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Indian Journal of Community Medicine

Oral Submucous Fibrosis A Distressing Disease with Malignant Potential

Author(s): N. Afroz, S.A. Hasan, S. Naseem

Vol. 31, No. 4 (2006-10 - 2006-12)

N. Afroz(1), S.A. Hasan(2), S. Naseem(1)

Introduction

Oral submucous fibrosis (OSMF) is a chronic progressive and irreversible disease affecting the oral, oropharyngeal and sometimes the esophageal mucous. OSMF is a disease that causes changes similar to those of systemic sclerosis (scleroderma) but limited to oral tissues. The disease is seen in those from Indian subcontinent and from many parts of South-East Asia such as Taiwan.

In their review, Pillai et al1 concluded that the etiology is unknown but is probably multifactorial. Main contributing factor as thought by Jayanthi et al2, is the use of pan which typically consists of areca nut, tobacco and crude lime wrapped in betel leaf. Experimentally, an alkaloid component of the areca nut, “Arecoline” can induce fibroblast proliferation and collagen synthesis and may penetrate the oral mucosa to cause progressive cross linking of collagen Fibres3,4. Tobacco chewing and smoking are not considered to play a role in the development of this disease. In this study we tried to analyze various clinico pathological aspect of the oral submucous fibrosis including the natural course of the disease.

Material and Methods

The present study was conducted over a period of one year. Study included 58 patients of OSMF, attending ENT Department of J.N. Medical College, Aligarh. Patients complaints were noted, history of chewing pan, pan masala, gutkha and areca nut with frequency and duration of use obtained in detail and thorough ENT checkups were done, with special attention being paid to ulceration of mucosa, white fibrotic bands and extent of lesion causing diffi culty in opening mouth as well as in protrusion of tongue. Ear was examined for the state of tympanic membrane.

Anterior and posterior rhinoscopy was performed to rule out nasal pathology. Biopsy of the lesion involving oral mucosa (e.g. soft palate/buccal mucosa) was taken, fixed in 10% neutral formalin, processed and stained with H and E stain and Van Gieson’s stain. Patients were managed with local injections of hydrocortisone acetate and hyaluronidase, along with topical vitamin A, oral multivitamin and iron supplementation. Patients were followed up and results of treatment noted.

Results

Almost Of the 58 patients of OSMF, 14 were in age group of 11-20 years, 38 patients were in the age group of 21-30 years, while rest of the 6 cases belonged to 4th decade. Male: female ratio was 4:1. Duration of illness ranged from 1 to 3 years. Regarding the use of Areca catechu (betel leaves and betel nut), 48 patients were Pan Masala users. Out of these 48 cases, 32 patients also used to eat Pan. Rest of the 10 patients were smokers and had the habit of tobacco chewing. Most of the patients had liking for spicy food and used to have spicy foods before the abnormality developed fully. Main complaints were diffi culty in opening the mouth and diffi culty in swallowing (86.2%), followed by complaints of repeated ulceration and vesication (76.2%), burning sensation in mouth (74.1%) and intolerance to spicy foods (60.4%). Most common site to be involved by OSMF was soft palate (91.4%), followed by buccal mucosa (72.4%), retro molar region (70.7%) and tongue (8.6%).

Mobility of tympanic membrane was found to be decreased in 6 cases, perforation was observed in 5 cases. Rest of the ears were found to be normal.

Histopathology was done to see the status of mucosa, subepithelial zone, muscle and vasculature. Examinations revealed subepithelial fibrosis in all the specimens, though the degree of fibrosis varied. Table 1 is showing various other histopathological changes in the biopsy specimens. Partial response to local and the systemic treatment was observed in 75% of the cases. Ulceration and intolerance to spicy food was improved. While trismus and dysphagia partly improved in 70% of the cases.

Discussion

The hospital based prevalence of oral submucous fibrosis patients in our study was about 3.5 per 1000 patients attending ENT OPD, slightly higher than that reported by Murti et al5 possibly because of increase in use of Pan Masala (Gutkha) in recent times. Mostly the patients belonged to 3rd and 2nd decade due to increase in the habits of chewing of pan, betel nut and pan masala (gutkha) in this age group. The results of this study shows that chronic irritation caused by chewing of pan, betel nut, pan masala, tobacco and other habits like smoking, excessive use of chillies/spices can lead to fibrotic changes in oral mucosa similar to the observations made by Sirsat and Khandolkar5.

Histopathology showed thinned out mucosa and thickened avascular subepithelial connective tissue in most of the cases. With the use of Van Gieson’s Stain, similar to the fi ndings of Hanner et al6, we noticed that in contrast to collagen in normal buccal mucosa, which exhibits an undulated bundular pattern, thickened collagen present in stained a faint grayish pink rather than the customary deep red when stained with this method. It is this dense fibrosis involving the tissues around the Pterygomandibular raphe that caused varying degree of trismus7.

Table – I. Histopathological Changes in the Biopsy Specimens of Soft Palate in 58 Patients with Oral Submucous Fibrosis

Fibrosis Muscle changes* Dysplasia Chronic inflammation
(Mainly lymphocytes)
  Mild Moderate Severe of striations Atrophy muscle fibers Loss of Edema Mild Moderate Severe Mild Moderate cross
Number 12 36 6 3 9 3 15 3 2 7 51
Percentage 26.9% 62.0% 10.4% 5.2% 15.6% 5.2% 25.86% 5.17% 3.45% 12.06% 87.94%

In our study though the partial response to treatment was observed, a close regular follow up is required in most cases as the fibrosis often recurs and disease carries malignant potential. Management of OSMF is only palliative and does little to prevent the 8 progressive nature of the disease as well as its malignant potentialla: Therefore, it has been concluded that most important measure is prevention, and that the use of pan/ gutkha/ pan masala should be forbidden in patients.

References

  1. Pillai R, Balaram P, Reddiar KS. Pathogenesis of oral submucous fibrosis. Relationship to risk factors associated with oral cancer. Cancer, 1992, 69: 2011-2020.
  2. Jayanthi V, Probert CSJ, Sher KS, Mayberry JF. Oral submucosal fibrosis – a preventable disease. Gut, 1992, 33: 4-6.
  3. Maher R, Lee AJ, Warnakulasuriya Kaas et al. Role of areca nut in the causation of oral submucous fibrosis: a case control study in Pakistan. J. Oral Pathol Med. 1994; 23: 65-69.
  4. Harvey W, Saitt A, Meghi S, Carniff JP. Stimulation of human buccal fibroblasts in vitro by betel nut alkaloids. Arch Oral Biol, 1986; 31: 45-49.
  5. Murti PR, Bhonsle RB, Pindborg JJ et al. Malignant transformation rate in oral submucous fibrosis over a 17 year period. Community Dent Oral Epidemiol,1985;13: 340-341.
  6. Hanner et al. Altered staining reaction of connective tissue in 53 SMF patients. Journal of Dental Research, 1971, 50: 388-392.
  7. Bhonsle RB et al. Regional variations in OSMF in India. Community Dentistry. Oral Epidemiology,1987;15: 2225- 2229.
  8. Borle RM, Borle SR. Management of oral submucous fibrosis. J. Oral Maxillofac Surg, 1991; 49: 788-791.

(1)Deptt. of Pathology, (2)Deptt. of Otorhino Laryngology
J.N. Medical College A.M.U., Aligarh – 202002
E-mail: [email protected]
Received : 23.6.03

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