in the histopathological examination of these groups. Deepa Das A, Anita Balan, Sreelatha KT. JIAOMR. 2010; 22(2): 88-92.
  45. 45. OTHER THERAPIES Injection of Gold, Vitamin A & Collagenase.  Vasodilator injection can be used.  Chemotherapeutic agents like topical bleomycin can also be used in severe cases. 
  46. 46. “Pentoxifylline therapy : A new adjunct in the treatment of oral submucous fibrosis” 14 cases and 15 controls were included in the study. Test cases were given 400mg pentoxifylline 3 times daily for 7 months. Significant improvement was seen in objective criteria and subjective symptoms. Rajendran R, Rani V, Shaikh S. Indian J Dent Res 2006;17:1908
  47. 47. ORAL PHYSIOTHERAPY Muscle stretching exercises:  Includes forceful mouth opening with the help of sticks ballooning of mouth, hot water gargling.  Forceful mouth opening with mouth gag & acrylic surgical screw.  This is thought to put pressure on fibrous bands. 
  48. 48. DIATHERMY Microwave diathermy (Low current is used 20 Watts x 2450 cycles) is useful in some early or moderately advanced stages.  Acts by fibrinolysis of bands. 
  49. 49. ULTRASOUND It selectively raises the temperature in some well circumscribed areas.  It is an efficient deep heating modality.  Most of the heat generated by ultrasound is due to volume heating rather than structural heating.  Ultrasound used for therapeutic purpose has a frequency of about 0.8-1 MHz and an intensity of 0.5-3 w/cm2. 
  50. 50. “Physiotherapy for improving mouth opening & tongue protrusion in patients with Oral Submucous Fibrosis (OSMF) – Case Series.” 15 cases were treated with Ultrasound therapy, intensity from 0.7- 1.5 W/cm2 consecutively for 6 days/week for 2 weeks. The mean improvement in mouth opening was 6.26 mm & reducing their intensity of burning sensation. Vijayakumar M, Priya D. Intl J Pharmaceu Sci & Health Care. 2013: 2(3); 50-57.
  51. 51. TREATMENT Micronutrients and minerals TREATMENT DETAILS Milk from immunized cows Vitamin A, B complex, C, D and E, Fe, Cu, Ca, Zn, Mg, Se & others 45g milk powder twice a day for 3 months Lycopene 8mg twice a day for 2 months Pentoxyfilline 400mg 3 times a day for 7 months Intralesional inj (0.01-10U/mL) 3 times a day for 6 months Submucosal inj twice a week in multiple sites for 3 months Interferon gamma Steroids Auluck A, Rosin MP, Zhang L, Sumanth KN. Oral submucous fibrosis: a clinically benign but potentially malignant disease: Report of 3 cases and review of literature. J Can Dent Assoc 2008; 74; 735-740.
  52. 52. TREATMENT TREATMENT DETAILS Hyalase + dexamethasone Placental extracts Turmeric Chymotrypsin, hyaluronidase and dexamethasone Alcoholic extracts of turmeric (3g), turmeric oil (600 mg), turmeric oleoresin (600 mg) daily for 3 months Chymotrypsin (5000 IU), hyaluronidase (1500 IU) and dexamethasone (4 mg), twice weekly submucosal injections for 10 weeks Auluck A, Rosin MP, Zhang L, Sumanth KN. Oral submucous fibrosis: a clinically benign but potentially malignant disease: Report of 3 cases and review of literature. J Can Dent Assoc 2008; 74; 735-740.
  53. 53. SURGICAL TREATMENT Simple excision of the fibrous bands.  Split-thickness skin grafting following bilateral temporalis myotomy or coronoidectomy.  Nasolabial flaps & lingual pedicle flaps.  Surgery to create flaps is performed only in subjects in whom tongue is not involved.  CO2 –LASER surgery offers advantage in alleviating the functional restriction.  Cryosurgery- Liquid Nitrogen or Argon gas used preferably as sprays through „cryoprobe‟ guided by MRI/USG. The frozen tissue thaws & is either naturally absorbed by the body or dissolves & forms a scab. 
  54. 54. “The only way to keep your health is to eat what you don’t want, drink what you don’t like and do what you’d rather not.”

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