A Short Review on OSMF: Oral Sub Mucous Fibrosis

5BDS (HPU Shimla) 6BDS, Govt. Dental College Shimla Abstract Oral submucous fibrosis (OSMF) is a premalignant condition caused by betel chewing. OSMF is a premalignant condition that can lead to oral cancer. A risk that is further increased by concomitant tobacco consumption. OSMF is a diagnosis based on clinical symptoms and confirmation by histopathology. Major constituents of betel quid are arecoline from betel nuts and copper, which are responsible for fibroblast dysfunction and fibrotic band formation. Drug therapy include antifibrotic, anti-inflammatory, and antioxidants, homemade remedies including turmeric and tulsi . Prevention is most important in case of OSMF , because severe cases of OSMF are irreversible.


INTRODUCTION:
O ral submucous fibrosis is a chronic disease affecting the oral mucosa, as well as the pharynx and the upper two-thirds of the esophagus. There is substantial evidence that lends support to a critical role of areca nuts in the etiology behind oral submucous fibrosis (1). It is complex condition of the oral cavity. In simple word patients jaw become rigid to the point that he/she is unable to open mouth.This is common oral cavity problem among south Asian problem strongly associate with the practice of chewing areca nut and betel quid. People who have strong habit of chewing Pan, Pan Masala, Gutka, Mawa and Mainpuri tobacco have strong chances of having OSMF. Patients with OSMF have complaint of reduced mouth opening.
Background: In 1952, Schwartz coined the term atrophica idiopathica mucosa oris to describe an oral fibrosing disease he discovered in 5 Indian women from Kenya (2). Joshi subsequently coined the termed oral submucous fibrosis (OSF) for the condition in 1953 (3). Oral submucous fibrosis is a chronic debilitating disease of the oral cavity characterized by inflammation and progressive fibrosis of the submucosal tissues (lamina propria and deeper connective tissues). Oral submucous fibrosis results in marked rigidity and an eventual inability to open the mouth. (4) The buccal mucosa is the most com-monly involved site, but any part of the oral cavity can be involved, even the pharynx.

Etiology & Pathogenesis:
The pathogenesis of the disease is not well established, but the cause of oral submucous fibrosis is believed to be multifactorial. Factors include areca nut chewing, ingestion of chilies, genetic and immunologic processes, nutritional deficiencies, and other factors.
Previous studies on the pathogenesis of OSF have suggested that the occurrence may be due to: -Clonal selection of fibroblasts with a high amount of collagen production during the long-term exposure to areca quid ingredients (5) -Stimulation of fibroblast proliferation and collagen synthesis by arecanut alkaloids (6) -By decreased secretion of collagenase (7) -And by an increase in collagen cross-linkage as caused by upregulation of lysyl oxidase by OSF fibroblasts (8) -Smoking and alcohol consumption alone, habits common to areca nut chewers, have been found to have no effect in the development of oral submucous fibrosis ,but their addition to areca nut chewing can be a risk for oral submucous fibrosis . (9) -A genetic component is assumed to be involved in OSF Patients with increased frequency of HLA-A10, HLA-B7, and HLA-DR3 reported in people without a history of betel nut chewing or chili ingestion. (10,11) -Iron deficiency anemia, vitamin B complex deficiency and malnutrition are promoting factors that derange the repair of the inflamed oral mucosa, leading to defective healing and resultant scarring (10) Histopathology : Microscopically, the principal feature is atrophy of the epithelium and subjacent fibrosis Figure 1 (12). Epithelial dysplasia occasionally may be evident. The lamina propria is poorly vascularized and hyalinized; fibroblasts are few. A diffuse mild to moderate inflammatory infiltrate is present. Type I collagen predominates in the submucosa, whereas type III collagen tends to localize at the epithelium-connective tissue interfaceand around blood vessels, salivary glands, and muscle. (12) Epidemiology: Areca nut-derived products are commonly used by several hundred million individuals in the southern parts of Asia. Oral complications are most commonly observed on the lips, buccal mucosa, retromolar area, and soft palatal mucosa. The habit of chewing betel quid, containing fresh, dried, or cured areca nut, and flavoring ingredients is widespread in India, Pakistan, Bangladesh, and Sri Lanka and in immigrants coming from these regions. Tobacco is often used in conjunction with betel quid. The habit is more common among women in some geographic areas, which is also reflected in the gender distribution of oral submucous fibrosis. The global incidence of oral submucous fibrosis is estimated at 2.5 million individuals. The prevalence in Indian populations is 5% for women and 2% for men. Individuals in less than 20 years old seem to be affected more commonly by oral submucous fibrosis than individuals in other age groups. (1)

CLINICAL PRESENTATION:
OSMF is seen typically between the ages of 20 and 40 and is often associated with the habitual use of compounds containing areca (betel) nut and tobacco in various forms, including a quid form (paan) and a powdered form (gutka), where these are placed in the oral cavity for extended periods of time and often are replaced up to several times per day. Oral submucous fibrosis presents as a whitish yellow change that has a chronic, insidious biological course. It is characteristically seen in the oral cavity, but on occasion it may extend into the pharynx and the esophagus. Submucous fibrosis occasionally may be associated with vesicle formation. Over time, the affected mucosa, especially the soft palate and the buccal mucosa, loses its resilience and shows limited vascularity and elasticity. This process then progresses from the lamina propria to the underlying musculature. Fibrous bands are readily palpable in the soft palate and the buccal mucosa. The clinical result is significant trismus with considerable difficulty in eating.
Patient may give you , history of either all or few of these sypmtoms that include -

Management of OSMF:
Eliminating causative agents is part of the management of submucous fibrosis. Therapeutic measures include local injections of chymotrypsin, hyaluronidase, and dexamethasone, with surgical excision of fibrous bands and submucosal placement of vascularized free flap grafts. All methods of treatment, including surgical modalities, however, have proved to be of only modest help in this essentially irreversible condition.

Lifestyle Changes:
Avoid areca nut & other chronic irritant such as hot and spicy food.
Advice green leafy vegetables.

Intake of Vit. A, B complex rich diet & high protein diet.
Minimizing consumption of spicy foods, including chiles.
Maintaining proper oral hygiene.
Avoid hot fluids like tea, coffee Avoid alcohol

Physiotherapy:
It includes forceful mouth opening , repeated blooming of balloons ,heat therapy.

Medical Management:
Steroids: In patients with moderate OSF, sub mucosal intralesional injections given. Topical application of steroids may help, prevent further damage. The recommended dose is 75 to 100 mg twice a week for 4 to 6 weeks.
Placental extracts:Sur in 2003 reported that the rationale for using placental extract (PE) in patients with OSMF derives from its proposed antiinflammatory effect prevents the mucosal damage. (16) Recommended dose of placental extract is 2ml twice weekly for 4 to 6 weeks.

Hyaluronidase:
The use of topical hyaluronidase shows significant improvement than steroids alone. The recommended dose is 1500 i.u twice weekly for 4 to 6 weeks. According to Karkar in 1985 the combi-nation of steroids and topical hyaluronidase showed better long-term results than either used alone. (17)

Split-thickness skin grafting following bilateral temporalis myotomy or coronoidectomy:
Trismus associated with OSMF may be due to changes in the temporalis tendon secondary to OSMF; therefore, skin grafts may relieve. 5. Home remedies: Tulsi and turmeric (curcumin) along with life style modification is safe and efficacious remedy for the treatment of all grades of OSMF in all age groups with no limitation to its use. Tulsi and turmeric can provide a safer, low cost, and effective alternative to the present conventional treatment, which can be useful in a country like India.Mix 1 gm of turmeric powder and 1 gm of tulsi powder in glycerine to make a paste. The patients were instructed to apply this paste all over the oral mucosa 4-5 times per day and not to eat or drink anything for next 15 minutes. (21) Herbal treatment can provide a safer, low cost, and effective alternative to the present conventional treatment, which can be useful in a country like India. Further studies are going on to access the comparative efficacy with already existing treatment for OSMF. 6. Conselling of the patient: Sometimes a psychological conselling of the patient is required in advance cases of OSMF, as patient thinks they are going to suffer from oral cancer or they are going to die because of this condition. So , family support and social support along with conselling of patient becomes important in some advance cases.

CONCLUSION:
OSF is a disease with a high degree of incidence. It also carries a significant morbidity rate from oral cancer.