Oral Submucous Fibrosis

Oral submucous fibrosis is a chronic, progressive, scarring, high-risk precancerous condition of the oral mucosa seen  primarily on the Indian subcontinent and in Southeast Asia. It has been linked to the chronic placement in the mouth of a betel quid or paan and is found in 0.4% of India's villagers. The quid consists typically of areca nut and slaked lime, usually with

tobacco and sometimes with sweeteners and condiments, wrapped ina betel leaf. The slaked lime acts to release an alkaloid
(arecaidine) from the areca nut, producing a feeling of euphoria and well-being in the user.

ETIOLOGY
Excessive consumptions of red chilies.

Excessive "areca nut" chewing.

Nutritional deficiency: Deficiency of vitamin A, B complex and C, etc. as well as the deficiency of iron and zinc in the diet.
Immunological factors: oral submucous fibrosis exhibits increased number of eosinophils both in the circulation as well as int he tissue. Moreover, there is also presence of gammaglobulinemia and increased mast cell response, etc. All these actorsi ndicate an immunologic background of the disease.

Genetic factors: Some people are genetically more susceptible to this disease.

Protracted tobacco use: Excessive use of chewable tobacco.

Deficiency of micronutrients: Patients with deficiency of selenium, zinc, chromium and other trace elements may fail to prevent the free radical injury in the body and can therefore develop oral submucous fibrosis.

CLINICAL FEATURES
Age: 20 to 40 years of age.

Sex: Female are affected more often than males

Site: In submucous fibrosis, fibrotic changes are frequently seen in the buccal mucosa, retromolar area, uvula, soft palate, palatal
fauces, tongue, lips, pharynx and esophagus, etc. It is believed, that the disease initiates from the posterior part of the oral cavity and then it gradually spreads to the anterior locations.

PRESENTATION
In the initial phases of the disease, palpation of the mucosa elicits a "wet leathery" feeling.

Petechial spots may also be seen in the early stages of the disease over the mucosal surfaces of tongue, lips and cheek, etc.

Oral mucous membrane is very painful upon palpation at this stage.

One of the most important characteristic features of oral submucous fibrosis is the gradual stiffening of the oral mucosa with progressive reduction in the mouth opening (trismus).

In mild cases, there may be white areas on the soft palate, but in severe cases, it shows restricted movements. Patients also have a 'bud-like' shrunken uvula.

Thinning and stiffening of the lips causing microchelia and presence of circumoral fibrous bands. Areas of hypo or hyper pigmentation are seen in the oral mucosa.

Loss of stippling occurs in the gingiva, and it becomes depigmented and fibrotic.

Floor of mouth becomes blanched and it gives a leathery feeling during palpation.

Palate presents several fibrous bands, which are radiating from the pterygomandibular raphe to the anterior faucial pillars.

The faucial pillars may be thick and short and the tonsils are often placed between them.

When the disease progresses to the pharynx and esophagus, it causes extreme difficulty in deglutition.

Treatment:
Stoppage of all habits, grinding and rounding of sharp cuspal edge of teeth, routine extraction of all third molars are the preliminary steps in the treatment plan. The definitive treatment of OSF includes intralesional injections of collagenase, corticosteroids and fibrinolysis,etc. Systemic administration of steroids is also done in several cases.

Biopsy is mandatory before treatment and if the dysplastic features are present in the epithelium, steroids should be avoided from the treatment schedules.